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Supplementary material Ann Rheum Dis

Supplementary Table S2

Study Population Intervention Comparator/reference Assessed lesions and Results standard definitions Coari 1994 [19]* 6 PsA US of fingers n.a. . oedema (% of patients) 7.5 MHz transducer surrounding flexor and 100% stretching sheath extensor 100% oedema surrounding . Stretching of flexor flexor and extensor tendons sheath 50% joint effusion PIP and DIP . Joint effusion Fournié 2006 [20]* 20 PsA (25 fingers) US of symptomatic fingers n.a. . Extrasynovial findings: 19/25 fingers in PsA 21 RA (25 fingers) 13.5 MHz transducer periosteal reaction, vs 25/25 fingers in RA capsular , 4/25 fingers in of the distal PsA vs 11/25 fingers in RA phalanx, soft tissue Joint erosions 13/25 fingers in thickening, PD signal from PsA vs 19/25 fingers in RA finger pad, PD signal from In PsA nail, irregular sesamoid Periosteal reaction 9/25 fingers . Synovitis Capsular enthesophyte 3/25 . Tenosynovitis fingers . Joint erosions Enthesopathy 4/25 fingers Soft tissue thickening 8/25 fingers Doppler signal finger pad 2/25 fingers Doppler signal nail 2/25 fingers Irregular sesamoid bones 2/25 fingers

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

In RA No extrasynovial ultrasound findings. Lin 2015 [21]* 44 PsA (123 fingers) US of fingers Clinical diagnosis . Soft tissue inflammation Joint effusion 39 RA (122 fingers) 18 MHz transducer . Joint effusion 75/123 fingers in PsA vs 20 HC . Synovial thickening 82/122 fingers in RA (p<0.01) . Bone erosions Synovial thickening . Tenosynovitis 68/123 fingers in PsA vs . 78/122 fingers in RA (p<0.01) . Periosteal reaction Bone erosions . Teno-osteophyma 71/123 fingers in PsA vs 59/122 fingers in RA (p<0.01) Tenosynovitis 71/128 fingers in PsA vs 0/122 fingers in RA (p<0.01) Soft tissue inflammation 44/123 fingers in PsA vs 0/122 fingers in RA (p<0.01) Enthesitis 39/123 fingers in PsA Periosteal reaction 21/123 fingers in PsA vs 0/122 fingers in RA Teno-osteophyma 18/123 fingers in PsA vs 0/122 fingers in RA Zabotti 2016 [22] 26 early PsA US of the two most clinically Clinical diagnosis . Soft tissue oedema Performance of soft tissue 34 early RA involved joints defined as a diffuse oedema to diagnose PsA vs 16-18 MHz transducer enlargement of soft tissue RA around the flexor tendon Se (95%CI) 0.42 (0.23,0.63)

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

With prevalent involvement of with an increased PD Sp (95% CI) 0.97 (0.84,0.99) the hand signal from finger pad to LR+ (95%CI) 14.38 MCP joint evaluated by (1.98,104.44) volar scan (GS and PD 0-1) LR- (95%CI) 0.59 (0.43, 0.83) . Synovitis at MCP and PIP PPV (95%CI) 0.91 (0.60,0.98) according to the OMERACT NPV (95%CI) 0.68 (0.61,0.75) definition, (GS and PD 0-3) Performance of synovitis to . Erosions (discontinuity of diagnose PsA vs RA the bone surface visible in Se (95%CI) 59.6% (45.1-73.0) two perpendicular planes) Sp (95% CI) 8.8% (3.3-18.2) . Peritendon inflammation PPV (95%CI) 33.3% (23.9-43.9) of the extensor digitorum NPV (95%CI) 22.2% (8.6-42.2) . hypoechoic swelling of the Performance of erosions to soft tissue surrounding the diagnose PsA vs RA tendon (GS and PD 0-1) Se (95%CI) 3.8% (0.5-13.2) . Enthesitis at the central Sp (95% CI) 86.7% (76.3-93.7) slip (GS and PD 0-1) PPV (95% CI) 18.2% (2.2-51.8) NPV (95% CI) 54.1% (44.3-63.7) Tinazzi 2018 [23] 37 PsA US of the flexor compartment Clinical diagnosis . Peritendinous oedema Performance of soft tissue 47 PsA of the hands (fingers 2-4) with defined as diffuse oedema (GS) to diagnose PsA 10 HC GS and PD. hypo/isoechoic thickening vs RA 16-18 MHz transducer of the peritendinous soft Se (95%CI) 0.56 (0.42,0.75) tissues around flexor Sp (95% CI) 1 (0.92,1) tendon with vascular LR- (95% CI) 0.41 (0.27,0.6) signal at PD examination PPV (95% CI) 1 (0-1) NPV (95% CI) (0.67,0.81) . Flexor tenosynovitis in GS Performance of flexor and PD according to the tenosynovitis (GS) to diagnose OMERACT definition (0-1) PsA vs RA Se (95%CI) 0.38 (0.25,0.55)

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

. of the Sp (95% CI) 0.87(0.73,0.94) flexor tendon according to LR+ (95% CI) 2.84 (1.21,6.65) the OMERACT definition LR- (95% CI) 0.72 (0.54,0.95) (0-1) PPV (95% CI) 0.7 (0.49,0.84) NPV (95% CI) 0.62 (0.56,0.69) Performance of flexor tenosynovitis (PD) to diagnose PsA vs RA Se (95%CI) 0.21 (0.09,0.38) Sp (95% CI) 0.95(0.84,0.99) LR+ (95% CI) 4.86 (1.10,21.53) LR- (95% CI) 0.82 (0.68, 0.98) PPV (95% CI) 0.8 (0.47,0.94) NPV (95% CI) 0.59(0.55,0.63) Performance of flexor tendon entesophytes to diagnose PsA vs RA Se (95%CI) 0.11 (0.03,0.25) Sp (95% CI) 0.91 (0.79,0.97) LR+ (95% CI) 1.22 (0.33,4.53) LR- (95% CI) 0.98 (0.85, 1.13) PPV (95% CI) 0.5(0.21, 0.78) NPV (95% CI)0. 55 (0.52,0.59) Zabotti 2018 [24] 25 seropositive early RA US of the volar aspect of the Clinical diagnosis . Soft tissue oedema around Performance of soft tissue 23 seronegative early RA hands the flexor tendon defined oedema to diagnose PsA vs 25 early PsA as diffuse enlargement of RA 16-18 MHz transducer soft tissue around the Se (95%CI) 0.4 (0.21,0.61) flexor tendon with Sp (95%CI) 0.9 (0.77,0.97) increased PD signal from LR+ 4.2 (1.47,11.98) LR- 0.66 (0.47,0.93)

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

finger pad to MCP joint PPV 0.71 (0.46,0.087) evaluated by volar scan NPV 0.71 (0.64,0.77) . Peritendon inflammation Performance of peritendon of the extensor digitorum inflammation to diagnose PsA . Central slip enthesitis vs RA Se (95%CI) 0.36 (0.18,0.57) Sp (95%CI) 0.95 (0.83,0.99) LR+ (95%CI) 7.56 (1.77, 32.23) LR- (95%CI) 0.67 (0.50,0.91) PPV (95%CI) 0.81 (0.51,0.95) NPV (95%CI) 0.71(0.65,0.77) Performance of central slip enthesitis to diagnose PsA vs RA Se (95%CI) 0(0,0.13) Sp (95%CI) 0.88(0.74,0.96) LR+ (95%CI) 0 LR- (95%CI) 1.13 (1.02, 1.26) PPV (95%CI) 0 NPV (95%CI) 0.6 (0.57,0.63) Girolimetto Clin Rheumatol 37 PsA with dactylitis (48 US of dactylitic finger Dactylometer and . Peri-tendinous oedema Association of tenderness and 2019 [25] fingers) (volar+dorsal) the Leeds Dactylitis Index (LDI) defined as diffuse dactylitis duration with US 16–18 MHz transducer hypo/isoechoic thickening lesions of the extratendinous soft GS+PD tissues around flexor Local pain/tenderness was tendons associated to flexor peri- (pseudotenosynovitis) tendinous PD (p < 0.001), peri- with positive PD in the tendinous soft tissue oedema subcutaneous tissue in (p < 0.001) and subcutaneous long axis view (graded 0-1) PD (p < 0.001).

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

. Paratenonitis defined as a hypoechoic area GS flexor tenosynovitis of surrounding a tendon grade > 2 was seen in 96% of without synovial sheath, cases with shorter dactylitis with or without peri- duration. tendinous PD signal (graded 0-1) Peri-tendinous oedema and . OMERACT definition of subcutaneous PD were synovitis and tenosynovitis associated with a shorter (0-3) dactylitis duration (p < 0.001) . Enthesitis of extensor Extensor tendon involvement tendon at PIP joint was were present in the group with graded as present in GS a dactylitis duration longer when it washypoechoic than 24 weeks with in- creased thickness of the insertion into bone GS synovitis and intra- articular when compared to the PD was more frequent in body of tendon and the patients with a dactylitis contralateral joint (graded duration longer than 24 weeks 0-1) (p < 0.001). Girolimetto Clin Rheumatol 85 PsA dactylitis (100 fingers) US of dactylitic finger Dactylometer and . Peri-tendinous oedema Identification of lesions in 2019 (27) 3 centres Naples, Negrar, (volar+dorsal) the Leeds Dactylitis Index (LDI) defined as diffuse shorter and long duration Reggio Emilia (3 hypo/isoechoic thickening dactylitis ultrasonographers) 16–18 MHz linear transducer of the extratendinous soft tissues around flexor Flexor tenosynovitis was seen GS+PD tendons in 88% of dactylitis (grade > 2 (pseudotenosynovitis) in 46% of cases) with positive PD in the subcutaneous tissue in long axis view (graded 0-1)

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

. Paratenonitis defined as PD flexor tenosynovitis was a hypoechoic area observed in 72% of cases surrounding a tendon (grade > 2 in 57% of cases) without synovial sheath with or without peri- Soft tissue oedema was tendinous PD signal present in 91% of dactylitis (graded 0-1) and subcutaneous PD was . OMERACT definition of present in 85% of cases synovitis and tenosynovitis (0-3) Extensor tendon involvement . Enthesitis of extensor was evident in 12% of tendon at PIP joint was dactylitic fingers (with graded as present in GS associated PD signal in 10% of when it was hypoechoic cases) with in- creased thickness of the insertion into bone GS synovitis involving at least 1 when compared to the joint was observed in 40% of body of tendon and the cases; it was present more contralateral side (graded frequently at PIP level (28% of 0-1) cases); it was present at MCP and DIP level in 15% and 9% of cases

PD synovitis involving at least 1 joint was evident in 21% of cases; it was more frequently detected at PIP level (17% of cases); it was seen at MCP and DIP level in 7% and 4% of cases

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

Shorter dactylitis duration (<20 weeks) had a significantly higher prevalence of GS flexor tenosynovitis grade > 2 and PD flexor tenosynovitis (any grade) (p = 0.001 and p < 0.001)

Extracapsular soft tissue oedema and subcutaneous PDS were more common in the shorter disease duration

Synovitis in GS and PD mode was more frequent in patients with a dactylitis duration longer than/equal to 20 weeks Girolimetto J Rheumatol 2019 99 PsA dactylitis (116 fingers) US of dactylitic finger Dactylometer and . Soft tissue oedema Sonographic findings in [26] (volar+dorsal) the Leeds Dactylitis Index defined as diffuse symptomatic vs asymptomatic hypo/isoechoic thickening dactylitis 16–18 MHz linear transducer of the extratendinous soft tissues around flexor Significant association GS+PD tendons between clinical symptoms (pseudotenosynovitis) and the presence of a with positive PD signal in tenosynovitis degree greater the subcutaneous tissue in than or equal to 2 (p < 0.001). long axis view (0-1) . Paratenonitis defined as a US joint synovitis involving at hypoechoic area least one joint in fingers with surrounding a tendon

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191 Supplementary material Ann Rheum Dis

without a synovial sheath cold dactylitis in GS and PD (p with or without peri- < 0.001). tendinous PD signal (0-1) . OMERACT definition of synovitis and tenosynovitis (0-3) . Enthesitis of extensor tendon at PIP joint defined as a hypoechoic area and increased thickness of the tendon insertion into bone when compared to the body of tendon and the contralateral side(0-1)

Table S2. Summary of findings of the systematic literature review. * Studies obtained from the orginal SLR. PsA: psoriatic arthritis; RA: rheumatoid arthritis; HC: healthy control; US: ultrasonography; 95% CI: 95% confidence interval; Se: sensitivity; Sp: specificity; LR+: positive likelihood ratio; LR-: negative likelihood ratio; PPV: positive predictive value; NPV: negative predictive value; MCP: metacarpophalangeal joint, PIP: proximal interphalangeal joint; DIP: distal interphalangeal joints; GS: grey scale; PD: power Doppler.

Zabotti A, et al. Ann Rheum Dis 2020; 79:1037–1043. doi: 10.1136/annrheumdis-2020-217191