Development and Reliability of the Joint Tissue Activity and Damage Examination for Quantitation of Structural Abnormalities by Musculoskeletal Ultrasound in Hemophilic Joints

Abstract

Objectives Musculoskeletal ultrasound (US) is used increasingly to examine hemophilic arthropathy. However, quantitative algorithms to document findings are lacking. We developed and sought to validate a protocol quantifying hemophilic joint abnormalities. Methods Thirty‐one patients with hemophilia were examined serially for 2 years with musculoskeletal US (≈600 joint examinations and ≈6000 images). Based on the spectrum of pathologies, a quantitative algorithm, named Joint Tissue Activity and Damage Examination (JADE), was developed for soft tissue and osteochondral measurements, including power Doppler, using nominal group techniques. To study intra‐ and inter‐rater reliability, 8 musculoskeletal US–experienced hemophilia providers performed anatomic landmark recognition and tissue measurements on 86 images with arthropathic changes, with repetition 1 month later. Twenty‐three musculoskeletal US–inexperienced providers performed similar assessments. Inter‐operator reliability was established by 6 musculoskeletal US–experienced hemophilia providers, each acquiring images and JADE assessments of 3 hemophilic arthropathic joints. A radiologist and musculoskeletal sonographer functioned as adjudicators. The statistical analysis was performed with the intraclass correlation coefficient (ICC), Fleiss κ, and Cohen κ where appropriate. Results The musculoskeletal US–experienced providers showed excellent intra‐and inter‐rater reliability for tissue measurements (ICCs, 0.94–0.96). Agreement was good to excellent for landmark recognition (Fleiss κ, 0.87‐0.94). Inter‐operator reliability was excellent for measurements and landmark recognition (ICC, 0.90; Fleiss κ, 1.0). Agreement with adjudicators was mostly good to excellent. Musculoskeletal US–inexperienced providers showed excellent inter‐rater reliability for measurements (ICC, 0.96) and moderate agreement for landmark recognition (Fleiss κ, 0.58). Conclusions The JADE protocol appears feasible for quantifying hemophilic intra‐articular abnormalities. Musculoskeletal US–trained hemophilia providers showed high intra‐rater, inter‐rater, and inter‐operator reliability, supporting JADE as a protocol for clinical management and research.

Use of ultrasound for assessment of musculoskeletal disease in persons with haemophilia: Results of an International Prophylaxis Study Group global survey

“…26 Tailored educational strategies (Appendix S2) may be required to improve the utilization across different specialties for those interested in skill development or who obtain a medical directive to perform POCUS as part of their scope of practice. 10,[27][28][29][30][31] The utility of POCUS to assess an acute bleed versus no bleed is significant and the most salient perceived clinical application identified by this survey. Other perceived areas of use for POCUS may help inform where to focus the interest and effort for further education.…”

“…Respondents from those 24 countries stated that overall 26% of physiotherapists are using POCUS with the proportion usage as high as 67% in the UK and 50% in France 26 . Tailored educational strategies (Appendix ) may be required to improve the utilization across different specialties for those interested in skill development or who obtain a medical directive to perform POCUS as part of their scope of practice 10,27‐31 …”

Joint Bleeding Tendencies in Adult Patients With Hemophilia: It’s Not All Pharmacokinetics

“…Grayscale (B-mode) and PD settings were used in accordance with the manufacturer’s recommendations and images were acquired with a standardized, validated scanning protocol (Joint Tissue Activity and Damage Exam). 18 Power Doppler was used to assess vascular abnormalities. The MSKUS also included sonopalpation to evaluate compressibility and displacement of intra-articular material to distinguish between simple and complex (bloody) effusions.…”

Merging into the mainstream: the evolution of the role of point-of-care musculoskeletal ultrasound in hemophilia

“… 51 , the “Joint Activity and Damage Exam” (JADE) POC scanning and scoring protocol has been developed and validated by Volland et al . 75 as the first quantitative POC-MSKUS algorithm for precise measurements in hemophilic joints of adult PwH. The protocol evaluates for effusions and measures osteochondral surface defects, cartilage thickness, soft tissue expansion, and microvascular perfusion abnormalities on PD for ankles, elbows, and knees.…”

“…POC-MSKUS promises to improve our workflow, eliminating the need for sedation in children and allowing the early detection of HA in its subclinical stage; several gaps in knowledge continue to exist and questions remain unanswered. A number of scanning/scoring protocols 10 , 31 , 33 , 41 , 45 , 53 , 60 , 75 have become available, but they have not been globally standardized or validated, limiting their widespread use and implementation for that purpose. To achieve this goal, we need to reach a consensus regarding which sonographic biomarkers of HA should be included in the POC-MSKUS score(s) and what the POC-MSKUS definitions of pathologic conditions are 88 .…”