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Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative
  1. Peter V Balint1,
  2. Lene Terslev2,
  3. Philippe Aegerter3,
  4. George Arthur Willem Bruyn4,
  5. Isabelle Chary-Valckenaere5,
  6. Frederique Gandjbakhch6,
  7. Annamaria Iagnocco7,
  8. Sandrine Jousse-Joulin8,
  9. Ingrid Möller9,
  10. Esperanza Naredo10,
  11. Wolfgang A Schmidt11,
  12. Richard J Wakefield12,
  13. Maria-Antonietta D’Agostino13
  14. on behalf of the OMERACT Ultrasound Task Force members
    1. 1 3rd Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
    2. 2 Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
    3. 3 Department of Public Health and Biostatistics, UMR 1168 INSERM Université Versailles St-Quentin en Yvelines, GIRCI IdF, Paris, France
    4. 4 Department of Rheumatology, MC Groep Hospitals, Lelystad, The Netherlands
    5. 5 Department of Rheumatology, University Hospital of Nancy, Nancy, France
    6. 6 Rheumatology Department, University of Paris VI, CHU Pitié Salpétriére, Paris, France
    7. 7 Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
    8. 8 Rheumatology Department, Cavale Blanche Hospital and Brest Occidentale University, Brest, France
    9. 9 Department of Rheumatology, Instituto Poal de Reumatología and University of Barcelona, Barcelona, Spain
    10. 10 Department of Rheumatology, Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz and Autónoma University, Madrid, Spain
    11. 11 Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
    12. 12 Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds, UK
    13. 13 Rheumatology Department, APHP, Hôpital Ambroise Paré, INSERM U1173, Labex Inflamex, Université Versailles St-Quentin en Yvelines, Boulogne-Billancourt, France
    1. Correspondence to Professor Maria-Antonietta D’Agostino, Rheumatology department, Ambroise Paré Hospital, Boulogne-Billancourt 92100, France; maria-antonietta.dagostino{at}


    Objectives To evaluate the reliability of consensus-based ultrasound (US) definitions of elementary components of enthesitis in spondyloarthritis (SpA) and psoriatic arthritis (PsA) and to evaluate which of them had the highest contribution to defining and scoring enthesitis.

    Methods Eleven sonographers evaluated 40 entheses from five patients with SpA/PsA at four bilateral sites. Nine US elementary lesions were binary-scored: hypoechogenicity, thickened insertion, enthesophytes, calcifications, erosions, bone irregularities, bursitis and Doppler signal inside and around enthesis. Kappa statistics were used to evaluate reliability. Sonographers were also asked to state which lesions can be considered as inflammatory or structural and should be included in the final definition of enthesitis. Only the lesions, scored as present in at least 75% of the entheses considered as having an enthesitis, were included in the final definition.

    Results The prevalence of detected lesions was quite low except for enthesophytes (55%) and bone irregularities (54%). Reliability ranged from poor to good (the lowest for thickened enthesis (kappa 0.1 (95% CI 0 to 0.7)) and the highest for enthesophytes (kappa 0.6 (95% CI 0.5 to 0.7)). When adjusted for low prevalence, kappa values increased for all lesions, with the best result observed for detecting Doppler signal at insertion (0.9) and for bursitis (0.8). The US components included in the final definition were hypoechogenicity, increased thickness at enthesis, erosions and calcifications/enthesophytes and Doppler signal at insertion.

    Conclusion By using a consensus-based stepwise approach, a final reliable US score and definition of enthesitis in SpA/PsA were produced. Further studies are sought for implementing this score in clinical trials and practice.

    • enthesitis
    • ultrasonography
    • reliability
    • scoring system
    • spondyloarthritis
    • psoriatic arthritis

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    • Handling editor Josef S Smolen

    • Contributors Study design: M-AD’A, PA. Acquisition of data: AI, EN, FG, GAWB, IC-V, IM, LT, M-AD’A, PVB, RJW, SJ-J, WAS. Analysis and interpretation of data: M-AD’A, PA, LT, PVB. Manuscript: M-AD’A, LT, PVB. Statistical analysis: M-AD’A, PA.

    • Funding Unrestricted grant from AbbVie France.

    • Competing interests None declared.

    • Patient consent Not required.

    • Ethics approval The study was performed according to a pre-specified protocol and conducted in accordance with the Declaration of Helsinki and each patient gave written informed consent to participate.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators OMERACT Ultrasound Task Force members: Sibel Z Aydin, Artur Bachta, Marina Backhaus, Fred Joshua, David Bong, Paz Collado, Eugenio De Miguel, Emilio Filippucci, Jane E Freeston, Walter Grassi, Marwin Gutierrez, Hilde B Hammer, David Kane, Helen I Keen, Damien Loeuille, Peter Mandl, Carlos Pineda, Marcin Szkudlarek.