EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis

The increased information provided by modern imaging has led to its more extensive use. Our aim was to develop evidence-based recommendations for the use of imaging in the clinical management of the most common arthropathy, osteoarthritis (OA). A task force (including rheumatologists, radiologists, methodologists, primary care doctors and patients) from nine countries defined 10 questions on the role of imaging in OA to support a systematic literature review (SLR). Joints of interest were the knee, hip, hand and foot; imaging modalities included conventional radiography (CR), MRI, ultrasonography, CT and nuclear medicine. PubMed and EMBASE were searched. The evidence was presented to the task force who subsequently developed the recommendations. The strength of agreement for each recommendation was assessed. 17 011 references were identified from which 390 studies were included in the SLR. Seven recommendations were produced, covering the lack of need for diagnostic imaging in patients with typical symptoms; the role of imaging in differential diagnosis; the lack of benefit in monitoring when no therapeutic modification is related, though consideration is required when unexpected clinical deterioration occurs; CR as the first-choice imaging modality; consideration of how to correctly acquire images and the role of imaging in guiding local injections. Recommendations for future research were also developed based on gaps in evidence, such as the use of imaging in identifying therapeutic targets, and demonstrating the added value of imaging. These evidence-based recommendations and related research agenda provide the basis for sensible use of imaging in routine clinical assessment of people with OA

Doctor of Philosophy

dissertationAltered mechanics are believed to initiate osteoarthritis in hips with acetabular dysplasia. Periacetabular osteotomy (PAO) is the preferred surgical treatment; however, it is unknown if the procedure normalizes joint anatomy and mechanics. Changes in three-dimensional (3D) morphology and chondrolabral mechanics were quantified after PAO. Finite element (FE) models demonstrated that PAO improved the distribution of coverage, reduced stress, increased congruity, and prevented cartilage thinning. However, changes in mechanics were not consistent. In fact, one patient exhibited increased stress after surgery, which was believed to be a result of over-correction. Therefore, methods to integrate morphologic and biomechanical analysis with clinical care could standardize outcomes of PAO. FE simulations are time-intensive and require significant computing resources. Therefore, the second aim was to implement an efficient method to estimate mechanics. An enhanced discrete element analysis (DEA) model of the hip that accurately incorporated cartilage geometry and efficiently calculated stress was developed and analyzed. Although DEA model estimates predicted elevated magnitudes of contact stress, the distribution corresponded well with FE models. As a computationally efficient platform, DEA could assist in diagnosis and surgical planning. Imaging is a precursor to analyzing morphology and biomechanics. Ideally, an imaging protocol would visualize bone and soft-tissue at high resolution without ionizing radiation. Magnetic resonance imaging (MRI) with 3D dual-echo-steady-state (DESS) is a promising sequence to image the hip noninvasively, but its accuracy has not been quantified. Therefore, the final aim was to implement and validate the use of 3D DESS MRI in the hip. Using direct measurements of cartilage thickness as the standard, 3D DESS MRI imaged cartilage to ~0.5 mm of the physical measurements with 95% confidence, which is comparable to the most accurate hip imaging protocol presented to date. In summary, this dissertation provided unique insights into the morphologic and biomechanical features following PAO. In the future, DEA could be combined with 3D DESS MRI to efficiently analyze contact stress distributions. These methods could be incorporated into preoperative planning software, where the algorithm would predict the optimal relocation of the acetabulum to maximize femoral head coverage while minimizing contact stress, and thereby improve long-term outcomes of PAO

Advances in FAI Imaging: a Focused Review

Purpose of review: Femoroacetabular impingement (FAI) is one of the main causes of hip pain in young adults and poses clinical challenges which have placed it at the forefront of imaging and orthopedics. Diagnostic hip imaging has dramatically changed in the past years, with the arrival of new imaging techniques and the development of magnetic resonance imaging (MRI). This article reviews the current state-of-the-art clinical routine of individuals with suspected FAI, limitations, and future directions that show promise in the field of musculoskeletal research and are likely to reshape hip imaging in the coming years. Recent findings: The largely unknown natural disease course, especially in hips with FAI syndrome and those with asymptomatic abnormal morphologies, continues to be a problem as far as diagnosis, treatment, and prognosis are concerned. There has been a paradigm shift in recent years from bone and soft tissue morphological analysis towards the tentative development of quantitative approaches, biochemical cartilage evaluation, dynamic assessment techniques and, finally, integration of artificial intelligence (AI)/deep learning systems. Imaging, AI, and hip preserving care will continue to evolve with new problems and greater challenges. The increasing number of analytic parameters describing the hip joint, as well as new sophisticated MRI and imaging analysis, have carried practitioners beyond simplistic classifications. Reliable evidence-based guidelines, beyond differentiation into pure instability or impingement, are paramount to refine the diagnostic algorithm and define treatment indications and prognosis. Nevertheless, the boundaries of morphological, functional, and AI-aided hip assessment are gradually being pushed to new frontiers as the role of musculoskeletal imaging is rapidly evolving.info:eu-repo/semantics/publishedVersio

Imaging findings after meniscal repair with degradable polyurethane scaffold: preliminary results.

Purpose / Introduction: To date, there are no satisfactory solutions to the meniscal originated knee pain post meniscal tear repair. In this study a newly developed polyurethane material that has the intended properties of reducing pain and inducing tissue growth in a damaged meniscus is tested. Materials and Methods: All patients will be imaged using conventional and dynamic MR imaging techniques at 1 week and 3, 12 and 24 months after surgery. The influx of gadolinium contrast in a tissue during the first three minutes after injection gives a measure of the vascularisation, capillary permeability, perfusion and composition of the interstitial fluid. It can be measured using dynamic MRI and is represented as a Time Intensity Curve (TIC). This curve permits an evaluation of the healing process after surgery. Discussion / Conclusion: Thus far 11 patients have received meniscal implants. Eight medial and three lateral menisci were operated. All implants covered the posterior horn with 3 reaching halfway into the meniscal body and one extending into the anterior horn. The average length of the scaffold meniscus measured on MR imaging was 45mm. In the first week after surgery, the capsule and suture area display fast and intense enhancement typical for post-operative inflammation and the formation of early scar-tissue. There is no enhancement in the base or the tip of the scaffold meniscus. After three months the speed and intensity of enhancement in the capsule and suture area between the remnants of the native meniscus and the scaffold have decreased indicating maturation of scar-tissue. However, the base of the scaffold meniscus now shows enhancement. This can only be explained by proliferation of blood vessels from the capsule and theresidual meniscus wall into the scaffold meniscus. The tip of the matrix shows limited enhancement in some patients after three months. On anatomical MR images, the signal intensity (SI) of the implanted scaffold is close to that of water on both T1- and T2-weighted spin echo and turbo spin echo sequences in the first week. After three months the SI decreases but is still clearly higher than that of the native meniscus. The implants in the posterior horn all had a normal position and no loosening of the sutures or tears of the scaffold were found. After three months, one of the patients had slight expulsion of body of the scaffold meniscus but this is a common finding in transplanted menisci

Stratification of patellofemoral pain using clinical, biomechanical and imaging features

Patellofemoral pain (PFP) is a common musculoskeletal complaint and the efficacy of current therapies aimed at PFP is limited. The aetiology of PFP is widely considered to be multifactorial and as a result the clinical presentation is often heterogeneous. In an attempt to address this issue, an international PFP consensus statement, published in 2013, highlighted the need to sub-group patients with PFP to enable more stratified interventions. A multi-methodological approach was used in this thesis. A systematic review of the existing imaging literature in PFP demonstrated that PFP is associated with a number of imaging features in particular MRI bisect offset and CT congruence angle and that some of these features should be modifiable with conservative treatment. A retrospective analysis investigating the overall 3D shape and 3D equivalents of commonly used PFJ imaging features demonstrated no differences between a group with and without PFP, challenging the current perceptions on the structural associations to PFP. A cross-sectional cluster analysis using modifiable clinical, biomechanical and imaging features identified four subgroups that are present in PFP cohort with a Weak group showing the worst prognosis at 12 months. Lastly, a pragmatic randomised controlled feasibility study comparing matched treatment to usual care management showed that matching treatment to a specific subgroup is feasible in terms of adherence, retention and conversion to consent. In summary, the findings of this thesis improves our understanding of the structural associations to PFP; the subgroups that exist within the PFP population; the natural prognosis of these PFP subgroups; and the feasibility of targeting treatment at PFP subgroups within a clinical trial