Development and Preliminary Validation of an Omeract Magnetic Resonance Imaging (MRI) Scoring System for Ankle Enthesitis in Spondyloarthritis

Ashish J Mathew¹, Simon Krabbe², Iris Eshed³, Frédérique Gandjbakhch⁴, Robert G. Lambert⁵, Paul Bird⁶, Kay-Geert Hermann⁷, Susanne J Pedersen⁸, Maria Stoenoiu⁹, Violaine Foltz¹⁰, Walter P. Maksymowych¹¹, Daniel Glinatsi², Ida K Haugen¹², Jacob L. Jaremko¹³, Rene P Poggenborg¹⁴, Joel Paschke¹⁵, Jean Denis Laredo¹⁶, Philip G. Conaghan¹⁷ and Mikkel Østergaard¹⁸, ¹Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India, Vellore, India, ²Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark, ³Department of Radiology, Sheba Medical Center, Israel, Tel Hashomer, Israel, ⁴Service de Rhumatologie, Groupe Hospitalier Pitie Salpetriere, Paris, France, Paris, France, ⁵University of Alberta, Edmonton, Canada, Edmonton, AB, Canada, ⁶University of New South Wales, Sydney, Australia, Sydney, Australia, ⁷Radiology, Charité Universitätmeidzin, Berlin, Germany, Berlin, Germany, ⁸Depart of Rheumatology VRR, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark, Copenhagen, Denmark, ⁹Université catholique de Louvain, Brussels, Belgium, Brussels, Belgium, ¹⁰UPMC University Paris 06, Pitié-Salpétrière Hospital, Paris, France, Paris, France, ¹¹Department of Medicine, CaRE Arthritis and University of Alberta, Edmonton, Canada, Edmonton, AB, Canada, ¹²P.O. Box 23 Vinderen, Diakonhjemmet Hospital, Oslo, Norway, Oslo, Norway, ¹³Radiology, University of Alberta, Edmonton, Canada, Edmonton, AB, Canada, ¹⁴Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark, Glostrup, Denmark, ¹⁵CaRE Arthritis, Edmonton, Canada, Edmonton, AB, Canada, ¹⁶Hôpital Lariboisière, APHP and Université Paris-Diderot, Paris, France, Paris, France, ¹⁷University of Leeds, Leeds, UK, Leeds, United Kingdom, ¹⁸Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup Copenhagen Center for Arthritis Research, Copenhagen, Denmark

Meeting: 2018 ACR/ARHP Annual Meeting

Keywords: Enthesitis, MRI and spondylarthritis

Session Information

Date: Sunday, October 21, 2018

Title: Imaging of Rheumatic Diseases Poster I: MRI

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

Background/Purpose: Enthesitis is a key feature in spondyloarthritis (SpA). MRI allows sensitive visualization of entheseal inflammation and damage, but no validated, internationally accepted MRI scoring systems exist. The objective of this study was to develop and perform preliminary validation of a novel OMERACT MRI scoring system for assessing ankle enthesitis in SpA patients.

Methods: A systematic literature review (SLR) of MRI studies on enthesitis in SpA identified key inflammatory and structural pathologies. Accordingly, pathologies to score and definitions of these were agreed by consensus within the OMERACT MRI in arthritis working group, followed by 3 internet-based multireader scoring exercises, with calibration sessions in between. In Exercise 1 the Achilles tendon and plantar fascia entheses in 10 ankle MRIs (sagittal T1-weighted (T1W) and sagittal and axial fat suppressed T2W images) were scored by 15 readers with varying expertise in ankle MRI. Each enthesis was assessed for peritendon hypersignal, intratendinous hypersignal, entheseal bone marrow edema, retrocalcaneal bursitis, tendon thickening, bone spur and erosion. Each parameter was scored 0-3 (no, mild, moderate, severe). After a calibration session leading to minor modifications, and development of reader rules, Exercise 2 comprised scoring of 16 ankle MRIs (specifications as above), by 15 readers. In Exercise 3, ankle MRIs (sagittal fat-suppressed T2W) of 21 patients before and after biological therapy were scored for the inflammatory variables by 10 readers, blinded to chronological order. Inter-reader agreement was calculated using single measure, two-way random effects, absolute agreement intraclass correlation coefficients (ICCs) for sum scores of inflammatory and structural lesions (patient level), and Cohen’s kappa for scores at lesion level.

Results: Exercise 1: Mean pairwise inter-reader ICCs were 0.40 and 0.41 for inflammatory and structural variables, respectively. Exercise 2: Mean pairwise inter-reader ICCs were 0.64 (Range: 0.17 – 0.93) for inflammatory variables, while 0.45 (Range 0.08 – 0.91) for structural variables. Exercise 3: The mean pairwise inter-reader ICC for inflammatory variables was 0.81 (Range: 0.57 – 0.95) for baseline scores and 0.81 (Range: 0.57 – 0.92) for change scores. Table 1 shows ICCs and kappas for all readers and for 4 preselected readers (the participating radiologist and the 3 rheumatologists with highest interreader agreement in Exercise 2).

Conclusion: Initial steps in developing an OMERACT MRI enthesitis scoring system at the ankle have been performed, and good reliability (particularly for inflammatory variables) has been demonstrated.

Table 1: Inter-reader agreement on patient level (ICC for inflammation sum scores) and lesion level (kappa for inflammatory parameters) on baseline and change score in Exercise 3

		All readers together			Radiologist + Best 3 from Exercise 2
		Mean	Median	Range	Mean		Median	Range
Patient level (ICC)
Sum score of all parameters	Baseline	0.81	0.83	0.57 – 0.95		0.91	0.91	0.90 – 0.94
Sum score of all parameters	Change	0.80	0.82	0.57 – 0.92		0.85	0.84	0.79 – 0.91
Lesion level (kappa values)
All parameters	Baseline	0.68	0.67	0.45-0.85		0.81	0.81	0.76 – 0.85
All parameters	Change	0.48	0.48	0.24 – 0.68		0.57	0.58	0.46 – 0.65
Bone marrow edema	Baseline	0.86	0.86	0.75 – 0.97		0.88	0.89	0.84 – 0.92
Bone marrow edema	Change	0.53	0.52	0.30 – 0.82		0.54	0.47	0.45 – 0.76
Peri-tendon hypersignal	Baseline	0.62	0.64	0.29 – 0.87		0.78	0.79	0.68 – 0.87
Peri-tendon hypersignal	Change	0.47	0.49	0.16 – 0.75		0.53	0.50	0.42 – 0.75
Intra-tendon hypersignal	Baseline	0.51	0.55	0.02 – 0.89		0.81	0.79	0.77 – 0.89
Intra-tendon hypersignal	Change	0.41	0.41	0.09 – 0.64		0.52	0.54	0.35 – 0.63
Retro-calcaneal bursitis	Baseline	0.49	0.55	-0.12 – 0.93		0.60	0.57	0.42 – 0.78
Retro-calcaneal bursitis	Change	0.26	0.24	-0.28 – 1.00		0.42	0.45	0.15 – 0.67

Disclosure: A. J. Mathew, None; S. Krabbe, None; I. Eshed, None; F. Gandjbakhch, None; R. G. Lambert, None; P. Bird, None; K. G. Hermann, None; S. J. Pedersen, None; M. Stoenoiu, None; V. Foltz, None; W. P. Maksymowych, None; D. Glinatsi, None; I. K. Haugen, None; J. L. Jaremko, None; R. P. Poggenborg, None; J. Paschke, None; J. D. Laredo, None; P. G. Conaghan, None; M. Østergaard, None.

To cite this abstract in AMA style:

Mathew AJ, Krabbe S, Eshed I, Gandjbakhch F, Lambert RG, Bird P, Hermann KG, Pedersen SJ, Stoenoiu M, Foltz V, Maksymowych WP, Glinatsi D, Haugen IK, Jaremko JL, Poggenborg RP, Paschke J, Laredo JD, Conaghan PG, Østergaard M. Development and Preliminary Validation of an Omeract Magnetic Resonance Imaging (MRI) Scoring System for Ankle Enthesitis in Spondyloarthritis [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 9). https://acrabstracts.org/abstract/development-and-preliminary-validation-of-an-omeract-magnetic-resonance-imaging-mri-scoring-system-for-ankle-enthesitis-in-spondyloarthritis/. Accessed .

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