The Copenhagen Standardised MRI protocol to assess the pubic symphysis and adductor regions of athletes: outline and intratester and intertester reliability.

BACKGROUND: There is currently no standardised MRI evaluation protocol for athletes who present with symptoms that may relate to the pubic symphysis, the pubic bones, and the adductor muscle insertions. We outline the protocol and reliability data. MATERIAL AND METHODS: Three musculoskeletal radiologists developed an 11-element MRI evaluation protocol defined according to precise criteria and illustrated in a pictorial atlas. Eighty-six male athletes (soccer players and non-soccer players) underwent standardised 3 Tesla MRI of the pelvis. Two external musculoskeletal radiologists were trained to use the protocol and pictorial atlas during two sessions of 2-4 h each. Each radiologist rated all 86 MRI independently. One radiologist evaluated the scans once, the other twice 2 months apart. Cohen κ statistics were used to determine intraobserver and interobserver agreement. RESULTS: The main findings were (1) substantial intraobserver (κ range 0.65-0.67) and moderate interobserver (κ range 0.45-0.52) agreement in rating pubic bone marrow oedema, (2) substantial to moderate intraobserver (κ range 0.49-0.72) and moderate-to-fair interobserver (κ range 0.21-0.52) agreement in rating most other MRI findings, (3) slight intraobserver and interobserver (κ range -0.06-0.05) agreement in rating adductor longus tendinopathy. CONCLUSIONS: The Copenhagen Standardised MRI protocol demonstrated moderate-to-substantial reliability in rating bone marrow oedema, and varied from fair-to-substantial agreement for the majority of MRI features, but showed only slight agreement in rating adductor longus tendinopathy. This rigorous investigation also confirms that while MRI evaluation seems to provide reasonable reliability in rating pubic bone marrow oedema, the evaluation of adductor tendinopathy in a clinical and research setting needs further resolution by continued development and testing of MRI acquisition protocols.

Imaging in juvenile idiopathic arthritis with a focus on ultrasonography.

Early therapeutic intervention and use of new highly efficacious treatments have improved the outcome in many patients with juvenile idiopathic arthritis (JIA), but have also led to the need for more precise methods to evaluate disease activity. In adult rheumatology, numerous studies have established the importance of magnetic resonance imaging (MRI) and ultrasonography (US), and MRI is considered the reference standard. Nevertheless, due to differences in disease characteristics and the unique features of the growing skeleton, the findings obtained in adults are not directly applicable to children and adolescents. For paediatric patients, US offers specific advantages over MRI, because it is non-invasive, does not require sedation or general anesthesia (which facilitates repeated examinations for follow-up), is quickly accessible bedside, and is easy to combine with clinical assessment (interactivity). Agitation of the patient is rarely a problem, and hence young children can be seated on a parent's lap or play while being examined, and multiple locations can be assessed during a single session. Furthermore, modern high-frequency US transducers used by experienced US examiners can provide unsurpassed resolution of the superficial musculoskeletal structures in children. US is also the best available technique for imaging guidance of steroid injections. Unfortunately, there are still no validated MRI or US scoring systems for evaluating inflammatory and joint damage abnormalities in JIA, and few US studies have been conducted. Sonographic assessment of disease activity has, however, been proven to be more informative than clinical examination and is also readily available at points of care. This review summarises the literature on imaging in JIA, focusing on US and the important role this technique will play in JIA in the future.

Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology.

OBJECTIVE: To develop clinical guidelines for musculoskeletal ultrasound (MSKUS) referral in Europe. METHODS: Sixteen musculoskeletal radiologists from seven European countries participated in a consensus-based interactive process (Delphi method) using consecutive questionnaires and consensus procedure meetings at several European radiology meetings. The evaluation of musculoskeletal diseases was established by literature reviews, followed by consensus on clinical utility in three consensus meetings. This involved a thorough, transparent, iterative approach which including interview, questionnaire, Delphi and standard setting methodologies. European MSK radiologists with a special interest in MSKUS formed two different expert groups who worked on reaching a consensus in the first two meetings. The third meeting resolved questions that did not achieve a consensus level of 67% using the first two questionnaires. RESULTS: On expert consensus, the use of MSKUS is indicated to detect joint synovitis, fluid and septic effusion for potential aspiration, and poorly indicated to detect loose bodies. Recommendations for most appropriate use of musculoskeletal ultrasound are reported in six areas relevant to musculoskeletal ultrasound: hand/wrist, elbow, shoulder, hip, knee and ankle/foot. CONCLUSION: A comprehensive evidence-based, expert consensus-defined educational framework on clinical ultrsound is presented. This should facilitate referrals for this important imaging technique throughout Europe. KEY POINTS: Musculoskeletal ultrasound is indicated for detecting joint synovitis, effusions and fluid collections. • Musculoskeletal ultrasound is poor at detecting loose bodies. • Musculoskeletal ultrasound is relevant for most joints.

Imaging of neuropathies about the ankle and foot.

Neuropathies about the ankle and foot may be the cause of chronic pain and disability. In most cases, these conditions derive from mechanical or dynamic compression of a segment of a nerve within a narrow osteofibrous tunnel, an opening in a fibrous structure, or a passageway close to a ligament or a muscle. Although the evaluation of nerve disorders primarily relies on neurological examination and electrophysiology, diagnostic imaging is currently used as a complement to help define the site and etiology of nerve compression and exclude other disease possibly underlying the patient' symptoms. In this article, a review of the anatomical and pathological features of nerve entrapments in the distal lower extremity is presented on ultrasound and magnetic resonance imaging, according to the nerve involved.

Pseudoaneurysm of the posterior circumflex humeral artery diagnosed by sonography.

We report a rare case of a pseudoaneurysm of the posterior circumflex humeral artery, probably related to a steroid injection in the shoulder 3 months earlier. The clinical presentation was atypical and the location not previously described in the literature. The patient was referred with a painless, nonpulsatile mass in the posterior shoulder region and was suspected of a malignant soft-tissue tumor. Sonography, including power Doppler imaging, demonstrated a pseudoaneurysm, with the intralesional blood-filled cavity developed from the posterior circumflex humeral artery. The diagnosis was confirmed by pathologic examination of the surgical specimen.

[Ultrasound reflecting the morphological properties in soft tissue].

Ultrasound (US) is an image modality providing the examiner with real-time images which reflect the morphological properties in soft tissue. Different types of transducers are used for different kind of exams. US is cheap, fast, and safe. US is widely used in abdominal imaging including obstetrics and gynaecology plus cardiology. Furthermore, US has gained significant interest in rheumatology, orthopaedics and anaesthetics. Colour Doppler and spectral Doppler is useful in vascular imaging. The use of US contrast increases accuracy in liver imaging. US can guide for different interventional procedures.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the wrist region. A descriptive interventional study.

BACKGROUND: The wrist region is one of the most complex joints of the human body. It is prone to deformity and functional impairment in juvenile idiopathic arthritis (JIA), and is difficult to examine clinically. The aim of this study was to evaluate the role of ultrasonography (US) with Doppler in diagnosis of synovitis, guidance of steroid injections, and follow-up examinations of the wrist in JIA. METHODS: In 11 patients (median age 12.5 years, range 2-16), 15 wrists with clinically active arthritis were assessed clinically by US and color Doppler (Logiq 9, GE, 16-4 MHz linear transducer) prior to and 1 and 4 weeks after US-guided steroid injection. RESULTS: US detected synovitis in the radio-carpal joints, the midcarpal joints, and the tendon sheaths in 87%, 53% and 33% of the wrists, respectively. Multiple compartments were involved in 67%. US-guidance allowed accurate placement of steroid in all 21 injected compartments, with a low rate of subcutaneous atrophy. Synovial hypertrophy was normalized in 86% of the wrists, hyperemia in 91%, and clinically active arthritis in 80%. CONCLUSIONS: US enabled detection of synovial inflammation in compartments that are difficult to evaluate clinically and exact guidance of injections, and it was valuable for follow-up examinations. Normalization of synovitis was achieved in most cases, which supports the notion that US is an important tool in management of wrist involvement in JIA.

Comparison of ultrasonography with Doppler and MRI for assessment of disease activity in juvenile idiopathic arthritis: a pilot study.

BACKGROUND: In juvenile idiopathic arthritis (JIA), the trend towards early therapeutic intervention and the development of new highly effective treatments have increased the need for sensitive and specific imaging. Numerous studies have demonstrated the important role of MRI and US in adult rheumatology. However, investigations of imaging in JIA are rare, and no previous study has been comparing MRI with Doppler ultrasonography (US) for assessment of arthritis. The aim of the present study was to compare the two imaging methods regarding their usefulness for evaluating disease activity in JIA, and to compare the results with those obtained in healthy controls. METHODS: In 10 JIA patients (median age 14 years, range 11-18), 11 joints (six wrists, three knees, two ankles) with arthritis were assessed by color Doppler US and MRI. The same imaging modalities were used to evaluate eight joints (three wrists, three knees, two ankles) in six healthy age- and sex-matched controls. The US examinations of both the patients and controls were compared with the MRI findings. RESULTS: In 10 JIA patients, US detected synovial hypertrophy in 22 areas of 11 joints, 86% of which had synovial hyperemia, and MRI revealed synovitis in 36 areas of the same 11 joints. Erosions were identified by US in two areas of two joints and by MRI in six areas of four joints. Effusion was shown by US in nine areas of six joints and by MRI in 17 areas of five joints. MRI detected juxta-articular bone marrow edema in 16 areas of eight joints. CONCLUSIONS: The results of this pilot study indicate that both MRI and US provide valuable imaging information on disease activity in JIA. Importantly, the two techniques seem to complement each other and give partly different information. Although MRI is considered to be the reference standard for advanced imaging in adult rheumatology, US seems to provide useful imaging information that could make it an option in daily clinical practice, in JIA as well as in adult rheumatology. However, the current work represents a pilot study, and thus our results need to be confirmed in a larger prospective clinical investigation.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study.

BACKGROUND: The ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used for guidance of steroid injection and to assess treatment efficacy. METHODS: Forty swollen ankles regions were studied in 30 patients (median age 6.5 years, range 1-16 years) with JIA. All patients were assessed clinically, by US (synovial hypertrophy, effusion) and by color Doppler (synovial hyperemia) before and 4 weeks after US-guided steroid injection. RESULTS: US detected 121 compartments with active disease (joints, tendon sheaths and 1 ganglion cyst). Multiple compartments were involved in 80% of the ankle regions. The talo-crural joint, posterior subtalar joint, midfoot joints and tendon sheaths were affected in 78%, 65%, 30% and 55% respectively. Fifty active tendon sheaths were detected, and multiple tendons were involved in 12 of the ankles. US-guidance allowed accurate placement of the corticosteroid in all 85 injected compartments, with a low rate of subcutaneous atrophy (4,7%). Normalization or regression of synovial hypertrophy was obtained in 89%, and normalization of synovial hyperemia in 89%. Clinical resolution of active arthritis was noted in 72% of the ankles. CONCLUSIONS: US enabled exact anatomical location of synovial inflammation in the ankle region of JIA patients. The talo-crural joint was not always involved. Disease was frequently found in compartments difficult to evaluate clinically. US enabled exact guidance of steroid injections, gave a low rate of subcutaneous atrophy and was proved valuable for follow-up examinations. Normalization or regression of synovial hypertrophy and hyperemia was achieved in most cases, which supports the notion that US is an important tool in the management of ankle involvement in JIA.

Ultrasonography and color Doppler of proximal gluteal enthesitis in juvenile idiopathic arthritis: a descriptive study.

BACKGROUND: The presence of enthesitis (insertional inflammation) in patients with juvenile idiopathic arthritis (JIA) is difficult to establish clinically and may influence classification and treatment of the disease. We used ultrasonography (US) and color Doppler (CD) imaging to detect enthesitis at the small and deep-seated proximal insertion of the gluteus medius fascia on the posterior iliac crest where clinical diagnosis is difficult. The findings in JIA patients were compared with those obtained in healthy controls and with the patients' MRI results. METHODS: Seventy-six proximal gluteus medius insertions were studied clinically (tenderness to palpation of the posterior iliac crest) and by US and CD (echogenicity, thickness, hyperemia) in 38 patients with JIA and in 38 healthy controls, respectively (median age 13 years, range 7-18 years). In addition, an additional MRI examination of the sacroiliac joints and iliac crests was performed in all patients. RESULTS: In patients with focal, palpable tenderness, US detected decreased echogenicity of the entheses in 53% of the iliac crests (bilateral in 37% and unilateral in 32%). US also revealed significantly thicker entheses in JIA patients compared to healthy controls (p < 0.003 left side, p < 0.001 right side). There was no significant difference in thickness between the left and right sides in individual subjects. Hyperemia was detected by CD in 37% (28/76) of the iliac crests and by contrast-enhanced MRI in 12% (6/50). CONCLUSIONS: According to US, the gluteus medius insertion was thicker in JIA patients than in controls, and it was hypoechoic (enthesitis) in about half of the patients. These findings may represent chronic, inactive disease in some of the patients, because there was only limited Doppler flow and MRI contrast enhancement. The present study indicates that US can be useful as an adjunct to clinical examination for improved assessment of enthesitis in JIA. This may influence disease classification, ambition to treat, and choice of treatment regimen.

Rheumatoid arthritis bone erosion volumes on CT and MRI: reliability and correlations with erosion scores on CT, MRI and radiography.

OBJECTIVES: To investigate intramodality and intermodality agreements of CT and MRI erosion volumes in metacarpophalangeal (MCP) joints in rheumatoid arthritis (RA), and to compare the volumes with erosion scores for CT, MRI and radiography. METHODS: In total, 17 patients with RA and four healthy controls underwent unilateral CT, MRI and radiography of second to fifth MCP joints in one hand. Erosion volumes (using OSIRIS software) and scores were determined from CT, MRI and radiography (scores only). RESULTS: CT, MRI and radiography detected 77, 62 and 12 erosions, respectively. On CT, the mean erosion volume was 26 mm(3) (median 10; range 0 to 248) and 30 mm(3) (18; 1 to 163) on MRI. Total erosion volumes (per patient/control) were 97 mm(3) (29; 0 to 485) on CT and 90 mm(3) (46; 0 to 389) on MRI. For volumes, Spearman correlation coefficients were 0.96 to 0.99 (CT vs CT), 0.95 to 0.98 (MRI vs MRI) and 0.64 to 0.89 (CT vs MRI), all p<0.01. MRI erosion volumes correlated with the Outcome Measures in Rheumatology Clinical Trials/Rheumatoid Arthritis Magnetic Resonance Imaging Score (OMERACT RAMRIS) erosion scores (0.91 to 0.99; p<0.01) and the Sharp/van der Heijde erosion score (0.49 to 0.63; p<0.01). CONCLUSION: Very high intramodality and high intermodality agreements of CT and MRI erosion volumes were found, encouraging further testing in longitudinal studies. A close correlation with CT and MRI erosion volumes supports the OMERACT RAMRIS erosion score as a valid measure of joint destruction in RA.

Ultrasonography of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis: a comparison with magnetic resonance imaging, conventional radiography and clinical examination.

Signs of inflammation and destruction in the finger joints are the principal features of rheumatoid arthritis (RA). There are few studies assessing the sensitivity and specificity of ultrasonography in detecting these signs. The objective of the present study was to investigate whether ultrasonography can provide information on signs of inflammation and destruction in RA finger joints that are not available with conventional radiography and clinical examination, and comparable to the information provided by magnetic resonance imaging (MRI). The second to fifth metacarpophalangeal and proximal interphalangeal joints of 40 RA patients and 20 control persons were assessed with ultrasonography, clinical examination, radiography and MRI. With MRI as the reference method, the sensitivity, specificity and accuracy of ultrasonography in detecting bone erosions in the finger joints were 0.59, 0.98 and 0.96, respectively; they were 0.42, 0.99 and 0.95 for radiography. The sensitivity, specificity and accuracy of ultrasonography, with signs of inflammation on T1-weighted MRI sequences as the reference method, were 0.70, 0.78 and 0.76, respectively; they were 0.40, 0.85 and 0.72 for the clinical examination. With MRI as the reference method, ultrasonography had higher sensitivity and accuracy in detecting signs of inflammation and destruction in RA finger joints than did clinical and radiographic examinations, without loss of specificity. This study shows that ultrasonography has the potential to improve assessment of patients with RA.

Are bone erosions detected by magnetic resonance imaging and ultrasonography true erosions? A comparison with computed tomography in rheumatoid arthritis metacarpophalangeal joints.

The objective of the study was, with multidetector computed tomography (CT) as the reference method, to determine whether bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) joints detected with magnetic resonance imaging (MRI) and ultrasonography (US), but not with radiography, represent true erosive changes. We included 17 RA patients with at least one, previously detected, radiographically invisible MCP joint MRI erosion, and four healthy control individuals. They all underwent CT, MRI, US and radiography of the 2nd to 5th MCP joints of one hand on the same day. Each imaging modality was evaluated for the presence of bone erosions in each MCP joint quadrant. In total, 336 quadrants were examined. The sensitivity, specificity and accuracy, respectively, for detecting bone erosions (with CT as the reference method) were 19%, 100% and 81% for radiography; 68%, 96% and 89% for MRI; and 42%, 91% and 80% for US. When the 16 quadrants with radiographic erosions were excluded from the analysis, similar values for MRI (65%, 96% and 90%) and US (30%, 92% and 80%) were obtained. CT and MRI detected at least one erosion in all patients but none in control individuals. US detected at least one erosion in 15 patients, however, erosion-like changes were seen on US in all control individuals. Nine patients had no erosions on radiography. In conclusion, with CT as the reference method, MRI and US exhibited high specificities (96% and 91%, respectively) in detecting bone erosions in RA MCP joints, even in the radiographically non-erosive joints (96% and 92%). The moderate sensitivities indicate that even more erosions than are seen on MRI and, particularly, US are present. Radiography exhibited high specificity (100%) but low sensitivity (19%). The present study strongly indicates that bone erosions, detected with MRI and US in RA patients, represent a loss of calcified tissue with cortical destruction, and therefore can be considered true bone erosions.

Sonography of the knee: intra-articular pathology.

MRI is the gold-standard imaging technique for evaluation of the intra-articular structures of the knee, and the use of sonography remains controversial. Sonography nevertheless is a useful alternative in several conditions: Inflammatory joint diseases, where it is appropriate for early diagnosis and follow-up of joint effusion and synovitis; peri-articular masses, where it is the best modality for guidance of needle puncture or biopsy; suspected meniscus or ligament lesion, where it may provide a positive diagnosis but is not sufficient to exclude intra-articular lesions; and loose bodies, where it is an outstanding modality for diagnosing lesions not evident on radiographs.

Ultrasonography of the metatarsophalangeal joints in rheumatoid arthritis: comparison with magnetic resonance imaging, conventional radiography, and clinical examination.

OBJECTIVE: To compare ultrasonography (US) with magnetic resonance imaging (MRI), conventional radiography, and clinical examination in the evaluation of bone destruction and signs of inflammation in the metatarsophalangeal (MTP) joints of patients with rheumatoid arthritis (RA). METHODS: Two hundred MTP joints of 40 patients with RA and 100 MTP joints of 20 healthy control subjects were assessed with B-mode US, contrast-enhanced MRI, conventional radiography, and clinical examination for signs of bone destruction and joint inflammation. RESULTS: With MRI considered the reference method, the sensitivity, specificity, and accuracy of US for the detection of bone erosions were 0.79, 0.97, and 0.96, respectively, while the corresponding values for radiography were 0.32, 0.98, and 0.93. The sensitivity, specificity, and accuracy of US for the detection of synovitis were 0.87, 0.74, and 0.79, while for clinical examination, the corresponding values were 0.43, 0.89, and 0.71. Erosive disease was identified in 26 patients by US, compared with 20 patients by MRI and 11 patients by radiography. Evaluation by US indicated signs of inflammation in 36 patients, while MRI and clinical examination revealed signs of inflammation in 31 patients and 20 patients, respectively. US and MRI volume-based gradings of synovitis showed intraclass correlation coefficients of 0.56-0.72 (P < 0.0001). The MRI and radiographic visualizations of US-detected bone changes were closely related to their size-based gradings on US. CONCLUSION: US enables detection and grading of destructive and inflammatory changes in the MTP joints of patients with RA. By comparison with MRI, US was found to be markedly more sensitive and accurate than clinical examination and conventional radiography. Considering the early and frequent involvement of the MTP joints, evaluation of these joints by US may be of major clinical importance in RA.

Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis.

OBJECTIVE: To evaluate the interobserver agreement of ultrasonographic assessment of finger and toe joints in patients with rheumatoid arthritis (RA) by 2 investigators with different medical backgrounds. METHODS: Ultrasonography and clinical examination were performed on 150 small joints of 30 patients with active RA. A General Electric LOGIQ 500 ultrasound unit with a 7-13-MHz linear array transducer was used. In each patient, 5 preselected small joints (second and third metacarpophalangeal, second proximal interphalangeal, first and second metatarsophalangeal) were examined independently on the same day by 2 ultrasound investigators (an experienced musculoskeletal radiologist and a rheumatologist with limited ultrasound training). Joint effusion, synovial thickening, bone erosions, and power Doppler signal were evaluated in accordance with an introduced 4-grade semiquantitative scoring system, on which the investigators had reached consensus prior to the study. RESULTS: Exact agreement between the 2 observers was seen in 91% of the examinations with regard to bone erosions, in 86% with regard to synovitis, in 79% with regard to joint effusions, and in 87% with regard to power Doppler signal assessments. Corresponding intraclass correlation coefficient values were 0.78, 0.81, 0.61, and 0.72, respectively, while unweighted kappa values were 0.68, 0.63, 0.48, and 0.55, respectively. Ultrasonography showed signs of inflammation in 94 joints, while clinical assessment revealed tenderness and/or swelling in 64 joints. CONCLUSION: An experienced radiologist and a rheumatologist with limited ultrasound training achieved high interobserver agreement rates for the identification of synovitis and bone erosions, using an introduced semiquantitative scoring system for ultrasonography of finger and toe joints in RA. Signs of inflammation were more frequently detected with ultrasound than with clinical examination. Ultrasonography may improve the assessment of RA patients by radiologists and rheumatologists.

Contrast-enhanced power Doppler ultrasonography of the metacarpophalangeal joints in rheumatoid arthritis.

The aim of this study was to examine, with dynamic contrast-enhanced MRI as the reference, if contrast-enhanced power Doppler ultrasonography (CE PDUS) of rheumatoid arthritis (RA) metacarpophalangeal (MCP) joints provides additional information for evaluation of synovial inflammation compared with PDUS. One MCP joint in each of 15 RA patients and 3 healthy control persons were examined with PDUS before and after intravenous bolus Levovist contrast injection. Corresponding rates of early synovial enhancement (RESE), previously shown to be closely related to histopathological synovitis, were calculated from dynamic contrast-enhanced MR images obtained the same day. Prior to ultrasonography, the joint was evaluated clinically. Levovist increased the flow signal in 7 of 9 joints with pre-contrast flow-signal and in 0 of 9 without pre-contrast signal. No healthy controls showed CE PDUS signal. The results of CE PDUS and dynamic MRI were closely related: RESE in joints with CE PDUS signal was significantly higher than in joints without CE PDUS signal (Mann-Whitney test, p<0.001). Among the patients with pre-contrast PDUS signal no statistically significant difference in RESE values was found between joints with and without post-contrast flow-signal increase. No correlation was found between clinical examination and CE PDUS. Based on comparisons with dynamic contrast-enhanced MRI, PDUS appears to be reliable for assessment of synovitis in RA MCP joints. Intravenous contrast injection may provide additional information in selected cases but did not in the present study increase the sensitivity of the method.