Paediatric US

Working group OMERACT > ULTRASONOGRAPHY DEFINITIONS FOR SYNOVITIS GRADING IN CHILDREN

MENTOR:

L TERSLEV  

Convenors: P Collado, J Vojinovic

Website responsible: P Collado

Objective of the subgroups work: 

1. Development of US scoring systems for inflammatory synovitis

2. Investigation of reliability, and when reliable

3. Truth, Discrimination and feasibility

What is the contribution of the subgroup work to the OMERACT work?

Imaging (US and MRI) has been voted to become middle onion domain for clinical trials in JIA (2018)

Description of the previous work

So far, previous works have resulted in the following publication:

1.- "Is ultrasound a validated imaging tool for the diagnosis and management of synovitis in juvenile idiopathic arthritis? A systematic literature review" Arthritis Care Res 2012

 2.- “Musculoskeletal ultrasound in pediatric rheumatology: European preliminary results of the survey of the pediatric ultrasound group of the omeract ultrasound task force” Rheumatology 2014

 3.- “Definitions for the sonographic features of joints in healthy children”  Arthritis Care Res 2015

4.- “Toward standardized musculoskeletal ultrasound in pediatric rheumatology” Arthritis Care Res 2016

5.- “Preliminary definitions for the sonographic features of synovitis in children”  Arthritis Care Res 2017

6.- “Amendment of the OMERACT ultrasound definitions of joints features in healthy children when using the Doppler technique” Pediatr Rheumatol Online J. 2018

7.- “Age-related vascularization and ossification of joints in children: an international pilot study to test multi-observer ultrasound reliability.”  Arthritis Care Res 2017

Reporting back of work done since ACR 2017

-

Next steps and discussion points

1. Tenosynovitis in children with inflammatory arthritis

    

   Background:

   In children with juvenile idiopathic arthritis (JIA) clinical examination seems to be not very reliable in terms of detection of inflammatory changes in joints and joint structures. For the determination of the extent of inflammation imaging plays an increasing role in pediatric rheumatology. Synovitis has been thoroughly studied both in musculo-skelettal ultrasound (MSUS) and magnetic resonance imaging (MRI). In contrast to adult rheumatomlogy, in pediatric rheumatology only little knowledge exists on the presence of tenosynovitis and only few articles have been published on that topic. All publications point to the presence of tenosynovitis frequently clinically not detectable and frequently present in patients with clinically inactive disease.

   Tenosynovitis represents disease activity and being clinically not detectable the influence on the outcome of the patient hasn’t neither been addressed nor measured so far, although tenosynovitis could be one major factor for the loss of hand function.

    

   Objective:

   To study tenosynovitis in children with inflammatory arthritis and to develop a scoring system for grading tenosynovitis as a measurement for disease activity.

    

   Methods:

   Following the OMERACT filter 2.0 the following steps will be taken:

   - Literature Review and definition of the items/sites of tenosynovitis

   - Consensus process on definition and grading of US tenosynovitis

   - Reliability of US-assessed (presence and grade) tenosynovitis in JIA

   - Construct validity of US in detecting and scoring tenosynovitis as compared with MRI

   - Construct validity of US in detecting and scoring tenosynovitis as compared with hand measurements (e.g. power, grip etc.)

   Participants:

   Paz Collado and Nikolay Tzaribachev supervised by Esperanza Naredo. Everybody from the OMERACT MSUS work group is invited.

   Literature:

   Children

   Javadi S, Kan JH, Orth RC, DeGuzman M. Wrist and ankle MRI of patients with juvenile idiopathic arthritis: identification of unsuspected multicompartmental tenosynovitis and arthritis.AJR Am J Roentgenol. 2014 Feb;202(2):413-7.

    

   Lambot K, Boavida P, Damasio MB, Tanturri de Horatio L, Desgranges M, Malattia C, Barbuti D, Bracaglia C, Müller LS, Elie C, Bader-Meunier B, Quartier P, Rosendahl K, Brunelle F. MRI assessment of tenosynovitis in children with juvenile idiopathic arthritis: inter- and intra-observer variability. Pediatr Radiol. 2013 Jul;43(7):796-802.

    

   Brown A, Hirsch R, Laor T, Hannon MJ, Levesque MC, Starz T, Francis K, Kwoh CK. Do patients with juvenile idiopathic arthritis in clinical remission have evidence of persistent inflammation on 3T magnetic resonance imaging? Arthritis Care Res (Hoboken). 2012 Dec;64(12):1846-54.

    

   Collado P, Gamir ML, López-Robledillo JC, Merino R, Modesto C, Monteagudo I. Detection of synovitis by ultrasonography in clinically inactive juvenile idiopathic arthritis on and off medication. Clin Exp Rheumatol. 2014 Jul-Aug;32(4):597-603.

    

   Magni-Manzoni S, Scirè CA, Ravelli A, Klersy C, Rossi S, Muratore V, Visconti C, Lanni S, Merli P, Montecucco C. Ultrasound-detected synovial abnormalities are frequent in clinically inactive juvenile idiopathic arthritis, but do not predict a flare of synovitis. Ann Rheum Dis. 2013 Feb;72(2):223-8.

    

   Hendry GJ, Gardner-Medwin J, Steultjens MP, Woodburn J, Sturrock RD, Turner DE. Frequent discordance between clinical and musculoskeletal ultrasound examinations of foot disease in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2012 Mar;64(3):441-7.

    

   Pascoli L, Wright S, McAllister C, Rooney M. Prospective evaluation of clinical and ultrasound findings in ankle disease in juvenile idiopathic arthritis: importance of ankle ultrasound.

   J Rheumatol. 2010 Nov;37(11):2409-14.

   Rooney ME, McAllister C, Burns JF. Ankle disease in juvenile idiopathic arthritis: ultrasound findings in clinically swollen ankles. J Rheumatol. 2009 Aug;36(8):1725-9.

    

   Karmazyn B, Bowyer SL, Schmidt KM, Ballinger SH, Buckwalter K, Beam TT, Ying J. US findings of metacarpophalangeal joints in children with idiopathic juvenile arthritis. Pediatr Radiol. 2007 May;37(5):475-82.

    

    

   Adults

    

   Haavardsholm EA, Østergaard M, Ejbjerg BJ, Kvan NP, Kvien KT. Introduction of a novel magnetic resonance imaging tenosynovitis score for rheumatoid arthritis: reliability in a multireader longitudinal study. Annals of the Rheumatic Diseases 2007;66:1216-1220.

    

   Schirmer C, Scheel AK, Althoff CE, et al, Hermann KG. Diagnostic quality and scoring of synovitis, tenosynovitis and erosions in low-field MRI of patients with rheumatoid arthritis: a comparison with conventional MRI. Annals of the Rheumatic Diseases 2007;66:522-529.

    

   Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Esperanza Naredo, Maria Antonietta D'Agostino, Richard J Wakefield, Ingrid Möller, Peter V Balint, Emilio Filippucci, Annamaria Iagnocco, Zunaid Karim, Lene Terslev, David A Bong, Jesús Garrido, David Martínez-Hernández, George A W Bruyn on behalf of the OMERACT Ultrasound Task Force*. Annals of the Rheumatic Diseases 2013;72:1328-1334.

2. Proposal

Project: Joint ossification of healthy children and JIA-patients 

Pediatric Ultrasound Special Interest Group, OMERACT Ultrasound Group

Project Coordinator on behalf of the Pediatric Ultrasound special Interest Group:

Daniel Windschall, MD, Germany

Email: d.windschall@asklepios.com

Objectives:

Accurate musculoskeletal ultrasound (MSUS) assessment of disease activity and joint damage is essential in the clinical management of children with Juvenile idiopathic Arthritis (JIA). Several studies have described improved sensitivity for detection of joint inflammation with the use of ultrasound as compared with clinical assessment. But there is still a lack of validated normal B-Mode and Power Doppler sonographic findings in different age groups. The development of the skeletal system with different stages of maturity of the ossification nuclei, has to be taken into account performing MSUS in children.

At birth, cortical bone is present in most of the long bone diaphyses representing the primary ossification center. The secondary ossification centers in the epiphyses will only subsequently become apparent. In a recently published ultrasound study assessing the skeletal development of newborns, the dimension of the ossification centers correlated well with the age and maturity of the newborns. Children with juvenile idiopathic arthritis may have an accelerated bone development following  inflammation and hypervascularization of affected joints. It seems to be very  important and helpful for the rheumatologist to assess the skeletal maturity of examined joints in children. The OMERACT pediatric ultrasound subtask group has recently agreed a new four-degree score to assess the ossification stage of different joints. The first practical study assessing skeletal maturity by the new semiquantitative score in healthy children showed a very good applicability and was found to correlate well with the age of probands. A very good interobserver and intraobserver agreement shown by high kappa values and intraclass coefficients was calculated. The semiquantitative score seemed to be a very practicable tool and should be tested now on different joints of a higher count of probands and patients e.g. with juvenile idiopathic arthritis.

Scientific/Medical Rationale – Aim of the project

1. One objective of the project is to evaluate the development of ossification in several joints in healthy children and to produce an atlas of childhood ossification with sonographic anatomic landmarks for age- and sex-dependent ossification in children.

2. A second objective includes the evaluation of accelerated ossification in joints of patients with JIA.

3. A third objective is to validate the recently agreed ossification score in different joints in healthy children and patients with JIA.

Procedures/ Agenda

1. Literature Review “ossification”

2. Healthy joints (images, multi-observer exercise)

3. JIA patients (images, multi-observer exercise)

Few References/ Prework

1. Magni-Manzoni S, Collado P, Jousse-Joulin S, Naredo E, D'Agostino MA, Muratore V, et al. Current state of musculoskeletal ultrasound in paediatric rheumatology: results of an international survey. Rheumatology 2014;53:491-6.

2. Lanni S, Wood M, Ravelli A, Magni Manzoni S, Emery P, Wakefield RJ. Towards a role of ultrasound in children with juvenile idiopathic arthritis. Rheumatology (Oxford) 2013;52:413-20.

3. Collado P, Jousse-Joulin S, Alcalde M, Naredo E, D`Agostino MA. Is ultrasound a validated imaging tool for the diagnosis and management of synovitis in juvenile idiopathic arthritis? A systematic literature review. Arthritis Care Res 2012;64:1011-9.

4. Magni-Manzoni S, Epis O, Ravelli A, Klersy C, Veisconti C, Lanni S, et al. Comparison of clinical versus ultrasound determined synovitis in juvenile idiopathic arthritis. Arthritis Rheum 2009;61:1497-504.

5. Breton S, Jousse-Joulin S, Cangemi C, de Parscau L, Colin D, Bressolette L, et al. Comparison of clinical and ultrasonographic evaluations for peripheral synovitis in juvenile idiopathic arthritis. Semin Arthritis Rheum 2011;41:272-8.

6. Roth J, Jousse-Joulin S, Magni-Manzoni S, Rodriguez A, Tzaribachev N, Iagnocco A, et al., Outcome measures in Rheumatology Ultrasound Group. Definitions for the sonographic features of joints in healthy children. Arthritis Care Res 2015;67:136-42.

7. Collado P, Vojinovic J, Nieto JC, Windschall D, Magni Manzoni S, Bruyn GAW, et al., on behalf of the OMERACT Ultrasound Group. Toward standardized musculoskeletal ultrasound in paediatric rheumatology: normal age-related ultrasound findings. Arthritis Care Res 2016;68:348-56.

8. Windschall D, Collado P, Vojinovic J et al. on behalf of the OMERACT Ultrasound Group. Age-related vascularization and ossification of joints in healthy children by B-Mode and Doppler ultrasound: results of an international multi-observer study by the OMERACT Pediatric Ultrasound task force. Arthritis Care  Res July 2017.

9. Collado P. Windschall D, Vojinovic J et al. on behalf of the OMERACT Ultrasound Group Amendment of the OMERACT ultrasound definitions of joints' features in healthy children when using the DOPPLER technique.. Pediatr Rheumatol Online J. 2018 Apr 10;16(1):23. doi: 10.1186/s12969-018-0240-

10. Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. Stanford University Press Stanford 1959

11. Pyle SI, Hoerr NL. A radiographic standard reference for the growing knee, 2nd edn. Thomas, Springfield, I11 1969

12. Paesano PL, Vigone M, Siragusa V, Chiumello G, Del Maschio A and Mora S. Assessment of skeletal maturation in infants: comparison between two methods in hypothyroid patients. Pediatr Radiol 1998; 28:622-626

13. Windschall D, Pommerenke M, Haase R. Ultrasound assessment of the skeletal development of the proximal femoral, distal femoral and proximal tibial epiphyses in premature and mature neonates. Ultrasound Med Biol 2016;42:451-8.