A systematic review of ultrasonography in osteoarthritis

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A systematic review of ultrasonography in
osteoarthritis
H I Keen,1 R J Wakefield,2 P G Conaghan2
c Additional supplementary fig
ABSTRACT
Doppler signal in osteoarthritis. In the first review,
1 is published online only at
Background: Ultrasonography has been increasingly
10 of the 54 manuscripts reviewed utilised ultra-
http://ard.bmj.com/content/
utilised to aid the understanding and management of
sonography to assess synovitis in osteoarthritis.2
vol68/issue5
rheumatic conditions. In recent years there has been a
Six of the 53 manuscripts reviewed in the second
1 School of Medicine and
focus on the validity and utility of ultrasonography in
review article utilised Doppler signal in osteoar-
Pharmacology, University of
demonstrating joint pathology, although this has largely
thritis.1
Western Australia, Perth,
Australia; 2 Section of
focused on inflammatory arthritis.
There are no published systematic reviews
Musculoskeletal Disease, Leeds
Aims: To undertake a systematic review of the published
focusing on the application of ultrasonography to
Institute of Molecular Medicine,
literature evaluating ultrasonography as an assessment
osteoarthritis. We wanted to examine the pub-
University of Leeds, Leeds, UK
tool in osteoarthritis.
lished literature to assess the role of ultrasonogra-
Correspondence to:
Methods: Medline and Pubmed were searched to
phy
in
assessing
structural
pathology
in
Dr H I Keen, School of Medicine
identify original manuscripts, published before June 2008,
osteoarthritis, and to examine the validity of
and Pharmacology, Royal Perth
utilising ultrasonography to assess the joints of cohorts of
ultrasonography as an assessment tool in osteoar-
Hospital, Level 3, MRF Building,
thritis, with particular respect to the performance
Rear 50 Murray Street, Perth,
subjects with osteoarthritis. Data were extracted from
WA 6000, Western Australia;
manuscripts meeting the inclusion criteria, with a
metrics of these tools. To do this, a systematic
helen.keen@uwa.edu.au
particular focus on the pathology imaged, the definitions
review was undertaken. The function of this
used, scoring systems and their metric properties.
review is to update the literature reviews by
Accepted 23 January 2009
Results: Forty-seven studies were identified that utilised
Joshua and colleagues,1 2 with a focus on osteoar-
ultrasonography to assess structural pathology in
thritis, and to broaden the search to include
osteoarthritis. Doppler function was only assessed in 10
ultrasonography-detectable pathologies other than
studies and contrast agents in one. There was hetero-
synovitis and Doppler signal, including tendon and
geneity with regard to the pathology examined, the
ligament disorders, cartilage pathology and cortical
definition of pathology, quantification and the reporting of
pathology including osteophytosis. In addition,
these factors. There was also a lack of construct and
definitions of pathologies and scoring systems
criterion validity and data demonstrating reliability and
utilised in osteoarthritis were examined.
sensitivity to change.
Conclusions: Whereas there is increasing evidence of
METHODS
the validity of ultrasonography in detecting structural
Pubmed was searched for articles first published
pathology in inflammatory arthritis, more work is required
between 1955 and June 2008. The search was
to develop standardised definitions of pathology and
limited to humans and English language. The
to demonstrate the validity of ultrasonography in
search terms were ‘‘[ultrasound or sonography]
osteoarthritis.
and osteoarthritis’’. The titles and abstracts of the
244 manuscripts identified were reviewed. Medline
was searched using [MESH subject heading ‘‘ultra-
Osteoarthritis has traditionally been imaged with
sonography’’ or the keyword ‘‘ultrasonography’’]
conventional radiographs. However, in recent
and [MESH headings ‘‘osteoarthritis’’ or ‘‘osteoar-
years, novel imaging techniques such as ultrasono-
thritis, knee’’ or ‘‘osteoarthritis, hip’’ or the key-
graphy have been utilised to obtain a better
word ‘‘osteoarthritis’’]. The search was limited to
understand of this disease. Although the applica-
humans and English language. A total of 148
tion of ultrasonography to inflammatory diseases
articles was identified. Of the articles identified,
has been common and widespread, it has been
147 were duplicates, therefore the titles and
applied to osteoarthritis less frequently.
abstracts of 245 articles were assessed with regard
Two recent systematic reviews by Joshua and
to inclusion and exclusion criteria. Articles were
colleagues1 2 examined the validity of ultrasono-
excluded if they were not original articles pertain-
graphy as an outcome measure according to the
ing to the use of B-mode ultrasonography in the
principles of truth and discrimination; components
assessment of a joint in a cohort of subjects with a
of the OMERACT filter. The first addressed the
diagnosis of osteoarthritis at baseline. Review
validity and reproducibility of ultrasonography in
articles (n = 48), case reports (n = 15), letters
assessing synovitis only;2 the second, power
(n = 1), position statements (n = 1), recommen-
Doppler in musculoskeletal disease.1 These reviews
dations (n = 2), practice audits (n = 1), pictorial
demonstrated that most of the work validating
reviews (n = 1), studies ex vivo (n = 7) and
ultrasonography has been undertaken in inflam-
second reports (n = 2) were excluded. In addition,
matory diseases, such as rheumatoid arthritis, and
articles that utilised ultrasonography only for
has largely studied the hand, knee or ankle joints. A
guiding injections and did not report any validity
minority of work examined in these systematic
data or findings of the ultrasonography examina-
reviews pertained to either synovitis or power
tion were excluded (n = 6). Manuscripts utilising
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ultrasonography to measure only rotational angles were also
Data were extracted and inserted into a spreadsheet developed
excluded (n = 3). Of the remaining articles, 58 did not assess a
for this review based on similar published reviews.1 2
cohort with a diagnosis of osteoarthritis at baseline, 46 did not
This covered descriptive aspects of trial methodology, a
utilise B-mode ultrasonography and 16 did not examine a joint
description of the ultrasonography-detected findings in osteoar-
structure. An additional nine publications were identified by
thritis cohorts, issues relating to the validity of ultrasonography
experts in the field and searching the bibliographies of recent
in assessing osteoarthritis, the relationship between ultrasono-
review articles. Therefore 47 manuscripts were included in this
graphy findings and symptoms of osteoarthritis and the clinical
review (see supplemental fig 1 available online only and table 1).
utility of ultrasonography in osteoarthritis.
Table 1
Description of the studies identified utilising ultrasonography to assess joints in a cohort with
osteoarthritis
Definition of
osteoarthritis
Comparator
First author
No with
cohort
group
Joint region
(reference no)
Year
osteoarthritis
described
examined
imaged
Doppler
Fam3
1982
50
U
Y
Knee
N
Aisen4
1984
7
N
Y
Knee
N
Baratelli5
1986
16
N
Y
Hip
N
McCune6
1990
9
N
Y
Knee
N
Iagnooco7
1992
60
U
Y
Knee
N
Jonsson8
1992
6
N
Y
Knee, hip
N
Martino9
1993
18
N
Y
Knee
N
Lennox10
1994
25
N
Y
Knee
N
Ostergaard11
1995
2
N
Y
Knee
N
Arslan12
1999
10
N
Y
SI joint
P
Monteforte13
1999
126
Y
Y
Knee
N
Baratto14
2000
10
N
N
C spine
N
Iagnocco15
2000
57
Y
Y
Hand
N
Schmidt16
2000
10
Y
Y
Knee
C
Giovagnorio17
2001
2
Y
Y
Knee
P
Qvistgaard18
2001
41
Y
N
Knee, hip
N
Reardon19
2001
12
N
Y
Hip
N
Walther20
2001
13
N
Y
Knee
P
Falsetti21
2002
100
N
Y
Shoulder
N
Walther22
2002
24
U
Y
Hip
P
Falsetti23
2003
265
U
Y
Foot
N
Filippucci24
2003
2
N
Y
Hand, knee, foot
N
Monteforte25
2003
14
N
N
C spine
N
Tarhan26
2003
58
Y
Y
Knee
N
Karim27
2004
19
N
Y
Knee
N
D’Agostino28
2005
600
Y
N
Knee
N
Iagnocco29
2005
110
U
N
Hand
N
Naredo30
2005
90
Y
Y
Knee
N
Pourbagher31
2005
10
N
N
Hip
N
Yoon32
2005
26
N
N
Knee
P
Acebes33
2006
30
N
N
Knee
N
de Miguel Mendieta34
2006
101
Y
N
Knee
N
Jan35
2006
36
Y
N
Knee
N
Jung36
2006
51
Y
N
Knee
N
Kristoffersen37
2006
71
Y
Y
Knee
C
Mandl38
2006
32
Y
Y
Hand
N
Qvistgaard39
2006
100
Y
N
Hip
N
Su40
2006
18
N
N
Hip
N
Tarasevicius41
2006
33
N
N
Hip
N
Altinel42
2007
61
U
N
Knee
N
Atchia43
2007
10
N
N
Hip
N
Lee44
2007
42
N
Y
Knee
N
Robinson45
2007
120
U
N
Hip
B
Keen46
2008
37
Y
N
Hand
N
Keen47
2008
7
N
N
Hand
P
Kim48
2008
30
Y
N
Knee
N
Song49
2008
41
Y
Y
Knee
P
Including study details, the joint region scanned and whether information regarding the image acquisition, definition of pathology
and scoring system were described. B, both colour and power Doppler; C, colour Doppler; C spine, cervical spine; E, described
elsewhere; N, no; P, power Doppler; SI, sacroiliac; U, unclear; Y, yes.
612
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The performance metrics were evaluated using criterion and
sternoclavicular joint. The definition of osteoarthritis was not
construct validity, reliability and responsiveness to change.
consistent and was not specified in approximately half the
Criterion (or direct) validity is determined by comparing the
papers. American College of Rheumatology criteria were often
technique with a gold standard.50 For the purpose of this review,
used to identify clinical disease. Radiographic criteria were also
this was considered a comparison against either direct macro-
commonly used, using different Kellgren Lawrence or Altman
scopic or microscopic visualisation of the pathology, for
grades to define the cohort. Other studies used diagnostic
example by arthroscopy, examination during surgery, or
criteria specific to their study, such as a combination of clinical
histopathological examination. Construct (or indirect) validity
symptoms, signs, the American College of Rheumatology
is determined by comparing the technique against other
criteria and radiographic criteria. Some manuscripts used terms
modalities known to measure the same pathology; for example,
such as ‘‘clinical diagnosis’’ or ‘‘typical changes’’ without
comparing ultrasonography-detected synovitis against magnetic
further clarification. It was also common for no definition to
resonance imaging (MRI) or computed tomography (CT)-
be provided.
detected synovitis.50 Comparison against MRI, scintigraphy,
conventional radiography, clinical examination, laboratory tests
Technical aspects of ultrasonography machines and image
and bone mineral density were all considered measures of
acquisition reported in the studies
construct validity.
The vast majority of studies employed grey-scale ultrasono-
Reproducibility is intrinsic to both the validity of a technique
graphy, and most (42, 89%) reported the transducer character-
as an outcome in clinical trials and also to its ability to
istics. Doppler, either power (six, 13%) or colour (three, 6%)
demonstrate changes over time. Reproducibility is generally
were used in 10 studies, and contrast was examined in only one
determined through examining inter and intra-observer relia-
study. The Doppler specifications were reported in five, were
bility. For this review, both were subanalysed according to
unclear in one and were not reported in one manuscript.
whether the assessments were made through repeated image
The majority (40, 85%) of manuscripts provided some
acquisition or re-reading stored images. In addition, responsive-
description of the probe and joint position during image
ness to changes with time were also recorded, as these examine
acquisition; however, there was variability between studies
discrimination and also further address construct validity.50 A
imaging the same joint region as to how the images were
brief summary of the findings of each manuscript was included.
acquired.
RESULTS
Pathologies imaged and scoring systems
Characteristics of the studies
The pathologies examined most commonly were effusion,
Forty-seven articles published between 1982 and 2008 were
followed by synovial thickening or hypertrophy, cartilage
included in the review. The findings are summarised in table 1.
parameters, vascularity, Baker’s cysts, osteophytes, tendon
The majority of studies were published after 2000. The knee
and ligament abnormalities, meniscal changes, bursitis, erosions
has been examined more extensively than other joints,
and panniculitis. Definitions of the imaging appearance of the
followed by the hip, hand, foot, tempromandibular joint and
pathology imaged were provided in approximately half of the
Table 2
Validity of ultrasonography-detected cartilage pathology described in the manuscripts, including definitions, scoring systems, comparator and
results
First author
Definition in
(reference no)
Pathology imaged
manuscript
Scoring system
Comparator
Results
de Miguel Mendieta34
Meniscal lesion
Y
Present or absent
Symptoms
N/A
Naredo30
Meniscal extrusion
Y
Present or absent
Clinical examination
Meniscal displacement associated with higher
pain scores, medial joint pain and worse
CR
radiographic grade
Symptoms
Giovagnorio17
Typical signs of
Y
Present or absent
Clinical examination
Ultrasonography findings did not correlate
arthritis (including
with laboratory or clinical findings
Laboratory
cartilage thinning)
Keen46
Joint space
Y
Present or absent
Radiography
Ultrasonography detected more joint space
narrowing
narrowing than radiography
Kim48
Cartilage
N
NS
Scintigraphy
No correlation
Iagnocco7
Cartilage thickness
Y
Measured in mm
N/A
N/A
Jonsson8
Cartilage thickness
Y
Measured in mm
MRI
No comparison made due to technical
difficulties
Radiography
Jung36
Cartilage thickness
N
Measured in mm
Laboratory biomarkers
N/A
Martino9
Cartilage thickness
N
Measured in mm
Pathology
Good correlation between ultrasonography
measurements and histology
McCune6
Cartilage thickness
N
Measured in mm
Pathology
Good correlation between ultrasonography
measurements and histology
Cartilage clarity
N
7-Point scale
Cartilage sharpness
N
7-Point scale
Monteforte13
Cartilage thickness
N
NS
N/A
N/A
Ostergaard11
Cartilage thickness
N
Measured in mm
MRI
Moderate correlation between
ultrasonography and MRI
Tarhan26
Cartilage sharpness
N
7-Point scale
MRI
Reasonable correlation between
ultrasonography and MRI detected cartilage
sharpness and clarity
CR, conventional radiography; DE, described elsewhere; MRI, magnetic resonance imaging; N, No; N/A, not applicable; NS, not stated; Y, Yes.
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Table 3
Validity of ultrasonography-detected tendon and ligament pathology described in the literature, including definitions, scoring systems,
comparator and results
First author
Definition in
Scoring system
(reference no)
Pathology imaged
manuscript
used
Comparator
Results
Altinel42
Patella tendon
NS
4-Point scale
N/A
N/A
Falsetti23
Enthesitis
Y
4-Point scale
CR
Good agreement between
ultrasonography and CR for
Plantar fasciitis
Y
4-Point scale
enthesophytes and erosions
Falsetti21
Enthesitis
Y
Present/absent
Clinical examination
Ultrasonography detected more
disease than clinical examination
Enthesophytes
N
Present/absent
CR
or CR
Tenosynovitis/tendinosis
N
Present/absent
Kim48
Patella tendon
N
NS
Scintigraphy
No correlation
Medial and lateral collateral ligaments
N
NS
Lennox10
Diameter of quadriceps muscle
N
Measured in mm
N/A
N/A
Monteforte13
Thickness of patella and quadriceps
N
Measured in mm
N/A
N/A
tendons
Naredo30
Tendon and ligament lesions
DE
NS
Clinical examination
No abnormalities found
CR
Symptoms
Reardon19
Quadriceps muscle thickness
N
NS
N/A
N/A
Su40
Posterior structure tears
N
Graded as fully
N/A
N/A
continuous, partly
continuous or fully
discontinuous
Yoon32
Anserine tenobursitis
Thickness of PA
Measured in mm
Clinical examination
Ultrasonography detected
pathology in only two of 26 with
Bursitis .2 mm
Present or absent
the clinical syndrome
Thickening of tendon
Measured in mm
CR
Loss of normal
Present or absent
fibrillations
CR, conventional radiography; DE, described elsewhere; N, No; N/A, not applicable; NS, not stated; PA, pes anserinus; Y, Yes.
studies, and again, no standard definition of pathology was used
although the Doppler signal was not examined in these studies.
across the studies (tables 2, 3, 4 and 5). The ultrasonography
Cortical irregularities have similarly rarely been defined.
appearance of cartilage, when defined, was generally considered
Erosions have been defined in one study,29 and osteophytes in
a sonolucent or anechoic band overlying cortex. Cartilage
two studies.46 47 Synovial pathologies, including synovial hyper-
thinning was the most common pathology examined, although
trophy, effusion and Doppler signal, were most often studied
clarity and sharpness was also measured, although definitions of
and usually defined. As a definition of synovial hypertrophy and
these abnormalities were not given.6 26 Tendon and ligament
effusion has been published by the OMERACT ultrasonography
pathologies were also rarely defined. Enthesitis was examined
group,51 which can be used in future studies, the definitions
by one group,21 23 with definitions encompassing features of
used in previous published manuscripts are perhaps less
heterogeneous hypoechogeneicity, tendon thickening, cortical
interesting than other aspects of the imaging. For example, in
irregularities (erosions and enthesophytes) and oedema,
reviewing the articles it became clear that there was no
Table 4
Validity of ultrasonography-detected cortical pathology described in the literature including definitions, scoring systems, comparator and
results
First author
Definition in
Scoring system
(reference no)
Pathology imaged
manuscript
used
Comparator
Results
Falsetti21
Acromial irregularity
N
Present/absent
CR
Of the nine with ultrasonography-detected
pathology, eight had CR pathology
Kim48
Bony spurs
N
NS
Scintigraphy
Correlation between ultrasonography-detected
osteophyte length and scintographic uptake
Keen46
Osteophytes
Y
Counted
CR
Ultrasonography detected more osteophytosis
than radiography
Keen47
Osteophytes
Y
4-Point scale
N/A
N/A
Qvistgaard39
Osteophytes
N
4-Point scale
Radiography
Weak correlation between ultrasonography
findings and Kellgren CR score
Robinson45
Osteophytes
N
4-Point scale
Clinical symptoms
Ultrasonography findings did not correlate
with symptoms
Clinical response
Jung36
Osteophyte length
Y
Measured in mm
Laboratory biomarkers
Osteophyte length correlates with
biochemical markers
Iagnocco7
Erosions
Y
Present or absent
CR
Ultrasonography detected erosions in 16/101
subjects
CR detected erosions in 22/101 subjects
Ostergaard11
Erosions
N
Counted
MRI
Ultrasonography detected 38% of MRI
erosions
CR, conventional radiography; DE, described elsewhere; MRI, magnetic resonance imaging; N, No; N/A, not applicable; NS, not stated; Y, Yes.
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standardisation with regard to the positioning of the joint,
acquisition was reported in three studies, intra-reader reporting
planes in which images were obtained and the scoring of
was reported in four, inter-reader acquisition was reported in
synovial pathologies. Eleven of the studies examining synovitis
three and inter-reader reporting was reported in two.
clearly differentiated between synovial hypertrophy and effu-
sion, whereas in 12 studies they were either considered together
Discriminate validity of ultrasonography
or it was unclear. In addition, some studies required an arbitrary
Only eight studies examined the ability of ultrasonography to
minimal thickness of synovial hypertrophy and effusion28 30 44
detected changes over time. Those studies, the joints, interven-
before considering the pathology to be present. The scoring
tions and pathologies studied are presented in table 6.
systems used were usually reported, but again demonstrated
The general trends were a reduction in pathology with time
great variety, being either dichotomous, ordinal or continuous
after therapy, although only one of the studies was a
(tables 2, 3, 4 and 5).
randomised controlled trial, the others being observational case
series.
Validity of ultrasonography
Most studies addressed the construct validity of ultrasonogra-
DISCUSSION
phy (n = 27), with little examination of criterion validity
This review demonstrates that since the start of the new
(n = 9). Two studies found reasonable correlation between
millennium there has been increasing evidence of the applica-
ultrasonography-detected cartilage thickness and histological
tion of ultrasonography to osteoarthritis. However, for ultra-
cartilage thickness6 9 and one study demonstrated reasonable
sonography to be fully useful in assessing therapies and
correlation between ultrasonography-detected cartilage thick-
responses, it first needs to be validated as an outcome tool. In
ness and MRI.11 A paucity of information is available about the
this review, we have identified manuscripts that use ultrasono-
construct validity of ultrasonography-detected qualitative car-
graphy to evaluate osteoarthritis and demonstrated that further
tilage changes (table 2), and quantitative changes were limited
work is required to validate ultrasonography in osteoarthritis.
to measurements of thickness, as unlike MRI, it is difficult to
utilise ultrasonography to detected total volumes. Tendon and
Generally, the descriptions of ultrasonography technicalities,
ligament changes were usually compared against clinical
such as information about the machine and probe specifications
examination, with varying results. For example, little correla-
and the position of the scan in obtaining images was adequately
tion was found between ultrasonography and clinical diagnoses
described. The quality of reporting of the pathologies imaged,
of anserine tenobursitis,32 whereas there was good correlation
their definitions and scoring was less well described and, when
between ultrasonography and clinical and radiographic changes
present, demonstrated marked heterogeneity between studies.
of enthesitis at the shoulder and foot.21 23
There are no well accepted definitions of ultrasonography
pathology in osteoarthritis, although definitions of synovial
The validity of ultrasonography in detecting cortical irregula-
hypertrophy, effusion, tenosynovitis, enthesitis and erosion
rities was infrequently studied (table 4), with ultrasonography
have been developed by the OMERACT ultrasonography group
being found to be more sensitive to osteophytosis than
for use in inflammatory arthritis.51 These definitions were
radiography in the small joints of the hand,46 but less sensitive
applied to osteoarthritis in some publications,46 47 but not
to erosions.29 This was thought partly to be because osteophytes
routinely, which may reflect the fact that the recommendations
overhanging erosions may shadow underlying erosions prevent-
were only published in late 2005. In addition, the validity of
ing visualisation by ultrasonography. It may also be related to
applying definitions developed for inflammatory arthritis to
the positioning of the erosions. Whereas rheumatoid erosions
osteoarthritis needs consideration.
tend to be peri-articular, osteoarthritis erosions, as seen radio-
The scoring systems utilised were also not always described,
graphically, may be within the central portion of the joint and
and again demonstrated marked heterogeneity, generally being
inaccessible with ultrasound.
dichotomous, ordinal (based on qualitative, semiquantitative or
Ultrasound performs comparably to MRI in detecting
quantitative domains) or continuous scales (such as simple
effusion, synovial hypertrophy and popliteal cysts (tables 2, 3,
numeric counts or measuring in millimetres). Most of the
4 and 5). The validity of ultrasonography-detected cartilage
literature examined pathology in grey scale, with a paucity of
changes has only been assessed in comparison with MRI or
publications utilising
Doppler or
contrast agents.
The
histology at the knee joint (table 2). Ultrasonography was more
OMERACT ultrasonography group has recently been working
sensitive and specific than clinical examination in detecting
towards recommendations for a scoring system for synovitis in
effusion and synovial hypertrophy, although this has been
inflammatory arthritis, which will soon be published. This is
examined exclusively at the knee joint (table 5). The knee joint
too new to see reflected in the published literature; however,
has also been the focus of comparison between ultrasonogra-
again, whether this is applicable to osteoarthritis needs
phy-detected synovial pathology and MRI and arthroscopy.11 27
consideration.
The ability of ultrasonography to detect synovitis changes has
Whereas ultrasonography appears to be more sensitive for the
been examined at the hip,22 and fluid aspiration has been
detection of synovitis in osteoarthritis than clinical examina-
compared with ultrasonography-detected effusions in the hip
tion, with reasonable sensitivity compared with MRI or
and hand.15 39
histology, there is little evidence to confirm the validity of
No consistent relationship between clinical symptoms and
ultrasonography in detecting bony pathology in osteoarthritis,
ultrasonography-detected pathology is found in this review,
and the evidence regarding the detection of cartilage pathology
although symptomatic joints tend to have more ultrasonogra-
is largely limited to the detection of focal cartilage thickness.
phy-detected pathology than controls/healthy joints.
The clinical utility of ultrasonography in detecting cartilage in
vivo is questioned, as the physical properties of ultrasonography
Reproducibility of ultrasonography
make load-bearing cartilage difficult to image reliably due to
A minority of studies reported any reproducibility data,
acoustic shadowing. This review has also highlighted a paucity
although when reported it was reasonably good. Intra-reader
of information on the responsiveness of ultrasonography in
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Table 5
Validity of ultrasonography detected synovial pathology described in the literature including definitions, scoring systems, comparators and
results
Definition of imaging
First author
appearance of
(reference no)
Structure imaged pathology
Scoring system
Comparator
Results
Acebes33
Baker’s cyst
N
Maximal area calculated in two
Clinical examination
Clinical and ultrasonography parameters
planes using software
decrease after therapy
Synovial
N
Maximal area calculated in two
Symptoms
hypertrophy
planes using software
Arslan12
Vascular flow (RI)
Y
RI
CT
All osteoarthritis subjects had sacroilitis on CT;
however, only 50% had Doppler flow on
ultrasonography
Atchia43
Hip joint
DE
DE
N/A
N/A
Baratelli5
Joint capsule
Y
Measured in mm
N/A
N/A
thickness
D’Agostino28
Synovial
Y
Present or absent
Clinical examination
Synovitis found more commonly with
hypertrophy
ultrasonography than CE although there was a
strong association between ultrasonography
synovitis and clinical effusion
Effusions
Y
Present or absent
CR
Ultrasonography synovitis associated with KL
grade .2
Symptoms
Ultrasonography synovitis was associated with
early morning stiffness and sudden aggravation of
pain in past 2 weeks
de Miguel
Effusion
Y
Present or absent
Symptoms
Symptomatic knees were more likely to
Mendieta34
demonstrate effusion and Baker’s cyst than
Bursitis
Y
Present or absent
asymptomatic knees
Baker’s cyst
Y
Present or absent
Fam3
Popliteal cysts
Y
Present or absent
CR
Ultrasonography found cysts in 29/100 knees
Arthrogram
Arthrogram used to confirm two cysts
Symptoms
Ultrasonography popliteal cyst correlated with
increasing radiographic grade cysts in 17/36
knees with KL grade .2, but only 12/64 knees
with KL grade 2
Giovagnorio17
Vascularity
Y
Present or absent
Clinical examination
GS findings not correlated with laboratory
markers or CE
Synovial
N
Present or absent
Laboratory
PD signal related to ESR
thickening,
biomarkers
effusion.
Iagnocco15
Effusion
Y
Measured in mm
Aspiration of fluid
Ultrasonography is able to detect joint effusion
Jan35
Synovial sac
N
Measured in mm
Symptoms
Pain correlated with ultrasonography-detected
thickness
sac thickness
Jung36
Capsular
Y
Measured in mm
Laboratory
Subjects with capsular distension and effusion
distension
biomarkers
have higher levels of COMP and HA
Effusion
Y
Measured in mm
Synovial
Y
Present or absent
proliferation
Karim27
Synovitis
Y
4-Point scale (based on morphology) Clinical examination
Ultrasonography has higher sensitivity and
specificity than CE compared with arthroscopy
Effusion
Y
Present or absent
Direct visualisation
Keen47
Synovitis
Y
4-Point scale
N/A
N/A
Vascularity
Y
4-Point scale (semiquantitative)
Kim48
Effusion
Y
Measured in mm
Scintigraphy
Ultrasonography-detected effusion correlated
with uptake in medial femoral and tibial condyles
Synovitis
Y
U
Kristoffersen37
Synovial
Y
NS
Clinical examination
N/A
hypertrophy
Fluid
Y
NS
Symptoms
Hyperaemia
Y
RI
Lee44
Synovial
Y
Present or absent
Biochemical markers
Synovial proliferation not associated with
proliferation
biochemical markers
Naredo30
Bursitis
Y
NS
Clinical examination
Ultrasonography effusion was associated with
higher VAS pain at rest and on motion
Effusion
Y
NS
CR
Popliteal cyst
Y
NS
Symptoms
Ostergaard11
Effusion
Y
Measured in mm
MRI
Ultrasonography detected 100% of effusions,
100% Baker’s cysts, 57% synovial thickening
Synovial thickness Y
Measured in mm
Clinical examination
Ultrasonography and MRI showed moderate
correlation with synovial membrane thickness
and effusion
Qvistgaard39
Synovial profile
Y
3-Point scale (semiquantitative)
Fluid aspiration
No correlation between fluid aspiration and fluid
on ultrasonography
Effusion
Y
3-Point scale (semiquantitative)
Global synovitis
N
3-Point scale (semiquantitative)
Continued
616
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Table 5
Continued
Definition of imaging
First author
appearance of
(reference no)
Structure imaged pathology
Scoring system
Comparator
Results
Robinson45
Effusion
Y
Present or absent
Clinical symptoms
Ultrasonography did not predict clinical response
Capsular thickness Y
Measured in mm
Clinical response
Ultrasonography findings did not correlate with
symptoms
Vascularity
N
Present or absent
Schmidt16
Synovial thickness N
3-Point scale based on measurement Clinical examination
No agreement between CE and ultrasonography
in mm
in detecting synovitis
Direct visualisation
Agreement between GS ultrasonography and
arthroscopy as to presence of villi was 80–85%
Histology
All knees with histological pannus had Doppler
signal within hypoehcoic synoial hypertrophy
Song49
Effusion
Y
4-Point scale based on measurement Clinical examination
Effusion found by ultrasonography in 78%, by MRI
in mm
81%
Synovial
Y
4-Point scale based on measurement MRI
No correlation between lateral recess effusion
hypertrophy
in mm
and MRI
Vascularity
N
4-Point scale semiquantitative
Poor correlation between contrast enhancement
and MRI
Tarasevicius41
Capsular
Y
Measured in mm
N/A
N/A
distension
Tarhan26
Synovial
Y
4-Point scale based on measurement MRI
Synovial thickening (ultrasonography 34%, MRI
hypertrophy
in mm
50%)
Popliteal cysts (ultrasonography 40%, MRI 35%)
Effusion
Y
4-Point scale based on measurement Clinical examination
Increased changes with increasing radiographic
in mm
grade
Walther22
Synovial thickness N
4-Point scale, based on measurement Histology
PD valid in detecting vascularity of synovium
in mm
Effusion thickness
Y
4-Point scale, based on measurement
in mm
Vascularity
Y
4-Point scale and software
Walther20
Synovial thickness N
4-Point scale, semiquantitative
Histology
Good correlation between PD signal and
and effusion
histological vascularity scores
CE, clinical examination; COMP, cartilage oligomeric matrix protein; CR, conventional radiography; CT, computed tomography; DE, described elsewhere; ESR, erythrocyte
sedimentation rate; GS, grey scale; HA, hyaluronic acid; KL, Kellgren Lawrence; MRI, magnetic resonance imaging; N, No; N/A, not applicable; NS, not stated; PD, power Doppler;
RI, resistive index; U, unclear; VAS, visual analogue scale; Y, Yes.
osteoarthritis and a lack of information about the feasibility of
most utilised in medical literature searches and the extensive
this imaging technique. Furthermore, there is a paucity of
duplication of manuscripts found was reassuring. Second, we
reliability data presented in the literature with regard to inter-
limited the search to studies utilising ultrasonography in
reader and intra-reader reliability in image acquisition and the
osteoarthritis, excluding studies that imaged joint pathologies
scoring of stored images.
in other joint diseases only. If the validity of ultrasonography in
This review has limitations. First, only two databases were
detecting synovial, cortical, cartilage and tendon changes in
searched, meaning that some manuscripts may have been
other joint diseases (ie, rheumatoid arthritis) can automatically
missed. However, the two databases searched are arguably the
be applied to osteoarthritis, then the scope of this review is
Table 6
Studies demonstrating changes in ultrasonography-detected pathology in response to intervention
First author
(reference no)
Joint
Intervention
Findings
Acebes33
Knee
Intra-articular steroids
Popilteal cyst size and wall thickness decreased
after therapy
Baratto14
C spine
Low power modulated laser stimuli Reduction in soft tissue thickness with therapy
Iagnocco15
Hand
Intra-articular saline
Ultrasonography can demonstrate capsular
distension post-intra-articular saline
Jan35
Knee
Repetitive short-wave diathermy
Decrease in suprapatella sac thickness in the
treatment group, but not in control group
Decrease in pain index after therapy correlated
with decrease in synovial sac thickness
Monteforte25
C spine
Laser therapy
Subcutaneous tissue thickness reduced after laser
therapy
Reardon19
Knee
Observation post-surgery
No significant increase in quadriceps thickness
Symptomatic side remained significantly thinner
than other side
Su40
Hip
Observation post-total hip
Posterior structure integrity improved with time
replacement
Tarasevicius41
Hip
Observation post-total hip
Capsular distension at 6 months improves at
replacement
12 months
C spine, cervical spine.
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limited. However, it may not be correct to assume that validity
6.
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contained in such publications will be warranted in devising
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Another limitation (albeit a reflection of the published
20.
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literature, rather than a methodological problem in this review)
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A systematic review of ultrasonography in
osteoarthritis

H I Keen, R J Wakefield and P G Conaghan

Ann Rheum Dis 2009 68: 611-619
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