Characterization of digital annular pulleys and their entheses: an ultrasonographic study with anatomical and histological correlations.

OBJECTIVES: Digital annular pulleys (DAP) are important anatomical structures for finger function. The anatomy, histology, and imaging assessment of DAP, particularly at the level of their entheses is still not clearly defined. The advent of high-frequency ultrasound (US) transducers opened new perspectives in evaluating sub-millimeter scale structures, such as pulleys, paving the way for their global assessment. The study aimed at characterizing DAP from an anatomical, histological, and US perspective, focusing on the detection and complete description of pulley entheses. METHODS: US assessment and gross anatomy dissection were conducted on 20 cadaveric hands to study DAP thickness and structure including enthesis identification. The results of the US and anatomical measurements were correlated. DAP entheses identified by US were characterized via histological analysis. DAP in 20 healthy controls (HC) were detected and measured by US. The A1, A2, and A4 DAP entheses were assessed using a new dynamic maneuver to better evaluate those structures. RESULTS: 1200 DAP (400 cadaveric, 800 HC) were analyzed. The cadaveric study demonstrated strong correlation between anatomical and US measurement of DAP (r = 0.96). At histological level, DAP entheses at the volar plate, sesamoid bones, or phalangeal ridges contained fibrous and fibrocartilaginous tissue. The US assessment of A1, A2, and A4 DAP in HC allowed the identification of 718/720 (99.73%) entheses. CONCLUSION: US is an effective tool to detect and study DAP. DAP entheses reveal both fibrous and fibrocartilaginous characteristics. A newly described maneuver to optimize DAP enthesis visualization enhances their detection by US.

Ultrasound evaluation of interstitial lung disease in rheumatoid arthritis and autoimmune diseases.

The interpretation of lung ultrasound (US) is the result of the analysis of artifacts, rather than exact representations of anatomical structures, which appear when changes in the physical properties of the lung occur. Its application to the study of interstitial lung disease (ILD) associated with autoimmune diseases has aroused great interest in the last 10 years, as evidenced by a growing number of publications studying its usefulness in the diagnostic process, as a prognostic marker, and as an aid in monitoring of patients. The main elements in lung US interpretation in ILD are the B lines and the changes in the pleural line. B lines are vertical artifacts that are generated when there is a partial decrease in the air content of the lung parenchyma and/or the volume of the interstitial area expands. Pleural line alterations that can be seen are irregularities, thickening, fragmentation, or subpleural nodules. Both the B lines and the changes in the pleural line have shown a significant positive correlation with the evidence on chest computed tomography (high-resolution computed tomography [HRCT]) of ILD associated with autoimmune diseases, with sensitivity and negative predictive values of up to 100%. These results, together with the safety, accessibility, and low cost of lung US, support this imaging technique as a promising screening method for optimizing the indication for HRCT. The role of lung US regarding sensitivity to change needs further investigation with multicenter prospective studies.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies.

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Use of ultrasound to diagnose and monitor interstitial lung disease in rheumatic diseases.

Interstitial lung disease (ILD) is one of the most relevant extra-articular manifestations of rheumatic diseases resulting in a substantial increase in morbidity and mortality. Early diagnosis and close monitoring to identify patients at high risk of progression are crucial to establish the need for targeted treatment with immunomodulatory and antifibrotic drugs, with potential ability to change the course of the disease. However, there are unmet needs in this field as pulmonary auscultation, chest radiography, or pulmonary function studies do not allow identification of the most incipient stages of the disease. High-resolution computed tomography (HRCT), which is the current gold standard for diagnosis and evolutionary control, is problematic owing to ionizing radiation, cost, and accessibility. In this context, lung ultrasound (LUS) is an attractive tool in a growing research and validation process. The identification of vertical artifacts, such as B lines, and alterations of the pleural line present a good correlation with the presence of ILD by HRCT and have a good concordance with the extent and severity of the disease, with sensitivity and negative predictive values of up to 100%. Regarding the monitoring of the evolution, the validation process of LUS is in a more preliminary phase but data is encouraging. All this, together with its safety, accessibility, low cost, and good patient acceptance, postulate LUS as a useful tool for the screening of ILD and for the optimization of the indications of HRCT. Key Points • The good sensitivity and negative predictive values of LUS postulate this technique as a useful tool for the screening of ILD and for the optimization of the indications of HRCT in rheumatic diseases.

Diagnostic potential of ultrasound in carpal tunnel syndrome with different etiologies: correlation of sonographic median nerve measures with electrodiagnostic severity.

BACKGROUND: Carpal tunnel syndrome (CTS) is the commonest entrapment neuropathy. The aim of this study was to assess the accuracy and validity of high resolution musculoskeletal ultrasound (US) in the diagnosis of CTS in the Saudi population. METHODS: Sixty patients were diagnosed clinically to have CTS involving 89 wrists that were confirmed by neurophysiologic studies. Each affected wrist was characterized as idiopathic or associated with either diabetes mellitus or hypothyroidism and were assigned a severity grade based on results of neurophysiologic studies. Seventy-six healthy wrists from fifty age, sex and BMI matched healthy subjects were included in the control group. High resolution ultrasound (US) was performed to assess median nerve cross sectional area distal (CSAd) at the entry to the carpal tunnel and proximally (CSAp) at the level of pronator quadratus muscle with a further calculation of their difference (ΔCSA) and their mean average or CSAd+CSAp/2 (CSApd). RESULTS: There was a significant difference between both groups regarding mean ± SD of CSAd, CSAp, ∆CSA, and CSApd (p = 0.0001). A positive significant correlation was also found between the CSAd, ∆ CSA and the CSApd measurements with neurophysiologic severity grade of CTS (P = 0.001). A ∆CSA threshold of 2.5 mm2 showed the highest sensitivity and specificity to diagnose CTS in Saudis. CONCLUSION: High resolution ultrasound is a valid and accurate diagnostic modality in carpal tunnel syndrome and correlated to CTS severity. A ∆CSA greater than 2.5 mm2 is considered a valid diagnostic value for CTS in our Saudi population. CTS in our patients with diabetes tend to have greater median nerve US measurement values.

Development of semiquantitative ultrasound scoring system to assess cartilage in rheumatoid arthritis.

OBJECTIVES: To develop and test the reliability of a new semiquantitative scoring system for the assessment of cartilage changes by ultrasound in a web-based exercise as well as a patient exercise of patients with RA. METHODS: A taskforce of the Outcome Measures in Rheumatology Ultrasound Working Group performed a systematic literature review on the US assessment of cartilage in RA, followed by a Delphi survey on cartilage changes and a new semiquantitative US scoring system, and finally a web-based exercise as well as a patient exercise. For the web-based exercise, taskforce members scored a dataset of anonymized static images of MCP joints in RA patients and healthy controls, which also contained duplicate images. Subsequently, 12 taskforce members used the same US to score cartilage in MCP and proximal interphalangeal joints of six patients with RA in in a patient reliability exercise. Percentage agreement and prevalence of lesions were calculated, as intrareader reliability was assessed by weighted kappa and interreader reliability by Light's kappa. RESULTS: The three-grade semiquantitative scoring system demonstrated excellent intrareader reliability (kappa: 0.87 and 0.83) in the web-based exercise and the patient exercise, respectively. Interreader reliability was good in the web-based exercise (kappa: 0.64) and moderate (kappa: 0.48) in the patient exercise. CONCLUSION: Our study demonstrates that ultrasound is a reliable tool for evaluating cartilage changes in the MCP joints of patients with RA and supports further development of a new reliable semiquantitative ultrasound scoring system for evaluating cartilage involvement in RA.

The peripheral nerves: update on ultrasound and magnetic resonance imaging.

The motor and sensory branches of the somatic peripheral nervous system (PNS) can be visualised by different imaging systems. This article focuses on imaging of peripheral nerves by magnetic resonance imaging (MRI) and high-resolution ultrasound (US). The anatomic basis of the peripheral nerve image, common pathologies and clinical value of US and MRI imaging of peripheral nerves are reviewed.

Sonographic and Anatomic Description of the Subtalar Joint.

Our study provides a detailed anatomic and sonographic description of the subtalar joint, a single joint that, anatomically, is divided into the anterior subtalar joint (ASTJ) and the posterior subtalar joint (PSTJ). Cadaver specimens of the ankle and foot were examined in detail by ultrasound (US), and the subtalar joints of all the specimens were injected with colored latex of a contrasting color under US guidance. Compatible with other studies, examination of the sections revealed lack of communication between the ASTJ and the PSTJ and communication between the PSTJ and the posterior recess of the tibiotalar joint. A recommended list of standardized ultrasound scans was developed using a Delphi consensus process, which allows sonographers to evaluate both the ASTJ and PSTJ from the medial, lateral and posterior aspects. The recommended ultrasound scans were found to be applicable based on a test of agreement between images acquired in cadaver specimens and images acquired in four centers using healthy patients.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology.

BACKGROUND: In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines. OBJECTIVES: To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology. METHODS: The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures). RESULTS: Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts. CONCLUSIONS: This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

The Rotator Interval - A Link Between Anatomy and Ultrasound.

Shoulder pathologies of the rotator cuff of the shoulder are common in clinical practice. The focus of this pictorial essay is to discuss the anatomical details of the rotator interval of the shoulder, correlate the anatomy with normal ultrasound images and present selected pathologies. We focus on the imaging of the rotator interval that is actually the anterosuperior aspect of the glenohumeral joint capsule that is reinforced externally by the coracohumeral ligament, internally by the superior glenohumeral ligament and capsular fibers which blend together and insert medially and laterally to the bicipital groove. In this article we demonstrate the capability of high-resolution musculoskeletal ultrasound to visualize the detailed anatomy of the rotator interval. MSUS has a higher spatial resolution than other imaging techniques and the ability to examine these structures dynamically and to utilize the probe for precise anatomic localization of the patient's pain by sono-palpation.

Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome is characterized by exertional pain and elevated intracompartmental pressures affecting the leg in physically active young people. In patients who have failed conservative measures, fasciotomy is the treatment of choice. This study presents a new method for performing fasciotomy using high-resolution ultrasound (US) guidance and reports on the clinical outcomes in a group of these patients. Over a 3-year period, 7 consecutive patients with a total of 9 involved legs presented clinically with anterior compartment chronic exertional compartment syndrome, which was confirmed by intracompartmental pressure measurements before and after exercise. After a US examination, fasciotomy under US guidance was performed. Preoperative and postoperative pain and activity levels were assessed as well as number of days needed to "return to play." All patients had a decrease in pain, and all except 1 returned to presymptomatic exercise levels with a median return to play of 35 days.

Ultrasound-Guided Fasciotomy for Anterior Chronic Exertional Compartment Syndrome of the Leg.

Chronic exertional compartment syndrome is characterized by exertional pain and elevated intracompartmental pressures affecting the leg in physically active young people. In patients who have failed conservative measures, fasciotomy is the treatment of choice. This study presents a new method for performing fasciotomy using high-resolution ultrasound (US) guidance and reports on the clinical outcomes in a group of these patients. Over a 3-year period, 7 consecutive patients with a total of 9 involved legs presented clinically with anterior compartment chronic exertional compartment syndrome, which was confirmed by intracompartmental pressure measurements before and after exercise. After a US examination, fasciotomy under US guidance was performed. Preoperative and postoperative pain and activity levels were assessed as well as number of days needed to "return to play." All patients had a decrease in pain, and all except 1 returned to presymptomatic exercise levels with a median return to play of 35 days.

How does a cadaver model work for testing ultrasound diagnostic capability for rheumatic-like tendon damage?

To establish whether a cadaver model can serve as an effective surrogate for the detection of tendon damage characteristic of rheumatoid arthritis (RA). In addition, we evaluated intraobserver and interobserver agreement in the grading of RA-like tendon tears shown by US, as well as the concordance between the US findings and the surgically induced lesions in the cadaver model. RA-like tendon damage was surgically induced in the tibialis anterior tendon (TAT) and tibialis posterior tendon (TPT) of ten ankle/foot fresh-frozen cadaveric specimens. Of the 20 tendons examined, six were randomly assigned a surgically induced partial tear; six a complete tear; and eight left undamaged. Three rheumatologists, experts in musculoskeletal US, assessed from 1 to 5 the quality of US imaging of the cadaveric models on a Likert scale. Tendons were then categorized as having either no damage, (0); partial tear, (1); or complete tear (2). All 20 tendons were blindly and independently evaluated twice, over two rounds, by each of the three observers. Overall, technical performance was satisfactory for all items in the two rounds (all values over 2.9 in a Likert scale 1-5). Intraobserver and interobserver agreement for US grading of tendon damage was good (mean κ values 0.62 and 0.71, respectively), with greater reliability found in the TAT than the TPT. Concordance between US findings and experimental tendon lesions was acceptable (70-100 %), again greater for the TAT than for the TPT. A cadaver model with surgically created tendon damage can be useful in evaluating US metric properties of RA tendon lesions.

Sonographic evaluation of the distal iliopsoas tendon using a new approach.

Sonography of the iliopsoas tendon plays an important role in the diagnosis and preoperative and postoperative management for the increasing number of patients under consideration for arthroscopically guided hip interventions such as iliopsoas tenotomy in a variety of conditions, including arthropathy, periarticular calcifications, and cam-type deformities of the femoral head. The ability to visualize the iliopsoas tendon pre-operatively can be helpful diagnostically in patients presenting with hip pain and can aid in planning surgery, while evaluating the tendon postoperatively is important in the assessment of causes of postoperative pain and other potential complications. We present a novel technique for visualizing the distal iliopsoas tendon complex in the longitudinal axis at its insertion on the lesser trochanter on sonography.

Soleus muscle injury: sensitivity of ultrasound patterns.

OBJECTIVE: To assess the sensitivity of ultrasound in detecting soleus muscle lesions diagnosed on magnetic resonance imaging (MRI) and to characterize their location, ultrasound pattern, and evolution. MATERIALS AND METHODS: Ultrasound and MRI studies were performed between May 2009 and February 2013 on all patients who presented to the Medical Services Clinic of the Catalan Sport Council with the initial onset of sharp pain in the calf compatible with injury of the soleus muscle. An inter-observer ultrasound reliability study was also performed. RESULTS: A total of 55 cases of soleus injury were studied prospectively (22 with right leg involvement, 33 left) by ultrasound and MRI, which was utilized as the "gold standard." In MRI studies, 24 cases (43.7%) had myofascial injuries that were localized in the posterior aponeurosis (PMF) in 15 cases (27.3%) and in the anterior aponeurosis (AMF) in 9 (16.4%). Thirty-one cases (56.3%) were musculotendinous injuries, with 9 cases (16.4%) in the medial aponeurosis (MMT), 11 cases (20%) in the lateral aponeurosis (LMT), and 11 cases (20%) in the central tendon (CMT). In comparison to MRI, ultrasound was able to detect injury to the soleus in 27.2% of cases. No injuries were detected by ultrasound alone. Posterior myofascial injuries were more likely to be detected by ultrasound than anterior myofascial injuries or all types of musculotendinous injuries. Ultrasound patterns for each type of injury were described. CONCLUSION: Ultrasound is not a sensitive technique for detecting and assessing soleus traumatic tears compared with MRI, although the sensitivity is enhanced by a thorough anatomically based ultrasound examination. Timing of the ultrasound examination may be of importance. Each type of soleus injury appears to have a characteristic ultrasound pattern based on a defect of connective expansions, the existence of small myofascial filiform collections, and the rarefaction of the fibrillar area.