Psoriatic arthritis: what ultrasound can provide us.

Ultrasound (US) is a valuable imaging technique for detection and characterisation of the inflammatory process in arthritides. US has widely been applied to psoriatic arthritis (PsA) in both clinical and research fields, especially focusing on enthesitis. US has proven to be useful to establish a diagnosis of PsA, to recognise subclinical involvement, (such as enthesis abnormalities in patients with PsA, and in patients with only clinically apparent skin psoriasis despite the absence of clinical symptoms of arthritis), to estimate disease activity, and to allow therapy monitoring showing structural and inflammatory changes (not only in joints and tendons, but also in domains not assessed in usual rheumatology care, such as the skin and nails).

The Italian MSUS Study Group recommendations for the format and content of the report and documentation in musculoskeletal ultrasonography in rheumatology.

OBJECTIVE: The objective of this study was to draw up a set of recommendations for the format and content of the musculoskeletal ultrasonography (MSUS) report in rheumatology. METHODS: A panel of rheumatologists, members of the MSUS Study Group of the Italian Society of Rheumatology, met in order to identify the main discrepancies in the MSUS report. A set of 15 recommendations was then defined, aimed at resolving the main discrepancies. They consisted of information about the motivations for the MSUS examination, the equipment, the US modalities and scanning technique, a list of the examined structures and findings, the scoring/grading systems, the number of images and main findings to include and conclusions. Subsequently a Delphi-based procedure was started in order to obtain agreement on a core set of recommendations. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS: Three complete rounds were performed. The response rate was 85.2% for the first round, 78.3% for the second and 88.9% for the third. Finally, consensus was obtained for 14 of 15 statements. These 14 statements represent the recommendations of the group for the format and content of the report and documentation in MSUS in rheumatology. CONCLUSION: To the best of our knowledge, our group has produced the first recommendations for the format and content of the report and documentation in MSUS in rheumatology. The report is an integral part of the MSUS examination and its use in a homogeneous form can help in the correct interpretation of the findings.

Ultrasound in connective tissue diseases.

Rheumatologists have been using ultrasound (US) for the evaluation of patients affected by rheumatic disease for a long time. Actually this approach is becoming more and more diffuse and US is used for multiple purposes: diagnosis, disease activity assessment, prognosis, and therapy monitoring. The real 'new' step for the rheumatologist has been moving from the 'usual' musculoskeletal US to other fields of US, such as the assessment of vascular involvement (both macro and micro), skin, lung and even nails. In this paper we review the published literature related to the use of musculoskeletal, skin and lung US in patients affected by connective tissue diseases.

Ultrasound imaging in psoriatic arthritis and ankylosing spondylitis.

Musculoskeletal ultrasound (US) is a reliable imaging technique which has a key role in the assessment of patients with psoriatic arthritis (PsA) and ankylosing spondylitis (AS). US can help in the diagnosis of the disorder, in the evaluation of the extent of the joint and enthesis involvement and in therapy monitoring because it can reflect both morphostructural changes and inflammatory activity. Several studies have reported that US revealed pathological findings at joints and enthesis in a large number of PsA patients who do not complain of active pain and/or swelling at the time of the clinical examination and in psoriasis patients with no signs of musculoskeletal disease. The application of US in the evaluation of nail and skin involvement in patients affected by psoriasis, with or without arthritis, and the imaging of sacroiliac joints is an interesting approach. US has already become commonplace in both clinical and research fields, and improvements in US technology will offer further possibilities for future research.

Ultrasonographic evaluation of entheses in patients with spondyloarthritis: a systematic literature review.

OBJECTIVES: Enthesitis represents a characteristic features of spondyloarthritis (SpA) and, in the context of the early management of the disease, its reliable assessment has emerged as a central issue. Musculoskeletal ultrasonography (US) has proven to be of value in the assessment of peripheral entheses. Our aim was to systematically review the literature from 2010 to 2013 in order to summarise the evidence on the evaluation of entheses by US in patients with diagnosed or suspected SpA. METHODS: PubMed and Embase were searched developing a search strategy based on terms related to SpA and US. The target population were patients with SpA or suspected SpA, the intervention was entheseal US, the outcomes were the prevalence of US abnormalities, the reliability, the diagnostic accuracy, the sensitivity to change. The possible comparators were clinical evaluation and other imaging techniques. Cohort studies (cross-sectional or longitudinal), case-control studies, diagnostic accuracy studies, systematic literature reviews and meta-analyses were eligible for inclusion. RESULTS: Out of 3368 retrieved references, 34 papers were finally included. 22 of which reported information on the prevalence of US findings, yielding highly variable results. US was sufficiently reliable, as reported in 6 papers. A minority of studies reported data on sensitivity to change, which was good, and on the application of US for differential diagnosis and diagnosis of SpA, thus demonstrating the value of US also in this context. CONCLUSIONS: US confirms its validity and reliability in the assessment of entheseal involvement in patients with SpA. Further application in the help of diagnosis will be provided by future research.

Ultrasound imaging for the rheumatologist XLIII. Ultrasonographic evaluation of shoulders and hips in patients with polymyalgia rheumatica: a systematic literature review.

OBJECTIVES: Musculoskeletal ultrasonography (US) has lately been applied to patients with polymyalgia rheumatica for the examination of shoulders and hip, and included in the 2012 PMR classification criteria. We aimed to perform a comprehensive overview of the literature on this topic with a systematic review. METHODS: We searched PubMed, Embase, the Cochrane library and the proceedings from EULAR and ACR congresses (2011-2012). We included studies evaluating patients with confirmed or suspected PMR, undergoing US of shoulders and/or hips. The diagnosis of PMR could be based on expert opinion or diagnostic criteria. Cohort, case-control, diagnostic accuracy studies and case-series were eligible for inclusion. The features of the included studies were presented. When available, sensitivities and specificities were calculated for primary studies. RESULTS: Out of 1736 papers identified by our search, 13 articles and 1 abstract were finally included in the review. Eight studies focused on shoulder US, 1 on hip US, 4 on both. Studies were extremely variable in terms of population, US examination, reference standard and control population. In general, at the shoulder, pathological bilateral US findings in most studies were more prevalent in patients with PMR compared to controls. When sensitivity and specificity could be calculated, bilateral findings were more sensitive. Notably, less information was available on hip US. CONCLUSIONS: US (especially in shoulder examination) is confirmed to be a potentially useful instrument to integrate clinical information in the management of patients with PMR. Its additional value in conjunction with the new classification criteria should be further tested.

Ultrasound imaging for the rheumatologist XLIV. Ultrasound of the shoulder in healthy individuals.

OBJECTIVES: To investigate the prevalence of shoulder ultrasound (US) detectable abnormalities in asymptomatic individuals of various ages and to correlate the US findings with clinical data. METHODS: 97 healthy subjects were enrolled in the present study. They were subgrouped according to their age, as follows: group I (20-29 years); group II (30-39 years); group III (40-49 years); group IV (50-59 years); group V (>60 years). A physical examination of both shoulders, based on a series of provocative maneuvers, was carried out. The US assessment was performed by using a Logiq9 machine equipped with a multi-frequency linear probe working at 12MHz and included the study of a number of structures for the evaluation of local abnormalities, as follows: the long head of biceps tendon (synovial effusion (SE), synovial hypertrophy (SH), power Doppler (PD) signal); the subacromion-subdeltoid and sub-scapularis bursae (SE, SH, PD signal); the rotator cuff tendons (tendinosis, calcifications, tears, impingement); the acromionclavicular (ACJ) and gleno-humeral joints (SE, SH, PD signal, osteophytes, erosions, fibrocartilage calcifications, cartilage abnormalities, tophaceous deposits). In addition, deltoid, throchite and throchine enthesopathy were searched for. RESULTS: 194 shoulders were studied in total. A low but variable percentage of joints of healthy individuals (3.1-13.4%) showed positive provocative maneuvers. 138 shoulders (71.1%) did not show any US abnormalities. The most frequent changes were SE of ACJ (25.5%), osteophytes of ACJ (23.3%), and supraspinatus tendinosis (20.6%). The prevalence of abnormalities progressively increased with age. Sub-clinical involvement was present in most cases, being provocative maneuvers positive only in a low percentage of joints. CONCLUSIONS: The present study demonstrated the presence of a wide set of US-detectable changes in healthy subjects, that were more frequently present in elderly individuals. The absence of any clinical sign of local pathology cannot exclude the presence of local abnormalities.

Ultrasound imaging for the rheumatologist. XLVII. Ultrasound of the shoulder in patients with gout and calcium pyrophosphate deposition disease.

OBJECTIVES: This study was aimed at determining the prevalence of ultrasound (US) morpho-structural changes in the shoulders of patients with crystal-related arthropathies, and at investigating the relationship between them and the clinical findings. METHODS: Eighty-eight patients with a crystal proven diagnosis of gout or calcium pyrophosphate dihydrate (CPPD) disease attending the in-patient and the out-patient clinics of four Italian Rheumatology Departments were consecutively enrolled in this multi-centre study. All patients were clinically examined by an expert rheumatologist who recorded clinical and laboratory data in addition to the presence/absence of spontaneous shoulder pain and performed the Hawkins, Jobe, Patte, Gerber, and Speed tests. In each centre, US examinations were carried out by a rheumatologist expert in musculoskeletal US blinded to clinical data, using a MyLab TWICE XVG machine (Esaote SpA, Genoa, Italy) equipped with a linear probe operating at 4-13 MHz, and a Logiq 9 machine (General Electrics Medical Systems, Milwaukee, WI, USA) with a linear probe operating at 9-14 MHz. Shoulders were scanned to detect peri-articular inflammation, rotator cuff pathology and joint involvement, and to reveal US signs indicative of crystal deposits. RESULTS: A total of 88 patients, 39 with gout, 46 with CPPD disease, and 3 with both gout and CPPD disease, were enrolled. In total, 176 shoulders were clinically assessed, of which 54/176 (30%) were painful and 74/176 (42%) were clinically normal shoulders. All US findings indicative of peri-articular synovial inflammation were more frequently detected in patients with CPPD disease than in gouty patients. In 50 out of 176 (28.4%) shoulders, US allowed the detection of at least one finding indicative of synovial inflammation. Chronic tendinopathy was a frequent US finding both in gout patients and in patients with CPPD disease and the supraspinatus tendon was the most frequently involved one. In CPPD disease the supraspinatus tendon was found ruptured in a number of shoulders seven times higher than in gouty patients. The osteophytes were found at acromion-clavicular joint in nearly 80% of the shoulders in CPPD disease and in 60% in the gouty patients. CONCLUSIONS: The results of this study confirm the high specificity of US findings indicative of crystal deposits at hyaline cartilage level and indicate that the supraspinatus tendon and the fibrocartilage of the acromion-clavicular joint are the most frequently affected structures of the shoulders in patients with crystal-related arthropathies.

Ultrasound imaging for the rheumatologist XLVI. Ultrasound guided injection in the shoulder: a descriptive literature review.

Shoulder pain represents one of the most frequent clinical conditions in the general population and it can be generated by a large spectrum of pathologies. The most frequent approach of most rheumatologists to shoulder pain, in daily clinical practice, mainly based on their personal experience, is to locally inject drugs. Since the literature on this topic provides conflicting results due to the wide heterogeneity in the study designs, we decided to report the most relevant studies. Not enough data are available to assess whether US-guided injections are more efficient in controlling shoulder pain with respect to the landmark approach. However, it is likely that US-guided technique shows a more rapid improvement, possibly by providing a higher corticosteroid volume injected right where it is needed. When injecting hyaluronic acid, a more accurate localisation of the medicament might be useful to improve efficacy and avoid adverse effects (i.e. pain), however, there are no studies comparing the blind approach to the US-guided one. Finally, new treatments for shoulder pain have been used but they still need future validation in more appropriate RCTs.

Ultrasound imaging for the rheumatologist XLVIII. Ultrasound of the shoulders of patients with rheumatoid arthritis.

OBJECTIVES: To investigate the prevalence of ultrasonographic (US) shoulder abnormalities in patients with rheumatoid arthritis (RA) and to investigate the relationship between US findings and demographic and clinical features. METHODS: Consecutive patients attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US of bilateral shoulders was performed at the same time, examining tendons, bursae, gleno-humeral and acromion-clavicular joints. The presence of signs of inflammation, bone erosions or rotator cuff pathology was evaluated. RESULTS: A total of one hundred patients were enrolled, mean age (SD) 59.6 (14.7) years, median disease duration (IQR) 56.5 (34.7, 96.5) months, 98% of them were on DMARDs and 22% on biologics. Shoulder tenderness was reported by 44% of patients. 34% of patients showed at least one sign of inflammatory involvement, and 25% of them presented with humeral head erosions. Signs of rotator cuff pathology were seen in 49% of patients. Agreement between the presence of spontaneous pain and US inflammatory abnormalities was moderate (kappa 0.501). Patients with inflammatory involvement of the shoulders had significantly higher DAS28, HAQ, VAS pain, acute phase reactants and disease duration compared to patient with no inflammatory signs, they were more frequently RF positive and reported more frequently spontaneous pain. CONCLUSIONS: US assessment of the shoulder in RA patients can be considered of value, especially in patients with relevant indicators of disease activity and severity.

Ultrasound imaging for the rheumatologist XLV. Ultrasound of the shoulder in psoriatic arthritis.

OBJECTIVES: The aims of this study were to investigate the prevalence of ultrasound (US) pathologic abnormalities in the shoulders of psoriatic arthritis (PsA) patients and to compare them with the main clinical findings. METHODS: Ninety-seven PsA patients were enrolled in the study. The subacromial/subdeltoid bursa, the sheath of the long biceps tendon, the glenohumeral joint and the acromion-clavicular joint were examined for the presence of synovial effusions and synovial hypertrophy. Rotator cuff tendons (supraspinatus, subscapularis, infraspinatus) were imaged for tendinosis, calcifications and total or partial tears, while deltoid enthesis were evaluated for local enthesitis and the lesser and greater tuberosity of the humerus for the presence of enthesophytes. RESULTS: Tendinosis represented the most frequent abnormal finding. Supraspinatus tendinosis was detected more often than subscapularis and infraspinatus tendinosis. When considering tendon tear, supraspinatus was also the most frequently involved anatomical structure. Clinical examination frequently failed to detect abnormalities in patients in whom US examination showed pathological findings. This is particularly true for tendon involvement, i.e. effusion within the sheath of the biceps tendon was imaged in 43 shoulders but clinical assessment reported abnormalities only in 22 shoulders (p<0.0001). CONCLUSIONS: US examination appears to be a useful and sensitive imaging technique, specifically in identifying joint and tendon involvement of the shoulder.

Ultrasound imaging for the rheumatologist XLI. Sonographic assessment of the hip in OA patients.

OBJECTIVES: To investigate the prevalence of ultrasound (US) detectable abnormalities in the hip joints of patients with osteoarthritis (OA) and correlate them with clinical findings and measures of disease severity. METHODS: Consecutive patients with hip OA were investigated by clinical and US examinations. Bilateral US of the hip joints was performed by using a Logiq9 machine, equipped with a multi-frequency linear probe, operating at 9 MHz; in addition, power Doppler (PD) was applied (frequency 7.5 MHz; PRF 750 Hz). Clinical evaluation included the registration of demographic data, disease duration, current and previous joint pain and Lequesne index. US study included the assessment of both inflammatory and structural abnormalities at the level of hip joint (joint effusion, synovial hypertrophy, local pathologic vascularisation at PD, osteophytes) and periarticular soft tissues (iliopsoas bursitis, trochanteric bursitis, iliopsoas tendinopathy, gluteus medius tendinopathy and gluteus minimus tendinopathy). RESULTS: One hundred and fifty hips of 75 patients were studied. Clinical examination demonstrated the presence of current hip pain in 80% of patients and previous hip pain in 85.7% of cases. The mean Lequesne Index was 11.9±4.9. US detected effusion in 50% of the joints, synovial hypertrophy in 41.3%, PD signal in 0.7%, osteophytes in 77.3%; at periarticular level, trochanteric bursitis was found in 24.7% of patients, gluteus tendinopathy in 22.7%, iliopsoas tendinopathy in 7.3% and finally iliopsoas bursitis in 1.3%. The presence of current and previous hip pain significantly correlated with the presence of effusion (p=0.01); age and disease duration significantly correlated with the presence of osteophytes (p=0.01). Various US-detected abnormalities were found also in asymptomatic patients. Statistically significant differences between the 2 subgroups of symptomatic and asymptomatic patients were registered for effusion (p=0.003). CONCLUSIONS: In hip OA, US is a useful imaging tool for analysing both inflammatory and structural damage lesions as well as for differentiating the involvement of joint structures and periarticular soft tissues. In addition, US was able to detect a wide set of abnormalities even in asymptomatic patients, confirming that it is more sensitive than clinical examination in detecting musculoskeletal involvement.

Ultrasound imaging for the rheumatologist XXXVIII. Sonographic assessment of the hip in psoriatic arthritis patients.

OBJECTIVES: The aims of our study were to investigate the prevalence of ultrasound (US) pathological abnormalities in the hip of psoriatic arthritis (PsA) patients and compare them with the clinical findings. METHODS: Sixty-five PsA patients were enrolled in the study. Bilateral examination of the hip was performed to detect joint effusion, synovial hypertrophy, irregularity of femoral head and neck profile as seen in erosions and/or osteophytes. RESULTS: Joint effusion was detected in 20 out of 130 hips (15%). Synovial hypertrophy was present in 12 out of 20 hips (60%) associated with effusion (9.3% of all hip joints) and only 1 of them showed PD signal. Small effusion without synovial proliferation was imaged in 8 out of 20 hips (40%). On the whole 14 out of 65 patients (21%) had joint effusion with or without synovial hypertrophy using US. No erosions of the femoral head and neck profile were detected whilst osteophytes were imaged in 27 joints (20%). No US abnormalities were demonstrated in 18 hips with pain/tenderness on physical examination, whilst joint effusion was seen in 8 joints which were asymptomatic. CONCLUSIONS: US is a useful imaging method to evaluate hip involvement in PsA that could be integrated into routine PsA management even if patients do not complain of hip involvement.

Ankylosing spondylitis: how diagnostic and therapeutic delay have changed over the last six decades.

OBJECTIVES: Ankylosing spondylitis (AS) is a chronic, progressive, and disabling disease, but the diagnosis is often missed and markedly delayed. An early diagnosis is important to establish a treatment to reduce disability and modify the natural course of disease. The aim of this study was to investigate the diagnostic (DD) and therapeutic (TD) delay according to the decade of diagnosis. The DD and TD correlation with radiological severity score and the new imaging techniques used in diagnosis (magnetic resonance [MRI], computerised tomography, scintigraphy for sacroiliac joints) were also investigated. METHODS: 135 AS patients (45 female and 90 male, 36.5±10.2 years old at diagnosis) with disease onset between 1950 and 2008, were investigated; the time from onset to diagnosis (DD) and treatment (TD), the New York and ASAS criteria fulfilment, the New York sacroiliac radiological score, bamboo spine presence at first visit and the new imaging technique used at diagnosis were recorded and their correlations were analysed. RESULTS: The New York and ASAS criteria were met at the first visit, by 87% and 96%, respectively. The delay from onset of symptoms to diagnosis and treatment was 9±8 and 12±11 years, respectively, but decreased significantly between different decades (p<0.001). The severity of sacroiliitis (mean 2±1; 17/135, 12.5% - IV grade sacroiliitis at diagnosis) and bamboo spine (3.7% at diagnosis) correlated with DD and TD (p<0.001). Sacroiliac MRI use at diagnosis significantly decreased both DD and TD (p>0.001 and p<0.05, respectively). CONCLUSIONS: DD and TD were correlated to radiological severity; they progressively decreased over 6 decades.

Ultrasound imaging for the rheumatologist. XLII. Assessment of hip pain in rheumatic patients: the radiologist's view.

Hip pain is a common complaint in daily practice and the identification of the underlying pathologic condition is the first step for an adequate treatment. In this review, we discuss the available evidence for the application of conventional radiography, computed tomography and magnetic resonance imaging in rheumatologic patients with painful hip, presenting the main imaging findings due to osteoarthritis, inflammatory arthritis (rheumatoid arthritis and spondyloarthritides), osteonecrosis and some other soft tissue involvement (bursitis and synovial cyst) that could be the cause of hip pain. Because different imaging techniques show different sensitivity and specificity, the choice of technique to use depends on the type and stage of the disease itself.

Ultrasound imaging for the rheumatologist XL. Sonographic assessment of the hip in rheumatoid arthritis patients.

OBJECTIVES: The aim of the present study was to correlate clinical and laboratory data with those obtained by ultrasound (US) evaluation of the hip in a cohort of patients with rheumatoid arthritis (RA). METHODS: Fifty-two RA patients attending the Rheumatology Departments involved in the present study were enrolled. Demographic (age, gender), clinical (body mass index, disease duration, treatments, history or current hip pain, tenderness by internal or external hip rotation or palpation of the greater trochanteric region), laboratory (erythrosedimentation rate, C-reactive protein, rheumatoid factor and antibodies anti-citrullinated peptides) and clinimetric data (disease activity score 28 - DAS28, Health Assessment Questionnaire - HAQ, Lequesne index) were collected. All patients underwent an US examination of both hips according to international guidelines. RESULTS: A total of 100 hips were scanned in 52 patients with RA. Approximately half of the patients reported a history of hip pain, one fourth complained of current pain, and the physical examination (internal and/or external rotation and palpation of the greater trochanteric region) evocated pain up to 19% and 22% of the patients, respectively. US examination found signs of hip joint abnormalities in 42% of the patients; US changes indicative of hip joint inflammation and damage were detected respectively in 24% and 32% of the cases. No patient presented power Doppler signal in the hip joint. A significant correlation between US pathological findings at hip level was found with clinical data (current pain and evocated pain by internal or external hip rotation). Furthermore, US cartilage lesion correlated with age of the patient, and US bone erosions with the disease duration. No correlation was found between the sonographic assessment and laboratory data, DAS 28, and Lequesne index. CONCLUSIONS: US abnormalities at hip joint level obtained in the present study correlated with clinical findings, while no correlation was found with DAS28 or laboratory data. Further investigations are encouraged to clarify the US additional value at hip level in patients with RA.

Ultrasound imaging for the rheumatologist. XXXI. Sonographic assessment of the foot in patients with rheumatoid arthritis.

OBJECTIVES: The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with rheumatoid arthritis (RA) and to compare them with the clinical findings. METHODS: One hundred RA patients were enrolled in the study. Bilateral US examination of metatarsophalangeal (MTP) joints, proximal interphalangeal (PIP) joints, midfoot joints (talonavicular, calcaneo-cuboid, medial, intermediate and lateral navicular-cuneiform and cuneiform-metatarsal joints and cuboid-4th and 5th metatarsal joints) were examined for synovitis and erosion. In addition the plantar fascia and the insertion of the anterior and posterior tibialis and peroneous brevis tendons were imaged. RESULTS: Effusion with synovial proliferation was visualised only at MTP joints in 84 out of 200 (42%) feet, at MTP plus at least one joint of the midfoot in other 41 out of 200 (20%) feet (making a total of 125 out of 200 (62%) MTP joints) exclusively in one or more joints of the midfoot in 7 out 200 (3%) feet, in the PIP joint of the 2nd and 3rd toes in 3 (1.5%) and 4 (2%) feet respectively, while no effusion with synovial proliferation was visualised in the PIP joint of the 4th and 5th toes. Synovitis was present most frequently in the 2nd MTP joint whilst erosions were most frequently imaged in the 5th MTP joint. CONCLUSIONS: US examination appears to be a useful imaging technique to study joint and tendon involvement of the foot in RA patients. Moreover, US examination of the foot is more sensitive than clinical examination in the detection of joint inflammation and allows for a better understanding of the features and the progression of the disease.

Ultrasound imaging for the rheumatologist XXXV. Sonographic assessment of the foot in patients with osteoarthritis.

OBJECTIVES: The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with osteoarthritis (OA) and to compare them with clinical findings. METHODS: Consecutive patients with foot OA were investigated by clinical and US examinations. Bilateral US of the midfoot and forefoot joints was performed by using a Logiq9 machine, equipped with a multi-frequency linear probe, operating at 14 MHz; in addition, power Doppler was applied (frequency 7.5 MHz; gain 50%; PRF 750 Hz). Clinical evaluation included the registration of demographic data, disease duration, current treatment undergone, joint swelling and tenderness. US study included the assessment of both inflammatory (joint effusion, synovial hypertrophy, local pathologic vascularisation at PD, big-toe bursitis) and structural (osteophytes, MTP joints subluxation) abnormalities. RESULTS: One hundred patients were studied. At midfoot level, clinical examination demonstrated signs suggestive for joint inflammation (tenderness and/or swelling) in at least one joint in 43/200 feet (21.5%) of 23 patients; US showed inflammatory abnormalities in 87/200 feet (43.5%) of 63 patients and structural lesions in 100/200 feet (50%) of 70 patients. At forefoot level, clinical examination found inflammatory signs in at least one joint in 128 feet (64%) of 64 patients; US showed inflammatory abnormalities in at least one joint in 176 feet (88%) of 88 patients and structural lesions in 189 feet (86%) of 86 patients. CONCLUSIONS: US is a useful imaging tool for analysing both inflammatory and structural damage lesions at foot joints level in OA. In addition, it demonstrated to be more sensitive than clinical examination in the detection of inflammatory abnormalities.

Ultrasound imaging for the rheumatologist XXXVI. Sonographic assessment of the foot in gout patients.

OBJECTIVES: This study aims to investigate the relationship between clinical and US findings together with the prevalence and distribution of US findings indicative of monosodium urate (MSU) crystal deposition within the foot in patients with gout. METHODS: A total of 50 patients with gout attending the in-patient and the out-patient clinics of the Rheumatology Departments were prospectively enrolled in this multi-centre study. Multiplanar examination of the following 15 joints was performed: talo-navicular, navicular-cuneiform (medial, intermediate and lateral), calcaneo-cuboid, medial, intermediate and lateral cuneiform-metatarsal, cuboid-4th metatarsal, cuboid-5th metatarsal and all five metatarsophalangeal (MTP) joints. RESULTS: The following US findings were indicative of gout: enhancement of the superficial margin of the hyaline cartilage, intra-articular tophus, and extraarticular tophus. In 46 patients, a total of 1380 foot joints were investigated. In 1309 joints that were not clinically involved, US detected signs indicative of joint inflammation in 9% (121/1309). Talo-navicular joint and the first MTP joint were the joints in which the highest number of US findings were found at mid-foot and fore-foot, respectively. At MTP joint level, dorsal scans allowed the detection of a higher number of US findings indicative of joint inflammation, and MSU crystal deposits rather than on the volar plane. CONCLUSIONS: This study demonstrated that US detected a higher number of inflamed foot joints than clinical examination, and that the first MTP and the talo-navicular joints were the anatomic sites with the highest prevalence of US signs of MSU crystal aggregates.

Ultrasound Imaging for the rheumatologist XXVII. Sonographic assessment of the knee in patients with rheumatoid arthritis.

The aims of our study were to investigate the prevalence of ultrasound (US) pathologic abnormalities and to compare them with the clinical findings in the knee of rheumatoid arthritis (RA) patients. One hundred RA patients were enrolled in the study. Bilateral US examination of the knee was performed to visualise the presence of effusion, synovial proliferation, bone erosions, femoral cartilage abnormalities, quadricipital and/or patellar enthesopathy. The popliteal fossa and the calf region were also evacuate to detect popliteal cyst. We observed joint effusion in 140 out of 200 (70%) knees. Synovial hypertrophy was present in 115 out of 140 (82%) knees associated with effusion and in 22 out of 115 (19%) knees intra-articular power Doppler (PD) signal was found. Hyperechoic spots within the cartilage layer, suggestive of pyrophosphate crystals deposit, were detected in the knees of 3 patients. US signs of quadricipital and/or patellar enthesopathy were detected in 53 out 200 (26%) knees. Bone erosions were visualised in 16 out 200 (8%) knees. Popliteal cyst was found in 66 out of 200 (33%) joints. US examination of the knee is more sensitive than clinical examination in the detection of joint inflammation and allows for the identification of different patterns of pathologic changes at knee level, including morphostructural changes at both cartilage and tendon level.