M. Mortada

Multiple versus single ultrasound guided suprascapular nerve block in treatment of frozen shoulder in diabetic patients.

BACKGROUND Suprascapular nerve block (SSNB) is used in the management of frozen shoulder. There are no evidences from the literature that can determine how many blocks and the interval between them. OBJECTIVE To compare between single and multiple (nine) SSNB in the treatment of diabetic frozen shoulder. METHODS Ninety six patients with Type 2 diabetic and a frozen shoulder divided into 2 equal groups. Patients in group1 were subjected to single SSNB. Patients in group 2 were subjected to multiple (nine) SSNB. Participants were assessed clinically and by ultrasound at baseline and after 3 weeks and 4 months. RESULTS After 3 weeks, there was a significant improvement of all clinical & ultrasound parameters in both groups. But the improvement in group 2 was significantly better than the improvement in group 1. Also after 4 months, all parameters in both groups showed a further improvement in comparison with the base line parameters but still there was a highly significant improvement in group 2 versus group1. CONCLUSION A course of multiple (nine) injections for suprascapular nerve block gave a better outcome than a single injection for suprascapular nerve block.

Reliability of a Proposed Ultrasonographic Grading Scale for Severity of Primary Knee Osteoarthritis.

Objectives The objective of this study was to examine the concordance of a grading scale (0–4) of medial femoral osteophytes in knee joint detected by ultrasound (US) compared with the corresponding grades (0–4) of Kellgren–Lawrence (K&L) scale of conventional radiography and clinical joint examination. Patients and Methods A cross-sectional observational study included 160 patients with knee pain who fulfilled the American College of Rheumatology (ACR) criteria for knee osteoarthritis (KOA) and 20 patients with knee pain who have not fulfilled the ACR criteria for KOA. All patients were subjected to clinical assessment (Western Ontario and McMaster Universities Index of Osteoarthritis and global visual analog scale) and radiological assessment in the form of X-ray grading according to K&L grading scale and ultrasonographic assessment of medial femoral osteophytes according to a scale that was proposed by the first author and consisted of five grades (0–4), where grade 0 denoted no osteoarthritis and grade 4 denoted the most advanced grade of KOA. Grade 2 was divided into two subgrades A and B with grade 2B considered as a more advanced stage than grade 2A. Results The proposed US grading scale had high sensitivity and specificity in detecting the different grades of KOA compared with K&L grading scale (a total sensitivity of 94.6% and a total specificity of 93.3%). Intra- and interreader reliability of US was excellent (kappa >0.93 and >0.85, respectively). Conclusions US can reliably detect the severity of KOA. Good agreement was found between the proposed US grading scale and K&L grading scale. The proposed US grading scale is simple and reliable.

SAT0404 Efficacy and Safety of Hydrodissection of Median Nerve as a Treatment of Idiopathic Carpal Tunnel Syndrome

Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Ultrasound guided hydrodissection (UGH) of median nerve is a new method of treatment of CTS1. Ultrasonography (US) has the ability to determine the effectiveness of various treatment modalities in CTS2. Objectives To test the safety and efficacy of UGH of median nerve as a new method of treatment of idiopathic CTS. Methods Sixty five consecutive cases of idiopathic carpal tunnel syndrome (in 45 patients) diagnosed by motor & sensory median nerve conduction studies and by US measurement of cross-sectional area (CSA) of the median nerve measured at the tunnel inlet. Patients were grouped according to CSA into 3 groups: mild(CSA10-13mm2), moderate (CSA: □13-15mm2) and sever (CSA □ 15 mm2). All patients underwent UGH of median nerve with 10 ml of normal saline (9% Nacl) using a 25-gauge needle. After hydrodissection, a series of about 100 perforations of the flexor retinaculum was made using ultrasound to visualize the needle tip to insure that the tip perforated the retinaculum on each pass, and did not contact the median nerve. At the end of the procedure, 40 mg of triamcinolone acetonide was injected. Tingling & numbness during day (DTN) and night (NTN) graded on a visual analogue scale (0-10) were determined on the initial (W0) and 6 months after treatment (W24). Sonographic CSA of the median nerve was determined at (W0) and (W24). Any post procedure complications were reported. Results There was a significant reduction in Tingling & numbness during day (DTN) (mean value± SD) between W0 (6.87± 1.1) and W24 (1.15 ± 0.9) p< 0.001. Night tingling and numbness reduced significantly between W0 (7.18 ± 1.2) and W24 (1.3±0.4) p< 0.001. only 4 (7.3%) cases reported no improvement at W24. Sonographic CSA of the median nerve reduced significantly between W0 (16 ± 5.7) and W24 (12.5±4.4) p< 0.001. While at W0 classification of groups according to sonographic CSA was as follow: 21 (33.3%) mild cases, 15 (23.8%) moderate cases and 27(42.9%) severe cases, at W24: 46.7% of cases in mild group, 13% of cases in moderate group and 7.4% of cases in severe group (22.2% of cases in all groups) reclassified sonographically as normal cases. 9 cases (14.3%) did not come for follow up. Safety:10(15.9%) cases reported pain at needle site that resolved 2 weeks after the procedure. Conclusions Hydrodissection of median nerve is a safe and effective procedure in management of idiopathic CTS. To the best of our knowledge this the first study to detect the effect of hydrodissection of median nerve by US in cases of CTS. References Malone GD, Clark BT and Wei N. Ultrasound-guided percutaneous injection, hydrodissection, and fenestration for carpal tunnel syndrome: description of a new technique. Journal of Applied Research. 2010. Mar; 10 (3): 116-123 Soyupek F, Soyupek A, Kutluhan S, et al. Determining the effectiveness of various treatment modalities in carpal tunnel syndrome by ultrasonography and comparing ultrasonographic findings with other outcomes. Rheumatol Int. 2012 Oct;32(10):3229-34. Disclosure of Interest None Declared

Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force

Objectives To assess the reliability of the OMERACT ultrasound (US) definitions for the identification of calcium pyrophosphate deposition disease (CPPD) at the metacarpal-phalangeal, triangular fibrocartilage of the wrist (TFC), acromioclavicular (AC) and hip joints. Methods A web-based exercise and subsequent patient-based exercise were carried out. A panel of 30 OMERACT members, participated at the web-based exercise by evaluating twice a set of US images for the presence/absence of CPPD. Afterwards, 19 members of the panel met in Siena, Italy, for the patient-based exercise. During the exercise, all sonographers examined twice eight patients for the presence/absence of CPPD at the same joints. Intraoberserver and interobserver kappa values were calculated for both exercises. Results The web-based exercise yielded high kappa values both in intraobserver and interobserver evaluation for all sites, while in the patient-based exercise, inter-reader agreement was acceptable for the TFC and the AC. TFC reached high interobserver and intraobserver k values in both exercises, ranging from 0.75 to 0.87 (good to excellent agreement). AC reached moderate kappa values, from 0.51 to 0.85 (moderate to excellent agreement) and can readily be used for US CPPD identification. Conclusions Based on the results of our exercise, the OMERACT US definitions for the identification of CPPD demonstrated to be reliable when applied to the TFC and AC. Other sites reached good kappa values in the web-based exercise but failed to achieve good reproducibility at the patient-based exercise, meaning the scanning method must be further refined.

SAT0631 Inter-observer and intra-observer reliability of the omeract ultrasonographic (US) criteria for the diagnosis of calcium pyrophosphate deposition disease (CPPD) at the metacarpal-phalangeal (MCP), wrist, acromion-clavicular (AC) and hip joints

Background The OMERACT US subtask force “US in CPPD” recently created the definitions for US identification of crystal deposits in joints and tested the reliability at the knee [1]. Objectives To assess the inter/intra-observer reliability of US on detecting CPPD at triangular fibrocartilage complex (TFCC) of the wrists, fibrocartilage of the AC joint, hip labrum (HL), hyaline cartilage (HC) of the metacarpal (MC) and femoral head. Methods The OMERACT criteria for CPPD were used for the exercise [1] using a 2 steps approach. First, the panel of experts gave a dichotomous score (presence/absence of CPPD) of 120 images of the sites included, using a web platform. The images were evaluated twice to assess the inter/intra-observer reliability. Then, the experts met in Siena for a patient based exercise. Bilateral evaluation of TFCC, AC, HL /HC of the hip and HC of the II-III MCP of 8 patients was carried out twice in a day, using a dichotomous score for CPPD. 8 US machines (3 GE, 1 Samsung and 4 Esaote) equipped with high resolution linear probes were used. Results Reliability values of static exercise were high for all sites, demonstrating that definitions were clear. The results of the second step are presented in table 1. On live scanning, the TFCC resulted the most reliable site for CPPD assessment, followed by AC. Other sites demonstrated lower kappa values and thus are not reliable for CPPD assessment. Conclusions TFCC of the wrist is the most reliable site for CPPD. By adding these results to the previous [2], we confirm that the OMERACT definitions for CPPD can be applied reliably at the knee (meniscus and HC), TFCC and AC, usually the most involved sites in CPPD. The next step of the OMERACT subtask force will be to test these findings in a longitudinal observational study. References Filippou G, Scirè CA, Damjanov N et al. Definition and reliability assessment of elementary US findings in CPPD. Results of an international multi-observer study by the OMERACT sub-task force “US in CPPD”. J Rheumatol, in press. Disclosure of Interest None declared

AB0967 Ultrasonographic Features of Neuropathic (Charcot) Arthropathy of Ankle Joint

Background neuropathic osteoarthropathy (Charcot arthropathy) is a progressive condition that is characterized by joint dislocations, pathologic fractures, and debilitating deformities. It occurs most commonly in the lower extremity, at the foot and ankle. Although magnetic resonance imaging (MRI) is the modality of choice to examine patients with suspected neuropathic osteoarthropathy, for its ability to depict bone and soft tissues changes, ultrasonography (US) may be able to identify pathological changes in cases of Charcot arthropathy. Up to the best of our knowledge this the first study of ultrasonographic feature of neuropathic ankle joint. Objectives Our aim was to characterize the ultrasonographic features of patients with neuropathic (Charcot) arthropathy of ankle joint. Methods In this retrospective study, all 26 patients between January 2013 and December 2015 with neuropathic (Charcot) arthropathy of ankle joint proved by X ray and/or MRI were enrolled. We collected and analyzed 26 patients, on whom high-resolution (5–15 MHz) muculoskeletal US of ankle and small joints of the affected feet had been carried out. Results Ages of our patients ranged from 38 to 67years (57.3± 6.4). Most of our patients (25 patients) 96.2% had diabetes mellitus and all of our patients had peripheral neuropathy. According to the modified Eichenholtz classification system; 3 patients (11.5%) were in grade 0, 11 patients (42.3%) were in grade 1, 10 patients (38.5%) were in grade 2, and 2 patients (7.7%) were in grade 3. Ultrasonographic findings were: Effusion/synovitis of ankle joints (100%), High Doppler activity (grade 2 or 3) in ankle joint was present in 92.3% of our patients, bone irregularities in distal fibula 73.1%, bone irregularities in distal tibia were found in 34.6%, tendonitis of tibialis posterior 65.4%, proneal tendonitis were found in 50%. Double contour sign were present in 2 ankle joints (7.7%). Arthritis (effusion/synovitis) in mid tarsal joints were found in 92.3% of patients with high Doppler activity in 65.4% and bone irregularities in57.7%. Conclusions The main US features of neuropathic (Charcot) arthropathy of ankle joint are: effusion, synovitis, high grade Doppler activity, bone irregularities of the distal fibula and involvement of mid tarsal joints (synovitis, high Doppler activity and bone irregularities). Disclosure of Interest None declared

SAT0522 Efficacy and Safety of Ultrasonographic Guided Percutaneous Needle Planter Fasciotomy as A Treatment for Chronic Planter Fasciitis: Table 1.

Background Plantar fasciitis (PF) is the most common cause of heel pain. Approximately 10% of the cases develop recalcitrant symptoms and are offered various forms of surgical intervention. Ultrasound guided needle planter fasciotomy is a minimal invasive method that may help this group of patients (1). Objectives To assess the efficacy and safety of ultrasonographic guided percutaneous needle planter fasciotomy as a treatment for chronic planter fasciitis. Methods ultrasound guided planter fasciotomy (1) was carried out in one hundred and seven patients who had chronic planter fasciitis that did not respond to conservative treatment including medical treatment, physiotherapy and local corticosteroid injection. Following induction of local anesthesia, a 14-gauge needle was guided toward and into the plantar fascia by real-time sonography.Visual analogue scale (VAS) for heel pain and ultrasonographic character of planter fascia (thickness and echogenicity) were assessed on the initial (W0), 2 weeks later (W2) and 6 months after treatment (W24). Results A highly significant difference was found between VAS and sonographic findings before and after fasciotomy. Patients improved significantly at 2 weeks compared to baseline and also at 6 months compared to baseline and 2 weeks (table 1). Nighty seven (90.7%) of patients stated that “the procedure had been worthwhile”. There were no complications during or following needle fasciotomy.Table 1. Comparison between VAS and sonographic findings at Baseline, 2 weeks and 6 months post-injection Baseline Two weeks Six months P VAS 80 (60–100) 20 (10–60) 10 (0–80) 0.000** Sonography  Fascia thickness 6.9 (4.8–8.3) 6.1 (5.1–7.9) 5.3 (4.6–7.3) 0.000**  Echogenecity 2.5 (1–3) 2 (1–3) 1 (0–3) 0.000** VAS visual analogue scale. **Highly significant difference p<0.001. Analysis was done by Kruskal Wallis tests. Post-Hoc tests were done also and revealed highly significant difference between baseline & 2 weeks (P=0.000), between baseline & 6 months (P=0.000), and between 2 weeks & 6 months (P=0.000) regarding VAS and sonographic findings. Conclusions Ultrasonographic guided percutaneous needle planter fasciotomy is a safe and an effective method in patients with chronic planter fasciitis who did not respond to conservative treatments including local corticosteroid injections. References Folman et al, Foot and Ankle Surgery 11 (2005) 211–214 Disclosure of Interest None declared

AB0761 Efficacy of per-Cutaneous Ultrasound Guided Drainage of Degenerative Meniscal Cysts in Knee Osteoarthritis Patients

Background Meniscal cysts presented in about 4% of patients with knee osteoarthritis [1]. Meniscal cysts may result in pain and disability in the knee. Ultrasound may be used for therapeutic aspiration of the cyst [2]. Objectives To evaluate the efficacy of ultrasound guided percutaneous drainage of symptomatic meniscal cysts in patients with knee osteoarthritis. Methods Ultrasound guided percutaneous drainage of symptomatic meniscal cysts were performed in 38 patients with Knee osteoarthritis in the period between January 2013 and December 2015. Thirty cysts were related to the medial meniscus and 8 cysts were related to the lateral meniscus. Cysts were injected with local anaesthetic before completion of procedure. All 38 patients were subsequently followed up one month and 6 months after the aspiration with the primary outcome measures were the Western Ontario and McMaster Universities OA Index total pain score WOMAC (a Likert scale), patient global assessment (PGA) questionnaires and musculoskeletal ultrasonography assessment. Results In every case the procedure was well tolerated. Complete aspiration of the cyst were performed in 15 patients (39.5%) and partial aspiration were performed in 23 patients (60.5%). Before aspiration US meniscal cyst measurements 29.5±9.2 mm * 13.6±4.5 mm. At the end of the 1st month, there was a reduction of 50% in the WOMAC pain score. 89.4% (34 patients) felt that their knee pain had improved compared to baseline. At this time point just US meniscal cyst measurements 19.5±5.2 mm * 11.6±4.1 mm. At the end of the 6th month post aspiration, there was a reduction in the WOMAC pain score of 30%. At this time point just 78.9% (30 patients) felt that their knee pain had improved compared to baseline. At this time point just US meniscal cyst measurements 25.5±6.2 mm * 13.6±3.6 mm. Patient outcomes did not significantly correlate with any meniscal cyst characteristic. Complete aspiration was associated with better outcomes. Conclusions Ultrasound-guided percutaneous aspiration of degenerative meniscal cysts is a well-tolerated, simple, and safe procedure for patients with knee osteoarthritis. References Campbell SE, Sanders TG, Morrison WB. MR imaging of meniscal cysts: incidence, location, and clinical significance. AJR Am J Roentgenol. 2001;177 (2): 409–13. P. J. MacMahon, D. D. Brennan, D. Duke, S. Forde, and S. J. Eustace, “Ultrasound-guided percutaneous drainage of meniscal cysts: preliminary clinical experience,” Clinical Radiology, vol. 62, no. 7, pp. 683–687, 2007. Disclosure of Interest None declared

AB0966 Colour Doppler Ultrasonography Is Specific but Not Sensitive in Diagnosis of Carpal Tunnel Syndrome

Background Carpal tunnel syndrome (CTS) is the most common form of peripheral entrapment neuropathies. Ultrasonography (US) has been used to diagnose CTS with a good sensitivity and specificity.There is no consensus about the role of colour Doppler US in diagnosis of CTS (1). Objectives To assess the diagnostic role of color Doppler ultrasonography in idiopathic CTS. Methods This study included 2 groups. The first group included 35females middle aged (32.1±4.8) patients with idiopathic CTS. The second group included 35 healthy middle aged (40.1±7.6) females. The diagnosis of CTS was done clinically and by nerve conduction studies.Ultrasonography of the median nerve was performed to find colour Doppler signals, wrist cross sectional area, forearm cross sectional area, flattening ratio, flexor retinaculum bowing and pronator quadratus ratio by use of high frequency (5–12MHz) linear probe diagnostic ultrasound. Results There was a statistical highly significant difference between control group and patients with CTS regarding colour Doppler signal (p=0.00).the specificity of CDUS in diagnosis of CTS was excellent (100%) but its sensitivity was poor (22.9%) with an accuracy of 61.4%. As regards the other US parameters, flattening ratio was the most accurate method (86.4%) with a senstivity (88.7%) and a specificity of (83.3%).There was a statistical highly significant positive correlation between nerve conduction study grading and Color Doppler ultrasonography (p=0.005). Conclusions CDUS is a highly specific test in evaluation of idiopathic CTS. It represents a useful confirmatory tool in diagnosis. Flattening ratio is the most accurate grey scale US parameter and highly correlated with CT severity. References Akcar N, et al. (2010).Korean Journal of Radiology; 11 (6): 632–639. Disclosure of Interest None declared

FRI0546 Multiple Versus Single Ultrasound Guided Suprascapular Nerve Block in Treatment of Frozen Shoulder in Diabetic Patients

Background Frozen shoulder, is characterized by pain and significant loss of both active range of motion and passive range of motion of the shoulder. Suprascapular nerve block is used with increasing frequency by anesthetists and rheumatologists in the management of frozen shoulder. There are no evidences in the literature that can determine how many blocks to use and the interval between them (1). Objectives To compare between single and multiple (nine) SSNB in the treatment of diabetic frozen shoulder. Methods This study included 96 type 2 diabetic patients with frozen shoulder divided into 2 equal groups. Patients in group1 were subjected to single SSNB in addition to an exercise program 3 times per week for 3 weeks. Patients in group 2 were subjected to multiple (nine) SSNB 3 times per week in addition to the previous exercise program. Ultrasound was used to guide the needle during SSNB. Participants will be assessed at baseline (following recruitment) and then after 3 weeks, and 4 months. In addition to demographics, assessments included the following measures: The shoulder pain and disability index (SPADI), Patient global assessment using: Visual Analogue Scale, Night pain using: Visual Analogue Scale and Active range of movement was measured using a goniometer in three planes: abduction, internal, and external rotation. Results Forty two patients completed the study group 1, but the number of patients in group 2 was forty patients. At the first follow up (after 3 weeks), there was a significant improvement of all parameters of SPADI scale (pain, disability and total), night pain and patient global assessment in both groups in comparison with the base line parameters (p≤0.001). But the improvement in group 2 in which we used the multiple injection protocol was significantly better than the improvement in group 1 in which a single injection protocol was used. Also at the second time point of follow up (after 4 months), all parameters in both groups showed a further improvement in comparison with the base line parameters but still there was a highly significant improvement in group 2 versus group1 (p≤0.001). Improvement of active range of motion (ROM) in all directions was highly significant in both groups at the 1st time points of follow up (after 3 weeks) in comparison with base line ROM measures and continue to improve at the 2nd time points of follow up (after 4 months). Conclusions Course of multiple (nine) injections for suprascapular nerve block gave a better improvement than a single injection for suprascapular nerve block as regards pain, disability, active range of motion and patient global assessment. Up to the best of our knowlege this the first study to compare between different regimens of SSNB. References Fernandes MR, Barbosa MA, Sousa AL, Ramos GC. Rev Bras Reumatol. 2012 Aug;52(4):616-22. Disclosure of Interest None declared