1261: Scoring Structural Damage in Rheumatoid Arthritis by Ultrasound: Results from a Delphi Process and Web-Based Reliability Exercise by the OMERACT Ultrasound Working Group

Peter Mandl¹, Irina Gessl¹, Georgios Filippou², Silvia Sirotti³, Lene Terslev⁴, Carlos Pineda⁵, Helen Keen⁶, Marina Backhaus⁷, David Bong⁸, Edoardo Cipolletta⁹, Paz Collado¹⁰, Christian Dejaco¹¹, Andrea Delle Sedie¹², Christina Duftner¹³, Hilde Berner Hammer¹⁴, Annmaria Iagnocco¹⁵, Zunaid Karim¹⁶, Esperanza Naredo¹⁷, Wolfgang Schmidt¹⁸, Marcin Szkudlarek¹⁹, Giorgio Tamborrini²⁰, Priscilla Wong²¹, Emilio Filippucci⁹, Peter Balint²² and Maria-Antonietta D'Agostino²³, ¹Medical University of Vienna, Vienna, Austria, ²Rheumatology Department, Luigi Sacco University Hospital, Siena, Italy, ³Università degli Studi di Milano, Milano, Italy, ⁴Copenhagen University Hospital Glostrup, Glostrup, Denmark, ⁵Instituto Nacional de Rehabilitacion, Ciudad de México, Mexico, ⁶University of Western Australia, Perth, Australia, ⁷Park-Klinik Weissensee Academic Hospital of the Charité, Berlin, Germany, ⁸Instituto Poal de Reumatologia, Universitat de Barcelona, Barcelona, Spain, ⁹Polytechnic University of Marche, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Jesi, Italy, ¹⁰Division of Rheumatology, Hospital Universitario Severo Ochoa, Madrid, Spain, ¹¹Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy, and Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria, ¹²University of Pisa, Pisa, Pisa, Italy, ¹³Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria, ¹⁴Diakonhjemmet hospital, Jar, Norway, ¹⁵Academic Rheumatology Centre, University of Turin, Turin, Italy, ¹⁶Department of Rheumatology, Mid Yorkshire NHS Trust, Yorkshire, United Kingdom, ¹⁷Hospital General Universitario Gregorio Marañón and Complutense University, Madrid, Spain, ¹⁸Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology, Berlin-Buch, Berlin, Germany, ¹⁹Department of Rheumatology, Copenhagen University Hospital at Køge, Copenhagen, Denmark, ²⁰Ultrasound Center and Institute for Rheumatology, Basel, Switzerland, ²¹Division of Rheumatology, The Chinese University of Hong Kong, Hong-Kong, Hong Kong, ²²3rd. Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary, ²³Catholic University of Sacred Heart, Roma, Italy

Background/Purpose: Structural damage in rheumatoid arthritis (RA) includes bone erosions, cartilage changes, and joint malalignment; historically evaluated with conventional radiography. Ultrasound (US) has been shown to be a valid tool for the evaluation of both cartilage changes and bone erosions in RA. We aimed to obtain agreement on the definitions of elementary lesions and develop semiquantitative scoring systems for assessing structural damage by US and to validate these in a web-based reliability exercise.

Methods: A Delphi survey of statements was prepared by an OMERACT US Working Group (USWG) task force based on a previously published systematic literature review (1) and circulated between members of the group, including definitions on normal US appearance of joint components, scanning technique, definitions of elementary lesions and scoring systems for bone erosions and joint malalignment. Definitions and a US scoring system for scoring cartilage change were recently developed and validated by the USWG (2) After agreement was achieved (≥75% of grades 4-5 on 1-5 Likert scale) on the statements, still images of metacarpophalangeal and proximal interphalangeal joints 2-5 in healthy controls and in RA patients with varying degrees of pathology were acquired by the USWG task force members. A dataset of 100 anonymised images, representing various grades of the 3 components of structural damage were created and utilised in two rounds of a web-based exercise. Intra- and inter-reader reliability of the three scoring systems was assessed using kappa statistics.

Results: 19 USWG members needed four Delphi rounds to reach agreement on a total of 9 statements. 4/12 statements were approved in the first, 2/6 in the second, 1/5 in the third and 2/2 in the fourth round. The final scoring systems and representative images are shown in Table 1 & Figure 1. Twenty-two members participated in the web-based reliability exercise. The intra-reader reliability was almost perfect for bone erosion (kappa: 0.87) and cartilage change (kappa: 0.83) and substantial for malalignment (kappa of 0.72). The inter-reader reliability was almost perfect for bone erosion (kappa: 0.85), and substantial for cartilage change (kappa: 0.79) and malalignment (0.62).

Conclusion: This first attempt to create a composite US damage instrument based on scoring systems encompassing all aspects of structural damage, demonstrates that US is a reliable tool for evaluating and scoring bone erosions, cartilage change and malalignment in the finger joints of RA patients.
Table 1. Final definitions of scoring systems of elementary lesions of structural damage in rheumatoid arthritis

Figure 1. Representative images of the scoring systems for bone erosion (A), cartilage change (B) and malalignment (C)
Disclosures: P. Mandl, None; I. Gessl, Eli Lilly, Boehringer-Ingelheim, Gilead; G. Filippou, None; S. Sirotti, None; L. Terslev, None; C. Pineda, None; H. Keen, None; M. Backhaus, None; D. Bong, None; E. Cipolletta, None; P. Collado, None; C. Dejaco, Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi; A. Delle Sedie, None; C. Duftner, None; H. Hammer, None; A. Iagnocco, None; Z. Karim, None; E. Naredo, AbbVie, Roche, Bristol-Myers Squibb(BMS), Pfizer, UCB, Eli Lilly, Novartis, Janssen, Celgene, GmbH; W. Schmidt, None; M. Szkudlarek, None; G. Tamborrini, None; P. Wong, None; E. Filippucci, None; P. Balint, None; M. D'Agostino, Sanofi, Novartis, Bristol-Myers Squibb(BMS), Janssen, Celgene, Roche, AbbVie, UCB, Eli Lilly.