Effects of etanercept versus sulfasalazine in early axial spondyloarthritis on active inflammatory lesions as detected by whole-body MRI (ESTHER): a 48-week randomised controlled trial.

PURPOSE: To evaluate the potential of etanercept versus sulfasalazine to reduce active inflammatory lesions on whole-body MRI in active axial spondyloarthritis with a symptom duration of less than 5 years. METHODS: Patients were randomly assigned to etanercept (n=40) or sulfasalazine (n=36) treatment over 48 weeks. All patients showed active inflammatory lesions (bone marrow oedema) on MRI in either the sacroiliac joints or the spine. MRI was performed at weeks 0, 24 and 48 and was scored for active inflammatory lesions in sacroiliac joints and the spine including posterior segments and peripheral enthesitis by two radiologists, blinded for treatment arm and MRI time point. RESULTS: In the etanercept group, the reduction of the sacroiliac joint score from 7.7 at baseline to 2.0 at week 48 was significantly (p=0.02) larger compared with the sulfasalazine group from 5.4 at baseline to 3.5 at week 48. A similar difference in the reduction of inflammation was found in the spine from 2.2 to 1.0 in the etanercept group versus from 1.4 to 1.3 in the sulfasalazine group between baseline and week 48, respectively (p=0.01). The number of enthesitic sites also improved significantly from 26 to 11 in the etanercept group versus 24 to 26 in the sulfasalazine group (p=0.04 for difference). 50% of patients reached clinical remission in the etanercept group versus 19% in the sulfasalazine group at week 48. CONCLUSION: In patients with early axial spondyloarthritis active inflammatory lesions detected by whole-body MRI improved significantly more in etanercept versus sulfasalazine-treated patients. This effect correlated with a good clinical response in the etanercept group.

[Technique and diagnostic value of musculoskeletal ultrasonography in rheumatology. Part 6: ultrasonography of the wrist/hand]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik -- Teil 6: Sonographie der Hand- und Fingergelenke.

Sonography of the hands is especially helpful in the diagnosis of early arthritis. Sonography allows for a very sensitive detection of small joint-effusion, tenosynovitis and small erosive bone lesions earlier than conventional radiography. Musculoskeletal sonography is also helpful in morphological analysis of changes of the median nerve in patients with carpal tunnel syndrome. The following standard scans are suggested for the sonographic evaluation of the wrist: 1. dorsal longitudinal scan along the radio-carpal joint, 2) along the ulno-carpal joint, and 3) dorsal transverse scan along the wrist to detect joint fluid collection, synovitis, tenosynovitis, ganglia, irregularities of the bone surface in osteoarthritis, and erosions due to inflammatory disease, 4) volar longitudinal scan along the radio-carpal joint, and 5) along the ulno-carpal joint, and 6) volar transverse scan along the wrist to diagnose the same objective as the above mentioned scans and to evaluate the median nerve in cases of carpal tunnel syndrome. Optional scans are the following: 7) ulnar longitudinal 8) transverse scan along the ulnar joint space and the extensor carpi ulnaris muscle to detect tenosynovitis and caput ulnae syndrome, 9) radial longitudinal, and 10). transverse scan along the joint space to diagnose synovitis and tenosynovitis. The following standard scans are suggested for the sonographic evaluation of the fingers: 1) volar longitudinal, 2) volar transverse scan in extension along the finger joints to detect effusion and synovial proliferation, tenosynovitis, irregularities of the bone surface (osteophytes, erosions), 3) dorsal longitudinal scans in extension and flexion >70 degrees along the CMC I, MCP, PIP and DIP joints to evaluate effusion and synovial proliferation, tenosynovitis or tendinitis, irregularities of the bone surface (osteophytes, erosions), and 4) dorsal transverse scans along the finger joints to evaluate these structures in an additional dimension. Optional 5) scans include the following: medial longitudinal scan along the MCP I, II, PIP and DIP joints, and 6) lateral longitudinal scan along the MCP V, PIP and DIP joints to evaluate the erosive bone process and joint instability. A linear transducer with a frequency of between 7.5 and 12 MHz is recommendable. The anterior distance between the bone and the joint-capsule of the wrist is > or = 3 mm in probable and > or = 4 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left wrist is > or = 1 mm, and they are definite if the difference is > or = 2 mm. A carpal tunnel syndrome is probable with a cross-sectional area of the median nerve of > or = 12 mm(2).

[Technical aspects and value of arthrosonography in rheumatologic diagnosis. 4: Ultrasound of the elbow]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 4: Sonographie des Ellenbogens.

Musculoskeletal ultrasonography is an important imaging technique in the diagnosis of rheumatic diseases especially for early manifestation. It allows sensitive detection of small joint fluid collections as well as differentiation of soft tissue lesions and bone lesions. The following standard scans are suggested for sonographic evaluation of the elbow: 1) anterior humeroradial longitudinal scan, 2) anterior humeroulnar longitudinal scan to detect effusions, synovial proliferation, loose joint bodies, bone lesions (osteoarthritis/arthritis), 3) anterior transverse scan over the trochlea to evaluate these structures in an additional dimension, 4) posterior longitudinal scan and 5) posterior transverse scan of the olecranon fossa with flexed/extended elbow to evaluate the same objectives as the above mentioned scans and additionally to detect olecranon bursitis, and optional 6) distal dorsal longitudinal scan to differentiate soft tissue lesions such as rheumatoid nodules or gout tophi, 7) anterior transverse scan over the radius head to evaluate lesions of the radius head, tendopathy, calcinosis, 8) lateral humeroradial longitudinal scan to evaluate epicondylitis, 9) medial humeroulnar longitudinal scan to evaluate calcinosis, epicondylitis, signs of compression of the ulnar nerve. A linear transducer with a frequency of about 5-7.5 MHz is recommendable. The anterior distance between trochlea and the capitulum of the humerus between the bone and the joint-capsule of the elbow is > or = 2 mm in probable and > or = 3 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between the right and left elbow is 1 mm, and they are definite if the difference is > or = 2 mm.

[Technique and diagnostic value of musculoskelatal ultrasonography in rheumatology. Part 5: Ultrasonography of the shoulder]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik -Teil 5: Sonographie des Schultergürtels.

Shoulder-related symptoms are very common in rheumatic diseases. For the evaluation of the diagnosis as well as for therapy and prognosis, an anatomic assignment is essential. Clinical investigations alone are often not capable to do this. Ultrasonography is a method to delineate bony surfaces as well as the soft tissues around the shoulder joints statically and even dynamically. For the purpose of rheumatic diseases, ultrasound standard scans help to detect the lesions at the biceps tendon, the bursae, the rotator cuff, the humeral head as well as in the acromial and sternoclavicular joints. Considering the limitations of the method (obesity, frozen shoulder, no findings under bony structures) and knowing the pitfalls and errors of the method, ultrasonography is a reliable, quick and low cost method for the diagnosis of rheumatic shoulder joint pathology. Compared to computer tomography and magnetic resonance imaging, ultrasonography should be used as a screening method. The following standard scans are suggested for sonographic evaluation of the shoulder: 1) anterior transverse scan and 2) anterior longitudinal scan at the bicipal groove to detect synovitis and tenosynovitis, 3) anterior transverse scan at the coracoacromiale window in the neutral position, 4) at maximal external rotation and 5) at maximal internal rotation to evaluate the rotator cuff, bursitis, synovitis and erosions, 6) anterior longitudinal scan at 90 degrees to the coracoacomiale window at maximal internal rotation to describe these findings in an additional dimension, 7) anterior-lateral longitudinal scan at the anterior lateral acromion to tuberculum majus to evaluate the distal part of the supraspinatus muscle, 8) posterior transverse scan at the fossa infraspinata lateral under the spina scapulae, 9) axillary longitudinal scan to evaluate synovitis, synovial proliferation, erosions at the humeral head, lesions at the glenoidale labrum, 10) anterior transverse scan at the acromioclavicular joint and 11) anterior oblique scan at the sternoclavicular joint to detect synovitis, synovial proliferation, erosion, osteophytes.

[Technique and value of arthrosonography in rheumatologic diagnosis--3: Ultrasound diagnosis of the ankle joint, foot and toes]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik--Teil 3: Sonographie der Sprunggelenke, des Fusses und der Zehen.

The clinical investigation of ankles, feet, and toes is frequently equivocal in rheumatology. Sonography can distinguish between underlying pathologies. We suggest following standard scans: 1) anterior longitudinal scan to diagnose effusions in the ankle and talonavicular joints, to display erosive and osteoarthrotic pathologies, and to diagnose tenosynovitis of the extensor tendons; 2) anterior transverse scan to document the findings in an additional dimension; 3) lateral transverse scan and 4) lateral longitudinal scan to diagnose tenosynovitis of the peroneus tendons; 5) medial transverse scan and 6) medial longitudinal scan to diagnose tenosynovitis of the flexor tendons; 7) posterior longitudinal scan and 8) posterior transverse scan to evaluate the Achilles tendon, the retrocalcaneal bursa, and the posterior recess of the ankle joint. Additionally we suggest optional scans: 9) plantar longitudinal scan for the plantar fascia and the plantar calcaneal surface; 10) distal anterior longitudinal scan to evaluate the midtalar joints; 11) distal anterior longitudinal scan to evaluate the toes; and 12) plantar, distal transverse scan to evaluate the flexor tendons of the toes. Additionally, the correlating longitudinal and transverse scans can be used to confirm the findings. The frequency of the transducer should be about 7.5 MHz for ankles and the peroneus, flexor, and extensor tendons. Ten to over 20 MHz are possible for more superficially located structures. Using modern equipment with higher resolution a hypoechoic border may be normal up to 3 mm in the ankle joints, the MTP joints, and around the peroneus tendons, and up to 4 mm around the tibialis posterior tendons.

[Technique and value of arthrosonography in rheumatologic diagnosis. 2: Ultrasound diagnosis of the hip area]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 2: Sonographie der Hüftregion.

The clinical investigation of the hips in patients with rheumatic diseases is often equivocal. Thus, ultrasonography of this region is very relevant for rheumatologists. We suggest following standard scans: 1) anterior longitudinal scan to detect synovitis of the hip joint, iliopectineal bursitis, irregularities of the bone surface in osteoarthritis, Perthes' disease, and erosions due to inflammatory disease, 2) anterior transverse scan to evaluate these structures in an additional dimension, 3) lateral longitudinal scan of the hip joint with the same objective as the above mentioned scans; 4) lateral longitudinal scan, and 5) lateral transverse scan of the greater trochanter to diagnose trochanteric bursitis and bone irregularities due to enthesiopathy, and 6) dorsal oblique scan (optional) to diagnose hip joint effusions and pannus that localize in the dorsal region. Rotation of the joint is necessary to detect small effusions. The transducers should have a medium frequency of 5 to 7.5 MHz. In obese or muscular patients, 3.5 MHz transducers may be necessary to increase penetration. The anterior distance between the bone and the joint capsule of the hip joint is > or = 7 mm in probable and > or = 8 mm in definite synovitis or effusions. Synovitis or effusions are probable if the difference between right and left hip is > or = 2 mm, and they are definite if the difference is > or = 3 mm.

[Technique and value of arthrosonography in rheumatologic diagnosis. 1: Ultrasound diagnosis of the knee joint]. / Technik und Stellenwert der Arthrosonographie in der rheumatologischen Diagnostik. Teil 1: Sonographie des Kniegelenks.

Within the last few years, ultrasonography (US) of joints has attained a firm position for the diagnosis of joint diseases. Degenerative as well as inflammatory changes can be recognized using this method. With new, higher resolution techniques even bone surfaces and tendon textures can be visualized in greater detail. The advantages of sonography are general availability and low costs. When used properly, as a non-invasive procedure US has no detrimental effects on patients. The disadvantages of this technique result from its physical limitations, such as high reflection of US on bone and the negative correlation between resolution and penetration which makes US imaging difficult in deeper regions. The current technical development of probes and imaging processing, however, promises better deep structure imaging in the future. The quality of ultrasound examination always depends on the technical equipment, as well as on the patients' individual tissue constitution and the experience of the physician. It is possible to avoid misinterpretation and to increase the diagnostic value of US by using a standardized technique and professional knowledge of the specific aspects of the method. The significance of qualified education and sufficient training of sonographers is to be stressed. The aim of this article is to deliver a basic contribution to the standardization and quality assurance of joint US and to indicate the value of this method. In addition to the overview the authors propose guidelines for performance and interpretation of joint US. Due to the major significance of the knee joint in rheumatology it was decided to begin the work in this area.

[Imaging diagnosis in suspected inflammatory rheumatoid axial skeleton diseases (sacroilitis)]. / Bildgebende Diagnostik bei Verdacht auf entzündlich rheumatische Achsenskeletterkrankungen (Sakroiliitis).

Involvement of the sacroiliac joints is a hallmark of the spondyloarthropathies, especially in ankylosing spondylitis. The conventional diagnostic imaging of sacroiliitis in early stages might cause problems, because sensitivity of conventional radiographic methods is known to be too low in early stages of the disease. Magnetic resonance imaging of the sacroiliac joints certainly enables one to detect acute as well as chronic inflammatory changes in all stages of the disease. The potential disadvantages of this method are the dependency on the examiner, the lack of standardization, and the relatively high costs. Therefore, the "Workgroup of Diagnostic Imaging in Rheumatology of the Regional Center of Rheumatology of Berlin" including experienced rheumatologists, skeletal radiologists, and orthopedists acquired an imaging graduation for detection of sacroiliitis in consideration of the clinical background, the technical details of the methods, questions of ionizing radiation exposure, and cost effectiveness.