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Course 3.6. The importance ofgrey-scale ultrasonographyin current medical practiceof rheumatoid arthritis patients

Rodica Traistaru

Didactic Module 3SPECIAL ULTRASOUND

E-EDUMED e-Learning Educational Center in MedicineAgreement N. LLP/LdV/TOI/RO/2010/006

This project has been funded with support from the European Commission.This communication reflects the views only of the author, and the Commission cannot be held responsible

for any use which may be made of the information contained therein.


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List of abbreviations

CR= Conventional Radiography F = figure

L = Left; R= Right LS = Longitudinal scan MUS = Musculoskeletal ultrasonography OA = Osteoarthritis

RA = Rheumatoid Arthritis RN = Rheumatoid Nodule SH = Synovial Hypertrophy TS = Transversal scan US = Ultrasonography


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Introduction (1)

RA = a progressive, deforming arthritis caused byimmune-mediated, active chronic proliferativesynovitis, which results in the formation of aninflammatory tissue

RA = involves multiple joints in a symmetricdistribution, notably the small joints of the distalextremities, with a high potential of evolution

RA = approximately 1% of the population isaffected; a greater prevalence in women (23:1)

The precocious diagnosis ofRA important for therapy beginning dealing with limiting the destructive character

of lesions and also the installation of functional disabilities


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Introduction (2)

RA = the most studied inflammatory disease inrheumatological MUS

MUS = an important tool in RA patient investigationand clinical care setting

first rheumatological ultrasound in RA = demonstration ofsynovitis of the knee in RA in 1978

doesnt involve ionizing radiation or contrast agents provides multiplanar images of cortical bone, tendons, muscle,

ligaments, synovium, bursa in real time enables the visualization of a lot of joints at a time low running costs + excellent patient acceptability has the ability to detect sub clinical synovitis and joint damage

with more sensitivity than CR

+ a better understanding of the rheumatic diseases

MUS = an ideal tool for rheumatologists


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US equipments used = two high frequency linear transducers

HRT LA13A (7,5 MHz), ESAOTE AU5 (F1)

HRT 12,5 MHz, HD 11 XE, Ultrasound System Philips (F2)

A real-time high-frequency US evaluate soft-tissue and other

changes in the joints

Cartilage, effusions =anechoic sound waves structures

Muscle, synovial tissue, peripheral nerves =

hypoechoic sound waves structures

Bone, calcifications, tendons, foreign bodies=hyperechoic sound waves structures

TECHNICAL GUIDENESSequipment and examination specifications (1)

F1

F2


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MUS of the joint structures in RA

Shoulder joint

Long biceps tendon tenosynovitis, tear (partial /total)

Subscapularis, supraspinatus, and infraspinatustendons tendinosis, partial tear, calcification

Subacromial-subdeltoid and subcoracoid bursae burisitis

Acromio-clavicular joint effusions, synovitis,

erosions, osteophytes Humeral head erosions


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1

57

84 *

7

193

4

5

1*

1 1

7

42

5

LS of anterior shoulder

RA patient

LS of medial anteriorshoulder

LS of shoulder

(internal rotation of hand)

12

3

567

1

4>>>>

TS of anterior shoulder

RA patient1. Humerus head (erosions )2. The biceps tendon( effusion)3. Subdeltoid bursa4. The deltoid muscle5. The subcutaneous tissue6. Rheumatoid nodule (>>)7. Skin8. Subscapularis tendon(tendinitis *)9. Supraspinatus tendon(tendinitis *)

7.5MHZ


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LS of anterior shoulderRA patient

24 *

1 1

5

2

7

7

1

1

Left Right

LS of shoulder(internal rotation of hand)

35

*

9

4

#

1

57

84 *

LS of medial anteriorshoulder

1

34


RA old patient

##

7

1

1. Humerus head (erosions )2. The biceps tendon3. Subdeltoid bursa4. The deltoid muscle5. The subcutaneous tissue6. Rheumatoid nodule (>>)7. Skin

8. Subscapularis tendon(tendinitis *)9. Supraspinatus tendon(tendinitis *)# synovial tissue hypertrophy with hyperechoic spots floating

7.5MHZ


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LS of medial anterior

shoulder

1

4

8

1

45

*


RA patient

11

54

2#2

3

12.5MHZ

1. Humerus head (erosions )(1 bicipital grove)2. The biceps tendon long head( effusion; # calcification)

3. Subdeltoid bursa (bursitis)4. The deltoid muscle5. The subcutaneous tissueand Skin8. Subscapularis tendon(tendinitis *)9. Supraspinatus tendon(tendinitis *, # calcification)

LS of shoulder

(internal rotation of hand)

1 1

1

1

5

3

9

9*

#

45

9*#

4

LS of anterior shoulder

RA patient

1 1

2 4

5

#

2

3


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MUS of the joint structures in RA

Knee joint Suprapatellar recess effusion, synovial

hypertrophy

Bone surfaces erosions, osteophytes Quadriceps and patellar tendons tendinosis,

enthesitis, partial / complete tear, calcification

Knee bursae bursitis

Gastrocnemius (medial - mg) semimembranous (sm) bursa Bakers cyst

Articular cartilage lesion

Medial collateral ligament partial / complete

tear


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= effusion (E)=synovial pannus (S)LS of knee in two patients with early RA

(A right suprapatellar recess;

B - left suprapatellar recess)

1. Femur2. Patella

3. Anterior tibial tuberosity4. Quadriceps tendon

5. Patellar tendon6. Corpus adiposum

7. Recessus suprapatellarisE = effusion with dorsal reflex enhancement

+ = synovial fluid> The thinning of the cartilage layer

B

1 1 11

22 2

24

4

6 6

7

A

11

1 1

22

2

44

44

6 6

7 ++ +

44

RA patient, left knee with significant

disability (LS and TS)

LS TS

1 1

77

+

3>>


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*

1. Femur. 2. Patella. 3.Tibia4. Quadriceps tendon

5. Patellar tendon (enthesitis *)6. Corpus adiposum7. Recessus suprapatellaris

8. Medial part of the m. gastrocnemius9. Collateral longitudinal ligament ( partial tear)

E = effusion with dorsal reflex enhancement+ = synovial fluid

> The thinning of the cartilage layer

LS of left knee in RA patientSupra (A) and infra (B) patellar

A B

4 5

3

1

7 +SH

LS of right knee

A B

1

13

4 5

+2

8

>>

1 3

LS of right knee (in frontal plan)Medial Lateral

1 13

9 9

LS of popliteal fossa

Two popliteal cysts. The > >indicate hyperechopic spots

floating in the anechoicsynovial fluid


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4. Superpose levels SH

1. Uniform SH 2. Vilonodular SH

3. Combined SH

3. Combined SH

The main morphological patterns of synovial inflammation havedescribed in knee RA:1. Hypoechoic tissue which is uniformly distributed in the joint cavity

(diffuse appearance)2. Hypoechoic appearance but exhibits a villous pattern

(vilonodular appearance)3. Combined SH

4. Superpose levels SH


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Left Right

1. Femur. 2. Patella. 3.Tibia4. Quadriceps tendon

5. Patellar tendon ( partial tear, enthesitis *)6. Corpus adiposum

7. Recessus suprapatellarisE = effusion with dorsal reflex enhancement

+ = synovial fluid> osteophyte

1 1

77

44

55

3

311

66

+

*

>

LS of knees supra-pattelar

LS of knees infra-pattelar

Persistent sero+ RA inan old patient(68years) with OA ofknee


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LS of Achilles regionA relaxation; B contraction

RA patient

A

B

1 1

65

7

6

5

>1

55

4

1

6

7

6

7

*

>

1. Achilles tendon (tendinitis *)2. Soleus muscle

3. Flexor halucis longus muscle4. Tibia5. Talus6. Kagers triangle (hypoechoic fat deep)7. Peritendon (peritendinitis >>)

LS of Achilles regionRA patient

1

2

3

4

>>7

6

LS of Achilles region

A left; B rightRA patient

A B

1

2

4 5 4

623

RN

7.5MHz


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Conclusions

Uses of MUS in RA patients DIAGNOSIS

Early diagnosis of RA

Site-specific diagnosis

Overall diagnosis (positive, differential)

MANAGEMENT (complex treatment) Guiding injections (improving injection placement)

Aiding with prognostication

Identifying subclinical inflammatory disease

CLINICAL TRIALS Aiding with prognostication

Monitoring outcomes of treatment program

New developments in imaging in RA (high frequency and Power Doppler US

and magnetic resonance imaging) can provide essential informationfor new management strategies

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