Ultrasonographic Assessment of Fifth Metatarsophalangeal Joint Erosion in Rheumatoid Arthritis: Which Aspect Is Better?

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint

OBJECTIVE

To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy.

METHODS

From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up.

RESULTS

Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period.

CONCLUSION

Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.

Ultrasonography supplements clinical exam to improve early rheumatoid arthritis disease activity monitoring in metatarsophalangeal joints

INTRODUCTION

Compared with clinical examination (CE), ultrasonography (US) provides additional and more accurate assessment of inflammation and visualization of structural damage. To better understand the effectiveness of US in metatarsophalangeal joints (MTPJs), we compared disease activity in MTPJs 2-5 assessed by CE and US, with magnetic resonance imaging (MRI) as reference standard.

METHOD

Treatment-naïve adult patients with early RA (ACR criteria, disease duration < 2 years) were consecutively recruited. MTPJs 2-5 were assessed for swelling and tenderness, and imaged by US (Esaote MyLab70). The most symptomatic foot was imaged by peripheral MRI (1.0 Tesla). US was semiquantitatively graded for synovial thickening (ST) and power Doppler (PD) (0-3), and erosions (yes/no). MRI was semiquantitatively graded for bone marrow edema (BME), synovitis, and erosions (OMERACT). Kappa agreement, sensitivity, specificity, and predictive values were analyzed using cut-offs at ST ≥ 2, PD ≥ 1, and MRI synovitis and BME at both ≥ 1 and ≥ 2.

RESULTS

This study included 39 patients (85% female, mean (SD) age = 51.6 (10.3)). Using MRI synovitis and BME grade ≥ 2 as the reference, PD had superior sensitivity (82%) and kappa agreement (k = 0.43) than swollen joint count (55%, k = 0.20), but similar high specificity (88%, 83%). ST and PD were often observed in clinically asymptomatic MTPJs. US detected very few MRI erosions, but several observed erosions corresponded to grade ≥ 2 MRI erosions.

CONCLUSION

Clinical swelling and PD are highly specific for active inflammation in the MTPJs. US supplemented CE by allowing observation of subclinical inflammation and structural damage. Key Points • Ultrasonography detected many subclinical synovial inflammations in metatarsophalangeal joints (MTPJs), many confirmed by MRI • Ultrasonography may best be used clinically to supplement clinical examination by assessing non-swollen joints • Ultrasonography provided quick method of visualizing bone erosions that were grade ≥ 2 on MRI.

Adult Inflammatory Arthritides: What the Radiologist Should Know

Developments and improvements in knowledge are rapid and ongoing in both the radiologic and rheumatologic fields. During the past decade, the roles of imaging and the radiologist in the assessment and management of many inflammatory rheumatologic diseases have undergone several changes. To remain effective in patient care, the radiologist needs to be aware of these changes when recommending and interpreting imaging examinations for the referring physician. The goal of contemporary rheumatoid arthritis (RA) management is to redefine RA as a disease that is no longer characterized by erosions, which reflect established or long-standing untreated disease. Most cases of RA are now diagnosed clinically, but imaging increases diagnostic confidence, is superior to clinical examination for the detection of joint inflammation, and plays an important role in patient management. The concept of the seronegative spondyloarthritides has recently been redefined by the Assessment of SpondyloArthritis International Society (ASAS). This new set of ASAS classification criteria divides the spectrum of spondyloarthritis on the basis of predominantly axial skeletal clinical manifestations or predominantly peripheral skeletal clinical manifestations. For axial spondyloarthritis, magnetic resonance imaging and radiography play crucial roles for classification and diagnosis. For both peripheral spondyloarthritis and psoriatic arthritis, the radiologist can provide important information that influences classification and diagnosis, including documenting radiologic evidence of juxta-articular new bone formation, diagnosing sacroiliitis, or delineating the presence and extent of enthesitis and dactylitis. The radiologist's familiarity with recent classification criteria, in addition to the traditional diagnostic characteristics of the individual inflammatory arthritides, maximizes the productive interface between the radiologist and the rheumatologist. ^©RSNA, 2016.