Emanuele Fabbro

Dynamic high-resolution ultrasound of the shoulder: How we do it

Ultrasonography (US) is an established and well-accepted modality that can be used to evaluate articular and peri-articular structures around the shoulder. US has been proven to be useful in a wide range of rotator cuff diseases (tendon tears, tendinosis, and bursitis) as well as non-rotator cuff abnormalities (instability problems, synovial joint diseases, and nerve entrapment syndromes). Diagnostic accuracy of shoulder US when evaluating rotator cuff tears can reach 91-100% for partial and full thickness tears detection, respectively, having been reported to be as accurate as magnetic resonance imaging in experienced hands. US is cheap, readily available, capable to provide high-resolution images, and does not use ionizing radiations. In addition, US is the only imaging modality that allows performing dynamic evaluation of musculoskeletal structures, that may help to further increase diagnostic performance. In this setting, a standardized imaging protocol is essential for an exhaustive and efficient examination, also helping reducing the intrinsic dependence from operators of US. Furthermore, knowledge of pitfalls that can be encountered when examining the shoulder may help to avoid erroneous images interpretation. In this article we use detailed anatomic schemes and high-resolution US images to describe the normal US anatomy of soft tissues, articular, and para-articular structures located in and around the shoulder. Short video clips emphasizing the crucial role of dynamic maneuvers and dynamic real-time US examination of these structures are included as supplementary material.

Ultrasound Assessment of the Rotator Cuff Cable: Comparison Between Young and Elderly Asymptomatic Volunteers and Interobserver Reproducibility

Our aim was to characterize rotator cable ultrasound appearance in shoulders of different-aged asymptomatic volunteers, also estimating interobserver reproducibility. We studied 83 shoulders in 42 young volunteers (mean age 26 ± 7.0 years, range 21-35 years) and 66 shoulders in 36 elderly volunteers (65-81 years, 73 ± 4.9 years), noting rotator cable visibility and its minimum thickness and width. Interobserver reproducibility was tested in elderly volunteers by two blinded observers. χ(2), U Mann-Whitney, t-test, Bland-Altman, and κ statistics were used. Rotator cable was less frequently detected in younger than elderly volunteers (25/83 vs. 36/66 shoulders; p = 0.002). Young subjects had thicker (1.5 ± 0.2 mm, range 1.3-1.8 mm vs. 1.1 ± 0.1 mm, 0.9-1.3 mm; p < 0.001) and wider rotator cable (5.8 ± 0.7 mm, 4.5-7.1 mm vs. 4.0 ± 1.2 mm, 2.5-7.1 mm; p < 0.001) than elderly volunteers. Thickness and width reproducibility index were 89% and 94%, respectively; κ = 0.87. Ultrasound demonstrated different rotator cable consistency in younger and elderly asymptomatic patients, with high interobserver reproducibility.

RE: A Simple Technique to Restore Needle Patency During Percutaneous Lavage and Aspiration of Calcific Rotator Cuff Tendinopathy

To the Editor, We read with great interest the article by Jelsing et al [1] entitled “A Simple Technique to Restore Needle Patency During Percutaneous Lavage and Aspiration of Calcific Rotator Cuff Tendinopathy,” published in the March 2013 issue of PM&R. Calcific tendinitis is a very common condition in the general population, and ultrasound-guided procedures aimed at treating it with minimal invasiveness are increasingly being performed around the world. In this setting, we believe that any advance in technical knowledge should be welcomed. Thus we offer a few considerations on the work of Jelsing et al [1]. The unclogging technique described in the article has been lready reported recently [2], as we occasionally use 18-G, -cm-long spinal needles to unclog 16-G needles without reoving them from the rotator cuff tendon. In our experience, his technique is helpful in selected cases of very hard calcificaions. However, in clinical practice at our institution, the cloging of the needles is a rather uncommon event. We use two 6-G needles [3], which are certainly less prone to becoming bstructed during the procedure, compared with a single 19-G eedle, as reported by Jelsing et al [1]. Of note, the use of arge-bore needles also has been demonstrated not to be harmful or rotator cuff tendons in the long term [3]. The use of warm aline solution has been demonstrated to help dissolve and ubsequently remove calcium, which also theoretically helps educe the rate of needle occlusion [4]. We agree with Jelsing et al [1] that needle substitution, mplying a second penetration of the rotator cuff tendon, hould be avoided. However, withdrawing the clogged neele into the overlying deltoid muscle means that the calcific ebris is deployed within muscle fibers immediately around he subacromial-subdeltoid bursa. We prefer to avoid any imilar events because migration of calcium within the subcromial-subdeltoid has been reported to influence the ocurrence of postprocedure bursitis [5]. Davide Orlandi, MD Emanuele Fabbro, MD Scuola di Specializzazione in Radiodiagnostica Universita degli Studi di Genova Genoa, Italy

Effect of intra-articular injection of intermediate-weight hyaluronic acid on hip and knee cartilage: in-vivo evaluation using T2 mapping

ObjectivesWe used T2 mapping to quantify the effect of intra-articular hyaluronic acid administration (IAHAA) on cartilage with correlation to clinical symptoms.MethodsOne hundred two patients with clinical and MRI diagnosis of hip or knee grade I-III chondropathy were prospectively included. All patients received a standard MRI examination of the affected hip/knee (one joint/patient) and T2-mapping multiecho sequence for cartilage evaluation. T2 values of all slices were averaged and used for analysis. One month after MR evaluation 72 patients (38 males; mean age 51±10 years) underwent IAHAA. As a control group, 30 subjects (15 males; 51 ± 9 years) were not treated. MR and WOMAC evaluation was performed at baseline and after 3, 9, and 15 months in all patients.ResultsT2 mapping in hyaluronic acid (HA) patients showed a significant increase in T2 relaxation times from baseline to the first time point after therapy in knees (40.7 ± 9.8 ms vs. 45.8 ± 8.6 ms) and hips (40.9 ± 9.7 ms; 45.9 ± 9.5 ms) (p < 0.001). At the 9- and 15-month evaluations, T2 relaxation dropped to values similar to the baseline ones (p < 0.001 vs. 3 month). The correlation between T2 increase and pain reduction after IAHAA was statistically significant (r = 0.54, p < 0.01) in patients with grade III chondropathy.ConclusionsT2 mapping can be used to evaluate the effect over time of IAHAA in patients with hip and knee chondropathy.Key points• T2 relaxation times change over time after hyaluronic acid intra-articular administration• T2 relaxation times of the medial femoral condyle correlate with WOMAC variation• T2 relaxation times are different between Outerbridge I and II-III

High-resolution ultrasound of the extrinsic carpal ligaments

Thanks to its intrinsic high spatial resolution, ultrasound is an ideal imaging modality for examining very thin, superficial structures, and this makes it very helpful in the evaluation of extrinsic carpal ligaments. These structures, which arise from the radius and ulna and insert on the carpal bones, are extremely important for wrist stability. Previous studies have assessed the use of ultrasound to study the extrinsic carpal ligaments in cadavers, healthy asymptomatic subjects, and patients with rheumatoid arthritis. In the present report, we review the normal anatomy, biomechanics, and ultrasound appearance of these ligaments.

Hip Intra-articular Injections

Intra-articular injections of the hip can be performed to treat a number of pathologic conditions. The drugs administered in these cases may be anti-inflammatory agents, such as steroids that may be indicated for patients with advanced hip osteoarthritis (OA) refractory to other treatments or viscosupplementants, such as hyaluronic acid, that can be used to treat patients with mild to moderate OA. Anesthetics may be injected for diagnostic purposes to differentiate intra- and extra-articular pathology.

Hip Insertional Tendinopathy

Tendons around the hip can develop degenerative changes at the site of insertion as a result of chronic microtraumatism due to overload or previous poorly healed acute injuries. Accurate anamnestic data collection and clinical examination are essential to differentiate this condition from acute or subacute traumatic injuries and other periarticular or intra-articular pathologies. Tendon insertions in the anteromedial and posterior compartments such as adductors, rectus femoris, and hamstrings are more frequently affected in young active individuals playing different sports like running, cycling, or football. On the other hand, chronic tendinopathy of the lateral compartment is most commonly found in middle-aged to elderly women and is generally referred to as “greater trochanteric pain syndrome” since it cannot be distinguished clinically from trochanteric bursitis, which the condition is often associated.

Drainage of Articular Ganglia Around the Ankle

Ganglion cysts are the most common benign soft-tissue lesions of the ankle. They predominantly occur in young adults. In 60–70 % of cases, the ganglion cyst originates from the subtalar joint and communicates with the synovial joint via a pedicle. In 20 % of the cases, ganglia are found on the anterior aspect of the ankle, arising from the tibiotalar joint or from the talonavicular joint.