Doppler techniques

Over the last decade, there has been a growing body of evidence on the validity of Doppler ultrasound for assessing inflammatory changes in target anatomic structures involved in rheumatic diseases such as joints, tendons, entheses and vessels. The enhanced sensitivity for detecting low-velocity flow in synovium vessels achieved by current Doppler techniques has lead to the incorporation of Doppler US in the assessment of joint and inflammatory enthesis lesions. This review offers an overview of the key aspects of current applications and limitations of Doppler ultrasound in inflammatory rheumatic diseases. The basic principles of Doppler modes, Doppler scanning method, and Doppler artefacts and pitfalls in rheumatology ultrasound are also described.

A brief history of ultrasound in rheumatology: where we are now

Ultrasound is gradually becoming established as an indispensable tool within the rheumatology clinical setting. Falling costs, improved educational opportunities, standardisation and developments in therapeutics have all led to the greater acceptability of the technique. This review will highlight how far ultrasound has come in a relatively short period of time by providing an overview of how it is being applied in rheumatology today.

Interventional ultrasound: a critical overview on ultrasound-guided injections and biopsies

Over the last decades ultrasound-guided procedures have become increasingly diffused in rheumatology, mainly thanks to the technical advances achieved in the ultrasound (US) field, combined with the greater availability, good portability and reduced cost of US devices, compared to other imaging techniques already used in rheumatology units. The direct visualisation of the tissue under analysis and the real-time imaging performance enabled by US-guidance account for an improved accuracy and directness in needle placement in a number of rheumatology interventions such as tendon and intra-articular injections. Compared with blind procedures, US-guided injections are more accurate and safe and they result in better clinical outcome in terms of joints improvement in function and decreased risk of damages caused by needle misplacement. The accuracy in needle placement of US-guided injections has proven to be important not only in common intra-articular injections, but especially in case of complex anatomical areas like the hip, facet and atlanto-occipital joints, where blinded injections are deemed poorly accurate and thus highly risky. Moreover US guidance can be successfully employed in more complex procedures such as synovial biopsy, portal establishment or arthroscopy, where US can also be combined with other imaging techniques. Overall the employment of US-guided procedures is considered to be safe and well-tolerated, and increases the accuracy and therapeutic effectiveness of the interventions performed. This may pave the way for a more widespread employment of US-guidance in rheumatology units, and new studies could further explore the therapeutic advantages of these procedures.

A brief history of ultrasound in rheumatology: where we were

Ultrasonography in the '70s was a well-known and widely used method within several medical specialties but not in rheumatology. Initial development of the field was led by radiologists who mainly investigated the potential of ultrasound in the assessment of large joints. In the late '80s, the first studies supporting the role of ultrasound in the detection of soft tissue changes and bone erosions in the hands of patients with rheumatoid arthritis were published. In the '90s, the dramatic improvement of spatial resolution due to the new generation high frequency probes opened up new avenues for the exploration of otherwise undetectable anatomical details. Ultrasound research during this period was enhanced by the growing use of colour Doppler and power Doppler and by the first prototypes of three dimensional ultrasound. Over the last 10 years, the buzz words in ultrasound research in rheumatology have been standardisation, early diagnosis and therapy monitoring.

Ultrasound versus low-field magnetic resonance imaging in rheumatic diseases: a systematic literature review

OBJECTIVES

US and MRI play a significant role in the diagnosis of rheumatic diseases and in monitoring treatment response. This systematic review summarises and evaluates available evidence on the value of low-field MRI compared to US in rheumatic diseases.

METHODS

A computerised literature search was conducted by a single reviewer to identify relevant published articles on the diagnostic accuracy of low-field MRI compared to US in rheumatic diseases. The literature search comprised the period from January 1998 to September 2013.

RESULTS

The search yielded a total of 1055 articles that were reviewed by title or abstract; finally, 23 articles fulfilling all inclusion criteria were included in the analysis. Our results show that low-field MRI is probably more sensitive than US in the detection of erosions, due to its higher multiplanar capacity. In OA there was a good correlation between US and MRI measurements for cartilage thickness and for effusion in the superior and in the lateral recesses.

CONCLUSIONS

There are still few studies comparing US and low-field MRI for their diagnostic and prognostic value in rheumatology and it is currently difficult to draw any firm conclusions on the preferred imaging technique to answer specific clinical questions.

Becoming a musculoskeletal ultrasonographer

Over the last decade, increasing numbers of rheumatologists have incorporated musculoskeletal ultrasound (MSUS) as a valuable diagnostic tool into their clinical practice. Some countries have established training programmes for MSUS. The European League Against Rheumatism has developed education guidelines for the content and conductance of MSUS courses and it would be useful to standardise rheumatology MSUS training worldwide. A thorough knowledge of anatomy, US physics and technology, US scanning methods, US pattern of normal and pathological musculoskeletal tissues, definitions for US pathology, artefacts and pitfalls in both greyscale and Doppler modalities is necessary to perform efficient MSUS. MSUS training includes attending theoretical-practical and online courses, as well as studying textbooks and using digital video discs (DVDs). Having access to US equipment and performing supervised normal and pathological MSUS examinations for a training period are mandatory for consolidating MSUS learning. A proposal to accredit and certificate competence in MSUS is now being discussed.

Assessment of enthesopathy in patients with fibromyalgia by using new sonographic enthesitis index

OBJECTIVE

The aim of the present study is to determine the frequency of enthesopathy in fibromyalgia (FM) by using a newly developed ultrasonography (US) method, the Madrid Sonography Enthesitis Index (MASEI).

METHODS

This study was conducted on 38 consecutive patients with FM and 48 healthy sex- and age-matched controls. Six entheseal sites (olecranon tuberosity, superior and inferior poles of patella, tibial tuberosity, superior and inferior poles of calcaneus) on both lower limbs were evaluated. All US findings were identified according to MASEI. Scores of patients and controls were compared by Student's t-test and Mann-Whitney U-test. Validity was analysed by receiver operating characteristic curve. Values of P < 0.05 were considered significant.

RESULTS

Total enthesitis score was 7.39 ± 4.99 (mean ± SD) among FM patients and 3.7 ± 3.22 among healthy controls (P < 0.001). The receiver operating characteristic curve established an ultrasound score of > 3.5 in the FM group as the best cut-off point to differentiate between cases and controls. No statistically significant correlation was found between the MASEI score and the FM disease duration, and the location of the tender points.

CONCLUSIONS

Misdiagnoses of FM are harmful to patients and the community, and the presence of enthesopathy among FM patients increases. Its detection with the MASEI score may help to discriminate FM patients presenting with ill-defined symptoms and signs, in order to prevent mistreatment.

Value of ultrasound in rheumatologic diseases

The use of musculoskeletal ultrasound in rheumatology clinical practice has rapidly increased over the past decade. Ultrasound has enabled rheumatologists to diagnose, prognosticate and monitor disease outcome. Although international standardization remains a concern still, the use of ultrasound in rheumatology is expected to grow further as costs fall and the opportunity to train in the technique improves. We present a review of value of ultrasound, focusing on major applications of ultrasound in rheumatologic diseases.

[Metatarsophalangeal arthrodesis of the hallux and arthroplastic resection of the second to fifth metatarsal heads in the rheumatic foot]

The objective of this study is to assess the clinical and radiologic results of patients with rheumatic forefoot who underwent metatarsophalangeal arthrodesis of the first ray and arthroplastic resection of the second to fifth metatarsal heads at the National Rehabilitation Institute.

MATERIAL AND METHODS

This is a prospective comparative study of the clinical and radiological status before and after the surgical procedure; it is a descriptive, observational single-group study. From April 2006 to December 2011, 31 surgical procedures were performed in 29 female and two male patients. The SPSS 17.0 software was used for the statistical analysis. Efficacy and quality of life indicators were compared using mean comparison tests (Student t test), the indicator of patient safety by means of frequency analysis, and the comparative analysis of the occurrence of complications throughout time.

RESULTS

The mean preoperative visual analog scale score was 6.2 +/- 1.3, with an average of 1.6 +/- 2.5, with statistical significance, with p < 0.0001 and t = 7.97. Radiographic measurements of the hallux valgus angle showed a remarkable improvement.

CONCLUSIONS

The surgical procedure described is reliable and efficacious, as patients had an important improvement in quality of life, with pain relief and adaptation to their activities of daily living after surgery.

Increased enthesopathy in patients with familial Mediterranean fever: evaluation with a new sonographic enthesitis index

OBJECTIVES

The aim of this study was to determine the frequency of enthesopathy in familial Mediterranean fever by using a newly developed sonographic method, the Madrid Sonographic Enthesitis Index (MASEI).

METHODS

The study included 50 consecutive patients with familial Mediterranean fever and 57 healthy sex- and age-matched control participants. Six entheseal sites (olecranon tuberosity, superior and inferior poles of the patella, tibial tuberosity, and superior and inferior poles of the calcaneus) on both lower limbs were evaluated. All sonographic findings were identified according to MASEI. Validity was analyzed by receiver operating characteristic curves. P < .05 was considered significant.

RESULTS

Mean total enthesitis scores ± SD were 7.54 ± 4.99 for patients and 3.63 ± 3.03 for controls (P < .001). No statistically significant correlation was found between the MASEI score and familial Mediterranean fever duration or colchicine treatment duration. There was no difference between the MASEI score and the presence or absence of arthritic involvement among the patients. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval, 0.649-0.839). When analyzed by sex, men with familial Mediterranean fever had significantly higher MASEI scores than women (P < .05).

CONCLUSIONS

This study showed significant enthesopathy in patients with familial Mediterranean fever. The findings support the hypothesis that familial Mediterranean fever and spondyloarthropathy may have common inflammatory mechanisms and suggest that the MASEI scoring system can be incorporated into clinical protocols for studying patients with familial Mediterranean fever in daily practice.

Ultrasound of the knee in rheumatology

Knee ultrasound is a very useful tool for the clinical examination of rheumatic patients. In the last years many papers have been focused on this subject, exhibiting a high degree of improvement since the first musculoskeletal ultrasound paper concerning the knee was published 30 years ago. Apart from the accurate description of anatomic landmarks and structures and also of the basic pathological findings (fluid, synovitis, enthesitis, osteophytes), rheumatologic research has focused on inflammatory findings quantification and their reaction to remissive treatments. The aim of this review is to describe the normal ultrasonographic appearance of knee structures concisely and mainly to analyse the literature about pathological findings in the knee joint.

Ultrasound imaging for the rheumatologist. XLII. Assessment of hip pain in rheumatic patients: the radiologist's view

Hip pain is a common complaint in daily practice and the identification of the underlying pathologic condition is the first step for an adequate treatment. In this review, we discuss the available evidence for the application of conventional radiography, computed tomography and magnetic resonance imaging in rheumatologic patients with painful hip, presenting the main imaging findings due to osteoarthritis, inflammatory arthritis (rheumatoid arthritis and spondyloarthritides), osteonecrosis and some other soft tissue involvement (bursitis and synovial cyst) that could be the cause of hip pain. Because different imaging techniques show different sensitivity and specificity, the choice of technique to use depends on the type and stage of the disease itself.

[Ultrasound in the musculoskeletal system - possibilities and limits]

Since the early 1990's, ultrasound through the development of high-resolution probes in the musculoskeletal system has become more and more important. The development of ultrasound technology has gone hand in hand with the development of know-how in different clinical fields, so that diagnostic ultrasound has now become an indispensable diagnostic tool in orthopedics/traumatology, rheumatology and neurology. The following article will arouse curiosity and interest in musculoskeletal ultrasound.

Early prediction of left ventricular systolic dysfunction in patients of asymptomatic chronic severe rheumatic mitral regurgitation using tissue Doppler and strain rate imaging

AIMS

Identification of subclinical left ventricular (LV) dysfunction in patients with rheumatic mitral regurgitation (MR) facilitates optimal surgical results and better postoperative LV function. This study is designed to assess the role of tissue Doppler and strain rate (SR) imaging in early detection of LV systolic dysfunction in patients with asymptomatic chronic severe MR.

METHODS AND RESULTS

Patients were studied under four groups. Group I: Normal subject (n = 25). Group II: Patients with chronic severe MR with ejection fraction (EF) > 60% and end-systolic dimension (ESD) ≤ 40 mm (n=23). Group III: Patients with chronic severe MR with EF ≥ 60% and ESD 41-50 mm (n = 27). Group IV: Patients with chronic severe MR with EF < 60% with any ESDs (n = 25). With decrease in EF and increase in ESD there was decrease in systolic velocity and increased in precontraction time and contraction time was noted. The tissue Doppler systolic indices between groups were statistically significant P < 0.05 and showed significant correlation value r = 0.45 between groups. Strain (S) and SR significantly decreased with decrease in EF and increase in ESD P < 0.05, r = 0.45 between different groups.

CONCLUSION

Our study showed significant correlation between tissue Doppler systolic indices and SR imaging with EF and ESD.

Ultrasound assessment of the elbow

Ultrasonography of the elbow is a very helpful and reliable diagnostic procedure for a broad spectrum of rheumatic and orthopedic conditions, representing a possible substitute to magnetic resonance imaging for evaluation of soft tissues of the elbow. Musculoskeletal ultrasound (US) shows many advantages over other imaging modalities, probably the most important being its capability to perform a dynamic assessment of musculoskeletal elements with patient's partnership and observation during examination. In addition, ultrasonography is cost effective, easy available, and has excellent and multiplanar capability to visualize superficial soft tissue structures. Among all imaging procedures, US is highly accepted by patients. US assessment of the elbow requires good operator experience in the assessment of normal anatomy, and suitable high-quality equipment. US of the elbow provides detailed information including joint effusions, medial and lateral epicondylitis, tears of the distal biceps and triceps tendons, radial and ulnar collateral ligament tears, ulnar nerve entrapment, cubital or olecranon bursitis and intra-articular loose bodies. The aim of this paper is to review the screening technique and the basic normal and pathological findings in elbow US.

Ultrasound imaging for the rheumatologist XXXIX. Sonographic assessment of the hip in fibromyalgia patients

Fibromyalgia syndrome (FMS) is a common form of non-inflammatory rheumatism within the general population with symptoms often mimicking those of arthritis or muscle disorders. Arthralgic symptoms in the region of the hip are commonly mentioned by patients with FMS and one of the diagnostic trigger points for the condition is found around the greater trochanter. To date, no formal imaging studies using ultrasound (US) have been performed in FMS. This study describes the correlation between clinical and US findings in patients presenting with primary FMS to rheumatology clinics. In the majority of the patients, no significant pathological US abnormalities were detected.

Entheseal ultrasound abnormalities in patients with SAPHO syndrome

This study was conducted to investigate the presence and characteristics of the ultrasound lesions that may be found in the entheses of patients with SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome. This cross-sectional study included 15 patients with SAPHO syndrome and 30 healthy controls matched for age, sex and body mass index. Subjects with regular sport activities as well as those with other rheumatic conditions were excluded from the study. Ultrasonography was used in both groups to study 14 entheses of the upper and lower extremities. Different elementary lesions representative of enthesis damage were defined. A total of 210 entheses in the study group and 420 in the control group were evaluated. Only one patient presented clinical enthesitis. In the study group, seven of the 15 patients (47%) showed morpho-structural entheseal alterations, versus only four of the 30 controls (13.3%; p < 0.001). The subjects with SAPHO showed ultrasound alterations in 32/210 entheses (15%), while the controls showed alterations in 20/420 entheses (4.8%), p < 0.001. The entheses with the largest number of morpho-structural alterations were those of the patellar and Achilles tendon. None of the controls showed power Doppler signal at enthesis or perienthesis level. Ultrasound evidence of enthesopathy seems to be a common feature in this series of patients with SAPHO syndrome.

Ultrasound revealing subclinical enthesopathy at the greater trochanter level in patients with spondyloarthritis

This study was conducted to determine the prevalence of subclinical entheseal involvement at the greater trochanter level by ultrasound in patients with spondyloarthritis. Forty-six patients with spondyloarthritis and 46 healthy age- and sex-matched controls were studied. All patients with no clinical evidence of enthesopathy at the greater trochanter underwent an ultrasound examination. The following three entheses were scanned bilaterally: anterior insertion of gluteus minimus, anterior insertion of gluteus medius, and posterior insertion of gluteus medius. Ultrasound findings of enthesopathy were thickening, calcifications, bone erosions, enthesophytes, bursitis, and power Doppler signal. A total of 276 entheses were evaluated in spondyloarthritis patients. In 112 out of 276 (40.5%), grayscale ultrasound found enthesopathy. The enthesis with the highest number of signs of enthesopathy was the anterior insertion of gluteus medius (46/276) (16%), followed by posterior insertion of gluteus medius (37/276) (13.4%) and anterior insertion of gluteus minimus (29/276) (10.5%). In the healthy population, ultrasound found entesopathy in 80 out of 276 (29%) entheseal sites (p < 0.0001). Posterior insertion of gluteus medius enthesis was the more frequently involved (34/276) (12.3%), followed by anterior insertion of gluteus medius (24/276) (8.6%) and anterior insertion of gluteus minimus (22/276) (7.9%). Power Doppler was found more frequently in patients with spondyloarthritis compared with healthy controls (1% vs 0%). Our results show a higher prevalence of subclinical enthesopathy at the greater trochanter level in patients with spondyloarthritis than in age- and sex-matched healthy controls.

[Musculoskeletal ultrasound I - «pearls and crystals»]

This article reviews the applications of high resolution ultrasound (HRUS) which were discussed at the SGUM congress in Davos in the talk «pearls and crystals». Sonography is an excellent and validated tool in the diagnostics and assessment e.g. of spondylo-arthritis and crystal deposition diseases. Enthesitis is a typical feature of SpA. The Sensitivity of HRUS diagnosing enthesitis is higher compared to the clinical examination. High frequency US probes allow furthermore an accurate assessment in crystal deposition diseases. Sonography is able to detect various typical pathologies in gout, pseudogout and apatite deposition disease. Will HRUS in the near future be able to replace microscopy in the diagnostics of crystal deposition diseases?

Ultrasound imaging for the rheumatologist XXXIV. Sonographic assessment of the painful foot

The foot is increasingly the focus of attention for rheumatologists when assessing patients presenting to a clinic and may represent underlying intra-articular inflammatory pathology or involvement of the surrounding soft tissues. This study describes the correlation between clinical and ultrasound (US) findings in patients presenting with a variety of rheumatic disorders linked with foot pain. Poor correlation was found between conventional clinical examination and US in cases with joint inflammation, tendonitis and, more particularly, those cases with enthesopathy.

[Ultrasonographic semiology--correlation between anatomy and sonography of musculoskeletal tissue]

Diagnostic ultrasound (US) as noninvasive, non-ionisating and cost-effective imaging diagnostic technique has emerged as a useful imaging modality in rheumatology for the assessment of joint and soft tissue pathology. It can detect both early inflammatory soft tissue lesions (synovitis, tenosynovitis) and early erosive bone lesions in arthritis. Thus Power Doppler ultrasonography can differentiate active from inactive joint processes allowing monitoring of the new anti-inflammatory drugs used to treat inflammatory rheumatological diseases. In the process of learning the diagnostic technique memorizing and recognition of specific sonografic presentation of the different tissue structures, pathological processes, artifacts and pitfalls known as basic sonografic semiology is essential for appropriate interpretation of ultrasound image. In this paper ultrasound appearance of normal and basic pathological findings of different structures and tissues of musculoskeletal system is described and illustrated.