Hip Inflammation MRI Scoring System (HIMRISS) to predict response to hyaluronic acid injection in hip osteoarthritis

Open-Label Pilot Study of a Single Intra-Articular Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid (HANOX-M-XL) for the Treatment of the First Metatarsophalangeal Osteoarthritis (Hallux Rigidus): The REPAR Trial

Purpose:

The purpose of this study was to obtain information on safety and short-term efficiency of a single intra-articular injection of mannitol-modified cross-linked hyaluronic acid (HANOX-M-XL) in patients with painful first metatarsophalangeal joint osteoarthritis (1stMTPJ-OA).

Methods:

The study involved an observational, single-arm, prospective multicentre trial, with a 3-month follow-up. Inclusion criteria were patients with symptomatic 1st MTPJ-OA not relieved by analgesics and / or non-steroidal-anti-inflammatory drugs and / or foot orthotic. All patients received a single, imaging-guided intra-articular (IA) injection of 1 mL of HANOX-M-XL in the 1st MTPJ. The primary outcome was the change in pain between the date of injection and month 3. The secondary outcomes were the patient assessment of effectiveness, the decrease in painkiller use and the influence of the radiographic score on the clinical efficacy.

Results:

Sixty-five participants (72.3% women, mean age = 60) were included in the trial. Coughlin-Shurnas radiological grade was 1 in 28 patients, 2 in 29, and 3 in 6. At baseline and month 3, the average pain (0-10) was 6.5 ± 1.8 and 2.8 ± 2.3, respectively. The change in pain score was highly significant (−3.1 ± 2.9; P < .0001). At baseline there was no statistically difference in pain between the radiological stages (P = .69). At endpoint, the average pain score was 2.0 ± 1.9 in x-ray stage 1, 3.1 ± 2.3 in stage 2 and 3.3 ± 2.4 in stage 3 (P = .001). Mild to moderate adverse reactions were reported by 15 patients. All were a transient increase of the hallux pain that occurred immediately and up to 6 hours after injection and resolved in 1 to 7 days.

Conclusion:

This pilot study suggests that a single IA injection of HANOX-M-XL is safe and mainly benefits patients with mild moderate 1st MTPJ-OA. Further randomized controlled trials are necessary to confirm these preliminary encouraging results.

Automatic Assessment Of Hip Effusion From MRI

Joint effusion is a hallmark of osteoarthritis (OA) associated with stiffness, and may relate to pain, disability, and long-term outcomes. However, it is difficult to quantify accurately. We propose a new Deep Learning (DL) approach for automatic effusion assessment from Magnetic Resonance Imaging (MRI) using volumetric quantification measures (VQM). We developed a new multiplane ensemble convolutional neural network (CNN) approach for 1) localizing bony anatomy and 2) detecting effusion regions. CNNs were trained on femoral head and effusion regions manually segmented from 3856 images (63 patients). Upon validation on a non-overlapping set of 2040 images (34 patients) DL showed high agreement with ground-truth in terms of Dice score (0.85), sensitivity (0.86) and precision (0.83). Agreement of VQM per-patient was high for DL vs experts in term of Intraclass correlation coefficient (ICC)= 0.88[0.80,0.93]. We expect this technique to reduce inter-observer variability in effusion assessment, reducing expert time and potentially improving the quality of OA care.Clinical Relevance- Our technique for automatic assessment of hip MRI can be used for volumetric measurement of effusion. We expect this to reduce variability in OA biomarker assessment and provide more reliable indicators for disease progression.

Development of a technique for MRI gold-standard direct volumetric measurement of complex joint effusion, and validation at the hip

OBJECTIVE

Accurate joint fluid quantification on MRI cannot simply rely on measuring the maximum fluid depth or using an ellipsoid approximation as this does not fully characterize the complex shape of a fluid-filled joint. As per the Outcome Measurement in Rheumatology (OMERACT) filter, we sought to evaluate the feasibility, reliability, and validity of a semi-automated supervised technique to quantify hip effusion volume.

MATERIALS AND METHODS

Ninety-three hip osteoarthritis patients were imaged with coronal short TI inversion recovery (STIR) and sagittal intermediate weighted fat-suppressed (IWFS) sequences at two time points (Fig. 1). Volumetric quantitative measurement (VQM) of joint fluid and measurement of the largest femoral neck fluid thickness (FTM) was performed using the custom MATLAB software. Self-reported Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and clinical measures of pain, stiffness, and function were recorded.

RESULTS

Inter-observer reliability was significantly higher for VQM than FTM (ICC = 0.96 vs. 0.85, p < 0.05). VQM and FTM correlated moderately (r = 0.76, p < 0.0001). There was significantly more articular fluid in symptomatic than asymptomatic hips at baseline (mean = 9.8 vs. 5.9 mL). Volumetric quantitative measurement generally displayed more frequent and stronger correlations to clinical parameters than FTM. Volumetric quantitative measurement required 3.9 min/hip vs. < 1 min/hip for femoral neck fluid thickness.

CONCLUSION

Volumetric quantitative measurement of joint effusion can serve as an MRI gold-standard, could apply to other joints and collections, and is highly suited to future automation.

Quantification of hip effusion-synovitis and its cross-sectional and longitudinal associations with hip pain, MRI findings and early radiographic hip OA

BACKGROUND

Hip effusion-synovitis may be relevant to osteoarthritis (OA) but is of uncertain etiology. The aim of this study was to describe the cross-sectional and longitudinal associations of hip effusion-synovitis with clinical and structural risk factors of OA in older adults.

METHODS

One hundred ninety-six subjects from the Tasmanian Older Adult Cohort (TASOAC) study with a right hip STIR (Short T1 Inversion Recovery) Magnetic Resonance Imaging (MRI) on two occasions were included. Hip effusion-synovitis CSA (cm2) was assessed quantitatively. Hip pain was determined by WOMAC (Western Ontario and McMaster Universities Osteoarthritis) while hip bone marrow lesions (BMLs), cartilage defects (femoral and/or acetabular) and high cartilage signal were assessed on MRI. Joint space narrowing (0-3) and osteophytes (0-3) were measured on x-ray using Altman's atlas.

RESULTS

Of 196 subjects, 32% (n = 63) had no or a small hip effusion-synovitis while 68% (n = 133) subjects had a moderate or large hip effusion-synovitis. Both groups were similar but those with moderate or large hip effusion-synovitis were older, had higher BMI and more hip pain. Cross-sectionally, hip effusion-synovitis at multiple sites was associated with presence of hip pain [Prevalence ratio (PR):1.42 95%CI:1.05,1.93], but not with severity of hip pain. Furthermore, hip effusion-synovitis size associated with femoral defect (βeta:0.32 95%CI:0.08,0.56). Longitudinally, and incident hip cartilage defect (PR: 2.23 95%CI:1.00, 4.97) were associated with an increase in hip effusion-synovitis CSA. Furthermore, independent of presence of effusion-synovitis, hip BMLs predicted incident (PR: 1.62 95%CI: 1.13, 2.34) and worsening of hip cartilage defects (PR: 1.50 95%CI: 1.20, 1.86). While hip cartilage defect predicted incident (PR: 1.11 95%CI: 1.03, 1.20) and worsening hip BMLs (PR: 1.16 95%CI: 1.04, 1.30).

CONCLUSIONS

Hip effusion-synovitis at multiple sites (presumably reflecting extent) may be associated with hip pain. Hip BMLs and hip cartilage defects are co-dependent and predict worsening hip effusion-synovitis, indicating causal pathways between defects, BMLs and effusion-synovitis.

The Differences in Imaging Findings Between Painless and Painful Osteoarthritis of the Hip

Purpose:

In osteoarthritis of the hip, the pain may be strong even if the deformity is mild, but the pain may be mild even if the deformity is severe. If the factors related to the pain can be identified on imaging, reducing such factors can alleviate the pain, and effective measures can be taken for cases where surgery cannot be performed. In addition, imaging findings related to the pain are also important information for determining the procedures and the timing of surgery. Thus, the purpose of this study was to identify the differences in features of osteoarthritis seen on imaging between painless and painful osteoarthritis of the hip.

Methods:

The subjects were the patients with hip osteoarthritis who visited our department in 2015 and who underwent x-ray, computed tomography (CT), and magnetic resonance imaging (MRI), a total of 29 patients (54 hip joints; mean age 63 years; 8 males and 21 females). The degree of osteoarthritis was determined using the Tönnis grade from the x-ray image. The cartilage morphology, intensity changes of bone marrow on MRI (subchondral bone marrow lesions [BMLs]), osteophytes, joint effusions, and paralabral cysts were scored based on the Hip Osteoarthritis MRI Scoring System (HOAMS). The cross-sectional area of the psoas major muscle at the level of the iliac crest was measured on CT, and the psoas index (PI; the cross-sectional area ratio of the psoas major muscle to the lumbar 4/5 intervertebral disc) was calculated to correct for the difference in physique. Then, the relationships between these and visual analog scale (VAS) scores of pains were evaluated.

Results:

The average VAS was 55.4 ± 39 mm. The PI and all items of HOAMS correlated with the VAS. The average VAS of Tönnis grade 3 osteoarthritis was 75.8 ± 26 mm. When investigating only Tönnis grade 3 osteoarthritis, the differences between cases with less than average pain and those with above average pain were the BML score in the central-inferior femoral head (P = .0213), the osteophyte score of the inferomedial femoral head (P = .0325), and the PI (P = .0292).

Conclusion:

Investigation of the differences between painless and painful osteoarthritis of the hip showed that the cases with more pain have BMLs of the femoral head on MRI that extend not only to the loading area, but also to the central-inferior area. Even with the same x-ray findings, the pain was stronger in patients with severe psoas atrophy. Thus, the instability due to muscle atrophy may also play a role in the pain of hip osteoarthritis.

Diagnostic and interventional radiology fundamentals of synovial pathology

The synovial membrane is a specialized mesenchymal tissue that lines the diarthrodial joints surfaces, bursae, and tendon sheaths of the body. This article aims to provide an overview of the fundamentals of synovial tissue, with particular regard to the imaging findings of the main pathologic processes that can affect the synovia and the role of image-guided interventions. (www.actabiomedica.it)

EUROVISCO Recommendations for Optimizing the Clinical Results of Viscosupplementation in Osteoarthritis

OBJECTIVES

The 3 aims of the work were to identify population subgroups that can benefit the most from viscosupplementation (VS), to provide recommendations on injection techniques, and to discuss VS appropriateness in clinical situations that are commonplace in daily practice.

METHODS

The task force members voted on their degree of agreement on 27 statements, 36 recommendations, and 22 clinical scenarios using a 9-point scale. The strength of agreement/appropriateness/recommendation (SOA/SOR) was classified as strong if the median agreement score was ≥8. The level of consensus (LOC) was also obtained.

RESULTS

Among the assumed predictors for VS failure, obesity, radiographic severity, large synovial fluid effusion, severe patellofemoral involvement, major malalignment, and gross joint instability received a large majority of agreements. The lateral mid-patellar approach was recommended for knee injection. Imaging guidance was unanimously recommended for hip and ankle. Agreement was achieved to strictly respect the dosing regimen proven by controlled trials. There was agreement for treating with VS patients with mild to moderate knee and hip OA, with normal weight or moderate overweight, insufficiently improved by first-line therapies, or who do not wish get oral treatment or who have contraindications to pain killers. The group considered the patient's wishes as a key element in therapeutic decision making.

CONCLUSION

Based on literature data and clinical experience, the EUROVISCO group proposed a set of recommendations for optimizing the results of VS, aimed to help practitioners, especially in some cases in which the patients' specificities make the therapeutic decision difficult.