Comparison of clinical versus ultrasound‐determined synovitis in juvenile idiopathic arthritis

Abstract

Objective. To compare clinical evaluation and ultrasonography (US) in the assessment of joint synovitis in children with juvenile idiopathic arthritis (JIA). Methods. Thirty-two patients underwent clinical evaluation of 52 joints by 2 pediatric rheumatologists. Joints were assessed for swelling, tenderness/pain on motion, and restricted motion. The same joints were scanned independently by an experienced sonographer for synovial hyperplasia, joint effusion, and power Doppler (PD) signal. Results. In total, 1,664 joints were assessed both clinically and with US. On clinical examination, 98 joints (5.9%) were swollen, 59 joints (3.5%) were tender, and 40 joints (2.4%) had restricted motion. On US evaluation, 125 joints (7.5%) had synovial hyperplasia, 153 joints (9.2%) had joint effusion, and 53 joints (3.2%) had PD signal. A total of 104 (6.3%) and 167 (10%) joints had clinical and US synovitis, respectively. Of the 1,560 clinically normal joints, 86 (5.5%) had subclinical synovitis (i.e., had synovitis on US). US led to classifying 5 patients as having polyarthritis who were classified as having oligoarthritis or were found to have no synovitis on clinical evaluation. US variables were moderately correlated with clinical measures of joint swelling, but poorly correlated with those of joint tenderness/pain on motion and restricted motion. Overall, correlations were lower for PD signal than for synovial hyperplasia and joint effusion. Conclusion. We found that subclinical synovitis as detected by US is common in children with JIA. This finding may have important implications for patient classification and may affect the choice of the optimal therapeutic strategy in individual patients.

Clinical and Ultrasound‐Based Composite Disease Activity Indices in Rheumatoid Arthritis: Results From a Multicenter, Randomized Study

“…However, utilization of multimodal indices in which the SJC was supplemented also by joints in which synovitis was detected by either GS or PD ultrasound would have allowed an additional 67.8% and 32.3% of patients (DAS28-derived and SDAI-derived indices, respectively) to be classified as having HDA at the screening visit. Taken together, these 2 findings suggest a discrepancy between clinical and ultrasound examinations, in accordance with results from several studies (33)(34)(35). Supplementation of the SJC of the SDAI with ultrasound data increased disease activity; however, this increase was smaller in magnitude as compared to that seen with DAS28 indices.…”

“…However, this would pose an overall effect and would still allow the comparison between multimodal and clinical indices. Despite the higher sensitivity of ultrasound for the detection of subclinical synovitis (33)(34)(35), multimodal indices showed better reliability than clinical indices. In our study, such indices failed to demonstrate superior discriminant capacity as compared to their clinical counterparts; however, since the responsiveness to change of a health status measurement instrument is closely related to its reliability (43), our data might suggest that multimodal indices, and indeed global synovitis scores based on ultrasound (28,29), which have been shown to be more reliable than their clinical counterparts, may potentially also be more responsive measures than clinical indices.…”

“…Several studies have investigated the use of ultrasound in detecting and evaluating subclinical disease (33)(34)(35)(36)(37). Sonography detected synovitis as a surrogate of subclinical disease activity in almost two-thirds of patients with early, untreated oligoarthritis, whereas one-third of patients could be reclassified as having polyarticular disease (33).…”

Definitions for the Sonographic Features of Joints in Healthy Children

“…With new treatments, the induction of sustained remission is possible for an increasing percentage of children but cannot always be reliably demonstrated on clinical examination alone (7)(8)(9)(10). In addition, the exact determination of remission status is important for the decision to taper medication, thereby preventing side effects from long-term use.…”

“…An abundant number of studies have emerged in the literature over the past 2 decades for adult rheumatology, which included validation of the US detection of synovitis with histology and magnetic resonance imaging (MRI), standardization of the scanning technique, normative data acquisition, as well as documenting the responsiveness to change (11)(12)(13)(14)(15). These aspects have nevertheless only been partially addressed for pediatric patients (2,10,16); very few publications have started to collect information (16,17).…”