Gina M. Allen

Ultrasound elastography for musculoskeletal applications

Ultrasound elastography (EUS) is a method to assess the mechanical properties of tissue, by applying stress and detecting tissue displacement using ultrasound. There are several EUS techniques used in clinical practice; strain (compression) EUS is the most common technique that allows real-time visualisation of the elastographic map on the screen. There is increasing evidence that EUS can be used to measure the mechanical properties of musculoskeletal tissue in clinical practice, with the future potential for early diagnosis to both guide and monitor therapy. This review describes the various EUS techniques available for clinical use, presents the published evidence on musculoskeletal applications of EUS and discusses the technical issues, limitations and future perspectives of this method in the assessment of the musculoskeletal system.

Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis

Objectives Early therapy improves outcomes in rheumatoid arthritis (RA). It is therefore important to improve predictive algorithms for RA in early disease. This study evaluated musculoskeletal ultrasound, a sensitive tool for the detection of synovitis and erosions, as a predictor of outcome in very early synovitis. Methods 58 patients with clinically apparent synovitis of at least one joint and symptom duration of ≤3 months underwent clinical, laboratory, radiographic and 38 joint ultrasound assessments and were followed prospectively for 18 months, determining outcome by 1987 American College of Rheumatology (ACR) and 2010 ACR/European League Against Rheumatism criteria. Sensitivity and specificity for 1987 RA criteria were determined for ultrasound variables and logistic regression models were then fitted to evaluate predictive ability over and above the Leiden rule. Results 16 patients resolved, 13 developed non-RA persistent disease and 29 developed RA by 1987 criteria. Ultrasound demonstrated subclinical wrist, elbow, knee, ankle and metatarsophalangeal joint involvement in patients developing RA. Large joint and proximal interphalangeal joint ultrasound variables had poor predictive ability, whereas ultrasound erosions lacked specificity. Regression analysis demonstrated that greyscale wrist and metacarpophalangeal joint involvement, and power Doppler involvement of metatarsophalangeal joints provided independently predictive data. Global ultrasound counts were inferior to minimal power Doppler counts, which significantly improved area under the curve values from 0.905 to 0.962 combined with the Leiden rule. Conclusion In a longitudinal study, extended ultrasound joint evaluation significantly increased detection of joint involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA.

Clinical indications for musculoskeletal ultrasound: A Delphi-based consensus paper of the European society of musculoskeletal radiology

AbstractObjectiveTo develop clinical guidelines for musculoskeletal ultrasound (MSKUS) referral in Europe.MethodsSixteen 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.ResultsOn 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.ConclusionA 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.

Magnetic resonance imaging, ultrasound and real-time ultrasound elastography of the thigh muscles in congenital muscle dystrophy

Congenital muscle dystrophy includes a range of genetic disorders characterized by muscle weakness and contractures. We report the magnetic resonance (MR), ultrasound (US) and real-time sonoelastography (RTE) imaging findings of the thigh muscles of a 15-year-old boy with Bethlem myopathy diagnosed with clinical, electromyographic and histopathological criteria. Ultrasound and MR showed hyperechoic appearance and high signal intensity on T1- and T2-weighted sequences respectively at the periphery of the vastus lateralis and the long head of the biceps femoris muscles, and at a central area within the rectus femoris muscles. RTE was employed to examine the elastic properties of the muscle. The elastograms were presented as colour-coded maps superimposed on the B-mode images and revealed that the elastographic pattern correlated with the MR and US pattern of involvement. The abnormal muscle areas were stiffer (blue) than the normal-appearing areas (green), a finding that probably correlates with the presence of dystrophic collagen at the affected areas. This report suggests that RTE could be used as an additional imaging tool to evaluate the pattern of muscle changes in congenital myopathy. Further studies are needed to investigate the specificity and clinical value of RTE in the diagnosis and monitoring of neuromuscular disease.

Imaging of the carpal tunnel.

Most patients with symptoms related to the carpal tunnel have idiopathic median nerve compression. Imaging has little role in the care of most cases because steroid injection, therapeutic ultrasound, and surgery have established roles. However, cases with atypical presentation, mass lesions, synovitis, or failed carpal tunnel surgery will benefit from imaging. In this article we review the anatomy of the carpal tunnel, the diseases affecting this region, and then discuss the use of conventional radiographs, computed tomography, ultrasound, and magnetic resonance imaging (MRI), outlining the strengths and weaknesses of each method while listing the signs of disease. We conclude that both ultrasound examination and MRI are powerful and often complementary techniques.

Traumatic correction of Linburg-Comstock anomaly: a case report.

Linburg-Comstock anomaly describes an anatomical variant of flexor tendons of the hand. Flexor pollicis longus (FPL) sends a connecting tendon to flexor digitorum profundus (FDP), causing simultaneous flexion at the distal interphalangeal joint (DIPJ) of the index finger when the interphalangeal joint (IPJ) of the thumb is flexed. Epidemiological studies have revealed a unilateral prevalence as high as 31% of individuals; however, the condition rarely causes symptoms. The anomaly can present with a restrictive flexor tenosynovitis, requiring explorative surgery to confirm the diagnosis and disconnection of the anomalous tendon slip to relieve symptoms. We describe the case of a rock climber who suffered a forced extension injury to the DIPJ of the right index finger, resulting in traumatic rupture of his anomalous FPL-FDP connecting tendon. This is the first reported case of rupture of a Linburg-Comstock anomaly. Through rupture of this anomalous tendon, the patient can be viewed as having corrected his aberrant tendon to conform with the more prevalent anatomical configuration and function. We identified the rupture using dynamic ultrasound of the wrist; to our knowledge, this technique has not been described previously in the literature. We recommend the use of this imaging modality to confirm diagnosis, thus avoiding explorative surgery.

High-resolution ultrasound in the diagnosis of upper limb disorders: a tertiary referral centre experience.

The purpose of this study is to determine the reliability of high-resolution ultrasound (HRUS) in the diagnosis of upper limb disorders compared with the initial clinical opinion. We prospectively studied 178 patients referred for HRUS examination (47.2% hand, 34.8% wrist, and 18% elbow examinations) by recording the clinical opinion, the specific ultrasound diagnosis, and the final diagnosis, as established by surgery (79.9%) or follow-up (20.1%). HRUS examination was highly reliable in diagnosing cystic lesions, synovial disease, ligament injury and foreign bodies (100%), and slightly less reliable for solid lesions (82.1%) and nerve, bone, and tendon disorders (97%, 91.7%, 86.5%, respectively). HRUS examination resulted in significantly more correct diagnoses (92.1%) than the clinical opinion (70.8%) (McNemar test, P = 0.001). The agreement between the HRUS diagnosis and the clinical opinion was slight (Kappa test, k = 0.16). HRUS examination is more reliable than clinical examination in diagnosing upper limb disorders.

Ultrasound-guided intervention in the ankle and foot.

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Mortons neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

OP0052 Use of ultrasound to predict persistence in patients with very early synovitis

Background Early identification of patients at risk of persistent as opposed to spontaneously resolving arthritis is essential to allow the prompt institution of therapy and to provide vital information from the patient’s perspective. Currently available prediction strategies for persistent disease include that developed by Visser et al1. The identification of biomarkers that can improve such prediction strategies is an important goal. We have previously shown that data from ultrasound joint assessment adds to the accuracy of the Leiden Rule for prediction of RA. Here we present data on the utility of ultrasound to predict persistence in a very early synovitis cohort. Objectives To evaluate musculoskeletal ultrasound (MSUS) detection of synovitis and erosions as a predictor of persistent disease in patients with very early synovitis. Methods 91 patients with clinically apparent synovitis of at least one joint and duration ≤3 months of any symptom attributable to inflammatory arthritis were followed prospectively for 18 months and underwent clinical, laboratory, radiographic and 38 joint ultrasound (MSUS) assessments at baseline. MSUS variables included power Doppler (PD) and greyscale (GS) defined on 0-3 categorical scales. Sensitivity and specificity for persistent disease (at 18 months of follow-up) were determined for MSUS variables. Logistic regression models were used to evaluate the predictive ability of MSUS over and above the Visser score. Results 35 (38%) patients had resolving disease, whilst 56 (62%) developed persistent disease (including both RA and non-RA phenotypes). Ultrasound demonstrated subclinical joint involvement in both patient groups for all joint regions assessed. However power Doppler (PD) and Greyscale (GS) median joint counts were all significantly higher in the patients with persistent disease compared with those with resolving disease (PD: 10 vs 3 joints, p<0.001 and GS: 14 vs 4 joints, p<0.001, respectively). 18 patients (32.1%) with persistent disease had erosions of hands or feet detectable at baseline by ultrasound, not present in any patients with resolving disease (p<0.001). Global ultrasound joint counts and several individual MSUS variables, particularly at the MCP and PIP joints, were associated with persistence independently of the Visser score. Logistic regression analysis showed that compared to the Visser score alone, the Visser score with added MSUS variables GS≥2 at the MCP joints and PD≥2 at the PIP joints improves area under the curve values significantly (0.816 and 0.912 respectively, p<0.01). Conclusions Subclinical disease detected by ultrasound is more common in persistent than resolving disease. We have identified a number of ultrasound variables that provide important prognostic information on the development of persistent disease and have shown that useful data can be gathered from the assessment of a limited number of joints. Larger studies are required to fully evaluate the optimal weightings of these variables for use in a persistence algorithm. References [1] Visser H, le Cessie S, Vos K, Breedveld FC, Hazes JM. How to diagnose rheumatoid arthritis early: a prediction model for persistent (erosive) arthritis. Arthritis Rheum 46(2):357-65. Disclosure of Interest A. Filer Grant/Research support from: Cellzome and Pfizer, M. Cader: None Declared, A. Abhishek: None Declared, G. Allen: None Declared, C. Buckley Grant/Research support from: Wyeth, Cellzome, UCB and Pfizer, P. de Pablo: None Declared, K. Raza Grant/Research support from: Wyeth, Cellzome, UCB and Pfizer

SAT0107 Ultrasound defined tenosynovitis improves the prediction of rheumatoid arthritis and persistent disease in patients with very early synovitis

Background Tenosynovitis (TS) is a common manifestation of rheumatoid arthritis and postulated to be an early marker of disease but requires imaging to reliably detect its presence. The prevalence of tenosynovitis in patients with very early arthritis is unknown and there have been no studies on tenosynovitis as a predictor of the development of either rheumatoid arthritis (RA) or persistent disease. Objectives 1) to establish the prevalence of tenosynovitis assessed by ultrasound in patients with unselected very early arthritis, 2) to explore whether the presence of tenosynovitis defined by ultrasound improves the prediction of RA or persistence compared with corresponding predictive algorithms, i.e. the Leiden and Visser score. Methods We included 91 patients with clinically apparent synovitis of at least one joint and duration ≤3 months of any symptom attributable to inflammatory arthritis. Patients were followed prospectively for 18 months and underwent clinical, laboratory, radiographic and ultrasound assessments at baseline. We used ultrasound of hand, wrist, shoulder and ankle tendons to establish the prevalence of tenosynovitis detected by greyscale and power Doppler modalities. Ultrasound tenosynovitis variables were then analysed for their ability to improve sensitivity and specificity by calculating area under the curve (AUC) values, and comparing with predictive algorithms: the Leiden score for RA and the Visser score for persistent disease. Results Out of the 91 patients, 39 patients developed very early rheumatoid arthritis (VERA), 17 developed very early non-rheumatoid arthritis (VENRA) and 35 had resolving disease at follow-up. All patient groups had evidence of tenosynovitis at baseline (92%, 71%, and 71% respectively). Symmetrical PD involvement of wrist extensor tendons was more prevalent in VERA patients compared with patients with VENRA (36% vs. 6%, p<0.05) and resolving disease (11%) but there were no other significant differences in tenosynovitis distribution between VERA and VENRA groups. Tenosynovitis variables did not improve Leiden score AUC values for the prediction of RA. In contrast, tenosynovitis variables including wrist flexor and hand extensor tenosynovitis had good specificity (both 94%) for persistent disease. Tenosynovitis of the hands was more common among patients with persistent disease (VERA and VENRA) compared with patients with resolving disease (63% vs. 17%, p<0.001). Compared to the Visser score alone, presence of hand tendon or wrist flexor tendon PD involvement improved area under the curve values for the prediction of persistent arthritis, independent of the Visser score (0.816 and 0.878, p<0.05). However ultrasound assessment of tenosynovitis conferred no additional benefit and was less useful than the additional predictive value gained from ultrasound greyscale or PD scanning for joint involvement. Conclusions Tenosynovitis is common in very early arthritis and symmetrical wrist extensor tendinitis is significantly more common in very early RA. We have identified tenosynovitis ultrasound variables that are predictive for persistent disease. However these have inferior predictive value compared to ultrasound assessment of joints alone in very early disease. Disclosure of Interest A. Filer Grant/Research support from: Cellzome and Pfizer, M. Cader: None Declared, A. Abhishek: None Declared, G. Allen: None Declared, C. Buckley Grant/Research support from: Wyeth, Cellzome, UCB and Pfizer, P. de Pablo: None Declared, K. Raza Grant/Research support from: Wyeth, Cellzome, UCB and Pfizer