Session Information
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose:
Rheumatologists commonly use synovial fluid analysis to help establish a diagnosis in patients with joint effusions. Although tenosynovial (TS) effusions are common in rheumatic conditions, there is no guide to inform the interpretation of fluid aspirated from tendon sheaths. Musculoskeletal ultrasound (MSUS) has allowed for routine aspiration of TS effusions. To better characterize TS fluid and MSUS findings in rheumatic diseases, we organized a multi-center collaboration to prospectively analyze TS findings on patient aspirations. This is an interim report of the first eight months of the study.
Methods:
Patients with TS aspiration planned as part of routine care were included. We are collecting information on patient demographics, underlying rheumatic disease, involved tendon location, duration of TS symptoms, TS fluid characteristics, MSUS appearance and tendon specific diagnosis. Specific TS fluid data collected includes volume (hemocytometer used if fluid volume below clinical laboratory threshold), gross appearance, leukocyte count, and crystal identification. This interim descriptive analysis reports on the patient and disease characteristics of subjects enrolled to date.
Results:
59 of 100 subjects have been enrolled at 10 participating sites. Table 1 reports the patient characteristics, involved tendons and volume of TS fluid aspirated. Four patients presented after trauma to the involved tendon. 78% of all TS aspirations were derived from 5 locations: 4th extensor compartment, bicipital tendon, extensor carpi ulnaris, posterior tibial and peroneal tendons. 14 (24%) of the aspirations had a fluid volume of <0.5mL.
Table 2 shows the established rheumatologic diagnosis, and diagnosed cause of TS effusion after the aspiration. Of note, only 4 aspirations were from patients known to have a crystalline diagnosis, but a total of 12 were diagnosed after aspiration. Rheumatoid arthritis was the most common patient diagnosis to require a TS aspiration. Only one case of infection – coccidioidomycosis was diagnosed so far.
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Table 1. General patient characteristics |
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Characteristics |
Results N=59 |
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Age (years) Mean (range) |
60 (21-95) |
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Gender, N (%) Males Females |
20 (33.9) 39 (66.1) |
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Duration of tendon disease < 1 week >1 week to <1 month >1 month to <1 year >1 year |
2 (3.4) 8 (13.6) 34 (57.6) 15 (25.4) |
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Involved tendon N (%)* Wrist extensor compartment 4 Bicipital tendon Posterior tibial tendon Wrist extensor compartment 6 / ECU Peroneal tendon Extensor digitorum longus, lower limb Wrist extensor compartment 1 Anterior tibial tendon Wrist extensor compartment 2 Wrist extensor compartment 3 Wrist flexor tendon Finger flexor tendon, second digit |
18 (30.5) 9 (15.3) 7 (11.9) 7 (11.9) 5 (8.5) 4 (6.8) 3 (5.1) 2 (3.4) 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) |
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Aspirated fluid volume, mL Mean (Range) |
1.3 (0.03 – 5.0) |
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Aspirated fluid volume below 0.5 mL, N (%) |
14 (23.7) |
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N: number; %: percentage; ECU: extensor carpi ulnaris; mL: milliliters;*percentages do not add up to 100 due to rounding to one decimal place. |
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Table 2. Patient level diagnosis pre-aspirations, and tenosynovial level diagnosis post-aspiration |
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Pre-existing Rheumatic Diagnosis at Presentation |
Patients, N |
Tenosynovial Diagnosis Post-aspiration, N |
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Uncertain/No diagnosis |
25 |
9 |
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Rheumatoid arthritis |
11 |
11 |
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Seronegative inflammatory arthritis |
10 |
10 |
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CPPD |
3 |
9 |
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Mechanical |
0 |
9 |
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Gout |
1 |
3 |
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Vasculitis |
2 |
0 |
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Polymyalgia rheumatica |
0 |
3 |
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Tendonitis |
3 |
0 |
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Drug-induced |
0 |
2 |
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Systemic lupus erythematosus |
2 |
1 |
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Infection |
1 |
1 |
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Osteoarthritis |
1 |
0 |
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IRIS |
0 |
1 |
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CPPD: calcium pyrophosphate deposition; IRIS: immune reconstitution inflammatory syndrome; N: number. |
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Conclusion:
TS pathology occurs in a variety of inflammatory and non-inflammatory diseases commonly seen in rheumatology. MSUS guidance allows aspiration of very small volumes of TS fluid. Automated cell counts may not be possible on the small volumes obtained, but can be determined using a manual hemocytometer. TS aspirates can be used to establish a diagnosis, particularly crystalline forms of arthritis. The distribution of TS effusions could be used to focus teaching and performance of MSUS to the most frequently affected areas.
To cite this abstract in AMA style:
Aslam F, Cannella AC, Sharp V, Kao L, Arnason J, Albayda J, Bakewell C, Sanghvi SB, Fairchild R, Torralba K, Evangelisto AM, DeMarco P, Kissin EY. Tenosynovial Aspiration By Ultrasound Guidance: Even Small Volumes Can Have a Big Impact [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/tenosynovial-aspiration-by-ultrasound-guidance-even-small-volumes-can-have-a-big-impact/. Accessed .« Back to 2018 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/tenosynovial-aspiration-by-ultrasound-guidance-even-small-volumes-can-have-a-big-impact/