Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor

Comprehensive and reliable sonographic assessment and scoring system for inflammatory lesions of the paediatric ankle

OBJECTIVE

The clinical decision-making process in paediatric arthritis lacks an objective, reliable bedside imaging tool. The aim of this study was to develop a US scanning protocol and assess the reliability of B-mode and Doppler scoring systems for inflammatory lesions of the paediatric ankle.

METHODS

As part of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) US group, 19 paediatric rheumatologists through a comprehensive literature review developed a set of standardized views and scoring systems to assess inflammatory lesions of the synovial recesses as well as tendons of the paediatric ankle. Three rounds of scoring of still images were followed by one practical exercise. Agreement among raters was assessed using two-way single score intraclass correlation coefficients (ICC).

RESULTS

Of the 37 initially identified views to assess the presence of ankle synovitis and tenosynovitis, nine views were chosen for each B-mode and Doppler mode semi-quantitative evaluation. Several scoring exercises and iterative modifications resulted in a final highly reliable scoring system: anterior tibiotalar joint ICC: 0.93 (95% CI 0.92, 0.94), talonavicular joint ICC: 0.86 (95% CI 0.81, 0.90), subtalar joint ICC: 0.91 (95% CI 0.88, 0.93) and tendons ICC: 0.96 (95% CI 0.95, 0.97).

CONCLUSION

A comprehensive and reliable paediatric ankle US scanning protocol and scoring system for the assessment of synovitis and tenosynovitis were successfully developed. Further validation of this scoring system may allow its use as an outcome measure for both clinical and research applications.

Ankle and foot pathologies in early rheumatoid arthritis, what can ultrasound tell us?

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune polyarticular disease. Despite being commonly affected in RA, the ankle and foot do not receive much attention, particularly in early disease. The precise diagnosis of their involvement and its impact on health is a clinical challenge that requires accurate assessment.

AIM

To determine the role of ultrasound in evaluation of ankle and foot pathologies and assess its impact on functional activity in newly diagnosed RA patients.

METHODS

The study was conducted on 152 RA patients and 52 healthy controls. Patients were subjected to history taking, clinical examination, and ultrasound scan. Impact on health was measured by health assessment questionnaire, as well as foot function index.

RESULTS

In a cohort of patients with early RA with median duration of 1 month, tibialis posterior (TP) tenosynovitis (45.4%) was the most common pathology, followed by tibiotalar (TTJ) synovitis (39.8%), and peroneal tenosynovitis (39.1%). In terms of disease duration, TTJ (P = .001) foot pathologies were less common in early RA and tended to worsen over time, whereas TP (P = .048) and peroneal tenosynovitis (P = .011) were more common in early RA. In multivariate analysis TTJ, subtalar synovitis, forefoot pathologies, TP tenosynovitis, and Achilles enthesitis were found to be significant predictors of functional disability. The most important predictors of ankle pain were TTJ synovitis, TP tenosynovitis, peroneal tenosynovitis, and plantar fasciitis.

CONCLUSION

Ankle and foot involvement is a common issue of early RA, and it has a significant impact on quality of life. Ultrasound is a reliable tool for evaluating various abnormalities in this complex area, allowing for better management.

Ultrasound of Subtalar Joint Synovitis in Patients with Rheumatoid Arthritis: Results of an OMERACT Reliability Exercise Using Consensual Definitions

OBJECTIVE

To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA).

METHODS

Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen's and Light's κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal.

RESULTS

Mean weighted Cohen's κ for SH, PD, and JE were 0.80 (95% CI 0.62-0.98), 0.61 (95% CI 0.48-0.73), and 0.52 (95% CI 0.36-0.67), respectively. Weighted Cohen's κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were -0.04 to 0.79, 0.42-0.95, and 0.28-0.77; 0.31-1, -0.05 to 0.65, and -0.2 to 0.69; 0.66-1, 0.52-1, and 0.42-0.88, respectively. Weighted Light's κ for SH was 0.67 (95% CI 0.58-0.74), 0.46 (95% CI 0.35-0.59) for PD, and 0.16 (95% CI 0.08-0.27) for JE. Weighted Light's κ for SH, PD, and JE were 0.63 (95% CI 0.45-0.82), 0.33 (95% CI 0.19-0.42), and 0.09 (95% CI -0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27-0.64), 0.35 (95% CI 0.27-0.4), and 0.04 (95% CI -0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75-0.89), 0.66 (95% CI 0.56-0.8), and 0.18 (95% CI 0.04-0.34) for posterolateral STJ, respectively.

CONCLUSION

Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Sonographic and Anatomic Description of the Subtalar Joint

Our study provides a detailed anatomic and sonographic description of the subtalar joint, a single joint that, anatomically, is divided into the anterior subtalar joint (ASTJ) and the posterior subtalar joint (PSTJ). Cadaver specimens of the ankle and foot were examined in detail by ultrasound (US), and the subtalar joints of all the specimens were injected with colored latex of a contrasting color under US guidance. Compatible with other studies, examination of the sections revealed lack of communication between the ASTJ and the PSTJ and communication between the PSTJ and the posterior recess of the tibiotalar joint. A recommended list of standardized ultrasound scans was developed using a Delphi consensus process, which allows sonographers to evaluate both the ASTJ and PSTJ from the medial, lateral and posterior aspects. The recommended ultrasound scans were found to be applicable based on a test of agreement between images acquired in cadaver specimens and images acquired in four centers using healthy patients.

Ankle Evaluation in Active Rheumatoid Arthritis by Ultrasound: A Cross-Sectional Study

Ankle joint evaluation is underestimated in many clinical and sonographic scores used for evaluation and follow-up of rheumatoid arthritis (RA) patients. Agreement on examination parameters is poor among sonographic scores that include the ankle joint. More effort is needed to detect the value of ankle joint examination in RA and assessment of ultrasonographic signs according to frequency, disease duration and activity. The objective of this study was to use ultrasound (US) to detect ankle involvement in active RA and to compare findings with disease duration, disease activity and assessment of ankle bone erosion. A total of 63 RA patients with active disease and 20 controls were included in the study. The tibiotalar and talonavicular joints were examined by US for synovitis and/or effusion in gray-scale and power Doppler modes. The anterior, lateral and posterior ankle tendons were examined for tenosynovitis and tendinosis. Mean age was 35.1 ± 8.3 y, mean disease duration was 22.7 ± 9.6 mo and the mean 28-joint Disease Activity Score-erythrocyte sedimentation rate was 3.05 ± 0.66. Ankle involvement was seen in 28 patients (44.4%). The most frequent pathologies detected were tenosynovitis (30.2%), followed by synovitis (18.3%), erosion (8.7%) and tendinosis (4%). The earliest sonographic signs were tenosynovitis, followed by synovitis, erosion and tendinosis. The right ankle exhibited greater involvement than the left ankle, which was significant with respect to erosions (p = 0.009). The most common tendon affected by tenosynovitis was the tibialis anterior (22.2%), followed by the tibialis posterior (20.6%). Tenosynovitis, especially of the tibialis anterior and posterior, tibiotalar synovitis and erosions should be considered in future US ankle scores for the assessment of RA.

Musculoskeletal ultrasonography delineates ankle symptoms in rheumatoid arthritis

OBJECTIVES

To clarify the use of musculoskeletal ultrasonography (US) of ankle joints in rheumatoid arthritis (RA).

METHODS

Consecutive RA patients with or without ankle symptoms participated in the study. The US, clinical examination (CE), and patients' visual analog scale for pain (pVAS) for ankles were assessed. Prevalence of tibiotalar joint synovitis and tenosynovitis were assessed by grayscale (GS) and power Doppler (PD) US using a semi-quantitative grading (0-3). The positive US and CE findings were defined as GS score ≥2 and/or PD score ≥1, and joint swelling and/or tenderness, respectively. Multivariate analysis with the generalized linear mixed model was performed by assigning ankle pVAS as a dependent variable.

RESULTS

Among a total of 120 ankles from 60 RA patients, positive ankle US findings were found in 21 (35.0%) patients. The concordance rate of CE and US was moderate (kappa 0.57). Of the 88 CE negative ankles, US detected positive findings in 9 (10.2%) joints. Multivariate analysis revealed that ankle US, clinical disease activity index, and foot Health Assessment Questionnaire, but not CE, was independently associated with ankle pVAS.

CONCLUSION

US examination is useful to illustrate RA ankle involvement, especially for patients who complain ankle pain but lack CE findings.

Is ankle involvement underestimated in rheumatoid arthritis? Results of a multicenter ultrasound study

The aim of this study is to investigate the prevalence of subclinical ankle involvement by ultrasound in patients with rheumatoid arthritis (RA). The study was conducted on 216 patients with RA and 200 healthy sex- and age-matched controls. Patients with no history or clinical evidence of ankle involvement underwent US examination. For each ankle, tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF) were assessed. The following abnormalities were recorded: synovitis, tenosynovitis, bursitis, enthesopathy and rupture. BMI, DAS28, RF ESR and CRP were also obtained. A total of 432 ankles of patients with RA and 400 ankles of healthy controls were assessed. In 188 (87%) patients with RA, US showed ankle abnormalities whereas, in control group, US found abnormalities in 57 (28.5 %) subjects (p = 0.01). The most frequent US abnormality in RA patients was TP tenosynovits (69/216) (31.9 %), followed by PL tenosynovitis (58/216) (26.9 %), TT synovitis (54/216) (25 %), PB tenosynovitis (51/216) (23.6 %), AT enthesopathy (41/216) (19 %) and AT bursitis (22/216) (10.2 %). In 118 RA patients out of 216 (54.6%), a positive PD was found. No statistically significant correlation was found between the US findings and age, disease duration, BMI, DAS28, RF, ESR and CRP. The present study provides evidence of the higher prevalence of subclinical ankle involvement in RA patients than in age- and gender-matched healthy controls identified by US.

Ultrasonography shows significant improvement in wrist and ankle tenosynovitis in rheumatoid arthritis patients treated with adalimumab

OBJECTIVE

Tenosynovitis is common in rheumatoid arthritis (RA) but knowledge is limited regarding its response to anti-inflammatory treatment. This study used ultrasonography (US) to examine the distribution and responsiveness of tenosynovitis to anti-tumour necrosis factor (anti-TNF) treatment in RA patients.

METHODS

Twenty patients with RA were examined at baseline and 1, 3, 6, and 12 months after starting adalimumab treatment, and grey-scale (GS) and power Doppler (PD) US scoring (semi-quantitative range 0-3) of wrist and ankle tendons was performed in addition to assessment of the 28-joint Disease Activity Score (DAS28), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR).

RESULTS

The extensor carpi ulnaris (ECU) tendon in the wrists and the closely related tendons tibialis posterior (TB) and flexor digitorum longus (FDL) in the ankles were most often inflamed. Median sum scores for this reduced number of tendons at baseline/12-month follow-up were 5/0.5 for GS (p < 0.001) and 4/0 for PD (p < 0.05), with reductions in the US scores during follow-up as large as those found for sum scores of all tendons. The standardized response means (SRMs) for sum GS or PD scores of the reduced number of tendons were higher (range -0.53 to -0.93) than for the sum scores of all tendons (-0.23 to -0.74), and showed larger responsiveness than CRP (-0.10 to -0.43) and ESR (-0.03 to -0.71).

CONCLUSION

Bilateral assessments of ECU, TB, and FDL tendons were as sensitive to change as the sum scores of all tendons, and scoring of this reduced number of tendons is suggested to be included in US scorings for follow-up of RA patients.

Looking through the 'window of opportunity': is there a new paradigm of podiatry care on the horizon in early rheumatoid arthritis?

Over the past decade there have been significant advances in the clinical understanding and care of rheumatoid arthritis (RA). Major paradigm changes include earlier disease detection and introduction of therapy, and 'tight control' of follow-up driven by regular measurement of disease activity parameters. The advent of tumour necrosis factor (TNF) inhibitors and other biologic therapies have further revolutionised care. Low disease state and remission with prevention of joint damage and irreversible disability are achievable therapeutic goals. Consequently new opportunities exist for all health professionals to contribute towards these advances. For podiatrists relevant issues range from greater awareness of current concepts including early referral guidelines through to the application of specialist skills to manage localised, residual disease activity and associated functional impairments. Here we describe a new paradigm of podiatry care in early RA. This is driven by current evidence that indicates that even in low disease activity states destruction of foot joints may be progressive and associated with accumulating disability. The paradigm parallels the medical model comprising early detection, targeted therapy, a new concept of tight control of foot arthritis, and disease monitoring.

'Podiatrists are experts on foot disorders: both patients and rheumatologists can profit from the involvement of a podiatrist'

- Korda and Balint, 2004 [1].