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1 Ved Chaturvedi, MD, DM Research & Referral Hospital New Delhi President Indian Rheumatology Association MSK Ultrasound..A decade experience of bedside MSK US by a clinician. Was it worth it.?

2 1991 :super specialties perceptions Cardiology..ECHO Angioplasty Gastro Endoscopy Neurology MRI Endocrinology..Hormone

3 Clinical Immunology & Rheumatology Nothing Antibodies..Pathologist Peeping in the joint.??

4 Perception of peeping in joint Respect in society Immediate diagnosis Direct patient-doctor relationship

5 MSK Ultrasound..

6 2003 Many OA patients with discomfort on back of knee?bakers cyst

7 2003 MSK Ultrsound Joint probe

8 2003

9 Scanning Technique

10 C/o: Pain in the poplitial region

11 USS Knee joint - Baker s cyst in OA

12 Baker cyst

13 Baker cyst

14 Baker cyst

15 Ruptured baker s cyst

16 Baker cyst with synovial hypertrophy

17 Baker s cyst in RA Synovial effusion & proliferation Synovial proliferation

18 Baker's cyst

19 Bakers cyst.more common in OA.. Thick walled 32 Thin walled 68 Small (<2.5 ) 62 Big (> 2-5 ) 38 RA 22 OA 52 Spa 10 Idiopathic 16 Bakers cyst.more common in OA.. Ved Chaturvedi API CON 2004

20 MSK US : Learning Phase

21 History MSK ultrasound ECHO Joint probe acquired 2004.Conducted First National workshop 2004 : EULAR course 2009 :IRACON Jaipur 2011 : Faculty SGPGI workshop 2011 : Faculty CMC Vellore workshop 2013 : Guest Lecture JIPMER 2013 : Faculty APLAR Indonesia

22 Was it worth it? Can See entire course of tendon in longitudinal plane despite an oblique course Guidance of aspiration, biopsy & injection therapy Assessment of synovial thickening/ detection of fluid collections Undifferentiated arthropathy

23 Why US superior Satisfaction Long history taking in MSK disease

24 18 Yr old girl BL knee effusion RF positive Already on DMARDS, No response History retaken Fall fr cycle at onset

25

26 Knee is good to begin with

27 Suprapatellar Effusion

28 Synovial Hypertrophy in suprapatellar Fossa

29 Synovial Polyp

30 Two cardinal words Black White In between

31

32 Anecheoic Black Hyperecheoic White Hypoechoeic..In between..grey

33 Different tissue Muscle.Hyperechoic, Tendons.Hyperechoic Nerve More Hyperechoic. Gas. Hyperechoic Fluid..Anaechoic

34 Sonographic characteristics of normal tissues

35 HLA B27 Associated SpA

36 Heel pain

37

38

39 Case 45 yr old man Pain right heel x 2 mnths Tendonitis of the Achilles tendon Managed with local injection!!!

40 Normal Achilles tendon

41 Achilles tendinitis and retrocalcaneal bursitis

42 Rupture Achilles tendon

43 Erosion calcaneum

44 Erosion calcaneum

45 Steroid in Retro-calcaneum Bursa

46 Steroid crystals in RCB

47

48 Plantar fascitis

49 Normal Plantar fascia

50 Tenosynovitis of Tibialis posterior

51 Doppler image Tibialis posterior

52 Normal Hip Joint

53 Hip joint effusion

54 Hip joint Effusion

55 Foreign Body Synovitis

56 Case 25 Yr old lady Polyarthralgia x 2 mnths On exam : NAD

57

58

59

60

61 IMP: EARLY RHEUMATOID ARTHRITIS

62 Case 40 yr old man Chronic persistent poly-arthritis No inflammatory features

63 Polyarthritis with no inflammatory features & deformities

64 Snow storm appearance

65 Double contour sign

66 Case 32 Yr old lady Pain and swelling in small joints of hands & feet and pain right shoulder joint X 8 mnths On Exam:

67 USS of the wrist joint Synovial effusion with proliferation and bony erosive changes Power Doppler shows an increased flow.

68 Bone erosion Longitudinal transverse

69 Erosive RA

70

71 Joint procedures : MCP

72 Case 52 yr old man On T/t for RA with Infliximab Developed lump right axilla On exam: large non-tender axillary nodes

73

74 Lymphoma

75 Synovial Sarcoma

76 Synovial Chondromatosis Multiple cartilaginous bodies in the synovium

77 Artifacts : Anisotropy Focal areas of hypoechogenicity when the probe is not at 90 to the linear structure being imaged Solution: Scan in multiple planes

78 Drawbacks Anisotropy Shadowing from bony surfaces/ calcifications Detailed knowledge of anatomy is essential Operator dependent

79 Take Home Message Clinical Correlation like ECHO Cardiography Dynamic examination Ability to scan multiple joints Intervention Satisfaction

80 Comparison with clinical measures PDUS is superior to DAS28 in evaluating disease activity, and predicting joint destruction PDUS is better than the DAS28 for predicting a response to therapy GSUS and PDUS are both more reliable than the clinical scores Rheumatol. Int. 32, (2012) Arthritis Care Res. 63, (2011) Arthritis Rheum. 64, (2012).

81 Predictive markers Synovial vascularity detected by PDUS predicts higher risk of radiographic progression compared with treatmentresponsive joints (vascularity improvement of 70% at week 8; relative risk ) Other factors which predict erosions and poorer outcome: Synovitis (GSUS, OR 3.14; PDUS, OR 2.79) ECU tenosynovitis Distal ulna erosions Semin. Arthritis Rheum. 41, (2012

82 Clinician perspective.. Mostly useful for conditions which we see day to day Rotator cuff, some sports medicine & Orthopedic conditions may not be our cup of tea Not to get scared of detail anatomy, most of time not needed i Many future uses, but one would see what mind knows

83 Clinicians perspectives Time consuming Spoils clothes Lady attendant Jelly & cold whether can be troublesome Sometime one feels.was it worth it.yes.yes yes

84 Keep it up in-spite of obstacles..

85 Ved Chaturvedi, MD, DM Research & Referral Hospital New Delhi President Indian Rheumatology Association MSK Ultrasound..A decade experience of bed side MSK US by a clinician.was it worth it.?

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