Relationship Between Ultrasound and Physical Examination in the Assessment of Enthesitis in Patients With Spondyloarthritis: Results From the DEUS Multicenter Study.

OBJECTIVE: The study objectives were (i) to explore the agreement between the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and physical examination in assessing enthesitis in patients with spondyloarthritis (SpA) and (ii) to investigate the prevalence and clinical relevance of subclinical enthesitis in this population. METHODS: Twenty rheumatology centers participated in this cross-sectional study. Patients with SpA, including axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA), underwent both ultrasound scan and physical examination of large lower limb entheses. The OMERACT ultrasound lesions of enthesitis were considered, along with a recently proposed definition for "active enthesitis" by our group. Subclinical enthesitis was defined as the presence of "active enthesitis" in ≥1 enthesis in patients with SpA without clinical enthesitis (ie, number of positive entheses on physical examination and Leeds Enthesitis Index score = 0). RESULTS: A total of 4,130 entheses in 413 patients with SpA (224 with axSpA and 189 with PsA) were evaluated through ultrasound and physical examination. Agreement between ultrasound and physical examination ranged from moderate (ie, enthesophytes) to almost perfect (ie, power Doppler and "active enthesitis"). Patellar tendon entheses demonstrated the highest agreement, whereas Achilles tendon insertion showed the lowest. Among 158 (38.3%) of 413 patients with SpA with clinical enthesitis, 108 (68.4%) exhibited no "active enthesitis" on ultrasound. Conversely, of those 255 without clinical enthesitis, 39 (15.3%) showed subclinical enthesitis. Subclinical enthesitis was strongly associated with local structural damage. However, no differences were observed regarding the demographic and clinical profiles of patients with SpA with and without subclinical enthesitis. CONCLUSION: Our study underscores the need for a comprehensive tool integrating ultrasound and physical examination for assessing enthesitis in patients with SpA.

Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study.

OBJECTIVES: To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population. METHODS: In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). 'Active enthesitis' was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas). RESULTS: In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses. CONCLUSIONS: This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.

A Novel Technique for the Evaluation and Interpretation of Elastography in Salivary Gland Involvement in Primary Sjögren Syndrome.

Ultrasound (US) of major salivary glands (MSG) evaluates echogenicity, border features and vascularization, with elastography, it can detect tissue elasticity and glandular fibrosis, related to inflammation in Primary Sjögren's syndrome (pSS). This study aimed to develop a novel technique by pixel analysis for evaluation and interpretation of elastography in MSG in pSS. A cross-sectional and observational multicenter study was conducted. The US of MSG performed in orthogonal planes in grayscale, Doppler, and shear-wave elastography. For elastography images of each gland were analyzed with the open-source program ImageJ to perform a pixel analysis. Statistical analysis was performed with the IBM-SPSS v25 program. Fifty-nine women with a mean age of 57.69 (23-83) years were recruited; pSS mean duration of 87 (5-275) months, and 12 healthy women without sicca symptoms as a control group with a mean age of 50.67 (42-60) years. Intragroup analysis showed p-values >0.05 between sicca symptoms, ocular/dryness tests, biopsy, US, and pixel analysis; correlation between Hocevar and pixel analysis was not found (rho < 0.1, p >0.5). MSG anatomical size was 41.7 ± 28.2 mm vs. 67.6 ± 8.8 mm (p ≤ 0.0001); unstimulated whole saliva flow rate was 0.80 ± 0.80 ml/5 min vs. 1.85 ± 1.27 ml/5 min (p = 0.016). The elastography values (absolute number of pixels) were 572.38 ± 99.21 vs. 539.69 ± 93.12 (p = 0.290). A cut-off point risk for pSS identified with less than 54% of red pixels in the global MSG mass [OR of 3.8 95% CI (1.01-15.00)]. Pixel analysis is a new tool that could lead to a better understanding of the MSG chronic inflammatory process in pSS.

Tenosinovitis en artritis reumatoidea, evaluación por ultrasonido y resonancia magnética / Tenosynovitis in rheumatoid arthritis, ultrasound and magnetic resonance evaluation

La tenosinovitis es una manifestación frecuente de la artritis reumatoidea (AR), asociada a la presencia de rupturas tendinosas, discapacidad funcional y procesos erosivos de las articulaciones adyacentes. En los últimos años el manejo clínico de la AR ha sido respaldado por diferentes métodos de evaluación por imágenes, como la ultrasonografía (US) y la resonancia magnética (RM). Estas son herramientas de gran utilidad en la práctica clínica porque permiten la detección precoz de la actividad de la enfermedad y, por lo tanto, un tratamiento oportuno. Por medio de diferentes escalas de evaluación del daño articular y periarticular (como el tendinoso) es posible valorar el estado de la enfermedad y la respuesta al tratamiento. La presente revisión tiene como objetivo describir las escalas de evaluación de la RM y la US en la valoración de la tenosinovitis en pacientes con AR.

Tenosynovitis is a frequent manifestation of Rheumatoid Arthritis (RA), it is associated with tendon ruptures, functional disability, and erosive processes in the adjacent joints. In recent years, RA clinical management has been supported by different imaging methods such as ultrasound (US) and magnetic resonance (MR). These methods are particularly useful tools in clinical practice because they allow the early detection of disease activity and, therefore, prompt treatment. Through different evaluation scales of joint and periarticular damage (such as tendon) they also make possible to assess the state of the disease and the treatment response. The present review aims to describe the scores described for MRI and US to evaluate tenosynovitis in RA patients.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study.

OBJECTIVES: To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA. METHODS: In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs. RESULTS: Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation. CONCLUSIONS: The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

Levels of Cytokines and MicroRNAs in Individuals With Asymptomatic Hyperuricemia and Ultrasonographic Findings of Gout: A Bench-to-Bedside Approach.

OBJECTIVE: To assess potential associations among serum cytokines and microRNA (miR) levels with ultrasound (US) findings suggestive of urate deposits in chronic asymptomatic hyperuricemia and gout. METHODS: All participants underwent musculoskeletal US and measurements of serum interleukin-1ß (IL-1ß), IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, interferon-γ, tumor necrosis factor, monocyte chemoattractant protein 1, and epithelial neutrophil-activating peptide 78, as well as miR-146a, miR-155, and miR-223 levels. RESULTS: Thirty individuals with asymptomatic hyperuricemia, 31 normouricemic controls, and 30 patients with gout were included. The frequency of synovitis and double contour sign using US was similar between asymptomatic hyperuricemia (67% and 27%, respectively) and patients with gout (77% and 27%, respectively), and each had a higher frequency than controls (45% and 0%, respectively). Serum IL-6 and IL-8 levels were similar between patients with asymptomatic hyperuricemia (mean ± SD 69.7 ± 73.4 and 18.5 ± 25.6 pg/ml, respectively) and gout (mean ± SD 75.8 ± 47.6 and 24.4 ± 31.7 pg/ml, respectively), and higher than controls (mean ± SD 28.2 ± 17.6 and 7.4 ± 6.0 pg/ml, respectively). A similar distribution was observed for miR-155 levels in asymptomatic hyperuricemia, patients with gout, and controls (mean ± SD 0.22 ± 0.18, 0.20 ± 0.14, and 0.08 ± 0.04, respectively). Associations between morphostructural abnormalities suggestive of urate deposits (regardless of clinical diagnosis) and serum markers were assessed. Subjects with urate deposits had higher IL-6 (257.2 versus 47.0 pg/ml; P = 0.005), IL-8 (73.2 versus 12.0 pg/ml; P = 0.026), and miR-155 (0.21 versus 0.16; P = 0.015) levels than those without deposition findings. CONCLUSION: In individuals with chronic asymptomatic hyperuricemia, the presence of synovitis and double contour sign by US may represent a subclinical manifestation of monosodium urate crystal nucleation, capable of triggering inflammatory pathways (IL-6 and IL-8) and mechanisms of intercellular communication (miR-155), similar to what is observed in patients with gout.

Falta de asociación entre inflamación subclínica evaluada por ultrasonido y niveles de citocinas en artritis reumatoide / Lack of association between ultrasound-defined subclinica inflammation and cytokines levels in rheumatoid arthritis

Antecedentes: La artritis reumatoide (AR) es una enfermedad autoinmune crónica que se caracteriza por proliferación sinovial, ruptura de cartílago y destrucción ósea. Los biomarcadores en AR no se utilizan en forma rutinaria para evaluar la inflamación y tampoco la remisión. El ultrasonido musculoesquelético (US) visualiza los cambios en las articulaciones y el daño morfoestructural, mejorando la evaluación de la sinovitis.Objetivo: Identificar y describir la inflamación subclínica en pacientes con AR en re-misión, utilizando US.Métodos: Se incluyeron pacientes con AR en remisión. Se realizó una evaluación clí-nica con DAS28; se tomó muestra de sangre para analizar citocinas. Un ecografista reumatólogo sin acceso a datos clínicos realizó un conteo ecográfico utilizando el sco-re-7. Se utilizaron parámetros de tendencia central, análisis de correlación bivariada y X cuadrado. Se estableció un nivel de confianza del 95% y, por tanto, cualquier valor p ≤0.05 se consideró significativo.Resultados: Se incluyeron 38 pacientes con AR. La edad media fue de 45,26±12,24 años. Los niveles de citocinas asociadas al tiempo de la AR desde la remisión, no fue-ron estadísticamente significativas. El ultrasonido en los pacientes evidenció al menos una de las lesiones elementales; en escala de grises, la sinovitis ocurrió en un 94,7%; sinovitis con señal Doppler de poder (DP) 52,6%; en cuanto a erosiones, se registra-ron, respectivamente, un 55,3% en escala de grises y un 15,8% con DP. DAS28 >2,04 fue positivo al asociarse con el recuento de articulaciones dolorosas y significativo (p=0,009). Conclusión: La asociación entre la sinovitis clínica y en ecografía no tiene correlación con los criterios de AR en remisión, independientemente de cuán estricta sea su aplicación.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease, character-ized by synovial proliferation, cartilage breakdown and bone destruction. Biomarkers are not routinely used to evaluate inflammation neither remission. Musculoskeletal ultrasound visualizes joint changes and morpho-structural damage improving the as-sessment of synovitis.Objective: To identify and describe subclinical inflammation in patients with RA in remission using US.Methods: RA patients in remission were included. A clinical evaluation and DAS28 score performed; a blood sample took to analyze cytokines. A rheumatologist ultraso-nographer blinded to clinical data performed a US 7-score joint count. Central tenden-cy parameters, bivariate correlation analysis, and X Square were used. A confidence level of 95% was set and, therefore, any p-value ≤0.05 was considered as significant.Results: 38 RA patients were included. Mean age was 45.26±12.24 years. Cytokines associated with the time since remission was not statistically significant. Patients dis-played at least one of US elementary lesions; gray-scale synovitis occurred in 94.7%; synovitis with PD signal 52.6%; gray-scale erosions 55.3% and erosions with PD 15.8% respectively. DAS28 >2.04 positive for tender joint count was significant (p=0.009).Conclusion: The association between the clinical and US synovitis does not correlate with RA remission criteria no matter how strict is its application.

Usefulness of measuring common carotid intima-media thickness: ultrasound diagnosis of sub-clinical atherosclerosis in rheumatic diseases. A literature review / Medición del grosor de la íntima-media carotídea: utilidad y diagnóstico ecográfico de aterosclerosis subclínica en enfermedades reumáticas. Revisión de la literatura

INTRODUCTION: Patients with rheumatic diseases have an increased cardiovascular risk due to systemic inflammation and endothelial dysfunction, which promotes accelerated atherosclerosis. One way to measure cardiovascular risk, is through the carotid intima-media thickness which is an inexpensive and non-invasive predictor of cardiovascular events. OBJECTIVE: To examine the evidence to determine the usefulness of ultrasound in the diagnosis of sub-clinical atherosclerosis in rheumatic diseases assessed by carotid intima-media thickness (IMT). MATERIALS AND METHODS: A systematic literature search was performed, using electronic databases of PubMed, for articles published from January 2005 to May 2015, with no lan-guage restriction. Observational cohort studies that assessed the prevalence of sub-clinical atherosclerosis using the IMT were included. RESULTS: A total of 56 studies were identified for analysis, with almost all (95.7%) reporting an increased IMT in relation to the control group. CONCLUSIONS: Patients with rheumatic diseases have an increased cardiovascular risk assessed using IMT. This measurement, assessed by carotid ultrasound, may help detect the risk of sub-clinical cardiovascular disease in these populations, allowing to establish a therapeutic strategy to reduce the risk of morbidity and mortality in these patients.

INTRODUCCIÓN: Los pacientes con enfermedades reumáticas tienen un aumento del riesgo cardiovascular debido a inflamación sistémica y disfunción endotelial, lo que promueve una acelerada aterosclerosis. Una de las formas de medir el riesgo cardiovascular es a través del grosor de la íntima-media, evaluada por ultrasonido carotídeo, el cual es un predictor de acontecimientos cardiovasculares de bajo costo y naturaleza no invasiva. OBJETIVO: Revisar la evidencia que describe la utilidad y valor del diagnóstico ecográfico de aterosclerosis subclínica en enfermedades reumáticas, evaluadas mediante el grosor de la íntima-media carotídea (GIMc). MATERIALES Y MÉTODOS: Se realizó una revisión de la literatura de la base de datos electrónica PubMed. Se incluyeron artículos desde enero de 2005 a mayo de 2015, sin restricción de idioma. Se incluyeron estudios observacionales de cohorte que evaluaron la prevalencia de aterosclerosis subclínica mediante la medición del GIMc y estudios de meta-análisis. Se verificó la calidad metodológica de los artículos y se extrajo la información relevante de cada uno. RESULTADOS: Se identificaron 56 artículos que cumplieron los requisitos. El 95,7% coincidió con el aumento del GIMc en relación con el grupo control, como marcador predictivo de aterosclerosis subclínica. CONCLUSIONES: Los pacientes con enfermedades reumáticas tienen un aumento del riesgo cardiovascular medido a través del GIMc, como lo muestran varios estudios. Esta medición realizada por ultrasonido carotídeo podría ayudar a detectar el riesgo de enfermedad cardiovascular subclínica en estas poblaciones, lo que permitiría al clínico implementar medidas terapéuticas para reducir el riesgo de morbimortalidad en estos pacientes.

Polymorphic variation of hypoxia inducible factor-1 A (HIF1A) gene might contribute to the development of knee osteoarthritis: a pilot study.

BACKGROUND: Osteoarthritis (OA) is a multifactorial degenerative condition of the whole joint with a complex pathogenesis whose development and progression is significantly mediated by interactions between the joint cartilage and articular tissues, particularly, proinflammatory mediators and oxidative stress, which results in cartilage deterioration and subchondral bone destruction. HIF-1 alpha regulates oxygen homeostasis in hypoxic tissues such as joint cartilage; efficiency of transcriptional activity of the HIF1A gene is strongly influenced by the presence of polymorphic variants. Given the loss of articular cartilage and with intention to restore damaged tissue, WISP-1 participates in the development of subchondral bone; further, its expression is highly increased in chondrocytes of OA patients. The aim of this study was to evaluate gene frequencies of HIF1A and WISP1 polymorphisms in Mexican patients suffering from knee OA. METHODS: We determined HIF1A rs11549465 (P582S), rs11549467 (A588T), and rs2057482 (C191T), and WISP1 rs2929970 (A2364G) polymorphisms in 70 Mexican patients with knee OA and compare them to those present in 66 ethnically matched healthy controls. Genotyping for these polymorphisms was performed by Real-Time PCR using TaqMan probes. RESULTS: Gene frequencies exhibited a significant increase of the CC genotype of rs11549465 polymorphism in knee OA patients as compared with those present in controls (P = 0.003 OR = 5.7, 95% CI = 1.7-21.6); CT genotype and T allele showed decreased frequency in the knee OA group vs. the controls (P = 0.003 OR = 0.2, CI = 0.05-0.6; and P = 0.004 OR = 0.2, CI = 0.05-0.65, respectively). Allele frequencies of the other polymorphic variants were similar in both patients and controls. CONCLUSIONS: These results suggest that the presence of the rs11549465 SNP (HIF1A) plays a role protective in the loss of articular cartilage in our population, and offers the possibility to further study the molecular mechanisms within cartilage and subchondral bone.

Evaluación ecográfica de la glándula salival desde la perspectiva de reumatología / Evaluation of salivary gland by ultrasound from the perspective of rheumatology

The major salivary glands have multiple functions as wet oral mucosa, facilitate swallowing of food, digestion of carbohydrates, control the bacterial flora of the mouth, promote tooth mineralization and immune function by secretory IgA, which they can be altered by some conditions like autoimmune diseases or tumor. Ultrasound is a useful tool for the study of these glands, with the advantage of being safe, inexpensive, reproducible, noninvasive technique. In this review, we make a description of the anatomy and ultrasound anatomy of the major salivary glands and a brief description of the usefulness of elastography in some pathologies of these glands...

Las glándulas salivales mayores tienen múltiples funciones, como humedecer la mucosa oral, facilitar la deglución de alimentos, digestión de carbohidratos, control sobre la flora bacteriana de la boca, favorecen la mineralización de los dientes así como la función inmunológica por la secreción de IgA, las cuales pueden verse alteradas por la afección de enfermedades autoinmunes o tumorales. La ecografía es una técnica útil para el estudio de estas glándulas, con la ventaja de ser inocua, de bajo costo, reproducible y no invasiva. En esta revisión se hacen una descripción de la anatomía y sonoanatomía de las glándulas salivales mayores y una breve descripción de la utilidad de la elastografía en algunas patologías de estas glándulas...

Documentación de imágenes y reporte ecográfico / Documentation of images and ultrasonographic report

Documentation of images as well as ultrasound report must be perform with a clear and well done process in which precision should reflect the systematic image adquisition. The ultrasound report elaboration should be uniform and include technical aspects that could lead to the analysis of the images and a diagnostic impression. Traditionally the ultrasound report is considered less important than the performance of the ultrasound itself, but nowadays for clinicians and ultrasonographers, represents the most important tool in daily practice...

Tanto la documentación de imágenes como el reporte de los hallazgos ecográficos deben tener un proceso claro, preciso y reflejar la sistematización de la adquisición de la imagen. El reporte ecográfico debe tener una estructura uniforme, en el que se deben plasmar los aspectos técnicos del estudio realizado, se debe analizar la redacción de los hallazgos y la impresión diagnóstica. Al reporte ecográfico tradicionalmente se le ha dado poca importancia y la información al respecto es escasa, pero para el ecografista debe ser una herramienta fundamental del quehacer cotidiano...

Tendón de aquiles y su estudio ultrasonográfico: más allá de sus alteraciones inflamatorias / Achilles tendon and ultrasound study: beyond their inflammatory disorders

The Achilles tendon is formed by the union of the soleus and gastrocnemius tendons, its function is to perform plantar flexion. The prevalence of its injury is unknown, but has a multifactorial etiology and occurs most frequently in male than female by a 3:1 ratio, mostly between the fourth and fifth decades of life. The mechanisms of injury include increased weight bearing with the knee in extension, sudden and violent dorsiflexion, and direct trauma. With ultrasound tendon ruptures, complete or partial, Achilles tendinopathy and postoperative changes unrelated to inflammatory process are detected. Ultrasound is a safe imaging technique, low-cost and can be performed in real time, with good rates of sensitivity and specificity compared to other techniques...

El tendón de Aquiles está formado por la unión de los tendones de los músculos sóleo y gastrocnemio, cuya función es realizar flexión plantar. La prevalencia de su lesión es desconocida, su etiología es multifactorial, y se presenta con mayor frecuencia en el género masculino que en el femenino en una proporción de 3:1, entre la cuarta y quinta décadas de la vida. Los mecanismos de lesión incluyen incremento en el soporte de peso con la rodilla en extensión, dorsiflexión súbita y violenta y trauma directo. Con la US se detectan rupturas del tendón de Aquiles completas o parciales, tendinopatía y cambios postoperatorios no relacionados a proceso inflamatorio; la US es un método inocuo, de bajo costo y se realiza en tiempo real; tiene buena sensibilidad y especificidad...

Evaluación del sistema nervioso periférico por ultrasonido / Peripheral nervous system evaluation by ultrasound

Diseases of the peripheral nerves are common in the field of neurology, they are not infrequent to occur in association with orthopedic or rheumatic diseases, sometimes they can be confused or categorized as primary diseases of the musculoskeletal system. Ultrasound is a valuable and inexpensive tool to characterize the neural fibers and its components. New technologies help to localize, assess and perform dynamic maneuvers that enhance diagnostic accuracy in peripheral nerves. The aim of this article is to familiarize with the exploration of peripheral nerves. The typical test of nerves begins in the transverse plane, following the nerve from proximal to distal in the area of interest. Ultrasound is useful as a method when suspected pathology, as a monitoring tool and as part of precise interventional procedures...

Las enfermedades de los nervios periféricos son comunes en el campo de la Neurología, pueden presentarse en asociación con enfermedades ortopédicas o reumáticas, y son en ocasiones confundidas o categorizadas como enfermedades primarias del sistema musculoesquelético. El ultrasonido es una herramienta valiosa y de bajo costo que permite caracterizar la fibra neural. Con el avance tecnológico de los equipos actuales es mucho más fácil localizar, evaluar y realizar procedimientos invasivos en los nervios periféricos. El objetivo de este artículo es familiarizarse con la exploración de nervios periféricos. El examen típico comienza en el plano transverso, siguiendo al nervio desde proximal a distal en el área de interés. El ultrasonido tiene su utilidad como método diagnóstico de primera línea ante la sospecha de patología, como herramienta de seguimiento, así como parte de procedimientos intervencionistas precisos...

[Usefulness, validity, and reliability of ultrasound in the diagnosis of osteoarthritis: a critical review of the literature]. / Utilidad, validez y confiabilidad del ultrasonido en el diagnóstico de la osteoartritis: una revisión crítica.

Ultrasound is outstripping other diagnostic imaging techniques in the evaluation of osteoarthritis (OA). Due to its sub-millimetric resolution, ultrasound has the ability to detect minimal morphostructural abnormalities, even from preclinical or asymptomatic disease stages located in the main joint structures predominantly affected by OA: articular cartilage, synovial membrane, and subchondral bone. As of today, ultrasound has proven to be a useful tool for the detection of abnormalities occurring within soft tissues, including synovial hypertrophy, fluid accumulation, and synovial cysts, as well as bony abnormalities, such as osteophyte formation. Additionally, power Doppler signal correlated with histologic evidence of synovial membrane vascularization. In order to describe the ultrasonographic findings of OA, its utility, reliability, and validity as a diagnostic and monitoring tool, a critical review of the literature of hand, hip, and knee OA is provided.

[Giant Baker's cyst treated with intralessional methotrexate]. / Quiste de Baker gigante tratado con metrotrexato intralesional.

INTRODUCTION: Synovial cyst is composed by a fibrous wall; lining by a thin layer of synovial cells containing synovial fluid, the prototype of these, in the knee is the Baker's cyst, which is located abnormally in the gastrocnemius semimembranous bursa. Baker's cyst prevalence ranges from 5 - 38%. Clinical diagnosis is supported by the presence of increased volume of soft tissues located in the popliteal region. CLINICAL CASE: A 74 year-old woman with longstanding active rheumatoid arthritis who developed a large, recurrent Baker's cyst. The Baker's cyst had two flare-ups of pain and soft tissue swelling which eventually limited knee movements; was treated with needle aspiration guided by ultrasound and synovectomy with methotrexate twice. At 18-months follow-up, the patient remains without evidence of recurrence. CONCLUSIONS: Local infiltration of methotrexate represents an alternative therapy for those refractory Baker's cyst with partial response to conventional treatment, where the surgical procedure carries a high risk.

Elastografía como método de evaluación de la biomecánica muscular / Application of elastography or sonoelastography (SE) in muscle biomechanics

La elastografía o sonoelastografía (SE) es una técnica de imagen introducida apenas hace poco más de una década. Se basa en la premisa de que hay una diferencia en la elasticidad del tejido sano comparado con el tejido patológico y esta diferencia podría ser medida en base a la tensión aplicada al tejido. Las propiedades elásticas de los tejidos blandos dependen de su conformación molecular y de su organización estructural, tanto micro como macroscópica. La SE se obtiene cuando sobre la imagen anatómica ecográfica en escala de grises se superpone la imagen paramétrica en color que expresa la velocidad de deformidad de los tejidos; los tejidos suaves tienden a desarrollar una mayor deformidad y tejidos con mayor rigidez presentan menor deformidad. Aunque inicialmente se usó para identificar tejido neoplásico en mama al considerarlo más rígido que el tejido benigno, con el tiempo ha demostrado ser una herramienta útil para determinar de manera no invasiva la actividad muscular, siendo aplicada en la evaluación de lesiones musculares traumáticas, síndromes miofasciales dolorosos y rigidez muscular en parálisis cerebral posterior a la aplicación de toxina botulínica, así como en otras condiciones, como engrosamiento cutáneo en esclerodermia, tendinopatía del Aquiles, epicondilitis lateral, quistes sinoviales y gangliones. No obstante, este método tiene ciertas limitaciones, como la amplia variedad de técnicas y algoritmos de procesamiento, que dificultan la interpretación de los datos y también porque para poder obtener la imagen es necesario hacer una correcta compresión de los tejidos. Actualmente los sistemas de Elastografía cuentan con un software que permite una retroalimentación acerca de la presión ejercida que aunado a una estandarización de la técnica ayudarán a aumentar su valor clínico en las enfermedades musculoesqueléticas. Se hace una revisión de la aplicación de SE en la biomecánica muscular.

Elastography or sonoelastography (SE) is an imaging technique recently introduced just over a decade. Is based on the premise that there is a difference in healthy tissue elasticity compared with pathologic tissue and this difference could be measured based on the voltage applied to the tissue. The elastic properties of the soft tissue depends on their molecular conformation and their structural organization macroscopic and microscopic. The SE is obtained when the anatomic image on grayscale ultrasound overlaps parametric color image that expresses the rate of deformity of the tissues, soft tissues tend to develop greater deformity and tissue deformity have lower rigidity. Although initially used to identify neoplastic breast tissue to consider stiffer than benign tissue, over time has proven to be a useful tool for non-invasively determining muscle activity, being applied in the evaluation of traumatic muscle injuries, myofascial syndromes painful muscle stiffness in cerebral palsy after botulinum toxin application as well as other conditions such as scleroderma skin thickening, Achilles tendinopathy, lateral epicondylitis, ganglion cysts and synovial. However this method has some limitations as the wide variety of techniques and processing algorithms, which make the interpretation of the data and also because in order to get the image you need to make a correct compression of tissues. Elastography systems currently have software that allows feedback about the pressure that coupled with standardization of the technique will help increase its clinical value in musculoskeletal diseases. A review of the application of SE in muscle biomechanics.

Clinical anatomy of the pelvis and hip.

The contents of this review may appear odd. After a brief description of the coxofemoral joint, the entities discussed include ilioinguinal neuropathy within the context of the nerves that may be damaged during lower abdominal surgery, meralgia paresthetica, piriformis syndrome with the appropriate caveats, trochanteric syndrome, "ischial bursitis" and trochanteric syndrome caused by ischemia. These cases were chosen to stress our belief that rheumatologists are first and foremost internists. We further believe that being current in other pathologies such as peripheral neuropathies and certain vascular syndromes sooner or later benefits our patients.

Clinical anatomy of the ankle and foot.

This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fasciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Morton's neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.

Clinical anatomy of the knee.

The clinical anatomy of several pain syndromes of the knee is herein discussed. These include the iliotibial tract syndrome, the anserine syndrome, bursitis of the medial collateral ligament, Baker's cyst, popliteus tendon tenosynovitis and bursitis of the deep infrapatellar bursa. These syndromes are reviewed in terms of the structures involved and their role in knee physiology. All of the discussed structures can be identified in their normal state and more so when they are affected by disease. The wealth of information gained by cross examination of the medial, lateral, posterior and anterior aspects of the knee brings to life knowledge acquired at the dissection table, from anatomical drawings and from virtual images.

La ultrasonografía en el estudio del tobillo y pies dolorosos / Ultrasonography in the study of painful foot and ankle

La ultrasonografía es una excelente herramienta para el estudio de la patología de tobillo y pie, ya sea aguda o crónica, con la ventaja de ser en tiempo real, lo que permite hacer una correlación entre los hallazgosy el área sintomática. Las estructuras de esta región son las más afectadas durante el curso de enfermedades inflamatorias como Artritis reumatoide y Espondiloartritis, lo cual produce dolor y deformidad; por lo tanto, es fundamental evaluarlas en forma dinámica en etapas tempranas para limitar el daño. La ultrasonografía puede ser de utilidad para detectar tendinopatía, tenosinovitis de los flexores y extensores, sinovitis, afección de ligamentos, masas de tejidos blandos, quistes ganglionares, fascitis plantar, neuroma de Morton y cuerpos extraños, entre otros. Varios estudios han demostrado que la infiltración guiada por ultrasonografía mejora la asertividad y la respuesta. en esta revisión se expondrá la aplicación de la técnica en el estudiode la patología de tobillo y pie.

Ultrasonography is an excellent tool for studying the pathology of ankle and foot, either acute or chronic, with the advantage of being in real time which allows a correlation between the findings and the symptomatic area. The structures of this region are most affected during the course of inflammatory disease like rheumatoid arthritis and spondyloarthritis which causes pain and deformity; therefore it is essential to dynamically evaluate them in the early stages to limit the damage. Ultrasonography may be useful to detect tendinopathy, tenosynovitis of the flexor and extensor synovitis, a condition of ligaments, soft tissue masses, ganglion cysts, plantar fasciitis, Morton's neurona and foreign bodies, among others. Several studies have shown that ultrasound-guided injection improves assertiveness and response. In this review we will present the application of the technique in the study of the pathology of ankle and foot.