Ultrasound in rheumatology

Etablierung und Validierung eines didaktischen muskuloskelettalen Ultraschallkurses für Dermatologen unter Verwendung eines innovativen Hand‐Ultraschallsystems – die MUDE‐Studie (Muskuloskelettaler Ultraschall für Dermatologen)

HINTERGRUND

Der muskuloskelettale Ultraschall (MSUS) schmerzhafter Gelenke spielt bei der Früherkennung der Arthritis, wie zum Beispiel der Psoriasisarthritis, eine wichtige Rolle. Pathologische Befunde können bei der klinischen Untersuchung übersehen werden, insbesondere wenn sie von Ärzten durchgeführt werden, die nicht in der Durchführung geschult sind. Das Ziel dieser Studie war die Untersuchung eines Pilot-MSUS-Kurses anhand des MUDE-Protokolls, welches speziell für Dermatologen entwickelt wurde.

METHODIK

Um den Grad der MSUS-Expertise der Teilnehmer zu ermitteln, wurde vor dem Kurs eine Umfrage mittels SurveyMonkey^® durchgeführt. Das Kurskonzept umfasste nur die wichtigsten Ultraschallschnitte aller Gelenke und konzentrierte sich auf die Erkennung von Gelenkergüssen und Hyperperfusion der Synovia. Der Kurs bestand aus drei Modulen und wurde über sechs Monate durchgeführt. Das tragbare Butterfly IQ^® System in Kombination mit einem Apple iPad wurde allen Teilnehmern zur Verfügung gestellt, um das Üben zwischen den Kursen zu ermöglichen. Die abschließende Lehrevaluation wurde als objective structured clinical examination (OSCE) durchgeführt.

ERGEBNISSE

Zwölf Dermatologen nahmen teil. Die Umfrage ergab keine Vorkenntnisse des MSUS. Die Gesamtpunktzahl aller Teilnehmer in der OSCE betrug 21,86 (87,44 %) von insgesamt 25 Punkten, was der Schulnote "gut" entsprach.

SCHLUSSFOLGERUNG

Das innovative Lehrkonzept MUDE eignet sich somit, unabhängig von Vorkenntnissen, in besonderer Weise für die Ausbildung von Dermatologen im MSUS.

Establishment and validation of a didactic musculoskeletal ultrasound course for dermatologists using an innovative handheld ultrasound system - the MUDE study (Musculoskeletal Ultrasound in Dermatology)

BACKGROUND

In the early detection of arthritis, such as psoriatic arthritis, musculoskeletal ultrasound (MSUS) of painful joints plays an important role in diagnosis. Pathological findings can be missed during clinical examination, especially if conducted by physicians who are not trained. The objective of this study was to examine a pilot MSUS course designed specifically for dermatologists, the MUDE protocol.

METHODS

To assess the degree of MSUS expertise of the participants, a questionnaire using SurveyMonkey^® was completed before the course. The course concept covered only the most important ultrasound sections of all joints and focused on the detection of joint effusion and hyperperfusion. The course consisted of three modules and was carried out over six months. The portable Butterfly IQ^® system in combination with an Apple iPad was provided to enable practice between the courses. The final teaching evaluation was carried out as an objective structured clinical examination (OSCE).

RESULTS

Twelve dermatologists participated. The survey revealed no prior knowledge of MSUS. The overall score of all participants in the OSCE was 21.86 (87.44 %) out of a total of 25 points, which corresponded to the school grade good.

CONCLUSION

The innovative MUDE protocol is thus particularly suitable for the training of dermatologists in MSUS, irrespective of prior knowledge.

Machine Learning in Rheumatic Diseases

With advances in information technology, the demand for using data science to enhance healthcare and disease management is rapidly increasing. Among these technologies, machine learning (ML) has become ubiquitous and indispensable for solving complex problems in many scientific fields, including medical science. ML allows the development of guidelines and framing of the evaluation system for complex diseases based on massive data. In the analysis of rheumatic diseases, which are chronic and remarkably heterogeneous, ML can be anticipated to be extremely helpful in deciphering and revealing the inherent interrelationships in disease development and progression, which can further enhance the overall understanding of the disease, optimize patients' stratification, calibrate therapeutic strategies, and predict prognosis and outcomes. In this review, the basics of ML, its potential clinical applications in rheumatology, together with its strengths and limitations are summarized.

Evaluation of quality and reliability of musculoskeletal ultrasound videos on YouTube

OBJECTIVES

To evaluate musculoskeletal ultrasound (MSUS) video contents on YouTube, regarding their quality, reliability, and educational value.

METHOD

The first three pages for the keywords 'Musculoskeletal Ultrasound', 'joint ultrasound', and 'articular ultrasound' were searched through YouTube website. The quality of the videos was assessed according to the European League Against Rheumatism (EULAR) Guidelines and EULAR Competency Assessment in MSUS. The reliability was evaluated with modified DISCERN tool.

RESULTS

After the exclusion criteria applied, 58 videos were evaluated. The video quality analysis showed that probe holding (68.9%; median: 5, range: 0-5), scanning technique (63.8%; median: 4, range: 0-5), identification of anatomic structures (72.4%; median: 4, range: 0-5), and description of ultrasound findings (65.5%; median: 4, range: 0-5) were found to be sufficient, whereas ultrasound machine settings adjustments (1.7%; median: 0, range: 0-4) and final ultrasound diagnosis (12.1%; median: 0, range: 0-5) were insufficient. The total median value of the modified DISCERN scale was 2 (percentile: 2-2, range: 0-3).

CONCLUSION

MSUS video contents on YouTube are insufficient for educational purposes on MSUS training. There is a need for affordable, easily accessed, standardized, and peer-reviewed online training programmes on MSUS and MSUS-guided injections.

A Systematic Review of the Inclusion of Non-Inflammatory Ultrasonographic Enthesopathy Findings in Enthesitis Scoring Indices

Ultrasound has advanced the diagnosis and management of patients with inflammatory rheumatic conditions. It can be used to identify and monitor enthesitis, a cardinal feature of spondyloarthropthies. Several enthesitis scoring systems utilizing ultrasound to determine entheseal involvement have been developed. These scoring systems generally rely on determining the presence or absence of erosions, tendon enlargement, power Doppler signal, or enthesophytes. This systematic review identified ultrasound scoring systems that have been utilized for evaluating enthesitis and what key components derive the score. Review of these scoring systems, however, demonstrated confounding as some of the score components including enthesophytes may be seen in non-inflammatory conditions and some components including erosions can be seen from chronic damage, but not necessarily indicate active inflammatory disease. What is furthermore limiting is that currently there is not an agreed upon term to describe non-inflammatory enthesopathies, further complicating these scoring systems. This review highlights the need for a more comprehensive ultrasound enthesopathy scoring index.

A Narrative Review of the Classification and Use of Diagnostic Ultrasound for Conditions of the Achilles Tendon

Enthesitis is a cardinal feature of spondyloarthropathies. The Achilles insertion on the calcaneus is a commonly evaluated enthesis located at the hindfoot, generally resulting in hindfoot pain and possible tendon enlargement. For decades, diagnosis of enthesitis was based upon patient history of hindfoot or posterior ankle pain and clinical examination revealing tenderness and/or enlargement at the site of the tendon insertion. However, not all hindfoot or posterior ankle symptoms are related to enthesitis. Advanced imaging, including magnetic resonance imaging (MRI) and ultrasound (US), has allowed for more precise evaluation of hindfoot and posterior ankle conditions. Use of US in diagnosis has helped confirm some of these cases but also identified other conditions that may have otherwise been misclassified without use of advanced imaging diagnostics. Conditions that may result in hindfoot and posterior ankle symptoms related to the Achilles tendon include enthesitis (which can include retrocalcaneal bursitis and insertional tendonopathy), midportion tendonopathy, paratenonopathy, superficial calcaneal bursitis, calcaneal ossification (Haglund deformity), and calcific tendonopathy. With regard to classification of these conditions, much of the existing literature uses confusing nomenclature to describe conditions in this region of the body. Some terminology may imply inflammation when in fact there may be none. A more uniform approach to classifying these conditions based off anatomic location, symptoms, clinical findings, and histopathology is needed. There has been much debate regarding appropriate use of tendonitis when there is no true inflammation, calling instead for use of the terms tendinosis or tendonopathy. To date, there has not been clear examination of a similar overuse of the term enthesitis in conditions where there is no underlying inflammation, thus raising the need for more comprehensive taxonomy.

Peritenon Extensor Tendon Inflammation in Psoriatic Arthritis Is an Enthesitis-related Lesion

Objective.

To analyze the association between enthesitis, synovitis, and peritenon extensor tendon inflammation (PTI) in psoriatic arthritis (PsA).

Methods.

PsA patients with swelling of metacarpophalangeal joints were included. Greyscale and power Doppler (PD) were used for synovitis and PTI ultrasound identification. Madrid Sonographic Enthesis Index (MASEI) was used for enthesitis assessment. PD activity was evaluated using PD item of MASEI and PD Outcome Measures in Rheumatology (OMERACT) definition.

Results.

Synovitis had no association with enthesitis. PTI was associated with PD MASEI and PD OMERACT. Only PD OMERACT showed a positive correlation with PTI.

Conclusion.

In PsA, PTI is associated to enthesitis, as opposed to synovitis.

Evaluation of joint cartilage thickness in healthy children by ultrasound: An experience from a developing nation

OBJECTIVES

Musculoskeletal ultrasound (MSUS) has a crucial role in clinical assessment and monitoring of patients with rheumatologic diseases. Early detection of joint cartilage destruction is difficult. MSUS is a cheap, noninvasive, nonhazardous bedside tool that can be used for detection of cartilage damage. We aimed to generate normative data of joint cartilage thickness of children in our population using this tool.

METHODS

Healthy children, aged between 2 and 12 years, not suffering from any joint disorders and not on any chronic medication were recruited. The thickness of joint cartilage at wrist, knee and ankle were measured by ultrasound as per European League Against Rheumatism standard scan criteria. The scans were done by a single observer.

RESULTS

Data of 409 children revealed median cartilage thickness at right wrist, knee and ankle joints as 2.20 (interquartile range [IQR] 1.60-3.00) mm, 2.40 (1.80-3.10) mm and 2.20 (1.80-3.00) mm, respectively. The right-left differences were not statistically significant except at the knee joint. Comparison between genders showed that boys had marginally thicker cartilage than girls at all three joints; this difference was statistically significant for the knee and ankle joints, but not at the wrist. Joint cartilage thickness showed a steady decline with age.

CONCLUSIONS

Measurement of joint cartilage thickness in children with MSUS and comparison with these normative values can help in better screening for joint-related disease in children.

Transcoracoacromial Ligament Glenohumeral Injection Technique: Accuracy of 116 Injections in Idiopathic Adhesive Capsulitis

PURPOSE

To describe a transcoracoacromial ligament glenohumeral injection technique that does not require radiographic guidance and to explore the accuracy of this injection technique in patients with idiopathic adhesive capsulitis.

METHODS

From February 2015 to April 2017, 89 consecutive patients (116 injections) with idiopathic adhesive capsulitis were included in the study. All of them received unguided glenohumeral injection via the transcoracoacromial ligament technique, and postprocedural fluoroscopic images were used to determine accuracy. The anterolateral corner of acromion, the superior lateral border of coracoid tip, and the curved depression of distal clavicle were identified. The needle entry site was located at the trisection point between the distal third and middle third of the superior lateral border of coracoid tip-curved depression of the distal clavicle line; needle trajectory was perpendicular to the plane formed by the 3 points, and the needle was advanced toward the humeral head. An injection was rated a success if the first fluoroscopic picture showed intra-articular contrast; it was rated a failure if contrast was not intra-articular or the needle needed to be redirected more than 2 times.

RESULTS

Out of 116 injections, 111 (95.7%) were successful. For 5 failed injections, there was 1 shoulder with more than 3 redirections and 4 shoulders with no intra-articular contrast (the needle hit the coracoid process in 1 shoulder, the needle rested in the anterior glenoid labrum in 2 shoulders, and the needle was inserted into the subscapularis in 1 shoulder).

CONCLUSIONS

The transcoracoacromial ligament glenohumeral injection technique is highly accurate and reproducible in patients with idiopathic adhesive capsulitis.

LEVEL OF EVIDENCE

Level IV, therapeutic retrospective case series.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

Sonographic Characteristics of Extensor Tendon Abnormalities and Relationship With Joint Disease Activity in Rheumatoid Arthritis: A Pilot Study

OBJECTIVES

To characterize abnormalities in the dorsal extensor tendons of the hand and determine the importance of these findings in rheumatoid arthritis.

METHODS

A retrospective cross-sectional study was done on 26 patients with rheumatoid arthritis who had sonography of their hands. B-mode and power Doppler joint activity were scored, and the extensor tendons were examined for B-mode changes and power Doppler signals. B-mode changes included anechoic fluid around tendons, hypoechoic tissue around tendons, paratendon tissue and tendon thickening, as well as vascularity around the tendon, for which peritendon power Doppler signals were recorded.

RESULTS

Forty-one hands and 205 joints were reviewed. Anechoic fluid around the tendons and peritendon power Doppler signals were observed in 41% and 39%, respectively; 44% and 28% of patients had B-mode and power Doppler scores in the upper tertile, respectively. For both B-mode and power Doppler scores, 3 categories or tertiles were created, 0 to 0.9, 1 to 1.9, and 2 to 3. We reported the percentage of patients with power Doppler and B-mode scores in this category. The severity of synovitis was associated with anechoic fluid around the tendons and peritendon power Doppler signals according to the Cochran-Mantel-Haenszel test. The common odds ratio was 3.52 (95% confidence interval, 1.45- 8.53) for anechoic fluid around the tendons and severe synovitis. The common odds ratio was 2.52 (95% confidence interval, 1.13-5.63) for peritendon power Doppler signals and severe synovitis.

CONCLUSIONS

Findings at the dorsal extensor tendons were anechoic fluid around tendons, hypoechoic tissue around tendons, peritendon power Doppler signals, and tendon thickening. Patients with anechoic fluid and power Doppler signals were found to have more severe disease activity at the joints based on B-mode and power Doppler scores.

Exploring a new ultrasound score as a clinical predictive tool in patients with rheumatoid arthritis starting abatacept: results from the APPRAISE study

Objectives

To explore whether changes in a composite (power Doppler/greyscale ultrasound (PDUS)) synovitis score, developed by the OMERACT-EULAR-Ultrasound Task Force, predict disease activity outcomes in rheumatoid arthritis (RA).

Methods

Patients with RA who were methotrexate inadequate responders starting abatacept were evaluated. Individual joint PDUS scores were combined in the Global OMERACT-EULAR Synovitis Score (GLOESS) for metacarpophalangeal joints (MCPs) 2–5, all joints (22 paired) and a reduced (9 paired) joint set. The predictive value of changes in GLOESS at week 1–16 evaluations for clinical status and response (Disease Activity Score (DAS)28 (C reactive protein, CRP) <2.6; DAS28(CRP) ≤3.2; DAS28(CRP) ≥1.2 improvement) up to week 24, and correlations between DAS28 and GLOESS were assessed.

Results

Eighty-nine patients completed the 24-week treatment period. Changes in GLOESS (MCPs 2–5) from weeks 1 to 16 were unable to predict DAS28 outcomes up to week 24. However, significant improvements in GLOESS (MCPs 2–5) were observed at week 12 in patients with DAS28 ≥1.2 improvement at week 24 versus those who did not achieve that clinical response. In patients achieving DAS28 ≥1.2 improvement or DAS28 ≤3.2 at week 24, changes in GLOESS (22 and 9 paired joint sets) were greater in patients who already achieved DAS28 ≥1.2 at week 12 than in those who did not. No significant correlations were found between changes in DAS28 and GLOESS definitions at any time point.

Conclusions

PDUS was not correlated with clinical status or response as measured by DAS28-derived criteria, and PDUS changes were not predictive of clinical outcome. The discrepancies require further exploration.

Trial registration number

NCT00767325; Results.

General applications of ultrasound in rheumatology: why we need it in our daily practice

Ultrasound (US) is a noninvasive imaging technique that continues to gain interest among rheumatologists because of its undoubted utility for the assessment of a wide range of abnormalities in rheumatic diseases. It also has a great potential to be used at the time of consultation as an extension of the clinical examination.Current data demonstrate that the standard clinical approach could result in an insensitive assessment of some the different aspects of the various rheumatic diseases for which US has become a feasible and effective imaging modality that allows early detection of anatomical changes, careful guidance for the aspiration and/or local treatment, and short- and long-term therapy monitoring at the joint, tendon, enthesis, nail, and skin levels. The spectrum of pathological conditions for which US plays a crucial role continues to increase over time and includes rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal-related arthropathies, connective tissue disorders, and vasculitis.It is expected that the inclusion of more longitudinal studies with a larger number of patients and more rigorous methodological approach will undoubtedly provide a better understanding of the significance of the abnormal US findings detected in order to provide the proper diagnostic and/or therapeutic approaches. In this article, we analyze the current potential applications of US in rheumatology and discuss the evidence supporting its use in the daily rheumatologic practice.

Short-term efficacy to conventional blind injection versus ultrasound-guided injection of local corticosteroids in tenosynovitis in patients with inflammatory chronic arthritis: A randomized comparative study

OBJECTIVE

To compare the short-term efficacy of conventional blind injection (CBI) versus ultrasound-guided injection (USGI) of corticosteroids (CS) injection in tenosynovitis in patients with chronic arthritis and to investigate if the USGI is a less painful procedure and if there are differences in the changes of US findings during the post injection follow-up.

METHODS

Patients presenting tenosynovitis requiring CS injection were involved. After clinical and US evaluation, patients were randomized to receive CBI or USGI. Efficacy of procedure was assessed by the improvement in both Health Assessment Questionnaire (HAQ) and pain visual analogue scale (VAS), including procedure-VAS global-VAS and local-VAS, after 1 and 4 weeks post-procedure. Power Doppler (PD) and greyscale (GS) US findings were also object of the follow-up. CBI or USGI under an aseptic technique were performed according the local guidelines using 20mg of methylprednisolone acetate.

RESULTS

A total of 114 patients were randomized to receive CBI (54 patients) or USGI (60 patients) procedure. No significant difference was observed in terms of gender, age and pain duration among CBI and USGI groups at baseline. USGI proved to be significantly less painful than CBI (P=0.0001). AUC analysis showed that during the follow up visits, the USGI procedure had significantly better response in HAQ, local-VAS and global-VAS (P=0.0001, P=0.012 and P=0.0001 respectively) compared to CBI. During the follow up period, a significant greater reduction in the PD scores was found in the USGI group compared to the CBI group (P=0.0002), whereas no statistical differences were found in the GS findings between the groups (P=0.5627).

CONCLUSION

Our study demonstrates superiority of USGI over CBI for CS injections in painful tenosynovitis, having better short-term outcomes measured by functional, clinical and US scores. These data support the use of USGI for tenosynovits in typical inpatient and/or outpatient in rheumatological practices.

Value of ultrasonography as a marker of early response to abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: results from the APPRAISE study

Objectives

To study the responsiveness of a combined power Doppler and greyscale ultrasound (PDUS) score for assessing synovitis in biologic-naïve patients with rheumatoid arthritis (RA) starting abatacept plus methotrexate (MTX).

Methods

In this open-label, multicentre, single-arm study, patients with RA (MTX inadequate responders) received intravenous abatacept (∼10 mg/kg) plus MTX for 24 weeks. A composite PDUS synovitis score, developed by the Outcome Measures in Rheumatology–European League Against Rheumatism (OMERACT–EULAR)-Ultrasound Task Force, was used to evaluate individual joints. The maximal score of each joint was added into a Global OMERACT–EULAR Synovitis Score (GLOESS) for bilateral metacarpophalangeal joints (MCPs) 2–5 (primary objective). The value of GLOESS containing other joint sets was explored, along with clinical efficacy.

Results

Eighty-nine patients completed the 24-week treatment period. The earliest PDUS sign of improvement in synovitis was at week 1 (mean change in GLOESS (MCPs 2–5): −0.7 (95% CIs −1.2 to −0.1)), with continuous improvement to week 24. Early improvement was observed in the component scores (power Doppler signal at week 1, synovial hyperplasia at week 2, joint effusion at week 4). Comparable changes were observed for 22 paired joints and minimal joint subsets. Mean Disease Activity Score 28 (C reactive protein) was significantly reduced from weeks 1 to 24, reaching clinical meaningful improvement (change ≥1.2) at week 8.

Conclusions

In this first international prospective study, the composite PDUS score is responsive to abatacept. GLOESS demonstrated the rapid onset of action of abatacept, regardless of the number of joints examined. Ultrasound is an objective tool to monitor patients with RA under treatment.

Trial registration number

NCT00767325.

Ultrasound Color histogram assessment allows better view of echotexture damage

INTRODUCTION

The colored ultrasound images can better highlight the joint echotexture damage.

OBJECTIVE

To detect echotexture changes in joints of patients with rheumatic diseases, through a color histogram, and to correlate the area measurements with the gray scale (GS).

METHODS

Four patients with chondrocalcinosis, 5 patients with osteoarthritis and 1 patient with psoriatic arthritis were evalutated. A total of 104 synovitis (SYN) and calcifications (calcif) measurements in cm2 were performed in the dorsal radiocarpal joint (DRR); triangular fibrocartilage complex (TFC); dorsal metacarpophalangeal joints (MCP) and lateral and medial knee suprapatellar recesses. For each GS measure, one was performed for each standard color image. Spearman was used for correlation analysis.

RESULTS

Mean±SD of image patterns: RGB (Red, Green and Blue) SYN 16.96±0.25cm2; indigo SYN 6.43±0.07cm2, RGB Calcif 0.03±0.00cm2; indigo Calcif 0.06±0.03cm2; GS SYN 16.13±0.35cm2 and GS Calcif 0.56±0.01cm2. Correlations of color images patterns RGB DRR SYN and indigo DRR SYN: r=1, p<0.001; indigo DRR SYN and RGB suprapattelar SYN: r=1, p<0.001; RGB MCP SYN and indigo MCP SYN: r=1, p<0.001; indigo DRR calcif and RGB TFC calcif: r=1 p<0.001; the RGB and indigo measurement standards when correlated with GS for SYN and calcifs were not statistically significant (p=0.333 to 0.667).

CONCLUSION

The RGB and indigo patterns seem to better define these echotexture damage.

The assessment of lesions of the Achilles tendon by ultrasound imaging in inflammatory arthritis: A systematic review and meta-analysis

OBJECTIVE

Ultrasound (US) is a highly sensitive, reliable and non-invasive tool, which allows for the assessment of lesions of tendons and entheseal sites. The aim of this systematic review and meta-analysis is to identify differences in US lesions of the Achilles tendon (AT) between people with inflammatory arthritis (IA) and healthy controls.

METHODS

An electronic literature search was performed on Medline, CINAHL, SportDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Odds ratios with 95% confidence intervals (CI) were determined. Meta-analysis was conducted on those studies that were considered to be homogenous.

RESULTS

A total of 13 high-to-medium quality studies met the inclusion criteria. The majority of studies reported US lesions in spondyloarthropathy (SpA), with limited evidence for other forms of IA. US lesions were not consistently defined with regard to Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions, and numerous scoring systems were used across the majority of studies. The mean AT thickness at the enthesis in people with SpA was 0.54mm thicker (95% CI: 0.10-0.97mm) with more frequent erosions in people with SpA (odds ratio = 7.43, 95% CI: 1.99-27.77, P = 0.003) and rheumatoid arthritis (RA) (odds ratio = 9.60, 95% CI: 1.23-74.94, P = 0.03), compared to controls. There was no significant difference in the frequency of enthesophyte formation in people with SpA compared to the controls (odds ratio = 2.48, 95% CI: 0.64-9.70, P = 0.19).

CONCLUSIONS

The systematic review identified that a majority of studies reporting US lesions were in SpA, but limited evidence relating to other forms of IA. Consistent application of the OMERACT US definitions and scoring of US lesions is required in future studies of AT disease in IA. Further work is also required to distinguish between US lesions reflective of inflammation and structural damage.

A sonographic technique to evaluate the anterior bundle of the ulnar collateral ligament of the elbow: imaging features and anatomic correlation

OBJECTIVES

The aim of this study was to test a sonographic technique used to view the anterior bundle of the ulnar collateral ligament (UCL), describe its sonographic characteristics in healthy volunteers, and verify these characteristics by determining interobserver variability and their correlations in cadavers.

METHODS

Sonographic studies of the anterior bundle of the UCL were performed on 48 elbows of asymptomatic healthy volunteers. The participants were examined by 3 experts, who identified the insertion sites of the anterior bundle and subjectively evaluated its echogenicity and echo texture. A sonographic examination of the anterior bundle of the UCL in a cadaveric elbow was performed, and the same aspects were evaluated.

RESULTS

In all cases, the anterior bundle of the UCL appeared as a triangular structure in the coronal plane and had a hyperechoic homogeneous echo texture in most of these cases. The cadaveric elbow had the same sonographic characteristics as the volunteers.

CONCLUSIONS

As shown by examining the interobserver variability and determining the correlation with cadaveric tissue, sonography proved to be a reliable tool for evaluating the normal aspects of the anterior bundle of the UCL.

Can ultrasound of plantar plate have normal appearance with a positive drawer test?

OBJECTIVES

The aims of this study were (1) to evaluate the reliability of ultrasound (US) examination in the identification and measurement of the metatarsophalangeal plantar plate (MTP-PP) in asymptomatic subjects and (2) to establish the correlation of US findings with those of physical examination and magnetic resonance imaging (MRI), once it is an important tool in the evaluation of the instability syndrome of the second and third rays.

MATERIALS AND METHODS

US examinations of the second and third MTP-PPs were performed in eight asymptomatic volunteers, totaling 32 MTP joints, by three examiners with different levels of experience in musculoskeletal US. Plantar plate dimensions, integrity and echogenicity, the presence of ruptures, and confidence level in terms of structure identification were determined using conventional US. Vascular flow was assessed using power Doppler. US data were correlated with data from physical examination and MRI.

RESULTS

MTP-PPs were ultrasonographically identified in 100% of cases, always showing homogeneous hyperechoic features and no detectable vascular flow on power Doppler, with 100% certainty in identification for all examiners. There was excellent US inter-observer agreement for longitudinal measures of second and third toe MTP-PPs and for transverse measures of the second toe MTP-PP. The MTP drawer test was positive for grade 1 MTP instability in 34.4% of joints with normal US results. Transverse MTP-PP measures were significantly higher in individuals with positive MTP drawer test. US measures and characteristics of MPT-PPs were positively correlated with those of MRI.

CONCLUSIONS

US is efficient in identifying and measuring MPT-PPs and may complement physical examination. A grade 1 positive MTP drawer test may be found in asymptomatic individuals with normal MPT-PPs, as assessed by imaging.

Feasibility of ultrasound imaging of osteochondral defects in the ankle: a clinical pilot study

Talar osteochondral defects (OCDs) are imaged using magnetic resonance imaging (MRI) or computed tomography (CT). For extensive follow-up, ultrasound might be a fast, non-invasive alternative that images both bone and cartilage. In this study the potential of ultrasound, as compared with CT, in the imaging and grading of OCDs is explored. On the basis of prior CT scans, nine ankles of patients without OCDs and nine ankles of patients with anterocentral OCDs were selected and classified using the Loomer CT classification. A blinded expert skeletal radiologist imaged all ankles with ultrasound and recorded the presence of OCDs. Similarly to CT, ultrasound revealed typical morphologic OCD features, for example, cortex irregularities and loose fragments. Cartilage disruptions, Loomer grades IV (displaced fragment) and V (cyst with fibrous roof), were visible as well. This study encourages further research on the use of ultrasound as a follow-up imaging modality for OCDs located anteriorly or centrally on the talar dome.

Is painless synovitis different from painful synovitis? A controlled, ultrasound, radiographic, clinical trial

OBJECTIVE

This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis.

METHODS

This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated.

RESULTS

There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal.

CONCLUSIONS

The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain.

Ultrasound evaluation of hand, wrist and foot joint synovitis in systemic lupus erythematosus

OBJECTIVES

To assess the prevalence and severity of inflammatory abnormalities of the hand, wrist and foot joints in SLE patients by US and to correlate them with clinical, laboratory and disease activity score parameters.

METHODS

Sixty-two consecutive SLE patients were enrolled in the present study and underwent clinical evaluation, laboratory tests and bilateral high-resolution US of the hand, wrist and foot joints. Joint effusion (JE), synovial hypertrophy (SH) and local pathological vascularization [power Doppler (PD)] were evaluated according to both a dichotomous score and a semi-quantitative (0-3) grading system. In addition, a global US score was calculated by summing the values given to each elementary lesion for every single joint and every joint group. US findings were correlated with physical examination, serological parameters (CRP, ANA, anti-dsDNA, ENA, aPL, C3 and C4 serum levels) and disease activity indexes (SLEDAI-2K, ECLAM).

RESULTS

US detected inflammatory joint abnormalities in 54/62 patients (87.1%); 72.6% presented involvement of the MTP joints, 46.7% the MCP joints, 19.3% the PIP joints and 53% the wrists. A total of 1984 joints were examined highlighting JE in 19.1% of cases, SH in 6.9% and positive PD in 1.1%. The global US inflammatory score had a mean value of 10.9 (s.d. 15.2). No correlations were found between US findings and SLE disease activity parameters.

CONCLUSION

US demonstrated a high prevalence of inflammatory joint abnormalities in SLE that were also present in asymptomatic patients. Interestingly, the foot joints were the most frequently involved. US is a valuable tool for detecting subclinical synovitis in SLE.

Recent advances in imaging in psoriatic arthritis

The recent introduction of effective therapies in psoriatic arthritis (PsA) has increased the demand for efficient tools for diagnosis, monitoring and prognostication of PsA, and has caused an increased research effort within imaging in this disease. The clinical appearance of PsA is very diverse, involving the spine, sacroiliac joints, peripheral joints and/or entheses, and accordingly imaging findings vary. In the present paper, we present a review of the recent advances in imaging in PsA, focusing primarily on ultrasonography and magnetic resonance imaging of peripheral disease manifestations.

CS injection of tenosynovitis in patients with chronic inflammatory arthritis: the role of US

OBJECTIVE

The main aim of this study was to investigate the short-term efficacy of CS loco-regional treatment performed under US guidance in tenosynovitis of patients with chronic inflammatory arthritis.

METHODS

Thirty consecutive patients affected by chronic arthritis and with clinical suspicion of tenosynovitis were recruited to undergo US assessment. In the sonographically proven cases, US-guided CS injection was performed. A visual analogue scale for pain (ranging from 0 to 10) and a tenderness score (ranging from 0 to 3) were used for the clinical evaluation. Sonographic pathological findings indicative of tenosynovitis were scored using a semi-quantitative 4-grade scoring system, for both grey-scale and power Doppler US, at baseline and during a follow-up visit at 2 weeks after the CS injection.

RESULTS

In 21 (70%) of 30 patients, the clinical suspicion of tenosynovitis was confirmed (9 with RA, 11 with PsA and 1 with ReA). In the other nine patients, US revealed synovitis of the adjacent joints, bursitis, oedema of the s.c. tissue or a partial tear. In all cases the appropriate needle placement and subsequent CS injection into the tendon sheath were obtained with US confirmation. A significant reduction in all clinical and sonographic scorings was found during the follow-up visit.

CONCLUSIONS

The present study shows the efficacy of US-guided peritendinous CS injections in the management of patients with chronic inflammatory arthritis presenting as US-proven tenosynovitis.

A Systematic Literature Review Analysis of Ultrasound Joint Count and Scoring Systems to Assess Synovitis in Rheumatoid Arthritis According to the OMERACT Filter

Objective.

The OMERACT Ultrasound Task Force is currently developing a global synovitis score (GLOSS) with the objective of feasibly measuring global disease activity in patients with rheumatoid arthritis (RA). In order to determine the minimal number of joints to be included in such a scoring system, and to analyze the metric properties of proposed global (i.e., patient level) ultrasound (US) scoring systems of synovitis in RA, a systematic analysis of the literature was performed.

Methods.

A systematic literature search of Pubmed and Embase was performed (January 1, 1984, to March 31, 2010). Original research reports written in English including RA, ultrasound, Doppler, and scoring systems were included. The design, subjects, methods, imaging protocols, and performance characteristics studied were analyzed, as well as the ultrasound definition of synovitis.

Results.

Of 3004 reports identified, 14 articles were included in the review. We found a lack of clear definition of synovitis as well as varying validity data with respect to the proposed scores. Scoring systems included a wide range and number of joints. All analyzed studies assessed construct validity and responsiveness by using clinical examination, laboratory findings, and other imaging modalities as comparators. Both construct validity and responsiveness varied according to the number and size of joints examined and according to the component of synovitis measured [i.e., gray-scale (GS) or power Doppler (PD) alone or in combination]. With regard to feasibility, time of evaluation varied from 15 to 60 min and increased with the number of joints involved in the examination.

Conclusions.

Ultrasound can be regarded as a valuable tool for globally examining the extent of synovitis in RA. However, it is presently difficult to determine a minimal number of joints to be included in a global ultrasound score. Further validation of proposed scores is needed.

Wrist ultrasound analysis of patients with early rheumatoid arthritis

In the present study, we evaluated 42 wrists using the semi-quantitative scales power Doppler ultrasound (PDUS) and gray scale ultrasound (GSUS) with scores ranging from 0 to 3 and correlated the results with clinical, laboratory and radiographic data. Twenty-one patients (17 women and 4 men) with rheumatoid arthritis according to criteria of the American College of Rheumatology were enrolled in the study from September 2008 to July 2009 at Universidade Estadual de Campinas (UNICAMP). The average disease duration was 14 months. The patients were 66.6% Caucasians and 33.3% non-Caucasians, with a mean age of 42 and 41 years, respectively. A dorsal longitudinal scan was performed by ultrasound on the radiocarpal and midcarpal joints using GE LOGIQ XP-linear ultrasound and a high frequency (8-10 MHz) transducer. All patients were X-rayed, and the Larsen score was determined for the joints, with grades ranging from 0 to V. This study showed significant correlations between clinical, sonographic and laboratory data: GSUS and swollen right wrist (r = 0.546), GSUS of right wrist and swelling of left wrist (r = 0.511), PDUS of right wrist and pain in left wrist (r = 0.436), PDUS of right wrist and C-reactive protein (r = 0.466). Ultrasound can be considered a useful tool in the diagnosis of synovitis in early rheumatoid arthritis mainly when the anti-cyclic citrullinated peptide and rheumatoid factor are negative, and can lead to an early change in the therapeutic decision.

Clinical manifestations and treatment of the pediatric rheumatoid patient

The management goal of juvenile rheumatoid arthritis (JRA) is to achieve early diagnosis and treatment so that arthritis can be resolved at an early stage, which avoids long-term damage and provides a good outcome of the affected inflammatory joints. This article describes presentation, classification, evaluation, and treatment of JRA as it relates to the foot and ankle. Because the course of JRA is complex and the optimal management is highly variable in each patient, this article can only offer recommendations. Actual treatment should be individualized to meet the conditions of each patient.