ELENI ANDIPA General Hospital of Athens G. Gennimatas

ELENI ANDIPA General Hospital of Athens G. Gennimatas

Technological advances over the last years have caused a dramatic improvement in ultrasound quality and resolution An established imaging modality for the diagnosis and follow up of patients with rheumatic diseases.

Absence of radiation Multiplanar imaging Bilateral examination Cost efficiency Availability Non-invasive Low patient discomfort Dynamic real time Extension of clinical evaluation

High quality equipment Multiple probes 5-20 MHz Color doppler Detailed anatomy Operator-dependant Learning curve

3D imaging-extended views Advantages in the acquisition process Machine dependent Evaluation of synovial perfusion Contrast media-harmonic Early diagnosis of arthritis Identification of subclinical synovitis Therapy monitoring Elastography Further research is required 3D imaging

Intra-articular structures Fluid Synovitis Bone erosion-osteophytes Cartilage Enthesopathy Peri-articular structures Bursae cysts Tendons Ligaments Muscles Nerves Skin

Abnormal hypoechoic or anechoic intraarticular material Displaceable Compressible No Doppler signal OMERACT US Group 2005 hypoechoic cartilage anechoic

US is highly sensitive in depicting very small quantities The most aspecific sign Absence of fluid makes joint disease less possible PIP volar aspect transverse

Abnormal hypoechoic intra-articular tissue Non-displaceable Poorly compressible May exhibit Doppler signal OMERACT US Group 2005 Dd from other elements, such as blood, pus or crystals can be difficult.

Rheumatoid arthritis Septic arthritis Crystal induced arthropathies Amyloid arthropathy Pigmented villonodular synovitis- PVNS Synovial chondromatosis Hemophilic arthropathy Dd cannot be based on US findings alone PVNS

fluid synovitis

Compression Color Doppler absence of Doppler signal does not exclude the possibility of synovitis FNA synovitis-increased vascularity

Color Doppler Correlation between disease activity and the degree of synovial inflammation, as this is documented with doppler technique

Dd fluid and synovial hypertrophy Dd active and inactive disease Follow up reduction of synovial hyperemia is associated with positive response to therapy

Intra-articular discontinuity of the bone surface Visible in two perpendicular planes OMERACT US group 2005 US can visualize more erosions than radiography Backhaus 1999 humerus head MCP joint

Cortical protrusions at the joint margin seen in two perpendicular planes Acoustic shadow OMERACT US group 2005 US more sensitive than radiography in the depiction of early osteoarthritis lesions.

One of the major methodological problems is to accurately quantify the changes seen in arthritis Synovial hypertrophy Effusion Doppler signal Bone erosion Which joints? Establishing accurate measurements is vital especially in cases of follow up. RAMRIS 2005 Szkudlarek 2003 Scheel 2005 Backhaus 2009 OMERACT 10 Sharp Symposium 2010 The ESPOIR Cohort 2010

Synovial hypertrophy. Grade 0-3 Vascularity. Grade 0-4 Osteophytes. Grade 0-3 Feydy Radiol Clin N Am 2009

Normal 1,2-1,9 mm Edema> 2,5 mm early stages Thinning Blurring surface chronic inflammation femoral condyle

Gouty arthritis Deposition of crystals on the cartilage Aggregates in the fluid Deposition of crystals within tendons Tophi- erosions US can reliably measure the tophi monitor the therapy Pseudogout. Double-contour sign Crystals in the fluid Gout. Double-contour sign, tophi, erosions Iagnocco Semin Ultrasound CT MRI 2011

Abnormally hypoechoic tendon or ligament at its bony attachement Visible in two perpendicular planes May exhibit Doppler signals Bony changes enthesophytes erosions irregularity plantar fascia OMERACT US Group 2005 achilles tendon

Hallmark of SpA Rheumatoid arthritis Crystal related arthropathies Osteoarthritis achilles tendon high sensitivity detect minimal entheseal abnormalities before MRI and clinical manifestation Kager fat

The synovial membrane lines also the tendon sheath and the bursa. US findings similar to the effusion and synovitis of joints. Bursitis is a common disease entity in RA olecranon bursitis subacromial subdeltoid bursitis

Synovial cysts are common complications of RA Result of increased intraarticular fluid One of the first pathological findings, described by US synovial hypertrophy increased vascularity ruptured massive

Degeneration of periarticular soft tissue Common in hand and foot Cystic masses filled with viscous fluid Lack synovial lining Anechoic Close to joint simple uncomplicated ganglion cyst ganglion cyst of the elbow compressing the ulnar nerve

giant cell tumor complicated ganglion cyst

Periarticular tendon examination is an important part of the evaluation of the joint Tendon ruptures and tenosynovitis are the most common pathologies in rheumatological diseases. tenosynovitis target pattern-transverse image

Hypoechoic or anechoic thickened tissue With or without fluid Seen in two planes May exhibit Doppler signal OMERACT US Group 2005 64-95% of patients with RA

Chronic synovial inflammation Weakening of the tendon Corticosteroids Involvement of supporting structures causes dislocation thinning of the supraspinatus dislocation of the long head biceps

Absence of the tendon Retraction Effusion Hypoechoic line hand, supraspinatus, patellar, tibialis posterior, Achilles extensor carpi ulnaris supraspinatus patellar tendon

Location Distance between the torn ends Early planning of surgical repair Dynamic evaluation achilles tendon flexor carpi unaris supraspinatus

Swelling Abnormal echotexture Discontinuity Dd from tendinitis partial tear tendinitis

US can depict ligaments Hand and wrist Elbow Shoulder Knee Foot Demonstrate pathology elbow: ulnar collateral ligament rupture of the talofibular ligament wrist: fibrocartilage complex

Inflammatory changes Ruptures rupture of the biceps milk-alkali syndrome gastrocnemious abscess

Frequent extra-articular manifestations in RA US is highly sensitive (88%) and specific (96%) in the diagnosis of CTS Normal: cross-sectional area CSA 10-12 mm 2 Pathological: CSA>15mm 2 increased CSA increased vascularity

High frequency probes >20 MHz Oedema, fibrosis, thickening Rheumatoid nodules normal skin nodules oedema, thickening

Diagnostic or therapeutic purposes Synovial biopsy Steroid injection Fluid aspiration Ganglia aspiration

Evaluation of patients with regional pain syndromes Identification of changes associated with early arthritis Study of inflammatory activity Therapy monitoring Guidance for invasive procedures Grassi Best Practice & Research 2005

Optimizing diagnosis Measuring disease activity Identifying prognostic factors Wells Ultrasound in Med. & Biol 2011 Iagnocco Semin Ultrasound CT MRI 2011

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