Cristina, Iannuccelli

Fulvia, Ceccarelli

Guido, Valesini

Iagnocco, Annamaria

Manuela Di Franco,

English

Institutional Research Information System University of Turin

DOI 10.1002/acr.20025Value of assessing the fifthmetatarsophalangeal joint in patients withearly rheumatoid arthritis: comment on thearticle by Sheane et alTo the Editors:We read with interest the article published in ArthritisCare & Research by Sheane et al on the value of exam-ining by ultrasonography (US) the fifth metatarsopha-langeal (MTP) joint for the early diagnosis of rheumatoidarthritis (RA) (1). We fully agree with Sheane et al on thevalue of examining this joint in patients suspected ofhaving RA. We were, however, surprised that our pre-viously published work was not included on their ref-erence list. Our work indicates that erosive disease wasmost commonly seen in the fifth MTP of all joints (2). USof the feet revealed erosive changes in 3 patients whohad negative US of their hands. One of these patientshad no evidence of erosive disease in any of the otherjoints of the hands or feet usually assessed by radiogra-phy. The table included in our previous publicationprovides the specific numbers.Graciela S. Alarco´n, MD, MPHRobert Lopez-Ben, MDUniversity of Alabama at Birmingham1. Sheane BJ, Beddy P, O’Connor M, Miller S, Cunnane G. Tar-geted ultrasound of the fifth metatarsophalangeal joint in anearly inflammatory arthritis cohort. Arthritis Rheum 2009;61:1004–8.2. Lopez-Ben R, Bernreuter WK, Moreland LW, Alarcon GS.Ultrasound detection of bone erosions in rheumatoid arthritis:a comparison to routine radiographs of the hands and feet.Skeletal Radiol 2004;33:80–4.DOI 10.1002/acr.20026Ultrasound of metatarsophalangeal jointsin an early inflammatory arthritis cohort:comment on the article by Sheane et alTo the Editors:We read with great interest the recent article publishedin Arthritis Care & Research by Sheane et al about the roleof ultrasonography (US) in the evaluation of the fifth meta-tarsophalangeal (MTP) joint in patients with early arthritis(EA) (1). In the assessment of patients with EA, it is veryimportant to distinguish between different forms of ar-thritides, such as rheumatoid arthritis (RA) and undiffer-entiated arthritis (UA), as early as possible after symptomdevelopment (2). Recently, US has been indicated as beingmore sensitive than clinical examination and conventionalradiography in the detection of joint erosive damage, and itis frequently applied in the assessment of patients affectedby EA (3). Sheane et al, who evaluated 30 patients with anew diagnosis of inflammatory arthritis, indicated that USexamination of the fifth MTP joint aids in the identifica-tion of early erosive disease and consequent diagnosis ofRA. Erosions, synovial hypertrophy, and power Doppler(PD) signal were evaluated, detecting the evidence of fifthMTP joint erosions in more than 50% of patients, whichwas significantly higher in those with a diagnosis of earlyRA compared with UA. Significant differences betweenradiographic- and US-detected erosions in the fifth MTPjoint were evident, with correlation between US-detectedsynovial hypertrophy and radiographic erosions. Wewould like to address the following comments.First, Sheane and colleagues seem to consider the pres-ence of synovial hypertrophy as indicative of synovitisand use those 2 terms as being synonymous. We wonder ifthis is correct, considering that Outcome Measures inRheumatology Clinical Trials (OMERACT) definitions re-fer to synovial hypertrophy and synovial fluid and do notmention the term “synovitis.” Second, we believe that theuse of warm water bath could influence the appearanceTable 1. US findings in 49 patients with early RA and UA*RA patients(n  25)UA patients(n  24)Totalpatients(n  49) PUS erosions fifth MTP joint 3 (12) 1 (4) 4 (8.1) NSUS synovial proliferation fifth MTP joint 3 (12) 2 (8.3) 5 (10.2) NSUS synovial effusion fifth MTP joint 6 (25) 3 (12.5) 9 (18.3) NSPD-positive fifth MTP joint 2 (8) 1 (4) 3 (6) NS* Values are the number (percentage) unless otherwise indicated. All comparisons of frequency betweenthe groups were made using Fisher’s exact test. All P values were 2-tailed, and the significance cutoff wasP  0.05. US  ultrasonography; RA  rheumatoid arthritis; UA  undifferentiated arthritis; MTP metatarsophalangeal; NS  not significant; PD  power Doppler.Arthritis Care & ResearchVol. 62, No. 1, January 15, 2010, pp 137–142© 2010, American College of RheumatologyLETTERS137of PD signal, due to vasodilatation correlated to increase oflocal temperature. The use of US gel and the avoidance ofprobe pressure over the area of interest are commonlyconsidered as reliable procedures for correct sonographicscanning of musculoskeletal structures and usually ensurea good image quality (4). Furthermore, after reading thisinteresting study by Sheane et al, we would like to reportour experience with 49 consecutive patients with EA whowere referred to the EA clinic of the rheumatology unit atSapienza University of Rome. In our cohort, we examinedMTP joints both by grey scale and PD US by using aPhilips/HP Image Point HX machine (Philips, Amsterdam,The Netherlands) equipped with a 14 MHz linear probeand PD (setting: frequency 7 MHz, pulse repetition fre-quency 700–1,000, gain 18–30 dB, low filter). US gel wasused. According to OMERACT definitions, we evaluatedsynovial fluid, synovial proliferation, PD, and erosions (5).All findings were scored by using a dichotomous assess-ment (0  absent, 1  present). US findings in MTP jointsof patients with EA, subgrouped according to a diagnosisof either RA or UA, are reported in Tables 1 and 2, whereUS modifications referred only to the fifth MTP joint andall MTP joints are described.In our cohort, US evaluation of the fifth MTP jointshowed a lower percentage of patients with bony erosionscompared with the study by Sheane et al (8.1% versus56.7%), confirming a higher prevalence in RA patientswith respect to UA (12% versus 4%). Moreover, we did notfind significant differences between the 2 groups of pa-tients concerning the presence of PD signal. The extensionof US evaluation to bilateral first to fifth MTP joints in all49 patients confirmed a similar prevalence of erosionsdetected by US (9.3% versus 8.1%). By a different point ofview, based on the analysis of MTP joint involvement, wedemonstrated significant differences between RA and UAconcerning the percentage of joints with erosions, synovialeffusion, and proliferation (P  0.008, P  0.001, and P 0.002, respectively).In conclusion, according to our experience, we agreewith Sheane and colleagues on the relevant role of US ofthe fifth MTP joint in the assessment of patients with EA.Considering, however, that all MTP joints were more fre-quently and earlier involved in RA than in UA, we proposethe extension of US evaluation to all of the MTP joints andnot only to the fifth. In our opinion, this procedure wouldnot significantly increase the time duration of a single USexamination session and would improve the entity of in-formation obtained, thereby helping to differentiate be-tween early RA and UA. Further studies on larger cohortsand longitudinal research studies are needed to confirmthese results.Fulvia Ceccarelli, MDAnnamaria Iagnocco, MDManuela Di Franco, MDCristina Iannuccelli, MDGuido Valesini, MDSapienza University of RomeRome, Italy1. Sheane BJ, Beddy P, O’Connor M, Miller S, Cunnane G. Tar-geted ultrasound of the fifth metatarsophalangeal joint in anearly inflammatory arthritis cohort. Arthritis Rheum 2009;61:1004–8.2. Visser H, le Cessie S, Vos K, Breedveld FC, Hazes JM. How todiagnose rheumatoid arthritis early: a prediction model forpersistent (erosive) arthritis. Arthritis Rheum 2002;46:357–65.3. Szkudlarek M, Narvestad E, Klarlund M, Court-Payen M,Thomsen HS, Ostergaard M. Ultrasonography of the metatar-sophalangeal joints in rheumatoid arthritis: comparison withmagnetic resonance imaging, conventional radiography, andclinical examination. Arthritis Rheum 2004;50:2103–12.4. Iagnocco A, Epis O, Delle Sedie A, Meenagh G, Filippucci E,Riente L, et al. Ultrasound imaging for the rheumatologist.XVII. Role of colour Doppler and power Doppler. Clin ExpRheumatol 2008;26:759–62.5. Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, BackhausM, D’Agostino MA, et al. OMERACT 7 Special Interest Group:musculoskeletal ultrasound including definitions for ultra-sonographic pathology. J Rheumatol 2005;32:2485–7.DOI 10.1002/acr.20027ReplyTo the Editors:We thank Drs. Alarco´n, Lopez-Ben, and Ceccarelli et alfor their interest in our work, and we welcome both theircomments and research findings in relation to the use ofUS in the setting of early inflammatory arthritis.Ceccarelli et al note the possible contrast in definitionbetween the terms “synovitis” and “synovial hypertro-phy.” Histologically, both names relate to a pathologicprocess within the joint, resulting from current or pre-vious inflammatory change within the synovium. Weused the word synovitis according to the US descriptionoutlined by Szkudlarek et al, who defined it as “a non-Table 2. US findings in 490 joints (first to fifth MTP) in patients with early RA and UA*RA MTP joints(n  250)UA MTP joints(n  240)Total joints(n  490) PUS erosions MTP joints 32 (12.8) 14 (5.8) 46 (9.3) 0.008US synovial proliferation MTP joints 53 (21.2) 11 (4.6) 64 (13.1)  0.001US synovial effusion MTP joints 66 (26.4) 36 (15) 102 (20.1) 0.002PD-positive MTP joints 10 (4) 8 (3.3) 18 (3.7) NS* Values are the number (percentage) unless otherwise indicated. All comparisons of frequency between thegroups were made using Fisher’s exact test. All P values were 2-tailed, and the significance cutoff was P  0.05.US  ultrasonography; MTP metatarsophalangeal; RA  rheumatoid arthritis; UA  undifferentiated arthritis;PD  power Doppler; NS  not significant.138 Letters

Ultrasound of metatarsophalangeal joints in an early inflammatory arthritis cohort: Comment on the article by Sheane et al

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Ultrasound of metatarsophalangeal joints in an early inflammatory arthritis cohort: Comment on the article by Sheane et al

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