REVIEW

Role of Ultrasonography in Knee Osteoarthritis

Win Min Oo, MBBS, MMedSc*† and Myat Thae Bo, MBBS†
involve the pathophysiology and progression of OA.8,9 This rela-
Abstract: Ultrasound has become popular among rheumatologists as the tively inexpensive technology with the added advantages of porta-
first-choice imaging investigation for the evaluation and monitoring of os- bility and real-time dynamic examination can lead to a diagnostics
teoarthritis (OA). Because of recent improvement in technology, ultra- service in the community.10 Modern US systems can use beam
sound has the ability to demonstrate and assess the minimal structural steering and compound imaging technologies to allow wider
abnormalities, which involve the pathophysiology and progression of fields of view. High-resolution probes with frequencies of up to
OA, such as articular cartilage, synovial tissue, bony cortex, and other soft 20 MHz are being applied in routine joint assessment.11 To ad-
tissue. Nowadays, ultrasonography is a promising technique for assessing dress the utility, reliability, and potential uses of US as an imaging
soft tissue abnormalities such as joint effusion, synovial hypertrophy, Ba- technique in knee OA, we searched the articles in MEDLINE (34),
ker cyst, and other structural changes including the decrease in cartilage EMBASE (65), EBM Reviews (29), AMED (3), Scopus (63),
thickness, meniscus bulging, and formation of osteophyte. Ultrasonogra- Web of Science (76), and the Cochrane Central Registers for Con-
phy not only possesses diagnostic potential in knee OA but also reveals trolled Trials from their conception up to September 2015. These
long-term predictability for disease progress as imaging biomarker. Ultra- databases were looked up individually for all possible terms and
sonography has also been proven as a useful tool in guiding therapeutic in- combination of terms to accommodate differences in their search
terventions and monitoring treatment effectiveness. This review addresses engines. Hand searches were also performed in addition to addi-
the utility, reliability, and potential utilization of ultrasonography as an im- tional searches through Google Scholar and Reference Manager
aging technique in knee OA. Search engines. The keywords used in combination (OR) are knee
Key Words: cartilage, knee osteoarthritis, musculoskeletal ultrasound, osteoarthritis, knee osteoarthrosis, osteoarthritis, ultrasonogra-
osteophytes, synovitis, ultrasonography phy, and ultrasound. The combination (AND) is used between
knee osteoarthritis/knee osteoarthritis and ultrasonography/ul-
(J Clin Rheumatol 2016;22: 324–329)
trasound. All key terms are limited to title/abstract. Then the
duplicate terms are removed, and among the maximum 105 full
O steoarthritis (OA) is the most common cause of rheumatic
disorder and a frequent health problem in the community
where symptomatic knee OA has been prevalent in 6% to 10% of
texts, articles concerning therapeutic ultrasound or animal
studies are excluded for narrative review.
the adult population. Traditionally, OA has been defined as degen-
erative changes in bone, cartilage, and the soft tissues of the joints. Cartilaginous Changes
Recently, OA is regarded as a failure of the joint as an organ, much Cartilage thickness ranges from 0.1 mm on the articular sur-
like renal or cardiac failure.1,2 Nondestructive synovial prolifera- face of the head of the proximal phalanx to 2.6 mm on the lateral
tion, joint effusions, popliteal cysts, tendonitis, and bursitis are femoral condyle of the knee joint.12 In 1984, ultrasound was
frequent findings in OA.3 Therefore, an imaging modality is req- used to determine the thickness of the articular cartilage, as
uisite in order to assess the various structures within and around well as to detect changes in its surface and internal characteris-
the joint, to measure a variety of the pathological aspects of OA.4 tics such as the ratings of clarity and sharpness.13 Loss of clar-
As a criterion standard, radiological imaging has been used ity of the cartilaginous layer and loss of the normal sharpness of
to diagnose and classify the severity of knee OA such as the the synovial space–cartilage interface are the earlier features of
Kellgren and Lawrence system.5 However, radiographs have sev- cartilage damage.9
eral limitations, such as the inability to evaluate soft tissue struc- The weight-bearing surfaces of the femoral cartilage can be
tures and the related inflammation.6 In addition, radiographic assessed by transverse suprapatellar scan with the knee in maxi-
features of OA do not agree with the symptoms of OA.7 mal flexion (Fig. 1) or with an infrapatellar transverse scan with
In recent years, the imaging techniques such as ultrasonogra- the leg fully extended. Cartilage is characterized in early OA by
phy (US) have been used for better understanding and assessing loss of the sharp contour and the various echogenicities of the
the pathology of different musculoskeletal diseases.4 Ultrasonog- cartilage matrix on the ultrasound images. An asymmetric
raphy affords the abilities of scanning multiple planes at the same narrowing of the cartilaginous band follows in the later disease
joint, providing a “one-stop” answer to many rheumatic problems, process. It was reported that multiple sonographers demon-
which is not answerable only by clinical examination. Ultrasonog- strated good reproducibility and high levels of agreement between
raphy has no hazard of ionizing radiation and can provide the US and histology in assessing the normal to moderately damaged
multiplanar nature of the modality. It can also visualize soft tissue cartilage.14 In addition, measurement of cartilage thickness is
structures such as the meniscal extrusion and cartilage, which rapid (several seconds), painless, and noninvasive.
It has been demonstrated that the ultrasonographic grading
From the *Rheumatology Department and Institute of Bone and Joint Research, (in vitro) of femoral cartilage correlated well with the histologic
Royal North Shore Hospital, Northern Clinical School, University of Syd- grading (OARSI Osteoarthritis Cartilage Histopathology Assess-
ney, NSW, Australia; and †University of Medicine, Mandalay, Myanmar. ment System)15 of anterior and middle areas of femoral articular
The authors declare no conflict of interest.
Correspondence: Win Min Oo, MBBS, MMedSc, Clinical administration 7C,
cartilage (ρ = 0.78, 0.89, both P < 0.001).16 According to this ul-
Rheumatology Department, Royal North Shore Hospital, Sydney, NSW, trasonographic grading, grade 1 showed a homogenously an-
Australia, 2065. E-mail: [email protected]; echoic cartilage band with sharp anterior and posterior margins;
[email protected]. grade 2 showed blurring or obliteration of the margin of the carti-
There was no financial support for this study.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
lage band; grade 3 included blurring, obliteration of the margin,
ISSN: 1076-1608 and narrowing of the cartilage band; grade 4 was coded if the car-
DOI: 10.1097/RHU.0000000000000436 tilage band could not be visualized.

324 www.jclinrheum.com JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016 Ultrasound in Knee Osteoarthritis

Noyes grading19 for cartilage degeneration, and this outcome

score includes assessment of local reduction of thickness, loss
of the normal sharpness of cartilage interfaces, and increased
echogenicity. The cartilage was evaluated as grade 0 if they
showed a monotonous anechoic band with sharp hyperechoic
anterior and posterior interfaces. Grade 1 changes include loss
of the normal sharpness of cartilage interfaces and/or increased
echogenicity of the cartilage. Grade 2A changes were as follows:
in addition to the previously mentioned changes, clear local thin-
ning (<50%) of the cartilage. Grade 2B changes showed local
thinning of the cartilage of more than 50% but less than 100%.
Grade 3 changes included 100% local loss of the cartilage tissue
(Fig. 2). The sum of cartilage grades in all 3 sites of the femoral
cartilage at the medial and lateral femoral condyles, as well as at
the intercondylar notch area (sulcus) had the highest correlation be-
tween US and arthroscopy (r s = 0.655, P < 0.001). However, it still
FIGURE 1. Suprapatellar transverse scan showing the normal needs further validation studies, which might include, for example,
hyaline cartilage. quantitative magnetic resonance imaging or histology as refer-
ences. Noninvasive knee US is a promising technique for screen-
Recently, it was reported that the semiquantitative ultrasono- ing and evaluating degenerative changes of articular cartilage.20
graphic grading system may well reflect the clinical symptoms
and functions in knee OA on evaluation against the visual analog Bony Changes
scale, Western Ontario and McMaster Universities Arthritis Index, The early bone changes in the OA joint are characterized by
and Lequesne index.17,18 The US grading system for femoral car- hyperechoic signal at the site of the attachment of the joint capsule
tilage has been proposed after validating against the arthroscopic to the bony cartilaginous margin, which will eventually form as

FIGURE 2. Typical examples of different cartilage degenerative US grades (0, 1, 2A, 2B, 3) in the knee joint.20 Reprinted with permission from Elsevier.

© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.jclinrheum.com 325

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Oo and Bo JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016

FIGURE 3. The US atlas for knee osteophyte detection.23 Reprinted with permission from Taylor & Francis.

osteophytes on the conventional radiography. In advanced dis- compartment and lateral compartment such as synovial hypertro-
ease, the bony profile of the osteophytes is evident.21 Moderate phy and Doppler activity, and (3) effusion. Bony changes demon-
to substantial validity was reported in comparing ultrasonographic strated a strong correlation between the morphological changes in
osteophytes to those seen on radiographs.22
A novel atlas for scoring osteophytes in the tibiofemoral joint
was used to prove that the US was more sensitive in detecting
osteophytes than plain radiographs at the medial compartment of
the tibiofemoral joint (Fig. 3). Furthermore, osteophyte size de-
tected with US, compared with only their presence, is a better pre-
dictor of the articular cartilage degeneration as there is a significant
correlation between osteophyte size (summed US grade) and the
arthroscopic grade of degenerative changes of the articular carti-
lage at the medial compartment.23 The grading of osteophyte size
was as follows: grade 0 included no osteophytes, that is, a smooth
cortical surface; grade 1 demonstrated small and distinct cortical
protrusion(s) of the bony surface; grade 2 showed larger protru-
sion(s) of the bony surface; grade 3 included very large protru-
sion(s) of the bony surface. However, it should be noted that this
result is based on a small trial of 26 patients.
Recently, US score is developed in knee OA and includes rel-
evant domains measuring (1) morphological changes in the me-
dial compartment and lateral compartment such as osteophyte
and meniscus extrusion, (2) inflammatory markers in medial FIGURE 4. Large effusion in the suprapatellar recess. Sagittal plane.

326 www.jclinrheum.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016 Ultrasound in Knee Osteoarthritis

is commonly detected in patients with knee OA (Fig. 4). Depend-

ing on the study, between 47% and 100% of patients were noted to
have synovitis and/or effusion of the symptomatic knee.25,26 A
large European League Against Rheumatism study of 600 people
with knee OA demonstrated synovial hypertrophy or effusion in
46%. Synovial hypertrophy was defined as synovial thickening
of ≥4 mm and effusion recorded as present or absent based on
the depth of fluid of more than 4 mm or less than 4 mm in the
suprapatellar recess.26 Ultrasonography is more sensitive than
clinical examination in detecting synovitis27 and correlates well
with magnetic resonance imaging and arthroscopic findings. Sy-
novitis or joint effusion detected by US also shows a relationship
with pain in knee OA.28–30
The serial arthroscopies performed on knees with symptom-
atic but preradiographic OA revealed a clear association between
the presence of synovitis and the future development of medial
cartilage loss (an odds ratio for progression of the arthroscopic
chondropathy score of 3.11 [1.07–5.69]), suggesting that, at its
FIGURE 5. Increased bidirectional Power Doppler signals in the earliest stages, before visible cartilage degeneration has occurred,
suprapatellar fat pad and quadriceps tendon around the ultrasonographic synovitis has a potential role in predicting the
suprapatellar recess. Sagittal plane (in black and white). structural progression of knee OA.31
Power Doppler can be utilized to assess synovial flow, which
the medial and lateral compartments and the corresponding denotes increased synovial vascularization (Fig. 5).32 Increased
Kellgren-Lawrence score. Total ultrasound score displayed sub- Doppler signal correlates with increased vascularity seen on histo-
stantial reliability and reproducibility, with interclass correlations logic examination of synovial tissue of knee OA.33 In a study that
coefficients ranging from 0.75 to 0.97. Construct validity was used a novel technique of digital synovial vascularization quantifi-
confirmed with statistically significant correlation coefficients cation with contrast enhancement for detecting synovitis in patients
(0.47–0.81, P < 0.01). However, relevance for longitudinal studies with knee OA, US of the superior recess revealed an effusion or
remains to be demonstrated, for example, during treatment.24 synovial thickening in 58% in B-mode, 63% in power Doppler so-
nography, and 95% with contrast medium enhancement.34
Soft Tissue Changes On the other hand, there were reports that no association be-
It has been increasingly recognized that synovitis plays a tween US features and the degree of knee pain was detected after
more important role in the pathogenesis of OA than previously 1-year follow-up,35 and further studies are still warranted to an-
thought. A small to moderate amount of synovitis and effusion swer which part of pain in knee OA is explained by soft tissue

FIGURE 6. Longitudinal ultrasonographic images of the medial joint line (in black and white). A, Position of probe footprint. B, Ultrasonographic
image of a normal knee shows distal femur (f ), proximal tibia (t), triangular outline of the medial meniscus (m, dashed arrows), and the linear
echoes produced by the medial collateral ligament (mcl, solid arrows). C, Ultrasonographic image shows medial meniscal extrusion (m, dashed
arrows). D, Ultrasonographic image in knee OA demonstrates medial meniscal extrusion (m) with resulting displacement of the medial
collateral ligament (arrows) and obvious osteophytes (*) proximal and distal to the joint line.11 Reprinted with permission from Elsevier.

© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.jclinrheum.com 327

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Oo and Bo JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016

pathology and whether US is the imaging method of choice to studies should establish the usefulness and value of US-detected
measure this pathology. changes in terms of effectiveness of therapeutic interventions.10
In a systemic review in 2009, a paucity of reliability data was
highlighted with regard to interreader and intrareader reliability in
LIMITATIONS
image acquisition and the scoring of stored images.4
Application of ultrasound to assess large joints seems still
challenging because of the inherent inability of ultrasound to pass
Monitoring and Intervention
through bony structures and scan deeper portions of the joint.41,42
In clinical trials in knee OA, outcome measures usually in- Thus, US visualization of the articular cartilage is limited by the
clude structural assessment, functional status, and the level of width of the acoustic windows that depends on the anatomy of
pain. Serological markers are unavailable for monitoring disease the joint. Even with advances in the resolution of the transducers,
progression in OA, and imaging markers using US abnormalities deeper structures are difficult to visualize as the higher-frequency
will be valuable in this scenario. Studies are still lacking to iden- transducers have lower tissue penetration.
tify and precisely determine a population in which OA progresses In patients with arthritis, however, assessment of the cartilage of
more rapidly.36 the weight-bearing areas can be difficult in patients with advanced
Recently, US prediction in the long-term progress of knee OA and/or painful knee resulting from limited maximal active flex-
OA is reported. After 1-year follow-up, meniscal protrusion ion. In addition, the cartilages of the patella and the tibia are always
(Fig. 6) and Baker cyst (Fig. 7) might be useful for long-term pre- inaccessible to US. Although US can be used to detect bone erosions,
diction of clinical or radiological outcome, although effusion, sy- it is not applicable for estimation of bone erosion depth, because it
novial hypertrophy, and infrapatellar bursitis seem to be more visualizes only the bone surface and not the subchondral bone.42
temporary phenomena.35 A longitudinal association between Ba- Moreover, US has been regarded as a highly operator-
ker cyst at baseline and radiological and clinical progression was dependent imaging method with poor reproducibility, partly due
found after 2-year follow-up.37 to the intrinsic real-time nature of US image acquisition.11 How-
In another study, increased meniscal bulging and presence ever, its usage is reassured by recent studies that have established
of Baker cyst/joint effusion were correlated with worse pain or moderate to good interobserver reliability.43–45
poorer function.38 Acquisition of US skills takes time depending on the
A 3-year multicenter European League Against Rheumatism trainee’s hand-eye coordination skills. A long learning curve may
prospective study determined the predictors for joint replacement be an important limiting factor in widespread use of US. In addi-
in more than 500 subjects with knee OA. The multivariate analysis tion, examination of multiple scanning planes in the clinical set-
demonstrated that the presence of a joint effusion (≥4 vs. <4 mm) ting can be time consuming. Focused examination is proposed
at baseline was a significant independent predictor of joint with concentration on a small number of scanning planes to re-
replacement at 3 years (hazard ratio, 2.63 [95% confidence duce examination time.46
interval, 1.70–4.06]).39
Ultrasonography has proved to be an effective and safe imag-
ing method for guiding intra-articular injections because of the ad- CONCLUSIONS
vantage of visualizing the proper needle positioning inside the Ultrasound provides a safe, cost-effective, and reliable tech-
joint cavity. In a study of 62 patients with symptomatic knee OA nique to assess knee OA. Ultrasonography is more sensitive than
to investigate the predictive value of US characteristics by defin- clinical examination and plain radiography in recognition of im-
ing responders as patients with numeric rating pain scale of 4 or portant abnormalities prevalent in knee OA. It is an excellent tool
less at 4 weeks after glucocorticoid injection, no US characteristic not only to recognize the bony profile but also to visualize the soft
of inflammation has the ability to reliably predict those who re- tissues, helping the rheumatologist to determine the type and ex-
spond to intra-articular glucocorticoids, requiring further study tent of these structural damages. The semiquantitative ultrasono-
in a large-scale trial.40 Given the disagreement between radio- graphic grading system has been validated and will be valuable
graphic morphological changes and symptoms in OA, further in monitoring disease progression. Ultrasonography also has the
potential to further clarify the role of soft tissues and provide
new insights in the disease genesis, pathology, progression, and
prediction of OA. However, the long learning curve is still an im-
portant limitation to be overcome for widespread application of
US in routine clinical practice.

REFERENCES
1. Arden N, Nevitt MC. Osteoarthritis: epidemiology. Best Pract Res Clin
Rheumatol. 2006;20:3–25.
2. Carmona L, Ballina J, Gabriel R, et al. The burden of musculoskeletal
diseases in the general population of Spain: results from a national survey.
Ann Rheum Dis. 2001;60:1040–1045.
3. Benito MJ, Veale DJ, FitzGerald O, et al. Synovial tissue inflammation in
early and late osteoarthritis. Ann Rheum Dis. 2005;64:1263–1267.
4. Keen HI, Wakefield RJ, Conaghan PG. A systematic review of
ultrasonography in osteoarthritis. Ann Rheum Dis. 2009;68:611–619.
5. Kellgren JH, Lawrence JS. Atlas of Standard Radiographs. Oxford:
Blackwell Scientific; 1963.
FIGURE 7. Baker cyst. Synovial hypertrophy and fluid in the Baker 6. Spector TD, Hart DJ, Byrne J, et al. Definition of osteoarthritis of the knee
cyst. Sagittal plane. for epidemiological studies. Ann Rheum Dis. 1993;52:790–794.

328 www.jclinrheum.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

JCR: Journal of Clinical Rheumatology • Volume 22, Number 6, September 2016 Ultrasound in Knee Osteoarthritis

7. Hannan MT, Felson DT, Pincus T. Analysis of the discordance between 28. Moller I, Naredo E, Moragues C, et al. Ultrasonographic finding in knee
radiographic changes and knee pain in osteoarthritis of the knee. osteoarthritis. A Nation-wide study in Spanish patients. Osteoarthr Cartil.
J Rheumatol. 2000;27:1513–1517. 2007;15(Suppl c):286:C159.
8. Hunter DJ, Zhang YQ, Niu JB, et al. The association of meniscal pathologic 29. Hill CL, Gale DG, Chaisson CE, et al. Knee effusions, popliteal cysts, and
changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis synovial thickening: association with knee pain in osteoarthritis.
Rheum. 2006;54:795–801. J Rheumatol. 2001;28:1330–1337.
9. Grassi W, Lamanna G, Farina A, et al. Sonographic imaging of normal and 30. Hall M, Doherty S, Courtney P, et al. Synovial pathology detected on
osteoarthritic cartilage. Semin Arthritis Rheum. 1999;28:398–403. ultrasound correlates with the severity of radiographic knee osteoarthritis
10. Patil P, Dasgupta B. Role of diagnostic ultrasound in the assessment of more than with symptoms. Osteoarthr Cartil. 2014;22:1627–1633.
musculoskeletal diseases. Ther Adv Musculoskelet Dis. 2012;4:341–355. 31. Ayral X, Pickering EH, Woodworth TG, et al. Synovitis: a potential
11. Keen HI, Conaghan PG. Ultrasonography in osteoarthritis. Radiol Clin predictive factor of structural progression of medial tibiofemoral knee
North Am. 2009;47:581–594. osteoarthritis—results of a 1 year longitudinal arthroscopic study in
422 patients. Osteoarthr Cartil. 2005;13:361–367.
12. Shepherd DE, Seedhom BB. Thickness of human articular cartilage in
joints of the lower limb. Ann Rheum Dis. 1999;58:27–34. 32. Schmidt WA, Völker L, Zacher J, et al. Colour Doppler ultrasonography to
detect pannus in knee joint synovitis. Clin Exp Rheumatol. 2000;18:
13. Aisen AM, McCune WJ, MacGuire A, et al. Sonographic evaluation of the
439–444.
cartilage of the knee. Radiology. 1984;153:781–784.
33. Walter M, Harms H, Krenn V, et al. Correlation of power Doppler
14. Naredo E, Acebes C, Möller I, et al. Ultrasound validity in the
sonography with vascularity of the synovial tissue of the knee joint in
measurement of knee cartilage thickness. Ann Rheum Dis. 2009;68:
patients with osteoarthritis and rheumatoid arthritis. Arthritis Rheum. 2001;
1322–1327.
44:331–338.
15. Pritzker KP, Gay S, Jimenez SA, et al. Osteoarthritis cartilage
34. Song IH, Althoff CE, Hermann KG, et al. Knee osteoarthritis. Efficacy of a
histopathology: grading and staging. Osteoarthr Cartil. 2006;14:13–29.
new method of contrast-enhanced musculoskeletal ultrasonography in
16. Tsai CY, Lee CL, Chai CY, et al. The validity of in vitro detection of synovitis in patients with knee osteoarthritis in comparison
ultrasonographic grading of osteoarthritic femoral condylar with magnetic resonance imaging. Ann Rheum Dis. 2008;67:19–25.
cartilage—a comparison with histologic grading. Osteoarthr Cartil.
2007;15:245–250. 35. Bevers K, Bijlsma JWJ, Vriezekolk JE, et al. The course of
ultrasonographic abnormalities in knee osteoarthritis: 1 year follow up.
17. Lee CL, Huang MH, Chai CY, et al. The validity of in vivo Osteoarthr Cartil. 2014;22:1651–1656.
ultrasonographic grading of osteoarthritic femoral condylar cartilage: a
comparison with in vitro ultrasonographic and histologic gradings. 36. Hunter DJ, Conaghan PG. Imaging outcomes and their role in determining
Osteoarthr Cartil. 2008;16:352–358. outcomes in osteoarthritis and rheumatoid arthritis. Curr Opin Rheumatol.
2006;18:157–162.
18. Chen YJ, Chen CH, Wang CL, et al. Association between the severity of
femoral condylar cartilage erosion related to knee osteoarthritis by 37. Bevers K, Vriezekolk JE, Bijlsma JW, et al. Ultrasonographic predictors for
ultrasonographic evaluation and the clinical symptoms and functions. clinical and radiological progression in knee osteoarthritis after 2 years of
Arch Phys Med Rehabil. 2015;96:837–844. follow-up. Rheumatology (Oxford). 2015;54:2000–2003.

19. Noyes FR, Stabler CL. A system for grading articular cartilage lesions at 38. Malas FÜ, Kara M, Kaymak B, et al. Ultrasonographic evaluation in
arthroscopy. Am J Sports Med. 1989;17:505–513. symptomatic knee osteoarthritis: clinical and radiological correlation. Int J
Rheum Dis. 2014;17:536–540.
20. Saarakkala S, Waris P, Waris V, et al. Diagnostic performance of knee
ultrasonography for detecting degenerative changes of articular cartilage. 39. Conaghan PG, D’Agostino MA, Le Bars M, et al. Clinical and
Osteoarthr Cartil. 2012;20:376–381. ultrasonographic predictors of joint replacement for knee osteoarthritis:
results from a large, 3-year, prospective EULAR study. Ann Rheum Dis.
21. Möller I, Bong D, Naredo E, et al. Ultrasound in the study and monitoring
2010;69:644–647.
of osteoarthritis. Osteoarthr Cartil. 2008;16(16 suppl 3):S4–S7.
40. Bevers K, Zweers MC, Vriezekolk JE, et al. Are ultrasonographic signs of
22. Abraham AM, Goff I, Pearce MS, et al. Reliability and validity of
inflammation predictors for response to intra-articular glucocorticoids in
ultrasound imaging of features of knee osteoarthritis in the community.
knee osteoarthritis? Clin Exp Rheumatol. 2014;32:930–934.
BMC Musculoskelet Disord. 2011;12:70.
41. Iagnocco A, Naredo E. Osteoarthritis: research update and clinical
23. Koski JM, Kamel A, Waris P, et al. Atlas-based knee osteophyte
applications. Rheumatology (Oxford). 2012;51(Suppl 7):vii2–vii5.
assessment with ultrasonography and radiography: relationship to
arthroscopic degeneration of articular cartilage. Scand J Rheumatol. 42. Ostergaard M, Court-Payen M, Gideon P, et al. Ultrasonography in arthritis
2016;45:158–164. of the knee. A comparison with MR imaging. Acta Radiol. 1995;36:19–26.
24. Riecke BF, Christensen R, Torp-Pedersen S, et al. An ultrasound score for 43. Naredo E, Moller I, Moragues C, et al. Interobserver reliability in
knee osteoarthritis: a cross-sectional validation study. Osteoarthr Cartil. musculoskeletal ultrasonography: results from a “teach the teachers”
2014;22:1675–1691. rheumatologist course. Ann Rheum Dis. 2006;65:14–19.
25. Kristoffersen H, Torp-Pedersen S, Terslev L. Indications of inflammation 44. Iagnocco A, Perricone C, Scirocco C, et al. The interobserver reliability of
visualized by ultrasound in osteoarthritis of the knee. Acta Radiol. 2006;47: ultrasound in knee osteoarthritis. Rheumatology (Oxford). 2012;51:
281–286. 2013–2019.
26. D’Agostino MA, Conaghan P, Le Bars M, et al. EULAR report on the use 45. Bevers K, Zweers MC, van den Ende CH, et al. Ultrasonographic analysis
of ultrasonography in painful knee osteoarthritis. Part 1: prevalence of in knee osteoarthritis: evaluation of inter-observer reliability. Clin Exp
inflammation in osteoarthritis. Ann Rheum Dis. 2005;64:1703–1709. Rheumatol. 2012;30:673–678.
27. de Miguel Mendieta E, Cobo Ibáñez T, Usón Jaeger J, et al. Clinical and 46. Backhaus M, Ohrndorf S, Kellner H, et al. Evaluation of a novel 7-joint
ultrasonographic findings related to knee pain in osteoarthritis. Osteoarthr ultrasound score in daily rheumatologic practice: a pilot project. Arthritis
Cartil. 2006;14:540–544. Rheum. 2009;61:1194–1201.

© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.jclinrheum.com 329

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.