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.     

Technique and diagnostic value of musculoskeletal ultrasonography in rheumatology. Part 6: ultrasonography of the wrist/hand

Sonography of the hands is especially helpful in the diagnosis of early arthritis. Sonography allows for a very sensitive detection of small joint-effusion, tenosynovitis and small erosive bone lesions earlier than conventional radiography. Musculoskeletal sonography is also helpful in morphological analysis of changes of the median nerve in patients with carpal tunnel syndrome. The following standard scans are suggested for the sonographic evaluation of the wrist: 1. dorsal longitudinal scan along the radio-carpal joint, 2) along the ulno-carpal joint, and 3) dorsal transverse scan along the wrist to detect joint fluid collection, synovitis, tenosynovitis, ganglia, irregularities of the bone surface in osteoarthritis, and erosions due to inflammatory disease, 4) volar longitudinal scan along the radio-carpal joint, and 5) along the ulno-carpal joint, and 6) volar transverse scan along the wrist to diagnose the same objective as the above mentioned scans and to evaluate the median nerve in cases of carpal tunnel syndrome. Optional scans are the following: 7) ulnar longitudinal 8) transverse scan along the ulnar joint space and the extensor carpi ulnaris muscle to detect tenosynovitis and caput ulnae syndrome, 9) radial longitudinal, and 10). transverse scan along the joint space to diagnose synovitis and tenosynovitis. The following standard scans are suggested for the sonographic evaluation of the fingers: 1) volar longitudinal, 2) volar transverse scan in extension along the finger joints to detect effusion and synovial proliferation, tenosynovitis, irregularities of the bone surface (osteophytes, erosions), 3) dorsal longitudinal scans in extension and flexion >70 degrees along the CMC I, MCP, PIP and DIP joints to evaluate effusion and synovial proliferation, tenosynovitis or tendinitis, irregularities of the bone surface (osteophytes, erosions), and 4) dorsal transverse scans along the finger joints to evaluate these structures in an additional dimension. Optional 5) scans include the following: medial longitudinal scan along the MCP I, II, PIP and DIP joints, and 6) lateral longitudinal scan along the MCP V, PIP and DIP joints to evaluate the erosive bone process and joint instability. A linear transducer with a frequency of between 7.5 and 12 MHz is recommendable. The anterior distance between the bone and the joint-capsule of the wrist is > or = 3 mm in probable and > or = 4 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left wrist is > or = 1 mm, and they are definite if the difference is > or = 2 mm. A carpal tunnel syndrome is probable with a cross-sectional area of the median nerve of > or = 12 mm(2).     

Technique and value of arthrosonography in rheumatologic diagnosis--3: Ultrasound diagnosis of the ankle joint,foot and toes

The clinical investigation of ankles, feet, and toes is frequently equivocal in rheumatology. Sonography can distinguish between underlying pathologies. We suggest following standard scans: 1) anterior longitudinal scan to diagnose effusions in the ankle and talonavicular joints, to display erosive and osteoarthrotic pathologies, and to diagnose tenosynovitis of the extensor tendons; 2) anterior transverse scan to document the findings in an additional dimension; 3) lateral transverse scan and 4) lateral longitudinal scan to diagnose tenosynovitis of the peroneus tendons; 5) medial transverse scan and 6) medial longitudinal scan to diagnose tenosynovitis of the flexor tendons; 7) posterior longitudinal scan and 8) posterior transverse scan to evaluate the Achilles tendon, the retrocalcaneal bursa, and the posterior recess of the ankle joint. Additionally we suggest optional scans: 9) plantar longitudinal scan for the plantar fascia and the plantar calcaneal surface; 10) distal anterior longitudinal scan to evaluate the midtalar joints; 11) distal anterior longitudinal scan to evaluate the toes; and 12) plantar, distal transverse scan to evaluate the flexor tendons of the toes. Additionally, the correlating longitudinal and transverse scans can be used to confirm the findings. The frequency of the transducer should be about 7.5 MHz for ankles and the peroneus, flexor, and extensor tendons. Ten to over 20 MHz are possible for more superficially located structures. Using modern equipment with higher resolution a hypoechoic border may be normal up to 3 mm in the ankle joints, the MTP joints, and around the peroneus tendons, and up to 4 mm around the tibialis posterior tendons.     

Imaging techniques in rheumatology: sonography in rheumatoid arthritis

Musculoskeletal ultrasonography has become an important diagnostic tool in rheumatoid arthritis. In Germany it is part of the rheumatology training, and many ultrasound courses provide further education. Only in the last five years the international importance of ultrasound in rheumatology has increased dramatically. Sonography can be performed as a bedside procedure and as an extension of the clinical investigation. It is easily tolerated by the patients, and it can be repeated any time. Sonography can have a great impact on therapeutic decisions. A > or = 5 MHz linear transducer is needed. Most transducers that are used for musculoskeletal ultrasound have about 7.5 MHz. Modern transducers with higher frequencies (>7.5 MHz) and high resolution improve the diagnostic value of the investigation. Sonography is superior to plain radiography to detect erosions as far as the region is accessible by ultrasound. It is more sensitive than the clinical investigation for the detection of synovitis, tenosynovitis, tendinitis, and bursitis as well as for the differentiation of these lesions. Color Doppler sonography aids in evaluating the activity of inflammation and in differentiating intraarticular structures. Carpal- and ulnar neuropathy occur secondary to rheumatoid arthritis and may lead to characteristic nerve swelling. Ultrasound-guided injections into joints and tendon sheets can be performed.     

Technique and diagnostic value of musculoskelatal ultrasonography in rheumatology. Part 5: Ultrasonography of the shoulder

Shoulder-related symptoms are very common in rheumatic diseases. For the evaluation of the diagnosis as well as for therapy and prognosis, an anatomic assignment is essential. Clinical investigations alone are often not capable to do this. Ultrasonography is a method to delineate bony surfaces as well as the soft tissues around the shoulder joints statically and even dynamically. For the purpose of rheumatic diseases, ultrasound standard scans help to detect the lesions at the biceps tendon, the bursae, the rotator cuff, the humeral head as well as in the acromial and sternoclavicular joints. Considering the limitations of the method (obesity, frozen shoulder, no findings under bony structures) and knowing the pitfalls and errors of the method, ultrasonography is a reliable, quick and low cost method for the diagnosis of rheumatic shoulder joint pathology. Compared to computer tomography and magnetic resonance imaging, ultrasonography should be used as a screening method. The following standard scans are suggested for sonographic evaluation of the shoulder: 1) anterior transverse scan and 2) anterior longitudinal scan at the bicipal groove to detect synovitis and tenosynovitis, 3) anterior transverse scan at the coracoacromiale window in the neutral position, 4) at maximal external rotation and 5) at maximal internal rotation to evaluate the rotator cuff, bursitis, synovitis and erosions, 6) anterior longitudinal scan at 90 degrees to the coracoacomiale window at maximal internal rotation to describe these findings in an additional dimension, 7) anterior-lateral longitudinal scan at the anterior lateral acromion to tuberculum majus to evaluate the distal part of the supraspinatus muscle, 8) posterior transverse scan at the fossa infraspinata lateral under the spina scapulae, 9) axillary longitudinal scan to evaluate synovitis, synovial proliferation, erosions at the humeral head, lesions at the glenoidale labrum, 10) anterior transverse scan at the acromioclavicular joint and 11) anterior oblique scan at the sternoclavicular joint to detect synovitis, synovial proliferation, erosion, osteophytes.     

Bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis

OBJECTIVE: Bone scintigraphy has been advocated as a useful diagnostic tool for patients with suspected osteonecrosis or in screening for multifocal disease. We evaluated the sensitivity of bone scanning relative to magnetic resonance imaging (MRI) in the diagnosis of osteonecrosis. METHODS: Forty-eight patients presented with suspected osteonecrosis of the shoulder, hip, knee, or ankle. All patients underwent simultaneous (< 3 months apart) bone scans and MRI studies as part of diagnostic investigations. Histological confirmation of osteonecrosis was obtained for all suspected lesions. The diagnostic result for each imaging modality was then assessed and compared. RESULTS: All 163 (100%) histologically confirmed lesions were identified by MRI, while only 91 lesions (56%) were identified by bone scan. There was complete congruency of bone scans with MR images in only 38% of patients (18/48). Bone scanning identified 72% of lesions (47/65) in oligofocal patients (< or = 2 joints involved) compared with 45% of the lesions (44/98) in multifocal patients (> or = 3 joints involved). Sensitivity of lesions was highest for the knee and hip and lower for the shoulder and ankle. Larger and later-stage lesions had a higher bone scan sensitivity. CONCLUSION: Our results demonstrated the low sensitivity of bone scintigraphy for diagnosing symptomatic osteonecrosis. It is least sensitive for early-stage lesions where it might be most useful to diagnose the disease. Our study also confirms that this test is less sensitive for joints other than the hip and is also not useful as a screening tool. Our study does not support the use of bone scans as a diagnostic or screening tool for osteonecrosis.     

Comparative study of intra-articular pressure dynamics in joints with acute traumatic and chronic inflammatory effusions: potential implications for hypoxic-reperfusion injury.

It has been proposed that the process of hypoxic-reperfusion injury contributes to the persistence of synovitis in the inflamed human joint. The generation of pathological, exercise induced, intra-articular pressure leading to occlusion of the synovial microcirculation is central to this mechanism. However, acute traumatic inflammatory joint effusions rarely result in chronic synovitis, suggesting that either the basic hypothesis is incorrect, or that joints with acute traumatic effusions show different intra-articular pressure dynamics. In this study the intra-articular pressure was measured at rest and during isometric exercise in five patients with acute traumatic joint effusions and in nine patients with chronic inflammatory joint effusions. The generation of intra-articular pressure in the patients with acute traumatic effusions was significantly lower at rest (mean 2.0 v 19.6 mm Hg) and during exercise (mean 13.7 v 222.5 mm Hg) than in the patients with chronic effusions. This was due to reflex muscular inhibition around the joint, which inhibited the pathological generation of intra-articular pressure. This difference in the ability to generate intra-articular pressure might mitigate against hypoxic-reperfusion injury in joints with acute traumatic effusions, thereby explaining the paradoxical clinical observation that patients with acute traumatic inflammatory joint effusions rarely develop chronic synovitis.     

Inflammatory changes of hip synovial structures in polymyalgia rheumatica

OBJECTIVE: To investigate the hip inflammatory lesions and to evaluate the accuracy of clinical examination compared to magnetic resonance imaging (MRI) in patients with polymyalgia rheumatica (PMR) with pelvic girdle symptoms. Secondary end-point was to evaluate the sensitivity and specificity of ultrasonography (US) compared to MRI in the assessment of hip lesions. METHODS: Case-control study of 20 consecutive PMR patients and 40 controls with different rheumatic conditions. Both groups were clinically assessed for the presence of hip synovitis, trochanteric, iliopsoas and ischiogluteal bursitis. Hip MRI was performed in all case-patients and in 10 controls. Both groups were examined by US. An additional group of 10 healthy controls was examined by hip US. RESULTS: Both MRI and US detected trochanteric bursitis in 100% of PMR patients, bilateral in 18/20 (90%), and in 12/40 (30%) controls (p < 0.001). Hip synovitis was detected in 17/20 (85%) by MRI and in 9/20 (45%) by US (p < 0.02) in case-patients and in 18/40 (45%) controls. In PMR, MRI and US showed iliopsoas bursitis in 10/20 (50%) and 6/20 (30%) and ischiogluteal bursitis in 5/20 (25%) and 4/20 (20%) with no differences compared to controls. Clinical examination showed a good accuracy for hip synovitis, trochanteric and ischiogluteal bursitis, while it overestimated the presence of iliopsoas bursitis. US was less sensitive than MRI for the detection of hip synovitis and iliopsoas bursitis (53% and 60%). CONCLUSION: Trochanteric bursitis represents the most frequent hip lesion in PMR. A careful physical examination allows to detect all inflammatory lesions excluding iliopsoas bursitis. US is less sensitive than MRI in the assessment of hip synovitis and iliopsoas bursitis.     

Femoral nerve palsy caused by a huge iliopectineal synovitis extending to the iliac fossa in a rheumatoid arthritis case

We report on a 54-year-old woman with rheumatoid arthritis who had severe femoral nerve palsy affected by a distended synovium in the hip joint. Surgical exploration demonstrated a perforation of the iliopectineal bursa connecting with the hip joint. The patient fully recovered from femoral nerve palsy after surgery. It was considered that synovitis of the hip joint had developed following huge iliopectineal bursitis.     

Clinical,radiographic, and genetic diagnosis of progressive pseudorheumatoid dysplasia in a patient with severe polyarthropathy

A 14-year-old boy presented with a 10-year history of the "sicca" form of seronegative juvenile idiopathic polyarthritis. Severely limited range of motion, pain, and capsular swelling in both small and large weight-bearing joints left him wheelchair-bound. Erythrocyte sedimentation rate and C-reactive protein were normal. Two-phase bone scan revealed tracer uptake of almost every joint at both early and late time points, indicating pathologic exudation and enhanced bone metabolism consistent with severe arthritis. However, radiographic studies revealed no erosive arthropathy but severe osteopenia, dysplastic bone changes, mega os trigonum, and platyspondylia. A magnetic resonance imaging (MRI) scan of the hips showed no signs of synovitis, pannus, or effusion but cartilage irregularities and subchondral cysts. These findings strongly suggested the diagnosis of progressive pseudorheumatoid dysplasia of childhood, an autosomal-recessive disorder of cartilage homeostasis. The patient carries a novel homozygous two-nucleotide deletion in exon 4 of the WISP3 gene. This genetic disorder is an important differential diagnosis of sicca polyarthritis.     

Validated measurement of periarticular bone mineral density at the knee joint by dual energy x ray absorptiometry

OBJECTIVE: The association of inflammatory arthritis with loss of periarticular bone mineral density (BMD) has been well established. However, changes in bone density cannot be quantified by conventional radiography. This study aimed at developing a new technique for measurement of periarticular bone density at the knee joint by dual energy x ray absorptiometry (DXA) and assessing the precision of this technique for selected areas around the knee. METHODS: To validate this technique for bone density assessment in both patient and control subjects, knee joints from healthy subjects and patients with inflammatory arthritis were selected for study. Posteroanterior (PA) and lateral scans of both knees were acquired with the Hologic 4500 elite bone densitometer. Each scan was repeated three times, with repositioning between scans. Knee scans were obtained with the forearm software and evaluated by subregion analysis. Seven femoral and seven tibial subregions of interest (ROIs) were selected on PA scans. Six ROIs were selected on lateral scans. Precision was determined for each ROI selected. RESULTS: 14 knee joints were studied in each group. Precision, expressed as percentage coefficient of variation (CV%), varied widely between subregions. PA scans were most appropriate for measurement of femoral bone density (CV% = 1.89-2.64%), whereas the best value obtained for ROIs within the tibia was on the lateral scan, where CV% for measurement of the proximal 5 mm was 2.67% in the patient group. CV% for BMD of the patella was excellent at 0.84% in the patient group. CONCLUSION: This new application of DXA can be used to measure periarticular bone density at the knee joint. Regions within the distal femur and patella have been identified as the optimal areas to study     

Ultrasonographic evidence of hip synovitis in patients with rheumatoid arthritis

One hundred non-operated hip joints in 50 adult patients with active rheumatoid polyarthritis were examined by ultrasonography as well as by clinical methods and X-ray. In 15 hip joints in 11 patients, ultrasonography indicated intra-articular effusion (a distance between the joint capsule and bone of more than 7 mm in 14 and a difference between the two sides of more than 1.5 mm for one hip). There were no subjective symptoms associated with five of these hip joints, the X-ray findings were normal for 11 hips, and careful clinical examination showed normal findings for one hip joint. The routine clinical examination used in the hospital had revealed pathological findings in only two of these hip joints. It is concluded that ultrasonography may reveal intra-articular effusion or synovitis in clinically and radiologically apparently normal hip joints of patients with active rheumatoid arthritis. The increase in pain and restricted motion was statistically significant in the hips for which ultrasonography indicated intra-articular effusion. Hips that appear pathological in ultrasonography are thus synovitis, and do not fall within the range of normal variation for healthy hip joints.     

Whole‐body bone scintigraphy provides a measure of the total‐body burden of osteoarthritis for the purpose of systemic biomarker validation

Objective

To evaluate the association of serum and synovial fluid cartilage oligomeric matrix protein (COMP) with systemic and local measures of osteoarthritis (OA) activity by bone scintigraphy.

Methods

Samples of serum and knee joint synovial fluid (275 knees) were obtained from 159 patients with symptomatic OA of at least 1 knee. Bone scintigraphy using ^99mTc‐labeled methylene diphosphonate was performed, and early‐phase knee scans and late‐phase whole‐body bone scans of 15 additional joint sites were scored semiquantitatively. To control for within‐subject correlations of knee data, generalized linear modeling was used in the correlation of the bone scan scores with the COMP levels. Principal components analysis was used to explore the contribution of each joint site to the variance in serum COMP levels.

Results

The correlation between synovial fluid and serum COMP levels was significant (r = 0.206, P = 0.006). Synovial fluid COMP levels correlated most strongly with the early‐phase knee bone scan scores (P = 0.0003), even after adjustment for OA severity according to the late‐phase bone scan scores (P = 0.015), as well as synovial fluid volumes (P < 0.0001). Serum COMP levels correlated with the total‐body bone scan scores (r = 0.188, P = 0.018) and with a factor composed of the bone scan scores in the shoulders, spine, lateral knees, and sacroiliac joints (P = 0.0004).

Conclusion

Synovial fluid COMP levels correlated strongly with 2 indicators of knee joint inflammation: early‐phase bone scintigraphic findings and synovial fluid volume. Serum COMP levels correlated with total‐body joint disease severity as determined by late‐phase bone scintigraphy, supporting the hypothesis that whole‐body bone scintigraphy is a means of quantifying the total‐body burden of OA for systemic biomarker validation.

     

A rare benign disorder mimicking metastasis on radiographic examination: a case report of osteopoikilosis

Osteopoikilosis (OPK) is a rare, autosomal dominant bone disorder, characterized by multiple, discrete round or ovoid radio densities scattered throughout the axial and appendicular skeleton. OPK is usually asymptomatic but rarely there may be slight articular pain and joint effusions. OPK is generally diagnosed incidentally on radiographic examinations and may mimic different bone pathologies, including bone metastases. Radionuclide bone scan has a critical role in distinguishing OPK from osteoblastic bone metastases. In this case report, we present a young man with right hip pain due to OPK, whose plain radiogram and computerized tomography findings thought cancer metastasis.     

Detection and initial characterization of synovial lining fragments in synovial fluid

OBJECTIVE: Free fragments of synovium have occasionally been seen in synovial fluid but have not been studied systematically. We wished to establish a method for the reliable detection of these fragments in joint and bursa effusions and begin to characterize them by histochemical and immunohistochemical methods. METHODS: Cell smears, wet drop preparations and cytospins were prepared from 39 consecutive joint and bursa effusions. Paraffin cell blocks were prepared from a subset. Analysis encompassed standard and polarized light microscopy, histochemistry, immunohistochemistry and transmission electron microscopy (EM). Synovial biopsy tissue from one different patient was examined for comparison. RESULTS: Tissue fragments were not seen in Wright-stained cell smears and only rarely in wet drop preparations. In contrast, variously sized fragments with the histological appearance of hyperplastic synovial lining were detected in ethanol-fixed, haematoxylin/eosin-stained cytospins from bursitis and all arthropathies studied [17/24 (71%) of non-inflammatory and 12/15 (80%) of inflammatory specimens]. Immunostaining revealed CD68 expression in a subset of cells in a pattern characteristic of hyperplastic synovial lining. Juxtaposed cells with morphological features of macrophage-like and fibroblast-like synoviocytes were seen by EM. CONCLUSIONS: Synovial lining fragments can be detected in effusions from diverse arthropathies and bursitis. They maintain important properties of the synovial lining and can be analysed by immunohistochemistry. They may afford the opportunity to study a relatively pure preparation of synovial lining cells without the need for cell culture, and to evaluate their possible role in augmenting or perpetuating synovitis or joint damage.     

Infrapatellar bursitis in children with juvenile idiopathic arthritis: a case series

Children with juvenile idiopathic arthritis (JIA) may infrequently present with localized anterior knee pain or swelling, in addition to generalize knee pain induced by JIA. We report five cases of deep infrapatellar bursitis in children with JIA. The clinical features, radiological findings, management, and outcome of five children with JIA and deep infrapatellar bursitis are reviewed. Three boys and two girls with a mean age of 9.8 years (range 6–14 years) were reviewed. Four children had persistent oligoarticular JIA, and one child had extended oligoarticular JIA. The presentation of deep infrapatellar bursitis was variable. In only one patient was the bursal swelling painful. Knee magnetic resonance imaging (MRI) was performed in four patients and demonstrated coexistent knee joint synovitis in three. Treatment included targeted corticosteroid injections into the deep infrapatellar bursa in two cases with complete resolution. One case was treated with corticosteroid injection by an outside health care provider with poor clinical response. Two cases are being treated with non-steroidal anti-inflammatory drugs and methotrexate. Deep infrapatellar bursitis can occur as an isolated finding or concurrently with knee joint synovitis in patients with JIA. Awareness of this entity is important because direct injection of the bursa may be needed for treatment, as the bursa does not communicate with the knee joint. Furthermore, when bursitis is suspected in JIA, MRI can be helpful to confirm the diagnosis, detect concurrent knee joint synovitis, and exclude other pathologies.     

Anterior sonography of glenohumeral joint in patients with inflammatory joint disease

Ultrasonography (US) was shown as an effective imaging modality in evaluating the shoulder. The shoulder joint is probably the most accessible joint for sonography in adults. However, inflammatory changes of the shoulder have received too little attention in US studies. Anterior access for US assessment of glenohumeral joint (GHJ) has not been investigated. Another problem of patients with acute synovitis of glenohumeral joint is the difficulty to perform a 90° abduction for the axillary US because of severe pain and active and passive limitation. We offer the anterior access for assessment of glenohumeral joint synovitis (GHS). Sonographic evaluation (Sonosite-Titan) was carried out in 25 patients with acute GHS and 15 healthy controls. The diagnosis of GHS was made after the patients underwent physical examination and the laboratory evidence was obtained. We used the anterior position of transducer applied laterally to coracoid processus along the anterior joint cavity. The problem of anterior joint cavity investigation in neutral position is a poor presentation of the joint and the application of the biceps tendon. The problem is simply resolved after supination of the hand and external rotation of the shoulder. We measured and compared upper, middle, and lower width of the anterior GHJ cavity. Echogenicity of joint cavity was assessed by comparison with adjacent tissues. Homogeneity and regularity of GHJ cavity was designated in both groups as well. We measured labrum-infraspinatus distance on posterior view for assessment of GHJ synovitis. All cases of GHJ synovitis were confirmed by a US Doppler study. US investigation of healthy controls enabled to find normal values of the width of the anterior GHJ cavity that was less than 7.4 mm. The synovitis group showed GHJ cavity expansion: 8.3±2.4 (p=0.001) and 10.5±3.1 (p<0.001) for the middle and the lower anterior part of the GHJ respectively. The upper part width was not different in synovitis and control groups. Anterior joint cavity extension to 7.4 mm and upper in its lower part was high sensitive (96%) and specific (86%) US sign of synovitis with the test power above 0.9. The posterior labrum-infraspinatus extension had high specificity for synovitis (100%), but only seven of 25 patients (28%) had increased (>2 mm) the value of the labrum-infraspinatus dimension, which was previously proposed as the US sign of synovitis. Echogenicity of the anterior joint cavity in healthy controls was moderately high (far more echogenic than deltoid muscle). Echogenicity of synovitis declined, and mild effusions were found to be common. Those were not to be seen on US of GHJ in neutral position and were revealed only in supination and external rotation of the shoulder. Intra-articular tissue of healthy controls was relatively echo-homogenic compared with nonhomogenic one of the synovitis group. Bone irregularity was found in patients with long-standing GHJ synovitis reflecting erosive process. A certain position of the shoulder and good knowledge of the normal anterior joint cavity parameters enabled us to diagnose synovitis by anterior shoulder sonography, with the patients experiencing minimal pain during movements.     

Nocturnal pain correlates with effusions in diseased hips.

Thirty-five of 50 patients with different hip joint disease had sonographic evidence of joint effusion. Arthrocentesis confirmed effusions in 30 of these 35 patients. Thirty-two of the 35 patients had nocturnal pain. Both nocturnal pain and sonographic evidence of effusion decreased after aspiration (15 patients) and aspiration and injection of corticosteroids (15 patients). In a further group of 61 patients who subsequently had Charnley arthroplasties, 35 had positive sonograms before operation. Of these, 25 had effusions confirmed at operation, the remaining 10 having synovitis and capsule thickening. Again a correlation was found with nocturnal pain. The sensitivity of sonography in detecting hip joint effusion was 92% with a specificity of 70%. Nocturnal pain had a lower sensitivity, 85%, but higher specificity, 94%.     

Sonographically guided procedures in rheumatology

OBJECTIVE: To provide some representative examples of sonographically guided arthrocentesis and intralesional injection therapy. METHODS: Sonographic evaluation was performed with high-frequency linear (13 MHz) and mechanical sector (20 MHz) transducers. The images were obtained in representative patients with rheumatoid arthritis and posttraumatic subacromial bursitis. RESULTS: Sonographically guided intralesional injection is a rapid and reliable procedure, especially in patients with arthritis, tenosynovitis, and bursitis. After target localization, needle placement can be performed under continuous sonographic monitoring. Sonographic guidance is particularly useful when fluid collections are small (less than 5 mm) and deep or when the inflammatory process is adjacent to anatomic structures that could be seriously damaged by the injection. CONCLUSIONS: Over the last few years, the rapid technologic advancements in ultrasonography have dramatically increased the potential applications of sonographically guided procedures. The simplicity and reliability of the technique might warrant rheumatologists to undergo sonographic training.     

Ultrasound imaging for the rheumatologist III. Ultrasonography of the hip

Ultrasonography (US) is a reliable and useful diagnostic tool for the assessment of hip pathology. It depicts changes within the coxo-femoral joint (synovitis, erosions, osteophytes) and in the adjacent peri-articular tissues (calcifications, tendonitis, enthesitis, bursitis) in many rheumatic diseases (rheumatoid arthritis, spondyloarthritis, osteoarthritis, polymyalgia rheumatica ) and in some orthopaedic disorders (septic arthritis, trauma, abscess, painful hip after arthroplasty). It is commonly used both in adults and in children. In the assessment of hip joint pathology, US exerts considerable diagnostic supremacy over physical examination. In fact, by virtue of its size and position, reliable physical examination of the hip is often difficult thus making US particularly useful as a bedside tool for the evaluation of a painful hip. Hip US has also proven to be of great practical benefit when performing aspiration and injection within the joint and in the periarticular soft tissues. The relatively limited acoustic windows available to the US beam is the principal limitation to hip US thereby making detailed examination of some important structures impossible together with the interpretation of power Doppler signal sometimes unreliable. In addition, the deep location of the hip can confer further problems to US scanning in obese or particularly muscular subjects.