Objectives
To determine the accuracy of ultrasound in early detection of bone erosions and monitoring disease activity in rheumatoid arthritis (RA) patients using magnetic resonance imaging (MRI) as a gold standard technique.
Material and Methods
This prospective study was carried out on 50 patients with known RA and 15 healthy controls. Conventional radiography was standardized and performed in two planes. Ultrasound (US) and MRI was performed to evaluate the presence of synovitis, tenosynovitis, and bursitis as well as erosions on ultrasound and MRI. The results in the study group were compared with those obtained in a control group.
Result
In the study group, the most frequent US finding of shoulder joint was Tenosynovitis of the long head of the biceps tendon. Tenosynovitis was observed in the long head of biceps tendon in 20 joints (40%). Erosions of the humeroscapular joint were detected by conventional radiography in 15 (30%), by US in 41 (82%), and by MRI in 46 (92%) of the shoulders examined, no statistically significant difference is noted between US and MRI in overall detection of erosion ( P = .333).
Conclusion
US is a helpful imaging method and in comparison with MRI in assessing the shoulder joint and, preferably with MRI, are recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results.
Rheumatoid arthritis (RA) is a chronic inflammatory disease that leads to bone and cartilage destruction . Shoulder pain is one of the most common complaints encountered in patients with RA pain in the shoulder may be caused by various intra and extra-articular pathology mechanisms. Clinical findings of the painful shoulder are similar or even equal for cases with different etiology .
Initially, the disease targets the glenohumeral joint and often causes erosions in the greater tuberosity. The acromioclavicular joint and the subacromial bursa may be affected by synovitis and severe cuff thinning is extremely common .
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Patients and methods
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Methods
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
US Examination
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Biceps tendon (transverse view)
Get Radiology Tree app to read full this article<
Biceps tendon (longitudinal and transverse views)
Get Radiology Tree app to read full this article<
Subscapularis tendon (longitudinal and transverse views)
Get Radiology Tree app to read full this article<
Supraspinatus (longitudinal and transverse views)
Get Radiology Tree app to read full this article<
Infraspinatus (longitudinal and transverse views)
Get Radiology Tree app to read full this article<
Erosions
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
MRI
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Statistical Analysis
Get Radiology Tree app to read full this article<
Results
Synovitis, Tenosynovitis, and Bursitis in the Study Group
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 1
US Versus MRI in Detection of Synovitis, Tenosynovitis, and Bursitis in the Study Group
US MRI_P_ Value Synovitis 15 33 <.0001 ∗ Tenosynovitis long head of biceps tendon 20 33 .0002 ∗ Bursitis 18 21 .2500 ∗
MRI, magnetic resonance imaging; US, ultrasound.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 2
Diagnostic Accuracy of US Versus MRI in Detection of Synovitis, Tenosynovitis of LHB Tendon, and Bursitis in the Study Group
Sensitivity (%) Specificity (%) PPV (%) NPV (%) Synovitis 45.5 100 100 48.75 Tenosynovitis LHB tendon 60.6 100 100 56.66 Bursitis 85.7 100 100 90.6
LHB, long head of biceps; MRI, magnetic resonance imaging; NPV, negative predictive value; PPV, positive predictive value; US, ultrasound.
Get Radiology Tree app to read full this article<
Erosions in the Study Group
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 3
Comparison of US with MRI in Assessing Erosion of the Shoulder Joint in the Study Group
US MRI None Isolated Confluent Generalized Total_P_ ∗ None 2 6 0 1 9 Isolated 0 17 7 1 25 .0313 Confluent 1 7 1 0 9 1.0000 Generalized 1 3 2 1 7 1.0000 Total 4 33 10 3 50 .333
MRI, magnetic resonance imaging; US, ultrasound.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 4
Diagnostic Accuracy of US in Comparison to MRI in Assessing Erosion of the Shoulder Joint in the Study Group
Sensitivity (%) Specificity PPV NPV Isolated 51.5 68 68 51.5 Confluent 10 83.3 11.1 81.6 Generalized 33.3 88.6 14.28 95.91 Overall 85.4 100 100 56.25
MRI, magnetic resonance imaging; NPV, negative predictive value; PPV, positive predictive value; US, ultrasound.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Table 5
Comparison of Conventional Radiography (CR) with US in Assessing Erosion of the Shoulder Joint in the Study Group
CR MRI None Isolated Confluent Generalized Total_P_ None 4 21 9 1 35 .008 ∗ Isolated 0 2 2 4 8 Confluent 0 5 0 0 5 Generalized 0 2 0 0 2 Total 4 30 11 5 50
CR, conventional radiography; MRI, magnetic resonance imaging; US, ultrasound.
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Comparisons with Control Group
Get Radiology Tree app to read full this article<
Discussion
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Get Radiology Tree app to read full this article<
Conclusion
Get Radiology Tree app to read full this article<
References
1. Carroll L., Hannawi S., Marwick T., et. al.: Rheumatoid arthritis—links with cardiovascular disease and the receptor for advanced glycation end products. Wien Med Wochenschr 2006; 156: pp. 42-52.
2. Sanja M.R., Mirjana Z.S.: Ultrasonographic study of the painful shoulder in patients with rheumatoid arthritis and patients with degenerative shoulder disease. Acta Rheumatol Port 2010; 35: pp. 50-58.
3. van der Heijde D.M.F.M.: Joint erosions and patients with early rheumatoid arthritis. Br J Rheumatol 1995; 34: pp. 74-78.
4. Thomas T., Noël E., Goupille P., et. al.: The rheumatoid shoulder: current consensus on diagnosis and treatment. Joint Bone Spine 2006; 73: pp. 139-143.
5. Wakefield R.J., Gibbon W.W., Conaghan P.G., 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: pp. 2762-2770.
6. Lehtinen J.T., Kaarela K., Kauppi M.J., et. al.: Incidence of glenohumeral joint involvement in seropositive rheumatoid arthritis. A 15-year end-point study. J Rheumatol 2000; 27: pp. 347-350.
7. Lehtinen J.T., Kaarela K., Belt E.A., et. al.: Incidence of acromioclavicular joint involvement in seropositive rheumatoid arthritis. A 15-year end-point study. J Rheumatol 1999; 26: pp. 1239-1241.
8. Kim H.A., Kim S.H., Seo Y.I.: Ultrasonographic findings of the shoulder in patients with rheumatoid arthritis and comparison with physical examination. J Korean Med Sci 2007; 22: pp. 660-666.
9. Perry D., Stewart N., Benton N., et. al.: Detection of erosions in the rheumatoid hand; a comparative study of multidetector computerized tomography versus magnetic resonance scanning. J Rheumatol 2005; 32: pp. 256-267.
10. Hermann K.G., Backhaus M., Schneider U., et. al.: Rheumatoid arthritis of the shoulder joint: comparison of conventional radiography, ultrasound, and dynamic contrast-enhanced magnetic resonance imaging. Arthritis Rheum 2003; 48: pp. 3338-3349.
11. Daenen B., Houben G., Baudin E., et. al.: Ultrasound of the shoulder. JBR-BTR 2007; 90: pp. 325-337.
12. Tehranzadeh J., Ashikyan O., Dascalos J.: Magnetic resonance imaging in early detection of rheumatoid arthritis. Semin Musculoskelet Radiol 2003; 7: pp. 79-94.
13. Middleton W.D.: Ultrasonography of the shoulder. Radiol Clin North Am 1992; 30: pp. 927-940.
14. Arnett F.C., Edworthy S.M., Bloch D.A., et. al.: The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: pp. 315-324.
15. Larsen A., Dale K., Eek M.: Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn (Stockh) 1977; 18: pp. 481-491.
16. Farin P., Jaroma H.: Sonographic detection of tears of the anterior portion of the rotator cuff (subscapularis tendon tears). J Ultrasound Med 1996; 15: pp. 221-225.
17. Molloy S., Ramakrishnan E., Murphy E., et. al.: Morbidity and mortality in rheumatoid patients during treatment with adalimumab and infliximab. Rheumatology 2004; 43: pp. 522-523.
18. Alasaarela E., Takalo R., Tervonen O., et. al.: Sonography and MRI in the evaluation of painful arthritic shoulder. Br J Rheumatol 1997; 36: pp. 996-1000.
19. Alasaarela E., Suramo I., Tervonen O., et. al.: Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography. Br J Rheumatol 1998; 37: pp. 1152-1156.
20. Keysser P., Osthus H., Jacobi E.: Ultrasound of the shoulder in patients with rheumatoid arthritis. Ann Rheum Dis 2003; 62: pp. 519.
21. Magarelli N., Guglielmi G., Di Matteo L., et. al.: Diagnostic utility of an echo-contrast agent in patient with synovitis using power Doppler ultrasound: a preliminary study with comparison to contrast-enhanced MRI. Eur Radiol 2001; 11: pp. 1039-1046.
22. Szkudlarek M., Court-Payen M., Strandberg C., et. al.: 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: pp. 2018-2023.
23. Bruyn G.A., Pineda C., Hernandez-Diaz C., et. al.: Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard. Agreement between US and MRI regarding shoulder synovitis in RA. Arthritis Care Res 2010; 62: pp. 1079-1086.
24. Strunk J., Lange U., Kurten B., et. al.: Doppler sonographic findings in the long bicipital sheath in patients with rheumatoid arthritis as compared with patients with degenerative diseases of the shoulder. Arthritis Rheum 2003; 48: pp. 1828-1832.
25. Bouffard J.A., Lee S.M., Dhanju J.: Ultrasonography of the shoulder. Semin Ultrasound CT MR 2000; 21: pp. 164-191.
26. Backhaus M., Kamradt T., Sandrock D., et. al.: Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum 1999; 42: pp. 1232-1245.
27. Bruyn G.A.W., Naredo E., Möller I., et. al.: Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Ann Rheum Dis 2009; 68: pp. 357-361.
28. Middleton W.D., Payne W.T., Teefey S.A., et. al.: Sonography and MRI of the shoulder: comparison of patient satisfaction. AJR Am J Roentgenol 2004; 183: pp. 1449-1452.