Philippe Peetrons

Developments in musculoskeletal ultrasound and clinical applications

ObjectiveUltrasound (US) technologies are rapidly advancing, offering several refined transducer technologies as well as soft and hardware facilities. The aim of this article is to outline US developments, from B-mode technologies over Doppler advances to more sophisticated technologies, and their potential clinical impact in the field of musculoskeletal (MSK) imaging.New advancesWhen using B-mode ultrasound, compound imaging and beam-steering are of help to decrease anisotropy in tendons and ligaments, that are less well depicted due to their oblique course. Doppler imaging has become sensitive in the detection of flow in small vessels, which is of particular value in rheumatologic conditions, tumour and overuse assessment. The use of US microbubble contrast agents improves detection of low-volume blood flow in smaller vessels by increasing the signal-to-noise ratio and thereby facilitating detection of angiogenetic vessels in inflammatory conditions or tumours. The use of US blood pool contrast agents enables molecular imaging in real-time, and thus the diagnostic potential of US is expanded, opening up a new field of US applications. Objective quantification of altered tissue (e.g., synovial proliferation, tumours) is still demanding and might be improved by the use of three-dimensional imaging and software tools as parametric evaluation. Real-time sonoelastography (EUS) is a new development for visualization of tissue elasticity by measurement of tissue displacement in terms of tissue stiffness changes, promising new insights into tendon disorders. Image fusion is an exciting development that enables superimposition of CT/MRI data sets on real-time US scanning. This technique might be helpful in guiding injections under real-time conditions even in regions less easily accessible by US as, for instance, the axial skeleton, and can additionally provide an interesting tool for teaching MSK imaging and ways to guide interventions.ConclusionIn summary, exciting developments are expanding the applications of US in the MSK field, offering the advantages of real-time performance, high tissue resolution and relative speed at a reasonable cost.

Carpal tunnel syndrome.

Ultrasound (US) of the carpal tunnel adds value to the usual electrophysiology diagnosis by confirming doubtful results or evaluating patients who do not improve after surgery. US sometimes provides the surgeon or the referring physician with important information about normal variants or common or even rare causes of the nerve compression. The size of the median nerve must be calculated in the short axis by measuring the nerve cross-sectional area where the nerve is the thickest, in most cases at the proximal entrance of the carpal tunnel. Because the threshold of the nerve size varies in the literature, it is best to consider the cross-sectional median nerve area <8 mm(2) to rule out and ≥12 mm(2) to rule in the diagnosis of carpal tunnel syndrome.

Measurements of response to chemotherapy using ultrasound in metastatic liver involvement

The liver is a frequent site of metastases and in several cases the only available target for assessing the activity of chemotherapeutic agents. A standard procedure for liver measurements by ultrasound was investigated. One hundred and twenty-three chemotherapy cycles were evaluated. This study shows that metastatic involvement of the liver can be measured by several ultrasound parameters which represent different features of the same process: the number and the surface of the nodules, the volume of the organ. Ultrasound parameters were correlated with liver function tests, CEA, hepatomegaly and measurements of other metastatic sites. The surface of metastases still appeared to be the most reliable criterion of response. Our results suggest that several liver ultrasound parameters may help to definitely assess the type of response to chemotherapy.

Recommendations of the ESSR Arthritis Subcommittee on Ultrasonography in Inflammatory Joint Disease

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee on the use of ultrasonography (US) in rheumatic disease, focused on the examination of joints in the adult population. The recommended examination technique and protocols used in a radiologic work-up are discussed. The main US features that can lead to a final diagnosis in the most common rheumatic diseases are addressed. The differential diagnosis that should be considered at image interpretation is presented. The role of US in interventional procedures and clinically important recent developments is also discussed.

Place de l′échographie dans l′étude de la paroi abdominale

Resume Objectifs Etudier la paroi abdominale normale en echographie et presenter une revue des differentes pathologies de cette region. Preciser la place de l′echographie en haute resolution et du Doppler par rapport au scanner. Materiel et methode Les patients ont beneficie d′une etude ultrasonique de la paroi abdominale mais egalement de la cavite abdominale in toto. L′indication du scanner a ete discutee en seconde intention dans les cas difficiles. Resultat Les pathologies de la paroi abdominale se repartissent de facon suivante : hernie inguinale, crurale, epigastrique, eventration, les hernies de Spiegel et de Petit. Le diagnostic differentiel comprend les hematomes de paroi, les abces, les adenopathies et les tumeurs. Le Doppler permet en cas de hernies incarcerees de preciser la viabilite des structures herniees. Dans un certain nombre de cas, une reduction echoscopique de la hernie a pu etre realisee. Conclusion L′echographie couplee au Doppler et aux manœuvres de reduction est un examen relativement simple, performant et suffisant dans la pathologie de la paroi abdominale.

Evaluation, par la laparoscopie, de la tomographie computée (TC) et de l’ultrasonographie (US) dans le diagnostic des métastases hépatiques et abdominales

Résumé73 patients porteurs d’une affection maligne histologiquement prouvée ont été soumis à une laparoscopie avec biopsies guidées sous contrôle de la vue, à une tomographie computée (TC) et/ou à une ultrasonographie (US). La laparoscopie a été utilisée comme test de référence. Le taux de faux négatifs est de 4 (TC) et 8% (US). La plupart de ces cas sont observés parmi les lymphomes et les affections hématologiques qui sont mieux investigués par la laparoscopie et des biopsies guidées. L’envahissement tumoral du péritoine et la réponse à la chimiothérapie anticancéreuse n’ont pas été reconnus par ces méthodes. Le taux de faux positifs est de 4 (TC) et 14% (US). Il pourrait être surestimé dans la mesure où la laparoscopie ne permet pas de démontrer avec certitude l’absence de métastase.Ces résultats préliminaires, quoique difficiles à interpréter en terme de précision des méthodes, mettent l’accent sur l’apport de la TC et de l’US dans l’identification des métastases hépatiques.SummarySeventy-three patients with histologically proven malignant disease were submitted to laparoscopy with guided needle biopsy, computed tomography (CT) and/or ultrasonography (US). Laparoscopy was used as reference test. False negative CT and US was 4 and 8% respectively. Most of these cases were observed among lymphomas and hematologic malignancies which are better investigated by laparoscopy and guided needle biopsy. Peritoneal dissemination and response to chemotherapy were not disclosed using these methods. False positive CT and US was 4 and 14%, respectively. These results are probably overestimated since negative laparoscopy cannot ascertain the lack of metastase.These preliminary data, although difficult to interpret in term of accuracy of the methods, point to the possible contributions of CT and US in detecting liver metastases.

Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses.

Objective To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses. Methods A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. Results 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds. Conclusions This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

L’échographie des lésions de l’appareil moteur liées au sport (jambe, cheville et pied)

Objectifs pedagogiques Apres le membre inferieur proximal, aborde lors des JFR 2004, et avant le membre superieur, envisage pour les JFR 2006, cette seance se propose, dans la decontraction et la bonne humeur, de continuer l’etude echographique des lesions de l’appareil moteur liees a la pratique du sport de loisir ou de competition par celle du membre inferieur distal (jambe, cheville et pied). A l’aide d’exposes pathologiques soutenus par des demonstrations echographiques en direct et enrichis par de larges discussions pluridisciplinaires, le but vise est, qu’en fin de seance, les participants : 1. connaissent les principales pathologies sportives de la jambe de la cheville et du pied, 2. soient capables d’en retrouver les signes en echographie, de confronter l’interet de cette technique a celui des autres modes d’imagerie et de voir dans quels cas on peut remplacer une imagerie lourde et onereuse par une echographie plus legere et peu couteuse, 3. evaluent, grâce a la participation des cliniciens, l’apport de l’echographie moderne dans cette pathologie. Couplee aux cliches simples, l’echographie apparait aujourd’hui capable de resoudre de nombreux problemes diagnostiques de la jambe, de la cheville et du pied en rapport avec la pratique d’un sport. Elle permet souvent de se dispenser d’IRM ou de TDM. Seront successivement etudiees les lesions de l’appareil propulseur du pied, des tendons de la cheville et de leur systeme retinaculaire, les entorses, les lesions de surface du squelette et celles de l’avant-pied des sportifs.