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The place of ultrasonography in knee joint

osteoarthritis: An update

Article · December 2011

DOI: 10.2217/ijr.11.59


2 56

4 authors, including:

Carlos Pineda C. Hernandez Díaz

Instituto Nacional de Rehabilitación Instituto Nacional de Rehabilitación


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Special Report

The place of ultrasonography in knee joint osteoarthritis:

an update

Ultrasound is gaining ground over conventional imaging methods in the assessment of musculoskeletal
changes in osteoarthritis. Systematic ultrasound scanning following established guidelines enables the
detection of even minimal and early abnormalities of cartilage, synovial tissue and subchondral bone.
Thus far, ultrasound has shown to be extremely sensitive in the detection of soft tissue changes in knee
osteoarthritis, including synovial proliferation and synovial fluid. Such abnormalities are correlated with
symptomatic flares and have associated prognostic implications. Although there has been some progression,
there is still a lack of standardization and validation over the definition and scoring of ultrasound signs

that are thought to reflect structural damage affecting different joint structures. Meanwhile, exciting
developments are expanding the applications of ultrasound in the musculoskeletal field; the application

of technologies such as sonoelastography, imaging coupling, 3D ultrasound and ultrasound contrast agents
in the field of osteoarthritis is expected to improve not only healthcare-related aspects but also our current
understanding of the pathophysiology of the disease.

keywords: cartilage n contrast-enhanced ultrasound n knee joint n menisci Carlos Pineda*1, Cristina
n ultrasound
n osteoarthritis n osteophytes n sonoelastography n subchondral bone n synovitis
Angelica Pena2 &
Pablo Villaseñor-Ovies1
Osteoarthritis (OA) is the most common form of joint capsule, cartilage and bone cortex [6] . 1
Musculoskeletal Ultrasound
arthritis and a leading cause of chronic disability, This endows US with exciting possibilities in Department, Instituto Nacional de
in large part due to lower extremity involvement. KOA, from outcome assessment and monitor- Rehabilitacion, Avenida Mexico-

Xochimilco No. 289, Arenal de

The knee is one of the most common joints ing therapeutic response, to understanding Guadalupe, Tlalpan, Mexico City
involved in OA. The prevalence of symptomatic pathogenesis and the role of inflammation. 14389, Mexico
Rheumatology Department, Instituto
knee OA (KOA) is reported to be as high as 16% Notwithstanding this, there is still a long way Nacional de Rehabilitacion, Mexico
in the elderly population [1,2] . to go. The recent systematic review in which City, Mexico

Author for correspondence:
Notwithstanding that the diagnosis of KOA is Keen et al. analyzed the overall usefulness of Tel.: +52 559 991 000 ext. 13227
based on symptoms and clinical findings, most US as an assessment tool in OA, arrived at carpineda@yahoo.com
cases require the assessment of structural damage two important conclusions [7] . First, the lack

through an imaging technique [3] . As in other of accepted definitions of US pathology in OA

joints, conventional radiography (CR), hitherto results in considerable heterogeneity between
the primary imaging tool in OA, shows late and studies and suboptimal quality regarding
indirect findings related to joint damage; what’s reports of the abnormal findings, their defini-

more, it has been long recognized that clinical tions and scoring. Also, data on validity of US
symptoms do not correlate with CR changes in as a tool for assessment in OA is scarce. This is
OA [4] . Joint space narrowing used in CR as a particularly true in the structural assessment of
surrogate of cartilage thickness, probably reveals bone and cartilage components of OA pathol-
little about cartilage health in early stages of the ogy. Box 1 shows the current indications, advan-
disease. More to the point, cartilage is not the tages and disadvantages of US as an assessment
only anatomic structure involved in the disease: device in KOA. The main purpose of this spe-
the capsule, ligaments, synovial membrane and cial report is to provide updated information
bursae may show structural abnormalities that about the value and current place of US in the
are invisible in CR. Thus, CR is far from an ideal assessment of OA of the knee. To accomplish
assessment tool of disease status and outcome this, pertinent literature published in the last
measure in OA [5] . 5 years was reviewed.
Ultrasound (US), on the other hand, offers
the possibility to depict different structures Scanning technique
within the knee in their finest details, includ- The US scan should follow a systematic tech-
ing the synovium, synovial f luid, menisci, nique [8] . However, variations in the acquisition

10.2217/IJR.11.59 © 2011 Future Medicine Ltd Int. J. Clin. Rheumatol. (2011) 6(6), xxx–xxx ISSN 1758-4272 1
Special Report Pineda, Hernández-Díaz, Pena & Villaseñor-Ovies

Box 1. Utility, advantages and limitations of ultrasound evaluation in knee

ƒƒ To corroborate clinical diagnosis
ƒƒ Detection of cartilage lesions
ƒƒ Detection of osteophytes, erosions and other cortical abnormalities
ƒƒ Identification of other typical structural abnormalities
ƒƒ To identify alternative sources of pain in a patient with or without an established diagnosis (i.e.,
anserine bursitis or iliotibial band syndrome)
ƒƒ To monitor structural damage progression
ƒƒ To evaluate pain exacerbation, especially related to inflammatory flares
ƒƒ Detection of joint effusion
ƒƒ Detection of synovial hypertrophy
ƒƒ To execute US-guided procedures
ƒƒ Safe, no contraindications

ƒƒ No ionizing radiation exposure
ƒƒ Noninvasive

ƒƒ Can be performed with prosthetic devices
ƒƒ Broadly available
ƒƒ Low running cost
ƒƒ Portable equipments (bedside procedure)
ƒƒ Well accepted by patients
ƒƒ Only mildly time consuming
Studies may be repeated several times
ƒƒ Multiregional and multistructural assessment
ƒƒ Dynamic assessment
ƒƒ Furthers the precision and understanding of clinical manoeuvres
ƒƒ Contralateral assessment easily done

ƒƒ Operator dependant
ƒƒ Long learning curve
ƒƒ Limited acoustic windows
ƒƒ Partial evaluation of the meniscus

ƒƒ Partial evaluation of the femoral cartilage

ƒƒ Limited evaluation of the cruciate ligaments
ƒƒ Unable to visualize the patelofemoral joint

ƒƒ Not fully validated for KOA

ƒƒ Lack of standardized definitions of OA pathology
KOA: knee osteoarthritis; OA: osteoarthritis; US: ultrasound.

technique such as voluntary quadriceps contrac- „„ Cartilage


tion with extended knee and varying degrees KOA results from both mechanical and biologi-
of flexion of the joint have been suggested to cal events that destabilize the normal coupling
increase sensitivity to detect joint effusion [9] . of degradation and synthesis of chondrocytes
The most sensitive position to detect fluid in and extracellular matrix; progressive degenera-
knee joints is at 30° flexion. A comprehensive tion with loss of cartilage and hypertrophy of
joint evaluation including dynamic examina- the subchondral bone are the most representative
tion of the anatomic recesses will provide infor- findings of the disease [11] . The US appearance of
mation about the presence and distribution of cartilage in the knee affected by OA is initially
both, synovial hypertrophy and joint effusion, characterized by a loss of the sharp contour and
providing targets for accurate interventional variations in the echogenicity of the cartilage
procedures [10] . matrix; these may be observed at the lateral
femoral condyle, medial condyle and inter-
OA pathology & US abnormalities chondylar notch. Initially, the chondrosynovial
OA arises from a chain of events that lead to margin becomes blurred and the clarity of the
abnormal remodeling affecting different com- cartilage layer is decreased. Later, an asymmet-
ponents of the joint anatomy (Table 1) . ric narrowing of the cartilage layer takes place;

2 Int. J. Clin. Rheumatol. (2011) 6(6) future science group

The place of ultrasonography in knee joint osteoarthritis: an update Special Report
Table 1. Joint elements and ultrasound findings in knee osteoarthritis.
Component Main ultrasound findings
Structural damage
Cartilage Loss of normal sharpness;
Heterogeneous structure;
Irregularities in thickness.
Subcondral bone Cortical irregularities;
Bone erosions†: an intra-articular discontinuity of the bone surface that
is visible in two perpendicular planes;
Osteophytes: characteristic bone step-ups of the bone profile, located
at the edges of the joint surfaces, with or without acoustic shadow.
Meniscus Extrusion or subluxation, with or without displacement of collateral
Tendons and ligaments Coexistence of soft tissue abnormalities;
Early loss of thickness of quadriceps tendon.
Inflammatory markers

Synovial hypertrophy† Abnormal hypoechoic intra-articular tissue that is nondisplaceable and
poorly compressible that may exhibit Doppler signal.

Synovial fluid† Fluid collection within the joint, defined as abnormal hypoechoic or
anechoic intra-articular material that is displaceable and compressible
but does not exhibit Doppler signal.

These definitions were generated by the Outcome Measures in Rheumatoid Arthritis Clinical Trials
(OMERACT) by consensus for common pathological lesions seen in patients with inflammatory
arthritis, mainly rheumatoid arthritis [43] . Their use has extended to include conditions that are not of
a pure inflammatory nature, like osteoarthritis.

nearly complete loss of articular cartilage can association between bone marrow abnormalities
be observed in patients with most advanced OA outlined in MRI and subchondral cystic changes
[12] . Studied ex vivo in a group of patients with in the joint [16] . In any case, chronic damage to

KOA programmed for arthroplasty, these US subchondral bone results in new bone formation.
findings showed good correlation with OA histo- The early bone changes in KOA are detected
logical scores and individual findings included: as hyperechoic signals in the area of the attach-
cartilage flaking and fibrillation, chondrocyte ment of the joint capsule to the osteocartilagi-

enlargement, hyalinization, pitting and cartilage nous margin, where osteophytes as step-ups of
loss [13] . Furthermore, Naredo et al. studying bony prominences at the end of the normal bone
cadavers demonstrated that US measurement of contour, with or without posterior shadow, are

the femoral condylar thickness is highly repro- often depicted [12] . Nevertheless, it is important
ducible and accurate when compared with direct to acknowledge that the validity of US-detected
measurements of the cartilage thickness [14] . cortical changes in OA, including osteophytes,
enthesophytes, cortical irregularities and ero-

„„ Subchondral bone sions, needs further investigation. For example,

Although it remains unknown whether the studies addressing the performance and validity
changes observed in the subchondral bone pre- of US in detecting knee osteophytes, one of the
cede or follow the onset of OA, several studies cardinal features of the disease, did not appear
point towards an active role of the subchondral in our review of the literature. Our group has
bone in the pathogenic pathways that take place recently proposed a simple scoring system to
in OA. Its partaking probably occurs through assess severity of KOA, which is essentially based
various mechanisms including defects in its on sonographic characteristics of cortical abnor-
shock absorbent properties, osteocyte dysfunc- malities, particularly osteophytes [17] (Figure 1) .
tion and the production of soluble substances
that regulate both bone and cartilage turnover „„ Meniscus
and immune function. In addition, a crucial role The menisci of the knee are crescent-shaped
is believed to be played by the vascular invasion fibrocartilage wedges that lie between the con-
of bone marrow tissue into this region, con- dyles of the femur and the tibia. The menisci act
tributing to the degradation of adjacent hya- to disperse the weight of the body and reduce
line cartilage [15] . This may explain the strong friction during movement. In KOA, US often

future science group www.futuremedicine.com 3

Special Report Pineda, Hernández-Díaz, Pena & Villaseñor-Ovies

Figure 1. Osteophytes defined as a bony prominence at the end of the normal bone
contour or at the margin of the joint seen in two perpendicular planes, with or without
acoustic shadow. A semi-quantitative scale according to the size of the outgrowth was used; (A)
minimum (B) mild (C) moderate (D) severe.

shows protrusion of the meniscus as a rounded pain exacerbation [23] . Accordingly, de Miguel-

hyperechoic structure that projected out of the Mendieta et al. showed that patients with KOA
tibia plateau and femoral condyle habitually dis- and recent onset pain had higher prevalence of
placing the collateral ligaments. This sign needs Baker`s cyst and joint effusion, as compared with
further standardization and validation, however painless OA knees [18] . In agreement with this,

it has been described in 40–58% of patients with both suprapatellar pouch effusion and synovitis
KOA [18,19] and it seems to be correlated with correlate with pain and functionality [24] . On the
joint space narrowing and pain [20,21] . other hand, sonographic inflammation markers

have also been observed in an important propor-

„„ Tendons & ligaments tion of patients not selected by their pain-flare
Soft tissue involvement often coexists with status [25] . Joint effusion as a proxy for inflam-
KOA. US examination is often useful in reveal- mation is fairly common in KOA and can occur

ing disruption of the periarticular tissue that with or without synovitis [26] . Fluid in the knee
contributes to symptoms and disability in vari- appears as an anechoic intra-articular signal,
ous stages of the disease (i.e., anserine bursitis). with variable distribution and often presents in
Nevertheless, US examination may also be multiple compartments, with the most common
important in early KOA providing informa- site being the suprapatelar pouch (Figure 2) [27] .
tion about soft tissue involvement. Monteforte New high frequency probes are able to detect
et al. demonstrated diminution of thickness and even minimal amounts of fluid [28] . In a large
quadriceps tendons in patients with early KOA prospective study of painful KOA [29] , the pre-
as compared with healthy controls [22] . dictive potential of different disease variables was
analyzed using joint replacement as the outcome
„„ Synovium & synovial fluid measure. Among the two sonographic variables
Inf lammation is frequently ascertained in that were studied, effusion and synovitis, only
KOA particularly during flares of knee pain. the first was a predictor of joint replacement,
Approximately 50% of patients with these char- even after adjustment for other characteristics
acteristics show US evidence of synovitis and/ of the disease. This study established that a
or effusion as a possible explanation for their feature of synovial inflammation in KOA is an

4 Int. J. Clin. Rheumatol. (2011) 6(6) future science group

The place of ultrasonography in knee joint osteoarthritis: an update Special Report

Figure 2. Spectrum of soft tissue and structural joint damage in knee osteoarthritis. (A)
Asymmetric narrowing of the cartilage layer (marked by the dotted line). (B) Meniscal protrusion
(arrow) with displacement of medial collateral ligament (arrow-head). (C) Short axis view of the
suprapatelar pouch showing synovitis (synovial hypertrophy [★] and effusion [†]). (D) Power Doppler
image of the suprapatelar pouch demonstrating synovial hypervascularity.

independent predictor of joint replacement. The

conventional US equipment but using additional
fact that US-detected effusion but not clinically software [33] . The feasibility of US elastogra-
detected effusion was a predictive variable shows phy of articular cartilage employing instanta-
that the greater sensitivity that US has over clini- neous static compression, using high-resolution
cal examination in the detection of joint effusion (55 MHz) US elastography in vitro as a potential
[30] has important predictive consequences. arthroscopic technique has been developed by

Popliteal cysts appear as hypoechoic or Ginat et al. [34] .

anechoic masses arising between the semimem-
branous and medial head of gastrocnemius mus- „„ Hybrid imaging modalities
cles with the knee in full extension [31] . Popliteal The role of new hybrid imaging techniques

cysts appear in 15–36% of patients with KOA integrated within the US equipment, enable the
and seem to be more prevalent in symptomatic fusion of real-time MRI and US images. This
OA [18] . technique has been used to study the small joints

in patients with OA and rheumatoid arthritis,

Technological innovations concluding that fusion imaging offers a compos-
Technological progress takes the form of useful ite set of information with accurate anatomical
applications that may add considerable value to correlations [35] . The application of fusion tech-

US assessment of KOA and is currently repre- niques in large joints remains to be evaluated.
sented by the development of new software, vol-
umetric probes and intraoperating arthroscopic „„ 3D US techniques
transducers. It is additionally represented by the The presence of an elementary OA lesion, syno-
application of sonoelastography, fusion imaging vial hypertrophy, was evaluated by means of 3D
and 3D-US techniques. US along with synovial fluid analysis including
concentrations of vascular endothelial growth
„„ Sonoelastography factor, TGF‑b and serum inflammatory mark-
Sonoelastography is an ultrasonographic imag- ers in 22 KOA patients. Stereoscopic views of
ing technique that allows a noninvasive estima- proliferative synovium ranged from simple pro-
tion of tissue stiffness [32] . It is based on the liferations to shrubby structures. Growth factors
fact that soft tissues have greater displacement were significantly higher in patients with com-
than hard tissue when externally compressed. plex synovial proliferation. 3D technology was
Sonoelastography allows calculation and com- useful in delineating the synovium shape. This
parison of tissue displacement before and advanced imaging technique may have a possible
after tissue compression. It is performed with impact on future imaging in rheumatology [36] .

future science group www.futuremedicine.com 5

Special Report Pineda, Hernández-Díaz, Pena & Villaseñor-Ovies

However, as stated by Chao and Jalunian, 3D advanced KOA. The authors suggested that pho-
power Doppler US is yet to be formally studied noarthrography and US can be used as param-
in OA. The ability to image the synovial vascular eters for following up cartilage in KOA [39] .
tree may improve our understanding of the role
of angiogenesis in OA, allowing us to compare „„ Contrast-enhanced US
its nature and extent with those of the inflam- US contrast agents enhance blood scattering
matory arthritides [28] . reflection and increase the sensitivity of Doppler
signals. Microbubble contrast agents improve
„„ Biomarkers & US findings detection of low-volume blood flow in small ves-
Little is known about the relationship between sels by increasing the signal-to-noise ratio and
US findings and metabolism of bone and carti- thereby facilitating detection of angiogenetic
lage. Jung et al. studied 51 patients with estab- vessels in inflammatory conditions. Recently,
lished KOA exploring the relationship between contrast-enhanced US (CE‑US) was studied
US changes and synovial-cartilage biomarkers. in 41  patients with painful KOA. Compared
They observed that serum levels of hyaluronic with B‑mode grey scale US, power Doppler US
acid were significantly higher in patients with a showed greater capability to detect inflammation

greater degree of effusion and/or synovial prolif- (64 vs. 58%) at the suprapatellar pouch. Still,
eration, longer medial ostephytosis and capsular when a contrast agent was used, inflammation

distension, as compared with patients with less was detected in 95% of patients. Interestingly,
severe changes. Medial osteophytes and knee inflammation was detected in a lower propor-
joint distension also correlated with levels of car- tion of patients (82%) when contrast-enhanced
tilage oligomeric matrix protein. In addition, the MRI (CE‑MRI) was used. While this could
serum osteocalcin levels did not show any asso- imply that CE‑US has greater sensitivity than
ciation with US findings [37] . Recently, Kumm CE‑MRI to detect inflammation in OA, it may
et al. investigated the association between US have also been the result of a higher rate of false
findings in early-stage, symptomatic KOA and positive results and therefore less specificity; fur-
biomarkers of bone and cartilage metabolism in ther studies using different reference standards
106 individuals. Six different assays were used are required to solve this issue [40] .
for the assessment of bone/cartilage metabolism. The degenerative process of OA may be

Typical US signs of inflammation, including accompanied by nondestructive synovitis that

joint effusion, synovial hypertrophy, and Baker’s has been confirmed in KOA by arthroscopy his-
cysts were metabolically mirrored by biomarker tology and US [41] . The mechanism of painful
levels (urinary level of the C‑telopeptide frag- KOA is not clearly established. Among the pain

ments of type II collagen, serum concentration mediators are bradykinins. Icatibant, a brady-
of type II A procollagen amino–terminal pro- kinin receptor‑2 antagonist has been reported
peptide and cartilage oligomeric matrix pro- to have an analgesic effect in KOA, however, its

tein) among women. Synovitis was correlated role in the inflammatory process is not clear. A
with an increased synthesis of type I collagen randomized, double-blind, placebo-controlled
and decreased expression of type II collagen in study comparing CE‑US using sulfur hexafluo-
premenopausal women. The authors confirmed ride microbubbles (SonoVue®) to CE‑MRI in

that US findings in soft tissue played a major assessing the antiinflammatory and analgesic
role in the variability of biomarkers of bone effects of icatibant was performed. Good agree-
and cartilage metabolism in patients with early- ment was observed between the two imaging
stage KOA [38] . In a different study that aimed techniques in the assessment of inflammatory
to examine the relationship between three dif- changes in KOA. The analgesic effect of the
ferent parameters: phonoarthrography (a mea- study drug was clearly shown. However, the
surement system based on analysis of high fre- authors could not find an antiinflammatory
quency acoustic emission signals for assessing effect by CE‑US. Only CE‑MRI of the lateral
the dynamic integrity of knee joints), US and recess demonstrated a statistically significant
biochemical markers and the severity of KOA, improvement in the icatibant group, but this
Bassiouni et al. studied 100 osteoarthritic knees might have been an incidental finding [42] .
together with 50 normal knees. Results showed Exciting developments are expanding the
that phonoarthrography values were inversely applications of US in the musculoskeletal field,
correlated with cartilage thickness. Mean levels offering the advantages of real-time perfor-
of matrix metalloproteinase‑3 and tissue inhibi- mance, high tissue resolution and relative speed
tor of proteinase were significantly elevated in at a reasonable cost.

6 Int. J. Clin. Rheumatol. (2011) 6(6) future science group

The place of ultrasonography in knee joint osteoarthritis: an update Special Report
Conclusion & future perspective process, classification, progression and response
US is a safe, low cost, useful tool that provides an to therapy.
extensive evaluation of the different structures Newer modalities in US enhance spatial reso-
within the knee and their involvement in the lution and the ability to detect subtle inflam-
degenerative process that prominently affects mation with exciting possibilities in OA from
this joint. US enables rheumatologists a straight- disease monitoring to understanding pathogen-
forward detection of structural damage such as esis. Unfortunately, new technologies will come
cartilage degeneration and new bone formation. with higher costs and increased complexity to
Yet, scientific studies that submit US through the issue of standardization.
the different components of the Outcome
Measures in Rheumatoid Arthritis Clinical Acknowledgments
Trials (OMERACT) filters in OA are expected The authors wish to thank Monica Macias, Luis Enrique
to appear in the next few years. Standardization Martinez and Araceli Bernal, who provided important sug-
of US findings will enable the generation of gestions, information and ideas for the manuscript.
damage scoring systems in KOA which will in
turn provide the grounds of much needed dis- Financial & competing interests disclosure

ease monitoring and therapy evaluation. The authors have no relevant affiliations or financial
On the other hand, US is an excellent and involvement with any organization or entity with a

inexpensive imaging technique to detect syno- financial interest in or financial conflict with the subject
vitis, and this has offered the grounds to estab- matter or materials discussed in the manuscript. This
lish its association with symptom flares and in includes employment, consultancies, honoraria, stock own-
the long term with negative disease outcomes ership or options, expert testimony, grants or patents received
(joint replacement). It is fair to anticipate the or pending, or royalties.
upcoming of US studies that will show the rel-
PrNo writing assistance was utilized in the production of
evance of the inflammatory flares in the disease this manuscript.

Executive summary
ƒƒ Imaging is mandatory in the evaluation of knee osteoarthritis (KOA).

ƒƒ Conventional radiography is far from an ideal assessment method of osteoarthritis.

ƒƒ Ultrasound (US) is being increasingly recognized as a powerful tool in the diagnosis, evaluation of extent and follow-up of patients with

ƒƒ The use of a methodical technique is necessary for accurate and global evaluation of the knee joint.
US findings, value & meaning
ƒƒ US shows knee joint changes both in early and late disease KOA.

ƒƒ US has great value in demonstrating inflammatory signs in KOA.

ƒƒ US has still to show it is an accurate and reproducible method to identify structural abnormalities. Once this is accomplished,
rheumatologists will have a powerful tool for monitoring of disease progression and response to therapy.
Technological innovations

ƒƒ Technological developments may add significant value to US assessment of KOA in the near future. Some of the most promising ones
are: imaging fusion, sonoelastography and 3D US.

References 3 Altman R, Asch E, Bloch D et al. 6 Keen H, Conaghan P. Usefulness of

Papers of special note have been highlighted as: Development of criteria for the classification ultrasound in osteoarthritis. Rheum. Dis.
n of interest and reporting of osteoarthritis. Classification Clin. North. Am. 35, 503–519 (2009).
nn of considerable interest of osteoarthritis of the knee. Arthritis Rheum. 7 Keen H, Wakefield R, Conaghan P. A
29, 1039–1049 (1986). systematic review of ultrasonographty in
1 Peláez-Ballestas I, Helena-Sanin L,
Moreno-Montoya J et al. Epidemiology of the 4 Hannan M, Felson D, Pincus T. Analysis of osteoarthritis. Ann. Rheum. Dis. 68, 611–619
rheumatic diseases in México. A study of the discordance between radiographic (2009).
5 regions based on the COPCORD changes and knee pain in osteoarthritis of nn An updated systematic review that
methodology. J. Rheumatol. 38(Suppl. 86), the knee. J. Rheumatol. 27, 1513–1517
addresses strengths and weaknesses of
3–8 (2011). (2000).
ultrasound as a tool to evaluate
2 Felson D, Naimark A, Anderson J et al. 5 Wenham C, Conaghan P. Imaging the osteoarthritis. Based on its findings, an
The prevalence of knee osteoarthritis in painful osteoarthritic knee joint: what have agenda towards ultrasound validation and
the elderly. Arthritis Rheum. 30, 914–918 we learned? Nat. Clin. Pract. Rheum. 5, standardization is suggested.
(1987). 149–158 (2009).

future science group www.futuremedicine.com 7

Special Report Pineda, Hernández-Díaz, Pena & Villaseñor-Ovies

8 Backhaus M, Burmester G, Gerber T et al. 22 Monteforte P, Sessarego P, Rovetta G. Eng. Med. Biol. Soc. (Suppl.) 6644–6647
Guidelines for musculoskeletal ultrasound in Sonographic assessment of soft tissue (2006).
rheumatology. Ann. Rheum. Dis. 60, 641–649 alterations in osteoarthritis of the knee. 35 Iagnocco A, Perella C, D’Agostino MA et al.
(2001). G. Ital. Med. Lav. Erg. 30, 75–77 (2008). Magnetic resonance and ultrasonography
9 Ike R, Somers E, Arnold E, Arnold W. 23 D`Agostino M, Conaghan P, Le Barse M et al. real-time fusion imaging of the hand and wrist
Ultrasound of the knee during voluntary EULAR report on the use of ultrasonography in osteoarthritis and rheumatoid arthritis.
quadriceps contraction: a technique for in painful knee osteoarthritis. Part 1: Rheumatology (Oxford) 50(8), 1409–1413
detecting otherwise occult effusions. Arthritis prevalence of inflammation in osteoarthritis. (2011).
Care Res. 62, 725–729 (2010). Ann. Rheum. Dis. 64, 1703–1709 (2005). 36 Ju JH, Kang KY, Kim IJ et al. Three-
10 Mandl P. Ultrasound of the knee: how to 24 Naredo E. Usón J, Moragues J et al. dimensional ultrasonographic application for
differentiate between normal and abnormal Ultrasonographic findings in knee analyzing synovial hypertrophy of the knee in
amounts of fluid. Ann. Rheum. Dis. osteoarthritis. A nation-wide study in Spanish patients with osteoarthritis. J. Ultrasound
70(Suppl. 3), 30 (2011). patients. Osteoarthritis Cartilage 15, C159 Med. 27(5), 729–736 (2008).
11 Bijlsma J, Berenbaum F, Lafeber F. (2007). 37 Jung YO, Do JH, Kang HG et al. Correlation
Osteoarthritis: an update with relevance for 25 Iagnocco A, Meenagh G, Riente L et al. of sonographic severity with biochemical
clinical practice. Lancet 377, 2115–2126 Ultrasound imaging for the markers of synovium and cartilage in knee
(2011). rheumatologist XXIX. Sonographic osteoarthritis patients. Clin. Exp. Rheumatol.
12 Möller I, Bong D, Naredo E et al. Ultrasound assessment of the knee in patients with 24, 253–259 (2006).

in the study and monitoring of osteoarthritis. osteoarthritis. Clin. Exp. Rheum. 28, 38 Kumm J, Tamm A, Lintrop M, Tamm A.
Ostearthritis Cartilage 16, S4–S7 (2008). 643–646 (2010). Association between ultrasonographic

13 Tsai C, Lee C, Chai C et al. The validity of 26 Kristoffersen H, Torp-Pedersen L, Terslev E findings and bone/cartilage biomarkers in
in vitro ultrasonographic grading of et al. Indications of inflammation visualized patients with early-stage knee osteoarthritis.
ostearthritic femoral condylar cartilage – a by ultrasound in osteoarthritis of the knee. Calcif. Tissue. Int. 85, 514–522 (2009).
comparison with histology grading. Acta Radiologica. 47, 281–286 (2006). n Highlights the association between tendon
Osteoarthritis Cartilage 15, 245–250 (2007). 27 Meenagh G, Filippucci A, Iagnocco A et al. calcification, synovial thickening and
14 Naredo E, Acebes C, Möller I et al.
Ultrasound imaging for the
rheumatologist VIII. Ultrasound imaging in
suprapatellar effusion and bone/cartilage
Ultrasound validity in the measurement of biomarkers in early-stage knee osteoarthritis.
knee cartilage thickness. Ann. Rheum. Dis. osteoarthritis. Clin. Exp. Rheum. 25, 172–175
39 Bassiouni HM, El-Deeb M, Kenawy N,
68, 1322–1327 (2009). (2007).
Abdul-Azim E, Khairy M. Phonoarthrography,
15 Punzi L, Oliviero F, Ramonda R. New 28 Chao J, Jalunian K. Ultrasonography in musculoskeletal ultrasonography, and
horizons in osteoarthritis. Swiss. Med. Wkly osteoarthritis: recent advances and prospects biochemical biomarkers for the evaluation of

140, 1–13 (2010). for the future. Curr. Opin. Rheum. 20, knee cartilage in osteoarthritis. Mod.
560–564 (2008). Rheumatol. 21(5), 500–508 (2011).
16 Roemer FW, Frobell R, Hunter DJ et al.
MRI-detected subchondral bone marrow 29 Conaghan P, D`Agostino M, Le Barse M et al. 40 Song IH, Althoff CE, Hermann KG et al.
signal alterations of the knee joint: Clinical and ultrasonographic predictors of Knee osteoarthritis efficacy of a new method
terminology, imaging appearance, relevance joint replacement for knee osteoarthritis: of contrast-enhanced musculoskeletal

and radiological differential diagnosis. results from a large, 3 year, prospective ultrasonography in detection of synovitis in
Osteoarthritis Cartilage 17(9), 1115–1131 EULAR study. Ann. Rheum. Dis. 69, patients with knee osteoarthritis in
(2009). 644–647 (2010). comparison with magnetic resonance imaging.

17 Hernández-Díaz C, León-Hernández R, n Established that one ultrasound feature of Ann. Rheum. Dis. 67(1), 19–25 (2008).
Bernal A et al. Simplified ultrasound scoring synovial inflammation in osteoarthritis – n Evaluates the usefulness of contrast-enhanced
system to assess knee osteoarthritis: a proposal. joint effusion is, among other variables, an ultrasound in osteoarthritis. A major finding
Ann. Rheum. Dis. 70(Suppl. 3), 370 (2011). independent predictor of joint replacement. was that contrast-enhanced ultrasound found

18 de Miguel-Mendieta E, Cobo-Ibañez T, 30 Young Hong B, Seon Hoon L, Rim Cho Y inflammation in a greater proportion of
Uson-Jaeger J et al. Clinical and et al. Detection of knee effusion by patients than contrast-enhanced MRI,
ultrasonographic findings related to knee pain ultrasonography. Am. J. Phys. Med. Rehabil. suggesting greater sensitivity.
in osteoarthritis. Osteoarthritis Cartilage 14, 89, 715–721 (2010). 41 Benito MJ, Veale DJ, Fitzgerald O, van den
540–544 (2006). 31 Keen H, Conaghan P. Usefulness of Berg WB, Bresnihan B. Synovial tissue
19 Naredo E, Cabero F, Palop M et al. ultrasound in osteoarthritis. Rheum. Dis. inflammation in early and late osteoarthritis.
Ultrasonographic findings in knee Clin. North. Am. 35, 503–519 (2009). Ann. Rheum. Dis. 64(9), 1263–1267 (2005).
osteoarthritis. A comparative study with 32 Hall TJ. AAPM/RSNA physics tutorial for 42 Song IH, Althoff CE, Hermann KG et al.
clinical and radiographic assessment. residents: topics in US beyond the basics – Contrast-enhanced ultrasound in monitoring
Osteoarthritis Cartilage 13, 568–574 (2005). elasticity imaging with US. Radiographics the efficacy of a bradykinin receptor‑2
20 Iagnocco A. Imaging the joint in 23(6), 657–671 (2003). antagonist in painful knee osteoarthritis
osteoarthritis: a place for ultrasound? Best 33 Garra BS. Imaging and estimation of tissue compared with magnetic resonance imaging.
Pract. Res. Clin. Rheumatol. 24, 27–38 (2010). elasticity by ultrasound. Ultrasound Q. 23(4), Ann. Rheum. Dis. 68(1), 75–83 (2009).
21 Checa A. Significance of meniscus extrusion 255–268 (2007). 43 Wakefield R, Balint P, Szkudlarek M et al.
in chondrocalcinosis. a sonographic and 34 Ginat DT, Hung G, Gardner TR, Konofagou Musculoskeletal ultrasound including
arthroscopic perspective. J. Rheumatol. 35, EE. High-resolution ultrasound elastography definitions of ultrasonographic pathology.
1676 (2008). of articular cartilage in vitro. Conf. Proc. IEEE J. Rheumatol. 32, 2485–2487 (2005).

8 Int. J. Clin. Rheumatol. (2011) 6(6) future science group

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