EULAR recommendations for the use of imaging in the clinical management of peripheral joint ...

12 Pages·2017·0.42 MB·English

Recommendation
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EULAR recommendations for the use of imaging n
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in the clinical management of peripheral joint e
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osteoarthritis D
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Garifallia Sakellariou,1 Philip G Conaghan,2 Weiya Zhang,3 Johannes W J Bijlsma,4 t p
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Pernille Boyesen,5 Maria Antonietta D’Agostino,6,7 Michael Doherty,3 Daniela Fodor,8 blis
Margreet Kloppenburg,9 Falk Miese,10 Esperanza Naredo,11 Mark Porcheret,12 he
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Annamaria Iagnocco13 a
s
1
0
.1
► Additional material is ABSTRACT has not been clearly defined. Despite this limita- 136
published online only. To view Theincreasedinformationprovidedbymodernimaging tion, the increased availability of modern imaging /a
please visit the journal online hasledtoitsmoreextensiveuse.Ouraimwasto has expanded its use, with possible excesses1 nn
(http://d x. doi. org/ 10. 1136/ developevidence-basedrecommendationsfortheuseof leading to increased costs. A European League rh
annrheumdis- 2016- 210815). imagingintheclinicalmanagementofthemost AgainstRheumatism(EULAR)taskforcewasthere- eu
m
For numbered affiliations see commonarthropathy,osteoarthritis(OA).Ataskforce fore created to develop evidence-based recommen- dis
end of article. (includingrheumatologists,radiologists,methodologists, dations on the use of imaging in the management -2
primarycaredoctorsandpatients)fromninecountries of symptomatic, peripheral joint OA, for clinicians 01
Correspondence to defined10questionsontheroleofimaginginOAto whotreatOAintheirclinicalpractice. 6-2
Professor Philip G Conaghan, supportasystematicliteraturereview(SLR).Jointsof 1
0
Laenedd Ms Iunssctuitluotsek eolfe tRahl eMumedaitciicn e, interestweretheknee,hip,handandfoot;imaging METHODS 815
Chapel Allerton Hospital, modalitiesincludedconventionalradiography(CR),MRI, A group selected from a range of expertise (rheu- o
Leeds  LS7  4SA, UK; ultrasonography,CTandnuclearmedicine.PubMedand matologists, radiologists, primary care physicians, n 7
p. conaghan@ leeds. ac. uk EMBASEweresearched.Theevidencewaspresentedto methodologists and patients) and representing nine A
GeqSu aanlldy. PGC contributed trehceotmasmkefnodrcaetiownhs.oTshuebssetrqeunegnthtlyodfeavgerleoepmedenttheforeach cthoeunfitrrsitesmeweatsingin,ctlhuedefodcuinsotfhtehetarsekcofmormcee.ndDautiroinngs pril 20
recommendationwasassessed.17011referenceswere 1
(symptomatic OA affecting the knee, hip, hand or 7
Received 12 November 2016 identifiedfromwhich390studieswereincludedinthe foot) was clarified. Clinically relevant questions on . D
Revised 25 February 2017 SLR.Sevenrecommendationswereproduced,covering o
the application of imaging in OA were proposed w
Accepted 5 March 2017
thelackofneedfordiagnosticimaginginpatientswith n
Published Online First and nine research questions were selected by con- lo
7 April 2017 typicalsymptoms;theroleofimagingindifferential sensus to guide a detailed systematic literature ad
diagnosis;thelackofbenefitinmonitoringwhenno e
review (SLR). Two questions that covered the same d
therapeuticmodificationisrelated,thoughconsideration area were subsequently combined. The areas of fro
isrequiredwhenunexpectedclinicaldeteriorationoccurs; diagnosis, prognosis, follow-up and treatment were m
CRasthefirst-choiceimagingmodality;considerationof h
howtocorrectlyacquireimagesandtheroleofimaging covered. The questions were rephrased according ttp
irnesgeuaridchingwelorecaallsinojedcetivoenlos.peRdecboamsemdenodnagtiaopnssifnorfuture toroeustecaotrhmceheq(upPeoIsCptiuOolna)ts(i)os.ene, oninlitneervseunptipolnem, enctoamrypafirliesoSn1, ://ard.b
evidence,suchastheuseofimaginginidentifying m
therapeutictargets,anddemonstratingtheaddedvalue An SLR was performed by one of the authors j.c
(GS), with checking of all extractions by one of o
ofimaging.Theseevidence-basedrecommendationsand m
relatedresearchagendaprovidethebasisforsensible three other authors experienced in SLRs. The o/
search strategies were based on both MeSh terms n
useofimaginginroutineclinicalassessmentofpeople and free text. The searches were performed separ- Ja
withOA. ately for each joint (see online supplementary file nu
a
S2 search strategies). The titles and abstracts of the ry
referencesthat were retrieved were screened by the 1
8
INTRODUCTION same author according to predefined inclusion and , 2
Osteoarthritis (OA) is a major cause of pain and exclusion criteria, based on the PICO for each 02
3
disability worldwide. Although conventional radi- question, and potentially relevant articles were b
ography (CR) is the most commonly used tech- evaluated in their full text. Studies in English y g
nique to evaluate structural features of OA, includingadults(≥18)withsymptomaticOAofthe u
e
ismigangifiincgantovaedrvatnhceeslhasatvedbeeceandem, aadlleowinintgheafiemldooref ksinoene.,Ihmipag,inhganmdoadnadlitifeosotinwcleurdeedeliwgiebrleeCfoRr,iMncRluI-, st. P
ro
accurate evaluation of both bone and soft-tissue ultrasonography (US), CT and nuclear medicine te
abnormalities.WhilenewermodalitiessuchasMRI techniques (scintigraphy, positron emission tomog- cte
andultrasoundhaveincreasedtheunderstandingof raphy). Randomised controlled trials (RCTs), sys- d
b
the multiple pathologies contributing to the OA tematic reviews and meta-analyses, controlled y
TCoo ncaitgeh:a Sna PkGel,l aZrhioaun gG W, , phenotype, it is not clear how they should be used clinical trials, case–control studies, cross-sectional cop
e2t0 a1l7. ;A7n6n:1 R4h8e4u–m1 4D9i4s . itnicerofuotrinOeAcardei.aTgnhoesirso,lemoafniamgeamgienngtinancdlinfioclalolwpr-aucp- sstiound.ieSstuadnideschoahdorttosetxuadmieisnewtehreereolilgeibolfeimfoargiinngcluin- yrig
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1484 Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815
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the following: in making a diagnosis of OA; in detecting OA (834 duplicates). Of the remaining 4545, 4520 were excluded n
n
elementary lesions; for differential diagnosis; in the manage- based on the title and abstracts, leaving 25 articles for detailed R
h
ment of OA; in predicting outcome and therapeutic response; review. Nineteen articles were excluded after reviewing the full e
u
for follow-up of disease course and to guide treatment. The text,leavingsixarticlesforinclusion.Thehandsearchidentified m
samearticlescouldbeincludedinmorethanonesearch.Dueto two additional articles for inclusion, leading to a total of eight D
tshtreonvgarideteygroefejooifnthseitteersoagnedneiimtyagaicnrgosasndstuthdeiese,xpmecettaat-iaonnaloyfseas acortmicplelsetfienraelslyultinscolufdtehde(asdeeditoinolninalesseuaprcphleemsewnittahryrefifleereSn7c)e.sTahree is: firs
werenotprespecifiedbeforestudyselectionandextraction.The reportedintheonlinesupplementaryfileS8. t p
u
methodological quality of the included studies was not assessed b
by quality scores, but some aspects were considered for all Recommendations lish
studies, together with design-specific indicators. For all studies, Table 1 summarises the seven recommendations with their cor- ed
study design, sample size and setting sampling were considered. respondinglevelofevidenceandLOA.Eachrecommendationis as
For RCTs allocation concealment, drop-out rate as well as the presentedindetailbelow. 10
presence of funding, for diagnostic studies the adequacy of the .1
1
referencestandardandforcohortstudiesthepresenceofadjust- Overarchingstatements 36
mentforconfounderswerealsoevaluated.Eachaspectwaseval- 1. TheserecommendationspertainonlytosymptomaticOA. /a
n
uatedseparatelyasleadingtohigh,loworunclearriskofbias. 2. Imaging abnormalities of OA are commonly seen especially nrh
Duringthesecondmeeting,theresultsoftheliteraturereview withincreasingage. e
were presented and the experts developed ‘over-arching’ state- um
d
ments (background statements to preface the recommendations) is
anddraftedsevenrecommendationsthroughaprocessofdiscus- -2
0
sion and consensus. The number of recommendations emerged 1
Table1 Recommendations,levelsofevidenceandlevelof 6
throughthediscussionafterthepresentationoftheliterature.To agreement (LOA) -21
explore the presence of additional evidence concerning two 0
8
recommendations, two more research questions on (1) the dif- Levelof LOA,mean 1
ferent performance of various radiographic views in detecting Recommendation evidence (95%CI) 5 o
OA features and (2) the accuracy of imaging-guided compared 1. Imagingisnotrequiredtomakethe III–IV 8.7(7.9to9.4) n 7
withblindjointinjectionswereaddedtotheoriginaleight,with diagnosisinpatientswithtypical* A
presentationofOA. p
tSow1f,otrheaesdseedairtrcieohsnuqaltulse,listttehioreantTsuaarsenkdseFSao2rrc,chseeeascro(cnshefiesrtmoranetldeingtieheses)u.fipAnpfaltelemrweeovnratdaluirnaygtifioolnef 2. IronefcaOotmAypmaicneadnl/doperrdemsteoanktheaetalipoltnecsro,nnaifmtirivamegitonhrgeaiddsidaigtinoonsaisl IV 9.6(9.1to10) ril 2017
the recommendations and scored the perceived level of agree- diagnoses. . D
ment (LOA) for each statement using a 0–10 numeric rating 3. RoutineimaginginOAfollow-upisnot III–IV 8.8(7.9to9.7) ow
scale (0=fully disagree; 10=fully agree), reflecting both litera- recommended.However,imagingis nlo
tureevidenceandexpertopinion.Recommendationsforfurther recommendedifthereisunexpectedrapid ad
progressionofsymptomsorchangein e
researchwerethendevelopedbasedongapsintheSLRs. d
crelilnaitceasltcohaOrAacsteerviestriictysotoradnetaedrmdiitnioeniaflthis fro
RESULTS diagnosis. m
h
The searches in the electronic databases (PubMed, EMBASE) 4. Ifimagingisneeded,conventional(plain) III–IV 8.7(7.9to9.6) ttp
wseearrechpeesrfaonrdmDedecuepmbtoerth2e01e5ndfoorfthJaenuadardyiti2o0n1a5l sfeoarrcthhees.mTahine rmsaoodftdioatgilsirtsaiuepeshs.yTasorheombuaeldksetbiaemdaudgsiteeidodnbbaeylfodUriSaegoonrtohMseerRs,I ://ard
initial search resulted in 6858 records (615 duplicates). Of the .b
andbonebyCTorMRI. m
remaining 6243 articles, 4926 were excluded based on the title 5. Considerationofradiographicviewsis III 9.4(8.7to9.9) j.c
and abstracts, leaving 1317 articles for detailed review. All full- importantforoptimisingdetectionofOA om
text articles were retrieved, 986 articles were excluded after features;inparticularfortheknee, o/
reviewing the full text, leaving 331 articles for inclusion (see weightbearingandpatellofemoralviewsare n
onlinesupplementaryfileS3).Thehandsearchofthereferences recommended. Ja
of the included studies identified 33 additional articles, leading 6. Accordingtocurrentevidence,imaging II–III 8.7(7.5to9.7) nu
vtoanattototalmoofre36t4hasntudoinees firnesaellayrcahnaqlyuseesdti.oAnrtwicelreestuhsaetdwfeorreerealceh- ftereaatutmreesndtorenspootnpsreedaicntdniomna-gsuinrggiccaalnnotbe ary 1
recommendedforthispurpose. 8
question as appropriate. The number of articles included for 7. Theaccuracyofintra-articularinjection III–IV 9.4(8.9to9.9) , 2
each site and imaging is shown in online supplementary figure dependsonthejointandontheskillsofthe 02
3
S4. The complete results of the SLR with references are practitionerandimagingmayimprove b
repTohretedadidnittihoenaolnslienaercshupopnletmheenctaormypfialreisSo5n. of different radio- arecccoumramcye.nIdmeadgifnogrjiosinptasrttihcautlaarlryedifficultto y gu
accessduetofactorsincludingsite(eg,hip), e
grermapahinicinvgiew45s4r9e,su4lt4e9d6inw4e7re74exacrltuicdleeds (b2a2s5edduopnlictahtees)t.itOlefatnhde degreeofdeformityandobesity. st. P
Categoriesofevidence:Ia,evidenceformeta-analysisofrandomisedcontrolledtrials; ro
abstracts, leaving 53 articles for detailed review. Twenty-three Ib,evidencefromatleastonerandomisedcontrolledtrial;IIa,evidencefromatleast te
articleswereexcludedafterreviewingthefulltext,leaving30arti- onecontrolledstudywithoutrandomisation;IIb,evidencefromatleastoneothertype cte
cles for inclusion. The hand search identified one additional ofquasi-experimentalstudy;III,evidencefromnon-experimentaldescriptivestudies, d
ianrctilculdeedfo(rseienoclnulsinioens,uplepaldeminegnttaoryafilteotSa6l).of 31 articles finally fasruuoctmhhoaerxsitpiceeosrm,tocproambraomttihvitetLesOetAurd:eip0eo–sr,1tc0soonrrruemolapetiirnoiicnoanlsstruaodtriinecgslinasicncadallec.eaxspee–rcieonnctreolofstruedsipeesc;tIeVd,evidence by co
*Typicalfeaturesincludeusage-relatedpain,shortdurationmorningstiffness,age>40, p
The additional search on the added value of imaging to y
guide intra-articular procedures resulted in 5379 articles sOyAm,potsotmeosaartfhfercittiisn;gUoSn,eulotrraasofneowgrjaopinhtys.. righ
t.
Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815 1485
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3. Joint symptoms are also common and increase with age. different abnormalities detected by different imaging modal- n
n
Symptoms are not always causally related to imaging ities.40515387–101Onlyaminorityofstudiesexaminedthecor- R
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abnormalities. relation between the change in imaging features and symptoms e
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4. Full history and examination is always required before con- or relevant clinical outcomes (table 2) and only four US studies m
sideringtheneedforinvestigations,includingimaging. evaluated the change of imaging after treatment (see online D
5. Ma wodideernrainmgaegionfgsomfotdtiaslsiutiee,sbpornoyvidanedthcearctailpaagbeilpitaythtoolodgeyteicnt supMpolermeoevnetra,rythfierleeSw1e0r)e.1n0o2–1st1u1diescomparingclinicalfollow-up is: firs
OA. However, the increased information provided has not with imaging follow-up or strategies adding imaging to clinical t p
u
yet had any influence on clinical decision-making with management. b
respecttomanagement. The impact of imaging in the management of OA was also lish
specifically addressed by the literature search. Three studies ed
MakingadiagnosisofOA addressed this point. OneRCTevaluating the impact of MRI in as
Recommendation 1: Imaging is not required to make the diag- patients with knee pain assessed in a general practice setting 1
0
nosisinpatientswithtypical[i]presentationofOA. showed that MRI led to an increase in therapeutic confidence .1
1
Levelofevidence:III–IV.LOA(95%CI)8.7(7.9to9.4) but no significant changes in management.112 A cross-sectional 3
6
Although many studies applied imaging for diagnostic pur- study in an orthopaedic setting investigating the impact of CR /a
n
poses, there was a lack of studies in which imaging was applied over management decisions in knee OA showed that CR led to n
in addition to clinical findings to evaluate its additional impact the change in the opinion in 166/400 cases.113 A similar study rhe
on the certainty of diagnosis, which was a predefined criterion evaluating the impact of CR in the assignment of priority for um
d
forinclusion. surgeryinhipOAshowedarelativerisk(95%CI)of1.98(1.23 is
A single study examined the added value of US of hand and to 3.19) for an earlier assignment in patients with more severe -2
0
feet over clinical findings in a cohort of patients with suspected radiographic scores.114 No studies evaluated the impact of 1
6
or confirmed arthritis. When US was added to clinical findings, imagingforthemanagementofhandorfootOAandnostudies -2
the diagnostic confidence in differentiating OA from inflamma- specificallyaddressedtheissueofnon-surgicalmanagement. 10
8
tory arthritis significantly increased.2 Due to the absence of Recommendation 4: If imaging is needed, conventional (plain) 1
5
strong evidence supporting the use of different imaging modal- radiography should be used before other modalities. To make o
n
ities at different anatomical sites, the systematic use of imaging additionaldiagnoses,softtissuesarebestimagedbyUSorMRI 7
in the diagnostic process was not recommended in cases with and bone by CTor MRI. Level of evidence: III–IV. LOA (95% A
p
taynpdicacllincilcinalicaplrepsreensteantitoanti,onim. aHgoinwgevmeri,ghbtasbeed coonnstihdeerejodinwt hsietne CIT)h8e.7p(e7r.f9ortom9an.6c)e of imaging in the detection of OA elemen- ril 20
1
diagnoses other than OA are suspected. This aspect has been tary lesions was addressed by the SLR and highlighted hetero- 7
takenintoaccountinRecommendation2. geneity in the use of imaging modality, lesions considered and . D
o
Recommendation2:Inatypicalpresentations,imagingisrecom- reference standard. In fact, physical examination was frequently w
mended to help confirm the diagnosis of OA and/or make takenintoaccountasreferencestandard,whilesurgerywascon- nlo
alternative or additional diagnoses. Level of evidence: IV. LOA sidered in a minority of studies. Online supplementary file S11 ad
e
(95%CI)9.6(9.1to10) summarises the studies with surgery as the reference stand- d
Studies were eligible for inclusion if they investigated the ard.115–136 As expected, the use of CR was mainly to detect fro
added value of imaging for differential diagnosis over clinical bone and indirectly cartilage loss, MRI was used for bone, car- m
h
evaluation.Amongstudies evaluatingtheapplicationofimaging tilage and soft tissues, with a single study assessing US for the ttp
faodrdidtiioffneroenftiimaladgiinaggnaobsoisv,encolinstiucdalyfienvdailnuagtse.dTthheepiomspsiabclteoafppthlie- evaInluagteionneraolf,cCarRtilwagaes.the imaging modality that was most fre- ://ard
cation if imaging in atypical clinical scenarios was however quently used for diagnostic, prognostic and follow-up purposes. .b
m
recognised by the experts, which included this point in the However, no studies of the cost-effectiveness of each imaging j.c
recommendation. modalityortheirsequencewerefound.Intheabsenceofappro- o
m
priate literature, the experts decided to emphasise the role of o/
Monitoringdisease the most easily available and less costly imaging modality, pro- n
Recommendation 3: Routine imaging in OA follow-up is not posing as second-level investigations techniques that, due to Ja
n
recommended. However, imaging is recommended if there is their characteristics, are more suitable for the detailed assess- u
a
unexpectedrapid progressionofsymptomsorchangeinclinical mentofsofttissues(MRIandUS)orbone(CT). ry
characteristics to determine if this relates to OA severity or an Recommendation 5: Consideration of radiographic views is 18
additional diagnosis. Level of evidence: III–IV. LOA (mean, importantforoptimisingdetectionofOAfeatures;inparticular , 2
95%CI)8.8(7.9to9.7) fortheknee,weightbearingandpatellofemoralviewsarerecom- 02
3
A specific question addressed the use of imaging for the mended.Levelofevidence:III.LOA(95%CI)9.4(8.7to9.9) b
follow-up. The 117 studies (mostly cohort studies) retrieved This topic was addressed by an additional research question, y g
covered all jointsites except the footand all imaging modalities evaluatingtheoptimal combinationofradiographicviews inOA. ue
ienxccleupdteCdTst(usedeieosnlfionceussuepdploemnensetnarsyitifivgituyretoS9)c.hManogset.3o–f86theT8h3e Tinwcelundtye-ds.evIenntshtuisdiceosnctoemxtp,aarlilngstuddififeesreinntvvoilevwinsgfothreknteibeioOfeAmwoerrael st. P
ro
remaining studies investigated the trajectories of changes of compartment considered weightbearing views, both in extension te
elementary lesions detected by imaging when following OA and various degrees of flexion.7 8 10 17 25 118 123 137–147 188–191 cte
natural history or described the parallel changes between Studies comparing fully extended and flexed views in general d b
showed a moderate to good agreement between the two y
projections and similar sensitivity and specificity in detecting co
isTtiyfpfniceasls,faegaetu>re4s0,insycmlupdteomussaagfef-ercetliantgedonpeaoinr,asfheowrtjoidnutrsa.tion morning creafretirleangcee.11d7am13a8ge1,39 c1o4n8si1d4e9rinTghe aflretxherdoscvoiepwics dfienmdoinngstsrateads pyrig
h
t.
1486 Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815
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superiorityindetectingjointspacenarrowing,agreatersensitiv- projections.24143144149Withsurgeryasreferencestandard,the n
n
ity to change and reproducibility compared with extended skyline view had greater sensitivity and specificity to detect car- R
h
views.817140141143144 tilagedamageatthepatellofemoraljoint.150 e
u
Concerning the assessment of the patellofemoral compart- There were five studies assessing the hip. Three studies com- m
ment, skyline views had a greater inter-reader and intra-reader pared weightbearing and supine anteroposterior (AP) views of D
is
reliability and sensitivity to change compared with lateral the pelvis, one of them showing greater average and maximal : firs
t p
u
b
Table2 Studiescorrelatingchangesinimagingfindingswithsymptoms,functionorclinicaloutcome lis
h
e
Study d
a
Study N Site design Imaging Outcome s
1
Fukuietal.,2010103 68 Knee Cohort CR Correlationbetweenradiographicprogression Progressorshadmorepainanddisabilitycomparedwith 0
andpainandfunctionscores non-progressors .1
1
Ecksteinetal.,2014104 189 Knee Case– MRI CartilagelossinpatientsundergoingTKAvs OR(95%CI)forcartilagelossinpatientsundergoingTKAvs 36
control controls controls:1.36(1.08to1.70) /a
n
Kornaatetal.,2007105 182 Knee Cohort MRI CfuhnacntigoeninBMLs/changeinWOMACpainand NdeopseingdniinfigcaonnttdhifefecrheanncegsesinofWBOMMLAsCpainandfunction nrhe
u
Phanetal.,2006106 34 Knee Cohort MRI CartilageandBMLs/WOMAC Nosignificantcorrelationbetweencartilageloss,BMLsand m
WOMACchanges d
is
Zhangetal.,2011107 651 Knee Cohort MRI Changeinpainstatusaccordingtochangein ChangesinBMLsandsynovitisseverity(worseningor -2
BMLsandeffusion/synovitisscore improving)significantlyrelatedtotheriskoffrequentknee 01
pain(p=0.006forworseningBMLsandp=0.045for 6-2
improvingBMLsNosignificantcorrelationwithchangesin 1
effusionseverity 0
8
Haugenetal.,2013108 190 Hand Cohort CR Radiographicprogression/incidenttenderness Jointswithprogressionhadhigheroddsfortenderness,joints 15
withincidentKLG3or4hadhigheroddsfortenderness o
n
7
BMLs,bonemarrowlesions;CR,conventionalradiography;KLG,KellgrenandLawrencegrade;N,numberofparticipants;TKA,totalkneearthroplasty;WOMAC,WesternOntario A
MacMasterUniversitiesArthritisIndex. p
ril 2
0
1
Table3 Summaryofstudiesevaluatingimaginginthepredictionofresponsetotreatment:systemictreatment 7. D
Study o
w
Study N Site design Imaging Outcome n
lo
Gudbergsenetal., 192 Knee RCT CRMRI mJSW,alignmentandMRIscores/pain AmongallradiographicandMRIparameters,onlyeffusion a
d
2012156 reductioninresponsetovery-low-energy scorewassignificantlyrelatedtoareductioninpain e
d
Gudbergsenetal., 30 Knee RCT CRMRI KdiLeGtoarndlowM-ReInsecrgoyred/cihetangeinWOMACpain NosignificantassociationbetweenKLGandMRIscoreand from
2011157 andfunctionduringweightreductionat32 WOMAC h
weeks ttp
HellioleGraverand 1452 Knee RCT CR KLG/structuralprogressioninpatients NosignificantdifferencebetweenKLG2andKLG3intermsof ://a
etal.,201314 treatedwithcindunistatorplaceboat96 progressionofjointspacenarrowinginbothcindunistatand rd
weeks placebogroup .b
m
Caseetal.,2003158 82 Knee RCT CR KdiLcGlofaenndacmvesdipaalrJaScNet/aWmOoMlaAtC1r2eswpoeenksesto PcoamtiepnatrsedwiwthithKL2Gh1a–d2aabnedttneortre3s–p4onasnedtJoSNdicglroafdeena0c–v1sboth j.co
placeboandparacetamol m
Sawitzkeetal.,2008159 375 Knee RCT CR KLG/radiographicprogressionduring ORforradiographicprogressioncomparedwiththeplacebo o/
n
treatmentwithglucosamine,chondroitin groupwas<1inpatientswithKLG2kneesinalltreatment J
sulfateandcelecoxibat24months groups,whereasitwas>1inpatientswithKLG3kneesin an
alltreatmentgroups u
a
Mazzucaetal.,2010160 379 Knee RCT CR Alignment/radiographicprogressionin VaruskneesexhibitedagreaterlossofJSWthannon-varus ry
doxycyclinevsplaceboat30months kneesinpatientsreceivingdoxycycline 18
Knoopetal.,2014164 91 Knee Cohort MRI MRI/changeinWOMACfunctionin Theseverityofthepatellofemoraldamagewassignificantly , 2
0
responsetoexerciseprogrammeat relatedtolessimprovement 2
12weeks 3 b
Wenhametal.,2012168 65 Hand RCT MRI MRI/responsetoprednisolone5mgat Thebaselinenumberofjointswithdefinitesynovitisor y g
12weeks effusiondidnotcorrelatewithOARSIresponse u
e
Lequesneetal.,200284 163 Hip RCT CR JSW/structuralprogressioninpatients InpatientswithsmallerJSWtreatedwithavocadosoybean, s
treatedwithavocadosoybeanat2years thereductionofJSWwashalfthanintheplacebogroup;no t. P
differencesinpatientswithmoreJSW ro
Rozendaaletal., 222 Hip RCT CR KLG/WOMACpainandfunction,JSNin SignificantlybetterWOMACfunctionresponseinpatients tec
2009171 patientstakingglucosamineat2years withKLG1comparedwithKLG2;nodifferencesinWOMAC te
d
painandJSN b
Hoeksmaetal.,2005172 103 Hip RCT CR KLG/HarrisHipscoreandrangeofmotion Betterresponseintermsofrangeofmotioninlower y c
inresponsetomanualtherapyvsexercise comparedwithhigherradiographicgrades o
p
y
CORst,ecooanrtvhernittiisonRaelseraadrciohgSraopchieyt;yJISnNte,rjnoaintitosnpaal;ceRCnTa,rrroawndinogm;iJsSeWd,cojonintrtolslpedacteriwali;dWthO;MKLAGC,,KWelelgstreernnaOnndtaLraiworMenacceMgarsatdeer;UmniJvSeWrs,itmieisniAmrathlrjiotiisntInsdpeaxc.ewidth;N,numberofparticipants;OARSI, righ
t.
Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815 1487
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joint space width detected by the weightbearing view, the some imaging pathologies may have limited clinical signifi- n
n
remaining showing inconsistent results.151–155 Two studies com- cance. Tables 3 and 4 summarise the results of the 28 primary R
h
paringpelvis,hipandobliqueviewsprojectionsintermsofreli- studies in which imaging was applied to predict treatment e
ability and sensitivity to change demonstrated similar reliability response.14 84 156–176 Moreover, an existing SLR was available, um
forviewsdedicatedtothehipandviewsincludingallthepelvis, without a quantitative synthesis.177 The results on the predic- D
wthiethhacnodmapnadrabthleesfeonostitwiveirteyftooucnhda.nge.72 75 No studies assessing ttihoins roefasroenspotnhsee uwseereofmoimstalyginingcofnosristtehnits apcurorpssossetudwieass; nfoort is: firs
recommended. t p
u
b
Roleinprognosis lis
Recommendation 6: According to current evidence, imaging Treatment (imaging-guidedprocedures) h
e
features do not predict non-surgical treatment response and Recommendation 7: The accuracy of intra-articular injection d a
imaging cannot be recommended for this purpose. Level of depends on the joint and on the skills of the practitioner and s
evidence:II–III.LOA(95%CI)8.7(7.5to9.7) imaging may improve accuracy. Imaging is particularly recom- 10
Two specific research questions addressed the role of mended for joints that are difficult to access due to factors .11
3
imaging in prognosis, referring to both the prediction of the including site (eg, hip), degree of deformity and obesity. Level 6
natural history and to the prediction of non-surgical treatment ofevidence:III–IV.LOA(95%CI)9.4(8.9to9.9) /an
n
outcomes. A number of studies addressed the issue of the A search addressing the impact of imaging to guide rh
prognostic value of imaging as predictor of the natural history intra-articular injections was run specifically for OA in the e
u
of OA (see online supplementary figure S12), while only a beginning. Including only studies comparing imaging-guided to m
d
minority of studies, evaluating all joint sites, investigated the blind procedures, four primary studies were found for the knee is
role in predicting treatment response. Due to the heterogen- and one for the hand, and a qualitative SLR for the knee -20
1
eity in populations, interventions, treatment and study design, (table 5). The added value of US was addressed by four studies, 6
a meta-analysis was not possible. In addition, progression of whilefluoroscopicguidancewastestedinasinglestudy.179–183 -2
1
0
8
1
5
Table4 Summaryofstudiesevaluatingimaginginthepredictionofresponsetotreatment:intra-articulartreatment o
n
7
Study A
Study N Site design Imaging Outcome p
Barrettetal.,1990178 248 Knee Cohort CR Radiographicseverity/responseto Patientswithlesssevereradiographicgradehadabetter ril 2
0
intra-articularHAat6months responseintermsofpainatrest,atwalkingandatnight 1
7
Gaffney,1995189 84 Knee RCT CR OAseverity0–3/responsetointra-articular NoassociationbetweenimprovementinVASpainand . D
triamcinolonevsplaceboat3weeks radiographicscore o
w
Tohetal.,2002161 60 Knee Cohort CR Alignment,sclerosis,cysts,osteophytes, PatientswithlateralandmedialJSNhadlessWOMAC n
JSN/WOMACresponsetointra-articularHA responsecomparedwithpatientswithout lo
a
at12weeks d
e
Pendletonetal.,2008176 86 Knee Cohort US US/WOMACresponsetointra-articular HigherbaselineUSscores:significantimprovementsinall d
methylprednisolone WOMACsubscalesat1and6weeks fro
Chaoetal.,2010162 67 Knee RCT US USinflammation/WOMACresponseto Statisticallysignificantimprovementinpainsubscalesamong m
h
Anandacoomarasamy 32 Knee Cohort MRI tCraiarmtilcaigneolvoonleumate/1re2swpoeneskestointra-articular wwNoiitthhcooturhrteeilnaretfmliaomnainmbienattgworepyeantaibebnnatossremlinaelitiMesRIatmUeSaspuaretisenatnsdcoclminpicaarled ttp://a
etal.,2008163 HAat6months response rd.b
Drakonaki,2011190 51 Foot Cohort CRUS Positivetherapeuticresponse Nodifferencesintermsofresponseinpatientsshowing m
(intra-articular.methylprednisolone)at degenerativechangesonlyonUSandthoseshowingchanges j.c
o
12months inbothUSandCR m
Hanetal.,2014165 40 Foot Cohort CR Responsetointra-articularHA(VASpain) Patientswithearlyradiographicstagehadabetterresponse o/
at12months comparedwiththosewithadvancedradiographicstageat3 n J
and6months,butnotat12months a
n
Sunetal.,2011166 46 Foot Cohort CR KLG2and3/AOS,AOFASscoresin NosignificantdifferenceintheAOS,AOFASorclinical u
a
responsetointra-articularHA balancetestscoresbetweenKLG2and3atanytimepoint ry
Mallinsonetal.,2013167 31 Hand Cohort CRUS CRandUS/responsetointra-articular Nosignificantassociationbetweentreatmentresponseand 18
triamcinoloneat6weeks gradeforosteophytes,jointspacenarrowingandcapsule , 2
thickness 0
2
Atchiaetal.,2011169 77 Hip RCT US Synovitis/responsetointra-articular Thepresenceofsynovitissignificantlypredictedtheresponse 3 b
methylprednisoloneat6weeks y
Rennesson-Reyetal., 55 Hip Cohort CRUS EffusionandKLG/OARSIresponsetoHAat PatientswithKLG1–2hadabetter1monthresponse gu
2008170 6months comparedwithgrades3–4;non-differencesat3and es
6months,nodifferencesinpatientswithorwithouteffusion t. P
Deshmukhetal.,2011173 220 Hip Cohort CR KLG/painreliefaftermethylprednisolone PatientswithKLG3–4hadmorefrequentlydelayedrelief ro
injectionsat2weeks comparedwithKLG2 te
c
Robinsonetal.,2007175 120 Hip Cohort CRUS USosteophytesandcapsularthickening, NobaselineUSorradiographicvariablepredictiveofthe te
d
KLG/WOMACresponsetointra-articularCS outcome b
at12weeks y
c
o
AOFAS,AustralianOrthopedicFootandanklesociety;AOS,ankleosteoarthritisscore;CR,conventionalradiography;CS,corticosteroids;HA,hyaluronicacid;JSN,jointspacenarrowing; p
y
KULSG,,ulKtreallsgorneongaranpdhLya;wVrAeSn,cveisguraaldea;naNl,ognuuembscearleo;fWpaOrtMicAipCa,nWtse;sOteAr,noOstnetoaarirothMritaisc;MOaAstReSrI,UOnsivteerosaitritehsriAtisrthRreistiesaIrnchdeSxo.cietyInternational;RCT,randomisedcontrolledtrial; righ
t.
1488 Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815
Recommendation
A
n
Table5 Studiescomparingimaging-guidedtoblindinjectionsinOA n R
h
Study e
u
Study N Site design Imaging Outcome m
BumPark,2012191 99 Knee RCT US AccuracyofHAinjectionvsblindinjection OR(95%CI)foranaccurateinjectionwithUScompared D
Imetal.,2009179 99 Knee RCT US AccuracyofHAinjectionvsblindinjection Awcitchurbaltiendin:j4e.c6t8ion(0s.:9945t.5o%23(.U3S0-)guided)vs77.2%(blind); is: firs
p=0.01 t p
Jangetal.,2013180 126 Knee RCT US AccuracyofUS-guidedinplaininjection, Accuracy:US-guidedinplain95.1%;US-guided ub
US-guidedout-of-planeinjectionsandblind out-of-plain97.7%;blind78% lis
h
injectionoftriamcinolonehexacetonide p<0.05blindvsUS-guidedinjections e
d
Sibbittetal.,2011181 92 Knee RCT US US-guidedvsblindtriamcinoloneintermsof Significantdecreaseinpainonlyinpatientstreatedwith a
painrelief,painrelatedtotheinjection, US-guidedinjection;US-guidedprocedurewasrelatedto s 1
reinjectionrateandcost lowerpainandreinjectionrate,buthighercosts 0
Karalezlietal.,2007182 16 Hand Cohort CR Fluoroscopy-guidedvsblindinjectionsofHAin VASpainrelatedtotheprocedure:fluoroscopicguide:4.1 .11
thetrapezio-metacarpaljointintermsofpain (range3–6),anatomicguide5.6(range3–7);p<0.005 36
relatedtotheinjection Nosignificantdifferenceintermsofsafety /a
n
n
CR,conventionalradiography;HA,hyaluronicacid;N,numberofparticipants;OA,osteoarthritis;RCT,randomisedcontrolledtrial;US,ultrasonography;VAS,visualanaloguescale. rh
e
u
m
Inordertoretrievefurtherinformationonthistopic,anadd- d
itional search was performed (see online supplementary file S1 Table6 Futureresearchagenda is-2
0
for search strategies), including studies comparing blind to 1 Thereisaneedformethodologicallyrobuststudiestoexploretheaddedvalue 1
6
guidedinjectionsinOAandalsoinotherconditions.Thissearch ofimaging(anymodality)toclinicaldiagnosisordifferentialdiagnosis. -2
foundeightstudies,ofwhichthreewerealreadyincludedinthe 2 Whatisthecost-effectivenessofimaginginosteoarthritisclinicalpractice? 10
previousresults(seeonlinesupplementaryfileS13).184–188Most 3 Isimagingabletohelpinidentificationofsubgroups/phenotypesthatmay 81
5
of the studies were focused on the knee, with some studies on havedifferenttrajectoriesandenabletargetedtreatmentbasedonthese o
thehandand thefoot, whilenostudies were foundfor thehip. subgroups? n 7
All the additional studies investigated the impact of US. 4 Thereisaneedtounderstandifusingimagingtomeasureresponsetotherapy A
isofclinicalbenefit.Thismayrequireevaluationofnovelimagingtechnologies p
Awcitchurbalciyndwparsofcoeudnudrest;ohboewbeveettre,rthine rimesaugltisngonguthideedclicnoicmalpaoruetd- thatareabletosensitivelydetectchangeinrelevantjointstructures. ril 2
comes of the injection were less consistent across studies. For 5 Qualitystudiesarerequiredtoexploreimaging(anymodality)featuresthat 01
predictresponsetospecifictherapies. 7
these reasons, the systematic use of imaging to drive injections . D
6 Thereisaneedformoreresearchconcerningthebenefitsofimaginginless
wasnotrecommended,leavingthistooltodriveinjectioninspe- commonlystudiedosteoarthritissitessuchasthefootandshoulder. ow
cific situations, identified by the experts. Although the imaging n
7 Specificallyforhiposteoarthritis,whatistheaddedvalueofweightbearingvs lo
modality is not specified in the recommendation, there is pub- non-weightbearingX-rays? ad
lished evidence for the use of US, and imaging allows for real- e
8 Whatarethebenefitsofimagingguidanceinimprovingtheefficacyof d
timeevaluationofinjectionplacement. treatments? fro
m
Futureresearchagenda http
TbyhethmeoTsatsikmFpoorrcteanbtatsoepdicosntothderi(voeftfeuntucroenrseisdeearracbhlew)egraepsseilnectthede omvaenragcelimniecnatl afinndditnhgesfoinllowm-aukpinogf athedidaigsneaosseis, aonfdOinAco,nisnistethnet ://ard
evidenceandtheneedsarisingfromclinicalpractice(table6). results dealing with the prediction of the outcome of .b
m
non-pharmacological treatments. The absence of good study j.c
DISCUSSION information in these areas did not enable the Task Force to om
AholtwhoutoghusaeniummagbienrgoifnreOcAomcmlinenicdaaltitorniasls,hatvheesbeeeanremthadeefiorsnt raegceonmdamwenadsthsyesrteefmoraeticgeinmeraagtiendgininoradllerthteoseadadrreeasss.thAesreesteoapricchs on/
recommendations on the use of imaging in OA in clinical prac- inthefutureresearch. Ja
n
tice. The development of the recommendations started from In conclusion, seven recommendations covering different u
a
questions of clinical relevance selected by a task force of areas in the routine management of OAwere developed. These ry
experts, with the aim to focus on topics of interest for clinical are based on both available scientific evidence and expert 18
practice rather than research. The literature review identified a opinion to provide a valuable and sensible guide for the use of , 2
large number of studies, covering most joint sites. However, a imaginginclinicalpractice. 02
3
possible limitation of this work isthat we used a search term of b
‘osteoarthritis’ and not ‘pain’, and it is possible we missed Authoraffiliations y g
studiesthat imaged painful sites without specifically mentioning 1DivisionofRheumatology,IRCCSPoliclinicoSanMatteoFoundation,Universityof u
e
OAlAth;otuhgishmCaRywexapslastinilltthheepmauocsittyfroeqfufeonottlypaaipnplsiteudditeeschinnciqluudee,da. 2PLaeveiad,sPIanvsitait,uIttealoyfRheumaticandMusculoskeletalMedicine,UniversityofLeedsand st. P
NationalInstituteofHealthResearchLeedsMusculoskeletalBiomedicalResearch ro
substantial numberof studies focused onmodern imaging, MRI Unit,Leeds,UK te
andUSinparticular. 3AcademicRheumatology,ClinicalSciencesBuilding,UniversityofNottingham, cte
However, despite the amount of data available in the litera- NottinghamCityHospital,Nottingham,UK d
ture, onlya small part of this information was relevant forclin- 4DepartmentofRheumatology&ClinicalImmunology,UniversityMedicalCenter by
Utrecht,Utrecht,TheNetherlands c
siicntravaletsetpgigricaactitsoitcuned.iweFesoreirnivdtehesitnsitgiafirteeinadsg.oIntnh,epmaaradtnidcyiutliaoarrn,eaatlhsevraneleuewedaionsfgaimflaucarkgthinoegrf 56FDAraePnpHcaePr,tmHôenptitaolfARmheburomisaetoPloagréy,,SDeiarvkiocenhdjeemRmhuemtHatooslpoigtaiel,,OBosluol,ogNnoer-wBailylancourt, opyrig
h
t.
Sakellariou G, et al. Ann Rheum Dis 2017;76:1484–1494. doi:10.1136/annrheumdis-2016-210815 1489
Recommendation
A
7INSERMU1173,Laboratoired’ExcellenceINFLAMEX,UniversitéParisOuest- controls:amulticentrestudyusing3.0TeslaMRIandLyon-Schussradiography. nn
VersaillesSt.-Quentin,SaintQuentinenYvelines,France AnnRheumDis2010;69:155–62. R
82ndInternalMedicineDepartment,“IuliuHațieganu”UniversityofMedicineand 14 HellioleGraverandMP,ClemmerRS,RediferP,etal.A2-yearrandomised, h
e
Pharmacy,Cluj-Napoca,Romania double-blind,placebo-controlled,multicentrestudyoforalselectiveiNOSinhibitor, u
9DepartmentofRheumatology,LeidenUniversityMedicalCenter(LUMC),Leiden, cindunistat(SD-6010),inpatientswithsymptomaticosteoarthritisoftheknee. m
TheNetherlands AnnRheumDis2013;72:187–95. D
D1101uDDseesppelaadrrottmmrf,eennDttuoossffeDRldhiaoegrufn,moGastetiorcmloaagnnyd,yHInotesprviteanltiGoennaelrRaaldUionliovegrys,itMareiodiGcarelgFoacriuoltMy,aUranñivóenrs,ity 15 MpanlaattezezraouupcaoasnStedAr,ixoB-rrrakaynnebdeetaKrmaDd,iooDngireaappppphea.rPAeAnrt,thepritrtoiasgl.rReEhsfesfiueocmntoo2ff0oa0ls1itg;e4no4ma:r1etn7htr8it6ois–f9tinh4e.thmeesdtiaanldtiibnigal is: first p
Madrid,Spain 16 PavelkaK,ForejtováS,OlejarováM,etal.Hyaluronicacidlevelsmayhave u
U12KResearchInstituteforPrimaryCareandHealthSciences,KeeleUniversity,Keele, p2r0e0d4ic;t1iv2e:2v7a7lu–e83fo.rtheprogressionofkneeosteoarthritis.OsteoarthritisCartilage blish
13RheumatologyUnit,DipartimentodiScienzeClinicheeBIologiche,Universitàdegli 17 VignonE,PipernoM,LeGraverandMPH,etal.Measurementofradiographicjoint ed
StudidiTorino,Turin,Italy spacewidthinthetibiofemoralcompartmentoftheosteoarthriticknee: a
comparisonofstandinganteroposteriorandLyonschussviews.ArthritisRheum s 1
Acknowledgements TheauthorsthankMrsJaquelineMäderforparticipatingto 2003;48:378–84. 0
thedevelopmentoftherecommendations. 18 WirthW,DuryeaJ,HellioLeGraverandMP,etal.Directcomparisonoffixed .1
1
flexion,radiographyandMRIinkneeosteoarthritis:responsivenessdatafromthe 3
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19 BoegårdTL,RudlingO,PeterssonIF,etal.DistributionofMR-detectedcartilage n
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Funding TheauthorswouldliketothankEULARforfinancialsupportforthis 20 MazzucaSA,BrandtKD,BuckwalterKA,etal.Pitfallsintheaccurate um
work.PGCissupportedinpartbytheNationalInstituteforHealthResearch(NIHR) measurementofjointspacenarrowinginsemiflexed,anteroposteriorradiographic d
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Competinginterests None. 22 BruyèreO,HenrotinYE,HonoréA,etal.Impactofthejointspacewidth 10
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