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Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study

  • Musculoskeletal
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A Commentary to this article was published on 30 September 2023

Abstract

Objective

To assess the applicability of a semiquantitative index for symptomatic minor instability of the lateral elbow (SMILE).

Materials and methods

CT arthrograms of consecutive patients with lateral elbow pain who underwent ultrasound-guided CT arthrography at our orthopedic center between April 2019 and May 2022 were included. Images were acquired at 100 kVp and 80 mAs. An expert radiologist (R1) and a radiology resident (R2) retrospectively performed an independent, blinded evaluation of the arthrograms to assess the presence of imaging findings suggestive of elbow instability. The SMILE index (0–8) was obtained adding (I) radial head chondromalacia (0 − 1); (II) humeral capitellum chondromalacia (0 − 1); (III) humeral trochlear ridge chondromalacia (0 − 1); (IV) annular ligament laxity (0 − 2); (V) synovial thickening (0 − 1); (VI) humeroradial joint asymmetry (0 − 1); and (VII) capsular tear (0 − 1). R1 repeated the assessment after 14 days. Cohen’s weighted κ statistic and raw concordance were used to appraise reproducibility.

Results

Eighty patients (median age 49 years, interquartile range 40–53 years, 49, 61% males) underwent CT arthrography at our center, and 10 (12%) of them underwent bilateral elbow examination, leading to 90 included CT arthrograms. Median SMILE index was 4 (IQR: 2–5) for R1, 4 (IQR: 2–5) for R2, and 4 (IQR: 2–5) for the second assessment by R1. Intra-reader agreement was excellent (κ = 0.94, concordance 87%), while inter-reader agreement was substantial (κ = 0.75, concordance 67%).

Conclusion

The proposed SMILE index showed good reproducibility; further studies are warranted to correlate our index with clinical and surgical data.

Clinical relevance statement

Our scoring system allows a standardized evaluation of patients with lateral elbow pain and instability suitable for application into clinical practice, complementing the orthopedic surgeon’s clinical diagnosis with imaging findings that may aid treatment choices.

Key Points

• Lateral elbow pain is often interpreted clinically as lateral epicondylitis, but it can also encompass intra-articular pathology.

• The proposed arthrographic index allows comprehensive quantification of lateral elbow pathology with good reproducibility and application times.

• Our index provides the orthopedic surgeon with information regarding intra-articular findings, aiding treatment choices.

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Abbreviations

CTA:

Computed tomography arthrography

IQR:

Interquartile range

LEP:

Lateral elbow pain

MRA:

Magnetic resonance arthrography

SMILE:

Symptomatic minor instability of the lateral elbow

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The authors state that this work has not received any funding.

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Authors and Affiliations

  1. U.O.C. Radiodiagnostica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy

    Andrea Zagarella & Mauro Battista Gallazzi

  2. Scuola di Specializzazione in Radiodiagnostica, Università degli Studi di Milano, Milan, Italy

    Gianluca Folco, Caterina Beatrice Monti & Aldo Rizzo

  3. U.O.C. 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milan, Italy

    Paolo Arrigoni

  4. Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Milano, Milan, Italy

    Valeria Vismara & Simone Cassin

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  1. Andrea Zagarella
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Correspondence to Andrea Zagarella.

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Guarantor

The scientific guarantor of this publication is Dr. Andrea Zagarella.

Conflict of Interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and Biometry

One of the authors has significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

Ethical Approval

Institutional Review Board approval was obtained (Ethics Committee of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan; protocol code ElbowRetro001, approved on May 27, 2022).

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• Retrospective

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• Performed at one institution

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Zagarella, A., Folco, G., Monti, C.B. et al. Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study. Eur Radiol 34, 2742–2750 (2024). https://doi.org/10.1007/s00330-023-10233-x

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