[Critical analysis of the manoeuvres proposed for the diagnosis of the carpal tunnel syndrome]

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. It is mainly due to the compression of median nerve at the wrist and it may be idiopathic or secondary to different rheumatic or non rheumatic diseases, including occupational activities. Since signs and symptoms of CTS are characteristic, a careful examination of the affected patient may be very satisfactory for the diagnosis, in particular by means of some manoeuvres. In this review we described and commented the tests considered most useful in the diagnosis of CTS. We also analysed the diagnostic values of electromyography, the most important electrodiagnostic study for the CTS.

Intravenous immunoglobulins control scleromyxoedema

BACKGROUND

Scleromyxoedema is a variant of papular mucinosis affecting the skin and internal organs. The different therapeutic approaches proposed for scleromyxoedema are still unsatisfactory. Intravenous immunoglobulin (IVIg) has been successfully employed in the treatment of connective tissue diseases and vasculitides.

PATIENTS

The successful treatment of three cases of scleromyxoedema with IVIg is reported here.

CONCLUSIONS

The relatively low risk of the drug and the high effectiveness seen in three patients suggest that IVIg is a new treatment potentially useful in scleromyxoedema.

[Primary Sjögren's syndrome. A longitudinal study of 68 patients]

There are only few studies, regarding primary Sjögren's syndrome (pSS) long-term clinical course. Moreover, it has been often studied in a restricted number of patients, employing different recruitment and diagnostic criteria. During a 10 years follow-up, we longitudinally evaluate clinical course as well as severe complications and mortality rates in 68 patients with pSS, diagnosed according to the Fox's criteria. Patients were divided into 2 groups according to the autoantibodies pattern detected at the diagnosis: anti-Ro and/or La positive and anti-Ro La negative. Glandular manifestations of pSS were distinctively present in the majority of patients already at time of the diagnosis and serological findings remained typically constant during the whole follow-up. Increased IgG, IgA and ESR as well as low C4 serum levels were significantly prevalent in the Ro and/or La positive group. Finally, we did not found any significant increase in the mortality rate of pSS patients in comparison with the general population.

Vascular changes in psoriatic knee joint synovitis

OBJECTIVE

To evaluate the diagnostic utility of standard arthroscopy supported by a computerized image analysis system; and to examine and quantify the macroscopic appearance of blood vessels in selected anatomical areas, comparing 2 groups of patients with PsA and RA with refractory knee joint synovitis (KJS) for vascular marking (VM) features and VM scores, as well as for the relationship between respective VM scores and local and systemic KJS disease activity indices.

METHODS

Standard arthroscopy was carried out on 39 knees (20 PsA, 19 RA). Videorecordings of the examination were reanalyzed using a computer image analysis system and software. The appearance of vascular markings was assessed and separately scored for the areas of surface synovium (capsular, CVM), villous proliferation (villous, VVM), and synovium adherent to cartilage (pannus, PVM). Indices of systemic (erythrocyte sedimentation rate, ESR) and local KJS disease activity (clinical index) were obtained before arthroscopy. The morphology and scores of the distinct VM were compared between PsA and RA groups, as was the relationship between respective VM scores and ESR and KJS clinical indices.

RESULTS

Distinctive VM features were observed for PsA and RA KJS in each separate synovial architecture examined. VVM and CVM scores were significantly correlated with each other in PsA knees, and were significantly higher in PsA compared with RA. In both diseases, VVM and CVM scores were not related to KJS duration or activity or to ESR values, but in RA they were directly correlated with KJS activity. Moreover, the VVM capillary feature "meandering with tight convolutions," considered unique to psoriatic skin, was observed in the synovium of 13 PsA (65%) and one RA KJS (5.5%). The mean KJS duration of the PsA group with typical VVM was significantly lower than the group without VVM (2.6 +/- 1.77 vs 9.4 +/- 8.28 yrs).

CONCLUSION

Our macroscopic observations of distinct changes in VM expression in selected anatomical areas of PsA and RA KJS suggest possible pathogenetic differences between the 2 diseases. The typical morphology and higher intensity of villous vascularization, in both early and chronic disease, and the different clinical relevance of VVM scores in PsA compared with RA KJS support the potential use of vascular markings as reliable outcome measures of the PsA process in KJS.

Long-term therapy with plasma exchange in systemic sclerosis: effects on laboratory markers reflecting disease activity

Plasma exchange (PEX) is a technique that has been applied to the treatment of many immunological disorders, including connective tissue diseases. The crucial role of some humoral factors in the pathogenesis of systemic sclerosis (SSc) could explain the good clinical results obtained in terms of slowing down the disease progression, but the efficacy of PEX in the treatment of SSc is not yet well defined, owing to the lack of controlled studies and validated parameters of disease activity. To demonstrate the long-term efficacy of PEX in the treatment of SSc we treated a group of 28 SSc patients affected with recent onset and/or rapidly progressive disease. Most of these had a diffuse form of SSc, with anti-Sc170 antibody as a disease marker. Before and after long-term PEX treatment we evaluated disease activity parameters including the serum levels of interleukin 2 soluble receptor (sIL-2R) and aminoterminal type III procollagen peptide (PIIINP), plus the percentage of DR+ T cells in the peripheral blood. We also assessed clinical parameters of total skin score and total visceral score. The same parameters were evaluated in 25 SSc patients who did not satisfy the admission criteria for PEX, treated long-term with drugs only. At baseline, serum PIIINP and sIL-2R levels and the percentage of DR+ T cells were significantly increased in PEX patients as compared to others. Following long-term PEX treatment, all the laboratory parameters significantly decreased and the clinical scores showed a slight but not significant improvement. Conversely, in the other group of SSc patients treated for the same period with drugs only, no significant change of laboratory parameters was detected and the clinical scores slightly worsened. Our data suggest that long-term PEX therapy seems to be effective in slowing down the clinical course of patients with severe and rapidly progressive SSc.

[Comparison of ultrasonography and sialography vs. magnetic resonance in the diagnosis of the primary Sjogren's syndrome]

To date there is no agreement as to which imaging technique is best for the evaluation of the oral component of primary Sjögren's Syndrome (SS). The purpose of the present study has, therefore, been to determine the reliability of Magnetic Resonance (MR) in the evaluation of salivary alterations in patients with SS. The study involved 23 patients suffering from SS according to the European criteria. All the patients underwent ultrasonography and MR of the major salivary glands, parotid sialography and biopsy of the minor salivary glands. The first control group was made up of 50 healthy subjects who underwent parotid ultrasonography. The second control group comprised 23 subjects who underwent MR of the head and neck for other non parotid pathology. The ultrasonography, MR and sialography images were evaluated by a single observer during a single session and scored from 0 to 4. In the SS patients ultrasonography was abnormal in all 23 cases (100%): 3 patients showed grade 1 alterations (13%); 5 grade 2 (21.7%); 9 grade 3 (39.1%); 6 grade 4 (26.1%). In the healthy controls, grade 0 was found in 36 subjects (72%) while the remaining 14 subjects revealed grade 1 alterations (28%). Using MR imaging only one of the SS patients showed grade 0 alterations (4.3%), 7 showed grade 1 alterations (30.4%), 9 grade 2 (39.1%), 5 grade 3 (21.7%) and only 1 grade 4 (4.3%). MR imaging sensitivity was 95.8% while specificity was 100%. For ultrasonography, considering grade 1 as non pathological, we found a sensitivity of 88.4% and specificity of 100%. The MR score for SS patients was compared to that obtained with sialography and ultrasonography. There was a good correlation between MR and sialography (r = 0.528, p = 0.010) while the correlation between MR and ultrasonography was not statistically significant. This study confirms that, of the diagnostic procedures available for evaluation of salivary gland involvement in SS, the most useful initial examination is ultrasonography. When there is some doubt or there are subtleties, MR is a valid alternative to classical sialography.

[Diagnosis and classification of primary Sjögren syndrome. Comparison of 3 criteria sets in 219 cases]

In spite of all recent years' international meetings, the question of diagnostic criteria of primary Sjögren's syndrome (pSS) is still under debate. The aim of our study is to define sensitivity, specificity and diagnostic accuracy of 3 sets of criteria: those of the European Community Study Group (ECSG), those proposed by Fox, and those proposed by Daniels. We considered 219 subjects complaining of dry mouth and/or dry eyes and/or parotid swelling, evaluated for pSS. The following parameters were considered golden standard for the diagnosis of pSS: focus score > or = 2 foci/mm2, double positivity for SSA and SSB antibodies, and a sialographic grade > or = 2. Our study demonstrates that ECSG criteria show a high sensitivity and a good specificity, resulting in a diagnostic accuracy similar, and sometimes higher, than that obtained with Fox and Daniels' criteria.

Morphologic study of microcirculation in acromegaly by capillaroscopy

Although wide range investigations on the heart and great vessels have been reported in acromegaly, the field of microcirculation is still largely vacant. The nailfold is a window through which we can observe in vivo the vascular bed. This study investigates through nailfold capillaroscopy the morphology of cutaneous microcirculation in acromegaly in relationship with the usual hormonal parameters of disease activity. Twenty-five acromegalic patients and 26 normal subjects, age and sex matched, were studied. A subgroup of acromegalics (8 patients) was considered in stable remission, and the remaining 17 had active disease. Capillaroscopy was performed in each subject by in vivo computer aided stereomicroscopy (magnification, x400). The following morphological parameters were calculated: the number of tortuous loops, meandering capillaries, and capillaries per millimeter; avascular areas; visibility of subpapillary plexus; the capillary length; and intercapillary distance. We were unable to perform the exam in 4 of 25 patients because visibility was poor. The capillary number and length were significantly reduced in acromegalics compared to controls [8.9 +/- 1.5 vs. 10.3 +/- 1.2 no./mm (P = 0.0010) and 174 +/- 49 vs. 255 +/- 24 microm (P < 0.0001)]. Moreover, in acromegalics, the numbers of tortuous loops and meandering capillaries were significantly increased [19 +/- 8 vs. 13 +/- 5 (P = 0.0027) and 10 +/- 12 vs. 0.7 +/- 1.1 (P < 0.0001)]. The capillaroscopic alterations were still observed in a smaller group of 8 nondiabetic and nonhypertensive acromegalics. We found branch-like capillaries in 4 acromegalic patients, but not in the control group. Finally, we observed a meaningful different and ameliorated capillaroscopic morphology in acromegalic patients in stable remission compared to active disease patients as far as the total number (density) and meandering capillaries were concerned. In conclusion, our study shows that in acromegaly, morphological alterations also affect the peripheral microcirculation, which seems to be influenced by the activity of the disease. We believe that nailfold capillaroscopy may represent an additional useful tool in the follow-up of acromegalic patients.

Thrombosis of the subclavian vein in SAPHO syndrome. A case-report

The hallmark of SAPHO Syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) is osteitis of the anterior chest wall, which can be so pronounced as to cause thoracic outlet syndrome, thrombosis of the subclavian vein, and compression of the superior vena cava. Suggestive skin manifestations, namely palmoplantar pustulosis and severe acne, generally antedate the bone and joint lesions. We report a case of SAPHO syndrome that went unrecognized for many years and eventually caused compression and thrombosis of the right subclavian vein requiring cleidectomy. SAPHO syndrome should be considered in every patients with anterior chest wall inflammation, particularly when skin lesions are also present.

Chondrocalcinosis is a feature of Gitelman's variant of Bartter's syndrome. A new look at the hypomagnesemia associated with calcium pyrophosphate dihydrate crystal deposition disease

The occurrence of chondrocalcinosis in patients with Bartter's syndrome has been reported as a typical example of hypomagnesemia-associated calcium pyrophosphate dihydrate crystal (CPPD) deposition disease. However, hypomagnesemia is a feature of Gitelman's variant of Bartter's syndrome, whereas serum magnesium levels are normal in Bartter's syndrome strictly speaking. We managed four patients with chondrocalcinosis and hypomagnesemia who met criteria for Gitelman's disease, including hypomagnesemia, hypokalemia with normal or high urinary potassium excretion, hypocalciuria, and normal blood pressure. Based on our experience with these patients, we argue that many cases of chondrocalcinosis and hypomagnesemia ascribed in previously published articles to Bartter's syndrome were due to Gitelman's syndrome.

Clinical, laboratory and immunogenetic aspects of post-traumatic psoriatic arthritis: a study of 25 patients

OBJECTIVE

In a previous study we demonstrated that the prevalence of trauma preceding arthritis was higher in patients with psoriatic arthritis (PsA) than in patients with rheumatoid arthritis (RA) or ankylosing spondylitis (AS); of 300 consecutive patients with PsA, 25 (8%) had a history of trauma before (< 3 months) the onset of the disease. The present study was carried out to characterize the clinical, laboratory and immunogenetic profiles of post-traumatic (PT)-PsA.

PATIENTS AND METHODS

The clinical and laboratory features of 25 patients with PT-PsA were studied at onset (first 6 months) and after a follow-up period of 1-7 years, and were compared with those of 275 PsA patients without any history of trauma (nonPT-PsA). HLA typing was performed in PT-PsA patients, and synovial fluid (SF) analysis, including interleukin (IL)-1 and IL-6 determinations, was carried out in 12 subjects with PT-PsA and in 32 with nonPT-PsA.

RESULTS

No differences were observed between PT-PsA and nonPT-PsA patients with regard to their clinical evolution. ESR (p < 0.0001) and CRP (p = 0.005) were higher in PT-PsA than in nonPT-PsA patients at disease onset but not after follow-up. No differences were found in the other blood indices. SF analysis revealed higher IL-6 levels in PT-PsA than in nonPT-PsA patients (p < 0.0005).

CONCLUSION

Our study demonstrates that the prevalence of trauma preceding arthritis is higher in PsA than in RA or AS. Clinical and laboratory findings in patients with PT-PsA differed from those with nonPT-PsA only at disease onset (first six months), however, showing an abrupt clinical presentation and a more acute phase response. This pattern may be related to the higher levels of IL-6 found in the SF of PT-PsA than in nonPT-PsA patients. However, during the follow-up period the two groups became indistinguishable, and no difference was observed between PT-PsA and nonPT-PsA regarding the evolution of the disease.

'Autoantibody dominance' pattern following idiotypic manipulation of naive mice by immunization with anti-U1RNP antibodies

OBJECTIVE

To study the immune response and clinical findings in mice immunized with different epitope-specific anti-U1RNP antibodies purified from the sera of mixed connective tissue disease (MCTD) patients with various clinical manifestations.

METHODS

BALB/c mice were immunized with anti-U1RNP-IgG preparations from 3 patients with MCTD. Group 1 was immunized with U1 70 kD A-positive IgG, group 2 with U1 70 kD-negative, U1A, U1C, B-B'-positive IgG and group 3 with U1 70 kD, U1A, U1C-positive IgG. The induced autoantibody response in the mice was studied by ELISA and immunoblots and the clinical findings of MCTD in humans were assessed.

RESULTS

Immunoblot assays showed that mice immunized with different human anti-U1RNP antibodies developed predominantly autoantibodies directed against U1 68-70 kD epitope. This 'autoantibody dominance' pattern was not associated with clinical findings.

CONCLUSIONS

The restricted murine autoimmune response may provide clues to the diversified autoantibody production in autoimmune diseases and explain in part the changing patterns of clinical findings in individuals with MCTD.

A prospective study of fifty-three consecutive calcium heparin treated pregnancies in patients with antiphospholipid antibody-related fetal loss

OBJECTIVE

In this study the efficacy and safety of calcium heparin administered alone for the prevention of fetal loss related to antiphospholipid antibodies (aPL) were evaluated.

METHODS

Fifty-three consecutively ascertained pregnancies were followed in 53 patients who had a history of at least 2 consecutive miscarriages during the first trimester and/or 1 fetal death during the second or third trimesters. In addition, all patients had at least 2 positive aPL tests more than 8 weeks apart before pregnancy, or a positive aPL test at the beginning of pregnancy. They were treated with calcium heparin alone, self-administered subcutaneously 3 times daily at dosages varying between 15,000 and 37,500 units. Treatment was started soon after a sonogram demonstrated a live embryo and was continued throughout pregnancy until the end of puerperium.

RESULTS

All pregnancies terminated favourably between the 25th and 40th weeks (mean +/- SD: 36.69 +/- 2.91) with planned caesarean section in 27 cases and vaginal delivery in 26. Delivery was brought forward due to maternal and/or fetal complications in 18 cases (33.96%). Calcium heparin was associated with intravenous immunoglobulin therapy in 2 patients with fetal problems unresponsive to anticoagulant treatment alone. The newborns, 30 females and 25 males, had a mean birth weight of 2,828.3 g +/- 706.5 and a mean Apgar score at 5 minutes of 9.60 +/- 0.68. No malformations were observed. Thirty of the 37 examined placentas (81.08%) showed signs of thrombotic events. Only minor side effects of calcium heparin were observed during treatment.

CONCLUSION

Our study suggests that calcium heparin administered alone using the dosages and timing described here is effective in achieving the delivery of viable infants, and that it is well tolerated.

Clinical, laboratory and immunogenetic aspects of arthritis associated with chronic lymphocytic thyroiditis

OBJECTIVE

Synovial fluid effusions and/or arthritis may be found in patients with chronic lymphocytic thyroiditis (CLT), even in the absence of hypothyroidism. Sometimes these arthropathies can be attributed to the rheumatic diseases frequently associated with CLT, but in some instances the arthritis seems to be independent of any of the diseases known to cause arthritis, and therefore remains unclassified. This study was carried out in an attempt to characterize the type and outcome of arthritis associated with CLT.

METHODS

We performed a prospective study with a follow-up of 6.42 years (range 4-13) on 33 patients affected with CLT and presenting with arthritis. All conditions known to cause arthritis were previously excluded. Investigations included HLA typing, x-ray of the affected joints and, when possible, synovial fluid (SF) analysis with an interleukin (IL)-1 beta determination. Patients were divided based on their clinical presentation into two groups: those with polyarthritis and those with oligoarthritis.

RESULTS

During the follow-up, 8 out of 16 patients with polyarthritis developed severe rheumatoid arthritis, characterized by bone erosions, high levels of SF IL-1 beta and an increased frequency of HLA DR4. The other 8 patients had polyarthritis in a mild, non-erosive form, which responded well to symptomatic drugs. Oligoarthritis, found in 17 patients, also showed a mild evolution, with frequent spontaneous remissions. The non-rheumatoid polyarthritis and oligoarthritis patients were characterised by the absence of bone erosions, low levels of SF IL-1 beta and an increased frequency of HLA DR3.

CONCLUSIONS

We conclude that it is possible to find in association with CLT a type of inflammatory arthritis characterized by a mild, non-erosive evolution, low SF levels of IL-1 beta and an increased frequency of HLA-DR3. This arthritis seems to be independent of thyroid dysfunction and shows a clinical pattern similar to the arthritis usually found in connective tissue diseases.

Esophageal motor function in primary Sjögren's syndrome: correlation with dysphagia and xerostomia

The incidence of dysphagia in patients with primary Sjogren's syndrome (pSS) has been underestimated and all too often ascribed to xerostomia, without considering the possible presence of esophageal motor abnormalities affecting other nonscleroderma connective tissue diseases. Esophageal and salivary functions were prospectively evaluated in 27 females who met the four criteria proposed by Fox for the diagnosis of pSS, using esophageal manometry after wet swallows and Saxon's test, respectively. Dysphagia was graded using a standard symptoms questionnaire and results were compared with those obtained in a group of 21 healthy controls. Seven patients with pSS (26%) had no swallowing discomfort, 2 (7.4%) had mild dysphagia, 7 (26%) had moderate dysphagia, and 11 (40.6%) had severe dysphagia. Saxon's test revealed an overall decrease in the salivary flow rate compared to controls, with no difference between patients with or without dysphagia. Esophageal manometry demonstrated the absence of any lower or upper esophageal sphincter function abnormalities in all patients. In the patients with pSS as a whole, manometric study of the esophageal body showed a motor pattern comparable with that of controls, with no difference between patients with and without dysphagia. Defective peristalsis, ie, the presence of simultaneous contractions in more than 30% of wet swallows was detected, however, in the distal tract of the esophagus of six patients (22.2%) and in the proximal tract of three (11.1%). All these patients had severe dysphagia and the modified Saxon's test revealed a salivary secretion comparable with that of patients with a normal peristalsis. Dysphagia is a very common complaint in patients with pSS and does not seem to correlate with xerostomia, which is a constant and typical finding of the disease. About one third of patients with pSS have an abnormal esophageal peristalsis that is responsible for severe dysphagia, whereas decreased salivary outflow exacerbates the swallowing discomfort. This has to be taken into account and justifies the routine use of esophageal manometry in patients with pSS. The cause of dysphagia in pSS patients without peristaltic disorders of the esophagus has to be investigated.

Synovial fluid levels of proinflammatory interleukins and their inter-relationships in elderly vs younger onset rheumatoid arthritis

Elderly-onset rheumatoid arthritis (EORA) is thought to be different from younger-onset disease (YORA) for many reasons, including a more elevated acute phase response and a more abrupt onset; both events are mainly regulated by pro-inflammatory interleukins (ILs), in particular, IL-1, IL-6 and IL-8. To compare the synovial fluid (SF) levels of these ILs, and their relationship to local inflammation as well as the acute phase response, erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) in the two RA subsets, we determined white blood cell (WBC) number, total protein (TP), IL-1beta, IL-6 and IL-8 concentrations in the SF of 50 patients, 15 with EORA and 35 with YORA. Both ESR and CRP were higher in EORA than in YORA. IL-6 was higher in SF of EORA (2111.37 +/- 1425.03 pg/mL) than YORA (1077.53 +/- 757.62 pg/mL, p = 0.002), while no difference was observed for SF IL-1beta and IL-8. There was a weak correlation between SF IL-6 and IL-1beta in EORA, whereas SF ILs and CRP and/or ESR did not show any correlation in both groups. Our study indicates that in EORA, as in other diseases occurring in the elderly, there are elevated levels of IL-6. Higher SF levels of IL-6 may be, at least in part, responsible for the different behavior of EORA with respect to YORA.

Arthroscopic synovectomy in rheumatoid and psoriatic knee joint synovitis: long-term outcome

A long-term prospective study was performed to evaluate the safety and long-term outcome of surgical arthroscopy (AS) for persistent rheumatoid (RA) and psoriatic (PsA) knee joint synovitis (KJS). Local signs of joint inflammation (tenderness, swelling, "ballottement') and range of motion (ROM) were scored and the sum, taken as a global outcome measure, was recorded in 17 RA and 18 PsA knees, both before and at follow-up periods of 2, 6, 12, 24 and 36 months after surgical AS (knee joint synovectomy; meniscal curettage, cartilage shaving or chondrectomy, according to the degree of cartilage damage). A survival analysis (Kaplan-Meier) of the long-term outcome of surgical AS treatment and of the predictive value of clinical parameters of knee joint involvement was also performed. No intra- or post-operative morbidity, pain worsening or loss of joint motion was observed and all patients were discharged within 48 h. Comparison of the parameters of knee joint evaluation showed a significant reduction of the signs of joint inflammation and a significant increase in the ROM in all follow-up periods. At 36 months, the survival curves showed a 61.2% cumulative probability of clinical remission and 72.8% of definite improvement. No significant differences in the prognostic importance of RA, compared to PsA diagnosis, were observed, although higher percentages of PsA compared to RA knees (86.3% and 45.7% respectively) reached the end point of clinical remission at 36 months. KJS duration, radiographic severity and cartilage damage were not predictors of poor long-term outcome of AS synovectomy. Surgical AS treatment for PsA knees with more advanced cartilage damage gave a better long-term outcome. A total of 50.7% of operated knees reached the end point of a KJS relapse at 36 months, the majority (82%) within the initial 18 months of follow-up. Our study indicates that AS synovectomy is a safe procedure requiring short hospitalization which, in combination with second-line medical treatment, can reduce local inflammation in RA and PsA KJS, and preserve knee joint ROM for up to 3 yr.

Long-term sonographic follow-up of rheumatoid and psoriatic proliferative knee joint synovitis

The potential role of sonography in evaluating the response to therapy of persistent knee joint synovitis (KJS) was assessed in a longitudinal study in pre-and post-arthroscopic (AS) synovectomy in rheumatoid and psoriatic patients. At entry to the study ultrasound (US) detection of synovial proliferation was compared with arthroscopic visualization as the 'gold standard' reference. US joint effusion and synovial thickness measures and predominant patterns of synovial proliferation were recorded by comparing clinical and US indices before and at 2, 6 and 12 months after AS synovectomy, or after KJS relapse up to 24 months. A 12 month survival analysis of clinical and US outcomes of arthroscopic synovectomy was also performed. US detection of morphology and degree of synovial proliferation was correlated with AS macroscopic evaluation. After AS synovectomy, the clinical index and both US joint effusion and synovial thickness were significantly reduced, whereas US patterns of synovial proliferation did not show significant changes. US and clinical indices were significantly correlated in all follow-up measurements and US joint effusion was significantly increased in the relapsed compared with the non-relapsed KJS group. The probability at 12 months of reaching maximum improvement in US joint effusion and synovial thickness outcomes was 99 and 58%, respectively; that for clinical remission of KJS was 72%. Ultrasound evaluation has proven reliable and accurate by the arthroscopic gold standard in detecting changes of rheumatoid arthritis and psoriatic arthritis knee joint synovitis. The correlation of US with clinical findings in pre-and post synovectomy patients suggests that sonography can be used as an objective method in monitoring the response to therapy of inflammatory knee joint disease.