Didactic Module 3 SPECIAL ULTRASOUND

Course 3.6. The importance of grey-scale ultrasonography in current medical practice of rheumatoid arthritis patients
Rodica Traistaru
E-EDUMED e-Learning Educational Center in Medicine Agreement 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.

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

Introduction (1)
RA = a progressive, deforming arthritis caused by immune-mediated, active chronic proliferative synovitis, which results in the formation of an inflammatory tissue RA = involves multiple joints in a symmetric distribution, notably the small joints of the distal extremities, with a high potential of evolution RA = approximately 1% of the population is affected; a greater prevalence in women (23:1) The precocious diagnosis of RA
important for therapy beginning dealing with limiting the destructive character of lesions and also the installation of functional disabilities

Introduction (2)

RA = the most studied inflammatory disease in rheumatological MUS MUS = an important tool in RA patient investigation and clinical care setting
first rheumatological ultrasound in RA = demonstration of synovitis 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

TECHNICAL GUIDENESS equipment and examination specifications (1)

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

F1

F2

MUS of the joint structures in RA

Shoulder joint
Long biceps tendon tenosynovitis, tear (partial / total) Subscapularis, supraspinatus, and infraspinatus tendons tendinosis, partial tear, calcification Subacromial-subdeltoid and subcoracoid bursae burisitis Acromio-clavicular joint effusions, synovitis, erosions, osteophytes Humeral head erosions

7
>> >>

6 1

5 4 3 2 1

2 1

TS of anterior shoulder RA patient

7.5MHZ

5 4 1

7 8*

1. Humerus head (erosions ) 2. The biceps tendon ( effusion) 3. Subdeltoid bursa 4. The deltoid muscle 5. The subcutaneous tissue 6. Rheumatoid nodule (>>) 7. Skin 8. Subscapularis tendon (tendinitis *) 9. Supraspinatus tendon (tendinitis *)

LS of anterior shoulder RA patient

5 4

7 3 1

LS of medial anterior shoulder

LS of shoulder (internal rotation of hand)

7 3 7 # 1 4 # 1 1 4

5 2

*
1

LS of anterior shoulder 1. Humerus head (erosions ) RA patient 2. The biceps tendon

TS of anterior shoulder RA old patient

7.5MHZ

5 4 1

7 8*

3. Subdeltoid bursa 4. The deltoid muscle 5. The subcutaneous tissue 6. Rheumatoid nodule (>>) 7. Skin 8. Subscapularis tendon (tendinitis *) 9. Supraspinatus tendon (tendinitis *) # synovial tissue hypertrophy with hyperechoic spots floating

7 3

9 1

LS of medial anterior shoulder

Left Right LS of shoulder (internal rotation of hand)

5 3

2
1

2 1

2 1

4 2
3

TS of anterior shoulder RA patient

1. Humerus head (erosions ) (1 bicipital grove) 2. The biceps tendon long head ( effusion; # calcification) 3. Subdeltoid bursa (bursitis) 4. The deltoid muscle 5. The subcutaneous tissue and Skin 8. Subscapularis tendon (tendinitis *) 9. Supraspinatus tendon (tendinitis *, # calcification)

LS of anterior shoulder RA patient

12.5MHZ

5 4 3 # 9 1

*
1

5 8

*
1

4
1

5 1

*
1

LS of medial anterior shoulder

LS of shoulder (internal rotation of hand)

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

6 4 2 1

4 2 1 7

4 1 1

4 2 4

6 2 4

+
1

4 2 1

+
1

LS of knee in two patients with early RA (A right suprapatellar recess; B - left suprapatellar recess)

= effusion (E) =synovial pannus (S)

+
1

>>
1

3
TS

LS

RA patient, left knee with significant disability (LS and TS)

1. Femur 2. Patella 3. Anterior tibial tuberosity 4. Quadriceps tendon 5. Patellar tendon 6. Corpus adiposum 7. Recessus suprapatellaris E = effusion with dorsal reflex enhancement + = synovial fluid > The thinning of the cartilage layer

4 SH 7 1

5 3

2 1

5* 3

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

LS of right knee

9 1 3 1

>>

9
8

Two popliteal cysts. The > > indicate hyperechopic spots floating in the anechoic synovial fluid 3

1. Femur. 2. Patella. 3.Tibia 4. Quadriceps tendon 5. Patellar tendon (enthesitis *) LS of right knee (in frontal plan) 6. Corpus adiposum Medial Lateral 7. Recessus suprapatellaris 8. Medial part of the m. gastrocnemius 9. Collateral longitudinal ligament ( partial tear) E = effusion with dorsal reflex enhancement + = synovial fluid > The thinning of the cartilage layer

LS of popliteal fossa

1. Uniform SH

2. Vilonodular SH

4. Superpose levels SH

3. Combined SH 3. Combined SH

The main morphological patterns of synovial inflammation have described 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

4 7

+
1

4 7

Left

Right Persistent sero+ RA in an old patient (68years) with OA of knee

LS of knees supra-pattelar
6 5 6 5 3 1

>

LS of knees infra-pattelar

1. Femur. 2. Patella. 3.Tibia 4. Quadriceps tendon 5. Patellar tendon ( partial tear, enthesitis *) 6. Corpus adiposum 7. Recessus suprapatellaris E = effusion with dorsal reflex enhancement + = synovial fluid > osteophyte

2 3 4

LS of Achilles region RA patient

1. 2. 3. 4. 5. 6. 7.
1 2 4 6 5 2 3 4

Achilles tendon (tendinitis *) Soleus muscle Flexor halucis longus muscle Tibia Talus Kagers triangle (hypoechoic fat deep) Peritendon (peritendinitis >>)
RN

B LS of Achilles region A left; B right RA patient

>>

7.5MHz

7 6

>
6

7 5

A
1 6 5

1* 6

> 7
5

LS of Achilles region A relaxation; B contraction RA patient

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 information for new management strategies