Ultrasonography in early diagnosis of acromioclavicular joint degeneration: comparison with plain radiography Poster No.: C-2400 Congress: ECR 2013 Type: Authors: Scientific Exhibit E. Sanverdi 1, N. Aydin 1, E. Turkoz 1, Z. Yologlu 2 ; 1 Ankara/TR, 2 ANAKARA/TR Keywords: DOI: Arthritides, Decision analysis, Ultrasound, Plain radiographic studies, Musculoskeletal joint 10.1594/ecr2013/C-2400 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 10
Purpose The acromioclavicular joint (ACJ) is prone to degeneration because of its weak mechanical features. In the evaluation of the patients with shoulder pain that suggesting ACJ pathology, plain radiographs (PR) are mainly performed for quick look. Even PR is accepted as the initial modality in the routine radiologic algorithm of many of skeletal disorders, superficially located ACJ can easily be evaluated by ultrasonography (US). US is the technique that noninvasive, inexpensive and accurate. The aim of this study was to determine the correlation between US and PR in the evaluation of the early degeneration of ACJs in the patients with shoulder pain. Methods and Materials Materials: In the year of 2008 and 2009, ACJs of 132 patients (F/M: 64/68, age range: 40-55 with a mean age: 48 ± 4.3) who had shoulder pain were evaluated during their shoulder US examination. Methods: ACJs of the patients who had shoulder pain were evaluated during their shoulder US examination. US examination was performed with a high frequencied linear transducer (12.5 mhz). In addition to routine shoulder US evaluation, ACJs were examined while arm was in neutral position. Accompanying rotator cuff abnormalities were noted and classified. PRs were obtained in routine anterior -posterior shoulder projection with suprasternal groove centralization and without any inclination to cover whole shoulder bony structures. Even the unilateral ACJ radiographs are mainly obtained at 15# of cephaled inclination and midclavicular centralization, additional radiographs were not performed to avoid X- ray radiation. PRs of patients that were performed within maximum 2 week period of the US were retrospectively analyzed by two experienced radiologist with a random manner, unawares and by consensus. Findings obtained by both US and PR were graded on a 1-3 scale, and then compared. The joint space, bony surface, subchondral bone and joint capsule were scrutinized. Grading criteria of degeneration of ACJ were as follows ; Page 2 of 10
Grade-I (mild): capsular distention and/or irregularity along the joint surfaces Grade-II (mild): Grade-I plus subchondral sclerosis and/or subchondral cyst formation and/or osteophyte formation Grade-III (mild): Grade-II plus narrowing joint space and/or capsular hypertrophy and thickening Correlation between US and PR findings, and association between the degenerative findings with age and gender was scrutinized. Patients with history of previous trauma / surgery, and with diagnosis of rheumatologic / connective tissue diseases were not included by the study. Pearson's correlation and McNemar test were used for statistical analyses. Threshold was assessed as P # 0.5. Results There was a significantly greater proportion of positive findings compatible with the early degeneration of ACJ when comparing US to conventional radiography (P = 0.02) (Table 1). In the detection of grade-i degeneration, US was found to be significantly superior to PR (P = 0.02) (Table 2). In comparison to PR, non-/weakly ossified osteophytes and tiny subchondral cysts around the ACJs were accurately determined by US (P = 0.04, P = 0.03, respectively) (Figure 1). PR did not found to be correlated with US in the detection of grade-i and grade-ii degenerative changes of ACJs (r = 0.02, P = 0.02; and r = 0.04, P = 0.03, respectively). In the advanced cases revealing grade-iii degeneration US and PR showed similar diagnostic accuracy with a good correlation (r = 0.7, P = 0.03). Capsular hypertrophy-thickening could be differentiated from capsular distention only by US. Moreover, in comparison PR even after window level adjustments for soft tissues, capsular distention was detected by US with a significance ( P = 0.03) (Figure 2a - b). But subcondral sclerosis was the finding that detectable only by PR (Figure 3a - b). Advanced age revealed good correlation with degeneration of ACJ. (P = 0.02). But gender did not showed correlation with degeneration of ACJ (P = 0.07) Page 3 of 10
Images for this section: Table 1: Radiological findings of ACJ degeneration. ACJ: acromioclavicular joint Page 4 of 10
Table 2: Modality based distrubition of grading of ACJ degeneration. ACJ: acromioclavicular joint Page 5 of 10
Fig. 1: In the ultrasonography image a small subchondral cyst (arrow) is seen in the clavicular side of the ACJ. Note accompanying cortical irregularity, capsular thickening and narrowed joint space that compatible with grade-iii degeneration. ACJ: acromioclavicular joint. Page 6 of 10
Fig. 2: In comparison to anterior-posterior plain radiograph of the right shoulder(a), capsular distention (arrows) is prominently seen in the same case with ultrasonography (b). Page 7 of 10
Fig. 3: Plain radiograph in anterior-posterior projection (a) and ultrasonographic image (b)of same case. Degenerative cortical irregularity along the ACJ surfaces (arrows) is seen in both. Page 8 of 10
Conclusion In the evaluation of early changes in ACJ degeneration, US was found to be a reliable technique to PR. Even subchondral bone marrow edema that presenting earliest change of osteoarthritis could be assessed only by magnetic resonance imaging, US could be performed as an easy and inexpensive screening method especially in the patients with shoulder pain caused by rotator cuff lesions and who do not reveal proper response to accurate treatment. References 1. Alasaarela E, Tervonen O, Takalo R, Lahde S, Suramo I (1997) Ultrasound evaluation of the acromioclavicular joint. J Rheumatol, 24(10):1959-1963 2. Blankstein A, Ganel A, Givon U, et al. (2005) Ultrasonography as a diagnostic modality in acromioclavicular joint pathologies. Isr Med Assoc J, 7(1):28-30 3. Brown JN, Roberts SN, Hayes MG, Sales AD (2000) Shoulder pathology associated with symptomatic acromioclavicular joint degeneration. J Shoulder Elbow Surg, 9(3):173-176 4. Buttaci CJ, Stitik TP, Yonclas PP, Foye PM (2004) Osteoarthritis of the acromioclavicular joint: a review of anatomy, biomechanics, diagnosis, and treatment. Am J Phys Med Rehabil, 83(10):791-797 5. Ernberg LA, Potter HG (2003) Radiographic evaluation of the acromioclavicular and sternoclavicular joints. Clin Sports Med, 22(2):255-275 6. Iagnocco A (2010) Imaging the joint in osteoarthritis: a place for ultrasound? Best Pract Res Clin Rheumatol, 24(1):27-38 7. Jacobson JA (1999) Musculoskeletal sonography and MR imaging. A role for both imaging methods. Radiol Clin North Am, 37(4):713-735 8. Kock HJ, Jurgens C, Hirche H, Hanke J, Schmit-Neuerburg KP (1996) Standardized ultrasound examination for evaluation of instability of the acromioclavicular joint. Arch Orthop Trauma Surg, 115(3-4):136-140 9. Papatheodorou A, Ellinas P, Takis F, Tsanis A, Maris I, Batakis N (2006) US of the shoulder: rotator cuff and non-rotator cuff disorders. Radiographics, 26(1):e23 Page 9 of 10
10. Pennington RG, Bottomley NJ, Neen D, Brownlow HC (2008) Radiological features of osteoarthritis of the acromiclavicular joint and its association with clinical symptoms. J Orthop Surg (Hong Kong), 16(3):300-302 11. Wang SC, Chhem RK, Cardinal E, Cho KH (1999) Joint sonography. Radiol Clin North Am, 37(4):653-668 Personal Information Eser S. Sanverdi MD Department of Radiology, Hospital of Guven, Ankara, Turkey. E-mail: esersanverdi@yahoo.com Page 10 of 10