Alberto Aliprandi

Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up

HYPOTHESIS Local application of autologous platelet rich plasma (PRP) improves tendon healing in patients undergoing arthroscopic rotator cuff repair. STUDY DESIGN Prospective, randomized, controlled, double blind study; considering an alpha level of 5%, a power of 80%, 22 patients for group are needed. MATERIALS AND METHODS Fifty-three patients who underwent shoulder arthroscopy for the repair of a complete rotator cuff tear were randomly divided into 2 groups, using a block randomization procedure. A treatment group (N = 26) consisted of those who received an intraoperative application of PRP in combination with an autologous thrombin component. A control group (N = 27) consisted of those who did not receive that treatment. Patients were evaluated with validated outcome scores. A magnetic resonance image (MRI) was performed in all cases at more than 1 year post-op. All patients had the same accelerated rehabilitation protocol. RESULTS The 2 groups were homogeneous. The pain score in the treatment group was lower than the control group at 3, 7, 14, and 30 days after surgery (P < .05). On the Simple Shoulder Test (SST), University of California (UCLA), and Constant scores, strength in external rotation, as measured by a dynamometer, were significantly higher in the treatment group than the control group at 3 months after surgery (strength in external rotation [SER]: 3 ± 1.6 vs 2.1 ± 1.3 kg; SST: 8.9 ± 2.2 vs 7.1 ± 2.7; UCLA: 26.9 ± 3 vs 24.2 ± 4.9; Constant: 65 ± 9 vs 57.8 ± 11; P < .05). There was no difference between the 2 groups after 6, 12, and 24 months. The follow-up MRI showed no significant difference in the healing rate of the rotator cuff tear. In the subgroup of grade 1 and 2 tears, with less retraction, SER in the PRP group was significant higher at 3, 6, 12, and 24 months postoperative (P < .05). CONCLUSION The results of our study showed autologous PRP reduced pain in the first postoperative months. The long-term results of subgroups of grade 1 and 2 tears suggest that PRP positively affected cuff rotator healing.

Rotator Cuff Calcific Tendonitis: Short-term and 10-year Outcomes after Two-Needle US-guided Percutaneous Treatment— Nonrandomized Controlled Trial

PURPOSE To compare short- and long-term outcomes of patients with rotator cuff calcific tendonitis who did and did not undergo ultrasonographically (US)-guided percutaneous treatment. MATERIALS AND METHODS Institutional review board approval and informed patient consent were obtained. Of patients referred for US-guided treatment of rotator cuff calcific tendonitis, 219 (86 men, 133 women; mean age, 40.3 years +/- 10.9 [standard deviation]) were treated; 68 (31 men, 37 women; mean age, 40.2 years +/- 11.3) patients refused treatment and served as control subjects. After local anesthesia was induced, two 16-gauge needles were inserted into the calcific deposit. Saline solution was injected through one needle, and the dissolved calcium was extracted through the other needle. Shoulder joint function was assessed by using Constant scores, and pain was assessed by using visual analogue scale (VAS) scores. Mann-Whitney U and chi(2) tests were performed. RESULTS At baseline, no significant difference in age or sex distribution, Constant score, or VAS score was detected between treated and nontreated (control) patients. Compared with control subjects, treated patients reported a significant decrease in symptoms at 1 month (mean Constant score, 73.2 +/- 6.2 vs 57.5 +/- 3.9; mean VAS score, 4.8 +/- 0.6 vs 9.1 +/- 0.5), 3 months (mean Constant score, 90.2 +/- 2.6 vs 62.6 +/- 7.2; mean VAS score, 3.3 +/- 0.4 vs 7.3 +/- 1.8), and 1 year (mean Constant score, 91.7 +/- 3.1 vs 78.4 +/- 9.5; mean VAS score, 2.7 +/- 0.5 vs 4.5 +/- 0.9) (P < .001). Symptom scores were not significantly different between the groups at 5 years (mean Constant score, 90.9 +/- 3.6 vs 90.5 +/- 4.8; mean VAS score, 2.6 +/- 0.5 vs 2.8 +/- 0.7) (P >or= .795) and 10 years (mean Constant score, 91.8 +/- 5.0 vs 91.3 +/- 9.6; mean VAS score, 2.5 +/- 0.6 vs 2.7 +/- 0.6) (P >or= .413). CONCLUSION US-guided percutaneous treatment facilitated prompt shoulder function recovery and pain relief. Treated patients had better outcomes than did nontreated patients at 1 year. However, 5 and 10 years after the procedure, the nontreated group reported outcomes similar to those of the treated group.

Rotator Cuff Calcific Tendinitis: Does Warm Saline Solution Improve the Short-term Outcome of Double-Needle US-guided Treatment?

PURPOSE To determine whether saline temperature influences procedure performance and outcome in patients undergoing ultrasonography (US)-guided lavage for the treatment of rotator cuff calcific tendinitis (RCCT). MATERIALS AND METHODS This study was approved by the institutional review board, and informed consent was obtained from all patients. From December 2009 to May 2011, 462 patients (191 men and 271 women; mean age, 39.7 years) with painful RCCT diagnosed at US were prospectively enrolled and randomized into two groups. Operators subjectively classified calcifications as hard, soft, or fluid according to their appearance at US. US-guided percutaneous treatment of RCCT (local anesthesia, double-needle lavage, intrabursal steroid injection) was performed with warm saline (42°C, 107°F) in 229 patients and with room-temperature saline in 233. Operators and patients were not blinded to saline temperature. The ease of calcium dissolution was subjectively scored (easy=1, intermediate=2, difficult=3). Procedure duration was recorded. Patient discomfort was assessed by using a visual analog scale (VAS). The occurrence of postprocedure bursitis was recorded. Statistical analyses were performed with Mann-Whitney U, χ2, and analysis of variance tests. RESULTS Procedure duration was significantly shorter (P<.001) in patients treated with warm saline (mean, 576 seconds±121) than in those treated with room-temperature saline (mean, 777 seconds±151). Calcium dissolution was significantly easier in patients treated with warm saline (median score, 1) than in those treated with room-temperature saline (median score, 2). Subgroup analysis according to calcification appearance at US showed a significant difference between groups for both soft (P=.003) and hard (P<.001) calcifications. No overall significant differences were found for VAS score (warm saline group: baseline=8.9±0.6, 1 month=4.7±0.6, 2 months=4.0±0.7, 3 months=3.4±0.4, 1 year=3.0±0.7; room-temperature saline group: baseline=9.2±0.4, 1 month=4.5±0.7, 2 months=4.1±0.9, 3 months=3.1±0.7, 1 year=3.2±0.8; P=.491). Postprocedural bursitis was observed in eight patients in the warm saline group and 20 in the room-temperature saline group (P<.022). CONCLUSION In the treatment of RCCT, warm saline appears to reduce procedure duration and improve calcification dissolution while reducing the frequency of postprocedural bursitis.

Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks

Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.

Ultrasound guidance to perform intra-articular injection of gadolinium-based contrast material for magnetic resonance arthrography as an alternative to fluoroscopy: the time is now

Abstract Magnetic resonance (MR) imaging has been definitively established as the reference standard in the evaluation of joints in the body. Similarly, magnetic resonance arthrography has emerged as a technique that has been proven to increase significantly the diagnostic performance if compared with conventional MR imaging, especially when dealing with fibrocartilage and articular cartilage abnormalities. Diluted gadolinium can be injected in the joint space using different approaches: under palpation using anatomic landmarks or using an imaging guidance, such as fluoroscopy, computed tomography, or ultrasound. Fluoroscopy has been traditionally used, but the involvement of ionizing radiation should represent a remarkable limitation of this modality. Conversely, ultrasound has emerged as a feasible, cheap, quick, and radiation-free modality that can be used to inject joints, with comparable accuracy of fluoroscopy. In the present paper, we discuss the advantages and disadvantages of using fluoroscopy or ultrasound in injecting gadolinium-based contrast agents in joints to perform magnetic resonance arthrography, also in view of the new EuroSAFE Imaging initiative promoted by the European Society of Radiology and the recent updates to the European Atomic Energy Community 2013/59 directive on the medical use of ionizing radiation.Key Points• Intra-articular contrast agent injection can be performed using different imaging modalities• Fluoroscopy is widely used, but uses ionizing radiation• Ultrasound is an accurate, quick, and radiation-free modality for joint injection• X-rays should be avoided when other radiation-free modalities can be used

The value of true-FISP sequence added to conventional gadolinium-enhanced MRA of abdominal aorta and its major branches

To test true-fast imaging with steady-state precession (true-FISP) added to gadolinium-based MR angiography (Gd-MRA) for imaging abdominal aorta and major abdominal vessels, 35 consecutive patients (age 67+/-11 years) with known or suspected abdominal and/or peripheral vascular disease were studied with sagittal and axial 2D true-FISP during free breathing and coronal 3D fast low-angle shot (FLASH) Gd-MRA (breath-holding, 0.2 mmol/kg of Gd-DOTA at 2 ml/s). We evaluated: suprarenal aorta, celiac trunk, superior mesenteric artery, right renal artery, left renal artery, infrarenal aorta, inferior mesenteric artery, aortic bifurcation/common iliac arteries, lumbar arteries and aortic atheromasia. The possible presence of accessory renal arteries, collateral vasculature and vascular prosthesis/stent was evaluated. A quality four-point score was assigned to each item on both sequences, from 0 (not visible) to 3 (good-to-excellent image quality) and Wilcoxon test was used. Main diagnoses resulted: normal or atheromasic aorta (n=25); aortic aneurysm (n=2); patent aorto-iliac surgical prosthesis (n=2); patent vascular iliac stent (n=2); aneurysm of iliac artery (n=1); patent aortic endovascular prosthesis (n=1); patent aorto-femural bypass (n=1) and aorto-iliac surgical prosthesis endoleak (n=1). We also found three patients with accessory renal arteries, two with collateral circulation, and three with surgical aorto-iliac prosthesis. The score of true-FISP (25.9+/-4.1, median 27) was significantly higher (p=0.003) than that of Gd-MRA (23.9+/-3.6, median 24). True-FISP was superior for visualizing inferior mesenteric artery (score 2.5+/-1.1 vs. 1.0+/-1.4; p<0.001) and atheromasic plaques (2.5+/-1.1 vs. 1.2+/-1.1; p<0.001). One collateral vasculature was demonstrated only with Gd-MRA. Summarizing, true-FISP is a power and fast non-breath-hold sequence to be added to Gd-MRA, obtaining an information increase.

Radiographically Undetectable Periprosthetic Osteolysis With ASR Implants: The Implication of Blood Metal Ions

Patients with ASR implants (resurfacing and large-diameter (XL) metal-on-metal (MoM) total hip arthroplasty), even if asymptomatic and with a stable prosthesis, may present extremely high blood metal ion levels. We report on a consecutive series of fourteen ASR revisions, focusing on osteolysis and their radiographic correspondence and their correlation with blood metal ion levels. At revision, seven hips revealed severe periacetabular osteolysis which was radiographically undetectable in six and asymptomatic in five. Seven hips with no acetabular osteolysis had significantly lower serum Cr and Co ion concentrations (respectively 25.2, 41.1 μg/l) compared to the seven hips with severe acetabular bone loss (respectively 70.1, 147.0 μg/l). Elevated blood metal ion levels should be considered as a warning of undetectable and ongoing periprosthetic osteolysis in asymptomatic patients with ASR prosthesis.

One-shot CT and MR arthrography of the shoulder with a mixture of iodinated and paramagnetic contrast agents using arthroscopy as a gold standard.

Purpose.Our aim was to perform computed tomography arthrography (CTA) and magnetic resonance arthrography (MRA) of the shoulder as a one-shot examination and to evaluate its value on the basis of arthroscopy as a gold standard.Materials and methods.Fifteen men and 16 women with planned arthroscopy for chronic (n=17) or traumatic tear of the rotator cuff (n=8), congenital atraumatic (n=1) or traumatic glenohumeral instability (n=2), traumatic tear of the rotator cuff with glenohumeral instability (n=1), or “frozen shoulder” (n=2) underwent plain helical CT in neutral position and intra-articular CT-guided injection of a mixture of iodinated and paramagnetic contrast agents (gadodiamide at 1:250 and iobitridol 350 at 1:5 in 20 ml of saline solution). CT helical scans in intra- and extrarotation and T1-weighted MRA scans in the neutral position were obtained. CTA and MRA were evaluated separately and jointly (CTA-MRA) in different blinded sessions, giving a 0–3 score to the agreement of CTA, MRA, and CTA-MRA with arthroscopy.Results.The injected volume of the solution ranged from 10 to 24 ml. No side effects were observed. CTA obtained a score of 2.33±0.62, MRA 2.47±0.52, and CTA-MRA 2.67±0.49. Significant differences were found for CTA-MRA versus CTA (p=0.0281) and MRA (p=0.0277). There was no significant difference for CTA versus MRA.Conclusions.CTA and MRA can be performed as a one-shot exam. CTA-MRA seems to give more information than CTA or MRA separately.

Femoro-acetabular impingement: what the general radiologist should know

Femoro-acetabular impingement (FAI) is a common condition in young active subjects, which can lead to the development of early osteoarthritis if not correctly diagnosed. Imaging evaluation of FAI, mainly based on plain film and magnetic resonance evaluation, must be performed according to precise guidelines and is fundamental for reaching a final diagnosis. The purpose of this paper is to provide a clinical and radiological overview of FAI by describing the most common clinical tests, the imaging techniques used in the diagnosis, and the main radiological signs that may be encountered.

MR imaging of the knee in patients with medial unicompartmental arthroplasty: comparison among sequences at 1.5 T

PurposeThis study was done to test a series of magnetic resonance (MR) imaging sequences of the knee after medial unicompartmental arthroplasty.Materials and methodsFour patients who had undergone Oxford III medial unicompartmental arthroplasty underwent 1.5-T MR imaging of the operated knee using coronal sequences: T1-weighted spin-echo (SE), T1-weighted turbo SE (TSE), proton-density (PD)- and T2-weighted TSE, T1-weighted gradient echo (GE), short-tau inversion recovery (STIR), multi echo data image combination (MEDIC), T2*-weighted GE, volumetric interpolated breath-hold examination (VIBE), and dual-echo steady state (DESS). For each sequence, we evaluated the visibility of the anatomical structures of the central pivot, lateral compartment, and anterior compartment using a semiquantitative score (0=total masking; 1=insufficient visibility; 2=sufficient visibility; 3=optimal visibility). The sum of the scores given to each sequence was divided by the maximal sum, obtaining a percentage visibility index. Friedman and sign tests were used for statistical analysis.ResultsMR examination time was 30–32 min. No patients reported pain, heat or other local discomfort. The visibility index ranged between 83% and 89% for the first four sequences without significant differences among them, 58% for STIR and 11%–36% for the last five sequences. Significant differences were found between each of the four first sequences and the remaining sequences (p<0.004) and between STIR and the last five sequences (p<0.008).ConclusionsMR imaging of the knee after medial unicompartmental arthroplasty was not associated with adverse events. An imaging protocol including SE, TSE and STIR sequences could be used to study the knee with unicompartmental arthroplasty.RiassuntoObiettivoTestare una serie di sequenze RM in pazienti portatori di protesi monocompartimentale mediale del ginocchio.Materiali e metodiQuattro pazienti portatori di protesi monocompartimentale mediale Oxford III sono stati sottoposti a RM a 1,5 T mediante scansioni coronali: spin-echo (SE) pesata in T1; turbo-SE (TSE) pesata in T1; TSE pesata in densità protonica (DP) e T2; gradient-echo (GE) pesata in T1; short tau inversion recovery (STIR); multi echo data image combination (MEDIC); GE pesata in T2*; volumetric interpolated breath-hold examination (VIBE); dual echo steady state (DESS). Per ciascuna sequenza è stata valutata la visibilità delle strutture anatomiche del pivot centrale, del compartimento laterale e del compartimento anteriore mediante un punteggio semiquantitativo (0=totale mascheramento; 1=insufficiente riconoscibilità; 2=sufficiente riconoscibilità; 3=ottimale riconoscibilità). La somma dei punteggi riportati da ciascuna sequenza è stata divisa per il valore massimo ottenibile, ottenendo un indice percentuale di riconoscibilità. Analisi statistica mediante test di Friedman e test dei segni.RisultatiL’indagine RM è durata circa 30–32 minuti. Nessun paziente ha lamentato dolore, riscaldamento o altre sensazioni locali. L’indice di riconoscibilità è risultato tra l’83% e l’89% per le prime quattro sequenze, senza differenze significative tra loro, 58% per la STIR e tra l’11% e il 36% per le ultime cinque sequenze. Sono risultate significative le differenze tra le prime quattro sequenze e le rimanenti sei sequenze (p<0,004) e tra la STIR e le ultime cinque sequenze (p<0,008).ConclusioniL’indagine RM del ginocchio con protesi monocompartimentale mediale non comporta l’insorgenza di eventi avversi. Le sequenze SE, TSE e STIR potrebbero essere utilmente incluse in un protocollo per lo studio del ginocchio con protesi monocompartimentale mediale.