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.     

膝周滑囊炎的鉴别诊断与治疗

目的 探讨膝关节周围滑囊炎的鉴别诊断与治疗方法。方法 回顾我院自2000年3月～2002年3月诊治的32例膝周滑囊炎，通过膝关节镜检查治疗后，经查体及患者主诉明确最后诊断。采取保守治疗，并进行临床随访分析。结果 随访8～40周，9例无膝内病变且仅为一种滑囊炎的3周以内治愈。23例合并2种以上滑囊炎(包括4例合并膝内病变者)3～5周治愈。结论 对膝周滑囊炎，根据主诉及查体，先区分关节内外，再辨别疼痛部位，可以进行鉴别诊断。本病保守治疗可治愈。     

螺旋CT对坐骨结节滑囊炎的诊断价值

目的:探讨坐骨结节滑囊炎的CT表现及CT扫描的诊断价值。方法:回顾性分析42例坐骨结节滑囊炎的CT表现及手术病理结果对照。所有病例均行CT轴位平扫,其中36例常规轴扫后行薄层冠状扫描,32例尚行CT增强扫描。结果:CT平扫于坐骨结节与臀大肌之间的间隙内可见单个多房囊性水样密度肿块,边欠清,大小1cm～6cm直径,呈圆形或椭圆形。增强扫描示肿块内无明显强化,但分隔及边缘可有轻度强化。结论:坐骨结节滑囊炎的CT表现较有特征性,CT扫描具有极高的诊断价值。     

Synovial cysts of the hip joint and iliopsoas bursitis: A spectrum of imaging abnormalities

Synovium-related soft tissue disease around the hip constitutes a spectrum ranging from isolated iliopsoas bursitis to pure articular synovial herniations without bursal involvement. The clinical, pathologic, and radiographic features of these entities are discussed as they pertain to the variety of underlying disorders which predispose to their occurrence. Nine case reports are utilized to illustrate the variable clinical and radiographic presentations which may be encountered. Based upon these cases as well as those in the literature, an imaging algorithm has been developed which should eliminate unnecessary studies and allow prompt and accurate diagnosis.     

Non-Infectious Ischiogluteal Bursitis: MRI Findings

Objective

We wished to report on the MRI findings of non-infectious ischiogluteal bursitis.

Materials and Methods

The MRI findings of 17 confirmed cases of non-infectious ischiogluteal bursitis were analyzed: four out of the 17 cases were confirmed with surgery, and the remaining 13 cases were confirmed with MRI plus the clinical data.

Results

The enlarged bursae were located deep to the gluteus muscles and postero-inferior to the ischial tuberosity. The superior ends of the bursal sacs abutted to the infero-medial aspect of the ischial tuberosity. The signal intensity within the enlarged bursa on T1-weighted image (WI) was hypo-intense in three cases (3/17, 17.6%), iso-intense in 10 cases (10/17, 58.9%), and hyper-intense in four cases (4/17, 23.5%) in comparison to that of surrounding muscles. The bursal sac appeared homogeneous in 13 patients (13/17, 76.5%) and heterogeneous in the remaining four patients (4/17, 23.5%) on T1-WI. On T2-WI, the bursa was hyper-intense in all cases (17/17, 100%); it was heterogeneous in 10 cases and homogeneous in seven cases. The heterogeneity was variable depending on the degree of the blood-fluid levels and the septae within the bursae. With contrast enhancement, the inner wall of the bursae was smooth (5/17 cases), and irregular (12/17 cases) because of the synovial proliferation and septation.

Conclusion

Ischiogluteal bursitis can be diagnosed with MRI by its characteristic location and cystic appearance.     

Greater trochanteric pain syndrome: epidemiology and associated factors

OBJECTIVES: To describe the prevalence of greater trochanteric pain syndrome (GTPS); to determine whether GTPS is associated with iliotibial band (ITB) tenderness, knee osteoarthritis (OA), body mass index (BMI), or low back pain (LBP); and to assess whether GTPS is associated with reduced hip internal rotation, physical activity, and mobility. DESIGN: Cross-sectional, population-based study. SETTING: Multicenter observational study. PARTICIPANTS: Community-dwelling adults (N=3026) ages 50 to 79 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Greater trochanteric tenderness to palpation in subjects with complaints of hip pain and no signs of hip OA or generalized myofascial tenderness. RESULTS: The prevalence of unilateral and bilateral GTPS was 15.0% and 8.5% in women and 6.6% and 1.9% men. Odds ratio (OR) for women was 3.37 (95% confidence interval [CI], 2.67-4.25), but age and race were not significantly associated with GTPS. In a multivariate model, adjusting for age, sex, ITB tenderness, ipsilateral and contralateral knee OA, BMI, and LBP, ITB tenderness (OR=1.72; 95% CI, 1.34-2.19), knee OA ipsilaterally (OR=3.47; 95% CI, 2.72-4.42) and contralaterally (OR=1.74; 95% CI, 1.32-2.28), and LBP (OR=2.79; 95% CI, 2.22-3.50) were positively related to GTPS. In this complete model, BMI was not associated with GTPS (OR=1.10; 95% CI, 0.80-1.52 when comparing >or=30 with <25kg/m(2)). Hip internal rotation range of motion did not differ based on GTPS status. After multivariate adjustment, GTPS did not alter physical activity score, but bilateal GTPS was significantly associated with a higher 20-meter walk time and chair stand time. CONCLUSIONS: The higher prevalence of GTPS in women and in adults with ITB pain or knee OA indicates that altered lower-limb biomechanics may be related to GTPS. Slower functional performance in those with GTPS suggests that the study of targeted rehabilitation may be useful. A longitudinal study will be necessary to identify causal factors and outcomes of interventions.     

Ultrasound characteristics of gouty tophi in the olecranon bursa and evaluation of their reproducibility

Objectives

To describe the ultrasound characteristics of gouty tophi in the olecranon bursa and to evaluate their reproducibility.

Methods

A prospective study of the ultrasound features of 35 sites of tophi nodulations in the elbows of 31 men (mean 54.6 years). The findings were evaluated dynamically following pre-established standards. The static images were evaluated by another radiologist and were reviewed by the first examiner.

Results

The most frequent characteristics of tophi are: hyperechogenicity (91.7%), poorly defined contours (88.6%), multiple grouped nodules (85.6%) and heterogeneity (68.6%). Intra-observer agreement is almost perfect for echogenicity (K = 1.0), moderate for the involvement of the olecranon bursa (K = 0.47) and fair for other characteristics. Inter-observer agreement is substantial for the echogenicity (K = 0.65), fair for the echotexture (K = 0.27) and the presence of a perilesional hypoechoic halo (K = 0.34) and slight for other characteristics.

Conclusions

The most frequent characteristic of tophi is hyperechogenicity. The intra-observer and inter-observer concordance for echogenicity are almost perfect and substantial, respectively. Knowledge of characteristics of the tophi in the elbow and their intra and inter-observer reproducibility may assist in establishing parameters for monitoring treatment and setting up criteria for differential diagnosis of processes involving the olecraneon bursa.     

Ultrasonographic assessment of pes anserinus tendon and pes anserinus tendinitis bursitis syndrome in patients with knee osteoarthritis

Abstract

Objective. The aim of this study was to assess the ultrasonographic (US) findings of pes anserinus tendon and bursa in patients with knee osteoarthritis (OA) with or without clinical pes anserinus tendinitis bursitis syndrome (PATBS).

Methods. A total of 157 female patients with the diagnosis of knee OA on both knees (314 knees), and 30 age, and body mass index- matched healthy female controls without knee pain (60 knees), were included in the study. PATBS was clinically diagnosed. US evaluation parameters were the measurement of the thickness of pes anserinus tendon insertion region (PA) and examination of the morphologic intratendinous PA tissue characteristics and pes anserinus bursitis (PAB). Radiographic knee osteoarthritis graded I-IV according to Kellgren and Lawrence (KL) for each knee was recorded. Pain and functional status were assessed by the Visual Analog Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

Results. There were 183 PATBS (58.3%) clinical diagnoses among the 314 knees with OA. The mean thickness of PA in the patients with knee OA graded 1,2,3,4 with/without PATBS was significantly greater than the controls (p = 0.001). The mean thickness of PA in knees with OA KL graded 3 and 4 with/without PATBS, was greater than knees with OA KL graded 1 and 2 with/without PATBS (p < 0,05) (except knee OA KL graded 2 with PATBS versus knee OA KL graded 4 without PATBS).The knee OA KL graded 1,2,3,4 with PATBS had significantly more PAB and less loss of normal fibrillar echotexture of PA compared to controls and knees with OA KL graded 1,2,3,4 without PATBS (p < 0.05). The VAS scores of knees with OA KL graded 3, 4 with PATBS were significantly greater than those of knees with OA KL graded 3,4 without PATBS (p < 0.05). PA thickness was significantly associated with the KL grade (r: 0.336, p:0.001) and PATBS (r: 0.371, p < 0.001).

Conclusion. It is concluded that the mean thickness of PA in knees with OA with/without PATBS was significantly greater than the controls. The mean thickness of PA in knees with OA, KL graded 3 and 4 with/without PATBS, was greater than in knees with OA KL graded 1 and 2 with/without PATBS. The knee OA with PATBS had significantly more PAB, less loss of normal fibrillar echotexture of PA, and higher VAS scores compared to the knees with OA without PATBS. US can serve as a useful diagnostic tool for detection of PATBS in knee OA.