Antonio Barile

Ankle impingement syndromes

The ankle impingement syndrome is a frequent condition in both athletes and the normal population. We investigated this painful syndrome from both a clinical and a diagnostic viewpoint. Depending on what ankle tissue impinges on the other, it is possible to distinguish bone impingement, soft tissue impingement and peripheral nerve entrapment. For each of these pathologic conditions we investigated the diagnostic role of conventional radiography, Computed Tomography and Magnetic Resonance Imaging. The evidence of osteophytes, exostosis and presence of the os trigonum on plain films make clinical diagnosis easy in both anterior and posterior bone impingement. CT can provide useful information about the component of the posterior ankle. MRI always adds important information about chondral or subchondral bone injuries, synovial reaction and adjacent soft tissue involvement. The anterolateral impingement syndrome is caused by repeated injuries in plantar flexion and ankle intrarotation. MRI well detects the meniscoid injury thanks to high contrast sequences; it can also distinguish this syndrome from painful chondral and/or bony lesions at this level. MRI is also the method of choice to study sinus tarsi impingement, especially thanks to fat suppression sequences which increase MR diagnostic capabilities in this important anatomic area. Deep peroneal nerve entrapment, the medial plantar nerve entrapment syndrome and the tarsal tunnel syndrome are the most important entrapment neuropathies of the ankle. US and MRI are very useful to study the tendon and soft tissue abnormalities causing the anterior tarsal tunnel syndrome. CT and particularly MRI can easily detect many pathologic conditions causing the medial plantar nerve entrapment and the tarsal tunnel syndromes.

Talocalcaneal coalition : computed tomography and magnetic resonance imaging diagnosis

A correct evaluation of site and extension of the talocalcaneal coalition inducing biomechanical ankle alterations is very important for planning therapy. Four male patients were submitted to computed tomography (CT) and three of them were also examined by means of magnetic resonance imaging (MRI). In one patient, studied by CT only, a bilateral talocalcaneal coalition was present, while the other three patients, controlled with CT and MRI, were affected by monolateral talocalcaneal coalition which was of osseous type in one case and fibrocartilaginous in two cases. CT and MRI provided detailed information on type and extension of the coalition and both helped in distinguishing between osseous and fibrocartilaginous forms. Only MRI showed an area of subchondral ischemic disease of the posterior subtalar joint in one patient with monolateral fibrocartilaginous talocalcaneal coalition. Compared with CT, MRI proved to be more accurate in evaluation of the talocalcaneal coalition, due to its wider display capability.

Diagnostic imaging of malignant cartilage tumors

We compared the diagnostic capabilities of CT and MRI in the study of malignant cartilage tumors. Information about the characterization and the intra-/extraosseous spread of these lesions is of primary importance in the preoperative planning. Besides peripheral chondrosarcomas, arising from an osteochondroma and central chondrosarcomas, which are the most common malignant cartilaginous tumors, we also considered secondary, periosteal, dedifferentiated, clear cells and mesenchymal chondrosarcomas. Our study was performed using a standard MRI and CT protocol; in some cases, the examination was completed by the intravenous administration of a contrast agent. High contrast T2-weighted GE images can perfectly depict and differentiate the cartilage cap of an osteochondroma from the adjacent soft tissues. Evaluation of the growth of exostosis and of the thickness of its cap is essential in the assessement of malignant transformation. Both CT and MRI provide important information about peculiar aspects of the cartilaginous matrix such as the shape of calcifications-ossifications and lobulated growth, septa, septal enchancement and necrotic intratumoral areas, furthermore, CT perfectly shows the patterns of bone destruction. MRI should be considered as the most reliable imaging technique for the locoregional staging of malignant bone tumors thanks to its spatial and contrast resolution. CT plays a major role in the characterization of most bone tumors, especially those with a cartilaginous matrix.

Myxoid intraneural cysts of external popliteal ischiadic nerve. Report of 2 cases studied with ultrasound, computed tomography and magnetic resonance imaging

Peripheral neuropathy of the external popliteal ischiadic nerve caused by intraneural cysts is a very rare and peculiar pathological phenomenon compared with diseases associated with extraneural cysts or colliquative phenomena of solid nervous lesions. Two cases of peripheral neuropathy of the external popliteal ischiadic nerve caused by intraneural cysts and evaluated with ultrasound, computed tomography and magnetic resonance are described. The diagnostic efficacy of these imaging modalities is also evaluated with particular reference to MR capability to define the morphology of such lesions and their relationships to the surrounding structures. It is not yet possible to obtain a correct diagnosis about histopathologic features by means of the imaging techniques currently available. Nevertheless, they do provide information about the involvement of the neighboring areas, which are useful indications for possible surgical treatment of the disease.

Percutaneous image-guided cryoablation: current applications and results in the oncologic field

Percutaneous imaging-guided cryoablation (PICA) is a recently developed technique, which applies extreme hypothermia to destroy tumours under close imaging surveillance. It is minimally invasive, safe, repeatable, and does not interrupt or compromise other oncologic therapies. It presents several advantages over more established heat-based thermal ablation techniques (e.g. radiofrequency ablation; RFA) including intrinsic analgesic properties, superior monitoring capability on multi-modal imaging, ability to treat larger tumours, and preservation of tissue collagenous architecture. There has been a recent large increase in reports evaluating the utility of PICA in a wide range of patients and tumours, but systematic analysis of the literature is challenging due to the rapid pace of change and predominance of extensively heterogeneous level III studies. The precise onco-therapeutic role of PICA has not been established. This narrative review outlines the available evidence for PICA in a range of tumours. Current indications include curative therapy of small T1a renal tumours; curative/palliative therapy of small primary/secondary lung tumours where RFA is unsuitable; palliation of painful bone metastases; and urologic treatment of organ-confined prostate cancer. There is growing evidence to support its use for small hepatic tumours, and encouraging results have been obtained for breast tumours, extra-abdominal desmoid tumours, and management of higher-stage tumours and oligometastatic disease. However, the overall evidence base is weak, effectively restricting PICA to cases where standard therapy and RFA are unsuitable. As the technique and evidence continue to mature, the benefits of this emerging technique will hopefully become more widely available to cancer patients in the future.

Critical role of HIFU in musculoskeletal interventions.

Abstract Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a totally noninvasive ablation technique that in the last years had an important development in a large number of applications: in particular gynaecological disorders, bone lesions, prostate, breast, brain and other organs. This review of MRgFUS is focused on the technical aspects and the current clinical application in musculoskeletal interventions. More precisely, this paper aims to review the relatively scarce literature on this topic also in comparison with our 3-year experience in the use of this technique in the field of musculoskeletal interventions.

Musculoskeletal MRI: dedicated systems.

Abstract. The “dedicated” MRI units have characteristics of high diagnostic accuracy and lower installation and management costs as compared with whole-body systems. The dedicated MRI units are easy to install. The low weight allows their installation also under unfavorable circumstances. In a dedicated system cost-effectiveness and ease of installation must be accompanied by the capability of providing high-quality images. In our experience, the high number of examinations performed, the most part of which provided with the surgical controls, allowed an accurate evaluation of the diagnostic potentialities of the dedicated magnet. We were not able to perform the examinations in only 3 % of cases due to the physical shape of the patient and the clinical condition of the patient which may hinder the correct positioning of the limb. The overlapping of the diagnostic accuracy of the E-scan and Artoscan units in the study of the lower limbs, compared with whole-body units and surgery, prompted us to exploit the potentialities of the E-Scan in the study of the shoulder. We had a good correlation between E-Scan, whole-body units, and surgical findings, which confirmed the high diagnostic accuracy of the dedicated system. In conclusion, in our experience carried out in the musculoskeletal system, the dedicated magnets showed promising results. Their diagnostic reliability and utility was comparable to that obtained from conventional units operating at higher magnetic fields.

Joint impingement syndrome: clinical features

Joint impingement is a painful syndrome caused by the friction of joint tissues, which is both the cause and the effect of altered joint biomechanics. From the anatomical and clinical viewpoints, these syndromes are classified as bone impingement, soft tissue impingement and entrapment neuropathy, depending on what joint portion impinges on the others. We considered the most important impingement syndromes of the upper and the lower limbs from the clinical viewpoint. As for the upper limb, supraspinatus impingement is a frequent cause of shoulder pain in both athletes and the normal population; the painful subacromial arch is a typical sign of the rotator cuff impingement syndrome and of outlet and non-outlet impingement as well. As for the elbow, we considered both medial and lateral impingement. The carpal tunnel syndrome is the most common peripheral entrapment neuropathy of the upper limb; it is caused by compression of the median nerve at the wrist. We considered the main causes of carpal tunnel narrowing and the relative clinical findings. As for the lower limb, we considered the iliotibial band friction syndrome, which is the most common overuse syndrome of the knee and the ankle impingement syndrome. The latter includes anterolateral impingement (with chronic anterolateral and lateral pain and ankle instability), sinus tarsi impingement, anterior impingement (with pain during foot dorsiflection and posterior impingement. The tarsal tunnel syndrome is the most important ankle entrapment neuropathy causing burn pain and paresthesias in the toes and sole of the foot.

Lesions of the biceps pulley as cause of anterosuperior impingement of the shoulder in the athlete: potentials and limits of MR arthrography compared with arthroscopy

PurposeThis study aimed to evaluate the diagnostic possibilities of MR arthrography in the correct identification of complex tears of the biceps pulley and their possible correlation with anterosuperior impingement (ASI) development.Materials and methodsMR arthrography examinations of 23 athletes with clinical suspicion of ASI were reviewed. All examinations were obtained with a 1.5-T unit (Signa Horizon, GE Healthcare). The shoulders were studied with a dedicated surface coil with the patient’s arm in the neutral position and in internal and external rotation. In five patients, images in abduction-external rotation (ABER) were obtained. Within 2 month after MR arthrography, the athletes underwent arthroscopic surgery.ResultsMR arthrography images showed a spectrum of tears that, according to the Habermeyer classification, were subdivided into four groups: type 1 in three patients; type 2 in five; type 3 in seven; type 4 in eight. At arthroscopic evaluation, one patient presented type 1 lesion, five type 2, five type 3 and ten type 4. During arthroscopic dynamic manoeuvres, ASI signs were observed in three patients with type 3 lesion and in ten with type 4 lesion.ConclusionsMR arthrography is the imaging modality of choice for evaluating lesions of the rotator interval structures, and only complex lesions of the biceps pulley are related to the development of ASI.RiassuntoObiettiviScopo del presente lavoro è la valutazione delle potenzialità dell’artro-risonanza magnetica (RM) nell’identificazione di lesioni complesse della puleggia bicipitale e correlazione con lo sviluppo di impingement antero-superiore (IAS).Materiali e metodiSono stati revisionati gli esami artro-RM di 23 atleti con il sospetto clinico di IAS. L’esame è stato eseguito con magnete 1,5 tesla; la spalla è stata studiata con bobina dedicata con arto in condizioni basali ed in intra-extrarotazione. In 5 casi sono state effettuate acquisizioni in abduzione ed extrarotazione (ABER). Gli atleti sono stati sottoposti ad artroscopia entro i due mesi successivi.RisultatiSulla base dei reperti RM sono stati individuati 4 pattern lesionali principali secondo Habermeyer. All’esame artro-RM sono state riscontrate 3 lesioni di tipo 1, 5 lesioni di tipo 2, 7 lesioni di tipo 3 e 8 lesioni di tipo 4. L’artroscopia ha confermato una lesione di tipo 1, 5 lesioni di tipo 2, 5 lesioni di tipo 3 e 10 lesioni di tipo 4. Alle manovre dinamiche artroscopiche 3 lesioni di tipo 3 e 10 lesioni di tipo 4 presentavano segni compatibili con IAS.ConclusioniL’artro-RM è risultata essere una metodica estremamente valida per la diagnosi delle lesioni dell’intervallo dei rotatori; sulla base della nostra esperienza, soltanto le lesioni complesse della puleggia bicipitale, sono correlate allo sviluppo di IAS.

Musculoskeletal tumours: preliminary experience with perfusion MRI

PurposeOur study aimed to assess the role of magnetic resonance imaging (MRI) in the characterisation of musculoskeletal tumours and to identify specific perfusion patterns for the different tumours.Materials and methodsBetween January 2003 and September 2005, we evaluated the conventional and perfusion MRIs of 39 patients with musculoskeletal tumours. Dynamic MRI was performed with a 1.5-T and 1.0-T MRI unit before and after the intravenous administration of contrast material, using dedicated phased-array coils appropriate for the region to be studied and fast and ultrafast consecutive sequences. Postprocessing was done on an independent workstation (Advantage Windows, GE Medical System), with Functool (GE) software, which allowed a quantitative evaluation of enhancement as a function of time. The results were compared with the histopathological diagnoses obtained by biopsy or surgery.ResultsThe lesions identified in the 39 patients included 23 soft tissue tumours (12 benign, 11 malignant) and 16 bone tumours (ten benign, six malignant). Comparing the time-intensity diagrams of lesions of the same histological type, we found typical enhancement patterns for some bone tumours only, especially for bone, cartilaginous, fibrohistiocytic and pseudoinflammatory lesions. No typical enhancement pattern could be detected for any of the histological types of soft tissue tumour. Analysis of the slope of the time-intensity curves has a sensitivity and specificity of 64%–58% for soft tissue tumours and 86%–67% for bone tumours in determining the biological aggressiveness of the lesions.ConclusionsPerfusion MRI had moderate sensitivity and specificity in the differential diagnosis between lesions with high or low biological activity. Only in a few cases was it possible to find some correlation between perfusion patterns and lesion histology. The slope values should therefore be used in combination with conventional spin-echo images and other imaging and clinical data in order to narrow the field of the possible differential diagnoses and reliably predict the nature of the lesion.RiassuntoScopoValutare il ruolo della RM perfusionale nella caratterizzazione delle neoformazioni muscoloscheletriche; in particolare lo studio è volto alla ricerca di pattern perfusionali patognomonici per i diversi istotipi tumorali.Materiali e metodiNel periodo compreso tra gennaio 2003 e settembre 2005 sono stati valutati gli esami RM standard e RM perfusionali di 39 pazienti. Gli esami RM dinamici sono stati eseguiti con apparecchiature RM dotate di un magnete da 1,5 T e da 1,0 T, tramite bobine di superficie dedicate scelte in funzione del distretto da studiare prima e dopo somministrazione ev di MdC utilizzando sequenze rapide ed ultrarapide in successione. La post-elaborazione è stata eseguita in tutti i casi tramite il software Functool installato su una workstation indipendente (Advantage Windows, GE Medical System), che ha permesso, attraverso il posizionamento di una ROI, di effettuare una valutazione quantitativa dell’enhancement in funzione del tempo. I risultati sono stati confrontati con l’esame istologico ottenuto tramite biopsia o intervento chirurgico.RisultatiLe lesioni dei 39 pazienti esaminati sono risultate essere: 23 tumori dei tessuti molli di cui 12 benigni e 11 maligni e 16 lesioni ossee, di cui 10 benigne e 6 maligne. Confrontando le curve intensitàtempo (TIC) delle lesioni appartenenti ad uno stesso istotipo sono state identificate curve tipiche per alcune lesioni tumorali ossee (serie ossea, cartilaginea, fibroistiocitica) e per le lesioni infiammatorie. Non è stato possibile identificare una curva tipica all’interno dello stesso istotipo per le lesioni dei tessuti molli. È possibile valutare l’aggressività biologica delle lesioni muscolo-scheletriche tramite la pendenza delle curve intensità-tempo con livelli di sensibilità e di specificità che sono rispettivamente del 64%/58% per i tumori dei tessuti molli e del 86%/67% per i tumori ossei.ConclusioniLa RM perfusionale ha mostrato un discreto livello di sensibilità e specificità nella diagnosi differenziale tra lesioni ad elevata ed a bassa attività biologica e solo in alcuni casi è stato possibile riscontrare una correlazione tra pattern perfusionale e istologia della lesione. I valori di pendenza dovrebbero quindi essere usati insieme con le immagini spin echo convenzionali e con altri dati diagnostici e clinici per restringere le possibili diagnosi differenziali e per poter predire con una significativa attendibilità la natura della lesione.