I.S.Mu.L.T. Achilles Tendon Ruptures Guidelines

This work provides easily accessible guidelines for the diagnosis, treatment and rehabilitation of Achilles tendon ruptures. These guidelines could be considered as recommendations for good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care for the individual patient and rationalize the use of resources. This work is divided into two sessions: 1) questions about hot topics; 2) answers to the questions following Evidence Based Medicine principles. Despite the frequency of the pathology andthe high level of satisfaction achieved in treatment of Achilles tendon ruptures, a global consensus is lacking. In fact, there is not a uniform treatment and rehabilitation protocol used for Achilles tendon ruptures

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VII, nerves of the lower limb.

Funder: Università degli Studi di MilanoOBJECTIVES: To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton's neuroma) and provide clinical indications. METHODS: We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton's neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. RESULTS: Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. CONCLUSION: Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. KEY POINTS: • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area

Radiographic findings of femoroacetabular impingement in capoeira players

Purpose: Capoeira is a Brazilian martial art that requires extreme movements of the hip to perform jumps and kicks. This study evaluated a group of capoeira players to assess the prevalence of femoroacetabular impingement (FAI) in athletes practicing this martial art. Methods: Twenty-four experienced capoeira players (14 men, 10 women) underwent a diagnostic assessment, including clinical examination and standard radiographs of the pelvis and hips. The α-angle, head-neck offset, crossover sign, acetabular index, lateral centre-edge angle, and the Tönnis grade were assessed using the radiographs. Clinical relationships for any radiographic abnormalities indicating FAI were also evaluated. Results: Four subjects (17 %) reported pain in their hips. Forty-four hips (91.7 %) had at least one radiographic sign of CAM impingement, and 22 (45.8 %) had an α-angle of more than 60°. Eighteen hips (37.5 %) had at least one sign of pincer impingement and 16 (33.3 %) a positive crossover sign. Sixteen hips (33.3 %) had mixed impingement. There was a significant positive association between having an α-angle of more than 60° and the presence of groin pain (P = 0.002). A reduced femoral head-neck offset (P < 0.001) and an increased α-angle on the anteroposterior radiograph (P = 0.008) were independently associated with a higher Tönnis grade. Conclusion: High prevalence of radiographic CAM-type FAI among these skilled capoeira players was found. In these subjects, a negative clinical correlation for an increased α-angle was also detected. Additional caution should be exercised whenever subjects with past or present hip pain engage in capoeira. Level of evidence: Diagnostic, Level III

Radiographic analysis of shoulder anatomical arthroplasty

Arthroplasty is the standard treatment for advanced shoulder osteoarthritis. Modern prostheses designs have modular features whose size, shaft/head and body morphology can be adjusted. Total Shoulder Arthroplasty (TSA) provides better results. A complete X-ray follow-up is essential to assess the results and evaluate the survival rates of a shoulder prosthesis. Antero-posterior at 40° in both internal and external rotation (true AP view) and axillary view are recommended to assess the following parameters: orientation and translation of the humeral component, offset, size and height of the humeral head, acromio-humeral distance, distribution and fixation of the cement, stress shielding and cortical resorption, radiolucent lines, subsidence and tilt, glenoid wear and "bone stock", prostheses instability, glenoid component shift. Shoulder hemiarthroplasty can lead to glenoid wear; the true AP film at 40° of internal rotation provides the best profile of gleno-humeral joint to depict glenoid erosion. Shift of the glenoid component in TSA is identified as tilting or medial migration on true AP and axillary views in the early postoperative period (1-2 months) and at minimum of 2 years. An exhaustive radiographic analysis remains essential to monitor the prosthetic implant and detect early and late complications or risk factors of prosthetic loosening. © 2008 Elsevier Ireland Ltd. All rights reserved

Adult bacterial myositis: report of a single-center series of 26 cases

Bacterial infections involving muscle are quite uncommon and generally require specific predisposing factors. Bacterial myositis is more rarely described in the typical kind of patients observed in Internal Medicine (presence of multiple co-morbidities, partial/limited immune-deficiency, advanced age). Twenty-six patients suffering from bacterial myositis (8 women and 18 men; mean age 58.5 years, range 27-82) observed in a single Internal Medicine Unit were reported. Muscles involved were ileopsoas, thigh, paravertebral, gluteus, calf, forearm and rectus abdomen. Simultaneous presence of arthritis was registered in 17 patients and all patients presented relevant comorbidity. Main cultured bacteria were Staphylococcus aureus, Escherichia coli, other Gram-negative bacteria, Streptococcus spp. Multi-drug-resistance was observed in 14 out 26 (53.8%). Computed tomography, ultrasound and magnetic resonance imaging were utilized for diagnostic purposes. Antibiotic treatment was administered to all patients. Surgical debridement and drainage were performed in 12 patients; 7 patients were treated with percutaneous aspiration and drainage. At discharge, relevant functional impairment was present in 17 patients (65.3%). Four patients died (in-hospital mortality 7.6%, global mortality at three months 15.3%). Management of bacterial myositis is difficult and its prognosis is poor. In the near future, this demanding infection will be more frequently observed in Internal Medicine setting as comorbidity, which is very often the main characteristic of these patients

Femoroacetabular impingement: correlation between imaging parameters, sport activity, and chondral damage

BACKGROUND: Femoroacetabular impingement is characterized by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: pincer-FAI , cam-FAI and cam-pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages. METHODS: Forty-one patients, undergoing arthroscopic chondroartroplasty for cam and cam-pincer mixed form were considered. All patients underwent an X-Ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-Ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge Classification. RESULTS: The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50±0.23 and 0.33±0.19. The α angle predictive for a chondral damage of IV degree was 81.5°. The chondral damage of the patients suffering from cam-FAI and cam-pincer mixed form were respectively 3.53±0.80 and 3.00±1.41. CONCLUSIONS: From the results was possible to: 1) elaborate two tables providing a reliable indirect calculation of the alpha angle; 2) establish an alpha angle cut-off value indicative for a IV degree chondral damage; 3) show that pincer-FAI does not represent an aggravating factor for chondral damage; 4) show that the level of sports activity was related to the severity of chondral damage; and 5) show that a physically demanding occupation was not an aggravating factor for chondral damage

Diagnostic imaging: pitfalls in rheumatology

Although the diagnosis of arthritis and spondyloarthritis is based on clinical criteria, today the imaging methods are an indispensable aid to the rheumatologist. Imaging has not only the task of helping early diagnosis, but it has also a fundamental role in disease grading and therapeutic monitoring. In this scenario where many publications emphasize the importance of identifying synovitis and erosions at an early stage, it is essential to know the possible pitfalls which can determine both false positives and false negatives. The high variability of the musculoskeletal system anatomy makes it necessary to have a correct knowledge of all anatomical complexes, in order not to confuse them with the pathology. Moreover, the correct and standardized method of the execution and interpretation of the exams, such as ultrasound, is crucial to identifying and correctly monitoring the pathological hallmarks of the arthritis. This paper aims to provide an instrument to radiologists, highlighting the main imaging pitfalls in ultrasound and magnetic resonance which may be encountered in daily practice