High-resolution ultrasound of the midfoot: sonography is more
sensitive than conventional radiography in detection
of osteophytes and erosions in inflammatory
and non-inflammatory joint disease
Received: 5 January 2017 /Revised: 18 April 2017 / Accepted: 21 April 2017 / Published online: 6 May 2017
International League of Associations for Rheumatology (ILAR) 2017
Abstract This study aimed to compare the diagnostic value
of ultrasonography to conventional radiography in detecting
osteophytes and erosions in the midfoot joints in patients suf-
fering from inflammatory and non-inflammatory joint disease.
Patients with current foot radiographs were included and strat-
ified in two cohorts: inflammatory and non-inflammatory
joint disease. The ten midfoot joints of each foot were evalu-
ated by conventional radiography assessing the presence of
osteophytes and erosions and by ultrasonography determining
the presence of osteophytes, erosions, and joint effusion.
Power Doppler activity was scored semi-quantitatively from
0 to 3. A total of 2445 joints in 124 patients (90 with inflam-
matory joint disease, 34 with non-inflammatory joint disease)
were assessed. Ultrasonography detected significantly more
osteophytes than conventional radiography (344; 14.1% vs.
13; 0.5%), as well as more erosions (60; 2.5% vs. 3; 0.1%).
There was weak agreement between the two modalities (κ-
statistic 0.029–0.035). Power Doppler ultrasonography
demonstrated no significant difference in hyperperfusion
comparing patients with inflammatory joint disease and non-
inflammatory joint disease. Ultrasonography of the midfoot is
more sensitive than conventional radiography in the detection
of osteophytes and erosions in patients suffering from inflam-
matory and non-inflammatory joint disease. Thus, midfoot
ultrasonography may be a useful tool in the diagnosis of joint
diseases as rheumatoid arthritis and osteoarthritis.
Keywords Conventional radiography
Ultrasonography (US) and conventional radiography (CR) are
established imaging modalities for the assessment of cortical
bone lesions including erosions and osteophytes. When com-
pared to MRI, US has good sensitivity and specificity in the
detection of osteophytes and erosions in many joint regions
[1–3], rendering it an inexpensive and readily available alter-
native in clinical practice.
In recent years, there has been a strong effort in the assess-
ment of erosions to better identify RA patients with poor out-
come. Thus, now there is good evidence that US is more
effective in detecting erosions than CR in joints affected by
RA [2, 3], especially in the early course of the disease .
Whereas the majority of existing studies refer to the frequently
involved upper limb joints of RA patients, the midfoot joints
were so far only partly addressed in one study . Beside
erosions, also osteophytes can be assessed by both US and
CR. Osteophytes are the main feature of osteoarthritis, and
while largely unstudied in the foot, presence of osteophytes
in the knee is associated with structural progression and
* Wolfgang Hartung
Department of Rheumatology and Clinical Immunology, Asklepios
Medical Center, Kaiser-Karl-V-Allee 3, 93077 Bad
Clin Rheumatol (2017) 36:2145–2149