| Rheumatoid arthritis(RA)is a disabling inflammatory disease associated with synovitis.Synovitis causes swelling of the joints,limited movement,bone and cartilage destruction,and eventually deformity of the joints,which reduces the quality of life for patients and increases the financial burden.Treatment of RA is a long-term process.Although it cannot be cured,the prognosis of RA patients has been significantly improved by the application of biological and targeted disease-modifying antirheumatic drugs(DMARDs).However,there is still a subset of patients who do not achieve clinical remission or low disease activity,or even progression,and may eventually be classified as difficult-to-treat rheumatoid arthritis.The progression of RA depends on a variety of factors,with poor prognosis factors predicting faster progression.Therefore,early diagnosis,accurate assessment of disease activity,and identification of factors contributing to poor prognosis are critical in the diagnosis and treatment of RA,and a key basis for treatment decisions.Musculoskeletal ultrasound(MSUS),as a convenient,noninvasive,radiation-free and efficient imaging technique,is an extension of physical examination.MSUS is more sensitive and specific than physical examination in detecting soft tissue lesion.It can explore skin,nails,fat,fascia,tendons,ligaments,enthesis,bursa,cartilage,bone,and detect the anatomical locations and severity of lesions.Until now,MSUS has been widely used in the field of rheumatology,particularly in RA.The prognosis is poor for RA patients with large joint involvement in the lower limbs,but clinicians and patients tend to focus more on the upper limbs,especially the hands.We collected detailed and comprehensive patient data and used different research methods.First,starting from the foot,ankle and knee of the lower limb,we summarized the ultrasound features of different affected joints of RA and observed the clinical features of RA patients with foot-ankle lesion as the main manifestation.We analyzed the correlation between the ultrasound score of the foot-ankle lesion and RA disease activity.We then explored the value of ultrasound in early cartilage lesions in RA knee and analyzed the correlation between cartilage thickness and clinical features.Finally,hand-wrist ultrasound was used as a pointcut to discuss the impact of baseline ultrasound on RA treatment options and prognosis.The aim of our study is to elaborate on the multidimensional value of MSUS in the evaluation of RA joint lesions,treatment selection,and assessment of prognosis,and to help clinicians to pay more attention to lower limb joint lesions in RA patients.At the same time,it provides a reference for personalized treatment of RA in the future.Part One Correlation between ultrasonic features and disease activity in rheumatoid arthritis foot-ankle lesionsObjective: To summarize the ultrasonic features of foot-ankle lesions in RA patients and to discuss the correlation between foot-ankle lesions and RA disease activity.Methods:1.124 RA patients were included with at least one swollen foot-ankle site.2.The following information was recorded: gender,age,the duration of RA,the duration of foot-ankle swollen,28 joint swollen joint count(SJC28),28 joint tender joint count(TJC28),pain visual analog scale(VAS),health assessment questionnaire(HAQ),the disease activity score 28 joint based on erythrocyte sedimentation rate(DAS28-ESR),the disease activity score 28 joint based on C reaction protein(DAS28-CRP)and treatments.3.Levels of ESR,CRP,rheumatoid factor(RF),anti-cyclic citrullinated peptide(anti-CCP)antibody and anti-keratin antibody(AKA)were recorded.4.The patients’ feet and ankles were examined by ultrasound and semi-quantitatively graded for synovial hyperplasia,synovitis,tenosynovitis and bone erosion.Spearman correlation coefficient test was used to analyze the correlation between ultrasonic indicators and clinical features.Results:1.Lesions may occur throughout the foot in RA patients,with the most common site of involvement being the forefoot,followed by the hindfoot and midfoot.2.The highest to lowest rates of forefoot lesions were synovitis,tenosynovitis,synovitis combined with tenosynovitis,synovitis combined with bursitis,and bursitis.All the lesions in the midfoot were synovitis.Among the hindfoot lesions,the highest to lowest rates were tenosynovitis,synovitis combined with tenosynovitis,synovitis,effusion,and tenosynovitis combined with bursitis.3.Synovitis and bone erosion of the forefoot were common in the fifth metatarsophalangeal joint(MTP).The tenosynovitis of the hindfoot was common in the tibialis posterior.4.RA patients were divided into single-site and multi-site involvement groups based on lesion site.The duration of RA was shorter in the multi-site involvement group.SJC28,TJC28,VAS,CRP,DAS28-CRP,DAS28-ESR,synovial hyperplasia,synovitis,tenosynovitis scores and total ultrasound scores were higher in the multi-site involvement group than in the single-site involvement group(P<0.05).5.Based on the pattern of onset of foot-ankle lesion,RA patients were divided into an initial foot-ankle lesion group,a hand-foot synchronous lesion group,and a delayed foot-ankle lesion group.The SJC28,TJC28,VAS,HAQ,ESR,CRP,DAS28-CRP,DAS28-ESR,synovial hyperplasia,synovitis and tenosynovitis were higher in the hand-foot synchronous lesion group than in the initial foot-ankle lesion group(P<0.05).SJC28,TJC28,DAS28-CRP,DAS28-ESR,synovial hyperplasia,synovitis were higher in the hand-foot synchronous lesion group than in the delayed foot-ankle lesion group(P<0.05).6.The synovial hyperplasia score and the synovitis score of the whole foot in RA patients were both positively correlated with VAS(P<0.05),and the tenosynovitis score was positively correlated with SJC28,TJC28,DAS28-CRP,DAS28-ESR and CRP(P<0.05).The bone erosion score was positively correlated with RA duration and the duration of foot-ankle lesion(P<0.05).Summary:1.There are various forms of foot-ankle lesions in RA patients,including effusion,synovitis,tenosynovitis and bursitis,which occur in one or more forms.The most common lesions in the hindfoot is tibialis posterior tenosynovitis and MTP5 synovitis in the forefoot.2.Patients with multi-site involvement of foot-ankle and hand-foot synchronous lesion had higher disease activity,clinical symptoms and ultrasound inflammation.The longer the duration of foot-ankle lesion,the greater the risk of bone erosion.Part Two Correlation between knee femur condylar cartilage thickness and clinical features of rheumatoid arthritisObjective: To summarize the ultrasonic features of knee lesion in RA patients and explore the relationship between the thickness of femoral condylar cartilage(FCC)and clinical features of RA.Methods:1.70 RA patients,50 knee osteoarthritis(KOA)patients and 30 healthy controls(HC)were included.2.Gender,age,height,weight,past history,and body mass index(BMI)of the participants were recorded.The duration,SJC28,TJC28,VAS and DAS28-CRP were recorded for the RA group.3.Levels of ESR,CRP,RF and anti-CCP antibody were recorded.4.Both knees were examined by ultrasound.The lesions and cartilage morphology of the knee were observed and the lateral,intercondylar and medial FCC thicknesses were measured.The correlation between FCC thickness and clinical features was analyzed by Pearson correlation coefficient test.Results:1.The lateral,intercondylar and medial thickness of FCC were lower in RA group than HC group(P<0.01),there was no statistical significance in FCC thickness between RA and KOA group(P>0.05).2.FCC in the RA group showed no abnormalities 53.6%,blurred cartilage boundary 25%,uneven cartilage 16.4%,and partial/complete cartilage loss 5%.3.Ultrasonic lesions in the knee were more diverse in the RA group than in the KOA group.The incidence of cartilage lesion,effusion and osteophytes in RA group were lower than KOA group(P<0.05).There was no significant difference in the incidence of synovial hyperplasia and baker’s cyst between the two groups(P>0.05).In addition,the RA group observed doppler signals in synovial membrane,bone erosion,free body,enthesitis and peritendinitis.4.Patients with RA were divided into knee swollen/tender group and knee without swollen/tender group.The age,BMI,ESR,CRP,anti-CCP antibody and DAS28-CRP were higher in RA knee swollen/tender group than RA knee without swollen/tender group(P<0.05).There was no statistically significant difference in FCC thickness between the two groups(P>0.05).5.Taking 50 years old as the cut-off point,RA patients were divided into≤50 years old group and >50 years old group.FCC lateral thickness in RA group(≤50 years old)was thinner than HC group(≤50 years old)(P<0.05).6.According to RA duration,RA patients were divided into ≤2 years group,2-5 years group,and ≥ 5 years group.FCC lateral thickness was thinner in RA≥5 years group than RA≤2 years group(P<0.05).7.FCC lateral thickness was negatively correlation with RA duration(P<0.05),and had no correlation with DAS28-CRP(P>0.05).Summary:1.Multiple ultrasound presentations of RA knee lesions may be helpful in the differential diagnosis of RA and KOA.2.FCC injury may occur in RA patients regardless of whether they have clinical symptoms in the knee.RA patients younger than 50 years of age had a thinning of the FCC lateral thickness.The FCC lateral thickness was thinner in RA patients with more than 5 years of duration.Part Three Prognostic value of baseline ultrasound of hand-wrist in rheumatoid arthritisObjective: To summarize the ultrasound manifestations of the hand-wrist joint in RA patients and the baseline characteristics of ultrasound alleviation and progression,and discuss the impact of baseline ultrasound on RA prognosis.Methods:1.138 RA patients were included and ultrasound of the hand-wrist was performed twice at least 3 months apart.2.The following information was recorded: gender,age,RA duration,SJC28,TJC28,VAS,DAS28-ESR,frequency of ultrasound examination and treatments.3.Levels of ESR,CRP,RF,anti-CCP antibody and AKA were recorded.4.The hand and wrist joints of the patients were examined by ultrasound and semi-quantitatively graded for synovial hyperplasia,synovitis,tenosynovitis and bone erosion.The results of the first ultrasound of the hand-wrist were taken as a baseline.The subsequent power doppler ultrasound(PDUS)changes that showed alleviation or progression(compared with baseline)were regarded as the cut-off point.RA patients at the cut-off were divided into an alleviation group and a progression group.A logistic regression model was used to evaluate factors associated with RA progression.Results:1.The baseline ultrasound findings were as follows: no abnormalities14.5%,synovitis with/without bone erosion 29.6%,tenosynovitis with/without bone erosion 11.9% and synovitis combine with tenosynovitis with/without bone erosion 58.5%.2.At the cut-off,the patients were divided into the alleviation group and the progression group(55.1% vs.44.9%).In the progressive group,synovitis with/without bone erosion increased 22.5%,tenosynovitis with/without bone erosion increased 7.9%,and synovitis combine with tenosynovitis with/without bone erosion increased 14.5%.3.At baseline,the incidence of synovitis and tenosynovitis was higher in the alleviation group.The CRP,synovial hyperplasia,synovitis,tenosynovitis and total ultrasound scores were higher in the alleviation group than in the progression group,and there were statistically significant differences in the treatment plan between the two groups(P<0.05).At the cut-off,ESR,CRP,synovial hyperplasia,synovitis,tenosynovitis and total ultrasound scores were lower in the alleviation group than in the progression group.There was a statistically significant difference in the frequency of ultrasound examination between the two groups(P<0.05).4.According to the count of affected joint of the hand-wrist at baseline,RA patients were divided into pauciarticular group(1-4 joints)and polyarticular group(≥5 joints).There were statistically significant differences in ESR,CRP,DAS28-ESR,synovial hyperplasia,synovitis,tenosynovitis,bone erosion score,total ultrasonic scores,initial therapy schedule,and outcomes between the pauciarticular group and the polyarticular group(P<0.05).5.Patients with foot-ankle lesions at baseline were compared between the alleviation group and the progression group.At baseline,the synovitis,tenosynovitis and total ultrasound scores were higher in the alleviation group than in the progression group(P<0.05).There was a statistically significant difference in the treatment between the two groups(P<0.05).At the cut-off,57.1% of patients achieved ultrasound relief,42.9% progressed.6.The risk of progression was lower in RA patients with synovitis or a high synovial hyperplasia score at baseline compared with RA patients without synovitis or a low synovial hyperplasia score(P<0.01).Summary:1.The initial manifestation of RA in hand-wrist joint ultrasound may be synovitis or tenosynovitis.2.RA patients with more severe baseline ultrasound inflammation or more involved joints may achieve a higher proportion of relief after active treatment.RA patients with milder baseline ultrasound inflammation or less involved joints are easily overlooked.3.Baseline ultrasound(presence of synovitis,higher synovial hyperplasia score)may affect RA treatment strategies,aggressive treatment can help reduce the risk of RA progression.Conclusions:1.Ultrasound manifestations of RA are manifold.The first presentation may be synovitis,tenosynovitis or bursitis.The foot-ankle can be used as a supplement to the hand-wrist.2.RA patients with multi-site involvement may have higher disease activity,more severe clinical symptoms and ultrasound inflammation.The longer the duration of foot-ankle lesion,the greater the risk of bone erosion.RA patients may have an early onset of knee cartilage lesions,which are more common on the lateral side.The longer the duration of RA,the more severe the lesion may be.3.RA patients with milder ultrasound inflammation or less involved joints at baseline are easily overlooked.RA patients with more severe ultrasound inflammation or more involved joints at baseline do not indicate a poor prognosis,aggressive treatment and regular ultrasound evaluations may slow the risk of RA progression. |
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