Magnetic resonance imaging (MRI)-defined cartilage degeneration and joint pain are associated with poor physical function in knee osteoarthritis - the Oulu Knee Osteoarthritis study.

OBJECTIVE: The main aim was to investigate the associations between Magnetic Resonance Imaging (MRI)-defined structural pathologies of the knee and physical function. DESIGN: A cohort study with frequency matching on age and sex with eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee osteoarthritis (OA) and 57 asymptomatic subjects was conducted. The subjects underwent knee MRI, and the severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. WOMAC function subscores were recorded and physical function tests (20-m and 5-min walk, stair ascending and descending, timed up & go and repeated sit-to-stand tests) performed. The association between MRI-defined structural pathologies and physical function tests and WOMAC function subscores were evaluated by linear regression analysis with adjustment for demographic factors, other MRI-features and pain with using effect size (ES) as a measure of the magnitude of an association. RESULTS: Cartilage degeneration showed significant association with poor physical performance in TUG-, stair ascending and descending-, 20-m- and 5-min walk-tests (ESs in the subjects with cartilage degeneration anywhere between 0.134 [95%CI 0.037-0.238] and 0.224 [0.013-0.335]) and with increased WOMAC function subscore (ES in the subjects with cartilage degeneration anywhere 0.088 [0.012-0.103]). Also, lateral meniscus maceration and extrusion were associated with poor performance in stair ascending test (ESs 0.067 [0.008-0.163] and 0.077 [0.012-0.177]). CONCLUSIONS: After adjustments cartilage degeneration was associated with both decreased self-reported physical function and poor performance in the physical function tests. Furthermore, subjects with lateral meniscus maceration and extrusions showed significantly worse performance in stair ascending tests.

Associations between MRI-defined structural pathology and generalized and localized knee pain - the Oulu Knee Osteoarthritis study.

OBJECTIVE: To determine the associations between multi-feature structural pathology assessed using magnetic resonance imaging (MRI) and the presence of knee pain, and to determine the associations between the locations of structural changes and different knee pain patterns. METHOD: Eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee OA and 63 asymptomatic subjects underwent knee MRI. Severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. The associations between cartilage damage, bone marrow lesions (BMLs), osteophytes, Hoffa's synovitis, effusion-synovitis, meniscal damage and structural pathologies in ligaments, tendons and bursas and both the presence of pain and the knee pain patterns were assessed. RESULTS: The presence of Hoffa's synovitis (adjusted RR 1.6, 95% CI 1.2-1.3) and osteophytes in any region (2.07, 1.19-3.60) was significantly associated with the presence of pain. Any Hoffa's synovitis was associated with patellar pain (adjusted RR 4.70, 95% CI 1.19-3.60) and moderate-to-severe Hoffa's synovitis with diffuse pain (2.25, 1.13-4.50). Medial knee pain was associated with cartilage loss in the medial tibia (adjusted RR 2.66, 95% CI 1.22-5.80), osteophytes in the medial tibia (2.66, 1.17-6.07) and medial femur (2.55, 1.07-6.09), medial meniscal maceration (2.20, 1.01-4.79) and anterior meniscal extrusions (2.78, 1.14-6.75). CONCLUSIONS: Hoffa's synovitis and osteophytes were strongly associated with the presence of knee pain. Medial pain was associated most often with medially located structural pathologies.

Atlas-based knee osteophyte assessment with ultrasonography and radiography: relationship to arthroscopic degeneration of articular cartilage.

OBJECTIVES: To investigate intra- and inter-reader agreement of ultrasonography (US) and conventional radiography (CR) for the evaluation of osteophyte presence and size within the tibiofemoral joint. In addition, to correlate these findings with arthroscopic degeneration of the articular cartilage. METHOD: Forty adult patients with knee pain were enrolled in this study. Knee CR and US scanning of the medial and lateral bone margins were performed on all patients. A novel atlas for the US grading of knee osteophytes was used in the evaluation. The number and size of the osteophytes were evaluated semi-quantitatively in two rounds from both the CR images (four readers) and the US images (14 readers). The Noyes grading system was used for the evaluation of arthroscopic degeneration of the articular cartilage in 26 patients. RESULTS: On average, intra- and inter-reader US and CR agreement was substantial and comparable to each other (κ = 0.60-0.72). US detected more osteophytes than CR at both the medial (65% vs. 48%) and lateral (70% vs. 60%) compartments. A statistically significant correlation between CR- or US-based osteophyte and arthroscopy grades was observed only for US at the medial compartment (rs = 0.747, p < 0.001). CONCLUSIONS: The detection of knee osteophytes using the novel US atlas is as reproducible as reading conventional radiographs. US is more sensitive to detect knee osteophytes than CR. Furthermore, osteophytes detected with US correlate significantly with arthroscopic cartilage changes at the medial knee compartment whereas those detected by CR do not.

Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses.

OBJECTIVE: To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses. METHODS: A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS: 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds. CONCLUSIONS: This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

Diagnostic performance of knee ultrasonography for detecting degenerative changes of articular cartilage.

OBJECTIVE: To investigate the diagnostic performance of non-invasive knee ultrasonography (US) to detect degenerative changes of articular cartilage using arthroscopic grading as the gold standard. DESIGN: Forty adult patients referred to a knee arthroscopy because of knee pain were randomly selected for the study. Before the arthroscopy, knee US was performed and cartilage surfaces at medial and lateral femoral condyles as well as at intercondylar notch area (sulcus) were semi-quantitatively graded from US. Ultrasonographic grading was compared with the arthroscopic Noyes' grading for cartilage degeneration. RESULTS: Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic odds ratio for detecting arthroscopic cartilage changes in US varied between 52 and 83%, 50-100%, 88-100%, 24-46%, and 5.0-13.0, respectively, depending on the site. Correlation of severity of cartilage changes (grades) between US and arthroscopy varied from insignificant to significant depending on the site: at the sulcus area the correlation was highest (r(s)=0.593, P<0.001), at the medial condyle also significant (r(s)=0.465, P=0.003), and at the lateral condyle non-significant (r(s)=0.262, P=0.103). The sum of cartilage grades in all three sites of the femoral cartilage between US and arthroscopy had the highest correlation (r(s)=0.655, P<0.001). CONCLUSIONS: Positive finding in US is a strong indicator of arthroscopic degenerative changes of cartilage, but negative finding does not rule out degenerative changes. Non-invasive knee US is a promising technique for screening of degenerative changes of articular cartilage, e.g., during osteoarthritis.

Ultrasonographic findings in metatarsophalangeal and talocrural joints in healthy persons.

The objective of this study was to establish whether healthy persons have effusions detectable by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints. Fifty consecutive healthy persons without symptoms in ankles and feet were studied. Thirty-eight of them were women, and their mean age was 47.4 (range 23-62) years. Eighteen of the 500 MTP joints studied in nine persons and four of the 100 TC joints in three persons showed effusions upon investigation. One person had effusion in five MTP joints, one in four, two in two, and the remaining five in one MTP joint. None of the studied joints yielded pathological findings in Doppler US examination. These results indicate that the detection of effusion by grayscale US in the absence of Doppler US in MTP and TC joints can be found in healthy persons.

Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses.

OBJECTIVE: To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses. METHODS: We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels. RESULTS: The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses. CONCLUSION: We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

Verification of palpation-guided intra-articular injections using glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy).

OBJECTIVE: To examine a contrast medium method using a glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy) for the verification of palpation-guided injections in different joints and to assess the inter-reader reliability of the method. METHODS: A palpation-guided injection of an air-steroid-saline mixture was given into a joint or tendon sheath of 133 consecutive patients. The dynamic ultrasound monitor images of the joints and tendons involved were videotaped before and after the injection. A rheumatologist and two radiologists analyzed separately the video clips of each patient, under blinded conditions. The readers evaluated the accuracy of the injections and the difficulty of the reading process. The inter-reader agreement was assessed by calculating the percentual values and overall kappa coefficient between the readers. RESULTS: The overall accuracy of the successful injections was 76%, 80% and 82 % evaluated by the three readers. In six out of the ten injection sites the accuracy was higher than 80%. The clarity of the method evaluated by the readers was 8, 8 and 8.5 on a scale from 0 to 10. The inter-reader agreement assessed by percentual values was 84.2%, 85.0% and 88.7%. The kappa coefficient between all readers was 0.595 showing moderate agreement. CONCLUSION: The GAS-graphy method for the verification of palpation-guided injections is a simple procedure performable to any joint site and the result can be seen immediately on the monitor after the injection. The reliability of the method is good and it can be used in developing injection techniques as well as in medical or nurse education. The method can be used as an alternative for the radiographic contrast medium method in verifying successful palpation-guided intra-articular injections.

Power Doppler ultrasonography and synovitis: correlating ultrasound imaging with histopathological findings and evaluating the performance of ultrasound equipments.

OBJECTIVES: To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments. METHODS: 44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms. RESULTS: A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p<0.01) and 0.328 (p<0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow. CONCLUSIONS: A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.

Assessing the intra- and inter-reader reliability of dynamic ultrasound images in power Doppler ultrasonography.

OBJECTIVE: To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips. METHOD: 99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system. RESULTS: The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (kappa = 0.52-0.82). CONCLUSIONS: Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course.

OBJECTIVE: To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography. METHODS: The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results. RESULTS: Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae. CONCLUSIONS: Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.

Use of air-steroid-saline mixture as contrast medium in greyscale ultrasound imaging: experimental study and practical applications in rheumatology.

OBJECTIVES: To investigate experimentally the echogenicity of air, a steroid suspension and physiological saline mixed with water in order to find the best contrast medium for injections. To show the practical applications of an airsteroid-saline mixture as a contrast medium in rheumatology. METHODS: In vitro. First, quality assurance measurements were conducted twice on the ultrasound (US) equipment. Subsequently air, a steroid suspension, or physiological saline mixed with water, first alone and then in different combinations, were examined with US using quantitative image analysis. Clinical. The effectiveness of an air-steroid-saline mixture as contrast medium in ultrasonography was tested in joint, bursa and tendon sheath injections. RESULTS: In vitro. Based on the quality assurance measurements the physical performance of the US equipment was excellent. Verified visually and quantitatively the mixture of air, steroid and saline produced the best contrast on US. The importance of air bubbles producing contrast was obvious. Clinical application. Firstly, visualisation of the contrast medium with US made it possible to follow in real-time the passage of a drug to the target area. Secondly, the use of the contrast method verified the presence of steroid in the synovial target intended after a blind injection. Thirdly, anatomical and pathologic anatomical connections could be visualized using this contrast medium in the wrist, shoulder, knee, ankle and foot joint CONCLUSIONS: Verification of US system performance by quality assurance measurement is essential for US imaging. The air-steroid-saline contrast medium method of ultrasound scanning is a somewhat invasive, but inexpensive and rapid method. It can verify the existence or non-existence of an air-steroid-saline contrast medium in the desired place and in adjacent structures, thus showing possible pathologic anatomic connections. The method has a diagnostic and therapeutic value, and expands the interventional spectrum of sonographic imaging.

Relationship between clinically detected joint swelling and effusion diagnosed by ultrasonography in elbow joints in patients with rheumatoid arthritis.

The aim of this study was to compare the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in elbow joints in patients with rheumatoid arthritis (RA). Fifty consecutive patients with RA entered the study and 20 healthy persons formed a control group. Altogether 100 elbow joints of the RA patients and 40 of the controls were studied. All the clinical assessments were performed by one doctor and the US investigations by the other and they were blinded to each others results. In 77 elbow joints of the RA patients the clinical assessment and the US gave similar results, whereas they differed in the remaining 23 joints. The kappa coefficient between these investigations was 0.371. In the control group no elbow joint showed either swelling in the clinical assessment or effusion in the US investigation. The results of this study indicate that clinical assessment of swelling and evaluation of effusion by US in elbow joints in patients with RA show only fair agreement. Thus, US may improve the accuracy of diagnosis of synovitis in many cases in these patients.

Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course.

OBJECTIVE: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard". METHODS: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed. RESULTS: Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%). CONCLUSION: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

Ultrasound guided synovial biopsy using portal and forceps.

OBJECTIVE: To describe a new method for taking a synovial biopsy specimen under ultrasound guidance using portal and forceps. METHODS: Percutaneous ultrasound guided biopsy was performed for 37 patients with mono- or polyarthritis as outpatients. A portal to a planned area was built using a needle, guiding wire, and dilators, through which forceps could be inserted and samples taken. Biopsy samples were taken from small and large joints, bursae, and tendon sheaths. RESULTS: Representative synovial tissue in adequate amounts for histopathological evaluation was obtained in 33/37 cases--a success rate of 89%. The biopsy procedures were well tolerated, but one complication of skin infection was encountered. CONCLUSION: The new method of synovium biopsy under ultrasound guidance using sheath introducer set and flexible forceps can be performed on most joints and even bursae and tendon sheaths. The method gives sufficient samples for clinical work in most cases, but further work is needed before accepting this promising technique for scientific purposes.

Relationship between clinically detected joint swelling and effusion diagnosed by ultrasonography in metatarsophalangeal and talocrural joints in patients with rheumatoid arthritis.

OBJECTIVE: To assess the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints in patients with rheumatoid arthritis (RA). METHODS: Thirty consecutive patients with RA were studied. Altogether 288 MTP joints and 60 TC joints were evaluated. The clinical investigations were carried out by one doctor and the US investigations by another and they were blinded to each others' results. RESULTS: The clinical examination and US gave similar results in 194 MTP joints, whereas they differed in the remaining 94 MTP joints, and correspondingly the results were similar in 34 TC joints and differed in 26 TC joints. The kappa coefficient between these investigations was 0.165 in MTP joints and 0.043 in TC joints, showing very poor agreement. CONCLUSION: These preliminary results showed poor agreement between the clinical assessment of swelling and effusion detected by US in MTP and TC joints. Thus US may considerably improve the diagnosis of synovitis in patients with RA.

Intra-articular glucocorticoid treatment of the rheumatoid wrist. An ultrasonographic study.

Fifty consecutive patients with RA and clinical wrist synovitis were randomly allocated to either receive an injection of glucocorticoid into the radiocarpal joint or have the same amount of drug divided into the radiocarpal and midcarpal joints. Inferior radioulnar joint synovitis was treated with extra steroid injection only in the latter group. Patient's and doctor's assessments as well as ultrasonography improved significantly at month 3 in both groups. A statistical difference between the groups was found in the midcarpal joint measurement favouring the extra midcarpal injection. Ten wrists (20%) were normal when assessed with ultrasound at month 3 while 34 wrists (68%) were normal on clinical assessment.

Ultrasound guided injections in rheumatology.

Ultrasonography has gained popularity among rheumatologists especially in Europe as a bedside imaging method for diagnosing soft tissue lesions such as synovitis in joints, bursae and tendons. In addition to diagnosing the lesion ultrasound can be used to monitor needle position during the injection procedure. The aim of this paper is to describe injection techniques guided by ultrasound into the joints, bursae or tendon sheaths. We point out that the value of ultrasound in rheumatology is not only diagnostic but also therapeutic.

Ultrasound detection of plantar bursitis of the forefoot in patients with early rheumatoid arthritis.

OBJECTIVE: To study the plantar forefoot of patients with early rheumatoid arthritis (RA) by ultrasound to detect bursitis and to correlate sonographic findings with symptoms and clinical observations. METHODS: Clinical examination, dorsoplantar radiographs, and transverse sonographic scans of the plantar region of the forefoot were performed on 30 healthy persons as well as 25 patients with early RA and forefoot symptoms. RESULTS: In 8 patients the examiner could clinically suspect plantar bursitis. Ultrasound revealed 22 incidents of plantar bursitis in 14 of the 25 patients. Except for bursitis in the forefoot no inflammatory findings were detected by ultrasound in 6 patients. CONCLUSION: Not only metatarsophalangeal arthritis or flexor tenosynovitis but also plantar bursitis can promote symptoms of the forefoot. Ultrasound is a more objective procedure than clinical examination in diagnosing plantar bursitis. This finding has diagnostic and therapeutic implications.

Transient osteoporosis of the hip with joint effusion detected by ultrasonography.

Three cases of transient osteoporosis of the hip and their ultrasonographic findings are presented. Transient osteoporosis of the hip is an uncommon condition with pain in the hip area and limping. The diagnosis is supported by local radiological osteoporosis and other imaging methods. Exclusion of more common entities is required. Effusion of the hip joint detected by ultrasonography is also related to this condition, which must be taken into account in patients with hip pain.