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Ultrasonography of the metatarsophalangeal joints in rheumatoid arthritisComparison with magnetic resonance imaging conventional radiography and clinical examination.

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ARTHRITIS & RHEUMATISM
Vol. 50, No. 7, July 2004, pp 2103–2112
DOI 10.1002/art.20333
© 2004, American College of Rheumatology
Ultrasonography of the Metatarsophalangeal Joints in
Rheumatoid Arthritis
Comparison With Magnetic Resonance Imaging, Conventional Radiography, and
Clinical Examination
Marcin Szkudlarek,1 Eva Narvestad,1 Mette Klarlund,1 Michel Court-Payen,2
Henrik S. Thomsen,2 and Mikkel Østergaard1
examination revealed signs of inflammation in 31 patients and 20 patients, respectively. US and MRI
volume-based gradings of synovitis showed intraclass
correlation coefficients of 0.56–0.72 (P < 0.0001). The
MRI and radiographic visualizations of US-detected
bone changes were closely related to their size-based
gradings on US.
Conclusion. US enables detection and grading of
destructive and inflammatory changes in the MTP
joints of patients with RA. By comparison with MRI, US
was found to be markedly more sensitive and accurate
than clinical examination and conventional radiography. Considering the early and frequent involvement of
the MTP joints, evaluation of these joints by US may be
of major clinical importance in RA.
Objective. To compare ultrasonography (US) with
magnetic resonance imaging (MRI), conventional radiography, and clinical examination in the evaluation of
bone destruction and signs of inflammation in the
metatarsophalangeal (MTP) joints of patients with
rheumatoid arthritis (RA).
Methods. Two hundred MTP joints of 40 patients
with RA and 100 MTP joints of 20 healthy control
subjects were assessed with B-mode US, contrastenhanced MRI, conventional radiography, and clinical
examination for signs of bone destruction and joint
inflammation.
Results. With MRI considered the reference
method, the sensitivity, specificity, and accuracy of US
for the detection of bone erosions were 0.79, 0.97, and
0.96, respectively, while the corresponding values for
radiography were 0.32, 0.98, and 0.93. The sensitivity,
specificity, and accuracy of US for the detection of
synovitis were 0.87, 0.74, and 0.79, while for clinical
examination, the corresponding values were 0.43, 0.89,
and 0.71. Erosive disease was identified in 26 patients by
US, compared with 20 patients by MRI and 11 patients
by radiography. Evaluation by US indicated signs of
inflammation in 36 patients, while MRI and clinical
Rheumatoid arthritis (RA) is a chronic, systemic
autoimmune disease characterized by symmetric joint
inflammation and destruction that often involves the
small joints of the hands and feet, with progressive
destruction, deformity, and disability of the joints. Criteria for diagnosing RA include the presence of bone
destruction and signs of inflammation in the joints of the
hands and feet (1). With the new, aggressive treatment
strategies in early RA, there is a growing need for
sensitive and specific methods for earlier detection of
the signs of disease and monitoring of disease activity.
Visualization of bone erosions with radiography
is essential in the diagnosis and monitoring of RA.
However, radiography is not a sensitive imaging method
in RA, especially in the early stages of the disease (2,3).
Clinical examination of the joints, which is one of the
important tools in diagnosing and monitoring RA, is not
an optimal outcome measure due to poor reproducibility
1
Marcin Szkudlarek, MD, PhD, Eva Narvestad, MD, Mette
Klarlund, MD, PhD, Mikkel Østergaard, MD, PhD, DMSc: University
of Copenhagen Hvidovre Hospital, Hvidovre, Denmark; 2Michel
Court-Payen, MD, PhD, Henrik S. Thomsen, MD, DMSc: University
of Copenhagen Herlev Hospital, Herlev, Denmark.
Address correspondence and reprint requests to Marcin
Szkudlarek, MD, PhD, Department of Rheumatology, University of
Copenhagen Hvidovre Hospital, Kettegård Alle 30, 2650 Hvidovre,
Denmark. E-mail: marcin@dadlnet.dk.
Submitted for publication August 7, 2003; accepted in revised
form March 16, 2004.
2103
2104
SZKUDLAREK ET AL
Figure 1. Detection of an erosion in the right foot of a patient with early rheumatoid arthritis, which was visualized by magnetic resonance imaging
(MRI) (A and B) and ultrasonography (US) (C and D) but not by conventional radiography. In coronal (A) and axial (B) T1-weighted spin-echo MR
images, in the proximal lateral quadrant of the fifth metatarsophalangeal (MTP) joint, a bone erosion (arrows) is evident. The first MTP joint is
covered by a grid (A) (black perpendicular lines) to illustrate division of the joint into 4 quadrants: medial proximal, lateral proximal, medial distal,
and lateral distal. B-mode US in the longitudinal and transverse planes of the lateral aspect of the fifth metatarsal head shows an erosive (grade 3)
change (C and D) (arrows).
and accuracy (4). There is increasing evidence that
assessment of inflammatory and destructive joint
changes in RA with magnetic resonance imaging (MRI)
has high accuracy and strong diagnostic and prognostic
value (5–9). Ultrasonography (US) is a new method of
assessment of the small joints in RA (10). With the US
equipment now available, including high-frequency
linear-array transducers, it is possible to visualize and
grade signs of inflammation and destruction in the small
joints of the hands and feet (11).
The metatarsophalangeal (MTP) joints are
among the joints affected early in the course of RA (12).
Very few reports on the role of US in assessment of the
MTP joints in RA exist (13), and none have included
comparisons with other imaging techniques or with
clinical examination of the joints. The aim of the present
US OF RA MTP JOINTS VERSUS OTHER ASSESSMENT METHODS
study was to compare US with MRI, conventional
radiography, and clinical examination for the evaluation
of bone destruction and signs of inflammation in the
MTP joints in RA.
PATIENTS AND METHODS
Patients. Two hundred MTP joints of 40 patients with
RA and 100 MTP joints of 20 healthy control subjects were
examined. The healthy control subjects had no history of joint
symptoms or inflammatory activity in the joints. The RA
patients were recruited from 2 outpatient hospital–based arthritis clinics. The diagnosis of RA in all patients fulfilled the
1987 American College of Rheumatology (formerly, the American Rheumatism Association) classification criteria (1). The
inclusion criterion for the study was the presence of swelling or
tenderness in at least 3 joints in the following regions: the
metacarpophalangeal (MCP) joints, proximal interphalangeal
joints of the fingers, or MTP joints. The exclusion criteria were
severe deformity of the MTP joints and contraindications for
MRI. Corticosteroid injections, either intramuscular or intraarticular, were not allowed within 1 month prior to study
enrollment.
The median age of the RA patients and control
subjects was 56 years (range 23–78 years) and 52 years (range
25–78 years), respectively. The ratio of women to men was 3:1
in the RA group and 4:1 in the control group. The median
disease duration in patients with RA was 2 years (range 0–20
years). The group of patients with RA comprised 20 patients
with early disease (disease duration ⬍2 years) and 20 patients
with established disease (disease duration ⬎2 years). Twentyfive of the 40 patients with RA (14 in the group with
established disease and 11 in those with early RA) were
positive for IgM rheumatoid factor. Thirty-five patients with
RA were being treated with disease-modifying antirheumatic
drugs (26 receiving methotrexate, 7 receiving sulfasalazine, 1
receiving aurothiomalate, and 1 receiving D-penicillamine).
The study was conducted in accordance with the
Declaration of Helsinki and approved by the local ethics
committee. Signed informed consent was obtained from each
participant.
The US, MRI, and clinical and laboratory examinations of the individual subjects were performed on the same
day. Radiography was performed within 4 weeks of the other
examinations.
Clinical examination. Prior to undergoing evaluation
by US, all patients were assessed for clinical disease activity
(presence or absence of swelling and/or tenderness) in the
MTP joints. The number and localization of swollen and/or
tender joints were determined by a consultant rheumatologist.
Ultrasonography. US was performed with a General
Electric LOGIQ-500 unit using a 7–13-MHz linear-array transducer. B-mode US was done in the accessible aspects of the
first through fifth MTP joints of the right foot: in the first MTP
joint, the dorsal and medial aspects were evaluated (due to the
presence of the sesamoid bones under the plantar surface of
the joint), in the second to fourth MTP joints, the dorsal and
plantar aspects were evaluated, and in the fifth MTP joint, the
dorsal, lateral, and plantar aspects were evaluated. The as-
2105
sessed changes in the MTP joints were defined as follows: joint
effusion was defined as the compressible anechoic intracapsular area, synovitis as a hypoechoic synovial thickening (noncompressible hypoechoic intracapsular area), and bone erosions as pathologic changes in the bone surface of the area
adjacent to the joint, visualized in 2 planes.
The US examinations were primarily carried out by
quadrant for the presence or absence of bone erosions (Figure 1),
and by joint for the presence or absence of signs of inflammation (joint effusion and synovial thickening) (Figure 2). Furthermore, the findings on B-mode US were scored according
to a semiquantitative scale (ranging 0–3) for bone destruction
and for joint effusion. The scoring system was introduced in an
earlier study (11) and also included a 0–3 scale for synovial
thickening. For the present study, grade 3 synovial thickening
was further divided into grades 3 and 4 to encompass the more
advanced stages of synovial thickening. As in the previous
study, grades 0–1 were considered to be physiologic and grades
2–3 (or 4) were considered to be pathologic.
All US examinations were performed by the same
rheumatologist (MS), who was trained in the examination of
the small joints of the hands and feet (11). The visualized
changes were documented on hard-copy films and scored
during the US examinations on score sheets printed beforehand. The US examiner was not informed of the results of the
clinical and MRI examinations. The examination time was ⬃15
minutes.
Magnetic resonance imaging. On the same day as US,
MRI examinations were subsequently performed by acquiring
continuous axial and coronal pre- and post–Gd-DTPA T1weighted, spin-echo MR sequences of the first through fifth
MTP joints of the right foot, with a 1.0T Siemens Impact MR
unit equipped with a transmit/receive knee coil. The GdDTPA was administered intravenously at a concentration of
0.1 mmoles/kg body weight. The examined subjects were
placed in a supine position with the foot positioned in the coil
and maintained in neutral position. The parameters of the
applied coronal sequences were a repetition time (TR) of 500
ms, echo time (TE) of 15 ms, slice thickness of 3 mm, field of
view (FOV) of 140 mm, and matrix of 192 ⫻ 256; for the axial
sequences, the parameters were a TR of 450 ms, TE of 14 ms,
slice thickness of 3 mm, FOV of 160 mm, and matrix of 320 ⫻
512.
RA joint pathologies, as determined on MRI, were
defined in accordance with the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) international
recommendations (14). Bone erosions were defined as a
sharply marginated bone lesion, with correct juxtaarticular
localization and typical signal characteristics, which is visible in
2 planes, with a cortical break seen in at least 1 plane. Synovitis
was defined as an area in the synovial compartment that shows
above-normal post-gadolinium enhancement of a thickness
greater than the width of the normal synovium. The following
definition of joint effusion (not defined by the OMERACT
consensus) was also used: an intraarticular area, with correct
signal characteristics, that is not enhanced on post-gadolinium
sequences and is surrounded by the synovial membrane.
The MRI examinations were carried out by quadrant
for the presence or absence of bone erosions (Figure 1), and by
joint for the presence or absence of signs of inflammation
(joint effusion and synovial thickening) (Figure 2). Further-
2106
SZKUDLAREK ET AL
Figure 2. Signs of synovitis on MRI and US of the right foot of a
patient with established rheumatoid arthritis. Arrows indicate an
intracapsular area with synovitis. The patient had no clinical signs of
synovitis. Axial T1-weighted MR images were obtained before (A) and
after (B) intravenous contrast injection. In the second MTP joint, a
distinct postinjection contrast enhancement (grade 3 synovitis) is
evident. B-mode US in the longitudinal plane of the dorsal aspect of
the second MTP joint (C) shows signs of synovitis (grade 3). See Figure
1 for definitions.
more, synovitis was scored according to a semiquantitative
scale (ranging 0–4) as suggested by Klarlund et al (15). All
MRI examinations were evaluated on hard-copy films by the
same observer (MØ), who was trained in evaluation of MR
images in RA and who was blinded to the clinical and
ultrasonographic data.
Conventional radiography. Radiography of the right
foot was performed within 4 weeks of the other examinations,
using standard posteroanterior views. On radiography, bone
erosions, defined as irregular punched-out areas of subchondral bone and irregular articular surfaces (16), were evaluated.
The films were assessed for erosions by quadrant in the first
through fifth MTP joints by an experienced musculoskeletal
radiologist (EN), who was unaware of the findings of the other
examinations.
Biochemical assessment. A blood sample was obtained
from each patient, by withdrawing the blood through a cannula
inserted in the cubital vein, before the MRI examination. The
blood samples were assessed to determine the serum C-reactive
protein level. Information on the IgM rheumatoid factor status
was obtained from the medical records of the patients.
Statistical analysis. The agreement between imaging
methods and in comparison with clinical examination findings
was reported as overall agreement, which was defined as the
proportion of exact agreements to the overall number of trials,
with results expressed as a percentage. With MRI considered
as the reference method, the accuracy, sensitivity, and specificity of B-mode US for the evaluation of bone destruction and
signs of inflammation were calculated. Moreover, the agreement between US and MRI in terms of assessment of synovitis
US OF RA MTP JOINTS VERSUS OTHER ASSESSMENT METHODS
2107
Table 1. Detection of bone erosions by US, MRI, and radiography*
Quadrants with erosions
Joint (total
quadrants), group
MTP1 (240)
Total
Established RA
Early RA
Healthy controls
MTP2 (240)
Total
Established RA
Early RA
Healthy controls
MTP3 (240)
Total
Established RA
Early RA
Healthy controls
MTP4 (240)
Total
Established RA
Early RA
Healthy controls
MTP5 (240)
Total
Established RA
Early RA
Healthy controls
Total (1,200)
Total
Established RA
Early RA
Healthy controls
US
⫹
MRI
⫹
RAD
US
MRI
⫹
⫹
MRI RAD
US
⫹
RAD
US
only
MRI
only
RAD
only
Quadrants with
no erosions on
US, MRI, or
RAD
Agreement
US vs.
MRI, no.
(%)
RAD vs.
MRI, no.
(%)
Sensitivity
Specificity
US RAD
US RAD
1
1
0
0
13
10
2
1
0
0
0
0
0
0
0
0
9
5
3
1
3
2
1
0
1
0
0
1
213
62
74
77
228 (95)
73 (91)
76 (95)
79 (99)
223 (93)
68 (85)
77 (96)
78 (97)
0.82
0.06
0.96
0.99
5
5
0
0
9
9
0
0
0
0
0
0
3
3
0
0
2
1
1
0
5
5
0
0
4
4
0
0
212
53
79
80
230 (96)
71 (89)
79 (99)
80 (100)
219 (91)
59 (74)
80 (100)
80 (100)
0.74
0.26
0.98
0.97
9
9
0
0
9
9
0
0
0
0
0
0
0
0
0
0
1
1
0
0
4
4
0
0
3
3
0
0
214
54
80
80
235 (98)
75 (94)
80 (100)
80 (100)
224 (93)
64 (80)
80 (100)
80 (100)
0.82
0.41
0.99
0.99
1
1
0
0
4
4
0
0
0
0
0
0
0
0
0
0
3
3
0
0
5
4
1
0
2
2
0
0
225
66
79
80
232 (97)
73 (91)
79 (99)
80 (100)
229 (95)
70 (88)
79 (99)
80 (100)
0.50
0.11
0.99
0.99
12
12
0
0
10
10
0
0
1
1
0
0
3
3
0
0
7
3
3
1
1
0
0
1
4
4
0
0
202
47
77
78
228 (95)
73 (91)
77 (96)
78 (97)
222 (92)
63 (79)
80 (100)
79 (99)
0.92
0.54
0.95
0.97
28
28
0
0
45
42
2
1
1
1
0
0
6
6
0
0
22
13
7
2
18
15
2
1
14
13
0
1
1,066
282
389
395
1,153 (96)
365 (91)
391 (98)
397 (99)
0.79
0.32
0.97
0.98
1,117 (93)
324 (81)
396 (99)
397 (99)
* Except where indicated otherwise, values are the number of quadrants. Accuracy, sensitivity, and specificity were determined with magnetic
resonance imaging (MRI), considered to be the reference method. US ⫽ ultrasonography; RAD ⫽ plain radiography; MTP ⫽ metatarsophalangeal;
RA ⫽ rheumatoid arthritis.
was evaluated with an intraclass correlation coefficient (ICC),
by means of the statistical software package SPSS, release 9.0.1
(Chicago, IL).
(28 of 134 quadrants), while agreement between US and
MRI on the detection of erosions was 54% (73 of 134
quadrants). By US only, 16% (22 quadrants) showed
bone erosions, while by MRI only, 13% (18 quadrants)
RESULTS
Signs of bone destruction. Comparison of US,
MRI, and radiography. Among the 40 patients with RA
and 20 control subjects examined by US, MRI, and
radiography, 1,200 quadrants in the 300 MTP (first
through fifth) joints were assessed (Table 1). The overall
agreement between US and MRI was 96% (1,153 of
1,200 quadrants), while the overall agreement between
US and radiography was 93% (1,118 of 1,200 quadrants)
(data not shown). Eleven percent of the examined MTP
joints (134 of 1,200 quadrants) were scored as having
erosions by at least one of the methods. Agreement on
the presence of erosions between all methods was 21%
Table 2. MRI and radiographic detection of the bone changes
visualized with US, as compared with the size-based scoring of the US
findings*
US bone
changes
Grade 1 (n ⫽ 21)
Grade 2 (n ⫽ 75)
Grade 3 (n ⫽ 26)
Bone erosions Bone erosions No bone erosions
on MRI
on RAD
on MRI or RAD
0
47
26
0
20
14
21
22
0
* Values are the number of joints. US grading: grade 1 ⫽ irregularity
of the bone surface without formation of a defect seen in 2 planes;
grade 2 ⫽ formation of a defect in the surface of the bone seen in 2
planes; grade 3 ⫽ bone defect creating extensive bone destruction. See
Table 1 for definitions.
20
7
7
6
10
5
2
3
11
8
1
2
10
3
5
2
5
4
0
1
56
27
15
14
12
9
3
0
9
8
1
0
7
4
3
0
11
8
3
0
9
7
2
0
48
36
12
0
US
⫹
MRI
3
2
1
0
0
0
0
0
0
0
0
0
1
1
0
0
1
1
0
0
1
0
1
0
MRI
⫹
clinical
assessment
14
5
9
0
1
0
1
0
2
1
1
0
6
2
4
0
1
0
1
0
4
2
2
0
US
⫹
clinical
assessment
33
9
16
8
8
4
2
2
5
3
1
1
6
0
4
2
12
2
8
2
2
0
1
1
US
only
13
0
9
4
4
0
3
1
3
0
3
0
1
0
1
0
0
0
0
0
5
0
2
3
5
2
3
0
2
1
1
0
0
0
0
0
0
0
0
0
2
1
1
0
1
0
1
0
Clinical
MRI assessment
only
only
128
19
35
74
31
4
11
16
29
5
7
17
28
5
7
16
25
3
7
15
15
2
3
10
No
synovitis
by any
of the
methods
237 (79)
84 (84)
65 (65)
88 (88)
47 (78)
16 (80)
14 (70)
17 (85)
50 (83)
16 (80)
15 (75)
19 (95)
46 (77)
17 (85)
11 (55)
18 (90)
46 (77)
17 (85)
11 (55)
18 (90)
48 (80)
18 (90)
14 (70)
16 (80)
212 (71)
66 (66)
64 (64)
82 (82)
48 (80)
15 (75)
15 (75)
18 (90)
45 (75)
16 (80)
11 (55)
18 (90)
42 (70)
10 (50)
14 (70)
18 (90)
47 (78)
14 (70)
16 (80)
17 (85)
30 (50)
11 (55)
8 (40)
11 (55)
Clinical
assessment vs.
MRI, no. (%)
Agreement
US vs.
MRI, no.
(%)
0.87
0.78
0.88
0.90
0.95
0.84
US
0.43
0.50
0.46
0.40
0.50
0.34
Clinical
assessment
Sensitivity
0.74
0.79
0.81
0.70
0.68
0.73
US
0.89
0.93
0.94
0.83
0.93
0.77
Clinical
assessment
Specificity
* Except where indicated otherwise, values are the number of joints. Accuracy (agreement), sensitivity, and specificity were determined with MRI, considered to be the reference
method. See Table 1 for definitions.
MTP1 (60)
Total
Established RA
Early RA
Healthy controls
MTP2 (60)
Total
Established RA
Early RA
Healthy controls
MTP3 (60)
Total
Established RA
Early RA
Healthy controls
MTP4 (60)
Total
Established RA
Early RA
Healthy controls
MTP5 (60)
Total
Established RA
Early RA
Healthy controls
Total (300)
Total
Established RA
Early RA
Healthy controls
US
⫹
MRI
⫹
clinical
assessment
Joints with synovitis
Detection of signs of synovitis by US, MRI, and clinical examination*
Joint (total joints),
group
Table 3.
2108
SZKUDLAREK ET AL
US OF RA MTP JOINTS VERSUS OTHER ASSESSMENT METHODS
2109
Table 4. Signs of inflammation (synovitis and/or joint effusion) by US compared with clinical joint assessment (swelling and/or tenderness) in the
MTP joints of all study participants*
Joints with signs of inflammation
Joint
US ⫹ clinical
assessment
US only
Clinical
assessment
only
MTP1
MTP2
MTP3
MTP4
MTP5
Total
18
14
15
14
9
70
28
22
18
17
17
102
2
3
1
0
2
8
Joints with no signs
of inflammation on
US or clinical
assessment
No. of joints
examined
Agreement,
US vs. clinical
assessment,
no. (%)
12
21
26
29
32
120
60
60
60
60
60
300
30 (50)
35 (58)
41 (68)
43 (72)
41 (68)
190 (63)
* Values are the number of joints. See Table 1 for definitions.
showed bone erosions. Most of the erosions on US that
were not detected with MRI were located in the first and
fifth MTP joints (16 of 22 quadrants), while the MRIdetected erosions that were not visualized with US were
located predominantly in the second through fourth
MTP joints (14 of 18 quadrants).
All but 1 of the patients with RA had erosions
detected by US in the first or fifth MTP joints. The bone
changes registered as erosions by US in the healthy control
subjects were also located in the first or fifth MTP joints.
Specificity and sensitivity of US and radiography,
versus MRI. With MRI as the reference method, the
sensitivity of US for the detection of bone erosions in the
toe joints was 0.79, while it was 0.32 for radiography
(Table 1). The specificity of US as compared with MRI
was 0.97, and that of radiography as compared with MRI
was 0.98. The accuracy of US, i.e., the overall agreement
between US and MRI for the detection of bone erosions
in the toe joints, was 0.96, while the accuracy of radiography was 0.93.
Identification of subjects with erosive disease in the
MTP joints using the different methods. When erosive
disease was defined as the presence of at least 1 bone
erosion in the examined MTP joints, 11 patients were
considered to have erosive disease on radiography, 17 on
MRI, and 18 on US, among the group of patients with
established RA. All of the patients who were classified
as having erosive disease with radiography were also
considered to have erosive disease on US and MRI.
Among the group of patients with early RA, none had
erosive disease on radiography, 3 had erosive disease on
MRI, and 8 had erosive disease on US. One healthy
person was considered to have erosive disease by all
methods, while 1 healthy person had indications of
erosive disease on MRI, and 1 healthy person showed
erosive disease on US.
Comparison between grading of bone changes on
US and detection of bone erosions with MRI and conventional radiography. Grade 1 bone changes on US were
not detected either by MRI or by radiography, whereas
47 of 75 grade 2 bone changes on US were visualized
with MRI. All 26 grade 3 bone changes on US were
visualized with MRI and almost half of them (14 of 26)
with radiography (Table 2).
Signs of inflammation. Overall agreement between
US and MRI. The 300 MTP (first through fifth) joints of
the 40 patients with RA and 20 control subjects were
evaluated by US, MRI, and clinical assessment for signs of
inflammation. The overall agreement between US and
MRI on the detection of synovitis in the MTP joints was
79% (237 of 300 MTP joints). Of the examined MTP joints
with normal MRI findings, US revealed synovitis in 16%
(47 of 300); MRI revealed synovitis in 5% (16 of 300) of the
MTP joints with normal US findings (Table 3). US and
MRI simultaneously showed effusion in only 1 of the 300
examined MTP joints. US alone revealed joint effusion in
27 MTP joints, while MRI alone showed joint effusion in 2
MTP joints.
Sensitivity and specificity of US and clinical examination, versus MRI. The sensitivity of US for the detection of signs of synovitis, with T1-weighted MRI as the
reference method, was 0.87, while the sensitivity of the
clinical examination was 0.43 (Table 3). The specificity
of US was 0.74 and that of the clinical examination was
0.89, as compared with MRI. The accuracy of US, i.e.,
the overall agreement between US and MRI, for the
detection of signs of synovitis in the toe joints was 0.79,
while the accuracy of clinical examination was 0.71.
Overall agreement between US and clinical examination. The overall agreement on the presence or absence of signs of inflammation between US and clinical
assessment was 63% (190 of 300 examined toe joints)
2110
SZKUDLAREK ET AL
Table 5. Scoring of synovitis in all study participants by US and by
MRI, using their respective volume-based scales (0–4)*
Grade on US
Grade on MRI
0
1
2
3
4
0
1
2
3
4
88
32
11
2
0
9
4
2
1
0
23
8
14
13
0
7
9
25
29
13
0
0
0
2
8
* Values are the number of joints. The numbers in boldface represent
exact agreements between grades on US and grades on MRI. See
Table 1 for definitions.
(Table 4). Joint effusion and synovitis were visualized
with B-mode US in 102 of 300 joints, whereas these signs
of inflammation were detected in only 8 joints on the
clinical assessment (as joint swelling and/or tenderness).
Correlation between US and MRI gradings of synovitis. The ICCs for grading of synovitis on US and
grading of synovitis on MRI in the respective joints were
as follows: for the first MTP, the ICC was 0.56, for the
second MTP, 0.67, for the third MTP, 0.69, for the
fourth MTP, 0.72, and for the fifth MTP, 0.56 (P ⬍
0.0001). The detailed results concerning agreement between scoring on US and scoring on MRI are presented
in Table 5.
Identification of subjects with signs of joint inflammation by the different methods. Signs of inflammation in
1 or more of the MTP joints were found in 31 patients on
MRI, in 36 on US, and in 20 on clinical assessment.
Among the healthy control subjects, who by definition
(in accordance with the inclusion criteria) had no joint
symptoms or clinical signs of inflammatory activity in the
joints, 9 showed signs of inflammation on MRI and 10
on US, albeit at the lowest grade of synovial abnormality
considered to be pathologic (grade 2).
DISCUSSION
The increasing use of US in rheumatology and
lack of data on the US assessment of the toe joints in RA
prompted us to examine the performance of US in
imaging the MTP joints of a group of RA patients and a
control group of healthy subjects. Radiographic studies
have shown that the MTP joints are among the earliest
affected in the course of RA (17). Based on experiences
with assessment of signs of bone destruction and inflammation in RA finger joints, we have investigated the role
of US in assessment of the MTP joints in RA, with MRI
as the reference method.
Our study showed high overall agreement between US and MRI on assessment of bone erosions in
the MTP joints. Moreover, US had higher sensitivity and
equal specificity, compared with radiography, when
MRI was considered the reference method. There was a
clear site dependency of visualization of the destructive
bone changes, with best results for US in the first and
fifth MTP joints and poorer results in the second
through fourth MTP joints. These results are consistent
with those presented by Wakefield et al (18) for the
MCP joints. In their study, on the radial, dorsal, and
palmar aspects of the second MCP joint, where the
imaging options for US are optimal, the results of
assessment of bone destruction on US and MRI were
equal.
The assessment of potential target joints, e.g., the
first and fifth MTP joints, which was suggested earlier by
Alarcón et al (19) and Schmidt (20), did not provide
unequivocal results. Although all but 1 of the examined
RA patients with erosive disease on US had evidence of
bone erosions in the first or fifth MTP joints, all of the
observed bone changes in the healthy persons also had
the same localization.
The advantage of US compared with radiography
and MRI was most striking in the group of patients with
early disease (⬍2 years’ disease duration). All of the
patients with early RA had nonerosive disease on radiography, while almost half of them (8 of 20) already had
bone erosions on US and only 3 on MRI. Thus, US
showed more erosions than did MRI. However, this
finding may have been influenced by the fact that our
group used 3-mm–thick MR slices to assess the examined joints. Backhaus et al (21), who examined the finger
joints of a heterogeneous group of patients with joint
symptoms and used 1-mm–thick MR slices, showed no
benefit of US over MRI when assessing bone destruction. At the same time, Backhaus et al used a 7.5-MHz
transducer with a distance pad, an approach that may be
considered inferior to the use of modern high-frequency
transducers.
The detection of erosions on MRI and radiography was dependent on how advanced the bone changes
were considered to be on US (Table 2). In particular,
none of the mildest bone changes on US were visualized
by the other methods, suggesting that US may be capable
of showing bone changes earlier than both MRI and
radiography, due to its higher-detail resolution.
Similar to the visualization of bone destruction,
the assessment of signs of synovitis with B-mode US
showed good correlation with T1-weighted, contrastenhanced MRI. A considerable benefit of US as com-
US OF RA MTP JOINTS VERSUS OTHER ASSESSMENT METHODS
pared with clinical examination was shown, since US was
found to have higher sensitivity with a certain loss of
specificity, using MRI as the reference method.
B-mode US and T1-weighted, contrast-enhanced
MRI correlated well, with regard to both detection (as
expressed by overall agreement) and semiquantitative
volume-based grading (as expressed by the ICC) of
synovitis, suggesting that the visualized inflammatory
changes were similar or identical. A proportion of the
discrepancy between US and MRI may be explained by
US visualization of mild osteoarthritic changes, which
were not scored as synovitis on MRI due to minimal
postcontrast enhancement. Osteoarthritis in the MTP
joints may also be the reason that many of the control
subjects showed signs of synovitis on both US and MRI.
Furthermore, the higher frequency of detection of synovitis by US suggests that B-mode US shows both “active”
and fibrotic synovial tissue in the examined joints. Our
results are in accordance with those of Backhaus et al
(21), who showed a higher frequency of visualizing
synovitis in the finger joints with US than with MRI. The
improved accuracy of US, compared with conventional
methods, may be particularly clinically important in the
toe joints, because these joints are very frequently
involved and are considered among the most difficult to
assess clinically (22).
US of the small joints of the hands and feet has
not been studied with a histopathologic reference
method. Contrast-enhanced, T1-weighted MRI has been
shown to correlate well with the histopathologic and
miniarthroscopic signs of synovitis in the finger and knee
joints (7,23,24). On this basis, we found it justified to use
MRI as an indirect reference method.
MRI revealed joint effusion in only a few cases; a
contributing factor may have been that the analysis of
the MR images on films was carried out without the
possibility of adjusting the image contrast or magnifying
the joint structures. Moreover, the MRI contrast agent
may have diffused into the joint cavity, rendering the
assessment of joint effusion with MRI more difficult. In
contrast, US in our study enabled considerable magnification of the examined joints and the findings were
analyzed in real time, both in motion and under compression, suggesting that the detection of small joint
effusions is more effective with US compared with MRI.
For joints in which accessibility is problematic in US or
in which the amount of synovitis is minimal, joint
effusion may be used as indirect proof of the presence of
inflamed synovial tissue.
This report presents the results of evaluation of
the RA MTP joints by B-mode US. Further analyses and
2111
quantification of the US-detected signs of inflammation
by Doppler techniques, as suggested by several groups
(25–28), are warranted. Our study has shown that the
use of US allows detection and grading of destructive
and inflammatory changes in the MTP joints of patients
with RA, and the results are in high overall agreement
with those of MRI. After comparison with MRI, our
results revealed that US is markedly more sensitive and
accurate than clinical examination and conventional
radiography.
ACKNOWLEDGMENT
We thank Ms Susanne Østergaard for assistance with
the medical images.
REFERENCES
1. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF,
Cooper NS, et al. The American Rheumatism Association 1987
revised criteria for the classification of rheumatoid arthritis.
Arthritis Rheum 1988;31:315–24.
2. McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, Tan
PL, et al. Magnetic resonance imaging of the wrist in early
rheumatoid arthritis reveals a high prevalence of erosions at four
months after symptom onset. Ann Rheum Dis 1998;57:350–6.
3. Klarlund M, Ostergaard M, Jensen KE, Madsen JL, Skjodt H,
Lorenzen I, for the TIRA Group. Magnetic resonance imaging,
radiography, and scintigraphy of the finger joints: one year follow
up of patients with early arthritis. Ann Rheum Dis 2000;59:521–8.
4. Hansen TM, Keiding S, Lauritzen SH, Manthorpe R, Sorensen SF,
Wiik A. Clinical assessment of disease activity in rheumatoid
arthritis. Scand J Rheumatol 1979;8:101–5.
5. McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, Tan
PL, et al. Magnetic resonance imaging of the wrist in early
rheumatoid arthritis reveals progression of erosions despite clinical improvement. Ann Rheum Dis 1999;58:156–63.
6. McQueen FM, Benton N, Crabbe J, Robinson E, Yeoman S,
McLean L, et al. What is the fate of erosions in early rheumatoid
arthritis? Tracking individual lesions using x rays and magnetic
resonance imaging over the first two years of disease. Ann Rheum
Dis 2001;60:859–68.
7. Ostendorf B, Peters R, Dann P, Becker A, Scherer A, Wedekind
F, et al. Magnetic resonance imaging and miniarthroscopy of
metacarpophalangeal joints: sensitive detection of morphologic
changes in rheumatoid arthritis. Arthritis Rheum 2001;44:
2492–502.
8. Ostergaard M, Hansen M, Stoltenberg M, Jensen KE, Szkudlarek
M, Pedersen-Zbinden B, et al. New radiographic bone erosions in
the wrists of patients with rheumatoid arthritis are detectable with
magnetic resonance imaging a median of two years earlier. Arthritis Rheum 2003;48:2128–31.
9. McQueen FM, Benton N, Perry D, Crabbe J, Robinson E,
Yeoman S, et al. Bone edema scored on magnetic resonance
imaging scans of the dominant carpus at presentation predicts
radiographic joint damage of the hands and feet six years later in
patients with rheumatoid arthritis. Arthritis Rheum 2003;48:
1814–27.
10. Wakefield RJ, Gibbon WW, Emery P. The current status of
ultrasonography in rheumatology. Rheumatology (Oxford) 1999;
38:195–8.
11. Szkudlarek M, Court-Payen M, Jacobsen S, Klarlund M, Thomsen
2112
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
HS, Ostergaard M. Interobserver agreement in ultrasonography of
the finger and toe joints in rheumatoid arthritis. Arthritis Rheum
2003;48:955–62.
Hulsmans HM, Jacobs JW, van der Heijde DM, Albada-Kuipers
GA, Schenk Y, Bijlsma JW. The course of radiologic damage
during the first six years of rheumatoid arthritis. Arthritis Rheum
2000;43:1927–40.
Koski JM. Ultrasonography of the metatarsophalangeal and
talocrural joints. Clin Exp Rheumatol 1990;8:347–51.
Conaghan P, Edmonds J, Emery P, Genant H, Gibbon W,
Klarlund M, et al. Magnetic resonance imaging in rheumatoid
arthritis: summary of OMERACT activities, current status, and
plans. J Rheumatol 2001;28:1158–62.
Klarlund M, Ostergaard M, Lorenzen I. Finger joint synovitis in
rheumatoid arthritis: quantitative assessment by magnetic resonance imaging. Rheumatology (Oxford) 1999;38:66–72.
Meschan I. Roentgen signs in clinical practice. Philadelphia: WB
Saunders; 1966.
Belt EA, Kaarela K, Lehto MU. Destruction and arthroplasties of
the metatarsophalangeal joints in seropositive rheumatoid arthritis: a 20-year follow-up study. Scand J Rheumatol 1998;27:194–6.
Wakefield RJ, Gibbon WW, Conaghan PG, O’Connor P, McGonagle D, Pease C, et al. The value of sonography in the
detection of bone erosions in patients with rheumatoid arthritis: a
comparison with conventional radiography. Arthritis Rheum 2000;
43:2762–70.
Alarcón GS, Lopez-Ben R, Moreland LW. High-resolution ultrasound for the study of target joints in rheumatoid arthritis [letter].
Arthritis Rheum 2002;46:1969–70.
Schmidt WA. Value of sonography in diagnosis of rheumatoid
arthritis. Lancet 2001;357:1056–7.
Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ,
et al. Arthritis of the finger joints: a comprehensive approach
comparing conventional radiography, scintigraphy, ultrasound,
SZKUDLAREK ET AL
22.
23.
24.
25.
26.
27.
28.
and contrast-enhanced magnetic resonance imaging. Arthritis
Rheum 1999;42:1232–45.
Prevoo ML, Kuper IH, van ’t Hof MA, van Leeuwen MA, van de
Putte LB, van Riel PL. Validity and reproducibility of selfadministered joint counts: a prospective longitudinal followup
study in patients with rheumatoid arthritis. J Rheumatol 1996;23:
841–5.
Ostergaard M, Stoltenberg M, Lovgreen-Nielsen P, Volck B,
Jensen CH, Lorenzen I. Magnetic resonance imaging–determined
synovial membrane and joint effusion volumes in rheumatoid
arthritis and osteoarthritis: comparison with the macroscopic and
microscopic appearance of the synovium. Arthritis Rheum 1997;
40:1856–67.
Gaffney K, Cookson J, Blades S, Coumbe A, Blake D. Quantitative assessment of the rheumatoid synovial microvascular bed by
gadolinium-DTPA enhanced magnetic resonance imaging. Ann
Rheum Dis 1998;57:152–7.
Newman JS, Laing TJ, McCarthy CJ, Adler RS. Power Doppler
sonography of synovitis: assessment of therapeutic response: preliminary observations. Radiology 1996;198:582–4.
Hau M, Schultz H, Tony HP, Keberle M, Jahns R, Haerten R, et
al. Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis
by high-resolution ultrasound (multidimensional linear array).
Arthritis Rheum 1999;42:2303–8.
Qvistgaard E, Rogind H, Torp-Pedersen S, Terslev L, Danneskiold-Samsoe B, Bliddal H. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. Ann Rheum Dis 2001;60:690–3.
Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M,
Klausen T, Ostergaard M. Power Doppler ultrasonography for
assessment of synovitis in the metacarpophalangeal joints of
patients with rheumatoid arthritis: a comparison with dynamic
magnetic resonance imaging. Arthritis Rheum 2001;44:2018–23.
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