Francesco Pogliacomi

Multidetector computed tomography arthrography of the knee: diagnostic accuracy and indications.

PURPOSE To evaluate the diagnostic accuracy and indications of arthrography with multidetector computed tomography (arthro-MDCT) of the knee, in patients with absolute or relative contraindications to MRI and in patients with periarticular metal implants using diagnostic arthroscopy as the gold standard. MATERIALS AND METHODS After intra-articular injection of iodixanol and volumetric acquisition, 68 knees in patients of both sexes (30 females, 38 males, age range 32-60 years) were examined with a 16-detector-row CT scanner. The patients had arthralgia but no radiologically detected fractures. They could not be studied by MRI either because of absolute contraindications (subcutaneous electronic implants), surgical metal implants or claustrophobia. In 37 of 68 patients who had had previous knee surgery, the arthro-CT examination was preceded by an MRI on the same day. All examinations were interpreted by two experienced musculoskeletal radiologists. The findings were compared with arthroscopic findings carried out within 28 days of the CT study. RESULTS In non-operated patients the comparison between arthro-MDCT and arthroscopy showed sensitivity and specificity ranging between 86% and 100%. In the 37 operated knees, arthro-MDCT had an accuracy of 95% compared with 53% of the MRI. Inter-observer agreement was almost perfect (K=0.97) in the evaluation of all types lesions, both on MDCT and MRI. When arthro-MDCT was compared with MRI in post-operative patients by a McNemar test, a significant difference (p<0.05) was found between these two techniques. CONCLUSIONS Arthro-MDCT of the knee is a safe technique that provides accurate diagnosis in identifying chondral, fibrocartilaginous and intra-articular ligamentous lesions, in patients that cannot be evaluated by MRI, and in patients after surgical.

MDCT arthrography of the wrist: Diagnostic accuracy and indications

PURPOSE To evaluate the diagnostic accuracy and indications of arthrography with Multidetector Computed Tomography (arthro-MDCT) of the wrist in patients with absolute or relative contraindications to magnetic resonance imaging (MRI) studies and in patients with periarticular metal implants using diagnostic arthroscopy as the gold standard. MATERIALS AND METHODS After intra-articular injection of iodixanol and volumetric acquisition, 43 wrists in patients of both genders (18 females, 25 males, age range 32-60 years) were examined with a 16-detector-row CT scanner. Fifteen patients had prior wrist surgery. The patients had arthralgia, degenerative and traumatic arthropathies as well as limited range of motion, but no radiologically detected fractures. All examinations were interpreted by two experienced musculoskeletal radiologists. The findings were compared with arthroscopic findings carried out within 28 days of the CT study. RESULTS In non-operated and operated wrists the comparison between arthro-MDCT and arthroscopy showed sensitivity, specificity and accuracy ranging between 92% and 94% for triangular fibrocartilage complex (TFCC), between 80% and 100% for intrinsic ligaments located within the proximal carpal compartment, and between 94% and 100% for articular cartilage. Inter-observer agreement between two radiologists, in the evaluation of all types of lesions, was almost perfect (k=0.96) and statistically significant (p<0.05). CONCLUSIONS Arthro-MDCT of the wrist provides an accurate diagnosis to identify chondral, fibrocartilaginous and intra-articular ligament lesions in patients who cannot be evaluated by MRI, and in post-surgical patients.

Multidetector Computed Tomography Arthrography of the Shoulder: Diagnostic Accuracy and Indications

Background: The presence of subcutaneous implants, such as permanent defibrillators, is an absolute contraindication to the use of magnetic resonance imaging (MRI). Moreover, MRI is unadvisable in subjects with metallic hardware near the area of study, as artifacts generated by such materials distort image quality. Purpose: To evaluate the diagnostic accuracy and indications of arthrography with multidetector computed tomography arthrography (arthro-MDCT) of the shoulder in patients with absolute or relative contraindications to MRI and in patients with periarticular metal implants using diagnostic arthroscopy as the gold standard. Material and Methods: After intraarticular injection of iodixanol and volumetric acquisition, 70 shoulders in 70 patients (30 females, 40 males, age range 32–60 years) were examined with a 16-detector-row CT scanner. The patients had arthralgia but no radiologically detected fractures. They could not be studied by MRI because of absolute contraindications (subcutaneous electronic implants), surgical metal implants, or claustrophobia. In 28 of the 70 patients who had had previous shoulder surgery, the arthro-CT examination was preceded by an MRI on the same day. All examinations were interpreted by two experienced musculoskeletal radiologists. The findings were compared with arthroscopic findings carried out within 28 days of the CT study. Results: In the 42 non-operated patients, the comparison between arthro-MDCT and arthroscopy showed sensitivity and specificity ranging between 87% and 100%. In the 28 operated shoulders, arthro-MDCT had an accuracy of 94% compared with 25% with MRI. Interobserver agreement was almost perfect (κ=0.95) in the evaluation of all types of lesions, both on MDCT and MRI. When arthro-MDCT was compared with MRI in the postoperative patients by a McNemar test, a significant difference (P<0.05) was found between these two techniques. Conclusion: Arthro-MDCT of the shoulder is a safe technique that provides accurate diagnosis in identifying chondral, fibrocartilaginous, and intraarticular ligamentous lesions in patients who cannot be evaluated by MRI, and in patients after surgery.

Influence of surgical experience in the learning curve of a new approach in hip replacement: anterior mini-invasive vs. standard lateral

There is conflicting evidence regarding the potential benefit of minimally invasive surgery for total hip arthroplasty (THA), especially during the ‘learning curve’ of individual surgeons. Sixty patients who underwent THA between January and December 2010 were evaluated. The aim was to assess the anterior mini-invasive (MI) approach performed in 30 patients during the learning curve of a single experienced hip surgeon compared with the results of 30 patients operated upon through a standard lateral approach by the same surgeon. Operation and hospitalisation times, blood loss, number of transfusions, peri-operative complications and femoral/acetabular component placement were monitored. Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) were analysed before and 12 months after surgery. Pain Visual Analogue Scale (VAS) was also recorded 1 week and 1 month after surgery. Hospitalisation, blood loss, number of transfusions and VAS score 1 week postoperatively were significantly lower and operative time was significantly longer in the anterior MI approach. Similar functional outcomes 1 year after surgery, component positioning and complication rates were observed in both groups. The results suggest that anterior MI approach is a safe procedure during the learning curve of an experienced hip surgeon.

Bilateral ganglion cyst of the common peroneal nerve

Abstract. Ganglion cysts of the common peroneal nerve are rarely described in the literature and a bilateral lesion has not been previously reported. We present a case of a 41-year-old man with a bilateral cyst of the common peroneal nerve diagnosed with ultrasound and magnetic resonance imaging.

Magnetic resonance imaging comparison of intra-articular cavernous synovial hemangioma and cystic synovial hyperplasia of the knee.

Purpose: To identify and compare magnetic resonance imaging (MRI) characteristics, with and without intravenous contrast medium, of cavernous synovial hemangiomas and cystic synovial hyperplasia. Material and Methods: Four cases of cavernous synovial hemangioma and five of cystic synovial hyperplasia of the knee were studied retrospectively. The patients (5 F and 4 M; 15–25 years of age) all had long-standing knee pain. At clinical examination we observed elastic swelling and pain without significant joint effusion. The patients underwent conventional radiography and MRI without and following intravenous contrast medium before arthroscopic biopsy. Results: The radiographs were interpreted as negative in all patients. MRI examination without contrast medium revealed a similar multicystic appearance for both lesions. Following intravenous contrast agent administration, cavernous synovial hemangiomas demonstrated avid, rather homogenous enhancement, whereas cystic synovial hyperplasia demonstrated less intense, peripheral enhancement only. Arthroscopy with histological examination of the lesions confirmed the MRI diagnosis in every case. Conclusion: In our experience, cavernous synovial hemangioma and cystic synovial hyperplasia have a similar appearance on unenhanced MRI, but can be reliably differentiated on the basis of enhancement characteristics following intravenous contrast administration.

The Four-Strand Staggered Suture for Flexor Tendon Repair: In Vitro Biomechanical Study

PURPOSE To assess in vitro biomechanical properties of a 4-strand flexor tendon suture compared to 3 established suture techniques. This technique, which is made of 2 alternating and staggered sutures, one external to the tendon and the other internal, must be sufficiently resistant to withstand loads applied by modern, early active mobilization protocols. METHODS Forty flexor hallucis longus tendons were harvested from fresh cadavers, cut, and repaired using 4 different suture techniques (Strickland, Wolfe, modified Savage, and a new technique called 4-strand staggered). All repaired tendons were submitted to static loading trials to measure gap formation (2 mm) in relation to tensile force and breaking force of all 4 sutures. Twenty additional tendons were repaired with the new suture technique and submitted to dynamic trials under cyclic loading. RESULTS The 4-strand staggered suture technique proved to be statistically superior to Strickland and modified Savage techniques following the static loading trials for gap formation and breaking force. This technique is statistically superior to the Wolfe cruciate suture for breaking force and superior but not statistically significant for gap formation. The dynamic loading trials have shown that the 4-strand staggered suture can tolerate in vitro loads similar to those exerted by modern, early active mobilization protocols. CONCLUSIONS The suture technique created by the authors proved to hold superior biomechanical properties than the other techniques tested in this study and might be suitable for early active mobilization protocols.

Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures

Intramedullary nailing is one of the most commonly used surgical treatments for humeral diaphyseal fractures. Once an intramedullary fixation technique has been selected, the choice between antegrade or retrograde approach remains controversial. Forty patients with humeral diaphyseal fracture treated with Seidel antegrade intramedullary nailing through an “danterior deltoid incision” (ADI) were evaluated after an average period of 62 months. Clinical and functional evaluation of the shoulder was performed using the Constant Score. Results were excellent in 33 patients, good in 5 and acceptable in 2. Radiological assessment was performed using antero-posterior (AP) and latero-lateral (LL) radiographs of the humerus and AP and Neer radiographs of the shoulder. Radiographic findings demonstrated good consolidation of all fractures; nail and locking proximal screw malpositioning were detected in 2 cases (2 patients with acceptable results). The positive results obtained for shoulder function correlate with patient age and demonstrate that antegrade intramedullary nailing is a valid option for the treatment of humeral diaphyseal fractures, as long as it is performed through ADI access and with the appropriate surgical technique. Surgical technical errors will lead to functional problems of the shoulder, which in some cases will not be completely eliminated even after nail removal.

Total elbow arthroplasty in distal humeral nonunion: clinical and radiographic evaluation after a minimum follow-up of three years.

BACKGROUND Total elbow arthroplasties (TEAs) are usually indicated in chronic inflammatory arthropathies. This procedure has also recently been used in complex distal humeral fractures and nonunions in selected patients. This study analyzed the clinical and radiographic outcomes in patients treated for nonunions around the elbow region with a minimum follow-up of 3 years. METHODS Between May 2002 and June 2012, 20 patients affected with distal humeral nonunions were treated with TEA. All patients were assessed clinically using the Mayo Elbow Performance Score and radiographically to evaluate the positioning of the prosthetic components and signs of loosening. Statistical analyses were performed to investigate the presence of clinical and radiographic variables as predictive factors of poor functional outcomes. RESULTS The Mayo Elbow Performance Score of the affected arm improved significantly between the preoperative period and follow-up. Results were good or excellent in 90% of the patients even if a high rate of complications (30%) was encountered. The development of complications after surgery and stages II, III, and IV radiolucency, according to the Morrey criteria, were predictive factors of poor outcomes. CONCLUSIONS According to the satisfactory results observed in this study, TEA could be indicated in selected patients aged older than 70 years with low functional demands and affected with distal humeral nonunions in which obtaining a stable fixation is difficult.

Complex fractures of the distal radius treated with angular stability plates

Complex fractures of the distal radius are articular lesions and comminuted at the level of the epiphysis and metaphysis. Their treatment is difficult and in most cases surgical. Of all the different osteosynthesis methods available, internal fixation with plate and screws is the most commonly used. In particular, angular stability plates are superior in terms of rigidity and stability to conventional volar and dorsal plates. DVR plate has these mechanical characteristics, and its low profile has reduced frictions with surrounding soft tissues. For these reasons, this device implanted through a single volar approach, can stabilize the majority of volarly and dorsally displaced unstable distal radius fractures. In this study, 48 patients, affected by complex fractures of the distal radius treated with DVR volar plates, were assessed by the Mayo modified wrist score, the Italian version of the disability of the arm, shoulder and hand. The satisfactory results observed confirm the efficacy of this device.