Hallazgos ultrasonográficos a nivel de articulaciones de manos y pies en sujetos voluntarios asintomáticos / Ultrasound findings in hand and foot joints of asymptomatic volunteers

Resumen Introducción: Anormalidades ultrasonográficas se describen con cierta frecuencia en articulaciones de sujetos asintomáticos, las cuales generan incertidumbre en el contexto de evaluación y tratamiento de la enfermedad articular inflamatoria; a pesar de ello, en Colombia no existen estudios al respecto y la evidencia disponible es escasa, hecha en un bajo número de participantes y con transductores menores a 18 MHz en su gran mayoría. Objetivos: Describir los hallazgos ultrasonográficos articulares en manos y pies de un grupo de voluntarios asintomáticos, su asociación con las características sociodemográficas y la concordancia intra e interobservador de sus mediciones. Materiales y métodos: Estudio descriptivo y analítico en el que se incluyeron 182 voluntarios asintomáticos. Dos médicos con experiencia en ecografía musculoesquelética evaluaron el aspecto dorsal de 5.460 recesos articulares mediante la escala semicuantitativa de Szkudlarek y la utilización de un transductor lineal de 18 MHz. Resultados: La mediana de edad de los participantes fue de 42 arios, 60,4% de ellos mujeres. En 87% de los voluntarios se identificaron en total 232 hallazgos, el 68,1% correspondió a derrame articular, 29,3% a hipertrofia sinovial, 2,1% a erosiones y 0,4% a Doppler de poder. Los pies mostraron mayores hallazgos que las manos (70,7% vs. 29,3%). Las articulaciones en las que más se identificaron anormalidades fue la primera articulación metatarsofalángica (52%), la tercera metatarsofalángica (15%) y la radiocarpiana (9,5%). Se halló relación positiva entre el derrame articular y la hipertrofia sinovial con la edad, ocupación manual exclusiva y tiempo laboral mayor de 10 años. La concordancia intraobservador fue moderada (Kappa = 0,4591) y la interobservador fue leve (Kappa = 0,2155). Conclusiones: La ausencia de señal Doppler de poder, el no compromiso radioulnar distal, la ausencia de sinovitis acompañada de erosión y una mayor predominancia de alteraciones leves al nivel de las manos, sumado a la ausencia de hallazgos al nivel de la quinta articulación metatarsiana, constituyen hallazgos potencialmente específicos de sujetos asintomáticos que merecen ser confirmados como tal en futuros estudios.

Abstract Introduction: Ultrasound (US) abnormalities have often been described in the joints of asymptomatic subjects, which may lead to uncertainty in the evaluation and treatment of inflammatory joint disease. Despite this, the available evidence is scarce, with few participants, and in the vast majority with transducers less than 18Mhz. In Colombia there are currently no published studies about this topic. Objectives: To describe the ultrasound findings in hand and foot joints in asymptomatic volunteers, their association with sociodemographic characteristics, and intra- and inter-observer concordance of the measurements. Materials and methods: Descriptive and analytical study within 182 asymptomatic volunteers. Two physicians with musculoskeletal ultrasound experience evaluated the dorsal aspect of 5460 articular recesses using the semi-quantitative scale of Szkudlarek using a 18 MHz linear transducer. Results: The median age of the participants was 42 years, including 60.4% women. A total of 232 abnormal findings were identified in 87% of the volunteers, with 68.1% corresponding to joint effusion, 29.3% synovial hypertrophy, 2.1% erosions, and 0.4% positive power Doppler. The feet evaluation showed more findings than the hands (70.7 vs. 29.3%). The joints in which most abnormalities were identified were the first metatarsophalangeal joint (52%), third metatarsophalangeal joint (15%), and radiocarpal joint (9.5%). A positive association was found between joint effusion and synovial hypertrophy with age, exclusive manual activity, and occupation for more than ten years. The intra-observer concordance was moderate (Kappa = .4591) and the inter-observer was low (Kappa = .2155). Conclusions: The absence of power Doppler signal, the absence of abnormalities in distal radioulnar, the absence of synovitis accompanied by erosion, and a greater predominance of mild alterations in the hand joints, added to the absence of findings in the fifth metatarsal joint, can be potential specific findings of asymptomatic subjects and might be confirmed in future studies.

Knee and the farm animals: An unusual presentation of Brucella melitensis masquerading as tuberculosis

In many developed countries, brucellosis has been successfully eradicated. However, brucellosis, with its myriad presentations, continues to be a clinical and diagnostic challenge in primarily agrarian countries such as India. We present a case of a rare manifestation of brucellosis i.e., septic arthritis of the knee joint associated with a lytic lesion of the proximal tibia. The patient belonged to a Brucella endemic country, and clinical features were of chronic reactive knee arthritis with synovial hypertrophy and effusion. Advanced diagnostic methods played a pivotal role in excluding the diagnosis of tuberculosis, and thus unnecessary administration of antitubercular therapy and initiating focused narrowed anti-Brucella management, achieving the goal of antimicrobial stewardship also.

Correlación entre la actividad clínica por DAS-28 y ecografía en pacientes con artritis reumatoide / Correlation between clinical activity measured by DAS-28 and ultrasound in patients with rheumatoid arthritis

INTRODUCCIÓN: La artritis reumatoide es una enfermedad multifactorial, sistémica, crónica, autoinmune e inflamatoria, que afecta fundamentalmente las articulaciones. La ultrasonografía/ecografía ha demostrado utilidad en la detección de sinovitis subclínica; sin embargo, la mayoría de la evidencia disponible es en pacientes en remisión y la evidencia para la correlación con el índice de actividad clínica (DAS-28), en Colombia, es limitada. OBJETIVOS: Establecer la correlación entre la actividad clínica medida por DAS-28 y la ecografía, en pacientes con artritis reumatoide. MATERIALES Y MÉTODOS: Cuarenta pacientes con diagnóstico de artritis reumatoide que iniciaron terapia biológica o leflunomida, fueron incluidos en el estudio descriptivo, longitudinal, prospectivo para evaluar la correlación entre el DAS-28 y la ecografía, en la consulta basal y a los 4 meses.RESULTADOS: Se encontró; correlación entre el índice de actividad clínico de la enfermedad (DAS-28) y el índice de actividad ecográfico (DAS ecográfico), tanto por escala de grises (r=0,943,p<0,01) como por Power Doppler(r =0,946, p <0,01); también se encontró; correlación entre el DAS ecográfico por escala de grises y el DAS ecográfico por Power Doppler (r= 0,953 ,p <0,01). CONCLUSIONES: La ecografía es de utilidad en la detección de inflamación subclínica y los resultados son concluyentes cuando se compara el número de articulaciones inflamadas en la evaluación clínica, con el conteo obtenido en la evaluación ecográfica. La evaluación ecográfica sugiere que las manos son las articulaciones con mejor rendimiento para la medición del grado de sinovitis en la artritis reumatoide

NTRODUCTION: Rheumatoid arthritis is a multifactorial, systemic, chronic, autoimmune, and inflammatory disease that mainly affects the joints. Ultrasound has shown to be useful in detecting subclinical synovitis; however, most of the available evidence is in patients on remission, and the evidence on a correlation with the clinical activity measured by DAS-28, in our midst, is limited. OBJECTIVE: To establish the correlation between clinical activity measured by DAS-28 and ultrasound in patients with rheumatoid arthritis. MATERIALS AND METHODS: A total of 40 patients diagnosed with rheumatoid arthritis who were started on biological therapy or leflunomide were included in the descriptive, longitudinal, prospective study to evaluate the correlation between DAS-28 and ultrasound at baseline visit and 4 months later. RESULTS: A correlation was found between DAS-28 and ultrasound, both by using the grayscale (r = 0.943, p <.01) and the power Doppler (r = 0.946, p <.01). There was also a correlation between the ultrasound DAS by grayscale and ultrasound DAS by power Doppler (r = 0.953, p<.01). CONCLUSIONS: Ultrasound is a useful tool for detecting sub-clinical inflammation and the results are conclusive when comparing the number of swollen joints in the clinical evaluation with the count obtained in the ultrasound assessment. Ultrasound evaluation suggests that the hands are the joints with better performance for measuring the grade of synovitis in rheumatoid arthritis

El papel de la ultrasonografía para la evaluación subclínica de la artritis reumatoide en remisión. Revisión sistemática de la literatura / The role of ultrasound in the subclinical assessment of rheumatoid arthritis in remission. Systematic review of the literature

Existe interés en el papel que desempena˜ la ultrasonografía (US), particularmente la presenciade senal ˜ Doppler poder (DP) e hipertrofia sinovial en la evaluación de actividad subclínicaen la artritis reumatoide (AR) en remisión.Objetivo: Examinar la evidencia que determine la utilidad de la US y el DP en la evaluacióndel paciente con AR en remisión por clinimetría.Materiales y métodos: Se realizó una revisión sistemática de la literatura de bases de datoselectrónicas PubMed, EMBASE, Biomed Central, registro de ensayos clínicos de Cochrane ycomo fuentes secundarias las referencias de artículos en los cuales se utilizaron términosclave: ®arthritis, rheumatoid¼ o ®arthrits¼ y ®ultrasonography¼ o ®ultrasonography, doppler,pulsed¼ y ®remission induction¼, hasta el 2 de marzo de 2014, sin restricción de idioma. Seincluyeron estudios observacionales de cohorte que evaluaron la prevalencia de actividadsubclínica por US de pacientes adultos con AR en remisión clínica. Se verificó la calidadmetodológica de los artículos y se extrajo la información relevante de cada uno.Resultados: Se identificaron 13 estudios para el análisis. Se observó actividad de AR imaginológicaen 14,6 a 95% para hipertrofia sinovial por US y 1,2 a 64,5% por DP en pacientes enremisión por clinimetría.Conclusiones: En pacientes con AR en remisión clínica se observa actividad ecográfica subclí-nica variable, detectada por hipertrofia sinovial y senal ˜ DP intraarticular, esta última permitediferenciar pannus residual, del inflamatorio que correlaciona con recaída y progresión de laenfermedad, además de permitir ajuste terapéutico. Se requieren más estudios que evalúendesenlaces terapéuticos y pronósticos...

There is an interest in the role of ultrasound (US), particularly the presence of power Doppler(PD) signal and synovial hypertrophy in the evaluation of subclinical activity in rheumatoidarthritis patients (RA) on remission.Objective: Examine the evidence to determine the usefulness of US and PD in the evaluationof patients with RA in remission using clinimetric properties.Materials and methods: A systematic literature search was performed using electronic databasesPubMed, EMBASE, BioMed Central, Cochrane registry of clinical trials and secondaryreference sources of articles published up to 2 March 2014, with the key terms “arthritis,rheumatoid” or “arthritis” and “ultrasonography” or “ultrasonography, Doppler, pulsed” and“remission induction” were used until March 2, of the 2014, without language restriction.Observational cohort studies that assessed the prevalence of subclinical activity by US andPD in adult patients with RA in clinical remission were included. Methodological quality ofthe articles was verified and relevant information extracted from each one.Results: A total of 13 studies were identified for analysis. RA activity using these imagingtechniques was observed in 14.6 to 95% for US synovial hypertrophy and 1.2 to 64.5% for PDin remission patients using clinimetry...

Trigger Wrist

Triggering at the wrist during active flexion and extension of the fingers or wrists is very rare. It is caused by tumors, inflammation, and anomalous muscle belly. We report two cases of trigger wrist caused by synovial hypertrophy and fibroma of flexor tendon.

A Case of Rheumatoid Arthritis with Unilateral Knee Synovial Hypertrophy in Hemiplegia

A 64-year-old woman suffering right hemiplegia came in with pain and swelling on her left knee, general weakness and poor oral intake for 2 months. On physical examination we were able to palpate a mass with irregular margin around the left suprapatellar area. From the results of the magnetic resonance imaging (MRI), synovial proliferative disease, infectious arthritis, or gouty arthritis was suspected. We performed a blood laboratory test to detect rheumatologic diseases, knee joint aspiration, and bone scan for differential diagnosis, and were able to diagnose rheumatoid arthritis (RA) from the results of blood laboratory, physical examination, and bone scan. Consequently, we started medications for controlling RA. Herein, we report a case of rheumatoid arthritis with unilateral knee synovial hypertrophy in hemiplegia. If a right hemiplegic patient has recurrent pain on the left knee and synovial hypertrophy, and fails to respond to treatment for osteoarthritis, early detection by evaluation for rheumatic disease is crucial to prevent severe sequelae influencing rehabilitation of hemiplegia.

Steroid-induced Early Changes in the Femoral Head and Hip Joint in Rats / 대한정형외과학회잡지

PURPOSE: To determine if the early changes to the articular cartilage and synovium of the hip joint in relation to steroid-induced osteonecrosis of the femoral head is either as a preceding factor or as a secondary consequence in the pathomechanism. MATERIALS AND METHODS: Thirty-two Sprague Dawley rats were divided into two groups, 16 receiving a steroid injection and 16 as a control group. Tissue samples of the hip joint were taken from 4 rats from each group every 4 weeks over a 16 week period. The specimens were investigated for the early changes to the articular cartilage, subchondral bone of the femoral head and the synovium after H & E staining and toluidine blue stain. Five histological criteria were applied to determine the cartilage status. RESULTS: Histologically, there was a gradual increase in chondrocyte cloning in the steroid injection group. In addition, synovial hypertrophy and the enlargement of fatty cysts with the loss of hematopoietic cells were observed. CONCLUSION: Synovial hypertrophy and some evidences of articular cartilage degeneration associated with steroid-induced early femoral head osteonecrosis appears to be the result of a direct inflammatory reaction to the steroid injection. This suggests that early presentation of the pathologic lesion in the hip joint might occur without definitive radiological evidence of femoral head osteonecrosis.

Detection of Synovial Hypertrophy in Idiopathic Carpal Tunnel Syndrome Using Ultrasongraphy / 대한정형외과학회잡지

OBJECTS: Synovial thickness in carpal tunnel was measured by high-resolution ultrasonography to evaluate the relation of synovial hypertrophy in idiopathic carpal tunnel syndrome. MATERIALS AND METHODS: Thickness of synovium of flexor tendons in 46 hands of idiopathic carpal tunnel syndrome and 50 hands of normal control were measured quantitatively by high-resolution ultrasonography. The patients were classified into three groups according to the clinical severity: Group I had typical clinical symptoms and positive provocation test (17 cases) , Group II had sensory decreation on the dermatome of median nerve (21 cases) , and Group III had sensory decreation and thenar muscle weakness. The thickness of flexor tendons in the three groups and control group were statistically compared. RESULTS: The mean value of thickness of carpal tunnel syndrome was 1.06mm and that of control group was 0.87mm (p=0.012) . Positive correlation was revealed according to the clinically classified three groups. CONCLUSION: Synovial hypertrophy in carpal tunnel has positive relationships with idiopathic carpal tunnel syndrome, and it reveal possibly the progression of the disease.

Synovial Hypertrophy in Discoid Meniscus / 대한정형외과학회잡지

Arthroscopic surgery of the knee is now a widely performed orthopedic technique. Of this, arthrosoopic surgery of discoid meniscus is one of the most technically demanding procedures of this field. In our experience, discoid meniscus was appeared to be frequently accompanied with villous hypertrophied synovium, which obstructed the arthroscopic view. The purpose of this study is to prove the presence of synovial hypertrophy in discoid meniscus and to develop an adequate portal of entry for successful arthroscopic surgery of discoid meniscus. 155 cases of arthroscopy of the knee were performed at the Department of Orthopedic Surgery, College of Medicine, Seoul National University between January 1987 and March 1988. Of these, 25 cases were discoid menisci and they were all lateral. Operative findings were observed through arthroscopy and they were also reviewed by recorded video tapes in 25 cases of arthroscopic surgery of discoid meniscus and 57 cases of non-discoid meniscal lesions for the presence of synovial hypertrophy. Synovial biopsy was performed in selected cases with synovial hypertrophy for observation of histological findings. Hypertrophied synovium in discoid meniscus was mainly localized in anterior compartment and intercondylar area of tibia. Therefore, when conventional anterolateral or anteromedial portals were used, much difficulty was confronted because hypertrophied synovium obstructed the visual field and crowding with surgical instruments was occurred in restricted space of discoid meniscus. Much more clear visual field was obtained when the medial midpatellar portal was used instead of conventional portals. The conclusions of this study are as follows : 1. The incidence of discoid meniscus was 16.1%. 2. Synovial hypertrophy was present in all 25 cases of discoid meniscus and 21 cases among 57 non-discoid meniscal lesions(35%) on operative findings 3. Synovial biopsy of hypertrophied synovium showed irritative nonspecific inflammatory lesions but there was no histologicsl differences between discoid and non-discoid meniscus. 4. Medial midpatellar portal is considered to be better approach than conventional portals for clear visual field and less crowding with instruments in arthroscopic surgery of lateral discoid meniscus.