What does it entail? Arterial embolization is a method of interventional radiology whose purpose is to suppress the vascular supply of a tumour by provoking the occlusion of the nearby vessels with consequent ischemic necrosis of the lesion. The occlusion must occur as distally as possible: terminal arterioles deprived of collaterals only source of blood supply to the area where ischemia is to be induced. The vascular occlusion is provoked by material that stops the blood flow and facilitates thrombogenesis. The embolizing material is selectively inserted by catheterising the arterial vessels afferent to the tumour. In brief, this procedure, in the treatment of hypervascularizing benign lesions is currently considered to be the only treatment available. In surgical lesions it reduces the surgical risk and is able to improve the results of surgery. The primary aim of embolizing for palliative treatment is to control pain.Applications in the scope of musculoskeletal oncology The indication for embolization is made after a correct histological diagnosis and the subsequent staging of the tumour that will allow us to define its morphology, size, and its relationship with nearby structures. A biopsy must always be performed before embolization, because after this procedure the diffusedly necrotic tissue could produce some problems of histopathological diagnosis. Having defined the correct indication for embolization an angiograph of the region is performed to highlight the pathological vascularization of the lesion. Subsequently, by selective and super-selective catheterisation embolization of the lesion vessels that supply the tumoral mass is performed. At the end of the procedure an angiograph allows us to assess the territorial distribution and the quality of vascular occlusion. Arterial embolization in the treatment of tumours and pseudo-tumoral lesions of the bone and the soft tissues has been shown to arrest the growth of the lesion, facilitate a possible surgical operation, decrease the pain, control a possible hemorrhage of the tumour, and perhaps to stimulate an immune response "unmasking" by necrosis a part of the antigens of the tumour. The directions for application are:curative embolization that is used in the treatment of all benign, pseudo-tumoral and low-grade malignant lesions, such as aneurismal cysts, angiomas and hemangioendotheliomas to heal the aforesaid lesions;adjuvant embolization to facilitate locally the surgical treatment of aggressive benign and malignant lesions, such as OBL, TGC, neurinoma, chordoma and metastasis. The preoperative phase involves a reduction of the bleeding during the surgical operation and the reduction is size of the lesion, thus facilitating its removal. In the postoperative phase the procedure is useful for the control of possible hemorrhages and to complete the results of surgery;palliative embolization is used in the treatment of lesions that are not responsive to a suitable oncological surgical treatment due to their site, dimensions or diffusion. The object is the local control of the aggressiveness and pain.  The analgesic effect is correlated closely with the ischemic necrosis that determines a reduction in the size of the tumor and thus less compression on the periosteum whose fibres are responsible for pain, and a deceleration in the processes of neoplastic osteolysis and reduced risk of pathological fracture. In addition, the analgesic effect is greater than that produced by radiotherapy, since it is less influenced by the size of the tumoral mass. Arterial embolization is a method not without risks that should be performed only at specialized centers to reduce possible complications, that in certain segments, such as the spine, can be extremely disabling. The main complication is the embolization of non-lesional areas.Technique of the operation The procedure is performed in local anesthesia (in general anesthesia in pediatric patients); after puncture of the common femoral artery at the groin (alternative approaches: humeral or axillary). The catheter is inserted under fluoroscopic control by retrograde approach to reach the lesion to be embolized. The diagnostic examination (angiograph) for the precise evaluation of the type and degree of vascularization of the lesion is therefore performed, by the introduction of contrast medium through the catheter. If this study shows the feasibility of the procedure, an embolizing material is inserted that will obstruct the pathological vessels. The procedure can be repeated several times for long periods of time. In the absence of complications hospitalization for 24-48 hours is enough. The embolizing materialThe embolizing material differs in physical-chemical characteristics (liquids and solid) and type of occlusion (permanent or temporary). The liquid embolizing materials are: 1) N-Butyl (2) cyanoacrylate; 2) pure alcohol. The solid embolizing materials are: 1) Microspheres; 2) metal spirals; 3) Spongostan.

What is a meniscus tear?The knee joint is formed by two fibrocartilaginous structures called meniscus that act as shock-absorbants. The meniscus is C-shaped, with a triangular part and placed between the femur and tibia. It provides a wider surface for contact between the surfaces of the joints, increasing their congruence. One meniscus is medial (i.e. inside the knee – medial meniscus),  the other is lateral (i.e. outside the knee - lateral meniscus).A meniscus tear can occur in any age group. It commonly occurs when the knee joint is bent and the knee is then twisted with the foot blocked on the ground, or it can occur after flexion at maximum degrees under weight-bearing stress, followed by suddenly standing up again. When the meniscus tears, luxation can occur and the torn piece displace itself between the joint surfaces, impinging the joint mechanism and causing a “meniscal lock” (inability to extend the knee).A part from traumatic, meniscus tears can also be degenerative “degenerative meniscopathies”, where alterations of the fibrocartilaginous tissue are a result of repeated microtraumas, without a single specific trauma.How do you make diagnosis?Final diagnosis of torn meniscus is predominantly clinical, based on a correct physical examination done by a specialist, who cannot be replaced by instrumental examinations alone. Clinical history is very important, because the patient reports onset of symptoms. When the lesion is acute the onset of pain is usually a result of knee distortion; at the same time, the patient complains the perception of a “clunk”. In chronic lesions patients usually do not refer a specific distortion, but generally complain of recurrent pain and tenderness.On physical examination a limited range of motion may be seen, sometimes associated to effusion (swelling due to liquid inside the joint). Pain may be present at palpation on the medial and lateral compartment, together with other clinical signs of meniscus tear (McMurray Test, Appley Test, etc.).Arthocentesis (fluid drainage from the knee using a syringe) is rarely necessary and it may detect the presence of serum and blood in the liquid.Which are the most common instrumental examinations?X-rays of the knee in the two standard projections antero-posterior (AP) and latero-posterior (LL) are mandatory to exclude other bone or osteochondral lesions. For meniscus tears CT scan with contrast dye may be used, but the diagnostic gold standard is MRI (the most reliable for diagnosis of meniscus tears).Surgery: which options?Surgery of the meniscus today is done in arthroscopy, a mini-invasive technique that uses a camera and special instruments without opening the joint capsule.“Total meniscectomy” (surgical removal of the entire meniscus) was once the treatment of choice for meniscus tears, but numerous clinical studies have shown that total meniscectomy of the knee leads to a premature degenerative arthritis, especially in young athletes. Meniscectomy thus is reserved in cases when suture of the meniscus is not technically possible, as for example in complicated lesions or when the tear is not sufficiently close to the outer edge. However, whenever possible it should always be selective and not extended to the entire meniscus.That in the long term meniscectomy may evolve in arthrosis of the knee is renown since 1948, thanks to a famous scientific paper (T. J. Fairbanks. Knee joint changes after meniscectomy. J.B.J.S. Br. 1948).According to a more recent study conducted in 1996 by the French Society of Arthroscopy, meniscectomy performed when the anterior cruciate ligament is perfectly healthy, at 10 years from surgery presents radiologic evidence of arthrosis of the knee in 20-40% of cases, not necessarily accompanied by clinical pain. If meniscectomy is performed in presence of a complete lesion of the anterior cruciate ligament not reconstructed, at 25 years knee arthrosis is radiologically seen in 95% of patients.In young patients under 45 years of age with modern orthopaedic surgery torn meniscus can be replaced when lesions are too vast and complex to perform a total or partial meniscectomy. Replacement is performed with a homologous (from donor) meniscus replacement or with bovine collagen meniscus implant.How is post-operative rehabilitation done?Rehabilitation of a knee operated in arthroscopy is more simple than that for other surgery about the knee. Following medial meniscectomy the patient can walk with crutches 24 hours from surgery and recover complete joint movement in about two weeks. Often a few sessions of physiotherapy are needed: electrostimulation, stretching and proprioceptive rehabilitation of the knee may speed recovery. Lateral meniscectomy requires a longer recovery. On the contrary, suture of the meniscus with autologous graft and a meniscus implant need a different rehabilitation: a knee brace for 15-20 days that holds the knee fully extended while walking with no weight-bearing for 30 days to allow the meniscus suture or the graft to scar and stabilize. Two to three weeks after meniscus arthroscopy repair an athlete can return to running and after an average of 20 – 30 days from arthroscopy the patient can play soccer or other contact sports.Other useful information?The average time of hospitalization is one night, but surgery can also be performed in day hospital. Two to seven days are needed to return to a sedentary job, a heavy job requires about 3-4 weeks. The suture stitches are removed after 12-14 days from surgery. Usually the scar is limited to the arthroscopic accesses, 2 or 3 incisions about 1 cm long anterior to the knee. The scar must be kept dry for 15-20 days. During this time it is recommended not to go swimming or take a bath. Driving is allowed 12-14 days from surgery.Edited byMaurilio Marcacci MD, 1st Orthopaedic and Traumatologic Clinic; Stefano Zaffagnini MD, Giulio Maria Marcheggiani Muccioli MD, General Orthopaedics (Rizzoli-Sicilia Department).Istituto Ortopedico Rizzoli IRCCS, Bologna

Percutaneous vertebroplasty is a minimally-invasive therapeutic radiological procedure for the treatment of painful vertebral fractures due to osteoporosis and primary or secondary tumours.A third of all vertebral fractures are due to osteoporosis, which in Italy amount to 100,000 cases (a third of which produce severe vertebral pain). "Conventional" treatment involves long immobilization (30-60 days), combined analgesic therapy, with the risk of complications (thrombo-phlebitis or pneumonia).The first vertebroplasty was performed by Hervè Deramond in Amiens in 1984, due to an expanded angioma of the odontoid process. The operation consists of the percutaneous, CT-guided introduction of a needle of appropriate caliber through which, having reached the centre of the vertebral body, a few millilitres of cement is injected under arthroscopic control. The cement solidifies quickly and consolidates the vertebra almost immediately (Figures 1, 2 and 3). Percutaneous vertebroplasty is performed under local anesthesia.In 2002 38.000 vertebroplasties were performed in the United States, a 28% rise in comparison with the previous year.Indications The main indications are: Recent fracture due to osteoporosis, aching, unresponsive to the medical treatment Primary or secondary tumour responsible for pain (metastases, lymphomas, plasmocytomas, myelomas, angiomas, etc.).Side effects Sepsis Haemorrhagic dyscrasia Unstable fractures Posterior wall ruptureOsteoporotic fractures In osteoporotic fractures multiple vertebrae can be treated, at the most three in the same session. The choice of vertebra or vertebrae to treat is not based only on how they appear on radiographic examination; magnetic resonance also highlights vertebrae with intracancellous edema, a sign that fractures are recent; this finding has then to be correlated with the precise location of the pain reported by the patient (to do this it is useful to palpate for pain with the fingers).Most patients that have undergone this therapy have reported a reduction or resolution of the pain between the first hour and the 14th day, with a mean of 72 hours; this eliminates the need for wearing a corset, reduces or eliminates the assumption of analgesic drugs, and therefore improves the quality of life.Metastases In the vertebra involved by metastases vertebroplasty provides rapid stabilization and reduction/resolution of pain within 12-24h after treatment (radio- or chemotherapy achieve the objective of analgesia in 2-4 weeks) in 96-98% of cases, with significant improvement in the patient’s quality of life.Primary vertebral tumours (expansive Angioma, Myeloma, Plasmacytoma) As for metastases, vertebroplasty provided an immediate analgesic effect and the stabilization of the vertebra, thus avoiding the risk of its collapse. In conclusion, vertebroplasty appears to be a very effective procedure in the treatment of vertebral fracture due to osteoporosis and tumour.Figures

What is shoulder instability? Instability is defined as the symptom patients refer when the shoulder slips in its normal position. Shoulder joint instability may be caused by laxity, where it is difficult to keep the shoulder in site for alteration of bone and/or periarticular tissue development. Dislocation of the shoulder is often caused by trauma or microtraumas. An unstable shoulder can dislocate (the femoral head completely comes out of its normal lodging, the glenoid of the scapula), subluxate (partial dislocation of the humeral head) or present with pain in specific positions or movements due to abnormal gliding of the femoral head in during sports or work. When dislocation occurs frequently, even after a long period of time, it is called recurrent dislocation. Why does shoulder dislocation occur? The shoulder joint is a very special joint compared to the others of the human skeleton. The humeral head, approximately hemispheric in shape, loosely rests on a shallow concave vertical surface 3.5 cm high and 2.5 cm wide. This configuration allows the shoulder to have a wide range of motion in the three directions. However it is subjected to gravity therefore during motion joint stability is dependent on the connective tissues: joint capsule and glenoid labrum, ligaments and muscles with their respective tendons. Because of its particular conformation and anatomical distribution the shoulder dislocates more frequently in the antero-inferior direction. In these cases tears occur in bone and cartilage, ligament and tendon depending on the amount of the force and direction of the trauma, number of recurrences and individual resistance of the structures enduring stress. At what age does it most frequently occur? This pathology has a higher incidence in the second and third decades of life, is more frequent in males than in females and is related to the completion of muscle and joint development as well as to the peak of physical and working activity. However, although rarely, dislocations can occur also in other age groups: infants, adults or even elderly. How is diagnosis made? Medical history of the shoulder or of both shoulders, diffused laxity also in other joints (congenital diseases like Marfan’s syndrome generate laxity in all ligaments), the modality (for severe trauma or with no apparent trauma), the frequency, concomitant to specific body movements or positions, are all elements to be considered. At physical examination the patient must assist the orthopaedic surgeon by performing certain movements and specific manoeuvres to help define certain lesions excluding others which may co-exist. Attention must be paid to the fact that frequently the patient automatically tightens muscles and examination becomes difficult. Physical examination of the shoulder before surgery is useful because under anesthesia the muscles in the limb relax and dislocation can be evaluated better. For a sure diagnosis and to program therapy other instrumental examinations may be performed.  Which are the most appropriate instrumental examinations? Standard x-rays are necessary prior to shoulder reduction. Examinations useful to confirm diagnosis and for surgical staging are computerized axial tomography (CT) and magnetic resonance imaging (MRI) scans. CT shows conformation, joint relations and possible proximal humerus and glenoid surface bone damage and more specifically if there are fractures or bone fragments. MRI gives more complete information for connective tissue tears and muscle trophism. In selected cases, to obtain a clearer definition and image of the damaged structures and areas adjacent to the joint both CT and MRI can be performed using contrast dye injected directly in the joint. What treatment options are available? The treatment of choice after a first dislocation is conservative: reduction, orthopaedic bandaging and after about 4 weeks immobilization, progressive mobilization using elastics is started to strengthen the subscapularis (for anterior instability) or the subspinal (for posterior instability) muscles. If instability persists and should dislocations recur surgery may be considered. In the past 20 years surgical techniques for shoulder instability have brought about more precise surgery tailored on the specific tears and on the single patients. The decision as to when reparation surgery of the lesions and reinforcement of the capsule (capsulo-muscular plastic surgery) should be performed is taken together with the surgeon. However, at a certain point it is the same patient who feels the need to intervene on a situation of unease no longer tolerable with an everyday working and social life. The surgical technique chosen depends mainly on: age, frequency of the dislocations or if these are absent, duration of shoulder pain and degree of impediment during sports or working activities, muscle structure, level of weight-bearing during work, sports practiced as professionals or amateurs. It is important to rule out the presence of fractures associated to the dislocation, for this CT or MRI are very useful. Arthroscopy: what advantages? In the past 15 years improvements in arthroscopic techniques (small incisions to access the joint and small instruments controlled by microcameras) have greatly improved results. The advantage of not excising the muscles and the precision in repairing the tears makes this technique suitable for young patients (from 15 to 30 yrs of age), with a limited number of dislocations and with microinstablity. The technique uses “suture anchors” similar to microscrews (in titanium or resorbable polylactic acid) with nonresorbable highly resistant threads that are passed and tied to the joint capsule and to the glenoid labrum to recreate the normal capsular tension. This technique though cannot be used when fractures are present or when the tissue around the capsule is not strong enough. Traditional procedures, are indicated in patients who present simple dislocations, a surgical incision in the front part of the shoulder and the use of various types capsulo-muscular plastic surgery techniques guarantee correct tension.       This surgical procedure is always requires general or combined anesthesia (regional anesthesia with or without deep sedation) and hospitalization for 3 or 4 days. The upper limb is placed in an orthopaedic bandage for 4-5 weeks, then functional  rehabilitation of the shoulder is started, first passive and later active, assisted by a physiotherapist, preferably in water, with complete recovery of joint movement after 6-8 weeks. What happens when the shoulder is not operated? This question is frequently posed especially by patients with an unstable shoulder but with no dislocations and thus less invalidating. Some elderly patients have shoulder lesions without having had any real traumas, but with a history of heavy working activity or episodes of recurrent dislocations in youth always treated conservatively. These are painful lesions and the decrease in strength varying according to the extension of the lesion. In these cases and in this age group positive results of reparation surgery, are uncertain because of the instability present that was never corrected. Edited by Enrico Guerra, MD and Marco Nigrisoli, MD Shoulder and elbow surgery - Istituto Ortopedico Rizzoli, Bologna

Thermal ablation of bone lesions using Magnetic Resonance-guided (MRgFUS) Focused Ultrasound (GE-Insightec Exablate System) Thermal ablation of deep tissues using focused ultrasound is a radiological procedure finalized in the ‘80s for the treatment of uterine fibroids. Recently this technique was fine-tuned and is also used in ablation of bone lesions, such as metastases and osteoid osteomas.The source of ultrasound waves is formed by a focused transducer placed on the patient’s skin in correspondence of the deep lesion to treat. The cone-shaped ultrasound beam penetrates through soft tissues and concentrates in a specific target location generating for a few seconds a state of local hyperthermia (60-80°C) that determines irreversible necrosis of the treated tissue.Thermal ablation treatment using magnetic resonance-guided focused ultrasound (GE-Insightec Exablate System) at high density field allows, without using ionising radiation, to plan treatment at its best, monitor it in real time (thermometry) and enable the physician to immediately assess the treatment outcome.Treatment is usually performed in a single procedure. The patient is given local anaesthesia in the area to treat.There are no specific contraindications except for those common to all interventional procedures and to the use of magnetic resonance systems (pacemaker, metal prostheses, metal stents etc).Author: Ugo Albisinni MD, past Director of the structure of Radiology and diagnostic imaging.