Ultrasound abnormalities in septic arthritis are associated with functional outcomes.

OBJECTIVES: To describe the ultrasound abnormalities seen in septic arthritis and to assess their associations with clinical, biological, and radiological outcomes. METHODS: We prospectively included 34 patients with septic arthritis of a native joint (knee, n=19; shoulder, n=6; hip, n=4; ankle, n=3; or wrist, n=2). Ultrasonography was performed to record synovial-membrane thickness and vascularity, joint effusion, and abnormalities of adjacent soft tissues, at baseline then 4days, 2weeks, and 3months later. Motion-range limitation of the affected joint was evaluated after 3months. Radiography was performed at inclusion and after 3months. RESULTS: Mean age was 63.7±17.6years. After 3months, 20 (58.8%) patients had motion-range limitation with worsening of the total radiological score (P<0.001). The proportion of patients with synovitis was very high initially (96.4% at baseline, 96.3% after 4days, and 100% after 2weeks) then diminished to 77.8% after 3months (P=0.051). Synovial-membrane thickness was significantly higher after 4days and 2weeks compared to baseline (median, +17.3% and +20%, respectively; P=0.015) and was significantly lower after 3months compared to the earlier time points (median, -31.5%, P=0.015). A positive Doppler signal was common at baseline (n=18, 64.3%) then significantly less so after 3months (n=7, 25.9%; P=0.04). An unchanged or higher Doppler grade after 2weeks compared to baseline was associated with motion-range limitation at last follow-up (P=0.033). CONCLUSION: We report the first study on ultrasound evidence of synovitis, joint effusion, and soft tissue alterations at baseline and over time in patients with septic arthritis. Persistent synovitis and joint effusion 3months after starting antibiotic therapy was not associated with treatment failure. However, Doppler signal changes over the first 2weeks were associated with the 3-month functional outcome.

Three-dimensional versus two-dimensional ultrasonographic assessment of peripheral enthesitis in spondylarthritis.

To compare the intra- and interobserver reliability of three-dimensional (3D) volumetric versus conventional two-dimensional (2D) power Doppler ultrasonography (US) in the assessment of peripheral enthesitis in spondylarthritis (SpA). Sixteen patients with SpA according to ASAS criteria were included. Two rheumatologists (one experimented in musculoskeletal US (sonographer 1) and one beginner (sonographer 2)) performed independently a 2D US scoring of the enthesis using the Madrid Sonographic Enthesis Index score followed by a 3D acquisition of the same entheseal sites. The reading of the 3D acquisition was performed a minimum of 1 week apart. Intraobserver reliability was evaluated by a second reading of the same images. The duration of 2D US scanning, 3D US acquisition and reading was recorded. Intraclass correlation coefficients (ICCs) were used for the reliability analysis. Intraobserver reproducibility was good to excellent for 2D US and good for 3D US (ICC (95 %CI) 2D US 0.776 (0.471-0.916) and 0.96 (0.892-0.986) and ICC (95 %CI) 3D US 0.796 (0.498-0.921) and 0.703 (0.325-0.886) for sonographer 1 and 2, respectively). Interobserver reliability was slightly better for 3D US than for 2D US (ICC (95 %CI) 0.776 (0.471-0.916) for 3D US versus 0.641 (0.221-0.859) for 2D US). The mean time (±SD) for 2D US scanning was 23 min (±4) whereas the mean time for 3D US volume acquisition and reading was 16.5 min (±2.6) (p < 0.001). 3D US showed good intra- and interobserver reliability in the assessment of enthesitis in SpA and shortened the needed time for scanning. It can be performed by a nonexperienced examiner without loss of reliability.

Similar outcome despite slight clinical differences between lumbar radiculopathy induced by lateral versus medial disc herniations in patients without previous foraminal stenosis: a prospective cohort study with 1-year follow-up.

BACKGROUND CONTEXT: It has been claimed that lumbar radiculopathy induced by foraminal disc herniations had poorer outcome and different clinical features, including: 1-more progressive onset, but shorter duration between the first sign and request of medical care; 2-more severe radiculopathy; 3-less frequent/severe back pain; 4-less limitation of straight leg raising (SLR); 5-more frequent neurologic deficiencies; 6-poorer outcome. PURPOSE: To check whether this still holds true when including only patients without other reasons for foraminal stenosis, that is, whether patients with medial disc herniations had different features and outcome than those with more lateral disc herniations. STUDY DESIGN: All patients hospitalized to treat a lumbar radiculopathy within a 6-month period in two French rheumatology units in 2012 were included in this prospective study each time computed tomography scan or magnetic resonance imaging had already been performed and showed clear disc bulging/herniation but no features of medial or lateral spinal stenosis. PATIENT SAMPLE: Fifty-nine patients (31 males, 49 with sciatica only) were included: 31 (53%) had medial disc herniations and 28 (47%) had more lateral herniations (posterolateral in 3, foraminal in 20, and far lateral in 5). OUTCOME MEASURES: Outcome was assessed by a phone call 1 year after the baseline assessment using a standardized questionnaire. Patients were asked whether they experienced a relapse of their radiculopathy after discharge from the hospital; whether they had been operated or not; whether they felt it had improved or not; whether they felt cured or not; to assess their level of pain radiating in the leg when standing on a 0 to 10 verbal scale; and how long they could walk. METHODS: Features of patients with medial disc herniations were compared with patients with more lateral herniations. RESULTS: No significant differences according to the location of herniations were noticed for the speed of radiculopathy onset, time elapsed since onset, back pain (both lying or standing), and leg pain (both lying or standing), but slight significant differences (t test<0.05) were observed for other items: the 28 patients with lateral herniations were 8 years older (53.4 ±15.8 vs. 45.2±12.6), their herniations involved discs from upper levels of the lumbar spine (above L4-L5: 7/28 vs. 3/31), motor weakness was more frequent (25% vs. 3%), SLR was less restricted (65.0°±24.5° vs. 51.1°±25.7°), DN4 score of neuropathic pain was higher (4.4±2.1 vs. 3.2±1.8), anxiety level was higher (10.3±4.1 vs. 7.9±3.2), length of hospital stay was longer (5.7±2.4 days vs. 4.5±1.4 days), and physician's prognosis of a good outcome was poorer (6.6±2.2 vs. 8.0±1.6). However, at the end of follow-up (12.2±3.3 months), outcome was similar: 37% (vs. 41% for medial herniations) had transiently relapsed, 66% felt finally improved (vs. 63%), and walking capacity was nearly identical despite the fact that only 18% had to be operated (vs. 32% of those with medial herniations). CONCLUSIONS: Despite differences in clinical presentation, the outcome of radiculopathy induced by the more lateral lumbar disc herniations was not worse than the outcome of patients with only medial disc herniations. Previous claims of poorer outcome in foraminal herniations might be explained by the inclusion of patients with associated foraminal stenosis.