Agudeza diagnóstica del examen físico de rodilla en la artritis reumatoide: estudio clínico y sonográfico del derrame articular y quiste de Baker / Diagnostic accuracy of physical examination of the knee in rheumatoid arthritis: clinical and ultrasonographic study of joint effusion and Baker’s cyst

Introducción: En pacientes con artritis reumatoide (AR),el dolor en las rodillas puede ser inflamatorio, mecánico oextraarticular. La exploración física (EF) no siempredetecta el derrame articular o el quiste de Baker (QB) enlas rodillas de estos pacientes.Objetivo: Determinar la agudeza diagnóstica de la EF enel diagnóstico de derrame articular y QB en pacientes conAR evaluados con ultrasonografía osteomuscular(USME), la técnica de imagen de referencia.Material y método: Se utilizaron 3 equipos de ultrasonidomarca Toshiba Tosbee, Toshiba Capasee y SiemensSonoline, con transductores lineares de 7,5 MHz paradetectar derrame y QB en rodillas de pacientes con ARvalorados previamente por clínica por un reumatólogo,quien dictaminó si los había. Se registraron edad, sexo,duración de la AR, factor reumatoide, tratamiento, clasefuncional de AR (CFAR) y diagnóstico clínico previo alUSME.Resultados: Se evaluó a 40 pacientes (80 rodillas) conAR, el 80% eran mujeres, la edad promedio fue 61,3 ±15 años y la duración de la enfermedad, 9,5 ± 11,3 años;el factor reumatoide fue positivo en el 80% de los casos;CFAR I (3 pacientes), CFAR II (27), CFAR III (8),CFAR IV (2); el 55% de los pacientes recibíanmetotrexato. Hubo dolor referido por el paciente en 26rodillas (32,5%). Se comunicó derrame por USME en49 rodillas (61,2%) y QB en 14 (17,5%); derrame porEF en 35 rodillas (43,7%) y corroborado por USME en31 rodillas (38,75%), QB por clínica en 12 rodillas(15%) y corroborado por USME en 6 rodillas (7,5%).La sensibilidad de la EF para la detección de derrame fue 0,63 y la especificidad, 0,87; para la detección de QBfueron 0,43 y 0,91, respectivamente.Conclusiones: La EF mostró una agudeza diagnósticaaceptable para el clínico. El uso complementario de laUSME en la EF de los pacientes con AR puede ser unfactor decisivo en la conducta terapéutica y diagnóstica enpacientes con AR y afección de rodillas(AU)

Introduction: In patients with rheumatoid arthritis (RA),knee pain can be inflammatory, mechanical or extraarticular.The physical examination (PE) doesn’t alwaysdetect the presence of knee joint effusion or Baker’s cyst(BC) in the knees of these patients.Objective: To determine the diagnostic accuracy of PE inthe diagnosis of effusion and BC in patients with RAevaluated with musculoskeletal ultrasound (MSUS),using this technique as the gold standard for comparison.Material and method: Three different models ofultrasound machines with a 7.5 MHz linear probe wereused (Toshiba Tosbee, Toshiba Capasee and SiemensSonoline). A rheumatologist evaluated the presence orabsence of knee joint effusion or BC in patients. Weregistered age, gender, time of evolution of RA,rheumatoid factor, treatment, functional class of RA(FCRA) and previous clinical diagnosis to the MSUSstudy.Results: 40 patients (80 knees) with RA were evaluated.Eighty percent were women, mean age 61.3 ± 15 years.Time since onset of RA was 9.5 ± 11.3 years, rheumatoidfactor was positive in 80%, FCRA I (3 patients), FCRA II (27), FCRA III (8), FCRA IV (2). Fifty five percent ofthe patients received methotrexate. Patients reffered painin 26 knees (32.5%). Joint effusion was reported by theclinician in 35 knees (43.7%) and corroborated by MSUSin 31 knees (38.75%), BC was reported by the clinician in12 knees (15%) and corroborated by MSUS in 6 knees(7.5%). The sensitivity of the PE for detection of jointeffusion was 0.63 and specificity of 0.87, for the detectionof BC was 0.43 and 0.91, respectively.Conclusions: The PE showed acceptable diagnosticaccuracy for the clinician. The complementary use of theMSUS can change the therapeutic and diagnosticapproach in patients with RA(AU)

Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression.

OBJECTIVE: To evaluate the sensitivity to change of power Doppler ultrasound (PDUS) assessment of joint inflammation and the predictive value of PDUS parameters in disease activity and radiologic outcome in patients with early rheumatoid arthritis (RA). METHODS: Forty-two patients with early RA who started therapy with disease-modifying antirheumatic drugs underwent blinded sequential clinical, laboratory, and ultrasound assessment at baseline, 3 months, 6 months, and 1 year and radiographic assessment at baseline and 1 year. For each patient, 28-joint Disease Activity Score (DAS28) was recorded at each visit. The presence of synovitis was investigated in 28 joints using gray-scale ultrasonography and intraarticular power Doppler signal. Active synovitis was defined as intraarticular synovitis detected with power Doppler signal. The ultrasound joint count for active synovitis and an overall joint index for power Doppler signal were calculated. Sensitivity to change of PDUS variables was assessed by estimating the smallest detectable difference (SDD) from the intraobserver variability. RESULTS: The SDD for ultrasound joint count for active synovitis and ultrasound joint index for power Doppler signal was lower than mean changes from baseline to 3 months, 6 months, and 1 year. Time-integrated values of PDUS parameters demonstrated a highly significant correlation with DAS28 after 1 year (r = 0.63, P < 0.001) and a stronger correlation with radiographic progression (r = 0.59-0.66, P < 0.001) than clinical and laboratory parameters (r < 0.5). CONCLUSION: PDUS is a sensitive and reliable method for longitudinal assessment of inflammatory activity in early RA. PDUS findings may have a predictive value in disease activity and radiographic outcome.

[Diagnostic accuracy of physical examination of the knee in rheumatoid arthritis: clinical and ultrasonographic study of joint effusion and BakerÕs cyst]. / Agudeza diagnóstica del examen físico de rodilla en la artritis reumatoide: estudio clínico y sonogr‡fico del derrame articular y quiste de Baker.

INTRODUCTION: In patients with rheumatoid arthritis (RA), knee pain can be inflammatory, mechanical or extraarticular. The physical examination (PE) doesn't always detect the presence of knee joint effusion or Baker's cyst (BC) in the knees of these patients. OBJECTIVE: To determine the diagnostic accuracy of PE in the diagnosis of effusion and BC in patients with RA evaluated with musculoskeletal ultrasound (MSUS), using this technique as the gold standard for comparison. MATERIAL AND METHOD: Three different models of ultrasound machines with a 7.5 MHz linear probe were used (Toshiba Tosbee, Toshiba Capasee and Siemens Sonoline). A rheumatologist evaluated the presence or absence of knee joint effusion or BC in patients. We registered age, gender, time of evolution of RA, rheumatoid factor, treatment, functional class of RA (FCRA) and previous clinical diagnosis to the MSUS study. RESULTS: 40 patients (80 knees) with RA were evaluated. Eighty percent were women, mean age 61.3±15 years. Time since onset of RA was 9.5±11.3 years, rheumatoid factor was positive in 80%, FCRA I (3 patients), FCRA II (27), FCRA III (8), FCRA IV (2). Fifty five percent of the patients received methotrexate. Patients reffered pain in 26 knees (32.5%). Joint effusion was reported by the clinician in 35 knees (43.7%) and corroborated by MSUS in 31 knees (38.75%), BC was reported by the clinician in 12 knees (15%) and corroborated by MSUS in 6 knees (7.5%). The sensitivity of the PE for detection of joint effusion was 0.63 and specificity of 0.87, for the detection of BC was 0.43 and 0.91, respectively. CONCLUSIONS: The PE showed acceptable diagnostic accuracy for the clinician. The complementary use of the MSUS can change the therapeutic and diagnostic approach in patients with RA.

A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder.

OBJECTIVE: Local corticosteroid injections, commonly accepted by rheumatologists to be effective treating painful shoulder, have shown controversial results. High frequency ultrasonography is an accurate and safe imaging modality for guiding musculoskeletal injections. We prospectively compared the short term response to randomized blind injection versus sonographic-guided injection of local corticosteroid in patients with painful shoulder. METHODS: We studied 41 consecutive patients with painful shoulder. Patients with previous trauma or chronic inflammatory arthritis were excluded. No patient had received previous physiotherapy or local steroid injection in the shoulder. Patients were randomized to receive either a blind subacromial injection of 20 mg triamcinolone (Group 1, n = 20) or a sonographic guided injection of 20 mg triamcinolone (Group 2, n = 21) by the same rheumatologist blinded to the clinical evaluation. In both groups we recorded shoulder abnormalities and the location of the steroid postinjection by ultrasound. Each patient was clinically assessed within 5 days before injection and 6 weeks after injection by another rheumatologist without knowledge of the injection technique performed. Clinical assessment included demographic and clinical data, a visual analog scale (VAS) for pain (0-100), the Shoulder Function Assessment (SFA) scale (0-70), and postinjection adverse effects. No patient received physical therapy during the followup period. Initially, demographic, clinical, and ultrasonographic findings in both groups showed no significant differences. RESULTS: Six weeks after injection, the VAS and the SFA score showed a significantly greater improvement in Group 2 compared with Group 1 (mean VAS score change 34.9 for Group 2 vs 7.1 for Group 1, p < 0.001; and mean SFA score change 15 for Group 2 vs 5.6 for Group 1, p = 0.012). One patient in Group 1 reported mild postinjection adverse effects. CONCLUSION: We suggest that sonographic-guided corticosteroid injections should be indicated, at least, in patients with poor response to previous blind injection to ensure accurate medication placement in order to improve therapeutic effectiveness.

Un año de experiencia con ecografía en la práctica reumatológica / One year of experience with echography in rheumatology

La gran calidad de imagen del aparato locomotor lograda por las nuevas sondas lineales de alta frecuencia y las considerables ventajas de la ecografía, como la posibilidad de exploración dinámica, su rapidez, inocuidad y bajo coste, han motivado la creciente introducción de esta técnica en la práctica reumatológica. Presentamos la experiencia de nuestra sección de reumatología en el empleo de ecografía durante un año y analizamos su aportación como herramienta diagnóstica y como guía en las punciones aspirativas e infiltraciones peri o intraarticulares (AU)