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Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study
  1. Andrea Di Matteo1,2,
  2. Gianluca Smerilli1,
  3. Stefano Di Donato2,
  4. An Ran Liu3,
  5. Andrea Becciolini4,
  6. Federica Camarda5,
  7. Tomas Cazenave6,
  8. Edoardo Cipolletta1,
  9. Davide Corradini7,
  10. Juan José de Agustín8,
  11. Giulia Maria Destro Castaniti5,
  12. Eleonora Di Donato4,
  13. Luca Di Geso9,
  14. Emine Duran10,
  15. Bayram Farisogullari10,
  16. Marco Fornaro11,
  17. Francesca Francioso1,
  18. Pamela Giorgis6,
  19. Amelia Granel12,
  20. Cristina Hernández-Díaz13,
  21. Rudolf Horvath14,
  22. Jana Hurnakova14,
  23. Diogo Jesus15,16,
  24. Omer Karadag10,
  25. Ling Li17,
  26. Josefina Marin18,
  27. María Victoria Martire12,
  28. Xabier Michelena8,
  29. Erica Moscioni1,
  30. Laura Muntean19,
  31. Matteo Piga7,
  32. Marcos Rosemffet6,
  33. João Rovisco20,
  34. Didem Sahin2,
  35. Fausto Salaffi1,
  36. Liliana Saraiva20,
  37. Crescenzio Scioscia11,
  38. Maria-Magdalena Tamas19,
  39. Shun Tanimura21,
  40. Aliki Venetsanopoulou22,
  41. Lucio Ventura-Rios23,
  42. Orlando Villota24,25,
  43. Catalina Villota-Eraso25,
  44. Paraskevi V Voulgari22,
  45. Gentiana Vukatana26,
  46. Johana Zacariaz Hereter18,
  47. Helena Marzo-Ortega2,
  48. Walter Grassi1,
  49. Emilio Filippucci1
  1. 1 Rheumatology Unit, Department of Clinical and Molecular Sciences, 'Carlo Urbani' Hospital, Polytechnic University of Marche, Ancona, Italy
  2. 2 Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
  3. 3 Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
  4. 4 Department of Medicine, Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
  5. 5 Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Rheumatology Section, University of Palermo, Palermo, Italy
  6. 6 Instituto de Rehabilitación Psicofísica, Buenos Aires, Argentina
  7. 7 Rheumatology Unit, University of Cagliari, Cagliari, Italy
  8. 8 Rheumatology Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
  9. 9 Department of Internal Medicine, Provincial Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
  10. 10 Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
  11. 11 Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Rheumatology Unit, University of Bari, Bari, Italy
  12. 12 Rheumatology, Hospital San Roque de Gonnet, La Plata, Buenos Aires, Argentina
  13. 13 Rheumatology Department, Hospital Juárez de México, Mexico City, Mexico
  14. 14 Department of Paediatric and Adult Rheumatology, Motol University Hospital, Praha, Czech Republic
  15. 15 Rheumatology Department, Leiria Hospital Centre, Pousos, Portugal
  16. 16 Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
  17. 17 Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
  18. 18 Rheumatology Unit, Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
  19. 19 Department of Rheumatology, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
  20. 20 Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
  21. 21 Department of Rheumatology, The Hokkaido Medical Center, Sapporo, Japan
  22. 22 Department of Rheumatology, School of Health Sciences, University of Ioannina Faculty of Medicine, Ioannina, Greece
  23. 23 Division of Rheumatology, National Institute of Rehabilitation Luis Guillermo Ibarra, Ciudad de Mexico, Mexico
  24. 24 Division of Rheumatology, Fundación Hospital San Pedro, San Juan de Pasto, Colombia
  25. 25 Department of Rheumatology, Servicio Integral de Reumatología e Inmunología Doctor Orlando Villota, Pasto, Colombia
  26. 26 Rheumatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico di Sant'Orsola, Bologna, Italy
  1. Correspondence to Dr Andrea Di Matteo, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Polytechnic University of Marche, Ancona, Italy; andrea.dimatteo{at}


Objectives To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population.

Methods In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). ‘Active enthesitis’ was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas).

Results In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses.

Conclusions This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.

  • Ultrasonography
  • Spondylitis, Ankylosing
  • Arthritis, Psoriatic
  • Osteoarthritis
  • Fibromyalgia

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Handling editor Josef S Smolen

  • Contributors ADM, GS, WG and EF designed the study. ADM wrote the manuscript. SDD carried out the statistical analysis. EC contributed to the statistical analysis. LDG, DS, FS and HM-O contributed to the analysis of the data and interpretation of results. All other authors were included in the patients’ enrolment and acquisition of clinical and US data. All coauthors contributed to revising the manuscript critically and approved the final version to be published. ADM is the author responsible for the overall content as the guarantor.

  • Funding RH and JH were supported by the Ministry of Health, Czech Republic - Conceptual Development of Research Organization, Motol University Hospital, Prague, Czech Republic (00064203). HM-O is supported by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (LBRC). The views expressed are those of the authors and not necessarily those of the (UK) National Health Service (NHS), the NIHR or the (UK) Department of Health.

  • Competing interests ADM has received speaking fees from Janssen and has received support for attending meetings by Galapagos outside the submitted work. GS has received speaking fees and support for attending meetings by Novartis outside the submitted work. EC has received speaking fees from Novartis outside the submitted work. EDD has received speaking fees from Novartis and has received support for attending meetings by AbbVie outside the submitted work. MF has received speaking fees from Galapagos, AbbVie, Boehringer Ingelheim, Lilly and GSK and has received support for attending meetings by Pfizer outside the submitted work. XM has received speaking fees from AbbVie, Lilly Novartis, UCB and Janssen and has received support for attending meetings by UCB and Janssen outside the submitted work. MGR has received speaking fees from AbbVie, Raffo and Tecnofarma outside the submitted work. HM-O has received research grants from Janssen, Novartis, Pfizer and UCB and honoraria/speaker fees from AbbVie, Amgen, Eli Lilly, Janssen, Moonlake, Novartis, Pfizer, Takeda and UCB non-relevant to the submitted work. WG has received speaking fees from Accademia di Medicina, Janssen, Angelini Ethos, Galapagos, Biopharma and UVET outside the submitted work. EF has received speaking fees from AbbVie, Amgen, BMS, Janssen, Lilly, Novartis, Pfizer and Union Chimique Belge Pharma outside the submitted work.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.