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.

Power Doppler ultrasound of the hand and wrist joints in systemic sclerosis.

OBJECTIVES: This paper aims to investigate the prevalence and severity of hand and wrist joints power Doppler (PD) ultrasound (US) detected abnormalities in systemic sclerosis (SSc). METHODS: Hand and wrist joints of 46 consecutive SSc patients and 15 healthy controls were studied by using PDUS. Each joint was evaluated for the presence of effusion, synovial hypertrophy, hyperaemia, bone erosions and cortical irregularities; in addition, local tendons for tenosynovitis and hyperaemia, and median nerve for entrapment neuropathy were examined. RESULTS: Synovial hypertrophy was detected in 3% hand joints and in 46% wrists of SSc patients, with significant differences respect to controls (p=0.000004 and 0.000001, respectively). The prevalence of PD positivity was significantly higher in patients' hand joints (1.7%, p=0.001527) and wrists (43%, p=0.000001) than in healthy individuals. Seven percent of hand and 54% of wrist joints resulted to be positive for joint effusion with significant differences from controls (p=0.000001 and p=0.000013, respectively). The prevalence of cortical irregularities was significantly higher (p=0.006) than healthy subjects only at hand joints level. No significant difference was found for bone erosions. Tenosynovitis was found in 6% out of the 1.196 synovial tendon sites examined of SSc patients with significant differences compared to healthy subjects (p=0.000001); PD resulted to be positive in 29% of them, with significantly differences compared to controls (p=0.0038). CONCLUSIONS: This study, focused on hand and wrist joints PDUS assessment of inflammatory and structural abnormalities in SSc, demonstrated a varied and complex involvement both at joint and periarticular tissues level, showing that wrists were more frequently the site of inflammatory findings.

The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA.

OBJECTIVE: Musculoskeletal US can be useful in monitoring RA. It can be time-consuming and there is no consensus in defining the joints to evaluate. We assessed the validity, sensitivity to change and feasibility of a reduced 6-joint US score in patients with RA starting therapy with an anti-TNF agent. METHODS: A group of consecutive RA patients starting etanercept were investigated. The patients underwent clinical evaluation, laboratory tests and US assessment at baseline and 3 months. A semi-quantitative score (0-3) was used to evaluate synovial effusion (SE), synovial proliferation (SP) and power Doppler (PD) signal in 12 joints. A process of data reduction, based on the frequency of synovial site involvement by US-SE, US-SP and US-PD signal, was conducted to investigate the validity of a 6-joint US assessment. RESULTS: Forty-five RA patients were evaluated. A significant decrease in all clinical, serological and 12-joint US parameters was found at follow-up. A significant correlation between changes in the DAS-28 and changes in the US scores in the 12-joint assessment was observed at follow-up (P < 0.001). A reduced 6-joint US score was obtained, including wrist, second MCP and knee joints of both sides, detecting US-SE in 97.78% of patients, US-SP in 100% of patients and positive US-PD in 100% of patients. The 6-joint US score showed a highly significant correlation with changes in DAS-28 (P < 0.001). The 6-joint evaluation was quick and easy to do. CONCLUSION: A 6-joint US assessment may be a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA.

The interobserver reliability of ultrasound in knee osteoarthritis.

OBJECTIVE: To assess the interobserver reliability between sonographers with different levels of experience in detecting inflammatory and structural damage abnormalities in patients with knee OA. METHODS: After achieving consensus on definitions and scanning protocols, three ultrasonographers with different levels of experience in musculoskeletal US examined the knees of nine patients with OA. US examinations were conducted with independent blinded evaluations of inflammatory (joint effusion, synovial hypertrophy, power Doppler signal, Baker's cysts) and structural (osteophytes, cortical bone irregularities, femoral hyaline cartilage abnormalities, protrusion of the medial meniscus) lesions. All abnormalities were scored by applying a dichotomous scale (0-1). In addition, at each knee joint site global scores for joint inflammation, cortical bone abnormalities and cartilage damage were calculated by summing the single-lesion scores. Reliability was assessed using kappa (κ) coefficients. RESULTS: Seventeen knees were examined. Inflammatory abnormalities were observed with moderate to very good agreement (κ = 0.55-0.88) between the observers. From fair to very good agreement (κ = 0.31-0.82) was registered between sonographers for structural damage lesions. The overall κ was 0.716 for junior and 0.571 for beginner sonographers comparing their findings with those of senior sonographers. CONCLUSION: This represents the first ultrasonographic study focusing on the analysis of interobserver reliability between sonographers with different levels of experience in demonstrating inflammatory and structural abnormalities in knee OA. Globally, even considering some variable results that were mainly obtained by the evaluation of single components of bone involvement, US offered a reliable assessment of a wide set of abnormalities in knee OA.

Ultrasound in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovial inflammation that can lead to structural damage of cartilage, bone and tendons. Assessing the inflammatory activity and the severity is essential in RA to help rheumatologists in adopting proper therapeutic strategies and in evaluating disease outcome and response to treatment. In the last years musculoskeletal (MS) ultrasonography (US) underwent tremendous technological development of equipment with increased sensitivity in detecting a wide set of joint and soft tissues abnormalities. In RA MSUS with the use of Doppler modalities is a useful imaging tool to depict inflammatory abnormalities (i.e. synovitis, tenosynovitis and bursitis) and structural changes (i.e. bone erosions, cartilage damage and tendon lesions). In addition, MSUS has been demonstrated to be able to monitor the response to different therapies in RA to guide local diagnostic and therapeutic procedures such as biopsy, fluid aspirations and injections. Future applications based on the development of new tools may improve the role of MSUS in RA.

Osteoarthritis of the foot: a review of the current state of knowledge.

Foot osteoarthritis(OA)is very common disease that mainly affects older people deeply influencing their quality of life.The join most frequently involved in the articular degenerative process is the first metatarsophalangeal joint. Its severe impairment may lead to a specific clinical pattern known as hallux rigidus that often requires surgical treatment.Currently conventional radiograms of feet associated with an accurate clinical examination should be performed in order to diagnose foot OA.However, new imaging modalities as ultrasonography and magnetic resonance imaging are emerging as valuable tools to assess foot OA.Therapeutic options for foot OA consist of conservative strategies, including life-style modification and pharmacological treatment, options that are usually adopted in early-stage disease and in invasive surgical procedures reserved to late-stage conditions. At the present time there is a lack of evidence in international literature specifically dealing with foot OA, so further investigation on this topic is required to clarify its pathogenesis, the diagnostic pathway and the best clinical management.

Unilateral painful, swollen and erythematosus knee. Case report.

Musculoskeletal ultrasound (US) is gaining an increasing role in the assessment of a variegate set of joint and periarticular soft tissues abnormalities in rheumatology. In addition, US represents a useful technique in guiding local procedures such as aspiration of fluid collections and injections within the joints and periarticular musculoskeletal structures. We recently performed US in a patient with unilateral painful, swollen and erythematosus knee. Pre-patellar bursitis was demonstrated, without any signs of intra-articular abnormalities. US-guided aspiration of local effusion was performed; synovial fluid analysis demonstrated septic bursitis. Appropriate treatment determined the complete remission.

Ultrasound in the assessment of musculoskeletal involvement in systemic sclerosis.

Systemic sclerosis (SSc) is a chronic connective disease in which the musculoskeletal involvement affects especially the hands and feet. Ultrasound (US) represents an important tool in the assessment of the joint and soft tissue involvement in this rheumatic disorder. Few authors have investigated the role of US in the evaluation of joints and peri-articular tissues in SSc patients. The current available literature regarding US applications in the assessment of musculoskeletal involvement in SSc has shown that US seems to be a useful tool in detecting the presence of inflammatory and structural abnormalities involving both joints and soft tissues. The aim of the present paper is to review the role of US in the assessment of musculoskeletal involvement in SSc.