Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty.

INTRODUCTION: Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up. METHODS: Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing. RESULTS: From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28 years postsurgery (median 5 years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC. DISCUSSION: This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC. CONCLUSIONS: A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.

The Norwich Osteoarthritis of the Ankle MRI Score (NOAMS): a reliability study.

AIM: To define and test the inter- and intra-rater reliability of a grading system for staging osteoarthritis (OA) of the ankle with magnetic resonance imaging (MRI) (Norwich Osteoarthritis of the Ankle MRI Score, NOAMS). MATERIALS AND METHODS: The MRI features to be included in the score were defined by a multidisciplinary expert panel through a Delphi process. An anonymised randomised dataset of 50 MRI studies was created from patients with concurrent plain radiographs to include 10 ankles of each of the Kellgren-Lawrence grades 0 to 4. Two experienced musculoskeletal radiologists and two trainees scored each ankle MRI twice independently and blinded to the plain radiographs. RESULTS: The inter-rater kappa coefficient of agreement for cartilage disease was 0.88 (95% confidence interval [CI]: 0.85, 0.91) for experienced raters and 0.71 (95% CI: 0.67, 0.76) for trainees. Inter-rater agreement for subchondral bone marrow oedema and cysts varied from 0.73 to 0.82 for experienced raters and from 0.63 to 0.75 for trainees with lowest 95% CI of 0.48 and 0.63. When bone marrow lesions were combined into a total joint score the level of agreement increased to between 0.88 and 0.97 with lowest 95% CI of 0.86. Combining cartilage zone scores did not increase the reliability coefficients. CONCLUSION: An expert panel considered that cartilage degradation and subchondral bone marrow lesions were the most important features for staging the severity of ankle OA on MRI. Experienced observers can grade the severity of ankle OA on MRI with a clinically useful high degree of reproducibility.

Quantitative MRI in myositis patients: comparison with healthy volunteers and radiological visual assessment.

AIM: To assess whether magnetic resonance imaging (MRI)-based measurements of T2, fat fraction, diffusion tensor imaging, and muscle volume can detect differences between the muscles of myositis patients and healthy controls, and to identify how they compare with semi-quantitative MRI diagnosis. MATERIALS AND METHODS: Sixteen myositis patients and 16 age- and gender-matched healthy controls underwent MRI of their thigh. Quantitative MRI measurements and radiologists' semi-quantitative scores were assessed. Strength was assessed using an isokinetic dynamometer. RESULTS: Fat fraction and T2 values were higher in myositis patients whereas muscle volume was lower compared to healthy controls. There was no difference in diffusion. Muscle strength was lower in myositis patients compared to healthy controls. In a subgroup of eight patients, scored as unaffected by radiologists, T2 values were still significantly higher in myositis patients. CONCLUSIONS: Quantitative MRI measurements can detect differences between myositis patients and healthy controls. Changes in the muscles of myositis patients, undetected by visual, semi-quantitative scoring, can be detected using quantitative T2 measurements. This suggests that MRI T2 values may be useful for the management of myositis patients.

MRI in acute muscle tears in athletes: can quantitative T2 and DTI predict return to play better than visual assessment?

OBJECTIVES: To assess the ability of quantitative T2, diffusion tensor imaging (DTI) and radiologist's scores to detect muscle changes following acute muscle tear in soccer and rugby players. To assess the ability of these parameters to predict return to play times. METHODS: In this prospective, longitudinal study, 13 male athletes (age 19 to 34 years; mean 25 years) underwent MRI within 1 week of suffering acute muscle tear. Imaging included measurements of T2 and DTI parameters. Images were also assessed using modified Peetrons and British athletics muscle injury classification (BAMIC) scores. Participants returned for a second scan within 1 week of being determined fit to return to play. MRI measurements were compared between visits. Pearson's correlation between visit 1 measurements and return to play times was assessed. RESULTS: There were significant differences between visits in BAMIC scores (Z = - 2.088; p = 0.037), modified Peetrons (Z = - 2.530; p = 0.011) and quantitative MRI measurements; T2, 13.12 ms (95% CI, 4.82 ms, 21.42 ms; p = 0.01); mean diffusivity (0.22 (0.04, 0.39); p = 0.02) and fractional anisotropy (0.07 (0.01, 0.14); p = 0.03). BAMIC scores showed a significant correlation with return to play time (Rs = 0.64; p = 0.02), but modified Peetrons scores and quantitative parameters did not. CONCLUSIONS: T2 and DTI measurements in muscle can detect changes due to healing following muscle tear. Although BAMIC scores correlated well with return to play times, in this small study, quantitative MRI values did not, suggesting that T2 and DTI measurements are inferior predictors of return to play time compared with visual scoring. KEY POINTS: • Muscle changes following acute muscle tear can be measured using T2 and diffusion measurements on MRI. • Measurements of T2 and diffusion using MRI are not as good as a radiologist's visual report at predicting return to play time after acute muscle tear.

The use of a synthetic shoulder patch for large and massive rotator cuff tears - a feasibility study.

BACKGROUND: The aim of this study was to explore the feasibility of using a non-absorbable biocompatible polyester patch to augment open repair of massive rotator cuff tears (Patch group) and compare outcomes with other treatment options (Non-patch group). METHODS: Participants referred to orthopaedic clinics for rotator cuff surgery were recruited. Choice of intervention (Patch or Non-patch) was based on patient preference and intra-operative findings. Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and Constant score were completed at baseline and 6 months. Shoulder MRI was performed at baseline and 6 months to assess fat fraction and Goutallier classification pre- and post- treatment. Feasibility outcomes (including retention, consent and missing data) were assessed. RESULTS: Sixty-eight participants (29 in the Patch group, 39 in Non-patch group) were included (mean age 65.3 years). Conversion to consent (92.6%), missing data (0% at baseline), and attrition rate (16%) were deemed successful feasibility endpoints. There was significant improvement in the Patch group compared to Non-patch at 6 months in OSS (difference in medians 9.76 (95% CI 2.25, 17.29) and SPADI: 22.97 (95% CI 3.02, 42.92), with no substantive differences in Constant score. The patch group had a higher proportion of participants improving greater than MCID for OSS (78% vs 62%) and SPADI (63% vs 50%) respectively. Analysis of the 48 paired MRIs demonstrated a slight increase in the fat fraction for supraspinatus (53 to 55%), and infraspinatus (26 to 29%) at 6 months. These differences were similar and in the same direction when the participants were analysed by treatment group. The Goutallier score remained the same or worsened one grade in both groups equally. CONCLUSIONS: This study indicates that a definitive clinical trial investigating the use of a non-absorbable patch to augment repair of massive rotator cuff tears is feasible. In such patients, the patch has the potential to improve shoulder symptoms at 6 months. TRIAL REGISTRATION: ISRCTN, ISRCTN79844053, Registered 15th October 2014 (retrospectively registered).

MRI hip findings in asymptomatic professional rugby players, ballet dancers, and age-matched controls.

AIM: To investigate hip magnetic resonance imaging (MRI) findings in asymptomatic professional male rugby players and male ballet dancers compared to age-matched controls. MATERIALS AND METHODS: After ethics committee approval and consent from participants, 11 professional rugby players, 10 professional ballet dancers, and 10 controls completed activity and symptom questionnaires and underwent 3 T MRI of their self-declared dominant hip. Each scan was independently scored by two musculoskeletal radiologists for multiple features, including: joint morphology, acetabular labrum appearance, cartilage loss, and capsular thickness. Clinical and MRI features were assessed for variance by group using one-way analysis of variance (ANOVA) tests and Tukey post-hoc pairwise comparison of means. RESULTS: Labral tear prevalence was 87% with no significant difference between groups (p>0.05). Rates of paralabral cysts were significantly higher in ballet dancers (50%), compared to rugby players (0%) and controls (10%; p=0.01). Acetabular cartilage loss was present in 54% with no significant differences between groups. Superior capsular thickness was significantly greater in ballet dancers (5.3 mm) compared to rugby players (3.8 mm) and controls (3.8 mm; p=0.03). CONCLUSION: Despite the difference in type of activity between groups, there were equally high rates of labral tears and acetabular cartilage loss, questioning the role that sport plays in the development of these findings and their relationship to symptoms. The focally increased superior capsular thickness in ballet dancers may be an adaptive response to extreme ranges of movement.

Developing a standardized approach to virtual clinic follow-up of hip and knee arthroplasty.

AIMS: This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations. PATIENTS AND METHODS: Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi Consensus Technique. This consisted of an iterative sequence of online surveys, during which virtual documents, made up of a patient-reported questionnaire, standardized radiology report, and decision-guiding algorithm, were modified until consensus was achieved. We tested the patient-reported questionnaire on seven patients in orthopaedic clinics using a 'think-aloud' process to capture difficulties with its completion. RESULTS: A patient-reported 13-item questionnaire was developed covering pain, mobility, and activity. The radiology report included up to ten items (e.g. progressive periprosthetic bone loss) depending on the type of arthroplasty. The algorithm concludes in one of three outcomes: review at surgeon's discretion (three to 12 months); see at next available clinic; or long-term follow-up/discharge. CONCLUSION: The virtual clinic approach with attendant documents achieved consensus by orthopaedic experts, radiologists, and patients. The robust development and testing of this standardized virtual clinic provided a sound platform for organizations in the United Kingdom to adopt a virtual clinic approach for follow-up of hip and knee arthroplasty patients. Cite this article: Bone Joint J 2019;101-B:951-959.

Ultrasound-guided subacromial-subdeltoid bursa corticosteroid injections: a study of short- and long-term outcomes.

AIM: To assess shoulder pain and disability in patients undergoing corticosteroid injection into the subacromial-subdeltoid (SA-SD) bursa under ultrasound guidance, evaluating both short and long-term outcomes. MATERIALS AND METHODS: In this prospective, longitudinal, analytical study 376 patients referred for SA-SD bursa injection during a 6 month period were asked to complete a questionnaire assessing shoulder pain and disability in the form of the Shoulder Pain and Disability Index (SPADI). Patients were reassessed at 6 weeks and 12 months post-injection. Data were collated and analysed based on the diagnosis made at ultrasound. RESULTS: Almost two-thirds (63.6%) of patients irrespective of the underlying diagnosis showed improvement in pain and disability 6 weeks after injection, but this figure decreased significantly after 12 months to 27.3%. There was no significant difference in outcome between patients with a rotator cuff tendon tear and without a tear at 6 weeks; however, there was a difference between these two groups at 12 months with significantly fewer patients with a tear receiving benefit. CONCLUSION: The pattern of good short-term, but poorer long-term outcomes from SA-SD bursa injection is in line with previous studies; however, this study provides additional information on the effect of the underlying diagnosis on the potential outcome, specifically the presence or absence of a rotator cuff tendon tear.

Do ultrasound guided trochanteric bursa injections of corticosteroid for greater trochanteric pain syndrome provide sustained benefit and are imaging features associated with treatment response?

AIM: To assess intra-bursal corticosteroid injections (ICSI) efficacy and duration of action in the management of greater trochanteric pain syndrome (GTPS). The secondary aim was to identify patient and ultrasound (US) features predictive of treatment response. MATERIALS AND METHODS: Consecutive prospectively recruited patients undergoing US-guided ICSI therapy for GTPS received baseline pre-injection questionnaires assessing pain at rest and activity, demographics and comorbidities. Baseline US and radiography findings were reported prospectively. Follow-up was performed at 6 weeks and 6 and 12 months, and change in pain scores assessed using the Wilcoxon signed rank test. Logistic regression examined associations between demographics, US findings, and a clinically significant reduction in pain score (≥50%). RESULTS: Over 6 months, 127 patients were recruited with a median age of 63.5 years and 90% were female. The greatest pain reduction was between baseline and 6 weeks at activity (median 8 versus 5, p<0.001). The majority of patients noted a reduction in pain score, but the percentage of patients receiving a ≥50% reduction at 6 weeks, 6 months, and 12 months for pain at rest was 41%, 37%, and 36%, respectively. Regression models suggested only gluteus medius bursitis was weakly associated with pain reduction. CONCLUSION: ICSIs confer a benefit in pain reduction to a large proportion of patients in the short term, but this may not be reduced by a clinically significant amount. This small effect size and lack of predictive imaging features suggests initial management including subsequent steroid injection could be provided without imaging guidance in the majority of cases.

Comparative reliability and diagnostic performance of conventional 3T magnetic resonance imaging and 1.5T magnetic resonance arthrography for the evaluation of internal derangement of the hip.

OBJECTIVE: To compare the diagnostic accuracy of conventional 3T MRI against 1.5T MR arthrography (MRA) in patients with clinical femoroacetabular impingement (FAI). METHODS: Sixty-eight consecutive patients with clinical FAI underwent both 1.5T MRA and 3T MRI. Imaging was prospectively analysed by two musculoskeletal radiologists, blinded to patient outcomes and scored for internal derangement including labral and cartilage abnormality. Interobserver variation was assessed by kappa analysis. Thirty-nine patients subsequently underwent hip arthroscopy and surgical results and radiology findings were analysed. RESULTS: Both readers had higher sensitivities for detecting labral tears with 3T MRI compared to 1.5T MRA (not statistically significant p=0.07). For acetabular cartilage defect both readers had higher statistically significant sensitivities using 3T MRI compared to 1.5T MRA (p=0.02). Both readers had a slightly higher sensitivity for detecting delamination with 1.5T MRA compared to 3T MRI, but these differences were not statistically significant (p=0.66). Interobserver agreement was substantial to perfect agreement for all parameters except the identification of delamination (3T MRI showed moderate agreement and 1.5T MRA substantial agreement). CONCLUSION: Conventional 3T MRI may be at least equivalent to 1.5T MRA in detecting acetabular labrum and possibly superior to 1.5T MRA in detecting cartilage defects in patients with suspected FAI. KEY POINTS: • Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing labral tears. • Conventional 3T MRI is superior to 1.5T MRA for diagnosing acetabular cartilage defect. • Conventional 3T MRI is equivalent to 1.5T MRA for diagnosing cartilage delamination. • Symptom severity score was significantly higher (p<0.05) in group proceeding to surgery.

Response to Comment on "The extent of forest in dryland biomes".

Griffith et al do not question the quality of our analysis, but they question our results with respect to the definition of forest we employed. In our response, we explain why the differences we report result from a difference of technique and not of definition, and how anyone can adapt-as we did-our data set to any forest definition and tree cover threshold of interest.

Response to Comment on "The extent of forest in dryland biomes".

De la Cruz et al question the reliability of our results, claiming that we do not refer to the most appropriate spatial extent of drylands. In our response, we explain why we chose an existing and internationally recognized delineation of drylands among several options, and why our findings are due to a difference of remote sensing technique and not to the definition of drylands we have selected.

Response to Comment on "The extent of forest in dryland biomes".

Schepaschenko et al question our findings, claiming that we did not refer to all existing maps and that we did not account for all sources of uncertainty. In our response, we detail our selection criteria for reference maps, which clarify why the work of Schepaschenko et al was not used, and we explain why our uncertainty assessment is complete and how it was misunderstood by Schepaschenko et al.

Ultrasound and magnetic resonance imaging assessment of joint disease in symptomatic patients with cystic fibrosis arthropathy.

OBJECTIVES: Cystic fibrosis arthropathy (CFA) is a term commonly used for joint pain with and without swelling seen in some patients with CF. Early studies into CFA focused on the presence of rheumatoid factor and immunological changes on synovial biopsy, with parallels drawn between respiratory and joint activity. Identification of anti-cyclic citrullinated peptide antibodies (anti-CCP) as a marker of rheumatoid arthritis (RA), along with increased access to sensitive imaging techniques including ultrasound (US) and magnetic resonance imaging (MRI), offer great potential to investigate and more accurately understand the type(s) of inflammatory arthritis that may underlie CFA. The aim of this study was to phenotype an active CFA cohort using serology and imaging, as a basis for further work in this understudied area. METHODS: This was a prospective observational cohort study of symptomatic CFA patients presenting with joint pain. Participants underwent serological testing, clinical and US joint and entheseal assessment, as well as MRI of the most symptomatic joint/joint area. RESULTS: Ten symptomatic patients were studied with 9/10 having positive clinical findings. Inflammatory changes on US were seen in 8/10 cases. Five patients had positive findings on MRI (3 of whom had received IV gadolinium contrast). This included patients with significant erosive changes. One patient was anti-CCP positive suggestive of RA, and two were anti-nuclear antibody positive. CONCLUSION: Imaging, and to a lesser extent serology, identified inflammatory joint pathology in a proportion of cases, providing important data to explore in a large CFA cohort examining the clinical and imaging phenotype of this group.

Highlights of the annual scientific meeting of the 22nd congress of the European Society of Musculoskeletal Radiology (ESSR) 2015.

The meeting included a larger-than-usual number of scientific presentations covering a wide range of MSK topics, with new information related to imaging findings, imaging techniques, and interventional procedures. A large number of electronic posters were also available for review by the meeting participants, significantly adding to the educational content of the meeting. These are still available for review on the EPOS database via the ESSR website. The 23rd annual congress of the ESSR will be held in Zurich on June 9-11, 2016 where the main topic will be the knee and ankle.

Can a single isotropic 3D fast spin echo sequence replace three-plane standard proton density fat-saturated knee MRI at 1.5 T?

OBJECTIVE: To assess whether a single isotropic three-dimensional (3D) fast spin echo (FSE) proton density fat-saturated (PD FS) sequence reconstructed in three planes could replace the three PD (FS) sequences in our standard protocol at 1.5 T (Siemens Avanto, Erlangen, Germany). METHODS: A 3D FSE PD water excitation sequence was included in the protocol for 95 consecutive patients referred for routine knee MRI. This was used to produce offline reconstructions in axial, sagittal and coronal planes. Two radiologists independently assessed each case twice, once using the standard MRI protocol and once replacing the standard PD (FS) sequences with reconstructions from the 3D data set. Following scoring, the observer reviewed the 3D data set and performed multiplanar reformats to see if this altered confidence. The menisci, ligaments and cartilage were assessed, and statistical analysis was performed using the standard sequence as the reference standard. RESULTS: The reporting accuracy was as follows: medial meniscus (MM) = 90.9%, lateral meniscus (LM) = 93.7%, anterior cruciate ligament (ACL) = 98.9% and cartilage surfaces = 85.8%. Agreement among the readers was for the standard protocol: MM kappa = 0.91, LM = 0.89, ACL = 0.98 and cartilage = 0.84; and for the 3D protocol: MM = 0.86, LM = 0.77, ACL = 0.94 and cartilage = 0.64. CONCLUSION: A 3D PD FSE sequence reconstructed in three planes gives reduced accuracy and decreased concordance among readers compared with conventional sequences when evaluating the menisci and cartilage with a 1.5-T MRI scanner. ADVANCES IN KNOWLEDGE: Using the existing 1.5-T MR systems, a 3D FSE sequence should not replace two-dimensional sequences.

Hormone-releasing contraceptive implants: our experience of complex removals using preoperative ultrasound.

A known complication of hormone-releasing contraceptive implants is a nonpalpable device at time of intended removal. We report a preprocedure outpatient assessment that includes an ultrasound scan and surface marking. This technique, with avoidance of local infiltration anesthesia, facilitates implant removal and negates the need for concomitant imaging on the day of surgery. The cases we present were referred to our upper limb clinic after previous failed attempts at removal.

Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study.

OBJECTIVES: To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group. METHODS: In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation. FINDINGS: 100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed). CONCLUSIONS: In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention. TRIAL REGISTRATION NUMBER: NCT02012764 at ClinicalTrials.gov.

The responsiveness of novel, dynamic, contrast-enhanced magnetic resonance measures of total knee synovitis after intra-articular corticosteroid for painful osteoarthritis.

OBJECTIVE: Sensitive biomarkers are needed to understand synovial response to therapy in osteoarthritis (OA). Dynamic, contrast-enhanced magnetic resonance imaging (DCE MRI) provides quantitative, novel measures of synovial inflammation. This exploratory study examined DCE-assessed synovial response to intra-articular corticosteroid (IACS). METHODS: People with ACR clinical criteria OA knee underwent 3 T MRI pre- and 2 weeks post-IACS. Five MRI variables were assessed blindly: total synovial volume (semi-automated computer program), early enhancement rate (EER) and late enhancement ratio of the entire knee, synovial volume × late enhancement and a semi-quantitative (SQ) score (six sites scored 0-3). Clinical symptoms were assessed using pain visual analogue score (VAS) and WOMAC. RESULTS: 13 participants (5 male, mean age 63, mean pain VAS 66 mm mean body mass index (BMI) 31.3 kg/m(2)) were included. The majority of MRIs demonstrated no change in SQ score although the DCE variables changed to some extent in all. There was generally a reduction in synovial volume ((Wilcoxon test) median (interquartile range (IQR)) reduction 14 cm(3) (-1, 29)), EER (0.2% (-0.3, 0.6)) and late enhancement ratio (8% (-0.5, 41)). Synovial volume × late enhancement ratio demonstrated a substantive reduction (2250 (-930, 5630)) as well as the largest effect size, r = 0.45. There was a median 26% reduction in EER in participants with good symptomatic response to IACS, contrasting with a 23% increase in those who responded poorly. CONCLUSIONS: DCE MRI may be more sensitive than a SQ score at detecting post-therapy synovial changes. The association between EER and symptomatic response to IACS may reflect a closer relation of this biomarker to synovial inflammation than with volumetric assessment.