Sonographic assessment of calcium pyrophosphate deposition disease at wrist. A focus on the dorsal scapho-lunate ligament

Systematic literature review to inform the EULAR recommendations for the use of imaging in crystal-induced arthropathies in clinical practice

OBJECTIVE

To summarise current data regarding the use of imaging in crystal-induced arthropathies (CiAs) informing a European Alliance of Associations for Rheumatology task force.

METHODS

We performed four systematic searches in Embase, Medline and Central on imaging for diagnosis, monitoring, prediction of disease severity/treatment response, guiding procedures and patient education in gout, calcium pyrophosphate dihydrate deposition (CPPD) and basic calcium phosphate deposition (BCPD). Records were screened, manuscripts reviewed and data of the included studies extracted. The risk of bias was assessed by validated instruments.

RESULTS

For gout, 88 studies were included. Diagnostic studies reported good to excellent sensitivity and specificity of dual-energy CT (DECT) and ultrasound (US), high specificity and lower sensitivity for conventional radiographs (CR) and CT. Longitudinal studies demonstrated sensitivity to change with regard to crystal deposition by US and DECT and inflammation by US and structural progression by CR and CT. For CPPD, 50 studies were included. Diagnostic studies on CR and US showed high specificity and variable sensitivity. There was a single study on monitoring, while nine assessed the prediction in CPPD. For BCPD, 56 studies were included. There were two diagnostic studies, while monitoring by CR and US was assessed in 43 studies, showing a reduction in crystal deposition. A total of 12 studies with inconsistent results assessed the prediction of treatment response. The search on patient education retrieved two studies, suggesting a potential role of DECT.

CONCLUSION

This SLR confirmed a relevant and increasing role of imaging in the field of CiAs.

Which are the most frequently involved peripheral joints in calcium pyrophosphate crystal deposition at imaging? A systematic literature review and meta-analysis by the OMERACT ultrasound – CPPD subgroup

Objectives

To identify the prevalence of calcium pyrophosphate crystal deposition (CPPD) using ultrasound and conventional radiology at peripheral joints in patients with suspected or definite CPPD.

Methods

A systematic literature search was performed in PubMed and Embase using pre-defined search strategies from inception to April 2021 to identify studies that evaluated conventional radiology and ultrasound in detecting CPPD at peripheral joints, including definite or suspected CPPD [Research question 1 (RQ1) and Research Question 2 (RQ2), respectively]. For the meta-analysis, the first, second, and third sub-analysis included studies with the knee, and knee or wrist as the index joint for CPPD (without restrictions on the reference standard) and synovial fluid analysis or histology as a reference standard (without restrictions on the index joint), respectively.

Results

One-thousand eight hundred and twenty-seven manuscripts were identified, of which 94 articles were finally included. Twenty-two and seventy-two papers were included in RQ1 and RQ2, respectively. The knee had the highest prevalence for RQ1 and RQ2 by both conventional radiology and ultrasound, followed by the wrist with the highest prevalence for RQ1. The hand had the lowest CPPD prevalence. The third sub-analysis showed a higher CPPD prevalence on ultrasound than conventional radiology at the knee (only data available).

Conclusion

Among all peripheral joints, the knees and wrists could be regarded as the target joints for CPPD detection by imaging. Furthermore, ultrasound seems to detect a higher number of calcium pyrophosphate deposits than conventional radiology, even when using a more restrictive reference standard.

Ultrasound evaluation of the scapholunate ligament and scapholunate joint space in patients with wrist complaints in a rheumatologic setting

Aim

The aims of the study were to perform an ultrasound assessment of the dorsal portion of the scapholunate interosseous ligament and scapholunate joint space in patients with wrist complaints in a rheumatologic setting, to describe ultrasound abnormalities about scapholunate interosseous ligament region, and to correlate them with clinical data, presence of dorsal ganglion cysts and diagnoses of rheumatic diseases.

Material and methods

Seventy-four consecutive patients with wrist pain and/or swelling were evaluated by routine power Doppler ultrasound. Forty normal wrists were studied to confirm the normality values of the scapholunate joint.

Results

The mean width of the normal scapholunate joint was 2.49 mm (±0.49 SD), with a coefficient of variation on repeated measurements of 3.662%. The best predictors of scapholunate interosseous ligament degeneration were: older age (p <0.0001), male gender (p = 0.0049), and radiocarpal effusion (p = 0.0156). The presence of osteophytosis and calcifications of the scapholunate joint were higher (p <0.001) in rheumatic patients. Scapholunate calcifications showed a sensitivity of 98.2% and a specificity of 61.1% for calcium pyrophosphate deposition disease. Dorsal ganglion cysts were more frequent in younger subjects (p <0.0012) without rheumatic conditions (p <0.0001) or midcarpal synovitis (p <0.0001). Larger cysts often exhibited power Doppler signal (p <0.0001). The best predictors of scapholunate dissociation were: male gender (p = 0.0002), presence of midcarpal synovitis (p <0.0137), and higher grade of scapholunate interosseous ligament degeneration (p <0.0001). Scapholunate widening was greater (p = 0.0419) in calcium pyrophosphate deposition disease or rheumatoid arthritis than in other rheumatic conditions.

Conclusions

Ultrasound findings of scapholunate interosseous ligament degeneration and calcification, scapholunate space enlargement, and dorsal ganglion cysts should be considered in ultrasound reporting, since they add useful information about the diagnosis of associated rheumatic conditions.

The diagnostic value of conventional radiography and musculoskeletal ultrasonography in calcium pyrophosphate deposition disease: a systematic literature review and meta-analysis

OBJECTIVE

To examine and compare the accuracy of conventional radiography (CR) and musculoskeletal ultrasonography (US) in the diagnosis of calcium pyrophosphate (CPP) crystals deposition disease (CPPD).

DESIGN

A systematic search of electronic databases (PubMed, Embase, and Cochrane), conference abstracts and reference lists was undertaken. Studies which evaluated the accuracy of CR and/or US in the diagnosis of CPPD, using synovial fluid analysis (SFA), histology or classification criteria as reference tests were included. Subgroup analyses by anatomic site and by reference test were performed.

RESULTS

Twenty-six studies were included. Using SFA/histology as reference test, CR and US showed an excellent (CR AUC = 0.889, 95%CI = 0.811-0.967) and an outstanding (US AUC = 0.954, 95%CI = 0.907-1.0) diagnostic accuracy (p < 0.01), respectively. Furthermore, US showed a higher sensitivity (0.85, 95%CI = 0.79-0.90 vs 0.47, 95%CI = 0.40-0.55) and only a little lower specificity (0.87, 95%CI = 0.83-0.91 vs 0.95, 95%CI = 0.92-0.97) than CR. A considerable heterogeneity between the studies was found, with adopted reference test being the main source of heterogeneity. In fact, subgroup analysis showed a significant change in the diagnostic accuracy of CR, but not of US, using Ryan and McCarty criteria or SFA/histology as reference test (CR: AUC = 0.956, 95%CI = 0.925-1.0 vs AUC = 0.889, 95%CI = 0.828-0.950, respectively, p < 0.01) (US: AUC = 0.922, 95%CI = 0.842-1.0 vs AUC = 0.957, 95%CI = 0.865-1.0, respectively, p = 0.08) CONCLUSIONS: Although US is more sensitive and a little less specific than CR for identifying CPP crystals, both these two techniques showed a great diagnostic accuracy and should be regarded as complementary to each other in the diagnostic work-up of patients with CPPD.