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.?
1991 :super specialties perceptions Cardiology..ECHO Angioplasty Gastro Endoscopy Neurology MRI Endocrinology..Hormone
Clinical Immunology & Rheumatology Nothing Antibodies..Pathologist Peeping in the joint.??
Perception of peeping in joint Respect in society Immediate diagnosis Direct patient-doctor relationship
MSK Ultrasound..
2003 Many OA patients with discomfort on back of knee?bakers cyst
2003 MSK Ultrsound Joint probe
2003
Scanning Technique
C/o: Pain in the poplitial region
USS Knee joint - Baker s cyst in OA
Baker cyst
Baker cyst
Baker cyst
Ruptured baker s cyst
Baker cyst with synovial hypertrophy
Baker s cyst in RA Synovial effusion & proliferation Synovial proliferation
Baker's cyst
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
MSK US : Learning Phase
History MSK ultrasound 2003..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
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
Why US superior Satisfaction Long history taking in MSK disease
18 Yr old girl BL knee effusion RF positive Already on DMARDS, No response History retaken Fall fr cycle at onset
Knee is good to begin with
Suprapatellar Effusion
Synovial Hypertrophy in suprapatellar Fossa
Synovial Polyp
Two cardinal words Black White In between
Anecheoic Black Hyperecheoic White Hypoechoeic..In between..grey
Different tissue Muscle.Hyperechoic, Tendons.Hyperechoic Nerve More Hyperechoic. Gas. Hyperechoic Fluid..Anaechoic
Sonographic characteristics of normal tissues
HLA B27 Associated SpA
Heel pain
Case 45 yr old man Pain right heel x 2 mnths Tendonitis of the Achilles tendon Managed with local injection!!!
Normal Achilles tendon
Achilles tendinitis and retrocalcaneal bursitis
Rupture Achilles tendon
Erosion calcaneum
Erosion calcaneum
Steroid in Retro-calcaneum Bursa
Steroid crystals in RCB
Plantar fascitis
Normal Plantar fascia
Tenosynovitis of Tibialis posterior
Doppler image Tibialis posterior
Normal Hip Joint
Hip joint effusion
Hip joint Effusion
Foreign Body Synovitis
Case 25 Yr old lady Polyarthralgia x 2 mnths On exam : NAD
IMP: EARLY RHEUMATOID ARTHRITIS
Case 40 yr old man Chronic persistent poly-arthritis No inflammatory features
Polyarthritis with no inflammatory features & deformities
Snow storm appearance
Double contour sign
Case 32 Yr old lady Pain and swelling in small joints of hands & feet and pain right shoulder joint X 8 mnths On Exam:
USS of the wrist joint Synovial effusion with proliferation and bony erosive changes Power Doppler shows an increased flow.
Bone erosion Longitudinal transverse
Erosive RA
Joint procedures : MCP
Case 52 yr old man On T/t for RA with Infliximab Developed lump right axilla On exam: large non-tender axillary nodes
Lymphoma
Synovial Sarcoma
Synovial Chondromatosis Multiple cartilaginous bodies in the synovium
Artifacts : Anisotropy Focal areas of hypoechogenicity when the probe is not at 90 to the linear structure being imaged Solution: Scan in multiple planes
Drawbacks Anisotropy Shadowing from bony surfaces/ calcifications Detailed knowledge of anatomy is essential Operator dependent
Take Home Message Clinical Correlation like ECHO Cardiography Dynamic examination Ability to scan multiple joints Intervention Satisfaction
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, 1327 1333 (2012) Arthritis Care Res. 63, 1477 1481 (2011) Arthritis Rheum. 64, 1272 1282 (2012).
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 2.33 9.00) 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, 752 760 (2012
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
Clinicians perspectives Time consuming Spoils clothes Lady attendant Jelly & cold whether can be troublesome Sometime one feels.was it worth it.yes.yes yes
Keep it up in-spite of obstacles..
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.?