Elsevier

Joint Bone Spine

Volume 80, Issue 3, May 2013, Pages 295-300
Joint Bone Spine

Original article
Polyarticular sonographic assessment of gout: A hospital-based cross-sectional study

https://doi.org/10.1016/j.jbspin.2012.09.017Get rights and content

Abstract

Objective

To assess the sonographic frequency of synovial effusion, synovial hypertrophy, synovitis, and double contour sign at joints commonly affected by gout and whether these features differ according to serum urate levels, disease duration, and use of urate-lowering therapy.

Methods

Participants with gout were recruited from rheumatology clinics. A detailed clinical assessment was undertaken of gout history, co-morbidities, medication, alcohol consumption, height, weight, clinical synovitis, tophi, and serum urate. Sonographic examination of the metatarsophalangeal joints, ankles, knees, metacarpophalangeal joints, wrists and elbows for synovial effusion, synovial hypertrophy, synovitis and double contour sign was undertaken. The mean number of joints affected were compared according to serum urate (< 360 μmol/L versus  360 μmol/L), urate-lowering therapy (yes/no), and disease duration (≤ 5 years versus > 5 years).

Results

Forty patients participated in the study. Synovial effusion, synovial hypertrophy, synovitis, and double contour sign were identified in 36 (90%), 38 (95%), 24 (62%) and 37 (93%) participants respectively. Synovial effusion was seen most frequently at the knee (right 70%, left 68%) followed by the first metatarsophalangeal (right 48%, left 40%) and lesser metatarsophalangeal joints (right 45%, left 35%). Synovial hypertrophy, synovitis, and double contour sign were seen most frequently at the first metatarsophalangeal joint (hypertrophy: right 65%, left 60%; synovitis: right 18%, left 18%; double contour: right 60%, left 68%). These findings did not differ according to serum urate, disease duration, or use of urate-lowering therapy.

Conclusion

Polyarticular sonography frequently identifies synovial effusion, synovial hypertrophy, synovitis and double contour sign in patients with gout, particularly at the metatarsophalangeal joints and knees.

Introduction

Gout is one of the most prevalent inflammatory arthropathies. The classical initial manifestation of gout is acute onset of severe joint pain, most commonly affecting the 1st metatarsophalangeal joint (MTP joint), with associated swelling, erythema and exquisite tenderness. Such attacks typically resolve completely, even without treatment, although most patients experience recurrent acute attacks and may go onto develop a chronic erosive arthropathy, with characteristic radiographic appearances, or clinically detectable subcutaneous tophaceous deposits. With such classical presentations, diagnosis is relatively straightforward although definitive diagnosis requires monosodium urate (MSU) crystals to be identified by compensated polarised light microscopy of synovial fluid or tophaceous material [1]. However, clinical presentation can be atypical and diagnosis challenging. Joints characteristically affected by gout such as the 1st MTP joint and mid-tarsal joints, are not always easily amenable to joint aspiration, particularly by non-specialists.

Hence, there has been recent interest in using novel imaging modalities to diagnose gout [2], [3], [4], [5], [6], [7], [8], [9], [10]. Musculoskeletal sonography has the advantages of providing “real-time”, dynamic, high resolution images at low-cost and is becoming increasingly seen as part of everyday clinical practice in rheumatology [11], [12], [13]. Previous sonographic studies of gout have reported frequent synovial effusion, synovial hypertrophy, synovitis, and erosion even at asymptomatic joints during the intercritical period or at 1st MTP joints that have never been affected by gout [3], [4], [6]. Furthermore, the double contour sign, hyperechoic enhancement of the superficial margin of the articular cartilage, has been described as a specific sonographic feature of gout. The double contour sign was seen in 22% of 1st MTP joints in patients with gout in one study, and in at least one knee in 44% of gout patients in another study, but was absent in disease controls and normal subjects [4], [5]. However, these studies have focused largely on the 1st MTP joint or knee [4], [5], [6] with one further study recently describing findings at the MTP joints, knees and metacarpophalangeal joints (MCP joints) [9]. The only studies to have examined sonographic findings at other joint sites have examined only clinically symptomatic joints [3], [8].

In this cross-sectional observational study, we undertook a systematic sonographic examination of joints commonly affected by gout, irrespective of current or previous clinical involvement, in order:

  • to assess the frequency of synovial effusion, synovial hypertrophy, synovitis, and double contour sign at these joints in patients with gout and;

  • to examine how these features differ according to serum urate levels, disease duration, and use of urate-lowering therapy (ULT).

Section snippets

Methods

The study was a cross-sectional observational study undertaken in a community rheumatology hospital. Approval was obtained from the South Staffordshire Local Research Ethics Committee (09/H1203/78). Written informed consent was obtained from all participants. Procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.

Results

Forty participants were recruited to the study. Mean age was 64.5 years (SD 13.5). Thirty-one (78%) were male. All participants fulfilled the 1977 ARA preliminary criteria [14]. The diagnosis was confirmed by identification of MSU crystals in 21 participants (53%). Tophi were present in 17 (43%). Five participants (13%) reported currently experiencing an acute attack of gout. Mean serum urate level was 441 μmol/L (SD 133) and 13 participants (33%) had a serum urate level below 360 μmol/L (6 mg/dL).

Discussion

In this hospital-based cross-sectional observational study, synovial effusion, synovial hypertrophy, and the double contour sign were very frequent sonographic findings, each being seen in at least 90% of study participants. Synovitis was seen sonographically in 62% of participants. In contrast, clinical synovitis was an infrequent finding indicating that most participants would have been considered to be in the intercritical period at the time of assessment. Synovial effusion, synovial

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Acknowledgements

The authors would like to thank Dr Irena Zwierska for assistance with the preparation of the submission for research ethics committee approval, to the rheumatologists and research nurses at the Haywood Hospital who identified study participants, and to Professor George Peat and Dr Martyn Lewis who provided methodological and statistical advice respectively. This work was supported by the Haywood Hospital Trials and Education Fund.

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