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Aging changes tendon biology, healing capacity, and biomechanical properties and results in increased susceptibility to injuries. With the aging population, the socio-economic burden from tendinopathies is increasing. This article discusses the structure of tendons and the physiologic changes that occur with aging. We then discuss some of the most prevalent tendinopathies affecting the elderly population. Finally, we provide an overview of current knowledge on the nonsurgical management of tendinopathies and advanced imaging techniques to improve the aging and diseased tendon characterization.

Evaluate the efficacy of ultrasound-guided dry needling and open-release surgery in reducing pain and improving function in workers with lateral epicondylosis refractory to at least 6 months of nonsurgical management.We randomly assigned participants in a 1:1 ratio to receive dry needling or surgery. The primary outcome was the Patient Rated Tennis Elbow Evaluation (PRTEE) score at 6 months. Secondary outcome measures examined the impact of these techniques on professional activity, grip strength, and Global Rating of Change and Satisfaction scales. Statistical analyses included mixed-effects models and Fisher's exact tests.From October 2016 through June 2019, we enrolled 64 participants. Two participants were excluded, and data from 62 participants (48 ± 8 years, 33 men) with a mean duration of symptoms of 23 ± 21 months were analyzed. Baseline characteristics were similar in both groups. In the intention-to-treat analysis, no treatment-by-time interaction was observed (FUltrasound-guided dry needling resulted in comparable improvement in outcome scores on scales of pain, physical function, and global assessment of change and satisfaction than open-release surgery.ClinicalTrials.gov Identifier: NCT02710682 KEY POINTS: • In patients with chronic lateral epicondylosis, ultrasound-guided tendon dry needling provides comparable therapeutic efficacy to open-release surgery. • Ultrasound-guided tendon dry needling allows for an earlier return to work and may be less costly than open-release surgery. • Care management guidelines should recommend treatment by ultrasound-guided tendon dry needling before open-release surgery.

In this review article, we discuss the literature pertaining to the bibliometric analysis of academic radiologists' scholarly activity in order to identify current trends, knowledge gaps, and potential future directions. Current research provides cross-sectional analyses of bibliometrics on three main themes: academic ranking, gender disparity, and research funding. The most commonly used parameters are the publication and the citation counts, the h-index and the number of years in academia. The h-index correlates positively with academic ranking and, in the case of editorial board members, with the journal's impact factor. Scholars who have secured National Institutes of Health funding tend to have higher h-indexes than those who have not. Whereas gender balance has been achieved in medical school and in several medical specialties, women remain significantly fewer than men in most areas of radiology. The underrepresentation of women is particularly noticeable at higher academic ranks and in leadership positions, suggesting that significant barriers to female radiologists' career advancement exist. Scholarly productivity of radiology residents and the impact of research on academic productivity are subjects that have received less attention in the published literature. Future studies should focus on whether bibliometric parameters can be used as reliable measurements of scholarly activity to help determine appointments, promotions and grant allocations, and to assess interventions that promote gender parity.

It is not clear whether exercise therapy significantly improves knee biomechanics during gait in osteoarthritis (OA) patients. This study aimed to determine whether targeted exercises based on a knee kinesiography exam improve biomechanical markers (BMs) compared with conventional primary care (CPC) management.This was a secondary analysis of a cluster randomized controlled trial in which patients were assigned to one of three groups: (1) Control (CPC), (2) Exercise, and (3) ExerciseEducation. Fourteen known BMs in knee OA patients were assessed. The primary outcome was the global evolution ratio (GER), which was calculated as the sum of improved BMs over the sum of deteriorated BMs 6 months after baseline assessment. GER scores were categorized with three different sets of cut-off values into clinical levels: (a) Deteriorated, (b) Stabilized, and (c) Improved. Ordinal logistic regressions were performed on the per-protocol population to determine whether there was a relationship between group assignment and GER levels.Of the 221 eligible participants, 163 were included. Two different regression models showed that patients from Group 3 (ExerciseEducation) were 2.5-times more likely to be in an upper GER level (i.e., Stabilized or Improved) than patients from the control group (both odds ratio (OR) 2.46, Wald ΧResults suggest that targeted exercises can improve biomechanical markers in knee OA patients compared with CPC treatment. Further studies are needed to confirm these findings and refine the biomechanical markers to address to maximize patients' clinical outcomes.

Quantifying the rotator cuff (RC) muscles' viscoelasticity could provide outcome relevant information in patients with RC tears. MR-elastography requires robust diffusion-tensor imaging (DTI) to account for tissue anisotropy in muscles stiffness computation.To assess the repeatability of DTI parameters in the supraspinatus and infraspinatus muscles and to explore DTI tractography conformity with the muscles' anatomy.Prospective.Six healthy volunteers underwent three consecutive shoulder MRI sessions about 10 minutes apart.3T/T1-vibe Dixon and Spin echo EPI DTI (12 gradient encoding directions, b-values 500 and 800 sec/mmSupraspinatus and infraspinatus muscles were segmented on the T1-vibe Dixon sequence. DTI image quality was assessed using a quantitative threshold based on the signal-to-noise ratio (SNR). The eigenvalues (DTI parameters within-subject intersession repeatability was assessed with Bland-Altman analysis and the coefficient of variation (CV). Repeatability was considered good for CV 10%.The SNR between diffusion-weighted and non-diffusion-weighted images was greater than 3, which aligns with standards for estimating DTI parameters. The FA showed the lowest mean bias (-0.007; 95% confidence interval [CI] -0.031 to 0.018) whereas the λDTI of the supraspinatus and infraspinatus muscles achieved an adequate SNR, allowing the measurement of the DTI metrics with good repeatability, and thus can be used for optimizing stiffness estimation in these anisotropic tissues.2 TECHNICAL EFFICACY: Stage 2.

The tumor microenvironment (TME) consists of cellular and noncellular components which enable the tumor to interact with its surroundings and plays an important role in the tumor progression and how the immune system reacts to the malignancy. In the present study, we investigate the diagnostic potential of the TME in differentiating benign and malignant lesions using image quantification and machine learning.A total of 229 breast lesions and 220 cervical lymph nodes were included in the study. A group of expert radiologists first performed medical imaging and segmented the lesions, after which a rectangular mask was drawn, encompassing all of the contouring. The mask was extended in each axis up to 50%, and 29 radiomics features were extracted from each mask. Radiomics features that showed a significant difference in each contour were used to develop a support vector machine (SVM) classifier for benign and malignant lesions in breast and lymph node images separately.Single radiomics features extracted from extended contours outperformed radiologists' contours in both breast and lymph node lesions. Furthermore, when fed into the SVM model, the extended models also outperformed the radiologist's contour, achieving an area under the receiver operating characteristic curve of 0.887 and 0.970 in differentiating breast and lymph node lesions, respectively.Our results provide convincing evidence regarding the importance of the tumor periphery and TME in medical imaging diagnosis. We propose that the immediate tumor periphery should be considered for differentiating benign and malignant lesions in image quantification studies.

Objective To determine if T1- and T2*-mapping of the gluteal tendons can discriminate between participants with and without clinical findings of gluteal tendinopathy (GT) and if they correlate with clinical assessment. Materials and methods This prospective study was conducted between January and December 2016. MRI of the hip included spin echo, short-T1 inversion recovery, variable-flip angle, and variable echo-time gradient echo sequences. MRI studies were reviewed independently by two radiologists. Two other readers segmented the gluteal tendons and T1, mono- (T2*m) and biexponential T2* (short (T2*s) and long (T2*l) components) were computed. Results Ten participants with GT (median age; interquartile range: 63 (57–67) years, all women) and 9 participants without GT (57 (55–59) years, 8 women) (P = 0.06) were enrolled. The sensitivity and specificity of reader 1 for disease classification were 40% (95% confidence interval (CI): 17–61%) and 70% (CI: 47–91%), and those of reader 2 were 70% (CI: 43–86%) and 80% (CI: 53–96%), with fair inter-reader agreement (Kappa = .38). T1 values could not discriminate between the two groups. The gluteal tendons T2*m and T2*s showed diagnostic accuracy ranging from .80 to .89. The posterior gluteus medius tendon T2*m and T2*s respectively showed sensitivity and specificity of 90%, and strong correlation (Spearman’s rho = −.71; P = 0.02) with the Lower Extremity Functional Scale score. Conclusion Quantitative MRI could help gain new insight into healthy and diseased gluteal tendons to allow better diagnosis and treatment stratification for patients., Dans le cadre du programme SharedIt de Springer Nature, une version de l'article est accessible gratuitement, en lecture seule, à cette adresse : https://rdcu.be/cjHMS

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy. This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy–guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0 years; SD 8.8 years; range 26–61 years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1 years; SD 11.2 years; range 29–72 years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models. During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p

Ultrasonography is an acceptable modality to evaluate median nerve (MN) in patients with carpal tunnel syndrome (CTS). Additional investigations are needed to evaluate sonographic parameters and compare their performances with artificial intelligence (AI) methods. The aim of this study is to compare the performance of shear wave elastography, morphometry, and AI techniques to predict MN entrapment accurately. 200 wrists including 100 CTS and 100 control wrists were included. Twelve morphological and five elasticity parameters were measured from each MN. Two AI techniques namely, support vector machine (SVM), and convolutional neural network (CNN) were used to diagnose CTS. MN area with area under receiver-operating characteristic curve (AUC) of 0.949 and mean elasticity with AUC of 0.942 showed the highest performance to differentiate CTS from control wrists among morphological and elasticity parameters, respectively. The CNN achieved the best performance with AUC of 0.980, while SVM obtained AUC of 0.943 in testing dataset to diagnose CTC. MN is larger, stiffer, more irregular and extended in CTS patients. Deep learning technique yielded the highest performance in diagnosing CTS automatically. AI methods have vast potential to be implemented in clinical practice as an auxiliary tool for the assessment of CTS with high accuracy.

Objective: An important clinical gap reported by primary care physicians (PCPs) in managing knee osteoarthritis patients is the lack of validated tools to help them guide conservative treatment dec...

Objective The purpose of this study is to describe the MRI findings and evaluate the prevalence of supraspinatus myotendinous injuries. Materials and methods Among 1001 consecutive shoulders that underwent either conventional MRI or MR arthrography between January and December 2016, 843 shoulders were included. All MR images were retrospectively analyzed for identification and classification into the appropriate grade of acute or chronic rotator cuff myotendinous injuries. Other MRI findings, such as the presence of rotator cuff tendon insertional tears, and clinical information were also evaluated. Results At MRI, 0.47% (4/843) of shoulders had supraspinatus myotendinous injuries involving the anterior muscular bundle exclusively. Chronic grade III (n = 2), acute grade III (n = 1), and acute grade II (n = 1) injuries were identified in three men and one woman (mean age, 44 years) with a clinical history of trauma (n = 2) or of progressive shoulder pain (n = 2). A concurrent supraspinatus insertional tendon tear with either partial (n = 1) or full (n = 1) thickness was present in half the cases. Loss of tension of the myotendinous junction in grade III myotendinous junction injuries led to severe atrophy and fatty infiltration of the anterior supraspinatus. Conclusion Supraspinatus myotendinous junction injuries are uncommon at MRI. These lesions invariably involve the anterior bundle of the supraspinatus muscle and may occur with a concomitant insertional tendon tear. High-grade chronic injuries lead to selective atrophy and fatty infiltration of the anterior supraspinatus muscle.

Radiomics is a newcomer field that has opened new windows for precision medicine. It is related to extraction of a large number of quantitative features from medical images, which may be difficult to detect visually. Underlying tumor biology can change physical properties of tissues, which affect patterns of image pixels and radiomics features. The main advantage of radiomics is that it can characterize the whole tumor non-invasively, even after a single sampling from an image. Therefore, it can be linked to a "digital biopsy". Physicians need to know about radiomics features to determine how their values correlate with the appearance of lesions and diseases. Indeed, physicians need practical references to conceive of basics and concepts of each radiomics feature without knowing their sophisticated mathematical formulas. In this review, commonly used radiomics features are illustrated with practical examples to help physicians in their routine diagnostic procedures.

Purpose This systematic review (SR) aimed to identify the surgical interventions available for trapeziometacarpal osteoarthritis and document their efficacy on pain, physical function, psychological well-being, quality of life, treatment satisfaction, and/or adverse events. Methods This PROSPERO-registered SR’s protocol was developed based on the Cochrane intervention review methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Among 9049 potential studies identified, 1 SR, 18 randomized controlled trials, and 40 nonrandomized controlled trials were included. We identified 11 categories of surgical techniques: first metacarpal osteotomy, first metacarpal and trapezium partial resection, arthrodesis, trapeziectomy (T), T+ligament reconstruction (LR), T+tendon interposition (TI), T+ligament reconstruction and tendon interposition (LRTI), hematoma distraction arthroplasty (HDA), chondrocostal graft interposition, autologous fat injection, and manufactured implant use. These findings supported by low-quality evidence revealed moderately or largely superior effects of the following interventions: (1) trapeziectomy over T+LRTI using ½ flexor carpi radialis (FCR) and metacarpal tunnel (MT) or using abductor pollicis longus (APL) and FCR for adverse events; (2) trapeziectomy over T+TI using palmaris longus (PL) for pain; (3) T+LR with ½FCR-MT over T+LRTI with ½FCR-MT for physical function; (4) trapeziectomy by anterior approach over that by posterior approach for treatment satisfaction and adverse events; (5) T+LRTI using ½FCR-MT over T+TI with PL for pain; and (6) T+HDA over T+LR using APL-MT-FCR for pain, physical function, and adverse events. GraftJacket (Wright Medical Group, Memphis, TN), Swanson (Wright Medical Group, Letchworth Garden City, UK), and Permacol (Tissue Science Laboratories, Aldershot, UK) implants and hardware (plate/screw) would cause more complications than an autograft. The effect estimates of other surgical procedures were supported by evidence of very low quality. Conclusions This SR provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis. Some interventions showed a moderate-to-large superior effect on the studied outcome(s) compared with others. However, these findings must be interpreted with caution because of low-quality evidence. To provide stronger evidence, more randomized controlled trials and methodological uniformization are needed. Type of study/level of evidence Therapeutic I.

Background Little is known about long-term bone mineral density (BMD) changes and fractures in lung transplant recipients with cystic fibrosis (CF). We examined femur and lumbar spine (LS) BMD changes in men and women with CF up to 10 years post-transplant and documented post-transplant fracture prevalence. Methods Retrospective study of individuals who had undergone a lung transplant (2000–2015) and had a pre-transplant and at least one BMD measurement after transplant. Vertebral fractures were assessed on chest computed tomography scans and other fractures abstracted from medical records. Results The cohort consisted of 131 individuals; 53% males, median age: 28 years [interquartile range: 24–35] and 31% having pre-transplant low bone mass. Most recipients were given bisphosphonates after transplant with proportion reaching 94% at 10 years. Up to 10 years post-transplant, men experienced positive or little change in LS BMD, indicating minimal loss from pre-transplant values. In contrast, women displayed negative changes in BMD up to 5 years post-transplant before recovering pre-transplant BMD values by 10 years. Similar patterns were observed at the femur BMD where men demonstrated a lower bone loss and faster recovery towards pre-transplant values than women. After transplant, 88% of recipients maintained their pre-transplant bone status, 3% experienced an improvement, mostly progressing from low bone mass to normal status whereas 9% had a deterioration of their pre-transplant bone status. Twenty-seven recipients suffered fractures in the post-transplant period. Conclusions These findings underline that lung recipients with CF remain at risk of skeletal fragility despite prompt initiation of post-transplant anti-osteoporosis therapy.

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy.This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy-guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0 years; SD 8.8 years; range 26-61 years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1 years; SD 11.2 years; range 29-72 years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models.During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p .001) space was a predictor of therapeutic efficacy but not in the foraminal (p = .54), epidural (p = .89), or retrodural (p = .75) space.TFSI and IFSI led to preferential extraforaminal and retrodural injectate spread, respectively. Targeting the extraforaminal or juxta-articular facet space improved the clinical efficacy of steroid injections when treating cervical radiculopathy.• During intra-articular facet injection, the injectate spreads from the facet joint to the retrodural space and rarely reaches the epidural and/or foraminal spaces. • Epidural spread of the injectate during an anterolateral transforaminal steroid injection is the least effective for pain relief in patients with cervical radiculopathy. • Injection techniques targeting the extraforaminal or juxta-articular facet space are safer than transforaminal injections and effectively relieve pain in patients with cervical radiculopathy.

Traumatic and overuse hip injuries occur frequently in amateur and professional athletes. After clinical assessment, imaging plays an important role in diagnosis and in defining care management of these injuries. Ultrasonography (US) is being increasingly used in assessment of hip injuries because of the wide availability of US machines, the lower cost, and the unique real-time imaging capability, which allows both static and dynamic evaluation as well as guidance of point-of-care interventions such as fluid aspiration and steroid injection. Accurate diagnosis of hip injuries is often challenging, given the complex soft-tissue anatomy of the hip and the wide spectrum of injuries that can occur. To conduct a skillful US evaluation of hip injuries, physicians must have pertinent knowledge of the normal anatomy and should make judicious use of surface anatomy landmarks while using a compartmentalized diagnostic approach. In this article, common sports-related injuries of the anterior, lateral, and posterior hip compartments are discussed. This review includes assessment of joint effusion, acetabular labral tear, acute and chronic tendon injuries including tendinopathy, partial and full-thickness tears, snapping hip syndromes, relevant US-guided procedures, and some other conditions such as Morel-Lavallée lesion and perineal nodular induration. Principles of care management and current knowledge on imaging findings that may affect return to activity are also presented. Using an oriented US examination technique and having knowledge of the normal hip anatomy will help physicians characterize US findings of common sports-related hip injuries and make accurate diagnoses. Online supplemental material is available for this article.

Objective The aim of this study was to determine the relationship between rotator cuff tear (RCT) morphologic parameters and muscle atrophy and fatty infiltration, and patient-reported outcome measures, in patients with symptomatic full-thickness RCT. Methods Rotator cuff tear location, length, width, thickness, and musculotendinous junction position were assessed in 57 magnetic resonance imaging scans and correlated to the outcome measures using multivariate regression analysis. Results Supraspinatus tendon tear length (odds ratio [OR], 2.218; 95% confidence interval [CI], 1.460-3.370), supraspinatus musculotendinous junction position (OR, 2.037; 95% CI, 1.322-3.137), and infraspinatus tendon tear width (OR, 2.371; 95% CI, 1.218-4.615) were identified as the strongest determinants of supraspinatus muscle atrophy, supraspinatus muscle fatty infiltration, and infraspinatus muscle fatty infiltration, respectively. Conclusions The extent of supraspinatus tendon and musculotendinous junction retraction influences the development of supraspinatus muscle atrophy and fatty infiltration, whereas the extent of infraspinatus tendon tear width influences the development of infraspinatus muscle fatty infiltration. Morphologic parameters defining RCT at magnetic resonance imaging did not correlate with clinical shoulder function scores.

© 2020 American Congress of Rehabilitation Medicine Objectives: To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults. Data Sources: A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website. Study Selection: Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers. Data Extraction: CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: “essential,” “recommended,” “may be recommended,” and “not recommended.” Data Synthesis: Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization. Conclusions: Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted.

OBJECTIVE To synthesize the literature on the efficacy of existing nonsurgical interventions for trapeziometacarpal (TM) osteoarthritis (TMO). METHODS A medical librarian conducted an electronic search in 16 databases. Two authors independently carried out study selection, data extraction, and risk-of-bias assessment. The Agency for Healthcare Research and Quality guidance was followed to integrate a valid body of evidence from the existing systematic reviews. Intervention effects were estimated based on the Cochrane Collaboration review methodology. RESULTS We identified 17 systematic reviews, 34 randomized controlled trials (RCTs), and 6 nonrandomized controlled trials. Most of the studies had unclear or high risk of biases. Evidence of low-to-moderate quality supports the superiority of the following interventions for pain and/or physical function: 1) saline over steroid intraarticular injections confirmed by radiography, 2) saline injections over sham (i.e., pressure) in tender subcutaneous areas, 3) custom-made thermoplastic thumb orthosis over no intervention or a control, 4) custom-made thermoplastic hand-based TM joint orthosis over no intervention, 5) radial nerve mobilization over sham ultrasound, and 6) a combination of hand exercises and TM joint and median/radial nerve mobilization over sham ultrasound. CONCLUSION This comprehensive systematic review allowed collating evidence-based data on the efficacy of nonsurgical interventions for TMO. Steroid intraarticular injections would not be more effective than saline injections. Rehabilitative interventions (orthosis, exercises, nerve mobilization) would be efficacious. However, these findings must be treated with circumspection due to methodologic limitations in many studies.

Lateral epicondylosis (LE) of the elbow is a common syndrome found among working-age individuals, leading to degenerative changes of the common extensor tendon (CET). Ultrasound (US) is well suited for the investigation of LE because of its relative affordability and good spatial resolution. Among quantitative ultrasound (QUS) imaging techniques, homodyned-K (HK) statistical modeling of the echo envelope aims at characterizing tissue microstructures. The goal of this study was to assess the potential of HK parameters in detecting LE. In this prospective study, 30 LE elbows in 27 patients and 24 asymptomatic elbows in 13 volunteers underwent US imaging of the CET and radial collateral ligament (RCL). After US imaging examination per clinical standard practice, a long-axis, 3-second loop of a radiofrequency US image sequence of the CET and RCL was acquired using a Terason t3000 US scanner (Teratech, Burlington, MA) equipped with a linear 12L5-MHz transducer. Three statistical parameters based on HK modeling were estimated on the CET region-of-interest: 1) mean intensity normalized by its maximum value; 2) reciprocal 1/α of the scatterer clustering parameter; 3) coherent-to-diffuse signal ratio k. Moreover, HK parametric maps were calculated on the CET-RCL region based on local estimation of the same parameters, from which were extracted additional features, as well as area of the two regions. Random forest classifier modeling identified the most discriminating combination of 3 features or less. The best combination of features was: CET global estimate of 1/α, CET-RCL area, and inter-quartile range of local estimate of k. The area under the receiver operating characteristic curve, sensitivity, and specificity of the QUS-based model were 0.82 (95% confidence interval [CI], 0.80–0.85), 0.73, and 0.79, respectively. These values are comparable with values obtained in a meta-analysis: pooled sensitivity of 0.82 (95% CI, 0.76–0.87) and pooled specificity of 0.66 (95% CI, 0.60–0.72) when using US in the diagnosis of suspected LE.

OBJECTIVES To assess the prevalence of sonographic visualization of the rotator cable in patients with symptomatic full-thickness rotator cuff tears and asymptomatic controls and to correlate rotator cable visualization with tear size, muscular fatty infiltration and atrophy, and the functional outcome in the patients with rotator cuff tears. METHODS Fifty-seven patients with rotator cuff tears and 30 asymptomatic volunteers underwent shoulder sonography for prospective assessment of the rotator cable and rotator cuff tear and responded to 2 functional outcome questionnaires (shortened Disabilities of the Arm, Shoulder, and Hand [QuickDASH] and Constant). In the patients with rotator cuff tears, appropriate tests were used to correlate rotator cable visualization with the tear size, functional outcome, muscular fatty infiltration, and atrophy. RESULTS The patients with rotator cuff tears included 25 women and 32 men (mean age,57 years; range, 39-67 years), and the volunteers included 13 women and 17 men (mean age, 56 years; range, 35-64 years). The rotator cable was identified in 77% (23 of 30) of controls and 23% (13 of 57) of patients with rotator cuff tears. In the patients, nonvisualization of the rotator cable correlated with larger tears (P < 0.001) and higher grades of supraspinatus atrophy (P = .049) and fatty infiltration (P = .022). There was no significant correlation with functional outcome scores (QuickDASH, P = .989; Constant, P = .073) or infraspinatus fatty infiltration (P = .065). CONCLUSIONS Nonvisualization of the rotator cable was more prevalent in patients with symptomatic rotator cuff tears than asymptomatic controls and was associated with a larger tear size and greater supraspinatus fatty infiltration and atrophy. Diligent assessment of the supraspinatus muscle should be done in patients with rotator cuff tears without a visible rotator cable, as the integrity of these anatomic structures may be interdependent.

Background:Trapeziometacarpal osteoarthritis (TMO) is one of the most debilitating forms of hand osteoarthritis (OA). According to the recent EULAR guidelines1, 2and a systematic review,3the efficacy of topical/oral non-steroid anti-inflammatory drugs (NSAIDs), orthoses, hand exercises, and psychosocial interventions for hand OA or TMO are supported by scientific evidence. Cortisone injections and acetaminophen are generally not recommended.1, 3Besides, TMO management is suboptimal: only 21% of patients receive rehabilitative interventions prior to referral to hand surgeons.4Objectives:We aimed at documenting the types of treatment TMO patients employ and their healthcare resource use.Methods:A total of 227 TMO patients recruited from 16 healthcare institutions completed a questionnaire about 1) received interventions, 2) analgesic strategies, and 3) healthcare professional consultations.Results:Acetaminophen (64.3% of the participants), oral NSAIDs (31.7%), topical NSAIDs (11.9%), and nutraceuticals (7.9%) were the most commonly used medications. More than 70% of the participants reported having received cortisone injection(s) (72.5%) and orthosis (75.7%). More than half employed hand exercises, massage and heat/cold application. Relaxation/respiration, meditation, distraction, assistive devices, and joint protection principles were used by smaller percentages of participants (13.0-30.9%). Patients with TMO reported having consulted various types of healthcare professionals: family physicians, plastic/orthopaedic surgeons, radiologists-interventionists, rheumatologists, physiatrists, occupational/physical therapists, osteopaths, chiropractors, pharmacists, and acupuncturists. Only 4.8% of the participants reported having received psychosocial interventions.Conclusion:TMO patients use numerous types of modalities to relieve their pain. Provision of evidence-based interventions tailored to their needs is clearly needed.References:[1] Kloppenburg M, Kroon FP, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis.Annals of the rheumatic diseases.2019;78:16-24.[2] Geenen R, Overman CL, Christensen R, et al. EULAR recommendations for the health professional’s approach to pain management in inflammatory arthritis and osteoarthritis.Annals of the rheumatic diseases.2018;77:797-807.[3] Hamasaki T, Laprise S, Harris PG, et al. Efficacy of non-surgical interventions for trapeziometacarpal (thumb base) osteoarthritis: A systematic review.Arthritis Care & Research.2019; In press (https://doi.org/10.1002/acr.24084).[4] Gravås EMH, Tveter AT, Nossum R, et al. Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis - a cross-sectional study.BMC musculoskeletal disorders.2019;20:180-180.Acknowledgments:This study was supported by a discretionary fund of the Centre de recherche du CHUM (CRCHUM) to Choinière and from theMultidisciplinary Council of the CHUM. Hamasaki was supported by a Doctoral training award of the Fonds de recherche du Québec—Santé, a doctoral scholarship from the CHUM Foundation to Harris (Hand Surgery Branch) and from Choinière’s internal funds of the CRCHUM.Disclosure of Interests:None declared

OBJECTIVE. The purpose of this article is to show the sonographic anatomy of the extremities relevant to various ligamentous, tendinous, and articular injuries occurring in the hand, wrist, and ank...

Objectives To compare the accuracy of homodyned K quantitative ultrasound (QUS) with that of B-mode and Doppler ultrasound imaging for discriminating between lateral epicondylosis (LE) and asymptomatic elbows. Methods This prospective study received Institutional Review Board approval, and participants provided written informed consent. Between February 2015 and March 2017, 30 LE elbows in 27 patients and 24 asymptomatic elbows in 13 volunteers underwent B-mode, Doppler, and radiofrequency ultrasound imaging of the common extensor tendon (CET) and radial collateral ligament (RCL). Two readers classified the elbows independently on the basis of a review of B-mode and Doppler images. The global and local estimates of QUS parameters (μ n , 1/α, and k) were computed in the CET and CET-RCL regions, respectively, and the area of each region was calculated. A random-forest classifier identified the most discriminating 3-parameter combination: CET global estimate of 1/α, CET-RCL area, and local estimate of k. Results The patients with LE had a mean age of 50 years (range, 31-66 years), and the volunteers had a mean age of 50 years (range, 37-57 years). The area under the receiver operating characteristic curve, sensitivity, and specificity of reader 1, reader 2, and the QUS-based model were 0.80 (95% confidence interval [CI], 0.66-0.95), 0.72 (95% CI, 0.56-0.89), and 0.88 (95% CI, 0.72-1.04); 0.79 (95% CI, 0.66-0.93), 0.65 (95% CI, 0.47-0.82), and 0.84 (95% CI, 0.67-1.01); and 0.82 (95% CI, 0.80-0.85), 0.73, and 0.79, respectively. Conclusions An automated, computer-based QUS technique diagnosed LE with accuracy of 0.82. This technique could provide quantitative biomarkers for the characterization of LE disease.

Background Biomechanical and clinical parameters contribute very closely to functional evaluations of the knee joint. To better understand knee osteoarthritis joint function, the association between a set of knee biomechanical data and a set of clinical parameters of an osteoarthritis population (OA) is investigated in this study. Methods The biomechanical data used here are a set of characteristics derived from 3D knee kinematic patterns: flexion/extension, abduction/adduction, and tibial internal/external rotation measurements, all determined during gait recording. The clinical parameters include a KOOS questionnaire and the patient’s demographic characteristics. Canonical correlation analysis (CCA) is used (1) to evaluate the multivariate relationship between biomechanical data and clinical parameter sets, and (2) to cluster the most correlated parameters. Multivariate models were created within the identified clusters to determine the effect of each parameter’s subset on the other. The analyses were performed on a large database containing 166 OA patients. Results The CCA results showed meaningful correlations that gave rise to three different clusters. Multivariate linear models were found explaining the subjective clinical parameters by evaluating the biomechanical data contained within each cluster. Conclusion The results showed that a multivariate analysis of the clinical symptoms and the biomechanical characteristics of knee joint function allowed a better understanding of their relationships.

PURPOSE To evaluate if synovial inflammation and hypervascularization are present in a dog model of knee osteoarthritis and can be detected on conventional magnetic resonance imaging (MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), contrast-enhanced magnetic resonance imaging (CE-MRI), and quantitative digital subtraction angiography (Q-DSA) imaging. MATERIALS AND METHODS Six dogs underwent MRI and angiography of both knees before and 12 weeks after right knee anterior cruciate ligament injury. Synovial vascularity was evaluated on CE-MRI, DCE-MRI, and Q-DSA by 2 independent observers. Synovial inflammation and vascularity were histologically scored independently. Cartilage lesions and osteophytes were analyzed macroscopically, and cartilage volumetry was analyzed by MRI. Vascularity and osteoarthritis markers on imaging were compared before and after osteoarthritis generation, and between the osteoarthritis model and the control knee, using linear mixed models accounting for within-dog correlation. RESULTS In all knees, baseline imaging showed no abnormalities. Control knees did not develop significant osteoarthritis changes, synovial inflammation, or hypervascularization. In osteoarthritis knees, mean synovial enhancement score on CE-MR imaging increased by 13.1 ± 0.59 (P < .0001); mean synovial inflammation variable increased from 47.33 ± 18.61 to 407.97 ± 18.61 on DCE-MR imaging (P < .0001); and area under the curve on Q-DSA increased by 1058.58 ± 199.08 (P = .0043). Synovial inflammation, hypervascularization, and osteophyte formations were present in all osteoarthritis knees. Histology scores showed strong correlation with CE-MR imaging findings (Spearman correlation coefficient [SCC] = 0.742; P = .0002) and Q-DSA findings (SCC = 0.763; P < .0001) and weak correlation with DCE-MR imaging (SCC = -0.345; P = .329). Moderate correlation was found between CE-MR imaging and DSA findings (SCC = 0.536; P = .0004). CONCLUSIONS In this early-stage knee osteoarthritis dog model, synovial inflammation and hypervascularization were found on imaging and confirmed by histology.

Background Trapeziometacarpal osteoarthritis (TMO) is a highly prevalent, painful, and debilitating disorder. Unfortunately, TMO management remains suboptimal and this is in part due to the lack of knowledge on evidence-based care management. The aim of this systematic review (SR) is to document the efficacy of existing surgical interventions for reducing TMO pain. Methods We performed this SR according to the Cochrane intervention review methodology. Trials and SRs assessing surgical intervention efficacy on TMO were identified via 16 databases and hand search via the included references. Studies selection, data extraction and methodological quality assessment were conducted by two independent reviewers. Effect estimates of interventions were extracted from SRs when available, otherwise estimated from randomised controlled trials (RCTs). If RCTs were not available, non-RCTs (NRCTs) were referred to. Characteristics and efficacy of interventions were quantitatively analysed. In addition, we rated the level of evidence quality by using the GRADE tool. Results A total of 8 SRs, 16 RCTs and 41 NRCTs were identified. Most of these studies had unclear to high risk of biases which may have compromised their results. More than 40 comparisons of different surgical interventions were identified, including arthroscopic debridement (AD) (n=2 studies); 1 st metacarpal osteotomy (n=3); resection of 1 st metacarpal/trapezium (R) (n=3); arthrodesis (A) (n=14); trapeziectomy (T) (n=16); hematoma distraction arthroplasty (n=5); ligament reconstruction (LR) (n=5); tendon interposition (TI) (n=13); LRTI (n=17); and manufactured implants - Arex (n=1), Artelon (n=7), chondrocostal autograft (n=4), De la Caffiniere (n=5), Elektra (n=5), Graftjacket (n=1), Gore-Tex (n=6), Guepar (n=3), Ledoux (n=2), Maia (n=1), Marlex (n=5), porcine dermal collagen xenograft (n=2), pyrocarbon Pi 2 (n=5), PyroDisk (n=1), Pyrocardan (n=1), and Swanson (n=11). The effect sizes of most of the interventions were small (standardised mean differences 0.04–4.81, risk ratios 1.05–11.1) and/or their 95% confidence intervals included null value. Nonetheless, the superiority of the following interventions was supported by the evidence of very low to moderate quality: AD over conservative interventions; R+GraftJacket over R; A over R, T+TI and T+LRTI; partial T+chondrocostal autograft over T; T over T+porcine xenograft; T+TI over Artelon; T+LRTI+ bone tunnel over T+LRTI without tunnel for a short-term period; T+LRTI over T+LRTI+ Mitek anchor suture; T+Elektra over T+TI; PyroDisk over Pyrocardan. Conclusions This SR allowed collating comprehensive evidence on the efficacy of surgical interventions for TMO pain. Based on the available scientific evidence, arthrodesis appears superior to other interventions (R, T+TI and T+LRTI) to alleviate pain, however, adverse effects (e.g., nonunion) have been reported. Thus, it goes without saying that when choosing a proper surgical intervention for TMO, not only its analgesic effects but also the risk and gravity of adverse effects must be taken into consideration. Disclosure of Interest None declared

Background Different diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists. Methods A systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies. Results Diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it. Conclusions Our results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

Study Design Clinical commentary. Introduction Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options. Purpose The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF. Methods/Results/Discussion N/A for clinical commentary. Conclusions The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation. Level of Evidence 5.

It is generally recognized that the middle deltoid muscle fibers (MDMF) have an elevating effect on the humeral head at small abduction angles. These forces are normally counterbalanced by the coaptation effect of the rotator cuff (RC) muscles to maintain shoulder stability. With RC tears, this balance may be jeopardized leading to shoulder dysfunction. Conversely, not all patients with RC tears develop shoulder dysfunction. The purpose of this study was to investigate the coaptation/elevation forces (CEF) ratio of the MDMF in RC tears subjects and in volunteers, using magnetic resonance imaging (MRI).Magnetic resonance imaging images in 10 subjects with RC tears and in five volunteers were used to build a three-dimensional model of the shoulder. The CEF ratio of the MDMF was estimated by representing the glenohumeral joint as a pulley.The CEF ratio increased from the posterior to the anterior fibers of the MDMF.The median and interquartile range (IQR) of the CEF ratios of the posterior-third, middle-third, anterior-third and anterior-surface segments of the deltoid were: 0.16 (IQR = 0.23), 0.61 (IQR = 0.4), 1.42 (IQR = 0.41), 1.94 (IQR = 0.56) in subjects, and 0.06 (IQR = 0.24), 0.45 (IQR = 0.28), 1.32 (IQR = 1.01), 1.49 (IQR = 0.39) in volunteers. In the subjects, the CEF ratio of the anterior-surface segment was greater than all other segments (P ≤ 0.03).The CEF ratio of the MDMF increased from its posterior segment to its anterior segment, indicating a greater stabilizing effect of the anterior segment both in RC tears subjects and in volunteers. Strengthening of the anterior fibers of the MDMF could potentially improve shoulder function in subjects with RC tears.

Introduction/Background Previous studies shown that mechanical factors can be valuable biomarkers to help as a diagnostic aid, risk indicator of osteoarthritis (OA) progression and to be useful in guiding and monitoring treatments. Since the relationship between radiographic Kellgren-Lawrence (KL) grades and knee biomechanics and is not well understood, the study aims at assessing how knee kinematics differ with increasing KL grade. Material and method This cross-sectional study was carried out in Quebec, Canada primary care clinics. Knee OA patients with KL grade ≥ 2 and with pain ≥ 4/10 were recruited. Sociodemographic characteristics and KOOS were compiled. In-clinic 3D knee kinematics was analyzed using the KneeKG™ system. ANCOVAs were performed on 11 kinematic parameters with age as a covariate due to statistical difference between KL4 and KL2 group. A Bonferroni correction was also applied ( α = 0.05/11 = 0.005). Results Two hundred and ninety-four knee OA patients from 62 clinics participated in the study (62.2% women, mean age 63 ± 9.2) ( Table 1 ). KL grade of the most painful knee was equally distributed (34.4% KL2, 35.7% KL3 and 29.9 KL4). Half of participants had bilateral knee OA (52.0%), therefore, kinematic parameters was evaluated on 437 knees. Worst condition of KL4 group was confirmed by KOOS scores ( Table 2 ). Flexion-extension motion during gait was significantly reduced, translating in a more stiff gait pattern, as KL grade increased. KL4 group also exhibited a strongly accentuated dynamic varus alignment and thrust during gait ( Table 3 ). Conclusion Results show that knee function/kinematics of knee OA patients differ with increasing KL grade severity. This reinforces the value adding a functional assessment in the knee OA episode of care to personalize conservative treatment strategy as the progression of OA evolves.

BackgroundRotator cuff calcific tendinopathy is characterised by the deposition of hydroxyapatite crystals in one of the rotator cuff tendons and can be managed by ultrasound-guided lavage. However, evidence regarding the efficacy of ultrasound-guided lavage for rotator cuff calcific tendinopathy remains inconclusive. The aim of this systematic review and meta-analysis is to update the available evidence on the efficacy of ultrasound-guided lavage in adults with rotator cuff calcific tendinopathy.MethodsA literature search was conducted up to April 2018 in four bibliographic databases to identify randomised control trials that compared ultrasound-guided lavage alone with other interventions to treat rotator cuff calcific tendinopathy. Randomised control trials were assessed with the Cochrane Risk of Bias Tool. Meta-analyses and/or qualitative synthesis of the evidence were performed.ResultsThree randomised control trials were included. Pooled results for pain (n=226) indicated that ultrasound-guided lavage may significantly decrease pain when compared with shockwave therapy, with a mean difference of −1.98 out of 10 points (95% CI −2.52 to −1.45) in the short term and of −1.84 (95% CI −2.63 to −1.04) in the long term. Based on one trial (n=25), ultrasound-guided lavage significantly improved function when compared with shockwave therapy (pConclusionFor individuals with rotator cuff calcific tendinopathy, low-quality evidence suggests that ultrasound-guided lavage is more effective than shockwave therapy or a corticosteroid injection alone. Future trials could modify the present conclusions.Trial registration numberCRD42018095858.

Hip pain is a common clinical presentation of elderly patients in the emergency department. We report the clinical and imaging findings in 4 elderly patients with iliopsoas tendon tears who presented at our institution between October 2009 and June 2010. In 2 patients, the imaging diagnosis was significantly delayed. This injury is uncommon, and the clinical presentation in these patients may be misleading. Magnetic resonance is the imaging modality of choice after radiographs to assess these patients, and knowledge of the complex anatomy of the iliopsoas myotendinous unit helps in making the correct diagnosis. With aging of the population, the incidence of iliopsoas tendon tear is likely to increase.

Corticosteroids are routinely injected into soft tissues, tendon sheaths, bursae, and joints. These anti-inflammatory agents have different potency and solubility, and solubility is inversely correlated with the duration of action. Corticosteroids carry a low risk of complications but commonly cause systemic and local adverse effects. The use of intra-articular corticosteroid injections in the treatment of inflammatory arthritis and osteoarthritis is well established. Evidence also supports the use of injectable corticosteroids in the treatment of inflammatory tenosynovitis and bursitis associated with rheumatic diseases, trigger finger and de Quervain disease, and carpal tunnel syndrome. The role of corticosteroid injections in the management of rotator cuff disease remains unclear. Strong scientific evidence indicates that corticosteroid injections for lateral epicondylosis worsen the long-term outcomes of patients. This review article discusses the considerations related to the use of corticosteroid injections in the management of nonspinal musculoskeletal conditions.