Technique and value of arthrosonography in rheumatologic diagnosis. 1: Ultrasound diagnosis of the knee joint

Within the last few years, ultrasonography (US) of joints has attained a firm position for the diagnosis of joint diseases. Degenerative as well as inflammatory changes can be recognized using this method. With new, higher resolution techniques even bone surfaces and tendon textures can be visualized in greater detail. The advantages of sonography are general availability and low costs. When used properly, as a non-invasive procedure US has no detrimental effects on patients. The disadvantages of this technique result from its physical limitations, such as high reflection of US on bone and the negative correlation between resolution and penetration which makes US imaging difficult in deeper regions. The current technical development of probes and imaging processing, however, promises better deep structure imaging in the future. The quality of ultrasound examination always depends on the technical equipment, as well as on the patients' individual tissue constitution and the experience of the physician. It is possible to avoid misinterpretation and to increase the diagnostic value of US by using a standardized technique and professional knowledge of the specific aspects of the method. The significance of qualified education and sufficient training of sonographers is to be stressed. The aim of this article is to deliver a basic contribution to the standardization and quality assurance of joint US and to indicate the value of this method. In addition to the overview the authors propose guidelines for performance and interpretation of joint US. Due to the major significance of the knee joint in rheumatology it was decided to begin the work in this area.     

Technique and value of arthrosonography in rheumatologic diagnosis. 2: Ultrasound diagnosis of the hip area

The clinical investigation of the hips in patients with rheumatic diseases is often equivocal. Thus, ultrasonography of this region is very relevant for rheumatologists. We suggest following standard scans: 1) anterior longitudinal scan to detect synovitis of the hip joint, iliopectineal bursitis, irregularities of the bone surface in osteoarthritis, Perthes' disease, and erosions due to inflammatory disease, 2) anterior transverse scan to evaluate these structures in an additional dimension, 3) lateral longitudinal scan of the hip joint with the same objective as the above mentioned scans; 4) lateral longitudinal scan, and 5) lateral transverse scan of the greater trochanter to diagnose trochanteric bursitis and bone irregularities due to enthesiopathy, and 6) dorsal oblique scan (optional) to diagnose hip joint effusions and pannus that localize in the dorsal region. Rotation of the joint is necessary to detect small effusions. The transducers should have a medium frequency of 5 to 7.5 MHz. In obese or muscular patients, 3.5 MHz transducers may be necessary to increase penetration. The anterior distance between the bone and the joint capsule of the hip joint is > or = 7 mm in probable and > or = 8 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left hip is > or = 2 mm, and they are definite if the difference is > or = 3 mm.     

Technical aspects and value of arthrosonography in rheumatologic diagnosis. 4: Ultrasound of the elbow

Musculoskeletal ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft tissue lesions and bone lesions. The following standard scans are suggested for sonographic evaluation of the elbow: 1) anterior humeroradial longitudinal scan, 2) anterior humeroulnar longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions (osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa with flexed/extended elbow to evaluate the same objectives as the above mentioned scans and additionally to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radius head to evaluate lesions of the radius head, tendopathy, calcinosis, 8) lateral humeroradial longitudinal scan to evaluate epicondylitis, 9) medial humeroulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of compression of the ulnar nerve. A linear transducer with a frequency of about 5-7.5 MHz is recommendable. The anterior distance between trochlea and the capitulum of the humerus between the bone and the joint-capsule of the elbow is > or = 2 mm in probable and > or = 3 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between the right and left elbow is 1 mm, and they are definite if the difference is > or = 2 mm.     

Status of arthrosonography in rheumatologic diagnosis: examination technic, findings and their interpretation. I. The elbow joint

Between July 1984 and October 1985 the elbow joints of 135 patients were examined by arthrosonography. Of these 97 patients suffered from rheumatoid arthritis, 4 from psoriatic arthritis, 2 from suspected ankylosing spondylitis, 1 from gout, and 27 patients were found to be normal. The equipment used was a Kretz sector scanner Combison 320 and a Siemens Sonoline SL linear scanner. The examination was divided into three parts: longitudinal and transversal scans of the fossa olecrani, the fossa coronoidea and fossa radii. We found, that inflammation of the elbow joint has to be evaluated separately for each part of the joint. The more intense the inflammation, the more certain diagnosis becomes. Bursitis and rheumatoid nodules could be separated sonographically. Also synovialitic complications such as of the bone and the development of synovial cysts could easily be recognized. These arthrosonographical findings are a valuable help in the diagnostics of rheumatic diseases. Their interpretation, however, requires the input of all clinical data.     

Ultrasound imaging for the rheumatologist V. Ultrasonography of the ankle and foot

Ultrasonography (US) is a useful tool for imaging, which can be used for the assessment of joints and periarticular structures in all rheumatological disorders. In patients with pain and/or swelling of the ankle and foot, US provides information about the presence of joint effusion, synovitis, tenosynovitis, tendinosis, and tendons tears, helping in the differential diagnosis between joint or tendon/enthesis involvement. Moreover, US allows clinicians to monitor and guide needle positioning to inject pharmaceutical substances more safely and effectively even in hard-to-reach sites. US represents an accurate, safe and low-cost technique that can be used for the examination of the ankle and foot in rheumatic disorders.     

Magnetic resonance imaging of the foot and ankle

Beginning with its early success in the hip and knee, magnetic resonance has been universally acknowledged as a major advance in musculoskeletal imaging. Subsequent technical improvements encouraged its rapid adaptation for delineating wrist and shoulder joint pathology. In part because of the small, complex curvilinear structures involved, however, the required technology as well as the potential advantages of magnetic resonance imaging in the ankle and foot were realized only recently. This article illustrates some of the clinical applications of magnetic resonance imaging in foot and ankle pathology.     

Ligament and bone pathologic abnormalities more frequent in neuropathic joint disease in comparison with degenerative arthritis of the foot and ankle: Implications for understanding rapidly progressive joint degeneration

Objective

The variable disease progression of osteoarthritis (OA) and the basis for rapid joint deterioration in some subgroups of patients are poorly understood. To explore an anatomic basis for rapidly progressive OA, this observational study compared the magnetic resonance imaging (MRI) patterns of disease between patients with neuropathic joint disease (NJD) and patients with degenerative arthritis of the ankle and foot.

Methods

MR images of the foot and ankle of patients with early NJD (n = 7) and patients with OA (n = 15) were assessed. The anonomized MR images were dichotomously scored by a musculoskeletal radiologist for the presence of the following abnormalities per bone (of a total of 14 bones): cartilage defects, bone cysts, bone marrow edema, fractures, joint debris, joint effusions, tendinopathy, tendinitis, and ligament tears.

Results

Although the degree of cartilage damage and joint cyst formation was comparable between the groups, the degree of ligament tears, or change in MRI signal intensity in the ligaments, was significantly greater in patients with NJD compared with patients with OA (median of 3 tears versus 0, of 14 total bones; P < 0.01). Moreover, in patients with early NJD compared with patients with OA, there was a significantly greater degree of diffuse bone marrow edema (median of 6.5 tarsal bones versus 2 adjacent bones, of 14 total bones; P < 0.01), a greater number of bone fractures (median 4 versus 0; P < 0.01), and more frequent bone debris (median 4.5 versus 0; P = 0.013).

Conclusion

This analysis of NJD in the foot and ankle shows the predominance of bone and ligament abnormalities in NJD compared with the pattern of involvement in OA. These findings highlight the importance of structures other than articular cartilage in OA of the ankle and foot, and suggest that rapid joint degeneration in NJD may be more ligamentogenic or osteogenic in nature.

     

磁共振在脊柱关节病足部病变中的应用价值

目的 探讨脊柱关节病患者足部病变的磁共振(MR)表现,比较MR与X线在诊断该病中的价值.方法 46例(92足)脊柱关节病患者行足部MR扫描和X线检查,其中强直性脊柱炎37例,未分化脊柱关节病7例,炎性肠病关节炎2例;10名同年龄健康志愿者(20足)作为对照组.结果 46例脊柱关节病患者中,MR检查发现足部病变41例(89%),其中29例(63%)为单侧足部病变,12例(26%)表现为双侧足部病变.MR征象表现为关节积液,肌腱炎,软组织肿胀及骨质侵蚀性改变等;X线检查发现足部病变21例(46%),其中11例(52%)为单侧足部病变,10例(48%)表现为双侧足部病变.X线主要对骨质侵蚀性改变、关节旁骨赘形成、关节间隙变窄等改变较敏感;临床检查发现足部病变(关节疼痛、肿胀)15例(33%).10名健康志愿者足部MR和X线检查均未发现异常征象.结论 MR与X线相比能敏感发现脊柱关节病患者的足部病变,肌腱、韧带及其附着点是病变的常见解剖部位.     

Charcot arthropathy of the foot and ankle: modern concepts and management review

Charcot arthropathy (Charcot neuroarthropathy, diabetic neuropathic osteoarthropathy, or neuropathic arthropathy) remains a poorly understood disease, although recent research has improved our level of knowledge regarding its etiology and treatment. The effects of Charcot arthropathy are almost exclusively seen in the foot and ankle, and the diagnosis is commonly missed upon initial presentation. It has been well established that this complication of diabetes mellitus severely reduces the overall quality of life and dramatically increases the morbidity and mortality of patients. However, there are few high-level evidence studies to support management and treatment options at this point in time. The goal of this study is to evaluate the modern concepts of Charcot arthropathy through a review of the available literature and to integrate a perspective of management from the authors' extensive experience.     

经皮氧分压和踝肱指数测定对糖尿病足下肢动脉病变诊断的意义

目的探讨经皮氧分压和踝肱指数(ABI)在糖尿病足下肢动脉病变诊断中的意义。方法选取2015-01~2016-06在该院内分泌科住院的496例2型糖尿病患者,男295例,女201例,平均年龄(59.84±11.66)岁,糖尿病病程为0.1~35年。分为无糖尿病周围神经病变和下肢动脉病变组(CO组,95例)、糖尿病周围神经病变而无下肢动脉病变组(DPN组,139例)、下肢动脉病变而无糖尿病周围神经病变组(LEAD组,83例)、糖尿病周围神经病变和下肢动脉病变组[(N+A)组,179例]。分析各组经皮氧分压与ABI的差异。结果各组之间年龄、血压、BMI差异均无统计学意义(P0.05)。DPN组与LEAD组的病程相比差异无统计学意义(P0.05),其余两组之间病程比较差异均有统计学意义(P0.01)。CO组与DPN组、LEAD组与N+A组糖化血红蛋白相比差异无统计学意义(P0.05),其余两组之间比较差异均有统计学意义(P0.01)。CO组与DPN组相比,经皮氧分压、ABI差异无统计学意义(P0.05),其余两组之间经皮氧分压、ABI比较差异均有统计学意义(P0.05)。ROC曲线分析提示Tc PO2诊断下肢动脉病变优于ABI。结论 Tc PO2能很好地反映糖尿病患者的下肢微循环状态,其诊断下肢动脉病变优于ABI。     

Footwear interventions for foot pain,function, impairment and disability for people with foot and ankle arthritis: A literature review

ObjectiveTo conduct a literature review on the effectiveness of footwear on foot pain, function, impairment and disability for people with foot and ankle arthritis.MethodsA search of the electronic databases Scopus, Medline, CINAHL, SportDiscus and the Cochrane Library was undertaken in September 2017. The key inclusion criteria were studies reporting on findings of footwear interventions for people with arthritis with foot pain, function, impairment and/or disability. The Quality Index Tool was used to assess the methodological quality of studies included in the qualitative synthesis. The methodological variation of the included studies was assessed to determine the suitability of meta-analysis and the grading of recommendations, assessment, development and evaluation (GRADE) system. Between and within group effect sizes were calculated using Cohen’s d.Results1440 studies were identified for screening with 11 studies included in the review. Mean (range) quality scores were 67% (39–96%). The majority of studies investigated rheumatoid arthritis (n = 7), but also included gout (n = 2), and 1st metatarsophalangeal joint osteoarthritis (n = 2). Meta-analysis and GRADE assessment were not deemed appropriated based on methodological variation. Footwear interventions included off-the-shelf footwear, therapeutic footwear and therapeutic footwear with foot orthoses. Key footwear characteristics included cushioning and a wide toe box for rheumatoid arthritis; cushioning, midsole stability and a rocker-sole for gout; and a rocker-sole for 1st metatarsophalangeal joint osteoarthritis. Between group effect sizes for outcomes ranged from 0.01 to 1.26. Footwear interventions were associated with reductions in foot pain, impairment and disability for people with rheumatoid arthritis. Between group differences were more likely to be observed in studies with shorter follow-up periods in people with rheumatoid arthritis (12 weeks). Footwear interventions improved foot pain, function and disability in people with gout and foot pain and function in 1st metatarsophalangeal joint osteoarthritis. Footwear interventions were associated with changes to plantar pressure in people with rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and walking velocity in people with rheumatoid arthritis and gout.ConclusionFootwear interventions are associated with reductions in foot pain, impairment and disability in people with rheumatoid arthritis, improvements to foot pain, function and disability in people with gout and improvements to foot pain and function in people with 1st metatarsophalangeal joint osteoarthritis. Footwear interventions have been shown to reduce plantar pressure rheumatoid arthritis, gout and 1st metatarsophalangeal joint osteoarthritis and improve walking velocity in rheumatoid arthritis and gout.     

The value of synovial fluid assays in the diagnosis of joint disease: a literature survey

OBJECTIVE: To carry out a critical appraisal of the literature in an attempt to assess the current value of synovial fluid (SF) analysis in the diagnosis of joint disease. METHODS: A literature search was undertaken using the Medline, Biomed, Bids, Pubmed, and Embase electronic databases using the keywords: synovial fluid (SF) analysis, SF crystals, joint sepsis, acute arthritis, and SF cell counts, cytology, biomarkers, and microbiology. RESULTS: Publications fell into three main categories. Firstly, reports assessing the value of the three traditional assays (microbiology, white blood cell counts, and microscopy for pathogenic crystals). For these quality control evidence was found to be sparse, and tests for sensitivity, specificity, and reliability showed worrying variations. These poor standards in SF analysis may be due to lack of inclusion of some tests within routine pathology services. Secondly, claims for the usefulness of "new" assays (cytology and biochemical markers). For cytology, the supporting evidence was mainly anecdotal and there were no reports on specificity, sensitivity, and reliability. Interpretation difficulties are a major hindrance to the clinical use of biochemical assays, which remain primarily research tools. Finally, work on the diagnostic value of SF analysis in general. The appraisal confirmed that SF analysis remains of major diagnostic value in acute arthritis, where septic arthritis or crystal arthropathy is suspected, and in intercritical gout. CONCLUSIONS: Given the importance of SF tests, rationalisation of their use, together with improved quality control, should be immediate priorities. Further investigation is recommended into the contribution of SF inspection and white cell counts to diagnosis, as well as of the specificity and sensitivity of SF microbiological assays, crystal identification, and cytology.     

快速免疫色谱测定法在骨关节结核诊断及鉴别诊断中的价值

目的探讨快速免疫色谱法对活动性骨关节结核的诊断价值。方法采用ＩＣＴ快速免疫色谱法检测７５例活动性骨关节结核、６９例以肿瘤为主的骨病患者及７２名正常人血清中的抗体。结果骨关节结核组阳性率为８０％，其中脊柱结核阳性率为９０％，脊柱以外的关节结核阳性率为６１％，合并其它部位结核阳性率为７６％；骨病组３例阳性，正常组２例阳性，假阳性率分别为４％和３％。结论ＩＣＴ快速免疫色谱法是骨关节结核诊断和鉴别诊断的一项有用的辅助手段     

Common ankle disorders of the elderly: diagnosis and management

Ankle pain can be disabling for the geriatric patient. Unlike symptoms in younger individuals, symptoms in the elderly are often insidious in onset and result from chronic disease processes. Acute injuries, when they occur, are often managed differently than in younger patients. Accurate diagnosis is essential for appropriate treatment. An anatomic approach to diagnosis is presented along with guidelines for appropriate conservative and surgical treatment.     

Gout of ankle and foot: DECT versus US for crystal detection

Clinical Rheumatology - To compare dual-energy computed tomography (DECT) and ultrasound (US) in detecting monosodium urate (MSU) crystals in the ankle and foot in patients with acute gouty...     

糖尿病足病的流行病学及诊治现状

到2005年,预测全球范围内约有1.5亿糖尿病患者,其中大多数居住在发展中国家。糖尿病足溃疡累及约15%的糖尿病人群。根据一些前瞻性的