Ultrasonographic Assessment in Rheumatoid Arthritis

Hae-Rim Kim; Chong-Hyun Yoon

doi:10.4078/jkra.2009.16.2.74

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Kim and Yoon: Ultrasonographic Assessment in Rheumatoid Arthritis

Original Article

J Korean Rheum Assoc 2009;16(2):74-86.

Published online: 20 June 2009

DOI: https://doi.org/10.4078/jkra.2009.16.2.74

Ultrasonographic Assessment in Rheumatoid Arthritis

Hae-Rim Kim¹, Chong-Hyun Yoon²

¹Division of Rheumatology, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea

²The Catholic University of Korea, School of Medicine, Seoul, Korea

Received 5 June 2009 Accepted 15 June 2009

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The administration of disease-modifying antirheumatic drugs (DMARDs) in the early period of rheumatoid arthritis (RA) is critical for protecting against joint damage and inducing remission. Physicians need to identify patients at risk of progression to RA at the early stages of arthritis. Musculoskeletal ultrasonography (MSUS) allows the direct visualization of synovitis and bone erosion in the early phase, and may be useful for differentiating early rheumatoid arthritis from other inflammatory arthritis. Power Doppler sonography is a promising tool for assessing the disease activity and monitoring the effects of DMARDs. This article reviews the current status and recent advances in MSUS imaging in RA.

Keywords: Rheumatoid arthritis, Ultrasonography, Power doppler, Synovitis, Bone erosion

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Fig. 1.

Ultrasonographic findings of joint effusion. (A) Metacarpophalangeal joint, (B) metatarsophalangeal joint, (C) suprapatellar recess of the knee and (D) anterior talotibial joint.

Fig. 2.

Ultrasonographic findings of joint effusion can be graded according to the amount. (A) Grade 0 (no effusion), (B) grade 1 (minimal amount of fluid), (C) grade 2 (moderate amount of fluid without distension of the joint capsule), and (D) grade 3: extensive amount of fluid with distension of the joint capsule.

Fig. 3.

Ultrasonographic findings of synovial proliferation. (A) Olecrenon fossa of the elbow, (B) lateral recess of the knee, (C) metacarpophalangeal joint, and (D) dorsal carpal joint.

Fig. 4.

Ultrasonographic findings of bone erosion. (A) Small erosion in the talus, (B) irregular and moderate-sized erosions of the metacarpal head, (C) large and deep erosion of the metacarpal head, and (D) inflammatory pannus with increased vascularity on power Doppler ultrasound in the metatarsal joint.

Fig. 5.

Ultrasonographic findings of tenosynovitis. (A, B) Anechoic fluid accumulation in the sheath of posterior tibial tendon (longitudinal and transverse scans). (C, D) Hyperechoic synovial proliferation in the sheath of the extensor digitorum tendons (longitudinal and transverse scans).

Table 1.

Scoring systems of the ultrasonographic signs of synovitis

	Grade 0	Grade 1	Grade 2	Grade 3	Grade 4
Szkudlarek M (17)	No synovial thickening	Minimal synovial thickening (filling the angle between the periarticular bone, without bulging over the line linking the tops of the bones)	Synovial thickening (bulging over the line linking the tops of the bones but without extension along the bone diaphyses)	Synovial thickening (bulging over the line linking the tops of the bones and with extension to at least one of the bone diaphyses)
Scheel AK (58)	No effusion/ hypertrophy	Minimal effusion/ hypertrophy	Moderate effusion/ hypertrophy	Extensive effusion/ hypertrophy
Ostergaard M (50)	No synovial thickening	Minimal synovial thickening	Synovial thickening (bulging over the line linking the tops of the bones forming the joint without extension along the bone diaphyses)	Synovial thickening (bulging over the line linking the tops of the bones forming the joint with extension to one of the diaphyses)	Synovial thickening (bulging over the line linking the tops of the bones forming the joint with extension to one of the diaphyses)
Naredo E (14)	Absence	Mild	Moderate	Marked
Weidekamm C (60)	No change	Slight change	Moderate change	Strong changes

Table 2.

Scoring systems of the vascularity of synovitis using power Doppler sonography

	Grade 0	Grade 1	Grade 2	Grade 3
Naredo E (33)	Absence, No synovial flow	Mild, ≤3 isolated signals	Moderate, ＞3 isolated signals or confluent signal in less than half of the synovial area	Marked, Signals in more than half of the synovial area
Kubassova O (41)	No Doppler activity in the synovium	One or two single spots	Confluent areas covering up to half of the synovial area	Confluent areas covering more than half of the synovial area
Newman JS (34)		No flow	Mild or moderate flow	Intense flow
Strunk J (61)		Normal or minimal perfusion	Mild and moderate flow
Szkudlarek M (17)	No flow in the synovium	Single vessel signal	Confluent vessel signals in less than half of the area of the synovium	Vessel signals in more than half of the area of the synovium
Weidekamm C (60)	No vascularization	Small vascularization	Moderate vascularization	Strong vascularization

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