Changes in clavicle length in acute fractures within 3 weeks: a prospective ultrasonographic study of 59 patients.

BACKGROUND: Within traumatology a common indication for acute surgery of fractured clavicles is bone shortening over 2 cm. This indication is among but a few indications; which are recommended to be treated operatively within the very first weeks after a fracture. Theoretically clavicle fractures could become less shortened over time due to decreasing muscle pull. If this reduced shortening does indeed happen, some patients with initial bone shortening over 2 cm could perhaps be treated conservatively? However, it is unknown what happens to the length of the clavicle within the first weeks after a fracture. The aim of this study was to investigate if the length of the fresh fractured clavicles changes within the first three weeks. METHODS: Rested length measurements using navigation ultrasound were done on 59 patients with a fractured clavicle. Measurements were performed within the first three weeks after a lateral or mid-clavicular fracture. The inclusion period was from March 2014 to February 2016. Median age was 40 years and age range was 18-81 years. The data was analyzed using mixed linear models. RESULTS: The clavicle length showed no change within the first three weeks after fracture (p = 0.24). CONCLUSION: Fractured clavicles retain their length for the first three weeks.

Settings and artefacts relevant for Doppler ultrasound in large vessel vasculitis.

Ultrasound is used increasingly for diagnosing large vessel vasculitis (LVV). The application of Doppler in LVV is very different from in arthritic conditions. This paper aims to explain the most important Doppler parameters, including spectral Doppler, and how the settings differ from those used in arthritic conditions and provide recommendations for optimal adjustments. This is addressed through relevant Doppler physics, focusing, for example, on the Doppler shift equation and how angle correction ensures correctly displayed blood velocity. Recommendations for optimal settings are given, focusing especially on pulse repetition frequency (PRF), gain and Doppler frequency and how they impact on detection of flow. Doppler artefacts are inherent and may be affected by the adjustment of settings. The most important artefacts to be aware of, and to be able to eliminate or minimize, are random noise and blooming, aliasing and motion artefacts. Random noise and blooming artefacts can be eliminated by lowering the Doppler gain. Aliasing and motion artefacts occur when the PRF is set too low, and correct adjustment of the PRF is crucial. Some artefacts, like mirror and reverberation artefacts, cannot be eliminated and should therefore be recognised when they occur. The commonly encountered artefacts, their importance for image interpretation and how to adjust Doppler setting in order to eliminate or minimize them are explained thoroughly with imaging examples in this review.

An ultrasound score for knee osteoarthritis: a cross-sectional validation study.

OBJECTIVE: To develop standardized musculoskeletal ultrasound (MUS) procedures and scoring for detecting knee osteoarthritis (OA) and test the MUS score's ability to discern various degrees of knee OA, in comparison with plain radiography and the 'Knee injury and Osteoarthritis Outcome Score' (KOOS) domains as comparators. METHOD: A cross-sectional study of MUS examinations in 45 patients with knee OA. Validity, reliability, and reproducibility were evaluated. RESULTS: MUS examination for knee OA consists of five separate domains assessing (1) predominantly morphological changes in the medial compartment, (2) predominantly inflammation in the medial compartment, (3) predominantly morphological changes in the lateral compartment, (4) predominantly inflammation in the lateral compartment, and (5) effusion. MUS scores displayed substantial reliability and reproducibility, with interclass correlations coefficients ranging from 0.75 to 0.97 for the five domains. Construct validity was confirmed with statistically significant correlation coefficients (0.47-0.81, P < 0.01). CONCLUSION: The MUS score suggested in this study was reliable and valid in detecting knee OA. In comparison with standing radiographs of the knees, the score detected all aspects of knee OA with relevant precision.

Validity and reliability of 3D US for the detection of erosions in patients with rheumatoid arthritis using MRI as the gold standard.

PURPOSE: To test the reliability and validity of a 3D US erosion score in RA using MRI as the gold standard. MATERIALS AND METHODS: RA patients were examined with 3D US and 3 T MRI over the 2nd and 3rd metacarpophalangeal joints. 3D blocks were evaluated by two investigators. The erosions were estimated according to a semi-quantitative score (SQS) (0 - 3) and a quantitative score (QS) (mm²). MRI was evaluated according to the RAMRIS score. For the estimation of reliability, intra-class correlation coefficients (ICC) were used. Validity was tested using Spearman's rho (rs). The sensitivity and specificity were also calculated. RESULTS: 28 patients with RA were included. The ICC for the inter-observer reliability in the QS was 0.41 and 0.13 for the metacarpal bone and phalangeal bone, respectively, and 0.86 and 0.16, respectively, in the SQS.  The ICC for the intra-observer reliability in the QS was 0.75 and 0.48 for the metacarpal bone and phalangeal bone, respectively, and 0.83 and 0.60, respectively, in the SQS.  The correlation with MRI for the metacarpal bone was significant, with values of 0.73 (p = 0.0001) (SQ) and 0.74 (p = 0.0001) (SQS). For the phalangeal bone, bad correlation was found: 0.28 (p = 0.145) (SQ) and 0.26 (p = 0.57) (SQS). The sensitivity and specificity for the metacarpal bone were 86 % and 85 % respectively. For the phalangeal bone they were 60 % and 97 %, respectively. CONCLUSION: Good inter- and intra-observer reliability and correlation with MRI were seen in the assessment of erosions with 3D US in the metacarpal bone, while the results were low and insignificant for the phalangeal bone, indicating that 3D US still has room for improvement.

EFSUMB minimum training requirements for rheumatologists performing musculoskeletal ultrasound.

In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.

Ultrasound Doppler score correlates with OMERACT RAMRIS bone marrow oedema and synovitis score in the wrist joint of patients with rheumatoid arthritis.

PURPOSE: MRI is considered the standard of reference for advanced imaging in rheumatoid arthritis (RA). However, in daily clinical practice ultrasound (US) imaging with Doppler information is more versatile and often used for fast and dynamic assessment of joint inflammation. The aim was to compare low-field MRI scores with the US Doppler measurements in the wrist joint of patients with RA. MATERIAL AND METHODS: Fifty consecutive patients with RA (46 women & 4 men) completed both low-field dedicated extremity MRI (E-scan®, Esaote) and a high-end US (Sequioa®, Siemens) imaging of the wrist before initiating either biological treatment (n = 26) or intraarticular injection of Depomedrole® (n = 24). Mean age was 56 years (range 21 - 83 years); mean disease duration 87.2 months (range 4 - 349 months), mean DAS 28 4,8 (range 2 - 7). MRI was scored according to the OMERACT RAMRIS recommendations and US Doppler colour-fractions were determined. RESULTS: Using Spearman's rho, we found a relatively good to moderate correlation between the US colour-fraction and the total OMERACT bone marrow oedema and synovitis scores on MRI (r = 0.6; p < 0.001 and r = 0.4; p < 0.006 respectively). There was a trend but no significant correlation with the total OMERACT erosion score (r = 0.3; p = 0.06). CONCLUSION: Within limits, the OMERACT RAMRIS scores of inflammation in RA patients (bone marrow oedema and synovial enhancement) are comparable to the US colour-fraction measurements using a high-end US scanner. Both imaging modalities detect inflammation although showing different aspects of the inflammatory process in the wrist joint. The higher correlation between US colour-fractions and MRI bone marrow oedema indicates a potential importance of US Doppler in monitoring inflammatory disease changes in RA.

Characterization by biopsy or CEUS of liver lesions guided by image fusion between ultrasonography and CT, PET/CT or MRI.

PURPOSE: The aim of this study was to show the number of cases in which the use of fusion-guided ultrasonography (US) provided conclusive diagnosis of lesions in the liver seen on CT or MRI or PET/CT. A lesion is defined as a region that has suffered damage due to injury or disease. MATERIALS AND METHODS: Forty patients of whom 34 had confirmed neoplastic disease, referred to US evaluation or US-guided biopsy of liver lesions seen on CT (n = 35), MRI (n = 2) or PET/CT (n = 3), were prospectively included in the study. We used a LOGIQ prototype system with incorporated software for fusion imaging, and a convex-array 4 MHz transducer (GE Healthcare, Chalfont St. Giles, UK). All patients were initially examined with B-mode US, then by fusion-guided US and for some patients also with CEUS. All patients received follow-up after at least one year. RESULTS: Twenty-six lesions were initially indistinguishable with US. Of these, 9 became visible with fusion-guided US and another 4 became visible with CEUS, which facilitated a final diagnosis in 11 of these 13 patients. The median tumor size for all lesions included in the study was 1.5 cm (interquartile range: 1.0 - 2.4). There was no statistically significant difference in tumor size between the groups. CONCLUSION: We have successfully demonstrated an increase in the characterization of liver lesions by using fusion-guided US compared with conventional B-mode US.

Articular cartilage thickness measured with US is not as easy as it appears: a systematic review of measurement techniques and image interpretation.

BACKGROUND: Theoretically, the high spatial resolution of US makes it well suited to monitor the decrease in articular cartilage thickness in osteoarthritis. A requirement is, however, that the borders of the cartilage are correctly identified and that the cartilage is measured under orthogonal insonation. If US measurements are compared to measurements with other techniques, they should be corrected for the higher sound speed in cartilage. PURPOSE: To study whether investigators correctly identify the articular cartilage, whether they insonate orthogonally, and whether they correct for sound speed. MATERIALS AND METHODS: A literature search limited to the last 10 years of studies applying US to measure cartilage thickness. RESULTS: 15 studies were identified and they referred to another 8 studies describing methods of thickness measurement. 11 of the 15 studies identified the superficial cartilage border incorrectly, and 6 applied oblique insonation. 2 of the 15 studies corrected for sound speed. Of the further 8 studies, one might correctly identify the superficial cartilage border, 4 applied oblique insonation, and none corrected for sound speed. CONCLUSION: We found that the majority of studies over the last 10 years, evaluating articular cartilage thickness with US, underestimated the cartilage thickness by not including the leading interface as part of the cartilage. Since the cartilage is relatively thin, this error is substantial. Some investigators also overestimated cartilage thickness by using oblique insonation of the cartilage. By not correcting for the high sound speed in cartilage, most investigators underestimated the cartilage thickness.

Comparison of two co-registration methods for real-time ultrasonography fused with MRI: a phantom study.

PURPOSE: To test the accuracy of spatial registration of real-time ultrasonography (US) fused with MRI in a phantom. MATERIALS AND METHODS: An US prototype system (LOGIQ, GE Healthcare) with incorporated software for fusion imaging was used to test two methods of co-registration in a phantom: co-registration from specific points, where common reference points identifiable on both MRI and US images were marked, and plane registration, where common planes identifiable on both MRI and US images were marked. In two series we performed co-registration from points and in one series we performed co-registration from planes. The accuracy of the co-registration was measured at 3 measuring points, defined before initiation of the study, and it was calculated as the root mean square deviation (RMSD), which corresponds to the standard deviation. It was measured in millimeters. Two observers each performed 30 co-registrations for each series, totaling 180 co-registrations. The difference between the methods and the observers was calculated using analysis of variance (two-way ANOVA). RESULTS: Co-registration was significantly more accurate when using the measuring points as co-registration points than when using points covering a different area of the phantom (p < 0.0001). The mean calculated RMSD when using the measuring points as co-registration points was 1.3 mm (95 % CI: 1.1 - 1.5 mm), when using points away from the measuring points: 4.0 mm (95 % CI: 3.2 - 4.8 mm), and when using planes for the co-registration: 3.8 mm (95 % CI: 3.2 - 4.4 mm). CONCLUSION: Image fusion involving real-time US has high accuracy and is easy to use in a phantom. Working within the area given by the co-registration points optimizes the accuracy. Image fusion is a promising tool for clinical US, since it provides the potential of benefiting from different imaging modalities in one examination.

Musculoskeletal colour/power Doppler in sports medicine: image parameters, artefacts, image interpretation and therapy.

This review article discusses the aspects of sports medicine where musculoskeletal Doppler ultrasound has valuable contribution in diagnosis and/or treatment of some of the typical musculoskeletal sports injuries. Also, conditions where the Doppler ultrasound has no value are discussed. Some guidelines and recommendations are based on personal experience since no evidence in literature exists. The basic technical background of Doppler ultrasound and typical artefacts will be discussed, in order to understand and interpret the Doppler result. Recommendations for the Doppler settings are given in relevant sections. Ultrasound guided treatments where the Doppler result is used as a guide are mentioned and discussed.

Doppler ultrasonography of the anterior knee tendons in elite badminton players: colour fraction before and after match.

BACKGROUND: Anterior knee tendon problems are seldom reported in badminton players although the game is obviously stressful to the lower extremities. HYPOTHESES: Painful anterior knee tendons are common among elite badminton players. The anterior knee tendons exhibit colour Doppler activity. This activity increases after a match. Painful tendons have more Doppler activity than tendons without pain. STUDY DESIGN: Cohort study. METHODS: 72 elite badminton players were interviewed about training, pain and injuries. The participants were scanned with high-end ultrasound equipment. Colour Doppler was used to examine the tendons of 64 players before a match and 46 players after a match. Intratendinous colour Doppler flow was measured as colour fraction (CF). The tendon complex was divided into three loci: the quadriceps tendon, the proximal patellar tendon and the insertion on the tibial tuberosity. RESULTS: Interview: Of the 72 players, 62 players had problems with 86 tendons in the lower extremity. Of these 86 tendons, 48 were the anterior knee tendons. Ultrasound: At baseline, the majority of players (87%) had colour Doppler flow in at least one scanning position. After a match, the percentage of the knee complexes involved did not change. CF increased significantly in the dominant leg at the tibial tuberosity; single players had a significantly higher CF after a match at the tibial tuberosity and in the patellar tendon both before and after a match. Painful tendons had the highest colour Doppler activity. CONCLUSIONS: Most elite badminton players had pain in the anterior knee tendons and intratendinous Doppler activity both before and after match. High levels of Doppler activity were associated with self-reported ongoing pain.

Ultrasound colour Doppler measurements in a single joint as measure of disease activity in patients with rheumatoid arthritis--assessment of concurrent validity.

OBJECTIVE: Colour Doppler ultrasound (CDU) displays blood flow in the tissues and is able to detect hyperaemia. Because hyperaemia is part of the inflammatory response, the amount of CDU activity in the inflamed synovium may be used to quantify the inflammatory activity in RA. It has never been investigated if the amount of CDU activity in a single joint can be used to quantify disease activity in RA. METHODS: A total of 109 patients with RA and affection of the wrist joint underwent a standardized CDU examination assessing three positions in their most affected wrist at start up in biological treatment. On the same day the following measures of disease activity were collected: assessment of the number of tender and swollen joints, CRP, ESR and 28-joint disease activity score (DAS28). The amount of CDU activity was quantified by measuring the percentage of colour in the synovium--the colour fraction (CF). Correlation between CF and other measures of disease activity was calculated. RESULTS: There was a significant correlation between CF and DAS28 (r = 0.29; P < 0.001), swollen joint count (r = 0.35; P < 0.001), CRP (r = 0.5; P < 0.001) and ESR (r = 0.5; P < 0.001). No other significant correlations were found. CONCLUSION: A standardized ultrasound examination of a single affected wrist joint in patients with RA may be used as a measure of disease activity. More studies are needed to identify the number of joints needed to examine by CDU to obtain the best validity of Doppler measurements.

Quantification of colour Doppler activity in the wrist in patients with rheumatoid arthritis--the reliability of different methods for image selection and evaluation.

PURPOSE: The amount of colour Doppler activity in the inflamed synovium is used to quantify inflammatory activity. The measurements may vary due to image selection, quantification method, and point in cardiac cycle. This study investigated the test-retest reliability of ultrasound colour Doppler measurements in the wrist of patients with rheumatoid arthritis (RA) using different selection and quantification methods. MATERIALS AND METHODS: 14 patients with RA had their wrist scanned twice by the same investigator with an interval of 30 minutes. The images for analysis were selected either by the anatomical position only or by the anatomical position with maximum colour Doppler activity. Subsequently, the amount of colour Doppler was measured in an area defined by either the synovial tissue or by specific anatomical structures surrounding the synovial tissue. RESULTS: The best test-retest reliability was obtained when the images were selected guided by colour Doppler and the subsequent quantification was done in an area defined by anatomical structures. With this method, the intra-class coefficient ICC (2.1) was 0.95 and the within-subject SD (SW) was 0.017, indicating good reliability. In contrast, poor test-retest reliability was found if the images were selected by anatomical position only and the quantification was done in an area defined by the synovial tissue (ICC [2.1] = 0.48 and SW = 0.049). CONCLUSION: The study showed that colour Doppler measurements are reliable if the images for analysis are selected by anatomical position in combination with colour Doppler activity and the subsequent analysis is performed in an area defined by anatomical structures.

Effect of glucocorticosteroid injections in tennis elbow verified on colour Doppler ultrasonography: evidence of inflammation.

OBJECTIVES: It has previously been reported that lateral epicondylitis may be diagnosed with colour Doppler ultrasonography (US) by detecting hyperaemia inside the common extensor origin (CEO).This study reports on the association between Doppler US findings and the short-term response of US-guided corticosteroid injection in patients with LE. DESIGN: Case-only, blinded intervention study. SETTING: Secondary care at a government hospital. PATIENTS: 62 patients with LE verified by colour Doppler US. INTERVENTION: One US-guided corticosteroid injection was given into the CEO. MAIN OUTCOME MEASURES: Patients were evaluated at baseline before the injection and at 2 weeks of follow-up. Outcome measures were changes in pain score and US parameters (resistive index (RI) and the amount of colour within the CEO). Prognosticators for outcome were: use of computer mouse, symptom duration, elbow strain, RI, colour fraction, Likert pain score, pain at rest, pain during activity, age, height, weight, disease in dominant versus nondominant arm. RESULTS: All but one patient experienced improvement of general elbow pain perception at follow-up at 2 weeks. In parallel, Doppler US showed significant reduction in colour fraction (mean (standard deviation) with 95% confidence limits: baseline 0.14 (0.10), at follow-up 0.02 (0.02), p<0.0001). All but five patients showed a decrease in colour fraction; 74% decreased to 0. No clinical or US parameter could distinguish responders from non-responders. CONCLUSION: Corticosteroid injection has a marked short-term effect on pain and Doppler parameters. The reduction in hyperaemia mediated by an anti-inflammatory drug can be interpreted as evidence of an inflammatory component in LE.

Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology.

The paper explains the most important parameters for the use of colour and power Doppler in rheumatology. Recommendations for machine settings are given. The commonly encountered artefacts and their importance for image interpretation are explained.

Effect of knee position on ultrasound Doppler findings in patients with patellar tendon hyperaemia (jumper's knee).

PURPOSE: The purpose of this study is to see if changes in patient positioning result in significant changes in Doppler findings. MATERIALS AND METHODS: 30 consecutive patients with jumper's knee in the proximal portion of the patellar tendon formed the study group. The patellar tendon was scanned in the longitudinal plane with colour and spectral Doppler with the knee fully extended as well as, flexed at 15 degrees and 20 degrees . All subjects were randomised to either extension or 20 degrees flexion as the initial position. The amount of colour Doppler activity inside the tendon was expressed with the colour fraction (colour pixels/total pixels) in the proximal portion of the tendon. With spectral Doppler, the resistive index was measured ((peak systolic velocity--end-diastolic velocity)/ peak systolic velocity). RESULTS: The mean (+/- SE) colour fraction in the fully extended position and 20 degrees flexion was 36.7 +/- 3.4% and 13.3 +/- 3.4%, respectively (p<0.0001). The mean resistive index was 0.607 +/- 0.036 with full extension and 0.914 +/- 0.036 with 20 degrees flexion (p<0.0001). On an individual patient basis, a decrease in colour fraction was observed in all 30 patients (100%), whereas an increase in resistive index was observed in 29 patients (97%). Maximum perfusion was seen in all positions when flexion was the initial position. CONCLUSION: We advocate that for the examination of the patellar tendon by Doppler sonography, the patients should have fully extended and relaxed knees. Otherwise, the colour Doppler findings will underestimate the flow, and the spectral Doppler will overestimate peripheral vascular resistance.

Ultrasound in finger joints: findings in normal subjects and pitfalls in the diagnosis of synovial disease.

PURPOSE: Grey-scale ultrasound may be used to visualise the amount of synovial tissue in patients with rheumatoid arthritis (RA). Different scoring systems have been developed. None of the scoring systems have been tested on a larger group of healthy joints, and it is therefore unknown to what extent synovial tissue is seen on grey-scale ultrasound in healthy joints. The objective of this study was to test two scoring systems on healthy volunteers. MATERIALS AND METHODS: 24 healthy men and women between 30 and 54 years underwent scanning of the MCP, PIP and DIP joints of their dominant hand. Each person was scanned in 69 positions. The images were graded on a scale from 0 to 4 with two scoring systems (I and II). Scores 0 - 1 were defined as normal and 2 - 4 as pathological. With scoring system I, only markedly hypoechoic synovium was graded. With scoring system II, marked hypoechogenicity was not a criterion. RESULTS: With system I, 89 % of the joints obtained at least one pathological score. With system II, 95 % of the joints obtained at least one pathological score. With both systems, women obtained higher scores than men, and the number of high scores increased with increasing age. CONCLUSION: An unacceptably high number of joints obtained pathological scores with both scoring systems in healthy volunteers. This indicates that many of the scores interpreted as pathological in patients with RA may just be normal findings, with increasing numbers in older patients.

Ultrasound Doppler of the Achilles tendon before and after injection of an ultrasound contrast agent--findings in asymptomatic subjects.

UNLABELLED: The sensitivity of ultrasound Doppler has now reached a level at which perfusion can be detected even in normal, resting musculoskeletal tissues. To be able to distinguish normal from abnormal flow, the resistive index (RI) determined by spectral Doppler may be of value. Inflammation is associated with low RI values and a value of 1.00 is normal. PURPOSE: In tissues with no detectable flow, it has been assumed that RI may be defined as 1.00. This study was performed to test if normal tendinous vessels could be visualised with a contrast agent, and if such vessels had normal RI. MATERIALS AND METHODS: Ultrasound (US) was performed with a 14 MHz linear transducer. 22 asymptomatic tendons in 12 subjects were scanned, and only 5 ultrasonically normal tendons in 5 subjects were identified. In these 5 normal tendons, SonoVue was used to make vessels visible. The Achilles tendons and the peritendinous tissues were evaluated clinically. RESULTS: In all 5 ultrasonically normal tendons, arteries could be detected with Doppler after contrast injection and in all cases with normal RI values. All vessels were located in the mid-portion of the tendon. 18 tendons were categorised as normal by the clinician. CONCLUSION: After administration of a contrast agent, all Achilles tendons could be demonstrated to have arteries present in the mid-portion. The flow profile of these arteries was fully normal without diastolic component and with an RI of 1.00. This finding has implications for criteria of normality of tendons, which cannot be based exclusively on the presence or absence of Doppler activity. The majority of the tendons in this study had ultrasound abnormalities both on gray-scale and colour Doppler. It can be speculated that the abnormalities may be age-related degenerative changes and that age-stratified normal materials are needed to define normality. There was no consistency between US and clinical diagnosis.

Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise.

BACKGROUND: Intratendinous Doppler activity has been interpreted as an equivalent of neovessels in the Achilles tendon and as a sign of tendinosis (AT). AIM: To evaluate the vascular response as indicated by color Doppler activity after repeated loading of both symptomatic and non-symptomatic Achilles tendons. MATERIAL AND METHODS: Ten non-trained, healthy subjects ran 5 km. Ultrasound (US) Doppler activity was determined before and after the exercise. Eleven patients with chronic AT performed 3 x 15 heavy-load eccentric exercise. The Achilles tendons were scanned before and immediately after the exercise. RESULTS: Non-symptomatic: six Achilles tendons in five subjects had intratendinous Doppler activity before the exercise. All but two subjects (80%) had intratendinous Doppler activity after running. Symptomatic: all patients had Doppler activity in the tendons, with a median color fraction before eccentric exercise of 0.05 (range 0.01-0.33). The Doppler activity did not disappear after exercise. Tendons with a color fraction below the median at baseline increased significantly after the exercise (P=0.02). CONCLUSION: The mere presence of Doppler in the Achilles tendon does not per se indicate disease. Eccentric exercise does not extinguish the flow during or after one training session in patients with chronic AT.