See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/261570619

MRI Hand And Foot In Early Rheumatoid Arthritis With Normal Conventional

Radiography In Correlation To DAS-3

Article  in  Egyptian Rheumatologist · January 2008

CITATIONS

0READS

199

2 authors:

Some of the authors of this publication are also working on these related projects:

PET CT IN LYMPHOMA View project

Mohamed Elwakd

Faculty of Medicine, Cairo University, Cairo, Egypt.

19 PUBLICATIONS   117 CITATIONS   

SEE PROFILE

Ayman I. Kamel

Cairo University

18 PUBLICATIONS   108 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Mohamed Elwakd on 24 September 2014.

The user has requested enhancement of the downloaded file.

1

The Egyptian Rheumatologist ISSN 1110-1164

Personal non-commercial use only. The Egyptian Rheumatologist Copyright © 2008. All rights reserved.

MRI Hand and Foot in Early Rheumatoid Arthritis with Normal Conventional Radiography in Correlation to DAS-3

Mohamed M. El-Wakd1, Ayman I. Kamel2

1Lecturer of Rheumatology and Rehabilitation, Faculty of Medicine, Cairo Uni. 2Lecturer of Radiodiagnosis, Faculty of Medicine, Cairo Uni.

Abstract

Objective: The primary aim of the study was to detect the MRI changes in hand and foot in patients with early rheumatoid arthritis (RA) who had normal conventional radiography of both hands and feet. The secondary aim was to detect any correlation between the MRI changes and the disease activity score with three variables (DAS-3).Patients and Methods: Thirty adult patients with early RA, fulfilling the 1987 revised American College of Rheumatology (ACR) criteria for the classification of RA, with disease duration between 2-6 months were recruited in the study. All patients underwent a full history taking and thorough rheumatological examination. Disease activity score with three variables (DAS-3), including the Ritchie articular index (RAI), swollen joint count (SJC) and ESR, was calculated to every patient. Routine laboratory investigations were done. Normal conventional radiography of hands and feet was an inclusion criterion. MRI to the clinically dominant hand and foot was done to every patient.Results: 29 patients (96.7%) had MRI changes consistent with the inflammation and destruction. MRI changes were found in 66.7% of patients in hand and foot, in 20% in foot and in 10% in hand. SJC and ESR were statistically elevated in patients with MRI changes in hand and foot, in comparison with those with either hand or foot. The detected MRI changes were synovitis in 93.3%, erosions in 60%, bone marrow edema in 83.3%, tenosynovitis in 76.7% and foot bursitis in 66.7% of patients. According to the anatomical distribution, synovitis was detected in wrist joint in 76.7%, in MCP joints in 70%, in hindfoot joints in 60% and in MTP joints in 83.3% of patients. Erosions in wrist were detected in 40%, in MCP in 43.3%, in hindfoot in 36.7% and in MTP in 40% of patients. Bone marrow edema which is a unique MRI finding was detected in wrist in 66.7%, in MCP in 60%, in both hindfoot and MTP in 70% for each of patients. Tenosynovitis was detected in hand in 60% and in foot in 66.7% of patients.Conclusion: MRI hand and foot is an important imaging modality. It detected the pathologic manifestations at the early stages of RA especially the bone marrow edema that contains information about initial inflammatory activity and the potential for erosion development. Early disclosure of these pathological findings by MRI helps in initiating early aggressive therapy to keep the functional outcome. No correlation was found between the DAS-3 and MRI findings except the ESR which was statistically elevated in patients with erosion. This reinforced the importance of MRI in early RA. Also, MRI foot is important in early RA being involved alone in fifth of our patients.

Key words: MRI hand and foot, early rheumatoid arthritis.Egypt. Rheumatologist Vol. 30, No. 1, 2008: 1-6

The Egyptian Rheumatologist; Vol. 30, No. 1, 2008: 1-6

2

INtRODuCtION

The past several years have witnessed unprecedented advances in rheumatology, with the introduction of several new compounds capable of halting the progression of joint destruction and functional disability in patients with rheumatoid arthritis (RA).1

Before the introduction of these effective structure modifying treatments, rheumatology’s demand for imaging joint structure was modest, at best2. Accordingly, most rheumatologists focused primarily on clinical and laboratory features of the disease, and used imaging only sparingly if at all. However, the recent introduction of effective structure modifying treatments has changed the way that rheumatologists manage patients with RA. This has created new demands on imaging both in clinical practice and in clinical research to resolve even the slightest traces of erosive joint damage and to identify pre-erosive inflammatory features that can accurately predict which patients will go on to severe functional debility if they do not receive aggressive structure modifying treatment immediately.1

During the first few years of disease, inflammation rather than structural damage accounts for most functional disability in RA 3. By eliminating inflammation at this stage, therefore, one can achieve full functional recovery. Indeed, inflammation is potentially reversible at any stage of the disease. However, as structural damage accumulates an increasing proportion of functional disability becomes irreversible. Accordingly, current treatment strategies target early disease to limit cumulative structural damage4-5. However, 30% – 40% of cohorts with early RA do not progress, and therefore may not require aggressive treatment. Some have advocated treating all patients aggressively anyway in order to avoid missing those who might progress. However; such a catch-all strategy carries significant financial and toxicity implications.6

Diagnosing destructive RA during its earlier stage is crucial to the implementation of active and aggressive treatment, which is expected to alleviate RA joint damage, thereby reducing functional deterioration and improving the long-term outcome7-9. Conventional radiography of both the hands and feet is the traditional method used to diagnose RA. On the other hand, magnetic resonance imaging (MRI) has a potential for disclosing early signs of inflammation and joint destruction in RA that is superior to that of conventional radiography. MRI promised to tell more about synovitis, bone erosion, and the integrity of cartilage, ligaments and other articular tissues than radiography ever could.10

AIM OF WORK

The primary aim of this study was to detect the MRI changes in hand and foot in patients with early RA who had normal conventional radiography of both hands and feet which give a false impression about the non-erosive pattern of the disease.

The secondary aim was to detect if there is any correlation between the MRI changes and the disease activity score with three variables (DAS-3).

PAtIENtS AND MEtHODS

Patient and clinical assessment: this study included thirty adult patients who fulfilled the 1987 revised American Collage of Rheumatology criteria for the classification of RA11. They were recruited from the outpatient clinic of the rheumatology and rehabilitation department, faculty of medicine, Cairo University Hospitals, in the period from February 2005 till June 2007.

Our patients were selected upon:Fulfillment of the 1987 revised ACR criteria for the 1. classification of RA.11

Early RA with disease duration between 2-6 months 2. from the onset of the first articular manifestation. Normal conventional radiography of both hands and 3. feet.The medication used by the patients at the time of study 4. entry was non-steroidal anti-inflammatory drugs if any.

Exclusion criteria:Patients with disease duration more than 6 months.1. Patients on the disease modifying anti-rheumatic drugs 2. (DMARDs) or corticosteroids.

All patients underwent a full history taking, general and locomotor clinical examination. The disease activity score with three variables (DAS-3) was assessed and calculated to every patient using an internet program called “DAS calculator V1.1-B”. The 3 variables of DAS-3 were the Ritchie articular index (RAI) with score between 0-78, the swollen joint count (SJC) with score between 0-44 and erythrocyte sedimentation rate (ESR) in mm/1st hour.

All patients underwent routine laboratory investigations; including the complete blood count (CBC), liver and kidney function tests, and complete urine analysis. Rheumatoid factor (RF) by latex fixation test was done to all patients.

Conventional radiography of the wrists and hands were done to all patients in posteroanterior and oblique views, as well as to the ankles and feet in anterioposterior and oblique views. Films obtained were studied and scored using the modified Sharp/Van der Heijde method12. Any patient showed radiological manifestation of the RA was excluded from the current study.

MRI scan of the clinically dominant hand and wrist and to clinically dominant ankle and forefoot were done to all patients using a 1.5-T scanner (Gyroscan Intera, Real Time Interactive MR, Philips, Germany). Clinically dominant was defined as the site which is more tender to pressure and/or

El-Wakd1, Kamel - MRI Hand and Foot in Early Rheumatoid Arthritis with Normal Conventional Radiography

3

with signs of hyperthermia and/or swelling.13

The MRI technique done for the hand and wrist assessment: the patient lying prone with the limb overextended above his head and the hand was placed in the extremity coil, where it was fitted with the palm facing prone or supine according to the patient’s comfort, afterwards it is closely fitted within the coil using soft pad for anchoring the hand. The vertical and horizontal line axes were adjusted to the level of the bases of metacarpals to ensure proper image centralization. The examination protocol for all patients included the following, coronal T1WI, T2WI, STIR and gradient as well as sagittal and axial T2WI. Intravenous application of gadolinium diethylenetriaminepenta-acetic acid (Gd-DTPA; (0.1 mmole/kg of body weight), was administered followed by coronal and axial T1 images.

The MRI technique done for the foot and ankle; the patient is lying supine with his foot and ankle within the extremity coil. The foot is dorsiflexed so that the dorsal aspect of the foot is perpendicular to the examination couch and is immobilized in this position with a right angle foam pads to avoid forced dorsiflexion. The foot and ankle are raised so that the vertical alignment light lies at the level of the malleoli that correspond to the centre of the coil. This ensures that the ankle is at isocentre along the vertical axis. The patient is positioned so that the longitudinal alignment light lies in the midline. The examination protocol for all patients included the following, sagittal T1WI, T2WI &STIR as well as coronal and axial T1WI and gradient were also done. Intravenous application of Gd-DTPA was administered followed by sagittal, coronal and axial T1 images.

Sagittal and Axial images are often used for evaluation of the hindfoot, whereas coronal and axial images are often used for evaluation of the forefoot.

Definitions of lesions by MRI using the OMERACT/RAMRIS 14-15: Synovitis was defined as an area in the synovial compartment that shows above-normal post–gadolinium enhancement of a thickness greater than the width of the normal synovium. Enhancement (Signal intensity increase) is judged by comparison of T1-weighted images, obtained before and after IV gadolinium contrast. Bone erosion was defined as a sharply marginated bone lesion, with correct juxtaarticular localization and typical signal characteristics that is visible in 2 planes with a cortical break seen in at least 1 plane. On T1-weighted images: loss of normal low signal intensity of cortical bone and loss of normal high signal intensity of trabecular bone. Quick post-gadolinium enhancement suggests presence of active, hypervascularized pannus tissue in the erosion. Bone edema was defined as a lesion within the trabecular bone, with ill-defined margins and signal characteristics consistent with increased water content. Bone edema may occur alone or surrounding an erosion or other bone abnormalities. High signal intensity on T2-weighted fat-saturated and STIR images, and low signal intensity on T1-weighted images.14-15

These definitions were designed for wrist and MCP joints

and were adapted by Ostendorf’s study in 2004 for forefoot assessment13. The first MTP joint was added to the forefoot score, so that all 5 MTP joints were analyzed. Also, they added the tenosynovitis of the hands and feet to the scoring system (i.e., tissue surrounding the tendon showing high signal intensity on T2-weighted sequences, hypointense signal on T1-weighted images, and enhancement on the post Gd-DTPA images). Tenosynovitis was scored as follows: 0=not present, -1=present at the flexor tendons and+1= present at the extensor tendons.13

Analysis of the MRI findings: Each variable (Active synovitis, bone erosion, bone edema, tenosynovitis and foot bursitis) was scored as absent (0) or present (1). Active synovitis was detected in wrist (At inferior radioulnar, intercarpal and carpometacarpal joints), MCP (2nd to 5th MCP joints), ankle, hindfoot (Subtalar, intertarsal, tarsometatarsal joints) and all MTP joints. Erosions were detected at 14 sites within the wrist (distal ulna, distal radius, scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate, and 2nd to 5th metacarpal bases), MCP joint (2nd to 5th MCP joints), ankle, hindfoot and all MTP joints.

In total, MRI evaluated 30 wrist joints, 120 MCP joints, 30 ankle joints, 30 hindfoot joints and 150 MTP joints.

StAtIStICAL MEtHODS

Data were processed utilizing the Statistical Package for Social Sciences (SPSS version 10.00 for windows). Means and standard deviation (SD) are given for numerical variables. Student’s t-test was used for comparison of quantitative data. Pearson’s correlation coefficient test was performed to study the relation between two items. P value less than 0.05 was considered significant.

RESuLtS

The included 30 patients were 25 (83.3%) females and 5 males (16.7%). Their age ranged from 20 to 65 years with a mean of 37.9±12.6 years. The disease duration ranged from 2 to 6 months with a mean of 3.8±1.4 months.

Clinical results:The RAI ranged from 8-40 with a mean of 20.8±8.95. The SJC ranged from 3 to 12 with a mean of 5.87±2.26. The ESR ranged from 28 to 60 mm/1st hour with a mean of 40.67±8.7 mm/1st hour. The DAS-3 score ranged from 3.28 to 5.72 with a mean of 4.24±0.57. RF was positive in 25 (83.3%) patients.

Conventional radiography:All our patients had normal hands and feet conventional radiography. This was an inclusion criterion for selection of our patients.

Pathological MRI findings: Among the 30 studied patients, one patient had normal MRI study and 29 (96.7%) had MRI changes consistent with the inflammation and destruction. According to the anatomical

The Egyptian Rheumatologist; Vol. 30, No. 1, 2008: 1-6

4

site of affection, these 29 patients with MRI changes were subdivided into three groups. Group-1 included twenty patients (66.7%) with both MRI hand and foot involvement, group-2 included six patients (20%) with MRI foot involvement only and group-3 included three patients (10%) with MRI hand involvement only.

Table (1) showed the DAS-3 and its components in the different three groups. The mean SJC (6.9±2.05) of the group-1 was higher than that (3.83±0.75) of group-2 and the differences was very highly statistically significant (p<0.0001). Also, the mean SJC of group-1 was higher than that (3.67±0.57) of group-3 and the difference was very highly statistically significant (p<0.0001). No statistically significant difference between group-2 and group-3.

The mean ESR of the group-1 (44.45±7.83) was higher than that (32±3.84) of group-2 and the differences was very highly statistically significant (p<0.0001). Also, ESR of group-1 was higher than that (37±2.64) of group-3 and the difference was highly statistically significant (p<0.01). No statistically significant difference between group-2 and group-3. No significant differences between groups as regard RAI and DAS-3.

table 1: The mean±SD of the DAS-3 and its components in the three groups of patients:

group-1 group-2 group-3

RAI 21.58.43 20.7±0.75 20.7±0.58

SJC 6.9±2.05 3.83±0.75 3.67±0.57

ESR/1st h. 44.45±7.83 32±3.84 37±2.64

DAS-3 4.36±0.6 4.1±0.62 4.1±0.02

According to the pathological definition of OMERACT/RAMRIS14,15 and its adaptation by Ostendorf et al.13, synovitis was detected in 28 patients (93.3%), erosions in 18 patients (60%), bone edema in 25 patients (83.3%), tenosynovitis in 23 patients (76.7%) and foot bursitis in foot in 20 patients (66.7%).

There were no statistically significant differences of the demographic and clinical activity measures between patients with and without erosions except the ESR. The ESR in patients with erosion was statistically elevated compared with that in patients without erosions (p<0.05) as shown in table (2).

table 2: Demographic and clinical activity measures between patients with and without erosions:

Erosions (18 patients)

No erosions (12 patients) Sig.

Age 36.9±12.4 yr. 39.25±12 yr. NS

Disease duration 4±1.5 mo. 3.6±1.2 mo. NS

RAI 22.6±7.6 18.7±10.5 NS

SJC 6.2±2.4 5.3±2 NS

ESR 44.2±8.3 37.7±8.12 0.04

DAS-3 4.42±0.5 4 ± 0.6 NS

RF Positive in 15 patients

Positive in 10 patients NS

NS = non-significant.

There were no statistically significant differences of the demographic and clinical activity measures between patients with and without bone marrow edema as shown in table (3).

table 3: Demographic and clinical activity measures between patients with and without bone marrow edema:

Edema (25 patients)

No Edema (5 patients) Sig.

Age 36.2 ± 11.8 yr. 46 ± 11 yr. NS

Disease duration 3.88 ± 1.45 mo. 3.4 ± 0.9 mo. NS

RAI 21.2 ± 9.1 18.8 ± 8.6 NS

SJC 6 ± 2.3 5.2 ± 2.2 NS

ESR 41.6 ± 8.7 35.8 ± 7.4 NS

DAS-3 4.3 ± 0.6 4.1 ± 0.6 NS

RF positive 21 patients 4 patients NS

NS = non-significant.

There were no statistically significant differences of the demographic and clinical activity measures between patients with and without synovitis or tenosynovitis or foot bursitis.

According to the anatomical distribution of these pathologic MRI finding, the following was detected:

Hand:• for both wrist and MCP joints together, synovitis was detected in 23 patients (76.7%), erosions in 13 patients (43.3 %), bone marrow edema in 20 patients (66.7%) and tenosynovitis in 18 patients (60%).

Wris1. t: active synovitis was detected in 23 patients (76.7%) (Figure 1). Almost all the patients had inferior radiulnar, radiocarpal, intercarpal and carpometacarpal

El-Wakd1, Kamel - MRI Hand and Foot in Early Rheumatoid Arthritis with Normal Conventional Radiography

5

joint synovitis. Erosions were detected in 12 patients (40%). The most common sites for erosions were in the triquetrum (11 patients), capitate (10 patients), lunate (9 patients) and scaphoid (9 patients) (Figure 2 & 3). Bone marrow edema was detected in 20 patients (66.7%); either alone or in association with synovitis or erosions figure (1 & 2).

Fig. 1: Coronal STIR image of the left wrist showed high signal intensity bone edema in almost all carpal bones and the ulnar styloid process. Active synovitis with effusion of the inferior radioulnar joint indicated by white arrow head (TR=3460, TE=50).

Fig. 2: Coronal T1WI of the left wrist of the same patient in figure 1; showed low signal intensity bone edema surrounding the erosions in almost all carpal bones (TR=650, TE=22).

Fig. 3: Coronal T1WI of the right wrist showed erosions of scaphoid (S), capitates (C), lunate (L) & triquetriumin (T) (TR=650, TE=22).

MCP joints: active synovitis was detected in 21 patients 2. (70%). The 2nd (15 patients) and the 3rd (13 patients) MCP joints were the most frequently involved. Erosions were detected in 13 patients (43.3%) and bone marrow edema was detected in 18 patients (60%).

Fig. 4: Coronal T1WI of the right MCP joints showed erosions in 2nd & 3rd metacarpal heads (TR=650, TE=22).

tenosynovitis: it was detected in 18 patients (60%). The most frequently involved tendons were flexor digitorum (12 patients), extensor digitorum (10 patients) and extensor carpi ulnaris (6 patients).

Foot:• for ankle, tarsal and MTP joints altogether, synovitis was detected in 25 patients (83.3%), erosions in 14 patients (46.7%), edema in 21 patients (70%) and tenosynovitis 20 patients (66.7%).

Ankle and Hindfoot: active synovitis was detected in 1. 18 patients (60%). The most commonly synovitis was detected in tibiotalar (Ankle) joint being present in 16 patients (53.3%) followed by tarsometatarsal joint in 14 patients (46.7%), calcaneocuboid (The lateral part of the midtarsal) joint in 13 patients (43.3%), talonavicular (The medial part of the midtarsal) joint synovitis in 10 patients (33.3%), cuneonavicular joint in 8 (26.7%) patients, intercuniform joint in 7 patients (23.3%), talocalcanean (Subtalar) joint synovitis in 6 patients (20%) followed finally by cuneocuboid joint synovitis in 2 patients (6.7%). Erosions were detected in 11 patients (36.7%). Most erosion detected in calcaneous (8 patients), navicular (7 patients), talus (5 patients), cuboid (4 patients), and 1st and 2nd cuneiform (4 patients). Bone marrow edema was detected in 21 patients (70%).

Forefoot (The MTP joints): active synovitis was detected 2. in 25 patients (83.3%). Erosions were detected in 12 patients (40%). Bone marrow edema was detected in 21 patients (70%).

Tenosynovitis was detected in 20 patients (66.7%). Tibialis posterior tenosynovitis was observed in 20 patients (66.7%) and tibialis anterior tenosynovitis in 12 patients (40%). Bursitis was detected in 20 patients (66.7%), submetatarsal bursitis in 18 patients (60%), intermetatarsal bursitis in 15 patients (50%).

The Egyptian Rheumatologist; Vol. 30, No. 1, 2008: 1-6

6

Fig. 5: Sagittal STIR image showed tibiotalar synovitis and synovitis between the intermediate cuneiform and the base of the 2nd metatarsal distally and the intermediate cuneiform and the navicular bone proximally (TR=4901, TE=60).

DISCuSSION

Clinical, laboratory, and radiographic findings often differ in the early stages of RA, and at the time when erosions are first seen by conventional radiography, the disease is often quite established10. Because the effectiveness of any treatment for RA should be judged on preservation of joint structure, accurate measurement of joint pathology and reliable indicators of outcome are needed earlier in the disease process. In this context, MRI has become a valuable technique for early detection of bone erosions in RA.16

Therefore, the aim of our study was to evaluate the diagnostic value of hand and foot MRI in the early stages of RA. In order to use MRI to assess arthritis at the early stages of the disease, we focused on patients with disease duration between 2 and 6 months, who had not received treatment with DMARDs or corticosteroids, and in whom the conventional radiography of the hands and feet were normal. Secondarily, to detect the correlation between the MRI changes in the early stages of the disease and the disease activity score..

In this study, MRI was done on the clinically dominant hand and foot. The MRI features consistent with inflammation and erosions collectively were detected in 96.7% of our patients.

From the anatomical point of view, these MRI features were found in both hand and foot in 66.7% of patients, in the foot only in 20% of patients and in hand only in 10% of patients. This means that MRI changes were found in foot in 86.7% and in hand in 76.7% of patients.

From the pathological point of view, the first and most frequently observed MRI feature in the current study was the active synovitis that could not be detected by plain radiography. Since rheumatoid pannus is hypervascular, numerous studies have shown that intravenous administration of contrast material allows distinction between synovial proliferation and joint effusion17-20. Sugimoto’s study had shown that the introduction of this MRI criterion into the 1987 ARA revised criteria could improve diagnostic

performance in patients who are suspected of having early RA21. Active synovitis was found in 93.3% of our patients as a whole. In the hand, it was found in 76.7%; and specifically of the wrist and MCP joints, it was found in 76.7% and 70% of patients respectively. Active synovitis in the foot was found in 83.3% as a whole. In the hindfoot and MTP joints, it was observed in 60% and 83.3% respectively. Our results were comparable to Boutry’s study and higher than of the Ostendorf’s study13,17. In Boutry’s study, the synovitis in wrist, MCP and MTP were 93%, 90% and 97% respectively without hindfoot assessment17. In Ostendorf’s study, hand synovitis was detected in 48% while MTP synovitis was detected in all patients who did MRI foot and had normal MRI hand.13

The second most frequent MRI pathologic feature was the bone erosions. Bone erosions are more specific of early RA than synovitis. Once again, MRI has been shown to be more sensitive than plain radiography for the detection of bone abnormalities22. Bone erosions were found in 60% of our patients as a whole. In hand, it was detected in 43.3% and particularly in wrist and MCP joints in 40% and 43.3% respectively. Erosion in the foot was detected in 46.7% as a whole and particularly in hindfoot and MTP joints was observed in 36.7% and 40% respectively.

Several studies, however, have suggested that erosions occur in very early RA23-25. McQueen’s study26 and Klarlund’s study27 showed a carpal erosion prevalence of 45% and 50% respectively on MRI in early RA. These results were similar to our study but in contrast to the Boutry’s study that done on hand and MTP joints and showed a higher prevalence of erosions in wrist (80%) and MCP (77%) on average 5 months after the onset of the first symptoms17. In some reports, the capitate is the most common site for erosion26,28. Although it was frequently involved in our study (n=10), the triquetrum (n=11) was more frequently involved, consistent with Boutry’s observations17. The 2nd and 3rd MCP joints are also commonly involved in early RA15,17,29. We observed similar results. Among the few studies that investigate the role of MRI foot in early RA, our MTP erosions came higher than that of the Ostendorf’s study (10%) and lower than that of the Boutry’s study (77%)13,17. In the Ostendorf’s study, MRI foot done only for patients with normal MRI hand and not to all patients included in the study, and this might be responsible for the lower prevalence of MTP erosions13. Review of literature showed no previous MRI studies on the hindfoot in early RA.

The third pathologic feature was the bone marrow edema. MRI bone marrow edema is an important imaging feature in early RA as it contains information about two facts of rheumatoid joint disease likely to have a bearing on functional outcome: initial inflammatory activity, and the potential for erosion and development of structural joint damage30. It represents a cellular infiltrates within the bone; the histopathological studies suggest that a cellular infiltrate comprising lymphocytes and osteoclasts may be detected in subchondral bone and could mediate the development

El-Wakd1, Kamel - MRI Hand and Foot in Early Rheumatoid Arthritis with Normal Conventional Radiography

7

of erosions from the marrow towards the joint surface31. In the clinical studies, bone edema had been found to precede the development of frank erosions24,26 and the subchondral cysts32. It carries a 6.5-fold risk of bone damage at the same site within one year in McQueen’s study23 and was the strongest predictor of functional outcome at 6 years30. It is also speculated that bone edema may be reversible24,29. Bone edema was detected in 83.3% among all our patients. In the hand, it was observed in 66.7% of patients and specifically in wrist and MCP joints in 66.7% and 60% respectively. Bone edema in the foot was observed in 70% of patients and specifically in hindfoot and MTP joints was observed in 70% for each of them. Our results for hand edema was higher than of the Ostendorf’s study (36%) but was similar for the MTP edema (70%).13

The forth MRI feature was the tenosynovitis and is often found early in the course of RA33. As regard our patients; in the hand, it was found in 60% and frequently involved the flexor digitorum tendon. In the foot, it was found in 66.7% of patients and frequently involved the tibialis posterior tendon. Our results came in accordance with other studies. In Boutry’s study; hand tenosynovitis was found in 53% of cases and foot tenosynovitis in 60% of cases in accordance with previous reports.17,22,26,28

The last MRI feature was the foot bursitis and their recognition may constitute an additional predictor of early RA. In the present study, bursitis (Submetatarsal and intermetatarsal) was observed in 66.7% of our patients in accordance with the previous reports.17

Concerning the correlation between the disease activity measures and different MRI findings; our study demonstrated no correlation between the RAI, SJC, ESR, and hence DAS-3 among those with and without different MRI findings except the ESR which was statistically elevated in patients with erosion compared with that in patients without erosions.

In conclusion, in view of the current concept of a ‘window of opportunity’ early in the disease process, during which therapeutic intervention can alter the disease course and outcome, it is no longer acceptable to wait for bony lesions to appear in the plain radiography. And so, MRI hand and foot is important and should be done in early RA as it disclose the radiologic manifestations of the disease early and encourage the early use of the aggressive therapy aiming to improve the functional outcome of patients. Also, this was reinforced by the absence of correlation between the MRI findings and DAS-3. MRI foot is important in early RA being involved alone in 20% of our patients without detectable radiologic hand manifestations.

Corresponding author

REFERENCES

Peterfy CG. MRI of the wrist in early rheumatoid1. arthritis. Ann. Rheum. Dis. 2004 May; 63 (5): 473-7.

Clarke2. AE, St Pierre Y, Joseph L, Penrod J, Sibley JT, Haga M, et al. Radiographic damage in rheumatoid arthritis correlates with functional disability but not direct medical costs. J. Rheumatol. 2001 Nov; 28 (11): 2416-24.

Van der Heijde D. Radiographic3. progression in rheumatoid arthritis: Does it reflect outcome? Does it reflect treatment? Ann. Rheum. Dis. 2001 Nov; 60 Suppl 3: iii47-50.

Emery P. Evidence supporting the benefit of early4. intervention in rheumatoid arthritis. J. Rheumatol. Suppl. 2002 Nov; 66: 3-8.

Landewe RB. The benefits of early treatment in rheumatoid5. arthritis: Confounding by indication and the issue of timing. Arthritis Rheum. 2003 Jan; 48 (1): 1-5.

Paulus HE, Oh M6. , Sharp JT, Gold RH, Wong WK, Park GS, et al. Correlation of single time-point damage scores with observed progression of radiographic damage during the first 6 years of rheumatoid arthritis. J. Rheumatol. 2003 Apr; 30 (4): 705-13.

Dawes PT7. , Fowler PD. Treatment of early rheumatoid arthritis: A review of current and future concepts and therapy. Clin. Exp. Rheumatol. 1995 May-Jun; 13 (3): 381-94.

Young A, Van der Heijde8. DM. Can we predict aggressive disease? Baillieres Clin. Rheumatol. 1997 Feb; 11 (1): 27-48.

Emery P, Marzo H, Proudman S9. . Management of patients with newly diagnosed rheumatoid arthritis. Rheumatology (Oxford) 1999 Nov; 38 Suppl 2: 27-31.

Taouli B, Guermazi A10. , Sack KE, Genant HK. Imaging of the hand and wrist in RA. Ann. Rheum. Dis. 2002 Oct; 61 (10): 867-9.

Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF11. , Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988 Mar; 31 (3): 315-24.

Van der Heijde D. How to12. read radiographs according to the Sharp/Van der Heijde method. J. Rheumatol. 1999 Mar; 26 (3): 743-5.

Ostendorf B, Scherer13. A, Modder U, Schneider M. Diagnostic value of magnetic resonance imaging of the forefeet in early rheumatoid arthritis when findings on imaging of the metacarpophalangeal

The Egyptian Rheumatologist; Vol. 30, No. 1, 2008: 1-6

8

joints of the hands remain normal. Arthritis Rheum. 2004 Jul; 50 (7): 2094-102.

Ostergaard M14. , Peterfy C, Conaghan P, McQueen F, Bird P, Ejbjerg B, et al. OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRI acquisitions, joint pathology definitions and the OMERACT RA-MRI scoring system. J. Rheumatol. 2003 Jun; 30 (6): 1385-6.

Conaghan P, Edmonds J, Emery P, Genant H, Gibbon15. W, Klarlund M, et al. Magnetic resonance imaging in rheumatoid arthritis: summary of OMERACT activities, current status and plans. J.Rheumatol. 2001 May;28(5):1158-62.

Savnik A, Malmskov H16. , Thomsen HS, Graff LB, Nielsen H, Danneskiold Samsoe B, et al. MRI of the wrist and finger joints in inflammatory joint diseases at 1-year interval: MRI features to predict bone erosions. Eur. Radiol. 2002 May; 12 (5): 1203-10.

Boutry17. N, Larde A, Lapegue F, Solau Gervais E, Flipo RM, Cotten A. Magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis. J. Rheumatol. 2003 Apr; 30 (4): 671-9.

Kursunoglu Brahme S, Riccio T, Weisman18. MH, Resnick D, Zvaifler N, Sanders ME, et al. Rheumatoid knee: Role of gadopentetate-enhanced MR imaging. Radiology 1990 Sep; 176 (3): 831-5.

Konig H, Sieper J, Wolf KJ. Rheumatoid19. arthritis: Evaluation of hypervascular and fibrous pannus with dynamic MR imaging enhanced with Gd-DTPA. Radiology 1990 Aug;176 (2): 473-7.

Bjorkengren AG, Geborek P, Rydholm U, Holtas S, Petterson20. H. MR imaging of the knee in acute rheumatoid arthritis: Synovial uptake of gadolinium-DOTA. AJR Am. J. Roentgenol. 1990 Aug; 155 (2): 329-32.

Sugimoto H, Takeda A, Hyodoh K21. . Early-stage rheumatoid arthritis: Prospective study of the effectiveness of MR imaging for diagnosis. Radiology 2000 Aug; 216 (2): 569-75.

Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J22. , Wolf KJ, et al. Arthritis of the finger joints: A comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum. 1999 Jun;42 (6): 1232-45.

McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S23. , Tan PL, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement. Ann. Rheum. Dis. 1999 Mar; 58 (3): 156-63.

McGonagle24. D, Conaghan PG, O'Connor P, Gibbon W, Green M, Wakefield R, et al. The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: A controlled magnetic

resonance imaging study. Arthritis Rheum. 1999 Aug; 42 (8): 1706-11.

McGonagle D, Green M, Proudman S, Richardson C, Veale D, 25. et al. The majority of patients with rheumatoid arthritis have erosive disease at presentation when magnetic resonance imaging of the dominant hand is employed. Br. J. Rheumatol. 1997; 36 (Suppl 1): 121.

McQueen FM, Stewart N, Crabbe J, Robinson E26. , Yeoman S, Tan PL, et al. Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann. Rheum. Dis. 1998 Jun; 57 (6): 350-6.

Klarlund M, Ostergaard M27. , Jensen KE, Madsen JL, Skjodt H, Lorenzen I. Magnetic resonance imaging, radiography and scintigraphy of the finger joints: One year follow up of patients with early arthritis. The TIRA Group. Ann. Rheum. Dis. 2000 Jul; 59 (7): 521-8.

Pierre Jerome28. C, Bekkelund SI, Mellgren SI, Torbergsen T, Husby G, Nordstrom R. The rheumatoid wrist: Bilateral MR analysis of the distribution of rheumatoid lesions in axial plan in a female population. Clin. Rheumatol. 1997 Jan; 16 (1): 80-6.

Peterfy CG. Magnetic29. resonance imaging in rheumatoid arthritis: Current status and future directions. J. Rheumatol. 2001 May; 28 (5): 1134-42.

Benton N, Stewart30. N, Crabbe J, Robinson E, Yeoman S, McQueen FM. MRI of the wrist in early rheumatoid arthritis can be used to predict functional outcome at 6 years. Ann. Rheum. Dis. 2004 May; 63 (5): 555-61.

McQueen FM, Ostendorf B. What31. is MRI bone oedema in rheumatoid arthritis and why does it matter? Arthritis Res. Ther. 2006; 8 (6): 222.

Carrino JA32. , Blum J, Parellada JA, Schweitzer ME, Morrison WB. MRI of bone marrow edema-like signal in the pathogenesis of subchondral cysts. Osteoarthritis Cartilage 2006 Oct; 14 (10): 1081-5.

Grassi W33. , De Angelis R, Lamanna G, Cervini C. The clinical features of rheumatoid arthritis. Eur. J. Radiol. 1998 May; 27 Suppl 1: S18-24.

El-Wakd1, Kamel - MRI Hand and Foot in Early Rheumatoid Arthritis with Normal Conventional Radiography

9

View publication statsView publication stats