Life Expectancy of Patients Undergoing Total Knee Arthroplasty: Comparison With General Population.

BACKGROUND: This study aimed to analyze the life expectancy and cause of death in osteoarthritis (OA) patients who underwent total knee arthroplasty (TKA) and to identify risk factors that affect long-term mortality rate after TKA. METHODS: Among 601 patients, who underwent primary TKA due to OA by a single surgeon from July 2005 to December 2011, we identified patients who died after the operation using data obtained from the National Statistical Office of Korea. We calculated 5-, 10-, and 15-year survival rates of the patients and age-specific standardized mortality ratios (SMRs) compared to general population of South Korea according to the causes of death. We also identified risk factors for death. RESULTS: The 5-year, 10-year, and 15-year survival rates were 94%, 84%, and 75%, respectively. The overall age-specific SMR of the TKA cohort was lower than that of the general population (0.69; P < 0.001). Cause-specific SMRs for circulatory diseases, neoplasms, and digestive diseases after TKA were significantly lower than those of the general population (0.65, 0.58, and 0.16, respectively; all P < 0.05). Male gender, older age, lower body mass index (BMI), anemia, and higher Charlson comorbidity index (CCI) were significant factors associated with higher mortality after TKA. CONCLUSION: TKA is a worthwhile surgery that can improve life expectancy, especially from diseases of the circulatory system, neoplasms, and digestive system, in patients with OA compared to the general population. However, careful follow-up is needed for patients with male gender, older age, lower BMI, anemia, and higher CCI, as these factors may increase long-term mortality risk after TKA. LEVEL OF EVIDENCE: III.

Maintenance of the joint line and posterior condylar offset are the most notable variables for successful outcomes of revision total knee arthroplasty.

INTRODUCTION: Controversy regarding which variables should be prioritized for better outcomes in revision total knee arthroplasty (RTKA) exists. This study aimed to comprehensively analyze the variables affecting RTKA outcomes. MATERIALS AND METHODS: We retrospectively identified 87 RTKAs in 82 patients who were performed between March 2014 and February 2020. Range of motion (ROM), including flexion contracture (FC) and further flexion (FF), was analyzed according to the covariates. The covariates included mode of failure, joint line position, anteroposterior (AP) position, rotational alignment of the femoral component, and patellofemoral alignment. The differences between the final follow-up values of each RTKA variable and those of the native knee were evaluated. The clinical outcomes were evaluated. RESULTS: No significant differences were observed between the joint line positions of the RTKA and native knees. The patellar and AP positions of the femoral component were restored to pre-TKA values. The femoral component had an external rotation of 2.78° compared with the native knee. In multivariable stepwise regression analysis, restoration of the adductor tubercle joint line and posterior condylar offset (PCO) were significant variables affecting ROM. Septic RTKA (33 knees) resulted in poor FF outcomes (p = 0.030) and Western Ontario and McMaster Universities Osteoarthritis Index stiffness (WOMAC S) scores (p < 0.001), compared with aseptic RTKA (54 knees). CONCLUSIONS: Restoration of the joint line position and PCO are crucial factors for improved ROM in RTKA. Joint line elevation in RTKA resulted in worse ROM than joint line lowering. In addition, RTKA due to septic failure had inferior ROM and WOMAC S scores compared with RTKA due to aseptic failure. LEVEL OF EVIDENCE: Level III, cohort study.

How Does the Subchondral Bone Density Distribution of the Distal Humerus Change Between Early and Advanced Stages of Osteoarthritis?

BACKGROUND: The distribution of subchondral bone density in a joint represents stress that is applied to the joint. Knowing this information is important for understanding the pathophysiology of osteoarthritis (OA). In the elbow, however, this has not been studied before. QUESTIONS/PURPOSES: (1) Is advanced-stage elbow OA associated with more radially distributed subchondral bone density than earlier stages? (2) What demographic (age and sex) and radiographic (osteophyte location and carrying angle) factors are associated with increased radial shift in subchondral bone density? METHODS: Between March 2001 and December 2021, we treated 301 patients for elbow OA. We considered patients with plain radiographs and conventional CT scans as potentially eligible. Thus, 68% (206 patients) were eligible; a further 27% (80 patients) were excluded because of a history of any injury or surgery or known inflammatory joint disease, leaving 42% (126 patients) for analysis here. Their mean ± standard deviation age was 60 ± 10 years. Early OA with minimal joint space narrowing and osteophyte formation was found in 33% (42 of 126) of patients, and advanced OA was found in the remaining 67% (84 of 126). Three-dimensional distal humerus subchondral bone models were derived from CT images, and in the central intra-articulating portion, we measured the subchondral bone density in two different sites: where it articulates with the radius (SBDrad) and with the ulna (SBDulna). We further defined the SBDratio as the percent ratio of SBDrad to SBDulna. We also evaluated osteophyte severity based on its size at the radiocapitellar and ulnotrochlear joints, and alignment through measuring the carrying angle on radiographs. To assess interobserver reliability, two orthopaedic surgeons took measurements independently from each other. All measurements had excellent intraoberver and interobserver reliabilities. Then, we compared the subchondral bone parameters between early and advanced OA and performed a multivariable analysis of the factors associated with subchondral bone parameters, including age, sex, osteophyte location, and carrying angle. RESULTS: Radial versus ulna subchondral bone density (SBDratio) was modestly higher in patients with advanced OA (118% ± 17%) than in patients with early OA (109% ± 17%, mean difference 9% [95% CI 2.3% to 15.3%]; p = 0.01). With increasing radial deviation in subchondral bone density, cubitus valgus had a modest association (ß = 0.46 ± 0.23; p = 0.04) and severe osteophytes at the radiocapitellar joint had a large association (ß = 9.51 ± 3.06; p = 0.002). CONCLUSION: According to subchondral bone density distribution, stress concentration was more radially deviated in patients with the advanced stages of elbow OA than in those with the early stages. We also found that an increase in carrying angle is associated with radial deviation of stress. A future study that examines longitudinal changes in the subchondral bone density might be required to confirm changes in stress concentration with OA progression. CLINICAL RELEVANCE: This study gives us insight into the potential pathophysiology of elbow OA in relation to elbow alignment. Although debridement of osteophytes in the ulnotrochlear joint is the most frequently performed procedure in patients with advanced elbow OA, our finding suggests that some patients with an increased carrying angle might benefit from management of the radiocapitellar joint as well, or from being informed of the future development of OA in the radiocapitellar joint, because stress at this site can be increased with the advancement of OA.

Mid-term Results of Revision Total Hip Arthroplasty Using Delta Ceramic-on-Ceramic Bearing.

Background: Delta ceramic-on-ceramic (CoC) articulation affords excellent outcomes in primary total hip arthroplasty (THA). However, the safety and reliability of this bearing in revision THA need more evidence. This study aimed to report complications, radiological changes, clinical results, and survivorship of revision THA using Delta CoC articulation at minimum 5-year follow-up. Methods: We reviewed 118 revision THAs (113 patients: 68 men and 45 women) performed with use of Delta CoC bearing. Their mean age was 58.7 years (range, 30-90 years) and their mean body mass index was 24.6 kg/m2 (range, 15.2-32.5 kg/m2). These patients were followed up for 5-12 years (mean, 7.2 years). We evaluated squeak, grinding sensation, ceramic fracture, dislocation, periprosthetic joint infection (PJI), periprosthetic fracture, prosthetic loosening, ceramic wear, osteolysis, modified Harris hip score (mHHS), and survivorship with any reoperation after the revision as the endpoint. Results: Two patients (1.7%) had grinding sensation, but no patient had ceramic fracture. Reoperations were necessary in 9 hips (7.6%) due to PJIs in 2, stem loosening in 2, cup loosening in 2, recurrent dislocation in 2, and periprosthetic fracture in 1. No hip had measurable wear or osteolysis. The average mHHS improved from 53.3 points before the revision to 82.3 points at the final follow-up. Survivorship was 91.6% (95% confidence interval, 86.3%-96.9%) at 12 years. Conclusions: The Delta ceramic bearing appeared a reliable option for revision THA, showing encouraging mid-term results with acceptable survivorship and a low complication rate.

Presence of Night Pain, Neuropathic Pain, or Depressive Disorder Does Not Adversely Affect Outcomes After Total Knee Arthroplasty: A Prospective Cohort Study.

BACKGROUND: A considerable proportion of patients warranting total knee arthroplasty (TKA) have night pain, neuropathic pain, and/or depressive disorder, which may not be resolved by TKA. This prospective, longitudinal cohort study aimed to document the prevalence of night pain, neuropathic pain, and depressive disorder in patients with advanced knee osteoarthritis undergoing TKA and to determine whether the specific coexisting pain and/or disorder at the time of TKA adversely affected postoperative outcomes. METHODS: In this study, 148 patients undergoing TKA were longitudinally evaluated. The presence of night pain, neuropathic pain (determined using Douleur Neuropathique 4 [DN4]) and depressive disorder (determined using the Patient Health Questionnaire-9 [PHQ-9]) was determined before and 6 weeks, 3 months and 1 year after TKA. In addition, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol-5 Dimension (EQ-5D) scores were assessed before and 1 year after TKA. Potential associations of night pain, neuropathic pain, and/or depressive disorder with pre- and postoperative WOMAC and EQ-5D scores were examined in subgroup analyses. RESULTS: Preoperatively, 72% (n = 106) of patients reported night pain, and the prevalences of neuropathic pain and depressive disorder were 15% and 17%, respectively. Preoperatively, compared with patients without night pain, those with night pain had significantly poorer preoperative WOMAC scores, but no significant difference was seen between groups 1 year after TKA. Preoperatively, the WOMAC, EQ-5D, and EQ-5D health scores of patients with neuropathic pain were not significantly different from those of patients without neuropathic pain, and there was no difference in clinical outcome scores 1 year after TKA between these groups. Preoperatively, the patients with depressive disorder showed significantly poorer preoperative WOMAC, EQ-5D, and EQ-5D health scores than those without depressive disorder, but no significant differences in scores were observed 1 year after TKA between these groups. CONCLUSION: This study revealed a considerable prevalence of night pain, neuropathic pain, and depressive disorder in patients undergoing TKA and that patients with these specific conditions reported poorer functional and quality of life scores preoperatively. However, such adverse effects disappeared after TKA. Our study findings suggest that TKA can provide satisfactory outcomes for patients with these specific conditions.

Effectiveness of Online Video Instruction on Time to Start Ambulation and Duration of Hospital Stay, Satisfaction and Functional Recovery in Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: At the end of 2014, we implemented an online video to inform patients of the entire process from admission to rehabilitation after total hip arthroplasty (THA). In this study, we investigated the effectiveness of online video instruction in THA patients. METHODS: Electronic medical records of 184 patients undergoing THA in 2014 (pre-video group) and 182 patients in 2015 (post-video group) were reviewed. We compared 1) the time to start wheelchair ambulation, 2) walker or crutch ambulation, 3) the length of hospital stay, 4) postoperative satisfaction using visual analogue scale (0-10 points), and 5) modified Harris Hip Score (mHHS) at postoperative 6 weeks. RESULTS: In the post-video group, the time to start wheelchair ambulation (1.8 ± 0.6 vs. 2.4 ± 3.2 days, P = 0.021) and walker/crutch ambulation were faster (2.9 ± 1.2 vs. 3.8 ± 1.0 days, P = 0.016), and the hospital stay was shorter (8.2 ± 4.7 vs. 9.9 ± 7.8 days, P = 0.001) compared to the pre-video group. The visual analogue scale for satisfaction (7.84 ± 1.62 vs. 7.68 ± 1.85 points) and mHHS (89.59 ± 9.47 vs. 89.58 ± 8.59) were similar. CONCLUSION: Online video instruction is an effective tool to expedite ambulation and reduce the hospital stay without compromising the clinical outcome and postoperative complications after THA.

Current Incidence and Future Projection of Periprosthetic Fractures in South Korea: A Study Based on National Claim Database.

OBJECTIVE: To evaluate the current incidence and economic cost and to estimate the future burden of periprosthetic fracture (PF) after joint arthroplasties in South Korea. METHODS: This study was a retrospective registry-based study of patients who were diagnosed as periprosthetic fractures (PFs) in South Korea. Cases of PF from 2010 to 2017 in South Korea using Health Insurance and Review and Assessment (HIRA) database, which contains all medical claims for all South Korean patients, were identified. The operational definitions of PFs were identified from the Electronic Data Interchange (EDI) code of the Korean National Health Insurance Program (KHNIP). The annual incidence and medical costs during the period were calculated and the future increase of PF and its cost were projected through 2030 using generalized linear model with quasi-poisson link. RESULTS: During the 8-year period, 14,456 patients were treated due to PFs. The annual number of patients with PF remarkably increased from 1,322 in 2010 to 2,636 in 2017. The increment was prominent in age groups of 70-79 and ≧80. Total number of patients with PF were 9752 in women and 4704 in men during the study period. Mean personal costs were 1,155.4 USD in women and 1,185.5 USD in men. The total cost of PFs increased from 779,533 USD in 2010 to 3,888,402 USD in 2017. The personal cost of PFs also increased from 589.7 USD in 2010 to 1,475.1 USD in 2017. In 2017, the number of PF patients exponentially increased after 50 years of age especially in women. Estimated with our projection model, the number of PFs will increase by 2.5 times and the cost will increase by 10 times in the next 10 years. CONCLUSION: The incidence and cost of PFs are rising and will represent a serious socioeconomic burden in South Korea.

Physicians' Attitudes on Management of Osteopenia in South Korea.

BACKGROUND: Osteopenia patients have a risk of fracture and may develop osteoporosis. We investigated physicians' management of osteopenia patients in South Korea. METHODS: A survey was conducted using a questionnaire including 6 items: (1) do you think anti-osteoporosis medications are necessary in osteopenia patients?; (2) what is your preference to manage osteopenia patients, except for anti-osteoporosis medications?; (3) what is your indication for the anti-osteoporosis medication in osteopenia patients?; (4) what kind of anti-osteoporosis medication do you prefer to treat osteopenia patients?; (5) do you use bisphosphonates?; and (6) if not, what is the reason for not using?. RESULTS: Among the 173 participants, 150 (86.7%) replied that anti-osteoporosis medications were necessary in osteopenia patients. Indications for the medication were (1) past medical history of pathologic fracture in 85 (49.1%); (2) T-score <-2.5 on dual energy X-ray absorptiometry in 73 (42.2%); (3) previous history of osteoporosis in 44 (25.4%); (4) risk of fracture according to fracture risk assessment tool in 34 (19.7%); and (5) progressive bone loss in 31 (17.9%). One hundred and sixteen (67.1%) favored bisphosphonates, 93 (53.8%) selective estrogen-receptor modulator, and 24 (13.9%) hormone replacement therapy. Thirty-one (17.9%) replied that they do not use bisphosphonates due to (1) restricted reimbursement by the health insurance in 24 (77.4%); and (2) bisphosphonate-related complications in 19 (61.3%). CONCLUSIONS: Most respondents (86.7%) thought anti-osteoporosis medications were necessary in osteopenia patients, but 17.9% of the respondents did not use bisphosphonates. Restricted reimbursement by the national health insurance was the major obstacle against the use of bisphosphonates.

How does geometric change after open-wedge high tibial osteotomy affect anterior cruciate ligament status?

BACKGROUND: Open-wedge high tibial osteotomy (OWHTO) produces three- dimensional (3D) geometric changes. Among them, increased posterior tibial slope (PTS), and altered coronal inclination that induces unintended tibial translation may affect anterior cruciate ligament (ACL) status. The purpose of current study was to evaluate the geometric changes following OWHTO, such as increasing PTS and decreasing tibial subluxation, which may affect the status of ACL. METHODS: From April 2014 to December 2015, a total of 72 knees in 64 patients that underwent OWHTO, second-look arthroscopy, and magnetic resonance imaging (MRI) assessment, were enrolled. Preoperative and postoperative coronal and sagittal translation, joint line orientation angle, the distance between medial femoral notch marginal line and medial tibial spine, and PTS were evaluated. ACL status was arthroscopically graded from grade 1 (best) to 4 (worst). The MRI signal of the graft in three portions (proximal, middle, and distal) was graded from grade 1 (best) to 4 (worst). RESULTS: High grade (3: partial, and 4: complete rupture) was noted in 28 cases (38.9%) at the second-look arthroscopy compared with 10 cases (13.9%) at index arthroscopy. The MRI signal grade significantly increased at follow up MRI compared with preoperative MRI (P<0.01). An increased signal was commonly noted in the middle and distal portions of the graft. CONCLUSIONS: Geometric changes after OWHTO were related to ACL deterioration. The ACL was commonly affected at the middle and distal portions and rarely at the proximal portion. There is a possibility of impingement because of the geometric changes. LEVEL OF EVIDENCE: Level IV.

Comparison of Cervical Sagittal Alignment and Kinematics after Posterior Full-endoscopic Cervical Foraminotomy and Discectomy According to Preoperative Cervical Alignment.

BACKGROUND: The progression of cervical kyphosis due to injury to the facet joints and musculature is a major concern for posterior foraminotomy especially for patients with cervical lordosis of less than 10°. However, cervical hypo-lordosis (cervical lordosis < 10°) may be improved with the alleviation of pain and muscle spasms, which corresponds with the disappearance of a positive Spurling's test. When surgery is necessary, the spontaneous recovery of cervical curvature may be minimally offset using minimally invasive surgical techniques, such as posterior percutaneous endoscopic cervical foraminotomy (P-PECF). OBJECTIVES: The primary objective was to compare the changes in cervical kinematics between patients with cervical lordosis (≥ 10°, group I) and hypo-lordosis (< 10°, group II) after P-PECF. STUDY DESIGN: This study was a retrospective nested case-control study with the IRB No. H-1210-078-434. SETTING: University Medical Center, Seoul, Korea. METHODS: P-PECFs were performed for patients with a radiculopathy due to single-level unilateral cervical foraminal soft-disc herniations or foraminal stenosis with minimal degeneration of the disc/facet joints and a positive Spurling's test. A retrospective nested case-control study was performed for 23 patients with cervical lordosis of ≥ 10° (group I; M:F = 15:8; age, 52.3 ± 9.8 years) and 23 patients with cervical lordosis of < 10°(group II; M:F = 15:8; age, 46.3 ± 12.7 years). P-PECFs were performed using the methods previously reported, and all patients were discharged the next day without limitations on neck motion. The patients were followed at one, 3, 6, and 12 months postoperatively and yearly thereafter. The follow-up period was 25.8 ± 19.6 months. Clinical outcomes were assessed using the visual analogue pain score of arms. The cervical angles (C2-7, tangential method) were measured on neutral (CA), flexion (CAF), and extension (CAE) lateral radiographs, and range of motion (C-ROM) was calculated by conducting a radiological analysis. A linear mixed model was used to assess the linearity of the changes in cervical curvatures during the postoperative 12 months between the groups. RESULTS: Significant reductions in arm pain and negative results on Spurling's test were initially achieved in 21/23 patients in group I and in 23/23 patients in group II with means of 1.7 ± 0.31 months and 1.09 ± 0.09 months, respectively. Using the mixed effect models, the interactions between group and time were significant for the CA (P = 0.004), CAE (P < 0.001), and C-ROM (P < 0.001) but not the CAF (P = 0.392). The CA (adjusted-P < 0.001), CAE (adjusted-P < 0.001), and C-ROM (adjusted-P = 0.046) exhibited significant between-group differences at the pre-operation. However, during the follow-up, these parameters were significantly changed in group II, especially during the postoperative 3 months. The CA, CAE, and C-ROM changed by -11.73°, -19.87°, and 20.32°, respectively. Postoperatively, 17/23 patients in group II and 22/23 patients in group I exhibited cervical lordosis of ≥ 10°. LIMITATIONS: This study was retrospective in design, and the inherent selection bias and limited statistical power should be considered. CONCLUSIONS: Cervical hypo-lordosis less than 10° may not be a contra-indication for P-PECF when the change of cervical curvature is not a structural change. A larger study is necessary to identify prognostic factors. Key words: Alignment, cervical vertebrae, disc, percutaneous, endoscopes, biomechanical phenomena, surgery, lordosis, kyphosis.

Pharmacokinetics and microbiodistribution of 64Cu-labeled collagen-binding peptides in chronic myocardial infarction.

OBJECTIVES: The aim of the study is to evaluate the pharmacokinetics and microbiodistribution of Cu-labeled collagen-binding peptides. METHODS: The affinity constant (KD), association (ka), and dissociation rate constant (kd) for the peptide collagelin or its analog (named CRPA) binding to collagen were measured by biolayer interferometric analysis. Rats (n=4-5) with myocardial infarction or normal were injected intravenously with the Cu-labeled peptides or Cu-DOTA as a control. Dynamic PET imaging was performed for 60 min at 7-8 weeks after infarct. Fluorine-18 fluorodeoxyglucose PET imaging was performed to identify the viable myocardium. To validate the PET images, slices of heart samples from the base to the apex were analyzed using autoradiography and histology. RESULT: The peptides bound to collagen with a KD of ∼0.9 µmol/l. The Cu-peptides and Cu-DOTA accumulated in the infarct area (confirmed by autoradiography and histology images) within 1 min of injection and were excreted rapidly through the renal system. The blood clearance curves were biphasic with elimination half-lives of 21.9±2.4, 26.2±4.6, and 21.2±2.1 min for Cu-CRPA, Cu-collagelin, and the control Cu-DOTA, respectively. The clearance half-lives from the focal fibrotic tissue (24.1±1.5, 25.6±8.0, and 21.4±1.3 min, respectively) and remote myocardium (20.8±0.7, 21.0±5.5, and 19.1±2.4 min, respectively) were not significantly different. The uptake ratios of infarct-to-remote myocardium (1.93±0.18, 2.15±0.38, and 1.88±0.08, respectively) for Cu-CRPA, Cu-collagelin, and Cu-DOTA remained stable for the time period between 10 and 60 min. CONCLUSION: The distribution of the Cu-collagelin probes corresponds to the heterogeneous distribution of expanded extracellular space in the setting of myocardial infarction. The overall washout rate from the fibrous tissue was determined by the slow washout rate (t1/2≥20 min) of the peptides from the extracellular space to the vasculature, not by the dissociation rate (t1/2<2 min) of the Cu-peptides from collagen.

Regional Strain Analysis with Multidetector CT in a Swine Cardiomyopathy Model: Relationship to Cardiac MR Tagging and Myocardial Fibrosis.

PURPOSE: To investigate the use of cine multidetector computed tomography (CT) to detect changes in myocardial function in a swine cardiomyopathy model. MATERIALS AND METHODS: All animal protocols were in accordance with the Principles for the Utilization and Care of Vertebrate Animals Used in Testing Research and Training and approved by the University of Missouri Animal Care and Use Committee. Strain analysis of cine multidetector CT images of the left ventricle was optimized and analyzed with feature-tracking software. The standard of reference for strain was harmonic phase analysis of tagged cardiac magnetic resonance (MR) images at 3.0 T. An animal model of cardiomyopathy was imaged with both cardiac MR and 320-section multidetector CT at a temporal resolution of less than 50 msec. Three groups were evaluated: control group (n = 5), aortic-banded myocardial hypertrophy group (n = 5), and aortic-banded and cyclosporine A- treated cardiomyopathy group (n = 5). Histologic samples of the myocardium were obtained for comparison with strain results. Dunnett test was used for comparisons of the concentric remodeling group and eccentric remodeling group against the control group. RESULTS: Collagen volume fraction ranged from 10.9% to 14.2%; lower collagen fraction values were seen in the control group than in the cardiomyopathy groups (P < .05). Ejection fraction and conventional metrics showed no significant differences between control and cardiomyopathy groups. Radial strain for both cardiac MR and multidetector CT was abnormal in both concentric (cardiac MR 25.1% ± 4.2; multidetector CT 28.4% ± 2.8) and eccentric (cardiac MR 23.2% ± 2.0; multidetector CT 24.4% ± 2.1) remodeling groups relative to control group (cardiac MR 18.9% ± 1.9, multidetector CT 22.0% ± 1.7, P < .05, all comparisons). Strain values for multidetector CT versus cardiac MR showed better agreement in the radial direction than in the circumferential direction (r = 0.55, P = .03 vs r = 0.40, P = .13, respectively). CONCLUSION: Multidetector CT strain analysis has potential to identify regional wall-motion abnormalities in cardiomyopathy that is not otherwise detected using conventional metrics of myocardial function.

Noninvasive imaging of myocardial extracellular matrix for assessment of fibrosis.

PURPOSE OF REVIEW: Myocardial fibrosis is a common feature of many cardiomyopathies, including hypertrophic cardiomyopathy. Myocardial fibrosis has been shown to be reversible and treatable with timely intervention. Although early detection and assessment of fibrosis is crucial, adequate diagnostics are still in development. Recent studies have shown progress on noninvasive imaging methods of fibrosis using cardiovascular magnetic resonance (CMR) and nuclear imaging modalities. RECENT FINDINGS: T1 mapping and extracellular volume mapping (ECV) combined with CMR imaging are cutting edge methods that have the potential to assess interstitial myocardial fibrosis. Recent findings show that ECV measurement can be correlated to the extent of diffuse fibrosis. Comparatively, molecular imaging targets specific biomarkers in the fibrosis formation pathway and provides enhanced sensitivity for imaging early disease. Biomarkers include molecules involved in angiogenesis, ventricular remodeling, and fibrotic tissue formation, whereas collagen targeted agents can directly identify fibrotic tissue in the heart. SUMMARY: This review introduces novel methods of fibrosis imaging that utilize properties of extracellular matrix and its biomarkers. Changes in characteristics and cellular biomarkers of the extracellular space can provide significant information regarding fibrosis formation and its role in cardiomyopathy. Ultimately, these findings may improve detection and monitoring of disease and improve efficiency and effectiveness of the treatment.