Correlation between Hypervascularization of the First Annular Pulley on Color Doppler Imaging of Trigger Finger and Patients' Backgrounds.

OBJECTIVES: The aim of this study was to investigate the correlation between hypervascularization of the first annular (A1) pulley on color Doppler imaging of trigger finger and patients' backgrounds. METHODS: A total of 148 trigger digits from 144 patients were studied with ultrasound at the time of initial diagnosis. We observed the A1 pulley at the level of the metacarpophalangeal joint in a transverse image and noted the presence or absence of a signal in the A1 pulley on color Doppler imaging. Patients' ages, sexes, clinical grades, symptom durations, prevalence of interphalangeal joint contracture, and visual analog scale pain scores were compared between the groups with positive and negative Doppler findings. RESULTS: The 144 patients included 45 men and 99 women. Sixty-one of 148 digits (41%) showed positive Doppler findings in the A1 pulley. Patients' ages and visual analog scale scores in the Doppler-positive group were slightly greater than those in the Doppler-negative group (P = .03; P < .01, respectively). The digit with positive Doppler findings tended to be categorized into a severer grade and into the group with a shorter symptom duration (P < .01 for both). CONCLUSIONS: Hypervascularization of the A1 pulley tended to appear in an earlier period after the patients had become aware of symptoms, as frequently as their symptoms became severe, in conjunction with higher pain scores. Doppler imaging of the A1 pulley might help in better understanding patients' conditions.

Articular Surgery of the Ischemic Hand in Systemic Scleroderma: A Vascular Basis for Arthrodesis and Arthroplasty.

Hallmark deformities of systemic scleroderma are early onset and progressively disabling flexion contractures of the proximal interphalangeal (PIP) joints often in conjunction with extension or, less frequently, flexion contractures of the metacarpophalangeal (MCP) joints. Although surgical correction is generally recommended, a prevailing reluctance for operative treatment exists owing to the inherent ischemia of the disease with its potentially compromised healing capacity. Nonetheless, with recognition and preservation of the tenuous but well-defined and constant periarticular vascular networks of the PIP and MCP joints, articular reconstruction with uncomplicated wound healing can prove consistently successful for patients with scleroderma. This article describes the authors' preferred methods of PIP arthrodesis vascularized by the dorsal cutaneous arterial network and MCP silicone implant arthroplasty perfused by the dorsal metacarpal arterial plexus.

Neurovascular Advancement Flap to Release Flexion Contracture of the Proximal Interphalangeal Joint.

Various methods have been described to surgically release posttraumatic flexion contracture of the proximal interphalangeal joint. Extension of the distal digit often creates a soft tissue defect on the volar aspect of the finger. Although various flaps and skin grafting have been utilized for coverage of this defect, they can be associated with morbidity. We present our experience with a volar neurovascular advancement flap to achieve soft tissue release in proximal interphalangeal joint flexion contracture. This advancement flap is designed to include both digital neurovascular bundles and eliminates the need for a secondary procedure as it allows primary closure of the subsequent defect. It is indicated for contracture lengthening of 10 to 14 mm. Surgical considerations of flap design are discussed.

Noninvasively measuring oxygen saturation of human finger-joint vessels by multi-transducer functional photoacoustic tomography.

Imaging small blood vessels and measuring their functional information in finger joint are still challenges for clinical imaging modalities. In this study, we developed a multi-transducer functional photoacoustic tomography (PAT) system and successfully imaged human finger-joint vessels from ∼1 mm to <0.2 mm in diameter. In addition, the oxygen saturation (SO2) values of these vessels were also measured. Our results demonstrate that PAT can provide both anatomical and functional information of individual finger-joint vessels with different sizes, which might help the study of finger-joint diseases, such as rheumatoid arthritis.

Small, medium but not large arteries are involved in digital ulcers associated with systemic sclerosis.

OBJECTIVE: Digital ulcers (DU) are a burden in systemic sclerosis (SSc). Microangiopathy is a cardinal feature of SSc that plays a critical role in the development of DU. However, whether injury of medium or large vessels also contributes to DU in SSc remains controversial. METHODS: To measure concomitantly in SSc patients with and without active DU: (i) the Augmentation Index of the reflected wave (Aix_75) by radial applanation tonometry, an index of small and medium arterial function; (II) the aortic pulse wave velocity (PWV), a marker of large vessel injury (aortic stiffness). RESULTS: Sixty-three consecutive SSc patients were included (49 females, aged 60 [49-65] years, disease duration of 8.5 [5-13] years), including 10 (15.9%) with active DU. Patients with active DU versus those without had increased Aix_75 (35% [28-38] versus 28% [20-34], P=0.041) whereas no difference existed in PWV (7.0m/s [6.7-10.1] versus 7.6m/s [6.8-8.7], P=0.887), in systolic, diastolic, as well as aortic pulse pressure (P=0.126, 0.592, and 0.161, respectively). When compared to patients in the low tertile, patients having Aix_75 in the highest tertile had 10-fold more DU (OR=10.23; 95% CI 1.12 to 93.34, P=0.039). CONCLUSION: The presence of DU is associated with increased Aix_75 whereas there is no relation with PWV. These data suggest that small and medium arteries are involved in the occurrence of DU whether large vessel stiffness does not contribute. Whether Aix_75 is predictive of further DU remained to be studied.

Persistence of subclinical sonographic joint activity in rheumatoid arthritis in sustained clinical remission.

BACKGROUND: Sonographic assessment, measuring grey scale (GS) and power Doppler (PD) signals, is a sensitive tool for the evaluation of inflammatory joint activity in patients with rheumatoid arthritis (RA). We evaluated the persistence of PD and GS signals in previously clinically active RA joints that have reached a state of continuous clinical inactivity. METHODS: We performed sonographic imaging of 22 joints of the hands of patients with RA, selected all joints without clinical activity but showing ongoing sonographic signs of inflammation, and evaluated the time from last clinical joint activity. RESULTS: A total of 90 patients with RA with 1980 assessed joints were included in this study. When comparing the mean time from clinical swelling, we found a significantly longer period of clinical inactivity in joints showing low sonographic activity (mean±SD time from swelling of 4.1±3.2 vs 3.1±2.9 years for PD1 vs PD≥2, p=0.031 and 4.5±3.4 vs 3.3±3.2 years for GS1 vs GS≥2, p≤0.0001). CONCLUSIONS: We conclude that subclinical joint activity is long-lasting in RA joints in clinical remission, but attenuates over time. The latter conclusion is based on the observed shorter time duration from last clinical activity for strong compared with weaker sonographic signals.

Power Doppler signal calibration between ultrasound machines by use of a capillary-flow phantom for pannus vascularity in rheumatoid finger joints: a basic study.

Ultrasound allows the detection and grading of inflammation in rheumatology. Despite these advantages of ultrasound in the management of rheumatoid patients, it is well known that there are significant machine-to-machine disagreements regarding signal quantification. In this study, we tried to calibrate the power Doppler (PD) signal of two models of ultrasound machines by using a capillary-flow phantom. After flow velocity analysis in the perfusion cartridge at various injection rates (0.1-0.5 ml/s), we measured the signal count in the perfusion cartridge at various injection rates and pulse repetition frequencies (PRFs) by using PD, perfusing an ultrasound micro-bubble contrast agent diluted with normal saline simulating human blood. By use of the data from two models of ultrasound machines, Aplio 500 (Toshiba) and Avius (Hitachi Aloka), the quantitative PD (QPD) index [the summation of the colored pixels in a 1 cm × 1 cm rectangular region of interest (ROI)] was calculated via Image J (internet free software). We found a positive correlation between the injection rate and the flow velocity. In Aplio 500 and Avius, we found negative correlations between the PRF and the QPD index when the flow velocity was constant, and a positive correlation between flow velocity and the QPD index at constant PRF. The equation for the relationship of the PRF between Aplio 500 and Avius was: y = 0.023x + 0.36 [y = PRF of Avius (kHz), x = PRF of Aplio 500 (kHz)]. Our results suggested that the signal calibration of various models of ultrasound machines is possible by adjustment of the PRF setting.

Real-time optoacoustic tomography of indocyanine green perfusion and oxygenation parameters in human finger vasculature.

We interrogated whether optoacoustic tomography could be employed to study blood functional parameters and biodistribution of injected fluorescent agents in humans. Using a multichannel scanner at a frame rate of 10 images per second, we obtained cross-sectional images of the human finger in real time, before and after the administration of indocyanine green. We demonstrated that multispectral optoacoustic tomography can sense fast flow kinetics and resolve spatiotemporal characteristics of a common fluorochrome in human vasculature at clinically relevant concentrations. We further register ICG images with oxygen saturation maps and anatomical views of the proximal interphalangeal joint of a healthy volunteer.

Initial results of finger imaging using photoacoustic computed tomography.

We present a photoacoustic computed tomography investigation on a healthy human finger, to image blood vessels with a focus on vascularity across the interphalangeal joints. The cross-sectional images were acquired using an imager specifically developed for this purpose. The images show rich detail of the digital blood vessels with diameters between 100 µm and 1.5 mm in various orientations and at various depths. Different vascular layers in the skin including the subpapillary plexus could also be visualized. Acoustic reflections on the finger bone of photoacoustic signals from skin were visible in sequential slice images along the finger except at the location of the joint gaps. Not unexpectedly, the healthy synovial membrane at the joint gaps was not detected due to its small size and normal vascularization. Future research will concentrate on studying digits afflicted with rheumatoid arthritis to detect the inflamed synovium with its heightened vascularization, whose characteristics are potential markers for disease activity.

Structural deterioration of finger joints with ultrasonographic synovitis in rheumatoid arthritis patients with clinical low disease activity.

OBJECTIVE: In this study we investigated the relationship between synovial vascularity (SV) and structural alteration of finger joints in patients with RA and long-term sustained clinical low disease activity (CLDA). METHODS: RA patients with CLDA of >2 years (minimum 1 year of CLDA for study entry plus 1 year of observation) were analysed. Quantitative SV values were sequentially measured in each finger joint using power Doppler ultrasonography (0, 8, 20 and 52 weeks). Radiological progression of local finger joints was evaluated according to the Genant-modified Sharp score (0-52 weeks). RESULTS: Of the 25 patients enrolled, 15 patients were finally analysed after excluding 10 patients who failed to maintain CLDA during the observational period. Changes in radiological progression of MCP and PIP joints with positive SV were significantly greater than those in joints with negative SV. Joint space narrowing (JSN) was strongly related to structural alteration of finger joints. In joints with positive SV, changes in structural alteration did not relate to total SV values, which reflect total exposure to inflammation in an observational period. CONCLUSION: Even in patients with a long period of CLDA, finger joints with positive SV showed structural alteration, especially in the progression of JSN. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry, http://www.umin.ac.jp/ctr/, UMIN000007305.

[Microcirculatory investigations in hemophilia patients].

AIM: to evaluate microcirculation (MC) and its influencing factors in hemophilia patients. SUBJECTS AND METHODS: In 44 hemophilia patients with recurrent hemarthrosis, laser Doppler flowmetry was used to evaluate resting MC above the index fingers, knee and ankle joints during an occlusion test, with allowance made for muscle and adipose tissue mass. RESULTS: The increased perfusion value above the afflicted joints was found to correspond to the phase of an exacerbation of posthemorrhagic inflammation and to be a risk factor of recurrent hemarrthrosis. Analysis of the occlusion test above the knee joints and index fingers revealed a diminished MC reserve and a tendency to precapillary spasm. MC changes were more pronounced in a shortage of muscle and adipose tissue mass. CONCLUSION: Hemophilia patients must regularly do physical exercises to make skeletal muscles develop well in order to prevent an exacerbation of the joint inflammatory process.

Evaluation of finger joint synovial vascularity in patients with rheumatoid arthritis using contrast-enhanced ultrasound with water immersion and a stabilized probe.

PURPOSE.: To assess synovial microvascularity in finger joints with rheumatoid arthritis (RA) by contrast-enhanced ultrasound (CEUS), distinguishing between cases of active disease and those in remission; to standardize the technique for software analysis. METHODS.: Fifty-two finger joints of RA patients (26 with active disease and 26 in remission) were immersed in water and examined by CEUS using a fixed probe. Signal intensity curves were calculated with the software. RESULTS.: Contrast enhancement was detectable in all 26 patients with active RA (100%), but not in 25 of 26 patients in remission (96%); one of the latter patients (4%) showed minimal enhancement. The method's sensitivity and specificity in distinguishing active disease from remission were 100% and 96%. The grades of synovial enhancement correlated with clinical disease activity and software flow parameters. The peak contrast levels correlated with clinical activity, a peak of 9% representing the cutoff between remission and active disease. CONCLUSIONS.: CEUS with a fixed probe on finger joints immersed in water detected synovial vascularization in RA, producing results suitable for standardized software analysis and avoiding artifacts.

Colour Doppler ultrasonography evaluation of vascularization in the wrist and finger joints in rheumatoid arthritis patients and healthy subjects.

OBJECTIVES: To evaluate the presence of blood flow by colour Doppler ultrasonography (CDUS) in the wrist and finger joints of rheumatoid arthritis (RA) patients and healthy subjects and to define a cut-off value of CDUS resistive index (RI). METHODS: Forty-three patients with RA and 43 healthy controls were examined by CDUS. The wrists, second and third metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were evaluated in each patient and healthy subject. Spectral Doppler analysis was performed in order to characterize the type of flow and a mean RI was measured to define a cut-off level. The area under receiver operating characteristic curve was used to evaluate the screening method's performance. RESULTS: Flow was detected in 219 of the 430 total joints (50.9%) of RA patients (111 in the wrists, 49 in the MCP and 30 in the PIP joints). Healthy subjects had a quantifiable flow in 45 of the 430 joints (10.5%) and, in particular, 39 (86.4%) in the wrist, 5 (11.14%) in the MCP and 1 (2.2%) in the PIP joints. The intra- and inter-reader agreements for the detection of Doppler signal were very good (kappa 0.82 and 0.89, respectively). Mean RI values were 0.72±0.06 in RA patients and 0.86±0.06 in healthy subjects (p<0.01). At cut-off point of RI<0.79 the sensitivity was 89.6% and the specificity was 78.8% (positive likelihood ratio 4.22). CONCLUSION: DUS is a useful tool for the detection of abnormal blood flow in inflammatory joints of RA patients.

Detection of rheumatoid arthritis by evaluation of normalized variances of fluorescence time correlation functions.

Fluorescence imaging using the dye indocyanine green as a contrast agent was investigated in a prospective clinical study for the detection of rheumatoid arthritis. Normalized variances of correlated time series of fluorescence intensities describing the bolus kinetics of the contrast agent in certain regions of interest were analyzed to differentiate healthy from inflamed finger joints. These values are determined using a robust, parameter-free algorithm. We found that the normalized variance of correlation functions improves the differentiation between healthy joints of volunteers and joints with rheumatoid arthritis of patients by about 10% compared to, e.g., ratios of areas under the curves of raw data.

The outcome of direct-flow neurovascular island flaps in pulp defects.

OBJECTIVE: In this study we aimed to evaluate the results of the direct-flow neurovascular island flap (NIF) transfers in pulp defects. METHODS: We reviewed the records of 96 patients with 115 NIF transfers performed for pulp defect reconstruction. The injury mechanism was crush type injury in 70 patients (72.9%). Ninety-three patients (97%) were emergency cases. Pulp reconstruction was performed by means of pedicled island flap transfer. The results were evaluated with proximal interphalangeal joint range of motion, the Semmes Weinstein monofilament test, static two-point discrimination and cold intolerance assessments. The relations between the injury mechanism, patient satisfaction, cold intolerance and scar problems were analyzed. Also, the association between skin grafting and hook nail deformity was investigated. The level of significance was set at p<0.05. RESULTS: All flaps survived. The mean follow-up time was 41±20.3 (range: 12-108) months. We observed proximal interphalangeal joint flexion contracture in 11 (9.5%) cases. In seven of these, the limitation was less than 10 degrees. Hook nail deformity was seen in 8 fingers (7%). Cold intolerance was found in 16 (17%) cases. Semmes Weinstein monofilament and static-two point discrimination tests of flaps revealed satisfactory results. There was no relation between the injury mechanism and cold intolerance, patient satisfaction and scar problems (p>0.05). Among patients, 91.7% were satisfied with their results. CONCLUSION: The transfer of direct-flow island flaps, from the same finger, causes minimal morbidity on the donor site and appears to be a safe method, providing satisfactory functional and aesthetic results in the reconstruction of pulp defects.

[Functional and morphologic changes in the tendons and multimicrovacuolar collagen absorbing system of the three-phalanx fingers in disorder of arterial inflow].

Taking into account the fact, that unsatisfactory results of treatment of the thumbs traumatic damage are significantly caused by presence of anatomic disruption of the thumbs palm's own arteries with chronic tissue ischemia occurrence. One of consequences of damage of the three-phalanx thumbs interphalanx joints and the thumbs palm's own arteries is a formation of quickly progressing secondary flexing contracture of proximal interphalanx joints (PIPHJ). In the investigations accomplished there was established, that the changed tissues of the flexors tendons and their sheaths, forming cicatricial blockade distally to the primary trauma site, are taking part in a PIPHJ contracture development while arterial perfusion presence.The tissues damage severity, as well as a severity of clinical features of the tendons and their sheaths damage, depends on a degree of an arterial perfusion disorder present,

A transmissive laser speckle imaging technique for measuring deep tissue blood flow: an example application in finger joints.

BACKGROUND AND OBJECTIVE: Laser speckle perfusion imaging (LSPI) is a minimally invasive optical measure of relative changes in blood flow, providing real-time, high resolution, two-dimensional maps of vascular structure. Standard LSI imaging uses a light-reflective geometry that limits the measurement to a thin surface layer of 0.2-1 mm. The objective of this study was to test a new LSI instrument geometry with the laser source opposed to the image capture plane (light transmissive). Captured light then travels the entire tissue thickness (10-15 mm), sampling much deeper regions of interest than conventional optical imaging techniques. STUDY DESIGN: Reflective-light (conventional) and transmissive-light LSI modes were used to measure finger joint blood flow during a timed tourniquet occlusion of the brachial artery in volunteer participants. RESULTS: There was greatly increased visibility of vessels underlying the skin in the light-transmissive mode LSI mode. Established LSI algorithms were shown to still work in the light-transmissive mode, despite decorrelation due to finite laser coherence length and the light passing through a tissue thickness of 10-15 mm. CONCLUSION: Transmissive LSI can be used to measure blood flow deep (10-15 mm) into tissues. This could be useful for non-invasive measurements of finger joint synovial blood flow in diagnosing and treating peripheral vascular disorders, such as rheumatoid arthritis.

Change of synovial vascularity in a single finger joint assessed by power doppler sonography correlated with radiographic change in rheumatoid arthritis: comparative study of a novel quantitative score with a semiquantitative score.

OBJECTIVE: To investigate the relationship between synovial vascularity assessed by quantitative power Doppler sonography (PDS) and progression of structural bone damage in a single finger joint in patients with rheumatoid arthritis (RA). METHODS: We studied 190 metacarpophalangeal (MCP) joints and 190 proximal interphalangeal (PIP) joints of 19 patients with active RA who had initial treatment with disease-modifying antirheumatic drugs (DMARDs). Patients were examined by clinical and laboratory assessments throughout the study. Hand and foot radiography was performed at baseline and the twentieth week. Magnetic resonance imaging (MRI) was performed at baseline. PDS was performed at baseline and the eighth week. Synovial vascularity was evaluated according to both quantitative and semiquantitative methods. RESULTS: Quantitative PDS was significantly correlated with the enhancement rate of MRI in each single finger joint. Comparing quantitative synovial vascularity and radiographic change in single MCP or PIP joints, the level of vascularity at baseline showed a significant positive correlation with radiographic progression at the twentieth week. The change of vascularity in response to DMARDs, defined as the percentage change in vascularity by the eighth week from baseline, was inversely correlated with radiographic progression in each MCP joint. The quantitative PDS method was more useful than the semiquantitative method for the evaluation of synovial vascularity in a single finger joint. CONCLUSION: The change of synovial vascularity in a single finger joint determined by quantitative PDS could numerically predict its radiographic progression. Using vascularity as a guide to consider a therapeutic approach would have benefits for patients with active RA.

Magnetic resonance spin-labeling perfusion imaging of synovitis in inflammatory arthritis at 3.0 T.

OBJECTIVE: The aim of this study was to test the feasibility of arterial spin labeling (ASL) perfusion imaging of synovitis in inflammatory joint diseases on a clinical 3.0 T whole-body scanner. MATERIALS AND METHODS: Fifteen patients (geometric mean 47 years, range 8-69 years) with different types of inflammatory arthritis of the finger or wrist joints participated in the study. In addition to conventional spin-echo and dynamic contrast-enhanced FLASH3D sequences, a novel spin-labeling technique (FAIR-TrueFISP) for quantitative assessment of tissue perfusion was applied. Perfusion maps were calculated pixel-wise by means of the extended Bloch equations. RESULTS: Perfusion maps showed good image quality with clear visualization of hyperaemia in synovitis. The computed perfusion maps corresponded best to subtraction images of the dynamic series from 30 to 60 s after contrast-medium injection. The quantitative perfusion values of synovitis showed a good correlation with the disease activity. Perfusion values for inflamed synovium in phase of high activity were up to 230 ml/100 g tissue/min. CONCLUSION: The proposed modality allows for the assessment of disease activity in arthritis without the application of contrast-medium offering a new tool for therapy monitoring. As the technique provides quantitative information on hyperaemia, it potentially offers new insights in the pathophysiology of arthritic diseases.