Prevalence and distribution of cartilage damage at the metacarpal head level in rheumatoid arthritis and osteoarthritis: an ultrasound study

Increased 18F-FAPI uptake in bones and joints of lung cancer patients: characteristics and distributions

OBJECTIVE

This study investigated the distribution and characteristics of various bone and joint lesions on 18F-FAPI PET/CT in lung cancer patients.

METHODS

Seventy-four lung cancer patients who underwent 18F-FAPI PET/CT were reviewed. Bone and joint lesions with elevated 18F-FAPI uptake were recorded and analyzed. The distribution and maximum uptake value (SUVmax) of different benign lesions or bone metastases were presented. In addition, the SUVmax of bone metastases on 18F-FDG and 18F-FAPI-04 PET/CT were also compared.

RESULTS

In 53 patients, a total of 262 lesions presented 18F-FAPI accumulation. Bone metastases were mainly in vertebrae, pelvis, and ribs, while benign lesions were in vertebral margins, alveolar bone, and shoulder joints. The SUVmax of bone metastases was significantly higher than that of benign lesions ([Formula: see text] vs. [Formula: see text], [Formula: see text]), with NSCLC cases having higher SUVmax values than SCLC cases ([Formula: see text] vs. [Formula: see text], [Formula: see text]). Among benign lesions, arthritis and periodontitis demonstrated higher SUVmax than degenerative lesions (arthritis: [Formula: see text]; periodontitis: [Formula: see text]; degenerative diseases: [Formula: see text]; [Formula: see text] and [Formula: see text], respectively). The SUVmax of bone metastases was comparable between 18F-FDG and 18F-FAPI PET/CT. However, 18F-FAPI PET/CT was found to be superior in identifying cranial metastases compared to 18F-FDG PET/CT (TBRmet/brain: [Formula: see text] vs. [Formula: see text], [Formula: see text]).

CONCLUSION

This study demonstrated that 18F-FAPI PET/CT is a valuable imaging modality for detecting bone and joint lesions in lung cancer patients. The SUVmax of malignant lesions was higher than that of benign lesions, but cannot accurately distinguish benign and malignant lesions. The uptake of FAPI differs among lesions with different pathological types.

Cartilage evaluation by ultrasonography in patients with rheumatoid arthritis: a scoping review

BACKGROUND

This study aimed to provide an overview of ultrasonographic cartilage evaluation in patients with rheumatoid arthritis (RA) and identify research gaps in the utilization of cartilage evaluation.

METHODS

The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. A systematic literature search of the PubMed, Embase, and Cochrane Library databases was conducted for articles published up to July 2022 using the search term variations of "cartilage," "ultrasonography," and "rheumatoid arthritis." Studies that included patients with RA who underwent cartilage evaluation by ultrasonography were selected. Articles published in languages other than English and about juvenile idiopathic arthritis were excluded.

RESULTS

Twenty-nine articles were identified. Most were cross-sectional studies (86%), mainly involving the metacarpophalangeal (55%) and knee (34%) joints. Assessments were performed using quantitative, binary, and semi-quantitative methods in 15, 10, and 15 studies, respectively. Reliability assessments were conducted in 10 studies, which showed feasible reliability but were limited to the finger joints. The validity assessment was validated in one study each that compared cartilage thickness measurements with cadaveric specimens and histological and semi-quantitative methods with surgical specimens, respectively. Comparisons with conventional radiography were also performed in six studies, which showed significant correlations. However, there was heterogeneity in the examination and assessment methods, and no adequate longitudinal evaluation was conducted.

CONCLUSION

This review highlights the need for further research and validation of ultrasonographic cartilage assessment in patients with RA.

Vascular supply of the metacarpophalangeal joint

Objective

To describe in detail the arterial vasculature of metacarpophalangeal joints 2–5 on cadaver specimens and to compare it to ultrasound imaging of healthy subjects.

Methods

Eighteen hands of donated human cadavers were arterially injected and investigated with either corrosion casting or cryosectioning. Each layer of cryosectioned specimens was photographed in high-resolution. Images were then segmented for arterial vessels of the metacarpophalangeal (MCP) joints 2–5. The arterial pattern of the joints was reconstructed from the segmented images and from the corrosion cast specimens. Both hands of ten adult healthy volunteers were scanned focusing on the vasculature of the same joints with high-end ultrasound imaging, including color Doppler. Measurements were made on both cryosectioned arteries and Doppler images.

Results

The arterial supply of MCP joints 2–5 divides into a metacarpal and a phalangeal territory, respectively. The metacarpal half receives arteries from the palmar metacarpal arteries or proper palmar digital arteries, while the phalangeal half is supplied by both proper and common palmar digital arteries. Comparing anatomical and ultrasonographic results, we determined the exact anatomic location of normal vessels using Doppler images acquired of healthy joints. All, except three branches, were found with less than 50% frequency using ultrasound. Doppler signals were identified significantly more frequently in MCP joints 2–3 than on 4–5 (p < 0.0001). Similarly, Doppler signals differed in the number of detectable small, intraarticular vessels (p < 0.009), but not that of the large extraarticular ones (p < 0.1373). When comparing measurements acquired by ultrasound and on cadaver vessels, measurements using the former technique were found to be larger in all joints (p < 0.0001).

Conclusion

Using morphological and ultrasonographic techniques, our study provides a high-resolution anatomical maps and an essential reference data set on the entire arterial vasculature of healthy human MCP 2–5 joints. We found that Doppler signal could be detected in less than 50% of the vessels of healthy volunteers except three locations. Intraarticular branches were detected with ultrasound imaging significantly more frequently on healthy MCP 2–3 joints, which should be taken into account when inflammatory and normal Doppler signals are evaluated. Our study also provides reference data for future, higher-resolution imaging techniques.

The Reliability of Ultrasound in the Assessment of Hyaline Cartilage in Rheumatoid Arthritis and Healthy Metacarpal Heads

PURPOSE

 i) To assess the inter- and intra-observer reliability of ultrasound (US) in the evaluation of the hyaline cartilage (HC) of the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and in healthy subjects (HS) both qualitatively and quantitatively. ii) To calculate the smallest detectable difference (SDD) of the MH cartilage thickness measurement. iii) To correlate the qualitative scoring system and the quantitative assessment.

MATERIALS AND METHODS

 US examination was performed on 280 MHs of 20 patients with RA and 15 HS using a very high frequency probe (up to 22 MHz). HC status was evaluated both qualitatively (using a five-grade scoring system) and quantitatively (using the average value of the longitudinal and transverse measures). The HC of MHs from II to V metacarpophalangeal joint of both hands were scanned independently on the same day by two rheumatologists to assess inter-observer reliability. All subjects were re-examined using the same scanning protocol and the same US setting by one sonographer after a week to assess intra-observer reliability.

RESULTS

 The inter-observer agreement and intra-observer agreement were moderate to substantial (k = 0.66 and k = 0.73) for the qualitative scoring system and high (ICC = 0.93 and ICC = 0.94) for the quantitative assessment. The SDD of the MH cartilage thickness measurement was 0.09 mm. A significant correlation between the two scoring systems was found (r = -0.35; p < 0.001).

CONCLUSION

 The present study describes the main methodological issues of HC assessment. Using a standardized protocol, both the qualitative and the quantitative scoring systems can be reliable.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

High-Frequency Ultrasound Dataset for Deep Learning-Based Image Quality Assessment

This study aims at high-frequency ultrasound image quality assessment for computer-aided diagnosis of skin. In recent decades, high-frequency ultrasound imaging opened up new opportunities in dermatology, utilizing the most recent deep learning-based algorithms for automated image analysis. An individual dermatological examination contains either a single image, a couple of pictures, or an image series acquired during the probe movement. The estimated skin parameters might depend on the probe position, orientation, or acquisition setup. Consequently, the more images analyzed, the more precise the obtained measurements. Therefore, for the automated measurements, the best choice is to acquire the image series and then analyze its parameters statistically. However, besides the correctly received images, the resulting series contains plenty of non-informative data: Images with different artifacts, noise, or the images acquired for the time stamp when the ultrasound probe has no contact with the patient skin. All of them influence further analysis, leading to misclassification or incorrect image segmentation. Therefore, an automated image selection step is crucial. To meet this need, we collected and shared 17,425 high-frequency images of the facial skin from 516 measurements of 44 patients. Two experts annotated each image as correct or not. The proposed framework utilizes a deep convolutional neural network followed by a fuzzy reasoning system to assess the acquired data’s quality automatically. Different approaches to binary and multi-class image analysis, based on the VGG-16 model, were developed and compared. The best classification results reach 91.7% accuracy for the first, and 82.3% for the second analysis, respectively.

Sonographic assessment of cartilage damage at metacarpal head in rheumatoid arthritis: qualitative versus quantitative methods

OBJECTIVE

To test the validity of the Outcome Measure in Rheumatology (OMERACT) semiquantitative score by comparing with a quantitative method in the sonographic (US) assessment of hyaline cartilage at the metacarpal head (MH) in patients with rheumatoid arthritis (RA) and healthy subjects (HS).

METHODS

The hyaline cartilage from second to fifth MHs of both hands was scanned. Hyaline cartilage was scored semiquantitatively and quantitatively (by measuring cartilage thickness and comparing with reference values). In RA patients, radiographic joint space narrowing (JSN) was scored on the same joints using the Simple Erosion Narrowing Score (SENS).

RESULTS

Four-hundred and eight MHs in 51 RA patients and 320 MHs in 40 HS were evaluated. The OMERACT semiquantitative score was quicker to perform than the quantitative method (6.0 ± 0.5 vs 8.0 ± 1.5 min, p< 0.01). A significant correlation between the US scores (R = 0.68), and between the US scores and the JSN-SENS (R = 0.61 and R = 0.63, for semiquantitative and quantitative method, respectively) was found. The frequency of cartilage abnormalities was similar between the two US methods in RA patients (58.8% and 51.0% RA patients for semiquantitative and quantitative method, p= 0.46), while the former revealed more abnormalities in HS (27.5% and 7.5% of HS, p= 0.02).

CONCLUSION

The higher feasibility of the OMERACT semiquantitative score suggests its use as first-choice method in the evaluation of cartilage damage. However, despite its limits, the quantitative assessment of HC, providing patient-tailored information due to age- and sex-corrected cut-off values, may represent a valid supplement for optimizing the evaluation of cartilage damage in selected cases.

The sonographic identification of cortical bone interruptions in rheumatoid arthritis: a morphological approach

Bone erosions are the hallmark of structural damage in rheumatoid arthritis (RA). Among imaging techniques, ultrasonography (US) has emerged as an accurate, reliable, repeatable, low-cost and non-invasive imaging modality to detect erosive changes in RA. However, small interruptions of the cortical bone detectable by last generation US equipment do not necessarily represent bone erosions. According to the available data, in addition to cortical bone interruption itself, only a few morphological US findings have been proposed to define RA bone erosions. However, other additional features may be considered to facilitate the interpretation of US cortical bone interruptions in RA. These could be summarised using the following four domains: size, site, shape and scenery. This hypothesis article provides a critical literature review of US features characteristic of RA bone erosions and pictorial evidence supporting the potential role of a morphological analysis in the US identification of bone erosions in RA patients.

Plain language summary

The ultrasonographic morphology of cortical interruptions is helpful for the identification of bone erosions in rheumatoid arthritis: the "four Ss" approach Bone erosions are characteristic features of rheumatoid arthritis. They are associated with a more aggressive disease and with irreversible physical disability. In recent years, ultrasonography has emerged as an accurate and reliable technique for the detection of bone erosions, that appear as interruptions of the cortical bone with variable size. However, cortical bone interruptions do not necessarily represent bone erosions. Since bone erosions represent the earliest evidence of the destructive behaviour of RA, their identification is crucial.Besides the cortical interruption itself, only a few morphological ultrasonographic features were proposed to characterise bone erosions in rheumatoid arthritis.We believe that a morphological approach, including size, site, shape and scenery, may be considered to facilitate the interpretation of ultrasonographic cortical bone interruptions in rheumatoid arthritis.In this hypothesis article we carried out a critical review of the scientific literature and provided extensive pictorial evidence of the ultrasonographic spectrum of cortical interruptions supporting the potential role of considering the "four Ss" for the ultrasonographic identification of bone erosions in rheumatoid arthritis.

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Artificial Intelligence for Ultrasound Informative Image Selection of Metacarpal Head Cartilage. A Pilot Study

Objectives: This study aims to develop an automatic deep-learning algorithm, which is based on Convolutional Neural Networks (CNNs), for ultrasound informative-image selection of hyaline cartilage at metacarpal head level. The algorithm performance and that of three beginner sonographers were compared with an expert assessment, which was considered the gold standard.

Methods: The study was divided into two steps. In the first one, an automatic deep-learning algorithm for image selection was developed using 1,600 ultrasound (US) images of the metacarpal head cartilage (MHC) acquired in 40 healthy subjects using a very high-frequency probe (up to 22 MHz). The algorithm task was to identify US images defined informative as they show enough information to fulfill the Outcome Measure in Rheumatology US definition of healthy hyaline cartilage. The algorithm relied on VGG16 CNN, which was fine-tuned to classify US images in informative and non-informative ones. A repeated leave-four-subject out cross-validation was performed using the expert sonographer assessment as gold-standard. In the second step, the expert assessed the algorithm and the beginner sonographers' ability to obtain US informative images of the MHC.

Results: The VGG16 CNN showed excellent performance in the first step, with a mean area (AUC) under the receiver operating characteristic curve, computed among the 10 models obtained from cross-validation, of 0.99 ± 0.01. The model that reached the best AUC on the testing set, which we named “MHC identifier 1,” was then evaluated by the expert sonographer. The agreement between the algorithm, and the expert sonographer was almost perfect [Cohen's kappa: 0.84 (95% confidence interval: 0.71–0.98)], whereas the agreement between the expert and the beginner sonographers using conventional assessment was moderate [Cohen's kappa: 0.63 (95% confidence interval: 0.49–0.76)]. The conventional obtainment of US images by beginner sonographers required 6.0 ± 1.0 min, whereas US videoclip acquisition by a beginner sonographer lasted only 2.0 ± 0.8 min.

Conclusion: This study paves the way for the automatic identification of informative US images for assessing MHC. This may redefine the US reliability in the evaluation of MHC integrity, especially in terms of intrareader reliability and may support beginner sonographers during US training.

Effect of oblique headless compression screw fixation for metacarpal shaft fracture: a biomechanical in vitro study

Background

Metacarpal shaft fracture is a common fracture in hand trauma injuries. Surgical intervention is indicated when fractures are unstable or involve considerable displacement. Current fixation options include Kirschner wire, bone plates, and intramedullary headless screws. Common complications include joint stiffness, tendon irritation, implant loosening, and cartilage damage.

Objective

We propose a modified fixation approach using headless compression screws to treat transverse or short-oblique metacarpal shaft fracture.

Materials and methods

We used a saw blade to model transverse metacarpal neck fractures in 28 fresh porcine metacarpals, which were then treated with the following four fixation methods: (1) locked plate with five locked bicortical screws (LP group), (2) regular plate with five bicortical screws (RP group), (3) two Kirschner wires (K group), and (4) a headless compression screw (HC group). In the HC group, we proposed a novel fixation model in which the screw trajectory was oblique to the long axis of the metacarpal bone. The entry point of the screw was in the dorsum of the metacarpal neck, and the exit point was in the volar cortex of the supracondylar region; thus, the screw did not damage the articular cartilage. The specimens were tested using a modified three-point bending test on a material testing system. The maximum fracture forces and stiffness values of the four fixation types were determined by observing the force–displacement curves. Finally, the Kruskal–Wallis test was adopted to process the data, and the exact Wilcoxon rank sum test with Bonferroni adjustment was performed to conduct paired comparisons among the groups.

Results

The maximum fracture forces (median ± interquartile range [IQR]) of the LP, RP, HC, and K groups were 173.0 ± 81.0, 156.0 ± 117.9, 60.4 ± 21.0, and 51.8 ± 60.7 N, respectively. In addition, the stiffness values (median ± IQR) of the LP, HC, RP, and K groups were 29.6 ± 3.0, 23.1 ± 5.2, 22.6 ± 2.8, and 14.7 ± 5.6 N/mm, respectively.

Conclusion

Headless compression screw fixation provides fixation strength similar to locked and regular plates for the fixation of metacarpal shaft fractures. The headless screw was inserted obliquely to the long axis of the metacarpal bone. The entry point of the screw was in the dorsum of the metacarpal neck, and the exit point was in the volar cortex of the supracondylar region; therefore the articular cartilage iatrogenic injury can be avoidable. This modified fixation method may prevent tendon irritation and joint cartilage violation caused by plating and intramedullary headless screw fixation.

Turning the Page in Osteoarthritis Assessment with the Use of Ultrasound

PURPOSE OF REVIEW

This narrative review summarizes the last 5 years of published, peer-reviewed research on the use of musculoskeletal ultrasound (US) in osteoarthritis (OA).

RECENT FINDINGS

Multiple features relevant to OA can be visualized on US, including synovitis, erosion, enthesitis, osteophytes, cartilage damage, meniscal extrusion, and popliteal cysts. US can be used to confirm a diagnosis of OA or make an alternate diagnosis in the clinical setting. When a standardized protocol is used, US is a reliable modality for assessment of the features of OA. Findings on US can predict progression and response to therapy in OA of the hand and knee and can allow characterization of risk factors in a cost-effective, non-invasive, repeatable manner. US is becoming more widely used in OA imaging and has clear value in addition to radiography and clinical assessment. US will likely prove useful in defining phenotypes and providing treatment guidance in OA.