早期类风湿关节炎跖趾关节滑膜炎的临床检查与超声检查比较

A comparison of clinical examination and ultrasound in the detection of metatarsophalangeal joint synovitis in early rheumatoid arthritis

目的应用高频彩色多普勒超声检查早期类风湿关节炎(RA)患者的跖趾关节,调查跖趾关节滑膜炎在早期RA中的发病率及病变特点,并与临床检查结果相比较。方法对连续57例病史<1年的RA患者在入院当天进行跖趾关节体格检查,记录关节有无肿胀、触痛,前足挤压试验阳性情况。同日进行跖趾关节的超声检查,记录关节积液、滑膜增生、滑膜血流情况。以超声检查结果作为金标准,对跖趾关节的体格检查及超声检查结果进行一对一比较。结果 29例患者主诉有足趾痛和(或)行走时前脚掌疼痛症状(占50.9%)。体格检查发现85个跖趾关节肿/痛阳性(阳性率14.9%),45只足前足挤压试验阳性(阳性率39.5%)。对照组超声检查未发现有跖趾关节滑膜炎。RA组中有45例患者(占78.9%)超声检查发现87只足至少1个跖趾关节有滑膜炎。全部570个跖趾关节中共287个发现有滑膜炎(阳性率50.4%),以第2跖趾关节滑膜炎阳性率最高,其次为第3跖趾关节。23个关节增生的滑膜内可检测到血流信号(占有滑膜增生关节的9.8%)。查体肿/痛关节阳性诊断跖趾关节滑膜炎与超声检查诊断滑膜炎的Kappa值为0.134,二者一致性较低。以超声检查结果为金标准,关节肿/痛、挤压试验检测跖趾关节滑膜炎的敏感性、特异性、阳性预测值、阴性预测值、阳性似然比、阴性似然比分别为0.22、0.92、0.73、0.54、2.66、0.85和0.51、0.96、0.98、0.38、13.66、0.51。结论跖趾关节是早期RA较易累及的关节,临床检查虽有较高的特异性,但不够敏感,超声在检测跖趾关节滑膜炎中有较高的应用价值。

Objective Use the high frequency color Doppler ultrasound to check the metatarsophalangeal joints of the patients with early rheumatoid arthritis （RA） , in order to investigate the prevalence of US pathologic abnormalities in the metatarsophalangeal joints synovitis in early RA and to compare them with the clinical examination results. Methods 57 consecutive patients with RA （ disease duration 〈 1 year ） received clinical examination of metatarsophalangeal joints（ presence or absence of swelling and/or tenderness, forefoot squeezing test results） in the day of admission. Ultrasonography of MTPs was performed searching for joint effusion, synovial hypertrophy and power doppler, graded from 0 ~ 3 on a semi-quantitative scale on the same day. A joint-by-joint comparisons of clinical examination and ultrasound were made using the latter as the gold standard. Results 29 patients complained of toe pain and/or forefoot pain when walking （ 50. 9% ）. 85 metatarsophalangeal joints were swelling and/or tenderness positive（ 14. 9% ） and 45 feet had positive forefoot squeezing test（ 39. 5% ）. Ultrasound examination of the control group did not find the MTP synovitis. 45 patients in RA group（78.9% ） were found at least one metatarsophalangeal joint had synovitis in 87 feet by ultrasound examination. 287 MTPs had Synovitis of all 570 MTPs（50.4% ） ,Synovitis was present most frequently in the 2nd MTP joint,followed by the 3rd MTP. PD signal was found in 23 joints with synovial proliferation （9. 8% ）. The kappa coefficient between clinical examination and ultrasound in the detection of MTP synovitis was 0. 134, showing very poor agreement. With ultrasound as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of joint swelling and/or tenderness for the detection of MTP synovitis were 0. 22,0. 92,0. 73,0. 54,2. 66 and 0. 85 ,respectively ,while the corresponding values for forefoot squeezing test were 0. 51,0. 96,0.98, 0. 38, 13.66 and 0. 51. Conclusions Metatarsophalangeal joints are easily involved in early RA. Clinical examination has high specificity and positive predictive values ,but sensitivity and negative predictive values was low. Evaluation of MTPs by US may be of major clinical importance in RA.