Sonography of the first metatarsophalangeal joint and sonographically guided intraarticular injection of corticosteroid in acute gout attack

EURO-MUSCULUS/USPRM Dynamic Ultrasound Protocols for Ankle/Foot

ABSTRACT

In this dynamic scanning protocol, ultrasound examination of the ankle is described using various maneuvers to assess different conditions. Real-time patient examination and scanning videos are used for better simulation of daily clinical practice. The protocol is prepared by several/international experts in the field of musculoskeletal ultrasound and within the umbrella of European Musculoskeletal Ultrasound Study Group in Physical and Rehabilitation Medicine/Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.

Activation Status of NLRP3 Inflammasome in Peripheral Blood Mononuclear Cells From Patients With Gout Flare

BACKGROUND/OBJECTIVE

Although gout flares are featured by systemic signs of inflammation, cellular sources of inflammatory mediators are not yet properly characterized. Our objective was to evaluate serum levels and gene expression in peripheral blood mononuclear cells (PBMCs) of several molecules associated with the activation of NLRP3 inflammasome.

METHODS

Fifteen patients with gout flare and 15 individuals with asymptomatic hyperuricemia were cross-sectionally studied. Serum levels of interleukin 1β (IL-1β), IL-18, monocyte chemoattractant protein 1/chemokine (C-C motif) ligand 2 (CCL2), and vascular cell adhesion molecule 1 were measured as a reflection of systemic inflammation, whereas the expression of NLRP3, CASP1, IL18, and CCL2 genes was measured to assess the inflammatory characteristics of PBMCs.

RESULTS

Serum levels of IL-1β (1.27 [0.07-1.99] pg/mL vs. 0 [0-0.82] pg/mL, p = 0.032) and vascular cell adhesion molecule 1 (606 [435-748] pg/mL vs. 349 [305-422] pg/mL, p = 0.014) were significantly higher in patients with gout flare than in individuals with asymptomatic hyperuricemia, whereas differences in IL-18 and monocyte chemoattractant protein 1/CCL2 were not found. Notably, no differences were observed in the expression of NLRP3, CASP1, IL18, or CCL2 in PBMCs from individuals of one or another group.

CONCLUSIONS

Systemic inflammation during gout flares does not appear to be associated with NLRP3 inflammasome activation in PBMCs, suggesting that it may represent the systemic spread of local (synovial) inflammation to monosodium urate crystals, which provides a rationale for redirecting anti-inflammatory therapy from a systemic approach to one centered on the inflamed joint.

Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review

Purpose of Review

This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches.

Recent Findings

Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration.

Summary

Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.

[Lesion clearance combined with Ilizarov technique for treatment of tophi in first metatarsophalangeal joint with bone defect]

Objective

To evaluate the effectiveness of lesion clearance combined with Ilizarov technique for the treatment of tophi in first metatarsophalangeal (MTP) joint with bone defect.

Methods

Between July 2016 and June 2018, 14 cases of tophi in the first MTP joint with bone defect were treated by lesion clearance combined with Ilizarov technique. There were 12 males and 2 females. The average age was 39.3 years (range, 22-60 years). The disease duration ranged from 5 to 15 years, with an average of 11.2 years. The tophi volume ranged from 2.5 cm×2.7 cm×2.2 cm to 5.2 cm×2.9 cm×2.4 cm. The X-ray films showed that the length of the bone defect ranged from 2.0 to 4.6 cm, with an average of 3.4 cm. Preoperative visual analogue scale (VAS) score was 7.6±0.9; American Orthopaedic Foot and Ankle Society (AOFAS) score was 47.5±4.3; short-form 36 health survey scale (SF-36) score was 79.7±4.7.

Results

The incision primarily healed in 13 patients after operation. The skin necrosis at the edge of the incision occurred in 1 patient and recovered after symptomatic treatment. All 14 patients were followed up 12-16 months, with an average of 13.6 months. X-ray films showed that the first metatarsal column defects were repaired. The time of bone extension ranged from 2 to 6 weeks, with an average of 3.6 weeks. The time of bone healing ranged from 9 to 16 weeks, with an average of 11.2 weeks. During follow-up, no complication such as nerve, blood vessel, or tendon injury, needle tract infection, or stress fracture occurred. At last follow-up, VAS score was 1.4±0.5, AOFAS score was 86.6±4.8, and SF-36 score was 89.1±3.3, all of which were superior to preoperative scores, with significant differences ( t=22.532, P=0.000; t=22.702, P=0.000; t=6.124, P=0.000).

Conclusion

Lesion clearance combined with Ilizarov technique is a safe and effective method for the treatment of tophi in the first MTP joint with bone defect.

Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners®: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle

Gout is a condition that commonly affects the foot and ankle, and practitioners who treat these structures should be aware of the methods to diagnose and treat this form of arthritis. Practitioners also need to recognize extra-articular manifestations of the disease. Although the acutely red, hot, swollen joint is a common presentation, chronic tophaceous gout can be associated with pain, nodule formation, and cutaneous compromise. Since the underlying causes that lead to excessive monosodium urate deposition may be treatable, early and accurate diagnosis can be very beneficial and may even prevent articular degeneration.

Diagnosis and Treatment of Inflammatory Joint Disease

Arthritis damages the cartilage within joints, resulting in degenerative changes, including loss of function and joint instability. Ankylosing spondylitis (AS) is a chronic inflammatory condition affecting the spine and bone-to-tendon attachment area within the sacroiliac joint leading to back pain and progressive spinal stiffness. In the final stages, AS causes hyperkyphosis-a condition closely tied to the human leukocyte antigen-B27 gene. Rheumatoid arthritis is a chronic, systemic autoimmune disease characterized by the simultaneous inflammation of the synovium of multiple joints, leading to joint damage (e.g., destruction, deformation and disability). In the past, nonsteroidal anti-inflammatory drugs or conventional disease-modifying antirheumatic drug (DMARDs) have been used for the treatment of these autoimmune diseases, but biologic DMARDs have recently been introduced with excellent results. Gout is a chronic inflammatory disease that causes an alteration of joints resulting in severe pain. Specifically, gout is associated with an accumulation of uric acid within the body resulting from dysregulated purine metabolism, causing recurrent paroxysmal inflammation in the joints. Allopurinol and febuxostat are the primary treatment options for individuals with gout. It is necessary to have an accurate understanding of the pathogenesis, pathological ecology and treatment of AS, rheumatoid arthritis, and gouty arthritis, which are the representative diseases that may cause inflammatory arthritis.

Are ultrasound features at the first metatarsophalangeal joint associated with clinically-assessed pain and function? A study of people with gout, asymptomatic hyperuricaemia and normouricaemia

Background

The first metatatarsophalangeal joint (1st MTP joint) is a common location for sonographic evidence of urate deposition in people with gout and asymptomatic hyperuricaemia. However, it is unclear whether these are related to clinically-assessed pain and function. This study aimed to determine the association between ultrasound features and clinical characteristics of the 1st MTP joint in people with gout, asymptomatic hyperuricaemia and age- and sex-matched normouricaemic individuals.

Methods

Twenty-three people with gout, 29 with asymptomatic hyperuricaemia and 34 with normouricaemia participated in a cross-sectional study. No participant had clinical evidence of acute inflammatory arthritis at the time of assessment. Four sonographic features at the 1st MTP joint were analysed: double contour sign, tophus, bone erosion and synovitis. Clinical characteristics included in the analysis were 1st MTP joint pain, overall foot pain and disability, 1st MTP joint temperature, 1st MTP joint range of motion and gait velocity. Statistical analyses adjusted for the diagnostic group of the participant.

Results

After accounting for the diagnostic group, double contour sign was associated with higher foot pain and disability scores (P < 0.001). Ultrasound tophus was associated with higher foot pain and disability scores (P < 0.001), increased temperature (P = 0.005), and reduced walking velocity (P = 0.001). No associations were observed between ultrasound synovitis or erosion and the clinical characteristics.

Conclusions

Ultrasound features of urate crystal deposition, rather than soft tissue inflammation or bone erosion, are associated with clinical measures of foot-related functional impairment and disability even in the absence of clinical evidence of current acute inflammatory arthritis. This association persisted regardless of the diagnosis of the participant as having gout or asymptomatic hyperuricaemia.

Ultrasound Features of the First Metatarsophalangeal Joint in Gout and Asymptomatic Hyperuricemia: Comparison With Normouricemic Individuals

OBJECTIVE

The first metatarsophalangeal (MTP1) joint is frequently affected in gout. The aim of this study was to identify ultrasound features of the MTP1 joint in people with gout and people with asymptomatic hyperuricemia compared with normouricemic controls.

METHODS

Participants with gout (n = 23) and asymptomatic hyperuricemia (n = 29), and age- and sex-matched normouricemic control participants (n = 34), underwent a gray-scale and power Doppler ultrasound assessment of bilateral MTP1 joints by a single musculoskeletal radiologist. No participants had clinical evidence of joint inflammation at the time of scanning. The static images were later read by 2 musculoskeletal radiologists for the presence of the double contour sign, tophus, erosion, effusion, synovial hypertrophy, synovitis, and cartilage thickness.

RESULTS

Compared to normouricemic control participants, participants with gout and participants with asymptomatic hyperuricemia had more frequent double contour sign (odds ratio [OR] 3.91, P = 0.011 and OR 3.81, P = 0.009, respectively). Participants with gout also had more erosion (OR 10.13, P = 0.001) and synovitis (OR 9.00, P < 0.001) and had greater tophus and erosion diameters (P = 0.035 and P < 0.001, respectively). More severe erosion and synovitis grades and a less severe effusion grade were independently associated with gout compared with asymptomatic hyperuricemia (R²  = 0.65, P < 0.001).

CONCLUSION

Urate deposition, synovitis, and bone erosion are common at the MTP1 joint in people with gout, even in the absence of flare. Although individuals with asymptomatic hyperuricemia lack ultrasound features of inflammation or structural joint changes, they demonstrate a similar frequency of urate deposition.

Ultrasound-guided procedures in rheumatology. What is the evidence?

Ultrasound (US) is a cost-effective, noninvasive, and accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. It can play a relevant role in invasive procedures performed by the rheumatologist, potentially ensuring a higher degree of accuracy. However, US-guided injections are still underused, and the conventional blind injection the most commonly adopted approach. In this article, we analyze the current evidence supporting the use of US-guided procedures, emphasizing comparative studies between conventional and US-guided procedures and their benefits in the daily rheumatological practice.

The first metatarsophalangeal joint in gout: a systematic review and meta-analysis

Background

The aim of this review was to qualitatively synthesise studies that have investigated characteristics of the first metatarsophalangeal joint (1^st MTP) in gout and to undertake a meta-analysis to estimate the average prevalence of acute 1^st MTP arthritis across studies in people with gout.

Methods

Studies published in English were included if they involved participants who had a diagnosis of gout and presented original findings relating to the following outcome measures associated with the 1^st MTP: epidemiology; clinical features; structural and functional characteristics; and microscopic and imaging features.

Results

Forty-five studies were included in the qualitative synthesis. 1^st MTP pain was a prominent feature in people with gout. People with 1^st MTP gout reported walking- and general-disability. Structural and functional characteristics of 1^st MTP gout included hallux valgus, osteoarthritis, and restricted joint motion. Successful crystal aspiration ranged from 81 to 91 % and positive crystal identification via microscopy ranged from 83 to 93 % in patients with a history of 1^st MTP gout. Imaging features were common at the 1^st MTP including the double contour sign, tophi and erosions. Eleven studies involving 2,325 participants were included in the meta-analysis, providing an estimate of the average prevalence of acute 1^st MTP arthritis across studies of 73 % (95 % prediction interval 40–92 %; range 48–97 %; I² = 93 %).

Conclusions

1^st MTP acute arthritis is highly prevalent in people with gout and has a substantial impact on patient-reported pain and disability. Gout affects the structure and function of the 1^st MTP. Microscopic and imaging studies have demonstrated crystal deposition and joint damage at the 1^st MTP in people with gout.