Ultrasonographic evaluation of Achilles tendon: Is there any difference between ankylosing spondylitis, non-radiographic axial spondyloarthropathy and controls?

The association between sonographic enthesitis with sonographic synovitis and tenosynovitis in psoriatic arthritis patients

OBJECTIVES

To examine the association between sonographic enthesitis with sonographic synovitis and tenosynovitis in PsA patients, and the association between sonographic enthesitis and clinical characteristics.

METHODS

Consecutive PsA patients that fulfilled the ClASsification criteria for Psoriatic ARthritis (CASPAR) were prospectively recruited. Each patient was evaluated by comprehensive clinical and sonographic assessment (greyscale and Doppler), the latter including 52 joints, 40 tendons and 14 entheses [according to MAdrid Sonography Enthesitis Index (MASEI) plus lateral epicondyles] performed by an experienced sonographer blinded to the clinical data. The US enthesitis score was further categorized to inflammatory (hypoechogenicity, thickening, bursitis and Doppler) and structural (enthesophytes/calcifications and erosions) subcategories. Multivariate linear regression models assessed the association between enthesitis and the selected variables.

RESULTS

A total of 158 PsA patients [mean (s.d.) age 52.3 (13) years, 88 (55.7%) females] were analysed. Multivariate linear regression analyses showed a significant association between sonographic enthesitis and sonographic synovitis (β = 0.18, P = 0.008) and between sonographic enthesitis and sonographic tenosynovitis (β = 0.06, P = 0.02). These associations were derived from the enthesitis inflammatory subcategory of the MASEI (P < 0.05). Associations between enthesitis and synovitis were also demonstrated on the level of the elbow, knee and ankle joints (P < 0.05). In addition, sonographic enthesitis was significantly associated with older age, male sex, swollen joint count, CRP level and physical occupation.

CONCLUSIONS

Sonographic enthesitis is associated with sonographic synovitis and tenosynovitis. The severity of sonographic enthesitis may represent a marker for inflammatory activity in other musculoskeletal domains.

Ultrasound Assessment of Entheseal Sites and Anterior Chest Wall in Ankylosing Spondylitis: A Cross-Sectional Study

OBJECTIVES

The study was designed to evaluate entheseal sites and anterior chest wall (ACW) of patients with ankylosing spondylitis (AS) using ultrasound (US) and investigate the correlation between disease activity and US score.

METHODS

This prospective cross-sectional study included 104 patients with AS and 50 control subjects. Each patient underwent US scanning of 23 entheses and 11 sites of the ACW. The US features, including hypoechogenicity, thickness, erosion, calcification, bursitis, and Doppler signal, were evaluated. Disease activity was assessed based on C reactive protein (CRP), erythrocyte sedimentation rate (ESR), disease activity score-C reactive protein (ASDAS-CRP), and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).

RESULTS

The most commonly involved entheses on US were the Achilles tendon (AT) and quadriceps tendon (QT). The most involved site of ACW was the sternoclavicular joint (SCJ). Compared with the control group, significant differences were observed in the AS group in the rates of US enthesitis and ACW in AT (P = .01), SCJ (P = .00), and costochondral joint (CCJ) (P = .01). Patients with high or very high disease activity had a higher erosion score (P = .02). The erosion score was weakly positively associated with CRP, ESR, BASDAI, ASDAS-CRP, and ASDAS-ESR (correlation coefficient: 0.22-0.45).

CONCLUSIONS

The most commonly involved entheseal sites on US were AT and QT, while the site of ACW was SCJ. The US assessment of AS should take the ACW into account. High disease activity might indicate erosion in AS.

Prevalence of peripheral spondyloarthritis among patients with ultrasound-confirmed enthesitis: Single-center cross-sectional study

OBJECTIVE

The primary goal of this study was to determine the prevalence of peripheral spondyloarthritis (pSpA) in patients with ultrasonography (USG)-confirmed enthesitis. The secondary aim of the study was to reveal the demographic, clinical, and ultrasonographic differences of patients diagnosed with pSpA.

METHODS

Fifty-nine patients with USG-confirmed enthesitis were evaluated by a rheumatologist to evaluate if they met the Assessment of SpondyloArthritis International Society (ASAS) criteria for pSpA. Elementary lesions assessed by USG were based on the definition of the Outcome Measures in Rheumatology in Clinical Trials group which included hypoechogenicity, thickening, Doppler signal within 2 mm of bone, enthesophytes, bone erosions, and calcifications. For all patients, clinical and demographic data included: age, gender, smoking habits, body mass index, comorbid diseases, symptom duration, enthesitis region, the presence of bilateral enthesitis, entheseal pain visual analog scale (0-10), standardized enthesitis count following Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and SPondyloArthritis Research Consortium Canada (SPARCC) enthesitis index.

RESULTS

Eight (13.6%, 95% CI 6.0% to 25.0%) of 59 patients were diagnosed with pSpA according to the ASAS classification criteria. Participants diagnosed with pSpA had a longer duration of symptoms (54 vs 12 months), were more likely to present bilateral enthesitis (87.5% vs 49%) with higher SPARCC (11 vs 3) and MASES (6.5 vs 2) scores and higher C-reactive protein (7 vs 3.2 mg/L) concentrations. Entheseal Doppler signal and hypoechogenicity were also more frequently observed (50% vs 0% and 100% vs 49% respectively).

CONCLUSION

Peripheral SpA is not uncommon among patients presenting with enthesitis and more likely in cases with prolonged, extensive, and bilateral enthesitis with entheseal hypoechogenicity and Doppler signal. Musculoskeletal ultrasonography can facilitate the diagnosis of pSpA in patients presenting with enthesitis.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Evaluation of the early cervical structural change in patients with non-radiographic axial spondyloarthropathy

In this double-blind, controlled, cross-sectional study, we compared structural changes in the cervical vertebrae of patients with nonradiographic axial spondyloarthropathy (nr-axSpA), patients with ankylosing spondylitis (AS), and a control group. We used the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) to determine whether the involvement of the cervical spine occurs earlier and is more severe than that of the lumbar spine in axial spondyloarthropathy (axSpA). A statistically significant difference was found in the total mSASSS between the AS and nr-axSpA groups (p = 0.038), but not in the cervical and lumbar mSASSS. Although the duration of the symptoms was shorter in the nr-axSpA group than in the AS group, no statistically significant difference was found in the cervical mSASSS between the AS and nr-axSpA groups. In both the AS and nr-axSpA groups, the cervical mSASSS values were found to be higher than the lumbar mSASSS values for the majority of the patients (82.8 and 89.5%, respectively). This may indicate that structural changes in the cervical spine occur during an early period of axSpA.