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Development of Classification Criteria for Hand Osteoarthritis: Comparative Analyses of Persons with and Without Hand Osteoarthritis

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Development of Classification Criteria for Hand Osteoarthritis: Comparative Analyses of Persons with and Without Hand Osteoarthritis Osteoarthritis RMD Open: first published as 10.1136/rmdopen-2020-001265 on 25 June 2020. Downloaded from ORIGINAL RESEARCH Development of classification criteria for hand osteoarthritis: comparative analyses of persons with and without hand osteoarthritis Ida K Haugen ,1 David T Felson ,2,3 Abhishek Abhishek,4,5 Francis Berenbaum,6 Sita Bierma-Zeinstra,7 Tove Borgen,1,8 Gabriel Herrero Beaumont,9 Mariko Ishimori,10 Helgi Jonsson,11 Féline PB Kroon ,12 Emmanuel Maheu,13 Roberta Ramonda,14 Valentin Ritschl,15 Tanja A Stamm ,15 Desirée van der Heijde ,12 Ruth Wittoek,16 Elsie Greibrokk,1 Wilma Smeets,12 Margreet Kloppenburg12 To cite: Haugen IK, Felson DT, ABSTRACT Abhishek A, et al.Development Objectives Further knowledge about typical hand Key messages of classification criteria for hand osteoarthritis (OA) characteristics is needed for the osteoarthritis: comparative development of new classification criteria for hand OA. What is already known about this study? analyses of persons with and ► Current hand OA classification criteria are unable to Methods In a cross-sectional multi-centre international without hand osteoarthritis. classify persons with hand OA based on radiographic study, a convenience sample of patients from primary and RMD Open 2020;6:e001265. findings, and they are hampered by being insensitive secondary/tertiary care with a physician-based hand OA doi:10.1136/rmdopen-2020- to classify hand OA in the general population. 001265 diagnosis (n = 128) were compared with controls with hand complaints due to inflammatory or non-inflammatory ► What does this study add? Additional material is conditions (n = 70). We examined whether self-reported, ► published online only. To view Our study shows that radiographic findings, please visit the journal online clinical, radiographic and laboratory findings were associated especially in the DIP joints, demonstrate better (http://dx.doi.org/10.1136/rmdo with hand OA using logistic regression analyses. discrimination between hand OA and controls than pen-2020-001265). Discrimination between groups was assessed by calculating features by clinical examination. http://rmdopen.bmj.com/ the area under receiver operating curves (AUC). ► Among self-reported symptoms, best discrimination Received 10 April 2020 Results Strong associations with hand OA were observed for Revised 26 May 2020 between hand OA and controls was found for pain on Accepted 31 May 2020 radiographic osteophytes (OR = 1.62, 95% CI 1.40 to 1.88) and most days the previous 6 weeks in the DIP joints. joint space narrowing (JSN) (OR = 1.57, 95% CI 1.36 to 1.82) in the distal interphalangeal (DIP) joints with excellent How might this impact on clinical practice? discrimination (AUC = 0.82 for both). For osteophytes and JSN, ► Identification of typical hand OA features is needed we found acceptable discrimination between groups in the before new classification criteria can be developed proximal interphalangeal joints (AUC = 0.77 and 0.78, andtestedindecisionanalyticsoftware. respectively), but poorer discrimination in the first ► Widespread use of new classification criteria will on October 1, 2021 by guest. Protected copyright. carpometacarpal joints (AUC = 0.67 and 0.63, respectively). enable comparisons of disease prevalent and Painful DIP joints were associated with hand OA, but were less incidence across observational studies and testing able to discriminate between groups (AUC = 0.67). Age and of treatments in clinical trials. family history of OA were positively associated with hand OA, whereas negative associations were found for pain, stiffness and soft tissue swelling in metacarpophalangeal joints, pain and marginal erosions in wrists, longer morning stiffness, Rheumatology (ACR) criteria,1 which have © Author(s) (or their inflammatory biomarkers and autoantibodies. employer(s)) 2020. Re-use Conclusions Differences in symptoms, clinical findings, important shortcomings that might prevent permitted under CC BY-NC. No radiographic changes and laboratory tests were found in much-needed insight in hand OA patho- commercial re-use. See rights patients with hand OA versus controls. Radiographic OA genesis and testing of treatments in clinical and permissions. Published features, especially in DIP joints, were best suited to trials. Importantly, the criteria are based on by BMJ. discriminate between groups. clinical examination parameters often with For numbered affiliations see poor reliability without the possibility to end of article. classify hand OA based on radiographs. Correspondence to INTRODUCTION Moreover, they define OA as present Ida K Haugen; Hand osteoarthritis (OA) is currently being almost exclusively based on a combination [email protected] classified by the 1990 American College of of affected joints in the 2nd and 3rd Haugen IK, et al. RMD Open 2020;6:e001265. doi:10.1136/rmdopen-2020-001265 1 RMD Open RMD Open: first published as 10.1136/rmdopen-2020-001265 on 25 June 2020. Downloaded from fingers and the thumb base. Since the control group regarded as one entity. Surgically modified joints were in the development of the criteria mainly consisted of marked on the same diagram. They completed the Aus- persons with rheumatoid arthritis (RA), the criteria tralian/Canadian hand index pain (range 0–20), stiffness are not well suited to classify hand OA in a wider (range 0–4) and function subscales (range 0–36) and the population with rheumatic and musculoskeletal dis- Functional Index of Hand OA (range 0–30).56 eases (RMDs). Mainly severe hand OA will be classi- The patients self-reported painful locking of fingers, fied by the ACR criteria making them insensitive in numbness and tingling in the hands, current/past psor- the general population. Lastly, all hand OA pheno- iasis, current/past inflammatory bowel disease, and types are lumped together, without taking into con- family history of OA, bony swellings/nodes and psoriasis sideration that different phenotypes could have in first-degree relatives. different pathogenesis or treatment. Research on the natural disease course and development Clinical examination of effective treatment options is seriously hampered by the A physician or nurse examined all hand joints (bilateral lack of good classification criteria. For example, compar- 2nd–5th DIP, 1st–5th PIP, 1st–5th MCP and thumb base) isons of disease incidence and prevalence are difficult. for absence/presence of bony enlargement, pain on pres- Since different definitions of hand OA are used in clinical sure and soft tissue swelling. Malalignment was assessed in trials rather than the ACR criteria, it is challenging to per- the DIP, PIP (>15°) and the thumb base joints (squaring). form systematic reviews or meta-analyses.2 Members of the Absence/presence of dactylitis (2nd–5th fingers) and EULAR taskforce for evidence-based recommendations on tenosynovitis (2nd–5th fingers and thumb base) were hand OA diagnosis ranked the development of new classi- evaluated bilaterally. On the body homunculus, pain on fication criteria as a top research priority.3 pressure (upper and middle back, bilateral shoulders, Our aim is to identify features that are associated with elbows, wrists, knees and feet) or movement (neck, hand OA and that can discriminate hand OA and controls lower back, bilateral hips and ankles) was marked. Body in a population with hand complaints as a first step to weight and height were self-reported or measured. The develop new classification criteria for hand OA overall study personnel had previous experience in joint exam- and different hand OA phenotypes. ination, but no formal training was performed prior to the data collection. No reliability data was available. For each patient recruited into the study, the physicians METHODS were asked: ‘How likely is it that the hand complaints in this Study design patient are due to hand OA’ on a 0–10 scale (0 = ‘not likely’, We collected data on patients with hand complaints from 10 = ‘very likely’). For scores 0–7, the physician indicated Europe and North America. Patients were recruited from the cause of complaints on a list with 16 RMDs other than primary (2 centres) and secondary/tertiary care (10 cen- hand OA (response alternatives: ‘no’, ‘unclear’, ‘yes’). http://rmdopen.bmj.com/ tres). Physicians recruited patients with hand complaints, which could be due to either hand OA (ranging from mild to severe) or inflammatory and non-inflammatory Hand radiographs non-traumatic conditions. Strict numbers of patients Bilateral hand radiographs obtained at each centre were within each category were not provided. Patients with de-identified and read centrally by two trained readers unclear causes of their hand complaints were also (IKH, FK). The central readers have demonstrated excel- included. The treating physician made the diagnosis. lent inter-reader reliability in a previous clinical trial.7 – – – We aimed for approximately 200 patients in our data Bilateral 2nd 5th DIP, 1st 5th PIP, 1st 5th MCP, 1st car- on October 1, 2021 by guest. Protected copyright. set, a number targeted in previous classification criteria pometacarpal (CMC1) and scaphotrapeziotrapezoid efforts.4 The data collection was funded by the EULAR. (STT) joints were read according to a modified Kellgren- Lawrence scale (grade 0–4).8 All joints were read for Hand questionnaires osteophytes (grade 0–3) and joint space narrowing All patients responded to questions about hand com- (JSN, grade 0–3), and the DIP and PIP joints were also plaints, including symptom duration and duration of read for central erosions.9 The readers counted the num- morning stiffness in fingers and thumb base joints. On ber of joints within three joint groups (PIP, MCP and four separate hand diagrams, they marked the hand wrist) with marginal erosions.10 joints (bilateral 2nd–5th distal interphalangeal (DIP), A trained rheumatologist (MK) adjudicated the scoring 1st–5th proximal interphalangeal (PIP), 1st–5th metacar- of osteophytes and JSN in joints where one central reader pophalangeal (MCP) and thumb base) that had been scored no pathology and the other central reader scored painful and stiff during the last 48 hours and on most grade 2–3.
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