Utility of the Ultrasound Examination of the Hand and Wrist Joints in the Management of Established Rheumatoid Arthritis

Abstract

To investigate the usefulness of point-of-care hand and wrist joint ultrasound (US) examination in patients with established rheumatoid arthritis (RA). Fifty-one RA patients were evaluated using clinical disease activity measures and gray-scale and power Doppler (PD) US. Agreement between US and clinical findings and its impact on physicians' confidence and clinical decision were assessed. Agreement between intraarticular PD signal and joint swelling (JS) was moderate (82%; κ = 0.44). Agreement between PD signal and joint tenderness to palpation (TTP) was fair (75%; κ = 0.24). The greatest agreement between PD signal and clinical findings was seen in the 5th metacarpophalangeal (MCP) joint (96% JS, 88% TTP) and the poorest agreement was seen in the wrist (69% JS, 65% TTP) and 2nd (75% JS, 72% TTP) and 3rd (82% JS, 72% TTP) MCP joints. The presence of PD signal in nonswollen and/or nontender joints accounted for most of the disagreement in the wrists, while the opposite was true for the 2nd/3rd MCP joints. Agreement between sonographic synovial thickening and clinical findings was poor. Total sonographic synovial hypertrophy or PD score correlated significantly with physician-recorded, but not patient-recorded, clinical outcomes. US increased both physicians' confidence in their clinical decision (P < 0.0005, irrespective of Clinical Disease Activity Index score) and patients' confidence in physicians' medical decisions (88.4% of the cases). US modified biologic agent and/or disease-modifying antirheumatic drug (DMARD) use in 7 individual cases, but it did not affect the overall treatment plan (P > 0.15) or DMARD (P < 0.062) or biologic agent (P > 1.0) use in this group of RA patients. PD examination of the wrist and 2nd/3rd MCP joints might be feasible and clinically meaningful in evaluation of disease activity in patients with established RA. US examination of the hand/wrist joints in RA increases physicians' confidence in their clinical decision and can help to individualize DMARD and biologic agent use.