1Seagal Z.M., 2Surnina O.V., 1Brindin V.V., 1Seagal S.Z.
1 Federal state budget educational institution of the higher education "Izhevsk state medical academy" ministry of health of the
Russian Federation, Address: Russia, Udmurt republic, Ishevsk, Kommunarov Street, 281, 426033
Development of intraorganic transylumination and ultrasound monitoring in rheumatoid arthritis
Resume. Background. Nowadays about 4% of the world's population suffers from joint diseases. Rheumatoid arthritis (RA) occurs 0.5-1% of the total population, in Russia it founds in approximately 0.6% of the population.
Keywords: ultrasound, knee joint, rheumatoid arthritis, transillumination optometry, optical density.
Olga Vladimirovna Surnina
Candidate of Medicine of Medical Science, docent of Operative Surgery and Topographic anatomy, Izhevsk State
Medical Academy; head of department of ultrasonic diagnosis in Budgetary Institution of Health “Repablican Clinical
Diagnostic Center”. Address: 426034, Russia, Izhevsk, Kommunarov str. 281;
About 4% of the world's population suﬀer from joint diseases in the modern world. Rheumatoid arthritis (RA) occupies the leading position among inﬂammatory joint diseases and is found in all countries and among all the peoples of the world at approximately 0.5-1% of the total population, in Russia it founds in approximately 0.6% of the population. The incidence of rheumatoid arthritis is common among various age groups, but mostly aﬀects women of active age (women get rheumatoid arthritis 3 times more often than men). The annual incidence of new cases of RA is about 0.02% [3,11]. According to the data of multi- center researches the oﬃcial number of registered patients does not reﬂect the picture of the prevalence of RA in full. This discrepancy is due to late treatment of patients to the doctor, the diﬃculty of diagnosing initial stages of the disease, the inadequacy of the clinical examination, the course of the disease and its monitoring . It is important to carry out diagnostics in the early stages because treatment will be more eﬀective [2,22,24.30]. More commonly used diagnostic cri- teria for the diagnosis of RA are crite- ria of the American College of Rheumatology (ACR) 1987, which include a complex of clinical and laboratory and radiographic manifestations of the disease [8,3,9,17,15]. А large number of methods for diagnosing joint diseases are currently available: X-ray examination, magnetic resonance imaging (MRI), computed tomography (CT), arthroscopy, radionuclide methods, arthrocentesis, ultrasound. The comparative characteristics of these research methods are presented in the following table (Table 1)
X-ray examination has shortcom- ings in the diagnosis of joint damage in RA, such as: radiation load, the in- ability to conduct frequent researches and detect signs of the disease no earlier than 3-6 months from the onset of the disease. Lesions of the tendon-ligamentous apparatus are not detected by the X-ray method [4,17,27]. Short-coming of MRI is the duration and complexity of calculating the volume of synovial ﬂuid and optical density. Carrying out research using MRI is inaccessible and expensive. There are a number of contraindications, for example, the presence of large metal implants, the presence of pacemaker,the ﬁrst trimester of pregnancy [17,19]. The method of asseing the activity of RA of knee joints consists in ultrasound examination and evaluation of synovial eﬀusion and proliferation of the synovial membrane [21,23]. Various authors determined the sensibility, speciﬁcity and reliability of ultrasound (Table 2).
A laboratory analysis of the synovial eﬀusion joint obtained at intraar- ticular puncture are performed to conﬁrm the results of various diagnostic studies [8,13]. Changes in the indices are of low accuracy because they can be on the background of other inﬂammatory diseases. Disadvantages of arthrocentesis is the invasiveness of the method, the possibility of purulent infection with staphylococcal and streptococcal infection, which will transfer to inﬂam- mation, abscessing and infection of the knee joint, as well as acute septic arthritis . The authors consider it necessary to use transillumination optometry which currently receives little attention to clarify the nature of the process. This method is coordi- nated to record changes in the pulse and non-pulse level of the optical density of various organs sites.
Aim: development of a new clinical method for diagnosing and preventing complications of rheumatoid arthritis.
Materials and methods. The work is based on the analysis of the results of examination of healthy people and patients with joint pathology. Thesubjects were divided into two groups: the comparison group (without the pathology of the joints) and the main group (patients with rheumatoid arthritis). In all groups, the comparability of healthy and sick people by sex and age was observed (52.2 ± 8.1 years). A total of 850 people participated in the study. Patients were did CT, MRI, radiography, arthrocentesis of joints, ultrasound and optometry according to the method of Z.M. Seagal. The study was carried out on an ultrasonic scanner with a 7.5 MHz -millimeter linear scan sensor.Optometry for recording parameters of hemodynamics was carried out with the help of the device and the method Z.M.Seagal . Plusop- tometry was carried out by applying an optocoupler to the area under study with a breath-holding of the pa- tient. Projection suprapatellar bursa corresponds superolateral access. Place the positioning of the detector and pathﬁnder is located 1 centimeter proximal and lateral to the upper pole of the patella.
Statistical processing of the data was performed using the software package Microsoft Excel 2010. The average values of amounts of synovial ﬂuid, optical density and amplitude of pulse oscillations in a suprapatellar bursa and lateral synovial recess in normal and with rheumatoid arthritis were determinated. X±dx, y±dy are mean values, Sx, Sy are standard errors, t is a reliability, p is a level of signiﬁcance (probability of error), Δ± dΔ are lower and upper conﬁdence limits, S∆ is a standard deviation. The diﬀerences between the samples were estimated using the Student's t-test, calculated as the diﬀerence in the mean values divided by the sum of the error squares: if t<2, p>0,05 and the diﬀerences are not statisti- cally signiﬁcant and if t> 2 → p <0.05 and the diﬀerences are statistically signiﬁcant. The conclusion based on the results of the analysis is that the diﬀerences in the studied indices of the comparison group and the main group are reliable.
Results. During the ultrasound, the amount of synovial ﬂuid in the suprapatellar bursa and the bursa of the lat- eral inversion in the observation and comparison groups was determined, both in the largest topographic region for the accumulation of synovial ﬂuid and for the possibility of ultrasound echolocation. (Table 3.4)
In this case, the amount of synovial ﬂuid in both the suprapatellar bursa and the bursa of the lateral recess is found at times more than in norm and with other pathological changes. With transillumination optometry, the optical density was determined (Table 5,6) in norm and pathology. Research of the optical density of pa-rarticular regions was also performed in a suprapatellar bursa and a bursa of lateral recess after visualization of them in anultrasonography. In the projection of the location of the ﬂuid, according to ultrasound, optocoupler of the pulso-optometer was applied to the skin of the pararticular regions to obtain the values of the optical density of paraarticular tissues of the knee joint in healthy patients and in patients with RA. With RA, the optical density in the suprapatellar bursa is 2.7 times less than in norm (0,58) (Ta- ble 5). And 2 times less than normal in a bursa of lateral recess. (Table 6)
The research of hemodynamics of pararticular regions in this research was also carried out in a suprapatellar bursa and a bursa of lateral recess after visualization of it under ultrasonography.Inthe projection of the location of the ﬂuid, according to ultrasound, optocouplerpulso-optometer was applied to the skin of the pararticular regions to obtain the APO para- rticular tissue values of the knee joint in healthy patients, in patients with RA and osteoarthritis (OA ). APO in the suprapatellar bag is 13 times higher than the norm (3,29 ± 4,90), and in the bag of the lateral curvature it is 7 times.
In patients with rheumatoid arthri- tis, the ultrasonographyof the knee joint shows an increase in the amount of synovial ﬂuid, compared with the norm, both in the bursa of the lat- eral recess and in the suprapatellar bursa. Also in both bursae, a decrease in the optical density and an increase in the amplitude of the pulse oscillations are found in comparison with the normal indices. On the basis of the data obtained, the authors pro- posed a method for the diagnosis of rheumatoid arthritis of the knee joint, Patent № 2633631 "A method for di- agnosing rheumatoid arthritis of the knee joint." This method of diagnos- ing rheumatoid arthritis of the knee joint is performed by ultrasonic echo- location of anatomical structures. It involves determining the amount of synovial ﬂuid and is characterized in that the value of the optical density of the knee tissue and the amplitude of the pulse oscillations in the supra- patellar bursa are additionally meas- ured. With synovial ﬂuid content of 55.81 ml and above (2-4 ml), an optical density of 0.56 and below (0,58), the amplitude of pulse oscillations of 13.45 mm and above (3,29 ± 4,90 мм) is diagnosed with rheumatoid arthritis" . To assess the eﬀectiveness of treatment of rheumatoid arthritis, the authors proposed a "Method for controlling the eﬀectiveness of treatment of rheumatoid arthritis." Patent application № 2017121780. A method for predicting the eﬀectiveness of treating rheumatoid arthritis, including topical monitoring of paraarticular regions, characterized in that the eﬀectiveness of treatment is determined in the bag of lateral curvature of the knee by the change in the optical density of the knee joint tissues and the amplitude of pulse oscillations with ultrasound navigation after drug treatment and therapeutic exercise with an interval of 10 days .
Discussion. The development of RA is characterized by a signiﬁcant increase in synovial ﬂuid in all synovial bags and knee joints with the development of bursitis. In RA, due to the increase in liquid and ﬂocs present in this liquid, the optical density decreases. It is known that the dynamics of manifestations of RA is closely related to changes in blood ﬂow. With inﬂammation, the sensitivity of the vessels to the action of vasoconstrictor stimulus decreases, therefore, the blood ﬁlling of the aﬀected organ increases, and the walls of the vessels are sclerosed, so the APO will be increased. The change in hemodynamics by other well-known methods does not have reliable quantitative indices [6,28]. In this article, statistical values with echographic data are presented, therefore, one can judge the reliability of the results (Table 9).
The undoubted advantage of the claimed diagnostic technique is an increase in the level of safety, due to means of measuring the amount of synovial ﬂuid, optical density and amplitude of pulse oscillations in the suprapatellar bursa. The advantage of the claimed method is also that it is not invasive and low traumatic. The undisputed advantage of the claimed method is the greater availability of ultrasound diagnostics with respect to computer tomography and magnetic resonance imaging, as well as a smaller number of contraindications to the use of ultrasound diagnostics. This method of determining the optical density, taking into account the locality of the process, creates con- ditions for early warning, as a con- sequence, reducing the frequency of their complications. Transillumination optometry and ultrasound monitoring takes into account all the shortcomings of the above methods and is a comprehensive research method. The ultrasound method allows to timely detect the foci of pathological processes that occur with rheumatoid arthritis. With the help of a speciﬁc functional technique of transillumi- nation optometry, the sensitivity and reliability of ultrasound diagnostics can be increased. The undoubted advantage of the claimed method is an increase in the accuracy of diagnosics by specifying concrete quantitative indices. The advantage of the claimed method is also that it is not invasive and low traumatic.With the development of inﬂammation, the most accurate will be the indices of changes in hemodynamics and optical density. Changes in functional indices oﬀer the oppotrtunity of the appointment of timely treatment depending on the stage of the process.
1. The development of intraorganic transillumination monitoring in rheumatoid arthritis has a practical importance in the reliable diﬀerential diagnosis of pathologies and in evaluating the eﬀectiveness of treatment. This method is atraumatic, reliable and informative.
2. As a speciﬁc signs of the disease and the criteria for the eﬀectiveness of treatment can be used: the amount of synovial ﬂuid, the indications of optical density and the amplitude of pulse oscillations.
1. Alekseeva O.G. The time course of changes in biomarker levels and the ultra- sonic signs of inﬂammation in patients with rheumatoid arthritis / Alekseeva O.G., Novikov. A.A. // Rheumatology Science and Practice. — 2015. — v. 53 (5). — P. 485—492.
2. Balakin V.V. Osteoarthritis of the knee: clinical features, diagnosis, treat- ment/ Balakin V.V. // Modern rheumatology. — 2013. — v. 3. — P. 70— 75.
3. Bestaev D. V. Systemic manifestations of rheumatoid arthritis / Bestaev D.V., Karateev D.E., Nasonov E.L. // Rheumatology Science and Practice. — 2013. — v. 51. — P. 76—80.
4. Chernova T. O. Recommendations of the International society for clinical densitometry and recommended applications in clinical and diagnostic prac- tice / Chernova T.O., Gascan K.A., Sazonova N.I., Mylov N.M. // Medical Visu- alization. — 2008. — v. 6. — P. 83— 93.
5. Dolgov V. V. Photometry in the laboratory. / Dolgov V.V., Ovanesov E.N., Sit- nikova K.A. // Photometry in the laboratory: a guide for physicians. M.: «Rus- sian Medical Academy of Postgraduate Education», 2004. — 142 p.
6. Herman I.G. Modern ultrasonic diagnostics of rheumatoid arthritis of periph- eral joints: abstr. diss…c-te med. sc. / Herman I.G. - Moscow, 2007. – 22 p.
7. Karataev D.E. Rheumatoid arthritis / Karataev D.E., Nivicova D.S. // Informa- tion on rheumatic diseases: a methodical manual – 3rt edit., revised and supplemented – M.:The Russian rheumatological association "Nadezhda", 2015. – 55 p.
8. Mak-Nelly Y. Ultrasound of the musculoskeletal system / Mak-Nelly Y. // Ultrasound of the musculoskeletal system: a practical guide [ed. by G.I. Naza- renko]. – M.: Vidar, 2007. – P. 400
9. Maslyansky A.L. The diagnostic signiﬁcance of serological markers of rheu- matoid arthritis is / Maslyansky A.L. // Rheumatology Science and Practice. — 2012. — v. 54 (5). —С. 20 —24
10. Matveeva E.L., Some indicators of biochemical analysis of synovial ﬂuid / E.L.Matveeva, // The genius of orthopedic. — 2012. —v. 4. — P. 106
11. Mazurov V.I. Diseases of the joints/ Mazurov V.I. // Diseases of the joints: a guide for physicians [ed. by V.I. Mazurov]— SPb.:Spetslit, —2008. —397 p.
12. Mitrofanov V.A. Osteoarthritis: risk factors, pathogenesis and modern ther- apy / Mitrofanov V.A., Zhadenov I.I., Puchinyan D.M. // Saratov scientiﬁc medical journal. - 2008. —T. 2. — v. 2. — P. 23—30.
13. Orlyansky V. Guide to knee arthroscopy/ Orlyansky V., Golovakha M.L. // a guide for physicians. – Dnepropetrovsk: Porogi, 2007. –P. 152.
14. Osipyants R.A. Complex diagnostics of rheumatoid arthritis using high fre- quency sonography: abstr. diss…c-te med. sc. / Osipyants R.A. - Moscow, 2014, - 225 p.
15. Shatokhina S. N. Diagnosis of arthrosis by morphologic picture of synovial ﬂuid / Shatokhina S.N., Zar V.V., Voloshin V.P. et al. / / Bulletin of traumatol- ogy and orthopedics named. N. N. Priorova. — 2010. — v. 2. — P. 20—24.
16. Sigal Z. M. Ultrasonic and optical monitoring of applied anatomy and sur- gery./ Segal Z.M., Surnina O.V., Zonov N.V. // Actual problems of applied anatomy and surgery. – Saint Petersburg: Publishing house St. Petersburg, 2007. – 56-57 p.
17.Sirotko O. V. Topical issues of diﬀerential diagnosis of rheumatoid and reactive arthritis / Sirotko O.V. // Vestnik of Vitebsk state medical University. — 2010.
— T. 9. — v. 4. - P. 75—84.
18. The method for assessing the eﬀectiveness of treatment of rheumatoid ar- thritis of the knee joint // Patent of Russia № Application 2017121780.2017.
/ Z.M. Sigal, O.V. Surnina, V.V. Bryndin et al.
19. The method of diagnosing synovitis of the hip and knee joints with the deter- mination of the amount of ﬂuid in them // Patent of Russia № 2305489. 2007. Bull. No. 25. / I.R. Cousin, J.V. Pickelhaupt, R. V. Aleynikov
20. The method of diagnosis of rheumatoid arthritis of the knee joint // Patent of Russia No. 2017102836.2017. Bul. No. 29 / Z.M. Sigal, O.V. Surnina, S.Z.Sigal, et al.
21. The method of evaluating the activity of rheumatoid arthritis of the knee
// Patent of Russia № 2222259. 2004. Bull. No. 3. / V.D. Zavadovskaya, T.B. Perova, A.V. Khodinskaya, E.V. Saprykina
22. Bedson J. The discordance between clinical and radiographic knee osteoar- thritis: a systematic search and summary of the literature / Bedson J., Croft
P.R. // BMC MusculoskeletDisord. — 2008. — v. 9. — P. 116.
23. Bijsma JWJ. Compendium on Rheumatic Disease / Bijsma JWJ. // BMJ. — 2009. — P. 824.
24. Brandt К. D. Etiopatogenesis of osteoarthritis / Brandt K.D., Dieppe P., Radin E.L. // Rheum. Dis. Clin. North. Am. — 2008. — v. 34. — P. 531 — 559.
25. Dohn U.M. Are bone erosions detected by magnetic resonance imaging and ultrasonography true erosions? A comparison with computed tomography in rheumatoid arthritis metacarpophalangeal joints. / Dohn U.M. et al. // Arthri- tis Res Ther. — 2006. — v. 8. — P. 110.
26. McQueen F.M, Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement early rheumatoid arthritis reveals progression of erosions despite clinical improve- ment. / McQueen F.M., Stewart N., Crabbe J. et al. // Ann. Rheum. Dis. — 1999. — v. 58. — P. 156 — 163.
27. Sellam J. Osteoarthrosis: pathogenesis, clinical aspects and diagnosis / Sellam J., Herrero-Beamont G., Berenbaum F. // Аrthritis Rheum. — 2009. — v. 60(2) — P. 33.
28. Torp-Pedersen S.T. Settings and artefacts relevant in colour. Power Doppler ultrasound in rheumatology / Torp – Pedersen S.T., Terslev L. // Ann. Rheum. Dis. — 2008. — v. 67. — P. 143 — 149.
29. Wakeﬁeld R.J. The current status of ultrasonography in rheumatology / Wake- ﬁeld R.J. // Rheumatology. — 1999. — v. 38. — P. 195 — 201.
30. Zhang W. Osteoarthritis Research Society International recomendations for the management of hip and knee osteoarthritis / Zhang W., Moskowitz R.W., Nuki G. et al. // OARSI evidence-based, expert consensus guideless. Osteoar- thritis Cartilage. - 2008. — v. 16 (2) — P. 62 — 137.