- Email: [email protected]
Ultrasound guided tendon therapies: Options and evidence
Abstracts 6. Piscaglia F, Nolsøe C, Dietrich CF, Cosgrove DO, Gilja OH, Bachmann Nielsen M, Albrecht T, Barozzi L, Bertolotto M, Catalano O, Claudon M, Clevert DA, Correas JM, D’Onofrio M, Drudi FM, Eyding J, Giovannini M, Hocke M, Ignee A, Jung EM, Klauser AS, Lassau N, Leen E, Mathis G, Saftoiu A, Seidel G, Sidhu PS, Haar GT, Timmerman D, Weskott HP. The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): Update 2011 on non-hepatic applications. Ultraschall Med. 2012 Feb;33(1):33-59; Epub 2011 Aug 26. PMID: 21874631. 7. Nylund K, Maconi G, Hollerweger A, Ripolles T, Pallotta N, Higginson A, Serra C, Dietrich CF, Sporea I, Saftoiu A, Dirks K, Hausken T, Calabrese E, Romanini L,Maaser C, Nuernberg D, Gilja OH. EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound Part 1: Examination Techniques and Normal Findings (Long version). Ultraschall Med. 2017 Jun;38(3):273-284. PMID: 27604052. 8. Maconi G, Nylund K, Ripolles T, Calabrese E, Dirks K, Dietrich CF, HollerwegerA, Sporea I, Saftoiu A, Maaser C, Hausken T, Higginson AP, Nu¨rnberg D, PallottaN, Romanini L, Serra C, Gilja OH. EFSUMB Recommendations and Clinical Guidelines for Intestinal Ultrasound (GIUS) in Inflammatory Bowel Diseases. Ultraschall Med. 2018 Jun;39(3):304-317. PMID: 29566419.
Non-IBD findings in intestinal ultrasound Kirstin Taylor Consultant Gastroenterologist, Alfred Health, Melbourne, VIC, Australia Although intestinal ultrasound is most commonly used to assess patients with inflammatory bowel disease (IBD), there are other conditions that can mimic IBD and incidental diagnoses that may co-exist with IBD. Both will be addressed within this presentation.
SESSION 2A: MSK & RHEUMATOLOGY Calcific tendinosis David Lisle Radiologist, Brisbane Private Imaging, Brisbane, QLD, Australia Calcification may occur in tendons due to multiple mechanisms. These include: Degenerative: necrosis of tenocytes due to ischaemia or repetitive trauma ‘Traction spurs’: endochondral ossification at tendon or ligament insertions Crystallopathy Calcific tendinosis is a crystal arthropathy which results in abnormal deposition of calcium hydroxyapatite crystals in tendons, most commonly supraspinatus. Other tendons may be affected including flexor carpi ulnaris at the wrist, and the gluteal and rectus femoris tendons at the hip. Involvement of longus colli is a recently described, uncommon cause of acute neck pain. Regardless of location, the pathogenesis of calcific tendinosis is poorly understood. It is a condition characterised by multiple phases: Pre-calcification: cellular change in tendon Calcification: deposition of crystals to form a partly liquified deposit, which incites an inflammatory response and resorption Post-calcification: repair and restoration of tendon fibres The inflammatory/ resorptive response produces pain; up until this stage, the process is generally asymptomatic. Intratendinous calcific deposits may have various appearances on ultrasound including arc shaped, nodular, punctate and cystic. Small, degenerative calcifications are common, particularly in elderly patients. These tend to be sharply defined and arc shaped, with acoustic
S11
shadowing. Acutely painful calcifications tend to be larger and more amorphous in shape, without acoustic shadowing. Various therapeutic options are available. These have variable effectiveness and little in the way of high-level evidence, and include: Nothing: self-limiting Non-steroidal anti-inflammatory drugs (NSAIDS) Physiotherapy Extracorporeal shock wave lithotripsy Needling Surgery: Arthroscopic debridement Needling is usually performed under ultrasound guidance. It has several advantages including being minimally invasive, generally well tolerated, widely available, relatively inexpensive and quick. Most operators use a standard procedure with minor individual variations. First, there is injection of local anaesthetic into all tissue layers, including the calcification itself. This is followed by aspiration and breakup of the calcification with a larger needle (18 14 g). Barbotage is a term used to describe wash out of the calcification with saline or local anaesthetic combined with aspiration. This may be a double needle or single needle technique. Aspiration and break up is followed by injection of a combination of steroid and longer acting anaesthetic into the remaining calcification and tendon, and into the overlying subacromial bursa.
Ultrasound guided tendon therapies: Options and evidence David Lisle Radiologist, Brisbane Private Imaging, Brisbane, QLD, Australia Tendon injury is very common, particularly in active people. Common examples include pathology of the rotator cuff, common extensor and flexor tendons at the elbow, gluteal tendons at the greater trochanter, patellar tendon and Achilles tendon. Healthy tendon has an ordered structure that includes uniform flat-shaped tenocyte cells, collagen fibers organised and layered end-to-end and side-by-side, and a structurally organized extracellular matrix (ECM). Response of tendon to injury is a complex pathological process for which the term ‘tendinosis’ is used. This process consists of early disruption of collagen fibre orientation, followed by cell proliferation, angiogenesis, change in tenocyte cell shape, and collagen and extracellular matrix breakdown. Tendon cell death and depletion at the centre of the affected region leads to further collagen and extracellular matrix breakdown, followed by fatigue healing and degenerative changes. Treatment options for tendon pathologies include conservative measures such as modification of behavior, strapping, oral anti-inflammatories, and lithotripsy. Ultrasound guided injection techniques include HCLA into, or adjacent to, the tendon, dry needling of the affected tendon, autologous blood injection, platelet rich plasma (PRP) and autologous tenocyte injection (ATI). Surgical options such as debridement, division or reconstruction of the affected tendon may be used when conservative treatments have failed. ATI is a cell-based therapy that involves the harvesting of healthy tendon from the patient. The autologous donor tendon material is obtained using ultrasound guided percutaneous core biopsy, usually of the quadriceps or patellar tendon. Adequate volume of tendon, sterile technique and minimal trauma to the healthy tendon and adjacent tissues is essential. This material is cultured for 6 weeks to produce a suspension of tenocytes, which are injected under ultrasound guidance into the abnormal tendon. The aim of the procedure is to grow new tendon tissue within the abnormal structure, restore function and relieve pain. The presence of multiple available treatments implies that no single treatment is reliably effective. Various treatments may be advocated
S12
Ultrasound in Medicine & Biology
based on multiple factors such as individual experience and expertise, plus local availability. A review of these treatments will be presented, with an attempt to make sense of the currently available evidence.
SESSION 2B: CRITICAL CARE Echocardiography in management of the shocked patient Anthony McLean Head of Intensive Care Medicine, Nepean Hospital, Sydney, NSW, Australia The use of ultrasound has moved to centre stage in the management of haemodynamically unstable patient. The ability to apply rapidly, the mobility of devices, and bedside delivery are amongst the advantages in using it. In particular, the widespread application of echocardiography has greatly changed the way in which shocked patients are diagnosed and treated. Most importantly is the ability for the clinician to rapidly identify the type of underlying shock, identify pathophysiology that requires immediate treatment and then to clearly outline the need for further imaging or other diagnostic tests. The great majority of patients fall into either one of the following four shock categories, or not infrequently, experience a combination of these. The physician dealing with critically ill patients may have only attained skills in basic echocardiography such as with performing RACE (Rapid Assessment by Cardiac Echo) which is generally adequate in many patients. However an increasing number of clinicians now have advanced skills using a combination of Doppler techniques in addition to newer techniques such as strain or 3 D. These skills add to the diagnostic repertoire. The chart below is a guide to the evaluation in determining the type of shock in a deteriorating patient.
Cardiogenic shock:
Hypovolaemic shock Obstructive shock
RACE (basic)
Advanced
LV contraction -subjective - objective
cardiac output left atrial pressure pulmonary artery pressure LVOT obstruction valve function LV diastolic function dynamic maneuver: VTI change PLR -Fluid load tamponade as for basic
segmental wall defects valve abnormalities Interatrial septum shape chamber sizes IVC size/respiratory change pericardial tamponade - RA/RV compression -IVC dilatation Acute PE - RVA/LVA ratio -paradoxical septal motion Dynamic LVOT obstruction - small LVESV
Vasodilatory shock
Hyperdynamic ventricles small LVESV
Acute PE - RVA/LVA ratio - PSM - SPAP by TR signal - PAcT pulmonic outflow DLVOTO - CW&PW Doppler LVOT cardiac output LV contraction patterns
LV contraction patterns The application of echocardiography in the management of the shocked patient should be considered mandatory.
Volume 45, Number S1, 2019 SESSION 2C: VASCULAR Refinements in abdominal aortic aneurysm screening; a new screening tool and incorporation of body surface area correction Greg Jones Department of Surgical Sciences, Otago Medical School, Dunedin, New Zealand and on behalf of the Aotearoa New Zealand AAA Screening Working Group Abdominal aortic aneurysm (AAA) is an age-associated degenerative vascular disorder ranked as the 10th most common cause of death in male patients above the age of 55 years. While AAA-related mortality rates have been reported to be in a decline globally, in part likely due to reduced smoking rates, this condition remains a significant burden on our community and health system, particularly for Maori New Zealanders. While countries such as the United Kingdom have relatively recently introduced national screening programmes, there remains debate as to who should be screened. The question as to whether countries with aging populations, such as New Zealand and Australia, should introduce AAA screening programmes remains highly topical as AAA still represents a significant cause of preventable death. This talk will discuss our current understanding of AAA prevalence in both men and women and also compare this within specific subgroups, such as those with elevated cardiovascular disease (CVD) risk factor profiles or high AAA-specific risk scores. Two key observations of note were (1) significantly increased rates of AAA in those with elevated CVD risk and (2) an almost doubling of AAA prevalence in women when sex-specific AAA size thresholds were applied to screening. Based on a large series of locally-based pilot studies the Aotearoa New Zealand AAA Screening Working Group has developed a strategy which we believe will deliver a sex and ethnicity equitable AAA screening programme that also contributes to (broad) cardiovascular risk prediction. References: 1. Jones GT, et al. Comparison of three targeted approaches to screening for abdominal aortic aneurysm based on cardiovascular risk. Br J Surg. 2016;103:1139-46. 2. Jones GT, et al. Correcting for Body Surface Area Identifies the True Prevalence of Abdominal Aortic Aneurysm in Screened Women. Eur J Vasc Endovasc Surg. 2019;57:221-228.
Small infrarenal Aortic size - what does this imply? Greg Jones Department of Surgical Sciences, Otago Medical School, Dunedin, New Zealand and on behalf of the Aotearoa New Zealand AAA Screening Working Group While a relationship between large infrarenal aortic diameter and both cardiovascular disease (CVD) prevalence and all-cause mortality has been previously suggested, there is also evidence that small aortic size may also be associated with increased CVD risk. We examined a total of 4882 elderly (>50 years) participants (mean age 69.4) by duplex ultrasound to assess infrarenal abdominal aortic diameters and correlated these with each individual’s history of CVDs, including ischaemic heart disease (IHD), and associated risk factors. CVD prevalence showed a U-shaped relationship with aortic size (figure) and was significantly elevated in the upper and lower 12.5% tails of the aortic size distributions. These associations remained significant following adjustment for age, sex, diabetes, hypertension, dyslipidemia, obesity (body mass index) and smoking. A sub-group of 1032 participants
Non-IBD findings in intestinal ultrasound Kirstin Taylor Consultant Gastroenterologist, Alfred Health, Melbourne, VIC, Australia Although intestinal ultrasound is most commonly used to assess patients with inflammatory bowel disease (IBD), there are other conditions that can mimic IBD and incidental diagnoses that may co-exist with IBD. Both will be addressed within this presentation.
SESSION 2A: MSK & RHEUMATOLOGY Calcific tendinosis David Lisle Radiologist, Brisbane Private Imaging, Brisbane, QLD, Australia Calcification may occur in tendons due to multiple mechanisms. These include: Degenerative: necrosis of tenocytes due to ischaemia or repetitive trauma ‘Traction spurs’: endochondral ossification at tendon or ligament insertions Crystallopathy Calcific tendinosis is a crystal arthropathy which results in abnormal deposition of calcium hydroxyapatite crystals in tendons, most commonly supraspinatus. Other tendons may be affected including flexor carpi ulnaris at the wrist, and the gluteal and rectus femoris tendons at the hip. Involvement of longus colli is a recently described, uncommon cause of acute neck pain. Regardless of location, the pathogenesis of calcific tendinosis is poorly understood. It is a condition characterised by multiple phases: Pre-calcification: cellular change in tendon Calcification: deposition of crystals to form a partly liquified deposit, which incites an inflammatory response and resorption Post-calcification: repair and restoration of tendon fibres The inflammatory/ resorptive response produces pain; up until this stage, the process is generally asymptomatic. Intratendinous calcific deposits may have various appearances on ultrasound including arc shaped, nodular, punctate and cystic. Small, degenerative calcifications are common, particularly in elderly patients. These tend to be sharply defined and arc shaped, with acoustic
S11
shadowing. Acutely painful calcifications tend to be larger and more amorphous in shape, without acoustic shadowing. Various therapeutic options are available. These have variable effectiveness and little in the way of high-level evidence, and include: Nothing: self-limiting Non-steroidal anti-inflammatory drugs (NSAIDS) Physiotherapy Extracorporeal shock wave lithotripsy Needling Surgery: Arthroscopic debridement Needling is usually performed under ultrasound guidance. It has several advantages including being minimally invasive, generally well tolerated, widely available, relatively inexpensive and quick. Most operators use a standard procedure with minor individual variations. First, there is injection of local anaesthetic into all tissue layers, including the calcification itself. This is followed by aspiration and breakup of the calcification with a larger needle (18 14 g). Barbotage is a term used to describe wash out of the calcification with saline or local anaesthetic combined with aspiration. This may be a double needle or single needle technique. Aspiration and break up is followed by injection of a combination of steroid and longer acting anaesthetic into the remaining calcification and tendon, and into the overlying subacromial bursa.
Ultrasound guided tendon therapies: Options and evidence David Lisle Radiologist, Brisbane Private Imaging, Brisbane, QLD, Australia Tendon injury is very common, particularly in active people. Common examples include pathology of the rotator cuff, common extensor and flexor tendons at the elbow, gluteal tendons at the greater trochanter, patellar tendon and Achilles tendon. Healthy tendon has an ordered structure that includes uniform flat-shaped tenocyte cells, collagen fibers organised and layered end-to-end and side-by-side, and a structurally organized extracellular matrix (ECM). Response of tendon to injury is a complex pathological process for which the term ‘tendinosis’ is used. This process consists of early disruption of collagen fibre orientation, followed by cell proliferation, angiogenesis, change in tenocyte cell shape, and collagen and extracellular matrix breakdown. Tendon cell death and depletion at the centre of the affected region leads to further collagen and extracellular matrix breakdown, followed by fatigue healing and degenerative changes. Treatment options for tendon pathologies include conservative measures such as modification of behavior, strapping, oral anti-inflammatories, and lithotripsy. Ultrasound guided injection techniques include HCLA into, or adjacent to, the tendon, dry needling of the affected tendon, autologous blood injection, platelet rich plasma (PRP) and autologous tenocyte injection (ATI). Surgical options such as debridement, division or reconstruction of the affected tendon may be used when conservative treatments have failed. ATI is a cell-based therapy that involves the harvesting of healthy tendon from the patient. The autologous donor tendon material is obtained using ultrasound guided percutaneous core biopsy, usually of the quadriceps or patellar tendon. Adequate volume of tendon, sterile technique and minimal trauma to the healthy tendon and adjacent tissues is essential. This material is cultured for 6 weeks to produce a suspension of tenocytes, which are injected under ultrasound guidance into the abnormal tendon. The aim of the procedure is to grow new tendon tissue within the abnormal structure, restore function and relieve pain. The presence of multiple available treatments implies that no single treatment is reliably effective. Various treatments may be advocated
S12
Ultrasound in Medicine & Biology
based on multiple factors such as individual experience and expertise, plus local availability. A review of these treatments will be presented, with an attempt to make sense of the currently available evidence.
SESSION 2B: CRITICAL CARE Echocardiography in management of the shocked patient Anthony McLean Head of Intensive Care Medicine, Nepean Hospital, Sydney, NSW, Australia The use of ultrasound has moved to centre stage in the management of haemodynamically unstable patient. The ability to apply rapidly, the mobility of devices, and bedside delivery are amongst the advantages in using it. In particular, the widespread application of echocardiography has greatly changed the way in which shocked patients are diagnosed and treated. Most importantly is the ability for the clinician to rapidly identify the type of underlying shock, identify pathophysiology that requires immediate treatment and then to clearly outline the need for further imaging or other diagnostic tests. The great majority of patients fall into either one of the following four shock categories, or not infrequently, experience a combination of these. The physician dealing with critically ill patients may have only attained skills in basic echocardiography such as with performing RACE (Rapid Assessment by Cardiac Echo) which is generally adequate in many patients. However an increasing number of clinicians now have advanced skills using a combination of Doppler techniques in addition to newer techniques such as strain or 3 D. These skills add to the diagnostic repertoire. The chart below is a guide to the evaluation in determining the type of shock in a deteriorating patient.
Cardiogenic shock:
Hypovolaemic shock Obstructive shock
RACE (basic)
Advanced
LV contraction -subjective - objective
cardiac output left atrial pressure pulmonary artery pressure LVOT obstruction valve function LV diastolic function dynamic maneuver: VTI change PLR -Fluid load tamponade as for basic
segmental wall defects valve abnormalities Interatrial septum shape chamber sizes IVC size/respiratory change pericardial tamponade - RA/RV compression -IVC dilatation Acute PE - RVA/LVA ratio -paradoxical septal motion Dynamic LVOT obstruction - small LVESV
Vasodilatory shock
Hyperdynamic ventricles small LVESV
Acute PE - RVA/LVA ratio - PSM - SPAP by TR signal - PAcT pulmonic outflow DLVOTO - CW&PW Doppler LVOT cardiac output LV contraction patterns
LV contraction patterns The application of echocardiography in the management of the shocked patient should be considered mandatory.
Volume 45, Number S1, 2019 SESSION 2C: VASCULAR Refinements in abdominal aortic aneurysm screening; a new screening tool and incorporation of body surface area correction Greg Jones Department of Surgical Sciences, Otago Medical School, Dunedin, New Zealand and on behalf of the Aotearoa New Zealand AAA Screening Working Group Abdominal aortic aneurysm (AAA) is an age-associated degenerative vascular disorder ranked as the 10th most common cause of death in male patients above the age of 55 years. While AAA-related mortality rates have been reported to be in a decline globally, in part likely due to reduced smoking rates, this condition remains a significant burden on our community and health system, particularly for Maori New Zealanders. While countries such as the United Kingdom have relatively recently introduced national screening programmes, there remains debate as to who should be screened. The question as to whether countries with aging populations, such as New Zealand and Australia, should introduce AAA screening programmes remains highly topical as AAA still represents a significant cause of preventable death. This talk will discuss our current understanding of AAA prevalence in both men and women and also compare this within specific subgroups, such as those with elevated cardiovascular disease (CVD) risk factor profiles or high AAA-specific risk scores. Two key observations of note were (1) significantly increased rates of AAA in those with elevated CVD risk and (2) an almost doubling of AAA prevalence in women when sex-specific AAA size thresholds were applied to screening. Based on a large series of locally-based pilot studies the Aotearoa New Zealand AAA Screening Working Group has developed a strategy which we believe will deliver a sex and ethnicity equitable AAA screening programme that also contributes to (broad) cardiovascular risk prediction. References: 1. Jones GT, et al. Comparison of three targeted approaches to screening for abdominal aortic aneurysm based on cardiovascular risk. Br J Surg. 2016;103:1139-46. 2. Jones GT, et al. Correcting for Body Surface Area Identifies the True Prevalence of Abdominal Aortic Aneurysm in Screened Women. Eur J Vasc Endovasc Surg. 2019;57:221-228.
Small infrarenal Aortic size - what does this imply? Greg Jones Department of Surgical Sciences, Otago Medical School, Dunedin, New Zealand and on behalf of the Aotearoa New Zealand AAA Screening Working Group While a relationship between large infrarenal aortic diameter and both cardiovascular disease (CVD) prevalence and all-cause mortality has been previously suggested, there is also evidence that small aortic size may also be associated with increased CVD risk. We examined a total of 4882 elderly (>50 years) participants (mean age 69.4) by duplex ultrasound to assess infrarenal abdominal aortic diameters and correlated these with each individual’s history of CVDs, including ischaemic heart disease (IHD), and associated risk factors. CVD prevalence showed a U-shaped relationship with aortic size (figure) and was significantly elevated in the upper and lower 12.5% tails of the aortic size distributions. These associations remained significant following adjustment for age, sex, diabetes, hypertension, dyslipidemia, obesity (body mass index) and smoking. A sub-group of 1032 participants