Doppler ultrasound findings in healthy wrists and finger joints

Correlation between computerised findings and Newman's scaling on vascularity using power Doppler ultrasonography imaging and its predictive value in patients with plantar fasciitis

OBJECTIVES

The purpose of this study was to correlate findings on small vessel vascularity between computerised findings and Newman's scaling using power Doppler ultrasonography (PDU) imaging and its predictive value in patients with plantar fasciitis.

METHODS

PDU was performed on 44 patients (age range 30-66 years; mean age 48 years) with plantar fasciitis and 46 healthy subjects (age range 18-61 years; mean age 36 years). The vascularity was quantified using ultrasound images by a customised software program and graded by Newman's grading scale. Vascular index (VI) was calculated from the software program as the ratio of the number of colour pixels to the total number of pixels within a standardised selected area of proximal plantar fascia. The 46 healthy subjects were examined on 2 occasions 7-10 days apart, and 18 of them were assessed by 2 examiners. Statistical analyses were performed using intraclass correlation coefficient and linear regression analysis.

RESULTS

Good correlation was found between the averaged VI ratios and Newman's qualitative scale (ρ=0.70; p<0.001). Intratester and intertester reliability were 0.89 and 0.61, respectively. Furthermore, higher VI was correlated with less reduction in pain after physiotherapeutic intervention.

CONCLUSIONS

The computerised VI not only has a high level of concordance with the Newman grading scale but is also reliable in reflecting the vascularity of proximal plantar fascia, and can predict pain reduction after intervention. This index can be used to characterise the changes in vascularity of patients with plantar fasciitis, and it may also be helpful for evaluating treatment and monitoring the progress after intervention in future studies.

Usefulness of ultrasound imaging in detecting psoriatic arthritis of fingers and toes in patients with psoriasis

Background. Given that clinical evaluation may underestimate the joint damage and that early treatment can slow down psoriatic arthritis (PsA) progression, screening psoriasis patients with imaging tools that can depict early PsA changes would entail clear benefits. Objective. To compare the ability of X-ray and ultrasound (US) examination in detecting morphological abnormalities consistent with early PsA in patients with psoriasis, using rheumatological evaluation as the gold standard for diagnosis. Methods. Patients with chronic plaque psoriasis and no previous PsA diagnosis attending our outpatient dermatology clinic and reporting finger/toe joint and/or tendon pain underwent X-ray and US evaluation; they were subsequently referred to a rheumatologist for clinical examination and review of imaging findings. Results. Abnormal US and/or X-ray findings involving at least one finger and/or toe (joints and/or tendons) were seen in 36/52 patients: 11 had one or more X-ray abnormalities, including erosion, joint space narrowing, new bone formation, periarticular soft tissue swelling, and periarticular osteoporosis; 36 had suspicious changes on US. Conclusion. US proved valuable in detecting joint and/or tendon abnormalities in the fingers and toes of patients with suspicious changes. The dermatologist should consider US to obtain an accurate assessment of suspicious findings.

Musculoskeletal Ultrasonography in Healthy Subjects and Ultrasound Criteria for Early Arthritis (The ESPOIR Cohort)

Objective.

To confirm the occurrence of bone erosions and synovitis in healthy subjects detectable by ultrasound (US) and to establish US criteria for early arthritis.

Methods.

Our study involved 127 healthy subjects matched with a cohort of patients with early arthritis (the ESPOIR cohort). The second and fifth metacarpophalangeal (MCP) joints and the fifth metatarsophalangeal (MTP) joint of both hands and feet were assessed with US to detect bone erosion; and the second, third, fourth, and fifth MCP and the fifth MTP were evaluated for synovial thickening in B-mode US and synovial vascularity in power Doppler. Bone erosion and synovitis were defined according to the Outcome Measures in Rheumatology Clinical Trials consensus.

Results.

Bone erosion and grade 2–3 synovial thickening in B-mode were detected in 11% and 9% of healthy subjects. To consider the diagnosis of early arthritis, a cutoff at 1 case of synovial thickening in B-mode enabled discrimination between patients with early arthritis and healthy subjects, with a good sensitivity of 74.8% (95% CI 67.2%–82.3%) and a high specificity of 90.5% (95% CI 85.4%–95.6%). If higher specificity is required to confirm the diagnosis of early arthritis, cutoff at 2 cases of synovial thickening in B-mode or at 2 cases of bone erosion gave optimal results, with specificity of 98.4% (95% CI 96.2%–100%) and 100%, respectively, and lower sensitivity of 59.8% (95% CI 51.2%–68.3%) and 17% (95% CI 10.5%–23.5%) (area under the curve = 0.85 for synovitis and 0.63 for bone erosion). Neither the combination of power Doppler signal plus bone erosion, nor bone erosions plus synovial thickening on the same joint, were seen in healthy subjects.

Conclusion.

A single case of bone erosion or synovial thickening in B-mode is common in healthy subjects. However, more than 1 case of synovial thickening in B-mode or bone erosion is a strong argument for the diagnosis of early inflammatory arthritis.

Multispectral quantitative photoacoustic imaging of osteoarthritis in finger joints

We present in vivo experimental evidence that multispectral quantitative photoacoustic tomography (qPAT) has the potential to detect osteoarthritis (OA) in the finger joints. In this pilot study, two OA patients and three healthy volunteers were enrolled, and their distal interphalangeal (DIP) joints were examined photoacoustically by a multispectral PAT scanner. Images of tissue physiological/functional parameters including oxyhemoglobin, deoxyhemoglobin, oxygen saturation, and water content, along with the tissue acoustic velocity of all the examined joints, were simultaneously recovered using a finite element reconstruction algorithm for multispectral photoacoustic measurements. The recovered multispectral photoacoustic images show that the OA joints have significantly elevated water content, decreased oxygen saturation, and increased acoustic velocity compared to the normal joints.

Superiority of SDAI over DAS-28 in assessment of remission in rheumatoid arthritis patients using power Doppler ultrasonography as a gold standard

OBJECTIVE

To investigate the accuracy of composite scores in classifying RA patients who are in remission using the absence of inflammatory activity detected by ultrasound (US) as a gold standard.

METHODS

Ninety-seven RA patients who were classified by their rheumatologists as being in remission were studied. Disease activity was assessed by the DAS-28 and simplified disease activity index (SDAI). US examination was performed in mode B and power Doppler (PD) in 42 joints.

RESULTS

Synovial hypertrophy (SH) and PD were present in 92 (94.8%) and 41 (42.3%) patients. If we consider 'remission' to be the absence of joints with PD signal, no differences were found by DAS-28 between patients in remission and those not in remission, although differences were present by SDAI. We then calculated the sensitivity (S), specificity (Sp) and positive likelihood ratio (LR) of different SDAI cut-off points to predict absence of PD signal. SDAI < 5 had an S of 65% (95% CI 52, 76), Sp of 55% (95% CI 39, 69) and LR of 1.45 (95% CI 0.98, 2.15), whereas SDAI < 3.3 had an S of 57% (95% CI 44, 69), Sp of 74% (95% CI 58, 85) and LR of 2.24 (95% CI 1.25, 4.01).

CONCLUSIONS

Our results suggest that the SDAI classification of remission is closer to the concept of an absence of inflammatory activity, as defined by the absence of positive PD signal by US.

Ultrasound of enthesopathy in rheumatic diseases

Enthesopathy is the pathologic change of the insertion of tendons, ligaments and joint capsules on the bone. It is a cardinal feature of spondyloarthropathies (SpA), but it can occur in other rheumatic disease. Recent studies using magnetic resonance imaging (MRI) and ultrasonography (US) have demonstrated that enthesopathy can often be asymptomatic, in both the axial and peripheral skeleton. Therefore, a systematic US study of peripheral entheses could be useful in the diagnostic process of patients with rheumatic diseases, in particular SpA. Recently, power Doppler US (PDUS) has been proved to be useful for differentiating mechanical/degenerative and inflammatory enthesopathy and for monitoring the efficacy of therapy. This article reviews the main histopathologic aspects of enthesopathy and describes the normal US features of enthesis and the basic US features of enthesopathy, in its various stages. The usefulness of US and PDUS in the diagnosis and assessment of enthesopathy is discussed on the basis of the literature and our experience.

Established rheumatoid arthritis – new imaging modalities

New imaging modalities are assuming an increasingly important role in the investigation and management of rheumatoid arthritis. It is now possible to obtain information about all tissues within the joint in three dimensions using tomographic techniques such as magnetic resonance imaging (MRI) and high-resolution computerized tomography. Erosions are very clearly depicted using these modalities and MRI also allows imaging of soft tissues with assessment of joint inflammation. High-resolution ultrasound is a convenient clinical technique for the assessment of erosions, synovitis and tenosynovitis in real-time and facilitates diagnostic and therapeutic interventions such as joint aspiration and injection. Exciting experimental modalities are also being developed with the potential to provide not just morphological but functional imaging. Techniques such as positron emission tomography (PET) and single photon emission tomography (SPECT) can reveal actively metabolizing bone and the proliferation of synovial cells via radioactive labeling. Bioluminescence and fluorescence reflectance imaging are other approaches that allow imaging, and potentially the delivery of therapeutic agents, at a molecular level.

Ultrasonography and the rheumatologist

PURPOSE OF REVIEW

An update of the latest developments in ultrasonography in rheumatology. Indications, technical aspects and representative examples of the potential of ultrasonography are illustrated. Finally, education and training issues are briefly discussed.

RECENT FINDINGS

Ultrasonography can be used in rheumatology for a wide spectrum of indications including inflammatory arthritis, tendon pathology, bursitis, disease activity monitoring, disease progression monitoring, guided aspiration and guided injections. Latest-generation ultrasonography systems provide a very sensitive assessment of both grayscale and Doppler findings. The quality of results in ultrasonography is conditioned by a series of elements that include the characteristics of the equipment, knowledge of relevant anatomy and pathology, experience of the sonographer, techniques used and patient positioning.

SUMMARY

Ultrasonography is challenging the standards of rheumatological clinical practice. It is more sensitive than clinical examination in the detection of synovitis and more sensitive than conventional radiography in the detection of bone erosions. Ultrasonography-guided injections may improve therapy effectiveness if compared with the traditional blind approach. Three-dimensional ultrasonography with a volumetric probe and the power Doppler mode may represent a very useful tool for therapy monitoring in patients with chronic arthritis.

Ultrasonographic investigation of the Achilles tendon in elite badminton players using color Doppler

BACKGROUND

The most frequent injuries in badminton players are in the lower extremities, especially in the Achilles tendon.

HYPOTHESIS

The game of badminton may be related to abnormal intratendinous flow in the Achilles tendon as detected by color Doppler ultrasound. To a certain extent, this blood flow might be physiological, especially when examined after match.

STUDY DESIGN

Cohort study (prevalence); Level of evidence, 3.

METHODS

Seventy-two elite badminton players were interviewed regarding Achilles tendon pain (achillodynia) in the preceding 3 years. Color Doppler was used to examine the tendons of 64 players before their matches and 46 players after their matches. Intratendinous color Doppler flow was graded from 0 to 4. The Achilles tendon was divided into dominant (eg, right side for right-handed players and vice versa) and nondominant side and classified as midtendon, preinsertional, and calcaneal areas.

RESULTS

Of 72 players, 26 had experienced achillodynia in 34 tendons, 18 on the dominant side and 16 on the nondominant side. In 62% of the players with achillodynia, the problems had begun slowly, and the median duration of symptoms was 4 months (range, 0-36 months). Thirty-five percent had ongoing pain in their tendons for a median duration of 12 months (range, 0-12 months). Achillodynia was not associated with the self-reported training load or with sex, age, weight, singles or doubles players, or racket side. Forty-six players were scanned before and after match. At baseline, color Doppler flow was present in the majority of players, and only 7 (16%) players had no color Doppler flow in either tendon. After match, all players had some color Doppler flow in 1 or both tendons. Achillodynia and color Doppler flow were related in the nondominant Achilles tendon (chi-square, P = .008). The grades of Doppler flow also increased significantly after match in the preinsertional area in both the nondominant (P = .0002) and dominant (P = .005) side tendons.

CONCLUSION

A large proportion of the players had experienced achillodynia and habitually played with a degree of pain that demanded medication. The self-reported pain was associated with increased intratendinous color Doppler flow in the nondominant Achilles tendon. Doppler flow was found in most players before and in all players after the match and therefore may in part be a physiological response to activity.

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

BACKGROUND

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.

OBJECTIVE

To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.

METHODS

Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid-portion Achilles tendinosis. A unipolar coagulation device was used.

RESULTS

One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were "cured" after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0-10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.

CONCLUSIONS

Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid-tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.

Power Doppler ultrasonography and synovitis: correlating ultrasound imaging with histopathological findings and evaluating the performance of ultrasound equipments

OBJECTIVES

To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments.

METHODS

44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms.

RESULTS

A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p<0.01) and 0.328 (p<0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow.

CONCLUSIONS

A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.

Doppler ultrasound findings in healthy wrists and finger joints before and after use of two different contrast agents

OBJECTIVE

To examine the effect of contrast agents on Doppler ultrasound findings in the synovial membrane in the wrist and fingers of healthy volunteers.

MATERIALS AND METHODS

Eleven healthy subjects were included in the study (5 women and 6 men, mean age 38 years, range (20-60)). They had no clinical signs of inflammatory or degenerative joint diseases. A total of 66 joints were examined-6 joints for each subject: wrist and metacarpophalangeal (MCP) joints 1-5-before contrast injection and after Levovist and SonoVue injection with a 30 minute interval.

RESULTS

Colour Doppler activity was detected in 10/55 (18%) MCP joints before contrast injection and in 29/55 (53%) and 28/55 (51%) joints after Levovist (p<0.0001) and SonoVue injection (p = 0.0001), respectively. A significant increase in Doppler activity in the radial (p<0.05) and ulnar (p = 0.01) parts of the wrist joint was detected only after SonoVue injections. With spectral Doppler no difference was found in the resistive index (RI) in the vessels measured before as compared with those only detected after contrast injection.

CONCLUSION

The number of joints with colour Doppler activity in healthy volunteers was increased by the use of contrast agents. No changes in RI were detected. The value of contrast agents remains to be demonstrated in inflammatory diagnostics.

Doppler sonography in assessing disease activity in rheumatoid arthritis

The purpose of this study was to evaluate the use of spectral Doppler in the assessment of patients with rheumatoid arthritis (RA). The study group consisted of 32 patients with RA followed up clinically and by ultrasound using the resistive index (RI) measurements in the patients' wrists as indicator of inflammation. Lower RI values were recorded at baseline compared with data derived at 1-y follow-up examination from patients in remission and normal controls (p < 0.001). Discrimination by spectral Doppler between patients in remission and those who had a relapse within six months after the examination was possible with an accuracy of 95.6%. Patients in remission who had a flare-up within six months after the examination had significantly lower (p < 0.01) RI values vs. patients who remained in stable remission. In conclusion, RI measurements may serve as an objective marker of disease activity and potentially as a predictor of the disease course in RA.

Remitting seronegative symmetrical synovitis with pitting edema of the hands: Ultrasound, color doppler ultrasound, and magnetic resonance imaging findings

OBJECTIVE

To assess the value of gray-scale ultrasound (US), color Doppler ultrasound (CDUS), contrast-enhanced CDUS, and magnetic resonance imaging (MRI) in the diagnostic evaluation of the hands in patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE).

METHODS

Eight patients (5 men, 3 women; mean +/- SD age 69.3 +/- 7.2 years) with clinical diagnosis of RS3PE syndrome underwent US, CDUS, contrast-enhanced CDUS, and MRI. US was performed with a linear array transducer operating at 12 MHz. The US contrast agent (SHU 508; Levovist, Schering, Germany) was intravenously infused in a concentration of 300 mg/ml at a rate of 1 ml/minute.

RESULTS

All patients showed symmetric subcutaneous edema and synovitis of tendons and finger joints on both US and MRI. Vascularity was detected subcutaneously in tendon sheaths and in the joint synovia on CDUS and MRI. Detection of increased vascularity was improved after contrast administration compared with unenhanced CDUS (P < 0.01).

CONCLUSION

Ultrasound, CDUS, contrast-enhanced CDUS, and MRI are valuable tools in the diagnostic evaluation of involved anatomic structures in patients with RS3PE. Contrast-enhanced CDUS is superior to CDUS in assessment of inflammatory edema, effusion, and synovitis.