Diagnostic Performance of Superb Microvascular Imaging and Other Sonographic Modalities in the Assessment of Lateral Epicondylosis

Evaluating Bone Fracture Healing in a Rabbit Model Using Doppler Imaging Modes, Shear Wave Elastography, X-Ray, and Dual-Energy X-Ray Absorptiometry

OBJECTIVE

This study investigated methods of evaluating the bone fracture healing process using superb microvascular imaging (SMI; two modes color SMI [cSMI] and monochromeSMI [mSMI]), and shear wave elastography (SWE), relative to X-ray, dual-energy X-ray absorptiometry (DXA), and platelet endothelial cell adhesion molecule 1 (PECAM-1) also know as cluster of differentiation 31 (CD-31) staining in a rabbit model.

METHODS

This IACUC-approved study involved eight rabbits that underwent a bilateral fibula osteotomy and were followed for 7 or 21 days (Groups 1 and 2 with 4 rabbits in each). Ultrasound examinations using cSMI, mSMI, and SWE were performed on Days 0, 4, 7, 14, and 21 post-surgery. At the final time point, rabbits had X-ray imaging followed by euthanasia and DXA scan. Finally, the fracture areas underwent decalcification, and specimens were stained with CD-31 for pathological analysis. Ultrasound and X-ray findings were compared using ANOVAs or paired t-tests with CD-31 stains and DXA was used as a reference.

RESULTS

Comparing SMI ultrasound images between the last time points for Group 1 (Day 7) and Group 2 (Day 21) showed no statistical significance difference for cSMI (P = .14) and mSMI (P = .06), similarly when compared with CD-31 stains there was no statistical significance difference for cSMI in Group 2 (P = .13). The SWE ultrasound images from the last time points in Groups 1 and showed no statistical significance difference (P = .33), the same results were then compared with DXA and also showed no statistical significance difference (P = .14). When comparing results of the X-ray images from the last time points for Groups 1 and 2 a statistical significance difference was found (P = .01), and when X-ray images were compared with DXA there was a statistical significance difference (P < .001).

CONCLUSION

Compared with CD-31 stains cSMI on Day 21 was not statistically significant (P = .13). Results comparing SWE with DXA were also not statistically significant (P = .14). These results indicate the potential of using certain ultrasound imaging techniques to monitor the bone fracture healing process.

New Intestinal Ultrasound Score for Assessing Inflammatory Bowel Disease Activity and Identifying Severity

PURPOSE

The purpose of this study is to propose new ultrasound scores to assess inflammatory bowel disease (IBD) activity and to analyze their accuracy in assessing disease severity. In addition to this, to validate that intestinal ultrasound can be used as a follow-up tool for the assessment of IBD.

METHODS

One hundred and thirty-six adult IBD patients who underwent intestinal ultrasound. Patients were divided into two groups based on colonoscopic findings: 93 patients with UC, 43 patients with CD. UC patients and CD patients were divided into active and inactive groups based on colonoscopic findings, respectively. After forming scores, cut-off values, sensitivity, and specificity were calculated using receiver operating characteristic (ROC) analysis, respectively.

RESULTS

Both in UC patients and in CD patients, bowel wall thickness (BWT) and vascular index (VI) were much higher in the active group compared with the inactive group, CEUS mode III, IV, CDFI grades 3-4, fat wrapping, and lost stratification were more likely to imply active disease. In UC patients only, Young's modulus value was much higher in the active group compared with the inactive group.

CONCLUSION

The new intestinal ultrasound scores can be used to assess UC and CD activity and may be useful in identifying severe endoscopic activity in IBD.

Novel Ultrasonographic Evaluation of Microvascular Blood Flow for Non-Operative Management of Uncomplicated Acute Appendicitis in Children: A Prospective Clinical Study

OBJECTIVES

To determine whether superb microvascular imaging (SMI) provides a more precise delineation between reversible and irreversible stages of uncomplicated acute appendicitis managed non-operatively.

METHODS

This prospective clinical study examined pediatric patients with acute appendicitis initially treated non-operatively and evaluated using power Doppler (PD) and SMI. We determined case severity, monitor appendiceal blood flow (BF), and appendicitis reversibility. Complicated cases were excluded. Severity was classified using B-mode as well as PD, or SMI: Grade I, smooth wall/normal BF; Grade IIa, irregular wall/increased BF; Grade IIb, irregular wall/decreased BF; and Grade III, absence of wall/loss of BF.

RESULTS

This study examined a total of 100 patients with acute appendicitis, after excluding 29 patients. All 10 patients with normal BF on PD (Grade I) showed similar BF on SMI (Grade I). Among 29 patients with increased BF on PD (Grade IIa), corresponding increased BF was noted on SMI (Grade IIa), and all these patients showed full recovery. Of the 55 patients showing decreased BF on PD (Grade IIb), 52 showed increased BF on SMI (Grade IIa). The remaining three patients, identified with an impacted appendicolith, showed decreased BF on SMI (Grade IIb) and experienced treatment failure, subsequently developing abscesses. In all six patients with undetectable BF on PD (Grade III), SMI similarly could not detect appendiceal BF (Grade III), and non-operative management failed for these patients.

CONCLUSIONS

SMI offers an objective and effective means of delineating the threshold between reversible and irreversible stages in uncomplicated acute appendicitis following non-operative management.

Multiparametric Ultrasound Assessment of Carpal Tunnel Syndrome: Beyond Nerve Cross-sectional Area

Carpal tunnel syndrome (CTS), the most common mononeuropathy, results from compression of the median nerve within the fibro-osseous carpal tunnel. Diagnosis is typically based on clinical evaluation and confirmed by nerve conduction studies. However, ultrasound (US) has emerged as a valuable noninvasive adjunct for CTS confirmation, offering potential advantages over electrodiagnostic testing in terms of patient comfort and diagnostic accuracy. This review begins with a concise summary of carpal tunnel anatomy and CTS pathophysiology as a foundation for exploring the diverse applications of US in CTS evaluation. B-mode US assessment is presented with a focus on cross-sectional imaging and dynamic evaluations, including the transverse translocation and longitudinal gliding of the median nerve. We also review current methods for assessing vascularization in CTS and explore the usefulness of elastography in CTS evaluation. The advantages and limitations of each US method are elucidated, highlighting their practical utility in clinical practice.

Focal Versus Combined Focal Plus Radial Extracorporeal Shockwave Therapy in Lateral Elbow Tendinopathy: A Retrospective Study

Background: Lateral epicondylitis of the elbow, commonly known as tennis elbow, is a musculoskeletal disorder characterized by pain and degeneration of the common extensor tendon. Despite various treatments, optimal management remains debated. Objective: This study aimed to compare the effectiveness of focal extracorporeal shockwave therapy (F-ESWT) alone versus a combination of focal and radial pressure waves (F-ESWT+R-PW) in treating chronic lateral epicondylitis. Methods: This retrospective observational study included 45 patients diagnosed with chronic lateral epicondylitis divided into two groups based on the treatment received: group A (F-ESWT, n = 23) and group B (F-ESWT+R-PW, n = 22). Both groups underwent three weekly sessions of their respective treatments. Patients were also given a home exercise protocol. Primary outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Patient-Rated Tennis Elbow Evaluation (PRTEE) for pain and functional impairment at baseline (T0), 4 weeks (T1), 12 weeks (T2), and 24 weeks (T3) post-treatment. Secondary outcomes included grip strength and ultrasonographic measurements of common extensor tendon (CET) thickness and vascularization. Results: Significant improvements in VAS and PRTEE scores were observed in both groups at all follow-up points. Group B showed greater pain reduction at T1 (VAS: 3.0 ± 1.6 vs. 4.43 ± 1.47; p < 0.005) and T2 (VAS: p < 0.030) compared to group A. Functional outcomes (PRTEE) also favored group B at T1 (p < 0.030) and in the pain section at T2 (p < 0.020). Grip strength improved similarly in both groups. CET thickness showed no significant differences at T3. Vascularization decreased significantly in both groups, with a non-significant trend favoring group B. Conclusions: The combined F-ESWT+R-PW therapy proved more effective than F-ESWT alone in the short- to mid-term management of chronic lateral epicondylitis, significantly enhancing pain reduction and functional outcomes. The combination of focal and radial pressure waves offers a superior therapeutic approach, leveraging the distinct mechanisms of each modality for better clinical results. Further research is needed to confirm these findings and establish long-term efficacy.

Diagnostic Value of Superb Microvascular Imaging of the Rotator Cuff Interval for the Early Diagnosis of Frozen Shoulder

Purpose

To explore the early diagnostic value of superb microvascular imaging (SMI) features within the rotator cuff gap for frozen shoulder.

Patients and Methods

This prospective study enrolled patients with acute early-stage frozen shoulder seeking treatment at Zhabei Central Hospital in Jing'an District, Shanghai, between July 2021 and December 2022 were enrolled in this study. Healthy controls were collected in a 1:1 ratio from the same hospital's physical examination center. All participants underwent SMI and power Doppler ultrasound (PDUS) of the rotator cuff gap.

Results

The study included 79 patients with frozen shoulder and 77 healthy controls. Compared with the healthy control group, the patient group had a higher proportion of hypoechoic rotator cuff gap (81.0% vs 48.1%, P<0.001), a thicker coracohumeral ligament (2.60±1.01 vs 2.03±0.97, P<0.001), a thicker glenohumeral joint capsule (3.10±0.99 vs 2.46±1.17, P<0.001), and elevated blood grading using SMI (P<0.001) and PDUS (P=0.014). The highest area under the curve (AUC) was observed for SMI blood flow grading (AUC=0.824, 95% CI: 0.755-0.880, P<0.001), resulting in 82% sensitivity and 77% specificity when using a cutoff of 1. SMI blood flow grading was associated with external rotation <30° (P=0.007) and abduction <30° (P=0.013) but not with internal rotation <30° (P=0.630) or flexion <30° (P=0.562).

Conclusion

The grading of SMI blood flow may emerge as a valuable predictive indicator for the early stages of frozen shoulder. This simple ultrasound technique holds the potential to enhance the diagnostic process, enabling early initiation of treatment and potentially improving patient outcomes.

Evaluation of the thyroid gland vascularity during pregnancy using 2-dimensional color Superb Microvascular İmaging vascularization index technique

PURPOSE

We aimed to investigate maternal thyroid parenchymal vascularity with 2-dimensional color superb microvascular imaging vascularization index (2D-cSMIVI) levels and thyroid gland volume in the first, second and third trimesters.

METHODS

This longitudinal prospective study was carried out with participants selected from 30 healthy asymptomatic pregnant women. Ultrasonography (US) for the thyroid gland was performed in each trimester. The vascularization index (VI) values obtained by manually drawing the contours of the thyroid parenchyma in the longutidinal plane, using the free region of interest (ROI) with 2DcSMIVI mode. VI values obtained in each trimester, thyroid hormone levels (TSH, T3, T4) and thyroid volumes were compared.

RESULTS

We have detected that thyroid gland vascularity increased significantly as pregnancy progresses. The mean VI values of thyroid gland in third trimester were significantly higher than first and second trimester (p < 0.001), and the mean VI values of the thyroid gland in the second trimester were significantly higher than first trimester (p < 0.001). During pregnancy, we detected the increase in VI values, TSH levels and thyroid gland volumes.

CONCLUSION

Maternal thyroid gland gray scale findings, parenchymal vascularization, thyroid volumes should be evaluated routinely for the healthy fetal development. 2D-cSMIVI method allows us to evaluate vascularization with quantitative numerical values objectively. We have detected that the VI values and volume of the thyroid gland increases as pregnancy progresses. In the complex situation of pregnancy process, the thyroid gland can be evaluated quantitatively with SMI method effectively.

Assessment of common extensor tendon vascularization using superb microvascular imaging: a potential tool in the evaluation of extracorporeal shock wave therapy and therapeutic ultrasound effectiveness in lateral epicondylitis

BACKGROUND

Lateral epicondylitis, also known as tennis elbow, is the most common elbow pain in the adult age group.

PURPOSE

To evaluate common extensor tendon (CET) vascularity with superb microvascular imaging (SMI) before and after extracorporeal shock wave therapy (ESWT) and ultrasound (US) treatment in patients with lateral epycondylitis and to compare the effects of two different treatments on tendon vascularity.

MATERIAL AND METHODS

Patients with lateral epycondylitis were divided into two groups; 30 patients were treated with ESWT (group 1) and 30 patients were treated with therapeutic US (group 2). We performed a high-frequency (14-MHz) linear array transducer to evaluate tendon anatomy and vascularity before and after treatment in both groups.

RESULTS

The decrease in Patient-Rated Tennis Elbow Evaluation (PRTEE) score after treatment was statistically significant compared to pre-treatment for both groups (P < 0.001). Likewise, the decrease in visual analog scale (VAS) score after treatment was statistically significant compared to pre-treatment for both groups (P < 0.001). A significant difference was found between the CET SMI values of group 1 and group 2 after treatment, according to the chi-square test (P < 0.001). In the post-treatment VAS and PRTEE comparison of both groups, the score reduction in group 1 was higher than in group 2, and this decrease was statistically significant (P < 0.001).

CONCLUSION

We can evaluate CET vascularization with the SMI method as a new potential diagnostic tool in comparing the effectiveness of different treatments in cases of lateral epicondylitis.

The Use of Superb Microvascular Imaging in Evaluating Rheumatic Diseases: A Systematic Review

Background and Objectives: Superb microvascular imaging is an advanced Doppler algorithm that seems to be useful in detecting low-velocity blood flow without using a contrast agent. Increasing evidence suggests that SMI is a more sensitive tool than conventional Doppler techniques for evaluating rheumatic diseases, especially inflammatory arthritis. We aimed to assess the use of SMI in evaluating joints and extraarticular structures. Materials and Methods: Two reviewers independently reviewed the literature to provide a global overview of the possibilities of SMI in rheumatology. Original English-language articles published between February 2014 and November 2022 were identified through database (PubMed, Medline, Ebsco, the Cochrane Library, and ScienceDirect) searching, and analysed to summarise existing evidence according to PRISMA methodology. Inclusion criteria covered original research articles reporting applications of SMI on rheumatic diseases and musculoskeletal disorders secondary to rheumatic conditions. Qualitative data synthesis was performed. Results: A total of 18 articles were included. No systematic reviews fulfilled our inclusion criteria. Most studies focused on characterising the synovial vascularity of rheumatoid arthritis. There have been several attempts to demonstrate SMI's value for evaluating extra-articular soft tissues (fat pads or salivary glands) and large-diameter vessels. The quantitative importance of SMI vascular indices could become a useful non-invasive diagnostic marker. Studies on therapeutic applications are still scarce, and the majority of studies have gaps in reporting the methodology (ultrasound performance technique and settings) of the research. Conclusions: SMI has proved to be useful in characterising low-flow vascularity, and growing evidence indicates that SMI is a non-invasive and lower-cost tool for prognostic assessment, especially in inflammatory arthritis. Preliminary findings also suggest potential interest in evaluating the effect of treatment.

Comparison of conventional Doppler imaging techniques and superb microvascular imaging in determination of vascularization in undescended testes

AIM

Our aim was to gain an idea about testicular injury by comparing the reduced volume, which is one of the indirect indicators of testicular damage in undescended testes, and by evaluating the reduced microvascular blood flow by superb microvascular imaging, and also to determine whether superb microvascular imaging modes could detect microvascular blood flow in more detail in the decreased volume of undescended testes.

MATERIAL AND METHODS

We compared testicular blood flow in undescended testes via conventional Doppler imaging, color superb microvascular imaging, and monochrome superb microvascular imaging techniques with contralateral normally located testis and normal control group. Each sample of testicular tissue was evaluated using a qualitative method. Spot color encoding and linear flow color encoding counts determined in testicular parenchyma were counted separately and expressed as numerical data. The localization of the examined testes in the grayscale was noted (proximal inguinal canal, medial inguinal canal, distal inguinal canal, and scrotal). The volume of undescended testes was calculated automatically via a formula for volume.

RESULTS

Monochrome superb microvascular imaging is significantly superior in visualizing the vascularity of undescended testes compared with color Doppler, power Doppler and color superb microvascular imaging (p = 0.001). Also, undescended testes have a significantly lower blood flow compared with contralateral normal testes (p = 0.001). The volume of undescended testes was significantly lower than the contralateral normal testes.

CONCLUSIONS

The volume, structure and blood flow are indirect signs of testicular damage in undescended testes. Monochrome superb microvascular imaging can detect vascularity in undescended testes better than the conventional Doppler imaging technique and color superb microvascular imaging. Based on our findings, we can report that monochrome superb microvascular imaging can be used to evaluate testicular injury and vascularity of undescended testes.

Quantitative Diagnosis Progress of Ultrasound Imaging Technology in Thyroid Diffuse Diseases

High-frequency ultrasound (HFUS), the imaging modality of choice for thyroid screening, is most commonly used in the study of diffuse thyroid disease (DTD) with Hashimoto's thyroiditis (HT) and Graves' disease (GD). DTD can involve thyroid function and severely affect life quality, so early diagnosis is important for the development of timely clinical intervention strategies. Previously, the diagnosis of DTD relied on qualitative ultrasound imaging and related laboratory tests. In recent years, with the development of multimodal imaging and intelligent medicine, ultrasound and other diagnostic imaging techniques have gradually become more widely used for quantitative assessment of the structure and function of DTD. In this paper, we review the current status and progress of quantitative diagnostic ultrasound imaging techniques for DTD.

Correlation between Body Composition and Inter-Examiner Errors for Assessing Lumbar Multifidus Muscle Size, Shape and Quality Metrics with Ultrasound Imaging

Ultrasound imaging (US) is widely used in several healthcare disciplines (including physiotherapy) for assessing multiple muscle metrics such as muscle morphology and quality. Since measuring instruments are required to demonstrate their reliability, accuracy, sensitivity, and specificity prior to their use in clinical and research settings, identifying factors affecting their diagnostic accuracy is essential. Since previous studies analyzed the impact of sociodemographic but not body composition characteristics in US errors, this study aimed to assess whether body composition metrics are correlated with ultrasound measurement errors. B-mode images of the lumbar multifidus muscle at the fifth lumbar vertebral level (L5) were acquired and analyzed in 49 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, muscle perimeter and mean echo intensity were calculated bilaterally. A multivariate correlation matrix was calculated for assessing the inter-examiner differences with body composition metrics. Results demonstrated excellent reliability (intraclass correlation coefficient, ICC > 0.9) for assessing the muscle cross-sectional area and perimeter, and good reliability for assessing the muscle shape and mean echo intensity (ICC > 0.7). Inter-examiner errors for estimating muscle size were correlated with participants' age (p value, p < 0.01), weight (p < 0.05), total and trunk lean mass (both, p < 0.01) and water volume (p < 0.05). Greater shape descriptors and mean brightness disagreements were correlated with older ages (p < 0.05) and total lean mass (p < 0.05). No correlations between age and body composition metrics were found (p > 0.05). This study found US to be a reliable tool for assessing muscle size, shape and mean brightness. Although aging showed no correlations with body composition changes in this sample, it was the main factor correlated with US measurement errors.

Comparing the clinical application of strain elastography and shear wave elastography for the evaluation of lateral epicondylitis

PURPOSE

This study aimed to compare the diagnostic performance of gray-scale ultrasound (GSU), strain elastography (SE), and shear wave elastography (SWE) for lateral epicondylitis (LE).

METHODS

From November 2018 to March 2021, 87 common extensor tendons (CETs) of 70 patients were evaluated using elbow ultrasound. Patients were divided into two groups: patients with LE and those without lateral elbow pain. GSU, SE, and SWE findings from the two groups were compared, and the diagnostic performance was compared for significant variables.

RESULTS

Among the 70 patients, 41 with 44 CETs were clinically diagnosed with LE, and 29 with 43 CETs had no lateral elbow pain. Hypoechogenicity, calcification, and hyperemia were significantly different. Strain ratio (SR), stiffness, and shear wave velocity (SWV) were also significantly different. The diagnostic accuracy of stiffness and SWV was better than that of other significant findings. Furthermore, there were no superiorities in SR, stiffness, or SWV.

CONCLUSION

Both SE and SWE can be valuable diagnostic tools for diagnosing LE. The diagnostic performances of both SE and SWE were similar in the detection of LE.

ACR Appropriateness Criteria® Chronic Elbow Pain

Chronic elbow pain can be osseous, soft tissue, cartilaginous, and nerve related in etiology. Imaging plays an important role in differentiating between these causes of chronic elbow pain. This document provides recommendations for imaging of chronic elbow pain in adult patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Entrapment of the index finger radial collateral ligament in the metacarpophalangeal joint: A case report

Introduction

Digital collateral ligament injuries are common hand injuries that can cause significant pain and functional impairment. Ultrasonography can be useful in the evaluation of these ligamentous injuries, as it is both cost-effective and allows for easy, dynamic evaluation during imaging.

Case report

We report a rare sonographic finding of an index finger radial collateral ligament injury that was found to have a flap of the ligament entrapped within the metacarpophalangeal joint, which to our knowledge has not been described previously. We correlate this finding with an intraoperative image of the entrapment of the collateral ligament. We also report on the novel application of superb microvascular imaging to aid in the diagnosis of digital collateral ligament injury.

Discussion

This particular injury pattern has not been reported in the literature previously and likely explains the patient's lack of improvement with nonoperative management. Our finding is similar to a Stener lesion seen in a thumb ulnar collateral ligament injury in which the ligament is unable to heal due to entrapment. In addition, using superb microvascular imaging (SMI), we were able to visualize hyperemia to surrounding structures and the ligament itself which suggested an acute injury.

Conclusion

We anticipate that this case report will provide sonographers with knowledge and images of this specific injury pattern to the digital collateral ligaments.

The clinical application of ultrasonography with superb microvascular imaging-a review

Superb microvascular imaging (SMI) is among the latest doppler ultrasound methods. It uses an advanced clutter filter to eliminate artifacts caused by breathing, movement and retains the low-speed blood signals in microvessels. The great advantage of SMI is that it can intuitively detect very slow blood signals in microvessels, providing clinicians with more significant information about flow distribution in the target area. Therefore, it is speculated that SMI has important application value. The purpose of this article is to outline the application of SMI in different parts of the body.

Quantitative assessment of bladder wall vascularity index in children with acute cystitis using superb microvascular imaging

PURPOSE

The purpose of this study was to investigate the effectiveness of the vascularization index (VI) obtained using color superb microvascular imaging (cSMI) technique in assessment of the anterior urinary bladder wall in pediatric patients with acute cystitis (AC).

METHODS

The anterior bladder wall of 157 patients (age range 13-84 months, mean 43.62 ± 17.79 months) whose clinical and laboratory findings were proven of AC and 150 healthy asymptomatic participants (age range 13-84 months, mean 43.88 ± 18.11 months) with normal laboratory values were examined using cSMI. VI measurements were performed by manually drawing the contours of the anterior bladder wall using the free region of interest with 2-dimensional cSMI VI (2DcSMIVI) mode. The quantitative 2DcSMIVI values of the symptomatic group and the asymptomatic group were compared. The correlation between the 2DcSMIVI values and the anterior bladder wall thickness (BWT) were analyzed.

RESULTS

The mean 2DcSMIVI values of the BWT were significantly higher in symptomatic group when compared to the asymptomatic group (p<0.001). AC can be diagnosed with a 93% sensitivity, 92% specificity when 3.25% 2DcSMIVI designated as the cutoff value. There was a significant positive correlation between 2DcSMIVI values and BWT (p<0.001).

CONCLUSION

Two-dimensional cSMI VI can be used effectively in children as an imaging method in the diagnosis of AC.

Superb microvascular imaging (SMI) detects increased vascularity of the torn anterior cruciate ligament

PURPOSE

Ultrasound with superb microvascular imaging (SMI) is a novel microvascular imaging technology which may be useful to assess the vascularity of the torn anterior cruciate ligament (ACL) as a potential measure of healing potential following surgery. This study aimed to quantify the vascularity of the torn and intact ACL using ultrasound with SMI.

METHODS

23 patients (mean age ± standard deviation, 27.1 ± 12.8 years), who were diagnosed with an ACL tear with an intact contralateral ACL were enrolled (ACL injury group). Ten healthy volunteers (36.1 ± 4.9 years) who had intact ACLs in both knees were also recruited (ACL healthy controls). The vascularity of the ACL was assessed using SMI within 15 mm from the tibial insertion in both knees. The amount of the vascular signal was assessed using a semi-quantitative grading scale (vascularity grade: grade 0-3) and a quantified ratio of vascularized area with respect to total area of the region of interest (vascularity ratio).

RESULTS

In the ACL injury group, a significantly higher vascularity grade and ratio were observed in the torn ACL (vascularity grade 0-3: 1, 8, 7, and 7 patients, respectively; vascularity ratio: 1.3 ± 1.4%) than the contralateral intact ACL (vascularity grade 0-3: 21, 1, 1, and 0 patients, respectively; vascularity ratio: 0.1 ± 0.5%) (P < 0.001), whereas no significant difference was observed between both ACLs in the ACL healthy control group.

CONCLUSIONS

SMI was useful to assess the increased vascularity in torn ACL, which may reflect the potential for, or state of, ACL maturation following reconstruction or repair.

LEVEL OF EVIDENCE

Level III.

Evaluation of parenchymal vascularity of the thyroid gland with vascularization index by color superb microvascular imaging in patients with Graves' disease

Aim of the study

To determine the parenchymal vascularity of the thyroid gland with color superb microvascular imaging in patients with Graves’ disease, and compare the vascularization index values with healthy subjects.

Materials and methods

The thyroid glands of 37 patients whose laboratory and clinical findings were consistent with Graves’ disease, and 40 asymptomatic subjects with normal laboratory values, were examined using color superb microvascular imaging. Measurements of the vascularization index were performed with a free region of interest which was drawn along the outer margin of the gland on the color superb microvascular imaging mode. The vascularization index values obtained in the Graves’ disease and control groups were compared. A correlation analysis was performed between the vascularization index values and laboratory and grayscale US parameters.

Results

The median vascularization index value of the thyroid parenchyma in patients with Graves’ disease was significantly higher than in the asymptomatic group [median (min–max); 12 (2.3–32.1) vs 5.04 (1.1–10.8), p <0.001]. When the cutoff value of the vascularization index is determined as 6.3, Graves’ disease can be diagnosed with 83.8% sensitivity and 70% specificity.

Conclusions

The vascularization index obtained with color superb microvascular imaging can be a quantitative indicator of parenchymal vascularity in the diagnosis of Graves’ disease, and serve as a supportive tool.

Superb Microvascular Imaging in Assessment of Synovitis and Tenosynovitis in Juvenile Idiopathic Arthritis

ABSTRACT

The aim of this study is to evaluate the diagnostic utility of superb microvascular imaging (SMI) in assessment of synovitis/tenosynovitis in juvenile idiopathic arthritis in comparison to power Doppler ultrasound. Thirty juvenile idiopathic arthritis cases with active clinical findings and ultrasound features of effusion and/or tenosynovitis were further imaged with power Doppler and SMI. For classification of synovial inflammation, a semiquantitative scale (4 points) adopted by Outcome Measures in Rheumatology was used.A total of 35 knee, 2 hip, 2 ankle, 2 wrist, 2 elbow joints, and 6 flexor hallucis longus/tibialis posterior tenosynovitis were assessed. In knee joint, power Doppler and SMI scales were the same for 23 (65.7%) joints, SMI upgraded scale from 0 to 2 in single joint (2.9%); 1 to 2 (14.3%) in 5 joints; and 2 to 3 (17.1%) in 6 joints. For other joints, power Doppler and SMI scales were the same for 5 (62.5%) joints. Superb microvascular imaging upgraded scale from 1 to 2 (25%) in 2 joints and 1 to 3 (12.5%) in a single joint. For flexor hallucis longus/tibialis posterior tenosynovitis, power Doppler and SMI scales were the same for two cases (33.3%). Superb microvascular imaging upgraded scale from 0 to 2 in two cases (33.3%); and 2 to 3 (33.3%) in 2 cases. There was no case of SMI scale downgraded compared with power Doppler scale.Superb microvascular imaging is a feasible technique in the assessment of synovial inflammation and tenosynovitis in juvenile idiopathic arthritis. Superb microvascular imaging has higher sensitivity compared with power Doppler ultrasound in depiction of increased vascularity.

Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) - A systematic review

BACKGROUND

Reviews on the diagnostic performance of the examination tests for lateral elbow tendinopathy (LET) based on updated context-specific tools and guidelines are missing.

PURPOSE

To review the diagnostic accuracy of examination tests used in LET.

DESIGN

Systematic review following PRISMA-DTA guidelines.

METHODS

We searched MEDLINE, PubMed, CINAHL, EMBASE, PEDro, ScienceDirect, and Cochrane Library databases. The QUADAS-2 checklist was used to assess the methodological quality of the eligible studies. We included diagnostic studies reporting the accuracy of physical examination tests or imaging modalities used in patients with LET.

RESULTS

Twenty-four studies with 1370 participants were identified reporting the diagnostic performance of Ultrasound Imaging (USI) (18 studies), physical examination tests (2 studies) and Magnetic Resonance Imaging (MRI) (4 studies). Most studies (97%) were assessed with "unclear" or "high risk" of bias. Sonoelastography showed the highest sensitivity (75- 100%) and specificity (85- 96%). Grayscale with or without Doppler USI presented poor to excellent values (sensitivity: 53%-100%, specificity: 42%-90%). MRI performed better in the diagnosis of tendon thickening and enthesopathy (sensitivity and specificity: 81%-100%). The Cozen's test reported high sensitivity (91%) while a grip strength difference of 5%-10% between elbow flexion and extension showed high sensitivity (78%-83%) and specificity (80%-90%).

CONCLUSIONS

Cozen's test and grip strength measurement present high accuracy in the diagnosis of LET but are poorly investigated. USI and MRI provide variable diagnostic accuracy depending on the entities reported and should be recommended with caution when differential diagnosis is necessary. Substantial heterogeneity was found in inclusion criteria, operator/ examiner, mode of application, type of equipment and reference standards across the studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020160402.

Advanced Musculoskeletal Ultrasound Techniques: What Are the Applications?

OBJECTIVE. The purpose of this article is to cover technical advances in musculo-skeletal ultrasound from the viewpoint of the radiologist. CONCLUSION. Among the advances in musculoskeletal ultrasound that we highlight the use of ultrahigh-frequency transducers to visualize ever-finer anatomic detail, the expanding practical clinical applications for microvascular imaging, and the use of elastography to predict function and, possibly, healing potential.

Efficacy of superb microvascular imaging of ultrasound for diagnosis of gallbladder lesion

BACKGROUND/PURPOSE

The diagnosis of gallbladder (GB) lesions is occasionally difficult. Recently, superb microvascular imaging (SMI) of ultrasound has been developed as a novel microvascular imaging technique. We evaluated the feasibility of SMI for the diagnosis of GB lesions and compared microvascular imaging between benign and malignant GB lesions.

METHODS

Twenty patients with GB-protruded lesions or wall thickening who underwent SMI from August 2015 to July 2017 were included in this retrospective study. The measured outcomes were the quality of microvascular imaging when compared between normal SMI (N-SMI) and contrast-enhanced SMI (CE-SMI), and the microvascular findings (vascularity, vascular morphology, presence of branching, and presence of caliber change) when compared between benign and malignant GB lesions.

RESULTS

The quality of microvascular imaging of CE-SMI was evaluated as better than that of N-SMI, showing a significant difference (P < .001). From the CE-SMI microvascular findings, the evaluation of vascular morphology and the presence of caliber change showed a significant difference between benign and malignant GB lesions (P = .005, P < .001).

CONCLUSIONS

The evaluation of GB lesions using SMI was feasible with a contrast agent. Vascular morphology and the presence of caliber change may help in the differential diagnosis of GB lesions.

Quantitative Musculoskeletal Ultrasound

Ultrasound (US) imaging plays a crucial role in the assessment of musculoskeletal (MSK) disorders. Several quantitative tools are offered by US systems and add information to conventional US imaging. This article reviews the quantitative US imaging tools currently available in MSK radiology, specifically focusing on the evaluation of elasticity with shear-wave elastography, perfusion with contrast-enhanced US and noncontrast superb microvascular imaging, and bone and muscle mass with quantitative US methods. Some of them are well established and already of clinical value, such as elasticity and contrast-enhanced perfusion assessment in muscles and tendons. MSK radiologists should be aware of the potential of quantitative US tools and take advantage of their use in everyday practice, both for clinical and research purposes.

Ultrasound Microflow Imaging Technology for Diagnosis of Adhesive Capsulitis of the Shoulder

OBJECTIVES

To assess the diagnostic accuracy of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) at the subcoracoid triangle for adhesive capsulitis of the shoulder, to compare the diagnostic value of SMI with that of conventional ultrasound (US) and power Doppler ultrasound (PDUS) findings, and to investigate the correlation between vascular flow on SMI with clinical features.

METHODS

Our study included 39 patients with a diagnosis of adhesive capsulitis and 35 healthy patients as a control group. The echogenicity in the rotator interval and coracohumeral ligament thickness were assessed with conventional US. Vascular flow in the subcoracoid fat triangle was evaluated with SMI and PDUS (SMI and PDUS areas). A receiver operating characteristic curve analysis was performed to evaluate diagnostic accuracy. The correlation between US findings and the range of motion, pain intensity, and duration of symptoms was also evaluated.

RESULTS

The SMI area was higher in the adhesive capsulitis group than in the control group (2.95 versus 0 mm² ; P < .01). The visualization of vascular flow at the subcoracoid fat triangle was superior with SMI compared with PDUS (P < .01). In the receiver operating characteristic analysis, the SMI area showed higher diagnostic performance, with an area under the curve of 0.90 compared with other US findings. The area of SMI vascular flow was also negatively correlated with external rotation and forward flexion (P < .05) in the adhesive capsulitis group.

CONCLUSIONS

Measurement of vascular flow at the subcoracoid fat triangle using SMI facilitated the diagnosis of adhesive capsulitis. Superb Microvascular Imaging was superior to PDUS in diagnostic performance. Vascular flow was negatively correlated with the range of motion of external rotation and forward flexion.

Clinical Applications of Superb Microvascular Imaging in the Liver, Breast, Thyroid, Skeletal Muscle, and Carotid Plaques

This article reviews the clinical applications of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) in the liver, breast, thyroid, skeletal muscle, and carotid plaques. Diseases that are closely associated with angiogenesis can be diagnosed by SMI in a relatively early phase, and using SMI can prevent adverse reactions associated with the contrast agents used in contrast-enhanced ultrasound. Super Microvascular Imaging also shows particular value in grading disease activities and monitoring therapeutic responses. Although SMI has some limitations, such as a lack of clinical standards, it can add information to conventional ultrasound examinations and may become a noninvasive alternative to invasive diagnostic procedures for many clinical conditions.

Predictors for outcome in acute lateral epicondylitis

Background

Lateral epicondylitis or tennis elbow is a frequent condition with long-lasting symptoms. In order to identify predictors for treatment success and pain in lateral epicondylitis, we used data from a randomized controlled trial. This trial investigated the efficacy of physiotherapy alone or combined with corticosteroid injection for acute lateral epicondylitis in general practice.

Methods

The outcomes treatment success and pain score on VAS were assessed at 6, 12, 26 and 52 weeks. We ran a univariate binary logistic regression with generalized estimating equations (GEE) and subsequently an adjusted multilevel logistic regression to analyze the association between potential prognostic indicators and the outcome success/ no success. To assess the changes in pain score we used a two-level multilevel linear regression (MLR) followed by an adjusted MLR model with random effects.

Results

The most consistent predictor for reduced treatment success at all time points was a high Pain Free Function Index score signifying more pain on everyday activities. Being on paid sick-leave and having a recurring complaint increased short term treatment success but gave decreased long-term treatment success. The patients reporting symptoms after engaging in probable overuse in an unusual activity, tended towards increased treatment success at all time-points, but significant only at 12 weeks. The most consistent predictor of increased pain at all time points was a higher overall complaints score at baseline.

Conclusions: Our results suggest that in treating acute lateral epicondylitis, a consideration of baseline pain, a registration of the patient’s overall complaint on a VAS scale and an assessment of the patient’s perceived performance in everyday activities with the Pain Free Function Index can be useful in identifying patients that will have a more protracted and serious condition.

Trial registration

ClinicalTrials.gov Identifier: NCT00826462. Date of registration January 22, 2009. The Trial was prospectively registrated.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2758-y) contains supplementary material, which is available to authorized users.

Microvascular volume in symptomatic Achilles tendons is associated with VISA-A score

OBJECTIVES

The role of neovascularisation in tendinopathy is still poorly understood, potentially due to technical limitations of conventional power Doppler ultrasound. This study aimed to investigate the association between contrast-enhanced ultrasound (CEUS) microvascular volume (MV), Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and intrinsic Achilles tendon tenderness, as well as two different Power Doppler modes.

DESIGN

Cross-sectional study.

METHODS

20 individuals with uni- or bilateral Achilles tendinopathy completed a VISA-A questionnaire, and underwent microvascular volume measurements of the Achilles tendon mid-portion using both conventional, ultrasensitive (SMI™) power Doppler ultrasound and CEUS. Intrinsic tendon tenderness was assessed with sensation detection threshold to extracorporeal shock waves (ESW). Linear Mixed Model analysis was used to determine the association between microvascular volume (MV), VISA-A, and ESW-detection threshold for both symptomatic and asymptomatic Achilles tendons.

RESULTS

There was a significant association between VISA-A and MV (B=-5.3, 95%CI=[-8.5; -2.0], P=0.0004), and between MV and symptom duration (B=-1.7, 95%CI=[-3.2; -5.0], P=0.023). No significant associations were found between power Doppler ultrasound and CEUS-based MV or between CEUS-based MV and ESW-detection threshold. In comparison with conventional power Doppler ultrasound, SMI™ showed on average similar detection capacity for neovessels in the mid-portion of the Achilles tendon, whilst being superior for detecting neovessels within Kager's fat pad (t=3.46, 95%CI=[0.27; 1.03], P<0.005).

CONCLUSIONS

Our results indicate that CEUS-based MV of the Achilles tendon is moderately associated with Achilles tendon symptoms. In accordance, CEUS-detected MV could be a novel target for treatment as it seems to be more sensitive than PDU and is correlated with symptoms.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review

Background

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons.

Methods

A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article.

Results

There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia.

Conclusion

SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US.

Level of evidence

IV.