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1. ULTRASOUND & ITS CLINICAL USE IN RHEUMATOID ARTHRITIS BY:- DR. YASHASVI SHARMA (POST-GRADUATE RESIDENT) GUIDE:- DR. ALKA AGRAWAL (HOD& PROFESSOR) CO-GUIDE:- DR AMIT SHANKHWAR ( ASSOSCIATE PROFESSER MGM MEDICAL COLLEGE, INDORE (M.P.) DEPT OF RADIO-DIAGNOSIS MGM MEDICAL COLLEGE , INDORE (M.P.)

2. INTRODUCTION : Rheumatoid arthritis (RA) is a chronic inflammatory immune mediated disorder where synovial proliferation, pannus formation and bone erosions are histological hallmarks . High-resolution musculoskeletal ultrasound (MSUS) has been increasingly used in rheumatological practice worldwide. While MSUS B-mode or gray-scale (GS) used for imaging of anatomic structures , which enables visualization of synovial hypertrophy and/or effusion whereas power Doppler ( pD ) is used in blood flow detection , which allows visualization of the movement of blood vessels, therefore detecting increased microvascular blood flow seen in active synovitis . Both parameters seem worthy of utilization in the follow-up of RA patients. In addition, MSUS is also reliable for the detection of bone erosions as well as for the detection of subclinical synovitis and prediction of disease relapse and structural progression .

3. Material & methods : Methodology : The present study was conducted in 50 patients in the Department of Radiology, IMCHRC, Indore. Patients referred from Orthopaedics OPD with clinically suspected arthralgia & positive RA Factor with/without palindromic rheumatism were taken as study . B mode scan with colour doppler was conducted in all the patients. Instrumentation: SAMSUNG USG Machine with transducer LA3-16A and LA2-9A probe. Patient’s clinical history and examination findings were recorded prospectively. A pre-formed written consent is also taken.

4. Results : The sample was composed of 50 individuals who were case of clinically suspected arthralgia & positive RA factor with or without palindromic rheumatism. About 34 individuals with palindromic rheumatism , US of the flaring area showed significantly more Tenosynovitis, more signs of extracapsular inflammation, particularly periarticular inflammation. 16 individuals with arthralgia there was no signs of synovitis in US .

5. In patients with positive RA factor & palindromic rheumatism it was found that out of 34 individuals 22 female of mean age from 40-50 years & 12 males of mean age 50-60 years showed following abnormalities in the joint: Synovial membrane pathologies , including: Thickening , Hypervascularization , Fibrosis of the synovium , synovial sheaths and bursae . Exudate , which usually accompanies synovial pathology. Changes in tendons, i.e. Tenosynovitis with inflammation of the tendon , leading to tendon damage, i.e. a partial or complete tendon rupture . Osteochondral changes , including: cartilage damage , cysts , inflammation , erosions. Enthesopathies , that is tendon and ligaments attachments pathologies.

6. Thickened synovium of the radiocarpal and midcarpal joint cavities featuring intense vascularization on PDUS suggestive of active inflammatory process.

7. Lack of vascularization within a hyperechoic synovial membrane Indicates Fibrosis of synovial membrane of the knee joint.

8. A A. Pannus with Inactive erosion of the greater tuberosity of the head of humerus

9. B. Active erosions in the radiocarpal and midcarpal joints.

10. C. Inflamed adipose tissue of pre femoral appears hyperechogenic (swollen) and exhibits the features of vascularization. C

11. D. Synovial thickening, increased vascularization with exudation in fourth extensor compartment. D

12. Affected and healthy extensor carpi ulnaris . Persistent inflammation includes the tendon & tendon thickness is increased on gray-scale ultrasonography in such a way that the crossection of an oval structure becomes round. While a PDUS shows vessels infiltrating the tendon from within the inflamed synovium. Tenosynovitis of the sixth extensor compartment:-

13. Inflammatory changes of the enthesis of the patellar tendon of quadriceps femoris muscle with delamination, irregularities/erosions at the enthesis-bone junction.

14. PREVELANCE OF RA IN WOMEN & MEN :-

15. Discussion:- Out of total 50 patients , our study showed that , RA prevalence was twice more common in women & are more likely to progress to palindromic rheumatism early than compared to men. Onset is generally in adulthood, peaking in the 4th and 5th decades in both man and woman. In 34 individuals with palindromic rheumatism with/without positive RA factor hypervascularisation and thickening of synovial membrane was found in all of them . With Inflammation of joints being the second most common finding in 33 of them. Fibrosis of the synovium, synovial sheaths or bursae were found in 29 of them. Osteochondral erosions are late changes in rheumatism which was found least in our study in 14 individuals. Wrist joint was involved in all 34 individuals which suggests that wrist is most commonly involved in rheumatism. Metacarpophangeal joint & Proximal Inter-phalangeal joint were also involved in the most of individuals. The carpometacarpal joint is least involved in our patients. The distal interphalangeal joints were spared in all of them . The sixth compartment which conducts Extensor carpi ulnaris was found to be more involved in most of patients.

16. Since a pD signal can be also seen in healthy joints the adding of spectral Doppler and estimation of RI of flow in synovial membrane helped in differentiating healthy and inflamed joints (as low RI are seen in inflammed joints). The characteristic features of the swelling (i.e. effusion or synovial hypertrophy ) , which is essential for the correct evaluation of the pathological process , PD mode helped in interpretation of the inflammatory process by detecting and quantifying the neovascularization in the pannus, which reflects a real‑time activity. T he detection of tenosynovitis and anatomical destruction was shown by the loss of its normal fibrillary pattern and loss of demonstration of the tendon margins . The PD also provided an accurate information about the degree of activity of the inflammation . US is also sensitive in detecting early bone erosions in the accessible joints such as those of the hands and feet, which are the target joints for early RA structural damage. C artilage pathologies such as loss of the sharpness of the margins , loss of clarity of the cartilaginous layer , cartilage thinning , and irregularities of subchondral bone contour was easily interpreted b y US. US (by GS and PD) also detected residual inflammation in patients with RA considered to be in clinical remission.

17. Conclusion :- In our study the findings of US was very much similar with clinical presentation of the disease, the prevalence of RA was more commonly found in women in later stages of life with classical disease pattern of Distal interphalangeal (DIP) joints sparing and involvement of the 1st carpometacarpal joint was less common. US is an useful instrument to complement the physical examination of RA patients as method is quick and safe. US is practical, feasible and less expensive than MR. US has showed higher sens itivity than clinical assessment in detecting joint and tendon inflammation particularly in deeper anatomical areas such as the shoulder, hip, and ankle, which are more difficult to be assessed by physical examination. The limitation of US surely depends on our choice of equipment and selection of parameters to be utilized ( pD alone, pD plus GS, bone erosions, cartilage changes, synovial effusion, tenosynovitis, spectral Doppler) for predicting high accuracy value of progression of disease. But US is a reliable instrument to complement physical examination, appraise disease activity and monitor response to therapy in RA management in clinical use.

18. Keywords :- GS- GRAY SCALE PD- POWER DOPPLER CF-COLOUR FLOW US- ULTRASOUND

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