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Journal of Biomedical Research

Journal of Biomedical Research    2017, Vol. 31 Issue (2) : 162-169     https://doi.org/10.7555/JBR.31.20160088
Original Article |
Ultrasonographic evaluation of enthesitis in patients with ankylosing spondylitis
Huayong Zhang1,Jun Liang2,Junlan Qiu3,Fan Wang2,Lingyun Sun1()
1. Department of Rheumatologyand Immunology,
2. Departments of Rheumatology and Immunology,
3. 3Ultrasound Intervention, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China.
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Abstract

The aim of this study was to assess sensitivity and responsiveness of power Doppler ultrasound (PDUS) in detecting enthesitis for ankylosing spondylitis (AS) patients compared to clinical examinations. Twenty AS patients initiating etanerceptunderwent clinical and PDUS examinations of six bilateral entheseal sites at baseline and after 1, 2 and 3 months of treatment. Clinical and PDUS examinations identified at least one entheseal lesion in nine (45%) and 19 (95%) patients, respectively. Furthermore, of 240 entheseal sites examined in these 20 patients, PDUS detected 123 entheseal lesions (51.3% of sites), compared with only 47 entheseal lesions (19.6%) detected by clinical examination (P<0.05). The entheseal lesions found on PDUS were most commonly identified by calcification (33.3%), tendon edema (29.2%), abnormal blood flow (25.8%), a thickened tendon (22.1%), cortical irregularity (12.9%), bony erosions (9.6%) and bursitis at the tendon insertion to the bone cortex (7.1%). Improvements in clinical symptoms and laboratory parameters, and significant decreases in PDUS scores were observed following treatment with etanercept. Improvements in PDUS scores continued during follow-up in patients who entered remission following treatment. In conclusion, PDUS improves detection of structural and inflammatory abnormalities of the enthesis in AS compared to physical examination. In addition, PDUS may be useful inascertaining medications.

Keywords power Doppler ultrasound      enthesitis      ankylosing spondylitis     
Corresponding Authors: Lingyun Sun   
Issue Date: 22 March 2017
 Cite this article:   
Huayong Zhang,Jun Liang,Junlan Qiu, et al. Ultrasonographic evaluation of enthesitis in patients with ankylosing spondylitis[J]. Journal of Biomedical Research, 2017, 31(2): 162-169.
 URL:  
http://journal.hep.com.cn/jbr/EN/10.7555/JBR.31.20160088
http://journal.hep.com.cn/jbr/EN/Y2017/V31/I2/162
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Huayong Zhang
Jun Liang
Junlan Qiu
Fan Wang
Lingyun Sun
Characteristic Result (n=20)
Male/female, n 17/3
Age, years 25.5±9.6
Disease duration, years 4.3±3.1
BASDAI score 5.9±3.7
Extra-articular manifestations, n (%) 6 (30)
Patient VAS score, mm 64.5±27.7
Physician VAS score, mm 57.5±24.3
ESR, mm/hour 28±17
CRP, mg/L 21.6±14.8
Tab.1  Main clinical characteristics of 20 AS patients.
Fig.1  Pathological ultrasonographic appearances of Achilles tendon.

In a patient with ankylosing spondylitis, the pathological Achilles tendon is thickened and hypoechoic (↓). The fluid within the bursa mucosa exceeds normal ranges and can be accompanied by bursal hyperplasia (i.e., bursitis→). Bone irregularities are seen at the tendon enthesis insertion into the bone cortex (↑) (A). A blood-flow signal can be detected at the tendon insertion into the exposed bone cortex (B).

Entheseal abnormality
n (%)
Site
Lateral
humeral
epicondyle
The greater
trochanter
Quadriceps
tendon
ofthe femur
Tibial
tuberosity
Achilles
tendon
Plantar
aponeurosis
All sites
Calcification 16 (40.0) 30 (75.0) 17 (42.5) 10 (25.0) 3 (7.5) 4 (10.0) 80 (33.3)
Bone erosion 14 (35.0) 3 (7.5) 1 (2.5) 3 (7.5) 2 (5.0) 0 23 (9.6)
Bone irregularity 7 (14.5) 10 (25.0) 2 (5.0) 9 (22.5) 2 (5.0) 1 (2.5) 31 (12.9)
Tendon oedema 20 (50.0) 12 (30.0) 20 (50.0) 9 (22.5) 5 (12.5) 4 (10.0) 70 (29.2)
Thickening 7 (17.5) 6 (15.0) 11 (27.5) 13 (32.5) 11 (27.5) 5 (12.5) 53 (22.1)
Bursitis 0 0 1 (2.5) 5 (12.5) 11 (27.5) 0 17 (7.1)
Power Doppler 12 (30.0) 9 (22.5) 8 (20.0) 12 (30.0) 15 (37.5) 6 (15.0) 62 (25.8)
At least one PDUS abnormality 18 (45.0) 23 (57.5) 24 (60.0) 28 (70.0) 20 (50.0) 10 (25.0) 123 (51.3)
At least one clinical abnormality 7 (17.5) 3 (7.5) 14 (35.0) 7 (17.5) 13 (32.5) 3 (7.5) 47 (19.6)
Tab.2  PDUS and clinical manifestations of 240 tendon entheses.
Site Enthesitis with abnormal blood flow,
n(%)
Enthesitis without abnormal blood flow, n (%)
Stage 1 Stage
2a
Stage
3a
Total (1+2a+3a) Stage
2b
Stage 3b Total (2b+3b)
Lateral humeral epicondyle 3 (7.5) 7 (17.5) 2 (5.0) 12 (30.0) 4 (10.0) 2 (5.0) 6 (15.0)
Greater trochanter 5 (12.5) 7 (17.5) 6 (15.0) 18 (45.0) 3 (7.5) 2 (5.0) 5 (12.5)
Quadriceps tendon of the femur 8 (20.0) 6 (15.0) 6 (15.0) 20 (50.0) 4 (10.0) 0 4 (10.0)
Tibial tuberosity 6 (15.0) 5 (12.5) 9 (22.5) 20 (50.0) 7 (17.5) 1 (2.5) 8 (20.0)
Achilles tendon 3 (7.5) 7 (17.5) 5 (12.5) 15 (37.5) 2 (5.0) 2 (5.0) 5 (12.5)
Plantar aponeurosis 2 (5.0) 4 (10.0) 3 (7.5) 9 (22.5) 1 (2.5) 1 (2.5) 1 (2.5)
All sites 27 (11.3) 36 (15.0) 31 (12.9) 94 (39.2) 17 (7.1) 12 (5) 29 (12.1)
Tab.3  Staging of 123 abnormal entheseal sites.
Site Clinically positive enthesitis
(n = 47), n (%)
Clinically negative enthesitis
(n = 193), n (%)
Normal US US with abnormal blood flow US without abnormal blood flow Normal US US with abnormal blood flow US without abnormal
blood flow
Lateral humeral epicondyle 2 (28.6) 4 (57.1) 1 (14.3) 14 (41.2) 14 (41.2) 6 (17.6)
Greater trochanter 0 2 (66.7) 1 (33.3) 15 (48.4) 16 (51.6) 0
Quadriceps tendon of the femur 6 (42.9) 5 (35.7) 3 (21.4) 13 (36.1) 20 (55.6) 3 (8.3)
Tibial tuberosity 2 (28.6) 5 (71.4) 0 19 (54.3) 13 (37.1) 3 (8.6)
Achilles tendon 9 (69.2) 3 (23.1) 1 (7.7) 17 (60.7) 7 (25.0) 4 (14.3)
Plantar aponeurosis 2 (66.7) 1 (33.3) 0 20 (69.0) 9 (31.0) 0
All sites 21 (44.7) 20 (42.6) 6 (12.8) 98 (50.8) 79 (40.9) 16 (8.3)
Tab.4  Comparison of PDUS and clinical examination of entheses.
Fig.2  Ultrasonographic appearances of Achilles tendon before and after treatment in a patient with AS.

The Achilles tendon is not clear and hypoechoic (A, arrow), with a blood flow signal (B) before treatment. After three months of etanercept treatment, the ultrasonographic appearances reveals improvements in tendon structure (C) and blood flow (D).

Index/parameter Baseline Time post treatment
1 month 2 months 3 months
PDUS score 106 (77–136) 74 (51–89)** 51 (35–81)* 37 (29–63)*
BASDAI score 5.8 (4.1–8.0) 4.0 (3.2–7.0)** 2.8 (1.7–3.6)* 2.1 (0.9–2.8)
Patient VAS score 65 (45–88) 39 (35–60)** 27 (25–40)* 20 (10–28)
Physician VAS score 57 (35–75) 23 (14–35)** 15 (6–27) 11 (2–45)
ESR (mm/h) 28 (7–110) 13 (4–23)** 15 (2–43) 15 (5–77)
CRP (mg/L) 21 (0.2–82) 2 (0.2–21)** 3 (0.2–26) 3 (0.2–30)
Tab.5  PDUS scores and clinical parameters at baseline and after medical treatment
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