Davide Orlandi

Percutaneous Radiofrequency Ablation of Benign Thyroid Nodules Assisted by a Virtual Needle Tracking System

Our aim was to assess the feasibility and outcome of ultrasound (US)-guided percutaneous radiofrequency (RF) ablation of benign thyroid nodules assisted by a real-time virtual needle tracking (VT) system. Forty-five patients (34 females, mean age ± standard deviation (SD): 44 ± 16 y, range: 29-68 y) with 45 benign non-functioning thyroid nodules (mean volume ± SD: 13.5 ± 6.7 mL, range: 12-22 mL) underwent VT-assisted US-guided RF ablation. Nodule volume was evaluated before treatment and during 6-mo of follow-up. Complication rates and patient satisfaction after treatment were also evaluated. By use of the VT system, the tip of the RF electrode was identified during all ablation procedures. The overall mean volume reduction and complication rate were 72.6 ± 11.3% and 2.5%, respectively. Overall satisfaction at the 6-mo follow-up was rated by patients as positive in 42 cases (93%). The VT system could be useful in thyroid nodule ablation procedures because it is able to track the RF electrode tip even when the tip is obscured by the bubbles produced by the ablative process. VT-assisted RF ablation can be a tolerable, non-surgical treatment for patients with benign non-functioning thyroid nodules.

Is there a real diagnostic impact of elastosonography and contrast-enhanced ultrasonography in the management of thyroid nodules?

Ultrasonography (US) and the new applications US elastography (USE) and contrast-enhanced US (CEUS) are used in the screening of thyroid nodules, for which fine-needle aspiration biopsy (FNAB) is the best single diagnostic test. The aim of the study was to compare the sensitivity, specificity, positive predictive value (PPV), and accuracy of the four examinations in nodules with cytological and histological diagnoses. The study used data from US, FNAB, USE (elasticity (ELX 2/1) index), and CEUS (Peak index and time to peak (TTP) index) evaluated in 73 thyroid nodules in 63 consecutive patients likely to undergo surgery. Cytological-histological correlation was available for 38 nodules. No correlation emerged between nodule size and cytological results. A significant (P=0.03) positive correlation between cumulative US findings and cytological results was found. In addition, significant correlations between cumulative US findings and cytology (P=0.02) and between cumulative US findings and histology (P<0.0001) were found. US showed the best specificity and PPV, and FNAB the best sensitivity. There was no significant difference in the ELX 2/1 index, Peak index, or TTP index among nodules subdivided according to cytological scores. No significant correlation was found between ELX 2/1 index, Peak index, and TTP index, on the one hand, and nodule size, US cumulative findings, cytology, and histology on the other hand. The sensitivity of the ELX 2/1 index was high, but its specificity was very low. The accuracy and PPV of USE were lower than those of the other procedures. Only the correlation between Peak index and cumulative US findings reached a value close to significance. Our ultimate aim is to minimise unnecessary thyroidectomy. US and FNAB continue to play a central diagnostic role. The use of a US score showed high specificity and PPV. The specificity of FNAB was low in this selected series because of the numbers of indeterminate cytological responses. USE and CEUS are innovative techniques that need to be standardized. The ELX 2/1 index, Peak index, and TTP index seem to be unrelated to histology. The best statistical data on USE and CEUS concerned their sensitivity and PPV, respectively. At present, USE and CEUS are too time-consuming and of limited utility in selecting patients for surgery.

Dynamic high-resolution ultrasound of the shoulder: How we do it

Ultrasonography (US) is an established and well-accepted modality that can be used to evaluate articular and peri-articular structures around the shoulder. US has been proven to be useful in a wide range of rotator cuff diseases (tendon tears, tendinosis, and bursitis) as well as non-rotator cuff abnormalities (instability problems, synovial joint diseases, and nerve entrapment syndromes). Diagnostic accuracy of shoulder US when evaluating rotator cuff tears can reach 91-100% for partial and full thickness tears detection, respectively, having been reported to be as accurate as magnetic resonance imaging in experienced hands. US is cheap, readily available, capable to provide high-resolution images, and does not use ionizing radiations. In addition, US is the only imaging modality that allows performing dynamic evaluation of musculoskeletal structures, that may help to further increase diagnostic performance. In this setting, a standardized imaging protocol is essential for an exhaustive and efficient examination, also helping reducing the intrinsic dependence from operators of US. Furthermore, knowledge of pitfalls that can be encountered when examining the shoulder may help to avoid erroneous images interpretation. In this article we use detailed anatomic schemes and high-resolution US images to describe the normal US anatomy of soft tissues, articular, and para-articular structures located in and around the shoulder. Short video clips emphasizing the crucial role of dynamic maneuvers and dynamic real-time US examination of these structures are included as supplementary material.

Ultrasound-guided procedures around the wrist and hand: How to do

Ultrasound has emerged as a low-cost, radiation-free and effective imaging technique to detect joint abnormalities and to guide percutaneous procedures. Being superficial, wrist and hand tendons and joints represent a good target to perform such procedures using ultrasound guidance. This kind of approach allows for a clear and real-time visualization of the needles during their whole path. In this setting, the knowledge of technical aspects and tips is essential to act in the most accurate way on target tissues that can be as small as a few millimetres. The aim of this review is to summarize the local treatments of inflammatory and degenerative disease described in literature (such as treatment of De Quervains tenosynovitis, trigger finger, trapezio-metacarpal joint osteoarthritis, etc.), emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the wrist and hand.

Ultrasound-guided interventional procedures around the shoulder

Ultrasound is an established modality for shoulder evaluation, being accurate, low cost and radiation free. Different pathological conditions can be diagnosed using ultrasound and can be treated using ultrasound guidance, such as degenerative, traumatic or inflammatory diseases. Subacromial-subdeltoid bursitis is the most common finding on ultrasound evaluation for painful shoulder. Therapeutic injections of corticosteroids are helpful to reduce inflammation and pain. Calcific tendinopathy of rotator cuff affects up to 20% of painful shoulders. Ultrasound-guided treatment may be performed with both single- and double-needle approach. Calcific enthesopathy, a peculiar form of degenerative tendinopathy, is a common and mostly asymptomatic ultrasound finding; dry needling has been proposed in symptomatic patients. An alternative is represented by autologous platelet-rich plasma injections. Intra-articular injections of the shoulder can be performed in the treatment of a variety of inflammatory and degenerative diseases with corticosteroids or hyaluronic acid respectively. Steroid injections around the long head of the biceps brachii tendon are indicated in patients with biceps tendinopathy, reducing pain and humeral tenderness. The most common indication for acromion-clavicular joint injection is degenerative osteoarthritis, with ultrasound representing a useful tool in localizing the joint space and properly injecting various types of drugs (steroids, lidocaine or hyaluronic acid). Suprascapular nerve block is an approved treatment for chronic shoulder pain non-responsive to conventional treatments as well as candidate patients for shoulder arthroscopy. This review provides an overview of these different ultrasonography-guided procedures that can be performed around the shoulder.

Dynamic High-Resolution US of Ankle and Midfoot Ligaments: Normal Anatomic Structure and Imaging Technique

The ankle is the most frequently injured major joint in the body, and ankle sprains are frequently encountered in individuals playing football, basketball, and other team sports, in addition to occurring in the general population. Imaging plays a crucial role in the evaluation of ankle ligaments. Magnetic resonance imaging has been proven to provide excellent evaluation of ligaments around the ankle, with the ability to show associated intraarticular abnormalities, joint effusion, and bone marrow edema. Ultrasonography (US) performed with high-resolution broadband linear-array probes has become increasingly important in the assessment of ligaments around the ankle because it is low cost, fast, readily available, and free of ionizing radiation. US can provide a detailed depiction of normal anatomic structures and is effective for evaluating ligament integrity. In addition, US allows the performance of dynamic maneuvers, which may contribute to increased visibility of normal ligaments and improved detection of tears. In this article, the authors describe the US techniques for evaluation of the ankle and midfoot ligaments and include a brief review of the literature related to their basic anatomic structures and US of these structures. Short video clips showing dynamic maneuvers and dynamic real-time US of ankle and midfoot structures and their principal pathologic patterns are included as supplemental material. Use of a standardized imaging technique may help reduce the intrinsic operator dependence of US. Online supplemental material is available for this article.

Prevalence Study of Iliopsoas Bursitis in a Cohort of 860 Patients Affected by Symptomatic Hip Osteoarthritis

We used ultrasound to evaluate iliopsoas bursitis (IB) prevalence in 860 patients (568 males, 292 females, 62 ± 7 years) suffering from symptomatic Kellgren-Lawrence grade II-III-IV hip osteoarthritis. Lequesne index and visual analogue scale (VAS) were recorded. Anterior hip was scanned and images recorded. Maximum IB diameter was measured and drained (volume recorded). Two radiologists evaluated the presence of IB, joint effusion, synovial hypertrophy, communication between bursa and articular space. IB was found in 19/860 (2.2%) patients (16 males, 3 females, 65 ± 11 years; grade II osteoarthritis = 4; III = 9; IV = 6). Mean bursa diameter = 2.9 ± 0.9 cm, volume = 35 ± 34 mL. Effusion was present in 9/19 patients, hypertrophy in 6/19 and communication in 9/19. In patients with no IB, effusion was detected in 27/860 and hypertrophy in 25/860 (p < 0.001 compared with IB patients). κ = 1 for all. VAS index and Lequesne index were not significantly different between patients with or without IB (p ≥ 0.468). Ultrasound can detect associate findings in grade II-IV hip osteoarthritis patients with high reproducibility.

Ultrasound Assessment of the Rotator Cuff Cable: Comparison Between Young and Elderly Asymptomatic Volunteers and Interobserver Reproducibility

Our aim was to characterize rotator cable ultrasound appearance in shoulders of different-aged asymptomatic volunteers, also estimating interobserver reproducibility. We studied 83 shoulders in 42 young volunteers (mean age 26 ± 7.0 years, range 21-35 years) and 66 shoulders in 36 elderly volunteers (65-81 years, 73 ± 4.9 years), noting rotator cable visibility and its minimum thickness and width. Interobserver reproducibility was tested in elderly volunteers by two blinded observers. χ(2), U Mann-Whitney, t-test, Bland-Altman, and κ statistics were used. Rotator cable was less frequently detected in younger than elderly volunteers (25/83 vs. 36/66 shoulders; p = 0.002). Young subjects had thicker (1.5 ± 0.2 mm, range 1.3-1.8 mm vs. 1.1 ± 0.1 mm, 0.9-1.3 mm; p < 0.001) and wider rotator cable (5.8 ± 0.7 mm, 4.5-7.1 mm vs. 4.0 ± 1.2 mm, 2.5-7.1 mm; p < 0.001) than elderly volunteers. Thickness and width reproducibility index were 89% and 94%, respectively; κ = 0.87. Ultrasound demonstrated different rotator cable consistency in younger and elderly asymptomatic patients, with high interobserver reproducibility.

Do we still need fluoroscopy to perform injections in the musculoskeletal system

Dear Sirs, We read with great interest the paper by Goldberg-Stein and colleagues entitled “Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes” recently published in Skeletal Radiology [1]. The authors accurately described a technique to inject a mixture of steroid and anaesthetic into the retrocalcaneal bursa (RCB) using fluoroscopic guidance, showing 100 % feasibility with significant short-term pain reduction. Nevertheless, we are concerned about the unnecessary use of ionizing radiations to perform this procedure. Authors state that at their institution “image-guided RCB injections are performed under fluoroscopic or sonographic guidance, depending on the availability of resources”, declaring that the type of imaging guidance depends merely on the “clinical schedule” [1]. As clearly stated by the 2013/59/ directive issued by the European Atomic Energy Agency, each medical exposure should be justified, i.e. should “take into account the efficacy, benefits and risks of available alternative techniques having the same objective but involving no or less exposure to ionizing radiation” [2]. Similarly, the International Atomic Energy Agency raised a concern about significant and systemic use of inappropriate exposure in radiology [3]. The importance of improving justification regarding the use of radiology was highlighted in 2009, and this was clearly recognized as a desirable and achievable objective, implying that adoption of the justification principle should be encouraged through several measures such as statutory regulation or the support of professional and regulatory bodies [3]. Based on these assumptions, if an imaging modality without ionizing radiations such as ultrasound can be used to achieve the same result, it should always be used. This is the case of RCB, in which ultrasound can be effectively used as guidance during soft-tissue injections, being a real-time and radiation-free modality [4]. Gao et al. showed that ultrasound is able to analyse lower extremity bursae with high detection rates even in healthy young subject (in which the RCB is very thin) according to the anatomical relations of surrounding tissues and bones [5]. A recent paper compared ultrasound and fluoroscopic guidance to inject joints for magnetic resonance arthrography [6]. Regarding radiation exposure, the average effective dose of a fluoroscopic arthrogram was estimated as 0.17 mSv, a value almost ten times higher than a postero-anterior chest x-ray (0.02 mSv) [6]. Differently from joints, in RCB injections the involved soft tissues cannot be visualized directly using fluoroscopy, thus a longer procedure and a higher radiation dose may be hypothesized. In conclusion, we cannot see any good reason why fluoroscopy should be still used to inject soft tissues, except some institutional dispositions or the physician’s preference. Thus, the musculoskeletal radiology community should increase the * Carmelo Messina carmelomessina.md@gmail.com

A Few Considerations on “Sonoelastography of the Plantar Fascia”

Radiology: Volume 261: Number 3—December 2011 n radiology.rsna.org 995 Deep fascia is a dense connective tissue that is commonly arranged in sheets that form a stocking around the muscles and tendons beneath the superfi cial fascia ( 1 ). In the limbs, the deep fascia is formed by an aponeurotic layer (investing layer) continuous with the epimysium, perimysium, and endomysium with the intermuscular septa ( 2 ). In contrast to deep fascia, there has been considerable controversy with respect to the organization of superfi cial fascia ( 3 ). According to standard textbooks of anatomy, the superfi cial fascia or “subcutaneous tissue” is described as a layer of loose areolar connective or adipose tissue that connects the skin to the underlying bones or deep fascia ( 3 ). The superfi cial fascia has two layers: the external fatty layer and the deep membranous layer ( 2 , 3 ). Traditionally, the membranous layer of superfi cial fascia is known to be present in restricted areas of the body, such as the lower anterior abdominal wall (Scarpa fascia) and the perineum (Colles fascia) ( 3 ). However, recent studies prove that the membranous layer is consistently found in the superfi cial fascia in many regions of the body, including extremities ( 3 ). In our opinion, it is diffi cult to distinguish the investing layer of the deep fascia from the deep membranous layer of the superfi cial fascia on MR images because they fuse on each side ( 3 ). The second comment addresses the optimal technique for showing the abnormal signal intensity of the deep fascia. In our opinion, the fat-suppressed T2-weighted image is the most useful for detecting abnormalities in deep fascia because a high-signal-intensity fl uid collection along deep fascia is easily detected with this sequence. Although the low signal intensity (representing gas) in deep fascia on the fat-suppressed T2weighted image is a specifi c fi nding for necrotizing infectious fasciitis, it is not sensitive. It is not diffi cult to detect low signal intensity on a fat-suppressed T2weighted image when it is combined with a T1-weighted image.