Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study

Abstract

BackgroundThe ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used for guidance of steroid injection and to assess treatment efficacy.MethodsForty swollen ankles regions were studied in 30 patients (median age 6.5 years, range 1-16 years) with JIA. All patients were assessed clinically, by US (synovial hypertrophy, effusion) and by color Doppler (synovial hyperemia) before and 4 weeks after US-guided steroid injection.ResultsUS detected 121 compartments with active disease (joints, tendon sheaths and 1 ganglion cyst). Multiple compartments were involved in 80% of the ankle regions. The talo-crural joint, posterior subtalar joint, midfoot joints and tendon sheaths were affected in 78%, 65%, 30% and 55% respectively. Fifty active tendon sheaths were detected, and multiple tendons were involved in 12 of the ankles. US-guidance allowed accurate placement of the corticosteroid in all 85 injected compartments, with a low rate of subcutaneous atrophy (4,7%). Normalization or regression of synovial hypertrophy was obtained in 89%, and normalization of synovial hyperemia in 89%. Clinical resolution of active arthritis was noted in 72% of the ankles.ConclusionsUS enabled exact anatomical location of synovial inflammation in the ankle region of JIA patients. The talo-crural joint was not always involved. Disease was frequently found in compartments difficult to evaluate clinically. US enabled exact guidance of steroid injections, gave a low rate of subcutaneous atrophy and was proved valuable for follow-up examinations. Normalization or regression of synovial hypertrophy and hyperemia was achieved in most cases, which supports the notion that US is an important tool in the management of ankle involvement in JIA.

Juvenile idiopathic arthritis: what is the utility of ultrasound?

“…On follow-up, ultrasound can demonstrate normalization or regression of hyperaemia and synovial hypertrophy. 20,51 Similar findings have been shown when ultrasound is used to follow up disease response to antirheumatic drugs 52 and biologic therapies 53 in adults.…”

“…20 Shahin et al 43 and others have shown an association with circulating Interleukin 6 (amongst other cytokines) and the amount of joint vascularity demonstrated on PD. Colour and PD techniques can potentially be used in addition to B mode imaging to assess synovitis and thus disease activity.…”

“…[17][18][19] It has many advantages in children and is increasingly being utilized in JIA to confirm suspected clinical findings, define affected anatomical compartments, guide arthrocentesis and perform intra-articular therapy. 20 Ultrasound is an ideal modality to use in children, being well accepted, non-ionizing, dynamic, accessible and quick, and does not require sedation or general anaesthesia. It can be used to compare symptomatic and asymptomatic sites and is easily repeatable.…”

Ultrasound-detected synovial abnormalities are frequent in clinically inactive juvenile idiopathic arthritis, but do not predict a flare of synovitis

“…The lack of predictive value of positive PD signal was unexpected; however, as this ultrasound feature, which is a sign of increased synovial vascularisation, is considered a more reliable indicator of active synovitis than the grayscale technique alone 34–37. As opposed to greyscale abnormalities, this ultrasound feature was not detected in healthy children evaluated in our study and in other investigations 15,33.…”

Decreased Cartilage Thickness in Juvenile Idiopathic Arthritis Assessed by Ultrasonography

“…Further, US-guided joint injections have improved the accuracy of intraarticular corticosteroid injection (IACI) treatment 8,9 . US is also relatively inexpensive, does not require radiation, is well accepted even by small children, can be viewed at bedside, and enables the physician to view different anatomic locations in the same session 10 .…”