Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience

Resistance exercise and low-level laser therapy improves grip strength and morphological aspects in the ankle joint of Wistar rats with experimental arthritis

Rheumatoid arthritis (RA) is an inflammatory disease mainly affecting synovial joints. Photobiomodulation through low-level laser therapy (LLLT) and resistance exercise may improve the inflammatory process. Therefore, we analyzed the effects of resistance exercise, LLLT, and the combination of both treatments on hind paw grip strength and ankle joint histomorphometric aspects of Wistar rats subjected to experimental RA. A total of 64 male Wistar rats were divided into eight groups: control, control LLLT, control exercise, control LLLT and exercise, arthritis, arthritis LLLT, arthritis exercise, and arthritis LLLT and exercise groups. The experimental RA was induced by a complete Freund's adjuvant injection into the knee joint cavity. Climbing exercises and LLLT (660 nm; 5 J/cm² per point) were performed as the treatment. In addition, muscle strength was evaluated using the grip strength test, and morphometric evaluations were performed on the ankle joint. Generalized mixed models and multivariate analysis of variance tests were used for statistical analysis. Statistical significance was set at a p-value of .05. Arthritis LLLT, exercise, and LLLT and exercise had positive effects on grip strength between the groups (F[7.56] = 5.8, p < .004) and within the groups (F[4.3] = 9.9, p < .002) throughout the evaluations. Morphometry revealed degenerative lesions in the ankle joint as subintima with angiogenesis, inflammatory cells, flocculated articular cartilage, chondrocyte disorganization, and pannus in the arthritis group (p < .001). The treated groups exhibited morphological characteristics similar to those of the control group. LLLT and resistance exercise restored muscle strength and morphological aspects of the ankle joint in rats with experimentally induced RA.

Significant association between joint ultrasonographic parameters and synovial inflammatory factors in rheumatoid arthritis

BACKGROUND

Ultrasonography (US) can directly demonstrate joint inflammation, including grayscale (GS) signs of synovial hypertrophy and power Doppler (PD) techniques to demonstrate increased blood flow and vascularization. Recently, echogenicity, especially hypoechoic synovium, has also been associated with local inflammatory activity. However, only a few studies have demonstrated correlation between histopathologic and immunopathologic evaluation and US findings. The aim of this study was to clarify whether joint US findings including synovial hypertrophy, vascularity, and echogenicity can accurately characterize synovial pathophysiology in patients with active rheumatoid arthritis (RA).

METHODS

A total of 44 patients with RA were included, both treated (n = 25) and untreated (n = 19) and scheduled for US examination of the knee joint with synovial fluid (SF) aspiration and two treated patients also underwent synovial biopsy. US images were quantitatively analyzed using grayscale assessment of synovial hypertrophy and PD for vascularity and echogenicity. Levels of nine SF cytokines and growth factors were also measured.

RESULTS

Both US synovial hypertrophy and PD vascularity significantly correlated with SF inflammatory cytokine levels such as IL-6, IL-8, IL-1β and IL-10 in untreated patients. Angiogenic factors, including vascular endothelial growth factor (VEGF), only correlated with PD vascularity. In the treated patients, the associations between synovial hypertrophy and any cytokines were diminished, although synovial vascularity and echogenicity correlated with IL-6 and VEGF (p < 0.05). Histopathologic analysis revealed that hypoechogenicity of the synovium correlated with marked infiltration of lymphocytes and hypervascularity.

CONCLUSIONS

We demonstrated the pathophysiological origins of US findings in the joint. The degree of US vascularity of the synovium correlated with local inflammatory cytokine levels and angiogenetic factors in patients with active RA. Synovial echogenicity, and not hypertrophy, correlated with inflammation, especially in treated patients with RA.

Imaging of the Pediatric Temporomandibular Joint

Imaging of the temporomandibular joint in pediatric patients is a critical component in the evaluation and treatment of children with temporomandibular joint symptoms. MRI can provide detailed joint anatomy and identify inflammation, sometimes before symptom onset. Ultrasound scan is a convenient emerging modality to evaluate the joint and guide therapeutic injections. Radiography and computed tomography offer osseous detail to recognize early morphologic changes of the mandibular condyle and provide operative planning. Imaging promises to direct treatment to prevent future joint destruction and maintain function.

What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

BACKGROUND

Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US).

OBJECTIVE

To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015.

REVIEW METHODS

A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken.

MATHEMATICAL MODEL

A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated.

RESULTS

Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used.

LIMITATIONS

Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed.

CONCLUSION

Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015017216.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Knee joint synovitis: study of correlations and diagnostic performances of ultrasonography compared with histopathology

Objectives

Ultrasonography (US) is a fast, available and low-cost imaging tool used for detecting knee synovitis. Our aims were to assess the relationship between US and histology findings in appraising levels of inflammation and vascularity in the knee joint in subjects with inflammatory arthropathies; to determine whether differences exist in the appraisal between varying knee compartments and to compare US performances compared with gold standard histology for knee synovitis detection.

Methods

Subjects with actively inflamed knee joint having crystal arthropathies, rheumatoid arthritis, psoriatic arthritis or ostoearthritis were prospectively recruited from rheumatology clinics after giving their written consent between May and October 2015. Study was approved by the institutional ethics committee. The knee was divided into three compartments (medial, lateral, superior). Patients had a knee US followed by a knee arthroscopy with biopsies retrieval from each compartment. Biopsies were blindly scored for lining layer hyperplasia, inflammation, vascularity, CD68 and factor VIII staining. Correlation was determined using the Spearman’s correlation test.

Results

26 patients with active arthritis in a knee joint and recent onset of disease were prospectively included. Strong correlations were observed between US synovitis grade and histological inflammation score (r=0.63; P=0.002), US Doppler grade and histological score for vascularity (r=0.68; P<0.001); US measured synovial thickness and lining layer hyperplasia (r=0.61; P=0.002). Moderate correlation was found between US synovitis grade and CD68 score (r=0.49; P=0.02).

Conclusion

US findings correlate with histological inflammation and vascularity scores in actively inflamed knee joints. US accurately describes knee synovitis.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

High-Resolution US of Rheumatologic Diseases

For the past 15 years, high-resolution ultrasonography (US) is being routinely and increasingly used for initial evaluation and treatment follow-up of rheumatologic diseases. This imaging technique is performed by using high-frequency linear transducers and has proved to be a powerful diagnostic tool in evaluation of articular erosions, simple and complex joint and bursal effusions, tendon sheath effusions, and synovitis, with results comparable to those of magnetic resonance imaging, excluding detection of bone marrow edema. Crystal deposition diseases including gouty arthropathy and calcium pyrophosphate deposition disease (CPPD) have characteristic appearances at US, enabling differentiation between these two diseases and from inflammatory arthropathies. Enthesopathy, which frequently accompanies psoriatic and reactive arthritis, also has a characteristic appearance at high-resolution US, distinguishing these two entities from other inflammatory and metabolic arthropathies. The presence of Doppler signal in examined joints, bursae, and tendon sheaths indicates active synovitis. Microbubble echo contrast agents augment detection of tissue vascularity and may act in the future as a drug delivery vehicle. Frequently, joint, tendon sheath, and bursal fluid aspirations and therapeutic injections are performed under US guidance. The authors describe the high-resolution US technique including gray-scale, color or power Doppler, and contrast agent-enhanced US that is used in evaluation of rheumatologic diseases of the wrist and hand and the ankle and foot in their routine clinical practice. This article demonstrates imaging findings of normal joints, rheumatoid arthritis, gouty arthritis, CPPD, psoriatic and reactive arthritis, and osteoarthritis.

Sonographic Findings in Gouty Arthritis: Diagnostic Value and Association with Disease Duration

The objective of this work was to evaluate the sonographic features of gouty arthritis and correlate findings with disease duration. The study was conducted on 100 patients in ambulatory care aged ≥40 y. Inclusion criteria included mono- or oligo-arthritis with effusion of the knee or the first metatarsophalangeal (MTP) joint and no known history of gout. A complete medical history was obtained with emphasis on the known risk factors or causes of gouty arthritis. A 12-MHz Medison linear probe was used for ultrasonography (US). Synovial fluid analysis with polarizing light microscopy was performed on all patients. Ninety-eight knee joints and 33 first MTP joints were examined. Gouty arthritis was found by US in four forms: (i) floating echogenic foci in effusion fluid or Baker cysts, (ii) deposits on the cartilage surface (double contour sign), (iii) erosions and (iv) mature tophus/tophi. These were found in 78.9%, 42.3%, 39.4% and 28.2% of patients, respectively. The overall sensitivity and specificity of US in detecting gout (as defined by the clinical gold standard, i.e., detection of urate crystals by polarizing light microscopy) were 85.9% and 86.7%, respectively. Detection of echogenic foci in effusion fluid was associated with the shortest duration of symptoms (median duration 2 y) followed by double contour sign (3.5 y), erosions (4 y) and tophus (12.5 y). Sonographic findings in gout can be assigned a temporal pattern, with echogenic foci being associated with the shortest and full tophus formation with the longest disease duration.

Contrast-enhanced ultrasound in coxitis

OBJECTIVES

Hip involvement is common in rheumatological diseases but can be difficult to diagnose, especially in absence of MRI. B-mode ultrasound (US) detects joint capsule distention while distinguishing effusion from proliferative synovial tissue is strenuous since both appear hypoechoic. Power Doppler ultrasound (PDUS) often fails to detect vascularisation in the hip. We therefore evaluated contrast-enhanced ultrasound (CEUS) in the hip joint.

METHODS

We investigated 36 hip joints of patients with known rheumatological joint diseases presenting with hip pain and 5 hips of healthy controls using B-mode US, PDUS and CEUS. We assessed CEUS hypervascularisation semiquantitatively comparing to the periarticular tissue. In B-mode, we measured the distance between femoral neck and joint capsule (DNC) and compared the results to the avascular intraarticular margin (AIM) in CEUS using t-tests and crosstables.

RESULTS

PDUS signals were received in only 2/36 cases (5.6%). B-mode US established the diagnosis of coxitis in 64% of all symptomatic hip joints. In 4 cases (11%), the diagnosis was revised after the use of CEUS. In patients with definite coxitis, 14 hips (73.7%) showed CEUS hypervascularisation°2, five°1 (26.3%) and none°0 (χ²=3.277, P<0.001). The difference DNC/AIM was highly significant in patients with hip pain (P<0.001, 95% CI: 2.054-4.684) and those with definite coxitis (P<0.001, 95% CI: 3.268-7.258).

CONCLUSIONS

In most cases, clinical parameters together with B-mode US findings are sufficient to diagnose coxitis. However, CEUS is capable of visualizing and quantifying the degree of hypervascularisation and enables the discrimination between effusion and proliferative synovial tissue.

The role of ultrasound in diagnosis of the causes of low back pain: a review of the literature

Context:

Low back pain (LBP) is among the most prevalent musculoskeletal conditions in the developed countries. It is a common problem causing disability and imposing a huge economic burden to individuals and state organizations. Imaging plays an important role in diagnosis of the etiology of LBP.

Evidence Acquisition:

The electronic databases included: PubMed (1950 to present), Ovid SP Medline (1950 to present) and ISI (1982 to present) and Google Scholar. In every search engine another search was performed using various permutations of the following keywords: ultrasonography, ultrasound imaging, low back pain, back muscles, paraspinal muscles, multifidus, transverse abdominis, muscle size, spinal canal, sacroiliac joint and spondylolisthesis.

Results:

Magnetic resonance imaging (MRI) is widely used in evaluation of patients with LBP; however, high costs, limited availability and contraindications for its use have restricted MRI utilization. In a quest for a less expensive and readily available tool to investigate LBP, clinicians and researchers found ultrasonography (US) as an alternative. In this review we discuss the US application in diagnosis of some common causes of non-specific chronic LBP. Discussed topics include evaluation of spinal canal diameter, paraspinal and transabdominal muscles, sacroiliac joint laxity, pregnancy related LBP, sacroiliitis, and spondylolisthesis using US in patients with LBP.

Conclusions:

While the first researches on employing ultrasound in diagnosis of patients with LBP had been focused on spinal canal diameter, recent studies have been mostly performed to evaluate the role of transabdominal and paraspinal muscles on core stability and thereby LBP occurrence. On the other side, Doppler ultrasonography has recently played an important role in objective measurement of joint laxity as a common etiology for LBP. Doppler imaging also in pregnant patients with LBP has been recommended as a safe and sensitive method. As conclusion, according to recent and most prestigious studies, focusing more on transabdominal muscle thickness can be considered as future approach in investigations.

Value of contrast-enhanced ultrasonography for the detection and quantification of enthesitis vascularization in patients with spondyloarthritis

OBJECTIVE

To evaluate if contrast-enhanced ultrasound (CEUS) can improve the detection and quantification of the vascularization of mild enthesitis in spondyloarthritis (SpA) and to evaluate the influence of nonsteroidal antiinflammatory drugs (NSAIDs) on such detection.

METHODS

Fourteen patients with mildly active SpA were evaluated at 3 consecutive visits: at baseline while undergoing NSAID treatment (V1), after 1 week of stopping NSAIDs (V2), and after 1 week of resuming NSAIDs (V3). At each visit, enthesitis was evaluated clinically and by power Doppler US (PDUS). A selected enthesis with a doubtful PDUS vascularization signal was studied by CEUS in 2 steps: (1) using a dedicated technology that preserves microbubbles (Contrast Tuned Imaging technology [CEUS-CnTI]) and (2) using high PD (CEUS-PD) to destroy microbubbles. A linear mixed model statistical analysis, taking visits and contrast agent as fixed factors and the patient as a random factor, was used.

RESULTS

Disease activity and PDUS findings increased between V1 and V2 and then decreased between V2 and V3. As compared with PDUS alone, CEUS-PD and CEUS-CnTI each detected 1 supplementary vascularized enthesis at V1, CEUS-PD detected 1 vascularized enthesis and CEUS-CnTI detected 3 vascularized entheses at V2, and CEUS-PD and CEUS-CnTI each detected 2 vascularized entheses at V3. The mean inflammation score was increased by the use of CEUS (P = 0.04). This score increased between V1 and V2 (P = 0.03 by CEUS-PD and P = 0.01 by CEUS-CnTI) and decreased between V2 and V3.

CONCLUSION

CEUS improved the detection of enthesitis in SpA patients by confirming all doubtful enthesitis signals and confirming the absence of enthesis vascularization. The use of NSAIDs influenced the detection of vascularization.

Evaluation of the novel ultrasound score for large joints in psoriatic arthritis and ankylosing spondylitis: six month experience in daily clinical practice

Background

To evaluate the utility of the recently introduced SOLAR score (sonography of large joints in Rheumatology), which has been validated in RA patients, in a cohort of patients with Psoriatic Arthritis (PsA) and Ankylosing Spondylitis (AS) presenting with involvement of large peripheral joints.

Methods

The recently established SOLAR score has been designed to determine the degree of inflammation in the shoulder, the elbow, the hip and the knee joint in patients suffering from RA. Since large joints are frequently involved in PsA and AS, synovitis and synovial vascularity were scored semiquantitatively (grade 0–3) by grey scale (GSUS) and power Doppler ultrasound (PDUS) utilizing the validated scoring system. Each joint was scanned from different angles, the knee joint for example was divided into four areas to score for synovitis: the suprapatellar longitudinal, the medial longitudinal, the lateral longitudinal, and the posterior region. Each area was scored from 0–3, so a maximum score of 12 could be achieved. PsA and AS patients presenting with peripheral joint disease involving large joints were examined at baseline, 3 and 6 months after initiation of local or systemic therapy (DMARDs/Biologics). For evaluation of the inflammatory status, the erythrocyte sedimentation rate (ESR) was determined.

Results

A cohort of 126 patients were enclosed, and 83 of these were followed for 6 months. At baseline before modification of the therapy, patients received DMARDs (n = 83), DMARDs plus biologics (n = 30), or biologic monotherapy (n = 29). Following intervention, all US scores demonstrated a marked improvement. The GSUS and the PDUS scores for all joint areas, except the PDUS score of the hip, exhibited a significant improvement (p < 0.05), while the GSUS of the knee showed even a highly significant (p < 0.001) change. The ESR displayed a significant decrease from 27 to 19 mm (p < 0.002) representing good treatment response.

Conclusion

The SOLAR score, which has been recently introduced for RA patients, is a very suitable instrument for the qualitative and quantitative evaluation of large joint involvement in PsA and AS patients and allows for treatment monitoring.

The evolution of ultrasound in rheumatology

Musculoskeletal ultrasound is a powerful tool not only for evaluating joint and related structures but also for assessing disease activity. Ultrasound in rheumatology has rapidly evolved and been incorporated into routine clinical practice over the past decade. Moreover, technological development of equipment has made it more accessible for rheumatologists. We present a review of advances in ultrasound in rheumatology, focusing on major chronological developments.

Ultrasound of the knee

Ultrasound is one of the standard imaging modalities of the knee. In the recent decades many new ultrasound techniques have been introduced, including power Doppler, dynamic examination, and ultrasound-guided techniques. Some of them have clear advantages over magnetic resonance imaging-today's knee imaging gold standard-whereas others have failed to meet expectations. This pictorial article reviews and demonstrates the use of sonography in different knee joint pathologies underlining recent findings and their practical approach.

Noninvasive quantitative assessment of synovial pannus angiogenesis by contrast-enhanced gray-scale sonography in antigen-induced arthritis in rabbits

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the value of contrast-enhanced gray-scale sonography in quantitative assessment of synovial pannus angiogenesis in antigen-induced arthritis in rabbits.

MATERIALS AND METHODS

Twenty-four adult New Zealand White rabbits were divided into two groups. Inflammatory arthritis was induced by intra-articular injection of ovalbumin into right knee joints with 4 mg in low-dose group (LD, n = 12) and 8 mg in high-dose group (HD, n = 12). The left side of the knee on each rabbit was used as normal control. Contrast-enhanced gray-scale sonography with time intensity curve (TIC) was performed on the synovia of suprapatellar bursa and posterior capsules 4 weeks after the injection. Immunohistochemical examinations of synovia were applied to assess the microvessel density and the expression of vascular endothelial growth factor. Correlation analysis between sonographic and immunohistochemical findings was performed.

RESULTS

Contrast-enhanced gray-scale sonography of all right knees demonstrated intra-articular hypoechoic lesions with enhanced blood flow and no abnormal findings on all left knees. Parameters of TIC, including ascending curve (A), derived peak intensity (DPI), and area under curve (AUC) on arthritis joints were significantly higher in HD group compared to LD group (P < .05). Positive correlation was found between immunohistochemical findings and parameters of A, DPI, and AUC (P < .05). However, no correlation was found between other parameters (slope of descending rate, time to peak, time to rise, and initial intensity) and immunohistochemical findings.

CONCLUSIONS

Contrast-enhanced gray-scale sonography with TIC measurement could provide reliable method for noninvasive quantitative assessment of synovial pannus angiogenesis of arthritis in clinical settings.

Antigen-induced arthritis in rabbits: a comparative study between high-resolution ultrasound and contrast-enhanced ultrasound and pathologic findings

The objective of this study was to explore the feasibility and value of high-resolution ultrasound and contrast-enhanced ultrasound in evaluation of synovitis in rabbit knee joint in antigen-induced arthritis (AIA). Thirty-six rabbits were divided into three groups, each injected with different doses of ovalbumin (OVA) into the right knee joint. On week 1 and 4, 6 randomly selected in each group were killed. Each knee joint undergone the high-resolution ultrasound to measure capsule thickness and contrast-enhanced ultrasound to measure synovium thickness. The results from the ultrasound examinations were compared with those of pathologic examinations. Different OVA doses resulted in different modeling success rate, different pathological synovitis score, and different capsule and synovium thickness measured by ultrasound. The diagnostic accuracy of synovitis by ultrasound was high. The ultrasound measurement revealed that the capsule thickness on week 4 was lessened than that on week 1, while the synovial thickness on week 4 was greater than that on week 1. Both the joint capsule and synovium thickness measured by ultrasound were significantly and positively correlated to the pathologic synovitis score (P < 0.05). The synovial thickness on week 4 is more correlated to the synovitis score than the capsule thickness, rather than that on week 1. Injection of OVA of different doses results in different modeling success rate and synovitis severity. The high-resolution ultrasound and contrast-enhanced ultrasound can be used to determine whether the AIA was made successfully and evaluate the synovitis severity. In chronic inflammatory phase, the contrast-enhanced ultrasound has better effect.

Benefits of exercise in rheumatoid arthritis

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.

Quantitative Power Doppler Ultrasonography Is a Sensitive Measure of Metacarpophalangeal Joint Synovial Vascularity in Rheumatoid Arthritis and Declines Significantly Following a 2-week Course of Oral Low-dose Corticosteroids

Objective.

To investigate the stability over 2 weeks of ultrasonographic assessments of synovial thickness and vascularity in all 10 metacarpophalangeal joints of subjects with rheumatoid arthritis (RA) with a range of disease activities as measured by the validated Disease Activity Score-28 joint score (DAS28-ESR). And in subjects with severe disease activity, to compare the sensitivity of these measurements, acute-phase markers, and vascular endothelial growth factor to change in response to 2 weeks of oral prednisolone (7.5 mg daily).

Methods.

A group of 38 subjects with RA were enrolled, 13 (mean DAS28 2.1), 14 (mean DAS28 5.2), and 11 (mean DAS28 5.7) meriting oral corticosteroid treatment. Synovial thickness and vascularity were assessed by ultrasonography at 3 timepoints. Images were ranked by semiquantitative scale. Vascularity was also measured by quantitative determination of the power Doppler area (PDA).

Results.

In the whole RA cohort, baseline indices of synovial thickness and vascularity correlated with DAS28, as did PDA (r = 0.42, p < 0.05). In the RA groups on stable therapy, synovial thickness and vascularity showed little variation over 2 weeks. In the corticosteroid group, PDA had fold changes of −1.9-fold (p < 0.05) after 1 week and −2.2-fold (p < 0.05) after 2 weeks. These were the largest fold changes of all measured variables.

Conclusion.

Ultrasonographic measures can differentiate disease severity in RA correlating closely with DAS28. Quantitative power Doppler signal was significantly reduced within 1 week of oral prednisolone, a rapid kinetic suggesting that PDA may have value as a sensitive early marker of therapeutic response.

Intra-Articular Injections of Infliximab in the Treatment of Inflammatory Rheumatic Diseases: Case Reports and Review of Literature

Inflammatory chronic diseases involving joints together with other organs are usually treated with a systemic approach. In a few cases, where arthritis is not responsive to traditional treatments, an intraarticular (I.A.) therapy could be useful. Furthermore, patients not eligible for systemic therapy with anti-TNF or other DMARDs, as well as patients with an initial arthritis with the involvement of a single joint, such as the knee or hip joint, could use the I.A. injection therapy. In this article we report our experience with five patients affected by rheumatic inflammatory diseases, not responding to traditional systemic DMARDs-based therapies or not eligible for systemic use of biological response modifiers who underwent ultrasound-guided I.A. injection of Infliximab. Three of 5 patients showed a positive and long-lasting response to treatment with local Infliximab. Safety profile was good according to literature data. Moreover, in this article we review the literature on this therapeutic approach. This is the first report of I.A. use of Infliximab in the hip joint.

Heel fat pad involvement in rheumatoid arthritis and in spondyloarthropathies: an ultrasonographic study

BACKGROUND

Heel fat pad inflammation and degeneration have been frequently proved to cause talalgia. Painful heel fat pad is often confused with plantar fasciitis, and only magnetic resonance imaging (MRI) or ultrasonography (US) can differentiate these conditions. Scanty data are available about heel fat pad involvement in the course of chronic polyarthritis.

OBJECTIVE

To investigate with US the heel fat pad involvement in patients with rheumatoid arthritis (RA) and spondyloarthropathies (SpA); to describe and compare the clinical and sonographic features of this lesion in the two groups.

METHODS

The heels of 181 consecutive outpatients with RA and 160 with SpA were studied by US and radiography. A control group of 60 healthy subjects was examined by US.

RESULTS

Two different patterns of involvement of the heel fat pad were observed. The inflammatory-oedematous pattern was more frequent in patients with RA (6.6%) than in those with SpA (1.8%), and was associated with talalgia--even if it was not associated with plantar fasciitis or enthesophyte (bony spur). The degenerative-atrophic pattern was less frequent (1.1% in RA, 1.9% in SpA), and was associated with plantar fasciitis and subcalcaneal enthesophyte.

CONCLUSIONS

The inflammatory-oedematous lesion of the heel fat-pad is relatively frequent in RA and causes subcalcaneal pain. Degenerative-atrophic changes of the heel fat pad can be observed in RA and SpA, and seem to be associated with chronic abnormalities of the plantar fascia and of its enthesis.

Contrast-enhanced Coded Phase-inversion Harmonic Sonography of Knee Synovitis Correlates with Histological Vessel Density: 2 Automated Digital Quantifications

Objective.

To use contrast-enhanced coded phase-inversion harmonic B-mode sonography to assess the acoustic enhancement of the synovial area of the knee; and to compare the data with the histological vessel density.

Methods.

Eleven patients eligible for a knee arthroscopy were studied. Acoustic quantification was carried out by a digital image analysis program that detects the time-dependent increase [intensity (time) = k × time + C] of gray-level intensity in all the pixels of a specific region of interest (ROI) following intravenous injection of the microbubble contrast agent sulfur hexafluoride. Echo-guided synovial biopsies were carried out in the same ROI. Synovial vessel areas were quantified after Factor VIII immunostaining of synovial biopsies using an automated digital image analysis.

Results.

Significant (p < 0.05) correlations were observed between histological vessel density and percentage of the synovial area with a k value > 0.01 (r = 0.93) and kmaxvalues (r = 0.79), as well as between the 2 latter parameters (r = 0.72). The histological vessel density and the 2 acoustic parameters were also significantly correlated with the logarithm of erythrocyte sedimentation rate (r = 0.77, r = 0.87, r = 0.67, respectively) and with log C-reactive protein serum concentration (r = 0.69, r = 0.83, r = 0.62, respectively).

Conclusion.

Contrast-enhanced coded phase-inversion harmonic B-mode sonography coupled with an appropriate data analysis method is a new tool to identify and quantify vessel density in knee synovitis.

Correlation between synovial blood flow signals and serum vascular endothelial growth factor levels in patients with refractory rheumatoid arthritis

The objective of the study is to examine the relationship between synovial blood flow signals and vascular endothelial growth factor (VEGF) involved in angiogenesis by Doppler ultrasound. Twenty-one patients meeting the diagnostic criteria of the American College of Rheumatology (ACR) were enrolled in this study. Doppler ultrasound signals of blood flow in the wrist synovial membrane were measured and classified into three grades: grade 1 = no flow; grade 2 = mild flow; grade 3 = intense flow. A significant correlation was observed between blood flow signals in the wrist synovial membrane and serum VEGF levels (r = 0.5681, P = 0.0072). These results suggest that the measurement of Doppler ultrasound signals of blood flow in the wrist synovial membrane is useful in the evaluation of angiogenesis.

Quantitative assessment of synovial vascularity using contrast-enhanced power Doppler ultrasonography: correlation with histologic findings and mr imaging findings in arthritic rabbit knee model

Objective

To validate contrast-enhanced power Doppler ultrasonography (PD US) for the evaluation of synovial vascularity in an arthritic rabbit knee model in correlation with MR and histological findings.

Materials and Methods

Power Doppler ultrasonography was performed for carrageenin-induced arthritic left knee and control right knee of 13 rabbits, first without and then with sonic contrast agent enhancement (Levovist, Schering, Berlin Germany), followed by gadolinium-enhanced MR imaging. Synovial vascularity was quantitatively assessed by calculating the color pixel area in power Doppler sonography using a computer-aided image analysis program and by grading the enhancement on MR images: grade 1, enhancement of knee joint is less than one-third of the area; grade 2, one-third to two-thirds enhancement; and grade 3, more than two-thirds enhancement. Microvessel density (MVD) was measured on slides stained immunohistochemically for CD31 antigen for histological assessment.

Results

The mean area of color pixels in PD US changed from 4.37 to 16.42 mm² in the arthritic knee after enhancement (p < 0.05), whereas it changed from 0.77 to 2.31 mm² in the control knee (p < 0.05). Arthritic knees had greater power Doppler signal than control knees both before and after contrast administration (p < 0.05). The average MVD was 88 in arthritic knees and 46 in control knees. MVDs correlated with color pixel areas of contrast-enhanced power Doppler imaging in arthritic knees. In MR grading of arthritic knees, five were grade 2 and eight were grade 3. MVD and PD US revealed no significant difference between grade 2 and 3 arthritic knees (p > 0.05).

Conclusion

Sonic contrast-enhanced PD US improves the visualization of synovial vascularity and allows quantitative measurement in experimentally induced rabbit arthritic knees.

Sites of inflammation in painful rheumatoid shoulder assessed by musculoskeletal ultrasound and power Doppler sonography

Ultrasonography (US) and power Doppler sonography (PDS) was used to investigate causes of new onset of shoulder pain and sites of shoulder inflammation in 157 shoulders of 99 patients with rheumatoid arthritis (RA). US detected effusion and/or synovitis in 92/157 glenohumeral joints, subdeltoid bursitis in 56/157 shoulders and tenosynovitis of biceps tendon in 55/157 shoulders. Bursitis and/or tenosynovitis were accompanied by glenohumeral synovitis in 68/90 shoulders. 68% of serologically active and 12% of serologically inactive patients had glenohumeral synovitis. PDS showed increased microvascular blood flow in 33 of the 44 investigated shoulders. Glenohumeral synovitis was correlated to elevated C-reactive protein levels (p = 0.0001) and microvascular blood flow assessed by PDS (p = 0.02). This study shows that rheumatoid shoulder pain is not caused by glenohumeral synovitis in 32% of patients, despite serologically active RA. US and PDS are mandatory to elucidate the origin of inflammatory and noninflammatory shoulder pain.

Value of contrast-enhanced ultrasound in rheumatoid arthritis

The purpose of this review is to describe the spectrum of sonographic findings in rheumatic diseases with respect to the diagnostic potential using US contrast media which prove activity or inactivity in synovial tissue where new treatment regimes target. Synovial activity can be found in non-erosive and erosive forms of primary and secondary osteoarthritis, and in inflammatory forms of joint diseases like rheumatoid arthritis and peripheral manifestations of spondyloarthritis including, ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis and enteropathic arthritis. It can also be present in metabolic and endocrine forms of arthritis, in connective tissue arthropathies like systemic lupus erythematosus or scleroderma and in infectious arthritis. Ultrasound should be used as first-line imaging modality in suspected early cases of RA and other forms of arthritis, whereas contrast-enhanced ultrasound (CEUS) can further enable for sensitive assessment of vascularity which correlates with disease activity.

[Molecular imaging: future uses in arthritides]

Molecular imaging is an upcoming field in radiology as a result of great advances in imaging technology, genetics, and biochemistry in the recent past. Early-stage imaging of molecular pathological changes in cells opens the gates to new methods in medical treatment of diseases that otherwise would only be detected in advanced stages. Methods of imaging biochemical pathways with molecular agents are currently an issue of intensive research. This article reviews current modalities of molecular imaging in arthritis that should offer future perspective on early disease detection, diagnosis, and monitoring of treatment efficiency and how they can pave the way to optimized therapy.

Technology Insight: the role of color and power Doppler ultrasonography in rheumatology

An increasing number of rheumatologists have access to ultrasound equipment that provide both color and power Doppler modes, which can be used to investigate musculoskeletal and vascular pathologies. Musculoskeletal Doppler ultrasonography can be used to estimate levels of inflammation, to document the anti-inflammatory effect of agents such as corticosteroids and tumor necrosis factor inhibitors, to differentiate between inflammatory and degenerative disease, and to distinguish between normal and inflamed joints in cases of minor synovial swelling. Vascular Doppler ultrasonography can be used to determine organ involvement in small-vessel vasculitides, to delineate aneurysms in vasculitides of medium-sized arteries, and to assess the characteristic findings in large-vessel vasculitis. Numerous studies, including a meta-analysis, have been published on the use of temporal-artery ultrasonography for the diagnosis of giant cell arteritis. Duplex ultrasonography is a sensitive approach for detecting characteristic edematous wall swellings in active temporal arteritis and for assessing vasculitis of the axillary arteries (large-vessel giant cell arteritis) in patients with suspected temporal arteritis, polymyalgia rheumatica, or fever of unknown origin. Duplex ultrasonography can also be used to assess vasculitis of subclavian and carotid arteries in younger patients with Takayasu's arteritis and acute finger artery occlusions in patients with small-vessel vasculitides.

Neue Entwicklungen in der Gelenksonographie

Musculoskeletal ultrasonography has become an established imaging technique in rheumatology. The ability of ultrasonography to visualize soft tissue changes provides a possibility for differentiating between exudative and proliferative synovial tissue changes. Superficial cartilage and bone lesions can be detected earlier by ultrasonography than by conventional radiography. The application of Doppler and power Doppler ultrasonography is helpful for the detection of early inflammation. Current studies with ultrasound contrast media demonstrate its benefit in the differentiation of inflammatory processes. Musculoskeletal ultrasonography is helpful in the diagnosis of early arthritis, especially in patients with inconspicuous conventional radiography or suspicious clinical findings. It is a convenient method for follow-up analysis, and therefore has an impact on the monitoring of therapy. It is patient-friendly and is an important tool for the diagnostic work-up of arthritis.

Power Doppler Ultrasound in Musculoskeletal Disease: A Systematic Review

OBJECTIVE

To evaluate the performance characteristics of power Doppler ultrasound as a diagnostic and monitoring tool in the assessment of musculoskeletal disease through a systematic review of the literature.

METHODS

SEARCH STRATEGY

We performed a literature search of PUBMED (1966 to June 2005).

SELECTION CRITERIA

Only original research reports written in English involving musculoskeletal disease and power Doppler ultrasound were included. Reviews were noted but not included. Data Extraction/Reporting: The design, subjects, methods, imaging protocols, and performance characteristics studied in the research papers were reported.

RESULTS

Of 3568 identified reports, 139 involved power Doppler ultrasound of the musculoskeletal system. Fifty-three of these reports met the inclusion criteria. Ultrasound machine settings were specified in 63% of reports. Rheumatoid arthritis was the most commonly studied musculoskeletal disease (64% of papers). Validity was the most studied performance characteristic (94% of reports), while reliability and responsiveness were studied in 17 and 34%, respectively.

CONCLUSIONS

Although the majority of research reports of power Doppler ultrasound assessment of the musculoskeletal system evaluated validity, less than half reported reliability and responsiveness. Further work is needed to evaluate power Doppler ultrasound assessment of the musculoskeletal system before it can be used to guide clinical decisions or be used as an endpoint in clinical trials.

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.

Sonographie synovialer und erosiver entzündlicher Veränderungen

High-frequency sonography enables excellent detection of early erosions and synovial proliferations. Power Doppler sonography (PDUS) allows for an improved characterization of articular and peritendinous augmented volume, because detection of hypervascularity correlates with inflammatory activity and further is helpful in differentiation from effusion and inactive pannus. The use of contrast media improves the sensitivity of vascularity detection, because they allow for a delineation of vessels at the microvascular level. This is of increased interest, as the development of new therapeutic options targeting the microvascular level calls for earlier diagnosis and optimal assessment of disease activity. Because of good availability, cost effectiveness, and patient acceptance, sonography facilitates early diagnosis of synovial proliferations and erosions as well as therapy follow-up.

Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group

The purpose of this study way to assess the value of contrast enhanced gray-scale ultrasound (CEUS) in detection of vascularity in joints of patients with rheumatoid arthritis (RA) in a multicenter study of the International Arthritis Contrast Ultrasound (IACUS) study group. We assessed 113 joints in 113 patients (44 men, 69 women; mean age 51+/-14 years) with clinical diagnosis of RA. Gray-scale ultrasound (US), power Doppler US (PDUS) and CEUS, using a low mechanical index US technique, was performed. CEUS was done by bolus administration of the contrast agent SonoVue (Bracco, Milan, Italy) with a dosage of 4.8-ml SonoVue flushed with 10 ml saline. Detection of joint vascularity was performed for differentiation of active synovitis from inactive intra-articular thickening (synovitis/effusion). With the use of US and PDUS, active synovitis could be differentiated from inactive intra-articular thickening in 68/113 joints (60.1%), whereas CEUS enabled differentiation in 110/113 (97.3%) joints (p<0.0001). Thickness measurement of active synovitis was significantly improved after contrast administration (p=0.008). In conclusion, CEUS improves the differentiation of active synovitis from inactive intra-articular thickening. Since CEUS has shown an ability to improve assessment of vascularized synovial proliferation in RA affected joints, this technique may have further potential in monitoring therapy.