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doi:10.1136/ard.2007.077081
2008;67;651-655; originally published online 17 Aug 2007; Ann Rheum Dis
P G Conaghan
Birrel, M Kloppenburg, T Stamm, I Watt, J S Smolen, E Maheu, M Dougados and
A Pendleton, D Kane, H Guerini, C Schueller-Weidekamm, M C Kortekaas, F
H I Keen, F Lavie, R J Wakefield, M-A D’Agostino, H Berner Hammer, E Hensor,
hand osteoarthritis
ultrasonographic scoring system for features of
The development of a preliminary
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The development of a preliminary ultrasonographic
scoring system for features of hand osteoarthritis
H I Keen,
1
F Lavie,
2
R J Wakefield,
1
M-A D’Agostino,
3
H Berner Hammer,
4
E M A Hensor,
1
A Pendleton,
5
D Kane,
6
H Guerini,
2
C Schueller-Weidekamm,
7
M C Kortekaas,
8
F Birrel,
9
M Kloppenburg,
8
T Stamm,
10
I Watt,
8
J S Smolen,
7
E Maheu,
11
M Dougados,
2
P G Conaghan
1
1
Academic Unit of
Musculoskeletal Disease,
University of Leeds, Leeds, UK;
2
Rheumatology B, Cochin
Hospital, Paris France;
3
Ambroise Pare Hospital,
Boulogne-Billancourt, France;
4
Diakonhjemmet Hospital, Oslo,
Norway;
5
Musgrave Park
Hospital Campus Belfast Health
and Social Care Trust, UK;
6
Adelaide and Meath Hospital,
Dublin, Ireland;
7
Medical
University Hospital, Vienna,
Austria;
8
Department of
Rheumatology, Leiden University
Medical Center, Leiden, The
Netherlands;
9
Newcastle
University, Newcastle, UK;
10
Department of Internal
Medicine III, Division of
Rheumatology, Vienna Medical
University, Vienna, Austria;
11
Saint-Antoine Hospital, Paris,
France
Correspondence to:
Helen Keen, Academic Unit of
Musculoskeletal Disease, Chapel
Allerton Hospital, Chapeltown
Road, Leeds LS7 4SA, UK; h.i.
keen@leeds.ac.uk
Accepted 12 August 2007
Published Online First
17 August 2007
ABSTRACT
Objectives: Painful osteoarthritis (OA) of the hand is
common and a validated ultrasound (US) scoring system
would be valuable for epidemiological and therapeutic
outcome studies. US is increasingly used to assess
peripheral joints, though most of the US focus in
rheumatic diseases has been on rheumatoid arthritis. We
aimed to develop a preliminary US hand OA scoring
system, initially focusing on relevant pathological features
with potentially high reliability.
Methods: A group of experts in the fields of OA, US and
novel tool development agreed on domains and suggested
scaling of the items to be used in US hand OA scoring
systems. A multi-observer reliability exercise was then
performed to evaluate the draft items.
Results: Synovitis (grey scale and Power Doppler) and
osteophytes (representing activity and damage domains)
were included and evaluated as the initial components of
the scoring system. All three features were evaluated for
their presence/absence and if present were scored using
a 1–3 scale. The reliability exercise demonstrated intra-
reader k values of 0.444–1.0, 0.211–1.0 and 0.087–1.0
for grey scale synovitis, power Doppler and osteophytes
respectively. Inter-reader reliability k values were 0.398,
0.327 and 0.530 grey-scale synovitis, power Doppler and
osteophytes respectively. Without extensive standardisa-
tion, both intra- and inter-reader reliability were moder-
ately good.
Conclusions: The draft scoring system demonstrated
substantive to almost perfect percentage exact agree-
ment on the presence/absence of the selected OA
features and moderate to substantive percentage exact
agreement on semi-quantitative grading. This preliminary
process provides a good basis from which to further
develop an US outcome tool for hand OA that has the
potential to be utilised in multicentre clinical trials.
Osteoarthritis (OA) is the most common joint
disease
1
and is associated with significant health
economic consequences
23
The prevalence of radio-
graphic OA has been well documented in epide-
miological studies; however, the prevalence of
symptomatic hand OA is not well documented.
4
The Framingham study has estimated the preva-
lence to be as high as 26% of women and 12% of
men over 70.
4
While treatment recommendations
focus on a holistic approach, the pharmaceutical
options are currently largely limited to analgesics
5–7
However, the spectrum of pharmaceutical thera-
pies is expanding, with a recent increase in interest
in potential disease modifying therapies in OA.
89
OA is assessed clinically with attention to symp-
toms and signs, and confirmed by structural
changes on radiographs. Similarly, trials focus on
clinical and structural outcomes. The
Osteoarthritis Research Society International
(OARSI) group has recently published guidelines
for conduct of clinical trials of OA of the hand,
10
recommending conventional radiographs (CRs) as
the standard for assessing structural outcomes.
However, they acknowledged that other novel
imaging techniques may play a part and require
further validation.
Ultrasound (US) appears favourably placed to
assess OA both in the clinic and in clinical trials. It
has a higher resolution than CR, does not involve
ionising radiation, and allows multi-planar,
dynamic imaging of joints. In addition, recent
studies in inflammatory arthritis have demon-
strated US to be more sensitive to synovitis than
clinical examination
11–13
more sensitive than CR to
the presence of cortical defects,
14 15
and have
reasonable sensitivity compared with magnetic
resonance imaging for the presence of synovitis
and cortical defects
13 16
A group of experts in OA, US and outcome
measures, met under the auspices of the Disease
Characteristics in Hand OA Group (DICHOA), to
gain consensus on the content, and take prelimin-
ary steps towards validation of an US scoring
system for OA of the hand.
METHODS
Experts in OA, outcomes measures and ultrasono-
graphy from six countries (UK, Austria, France,
Ireland, Norway, the Netherlands) took part in this
process which consisted of three steps.
Systematic literature review
A systematic literature review was conducted to
identify original articles examining the validity of B
mode or Doppler US in OA of the hand between
1950 and February 2007. The aim was to identify
studies that had defined and attempted to measure
pathological features of hand OA detectable by US.
Pubmed was searched using the terms ‘‘ultrasono-
graphy and hand and osteoarthritis’’ and ‘‘ultra-
sound and hand and osteoarthritis’’. Ovid
MEDLINE was also searched using the terms
(Osteoarthritis, Hip/or osteoarthritis.mp. or
osteoarthritis/or Osteoarthritis, Knee/) and
(Hand/or Hand Bones/or hand Joints/or
hand.mp./or finger joint/or thumb/or base of
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thumb.mb./or metacarpophalangeal joint/or carpal bones/or
schapoid bone/or carpal Joints/or stt joint.mp./or finger joint/or
pip joint.mp./or dip.m.p.) and (Ultrasonography, Doppler/or
Ultrasonography/or Ultrasonography, Doppler, Colour/or
Ultrasonography.mp.). The abstracts were reviewed, and
articles were excluded if they did not include the use of B mode
US in hand OA, were not in English, were case reports, pictorial
reviews or review articles, or did not measure pathological
features of hand OA.
Iterative internet exercise
The next step was an iterative internet discussion, in order to
gain consensus on a draft scoring system developed.
Considerations included the joints to be evaluated, domains to
be scored, definitions of domains, and proposed scaling systems
for each domain. Through this process consensus was obtained
on a draft scoring system.
Reliability exercise
A workshop involving 15 experts took place at the Cochin
Hospital in Paris, France. This included a multi-observer US
reliability exercise to evaluate the draft scoring system. The US
reliability exercise involved seven ultrasonographers (DK, RJW,
MADA, AP, CSW, HG, HBH) using seven commercially
available real time scanners (Technos MPX, Esaote, Genoa,
Italy) and a LA435 linear multifrequency transducer of 8–
14 MHz. The B mode frequency used was 13 MHz. The power
Doppler settings were as follows: frequency of 10 MHz, pulse
repetition frequency (PRF) of 750 kHz, and medium wall filter.
The colour gain was 113 db and was set at the level at which
noise artefacts appeared and then gradually reduced, until only
a flow signal, if present, was left. Patients followed in the
Department of Rheumatology of Cochin Hospital were invited
to participate in this exercise. Seven patients with OA of the
hands were scanned by each ultrasonographer to determine
inter-reader reliability. Each ultrasonographer rescanned their
first patient of the day at the end of the session to assess intra-
reader reliability. The US examination imaged 15 joints of the
dominant hand; the first carpometocarpal joint, metacarpopha-
langeal joints 1–5, proximal interphalangeal joints 1–5 and distal
interphalangeal joints 2–5. The entire dorsal surface of the joint
was imaged in grey scale, and Power Doppler was assessed in
the dorsal longitudinal plane.
The inter- and intra-reader reliability was assessed according
to k scores, weighted k scores (k (w)),
17
percentage exact
agreement (PEA) and percentage close agreement (PCA).
Arbitrary qualitative labels have previously been assigned to k
values, whereby a k of ,0.2 is slight, 0.21–0.4 fair, 0.41–0.6
moderate, 0.61–0.8 substantial and .0.81 almost perfect.
18
PEA
is the percentage of observations that were given the same score,
while percentage close agreement is the number of observations
that are either given the same score or ¡1. We are not aware of
any standard qualitative interpretation of PEA and PCA, so have
applied the same cut-offs as for the k values. Inter-reader
reliability was assessed with regards to specific agreement as
well, which assesses the agreement specific to each category in
the domain. This is less likely to be affected by chance than the
PEA. In addition, in assessing intra-reader reliability, the
percentage of times the second observation was higher than
the first observation was assessed (%m2.m1) in order to
identify any potential bias.
The distribution of pathology in the subjects scanned was
assessed post hoc by examining the results of the reliability
exercise. Pathology was deemed present if four of seven scanners
(ie, a majority) scored the pathology as present on the
dichotomous scale.
RESULTS
Systematic literature review
Twenty-five articles were identified with the search; the
abstracts of these articles were reviewed. Twenty-three articles
were excluded; six were not in English, five articles did not
involve OA of the hand, three articles were reviews, two were
pictorial reviews, six articles utilised neither B mode or Doppler
US, and one did not attempt to define or measure pathological
features of hand OA. The remaining two articles are presented
in table 1.
Iterative internet exercise
Consensus was obtained that 15 joints of the hand would be
examined. The first carpometacarpal joint, metacarpophalan-
geal joints 1–5, proximal interphalangeal joints 1–5, and distal
interphalangeal joints 2–5. Domains to be scored reflected
domains of activity and damage: synovial hypertrophy and
effusion, power Doppler signal and osteophytosis.
Synovial hypertrophy and effusion were considered together
as a single domain ‘‘synovitis’’. The OMERACT definitions of
synovial hypertrophy and effusion developed for RA were
applied.
19
It was agreed that grey scale synovitis would be scored
as either present or absent (0–1), and also on a semiquantitative
scale of 0–3 analogous to the scoring systems developed in RA,
where 0 represented no synovitis, 1 mild synovitis, 2 moderate
synovitis and 3 severe synovitis.
Power Doppler signal was defined as a signal within a region
of grey scale synovitis. It was decided to assess both
dichotomous (present/absent, 0–1) and semiquantitative (0–3)
scales.
Osteophytes were defined for the purpose of this exercise as
cortical protrusions seen in two planes. Osteophytes were again
evaluated using both dichotomous and semiquantitative scales
(the latter scored at each joints as absent, mild, moderate or
severe on a scale of 0–3).
It was decided not to include erosions, cartilage parameters or
joint space narrowing because of concerns about reliable
definitions, acquisition, current available US technology and
feasibility related to duration of scanning (see also Discussion).
Reliability exercise
Intra- and inter-reader reliability for each domain and each
scaling system are presented in tables 2 and 3. The intra-reader k
values (table 3) varied from light to almost perfect depending on
the observer, domain and scoring scale. It was generally better
from dichotomous scales, with substantive to almost perfect
PEA for all observers for each domain. The semiquantitative
scales generally demonstrated slightly lower ks and PEA.
However, the PCA for the semiquantitative scales was
substantive for all observers and all domains. While the intra-
reader reliability was quite variable between readers; however,
as each reader scanned a different patient, the variability should
be interpreted cautiously, as those who scanned subjects with
less pathology may be expected to have better reliability. The
inter-reader ks (table 2) was fair to moderate, and once again,
the dichotomous scales were more reliable than the semiquan-
titative scales. The PEA ranged from fair to almost perfect, once
again depending on domain and scale. For synovitis, the PEA
was best towards the normal end of the semiquantitative scale.
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For the other domains, the results are more variable, for
example, agreement on osteophyte scores was better at the
extremes of the scale (scores of 0 and 3). There was no
consistent bias between or within readers with regards to the
second set of observations being higher than the first.
The distribution of pathologies in the subjects scanned is
demonstrated in table 4. Osteophytosis was seen in all proximal
interphalangeal and distal interphalangeal joints, but there was
a wide variation of pathology in other joints.
DISCUSSION
US has many features rendering it potentially valuable in
investigating structure in hand OA. This preliminary work
established that international experts in the field of US, OA and
outcome measures believe it is worthwhile pursuing this
imaging technique as a tool in hand OA. Also, even though
US is recognised as a valuable tool in imaging joints in
inflammatory diseases, the systematic literature review demon-
strated a paucity of information on the validity of US in hand
OA.
The development of a preliminary US hand scoring system
via an iterative internet exercise allowed experts to come to a
consensus as to what US detectable abnormalities in hand OA
were both important and feasible domains to be included. These
were grey-scale synovitis, power Doppler and osteophytosis. It
was felt that current technology would not allow cartilage
defects or joint space narrowing to be reliably or meaningfully
interpreted, despite these being cardinal pathological features of
Table 1 Papers obtained from a systematic literature review of ultrasonography in osteoarthritis of the hand
First author Year
Number of
subjects
Joint(s)
evaluated
US features
assessed
Feature
defined in
text
Quantification of
the feature
Inter-reader
reliability
Intra-reader
reliability
Construct
validity
Content
validity
Criterion
validity
Iagnocco
20
2005 110 PIP and DIP Erosions Yes Yes (number of erosions) Yes – Yes – –
Iagnocco
23
2000 57 CMC Effusion Yes Yes (depth of
articular triangle in mm)
– – Yes – –
CMC, first carpometocarpal joint; PIP, proximal interphalangeal joint; DIP, distal interphalangeal joint; US, ultrasound.
Table 2 Intra-reader agreement for the domains and scales used in the reliability exercise
Reader Reliability
Synovitis
(0–1 scale)
Synovitis
(0–3 scale)
Doppler
(0–1 scale)
Doppler
(0–3 scale)
Osteophytes
(0–1 scale)
Osteophytes
(0–3 scale)
1 PEA 80.0 80.0 80.0 73.3 73.3 66.7
PCA – 100.0 – 73.3 – 93.3
%m2.m1 66.6 66.7 0.0 0.0 100.0 100.0
k 0.602 0.679 0.471 0.348 0.375 0.561
k (w) – 0.923 – 0.305 – 0.813
2 PEA 80.0 60.0 86.7 80.0 93.3 80.0
PCA – 86.7 – 100.0 – 100.0
%m2.m1 0.0 16.7 0.0 0.0 100.0 66.7
k 0.471 0.474 0.667 0.536 0.842 0.719
k (w) – 0.673 – 0.830 – 0.935
3 PEA 73.3 40.0 80.0 26.7 53.5 40.0
PCA – 93.3 – 80.0 – 80.0
%m2.m1 50.0 77.8 66.7 63.6 71.4 77.8
k 0.444 0.172 0.571 0.088 0.087 0.172
k (w) – 0.637 – 0.439 – 0.453
4 PEA 66.7 53.3 60.0 53.3 93.3 80.0
PCA – 100.0 – 100.0 – 93.3
%m2.m1 60.0 57.1 33.3 28.6 0.0 100.0
k 0.074 0.356 0.211 0.132 – 0.664
k (w) – 0.753 – 0.276 – 0.763
5 PEA 60.0 53.3 86.7 73.3 93.3 73.3
PCA – 86.7 – 93.3 – 100.0
%m2.m1 16.7 28.6 0.0 25.0 0.0 50.0
k 0.224 0.255 0.595 0.250 0.762 0.620
k (w) – 0.545 – 0.637 – 0.900
6 PEA 100.0 100.0 100.0 100.0 100.0 93.3
PCA – 100.0 – 100.0 – 100.0
%m2.m1––––– 100.0
k 1.000 1.000 1.000 1.000 1.000 0.911
k (w) – 1.000 – 1.000 – 0.973
7 PEA 73.3 53.3 73.3 66.7 100.0 53.3
PCA – 86.7 – 93.3 – 100.0
%m2.m1 100.0 85.7 100.0 100.0 – 85.7
k 0.444 0.327 0.250 0.085 1.000 0.327
k (w) – 0.369 – 0.277 – 0.656
PEA, percentage exact agreement; PCA, percentage close agreement; k(w), weighted k; %m2.m1, percentage second scores
higher than first score.
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OA. Given that OARSI guidelines recommend that measures of
joint space narrowing are recorded in studies of structural
outcomes,
10
such a domain may need to be added to the tool in
the future. Erosions were also excluded from the tool, largely
due to perceived problems with the definition and reliability. US
may be a suitable medium to investigate the relationship
between erosive and non-erosive OA, although a single study
has found US to be less sensitive to erosions in hand OA than
CR.
20
Future development of this tool may need to revisit the
issue of whether to include erosions or not.
The reliability exercise demonstrated that the preliminary US
scoring tool was reliable. Intra-reader reliability (interpreted
with PCA or PEA) for the majority of observers and domains
was moderate to almost perfect, being generally higher when
the dichotomous scale was used. It is important to acknowledge
that variation between observers may be confounded by which
subject was used to assess intra-reader reliability. Reliability is
likely to be best when less pathology exists (as has been found
for the inter-reader reliability). As each observer scanned a
different subject to determine their intra-reader reliability,
results should be compared with caution.
Inter-reader reliability assessed with PEA was moderate to
almost perfect, being over 70% for each domain using a
dichotomous scale and being most reliable for the osteophyte
domain. Even utilising the semi-quantitative scaling, the lowest
PEA was 48% for synovitis, being higher for Doppler and
osteophytosis. Perhaps as would be expected, agreement was
generally greatest in the absence of pathology. Given there was
no formal or extensive standardisation process prior to the
exercise, these results are extremely encouraging. Finally,
problems with the draft system and future directions were
identified.
Despite limiting domains and numbers of joints scanned and
imaging only the dorsal surface of the joint, scanning each
subject took up to half an hour. This compares poorly with
scoring radiographs of hand OA, in which the most time-
consuming method has been shown to take an average of less
than 4 min.
21
The time taken in this exercise includes the
acquisition of images (which is not considered when scoring
CRs) and may decrease with increasing observer experience.
However, it is likely to be one of the major barriers to a feasible
US outcome measure in hand OA. We chose to examine 15
joints for the purpose of this preliminary exercise; however,
further consideration of which joints to include in a scoring
system, and whether to weight certain joints, is needed. The
restriction of scoring systems to limited joints, and weighting of
joints according to importance or significance requires further
clinical and imaging studies are required to determine the
relative significance of each joint or joint combinations.
We did not include erosions, joint space narrowing or cartilage
defects in this tool. This was not because these domains were not
felt to be of structural or pathological importance in OA, but
rather because we chose to focus on domains that were felt to be
feasible in a multicentre outcome measure given current
technology. Erosions can be difficult to visualise due to overlying
osteophytes, and in our experience where the cortical surface is
very damaged, it can be difficult to determine where an erosion
begins and an osteophyte ends. Furthermore the only study
examining the validity of US in detecting erosions in hand OA
found US to be less sensitive than CR.
20
While cartilage damage is
a cardinal feature of hand OA, there are several features of the US
appearance of degenerative cartilage, including thinning, trans-
parency and loss of clarity of the interface.
22
As cartilage changes
in OA are a spectrum, an appropriate scaling system would have
been complex, time consuming, and of uncertain significance
given that visualisation of cartilage is limited in the small joints of
the hand, even with flexion of the joint, due to joint structure. US
can only image surfaces of joints, the joint space in the central
portion can be obscured by osteophytes in OA of the hand, so it
was felt that trying to quantify joint space with US would not be
feasible.
In the early phase of OA cytokines stimulating osteoblasts are
released from the chondrocytes. Thus the osteophytes are early
signs of pathology in the cartilage. Given the high resolution of
US, small osteophytes not detected on CR may be clinically
relevant for early diagnosis of OA.
Table 3 Inter-reader agreement for the domains and scales used in the reliability exercise
Seven readers
Synovitis
(0–1 scale)
Synovitis
(0–3 scale)
Doppler
(0–1 scale)
Doppler
(0–3 scale)
Osteophytes
(0–1 scale)
Osteophytes
(0–3 scale)
PEA overall 70.8 47.5 72.7 65.0 83.5 54.2
Specific
agreement 0
64.8 65.0 81.0 80.8 64.1 65.2
Specific
agreement 1
75.0 32.5 51.8 22.3 89.2 37.1
Specific
agreement 2
– 36.8 – 31.7 – 39.1
Specific
agreement 3
– 37.7 – 13.6 – 67.2
k 0.398 0.247 0.327 0.229 0.530 0.378
Table 4 Demonstration of the distribution of pathology by joint.
Numbers represent the number of joints with pathology detected at each
joint site (the maximum number of joints that could be affected at any
site is seven, as seven subjects were examined)
Joint
Grey-scale
synovitis (n)
Power Doppler
signal (n) Osteophytes (n)
CMC1 4 3 5
MCP1 2 1 3
MCP2 3 0 3
MCP3 1 0 1
MCP4 1 0 1
MCP5 1 0 2
PIP1 6 2 7
PIP2 6 3 7
PIP3 6 3 7
PIP4 6 2 7
PIP5 6 2 7
DIP2 5 3 7
DIP3 4 2 7
DIP4 5 2 7
DIP5 4 1 7
CMC, carpometacarpal; MCP, metacarpal; PIP, proximal interphalangeal; DIP, distal
interphalangeal.
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The definitions we used may need further consideration. For
example, we chose to use a composite of synovial hypertrophy
and effusion to determine synovial inflammation, recognising
that the clinical and pathological relevance of the two are
uncertain. It was noted that effusion could occur in the absence
of synovial hypertrophy, and a scoring system that grades the
features separately may be of interest when time is not
constrained. In addition, it was noted that Doppler signal could
be seen within the capsule, but external to the hypoechoic areas
of synovial hypertrophy. This signal was not scored in this
exercise.
The determination of the clinical, pathological and prognostic
importance of US detected abnormalities in hand OA, and
relative importance of the joints involved was beyond the scope
of this exercise. Proof of concept and epidemiological studies
need to be undertaken to investigate these issues, and in the
future the domains included in US outcome measures for hand
OA may need to be revised.
This process has been a preliminary step in developing an US
scoring tool for hand OA. Very good PEA for dichotomous scales
were demonstrated in this exercise; however, the semiquanti-
tative results suggest that a standardisation process could
improve agreement. In addition, preliminary exercises might
allow for selecting the most reliable observers. Importantly, this
process has demonstrated that an US outcome measure suitable
for multicentre trials is feasible and likely to be reliable. In
addition it has provided a foundation upon which to further
develop this tool.
Acknowledgements: We are grateful to MSD for an unrestricted educational grant
that supported part of this work.
Competing interests: None.
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Extended report
Ann Rheum Dis 2008;67:651–655. doi:10.1136/ard.2007.077081 655
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