Tenosynovitis Research Articles

P214 Classifiable early RA shows heterogeneous imaging features and potential means of stratification

Abstract Background/Aims Synovitis and tenosynovitis (TS) are key findings seen in patients with rheumatoid arthritis (RA) on musculoskeletal ultrasound (MSUS). Both power Doppler TS (PDTS) and power Doppler synovitis (PDUS) have also been reported in preclinical-RA. We aimed to describe the prevalence of PDTS and PDUS in a treatment-naïve, new-onset RA trial cohort and their association with clinical and disease activity data. Methods The VEDERA (Very early Etanercept and Methotrexate versus Methotrexate with/without Delayed Etanercept in RA) trial recruited 120 treatment-naïve, new-onset RA patients fulfilling ACR-EULAR 2010 classification criteria with at least moderate DAS28-ESR to either first-line etanercept + methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT), and included clinical and dominant hand (MCP 1-5, wrist, flexor tendons 1-5 and extensor carpii ulnaris tendon) MSUS assessments. Joint Grey scale (GS), PDUS and PDTS were assessed semi-quantitatively and converted to dichotomous scale (absent = total score 0; present = total score ≥ 1). Patients were categorised in one of four groups based on presence of PDUS and/or PDTS: no PDUS or PDTS (PDUS-PDTS-), PDTS alone (PDUS-PDTS+), PDUS alone (PDUS+PDTS-) and both PDUS and PDTS (PDUS+PDTS+). Clinical and GS features are described for these groups. Results At time of diagnosis, 17% (20/120) were PDUS-PDTS-, 16% (19/120) PDUS-PDTS+, 15% (18/120) PDUS+PDTS- and 53% (63/120) PDUS+PDTS+. Table 1 details demographic, clinical and disease activity data. GS was present in 60% (12/20) and 74% (14/19) of PDUS-PDTS- and PDUS-PDTS+ groups respectively, while all patients with PDUS + (PDUS+PDTS- and PDUS+PDTS+ groups) demonstrated GS (table 1). The PDUS+PDTS+ group had the shortest symptom duration. PDUS-PDTS- group had lower DAS28ESR, tender/swollen joint counts (28 joints), CRP and pain. The two groups with PDTS + (with/without PDUS) had higher visual analogue pain scores. Conclusion Heterogeneous imaging features of classifiable, new-onset RA likely reflect different rates of progress along the continuum and presentation, and timing in capturing PDUS and PDTS. Severe clinical and imaging features associate with more rapid presentation. A minor proportion show no clear features of PDUS or GS yet are classifiable as RA indicating other contributors to diagnosis. MSUS features may offer a means of stratifying patients and tailoring treatment approaches. Disclosure R. Shukla: None. R. Levy: None. P. Ho: None. K. Mankia: None. R.J. Wakefield: None. P. Emery: None. M.H. Buch: None.

Importance of baseline musculoskeletal ultrasound findings in the prognosis of rheumatoid arthritis.

To investigate the prognostic value of baseline musculoskeletal ultrasound (MSUS) findings for rheumatoid arthritis (RA). We retrospectively analyzed 138 patients with RA. Patients' first MSUS record was considered as the baseline expression. The subsequent MSUS changes that showed alleviation or progression were regarded as the cutoff point. Grayscale ultrasound (GSUS) synovitis, power Doppler ultrasound (PDUS) synovitis, PDUS tenosynovitis (TS), and bone erosion were scored using a semi-quantitative scale. According to the ultrasound (US) results of the cutoff point, patients were divided into the alleviation group and the progression group. Laboratory results (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], rheumatoid factor [RF], anticyclic citrullinated peptide [anti-CCP] antibody, and anti-keratin antibody [AKA]), disease activity score in 28 joints (DAS28)-ESR, and US scores were compared between the two groups to analyze the prognostic value of US findings in RA. The alleviation group had higher levels of CRP, synovitis, TS, GSUS synovitis, PDUS synovitis, PDUS TS, and US total scores at baseline than the progression group (p < 0.05). The alleviation group received more aggressive treatment in their initial approach than the progression group (p < 0.05). The frequency of US examinations in the alleviation group was more than that in the progression group at follow-up (p < 0.05). Presence of baseline synovitis (OR 0.248, p = 0.006) and a higher GSUS synovitis score (OR 0.521, p = 0.006) were negatively correlated with RA progression. Presence of baseline synovitis and higher GSUS synovitis score do not always indicate worse prognosis of RA, which can be improved with aggressive treatment. Regular MSUS follow-up may have positive influences on prognosis. Key Points • The presence of synovitis at baseline and higher GSUS synovitis score do not necessarily imply poor prognosis of RA. • Prompt and powerful therapy and regular ultrasound follow-up can slow down the progression of RA and improve its prognosis. • Patients with slight and less arthritis at baseline might be ignored and get worse prognosis due to mild treatment strategies and irregular MSUS examination.

Ultrasound remission in patients with rheumatoid arthritis in clinical remission.

ObjectivesThe aim of the study was to assess ultrasound (US) remission in patients with rheumatoid arthritis (RA) in clinical remission using different definitions.Material and methodsThis was a cross-sectional study including patients with RA in clinical remission defined by disease activity score (DAS28)-erythrocyte rate (ESR) ≤ 2.6 for at least 6 months. Each patient underwent B-mode and power Doppler (PD) assessments of 42 joints and 20 tendons. B-mode and PD signal for synovitis and tenosynovitis (TS) were defined and graded semi-quantitatively (0–3) according to the outcome measures in rheumatology clinical trials (OMERACT). Several different definitions of US remission were examined: the absence of synovial hypertrophy (SH), TS on B-mode and PD signal, the absence of SH and PD signal, a grade ≤ 1 of SH and the absence of PD, a grade ≤ 1 of SH and PD, the absence of PD, or a grade of PD ≤ 1. The DAS28, clinical disease activity index (CDAI), simple disease activity index (SDAI), and the Boolean American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria were compared.ResultsThirty-seven patients were enrolled. The rate of remission according to the different composite indices was 70.2% for the SDAI, 64.8% for the CDAI, and 54% for the ACR/EULAR Boolean criteria. Synovial hypertrophy and TS in B-mode were detected in 94.6% and 40.5% of patients, respectively. Synovitis with PD signal was found in 59.5% and 13.5% of patients had TS with PD, respectively. Ultrasound remission at joints and tendons was found in 5.4–62.2% of patients. For the other remission criteria: CDAI, SDAI, and ACR/EULAR Boolean criteria, 7.7–60% of patients showed US remission at joints and tendons.ConclusionsClinical remission, even classified by strict composite indices, does not seem to be the closest method to the concept of absence of inflammatory activity; hence the interest of integrating US in assessing remission in practice.

Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair - carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome.

Hypothesis/BackgroundComplications involving the fingers and hand after arthroscopic rotator cuff repair (ARCR) include complex regional pain syndrome, carpal tunnel syndrome (CTS), and flexor tenosynovitis (TS). The aims of this study were to diagnose the complications after ARCR and investigate the risk factors that could predispose individuals to these finger and hand complications.MethodsFifty patients (50 shoulders) who underwent ARCR participated in this study. The patients’ ages ranged from 36 to 84 years (mean, 63 years). Before ARCR, we determined the disease history of the fingers and hand (CTS or TS) and subjectively assessed their symptoms using a questionnaire that included a scale ranging from 1 (no symptoms or no disability) to 5 (the worst symptoms or severest disability). ARCR was performed in all patients using suture anchors. The mean observation period after surgery was 15.5 months (range, 12-48 months). We diagnosed complications involving the fingers and hand after ARCR and investigated the preoperative, intraoperative, and postoperative risk factors that could predispose patients to these complications using univariable and multivariable analyses.ResultsAfter ARCR, 20 patients (20 hands) (40%) had complications of the fingers and hand. Among them, the diagnosis was CTS in 2 hands, TS in 15 hands, and both CTS and TS in 3 hands. None of the hands exhibited complex regional pain syndrome. These complications occurred at an average of 1.8 months (range, 0.1-4 months) after ARCR. In the 47 patients who did not have symptoms just before the operation, both univariable and multivariable analyses between the complication group (n = 17) and the no-complications group (n = 30) showed a significant difference in the presence of a past history of CTS or TS (complication frequency: past history: 88%, no past history: 25%) (P < .05) and the preoperative subjective assessment for edema of the fingers and hand (complication frequency: edema ≥ 2 points: 89%, edema < 2 points: 24%) (P < .05). There were no relationships between the other candidate intraoperative and postoperative factors and complications.ConclusionIn all 20 hands with complications of the fingers and hand after ARCR, the diagnosis was CTS or TS. Complications of the fingers and hand after ARCR easily occurred in patients with a past history of CTS or TS and in patients with edema as per a subjective assessment. We speculate that the ARCR triggered the occurrence of CTS and TS postoperatively in patients who had subclinical CTS or TS before surgery.

Ultrasound-guided intervention and hand tenosynovitis in patients with diabetes mellitus

Background: Flexor tenosynovitis is a frequent cause of hand pain in diabetic patients, and corticosteroid (CS) injection is usually efficiently used in the treatment protocol. Ultrasound (US) guidance is usually helpful for accurate needle placement and improves the outcome. Aim of the Work: The aim of the work was to evaluate the efficacy of US-guided injections compared to clinically guided injections, the treatment of flexor tenosynovitis in diabetic hands. Patients and Methods: Patients were divided into two matched groups of diabetic patients with flexor tenosynovitis: Group 1 – treated with local CS injection under US guidance and Group 2: treated with local CS injection under clinical guidance. Both the groups were assessed twice for pain and tenderness using visual analog scale (VAS) and Richie index, respectively, one before the injection and the second 1 month after. All affected tendons were assessed and graded by US and power Doppler at baseline and 1 month after the injection. Results: Both the groups were matched as regards the disease duration, age, and glycated hemoglobin A1c. The mean VAS for Group 1 was 8.1 ± 0.8 cm at baseline and 3.4 ± 0.7 cm in the second visit; greyscale US showed improvement in 16 patients (61%). The mean VAS was 8.3 ± 0.7 cm at visit one, while it dropped down to 4.5 ± 0.9 cm in visit two. Conclusion: US-guided injections of CSs are statistically superior to clinically guided in treating flexor tenosynovitis in diabetic patients.

Early detection and treatment of complications in the fingers and hand after arthroscopic rotator cuff repair

BackgroundComplications in the fingers and hand after arthroscopic rotator cuff repair (ARCR) have been reported to include carpal tunnel syndrome (CTS), flexor tenosynovitis (TS), and complex regional pain syndrome. These studies were conducted retrospectively; however, the reported complications have not been examined prospectively. The aim of this study was to evaluate the outcomes of early detection and treatment of the complications after ARCR.MethodsForty-six patients (48 shoulders) who underwent ARCR were prospectively examined to investigate complications in the fingers and hand after ARCR. We attempted to immediately detect and proactively treat these complications. We evaluated the outcomes of the early detection and treatment of the complications.ResultsComplications were observed in 17 hands (35%) and occurred an average of 1.5 months after ARCR. The symptoms in 3 hands resolved spontaneously, 2 hands were diagnosed with CTS, and 12 hands were diagnosed with TS. Of the 12 hands with TS, 11 exhibited no triggering of the fingers. Among the 14 hands diagnosed with CTS or TS, 13 hands (CTS: 2 hands, TS: 11 hands) were treated with corticosteroid injections; the mean interval between treatment initiation and symptom resolution was 1.0 months (0.5-3.0 months). None exhibited complex regional pain syndrome.ConclusionsWhen symptoms occur in the fingers and hand after ARCR, CTS or TS should be primarily suspected. The diagnosis of TS must be made carefully because most patients with TS have no triggering. For patients with CTS or TS after ARCR, rapid corticosteroid injection administration can lead to improvement in these symptoms.

Isolated Histoplasma Tenosynovitis in a Patient on Adalimumab

Isolated Histoplasma Tenosynovitis in a Patient on Adalimumab

THU0094 IN ACPA POSITIVE AT-RISK INDIVIDUALS WITHOUT CLINICAL ARTHRITIS, IS ULTRASOUND SUFFICIENTLY ACCURATE TO PREDICT PROGRESSION TO INFLAMMATORY ARTHRITIS?

Background:In a cohort of Anti-Cyclic Citrullinated Peptide Positive (ACPA+) At-Risk of developing inflammatory arthritis (IA) individuals without clinical synovitis, we previously demonstrated the predictive value of Power Doppler for progression depending on the number of joints involved (1). Here we update these results in a larger population combining all ultrasound (US) features and incorporating them in a multivariable analysis with clinical, genetic, immunological and serological markers.Objectives:To investigate the ability of US to predict progression to clinical arthritis using multivariable Cox analysis with and without including other variables.Methods:In a single centre prospective cohort, 488 at risk ACPA+ individuals with new musculoskeletal symptoms underwent an US scan of 30 small joints and 18 tendons at first visit (metacarpophalangeal, interphalangeal and metatarsophalangeal joints and flexor tendons, and extensor carpi ulnaris). The predictive value of US abnormalities (Power Doppler grade ≥ 1 (PD), Grey Scale grade ≥ 2 (GS), or erosion (E) presence) for progression to IA was analysed using Cox regression analysis and adjusted for tenosynovitis (TSV) presence, age, sex, ≥3 ULN CCP2 antibody titre and/or rheumatoid factor titre (RF), early morning stiffness duration, shared epitope (HLA-DRB1*01, *04 and/or *10), number of small joints tender, elevated CRP and intermittent symptoms. A complete dataset considering all variables was available for 324 patients.Results:Consecutive at-risk ACPA+ individuals (n=488, mean age 50.47 years old, 72.9% women) were followed up for at least 24 weeks or up to progression, for a median of 96 weeks (range 0.43-590). 130 of them (26.7%) developed IA after a median of 51.5 weeks (range 0.43 – 486).Multivariable analysis focusing on intra-articular ultrasound features showed that individuals with 1-3 joints with a PD signal or 1-2 with E were twice as likely to develop IA (Table 1), those with ≥ 4 joints with a PD signal were more than six times more likely (Figure 1). All variables data was available in 324 participants, showing a significant predictive value of TSV presence in ≥1 joint (HR= 1.973, p= 0.024, CI= 1.095-3.553), smoking exposure (HR= 2.597, p= 0.003, CI= 1.369-4.929), shared epitope positivity (HR= 1.979, p=0.044, CI= 1.019-3.843), ≥5 small joints tender (HR= 2.111, p= 0.030, CI= 1.073-5.463), and a high titre CCP and/or RF (HR= 4.334, p= 0.003, CI=1.651-11.374).Table 1.Multivariate Cox analysis of joint ultrasound features: non-adjusted for confoundersJoints InvolvedFeatureHRCIP-valuePPVNPVNSmall joints (wrists excluded)PD ≥1:1-3 joints≥4 joints2.1096.5241.364-3.2623.465-12.289&lt;0.0010.001&lt;0.00144%76.5%78.3%488GS ≥2:1-3 joints≥4 joints0.38120.3%30.8%71.9%E presence in ≥1 joint1.8651.206-2.8840.00547.6%76%Conclusion:In at-risk ACPA+ individuals, ultrasound alone - especially Power Doppler- is a powerful predictive factor of progression to IA, therefore of high clinical value for rheumatologists. The multivariable integrated risk prediction values indicates the role of other factors to be considered in future risk model development.

Incidence of De Quervain’s Tenosynovitis in Computer Operators

Background: De Quervain’s tenosynovitis is an inflammatory disease in which the pain is felt over the radial border of the wrist especially in the thumb with the ulnar deviation of the wrist. The objective of the study was to find out the incidence of De Quervain’s tenosynovitis in regular computer operators. Materials and Methods: Each participating person among the 147 regular computer operators was examined for the Finkelstein’s Test in order to diagnose the De Quervain’s tenosynovitis. Along with this a wrist pain questionnaire was asked to be filled in order to check the prevalence of wrist pain in regular computer operators. Results: Among 147 regular computer operators there were 74 (50.3%) males and 73 (49.7%) females with a mean age of 22.44 ± 1.81 years. Among 147 participating regular computer operators 99 (67.3%) showed the Finkelstein’s test positive whereas 48 (32.7%) showed the pain in Finkelstein’s test as being negative. Conclusion: It is concluded that the incidence of De Quervains Tenosynovitis among the regular computer operators on the basis of Finkelstien Test was quite high.

P240 Can ultrasound alone predict the need to treat ACPA positive individuals without synovitis?

Abstract Background In anti-cyclic citrullinated peptide antibody-positive (ACPA+) individuals without clinical synovitis (at-risk), to define the critical ultrasound (US) features sufficiently predictive for inflammatory arthritis (IA) to enable logical initiation of therapy. Methods In a single centre prospective cohort, at risk ACPA+ individuals with a new musculoskeletal symptoms underwent an US scan of 38 joints and 18 tendons at first visit. The predictive value of US abnormalities (Power Doppler (PD), Grey Scale (GS), erosion or tenosynovitis (TSV)) for progression to IA was analysed and the best predictive joints determined by Multivariable Cox Regression, adjusted for confounders. The US results were combined with clinical symptoms/findings to produce predictive models. Results Consecutive at-risk ACPA+ individuals (n = 457, mean age 50.3 years old, 74.2% women) were followed up for median of 15.4 months (range 0.1-127.4), a complete dataset with follow-up of at least 6 months was available for 319 of them. 135 (29.5%) developed IA after a median of 11.3 months (range 0.1-111.7). The negative predictive value of a US scan without any abnormality was 82%. In multivariable Cox regression, both PD and TSV were predictive of progression, with respectively hazard ratios of 1.2 (9=0.026) and 1.13 (p = 0.025). All US abnormalities had a high specificity (spec) but only moderate sensitivity (sens), PD was the most specific with a spec/sens of 0.94/0.23, followed by TSV with a spec/sens of 0.91/0.26 but the best area under the curve (AUC) of 0.599 (P = 0.0015). The addition ACPA titre (high compared to low), but not GS, improved spec/sens up to 0.92/0.34 and AUC to 0.964 (p &amp;lt; 0.001). A selection of US and clinical data of 14 joints also improved prediction, with an AUC of 0.670 (p &amp;lt; 0.001) and a spec/sens of 0.65/0.62. A selection of the 34 most predictive features reached the same sens/spec as the ACR/EULAR 2010 classification criteria for RA, showing a spec/sens of 0.80/0.56. Conclusion In at-risk ACPA+ individuals, the presence of sub-clinical US abnormalities are highly specific for progression to IA. The only moderate sensitivity can be improved by using joints or features selection in combination with clinical examination. These results are the first step in providing guidance for which at-risk ACPA+ individuals to treat. Disclosures L.M. Duquenne None. K. Mankia None. L. Garcia Montoya None. A. Di Matteo None. J. Nam None. P. Emery None.

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

BackgroundMagnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA.MethodsEighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements.ResultsSynovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05).ConclusionsPatient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.

Disseminated Gonococcal Infection: A Case Report of Arthritis-Dermatitis Syndrome

The bacteremic spread of the sexually transmitted pathogen, Neisseria gonorrhoeae ( N. gonorrhoeae ), results in disseminated gonococcal infection (DGI), which can lead to a variety of clinical signs and symptoms, such as multiple skin lesions, tenosynovitis and arthralgias/arthritis. The Centers for Disease Control and Prevention listed that drug-resistant N. gonorrhoeae (cephalosporin resistance) poses an urgent threat due to antimicrobial resistance. The authors describe the case of a young woman presenting in the emergency department (ED) with skin lesions and malaise. DGI was confirmed by blood cultures, nucleic acid amplification testing (NAAT) in cervical mucosa and urine gonococcal probe. One week of intravenous ceftriaxone was administrated with complete clinical and analytical resolution. The patient made a full clinical recovery. Clinicians must be aware of the signs and symptoms of this rare yet reemerging disease. J Med Cases. 2019;10(10):312-314 doi: https://doi.org/10.14740/jmc3381

MRI inflammation of the hand interosseous tendons occurs in anti-CCP-positive at-risk individuals and may precede the development of clinical synovitis

Interosseous tendon inflammation (ITI) has been described in rheumatoid arthritis (RA). Whether ITI occurs in at-risk individuals before the onset of clinical synovitis is unknown.ObjectivesTo investigate, by MRI, ITI in...

Automatic quantification of tenosynovitis on MRI of the wrist in patients with early arthritis: a feasibility study

ObjectivesTenosynovitis (inflammation of the synovial lining of the sheath surrounding tendons) is frequently observed on MRI of early arthritis patients. Since visual assessment of tenosynovitis is a laborious task, we investigated the feasibility of automatic quantification of tenosynovitis on MRI of the wrist in a large cohort of early arthritis patients.MethodsFor 563 consecutive early arthritis patients (clinically confirmed arthritis ≥ 1 joint, symptoms < 2 years), MR scans of the wrist were processed in three automatic stages. First, super-resolution reconstruction was applied to fuse coronal and axial scans into a single high-resolution three-dimensional image. Next, 10 extensor/flexor tendon regions were segmented using atlas-based segmentation and marker-based watershed. A measurement region of interest (ROI) was defined around the tendons. Finally, tenosynovitis was quantified by identifying image intensity values associated with tenosynovial inflammation using fuzzy clustering and measuring the fraction of voxels with these characteristic intensities within the measurement ROI. A subset of 60 patients was used for training and the remaining 503 patients for validation. Correlation between quantitative measurements and visual scores was assessed through Pearson correlation coefficient.ResultsPearson correlation between quantitative measurements and visual scores across 503 patients was r = 0.90, p < 0.001. False detections due to blood vessels and synovitis present within the measurement ROI contributed to a median offset from zero equivalent to 13.8% of the largest measurement value.ConclusionQuantitative measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. Further improvements in segmentation and exclusion of false detections are warranted.Key Points• Automatic measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores.• Blood vessels and synovitis in the vicinity of evaluated tendons can contribute to false detections in automatic measurements.• Further improvements in segmentation and exclusion of false detections are important directions of future work on the path to a robust quantification framework.

Tenosynovitis Associated With “Noodling” for Catfish

Tenosynovitis Associated With “Noodling” for Catfish

All forefoot’s pain are not morton’s neuroma-a pictorial review of the forefoot musculoskeletal conditions mimicking mortons neuroma

Introduction Ultrasound US and Magnetic resonance imaging MRI of the foot are often requested by foot and ankle specialists or general physicians GPs and the reason for these referral requests to Musculoskeletal Radiologists is usually forefoot and midfoot pain The request card for these patients usually states Morton rsquo s neuroma as a working suspected diagnosis However there are many other conditions that can mimic Morton rsquo s neuroma Materials and methods This article demonstrates multiple conditions that we have come across in our practice Between July and February we received consecutive patients from GP and specialists for ultrasound of foot with various clinical suspicions Standard ultrasonography of the foot was performed using high frequency probes by consultant muskuloskeltal radiologists Results Various differential diagnoses included intermetatarsal bursitis stress frature degenerative changes of the metatarsophalangeal and tarsometatarsal joints inflammatory arthropathy causing synovitis and joint effusions turf toe sesamoiditis freiberg rsquo s disease plantar plate disruption tenosynovitis of flexor or extensor tendons Additionally benign conditions have been detected at such as soft tissue disorders ganglions calluses adventitial bursitis plantar fibromatosis and haemangioma Furthermore malignant conditions such as giant cell tomour of tendon sheath and schwannomas were also detected Conclusion To improve the diagnosis of forefoot non specific foot pain healthcare professionals need to collect a complete and careful history perform thorough physical examinations and to be more aware about the possible conditions that lead to foorfoot foot pain This will avoid unnecessary visits to GPs orthopaedic surgeons and radiologists

Sinus tarsus mini incision approach with percutaneous reduction and fixation for Sanders II、III calcaneal fractures

Objective To explore the methods and clinical effect of the sinus tarsus mini incision approach with percutaneous fixation technique in the treatment of Sanders II, III calcaneus fractures. Methods From January 2015 to May 2016, the clinical data of 64 cases with Sanders II, III calcaneus fractures who were treated by sinus tarsus mini incision approach with percutaneous reduction and fixation were analyzed retrospectively. The average age was 46.64±10.51 years (range, 25-68) and 49 patients were males and 15 patients were females. According to Sander's classification, 39 patients were Sanders II and 25 were Sanders III fracture. Calcaneal varus was corrected and the length, width and height of bone were reduced by sinus tarsus mini incision approach with percutaneous fixation technique. Calcaneal fracture was treated by calcaneal bone plate combined with percutaneous screw fixation. Complications and operation procedure were recorded post-operation. Anteroposterior, lateral and axial views of preoperative and postoperative X-ray and CT scan were taken to assess the classification, restoration and intertion status of fracture. Radiological assessment was performed using Bohler's angle and Gissane's angle. Functional outcome was assessed using the Maryland foot score (MFS). Results All of the sixty-four patients were followed up for 12-18 months (average, 14.80±2.03). After surgery, only 4 cases of superficial necrosis of the incision were found, and the incisions were all healed and no infection occurred after surgery. No tendon tenosynovitis was seen after surgery. There were no fracture displacement, internal fixation failure, and fracture deformity healing cases. The mean time of bone union was 9.44±1.38 weeks (8-12 weeks) without fracture deformity healing case. The mean time of bone union was 9.17±1.16 weeks for the 23 cases with bone graft. For the 41 cases without bone graft, the bone healing average time was 9.91±1.62 weeks, and there is no statistically difference between cases with and without bone graft (t=1.936, P=0.061). Bohler's angle was 6.625°±4.904° (range, -5°-15°) preoperative, and improved to 31.031°±4.660° (range, 24°-40°), which had statistically significant difference (t=-28.863, P=0.000). Gissane's angle was from preoperative 76.094°±12.981° (range, 55°-105°) to 127.328°±6.486° (range, 115°-140°) at the time of the latest follow-up, and the difference had statistically significant (t=-28.246, P=0.000). Maryland Score: excellent 30 cases (22 cases of type II, 8 cases of type III), good 27 cases (15 of type II, 12 of type III), fair 7 cases (2 of type II, 5 of type III). The overall good rate was 89.06% (57/64). Conclusion The tarsal sinus minimally invasive small incision reduction and internal fixation combined with percutaneous reduction and fixation technique in the treatment of calcaneal fractures, exerts the advantages of small trauma, clear surgical exposure for reduction, reliable fixation, and low incision complications, which is applicable to treat the Sanders II, III calcaneal fractures. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal

Synovial involvement assessed by power Doppler ultra-sonography in systemic sclerosis: results of a cross-sectional study.

To characterize hand synovial manifestations assessed by power Doppler ultrasonography (PDUS) in a cohort of unselected patients fulfilling the 2013 ACR/EULAR classification criteria for SSc and to evaluate the associations of these synovial manifestations with the main general clinical and biological features of SSc. One hundred and three SSc patients were consecutively included and underwent PDUS evaluation of both hands assessing synovial and tenosynovial manifestations according to the OMERACT definitions. Clinical, biological and immunological SSc characteristics were recorded at the same time. Thirty-three patients (32%) had ultrasonographic synovial/tenosynovial involvement. The two main PDUS features were Doppler-positive/inflammatory synovitis (n = 18, 17.5%) and sclerosing tenosynovitis (TS) (n = 19, 18.4%). Inflammatory synovitis was more frequent in the wrist and MCP joints. Sclerosing TS was more frequent in men [odds ratio (OR) = 6.32, 95% CI: 2.17, 18.41; P = 0.001] and was associated with anti-RNA polymerase III antibodies (OR = 10.93, 95% CI: 1.84, 65.12; P = 0.01), diffuse SSc (OR = 18.24, 95% CI: 4.80, 69.32; P < 0.0001), interstitial lung disease (OR = 6.09, 95% CI: 1.86, 19.98; P = 0.001) and inflammatory arthralgia (OR = 14.64, 95% CI: 2.58, 83.10; P = 0.002). Inflammatory TS or synovitis were associated with CRP levels >5 mg/l (OR = 5.50, 95% CI: 1.81, 16.70; P = 0.001), pericarditis (OR = 7.81, 95% CI: 1.58, 38.71; P = 0.017) and inflammatory arthralgia (OR = 15.96, 95% CI: 2.80, 91.02; P = 0.002). Inflammatory synovitis and sclerosing TS were not significantly associated within an individual patient (OR = 2.77, 95% CI: 0.88, 8.70; P > 0.05). Ultrasonographic synovial involvement is frequent in patients fulfilling the 2013 ACR/EULAR classification criteria and PDUS may have a part to play in a more accurate and precise description of musculoskeletal manifestations of the disease, especially as the question of a treat-to-target approach is arising for SSc.

Factors influencing the outcomes of the traditional Chinese medicine percutaneous release treatment for the stenosal tendosynovitis

Objective The aim of this study is to analyze the factors influencing the outcomes of the traditional Chinese medicine (TCM) percutaneous release treatment for the stenosal tendosynovitis. Methods A total of 119 eligible participants, from outpatient of Dongzhimen Hospital during June, 2014 to April, 2017, were included into the study. The participants received TCM percutaneous release treatment, and were followed-up and assessed outcomes at 27 w. Responders were defined as participants with normal movement in week 27 compared with the baseline period. The NRS assessment in both groups was described, and the baseline characteristics of participants potentially related to cure response were mainly analyzed using Logistic regression analysis. Results Cure group and non-cure group were determined according to the cure response. And the outcomes of pain relief along the timeframe showed the feasibility of criteria of cure response. The uni-factor Logistic regression analysis showed that the factors age, course of disease, interventions and pain severity were significantly different between the cure and non-cure groups, and the multi-factor Logistic regression confirmed the four factors influenced the cure response of the TCM percutaneous release treatment for the stenosal tendosynovitis. The cutting knife was 5.85 fold than the traditional needling knife at increasing the cure response (OR=5.853, 95% CI 1.853-18.485; P=0.003). All the factors that age equal to or older than 60 years (OR=6.170, 95% CI 1.890-20.141; P=0.003), course of disease more than six months (OR=4.696, 95% CI 1.371-16.085; P=0.014) and pain severity from 6 to 7 (OR=5.184, 95% CI 1.416-18.975; P=0.013) were negatively associated with clinical response. Conclusions The patients with increasing age, long course of disease and distinct pain severity may be less likely to respond to the TCM percutaneous release treatment. These findings contribute to guiding clinical practice in terms of pretreatment patient selection. Further research is needed to confirm the association. Key words: Tenosynovitis; Trigger finger disorder; TCM Percutaneous release treatment; Cutting knife; Needling knife; Influencing factors; Regression analysis

The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development.

ObjectivesTenosynovitis (TS) is common in early arthritis. However, the value of US-defined TS in predicting RA development is unclear. We assessed the predictive utility of US-defined TS alongside US-defined synovitis and clinical and serological variables in a prospective cohort of early arthritis patients.MethodsOne hundred and seven patients with clinically apparent synovitis of one or more joint and symptom duration ⩽3 months underwent baseline clinical, laboratory and US assessment of 19 bilateral joint sites and 16 bilateral tendon compartments. Diagnostic outcome was determined after 18 months, applying the 2010 ACR/EULAR classification criteria for RA. The predictive values of US-defined TS for persistent RA were compared with those of US-defined synovitis, clinical and serological variables.ResultsA total of 4066 US joint sites and 3424 US tendon compartments were included in the analysis. Forty-six patients developed persistent RA, 17 patients developed non-RA persistent disease and 44 patients had resolving disease at follow-up. US-defined TS in at least one tendon compartment at baseline was common in all groups (RA 85%, non-RA persistent disease 71% and resolving 70%). On multi-variate analysis, US-defined digit flexor TS provided independent predictive data over and above the presence of ACPA and US-defined joint synovitis.ConclusionUS-defined digit flexor TS provided independent predictive data for persistent RA development in patients with early arthritis. The predictive utility of this tendon site should be further assessed in a larger cohort; investigators designing imaging-based predictive algorithms for RA development should include this tendon component as a candidate variable.