Sonographic appearance of chronic inflammatory rheumatism Poster No.: C-2237 Congress: ECR 2013 Type: Educational Exhibit Authors: H. Elfattach, F. Houari, O. Addou, M. Maaroufi, S. Tizniti ; 1 1 1 1 2 2 2 Fez/MA, Fès/MA Keywords: Inflammation, Connective tissue disorders, Arthritides, Education, Diagnostic procedure, Comparative studies, Ultrasound-Colour Doppler, Ultrasound, Conventional radiography, Musculoskeletal soft tissue, Musculoskeletal joint, Extremities DOI: 10.1594/ecr2013/C-2237 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 33
Learning objectives The optimal management of chronic inflammatory rheumatism requires tools that allow early and accurate disease diagnosis, prediction of poor prognosis and responsive monitoring of therapeutic outcomes. The musculoskeletal US has become a major imaging modality for rheumatologic indications and can be especially useful in the context of early and/or undifferentiated joint disease when detection of soft tissue and bone marrow abnormalities is desirable. The high-resolution image with innovative features such as tissue harmonics power Doppler technology improves the diagnostic capability. The purpose of our study was to show the role of ultrasonography in the diagnosis of rheumatoid arthritis, to assess its role as a first-line investigation compared to X-Ray imaging and illustrate the sonographic semiology patterns of inflammatory rheumatism. Page 2 of 33
Background Rheumatoid arthritis is a predominantly joint-based disease affecting approximately 1% of the world's population. It is a chronic systemic autoimmune disorder that primarily affects the synovium and if left untreated leads to disorganization and destruction of the joints. Synovial hypertrophy and angioneogenesis develop in the chronic phase of the condition, the hypertrophied synovium becoming locally invasive at the synovium-cartilage interface where it is thought to be responsible for causing bone erosions and subsequent joint destruction. We report a retrospective study of 50 patients with rheumatoid arthritis. Seen during the two-year period from January 2011 to January 2013. All patients were followed for consultation or hospitalized in the Rheumatology of the University Hospital Hassan II of Fez. They underwent ultrasound and x-ray imaging of their hands. The ultrasound examination was performed with a high frequency transducer 15 MHz to visualise the earlier abnormalities, including synovitis, tenosynovitis, bone erosions, enthesitis, and bursitis. The mean age was 50 years and mean duration of Reumatoid Arthritis was 5 years. 40 women and 10 men (sex ratio = 0.4). We will describe the characteristics of our population (table 1 and diagram 1). Page 3 of 33
Images for this section: Fig. 33: Frequency of our diagnosis results Fig. 31: our diagnosis results Page 4 of 33
Imaging findings OR Procedure details Imaging techniques 1. Musculoskeletal Ultrasound (US) : US is a relatively cheap, non ionsing, dynamic form of imaging that can provide both structural, functional and vascular information. The us is characterized by the flexible, repeatable and real-time imaging for clinical diagnosis, monitoring and intervention of rheumatologic practice. US allows the operator to make a clinical assessment of the patient at the time of imaging along with easily allowing examination of the contralateral side or additional joints. the potential difficulties with US assessment of the joints are the inability to compare temporal changes directly at the time of scanning, nonvisualization of internal bone structure, inability to assess bone edema, and inherent operator dependence of the technique. 2. Conventional radiography (CR) : CR has been widely used in both clinical and research settings to assess rheumatoid arthritis joint damage due to its feasibility, but it has limitations in early disease detection. CR has traditionally been the mainstay for imaging patients with rheumatoid arthritis; findings such as soft-tissue swelling, periarticular osteopenia, joint space loss, joint subluxation, and marginal erosions are all features that may be seen. However, information regarding the synovium is much more difficult to assess on radiographs. 3. MRI : The Magnetic resonance imaging is the golden standard in the field of rheumatism. It has the advantage of providing a more global view of the joint, including the articular surfaces and internal bone structure. The disadvantages of using MRI include motion artifact, the increased time necessary for the examination, feasibility and potentially invasive administration of a contrast agent. Normal Sonographic Anatomy (figures 1,2,3,4,5,6) Sonographically, tendons are echogenic fibrillar structures that consist of multiple parallel lines in longitudinal planes and multiple dotlike echoes in transverse planes. Page 5 of 33
The synovial sheath is depicted as a thin echogenic fluid-containing structure that surrounds the echogenic tendon fibers. The synovial fluid is usually but not always anechoic. Clinical presentation Patients most frequently present with pain and stiffness in one or multiple joints. The wrists, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints are the most commonly affected joints, but any synovial joint can be affected. Usually bilateral and symmetric. Women are more commonly affected than men. In addition to joint-based pathology, patients may present with extraarticular manifestations of the disease, such as enthesopathy, bursitis, tenosynovitis, and tendon rupture. Sonographic Technique The ultrasound examination was performed with a high frequency transducer 15 MHz to visualise the earlier abnormalities, including synovitis, tenosynovitis, bone erosions, enthesitis, and bursitis. All images were acquired by using a commercially available sonographic system with a 15MHz linear-array transducer. Gaining comparable pictures of the same anatomical area during different time A large standoff mound of gel was used to allow optimal visualization of the most superficial structures. The probe placed in an appropriate position for imaging of the specific areas of interest : Sonographic Technique of the wrist(figures 7,8,9,10) Sonographic Technique of the ankle(figures 11,12,13,14) Musculoskeletal Ultrasound findings The musculoskeletal US showed: 100 cases of synovitis, 40 of tenosynovitis, 5 bone erosions and 50 positive Doppler signals (Table 2). SEMIOLOGY PATTERNS 1. Synovitis : (figures 15,16,17,18,19,20) The synovial fluid is an abnormal hypoechoic or anechoic intraarticular material that can be displaced and compressed, but without Doppler signal. Page 6 of 33
The synovial hypertrophy that is represented by a hypoechoeic material that is non-displaceable, poorly compressible and may exhibit Doppler signal. The nondisplaceable nature of synovitis on ultrasound is important because this characteristic distinguishes joint fluid from synovial thickening; however, these two entities frequently coexist within one joint. The use of power Doppler has made it possible for US to determine the degree of synovial vascularity. This can be assessed semi-quantitatively by scoring the amount of PD signals within the joint capsule on a 0-3 scale. Power Doppler ultrasound (PDUS) is shown to correlate well with histologically detected synovitis in inflamed joints and is reliable in qualitative grading of the synovium vascularity. Ultrasound has the advantage of clinical correlation and dynamic assessment of the joints at the time of scanning and is increasingly being performed by rheumatology clinicians in the outpatient setting. 2. Bone erosions : (figures 21,22) The OMERACT definition of an erosion seen on ultrasound imaging is an intraarticular discontinuity of the bone surface that is visible in two perpendicular planes. US detects more RA joint erosions than CR especially in the context of early disease. Its limitations arise in areas where there is a poor acoustic window, such as in the mid-carpus, and the misinterpretation of normal anatomic variants as erosions. When compared with gold standard CT, US has a moderate sensitivity but a high specificity and accuracy in detecting MCPJ erosions in RA. 3. Tenosynovitis : (figures 23,24,25,26,27) The tenosynovitis on US is defined an hypoechoic or anechoic thickened tissue seen in two perpendicular planes with or without tendon sheath fluid and Doppler signal. Tenosynovitis is seen on ultrasound as an inflammation of the synovial sheath appearing on ultrasound as a concentric anechoic or hypoechoic swelling around the tendon. 4. Bursitis : (figure 28) Bursitis is characterised by an increase in the synovial fluid that usually appears as a sharply defined anechoic area. Its the fluid collections more or less limited, more or less compressible, often heterogeneous echogenicity. Its walls are generally highly vascularized in power Doppler. Page 7 of 33
5. Enthesopathy : (figures 29,30) the enthesis has appeared hypoechoic or heterogeneous with possible thickening of it. Cortical erosions; Enthesophytes; Ossification; Doppler + Bursitis may be associated. Page 8 of 33
Images for this section: Fig. 1: Normal sonographic appearances of the carpal tunnel. Transverse sonogram shows the flexsor surface of the left wrist with a normal small volume of anechoic synovial fluid in the tendon sheath between the flexor tendons. Page 9 of 33
Fig. 2: Normal sonographic appearances of the radiocarpal joint. Longitudinal sonogram shows the radiocarpal joint of the left wrist with a normal small volume of anechoic synovial fluid in the tendon sheath. Page 10 of 33
Fig. 3: Normal sonographic appearances of the metacarpophalangeal. Longitudinal sonogram Page 11 of 33
Fig. 4: Normal appearance of Metatarsophalangeal joint. Longitudinal section Page 12 of 33
Fig. 5: Normal sonographic appearances of the talo-tibial joint. Longitudinal sonogram Fig. 6: Normal Ultrasound appearance of the Achilles tendon in axial (A) and longitudinal section (B) Page 13 of 33
Fig. 7: Probe transverse to dorsal aspect of wrist: - Distal radioulnar joint; - Extensor tendons. Page 14 of 33
Fig. 8: Probe sagittal to dorsal aspect of wrist:distal radioulnar joint and Midcarpal joints. Page 15 of 33
Fig. 9: Probe longitudinal to metacarpophalangeal joint Page 16 of 33
Fig. 10: Probe longitudinal to proximal interphalangeal joint Page 17 of 33
Fig. 11: Probe Sagittal talocrural Page 18 of 33
Fig. 12: Probe axial (A) and sagittal (B) of the Achilles tendon Page 19 of 33
Fig. 13: Probe Sagittal plantar fascia Page 20 of 33
Fig. 14: Sagittal of the dorsal metatarsophalangeal joint Page 21 of 33
Fig. 15: Longitudinal sonograph showed the radiocarpal synovitis Fig. 16: B-mode and colour Doppler ultrasonography examined in longitudinal sonogram showed Active synovitis (+2) of the radiocarpal joint Page 22 of 33
Fig. 17: Longitudinal section showing normal appearance of the metacarpophalangeal joint (A) and synovitis of the first metacarpophalangeal joint, hypervascular on power doppler Fig. 18: Longitudinal sonograph demonstred Non active synovitis of the first metacarpophalangeal joint (A) and Active synovitis of the second metacarpophalangeal joint (B). Page 23 of 33
Fig. 19: Inactive synovitis of the proximal interphalangeal joint. Longitudinal section Page 24 of 33
Fig. 20: Subtalar joint synovitis with intraarticular effusion. Longitudinal section. Page 25 of 33
Fig. 21: Longitudinal section demonstrating the radial erosion (*) with hypervascular synovitis of radio carpal joint Fig. 22: Bone erosion with active synovitis of the second MCP joint. Longitudinal section Page 26 of 33
Fig. 23: Axial section showed the tenosynovitis of the extensor digitorum Fig. 24: Axial (A) section showing tenosynovitis of the extensor pollicis brevis with normal aspect of abductor pollicis longus and Longtitudinal (B) ultrasound shows tenosynovitis Of the extensor pollicis brevis with active power Doppler Page 27 of 33
Fig. 25: Significant tenosynovitis involving the long and short extensor carpi radialis tendons, hypervascular at color Doppler with multiples damages of the long digital extensor tendon. Fig. 26: Finger flexor tenosynovitis -B-mode (B) and Hypervascularization on power Doppler (C) Page 28 of 33
Fig. 27: Tenosynovitis of the peroneus brevis tendon. Longitudinal section. Fig. 28: Tear of the main body of right Achilles tendon communicating with a fluid collection. Axial view (A).Left retrocalcaneal Bursitis. Longitudinal section (B). Page 29 of 33
Fig. 29: Achilles enthesopathy with enthesophytes (A) and positive doppler signal (B). Longitudinal section Fig. 30: The exploration of the two Achilles tendons shows ossification of the both calcaneal insertion with Achilles enthesophytes. Longitudinal section Page 30 of 33
Fig. 32 Page 31 of 33
Conclusion Rheumatoid arthritis is a potentially devastating condition affecting a large proportion of the population; Treatment has significantly progressed in recent years and outcomes, particularly when disease is diagnosed and treated at an early stage, are now significantly improved. As techniques that detect early disease, ultrasound will become increasingly important in the diagnosis and management of this condition. Page 32 of 33
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