Size matters: observations regarding the sonographic double contour sign in different joint sizes in acute gouty arthritis

  • C. Löffler
  • H. Sattler
  • U. Löffler
  • B. K. Krämer
  • R. Bergner



In distinguishing urate arthritis (UA) from non-crystal-related arthritides, joint sonography including the detection of the double contour sign (DCS) and hypervascularization using power Doppler ultrasound (PDUS) is an important step in the diagnostic process. But are these sonographic features equally reliable in every accessible joint under real-life conditions?


We retrospectively analyzed 362 patients with acute arthritis and evaluated the DCS and the degree of PDUS hypervascularization in patients with gout and in those with arthritis other than urate arthritis (non-UA). We classified all joints into the groups small, medium, and large. Sensitivities, specificities, positive and negative predictive values (PPV/NPV), and a binary regression model were calculated. We also evaluated the influence of serum uric acid levels (SUA) on the presence of a DCS in each joint category.


Sensitivity of the DCS in gout was 72.5% in the entire cohort, 66.0% in large, 78.8% in medium, and 72.3% in small joints. In wrist joints the DCS sensitivity maxed at 83.3%, with a specificity of 81.8%. The lowest rates of DCS sensitivity were found in gout patients with elbow joint involvement (42.9%). In all joints except metatarsophalangeal joint 1 (MTP-1), the incidence of a DCS increased by the increment of SUA levels above 7.5 mg/dl (p < 0.001). PDUS signals were most commonly found in medium and small joints and were only scarce in large joints, independent of the underlying diagnosis.


In our study we detected different rates of accuracy regarding DCS and PDUS in patients with acute arthritis. The best results were seen in medium-size joints, especially wrists.


Gout Urate arthritis Double contour sign Ultrasound Joint 

Die Größe macht den Unterschied: Beobachtungen zum sonographischen Doppelkonturzeichen in unterschiedlichen Gelenken bei akuter Gichtarthritis



Bei der Unterscheidung zwischen Gichtarthritis und nichtkristallassoziierten Arthritiden ist die Arthrosonographie zur Detektion des Doppelkonturzeichens (DCS) und der Hypervaskularisation im Power-Doppler-Ultraschall (PDUS) ein wichtiger Schritt im diagnostischen Prozess. Aber sind diese sonographischen Zeichen unter Alltagsbedingungen gleichsam zuverlässig in allen untersuchbaren Gelenken?


Retrospektiv wurden die Daten von 362 Patienten mit akuter Arthritis und das DCS analysiert sowie die Hypervaskularisation im PDUS bei Fällen mit Uratarthritis (UA) vs. Nichturatarthritis (non-UA) ausgewertet. Alle Gelenke wurden der Größe nach in klein, mittel und groß eingeordnet. Es wurden Sensitivitäten, Spezifitäten, positive und negative prädiktive Werte und eine binäre Regression kalkuliert. Außerdem werteten die Autoren den Einfluss der Serumharnsäure auf die Detektierbarkeit eines DCS in jeder Gelenkkategorie aus.


Die Sensitivität des DCS bei Gicht in der gesamten Kohorte lag bei 72,5 %, bei großen Gelenken bei 66,0 %, bei mittleren betrug sie 78,8 % und bei kleinen 72,3 %. Die beste Sensitivität war bei Handgelenken mit 83,3 % bei einer Spezifität von 81,8 % zu verzeichnen. Die niedrigste Sensitivität fanden die Autoren bei Ellbogenmanifestation (42,9 %). Bei allen Gelenken außer dem Metatarsophalangealgelenk 1 (MTP-1) war die Inzidenz eines DCS bei Serumharnsäurewerten >7,5 mg/dl signifikant erhöht (p < 0,001). PDUS-Signale wurden unabhängig von der Diagnose am häufigsten bei mittleren und kleinen, dagegen kaum bei großen Gelenken gefunden.


In der vorliegenden Studie war die Genauigkeit der Vorhersage einer Gichtarthritis durch das DCS sowie das Auftreten von PDUS-Hypervaskularität je nach Gelenk unterschiedlich. Die besten Ergebnisse wurden in mittelgroßen Gelenken, insbesondere Handgelenken, erzielt.


Gicht Uratarthritis Doppelkonturzeichen Ultraschall Gelenk 


Compliance with ethical guidelines

Conflict of interest

C. Löffler, H. Sattler, U. Löffler, B.K. Krämer, and R. Bergner declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Nephrology, Endocrinology, Rheumatology, University Hospital MannheimUniversity of HeidelbergMannheimGermany
  2. 2.Department of Oncology, Rheumatology, NephrologyKlinikum LudwigshafenLudwigshafenGermany
  3. 3.Psychotherapy Clinic, Institute of PsychologyUniversity of HeidelbergHeidelbergGermany

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