Biopsy is not necessary for the diagnosis of soft tissue hemangiomas.

OBJECTIVE: To describe the clinical and ultrasonography (US) findings of soft tissue hemangiomas, and to compare with the results of histologic diagnosis after US-guided biopsy. METHOD AND MATERIALS: We retrospectively studied the files of 97 patients (48 female, 49 male; mean age, 34 years; range 4-84 years) with soft tissue hemangiomas diagnosed from 2004 to 2011. Mean follow-up was 9 years (range 7-13 years). Clinical presentation included intermittent mild pain associated with a soft tissue swelling/palpable mass in all patients, chronic pain and increased local heat in 29 patients, local swelling and decreased range of motion of the adjacent joint in 45 patients, and all the above symptoms in 23 patients. B-mode and color Doppler US evaluation included the site, location, size, shape, margins, presence of calcifications, echo structure and echogenicity. All patients had US-guided biopsy for histologic analysis. RESULTS: US-guided biopsy and histology confirmed the diagnosis of soft tissue hemangioma in 92 of the 97 lesions (94.8%). Histologic examination of the remaining five lesions showed nodular fasciitis (two lesions), endometriosis (one lesion), hemangioendothelioma (two lesions); US of these lesions showed variable size, irregular margins, and deep-seated location. Histologically documented soft tissue hemangiomas were most commonly superficial (74 lesions) and arteriovenous (45 lesions). Shape was most commonly oval (fusiform), margins were most commonly not well defined (irregular, hazing but circumscribed), phleboliths were more common in deep-seated lesions, echo structure was heterogeneous, and echogenicity was most commonly hyperechogen and involuting. CONCLUSION: Clinical presentation and typical B-mode and color Doppler US findings are adequate for the diagnosis of soft tissue hemangiomas without the need for biopsy and histologic analysis. If any clinical or US doubt, an US-guided biopsy should be performed.

Platelet-rich plasma for the treatment of patellar tendinopathy: clinical and imaging findings at medium-term follow-up.

PURPOSE: The purpose of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy, and report the quality and duration of the clinical improvement up to a medium-term follow-up. METHODS: Forty-three patients (mean age, 30.6 years; mean BMI, 24.7; 42 men, one woman) affected by chronic patellar proximal tendinopathy were enrolled in this trial. Eleven patients were affected by bilateral tendinopathy. They underwent three ultrasound guided intra-tendinous injections of five millilitres PRP, two weeks apart from each other. Patients were prospectively evaluated initially, then after two, six, and up to mean 48.6 ± 8.1 months of follow-up (minimum evaluation at 36 months). The following evaluation tools were used: Blanzina, VISA-P, EQ-VAS for general health, and Tegner scores. Patients' overall satisfaction and time to return to sport were also reported. RESULTS: Good and stable results were documented over time, with the VISA-P score increasing from 44.1 ± 15.6 at baseline to 61.4 ± 22.2 at two months, 76.6 ± 25.4 at six months, and 84.3 ± 21.6 at four years' follow-up. The same trend was confirmed by the other scores used, and 80 % of the patients were satisfied and returned to previous sports activities. Significantly poorer results were obtained in patients with a longer history of symptoms, and poor results were also observed in bilateral lesions. No correlation between ultrasonographic and clinical findings could be found. CONCLUSIONS: Multiple injections of PRP provided a good clinical outcome for the treatment of chronic recalcitrant patellar tendinopathy with stable results up to medium-term follow-up. Patients affected by bilateral pathology and presenting a long history of pain obtained significantly poorer results.

Post traumatic myositis ossificans: Sonographic findings.

PURPOSE: The aim of this paper is to describe the sonographic (US) features of post traumatic myositis ossificans (PTMO). METHODS: Fifteen patients with histopathological diagnosis of PTMO were included. The following US parameters were evaluated: presence of a mass, calcifications, power Doppler signals, and relationship with adjacent structures. RESULTS: Five patients (33.3%) were diagnosed as early PTMO and 10 (66.6%) as mature PTMO. In both early and mature PTMO, US showed an oval hypoechoic mass, without infiltrative borders, located in a muscular belly. In the early phase, a center of less echogenicity was observed, associated with an outer sheet-like hyperechoic peripheral rim, while, in the mature phase, peripheral calcification created more reflections and distal acoustic shadowing was observed. CONCLUSIONS: US is highly sensitive in the detection of PTMO, helps differentiate between PTMO and malignant soft tissue tumors, and can be used for follow-up of the lesions.

Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid, Separately and in Combination, for Hip Osteoarthritis: A Randomized Controlled Study.

BACKGROUND: The effectiveness of intra-articular platelet-rich plasma (PRP) injections has been evaluated in knee chondroplasty and osteoarthritis (OA); however, little evidence of its efficacy in hip OA exists. PURPOSE: To compare the therapeutic efficacy of autologous PRP, hyaluronic acid (HA), or a combination of both (PRP+HA) in hip OA. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients aged between 18 and 65 years who were treated with outpatient surgery and who had hip OA and pain intensity at baseline of >20 on a 100-mm visual analog scale (VAS) were recruited for this study. Exclusion criteria were extensive surgery; presence of excessive deformities; or rheumatic, infective, cardiovascular, or immune system disorders. The primary outcome measure was a change in pain intensity as assessed by the VAS at 2, 6, and 12 months after treatment. Secondary outcome measures were the Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and concentration of growth factors in PRP and their correlation with clinical outcomes. Clinical outcomes were evaluated by assessors and collectors blinded to the type of treatment administered. RESULTS: A total of 111 patients were randomly assigned to 3 groups and received 3 weekly injections of either PRP (44 patients), PRP+HA (31 patients), or HA (36 patients). At all follow-ups, the PRP group had the lowest VAS scores. In particular, at 6-month follow-up, the mean VAS score was 21 (95% CI, 15-28) in the PRP group, 35 (95% CI, 26-45) in the PRP+HA group, and 44 (95% CI, 36-52) in the HA group (P < .0005 [PRP vs HA] and P = .007 [PRP vs PRP+HA]; F = 0.663). The WOMAC score of the PRP group was significantly better at 2-month follow-up (mean, 73; 95% CI, 68-78) and 6-month follow-up (mean, 72; 95% CI, 67-76) but not at 12-month follow-up. A significant, "moderate" correlation was found between interleukin-10 and variations of the VAS score (r = 0.392; P = .040). Significant improvements were achieved in reducing pain and ameliorating quality of life and functional recovery. CONCLUSION: Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip OA without relevant side effects. The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP+HA did not lead to a significant improvement in pain symptoms.

Ultrasound imaging-guided percutaneous treatment of rotator cuff calcific tendinitis: success in short-term outcome.

OBJECTIVE: Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month. METHODS: A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month. RESULTS: In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis. CONCLUSION: The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults. ADVANCES IN KNOWLEDGE: Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).

Platelet-rich plasma injections for the treatment of refractory Achilles tendinopathy: results at 4 years.

BACKGROUND: Chronic Achilles tendinopathy is responsible for a severe reduction in physical performance and persistent pain. There is currently a number of therapeutic options and the local administration of growth factors is an emerging treatment strategy. In particular, platelet-rich plasma (PRP) is a widely used way to provide a local regenerative stimulus for tendon healing. The aim of this study was to document the mid-term results obtained after treating recalcitrant Achilles tendinopathy with injections of high concentrate, leucocyte-rich PRP. MATERIALS AND METHODS: Twenty-seven patients (mean age: 44.6 years; 22 men and 5 women) affected by chronic mid-portion Achilles tendinopathy (7 bilateral, for a total of 34 tendons), refractory to previous treatments, were enrolled. Patients were treated with three ultrasound-guided intra-tendinous injections of PRP at 2-week intervals. Patients were prospectively evaluated at baseline, and then at 2, 6, and up to a mean of 54.1 months of follow-up (minimum 30 months), using the following tools: Blanzina, VISA-A, EQ-VAS for general health, and Tegner scores. RESULTS: The VISA-A score showed a significant improvement: the baseline score of 49.9±18.1 increased to 62.9±19.8 at 2 months (p=0.002), with a further improvement at 6 months (84.3±17.1, p<0.0005), and stable results at 4.5 years (90.0±13.9). The EQ-VAS score also showed a similar positive trend. An evaluation of the activity level confirmed these findings, showing a significant improvement in the Tegner score over time (p=0.017 for the final evaluation). The longer duration of symptoms before treatment was associated with a slower return to sport (p=0.041). DISCUSSION: PRP injections produced good overall results for the treatment of chronic recalcitrant Achilles tendinopathy with a stable outcome up to a medium-term follow-up. Longer symptom duration was related with a more difficult return to sporting activity.

Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus.

LJM is frequently observed in young subjects with insulin-dependent diabetes mellitus (IDDM). Aim of this study was to evaluate whether non-insulin-dependent diabetes mellitus (NIDDM) increases the risk of LJM in elderly subjects. Thirty patients (15 males, 15 females, mean age 73.93 ± 12.72 years) with NIDDM in good glycemic control were compared with thirty non-diabetic elderly, well matched for sex and age (15 males, 15 females, mean age 74.3 ± 4.24 years), and with ten young normal subjects (5 males, 5 females, mean age 26.3 ± 1.56 years). In these subjects, the range of motion (ROM) of ankle, knee, hip, elbow and shoulder were measured with a double-armed goniometer. Moreover, abnormalities of supraspinatus, patellar and Achilles tendons were evaluated with a standardized ultrasound (US) procedure. A significant reduction in the mobility of all joints was found in elderly subjects, compared to younger ones, with exception for the knee and elbow flexion. Elderly patients with diabetes, compared with their age-matched counterpart, showed LJM for ankle dorso- and plantar flexion, hip flexion and adduction, shoulder abduction and flexion. Moreover, tendons sonographic abnormalities were more frequently observed in diabetics. Our data confirm that diabetes worsens the LJM in the elderly, increasing the cross-linking of collagen by the non-enzymatic advanced glycation end products formation.

Viscosupplementation with hyaluronic acid in hip osteoarthritis (a review).

BACKGROUND: Viscosupplementation (VS) with hyaluronic acid (HA) is largely used for knee osteoarthritis therapy, but the evidences for its usefulness in hip osteoarthritis (OA) are limited. METHODS: In this review, an extensive search of published trials on VS in hip OA was performed. From the selected papers the following data were extracted: sample size, inclusion/exclusion criteria, treatment procedures, evaluation methods, follow-up duration and clinical outcomes. RESULTS: The level of evidence was low in quite all the trials (no placebo controlled groups). A reduction of pain and an improvement of function after 3 months, persistent in the long term (12-18 months), was observed. Patients with mild morphological alterations responded better to therapy. Side effects were negligible, and were limited to pain and a sensation of heaviness in the injection site. No clear differences among Low (LMW) and High Molecular Weight (HMW) HA preparations were found in the clinical outcomes. However, for HMW-HA preparations, a lower number of injections was, in general, necessary in order to reach the therapeutic effect. CONCLUSIONS: Despite the initial promising results, some questions still remain open : 1) the characteristics of responders must be more precisely defined; 2) the treatment schedules, at present mainly based on the individual clinical experience, need a proper and accepted standardization. Finally, larger and placebo controlled trials are necessary to confirm the efficacy of VS in hip OA.

Ultrasonography is superior to computed tomography and magnetic resonance imaging in determining superficial resection margins of malignant chest wall tumors.

OBJECTIVE: The purpose of this study was to retrospectively analyze results obtained in 22 patients affected by malignant high-grade chest wall tumors evaluated preoperatively by ultrasonography as well as other imaging techniques. METHODS: Twenty-two patients with chest wall high-grade sarcomas routinely underwent computed tomography, magnetic resonance imaging, total body scintigraphy, and ultrasonography. Ultrasonography was always performed by the same person using an ultrasonography system with a 5- to 13-MHz probe and with color Doppler evaluation of the lesion. Scans were done with the patient positioned as during surgery. Tumor lateral margins were identified, and a line was marked at 4 cm. In 8 patients with local recurrence, the presence of micronodules was also studied. Results of computed tomography, magnetic resonance imaging, and ultrasonography were compared with the surgical specimens. RESULTS: Histologically, all surgical specimens excised according to ultrasonographic margins showed wide margins. Ultrasonography showed micronodules in 6 of 8 patients with local recurrence; histologically, they were all identified as sarcoma nodules. Ultrasonography failed in particular with cervical-mediastinal vessels. CONCLUSIONS: Our results confirm that ultrasonography is feasible and reliable in the study of superficial margins and for detection of micronodules of less than 0.5 cm in diameter.