1. Patient with ankle affection Individual US findings
Abstract Number: SAT0619
Ankle Evaluation In Active Rheumatoid Arthritis By Ultrasound: A Cross Sectional Study
Ahmed M. Elsaman 1, Ahmed R. Radwan1 and Ehab S. Mostafa2
1MD, Lecturer of Rheumatology, Department of Rheumatology and Rehabilitation, Faculty of Medicine, Sohag University, Sohag, Egypt
2MD, Lecturer of Rheumatology, Department of Rheumatology and Rehabilitation, Qena Faculty of Medicine, South Valley University, Qena, Egypt
Conclusion:
Ankle evaluation should be considered more in RA assessment. Tibialis anterior and posterior tendons, tibiotalar and talonavicular joints were the most frequently involved structures. Tenosynovitis appears earlier than synovitis. DAS28-ESR score was correlated to synovitis and tenosynovitis but not to erosion. Erosions and bilaterality correlated with disease duration. RF positivity has a positive correlation with positive ankle US findings.
Methods:
A total of 126 ankle joints and tendons of 63 active RA patients, aged above 18 years old were included in the study. US examination was done to the tibiotalar and talonavicular joints for synovitis and/or effusion on Greyscale (GS) mode and power doppler (PD). The anterior, lateral and posterior ankle tendons were examined for tenosynovitis and tendinosis.
Item
Right
Left
Total
Chi square
P value
Synovitis
13(20.6%)
10(15.9%)
23(18.3%)
0.479
0.489
B mode
11(17.5%)
9(14.3%)
20(15.9%)
0.238
0.626
Power Doppler
7(11.1%)
5(7.9%)
12(9.5%)
0.368
0.544
Tenosynovitis
23(36.5%)
15(23.8%)
38(30.2%)
2.411
0.120
22(34.9%)
12(19.0%)
34(27.0%)
4.028
0.045
4(6.3%)
8(6.3%)
0.000
1.000*
Tendinosis
1(1.6%)
5(4.0%)
1.874
0.385*
Erosions
2(3.2%)
11(8.7%)
4.881
0.027
Fig. a. Anterior sagittal view of the ankle joint showing synovitis of tibiotalar joint (arrow) with tenosynovitis of the distal part of tibialis anterior tendon on grey scale (arrow heads), tibia at the left side followed by talus bone. Fig. 1b. Anterior sagittal view of the tibialis anterior tendon sowing tenosynovitis on PD (arrow heads) and hypoechoic shadow. Tibia can be seen underlying the tendon.
Table 1. Ultrasonographic findings of both ankles
Results:
The mean age and ± standard deviation were 35.1±8.3 with the female-to-male ratio 2:1. The mean disease duration was 22.7±9.6 months. The mean DAS28-ESR 28 score was 3.05±0.66. The most frequent pathologies detected were tenosynovitis of the flexor, extensor or peroneal tendons (found in 30.2% of the affected ankles); followed by synovitis of the tibiotalar and talonavicular joints (18.3%); next was erosion (8.7%) and lastly tendinosis (4%). The earliest sonographic signs were tenosynovitis, followed by synovitis, erosion, and lastly tendinosis.
Item
DAS28
T test*/ ANOVA**
P value
Patient with ankle affection No
2.78±0.25
3.773*
0.001
Yes
3.40±0.84
Laterality
15.002**
<0.001
Unilateral
3.15±0.63
Bilateral
3.84±1.02
Side
11.066**
Right side only
3.26±0.66
Left side only
2.78±0.29
Synovitis
2.90±0.45
3.921*
3.72±0.98
Tenosynovitis  
2.87±0.38
4.001*
3.48±0.92
Tendinosis
3.06±0.67
0.250*
0.803
2.98±0.24
Erosions
3.00±0.60
2.020*
0.069
3.60±0.97
Individual US findings
Synovitis (a)
a vs b: 0.948*
0.347
Tenosynovitis (b)
a vs c: 0.336*
0.739
Erosions (c)
a vs d: 3.206*
0.004
Tendinosis (d)
b vs c: 0.365*
0.716
b vs d: 2.720*
0.010
c vs d: 1.990*
0.066
References
1. McKie S, O’Connor P. Imaging of the foot and ankle in rheumatoid arthritis. the foot and ankle in rheumatoid arthritis Philadelphia: Churchill Livingstone Elsevier. 2007:
2. Wells G, Becker J, Teng J, Dougados M, Schiff M, Smolen J, et al. Validation of the 28-joint Disease Activity Score (DAS28) and European League Against Rheumatism response criteria based on C-reactive protein against disease progression in patients with rheumatoid arthritis, and comparison with the DAS28 based on erythrocyte sedimentation rate. Ann Rheum Dis. 2009;68(6):
3. Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus T, Hartung W, et al. Evaluation of a novel 7‐joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Care & Research. 2009;61(9):
4. Perricone C, Ceccarelli F, Modesti M, Vavala C, Di Franco M, Valesini G, et al. The 6-joint ultrasonographic assessment: a valid, sensitive-to-change and feasible method for evaluating joint inflammation in RA. Rheumatology. 2012;51(5):
Introduction:
Ankle joint evaluation is underestimated in many clinical and sonographic scores used for evaluation and follow-up of rheumatoid arthritis (RA) patients. Moreover, sonographic scores which included the ankle joint had no agreement on examination parameters. More effort is needed to detect the value of the ankle joint examination in RA and also a description of the earliest and the most frequent ultrasonographic signs that should be considered in ankle assessment (1-4).
The objectives of this study were detection of ankle affection by ultrasound (US) in active RA and correlate this finding with disease duration, DAS28-ESR score and rheumatoid factor (RF).
Table 1. Clinical and Ultrasonographic findings in relation to disease activity measured by DAS28-ESR