The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography.

Objective. The ability to make an early, accurate diagnosis of rheumatoid arthritis (RA) has become increasingly important with the availability of new, expensive, and targeted therapies. However, plain radiography, the traditional method of detecting the characteristic bone erosions and an important adjunct in establishing a diagnosis of RA, is known to be insensitive. This study compared sonography, a modern imaging technique, with conventional radiography for the detection of erosions in the metacarpophalangeal (MCP) joints of patients with RA. Methods. One hundred RA patients (including 40 with early disease) underwent posteroanterior radiography and sonography of the MCP joints of the dominant hand. Twenty asymptomatic control subjects also underwent sonography. Erosion sites were recorded and subsequently compared using each modality. Magnetic resonance imaging (MRI) was performed on the second MCP joint in 25 patients with early RA to confirm the pathologic specificity of sonographic erosions. Intraobserver reliability of sonography readings was assessed using video recordings of 55 MCP joint scans of RA patients, and interobserver reliability was assessed by comparing 160 MCP joint scans performed sequentially by 2 independent observers. Results. Sonography detected 127 definite erosions in 56 of 100 RA patients, compared with radiographic detection of 32 erosions (26 [81%] of which coincided with sonographic erosions) in 17 of 100 patients (P < 0.0001). In early disease, sonography detected 6.5-fold more erosions than did radiography, in 7.5-fold the number of patients. In late disease, these differences were 3.4-fold and 2.7-fold, respectively. On MRI, all sonographic erosions not visible on radiography (n = 12) corresponded by site to MRI abnormalities. The Cohen-kappa values for intra- and interobserver reliability of sonography were 0.75 and 0.76, respectively. Conclusion. Sonography is a reliable technique that detects more erosions than radiography, especially in early RA. Sonographic erosions not seen on radiography corresponded to MRI bone abnormalities. This technology has potential in the management of patients with early RA/inflammatory arthritis and is likely to have major implications for the future practice of rheumatology.

[1]  Douglas G. Altman,et al.  Practical statistics for medical research , 1990 .

[2]  A C Brower,et al.  Use of the radiograph to measure the course of rheumatoid arthritis. The gold standard versus fool's gold. , 1990, Arthritis and rheumatism.

[3]  A. Feinstein,et al.  Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. , 1978, The New England journal of medicine.

[4]  Désirée van der Heijde,et al.  Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. , 1996 .

[5]  L S Freedman,et al.  Evaluating and comparing imaging techniques: a review and classification of study designs. , 1987, The British journal of radiology.

[6]  D. Felson,et al.  Imaging in rheumatoid arthritis: results of group discussions. , 1999, The Journal of rheumatology.

[7]  R A Dickson,et al.  The distribution of radiological joint damage in the rheumatoid hand. , 1979, Rheumatology and rehabilitation.

[8]  D Loreck,et al.  Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. , 1999, Arthritis and rheumatism.

[9]  G. Alarcón,et al.  The value of the Nørgaard view in the evaluation of erosive arthritis. , 1990, Journal of Rheumatology.

[10]  F. Arnett.  Revised criteria for the classification of rheumatoid arthritis. , 1990, Orthopedic nursing.

[11]  D. Symmons,et al.  What is early rheumatoid arthritis?: definition and diagnosis. , 1997, Bailliere's clinical rheumatology.

[12]  P. Emery.  The Roche Rheumatology Prize Lecture. The optimal management of early rheumatoid disease: the key to preventing disability. , 1994, British journal of rheumatology.

[13]  Michael J. Green,et al.  Persistence of mild, early inflammatory arthritis: the importance of disease duration, rheumatoid factor, and the shared epitope. , 1999, Arthritis and rheumatism.

[14]  A. van der Heide,et al.  Prediction of progression of radiologic damage in newly diagnosed rheumatoid arthritis. , 1995, Arthritis and rheumatism.

[15]  P. Emery,et al.  A preliminary study of ultrasound aspiration of bone erosion in early rheumatoid arthritis. , 1999, Rheumatology.

[16]  Michael J. Green,et al.  The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study. , 1999, Arthritis and rheumatism.

[17]  M. Østergaard.  MRI bone erosions and MRI bone lesions in early rheumatoid arthritis: comment on the article by McGonagle et al. , 2000 .

[18]  W. Grassi,et al.  Ultrasound examination of metacarpophalangeal joints in rheumatoid arthritis. , 1993, Scandinavian journal of rheumatology.

[19]  J. Buckland-Wright.  Microfocal radiographic examination of erosions in the wrist and hand of patients with rheumatoid arthritis. , 1984, Annals of the rheumatic diseases.

[20]  Kunio Doi,et al.  Comparison of Image Quality Obtained with Optical and Radiographic Magnification Techniques in Fine-Detail Skeletal Radiography: Effect of Object Thinkness1 , 1976 .

[21]  K. Wise.  The anatomy of the metacarpo-phalangeal joints, with observations of the aetiology of ulnar drift. , 1975, The Journal of bone and joint surgery. British volume.

[22]  F. Breedveld,et al.  Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis. , 1998, Arthritis and rheumatism.

[23]  F. Nørgaard.  EARLIEST ROENTGENOLOGICAL CHANGES IN POLYARTHRITIS OF THE RHEUMATOID TYPE: RHEUMATOID ARTHRITIS. , 1965, Radiology.

[24]  D. Brewerton.  A tangential radiographic projection for demonstrating involvement of metacarpal heads in rheumatoid arthritis. , 1967, The British journal of radiology.

[25]  E. Tindall,et al.  Treatment of rheumatoid arthritis with a recombinant human tumor necrosis factor receptor (p75)-Fc fusion protein. , 1997, The New England journal of medicine.

[26]  W. Buchanan,et al.  Observer differences in detecting erosions in radiographs of rheumatoid arthritis. A comparison of posteroanterior, Nørgaard and Brewerton views. , 1983, Journal of Rheumatology.

[27]  J A Swets,et al.  Measuring the accuracy of diagnostic systems. , 1988, Science.

[28]  P. Emery,et al.  The current status of ultrasonography in rheumatology. , 1999, Rheumatology.

[29]  E. Rummeny,et al.  Artificial bone erosions: detection with magnification radiography versus conventional high-resolution radiography. , 1994, Radiology.

[30]  J. T. Hayes,et al.  THE PATTERN OF BONE EROSION IN THE HAND AND WRIST IN RHEUMATOID ARTHRITIS. , 1965, Radiology.

[31]  M. Liang,et al.  The value of conventional views and radiographic magnification in evaluating early rheumatoid arthritis. , 1984, Arthritis and rheumatism.

[32]  O. Tervonen,et al.  Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography. , 1998, British journal of rheumatology.

[33]  M. Liang,et al.  The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. , 1988, Arthritis and rheumatism.