Objectives
To update the 2012 European Society of Musculoskeletal Radiology (ESSR) clinical consensus guidelines for musculoskeletal ultrasound referral in Europe.
Methods
Twenty-one musculoskeletal ...imaging experts from the ESSR participated in a consensus study based on a Delphic process. Two independent (non-voting) authors facilitated the procedure and resolved doubtful issues. Updated musculoskeletal ultrasound literature up to July 2017 was scored for shoulder, elbow, wrist/hand, hip, knee, and ankle/foot. Scoring of ultrasound elastography was included. The strength of the recommendation and level of evidence was scored by consensus greater than 67% or considered uncertain when the consensus was consensus less than 67%.
Results
A total of 123 new papers were reviewed. No evidence change was found regarding the shoulder. There were no new relevant articles for the shoulder, 10 new articles for the elbow, 28 for the hand/wrist, 3 for the hip, 7 for the knee, and 4 for the ankle/foot. Four new evidence levels of A were determined, one for the hip (gluteal tendons tears), one for the knee (meniscal cysts), one for the ankle (ankle joint instability), and one for the foot (plantar plate tear). There was no level A evidence for elastography, although for Achilles tendinopathy and lateral epicondylitis evidence level was B with grade 3 indication.
Conclusions
Four new areas of level A evidence were included in the guidelines. Elastography did not reach level A evidence. Whilst ultrasound is of increasing importance in musculoskeletal medical practice, the evidence for elastography remains moderate.
Key Points
• Evidence and expert consensus shows an increase of musculoskeletal ultrasound indications.
• Four new A evidence levels were found for the hip, knee, ankle, and foot.
• There was no level A evidence for elastography.
Introduction
For the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and ...the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery.
Patients and methods
Preoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union.
Results
Cases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing.
Conclusions
CT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.
To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).
European ...Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.
A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.
These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.
Objectives
To assess the diagnostic performance of median nerve (MN) flip-angle measurements, deformation during wrist flexion transit deformation coefficient (TDC), during compression compression ...deformation coefficient (CDC) and fascicular freedom to potentially identify fibrotic MN changes in patients with carpal tunnel syndrome (CTS).
Methods
This prospective study was performed with institutional review board approval; all participants provided oral and written informed consent. Wrists in 21 healthy participants and 29 patients with CTS were examined by ultrasound. MN movement during wrist flexion, MN deformation during transition over the flexor tendons (TDC) and during controlled compression (CDC) as well as fascicular freedom were assessed. Diagnostic properties of these parameters were calculated and compared to clinical findings and cross-section area measurements (ΔCSA).
Results
Low flip angles were associated with high ΔCSA at a receiver-operator characteristics area under the curve (AUC) of 0.62 (0.51-0.74). TDC AUC, 0.83 (0.73-0.92), 76.3% (59.8-88.6%) sensitivity, 88.5% (76.6-95.7%) specificity, restricted fascicular movement AUC, 0.86 (0.78-0.94), 89.5% (75.2-97.1%) sensitivity, 80.8% (67.5-90.4%) specificity and compression-based CDC AUC, 0.97 (0.94-1.00), 82.1% (66.5-92.5%) sensitivity, 94.2% (84.1-98.8%) specificity demonstrated substantial diagnostic power (95% confidence intervals
in parentheses
).
Conclusions
Fascicular mobility, TDC and CDC show substantial diagnostic power and may offer insights into the underlying pathophysiology of CTS.
Key Points
• Dynamic ultrasonography during wrist flexion and compression enables median nerve deformability assessment.
• Overall, reduced median nerve deformability is highly indicative of CTS.
• Median nerve compressibility shows higher diagnostic power than conventional cross-section area measurements.
To evaluate two different dual-energy computed tomography (DECT) post-processing protocols for the detection of MSU deposits in foot tendons of cadavers with verification by polarizing light ...microscopy as the gold standard.
A total of 40 embalmed cadavers (15 male; 25 female; median age, 82 years; mean, 80 years; range, 52-99; SD ± 10.9) underwent DECT to assess MSU deposits in foot tendons. Two postprocessing DECT protocols with different Hounsfield unit (HU) thresholds, 150/500 (=established) versus 120/500 (=modified). HU were applied to dual source acquisition with 80 kV for tube A and 140 kV for tube B. Six fresh cadavers (4 male; 2 female; median age, 78; mean, 78.5; range 61-95) were examined by DECT. Tendon dissection of 2/6 fresh cadavers with positive DECT 120 and negative DECT 150 studies were used to verify MSU deposits by polarizing light microscopy.
The tibialis anterior tendon was found positive in 57.5%/100% (DECT 150/120), the peroneus tendon in 35%/100%, the achilles tendon in 25%/90%, the flexor halluces longus tendon in 10%/100%, and the tibialis posterior tendon in 12.5%/97.5%. DECT 120 resulted in increased tendon MSU deposit detection, when DECT 150 was negative, with an overall agreement between DECT 150 and DECT 120 of 80% (
= 0.013). Polarizing light microscope confirmed MSU deposits detected only by DECT 120 in the tibialis anterior, the achilles, the flexor halluces longus, and the peroneal tendons.
The DECT 120 protocol showed a higher sensitivity when compared to DECT 150.
Over the past decade, imaging of inflammatory arthritis in juvenile arthropathies has significantly advanced due to technological improvements in the imaging modalities and elaboration of imaging ...recommendations and protocols through systematic international collaboration. This review presents the latest developments in ultrasound (US) and magnetic resonance imaging (MRI) of the peripheral and axial joints in juvenile idiopathic arthritis. In the field of US, the ultra-wideband and ultra-high-frequency transducers provide outstanding spatial resolution. The more sensitive Doppler options further improve the assessment and quantification of the vascularization of inflamed tissues, and shear wave elastography enables the diagnosis of tissue stiffness. Concerning MRI, substantial progress has been achieved due to technological improvements in combination with the development of semiquantitative scoring systems for the assessment of inflammation and the introduction of new definitions addressing the pediatric population. New solutions, such as superb microflow imaging, shear wave elastography, volume-interpolated breath-hold examination, and MRI-based synthetic computed tomography open new diagnostic possibilities and, at the same time, pose new challenges in terms of clinical applications and the interpretation of findings.
Abstract
The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in ...the many established and emerging applications.
Abstract
The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in ...the many established and emerging applications.
The objective of our study was to compare ultrasound (US) tophus and monosodium urate (MSU) deposit detection and US tophus size in the metatarsophalangeal (MTP) 1 joint with dual-energy CT (DECT) ...using two DECT postprocessing protocols in patients presenting with podagra.
Seventy-five consecutive patients with podagra (66 men and nine women; mean age, 65.6 years; age range, 33-88 years) and 75 control subjects with MTP 1 joint osteoarthritis (49 men and 26 women; mean age, 63.0 years; age range, 35-87 years) prospectively underwent US and DECT between 2016 and 2018 to assess the MTP 1 joint. Two Syngovia postprocessing DECT protocols with different minimum attenuation thresholds of 150 HU (DECT 150 protocol) versus 120 HU (DECT 120 protocol) and the same maximum attenuation threshold (500 HU) and constant kilovoltage setting of tubes A and B at 80 and 140 kVp were evaluated. Interobserver variability of the two DECT protocols was calculated and compared with that of US.
The postprocessing DECT 150 protocol was positive for tophus detection in 55 of 75 patients (73.3%) with podagra, whereas the postprocessing DECT 120 protocol detected MSU deposits in all 75 patients (100%). Tophus size assessed using the DECT 120 protocol showed an improved correlation with tophus size detected on US (
< 0.01). Interobserver variability of DECT was improved when using the DECT 120 protocol (
< 0.01).
The postprocessing DECT 120 protocol enables improved visualization of MSU deposits and provides more accurate information about tophus size that better correlates with tophus size on US compared with the standard postprocessing DECT 150 protocol.
Real-time sonoelastography is a new ultrasound-based technique able to assess tissue elasticity that has already shown feasibility in tumor diagnosis. The aim of this study was to assess the ...performance of real-time sonoelastography in depicting the Achilles tendons of healthy volunteers and to compare sonoelastography findings with conventional ultrasound findings.
Eighty asymptomatic Achilles tendons of 40 healthy volunteers (19 men, 21 women; mean age, 38 years; range, 20-76 years) were examined on real-time sonoelastography and ultrasound. The Achilles tendons were divided into the following thirds for image evaluation: proximal (musculotendinous junction), middle (2-6 cm above insertion at the calcaneus), and distal (insertion at the calcaneus). Longitudinal and axial images of each tendon third were obtained using ultrasound and real-time sonoelastography. Real-time sonoelastography images were evaluated by reviewers using an experimentally proven color grading system.
The Achilles tendons showed mainly a hard structured pattern (86.7%) (208/240 tendon thirds) on sonoelastography; however, mild softening was found in 12.1% (29/240) of the tendons. Distinct softening corresponding to alterations found also on ultrasound and, therefore, suggesting subclinical changes was detected in 1.3% (3/240). The overall correlation (kappa) between real-time sonoelastography and ultrasound findings was 1.00.
In healthy volunteers, the Achilles tendon appeared hard on real-time sonoelastography with excellent correlation to ultrasound. Further investigation including pathologic tendons should be performed to prove the value of real-time sonoelastography in the assessment of Achilles tendinopathy.
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