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.
Acute lateral patellar dislocation (LPD) is the most common acute knee disorder in children and adolescents, and may lead to functional disability. The purpose of this study was to identify key ...differences and correlations of the patellofemoral joint (PFJ) morphology between intact and contralateral injured knees in a first-time traumatic LPD population aged under 18 years.
The data were gathered prospectively from a cohort of 58 patients (35 girls and 23 boys). The prevalence and combined prevalence of patella alta (PA) and trochlear dysplasia (TD) in both knees of patients were evaluated using X-ray by two radiologists.
The PFJ of patients' intact knees had a lower rate of TD (1.72% vs. 5.2%) and a less common combination of PA with shallow femoral sulcus (SFS) (22.4% vs. 44.8%) but more frequent PA (62.1% vs. 41.4%) compared with their injured knees. We noted statistically significant positive correlations (SSPCs) between the femoral sulcus angle (FSA) and PA in patients with intact (
= 0.37;
< 0.005) and contralateral injured knees (
= 0.33;
< 0.05).
There were SSPCs between the FSA and PA in both gender and age groups of patients with intact and contralateral injured knees. The SSPCs between the FSA and PA of intact knees were higher in the patients with a more dysplastic PFJ anatomy (PA and TD) of the injured knees as compared to patients with only PA of the injured knees.
To explore the presence of intratendinous air in physically active males after different types of strenuous physical exercise.
To detect foci (air bubbles) in the quadriceps femoris tendon (QFT) and ...the proximal and distal parts of the patellar tendon, ultrasound examination was performed under two conditions: (1) after high-intensity cycling on a cycle ergometer (metabolic); (2) after 200 drop jumps (exercise-induced muscle damage). Based on the results of these two interventions, the presence of air in the tendons after 100 drop jumps was examined further with frequently repeated ultrasound measurements.
Foci were detected in exercise-induced muscle damage. Twenty-three of Sixty investigated tendons (38.3%) were observed to contain hyperechoic foci after 100 drop jumps. QFT foci were present in 13/23 cases (56.5%). The location of foci in the QFT was mostly lateral and centro-lateral (76.9%). The foci disappeared completely between 40 and 180 min after completing 100 drop jumps.
The presence of intratendinous air seems related to high-magnitude, high-force, high-strain exercise of the particular tendon areas. It might represent the stress response of tendons to overload condition.
Monitoring the muscle mechanical properties and functions of female athletes throughout their training season is relevant to understand the relationships between these factors and to predict ...noncontact injuries, which are prevalent among female athletes. The first aim of this study was to determine whether female handball players' passive stiffness of the hamstring muscles is associated with hamstring extensibility, strength of knee flexors and extensors, and lower limb stiffness. Additionally, the study monitored fluctuations in these factors over 25 weeks. The study utilized an isokinetic dynamometer to record hamstring passive stiffness, extensibility, and hamstring and quadriceps strength of 18 young handball players. Lower limb stiffness was determined from a countermovement vertical jump conducted on a force plate. The countermovement jump involved the calculation of the peak force during the eccentric phase and the mean force during the concentric phase. The results showed a positive correlation between hamstring passive stiffness and lower limb stiffness (
= 0.660,
< 0.01), knee flexion and extension strength (
= 0.592,
< 0.01 and
= 0.497,
< 0.05, respectively), and eccentric peak force (
= 0.587,
< 0.01) during jumping. The strength of knee extensors increased significantly after 6 weeks, and hamstring stiffness after 12 weeks of training. In conclusion, the increased hamstring stiffness following training did not match other factors associated with injury risk. Therefore, preventing multifactorial injury risk requires a comprehensive approach, and monitoring one factor alone is insufficient to predict noncontact injuries in female handball players.
Background
Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of ...a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.
Methods
Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.
Results
A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).
Conclusions
Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.
Key Points
• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder.
• The highest level of evidence was reached for five statements.
• Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).
Background
Although image-guided interventional procedures of the elbow and wrist are routinely performed, there is poor evidence in the literature concerning such treatments. Our aim was to perform ...a Delphi-based consensus on published evidence on image-guided interventional procedures around the elbow and wrist and provide clinical indications on this topic.
Methods
A board of 45 experts in image-guided interventional musculoskeletal procedures from the European Society of Musculoskeletal Radiology were involved in this Delphi-based consensus study. All panelists reviewed and scored published papers on image-guided interventional procedures around the elbow and wrist updated to September 2018 according to the Oxford Centre for Evidence-based Medicine levels of evidence. Consensus on statements drafted by the panelists about clinical indications was considered as “strong” when more than 95% of panelists agreed and as “broad” if more than 80% agreed.
Results
Eighteen statements were drafted, 12 about tendon procedures and 6 about intra-articular procedures. Only statement #15 reached the highest level of evidence (ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement). Seventeen statements received strong consensus (94%), while one received broad consensus (6%).
Conclusions
There is still poor evidence in published papers on image-guided interventional procedures around the elbow and wrist. A strong consensus has been achieved in 17/18 (94%) statements provided by the panel on clinical indications. Large prospective randomized trials are needed to better define the role of these procedures in clinical practice.
Key Points
•
The panel provided 18 evidence-based statements on clinical indications of image-guided interventional procedures around the elbow and wrist.
•
Only statement
#
15 reached the highest level of evidence: ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement.
•
Seventeen statements received strong consensus (94%), while broad consensus was obtained by 1 statement (6%).
Objectives
Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional ...Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.
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 foot and ankle in order 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 that was shared with all panel members for final approval.
Results
A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.
Conclusion
According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.
Key Points
•
The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.
• Strong consensus was obtained for all statements.
• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.
Background
Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these ...types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence.
Methods
An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed.
Results
Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).
Conclusions
This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus.
Key Points
• An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb
• Two statements reached the highest level of evidence
• Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%)
Objectives
Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance ...and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications.
Methods
In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications.
Results
Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts.
Conclusions
This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip.
Key Points
• Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip.
• The highest level of evidence was only reached for one statement.
• Strong consensus was obtained for all statements.
Objectives
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
.
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