Giulio Cocco

Objectives: Recently, a novel dynamic maneuver in which the retrocalcaneal soft tissues are squeezed (CoRi sign) has been described for the diagnosis of partial tears involving the deep fibers of the Achilles tendon. This cross‐sectional study aims to assess the prevalence of the CoRi sign in a cohort of patients with a clinical diagnosis of IAT. Methods: A consecutive cohort of 58 patients (32 males, 26 females) seen at our institution with a clinical diagnosis of IAT comprised the study group for a cross‐sectional study to assess the prevalence of the CoRi sign in the study population and to correlate the findings on static B‐mode and color/power Doppler sonography with the CoRi dynamic maneuver. Results: The prevalence of CoRi sign was 15.5% in the study cohort (9/58) and 26.4% (9/34) in the subgroup of IAT patients with bursal effusion in B‐mode coupled with synovial hyperemia in color/power Doppler. Of the nine patients with a positive dynamic maneuver, eight of them presented insertional tendinosis with intratendinous hyperemia at color/power Doppler; in addition, none showed Achilles bone spurs of the calcaneal tuberosity. Lastly, four of the nine patients with a positive CoRi sign showed tendon–bone junction hyperemia in the absence of a bone spur. Conclusions: Tendon undersurface disruption in IAT patients is not uncommon, and dynamic ultrasound imaging is valuable for diagnosis. Hyperemic retrocalcaneal bursitis, insertional tendinosis with intratendinous hyperemia, and tendon–bone junction hyperemia are the most common static sonographic findings, respectively, in CoRi‐positive patients. Level of Evidence: Level IV—cross‐sectional study.

Posterolateral elbow ganglion cysts are extremely rare and have been previously documented almost exclusively on clinical and magnetic resonance imaging reports. Herein, we describe the rare case of a 38‐year‐old man presenting with an asymptomatic lateral elbow lump. High‐resolution ultrasound obtained using high‐frequency linear transducers demonstrated a well‐defined anechoic cyst with a thin stalk extending toward the articular space, consistent with a posterolateral elbow ganglion. This case underscores the problem‐solving role of high‐resolution ultrasound in the evaluation of elbow lumps, enabling a prompt and accurate diagnosis of this entity despite its atypical and therefore unexpected location.

When assessing hip pain in athletes, it is important to focus on the extra-articular soft tissues that may clinically mimic joint pathology. One such extra-articular structure is the synovial bursa. Bursitis can clinically be misdiagnosed as joint-, tendon- or muscle-related pain. These pathological processes are a result of inflammation that is often secondary to acute trauma, overuse injuries, arthritis, or infection. Traumatic and overuse hip bursitis occur frequently in amateur and professional athletes and clinical presentation is often nonspecific. After clinical assessment, imaging plays an important role in diagnosis and in work-up of these lesions. Ultrasonography (US) is being increasingly used in the assessment of the hip because of the wide availability of US machines, the lower cost, and the unique real-time imaging capability which allows both static and dynamic evaluation as well as guidance of interventional procedures such as fluid aspiration and steroid injection. In order to obtain a correct diagnosis, an efficient US examination requires a thorough understanding of hip anatomy. In this setting, a structured approach based on identification of important US landmarks and compartmentalization of hip anatomy can significantly simplify the task. Sports physicians must be aware about the diagnostic and therapeutic possibilities offered by US in order to expedite rapid referral to a musculoskeletal specialist who can perform a point-of-care US examination of the hip by using a structured diagnostic approach. The purpose of this narrative review is to illustrate both the normal and pathological features of anterior and lateral hip compartments bursae using schematic diagrams and corresponding US images. We will concentrate on sport-related bursitis, of which we will discuss the etiology, clinic and principles of care management. Our aim is to promote the acquisition of these concepts in sports medicine in order to improve patient outcomes.

Background: The development of a meshoma, resulting from excessive contraction and folding of a prosthetic mesh after inguinal hernia repair, represents a rare but clinically relevant complication. Sometimes, a sinus tract or cutaneous fistula may also develop as a result of a local infection. Early diagnosis is often challenging due to a poorly specific clinical presentation that makes point-of-care ultrasound imaging pivotal for a prompt assessment. Case summary: A 46-year-old man presented with fever and recurrent left groin pain several years after open inguinal hernia repair with a plug-and-patch technique. A hyperechoic folded structure with posterior acoustic shadowing, consistent with a meshoma, surrounded by hypoechoic inflammatory changes of the soft tissues, was identified on ultrasound examination. Additionally, a thin hypoechoic linear tract extending from the meshoma to the skin surface was also identified, consistent with a cutaneous fistula. Despite partial clinical improvement with systemic antibiotic therapy, due to the persistent painful local mass, a surgical exploration was performed, confirming an infected meshoma with cutaneous fistulization. Complete removal of the prosthetic material led to full clinical resolution, with no recurrence during follow-up. Conclusion: Meshoma is an uncommon but potentially severe late complication of inguinal hernia repair. Ultrasound represents a valuable first-line imaging modality, allowing direct visualization of mesh folding and associated fistulous tracts and facilitating prompt surgical management.

Genodermatoses comprise a heterogeneous group of hereditary skin diseases, which are often characterized by fluctuating severity, incomplete penetrance, and age-related onset, and this makes them hard to identify and treat very early. Traditional dermatologic evaluation has still limited ability to evaluate subclinical disease or objective tracking treatment effects. High-frequency ultrasound has proved to be a non-invasive, reproducible imaging modality that can be used to visualize in detail the epidermis, the dermis and the hypodermis and detect some pathological changes that cannot be identified by clinical ex-amination. High-frequency ultrasound in combination with dermoscopy, reflectance confocal microscopy, and optical coherence tomography can improve disease diagnosis, and possibly objectively assess treatment result. This narrative review highlights the increasing role of ultrasound in genodermatoses.

Long-term patency in complex chronic total occlusion percutaneous intervention (CTO-PCI) is often hindered by a high-risk of stent-failure (HR-SF), impacting prognosis. Drug-coated balloon (DCB) angioplasty may offer an alternative after successful crossing. We evaluated an invest-to-treat DCB strategy, determined by plaque modification results. Patients with CTO wire-crossing and suboptimal lesion profile for stenting were enrolled at Campus Bio-Medico University Hospital of Rome (April-July 2024). After plaque preparation, results were classified as good, suboptimal, or poor based on residual stenosis and thrombolysis in myocardial infarction (TIMI) flow. Poor results received conventional stenting [drug-eluting stent (DES)]. Good results underwent a nine-month follow-up; suboptimal results underwent a three-month angiography. A "redo-DCB" approach was used for persistent suboptimal results within the invest-to-treat strategy. Of 32 CTO-PCIs performed, 29 completed the nine-month follow-up. 11 patients (38%) had poor outflow and required DES (DES-group). The other 18 patients (62%) were managed with DCB alone: six patients (21%) achieved good immediate results (DCB-group), and 12 (41%) were treated as "DCB-investment" due to suboptimal plaque modification (DCB-investment group). At the three-month follow-up, four patients (14%) showed improved angiographic results, while six (21%) had suboptimal outcomes and received redo-DCB after plaque modification; two (7%) of these required DES. At nine-months, 14 patients (48%) were successfully treated with a DCB-only approach. This prospective study demonstrates that a DCB strategy for CTO patients with HR-SF is feasible and safe. A DCB-only approach resulted in favorable early outcomes for most patients. In the case of suboptimal initial results, the redo-DCB strategy emerged as a promising alternative to extensive stenting.

We describe a case of an ultrasound-detected umbilical hernia in a 56-year-old female patient who underwent a skin ultrasound. With the patient in a standing position, the probe was positioned at the level of the umbilicus. Pressure was applied with the probe and then it was released; probe-induced Cocco sign was revealed.

Objective To describe an innovative, dynamic ultrasound technique for detecting abdominal hernias using the Color Doppler effect, particularly in small hernias and those that are challenging to identify with conventional ultrasound methods. Materials and Methods With the patient in a supine position, the ultrasound probe is positioned over the suspected hernia area without applying compression. The sonographer activates the Color Doppler box and instructs the patient to perform a Valsalva maneuver. Results During the Valsalva maneuver, the hernia sac becomes visible as a red Doppler signal moving toward the probe, clearly indicating its presence and motion. When the Valsalva maneuver is stopped and intra-abdominal pressure decreases, the hernia retracts back into the abdominal cavity, resulting in a blue signal moving away from the probe. The combination of the Color Doppler effect and the Valsalva maneuver enhances the detection of small hernias, where a narrow defect increases tissue velocity and generates clearer Doppler signals. This characteristic Doppler pattern is here proposed as a novel diagnostic indicator, referred to as the “Cocco Sign.” Conclusion This dynamic ultrasound assessment using the Color Doppler effect may significantly enhance the identification of hernias—especially small ones that are challenging to visualize with conventional ultrasound techniques. This innovative approach has the potential to significantly enhance the diagnosis of hernias.

Here, we describe a case of an asymptomatic 73-year-old female patient who suffered from type A acute aortic dissection with epiaortic arteries involvement and underwent surgical operation 9 years ago. A follow-up color Doppler ultrasound revealed a right vertebral artery intermittent flow reversal due to innominate artery dissection. To our knowledge, no previous studies have reported this intermittent flow reversal; therefore, supra-aortic trunks should be considered among the possible causes of vertebral artery flow reversal.

Superficial venous aneurysms of the upper extremities are a rare clinical entity, often underdiagnosed and misinterpreted as other soft tissue masses. We present the case of a 28-year-old male patient with a subcutaneous mass on the dorsum of the left hand, diagnosed as a superficial venous aneurysm by high-resolution ultrasound using a probe bandwidth of up to 18 MHz, unchanged at three-month Doppler-ultrasound examination. This case highlights the fundamental role of high-frequency ultrasound in the differential diagnosis and conservative management of such lesions.