Clinical evaluation during the acute exacerbation of knee osteoarthritis: the impact of diagnostic ultrasonography

We aimed to investigate (1) the probable correlation between clinical and ultrasonographic findings in chronic painful primary knee OA patients referred with acute flare-ups and (2) the impact of diagnostic ultrasonography (US) to determine the real source of pain in these patients. We included 100 patients consecutively who were admitted to our outpatient unit with a pain complaint on a single knee with the diagnosis of primary knee OA according to the ACR criteria. The control group consisted of the patients with pain-free knees at least during the last month, who were already included in the study group. The sonographic evaluation of the knee was performed by a physician who was blinded to the clinical evaluation and/or the physical and radiological evaluations. In the present study, sonographic findings were significantly more observed on the painful knees (p < 0.001). The most commonly encountered findings on the symptomatic knees were the suprapatellar effusion (55 %), the baker cyst (25 %), and the pes anserine bursitis. The distribution of the findings on the asymptomatic knees was as follows: 22 %, the suprapatellar effusion and 5 %, the Baker cyst. Effusion was detected in 55 % of the painful knees of our patients with knee OA. This finding was statistically significant compared to the painless knees of the subjects included. The results of our study also showed that there was a significant relation between the Kellgren–Lawrence grading and the frequency of suprapatellar effusion on US examination (p = 0.026). It was concluded that in chronic, primary, painful knee osteoarthritis, US is a valuable diagnostic method in the confirmation of synovitis and/or the inflammatory episode in spite of the absence of obvious clinical parameters. In advanced osteoarthritis, when we consider that the inflammatory episodes are expected findings, the early confirmation of the inflammation on US may be particularly valuable in the clinical setting.     

Ultrasonographic evaluation of pes anserinus tendino-bursitis in patients with type 2 diabetes mellitus

OBJECTIVE: To assess musculoskeletal ultrasonographic (US) findings in patients with type 2 diabetes mellitus (DM) with and without pes anserinus (PA) tendinitis or bursitis syndrome; and to determine possible etiologic factors such as systemic diabetic microvascular disease complications in these patients. METHODS: The knee joints were examined with an ultrasound real-time scanner using a 10 MHz electronic linear transducer in 48 patients with type 2 DM and 25 controls. The presence of systemic diabetic microvascular disease complications was evaluated. RESULTS: On examination 23 (23.9%) knees of the 14 (29.1%) patients with type 2 DM were found to have PA tendinitis or bursitis syndrome. US revealed that only 4 (8.3%) of the diabetic patients with PA tendinitis or bursitis syndrome had PA tendonitis findings. There were no significant differences in the thickness of PA tendons between the diabetic patients with bilateral knee PA tendinitis or bursitis syndrome (9 patients) and controls, or between the asymptomatic and symptomatic knees in patients with unilateral PA tendinitis or bursitis syndrome (5 patients). The prevalence of morphologic changes of the medial meniscus, effusion and synovitis in the suprapatellar recess, popliteal cyst, and radiographic osteoarthritis (OA) in the diabetic patients with PA tendinitis or bursitis syndrome was found to be increased. CONCLUSION: The prevalence of PA tendinitis or bursitis syndrome is not uncommon on examination in patients with type 2 DM. However, patients with clinically diagnosed PA tendinitis or bursitis syndrome less frequently have morphologic US changes of the PA tendons. Our results also suggest that structural changes such as meniscus lesions that occur in consequence of OA might have a role in the etiology of medial knee pain in diabetic patients.     

Magnetic resonance imaging and ultrasonographic evaluation of the patients with knee osteoarthritis: a comparative study

The objectives of the present work were (1) to establish the prevalence of the abnormalities detected by magnetic resonance imaging (MRI) and ultrasonography (US); and (2) to compare these imaging techniques in detail. The study group consisted of 58 patients with symptomatic knee OA and 16 volunteer control subjects. Knee joint was evaluated for femoral condylar cartilage changes, effusion, synovial thickening and popliteal cysts using MRI and US. All knees with OA had cartilage abnormalities on US examinations and normal cartilage was detected in less than 3% of these knees by MRI. Majority of the knees with OA had effusion using US (70%) or MRI (85%). Synovial thickening observed on US (34%) and MRI (50%) were common in the knees with OA. Popliteal cysts were detected in 40% of the knees with OA using US and 35% using MRI. This study confirmed that there was a significant correlation between the MRI and US techniques for evaluating the cartilage and soft tissue changes in the patients with knee OA. There were more significant differences between the controls and the symptomatic knees which had Kellgren-Lawrence (K-L) grade 2 or more OA for the cartilage and soft tissue abnormalities on MRI and US. The prevalence of cartilage changes, effusion, synovial thickening and popliteal cyst using MRI and US were increased as the radiographic grade of OA increased. US examinations could be an alternative to initial evaluation tool to MRI in patients with knee OA.     

Intra-articular methotrexate in the treatment of rheumatoid arthritis and psoriatic arthritis: a clinical and sonographic study

The aim of our study was to evaluate the effects of intra-articular methotrexate (MTX) in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Twenty-three consecutive patients, 10 with RA and 13 with PsA, with prevalent or unique arthritic involvement of one knee, were treated with intra-articular injections of MTX 10 mg every 7 days for 8 weeks. Before the beginning of the treatment and after 9 and 17 weeks, the patients underwent a clinical evaluation measuring maximal knee flexion angle, visual analog scale (VAS) and erythrocyte sedimentation rate (ESR). On the same days, an ultrasonographic examination of the involved knee was performed by two independent experienced operators. Synovial thickness in the suprapatellar bursa and the presence of joint effusion and Bakers cyst were assessed. An increase of the mean value of maximal knee flexion angle and a reduction of the mean values of ESR and VAS between T0, T9 and T17 were demonstrated. Ultrasonographic evaluation showed significant reduction of synovial thickness and joint effusion. No differences were detected for the presence of Bakers cyst. We may conclude that repeated intra-articular injections of MTX resulted in a decrease of local as well as systemic inflammatory signs. As far as we know, this is the first study that explores the effects of intra-articular MTX in RA and PsA both clinically and by ultrasonography.     

类风湿关节炎310膝次膝关节镜镜下分析

目的 探讨类风湿关节炎(RA)膝关节病变的关节镜下表现.方法 回顾分析2005年12月至2008年2月佛山市第一人民医院223例RA住院患者310膝次膝关节镜术中镜下所见,分析RA膝关节病变的特征.结果 310膝次中的305膝次(98.4%)有不同程度的滑膜增生,探查膝关节各区域以内侧间隙、髁间窝、外侧间隙滑膜增生明显增多,分别为274(88.4%)、267(86.1%)和258(83.2%)膝次,髌上囊滑膜增生最少见,为152膝次(49.0%);296膝次增生滑膜的镜下表现为珊瑚或棉絮样,9膝次表现为苔藓样增生.301膝软骨可见不同程度软骨变性或缺损,股骨内、外髁软骨变性合并软骨破坏或缺损分别为124、163膝.单纯软骨变性63膝.51膝的前交义韧带部分断裂,5膝次完全断裂,后交叉韧带部分断裂23膝,1膝次完伞断裂.内侧半月板撕裂、基本或完全消失的膝次分别为234、38膝次,外侧分别为214、45膝次.结论 RA膝关节多有滑膜增生,髁间窝及内、外侧问隙最多见,髌上囊相对较少;增生滑膜形态以珊瑚或棉絮样为主.RA膝关节软骨破坏常见,股骨内、外髁处最为明显;部分膝关节可见前、后交义韧带部分或完伞断裂;大部分RA膝关节有半月板病变.     

类风湿关节炎310膝次膝关节镜镜下分析

目的 探讨类风湿关节炎(RA)膝关节病变的关节镜下表现.方法 回顾分析2005年12月至2008年2月佛山市第一人民医院223例RA住院患者310膝次膝关节镜术中镜下所见,分析RA膝关节病变的特征.结果 310膝次中的305膝次(98.4%)有不同程度的滑膜增生,探查膝关节各区域以内侧间隙、髁间窝、外侧间隙滑膜增生明显增多,分别为274(88.4%)、267(86.1%)和258(83.2%)膝次,髌上囊滑膜增生最少见,为152膝次(49.0%);296膝次增生滑膜的镜下表现为珊瑚或棉絮样,9膝次表现为苔藓样增生.301膝软骨可见不同程度软骨变性或缺损,股骨内、外髁软骨变性合并软骨破坏或缺损分别为124、163膝.单纯软骨变性63膝.51膝的前交义韧带部分断裂,5膝次完全断裂,后交叉韧带部分断裂23膝,1膝次完伞断裂.内侧半月板撕裂、基本或完全消失的膝次分别为234、38膝次,外侧分别为214、45膝次.结论 RA膝关节多有滑膜增生,髁间窝及内、外侧问隙最多见,髌上囊相对较少;增生滑膜形态以珊瑚或棉絮样为主.RA膝关节软骨破坏常见,股骨内、外髁处最为明显;部分膝关节可见前、后交义韧带部分或完伞断裂;大部分RA膝关节有半月板病变.     

类风湿关节炎310膝次膝关节镜镜下分析

目的 探讨类风湿关节炎(RA)膝关节病变的关节镜下表现.方法 回顾分析2005年12月至2008年2月佛山市第一人民医院223例RA住院患者310膝次膝关节镜术中镜下所见,分析RA膝关节病变的特征.结果 310膝次中的305膝次(98.4%)有不同程度的滑膜增生,探查膝关节各区域以内侧间隙、髁间窝、外侧间隙滑膜增生明显增多,分别为274(88.4%)、267(86.1%)和258(83.2%)膝次,髌上囊滑膜增生最少见,为152膝次(49.0%);296膝次增生滑膜的镜下表现为珊瑚或棉絮样,9膝次表现为苔藓样增生.301膝软骨可见不同程度软骨变性或缺损,股骨内、外髁软骨变性合并软骨破坏或缺损分别为124、163膝.单纯软骨变性63膝.51膝的前交义韧带部分断裂,5膝次完全断裂,后交叉韧带部分断裂23膝,1膝次完伞断裂.内侧半月板撕裂、基本或完全消失的膝次分别为234、38膝次,外侧分别为214、45膝次.结论 RA膝关节多有滑膜增生,髁间窝及内、外侧问隙最多见,髌上囊相对较少;增生滑膜形态以珊瑚或棉絮样为主.RA膝关节软骨破坏常见,股骨内、外髁处最为明显;部分膝关节可见前、后交义韧带部分或完伞断裂;大部分RA膝关节有半月板病变.     

Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients

OBJECTIVE: To determine the frequency and localization of synovitis and enthesitis in patients with active, untreated polymyalgia rheumatica (PMR) by ultrasonography (US). METHODS: Polyarticular sonographic evaluation was carried out in 50 consecutive patients with PMR at disease onset. Results were compared with 50 consecutive patients with seronegative spondyloarthropathies (SpA) and 50 with seronegative and seropositive rheumatoid arthritis (RA) at disease onset. RESULTS: Synovitis and/or effusion was detected, in at least one joint, in 100% of patients with PMR. The most frequent alterations observed in patients with PMR were effusion in the subacromial-subdeltoid (SA-SD) bursa in 70% of patients, tenosynovitis of the long head of the biceps tendon (LHBT) in 68%, glenohumeral joint effusion in 66%, tenosynovitis of the flexor tendons in the carpal tunnel in 38%, radiocarpal effusion in 18%, wrist extensors tenosynovitis in 18%, coxofemoral joint effusion in 40%. knee effusion in 38%, and ankle effusion in 10%. Enthesitis and tendonitis of the anchoring tendons were relatively rare in all the articular sites. Comparison of the SpA and PMR patients showed that enthesitis (mostly in the elbow, knee, and heel) was significantly more frequent in SpA. There was a significant difference in glenohumeral and coxofemoral effusion between the PMR and SpA patients (66% vs 16% and 40% vs 14%, respectively). Comparison of PMR and RA patients showed no significant difference in the involvement of entheses, shoulder, hip, or wrist flexor tendons in the carpal tunnel. Synovitis of the elbow, knee, and wrist was significantly more frequent in the SpA and RA patients than in those with PMR. CONCLUSION: Synovitis was detected in at least one site in 100% of patients with PMR. SA-SD bursitis, LHBT tenosynovitis, carpal tunnel syndrome, and glenohumeral, knee and hip synovitis were the most frequent alterations in PMR. Enthesitis was relatively rare at any articular site.     

EULAR report on the use of ultrasonography in painful knee osteoarthritis. Part 1: prevalence of inflammation in osteoarthritis

Objectives: To assess the prevalence of inflammation in subjects with chronic painful knee osteoarthritis (OA), as determined by the presence of synovitis or joint effusion at ultrasonography (US); and to evaluate the correlation between synovitis, effusion, and clinical parameters. Methods: A cross sectional, multicentre, European study was conducted under the umbrella of EULAR-ESCISIT. Subjects had primary chronic knee OA (ACR criteria) with pain during physical activity ?30 mm for at least 48 hours. Clinical parameters were collected by a rheumatologist and an US examination of the painful knee was performed by a radiologist or rheumatologist within 72 hours of the clinical examination. Ultrasonographic synovitis was defined as synovial thickness ?4 mm and diffuse or nodular appearance, and a joint effusion was defined as effusion depth ?4 mm. Results: 600 patients with painful knee OA were analysed. At US 16 (2.7%) had synovitis alone, 85 (14.2%) had both synovitis and effusion, 177 (29.5%) had joint effusion alone, and 322 (53.7%) had no inflammation according to the definitions employed. Multivariate analysis showed that inflammation seen by US correlated statistically with advanced radiographic disease (Kellgren-Lawrence grade ?3; odds ratio (OR) = 2.20 and 1.91 for synovitis and joint effusion, respectively), and with clinical signs and symptoms suggestive of an inflammatory "flare", such as joint effusion on clinical examination (OR = 1.97 and 2.70 for synovitis and joint effusion, respectively) or sudden aggravation of knee pain (OR = 1.77 for joint effusion). Conclusion: US can detect synovial inflammation and effusion in painful knee OA, which correlate significantly with knee synovitis, effusion, and clinical parameters suggestive of an inflammatory "flare".     

Ultrasound of the knee during voluntary quadriceps contraction: A technique for detecting otherwise occult effusions

Objective

To describe 1) a technique that can detect synovial effusions not seen on static ultrasound (US) examination and 2) the characteristics of patients with knee osteoarthritis (OA) for whom this technique proved useful.

Methods

From reviewed records of 76 patients with knee OA (112 knees) that we had seen for US‐guided injections over a defined period, we found 45 knees with no detectable effusion on static US, of which 18 (14 patients) showed fluid when scanned during voluntary quadriceps contraction. For all patients, we had recorded effusion features (physical examination, presence and size on US), and success of joint entry was determined by getting synovial fluid and/or seeing an air echo or inflow of injected material.

Results

The 14 patients we studied were obese (mean ± SEM body mass index 32.7 ± 2.3 kg/m²; 3 morbidly obese), with moderate to severe OA by radiography in most (Kellgren/Lawrence class 3 or 4 in 10 of 14 knees for which radiographs were available). The suprapatellar synovial space seen by US was small (mean ± SEM depth 0.38 ± 0.04 cm). Arthrocentesis obtained 0.5–16 ml of synovial fluid (mean ± SEM 2.9 ± 0.6 ml), which correlated with the depth of effusion as seen on US with the quadriceps in maximum contraction (Spearman's ρ = 0.5597, P = 0.0157). In 4 knees where arthrocentesis failed to retrieve fluid, we observed at injection the inflow of material and a linear air echo.

Conclusion

US of the knee during voluntary quadriceps contraction can find effusions not detectable on static US. Such effusions provide targets for accurate aspiration and injection that would not be appreciated with static US.     

Power Doppler sonography in the evaluation and follow-up of knee involvement in patients with juvenile idiopathic arthritis

INTRODUCTION: This study was undertaken to evaluate the role of ultrasound (US), conventional color (CD) and power Doppler (PD) in the detection and quantification of inflammatory signs of the knee in children with juvenile idiopathic arthritis (JIA) and to correlate these findings with patient history, clinical, laboratory and radiological findings. PATIENTS AND METHODS: Thirty patients with JIA who had clinical signs of knee involvement as well as 15 healthy children as a control group where subjected to full clinical examination and laboratory investigations on the same day of US examination. The knee joints were evaluated with plain radiography, US, and color Doppler in 13 patients, while the remaining 17 were assessed with power Doppler. Fourteen patients were subjected to follow-up assessment. RESULTS: A highly significant difference in synovial thickening and cartilage thickness detected by US between JIA affected knees and those of controls (p < 0.0001). Knee effusion was demonstrated in 93% of patients. Synovial vessels were detected by Doppler in 76.7% of patients. A significant correlation was detected between the degree of vascularity detected by PD and knee score (p < 0.05), and JAFAR score (P < 0.05). On comparing the findings of the follow-up with those of the initial examination, a significant positive correlation was detected between the differences in the knee score and those in synovial thickness (p < 0.05), and with the vascularity scale detected by PD (p < 0.05). CONCLUSION: This study suggests the Doppler sonography as a non-invasive, low-cost, and readily available tool for the evaluation and follow-up of articular involvement in knees of JIA patients.     

Accuracy in detecting knee effusion with clinical examination and the effect of effusion,the patient's body mass index,and the clinician's experience

The purpose of this study was to determine the accuracy of detecting knee effusion with clinical examination and to evaluate whether the amount of effusion, patient obesity, and the clinicians' experience affect the clinicians' decisions in patients with knee osteoarthritis. Patients presenting with knee pain were examined by two residents with different levels of experience and underwent ultrasonographic examination, including measurement of effusion in the medial, mid, and lateral aspects of the suprapatellar bursa. One hundred seventy-two knees of 86 patients were examined. Of the knees investigated, 127 (73.8 %) had effusion. The consistency between ultrasonographic and resident examination were weak (κ?=?0.193, p?=?0.007 and κ?=?0.349, p?<?0.001), although the more experienced senior resident had a stronger agreement. The overall inter-rater agreement between the two residents was low (κ?=?0.254). The senior resident had a significantly higher accuracy ratio (p?=?0.036). In the knees without effusion, the two examiners had no agreement (κ?=??0.028, p?=?0.856); however, the ratios of the true decisions were similar (p?=?1.0). The accuracy of the less experienced resident's decisions was affected by effusion depth (p?=?0.005). Clinicians' decisions and their accuracy in detecting knee effusion during clinical examination were different, especially in the absence of effusion. The consistency between ultrasonography and residents was low. The accuracy of clinical examination was affected by effusion depth and experience, but not by patient obesity.     

Pes anserinus tendino-bursitis: what are we talking about?

We studied the ultrasonographic (US) features of the pes anserinus insersion (PA) and subcutaneous medial knee fat in patients clinically diagnosed of pes anserinus tendino-bursitis (PATB) syndrome. Thirty seven consecutive patients with suspected PATB were clinically evaluated and their knees examined using a 7.5 MHz linear probe. In twenty-three patients with unilateral clinical PATB (group A) the painful knee was compared with their painless opposite knee. Six patients with bilateral clinical PATB (group B) were compared with 6 healthy controls (group C). All patients were women with radiographic knee osteoarthritis in 93% and body mass index > 27 in 75%. US pes anserinus tendinitis was found in one symptomatic knee and pes anserinus bursitis in two symptomatic knees and in one asymptomatic knee. No US signs of panniculitis were found in patients and controls. In conclusion, patients diagnosed of PATB syndrome in rheumatology rarely have US tendinitis or bursitis of the PA.     

Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with grey scale and power Doppler ultrasonography

OBJECTIVE: To compare the clinical assessment of overall inflammatory activity in patients with rheumatoid arthritis (RA) with grey scale and power Doppler (PD) ultrasonography (US). METHODS: Ninety four consecutive patients with RA were included. Demographic and clinical data, C reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) were recorded for each patient. The presence of tenderness, swelling, and a subjective swelling score from 1 to 3 were independently assessed by two rheumatologists, who reached a consensus in 60 joints examined in each patient. All patients underwent a US examination by a third blinded rheumatologist, using PD. US joint effusion, synovitis, and PD signal were graded from 1 to 3 in the 60 joints. Joint count and joint index for effusion, synovitis, and PD signal were recorded. A 28 joint count for clinical and US variables was calculated. Interobserver reliability of the US examination was evaluated by a fourth blinded rheumatologist. RESULTS: US showed significantly more joints with effusion (mean 15.2) and synovitis (mean 14.6) than clinical examination (mean 11.5, p<0.05). A significant correlation was found between joint count and joint index for swelling, US effusion, synovitis, and PD signal. The 28 joint count for effusion, synovitis, and PD signal correlated highly with the corresponding 60 joint counts. US findings correlated better with CRP and ESR than clinical measures. Interobserver reliability was better for US findings than for clinical assessment. CONCLUSION: US is a sensitive method for assessing joint inflammatory activity in RA, complementary to clinical evaluation.     

Power Doppler sonography in the evaluation and follow-up of knee involvement in patients with juvenile idiopathic arthritis

Introduction This study was undertaken to evaluate the role of ultrasound (US), conventional color (CD) and power Doppler (PD) in the detection and quantification of inflammatory signs of the knee in children with juvenile idiopathic arthritis (JIA) and to correlate these findings with patient history, clinical, laboratory and radiological findings. Patients and methods Thirty patients with JIA who had clinical signs of knee involvement as well as 15 healthy children as a control group where subjected to full clinical examination and laboratory investigations on the same day of US examination. The knee joints were evaluated with plain radiography, US, and color Doppler in 13 patients, while the remaining 17 were assessed with power Doppler. Fourteen patients were subjected to follow-up assessment. Results A highly significant difference in synovial thickening and cartilage thickness detected by US between JIA affected knees and those of controls (p<0.0001). Knee effusion was demonstrated in 93% of patients. Synovial vessles were detected by Doppler in 76.7% of patients. A significant correlation was detected between the degree of vascularity detected by PD and knee score (p<0.05), and JAFAR score (P<0.05). On comparing the findings of the follow-up with those of the initial examination, a significant positive correlation was detected between the differences in the knee score and those in synovial thickness (p<0.05), and with the vascularity scale detected by PD (p<0.05). Conclusion This study suggests the Doppler sonography as a non-invasive, low-cost, and readily available tool for the evaluation and follow-up of articular involvement in knees of JIA patients.     

Distribution of effusion in knee arthritis as measured by high-resolution ultrasound

Information about the distribution of effusion within the arthritic knee joint should be considered in selecting an anatomical approach for arthrocentesis. We recorded ultrasound measurements of fluid distribution in the knees of patients attending our clinic for knee injections under ultrasound guidance. In a cross-sectional observational study, we used high-resolution ultrasound (US) to record measurements of maximum fluid depth in the medial, midline and lateral regions of the suprapatellar pouch (SPP) in 46 patients with arthritis attending for routine US-guided injection of the knee. Mean fluid depth [in millimetres, (SD)] was significantly greater in the lateral SPP [9.2 (5.1)] than in the medial [6.5 (4.6)] or the midline [5.9 (3.7)] regions with the knee in relaxed full extension (p < 0.001 for comparison of lateral SPP with both midline and medial SPP). Small effusions were more commonly detected in the lateral SPP than elsewhere. In patients with painful knee arthritis, fluid distributes maximally to the lateral SPP in the extended knee. This has implications regarding the anatomical approach to arthrocentesis that clinicians should choose to perform and teach.     

Ultrasonographic findings in hemiplegic knees of stroke patients

Clinical and radiologic asymmetric arthritic differences between paralyzed and nonparalyzed limbs of stroke patients have been reported. Arthritic pathology aggravates motor dysfunction and compromises rehabilitation. Musculoskeletal ultrasonography plays an important role in showing soft tissue and the articular cartilage of the knee. Fifty-nine patients with either ischemic or hemorrhagic stroke-induced right or left hemiplegia were recruited to evaluate soft-tissue and intra-articular cartilage changes in hemiplegic knees of stroke patients using ultrasonography. An additional 15 subjects (30 knees) without knee disease or a history of knee trauma or surgery were used as controls. There were significant differences in suprapatellar effusion and patellar tendinitis between hemiplegic and nonhemiplegic knees. Suprapatellar effusion and pes anserinus tendinitis were correlated with Brunnstrom stage. The length of time since stroke onset was not significantly correlated with positive ultrasonographic findings in hemiplegic knees. In conclusion, ultrasonography is useful for detecting periarticular soft-tissue changes and intra-articular lesions in hemiplegic knees of stroke patients.     

Clinic and ultrasound findings related to pain in patients with knee osteoarthritis

The aim of this study was to determine clinical and US factors associated with pain in patients with knee osteoarthritis (OA). The study included 143 patients. Patients were divided into two groups: group 1 consisted of 94 patients with unilateral or bilateral knee pain ≥3 cm during physical activity for at least 48 h prior to inclusion, measured by the visual analog scale from 0 to 10 cm. Group 2 consisted of 49 patients with knee OA without knee pain at least 1 month prior to inclusion. In both knees, range of motion was measured by goniometry and anteroposterior, and lateral knee radiographs were taken during weight-bearing. OA grading was performed in accordance with the Kellgren–Lawrence criteria by a specialist in radiology experienced in this field. A knee ultrasound (US) examination was performed in all patients by a blinded radiologist. Women were more often symptomatic than men (p < 0.005). Patients in group 1 tended to have a higher body mass index (BMI; p < 0.001). Radiographic grades III (52.1%) and II (37.2%) were most frequently found in group 1, whereas I (30.6%), II (46.9%), and III (22.4%) were found in group 2. When radiographic grades in both groups were compared, group 1 had greater radiographic grades than group 2 (p < 0.001). US findings in group 1 were effusion of the suprapatellar pouch (72.3%), Baker’s cyst (42.6%), protrusion of the anterior horn of the medial meniscus associated with medial collateral ligament displacement (9.6%), and loose body (9.6%). In group 2, the only US finding was Baker’s cyst (6.1%). Regression analysis revealed that BMI, degree of knee flexion, and thickness of the quadriceps tendon were factors that were related with pain in the knee. Increased BMI, decrease in the degree of knee flexion, and decreased quadriceps tendon thickness are factors that increase the risk of pain in knee OA.     

Knee joint synovitis in Sjögren's syndrome. Sonographic study

Ultrasound detects effusion and synovial proliferation caused by synovitis. The study was undertaken to evaluate the signs of synovitis in patients with primary Sj?gren's Syndrome (SS). Joint effusion was detected and synovial thickness was measured in the suprapatellar synovial bursa. Results have been compared with those obtained by sonographic assessment of knee joint in patients with secondary SS and RA. with secondary SS and connective tissue diseases, with RA, and in healthy subjects. Synovial thickening was demonstrated in all the diseases (higher grades of thickening were found in secondary SS with RA and in RA). Joint effusion was present with significantly higher frequency in secondary SS with RA and in RA. Results demonstrated signs of slight synovitis in primary SS. More severe synovitis was found both in secondary SS with RA and in RA. This is the first sonographic study demonstrating slight synovitis in primary SS.     

Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy

OBJECTIVE: To compare ultrasonography (US) with clinical examination in the detection of entheseal abnormality of the lower limb in patients with spondyloarthropathy (SpA). METHODS: 35 patients with SpA (ankylosing spondylitis 27; psoriatic arthritis 7; reactive arthritis 1) underwent independent clinical and ultrasonographic examination of both lower limbs at five entheseal sites-superior pole and inferior pole of patella, tibial tuberosity, Achilles tendon, and plantar aponeurosis. US was performed using an ATL (Advanced Technology Laboratories, Bothell, Washington, USA) high definition imaging 3000 machine with linear 7-4 MHz and compact linear 10-5 MHz probes to detect bursitis, structure thickness, bony erosion, and enthesophyte (bony spur). An enthesitis score was formulated from these US findings giving a possible maximum total score of 36. RESULTS: On clinical examination 75/348 (22%) entheseal sites were abnormal and on US examination 195/348 (56%) sites were abnormal. In 19 entheseal sites with bursitis on US, only five were detected by clinical examination. Compared with US, clinical examination had a low sensitivity (22.6%) and moderate specificity (79.7%) for the detection of enthesitis of the lower limbs. There was no significant correlation between the US score of enthesitis and acute phase parameters such as erythrocyte sedimentation rate (ESR) or C reactive protein (CRP). The intraobserver kappa value for analysis of all sites was 0.9. CONCLUSIONS: Most entheseal abnormality in SpA is not detected at clinical examination. US is better than clinical examination in the detection of entheseal abnormality of the lower limbs in SpA. A quantitative US score of lower limb enthesitis is proposed but further studies are required to validate it in SpA.