Heidi J. Siddle

Magnetic Resonance Arthrography of Lesser Metatarsophalangeal Joints in Patients with Rheumatoid Arthritis: Relationship to Clinical, Biomechanical, and Radiographic Variables

Objective. Our exploratory study of painful lesser metatarsophalangeal (MTP) joints in patients with rheumatoid arthritis (RA) primarily aimed to compare the clinical, biomechanical, and plain radiography findings with magnetic resonance (MR) arthrography findings. Our secondary aim was to compare standard unenhanced MR with MR arthrography in imaging the lesser MTP joints in RA. Methods. In 15 patients with RA, the more symptomatic forefoot was imaged using 3T MR imaging. Proton density fat-suppressed images were acquired through the lesser MTP joints prior to arthrography. Under ultrasound guidance, contrast agent was injected into 2 lesser MTP joints. T1-weighted fat-suppressed sequences were subsequently acquired. The MR images were read by 2 musculoskeletal radiologists and consensus was reached. Spearman’s correlation coefficient was used to assess the association between abnormalities seen on MR arthrography and the clinical, biomechanical, and plain radiography findings. Results. MR arthrography demonstrated pathology at 18 of 28 lesser MTP joints (64%) examined in patients with RA. MR arthrography abnormalities were associated with RA disease duration, forefoot deformity, Larsen score, subluxation, and peak plantar pressure. Unenhanced MR had a sensitivity of 78% and specificity of 90% for detecting pathology compared to MR arthrography. Conclusion. Capsule and plantar plate pathology occurs in the painful forefoot of patients with RA and is associated with features of disease and deformity at the lesser MTP joints. Compared with MR arthrography, standard MR imaging was highly specific and moderately sensitive for diagnosing lesser MTP joint pathology in patients with RA.

Foot health needs in people with systemic sclerosis: an audit of foot health care provision.

The vascular and cutaneous alterations evident in systemic sclerosis/scleroderma (SSc) place the foot at risk of ulceration. The UK Podiatry Rheumatic Care Association (PRCA)/Arthritis and Musculoskeletal Alliance standards of care recommend that all people with SSc should receive at least basic information about their foot health, and that those with foot problems should have access to self-management advice and care where needed. The aim of this study was to evaluate foot health services offered in Leeds (UK) for people with SSc, against nationally agreed standards of care. Ninety-one consecutive patients with SSc were selected from either the connective tissue disease outpatient clinic (n = 70) or the specialist rheumatology foot health clinic (n = 21) at Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust. All the patients completed a disease-specific audit tool developed by the UK PRCA that evaluates provision of foot health care for patients with SSc. Sixty-one patients (67%) reported having had foot problems at some point in time and 54 (59%) had current foot problems. Of these 54 patients, 17 (32%) had not received any foot care. Only 36 (39%) of the 91 patients had received any foot health information. This audit demonstrates that patients with SSc have a relatively high prevalence of self-reported foot problems. Foot health care and information are inadequate for people with SSc and foot problems, and preventative information is almost non-existent. Improved foot health information will better empower patients to self-manage low risk problems, and help identify high risk problems which require specialist care.

Anatomical location of erosions at the metatarsophalangeal joints in patients with rheumatoid arthritis

Objective. The aim of this study was to identify the anatomical location of erosions at the MTP joints in patients with RA using high-resolution 3T MRI. Methods. In 24 patients with RA, the more symptomatic forefoot was imaged using 3T MRI. T1-weighted, intermediate-weighted and T2-weighted fat-suppressed sequences were acquired through the MTP joints, together with three-dimensional volumetric interpolated breath-hold examination (3D VIBE) and T1-weighted fat-suppressed post-gadolinium contrast sequences. Images were scored for bone erosion in the distal and proximal part of the MTP joints using the RA MRI scoring (RAMRIS) system. The base of the proximal phalanx and the head of the metatarsal were divided into quadrants to determine the location of erosions (octants) in the dorsal-medial, dorsal-lateral, plantar-medial and plantar-lateral regions. Results. Seventeen females and seven males with a mean age of 55.5 years and disease duration of 10.6 years (range 0.6–36) were included. Eighteen patients were RF positive, the mean 44-joint DAS for CRP and ESR (DAS44CRP and DAS44ESR) were 2.5 (s.d. 0.8) and 2.6 (s.d. 0.9), respectively. In this cohort of patients with RA, irrespective of MTP joint location, octants located in the proximal part (metatarsal) of the joint and the plantar aspect of the joint were more eroded. Conclusion. This is the first study to report the anatomical location of erosions at the MTP joints in patients with RA. We noted that erosions were more commonly seen on the plantar aspect of the metatarsal head in RA, supporting the hypothesis of a relationship between biomechanical demands and bone changes in the forefoot.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology

Background In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines. Objectives To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology. Methods The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures). Results Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts. Conclusions This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Pressure and pain in Systemic sclerosis/Scleroderma - An evaluation of a simple intervention (PISCES): Randomised controlled trial protocol

BackgroundFoot problems associated with Systemic Sclerosis (SSc)/Scleroderma have been reported to be both common and disabling. There are only limited data describing specifically, the mechanical changes occurring in the foot in SSc. A pilot project conducted in preparation for this trial confirmed the previous reports of foot related impairment and reduced foot function in people with SSc and demonstrated a link to mechanical etiologies. To-date there have been no formal studies of interventions directed at the foot problems experienced by people with Systemic Sclerosis. The primary aim of this trial is to evaluate whether foot pain and foot-related health status in people with Systemic Sclerosis can be improved through the provision of a simple pressure-relieving insole.MethodsThe proposed trial is a pragmatic, multicenter, randomised controlled clinical trial following a completed pilot study. In four participating centres, 140 consenting patients with SSc and plantar foot pain will be randomised to receive either a commercially available pressure relieving and thermally insulating insole, or a sham insole with no cushioning or thermal properties. The primary end point is a reduction in pain measured using the Foot Function Index Pain subscale, 12 weeks after the start of intervention. Participants will complete the primary outcome measure (Foot Function Index pain sub-scale) prior to randomisation and at 12 weeks post randomisation. Secondary outcomes include participant reported pain and disability as derived from the Manchester Foot Pain and Disability Questionnaire and plantar pressures with and without the insoles in situ.DiscussionThis trial protocol proposes a rigorous and potentially significant evaluation of a simple and readily provided therapeutic approach which, if effective, could be of a great benefit for this group of patients.Trial registration numberISRCTN: ISRCTN02824122

Exploratory study to identify mechanical factors that may contribute to toe dactylitis in patients with psoriatic arthritis

Background Dactylitis (sausage digit) is one of the most commonly reported features of psoriatic arthritis (PsA), the second most common inflammatory arthritis after rheumatoid arthritis (RA). It has been hypothesised that dactylitis is a functional enthesitis at the proximal interphalangeal joints (hands and feet), causing multiple pathologies to varying levels of severity. Dactylitis results in synovitis, tenosynovitis, bone and soft tissue oedema to the digit, described as tender and non-tender dactylitis. Trauma and physical insult to the digit have been suggested as a possible cause. The aim of this study was to explore the mechanical factors that may contribute to toe dactylitis in patients with PsA.

Joint Orthopaedic and Rheumatology Clinics: Evidence to Support the Guidelines

Joint Orthopaedic and Rheumatology Clinics: Evidence to Support the Guidelines Heidi J. Siddle* Bsc (Hons), MSc, Michael R. Backhouse BSc (Hons), PGCert, Ray Monkhouse MB ChB, FRCS (Tr. & Orth), FRCS (Ed), Nick J. Harris FRCS (Tr. & Orth) & Philip S. Helliwell MA, FRCP, PhD Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK Foot Health Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, UK

MRI and high-resolution ultrasound of plantar plate pathology in the painful forefoot of patients with Rheumatoid Arthritis

Forefoot pain in Rheumatoid Arthritis (RA) is associated with functional and structural changes at the MTP joints. Previous cadaveric studies have suggested that forefoot deformities in RA might result from the failure of a complex ligamentous system and displacement of the plantar plates (PP). MRI and high resolution ultrasound (HRUS) have been reported to identify the PP and visualise tears in otherwise healthy subjects.

The EULAR points to consider for health professionals undertaking musculoskeletal ultrasound for rheumatic and musculoskeletal diseases

Musculoskeletal ultrasound has evolved into an important clinical decision-making tool by assisting in the diagnosis of inflammatory arthritis, monitoring disease activity and therapeutic response, and guiding interventions.1–7 The role of the non-medical health professional has advanced, with many undertaking training and using musculoskeletal ultrasound to improve patient care and in doing so, increasing their scope of practice. Health professionals with clinical expertise and experience using ultrasound are also providing training for colleagues and medical clinicians. As previously described among rheumatologists,8 ,9 the use of musculoskeletal ultrasound and training undertaken varies significantly between different professional groups and across Europe. Guidelines to support training for rheumatologists have been formulated10 but currently there are no recommendations to support the education and training needs of non-medical health professionals using musculoskeletal ultrasound. A European League Against Rheumatism (EULAR) task force was established to reach a consensus on the role of, and education and training needs of health professionals undertaking musculoskeletal ultrasound for the management of people with …

The OMERACT Ultrasound Group: A Report from the OMERACT 2016 Meeting and Perspectives

Objective. To provide an update from the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group on the progress for defining ultrasound (US) minimal disease activity threshold at joint level in rheumatoid arthritis (RA) and for standardization of US application in juvenile idiopathic arthritis (JIA). Methods. For minimal disease activity, healthy controls (HC) and patients with early arthritis (EA) who were naive to disease-modifying antirheumatic drugs were recruited from 2 centers. US was performed of the hands and feet, and scored semiquantitatively (0–3) for synovial hypertrophy (SH) and power Doppler (PD). Synovial effusion (SE) was scored a binary variable. For JIA, a Delphi approach and subsequent validation in static images and patient-based exercises were used to developed preliminary definitions for synovitis and a scoring system. Results. For minimal disease activity, 7% HC had at least 1 joint abnormality versus 30% in the EA group. In HC, the findings of SH and PD were predominantly grade 1 whereas all grades were seen in the EA cohort, but SE was rare. In JIA, synovitis can be diagnosed based on B-mode findings alone because of the presence of physiological vascularization. A semiquantitative scoring system (0–3) for synovitis for both B-mode and Doppler were developed in which the cutoff between Doppler grade 2 and grade 3 was 30%. Conclusion. The first step has been taken to define the threshold for minimal disease activity in RA by US and to define and develop a scoring system for synovitis in JIA. Further steps are planned for the continuous validation of US in these areas.