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.

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.

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.

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.

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.

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 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.

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.

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.

Imaging of intratendinous distribution of glucocorticosteroid in the treatment of Achilles tendinopathy. Pilot study of low-field magnetic resonance imaging correlated with ultrasound.

OBJECTIVE: Recently, a positive treatment effect of intratendinous injections of steroid in Achilles tendonitis (AT) has been described. Our aim was to test the localization and distribution of the injected steroid in both healthy (animal) tendons and in diseased human Achilles tendons. MATERIAL AND METHODS: Four pig tendons were injected in vivo and harvested. The harvested tendons were placed in 0.2 Tesla MRI scanner, in order to select the optimal MRI sequences for tracking and localizing the bolus injection. Three patients with AT were treated with intratendinous steroid injection. Injections were placed in the pathologic areas of the tendon guided by ultrasound (US). MRI and US were performed at baseline and again immediately and 60 minutes after injection. A final follow-up MRI was performed 1 month after the injection. RESULTS: In the animal model, significant recoil of the injected substance was seen in all cases. In all three patients the injection was readily distributed within the tendon and no recoil through the injection channel was found. One-month follow-up showed a total regression of hyperaemia on US as well as regression of intratendinous oedema on MRI in all 3 patients. CONCLUSION: It is possible to demonstrate the distribution pattern of injected steroid in diseased Achilles tendons by MR-imaging. In contrast to the recoil experienced in the healthy tendon of the animal, the lack of recoil of the injected volume through the injection channel in the sick human tendon may be caused by a derangement of the fibre structure, which allows the extra volume to be distributed within the lesion. This indicates that the effect on AT of intra-tendinous injections of steroid is due to a local intra-tendinous action of the drug.

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study.

BACKGROUND: High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated. OBJECTIVE: To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy. METHODS: Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid-portion Achilles tendinosis. A unipolar coagulation device was used. RESULTS: One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were "cured" after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0-10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring. CONCLUSIONS: Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid-tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.

Tetracycline for sclerosis of thyroid cysts. A randomized study.

In a prospective study, 53 consecutive patients with solitary thyroid cysts were randomized to ultrasonically guided cyst aspiration and subsequent flushing with isotonic saline (n = 30) or tetracycline hydrochloride (n = 23). The patients were followed up clinically and ultrasonically 1, 3, 6, and 12 months after treatment. If the cyst recurred, a repeated treatment was offered. Cure was defined as the absence of any residual nodule and an ultrasonic cyst volume of less than 1 mL 12 months after the last treatment. During follow-up, two patients without recurrence after saline treatment and six patients without recurrence after tetracycline treatment developed solid cold nodules. Fourteen (47%) of 30 patients in the saline group and ten (43%) of 23 patients in the tetracycline group were cured (not statistically significant). Tetracycline does not seem to offer any advantage over isotonic saline in the treatment of thyroid cysts, and some of these patients still need thyroid surgery.

Transrectal ultrasound in the diagnosis and staging of local disease after I125 seed implantation for prostate cancer.

A study was undertaken to assess the ability of transrectal ultrasound (TR/US), digital rectal examination (DRE), and Prostate Specific Antigen (PSA), to diagnose persistent prostate cancer following an I125 seed implant (SI). Twenty-six patients formed the study group. The median follow-up time was 38 months, and the range was 20 to 60 months. Eighty-eight percent (23/26) had suspicious lesions on TR/US, followed by ultrasound-guided biopsies. Biopsies were performed only on those patients having suspicious lesions on TR/US. Histologically proven adenocarcinoma was found in 81% (21/26) of the patients. Statistical evaluation was done using tissue obtained at biopsy as the "gold standard." The sensitivities for the DRE and PSA were 33% and 76%, respectively. The specificities for DRE and PSA were 50% and 0%, respectively. The positive predictive values for cancer were 91% by TR/US, 100% by DRE, and 89% by PSA. The negative predictive values were 13% for DRE and 0% for PSA. Overall detection rates (N = 26) were 81% for TR/US, 27% for DRE, and 62% for PSA. We conclude that ultrasound criteria for the presence of cancer are the same for both the post-irradiated prostate and the untreated prostate, and that TR/US is the most sensitive test for the diagnosis of persistent local cancer following I125 seed implantation.