Coxa pedis: can calcaneal pronation angle be considered a predictive sign of medial plantar arch overload?

PURPOSE: To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology. MATERIAL AND METHODS: One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined. RESULTS: The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (p < 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (p < 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (p < 0.0001). For plantar fascia enthesopathy, the result was borderline significant (p < 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (p < 0.0001). In contrast, no correlation with age was found. CONCLUSION: In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs.

Isolated distal grade III lateral collateral ligament injury: what is the real clinical impact in professional athletes?

The isolated III grade lateral collateral ligament injuries are rare, and there is limited literature available on their management. We report 3 cases of professional soccer players with isolated distal lateral collateral ligament III grade injury, confirmed by MRI studies. After undergoing MRI examinations, all three players resumed competitive activity without resting and experienced no consequences regarding joint stability. We assessed the significance of the lateral collateral ligament in providing lateral stabilization to the knee joint in professional footballers with clinical tears of the lateral collateral ligament. The other structures of posterolateral area that remain intact contribute to joint stability, and the lateral collateral ligament's extra-articular position appears to expedite the ligament's healing process. Therefore, we propose a possible conservative treatment approach, mostly for professional athletes and adolescent patients, involving a rehabilitation plan without the need for surgery.

Glenoid bone loss in anterior shoulder dislocation: a multicentric study to assess the most reliable imaging method.

PURPOSE: The aim of this multicentric study was to assess which imaging method has the best inter-reader agreement for glenoid bone loss quantification in anterior shoulder instability. A further aim was to calculate the inter-method agreement comparing bilateral CT with unilateral CT and MR arthrography (MRA) with CT measurements. Finally, calculations were carried out to find the least time-consuming method. METHOD: A retrospective evaluation was performed by 9 readers (or pairs of readers) on a consecutive series of 110 patients with MRA and bilateral shoulder CT. Each reader was asked to calculate the glenoid bone loss of all patients using the following methods: best fit circle area on both MRA and CT images, maximum transverse glenoid width on MRA and CT, CT PICO technique, ratio of the maximum glenoid width to height on MRA and CT, and length of flattening of the anterior glenoid curvature on MRA and CT. Using Pearson's correlation coefficient (PCC), the following agreement values were calculated: the inter-reader for each method, the inter-method for MRA with CT quantifications and the inter-method for CT best-fit circle area and CT PICO. Statistical analysis was carried out to compare the time employed by the readers for each method. RESULTS: Inter-reader agreement PCC mean values were the following: 0.70 for MRA and 0.77 for CT using best fit circle diameter, 0.68 for MRA and 0.72 for CT using best fit circle area, 0.75 for CT PICO, 0.64 for MRA and 0.62 for CT anterior straight line and 0.49 for MRA and 0.43 for CT using length-to-width ratio. CT-MRA inter-modality PCC mean values were 0.9 for best fit circle diameter, 0.9 for best fit circle area, 0.62 for anterior straight line and 0.94 for length-to-width methods. PCC mean value comparing unilateral CT with PICO CT methods was 0.8. MRA best fit circle area method was significantly faster than the same method performed on CT (p = 0.031), while no significant difference was seen between CT and MRA for remaining measurements. CONCLUSIONS: CT PICO is the most reliable imaging method, but both CT and MRA can be reliably used to assess glenoid bone loss. Best fit circle area CT and MRA methods are valuable alternative measurement techniques.

Shoulder Magnetic Resonance Arthrography with the Internal and External Rotation Positions of the Humeral Head in the Evaluation of SLAP Lesions.

We aimed to evaluate the diagnostic performance of shoulder MR arthrography (MRA) acquired in the neutral (N), internal rotation (IR), and external rotation (ER) positions of the shoulder to detect SLAP lesions. Three observers evaluated 130 MRAs to detect SLAP lesions and to calculate labral diastasis in this triple-blinded study. Sensitivity was much higher in the ER (92.5-97.5%) than in the N (60-72.5%) and IR (42.5-52.5%) positions, and the specificity of all the reviewers was 100% in all the positions. The diagnostic accuracy was higher in the ER too (97.7-99.2%). The diastasis length was significantly higher in the ER (median = 2.5-2.8 mm) than in the N (1 mm) and IR (0 mm) positions and was also significantly higher in those patients requiring surgery (p = 0.001). The highest inter-rater agreement values were observed in the ER both in SLAP detection (k = 0.982) and the diastasis length evaluation (ICC = 0.962). The diastasis length threshold in the ER that best separated the patients who did and did not require surgery was 3.1 mm (AUC = 0.833). In 14.6% of the cases, ER enabled the detection of SLAP lesions not identified in the N position. MRA with the ER improves the diagnosis of SLAP lesions and, together with the IR position, provides additional dynamic information about the diastasis of the lesions. It is recommended to perform additional ER and IR scans in the shoulder MRA protocol.

MRI evaluation of meniscal anatomy: which parameters reach the best inter-observer concordance?

PURPOSE: The aim of the study is to evaluate which MRI parameters achieve the best degree of inter-individual concordance in the description of meniscal fibrocartilage, regarding its morphology, signal and position. MATERIALS AND METHODS: Eighty-nine knee MRIs were included in the study, retrospectively re-evaluated by three radiologists who completed a binary report (normal/abnormal) describing the meniscus signal, position relative to the tibial plateau margin and morphology. The inter-individual concordance value was calculated using Cohen's test. RESULTS: We obtained different inter-individual concordance values according to the parameters considered. The concordance was poor in the description of the meniscal position relative to the tibial plateau margin (average k = 0.6); the result was comparable in the description of the meniscal morphology (average k = 0.56). The best results were obtained with the meniscal signal analysis (average k = 0.8). CONCLUSION: To the best of our knowledge, there are no studies in the literature assessing the concordance between multiple readers in the description of the parameters we studied. The results we obtained suggest that the most reliable parameter for describing meniscal fibrocartilage is its signal intensity, whereas morphology and position may lead to different interpretations that are not always unequivocal.

Magnetic resonance arthrography in patients with multidirectional instability: could inferior capsulsar width be considered the cornerstone in the diagnosis of non-traumatic shoulder instability?

OBJECTIVES: To provide quantitative anatomical parameters in patients with and without non-traumatic multidirectional instability using MR arthrography (MR-a). MATERIALS AND METHODS: One hundred and seventy-six MR-a performed from January 2020 to March 2021 were retrospectively evaluated. Patients were divided according to the presence of clinically diagnosed multidirectional shoulder instability (MDI). Each MR-a was performed immediately after intra-articular injection of 20 ml of gadolinium using the anterior approach. The width of the axillary recess, the width of the rotator interval, and the circumference of the glenoid were measured by three independent radiologists, choosing the average value of the measurements. The difference between the mean values of each of the three parameters between the two study groups was then assessed. RESULTS: Thirty-seven patients were included in the study (20 in the MDI group, 17 in the control group). The mean axillary recess width in the MDI group was significantly greater than in the control group (t(33) = 3.15, p = .003); rotator interval width and glenoid circumference measurements were not significantly different (t(35) = 1.75, p = .08 and t(30) = 0,51, p = .6, respectively). CONCLUSIONS: Inferior capsular redundancy may be an important predisposing factor in MDI, while glenoid circumference is not related to MDI. The relationship between the width of the rotator interval and shoulder instability remains debated.

MR arthrography: correlation between anatomic intraarticular variants of the long head of the biceps tendon (long head biceps tendon) and superior labral anterior to posterior (SLAP) lesions.

BACKGROUND: The purpose of this work is to characterize the anatomy of the intraarticular portion of the long head of the biceps tendon (long head biceps tendon) using magnetic resonance (MR) arthrography by investigating whether anatomical variants may facilitate the onset of a supraequatorial lesion (superior labral anterior to posterior, SLAP). MATERIALS AND METHODS: In 482 shoulder MR arthrographies, we considered the anatomical variants of the intraarticular portion of the long head of the biceps tendon classified according to Dierickx's arthroscopic classification; lesions of supraequatorial structures were considered in the data analysis. For each anatomical variant, correlation with SLAP and the odd ratio were statistically evaluated, using Fisher's exact (or chi-squared) test and logistic regression analysis, respectively. RESULTS: In the mesotenon-type variant, the SLAP frequency was higher than expected [χ2 (df = 4) = 14.9, p = 0.005] with a higher risk of developing a type I SLAP (p = 0.0003). In the adherent-type variant, the type II SLAP frequency was higher than expected [χ2 (df = 3) = 18.1, p = 0.0004] with a higher risk of developing type II SLAP (p = 0.0001). Two cases of "split" (SPL) long head biceps tendon had III and type IV SLAP, respectively. These patients have a higher risk for type IV SLAP [odds ratio (OR) 19.562, 95% confidence interval (CI) 1.604-238.541, p = 0.001]. An increased risk of developing SLAP type II was calculated for male subjects (OR 3.479, 95% CI 1.013-11.951, p = 0.019). CONCLUSIONS: It is possible that adherence of the long head biceps tendon to the supraspinatus more often predisposes to a lesion of the superior glenoid labrum (SLAP), in view of the close relationships between the fibrocartilage and the bicipital anchor, probably related to the limited excursion of the intraarticular long head biceps tendon.

Paramagnetic contrast medium in high-level athletes with lower limb muscle injuries: can it make the return to sport safer reducing the recurrence rate?

PURPOSE: The aim is to investigate whether contrast medium can improve accuracy in the assessment of healing muscle injury in high-level professional athletes. MATERIALS AND METHODS: Our series is a retrospective study including the records of 22 players (mean age 28 ± 5 SD) with lower limbs muscle injuries type 3a (Mueller-Wohlfarth). All athletes received two MRIs: the day after the injury and before resuming heavy effort activities. Contrast medium uptake was measured in the second MRI by comparing the mean enhancement at the lesion site (ME) with that of the healthy contralateral muscle (HM). The result is a percentage referred to as muscular contrast index (MC index). The difference between the mean MC index value between athletes with and without re-injury was assessed with both the Mann-Whitney and the Kruskal-Wallis test. RESULTS: Twenty-nine muscle injuries matched the inclusion criteria. The mean MC index values, adjusted for the variable of time elapsed between the last contrast examination and return to the field, were significantly different in the two study groups (p < .001). CONCLUSION: The contrast medium in the follow-up of muscle injuries may be useful in determining the degree of scar stability in a healing injury. Injuries with a high MC index were found to be 'unstable', with a higher rate of recurrence than those with a low MC index. Resumption of competitive activity after achieving not only clinical resolution but also a satisfactory MC index value may increase the safety of return to the field and reduce the recurrence rate.

Case report of a tibial fracture in a patient suffering from gout: An atypical site, the importance of differential diagnosis.

We present the case of a 60-year-old man with a history of severe tophaceous gout with polyarticular involvement who came to the emergency room due to direct trauma to the right forearm and knee. The knee X-ray and CT scan showed a lateral tibial plateau fracture characterized by the presence of a lytic bone lesion. The presence of a solid neoplasm was ruled out and a CT-guided biopsy was performed. Histological evaluation revealed findings typical for an advanced intraosseous gout. As there was no significant risk of progression of the lytic lesion, the fracture site was treated conservatively. This case is unique in the literature in terms of location and should be considered as an atypical site of intraosseous gout. Proper differentiation of a pathological fracture on an intraosseous gout location from a neoplastic lesion is essential to choose the correct therapy.

Inter-observer concordance in normal and pathological findings of the hip joint in plain radiographs.

BACKGROUND AND AIM: The purpose of the study was to compare the data obtained by two independent observers and statistically analyze the results using Cohen's K to highlight the concordance or discordance in the diagnosis of normality, pathology and, in particular, the type of femoro-acetabular impingement (FAI) on plain films. METHODS: the study was conducted retrospectively. The only inclusion criterium was the minimum age of 20 years. All patients underwent a radiographic examination of the pelvis in standard anteroposterior projection in orthostasis. RESULTS: A good concordance between the two operators in the examination of normal hip joint (k= 0.68 right/ 0,74 left) was found; a similar grade of agreement was found for the analysis of "pincer" type FAI (k = 0.73 right, 0,67 left). The best results in concordance were achieved in the examination of "cam" type FAI (k= 0.82 right, 0,88 left), "mixed" type FAI (k = 0.85 right, 0,86 left), and in findings of "coxa profunda" (k = 0.92 right, 0,88 left). CONCLUSION: We found a good concordance between the two readers; a few cases of disagreement were found in the diagnosis of "pincer" type FAI and absence of disease. This discrepancy may be due to the different weight given by the single observer to the clinical indication that leads the patient to examination, but also by the difficulty of a not dedicated radiologist to show some subtle signs indicative of early FAI.

MR- arthrography: anatomic variant from link between lateral meniscus and anterior and posterior cruciate ligaments. A case report and review of the literature.

Menisci congenital anomalies are rare morphologic abnormalities including accessory meniscus, discoid meniscus, double-layered meniscus, hypoplastic meniscus and ring-shaped meniscus (RSM). In a 35 year-old male patient, MR arthrography showed a bridging accessory bundle connecting the anterior cruciate ligament and posterior cruciate ligament with the posterior horn of the lateral meniscus. Arthroscopic examination showed a fan-like obstacle embracing the posterior horn of the lateral meniscus. It would be important to correctly identify this anatomical variant, because the bundle connecting the external meniscus to the ligaments of the central pivot can be misinterpreted as a meniscal fragment.

Role of ultrasound and magnetic resonance imaging in the prognosis and classification of muscle injuries in professional football players: correlation between imaging and return to sport time.

PURPOSE: To study distractive muscle injuries applying US and MRI specific classifications and to find if any correlation exists between the results and the return to sport (RTS) time. The second purpose is to evaluate which classification has the best prognostic value and if the lesions extension correlates with the RTS time. METHODS: A total of 26 male, professional soccer players (age 21.3 ± 5.6), diagnosed with traumatic muscle injury of the lower limbs, received ultrasound and MRI evaluation within 2 days from the trauma. Concordance between US and MRI findings was investigated. The relationships between MRI and US based injury grading scales and RTS time were evaluated. Correlation between injuries' longitudinal extension and RTS time was also investigated. RESULTS: The correlation between US and MRI measurements returned a Spearman value of rs = 0.61 (p = .001). Peetrons and Mueller-Wohlfahrt grading scales correlations with RTS time were r = 0.43 (p = .02) and r = 0.83 (p = < .001). The lesion's extension correlation with RTS time was r = 0.63 (p < .001). The correlation between the site of the lesion and its location with the RTS time were rs = 0.2 and rs = 0.25. CONCLUSIONS: Both US and MRI can be used as prognostic indicators along with the Peetrons (US) and the Mueller-Wohlfahrt (MRI) classifications. MRI is more precise and generates more reproducible results. The lesion craniocaudal extension must be considered as a prognostic indicator, while the injury location inside the muscle or along its major axis has doubtful significance.

Knee articular cartilage injury treatment with matrix-induced autologous chondrocyte implantation (MACI): correlation at 24 and 120 months between clinical and radiological findings using MR arthrography.

OBJECTIVE: To evaluate the long-term evolution of matrix-induced autologous chondrocyte implantation (MACI) with magnetic resonance (MR) arthrography and verify the correlation between radiological and clinical findings. MATERIALS AND METHODS: Twenty-six patients (20 m/6f) were diagnosed with knee chondral injuries and treated with MACI implantation. Each patient received MR arthrography and clinical examination at mid-term (range 22-36 months) and long term (range 96-194 months) after surgery. MR arthrography was performed with dedicated coil and a 1.5-Tesla MR unit. The modified MOCART scale was used to evaluate the status of chondral implants. Implant coating, integration to the border zone, and the surface and structure of the repaired tissue were evaluated. Presence of bone marrow oedema was evaluated. The Cincinnati Knee Rating System (CKRS) was used for clinical assessment. RESULTS: At long term, 4/26 patients had complete alignment; 5/26 had a complete integration of the margins; in 4/26 cases, the implant surface was undamaged; in 14/26 cases, the reparative tissue was homogeneous. In 9/26 cases, the implant showed isointense signal compared to articular cartilage, while the presence of subchondral bone oedema was documented in 19/26 cases. The average radiological score decreased from 59.2 (mid-term) to 38.6 (long term). The average clinical score decreased from 8.9 to 8.3. CONCLUSIONS: Decrease in clinical results was not significant (0.6 points p = .06), but mMOCART scores decreased significantly (p = .00003). Although imaging studies showed deterioration of the grafts, the patients did not have significant clinical deterioration (231/250).

Vacuum-assisted mechanical thrombectomy in extensively occlusive thrombosis of dialysis arteriovenous grafts with indigo system.

PURPOSE: To present a selected series of extensively occlusive thrombosis of arteriovenous graft treated with the Penumbra's Indigo System. MATERIALS AND METHODS: Ten patients with acute (within 72 h) extensively occlusive thrombosis of arteriovenous graft (mean extension = 30.1 (range = 15-45) cm) were treated at our institution with the Indigo System. Of the 10 cases, thrombosis was extended to venous outflow in 7 cases and to both arterial inflow and venous outflow in 3 cases. RESULTS: Both anatomic and clinical success were achieved in 8 of the 10 procedures (80.0%). In the 2 cases of technical failure, the patients underwent surgical thrombectomy with the finding of arteriovenous graft exhaustion, which was then replaced. The 6-month primary patency, primary-assisted patency, and secondary patency rates were 37.5% (3/8), 50.0% (4/8), and 62.5% (5/8). We reported 2 complications (one minor and one major adverse event). CONCLUSION: Percutaneous mechanical thrombectomy aspiration with Indigo System is a relatively safe and effective procedure and can be used even in extensively thrombosed arteriovenous graft.

Efficacy of Primary Stent-Graft Placement in the Treatment of Vascular Access Graft Outflow Tract Stenosis.

PURPOSE: The aim of this study is to present our personal experience using covered nitinol stent-graft in the treatment of outflow tract stenosis of arteriovenous grafts (AVGs) for hemodialysis access. MATERIALS AND METHODS: Between May 2015 and October 2017, we retrospectively evaluated 36 (24 males, 12 females; mean age: 65.6 years) patients with AVGs on hemodialysis who underwent percutaneous angioplasty followed by endovascular stent-graft deployment for the treatment of stenosis of the venous outflow of the AVG. Indication for treatment included early restenosis (<3 months after previous percutaneous transluminal angioplasty [PTA]), long stenosis (stenoses >50% extending for a length >5 cm), and recoil of the stenosis after PTA performed with a noncompliant high-pressure balloon. Of 36 patients, 27 (75%) required surgical thrombectomy prior to endovascular procedure. Technical success, clinical success, primary and secondary patency, and safety were evaluated. RESULTS: Technical success was 100%, and clinical success was 94.4%. Primary patency was 94.4%, 72.2%, 63%, 45.9%, and 45.9% at 1, 3, 6, 12, and 18 months (average: 215 days, range: 9-653 days); secondary patency was 94.4% and 86.1% at 1 and 3 months; 80.4% at 6, 12, and 18 months; and 53.6% at 24 months (average: 276.8 days, range: 9-744 days). No deaths were registered. CONCLUSIONS: In selected cases, the use of stent-graft represents an effective and safe solution for the treatment of stenotic complications of the venous outflow of AVGs, even in the setting of access thrombosis.

Evaluation of muscle tears in professional athletes using diffusion-weighted imaging and apparent diffusion coefficient: preliminary results.

PURPOSE: Many studies have evaluated the role of DWI in musculoskeletal diseases but less is known on muscle tears. Especially for professional athletes, muscle injuries are responsible for large time lost. The aim of this study was to investigate on potential relationship between the muscle tear degree and the diffusion characteristics. METHODS: In this retrospective study, patients signed a comprehensive consent form according to Good Clinical Practice guidelines before proceeding with all examinations. It satisfied all the requirements of the Declaration of Helsinki and the Italian national law for the protection of personal data. We have analyzed 38 professional athletes (36 males; mean age±standard deviation 27±8 years) with a muscle tear. They were 26 football and 12 athletics players, with clinically suspected injuries of the lower limbs muscles. All of patients underwent a 1.5-T MRI with standard protocol (STIR, TSE T2, SE T1, PD T2, PD fat sat T2) plus the DWI sequences with 0, 400 and 800 B-values (s/mm2). Per each B value, an experienced radiologist measured the signal intensity (SI, in arbitrary units [au]) using a region of interest (ROI) placed within the tear on DWI images. SI drop off at the third B value was calculated referred to the first B value. Similarly, ADC was measured using the ADC map in a small ROI within the tear. Bivariate associations were evaluated using the Student t test. Logistic regression was performed using the tear degree as dependent variable. Data were given as mean±standard deviation. RESULTS: According the Muller-Wohlfarth classification, the 38 muscle tears were classified in type 3a in 22/38 cases and 3b in 16/38 cases. At bivariate analysis, 3a-tears had a SI at the third B value (24±9 au) lower (P=0.003) than that of 3b-tears (34±9 au). Similarly, 3a-tears had a SI drop off (73±10%) lower (P=0.008) than that of 3b-tears (82±9%). ADC was not significantly associated to tear degree (P=0.093). At regression analysis, SI at the third B value was the only independent predictor of the tear degree (P=0.032), while the SI drop off was borderline significant (P=0.070). CONCLUSION: This preliminary data showed a positive correlation between the degree of muscle tears and the SI at the third B-value. Compared to 3a- tears, 3b-tears tend to show higher SI and a higher SI drop off.

[Diagnostic tools in neurodegenerative disorders of adult-elderly]. / Strumenti diagnostici dei disordini neurodegenerativi nell'adulto-anziano.

Neurodegenerative disorders are an inhomogeneous group of neurological diseases that affect a large part of the population because of the rise in life expectancy. Although clinical manifestations are important to make the correct diagnosis, the new advanced imaging technique represent a very useful tool for the diagnostic work-up.

[The cerebral perivascular spaces: review of the literature on diffuse or focal expansion]. / Gli spazi perivascolari encefalici: revisione della letteratura sulle dilatazioni focali o diffuse.

Virchow-Robin spaces (VRS) are pial-lined, interstitial fluid-filled structures that do not directly communicate with the subarachnoid space, accompany penetrating arteries and veins and can be visualized on magnetic resonance imaging. This article reviews the imageology characteristics, the functions, the causes and the relation with neurological disorders of VRS.

[Imaging and radioguided surgery of tumors NETs]. / Imaging e chirurgia radioguidata di tumori neuroendocrini.

Neuroendocrine tumors tend to grow slowly and are notoriously difficult to localize, at least in the early stages. Metastases are in most cases already present at the time of diagnosis. Somatostatin receptor scintigraphy improves detection of small and occult NET tumors. Intraoperative probe counting with a hand-held gamma probe can identify tumors even when they are small and impalpable, but receptor positive. This advanced operative approach may improve the survival of these patients.

[Radionuclide imaging of neurendocrine tumors: biological basis and diagnostic results]. / Imaging con radionuclidi dei tumori neuroendocrini: basi biologiche e risultati diagnostici.

Many radiopharmaceuticals have been successfully used in nuclear medicine to detect neuroendocrine tumors, and many of them are based on a specific mechanism of uptake, while others are non-specific probes. This "review" focuses on the clinical applications of metaiodobenzylguanidine, (111)In-pentreotide and positron emission tomography (PET) tracers. New avances in diagnostic imaging will be discussed. Molecular imaging serves these diagnostic functions and provides powerful means for non-invasively detecting disease.