In finger osteoarthritis, change in synovitis is associated with change in pain on a joint-level; a longitudinal magnetic resonance imaging study

ACR Appropriateness Criteria® Chronic Hand and Wrist Pain: 2023 Update

Chronic hand and wrist pain is a common presenting complaint. The intricate anatomy results in a variety of pain generators-multiple bones, articular cartilage, intrinsic ligaments, triangular fibrocartilage complex, joint capsules and synovium, tendons and tendon sheaths, muscles, and nerves-in a compact space. The need for imaging and the choice of the appropriate imaging modality are best determined by the patient's presentation, physical examination, and the clinician's working differential diagnosis. Radiography is usually appropriate as the initial imaging study in the evaluation of chronic hand or wrist pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Intra-Arterial Injection of Temporary Embolic Material Through a Needle Inserted into the Radial or Ulnar Artery for Distal and Proximal Interphalangeal Joint Osteoarthritis: A Retrospective Study of 92 Patients

PURPOSE

To assess the efficacy and safety of intra-arterial injection of imipenem/cilastatin sodium (IPM/CS) via a needle placed into the radial artery or ulnar artery (RA/UA) for distal interphalangeal and proximal interphalangeal joint osteoarthritis (DIP/PIP-OA).

MATERIALS AND METHODS

This is a retrospective single-arm cohort study. Ninety-two patients [92% women, mean (SD) age 55(8.3) years] with a primary DIP/PIP-OA meet the American College of Rheumatology criteria for hand osteoarthritis with pain ≥ 4 on the 0-10 numeric rating scale (NRS) were enrolled. All procedures were performed by injecting IPM/CS through a 24-gauge needle percutaneously inserted into the RA/UA. Two procedures were planned; the second procedure was scheduled 1-2 months after the first. NRS, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, Patient Global Impression of Change (PGIC) scale, and procedure-related adverse events were evaluated.

RESULTS

Technical success, defined as injection of IPM/CS into the RA/UA, was achieved in all patients. Clinical success, defined as a reduction of 2 points or more in the NRS at 12 months, was 77% (95% confidence interval 68-85%). The NRS improved from the baseline to 3, 6, and 12 months (7.8 ± 1.6 vs. 3.8 ± 2.6, 3.9 ± 2.7, and 4.0 ± 2.8, respectively, all p < 0.001). The QuickDASH score improved from the baseline to 12 months (27 ± 15 vs. 19 ± 17, p < 0.001) respectively. No major adverse events were observed.

CONCLUSIONS

Intra-arterial injection of IPM/CS is a feasible treatment option for DIP/PIP-OA.

Reliability of detection of ultrasound and MRI features of hand osteoarthritis: a systematic review and meta-analysis

OBJECTIVES

To systematically review the literature on inter- and intra-rater reliability of scoring US and MRI changes in hand OA.

METHODS

MEDLINE, EMBASE, CINHAL, Web of Science and AMED were searched from inception to January 2020. Kappa (κ), weighted kappa (κw) and intra-class correlation coefficients for dichotomous, semi-quantitative and summated scores, respectively, and their 95% CI were pooled using a random-effects model. Heterogeneity between studies was assessed and reliability estimates were interpreted using the Landis-Koch classification.

RESULTS

Fifty studies met the inclusion criteria (29 US, 17 MRI, 4 involving both modalities). The pooled κ (95% CI) for inter-rater reliability was substantial for US-detected osteophytes [0.66 (0.54, 0.79)], grey-scale synovitis [0.64 (0.32, 0.97)] and power Doppler [0.76, (0.47, 1.05)], whereas intra-rater reliability was almost perfect for osteophytes [0.82 (0.80, 0.84)], central bone erosions (CBEs) [0.83 (0.78, 0.89)] and effusion [0.83 (0.74, 0.91)], and substantial for grey-scale synovitis [0.64 (0.49, 0.79)] and power Doppler [0.70 (0.59, 0.80)]. Inter-rater reliability for dichotomous assessment was substantial for MRI-detected CBEs [0.75 (0.67, 0.83)] and synovitis [0.69 (0.51, 0.87)], slight for osteophytes [0.14 (0.04, 0.25)], and almost perfect for sum score of osteophytes, CBEs, joint space narrowing (JSN), and bone marrow lesions (BMLs) (0.81-0.89). Intra-rater reliability was almost perfect for sum score of MRI synovitis [0.92 (0.87, 0.96)], BMLs [0.88 (0.78, 0.98)], osteophytes [0.86 (0.74, 0.98)], CBEs [0.83 (0.66, 1.00)] and JSN [0.91 (0.87, 0.91)].

CONCLUSION

US and MRI are reliable in detecting hand OA features. US may be preferred due to low cost and increasing availability.

Administration of an adeno-associated viral vector expressing interferon-β in patients with inflammatory hand arthritis, results of a phase I/II study

OBJECTIVE

Inflammatory hand arthritis (IHA) results in impaired function. Local gene therapy with ART-I02, a recombinant adeno-associated virus (AAV) serotype 5 vector expressing interferon (IFN)-β, under the transcriptional control of nuclear factor κ-B responsive promoter, was preclinically shown to have favorable effects. This study aimed to investigate the safety and tolerability of local gene therapy with ART-I02 in patients with IHA.

METHODS

In this first-in-human, dose-escalating, cohort study, 12 IHA patients were to receive a single intra-articular (IA) injection of ART-I02 ranging 0.3 × 10¹²-1.2 × 10¹³ genome copies in an affected hand joint. Adverse events (AEs), routine safety laboratory and the clinical course of disease were periodically evaluated. Baseline- and follow-up contrast enhanced magnetic resonance images (MRIs), shedding of viral vectors in bodily fluids, and AAV5 and IFN-β immune responses were evaluated. A data review committee provided safety recommendations.

RESULTS

Four patients were enrolled. Long-lasting local AEs were observed in 3 patients upon IA injection of ART-I02. The AEs were moderate in severity and could be treated conservative. Given the duration of the AEs and their possible or probable relation to ART-I02, no additional patients were enrolled. No systemic treatment emergent AEs were observed. The MRIs reflected the AEs by (peri)arthritis. No T-cell response against AAV5 or IFN-β, nor IFN-β antibodies could be detected. Neutralizing antibody titers against AAV5 raised post-dose.

CONCLUSION

Single IA doses of 0.6 × 10¹² or 1.2 × 10¹² ART-I02 vector genomes were administered without systemic side effects or serious AEs. However, local tolerability was insufficient for continuation.

TRIAL REGISTRATION

NCT02727764.

Two-Year Changes in Magnetic Resonance Imaging Features and Pain in Thumb Base Osteoarthritis

OBJECTIVE

To investigate the two-year course of pain and osteoarthritic features on magnetic resonance imaging (MRI) in the thumb base.

METHODS

Patients in the Hand Osteoarthritis in Secondary Care (HOSTAS) cohort who had received radiographic examination, MRI, and clinical examination of the right thumb base at baseline and who had a 2-year follow-up period were studied. Pain on palpation of the thumb base was assessed on a 0-3 scale. MRIs were analyzed with the Outcome Measures in Rheumatology (OMERACT) thumb base osteoarthritis MRI scoring system for synovitis, bone marrow lesions (BMLs), subchondral bone defects, cartilage space loss, osteophytes, and subluxation. Radiographs were assessed for osteophytes and joint space narrowing. We studied the associations of changes in synovitis and BMLs with changes in pain using a logistic regression model adjusted for radiographic damage, with values expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

Of 165 patients, 83% were women and the mean age was 60.7 years. At baseline, 65 patients had thumb base pain. At 2-year follow-up, pain had decreased in 32 patients and increased in 33 patients. MRI features remained stable in most patients. Structural MRI features generally deteriorated, while synovitis and BMLs improved in some individuals and deteriorated in others. Change in radiographic osteophytes rarely occurred (n = 10). Increased synovitis (odds ratio [OR] 3.4 [95% CI 1.3-9.3]) and increased BMLs (OR 5.1 [95% CI 2.1-12.6]) were associated with increased pain. Decreased BMLs appeared to be associated with decreased pain (OR 2.7 [95% CI 0.8-8.9]), and reductions in synovitis occurred too infrequently to calculate associations.

CONCLUSION

Over 2 years, thumb base pain fluctuated, while MRI features changed in a minority of patients with hand osteoarthritis. Changes in synovitis and BMLs were associated with changes in pain on palpation, even after adjustment for radiographic damage.

Real-time versus static scoring in musculoskeletal ultrasonography in patients with inflammatory hand osteoarthritis

Objectives

Agreement between real-time and static ultrasonography has not been studied in musculoskeletal diseases. We studied this agreement in inflammatory hand OA.

Methods

Ultrasonography was performed blinded to clinical information of 30 joints of 75 patients with hand OA, treated with prednisolone in a randomized placebo-controlled double-blind trial. Images were scored real-time at acquisition and stored images were scored static (paired in known chronological order) for inflammatory features and osteophytes (score 0–3). Agreement between methods was studied at joint level with quadratic weighted kappa. At patient level intra-class correlations (ICC) of sum scores and change in sum-scores (delta baseline—week 6) were calculated. Responsiveness of scoring methods was analysed with generalized estimating equations (GEE) with treatment as independent and ultrasonography findings as dependent variable.

Results

Agreement at baseline was good to excellent at joint level (kappa 0.72–0.88) and moderate to excellent at patient level (ICC 0.58–0.91). Agreement for change in sum scores was poor to fair for synovial thickening and effusion (ICC 0.18 and 0.34, respectively), while excellent for Doppler signal (ICC 0.80). Real-time ultrasonography discriminated between prednisolone and placebo with a mean between-group difference of synovial thickening of −2.5 (95% CI: −4.7, −0.3). Static ultrasonography did not show a decrease in synovial thickening.

Conclusion

While cross-sectional agreement between real-time and static ultrasonography is good, static ultrasonography measurement of synovial thickening did not show responsiveness to prednisone therapy while real-time ultrasonography did. Therefore, when ultrasonography is used in clinical trials, real-time dynamic scoring should remain the standard for now.

Synovitis and bone marrow lesions associate with symptoms and radiographic progression in hand osteoarthritis: a systematic review and meta-analysis of observational studies

AIMS

To systematically review observational studies for the association between features detected on ultrasound (US) and magnetic resonance imaging (MRI) and, symptoms, signs and radiographic progression of hand osteoarthritis (OA).

METHODS

Medline, Web of Science, EMBASE, CINAHL and AMED were searched from inception to 14^th January 2020 to identify relevant studies. Quality of studies was assessed using the Newcastle-Ottawa scales and data were extracted. Odds ratios (OR) and linear regression coefficients and 95% confidence intervals (CI) were pooled using the random-effects model (METAN package, Stata v16.1). Heterogeneity and publication bias were assessed.

RESULTS

Thirty-two studies using US and MRI comprising 1,350 and 638 participants respectively were included. While only grey-scale synovitis (GSS) associated with AUSCAN-pain (pooled Regression coefficient (95% CI): 0.46 (0.13-0.79); 0-20 scale for AUSCAN-pain), US-detected osteophytes, GSS and power Doppler (PD) [pooled ORs (95% CI): 2.68(2.16-3.33), 2.38(1.74-3.26) and 2.04 (1.45-2.88)] as well as MRI-detected bone marrow lesions (BMLs), synovitis, osteophytes, and central bone erosions (CBEs) associated with joint tenderness [pooled ORs (95% CI): 2.59(2.12-3.18), 2.17(1.85-2.54), 2.15(1.55-2.99), and 2.41 (1.45-4.02)] respectively. US-detected GSS and PD associated with radiographic progression of CBEs [pooled ORs 5.37, 5.08], osteophytes [pooled ORs 5.17, 6.45], and joint space narrowing (pooled ORs 4.28, 4.36) whilst MRI-detected synovitis and BMLs associated with increasing KL grades with pooled ORs 2.92, 2.54 respectively.

CONCLUSIONS

US and MRI-detected structural and inflammatory changes associate with tenderness, whilst articular inflammation and subchondral bone damage associate with radiographic hand OA progression. There was inconsistent relationship between these changes and pain.

Efficacy of tocilizumab in patients with hand osteoarthritis: double blind, randomised, placebo-controlled, multicentre trial

OBJECTIVE

To evaluate the efficacy of tocilizumab, an antibody against IL-6 receptor, in patients with hand osteoarthritis.

METHODS

This was a multicentre, 12-week, randomised, double-blind, placebo-controlled study from November 2015 to October 2018. Patients with symptomatic hand osteoarthritis (pain ≥40 on a 0-100 mm visual analogue scale (VAS) despite analgesics and non-steroidal anti-inflammatory drugs; at least three painful joints, Kellgren-Lawrence grade ≥2) were randomised to receive two infusions 4 weeks apart (weeks 0 and 4) of tocilizumab (8 mg/kg intravenous) or placebo. The primary endpoint was changed in VAS pain at week 6. Secondary outcomes included the number of painful and swollen joints, duration of morning stiffness, patients' and physicians' global assessment and function scores.

RESULTS

Of 104 patients screened, 91 (45 to tocilizumab and 46 to placebo; 82% women; mean age 64.4 (SD 8.7) years) were randomly assigned and 79 completed the 12-week study visit. The mean change between baseline and week 6 on the VAS for pain (primary outcome) was -7.9 (SD 19.4) and -9.9 (SD 20.1) in the tocilizumab and placebo groups (p=0.7). The groups did not differ for any secondary outcomes at weeks 4, 6, 8 or 12. Overall, adverse events were slightly more frequent in the tocilizumab than placebo group.

CONCLUSION

Tocilizumab was no more effective than placebo for pain relief in patients with hand osteoarthritis.

Effusion attenuates the effect of synovitis on radiographic progression in patients with hand osteoarthritis: a longitudinal magnetic resonance imaging study

An exploratory study to determine the role of effusion, i.e., fluid in the joint, in pain, and radiographic progression in patients with hand osteoarthritis. Distal and proximal interphalangeal joints (87 patients, 82% women, mean age 59 years) were assessed for pain. T2-weighted and Gd-chelate contrast-enhanced T1-weighted magnetic resonance images were scored for enhanced synovial thickening (EST, i.e., synovitis), effusion (EST and T2-high signal intensity [hsi]) and bone marrow lesions (BMLs). Effusion was defined as follows: (1) T2-hsi > 0 and EST = 0; or 2) T2-hsi = EST but in different joint locations. Baseline and 2-year follow-up radiographs were scored following Kellgren-Lawrence, increase ≥ 1 defined progression. Associations between the presence of effusion and pain and radiographic progression, taking into account EST and BML presence, were explored on the joint level. Effusion was present in 17% (120/691) of joints, with (63/120) and without (57/120) EST. Effusion on itself was not associated with pain or progression. The association with pain and progression, taking in account other known risk factors, was stronger in the absence of effusion (OR [95% CI] 1.7 [1.0–2.9] and 3.2 [1.7–5.8]) than in its presence (1.6 [0.8–3.0] and 1.3 [0.5–3.1]). Effusion can be assessed on MR images and seems not to be associated with pain or radiographic progression but attenuates the association between synovitis and progression.

Key Points • Effusion is present apart from synovitis in interphalangeal joints in patients with hand OA. • Effusion in finger joints can be assessed as a separate feature on MR images. • Effusion seems to be of importance for its attenuating effect on the association between synovitis and radiographic progression.