类风湿关节炎患者足踝部体征和超声下病变的一致性

doi:10.19723/j.issn.1671-167X.2021.06.005

摘要/Abstract

摘要：

目的:探讨类风湿关节炎(rheumatoid arthritis, RA)患者踝部和跖趾(metatarsophalangeal, MTP)关节的体征与超声下炎性病变的一致性。方法: 纳入查体发现双踝和跖趾关节中至少1个部位有压痛和/或肿胀、且接受双足踝关节灰阶(greyscale, GS)和能量多普勒(power Doppler, PD)超声检查的RA患者,分析各关节部位压痛、肿胀的体征和超声病变的发生率,研究体征和超声下关节腔积液、滑膜炎或腱鞘炎三种炎性病变的一致性。结果: 纳入113例RA患者,平均年龄(52.5±12.6)岁,中位病程60(13,129)个月,基于红细胞沉降率的28个关节计数的疾病活动度评分[disease activity score in 28 joints based on erythrocyte sedimentation rate, DAS28(ESR)]为5.1±1.7,基于C反应蛋白的28个关节计数的疾病活动度评分[disease activity score in 28 joints based on C reactive protein, DAS28(CRP)]为4.6±1.5。查体发现在双踝和MTP 1~5关节中,踝关节压痛和肿胀最常见,分别为52.7%和31.9%;而超声发现GS阳性滑膜炎最多见于MTP2关节(34.1%),其次为踝关节(32.7%)和MTP1关节(27.9%); PD阳性滑膜炎最易出现在MTP1关节(14.2%), 其次为踝关节(12.4%)和MTP2关节(10.6%)。腱鞘炎的总体发生率为 41.1%, 其中超过半数为胫骨后肌腱鞘炎,GS和PD的阳性率分别为22.1%和17.6%。关节腔积液最多见于踝关节(9.7%),骨侵蚀最多见于MTP5关节(19%)。踝和MTP关节的临床体征与超声下三种炎性病变的总体一致性均较差(κ<0.2,P<0.05)。一致性相对最好的是踝关节肿胀与超声下炎性病变(κ=0.225,P<0.05), 其中与滑膜炎的一致性一般(κ=0.231,P<0.05),与腱鞘炎的一致性较差(κ<0.20,P<0.05)。关节腔积液与各关节的压痛或肿胀无一致性(P>0.05)。结论: RA患者中足踝部体征与超声下所见炎性病变的总体一致性较差,体格检查发现踝关节压痛/肿胀最多见,然而超声下所见病变更多见于MTP关节;超声可以额外发现足踝部关节的异常病变,有助于临床更准确地判断病变类型和程度。

关键词: 关节炎, 类风湿, 踝和足关节, 超声检查

Abstract:

Objective: To investigate the agreement between clinical signs (tenderness and/or swelling) in ankles and feet joints and ultrasound findings in patients with rheumatoid arthritis (RA). Methods: RA patients with at least 1 tender and/or swollen joint in bilateral ankles and metatarsophalangeal (MTP) joints detected by physical examination were enrolled and underwent ultrasound examination by greyscale (GS) and power Doppler (PD) mode. The agreement between clinical signs and ultrasound-detected inflammation (joint effusion, synovitis, or tenosynovitis) was analyzed. Results: In the study, 113 consecutive RA patients were included, with mean age of (52.5±12.6) years, median duration of 60 (13, 129) months, mean disease activity score in 28 joints based on erythrocyte sedimentation rate [DAS28 (ESR)] of 5.1±1.7,mean disease activity score in 28 joints based on C reactive protein[DAS28 (CRP)]of 4.6±1.5. The tenderness and swelling was most commonly detected in ankles (52.7% and 31.9%, respectively), while GS (+) synovitis was most frequently detectable in MTP2 (34.1%), followed by ankles (32.7%) and MTP1 (27.9%),and PD (+) synovitis was most frequently detectable in MTP1 (14.2%), followed by ankles (12.4%) and MTP2 (10.6%). The prevalence of tenosynovitis was 41.1%, which mostly located in tibialis posterior tendon (22.1% of GS positive and 17.6% of PD positive). The highest prevalence of joint effusion was detected in ankles (9.7%), while that of bone erosion in MTP5 (19%). The overall concordance rate between positive clinical signs and ultrasound-determined joint inflammation was poor in the above joints (κ<0.2, P<0.05), in which swelling had the highest κ coefficient with ultrasound-determined joint inflammation in ankles (κ=0.225, P<0.05). Moreover, swelling had the highest κ coefficient with synovitis in ankles (κ=0.231, P<0.05).The concordance between tenosynovitis and signs in ankles was also poor (κ<0.20, P<0.05). There was no significant agreement between joint effusion and clinical signs (P>0.05). Conclusion: The overall concordance between clinical signs and inflammation on ultrasound was poor in ankles and feet joints. Tenderness and swelling was more common in ankles, while more lesions were detected by ultrasound at MTP joints. Ultrasound is useful in assessing the lesions besides physical examination in patients with RA.

Key words: Arthritis, rheumatoid, Ankles and feet joints, Ultrasound

中图分类号:

R593.22

邓雪蓉,孙晓莹,张卓莉. 类风湿关节炎患者足踝部体征和超声下病变的一致性[J]. 北京大学学报（医学版）, 2021, 53(6): 1037-1042.

DENG Xue-rong,SUN Xiao-ying,ZHANG Zhuo-li. Agreement between ultrasound-detected inflammation and clinical signs in ankles and feet joints in patients with rheumatoid arthritis[J]. Journal of Peking University (Health Sciences), 2021, 53(6): 1037-1042.

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参考文献 17

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Items	Values
n	113
Age/year, $\overline{x}$±s	52.5 ± 12.6
Female, n (%)	93 (82.3)
Disease duration/months, M (P₂₅,P₇₅)	60.0 (13-129)
PGA/mm, $\overline{x}$±s	55.9±25.1
EGA/mm, $\overline{x}$±s	48.5±24.3
HAQ, M (P₂₅,P₇₅)	12.0 (3.5-23.5)
ESR/(mm/h), M (P₂₅,P₇₅)	35 (19-65)
CRP/(mg/L), M (P₂₅,P₇₅)	11.9 (5.5-36.4)
DAS28 (ESR), $\overline{x}$±s	5.1±1.7
DAS28 (CRP), $\overline{x}$±s	4.6±1.5
CDAI, $\overline{x}$±s	22.8±14.2
SDAI, $\overline{x}$±s	25.1±16.4

Joint	Tenderness		Swelling
Joint	n	%	n	%
Ankle	715	52.7	432	31.9
MTP1	244	18.1	108	8.0
MTP2	252	18.6	47	3.5
MTP3	591	21.7	40	3.1
MTP4	501	21.2	40	3.1
MTP5	538	22.6	80	6.2

Joint	GS (+) synovitis/%	PD (+) synovitis/%	Effusion/%	Bone erosion/%
Ankle	32.7	12.4	9.7	11.5
MTP1	27.9	14.2	4.0	16.4
MTP2	34.1	10.6	2.7	1.3
MTP3	23.0	8.0	0.9	0.9
MTP4	14.2	5.8	0	0.9
MTP5	11.5	9.3	0	19.0

Joint	Tenderness (+) & US (+)		Swelling (+) & US (+)
Joint	κ	P	κ	P
Ankle	0.128	0.054	0.225	0.000
MTP1	-0.024	0.694	0.058	0.232
MTP2	0.111	0.066	0.028	0.579
MTP3	0.083	0.033	0.014	0.832
MTP4	0.210	0.000	0.179	0.006
MTP5	0.127	0.039	0.079	0.230

Joint	T/S (+) & synovitis		T (+) & synovitis		S (+) & synovitis
Joint	κ	P	κ	P	κ	P
Ankle	0.069	0.234	0.018	0.769	0.231	0.001
MTP1	-0.037	0.566	0.060	0.350	0.056	0.277
MTP2	0.118	0.056	0.104	0.091	0.032	0.333
MTP3	0.020	0.764	0.095	0.153	0.086	0.029
MTP4	0.187	0.004	0.187	0.004	0.217	0.000
MTP5	0.137	0.023	0.127	0.039	0.076	0.230