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E Naredo,
J W J Bijlsma,
P G Conaghan,
C Acebes,
P Balint,
H Berner-Hammer,
G A W Bruyn,
P Collado,
M A D'Agostino,
J J de Agustin, [......],
B Manger,
L Mayordomo,
I Möller,
C Moragues,
E Rejón,
M Szkudlarek,
L Terslev,
J Uson,
R J Wakefield,
W A Schmidt
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ABSTRACT: To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses.
We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels.
The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses.
We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.
Annals of the rheumatic diseases 08/2008; 67(7):1017-22. · 8.11 Impact Factor
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J M Koski,
S Saarakkala,
M Helle,
U Hakulinen,
J O Heikkinen,
H Hermunen,
P Balint,
G A Bruyn,
E Filippucci,
W Grassi, [......],
E De Miguel,
E Naredo,
A K Scheel,
W A Schmidt,
I Soini,
M Szkudlarek,
L Terslev,
J Uson,
S Vuoristo,
H R Ziswiler
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ABSTRACT: To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips.
99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system.
The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (kappa = 0.52-0.82).
Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.
Annals of the Rheumatic Diseases 01/2007; 65(12):1658-60. · 8.73 Impact Factor
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ABSTRACT: To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments.
44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms.
A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p<0.01) and 0.328 (p<0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow.
A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.
Annals of the Rheumatic Diseases 01/2007; 65(12):1590-5. · 8.73 Impact Factor
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E Naredo,
I Möller,
C Moragues,
J J de Agustín,
A K Scheel,
W Grassi,
E de Miguel,
M Backhaus,
P Balint,
G A W Bruyn, [......], J M Koski,
L Mayordomo,
W A Schmidt,
W A A Swen,
M Szkudlarek,
L Terslev,
S Torp-Pedersen,
J Uson,
R J Wakefield,
C Werner
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ABSTRACT: To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography.
The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results.
Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae.
Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.
Annals of the Rheumatic Diseases 02/2006; 65(1):14-9. · 8.73 Impact Factor
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A K Scheel,
W A Schmidt,
K-G A Hermann,
G A Bruyn,
M A D'Agostino,
W Grassi,
A Iagnocco, J M Koski,
K P Machold,
E Naredo,
H Sattler,
N Swen,
M Szkudlarek,
R J Wakefield,
H R Ziswiler,
D Pasewaldt,
C Werner,
M Backhaus
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ABSTRACT: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard".
The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed.
Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%).
Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.
Annals of the Rheumatic Diseases 08/2005; 64(7):1043-9. · 8.73 Impact Factor
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ABSTRACT: To describe a new method for taking a synovial biopsy specimen under ultrasound guidance using portal and forceps.
Percutaneous ultrasound guided biopsy was performed for 37 patients with mono- or polyarthritis as outpatients. A portal to a planned area was built using a needle, guiding wire, and dilators, through which forceps could be inserted and samples taken. Biopsy samples were taken from small and large joints, bursae, and tendon sheaths.
Representative synovial tissue in adequate amounts for histopathological evaluation was obtained in 33/37 cases--a success rate of 89%. The biopsy procedures were well tolerated, but one complication of skin infection was encountered.
The new method of synovium biopsy under ultrasound guidance using sheath introducer set and flexible forceps can be performed on most joints and even bursae and tendon sheaths. The method gives sufficient samples for clinical work in most cases, but further work is needed before accepting this promising technique for scientific purposes.
Annals of the Rheumatic Diseases 07/2005; 64(6):926-9. · 8.73 Impact Factor
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ABSTRACT: The aim of this study was to compare the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in elbow joints in patients with rheumatoid arthritis (RA). Fifty consecutive patients with RA entered the study and 20 healthy persons formed a control group. Altogether 100 elbow joints of the RA patients and 40 of the controls were studied. All the clinical assessments were performed by one doctor and the US investigations by the other and they were blinded to each others results. In 77 elbow joints of the RA patients the clinical assessment and the US gave similar results, whereas they differed in the remaining 23 joints. The kappa coefficient between these investigations was 0.371. In the control group no elbow joint showed either swelling in the clinical assessment or effusion in the US investigation. The results of this study indicate that clinical assessment of swelling and evaluation of effusion by US in elbow joints in patients with RA show only fair agreement. Thus, US may improve the accuracy of diagnosis of synovitis in many cases in these patients.
Clinical Rheumatology 07/2005; 24(3):228-31. · 2.00 Impact Factor
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ABSTRACT: Fifty consecutive patients with RA and clinical wrist synovitis were randomly allocated to either receive an injection of glucocorticoid into the radiocarpal joint or have the same amount of drug divided into the radiocarpal and midcarpal joints. Inferior radioulnar joint synovitis was treated with extra steroid injection only in the latter group. Patient's and doctor's assessments as well as ultrasonography improved significantly at month 3 in both groups. A statistical difference between the groups was found in the midcarpal joint measurement favouring the extra midcarpal injection. Ten wrists (20%) were normal when assessed with ultrasound at month 3 while 34 wrists (68%) were normal on clinical assessment.
Scandinavian Journal of Rheumatology 02/2001; 30(5):268-70. · 2.47 Impact Factor
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J M Koski
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ABSTRACT: Ultrasonography has gained popularity among rheumatologists especially in Europe as a bedside imaging method for diagnosing soft tissue lesions such as synovitis in joints, bursae and tendons. In addition to diagnosing the lesion ultrasound can be used to monitor needle position during the injection procedure. The aim of this paper is to describe injection techniques guided by ultrasound into the joints, bursae or tendon sheaths. We point out that the value of ultrasound in rheumatology is not only diagnostic but also therapeutic.
The Journal of Rheumatology 10/2000; 27(9):2131-8. · 3.69 Impact Factor
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J M Koski
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ABSTRACT: To study the plantar forefoot of patients with early rheumatoid arthritis (RA) by ultrasound to detect bursitis and to correlate sonographic findings with symptoms and clinical observations.
Clinical examination, dorsoplantar radiographs, and transverse sonographic scans of the plantar region of the forefoot were performed on 30 healthy persons as well as 25 patients with early RA and forefoot symptoms.
In 8 patients the examiner could clinically suspect plantar bursitis. Ultrasound revealed 22 incidents of plantar bursitis in 14 of the 25 patients. Except for bursitis in the forefoot no inflammatory findings were detected by ultrasound in 6 patients.
Not only metatarsophalangeal arthritis or flexor tenosynovitis but also plantar bursitis can promote symptoms of the forefoot. Ultrasound is a more objective procedure than clinical examination in diagnosing plantar bursitis. This finding has diagnostic and therapeutic implications.
The Journal of Rheumatology 03/1998; 25(2):229-30. · 3.69 Impact Factor
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ABSTRACT: Three cases of transient osteoporosis of the hip and their ultrasonographic findings are presented. Transient osteoporosis of the hip is an uncommon condition with pain in the hip area and limping. The diagnosis is supported by local radiological osteoporosis and other imaging methods. Exclusion of more common entities is required. Effusion of the hip joint detected by ultrasonography is also related to this condition, which must be taken into account in patients with hip pain.
Clinical Rheumatology 07/1997; 16(4):404-8. · 2.00 Impact Factor
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ABSTRACT: Two cases of unilateral abnormal ultrasonographic findings in the hip joints are introduced. The correct diagnoses were detected by radiography after the failure of intra-articular glucocorticoid injections given as first aid. Ultrasonography (US) has poor specificity, since all phenomena causing effusion into the joint cavity may be detected as abnormal by US, and may include stress fractures and malignant myeloma, as we show here. In the case of an abnormal ultrasonographic finding in a joint, the recent radiological status should also be considered.
Clinical Rheumatology 04/1996; 15(2):181-4. · 2.00 Impact Factor
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J M Koski
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ABSTRACT: Clinical examination, dorsoplantar radiographs and transverse sonographic scans of the plantar region of the forefoot were performed on 35 healthy individuals as well as 25 patients with inflammatory joint disease and forefoot symptoms. The ultrasound revealed twenty plantar flexor tenosynovitides in 12 of the 25 patients. In 14 out of the 20 tenosynovitides there was no metatarsophalangeal effusion in the same digit. Thus, also plantar tenosynovitis and not only metatarsophalangeal arthritis can promote symptoms of the forefoot. Only in eight of the 20 tenosynovitides the clinical examination was positive. Ultrasound is a more objective procedure than clinical examination in diagnosing plantar tenosynovitis. This finding has not only a diagnostic but also a therapeutic implication.
Scandinavian Journal of Rheumatology 02/1995; 24(5):312-3. · 2.47 Impact Factor
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J M Koski
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ABSTRACT: An ultrasonographic method for detecting intraarticular effusion in subtalar and midtarsal joints was developed. An unechogenic zone in these joints is a sign of intraarticular effusion or synovitis. It is also possible to inject glucocorticoid into these small joints with the guidance of ultrasonography.
The Journal of Rheumatology 11/1993; 20(10):1753-5. · 3.69 Impact Factor
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J M Koski
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ABSTRACT: The central joints of 19 patients identified as suffering from polymyalgia rheumatica were examined using ultrasonography (US). At US 13 patients (68%) were found to have an effusion in the hip and/or glenohumeral joints. Synovial fluid analyses were conducted on the central joints of four patients. These findings suggest that at least one patient group with the syndrome of PMR could better be designated as having axial arthritis and this synovitis might play an important role in the understanding of their symptoms.
British journal of rheumatology 04/1992; 31(3):201-3.
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J M Koski
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ABSTRACT: Sixty radiocarpal and midcarpal joints in 30 healthy adults and 20 swollen wrists in 20 patients with chronic arthritis were examined by dorsal longitudinal ultrasonography (US). In five other patients intraarticular application of fluid into the radiocarpal joint could be seen as a change in the US scan. In 49 out of the 60 healthy wrists the unechogenic zone dorsally above the scaphoid bone was less than two millimetres, and the measurement did not change in dorsal or volar flexion. The side difference was less than one millimetre. In the healthy wrists the midcarpal area above bones was echogenic in US. In 15 radiocarpal and in 10 midcarpal joints out of the 20 swollen wrists, effusion could be depicted with US as an unechogenic zone. It was two millimetres or more in radiocarpal joint and it got bigger in dorsal and smaller in volar flexion.
Scandinavian Journal of Rheumatology 02/1992; 21(2):79-81. · 2.47 Impact Factor
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J M Koski
Scandinavian Journal of Rheumatology 02/1991; 20(1):49-51. · 2.47 Impact Factor
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ABSTRACT: The usefulness of ultrasonography in detecting intra-articular effusion of the hip joint is discussed in the light of three cases. In all these patients, effusion was demonstrated by ultrasonography and confirmed by aspiration of inflammatory synovial fluid from the joint, though the joint was clinically symptomless. It is recommended that all rheumatologists use ultrasonography.
Clinical Rheumatology 01/1991; 9(4):539-41. · 2.00 Impact Factor
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ABSTRACT: The ultrasonographic distance between the collum of the femur and the capsule of the hip joint was measured in 88 hips of 75 patients with chronic inflammatory joint disease and with hip joint symptoms or signs. In addition, 10 other hips were measured before soft tissue operation of the hip joint. The ultrasonographic distance was 7 mm or more in 29 out of 33 hips with synovial fluid in joint puncture and in seven out of nine hips with intra-articular effusion or synovitis in open surgery. Intra-articular injection of corticosteroid resulted in a significant decrease in the enlarged ultrasonographic distance, in joints both with and without synovial fluid. Joints not treated with steroid did not show any change. It is concluded that both joint effusion and synovitis without effusion can increase the anechogenic distance between the bone and the joint capsule.
British journal of rheumatology 07/1990; 29(3):189-92.
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J M Koski
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ABSTRACT: The nonechogenic space between the bone and the joint capsule was measured in ultrasonographic scans at six different sites in 60 elbow joints of 30 healthy adults as well as in 35 joints with clinical arthritis. The space could be demonstrated in all healthy joints on the volar side at the levels of the trochlea and the capitulum of the humerus. The space was more than 2 mm in three out of the 60 healthy joints at these levels, and the space did not increase in 30 degrees flexion of the joint. The means of the measurements were significantly higher at all six sites in the arthritic joints than in the healthy joints and on the volar site the space increased in 30 degrees flexion of the arthritic joint. The space was more than 2 mm in all arthritic joints at the levels of either the trochlea or the capitulum of the humerus. An ultrasonographic distance of more than 2 mm on the volar side of the elbow joint between the joint capsule and the bone is with high probability a sign of intraarticular effusion or synovitis. The effusion in the olecranon fossa can also be demonstrated in all cases.
Rheumatology International 02/1990; 10(3):91-4. · 1.88 Impact Factor
