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Development and validation of a Pediatric Internationally agreed UltraSound Hip synovitis protocol (PIUS-hip), by the
Daniel Windschall1,2, Ralf Trauzeddel3, Silvia Magni-Manzoni4
1Clinic for Paediatric and Adolescent Rheumatology, St.-Josef-Stift Sendenhorst, Sendenhorst, Germany. windschall@st-josef-stift.de.
Insights
A new musculoskeletal ultrasound (MSUS) protocol for juvenile idiopathic arthritis (JIA) hip synovitis detection shows high sensitivity and specificity. The Pediatric internationally agreed UltraSound hip synovitis protocol (PIUS-hip) uses B-Mode scoring and anterior recess size measurement.
Area of Science:
- Pediatric Rheumatology
- Medical Imaging
- Musculoskeletal Ultrasound
Background:
- Normal musculoskeletal ultrasound (MSUS) values for healthy children's hip joints exist, but data for juvenile idiopathic arthritis (JIA) patients are lacking.
- Internationally validated MSUS protocols for optimal synovitis evaluation in JIA are needed.
Purpose of the Study:
- To develop and validate the most sensitive MSUS protocol for detecting hip synovitis in JIA patients.
Main Methods:
- MSUS was performed on affected and unaffected hips in JIA patients.
- Synovitis was graded using the pediatric OMERACT score for B-Mode (BM) and power-Doppler Mode (PD).
- Anterior recess size, capsula thickness, and femoral head cartilage thickness were measured.
Main Results:
- The MSUS protocol demonstrated high sensitivity (97%) and specificity (85%) for detecting synovitis using B-Mode.
- Anterior recess size measurement (cutoff ≥7.2 mm) achieved 86% sensitivity and 94% specificity.
- Interobserver reliability for BM and PD positivity was excellent (kappa = 0.85).
Conclusions:
- The Pediatric internationally agreed UltraSound hip synovitis protocol (PIUS-hip) can be simplified.
- A single longitudinal scan with B-Mode scoring and anterior recess size measurement offers maximal sensitivity and specificity for synovitis detection in JIA hips.
Background:
Whilst musculoskeletal ultrasound (MSUS) normal values for examination of the hip joint have been established for healthy children, equivalent values for patients with juvenile idiopathic arthritis (JIA), as well as internationally validated MSUS protocols for the optimal evaluation of synovitis are lacking. This study aimed to develop and validate the most sensitive MSUS protocol for the detection of hip synovitis in JIA.
Methods:
In consecutive JIA patients with ≥ 1 clinically affected hip joint, affected and unaffected hips underwent MSUS. Disease, demographic and clinical findings were recorded. Synovitis was graded using the pediatric OMERACT score for B-Mode (BM) and power-Doppler Mode (PD) in the longitudinal and transverse scans and the sensitivity and specificity was analyzed. Additionally anterior recess size (bone to capsula distance), capsula thickness and femoral head cartilage thickness (transverse view) were measured. Published data provided further control data for anterior recess size (children without JIA). Interobserver reliability of BM and PD was tested using Fleiss-Kappa.
Results:
60 patients were enrolled who had 76 hips with and 32 without clinical arthritis. BM was positive (grade ≥ 1) in 74/76 of hips with clinical arthritis (97%, sensitivity 0.97 (0.93-1.0), specificity 0.85 (0.74-0.97) versus 2/32 (6%) in hips without arthritis. PD positivity frequency was 6 (8%) in hips with arthritis versus 0 in hips without. Anterior recess size (mean ± SD) was significantly wider in patients with clinical arthritis (9.9 ± 2.5 vs 5.5 ± 1.3, p-value 0.001). Use of the cut-off of ≥ 7.2 mm resulted in an area under the curve of at least 95%, with a sensitivity of 86% and specificity of 94%. Articular capsula and femoral head cartilage thickness did not differ between patients with and without arthritis. Recess size was comparable in the internal and external control groups (n = 449). Interobserver reliability of BM and PD positivity showed excellent agreement (kappa = 0.85).
Conclusions:
The Pediatric internationally agreed UltraSound hip synovitis protocol (PIUS-hip) could be limited to one longitudinal scan including B-Mode scoring plus measurement of anterior recess size for maximal sensitivity and specificity for synovitis.
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