The Role of Ultrasonography in the Assessment of Rheumatic Diseases. Current and Potential Role of Ultrasonography in Rheumatology

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1 The Role of Ultrasonography in the Assessment of Rheumatic Diseases Karina D. Torralba, MD, MACM, CCD, Assistant Professor of Medicine, Keck School of Medicine, University of Southern California Objective: At the end of this session, the participant is expected to understand current and potential applications of ultrasonography in the diagnosis and management of rheumatic diseases Ultrasonography is a relatively new modality in the evaluation and management of patients with rheumatologic disorders. There has been an increasing interest amongst rheumatologist in the use of this imaging modality over the past two decades. Current and Potential Role of Ultrasonography in Rheumatology Ultrasonography has played a role in the following general areas: Complements physical examination Evaluates for subclinical synovitis in a patient with seemingly normal joint exam In joints that are swollen, US can Distinguish between synovial hypertrophy vs effusion, evaluate for active synovitis (doppler), can distinguish tenosynovitis vs arthritis Increases accuracy of office- procedures Disease activity assessment Treatment response monitoring Management Early Rheumatoid Arthritis: Use of Ultrasound Current studies have established the value of ultrasonography in the diagnosis and management of specific rheumatic diseases (Table 1). Studies are ongoing to further confirm these studies, and to clarify the role of US as part of classification criteria for these conditions. Much of the interest lies in establishing the diagnosis of rheumatoid arthritis early on as conventional radiographs are relatively insensitive in detecting erosions. Updated 2010 classification criteria for rheumatoid arthritis by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) currently do not include radiologic imaging as part of the criteria. Studies are ongoing to standardize the use of ultrasonography in the assessment of RA.

2 Table 1. Distinguishing ultrasonographic features noted in certain rheumatologic conditions. Condition Rheumatoid arthritis Spondyloarthropathies Ankylosing spondylitis Psoriatic Arthritis Crohn s Disease Ulcerative Colitis Reactive arthritis (formerly Reiter s) Gout Pseudogout/Calcium pyrophosphate Deposition Disease US: Utility/Findings (joint and tendon findings unless otherwise specified) Evaluation of Early RA* Synovitis or synovial proliferation: echogenic tissue proliferating within the joint cavity which can show PDS signal; Effusion: anechoic or hypoechoic intra- capsular collection which bows the capsule Erosions: an interruption of the bone surface visible in two planes. Tenosynovitis: anechoic or hypoechoic halo around the tendon; in chronic tenosynovitis non- homogeneous or even hyperechoic material (synovial tissue hyperplasia) may be observed within the distended sheath. Increased vascularity may be visualized with power Doppler signal Doppler signals Joint Effusion, Synovitis, Bone erosions Tenosynovitis: anechoic or hypoechoic halo around the tendon; in chronic tenosynovitis non- homogeneous or even hyperechoic material (synovial tissue hyperplasia) may be observed within the distended sheath. Increased vascularity may be visualized with PDS Tendinitis/tendinosis: swelling of the tendon with loss of the normal fibrillar pattern and areas of decreased echogenicity; Tendon rupture: hypoechoic gap in the body of the tendon in partial tear, full- thickness discontinuity in complete tear. Enthesitis: loss of normal fibrillar echogenicity, increasing thickness or intralesional focal changes of tendon insertion, calcific deposits at insertion of the tendon, periosteal changes (erosions or new bone formation). soft tophus- like lesion: homogenously echoic echotexture hard tophus- like lesion: hyperechoic band generating a posterior acoustic shadow mixed tophi: features of both soft and hard tophus double contour: focal or diffuse enhancement of the superficial articular cartilage layer (independent from the deposition of MSU crystals), whose reflectivity is independent of the angle of insonation hyperechoic spots: spots less than 1 mm in size with the same echogenicity of the bony cortex snowstorm appearance: hyperechoic spots floating in synovial fluid within the joint cavity in acute inflammation double contour: thin hyperechoic band (either focal or diffuse) within the cartilage layer punctate pattern: hyperechoic rounded or amorphous- shaped

3 Hydroxyapatite crystal deposition disease Osteoarthritis Systemic Lupus Erythematosus Sjogren s Syndrome (parotid gland, joints) Scleroderma (skin) Polymyositis/ Dermatomyositis (skin, muscle) Polymyalgia Rheumatica Giant Cell Arteritis/Temporal Arteritis/Cranial Arteritis (involved artery) areas in fibro- cartilage or tendons homogeneous hyperechoic nodular or oval deposits in bursae or articular recesses hypoechoic pattern with associated posterior shadowing, even for calcification less than 2-3 mm Joint Effusion Synovitis Popliteal Cyst in Knee OA Mucous cyst in patients with Heberden s nodes Osteophyte (Irregularity of bone contour) Cartilage damage (loss of cartilage margin sharpness, homogenenicity of cartilage layer, cartilage thinning Synovitis, synovial proliferation, effusion, Femoral head perfusion (CD/PD) Parenchymal echogenicity Homogeneity Presence of hypoechogenic areas Hyperechogenic lines and/or dots Clarity of glandular boundaries Defect in blood flow response pre and post secretory simulation Joints: Effusion, synovitis soft tissue calcifications narrowing of the distance between phalangeal apex and skin surface Soft tissue calcifications Chronic Myositis: Higher muscle echogenicity and more pronounced atrophy was usually present Acute Myositis: Lower echogenicity, muscle edema, +PD Effusions: Tendon sheath (LHBT), joint (GH, hip), bursae (SA/SD) Tenosynovitis (Wrist extensors/flexors; peroneals, ankle flexors, posterior tibial) Entesopathy Intimal edema ( Halo sign ) Stenosis (mix of colors on CD) Occlusion (lack of Doppler) Inflamed vessel: smooth, homogeneous, hypoechoic, concentric wall thickening Takayasu s Arteritis Small, homogeneous, hypoechoic, concentric wall thickening brighter than TA/GCA Macaroni sign Behcet s Disease Enthesopathy Synovial proliferation, effusion, synovitis, erosions; Baker s cyst CD: Color Doppler; PD: Power Doppler; TA/GCA: Temporal Arteritis/Giant Cell arteritis; LHBT: long head of biceps tendon, GH: Glenohumeral: SA/SD: Subacromial/Subdeltoid

4 Office- based procedures under US guidance Goals of US- guided procedures - increasing accuracy - improving efficacy - decreasing morbidity (i.e. pain, tendon rupture) Accuracy US- guided procedures in general allow increased accuracy of arthrocentesis, including seemingly simple procedures such as knee aspirations. Multiple studies have been done comparing the accuracy and outcomes of palpation- guided (blind) procedures vs ultrasound- guided procedures. In general US- guided procedures for needle placement increases accuracy by at least 90%. Palpation guided procedures have success rates of 30-50%. Ultrasonography increases accuracy of knee arthrocentesis by 96-99%, vs 30% by palpation; increases accuracy of injection/arthrocentesis of PIP and MCP joints up to 96%, vs 59% by palpation. US increases accuracy of hip injections by %. Efficacy Knowing the general pathology of a joint by ultrasonography also affects decision making on need for injection. For example, ultrasound allows distinction of an effusion vs synovial proliferation/hypertrophy - effusions are suspected by clinical exam, and arthrocentesis may be considered; but when ultrasonography is done, confirms the presence of no effusion and only synovial hypertrophy, then arthrocentesis may then be deferred. Morbidity Arthrocentesis/Joint and tendon injections are associated with risks of pain, bleeding, tendon rupture, skin atrophy. It has been noted that up to 25% of palpation- guided tendon injections are intratendinous. US- guided tendon sheath injections affords better accuracy and potentially less risk of tendon rupture. Studies by WL Sibbitt et al, have shown that pain scores, and outcome measures are improved by doing ultrasonography as opposed to doing them blind/palpation- guided.

5 Table 2. Studies looking at effectiveness of US- guided joint procedures (sampling) Joints, +/- steroid, +/- control vs comparison Inflamed joints (shoulder, elbow, wrist, knee, ankle), Corticosteroid injection Palpation guided vs US guided Small, interm, large joints Corticosteroid injection Palpation guided vs US guided Hip- native adult hip Corticosteroid injection Hip, OA, Viscosupplementation Knee Arthrocentesis corticosteroid injection Palpation guided vs US guided Ankle, Hind+Mid foot Chronic inflammatory diseases, Peroneal tendon sheath Palpation guided vs US guided Variable, Results Improved joint function (VAS) Accuracy Reference Cunnington J, et al Improvements: 43% in Sibbitt WL, et al 2009 procedural pain, 58% in absolute pain at 2 weeks, 75% reduction in significant pain, 25% increase in responder rate, 62% decrease in nonresponder rate; effusion detection 200%, volume of aspirated fluid 337% 97% Accuracy Smith J, et al % less pain at 6 months Pourbagher MA, et al % less procedural pain 183% increased aspirated synovial fluid volumes Improved outcomes at 2 weeks Led to change in diagnosis in 56(82%) of 86 patients - cancelled in 15% of 242 proposed sites - done in 74 (8%) of additional sites Efficacy of steroid injections in patients aware of US results (3 months) US guided: 100% accurate Palpation- guided: 60% accurate 2/6 partially accurate, and 2/2 inaccurate injections were intratendinous Sibbitt WL, et al 2012 D Agostino MA, et al 2005 Muir J, et al. 2011

6 REFERENCES Use of US in Rheumatology McAlindon T, et al. American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice. Arthritis Care Res (11): Porta F, et al. The role of Doppler ultrasound in rheumatic diseases. Rheumatology (Oxford) (6): Rheumatoid arthritis, US Aletaha D, et al Rheumatoid Arthritis Classification Criteria. An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative. Arthritis Rheum 2010;62(9): Thiele R. Ultrasonography applications in diagnosis and management of early rheumatoid arthritis. Rheum Dis Clin North Am May;38(2): Wakefield RJ, Gibbon WW, Conaghan PG, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis. Arthritis Rheum 2000;43(12); Szkudlarek M,et al. Interobserver Agreement in Ultrasonography of the Finger and Toe Joints in Rheumatoid Arthritis. Arthritis Rheum 2003 Vol. 48, No. 4, April 2003, pp Backhaus M, et al. Evaluation of a novel 7- joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Rheum (9): Foltz V, et al. Power Doppler Ultrasound, but Not Low- Field Magnetic Resonance Imaging, Predicts Relapse and Radiographic Disease Progression in Rheumatoid Arthritis. Arthritis Rheum 2012 Vol. 64, No. 1, January 2012, pp Brown AK. Using Ultrasonography to facilitate best practice in diagnosis and management of RA. Nat Rev Rheumatol 2009;5(13): Walter M, Harms H, Krenn V, et al. Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis. Arthritis Rheum 2001;44(2): Filippucci E, et al. Ultrasound imaging for the rheumatologist VII. Ultrasound imaging in rheumatoid arthritis. Clin Exp Rheumatol 2007; 25: Scire CA, et al. Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: power Doppler signal predicts short- term relapse. Rheumatology (Oxford) 2009;48(9): Peluso G, et al. Clinical and ultrasonographic remission determines different chances of relapse in early and long standing rheumatoid arthritis ARD 2011;70(1): Gout, US Dalbeth N, Doyle AJ. Imaging of gout. An Overview. Best Pract Res Clin Rheum (12): Grassi W, et al. Crystal Clear Sonographic Assessment of Gout and Calcium Pyrophosphate Deposition Disease. Semin Arthritis Rheum Dec;36(3): Epub 2006 Sep 29.

7 Osteoarthritis, US Meenagh G, et al. Ultrasound imaging for the rheumatologist VIII. Ultrasound imaging in osteoarthritis Clin Exp Rheumatol 2007; 25: Spondyloarthropathies (inc Psoriatic arthritis), US Riente L, et al. Ultrasound imaging for the rheumatologist IX. Ultrasound imaging in spondyloarthritis. Clin Exp Rheumatol 207; 25: Gutierrez M, et al. A sonographic spectrum of psoriatic arthritis: the five targets. Clin Rheumatol 2010;29: Connective Tissue Diseases, US Riente L, et al. Ultrasound imaging for the rheumatologist XIV. Ultrasound imaging in connective tissue diseases. Clin Exp Rheumatol 2008; 26: Delle Sedie A, et al. Ultrasound imaging for the rheumatologist XV. Ultrasound imaging in vasculitis. Clin Exp Rheumatol 2008; 26; US- Guided Procedures Epis O, et al. Ultrasound imaging for the rheumatologist XVI. Ultrasound- guided procedures Clin Exp Rheumatol 2008; 26; Sibbitt WL, Et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections. J Rheumatol 2009;36: Sibbitt WL, et al. Does ultrasound guidance improve the outcomes of arthrocentesis andcorticosteroid injection of the knee. Scan J Rheumatol 2012;41: Jones A, et al, Importance of placement of intra- articular steroid injections. BMJ 1993;307: Im SH, et al.feasibility of sonography for intra- articular injections in the knee through a medial patellar portal. J Ultrasound Med 2009; 28: J US Med 2009;28: Cunnington J, et al. A randomized, double- blind, controlled study of ultrasound- guided corticosteroid injection into the joint of patients with inflammatory arthritis Arthritis Rheum (7): Raza K, et al. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology 2003;42: Smith J, et al. Accuracy of Sonographically Guided Intra- articular Injections in the Native Adult Hip. JUM March 1, 2009 vol. 28 no Pourbagher MA, et al. Accuracy and Outcome of Sonographically Guided Intra- articular Sodium Hyaluronate Injections in Patients With Osteoarthritis of the Hip. JUM October 1, 2005 vol. 24 no Karim Z, et al. The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. Arthritis Rheum 2001; 44(12);

8 D Agostino MA, et al. Impact of Ultrasound Imaging on Local Corticosteroid Injections of Symptomatic Ankle, Hind-, and Mid- Foot in Chronic Inflammatory Diseases. Arthritis Rheum 2005 Vol. 53, No. 2, April 15, 2005, pp Muir JJ, et al. The Accuracy of Ultrasound- Guided and Palpation- Guided Peroneal Tendon Sheath Injections. Am J Phys Med Rehabil 2011; 90(7):