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Relationships Between Ultrasound Enthesitis, Disease Activity and Axial Radiographic Structural Changes in Patients with Early S Spondyloarthritis RMD Open: first published as 10.1136/rmdopen-2017-000482 on 7 September 2017. Downloaded from ORIGINAL articLE Relationships between ultrasound enthesitis, disease activity and axial radiographic structural changes in patients with early spondyloarthritis: data from DESIR cohort Adeline Ruyssen-Witrand,1,2,3 Bénédicte Jamard,1 Alain Cantagrel,1,3,4 Delphine Nigon,1 Damien Loeuille,5 Yannick Degboe,4 Arnaud Constantin1,3,4 To cite: Ruyssen-Witrand A, ABSTRACT Jamard B, Cantagrel A, Background To search for association between Key messages et al. Relationships between ultrasound (US) enthesis abnormalities and disease activity, ultrasound enthesitis, disease spine and sacro-iliac joints (SIJ) MRI inflammatory lesions What is already known about this subject? activity and axial radiographic and spine structural changes in a cohort of patients ► The association between disease activity and structural changes in patients suspected for axial spondyloarthritis (SpA). enthesis ultrasound findings is not clear in the with early spondyloarthritis: data literature. from DESIR cohort. RMD Open Methods Patients: Of 708 patients included in the 2017;3:e000482. doi:10.1136/ DESIR(Devenir des Spondyloarthrites Indifférenciées What does this study add? Récentes) cohort, 402 had an US enthesis assessment rmdopen-2017-000482 ► Ultrasound peripheral enthesitis was not associated and were selected for this study. Imaging: Achilles, lateral with clinical disease activity in patients with early epicondyles, superior patellar ligament, inferior patellar ► Prepublication history and axial spondyloarthritis (SpA). ligament entheses were systematically US scanned additional material is available. ► Ultrasound peripheral enthesitis was not associated To view, please visit the journal and abnormalities were summed in US structural and with sacroiliitis nor with MRI spine inflammatory online (http:// dx. doi. org/ 10. power Doppler (PDUS) scores. Spine radiographs, SIJ lesions. and spine MRI scans were centrally scored modified 1136/ rmdopen- 2017- 000482). http://rmdopen.bmj.com/ ► Ultrasound enthesophyte presence was strongly Stoke Ankylosing Spondylitis Spine Score (mSASSS), associated with syndesmophyte presence. Received 20 April 2017 presence of MRI sacro-iliitis, Spondyloarthritis Research Revised 13 July 2017 Consortium of Canada and Berlin scores. Analysis: The How might this impact on clinical practice? Accepted 14 August 2017 associations between the US structural/PDUS scores and ► Ultrasound enthesophyte might be a marker of disease activity, C reactive protein (CRP), MRI SIJ and disease severity in axial SpA. spine inflammatory lesions and mSASSS were tested by Spearman's correlation tests. Results Among the 402 patients included (median age: bone, and a characteristic sign of spondy- 33.5 years, males: 48.5%), 55% had US enthesis structural 1 loarthritis (SpA). In axial SpA, the frequency on September 25, 2021 by guest. Protected copyright. Department of Rheumatology, abnormalities while 14% had PDUS abnormalities. There Purpan Teaching Hospital, of peripheral enthesitis has been found to was no association between US scores and Bath Ankylosing 1 Toulouse, France be within 25%–58%, but the real preva- 2 Spondylitis Disease Activity Index, CRP or inflammatory lesions Inserm UMR1027, Toulouse, on SIJ and spine MRI. There was a correlation between US lence of this feature depends on the type of France structural and PDUS scores and the mSASSS (respectively, assessment (ie, clinical, imaging or histolog- 3Department of Rheumatology, r=0.151, p=0.005; r=0.143, p=0.007). The proportion of Université Paul Sabatier ical). Peripheral enthesitis is usually revealed Toulouse III, Toulouse, France patients with syndesmophytes was higher in the case of US by clinical findings, such as localised pain, 4Inserm UMR 1043, Toulouse, enthesophytes (26% of syndesmophytes vs 6% in the absence tenderness and swelling. Nevertheless, there France of US enthesophytes, p<0.0001). are no definite clinical criteria for the diag- 5 Department of Rheumatology, Conclusion While the US abnormalities do not seem to be nosis of such manifestations, which may even CHU Brabois, Nancy, France a helpful tool for monitoring disease activity in axial SpA, US be asymptomatic. Histological examination of enthesophytes, strongly associated with axial syndesmophytes, Correspondence to might be a marker of interest for disease severity. the enthesis is the potential gold standard for Dr Adeline Ruyssen-Witrand, Trial registration number NCT01648907, date of evaluation of enthesitis, but is rarely carried Department of Rheumatology, registration : 20 July 2012. out due to ethical and practical constraints. Purpan Teaching Hospital, 1 Ultrasonography (US) has proved to be place du Dr Baylac, 31059 a sensitive and non-invasive tool to assess Toulouse Cedex 9, France; Enthesitis is the inflammation of insertions ruyssen- witrand. a@ chu- the presence of enthesitis, characterised by toulouse. fr of tendons, ligaments and capsules into the hypoechogenicity with loss of the tendon Ruyssen-Witrand A, et al. RMD Open 2017;3:e000482. doi:10.1136/rmdopen-2017-000482 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2017-000482 on 7 September 2017. Downloaded from fibrillar pattern, tendon thickening, local calcifications, criteria including ASAS 2009,12 Amor criteria,13 European enthesophytes and bone erosions. Moreover, the use Spondylarthropathy Study Group criteria14 or modified of power Doppler US (PDUS) allows the detection of New York criteria15 the HLA-B27 status and CRP levels. abnormal vascularisation of soft tissues in inflammatory Clinical enthesitis presence was assessed according to articular diseases.2–7 three different outcomes: 1) presence (yes/no) of an Recently, it has been suggested that enthesis US could enthesis pain during the physical examination of one be used for monitoring disease activity and therapeutic of the entheses that had had an US (including Achilles, response assessment.8–10 However, further studies are lateral epicondyle, superior patellar ligament, inferior needed to confirm the potential associations between US patellar ligament); 2) history of enthesis pain (yes/no) enthesis changes and disease activity or structural axial from one of the entheses that had had an US (same changes. entheses); 3) the Maastricht Ankylosing Spondylitis In this study, we investigated the prevalence of US Entheses Score (MASES: 0–13).16 The data set locked on enthesis abnormalities, the concordance between US 30 June 2010 was used for this study. abnormalities and enthesis pain and searched for asso- ciation between US enthesis abnormalities and disease US measurements activity, functional impairment, MRI inflammatory All US were performed in local centres by experienced lesions on sacro-iliac joints (SIJ) and spine and radio- rheumatologists or radiologists using a 12–16 MHz linear graphic structural changes on spine and pelvis X-rays in array transducer. Power Doppler settings were stan- a cohort of patients with early inflammatory back pain dardised with a pulse repetition frequency of 500–800 Hz. (IBP) suggestive of axial SpA (Devenir des Spondyloarth- The following entheses were scanned along long axis and rites Indifférenciées Récentes (DESIR) cohort). short axis views: left and right Achilles, lateral epicon- dyles, superior patellar ligament, inferior patellar liga- ment. These enthesis sites were selected by the scientific PATIENTS AND METHODS committee of DESIR cohort, based on the literature Study population review. The USs were performed in each patient included The DESIR cohort has already been described before.11 in the DESIR cohort blinded to the history of clinical Briefly, DESIR is a French prospective longitudinal enthesitis. cohort study monitoring 708 patients (aged between 18 For each site, the following abnormalities were sought and 50 years) over time with IBP suggestive of axial SpA and recorded on a standardised form: presence of according to the rheumatologist opinion for ≥3 months abnormal thickness, calcifications, enthesophytes, bony and <3 years in 25 centres across France between 2007 erosions defining structural enthesis changes and the and 2010. All patients included in the study had a collec- presence of power Doppler signals on the bone-enthesis tion of clinical data, blood samples, pelvis and spine junction defining inflammatory enthesitis, according to http://rmdopen.bmj.com/ plain X-rays, SIJ and spine MRI at baseline. Among these the Outcomes Measures in Rheumatology (OMERACT) patients, 402 had also a peripheral enthesis US and were definitions.17 Furthermore, a search was also made for selected for the present study. The present study involved any retrocalcaneal bursitis with power Doppler signals. the baseline database of the DESIR cohort. The US structural changes and inflammatory enthesitis Ethics, consents and permission were described according to the each enthesis site. All indi- The study complied with Good Clinical Practice Guide- vidual US structural abnormalities (including abnormal lines ( clinicaltrials. gov: NCTO 164 8907, https://clinical - thickness, bony erosions, calcifications and entheso- trials. gov/ ct2/ show/ NCT01648907) and was approved phytes, Achilles bursitis—each abnormality observed on September 25, 2021 by guest. Protected copyright. by the appropriate medical ethic committee (CPP Ile-de- receiving one point) on each enthesis (eight sites) were France III, submission number P070302).
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