Ultrasonographic and clinical assessment of peripheral enthesitis

in Indian spondyloarthritis patients

Dr Saumya Ranjan Tripathy Senior Resident, Department of Rheumatology

KGMU, Lucknow

Disclosures

• No disclosures

Background • Enthesitis is hypothesized to be the primary manifestation of

spondyloarthritis1

• Ultrasonography (USG) is an emerging tool to detect enthesitis

• Data on prevalence of enthesitis detected by USG in spondyloarthritis from India is lacking

1. Danda D, Shyam Kumar NK, Cherian R, Cherian AM. Enthesopathy: clinical recognition and significance. Natl Med J India.2001;14(2):90-92.

AIMS AND OBJECTIVES

1. Determine the prevalence of enthesitis in spondyloarthritis patients clinically and using ultrasonography

2. Correlate ultrasonographically detected enthesitis and clinical enthesitis (MASES enthesitis score)

3. Correlate ultrasonographically detected enthesitis with various disease activity scores

Methods

Inclusion criteria:• Patients satisfying ASAS

criteria for axial and/or peripheral spondyloarthritis

• Age 16-45 years

Exclusion criteria:• Trauma involving entheseal

sites• Diabetes mellitus• Previous surgery involving

knee or ankle• Corticosteroid injections at

the sites under evaluation in the last 6 weeks

• Peripheral neuropathy of lower limbs

Methods

B-mode settings used• Dynamic range (40-50dB)• Gray Scale frequency

(10-13 MHz)• Gray Scale gain (50-80 dB)

PD mode settings used: • Pulsed repetition frequency

(400-800 Hz) • PD-gain (highest possible

gain with minimum background noise)

Sonography with multi-frequency linear-array transducer (8-13MHz) of Logiq E; GE Medical Systems Ultrasound machine.

Methods The following entheseal sites were screened bilaterally:

1. Plantar fascia insertion on calcaneus 2. Achilles tendon insertion on calcaneus3. Quadriceps tendon insertion on superior pole of patella4. Patellar tendon origin from inferior pole of patella5. Patellar tendon insertion on tibia

Methods • USG parameters evaluated (Terslev et al, 2014 OMERACT

definitions):Sl. no. Parameter Presence Absent

1 Erosion 1 0

2 Increased thickness 1 0

3 Hypoechogenicity 1 0

4 Intra-tendinous calcification 1 0

5 Enthesophyte 1 0

6 Power Doppler signals (grade) 1-3(as per Kiris et al ,

2006)

0

USG SCORE TOTAL

PD SCORE ∑ (power Doppler grades @ all sites)

Methods • Clinical evaluation of peripheral enthesitis using MASES

(Maastricht Ankylosing Spondylitis Enthesitis Score)

• Prevalence of clinical and USG- detected enthesitis was estimated and compared

• Spearman’s correlation co-efficient was used to co-relate clinically and USG- detected enthesitis with MASES score, BASDAI, BASFI and ASDAS-ESR.

Results

• Fifty-two spondyloarthritis patients were recruited

Distribution of patients

Ankylosing Spondylitis (n=37)

Psoriatic arthritis (n=11)

Reactive arthritis (n=2)

IBD associated arthritis (n=2)

Results

0204060

Comparison between enthesitis detected clinically & by USG

Number of patients

94 %

69 %P <0.01

Representative USG images

Increased thickness and hypoechogenicity @ Achilles tendon

Erosion @ Achilles tendon in longitudinal and transverse planes

Intratendinous calcification and enthesophyte@ Achilles tendon

INTRA TENDINOUS CALCIFICATION

Representative USG images(POWER DOPPLER)

@ Achilles insertion Calcaneal insertion of Plantar fascia

@ Distal insertion of patellar tendon

on tibia

@ Proximal origin of patellar tendon from patella

@ Quadriceps tendon insertionon patella

Frequency of USG findings

Erosion

Increase

d thick

ness

Hypoech

ogenici

ty

Enthesophyte

IT calci

fication

Power doppler s

ignal

0

20

40

60

80

100

Total number of sites screened : 520 (52 patients X 10 sites each)

number of sites

28

92

65

2811

79

Frequency of entheseal sites involved

Achille

s

Plantar

fasci

a

Quadric

eps

Patella

r tendon orig

in

Patella

r tendon in

sertion0

1020304050607080

Number of en-theseal sites

71

28 2834

25

Correlation of USG scores and PD scores with MASES and disease activity indices

Correlation of USG score with BASDAI

0 5 10 15 200

2

4

6

8

10 r=-0.007p=0.96

USG Score

BAS

DAI

Correlation of USG score with BASFI

0

20

40

60

80 r=0.11,p=0.42

USG Score

BAS

FI

Correlation of USG score with ASDAS ESR

0

2

4

6 r=0.12,p=0.4

USG Score

ASD

AS E

SR

Correlation of USG score with MASES

0

5

10

15 r=0.14,p=0.29

USG Score

MAS

ES

Correlation of PD score with MASES

0

5

10

15 r=0.27,p=0.048

PD SCORE

MSA

ES

Correlation of PD score with ASDAS ESR

0

2

4

6 r=0.18,p=0.19

PD SCORE

ASD

AS E

SR

Correlation of PD score with BASFI

0

20

40

60

80 r=0.18,p=0.18

PD SCORE

BAS

FI

Correlation of PD score with BASDAI

0

2

4

6

8

10r=0.14,p=0.29

PD SCORE

BAS

DAI

USG-score and PD-score did not correlate with BASDAI, BASFI or ASDAS-ESR.

Other important observations • PD-signals were positive in 69.2 % of Spondyloarthritis patients – Including 27 sites without any other clinical or USG finding

• One patient with clinical enthesitis did not have USG findings including power Doppler signals

Discussion This observational study highlights

• The presence of subclinical enthesitis which may have future therapeutic implications

• Detection of subclinical enthesitis will help in diagnosis of spondyloarthritis

• However the study is limited by its small sample size

• Lack of correlation with activity indices needs further analysis

Conclusion

• Ultrasonography including Power Doppler is better than clinical examination for detection of enthesitis

Thank you