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. 2002 Oct;61(10):895–904. doi: 10.1136/ard.61.10.895

Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints

M Backhaus 1, G Burmester 1, D Sandrock 1, D Loreck 1, D Hess 1, A Scholz 1, S Blind 1, B Hamm 1, M Bollow 1
PMCID: PMC1753903  PMID: 12228160

Abstract

Objective: To carry out a prospective two year follow up study comparing conventional radiography, three-phase bone scintigraphy, ultrasonography (US), and three dimensional (3D) magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examination in detecting early arthritis. The aim of the follow up study was to monitor the course of erosions during treatment with disease modifying antirheumatic drugs by different modalities and to determine whether the radiographically occult changes like erosive bone lesions of the finger joints detected by MRI and US in the initial study would show up on conventional radiographs two years later. Additionally, to study the course of soft tissue lesions depicted in the initial study in comparison with the clinical findings.

Methods: The metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints (14 joints) of the clinically more severely affected hand (soft tissue swelling and joint tenderness) as determined in the initial study of 49 patients with various forms of arthritis were examined twice. The patients had initially been divided into two groups. The follow up group I included 28 subjects (392 joints) without radiographic signs of destructive arthritis (Larsen grades 0–1) of the investigated hand and wrist, and group II (control group) included 21 patients (294 joints) with radiographs showing erosions (Larsen grade 2) of the investigated hand or wrist, or both, at the initial examination.

Results: (1) Radiography at the two year follow up detected only two erosions (two patients) in group I and 10 (nine patients) additional erosions in group II. Initial MRI had already detected both erosions in group I and seven (seven patients) of the 10 erosions in group II. Initial US had depicted one erosion in group I and four of the 10 erosions in group II. (2) In contrast with conventional radiography, 3D MRI and US demonstrated an increase in erosions in comparison with the initial investigation. (3) The abnormal findings detected by scintigraphy were decreased at the two year follow up. (4) Both groups showed a marked clinical improvement of synovitis and tenosynovitis, as also shown by MRI and US. (5) There was a striking discrepancy between the decrease in the soft tissue lesions as demonstrated by clinical findings, MRI, and US, and the significant increase in erosive bone lesions, which were primarily evident at MRI and US.

Conclusions: Despite clinical improvement and a regression of inflammatory soft tissue lesions, erosive bone lesions were increased at the two year follow up, which were more pronounced with 3D MRI and less pronounced with US. The results of our study suggest that owing to the inadequate depiction of erosions and soft tissue lesions, conventional radiography alone has limitations in the intermediate term follow up of treatment. US has a high sensitivity for depicting inflammatory soft tissue lesions, but dynamic 3D MRI is more sensitive in differentiating minute erosions.

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Figure 1 .

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Detection of soft tissue lesions (%) by the different modalities in group I (n=392 finger joints = 100%).

Figure 2 .

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Detection of bone lesions (%) by the different modalities in group I (n=392 finger joints = 100%).

Figure 3 .

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Detection of soft tissue lesions (%) by the different modalities in group II (n=294 finger joints = 100%).

Figure 4 .

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Detection of bone lesions (%) by the different modalities in group II (n=294 finger joints = 100%).

Figure 5 .

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Images obtained by radiography (A-D), MRI (E-I), scintigraphy (J-M), ultrasound (N-P) of the clinically most severely affected left hand in a woman with RA aged 20 at the time of the initial examination (time 0) and 22 at the time of follow up. (A, B) Survey radiograph of the left hand at time 0 in dorsovolar projection (A) and with the hand in the volardorsal, semisupine (45°) position with abducted fingers, the so-called "zither player position" (B): demonstration of a narrowed joint cleft in PIP joint III and of a small cystoid brightening on the radial side without disruption of the border lamella at the head of the proximal phalanx of digit III (open arrow). There is partial loss of the subchondral border lamella at the ulnar base of the proximal phalanx of digit IV (closed arrow). These changes do not yet represent direct signs of arthritis (Larsen stage 1). (C, D) Follow up radiography of the left hand performed two years after the initial examination in the dorsovolar projection (C) and in the zither player position (D): the joint clefts of all PIP joints now clearly show narrowing. The cystoid brightening at the head of the proximal phalanx of digit III seen at time 0 is now definitely identified as an erosion, but only on the film obtained in the zither player position (thick arrow) and not on the dorsovolar projection. The partial loss of the subchondral border lamella at the ulnar base of the proximal phalanx of digit IV now shows recalcification. Newly developed cystoid lesions not disrupting the border lamellae (thin arrows) are seen on the radial side of the head of the proximal phalanx of digit II, on the ulnar side of the head of the proximal phalanx of digit V, at the metacarpal head of digit I, and in corresponding locations at the scaphotrapezoid joint. The new erosion in PIP joint III is a direct sign of arthritis affecting less than 25% of the joint area, corresponding to Larsen stage 2.

Figure 5 .

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(contd) (E, F, G) MRI of the left hand performed at time 0 using an unenhanced T1 weighted 3D gradient echo sequence. The figure only shows one coronal section (E) obtained before contrast administration and a corresponding postcontrast section (F, G). (E) A large erosion on the radial side of the head of the proximal phalanx of digit III (open arrow) can be seen, which is demonstrated by MRI in association with extensive synovitis (asterisk) at PIP III already two years before there is clear cut radiographic evidence of its presence (fig 5D). After contrast medium administration (F), this erosion is partly obscured by the pronounced enhancement of the synovitis (*) at PIP III. Additional, smaller erosions—likewise not demonstrated radiographically—are seen in the metacarpal head of digit IV (arrow with loop) (more clearly seen in other images), on the ulnar side of the head of the proximal phalanx of PIP IV (thin, white arrow), and on the ulnar side of the metacarpal head of digit V (white arrow ) (G). Florid, contrast-enhanced synovitis (*, s) is depicted at PIP joints I–V, and at MCP joints I, II, IV, V. Florid, contrast-enhancing tenosynovitis (t) is seen affecting the flexor tendons of fingers 1–5. The radiographically demonstrated (fig 5A) partial loss of the subchondral border lamella at the ulnar base of the proximal phalanx of digit IV corresponds to contrast-enhancing osteitis affecting the entire base of the phalanx at MRI (black arrow). (H, I) After two years of DMARD treatment the patient underwent follow up MRI of the left hand using the same parameters as at time 0 using a comparable section orientation. The known lesion on the radial side of PIP joint III shows regression but still shows pronounced enhancement reflecting florid activity. The erosion on the ulnar side of PIP joint IV (open arrow (I) shows progression in the presence of more extensive synovitis (*, I). The tenosynovitis on the flexor side of digit III has a higher signal intensity on the postcontrast image than at time 0.

Figure 5 .

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(contd) (J, K) Initial scintigraphy, phases II (J) and III (K), shows hot spots in PIP joints II, III, and IV and in the wrist (lunate bone or adjacent parts of ulnar and radial bones). (L, M) At follow up two years later, scintigraphy, phase II (L), shows hot spots in the wrist, MCP joints I and III, IP joint, PIP joints II and III. Scintigraphy, phase III (M), shows hot spots in the wrist, MCP joints I, III, and V, interphalangeal joint, and DIP joints II, III, and IV.

Figure 5 .

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(contd) (N, O, P) (N) The initial ultrasound examination showed synovitis of the proximal interphalangeal (PIP) joints II, III. Ultrasound shows a hypointense line indicating synovitis (*) in PIP joints II (left) and III (right). The flexor tendon sheaths (arrowheads) of the second and third fingers are distended as an indication of tenosynovitis (t, flexor tendon). The step-like interruption of the bone margin (arrow) of the head of the proximal phalanx of digits II and III is indicative of erosion. (O) The figure shows a hypointense line indicating synovitis (*) in PIP joints II (left) and III (right). The flexor tendon sheaths (arrowheads) of the second and third fingers show minimal distention as an indication of tenosynovitis (t, flexor tendon). Irregularities of the joint contour were found at the heads of the proximal phalanx II and III (arrows). Ultrasound shows a large erosion at the head (arrow) of MCP joint V (P, right side) in the dorsal aspect and in the flexed MCP joint, which was not seen at conventional radiography (figs 5A-D) but in both MRI examinations (initially and at the two year follow up, fig 5G). The left side shows a normal joint contour of MCP joint IV.

Selected References

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