Sickle cell bone disease and response to intravenous bisphosphonates in children

Children with sickle cell disease (SCD) have the potential for extensive and early-onset bone morbidity. This study reports on the diversity of bone morbidity seen in children with SCD followed at three tertiary centers. IV bisphosphonates were effective for bone pain analgesia and did not trigger sickle cell complications.

INTRODUCTION

To evaluate bone morbidity and the response to intravenous (IV) bisphosphonate therapy in children with SCD.

METHODS

We conducted a retrospective review of patient records from 2003 to 2019 at three Canadian pediatric tertiary care centers. Radiographs, magnetic resonance images, and computed tomography scans were reviewed for the presence of avascular necrosis (AVN), bone infarcts, and myositis. IV bisphosphonates were offered for bone pain management. Bone mineral density was assessed by dual-energy X-ray absorptiometry (DXA).

RESULTS

Forty-six children (20 girls, 43%) had bone morbidity at a mean age of 11.8 years (SD 3.9) including AVN of the femoral (17/46, 37%) and humeral (8/46, 17%) heads, H-shaped vertebral body deformities due to endplate infarcts (35/46, 76%), and non-vertebral body skeletal infarcts (15/46, 32%). Five children (5/26, 19%) had myositis overlying areas of AVN or bone infarcts visualized on magnetic resonance imaging. Twenty-three children (8/23 girls) received IV bisphosphonate therapy. They all reported significant or complete resolution of bone pain. There were no reports of sickle cell hemolytic crises, pain crises, or stroke attributed to IV bisphosphonate therapy.

CONCLUSION

Children with SCD have the potential for extensive and early-onset bone morbidity. In this series, IV bisphosphonates were effective for bone pain analgesia and did not trigger sickle cell complications.

POS0989 DEVELOPMENT OF INTERNATIONAL CONSENSUS ON A STANDARDIZED IMAGE ACQUISITION PROTOCOL FOR DIAGNOSTIC EVALUATION OF THE SACROILIAC JOINTS BY MRI – AN ASAS-SPARTAN COLLABORATION

Background

In 2009, ASAS published a ‘Definition of active sacroiliitis on MRI for classification of axial spondyloarthritis (axSpA)’. This definition relied on two MRI sequences to make this determination – semicoronal T1 and STIR. Since then, this approach has frequently been used for diagnosis, even though that was never the intent of the definition. In 2015, the European Society of Skeletal Radiology (ESSR) published its recommendations for an SIJ MRI image acquisition protocol (IAP) for diagnostic purposes that required 4 MRI sequences but there is still no IAP that has been widely accepted as a minimum standard worldwide. In 2020, an informal survey of 24 academic sites (12 Europe, 12 North America) confirmed that 24/24 sites performed a minimum of 3 MRI sequences for diagnosis (19 performed 4-8 sequences) because the 2-sequence protocol was considered inadequate.

Objectives

To develop the minimum requirements for a standardized IAP for MRI of the sacroiliac joints for diagnostic ascertainment of sacroiliitis.

Methods

All radiologist members of the ASAS and SPARTAN Classification in axSpA (CLASSIC) project, along with one European and one North American rheumatologist with extensive MRI experience in SpA clinical practice and research, were invited to participate in a consensus exercise. A draft IAP was circulated to all participants along with background information and justification for the draft proposal. Feedback on all issues was received by email, tabulated and recirculated. Participants were broadly in favour of the proposal and two months later a teleconference meeting took place and remaining points of contention were resolved. Examples of the proposed IAP performed on new, 10 and 22 years’ old MRI scanners were made available for review in DICOM format. Next the revised draft of the IAP was presented at the ASAS annual meeting to the entire membership on 14 January 2022, and voted on.

Results

A 4-sequence IAP, 3-semicoronal and 1-semiaxial, is recommended for diagnostic ascertainment of sacroiliitis and its differential diagnoses (Table 1). It must meet the following requirements: Semicoronal sequences should be parallel to the dorsal cortex of the S2 vertebral body, and include: 1) a sequence sensitive for the detection of active inflammation being T2-weighted with suppression of fat signal; 2) a sequence sensitive for the detection of structural damage in bone and bone marrow with T1-weighting; 3) a sequence that is designed to optimally depict the bone-cartilage interface of the articular surface and be sensitive for detection of bone erosion; plus 4) a semiaxial sequence sensitive for inflammation detection. The IAP was approved at the ASAS annual meeting by a vote of the entire membership with 91% in favour.

Table 1.

A standardized SIJ MRI Acquisition Protocol for diagnostic ascertainment of sacroiliitis

OrientationSequenceTarget Lesion(s)Semicoronal Parallel to the dorsal cortex of the S2 vertebral bodyT1-weighted Spin EchoStructural: Fat lesions, erosion, sclerosis, backfill, ankylosis.T2-weighted with suppressed fat signal (STIR, T2FS or equivalent)Inflammatory: Bone marrow edema (BME)T1-weighted with suppressed fat signal (2D or 3D T1FS)Structural: Erosion of the articular surfaceSemiaxial Perpendicular to semicoronalT2-weighted with suppressed fat signal (STIR, T2FS or equivalent)Inflammatory: Bone marrow edema (BME)

Conclusion

A standardized IAP for MRI of the sacroiliac joints for diagnostic ascertainment of sacroiliitis is recommended and should be comprised of a minimum of 4 sequences, in 2-planes, that will optimally visualize inflammation, structural damage, and the bone-cartilage interface.

Disclosure of Interests

Robert Lambert Paid instructor for: Novartis, Consultant of: Calyx, CARE Arthritis, Image Analysis Group, Xenofon Baraliakos Speakers bureau: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Paid instructor for: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Consultant of: Abbvie, Pfizer, MSD, UCB, Novartis, Lilly, Galapagos, Hexal, Grant/research support from: Abbvie, MSD, Novartis, Lilly, Stephanie Bernard Consultant of: Elsevier Amirsys, John Carrino Consultant of: Pfizer, Regeneron, Globus, Carestream, Image Analysis Group, Image Biopsy Lab, Torsten Diekhoff Speakers bureau: Novartis, MSD, Canon MS, Consultant of: Eli Lilly, Iris Eshed: None declared, Kay-Geert Hermann Speakers bureau: AbbVie, Pfizer, MSD, Novartis. Co-founder: BerlinFlame GmbH, Nele Herregods: None declared, Jacob L Jaremko: None declared, Lennart Jans: None declared, Anne Grethe Jurik: None declared, John O’Neill: None declared, Monique Reijnierse: None declared, Michael Tuite Consultant of: GE HealthCare, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB

POS0173 DATA-DRIVEN MRI DEFINITIONS FOR ACTIVE AND STRUCTURAL SACROILIAC JOINT LESIONS IN JUVENILE SPONDYLOARTHRITIS TYPICAL OF AXIAL DISEASE

Background

For classification in juvenile spondyloarthritis (JSpA), it is important to develop cut-offs for active and structural lesions typical of axial disease on MRI that are readily and consistently interpreted. Since the maturing sacroiliac joint (SIJ) looks different from the adult SIJ, the criteria developed for positive MRI in adults may not be applicable in JSpA.

Objectives

As part of a study developing classification criteria for axial disease in JSpA, we aimed to determine quantitative SIJ imaging lesion cut-offs for inflammatory and structural lesions typical of axial JSpA using majority imaging expert decision as the reference criterion.

Methods

Subjects were a retrospective cohort of children with SpA who met the provisional Pediatric Rheumatology International Trials Organization criteria for enthesitis/spondylitis-related juvenile idiopathic arthritis or had a rheumatologist JSpA diagnosis. All subjects had symptom onset prior to age 18 years and underwent MRI as part of a diagnostic evaluation for axial disease. To enable SIJ quadrant-based scoring, all MRIs included semi-coronal slices through the cartilaginous part of the joint on fluid sensitive sequences and on T1-weighted sequences for the assessment of inflammation and structural lesions, respectively. MRIs were reviewed by 6 musculoskeletal imaging experts who were blinded to clinical details. MRI evaluation of the SIJ was based on standardized lesion definitions that were decided by consensus of the central imaging team and represented a mix of definitions from ASAS and the Juvenile Arthritis MRI Score Outcome Measures in Rheumatology working group. Using a web-based interface, raters globally assessed the presence or absence of lesions typical of axial SpA and performed SIJ quadrant or joint based scoring. Lesion scores were generated by averaging the scores of all raters. Sensitivity and specificity of lesion cut-offs were calculated using rater majority (≥4/6 raters) on a global assessment of the presence/absence of active or structural lesions typical of axial SpA with high confidence (confidence of ±3 or stronger on confidence scale from -5, “Definitely No”, to +5, “Definitely Yes”) as the reference standard.

Results

Imaging from 243 subjects, 61% male, median age 14.9 years, had sequences available for detailed MRI scoring. Active inflammatory lesion typical of axial disease in JSpA was defined as bone marrow edema (BME) in at least 3 SIJ quadrants (sensitivity 98.6%, specificity 96.5%). For structural lesion typical of axial JSpA, the optimal cut-off was erosion in at least 3 quadrants or at least one of the following lesions in at least 2 SIJ quadrants: sclerosis, fat lesion, backfill, ankylosis (sensitivity 98.6%, specificity 95.5%).

Conclusion

We propose data-driven cut-offs for active inflammatory and structural lesions on MRI typical of axial disease in JSpA that have high specificity and sensitivity using central imaging global assessment as the reference standard.

Table 1.

Performance of cut-offs for inflammatory and structural lesions of axial disease

Cut-offs for number of SIJ quadrants (any location)Sensitivity (95% CI)Specificity (95% CI)Definite active lesionBME score ≥2100 (95.0-100)93.5 (88.7-96.7)BME score ≥398.6 (92.5-100)96.5 (92.5-98.7)BME, same location on ≥3 consecutive slices88.6 (78.7-94.9)98.8 (95.8-99.9)Definite structural lesionErosion ≥295.7 (88-99.1)96.8 (92.7-99)Erosion, same location on ≥2 consecutive slices94.3 (86-98.4)98.1 (94.5-99.6)Erosion ≥391.4 (82.3-96.8)98.7 (95.4-99.8)Sclerosis ≥262.9 (50.5-74.1)98.1 (94.5-99.6)Fat lesion ≥222.9 (13.7-34.4%)98.7 (95.4-99.8%)Backfill ≥220 (11.4-31.3)100 (97.7-100)Ankylosis ≥21.3 (0.2-4.7)100 (94.9-100)ANY of the following in ≥2 SIJ quadrants: erosion, sclerosis, fat lesion, backfill, ankylosis98.6 (92.3-100)93.6 (88.5-96.9)Erosion ≥3 quadrants OR ≥2 quadrants of at least one of the following lesions: sclerosis, fat, backfill, ankylosis98.6 (92.3-100.0)95.5 (91.0-98.2)

Disclosure of Interests

Pamela F. Weiss Consultant of: Pfizer

Novartis

Biogen

Lilly

(All <$5K in the past fiscal year), Timothy G. Brandon: None declared, Amita Aggarwal: None declared, Ruben Burgos-Vargas Speakers bureau: Not in the last three years.

Novartis, Consultant of: Not in the last four years.

BMS, Lilly, Novartis, Robert A. Colbert: None declared, Gerd Horneff Speakers bureau: Pfizer, Novartis, Janssen, Chugai, Abbvie, Grant/research support from: Pfizer, Novartis, MSD, Chugai, Roche, Abbvie, Rik Joos Speakers bureau: Galapagos, Pfizer, AbbVie, Novartis, Amgen, BMS, Lilly, Grant/research support from: Pfizer, AbbVie, Roche, Ronald Laxer Consultant of: Abbvie, Novartis, Sobi, Sanofi, Eli Lilly Canada, Eli Lilly, Kirsten Minden Speakers bureau: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Angelo Ravelli Speakers bureau: Abbvie, Novartis, SOBI, Angelini, Reckitt-Benkiser, Roche, Pfizer, Alexion, Grant/research support from: Novartis, Pfizer, Nicolino Ruperto Speakers bureau: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Consultant of: NR has received honoraria for consultancies or speaker bureaus from the following pharmaceutical companies in the past 3 years: 2 Bridge, Amgen, AstraZeneca, Aurinia, Bayer, Brystol Myers and Squibb, Celgene, inMed, Cambridge Healthcare Research, Domain Therapeutic, EMD Serono, Glaxo Smith Kline, Idorsia, Janssen, Eli Lilly, Novartis, Pfizer, Sobi, UCB., Grant/research support from: The IRCCS Istituto Giannina Gaslini (IGG), where NR works as full-time public employee has received contributions from the following industries in the last 3 years: Bristol Myers and Squibb, Eli-Lilly, F Hoffmann-La Roche, Novartis, Pfizer, Sobi. This funding has been reinvested for the research activities of the hospital in a fully independent manner, without any commitment with third parties., Judith Smith Consultant of: Consulting panel of pediatric rheumatologists identifying issues in juvenile spondyloarthritis for Novartis. Paid < $5000, Matthew L. Stoll Consultant of: Currently consulting for Novartis, Shirley ML Tse: None declared, Filip van den Bosch Speakers bureau: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Paid instructor for: Amgen, Eli Lilly, Consultant of: Abbvie, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB, Robert G Lambert Paid instructor for: Novartis, Consultant of: CARE Arthritis, Calyx, Image Analysis Group, Novartis, David M. Biko Employee of: Merck (1998-2000), Nancy A. Chauvin Employee of: Forest Pharmaceuticals - Research scientist (1996) and Novartis - Pharmaceutical sales representative (1997), Michael L. Francavilla: None declared, Jacob L Jaremko: None declared, Nele Herregods: None declared, Ozgur Kasapcopur Speakers bureau: Pfizer, Abbvie, Novartis and Roche, Mehmet YILDIZ: None declared, Alison M. Hendry: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Eli-Lilly, Janssen, Novartis, Pfizer, UCB Pharma, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, UCB Pharma, Grant/research support from: Abbvie, Novartis, Pfizer

Atlas of MRI findings of sacroiliitis in pediatric sacroiliac joints to accompany the updated preliminary OMERACT pediatric JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system: Part I: Active lesions

Magnetic resonance imaging (MRI) is an increasingly important tool for identifying involvement of the sacroiliac joints (SIJ) in juvenile idiopathic arthritis (JIA). The key feature for diagnosing active sacroiliitis is bone marrow edema (BME), but other features of active arthritis such as joint space inflammation, inflammation in an erosion cavity, capsulitis and enthesitis can be seen as well. Structural changes may also be seen. Systematic MRI assessment of inflammation and structural damage may aid in monitoring the disease course, choice of therapeutics and evaluating treatment response. In this pictorial essay, we illustrate normal MRI findings and growth-related changes of the SIJ in the pediatric population, as well as the different MRI features of SIJ inflammation. This atlas demonstrates fundamental MRI disease features of active inflammation in a format that can serve as a reference for assessing SIJ arthritis according to the updated preliminary JAMRIS (Juvenile Idiopathic Arthritis MRI Score) scoring system proposed by the MRI in JIA working group of Outcome Measures in Rheumatology and Clinical Trials (OMERACT). The atlas is intended to be read in conjunction with its companion Part 2, Structural Lesions.

POS1101 THE OMERACT KNEE INFLAMMATION MRI SCORING SYSTEM: VALIDATION OF QUANTITATIVE METHODOLOGIES AND TRI-COMPARTMENTAL OVERLAYS BY COMPARISON WITH THE MRI OSTEOARTHRITIS KNEE SCORE

Background:

Randomized controlled trials have targeted reducing the size of BML and degree of synovitis for the treatment of OA. We have developed the OMERACT Knee Inflammation MRI Scoring System (KIMRISS) and have recently refined it to maximize reliability and sensitivity to change. Innovations include electronic overlays for assessment of BML in 500 subregions, a web-based interface with direct online scoring, and real-time iterative calibration (RETIC) prior to reading exercises. Synovitis-effusion (S-E) is also scored on all consecutive sagittal slices on a web-based interface.

Objectives:

We aimed to test the feasibility, reliability, and responsiveness of KIMRISS versus an established method, MOAKS, in two multi-reader exercises.

Methods:

KIMRISS incorporates web-based graphic overlays for each of femur, tibia, and patella (range 0-500). S-E is recorded as the largest diameter perpendicular to the longest axis of this feature (range 0-100). All scores are pro-rated for a standardized number of MRI slices. In a pre-reading exercise for KIMRISS, readers scored sufficient cases in RETIC to attain scoring proficiency, pre-specified as an ICC of ≥0.80 and ≥0.70 for status and change scores of BML and S-E compared to developer reads. A new web-based scoring platform with overlays designating different subregions for scoring BML was developed for MOAKS. We compared reliability for status and change scores of BML and S-E in 2 international multi-reader exercises of baseline and one-year MRI scans from the Osteoarthritis Initiative: A. 4 expert readers and an OMERACT fellow scored 38 cases selected for MOAKS BML score ≥1. B. 7 expert readers and an OMERACT fellow scored 60 cases selected for MOAKS BML ≥3 and Kellgren-Lawrence (K-L) grade <3. Reliability was assessed by intra-class correlation coefficient (ICC) and Smallest Detectable Change (SDC), responsiveness by the standardized response mean (SRM), and feasibility using the System Usability Scale (SUS scoring range 0-100).

Results:

For exercises A/B, subjects were 55.3%/ 26.7% male, mean(±SD) age 61.7(±9.1)/61.9(8.8) years, and radiographic K-L grade ≤2 in 39.4%/100%. Change was small in both exercises (<5% of scoring range for KIMRISS and MOAKS BML and S-E) with comparable responsiveness (Table 1). Despite this, ICC for change was consistently good to very good for both BML and S-E and consistently better for KIMRISS (Table 1). Mean SUS scores were 88.2 for KIMRISS and 54.3 for MOAKS.

Table 1.

KIMRISS and MOAKS scores in Two International Multi-reader Exercises

MethodMRI featureScores mean (SD)SDC(% of max)P valueSRMBaselineOne-year Follow upChangeEXERCISE AMOAKSBML3.6 (2.9)3.4 (2.3)-0.2 (1.9)1.0 (2.2%)0.72-0.11Synovitis-effusion1.3 (0.8)1.5 (0.8)0.2 (0.4)0.4 (13.3%)0.0170.5KIMRISSBML15.7 (13.3)21.2 (22.5)5.5 (15.3)5.6 (1.1%)0.0220.36Synovitis-effusion21.8 (12.0)24.3 (11.9)2.5 (7.4)2.8 (2.8%)0.0430.34EXERCISE BMOAKSBML4.2 (2.6)3.7 (2.4)-0.5 (2.1)1.1 (2.4%)0.083-0.24Synovitis-effusion1.2 (0.7)1.3 (0.8)0.0 (0.5)0.4 (13.3%)0.590.0KIMRISSBML18.0 (17.5)15.9 (14.3)-2.1 (12.3)5.9 (1.2%)0.19-0.17Synovitis-effusion21.8 (9.3)22.9 (10.8)1.1 (7.1)2.2 (2.2%)0.250.15Intra-class Correlation Coefficients (95%CI)MethodMRI featureExercise AExercise BKIMRISS statusKIMRISS changeBML0.86 (0.78-0.92)0.88 (0.81-0.93)0.80 (0.70-0.87)0.72 (0.64-0.80)MOAKS statusMOAKS changeBML0.71 (0.46-0.85)0.76 (0.64-0.85)0.67 (0.56-0.77)0.69 (0.60-0.78)KIMRISS statusKIMRISS changeSynovitis-effusion0.88 (0.81-0.93)0.87 (0.79-0.92)0.75 (0.52-0.86)0.87 (0.82-0.91)MOAKS statusMOAKS changeSynovitis-effusion0.66 (0.4-0.79)0.52 (0.36-0.67)0.65 (0.52-0.75)0.48 (0.37-0.60)

Conclusion:

The KIMRISS method for scoring BML and Synovitis-Effusion scores highly for feasibility and demonstrates consistently high reliability when compared to MOAKS. Further validation for responsiveness is necessary in cases with greater change in MRI features than in the OAI dataset.

Disclosure of Interests:

None declared.

OP0149 RELIABILITY AND RESPONSIVENESS OF TWO OMERACT WHOLE-BODY MRI SCORES OF ENTHESEAL AND JOINT INFLAMMATION IN THE KNEE REGION IN SPONDYLOARTHRITIS

Background:

Inflammation in peripheral joints and entheses is common in spondyloarthritis (SpA). Whole-body magnetic resonance imaging (WB-MRI) allows assessment of the overall inflammatory status of arthritis patients including joints and entheses. The OMERACT MRI Whole-body scoring system for Inflammation in Peripheral joints and Entheses (MRI-WIPE) [1] has been developed and validated for the entire body assessment, including the knee, but not separately validated for the knee joint region. Detailed MRI scoring systems exist for heels, hands and feet, but although knee arthritis is a key cause of functional impairment, no detailed scoring system has been validated for inflammatory arthritides. The Knee Inflammation MRI Scoring System (KIMRISS) [2] was developed and validated in osteoarthritis and demonstrated good reliability.

Objectives:

To perform region-based development of whole-body MRI through validation of two knee region scoring systems in SpA.

Methods:

Assessment of inflammation was performed in the knee region on sagittal WB-MRIs using 2 scoring systems, MRI-WIPE and KIMRISS (Figure 1), in 4 iterative multi-reader exercises. In the final exercise, images (psoriatic arthritis, axial and peripheral SpA) were obtained before and after TNF-inhibitor.

Results:

In the final exercise (exercise 4), reliability was mostly good for experienced readers with the overall highest interreader agreement in the previous exercise (exercise 3). Median pairwise single measure intraclass correlation coefficients for osteitis and synovitis/effusion for status/change were 0.71/0.48 (WIPE osteitis), 0.48/0.77 (WIPE synovitis/effusion), 0.59/0.91 (KIMRISS osteitis) and 0.92/0.97 (KIMRISS synovitis/effusion) (Table 1). Wilcoxon signed-rank test showed significant change in synovitis/effusion for both methods and they correlated significantly regarding status in osteitis (0.92, p<0.001) and synovitis/effusion (0.89, p=0.001) and change in synovitis/effusion (0.89, p<0.001). Standardized response mean was 0.74 (WIPE synovitis/effusion) and 0.78 (KIMRISS synovitis/effusion).

Table 1.

MRI-WIPE knee and KIMRISS interreader reliability for OMERACT exercises 3 and 4

MRI-WIPE KneeKIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patientsType of scoreMean scoreICCMean scoreICCMean scoreICCMean scoreICCExercise 39 readers11Status3.6 (0-16)0.57 (-0.06-0.98)1.8 (0-4)0.47 (0.05-0.85)32.3 (1-224)0.87 (0.66-0.99)29.9 (11-60)0.34 (-0.62-0.87)11Change1.1 (-2-6)0.53 (0.03-0.90)0 (-2-1)0.32 (-0.13-0.76)27.7 (-9-131)0.58 (-0.30-0.96)-1.6 (-33-11)0.48 (-0.32-0.95)Exercise 33 readers11Status3.1 (0-16)0.83 (0.71-0.97)2.5 (0-5)0.59 (0.51-0.71)34.4 (0-233)0.89 (0.83-0.99)36.5 (16-78)0.59 (0.08-0.86)11Change0.9 (-3-6)0.72 (0.57-0.83)0 (-2-1)0.63 (0.49-0.76)19.3 (-23-86)0.46 (0.18-0.83)-1.8 (-45-17)0.89 (0.82-0.95)Exercise 49 readers10Change-0.25 (-4-5)0.38 (-0.35-0.94)-1.0 (-3-1)0.30 (-0.43-0.89)-0.45 (-37-65)0.26 (-0.86-0.97)-14.7 (-48-0.20)0.48 (-0.39-0.99)20Status2.9 (0-7)0.50 (-0.01-0.84)2.1 (0-4)0.44 (-0.21-0.79)15.2 (0-66)0.35 (-0.04-0.89)55.6 (1-122)0.54 (0.01-0.96)Exercise 43 readers10Change0.2 (-2-6)0.48 (0.16-0.66)-1.4 (-5-0)0.77 (0.70-0.82)5.8 (-27-111)0.92 (0.90-0.94)-20.7 (-65-28)0.97 (0.96-0.98)20Status2.3 (0-6)0.71 (0.60-0.80)2.7 (0-5)0.48 (0.42-0.57)11.4 (0-36)0.59 (0.39-0.71)69.4 (1-153)0.91 (0.87-0.93)

Sum scores are mean (range) of the patients scores. ICC values are mean (range). ICC is 2-way mixed model, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and KIMRISS may both be useful as part of modular whole-body evaluation in clinical studies.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. RMD Open. 2017;3(1):e000355

Acknowledgements:

We thank CARE Aarthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, the scoring exercises, and the web-based meetings. We thank all who participated in the SIG (Special Interest Group) virtual OMERACT meeting 29 October 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed in this study are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Robert G Lambert Consultant of: Parexel and Pfizer, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Violaine Foltz: None declared, Ashish Jacob Mathew: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

POS1323 SACROILIAC JOINT MRI ABNORMALITIES IN JUVENILE SPONDYLOARTHRITIS: AN UPDATE OF DEFINITIONS AND SCORING OF THE OMERACT JUVENILE IDIOPATHIC ARTHRITIS MRI SCORE

Background:

Preliminary definitions for SIJ lesions in the OMERACT Juvenile Idiopathic Arthritis Magnetic Resonance Imaging score has been reported1. Investigators identified the need to revise the JAMRIS-SIJ item definitions.

Objectives:

To update the JAMRIS-SIJ definitions and scoring method.

Methods:

The OMERACT JAMRI working group was convened to discuss the performance of the score in a reliability exercise using 30 patients. Twenty investigators (12 radiologists, 8 rheumatologists) decided which definitions and scoring methods to be revised, retained or added.

Results:

The revised JAMRI-SIJ is in the Table 1.

Table 1.

Revised OMERACT JAMRIS-SIJ.

ComponentDefinitionSegmentation/sliceScore range/sliceBone Marrow Edema (BME)An ill-defined area of high bone marrow signal intensity within the subchondral bone in the ilium or sacrum on fluid sensitive images4 quadrants/SIJ0-8BME IntensityPresence of hyperintensity of the marrow on fluid sensitive images using the signal of the presacral veins or cerebrospinal fluid as reference1 score/SIJ0-2BME DepthContinuing increased signal on fluid sensitive images of depth ≥ 5mm/ ≥ 1cm from the articular surface using the signal of the presacral veins or cerebrospinal fluid as reference1 score/SIJ0-2OsteitisAn ill-defined area of high bone marrow signal intensity within the subchondral bone in the ilium or sacrum on contrast enhanced T1 weighted sequences4 quadrants/SIJ0-8CapsulitisIncreased signal on fluid sensitive or contrast enhanced T1 weighted sequences involving the superior portion of the SIJ capsulesuperior halves/SIJ0-2Joint space fluidHigh signal intensity equivalent to the CSF on fluid sensitive sequences within the joint space of the cartilaginous portion of the SIJhalves/SIJ0-4Joint space enhancementIncreased signal intensity on contrast enhanced T1 weighted sequences within the joint space of the cartilaginous portion of the SIJhalves/SIJ0-4Inflammation in erosion cavityIncreased signal intensity on fluid sensitive or contrast enhanced T1 weighted sequences in an erosion cavity of the cartilaginous portion of the SIJhalves/SIJ0-4EnthesitisIncreased signal intensity in bone marrow and/or adjacent soft tissue on fluid sensitive or contrast enhanced T1 weighted sequences at sites where ligaments and tendons attach to a bone excluding retroarticular enthesitisScore per case0-1Damage DomainSclerosisA substantially wider than normal area of very low bone marrow signal intensity within the subchondral bone in the ilium or sacrum on a non-fat suppressed sequence, preferably a non-fat suppressed T1 weighted sequence. This feature must also be present on all other sequences, as available4 quadrants/SIJ0-8ErosionA focal loss of the low signal of cortical bone at the osteochondral interface and adjacent marrow matrix on T1 weighted images4 quadrants/SIJ0-8Fat metaplasia lesionHomogeneous increased signal intensity within the subchondral bone marrow on T1weighted images4 quadrants/SIJ0-8BackfillA high signal on non-contrast enhanced T1 weighted sequences in a typical location for an erosion, with signal intensity greater than normal bone marrow, clearly demarcated from adjacent bone marrow by an irregular band of low signal reflecting sclerosis at the border of the original erosionhalves/SIJ0-4AnkylosisPresence of signal equivalent to regional bone marrow continuously bridging a portion of the joint space between the iliac and sacral boneshalves/SIJ0-4

Statement of overarching consideration for all definitions: “[…] in comparison to physiological changes normally seen on MRI examinations of age- and sex-matched children, and visible in 2 planes wherever available.”

Conclusion:

Revised JAMRIS-SIJ has been developed. Validation steps are underway.

References:

[1]Otobo TM, et al. Preliminary Definitions for Sacroiliac Joint Pathologies in the OMERACT Juvenile Idiopathic Arthritis Magnetic Resonance Imaging Score (OMERACT JAMRIS-SIJ). The Journal of rheumatology. 2019;46(9):1192-7.

Acknowledgements:

The authors acknowledge The Hospital for SickKids Research Trainee Competition (RESTRACOMP) and Queen Elizabeth II/Edward Dunlop Foundation Scholarship In Science and Technology (QEII-GSST) at the University of Toronto for funding provided to Dr. Tarimobo M. Otobo. The authors also acknowledge Prof. Dr. Desiree van der Heijde for providing expert commentary.

Disclosure of Interests:

None declared

OP0252 ARTHRITIS AND ENTHESITIS IN THE HIP AND PELVIS REGION IN SPONDYLOARTHRITIS – VALIDATION OF TWO WHOLE-BODY MRI METHODS

Background:

Whole-body MRI (WB-MRI) allows assessment of the overall inflammation in arthritis patients, including joint and entheses. To enhance the use of WB-MRI in clinical trials, the OMERACT MRI in Arthritis Working Group developed the OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses in inflammatory arthritis (MRI-WIPE) [1]. This has been validated for the entire body, including the hip/pelvis region, but not for each individual region. More detailed scoring systems exist for heels, hands and feet but although hip arthritis is a key cause of functional impairment in spondyloarthritis (SpA), no detailed scoring system has been published for use in SpA. The Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS) was developed and validated in osteoarthritis showing good reliability.

Objectives:

To validate reliability, correlation and responsiveness of two WB-MRI scores for the hip/pelvis region in SpA.

Methods:

Inflammation in the hip/pelvis region was assessed on coronal WB-MRIs in 4 iterative multi-reader exercises using MRI-WIPE for the hip/pelvis region and HIMRISS (Figure 1). In final exercises, images (axial/peripheral SpA and psoriatic arthritis) were obtained before and after TNF-inhibitor.

Results:

In final exercises reliability was mostly good for the best calibrated readers. Median single-measure intraclass correlation coefficients were 0.58-0.65 (WIPE osteitis), 0.10-0.88 (HIMRISS osteitis), 0.38-0.72/0.52-0.60 (WIPE synovitis/effusion) and 0.68-0.89/0.78-0.85 (HIMRISS synovitis/effusion) (Table 1). The methods correlated significantly for status in osteitis (0.72, p=0.019) and for synovitis/effusion status (0.83, p=0.003) and change (0.73, p=0.017) (Table 1). In exercise 4 Wilcoxon signed-rank test showed significant change in osteitis between timepoints using WIPE hip/pelvis and SRM was large (1.23), while lower for WIPE synovitis/effusion and HIMRISS.

Table 1.

MRI-WIPE hip/pelvis and HIMRISS interreader reliability for OMERACT exercises 3-4

MRI-WIPE hip/pelvisHIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patients(cases)Type of scoreMeanscoreICCMeanscoreICCMeanscoreICCMeanscoreICCExercise 39 readers11Status2.3 (0-10)0.69 (0.23-0.93)1.4 (0-4)0.58 (-0.06-0.96)8.2 (1-60)0.84 (0.56-0.99)12.8 (3-25)0.52 (0.00-.91)11Change-0.2 (-1-1)NA-0.2 (-3-1)0.50 (0.10-0.87)-0.35 (-3-1)NA-1.8 (-17-10)0.50 (-0.05-0.89)Exercise 33 readers11Status1.8 (0-10)0.63 (0.46-0.93)1.7 (0-5)0.60 (0.34-0.80)6.6 (0-65)0.88 (0.77-0.94)12.8 (2-28)0.89 (0.87-0.91)11Change-0.12 (-1-1)NA-0.12 (-3-2)0.60 (0.48-0.83)-0.7 (-7-0)NA-1.6 (-21-8)0.78 (0.70-0.87)Exercise 49 readers10 (1-10)Status1.2 (0-4)0.21 (-0.39-0.91)1.1 (0-2)0.19 (-0.31-0.69)1.8 (0-6)0.07 (-0.17-0.83)16.4 (9-23)0.31 (0.00-0.89)10 (11-20)Status1.6 (0-6)0.51 (-0.08-0.99)1 (0-3)0.40 (-0.17-0.88)3.5 (1-8)0,08 (-0.21-0.95)11.2 (5-24)0.49 (0.00-0.94)10 11-20)Change-0.4 (-2-0)NA-0.39 (-2-0)0.22 (-0.68-0.83)-2.2 (-7-2)NA-5.2 (-18-0)0.57 (0.02-0.92)20 (1-20)Status1.4 (0-6)0.41 (-0.35-0.92)1.0 (0-3)0.27 (-0.07-0.75)2.7 (0-9)0.09 (-0.17-0.85)13.8 (5-25)0.45 (0.01-0.90)Exercise 43 readers10 (1-10)Status0.8 (0-4)0.29 (0.01-0.78)1.3 (0-2)-0.02 (-0.29-0.12)0.4 (0-2)-0.04 (-0.04-0.04)15.8 (5-26)0.73 (0.59-0.89)10 (11-20)Status1.8 (0-9)0.65 (0.52-0.76)1.2 (0-4)0.72 (0.62-0.81)1.7 (0-5)0.06 (-0.17-0.35)9.2 (2-26)0.68 (0.53-0.88)10 (11-20)Change-0.6 (-2-0)NA-0.5 (-3-1)0.52 (0.49-0.55)-0.2 (-2-1)NA-2.8 (-19-6)0.85 (0.82-0.88)20 (1-20)Status1.3 (0-9)0.58 (0.43-0.69)1.2 (0-4)0.38 (0.31-0.44)1.0 (0-5)0.10 (-0.09-0.33)12.5 (2-26)0.73 (0.69-0.77)

Sum scores and ICCs are mean (range). ICC is 2-way mixed, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and HIMRISS may be useful tools in modular WB-MRI evaluation of hip/pelvis inflammation in clinical trials in SpA.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. J Rheum. 2019;46(9)1239-42

Acknowledgements:

We thank CARE Arthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, scoring exercises, and the web-based meetings. We acknowledge the contribution of SIG (Special Interest Group) participants at the virtual OMERACT meeting October 29, 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Robert G Lambert Consultant of: Parexel and Pfizer, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Ashish Jacob Mathew: None declared, Violaine Foltz: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Consultant of: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

AB0594 IMPROVING OSTEOARTHRITIS CARE BY AUTOMATIC MEASUREMENT OF HIP EFFUSION USING AI

Background:

Osteoarthritis (OA) is the commonest disease affecting hip joints and has high prevalence across various age groups [1,2]. Effusion is a hallmark of OA and could represent a potential target for therapy [3–5]. Positive correlations of effusion to clinical outcomes are not well established, partly due to variability in manual assessment. Voxel-based volume quantification could reduce this variability [6].

Objectives:

We examine the inter-observer agreement of manual assessment of voxel-based effusion volume from coronal STIR MRI sequences at two time points and examine the feasibility of using Artificial Intelligence (AI) for standalone volume assessment.

Methods:

Our algorithm is based on Mask R-CNN [7] and was trained on labeled effusion regions in MRI slices from 68 patients with hip osteoarthritis. For validation, 2 human readers measured effusion from MRI STIR sequences of 25 patients at baseline and at 8 weeks follow-up. AI was used to measure effusion volume as an independent reader. Agreement between human readers and AI was assessed using absolute difference in volume (DV), Coefficients of Variation (CoV) and intraclass correlation coefficient (ICC).

Results:

Effusion regions detected by AI closely correlated with manual segmentation (Figure 1) for all samples. Differences in volumes measured by each pair of readers are summarized in Table 1. Agreement was excellent between human readers (ICC=0.99) and for each reader vs AI (ICC = 0.85-0.87).

Figure 1.

Mask overlays of regions of joint fluid detected by human readers (green, column 2) and AI (red, column 3) from 3 different patients. Raw MRI images are shown in column 1.

Table 1.

Comparison of volumes measured in cubic millimeters and agreement between each pair of readers (with AI as the 3rd reader)

Volumes measured by readersAgreement between reader pairsReaderOverall VolumeMean ± Standard DeviationReader PairDifference in VolumeMean ± Standard DeviationCoVICCReader 16943 ± 5845Reader 1-21127 ± 9000.210.99 [0.98, 1.0]Reader 27638 ± 5619Reader 1-AI3311 ±16430.350.87 [0.7, 0.94]AI11014 ± 4454Reader 2-AI4151 ± 49860.270.85 [0.66,0.94]

Conclusion:

Initial results of automatic effusion measurement using AI show high agreement with human experts. This has potential to reduce variability and save expert time in OA MRI assessment, and to lead to improved OA care.

References:

[1]Sharif B, Garner R, Hennessy D, Sanmartin C, Flanagan WM, Marshall DA. Productivity costs of work loss associated with osteoarthritis in Canada from 2010 to 2031. Osteoarthritis Cartilage. 2017 Feb;25(2):249–58.

[2]Sharif B, Kopec J, Bansback N, Rahman MM, Flanagan WM, Wong H, et al. Projecting the direct cost burden of osteoarthritis in Canada using a microsimulation model. Osteoarthritis Cartilage. 2015 Oct;23(10):1654–63.

[3]Loeuille D, Chary-Valckenaere I, Champigneulle J, Rat A-C, Toussaint F, Pinzano-Watrin A, et al. Macroscopic and microscopic features of synovial membrane inflammation in the osteoarthritic knee: correlating magnetic resonance imaging findings with disease severity. Arthritis Rheum. 2005 Nov;52(11):3492–501.

[4]Fernandez-Madrid F, Karvonen RL, Teitge RA, Miller PR, An T, Negendank WG. Synovial thickening detected by MR imaging in osteoarthritis of the knee confirmed by biopsy as synovitis. Magn Reson Imaging. 1995;13(2):177–83.

[5]Atukorala I, Kwoh CK, Guermazi A, Roemer FW, Boudreau RM, Hannon MJ, et al. Synovitis in knee osteoarthritis: a precursor of disease? Ann Rheum Dis. 2016 Feb;75(2):390–5.

[6]Quinn-Laurin V, Thejeel B, Chauvin NA, Brandon TG, Weiss PF, Jaremko JL. Normal hip joint fluid volumes in healthy children of different ages, based on MRI volumetric quantitative measurement. Pediatr Radiol. 2020 Oct;50(11):1587–93.

[7]He K, Gkioxari G, Dollár P, Girshick R. Mask r-cnn. In: Proceedings of the IEEE international conference on computer vision. openaccess.thecvf.com; 2017. p. 2961–9.

Acknowledgements:

Jacob Jaremko is supported by the AHS Chair in Diagnostic Imaging at the University of Alberta. Medical Imaging Consultants (MIC) funds musculoskeletal radiology fellowships for Vanessa Quinn-Laurin at the University of Alberta, and provides Jacob Jaremko and Robert Lambert with protected academic time. Banafshe Felfeliyan is supported by an Alberta Innovates Graduate Student Scholarship for Data-Enabled Innovation.

Disclosure of Interests:

None declared.

Characterization of soft tissue tumours with ultrasound, shear wave elastography and MRI

OBJECTIVE

To predict accurately whether a soft tissue mass was benign or malignant and to characterize its type using ultrasound, shear wave elastography and MRI. We hypothesized that with the addition of shear wave elastography, it would be possible to determine a threshold velocity value to classify a lesion as benign or malignant.

MATERIALS AND METHODS

A total of 151 consecutive, consenting adult patients were prospectively recruited to this study in a tertiary referral musculoskeletal oncology centre. All lesions were assessed with ultrasound, including B mode, Doppler and shear wave elastography measurements. One hundred thirty-eight patients also underwent MRI of the lesion. A histological diagnosis was obtained for all lesions.

RESULTS

Malignant lesions were larger than benign lesions and had a greater Doppler activity. There was no useful threshold shear wave velocity to differentiate between benign and malignant lesions. Longitudinal and transverse shear wave velocities were strongly positively correlated with each other. An inverse correlation was shown with lesion size and depth, regardless of whether it was benign or malignant. A logistic regression model combining the ultrasound and MRI characteristics did not confidently classify a lesion as benign or malignant and was inferior to expert opinion.

CONCLUSION

The strongest predictors of malignancy are large lesion size and high vascularity. The combination of all ultrasound characteristics (including shear wave elastography) and MRI features does not confidently classify a lesion as benign or malignant, and histological diagnosis remains the gold standard.

Can effusion-synovitis measured on ultrasound or MRI predict response to intra-articular steroid injection in hip osteoarthritis?

OBJECTIVES

Intra-articular steroid injection (IASI) is an effective therapy for hip osteoarthritis (OA), but carries risks and provides significant pain relief to only two thirds of patients. We attempted to predict response to IASI in hip OA patients using baseline clinical, ultrasound, and MRI data.

METHODS

Observational study of 97 subjects with symptomatic hip OA presenting for IASI. At baseline and 8 weeks we obtained hip MRI, grayscale and Doppler ultrasound, clinical range of motion (ROM), timed-up and go test (TUG) scores, and self-reported Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain, stiffness, and function scores. Bone-capsule distance (BCD) measurements of inflammation on hip ultrasound and MRI were measured at three locations: the proximal-most uncovered portion of the femoral head, the superficial-most (apex) portion of the femoral head, and the largest fluid pocket at the femoral neck.

RESULTS

Ultrasound and MRI BCD correlated with each other significantly and strongly at the apex and neck. Power Doppler findings did not correlate significantly with any other imaging indices. Eight weeks post-injection, WOMAC pain, function, and stiffness scores significantly improved and TUG time improved nearly to the level of significance, but there were no significant changes in ultrasound, MRI, or Doppler indices. Baseline variables were not significantly different between responder and nonresponder WOMAC pain or TUG time cohorts.

CONCLUSION

Basic measures of inflammation on ultrasound and MRI are highly related to each other, but provide little insight into patient function and pain after IASI. Other mechanisms to explain improvement in patient status after IASI are likely at work.

Serum cartilage oligomeric matrix protein (COMP) expression in individuals who sustained a youth sport-related intra-articular knee injury 3-10 years previously and uninjured matched controls

OBJECTIVE

This study investigates the relationship between a youth sport-related intra-articular knee injury and cartilage oligomeric matrix protein (COMP), a biomarker of cartilage turnover.

DESIGN

Participants included a sub-sample (n = 170) of the Alberta Youth Prevention of Early Osteoarthritis (PrE-OA) study group. Specifically, 85 individuals with a 3-10 year history of sport-related intra-articular knee injury and 85 age, sex and sport-matched controls. COMP levels were investigated in serum. Between group differences in COMP levels, COMP fragmentation patterns and, the relationship between serum COMP and clinical outcomes (i.e., Magnetic Resonance Imaging (MRI) Osteoarthritis Knee Score; MOAKS, Knee Osteoarthritis Outcome Score; KOOS, Fat mass index; FMI) were examined.

RESULTS

Participant median age was 22.3 years (range 16-26) and 63% were female. Although there was no difference in COMP levels between previously injured and uninjured females, previously injured males demonstrated an ∼15% greater (171.5 ng/ml, 95% CI 11.0-428.0, P = 0.04) serum COMP level than uninjured males. However after controlling for FMI, this difference was absent. Within the injured participants, COMP levels were associated with MOAKS_SYNOVITIS and FMI. Furthermore, COMP fragmentation patterns were distinct between injured and uninjured individuals.

CONCLUSIONS

In this study group, serum COMP levels were greater in injured males, but not females, compared to matched controls. However, after controlling for FMI, no differences in COMP were observed. A unique COMP fragmentation pattern was observed in injured vs uninjured participants. These results further the hypothesis that COMP levels and/or degradation of the protein may be a marker of cartilage injury which could predispose to later OA.

CCL22 is a biomarker of cartilage injury and plays a functional role in chondrocyte apoptosis

BACKGROUND

Osteoarthritis (OA) is one of the leading causes of disability worldwide. Previous history of knee injury is a significant risk factor for OA. It has been established that low-level chronic inflammation plays a pivotal role in the onset and pathogenesis of OA. The primary aim of this research was to determine if a history of knee joint injury is associated with systemic inflammation. A secondary aim was to determine if systemic inflammation is related to knee pain and joint structure.

METHODS

Differences in serum cytokine association networks, knee joint structural changes (MRI), and self-reported pain (i.e., Knee Injury and Osteoarthritis Outcome Score Pain subscale, KOOS_PAIN and Intermittent and Constant Osteoarthritis Pain score, ICOAP) between individuals who had sustained a youth (aged 15-26 years) sport-related knee injury 3-10 years previously and age- and sex-matched controls were examined. Proteins of interest were also examined in an OA rat model.

RESULTS

Cytokine association networks were found to differ significantly between study groups, yet no significant associations were found between networks and KOOS_PAIN or MRI-defined OA. A group of cytokines (MCP1/CCL2, CCL22 and TNFα) were differentially associated with other cytokines between study groups. In a pre-clinical rat OA model, serum CCL22 levels were associated with pain (r = 0.255, p = 0.045) and structural changes to the cartilage. CCL22 expression was also observed in human OA cartilage and furthermore, CCL22 induced apoptosis of isolated human chondrocytes.

DISCUSSION

These results suggest that CCL22 may be an early factor in the onset/pathogenic process of cartilage degeneration and/or related to pain OA.

MRI of the sacroiliac joints in spondyloarthritis: the added value of intra-articular signal changes for a 'positive MRI'

OBJECTIVE

To determine if intra-articular signal changes at the sacroiliac joint space on MRI have added diagnostic value for spondyloarthritis, when compared to bone marrow edema (BME).

MATERIALS AND METHODS

A retrospective study was performed on the MRIs of sacroiliac joints of 363 patients, aged 16-45 years, clinically suspected of sacroiliitis. BME of the sacroiliac joints was correlated to intra-articular sacroiliac joint MR signal changes: high T1 signal, fluid signal, ankylosis and vacuum phenomenon (VP). These MRI findings were correlated with final clinical diagnosis. Sensitivity (SN), specificity (SP), likelihood ratios (LR), predictive values and post-test probabilities were calculated.

RESULTS

BME had SN of 68.9%, SP of 74.0% and LR+ of 2.6 for diagnosis of spondyloarthritis. BME in absence of intra-articular signal changes had a lower SN and LR+ for spondyloarthritis (SN = 20.5%, LR+ 1.4). Concomitant BME and high T1 signal (SP = 97.2%, LR + = 10.5), BME and fluid signal (SP = 98.6%, LR + = 10.3) or BME and ankylosis (SP = 100%) had higher SP and LR+ for spondyloarthritis. Concomitant BME and VP had low LR+ for spondyloarthritis (SP = 91%, LR + =0.9). When BME was absent, intra-articular signal changes were less prevalent, but remained highly specific for spondyloarthritis.

CONCLUSION

Our results suggest that both periarticular and intra-articular MR signal of the sacroiliac joint should be examined to determine whether an MRI is 'positive' or 'not positive' for sacroiliitis associated with spondyloarthritis.

Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic review

Developmental dysplasia of the hip (DDH) is a common condition predisposing to osteoarthritis (OA). Especially since DDH is best identified and treated in infancy before bones ossify, there is surprisingly a near-complete absence of literature examining mechanical behavior of infant dysplastic hips. We sought to identify current practice in finite element modeling (FEM) of DDH, to inform future modeling of infant dysplastic hips. We performed multi-database systematic review using PRISMA criteria. Abstracts (n = 126) fulfilling inclusion criteria were screened for methodological quality, and results were analyzed and summarized for eligible articles (n = 12). The majority of the studies modeled human adult dysplastic hips. Two studies focused on etiology of DDH through simulating mechanobiological growth of prenatal hips; we found no FEM-based studies in infants or children. Finite element models used either patient-specific geometry or idealized average geometry. Diversities in choice of material properties, boundary conditions, and loading scenarios were found in the finite-element models. FEM of adult dysplastic hips demonstrated generally smaller cartilage contact area in dysplastic hips than in normal joints. Contact pressure (CP) may be higher or lower in dysplastic hips depending on joint geometry and mechanical contribution of labrum (Lb). FEM of mechanobiological growth of prenatal hip joints revealed evidence for effects of the joint mechanical environment on formation of coxa valga, asymmetrically shallow acetabulum and malformed femoral head associated with DDH. Future modeling informed by the results of this review may yield valuable insights into optimal treatment of DDH, and into how and why OA develops early in DDH.

Diagnositic value of pelvic enthesitis on MRI of the sacroiliac joints in enthesitis related arthritis

BACKGROUND

To determine the prevalence and diagnostic value of pelvic enthesitis on MRI of the sacroiliac (SI) joints in enthesitis related arthritis (ERA).

METHODS

We retrospectively studied 143 patients aged 6-18 years old who underwent MRI of the SI joints for clinically suspected sacroiliitis between 2006-2014. Patients were diagnosed with ERA according to the International League of Associations for Rheumatology (ILAR) criteria. All MRI studies were reassessed for the presence of pelvic enthesitis, which was correlated to the presence of sacroiliitis on MRI and to the final clinical diagnosis. The added value for detection of pelvic enthesitis and fulfilment of criteria for the diagnosis of ERA was studied.

RESULTS

Pelvic enthesitis was seen in 23 of 143 (16 %) patients. The most commonly affected sites were the entheses around the hip (35 % of affected entheses) and the retroarticular interosseous ligaments (32 % of affected entheses). MRI showed pelvic enthesitis in 21 % of patients with ERA and in 13 % of patients without ERA. Pelvic enthesitis was seen on MRI in 7/51 (14 %) patients with clinically evident enthesitis, and 16/92 (17 %) patients without clinically evident enthesitis. In 7 of 11 ERA-negative patients without clinical enthesitis but with pelvic enthesitis on MRI, the ILAR criteria could have been fulfilled, if pelvic enthesitis on MRI was included in the criteria. There is a high correlation between pelvic enthesitis and sacroiliitis, with sacroiliitis present in 17/23 (74 %) patients with pelvic enthesitis.

CONCLUSIONS

Pelvic enthesitis may be present in children with or without clinically evident peripheral enthesitis. There is a high correlation between pelvic enthesitis and sacroiliitis on MRI of the sacroiliac joints in children. As pelvic enthesitis indicates active inflammation, it may play a role in assessment of the inflammatory status. Therefore, it should be carefully sought and noted by radiologists examining MRI of the sacroiliac joints in children.

Limited role of gadolinium to detect active sacroiliitis on MRI in juvenile spondyloarthritis

OBJECTIVE

The aim of this study is to determine the added diagnostic value of contrast-enhanced (CE) magnetic resonance imaging (MRI) compared to routine non contrast-enhanced MRI to detect active sacroiliitis in clinically juvenile spondyloarthritis (JSpA).

MATERIALS AND METHODS

A total of 80 children clinically suspected for sacroiliitis prospectively underwent MRI of the sacroiliac (SI) joints. Axial and coronal T1-weighted (T1), Short-tau inversion recovery (STIR) and fat-saturated T1-weighted gadolinium-DTPA (Gd) contrast-enhanced (T1/Gd) sequences were obtained. The presence of bone marrow edema (BME), capsulitis, enthesitis, high intra-articular STIR signal, synovial enhancement and a global diagnostic impression of the MRI for diagnosis of sacroiliitis was recorded.

RESULTS

STIR and T1/Gd sequences had 100% agreement for depiction of BME, capsulitis and enthesitis. High intra-articular STIR signal was seen in 18/80 (22.5%) patients, 15 (83%) of whom also showed synovial enhancement in the T1/Gd sequence. Sensitivity (SN) and specificity (SP) for a clinical diagnosis of JSpA were similar for high STIR signal (SN = 33%, SP = 85%) and T1/Gd synovial enhancement (SN = 36%, SP = 92%). Positive likelihood ratio (LR+) for JSpA was twice as high for synovial enhancement than high STIR signal (4.5 compared to 2.2). Global diagnostic impression was similar (STIR: SN = 55%, SP = 87%, LR + =4 .2; T1/Gd: SN = 55%, SP = 92%, LR + = 6.9).

CONCLUSION

MRI without contrast administration is sufficient to identify bone marrow edema, capsulitis and retroarticular enthesitis as features of active sacroiliitis in juvenile spondyloarthritis. In selected cases when high STIR signal in the joint is the only finding, gadolinium-enhanced images may help to confirm the presence of synovitis.

Assessing the reliability of MRI-CBCT image registration to visualize temporomandibular joints

OBJECTIVES

To evaluate image quality of two methods of registering MRI and CBCT images of the temporomandibular joint (TMJ), particularly regarding TMJ articular disc-condyle relationship and osseous abnormality.

METHODS

MR and CBCT images for 10 patients (20 TMJs) were obtained and co-registered using two methods (non-guided and marker guided) using Mirada XD software (Mirada Medical Ltd, Oxford, UK). Three radiologists independently and blindly evaluated three types of images (MRI, CBCT and registered MRI-CBCT) at two times (T1 and T2) on two criteria: (1) quality of MRI-CBCT registrations (excellent, fair or poor) and (2) TMJ disc-condylar position and articular osseous abnormalities (osteophytes, erosions and subcortical cyst, surface flattening, sclerosis).

RESULTS

75% of the non-guided registered images showed excellent quality, and 95% of the marker-guided registered images showed poor quality. Significant difference was found between the non-guided and marker-guided registration (χ(2) = 108.5; p < 0.01). The interexaminer variability of the disc position in MRI [intraclass correlation coefficient (ICC) = 0.50 at T1, 0.56 at T2] was lower than that in MRI-CBCT registered images [ICC = 0.80 (0.52-0.92) at T1, 0.84 (0.62-0.93) at T2]. Erosions and subcortical cysts were noticed less frequently in the MRI-CBCT images than in CBCT images.

CONCLUSIONS

Non-guided registration proved superior to marker-guided registration. Although MRI-CBCT fused images were slightly more limited than CBCT alone to detect osseous abnormalities, use of the fused images improved the consistency among examiners in detecting disc position in relation to the condyle.

Value and limitations of diffusion-weighted imaging in grading and diagnosis of pediatric posterior fossa tumors

DWI reportedly accurately differentiates pediatric posterior fossa tumors, but anecdotal experience suggests limitations. In 3 years, medulloblastoma and JPA were differentiated by DWI alone in 23/26 cases (88%). Ependymoma (n = 5) could not be reliably differentiated from medulloblastoma or JPA. A trend toward increased diffusion restriction in higher grade tumors (1/14 grade I, 7%; 9/12 grade IV, 75%) had too much overlap to predict the grade of individual cases. The overlap in ADC between tumor types appeared partly due to technical factors (in small, heterogeneous, calcific, or hemorrhagic tumors) but also likely reflected true histologic variability, given that our 3 overlap cases included a desmoplastic medulloblastoma, an anaplastic ependymoma, and a JPA with restricted diffusion in its nodule. Simple structural features (macrocystic tumor, location off midline) aided in distinguishing JPA from the other tumors in these cases.

MRI demonstrates the extension of juxta-articular venous malformation of the knee and correlates with joint changes

OBJECTIVE

Juxta-articular venous malformations (VMs) are uncommon, but may cause early arthropathy of the knee in children and adolescents. We sought to describe the prevalence, extent and initial magnetic resonance imaging (MRI) features of knee arthropathy in children with VM adjacent to the knee joint.

METHODS

Thirty-five patients with VM adjacent to the knee who had MRI performed between 2000 and 2009 were identified through a keyword search of the radiology information system.

RESULTS

VM extended to the joint in 17 of the 35 patients (5.4-21.5 years, mean 11.8 years). Most of these 17 patients had joint changes (15/17, 88%), most commonly haemosiderin deposition (14/17, 82%). Other findings included the presence of subchondral bone lesions (eight, 47%), cartilage loss (six, 35%), synovial thickening (six, 35%), marrow oedema (six, 35%), joint effusion (five, 29%), subchondral cysts (five, 29%) and one loose body (6%). VM location and size did not correlate with the degree of articular involvement. Joint changes were present in focal as well as non-discrete VM.

CONCLUSION

We found that the frequency of arthropathy increased with extension of VM into the joint itself. This finding stresses the importance of early MRI evaluation of all juxta-articular VM.

Oesophageal and tracheal perforation in thyroid B-cell lymphoma

We report an unusual case of spontaneous oesophageal and tracheal perforation secondary to thyroid B-cell lymphoma in a previously healthy 76-year-old woman. Findings on chest radiography, CT and oesophagram are correlated to endoscopy, surgery and pathology. Such perforation is a rare and serious complication that should be specifically considered when a patient with a neck neoplasm develops acute respiratory or gastrointestinal symptoms.

Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?

AIM

To investigate whether radiographic deformities suggesting inadequate reduction would be associated with adverse clinical outcomes.

MATERIALS AND METHODS

Consecutive patients over 50 years of age (n=74) with non-operatively managed distal radius fractures were enrolled in a prospective cohort study. They had radiographs at cast removal ( approximately 6 weeks) and completed DASH (Disabilities of the Arm, Shoulder and Hand), SF-12 (health-related quality of life), and satisfaction surveys 6-months post-fracture. A reference-standard musculoskeletal radiologist, blinded to outcomes status, measured palmar (dorsal) tilt, radial angle, radial height, ulnar height, and intra-articular step and gap. Radiographic indices were correlated to each other and to the various patient-reported outcomes in univariate and multivariate regression analyses. DASH score was the primary study outcome.

RESULTS

Of the cohort studied (n=74, mean age 68.5 years, primarily white women), 71% had at least one "unacceptable" radiographic deformity by traditional criteria. Acceptable reduction varied from 60-99% depending on which single index was reported, and 44% of patients had more than two indices reported as unacceptable. Despite these radiographic findings, 6-months post-reduction, self-reported disability was low (DASH=24+/-17), health-related quality of life was near normal, and 72% were satisfied with their care. No radiographic index of wrist deformity (alone or in combination) was significantly correlated to any of the patient-reported outcomes.

CONCLUSION

Self-reported outcomes in older adults with conservatively managed wrist fractures were not related to the "acceptability" of radiographic fracture reduction. The proportion of acceptable reductions varied by 40% depending on which index was reported. Consequently, detailed reporting of these indices in older adults with distal radius fracture may be inefficient or perhaps even unnecessary.

Reliability of an efficient MRI-based method for estimation of knee cartilage volume using surface registration

OBJECTIVE

To aid in detection of osteoarthritis (OA) progression in serial magnetic resonance (MR) scans, we assessed feasibility and accuracy of rapid 3D image registration of the tibial plateau in normal and arthritic subjects, and inter-scan reliability of semi-automated cartilage volume measurement from these images.

DESIGN

Two T1 fat-suppressed knee MR scans were obtained 2 weeks apart in healthy adults (n = 9, age 23-48 years). Four scans of each of three patients with established OA were obtained over 2 years. At baseline, the tibial surface was digitized by semi-automated edge detection and medial tibial plateau cartilage volume was calculated from high-intensity voxels within a manually drawn region of interest (ROI). In subsequent scans, the digitized tibial surface was registered to the baseline location by photogrammetric 3D coordinate transformation, and cartilage volume was automatically recalculated by reuse of the ROI. We measured registration accuracy by root mean square (RMS) distance between registered tibial surfaces.

RESULTS

In normals, RMS distance between tibial surfaces in baseline and subsequent scans was 1/3 voxel length (0.121 mm), and medial tibial plateau cartilage volumes varied by 1.4+/-3.2%. Despite change in cartilage volumes by up to 20% over 2 years in arthritic patients, surface registration accuracy was unaffected (0.122 mm). User-supervised processing time was 15 min at baseline and 7 min in subsequent scans.

CONCLUSION

Tibial surfaces on magnetic resonance imaging (MRI) can be rapidly and accurately co-registered, even in arthritic knees, allowing direct visualization of changes over time. Compared to most current methods, cartilage volume measurement in registered images is faster and has equivalent inter-scan reliability in initially normal subjects.

Colo-colonic intussusception caused by a solitary Peutz-Jeghers polyp

A case of acute large bowel obstruction by colo-colonic intussusception in a healthy 19-year-old man is presented. The lead point of the intussusception is a rare solitary colonic Peutz-Jeghers polyp in the descending colon of a man without the full Peutz-Jeghers syndrome. The clinical presentation, imaging findings on plain radiographs, single contrast enema and CT, and findings at colonoscopy and surgery are correlated with pathology results and a brief review of the literature.

Estimation of spinal deformity in scoliosis from torso surface cross sections

STUDY DESIGN

Correlation of torso scan and three-dimensional radiographic data in 65 scans of 40 subjects.

OBJECTIVES

To assess whether full-torso surface laser scan images can be effectively used to estimate spinal deformity with the aid of an artificial neural network.

SUMMARY OF BACKGROUND DATA

Quantification of torso surface asymmetry may aid diagnosis and monitoring of scoliosis and thereby minimize the use of radiographs. Artificial neural networks are computing tools designed to relate input and output data when the form of the relation is unknown.

METHODS

A three-dimensional torso scan taken concurrently with a pair of radiographs was used to generate an integrated three-dimensional model of the spine and torso surface. Sixty-five scan-radiograph pairs were generated during 18 months in 40 patients (Cobb angles 0-58 degrees ): 34 patients with adolescent idiopathic scoliosis and six with juvenile scoliosis. Sixteen (25%) were randomly selected for testing and the remainder (n = 49) used to train the artificial neural network. Contours were cut through the torso model at each vertebral level, and the line joining the centroids of area of the torso contours was generated. Lateral deviations and angles of curvature of this line, and the relative rotations of the principal axes of each contour were computed. Artificial neural network estimations of maximal computer Cobb angle were made.

RESULTS

Torso-spine correlations were generally weak (r < 0.5), although the range of torso rotation related moderately well to the maximal Cobb angle (r = 0.64). Deformity of the torso centroid line was minimal despite significant spinal deformity in the patients studied. Despite these limitations and the small data set, the artificial neural network estimated the maximal Cobb angle within 6 degrees in 63% of the test data set and was able to distinguish a Cobb angle greater than 30 degrees with a sensitivity of 1.0 and specificity of 0.75.

CONCLUSIONS

Neural-network analysis of full-torso scan imaging shows promise to accurately estimate scoliotic spinal deformity in a variety of patients.