Rheumatology musculoskeletal ultrasound assessment of minimal synovial disease in hands, wrists and feet

Trickey, Jeanette (2022). Rheumatology musculoskeletal ultrasound assessment of minimal synovial disease in hands, wrists and feet. University of Birmingham. M.D.

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Abstract

Introduction
Ultrasound of joints and tendons is a useful tool in the diagnosis of early inflammatory arthritis. Advances in ultrasound technology in recent years have resulted in better resolution images, facilitating the detection of minimal musculoskeletal structural abnormalities including low grades of synovial hypertrophy, power Doppler signal and joint effusions. However, currently there is no definitive guidance as to what extent these changes may be due to inflammatory arthritis, or how much they are due to the normal ageing process.

Methods
Systematic literature review (SLR): Pubmed, Medline and EMBASE databases were searched: ultrasound, hands, feet, wrists, metacarpophalangeal, metatarsophalangeal, metacarpal, normal, healthy, control, synovial, hypertrophy, Doppler or synovitis. Two independent groups of reviewers assessed the abstracts and subsequent full papers.

Ultrasound of healthy subjects across the age range: Healthy adults (age 18 to 80 years) were recruited in 23 international centres with exclusion criteria: joint pain, hand osteoarthritis and history of inflammatory arthritis. Selected joints and tendons in hands, wrists and feet were scanned and graded according to a recent Outcome Measures in Rheumatology (OMERACT) consensus. Data from a comparison cohort of Rheumatoid Arthritis (RA) patients were taken from the Birmingham Early Arthritis Inception Cohort (BEACON).

Ultrasound findings in patients with clinically suspect arthralgia: The BEACON database was searched for patients with a baseline diagnosis of inflammatory arthralgia or clinically suspect arthralgia (CSA) who underwent routine ultrasound of selected hand, wrist and foot joints and tendons at time of enrolment and had 24 month follow up.

Results
SLR: In the 19 full papers included there was considerable heterogeneity in recruitment and definitions of HS, and in the reporting of ultrasound data. This has made it difficult to draw firm conclusions from the evidence gathered in this systematic literature review.

Ultrasound of healthy subjects across the age range: 954 healthy subjects were scanned with a mean age of 44.4 years old. There were significant differences in proportion of grade ≥1 synovial hypertrophy (SH) in metacarpophalangeal joints in older age groups. Prevalence of power Doppler grade ≥1 in all joints was low across the age range. There was variability in prevalence of grade ≥1 SH in wrist and metatarsophalangeal (MTP) joints between recruiting centres, leading to a reliability exercise and creation of new wrist and MTPJ ultrasound atlases. In the digit flexor and extensor carpi ulnaris tendons there was very low prevalence of ultrasound abnormalities with 85% of healthy having grade 0 for all tenosynovial hypertrophy (TSH), power Doppler (TPD) and effusion, with no significant differences across the age range. A comparison cohort of 144 RA patients was compared with a group of age- and sex-matched HS with significant difference in the proportion of TSH and TPD involvement between HS and RA subjects (p<0.001).

Ultrasound findings in patients with clinically suspect arthralgia: 43 patients with CSA at baseline diagnosis with 24 month BEACON follow up were included. Positive Rheumatoid factor was associated with development of inflammatory arthritis at 2 years, and ACPA positivity was significantly associated with progression to RA within 2 years (p<0.05). There was significantly more grade ≥1 SH in MCPJ 2 and 3 in those patients that progressed to an inflammatory arthritis by 24 months follow up (p<0.05).

Conclusions
This study provides a large amount of ultrasound data on selected joints and tendons for healthy subjects across the age range, and should provide a large control cohort to help further Rheumatology ultrasound research.

Type of Work:

Thesis (Doctorates > M.D.)

Award Type:

Doctorates > M.D.

Supervisor(s):