Impact of sex, age, body mass index and handedness on finger joint space width in patients with prolonged rheumatoid arthritis using computer-aided joint space analysis

The chondrogenic potential of the bovine tendon sheath-a novel source of stem cells for cartilage repair

The human hand is traumatized more frequently than any other bodily part. Trauma and pathological processes (eg, rheumatoid arthritis, osteoarthritis) commonly implicate the finger joints and specifically damage also the layer of articular cartilage. Endeavors are now being made to surgically repair such cartilage lesions biologically using tissue-engineering approaches that draw on donor cells and/or donor tissues. The tendon sheaths, particularly their inner layers, that is, the peritendineum, surround the numerous tendons in the hand. The peritendineum is composed of mesenchymal tissue. We hypothesize that this tissue harbors pluripotent mesenchymal stem cells and thus could be used for cartilage repair, irrespective of the donor's age. Using a bovine model (young calves vs adult cows), the pluripotentiality of the peritendineal stem cells, namely, their osteogenicity, chondrogenicity, and adipogenicity, was investigated by implementing conventional techniques. Subsequently, the chondrogenic potential of the peritendineal tissue itself was analyzed. Its differentiation into cartilage was induced by the application of specific growth factors (members of the TGF-β-superfamily). The characteristics of the tissue formed were evaluated structurally (immuno) histochemically, histomorphometrically, and biochemically (gene expression and protein level). Our data confirm that the bovine peritendineum contains stem cells whose pluripotentiality is independent of donor age. This tissue could also be induced to differentiate into cartilage, likewise, irrespective of the donor's age. Preliminary investigations with adult human peritendineal biopsy material derived from the hand's peritendineal flexor tendon sheaths revealed that this tissue can also be induced to differentiate into cartilage.

Evaluating high-resolution computed tomography derived 3-D joint space metrics of the metacarpophalangeal joints between rheumatoid arthritis and age- and sex-matched control participants

Introduction

Rheumatoid arthritis (RA) is commonly characterized by joint space narrowing. High-resolution peripheral quantitative computed tomography (HR-pQCT) provides unparalleled in vivo visualization and quantification of joint space in extremity joints commonly affected by RA, such as the 2nd and 3rd metacarpophalangeal joints. However, age, sex, and obesity can also influence joint space narrowing. Thus, this study aimed to determine whether HR-pQCT joint space metrics could distinguish between RA patients and controls, and determine the effects of age, sex and body mass index (BMI) on these joint space metrics.

Methods

HR-pQCT joint space metrics (volume, width, standard deviation of width, maximum/minimum width, and asymmetry) were acquired from RA patients and age-and sex-matched healthy control participants 2nd and 3rd MCP joints. Joint health and functionality were assessed with ultrasound (i.e., effusion and inflammation), hand function tests, and questionnaires.

Results

HR-pQCT-derived 3D joint space metrics were not significantly different between RA and control groups (p > 0.05), despite significant differences in inflammation and joint function (p < 0.05). Joint space volume, mean joint space width (JSW), maximum JSW, minimum JSW were larger in males than females (p < 0.05), while maximum JSW decreased with age. No significant association between joint space metrics and BMI were found.

Conclusion

HR-pQCT did not detect group level differences between RA and age-and sex-matched controls. Further research is necessary to determine whether this is due to a true lack of group level differences due to well-controlled RA, or the inability of HR-pQCT to detect a difference.

Fully automated joint space width measurement and digital X-ray radiogrammetry in early RA

Objectives

To study fully automated digital joint space width (JSW) and bone mineral density (BMD) in relation to a conventional radiographic scoring method in early rheumatoid arthritis (eRA).

Methods

Radiographs scored by the modified Sharp van der Heijde score (SHS) in patients with eRA were acquired from the SWEdish FarmacOTherapy study. Fully automated JSW measurements of bilateral metacarpals 2, 3 and 4 were compared with the joint space narrowing (JSN) score in SHS. Multilevel mixed model statistics were applied to calculate the significance of the association between ΔJSW and ΔBMD over 1 year, and the JSW differences between damaged and undamaged joints as evaluated by the JSN.

Results

Based on 576 joints of 96 patients with eRA, a significant reduction from baseline to 1 year was observed in the JSW from 1.69 (±0.19) mm to 1.66 (±0.19) mm (p<0.01), and BMD from 0.583 (±0.068) g/cm² to 0.566 (±0.074) g/cm² (p<0.01). A significant positive association was observed between ΔJSW and ΔBMD over 1 year (p<0.0001). On an individual joint level, JSWs of undamaged (JSN=0) joints were wider than damaged (JSN>0) joints: 1.68 mm (95% CI 1.70 to 1.67) vs 1.54 mm (95% CI 1.63 to 1.46). Similarly the unadjusted multilevel model showed significant differences in JSW between undamaged (1.68 mm (95% CI 1.72 to 1.64)) and damaged joints (1.63 mm (95% CI 1.68 to 1.58)) (p=0.0048). This difference remained significant in the adjusted model: 1.66 mm (95% CI 1.70 to 1.61) vs 1.62 mm (95% CI 1.68 to 1.56) (p=0.042).

Conclusions

To measure the JSW with this fully automated digital tool may be useful as a quick and observer-independent application for evaluating cartilage damage in eRA.

Trial registration number

NCT00764725.

Semi-Automated Quantification of Finger Joint Space Narrowing Using Tomosynthesis in Patients with Rheumatoid Arthritis

The purpose of the study is to validate the semi-automated method using tomosynthesis images for the assessment of finger joint space narrowing (JSN) in patients with rheumatoid arthritis (RA), by using the semi-quantitative scoring method as the reference standard. Twenty patients (14 females and 6 males) with RA were included in this retrospective study. All patients underwent radiography and tomosynthesis of the bilateral hand and wrist. Two rheumatologists and a radiologist independently scored JSN with two modalities according to the Sharp/van der Heijde score. Two observers independently measured joint space width on tomosynthesis images using an in-house semi-automated method. More joints with JSN were revealed with tomosynthesis score (243 joints) and the semi-automated method (215 joints) than with radiography (120 joints), and the associations between tomosynthesis scores and radiography scores were demonstrated (P < 0.001). There was significant, negative correlation between measured joint space width and tomosynthesis scores with r = -0.606 (P < 0.001) in metacarpophalangeal joints and r = -0.518 (P < 0.001) in proximal interphalangeal joints. Inter-observer and intra-observer agreement of the semi-automated method using tomosynthesis images was in almost perfect agreement with intra-class correlation coefficient (ICC) values of 0.964 and 0.963, respectively. The semi-automated method using tomosynthesis images provided sensitive, quantitative, and reproducible measurement of finger joint space in patients with RA.

Relationship between handedness and joint involvement in rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by autoimmune chronic joint inflammation, which is worsened by mechanical stress. It is still inconclusive whether joints on the right side or the dominant side get more damaged in RA since the limited number of patients analyzed in the previous study had made it difficult to separately analyze right-handed and left-handed patients. Here, we enrolled 334 RA patients, the biggest number of patients in studies to address this issue and separately analyzed right-handed and left-handed patients. As a result, we observed that joints on the dominant side got clinically and radiologically more involved in the right-handed patients (p ≤ 0.0030). Importantly, this tendency was also seen in the left-handed patients, while it was not statistically significant due to the small sample size. This tendency was observed in each component of clinical or radiological involvement. Thus, handedness influences the laterality of clinical and radiological joint involvement in RA.

Performance of computer-based analysis using temporal subtraction to assess joint space narrowing progression in rheumatoid patients

Our computer-based method can detect the chronological change in joint space width between baseline and follow-up images as the joint space difference index (JSDI). The aim of this study was to verify the sensitivity and specificity of our computer-based method in assessment of joint space narrowing progression in rheumatoid patients. Twenty-seven patients (24 women and 3 men) with rheumatoid arthritis underwent radiography of the bilateral hand at baseline and at 1 year. The joint space narrowing (JSN) of a total of 252 metacarpophalangeal (MCP) joints and 229 carpal joints was assessed by our computer-based method, setting the Sharp/van der Heijde method as the gold standard. We constructed a receiver operating characteristic curve by using the Sharp/van der Heijde method as the gold standard and set the optimal cutoff on JSDI for MCP, carpal, and MCP/carpal joints. We then calculated the sensitivity and specificity for each cutoff in assessment of JSN progression. At the most discriminant cutoff, the sensitivity and specificity of the computer-based method for MCP joints was 78.6 versus 85.3 %, respectively (AUC = 0.837; P < 0.001). Carpal joints revealed a lower sensitivity and specificity with 64.7 and 86.8 % (AUC = 0.775; P < 0.001). Furthermore, the sensitivity and specificity for MCP/carpal joints was 71.0 versus 83.6 %, respectively (AUC = 0.778; P < 0.001). The computer-based method presented a reliable assessment of JSN progression with high sensitivity and specificity and may be useful in follow-up assessment of the joint damage in rheumatoid patients.

Joint damage in rheumatoid arthritis: assessment of a new scoring method

INTRODUCTION

The aim of this study was to assess a novel approach for the quantification of finger joint space narrowing and joint destruction in patients with rheumatoid arthritis (RA) focusing on the peripheral hand articulations.

METHODS

A total of 280 patients with verified RA underwent computerized semi-automated measurements of joint space distance at the finger articulations based on radiographs. The Z-Score, which can differentiate between joint space alterations caused by RA versus age/gender-related changes, was calculated as a comparative parameter. The severity of joint space narrowing was also quantified by the Sharp Score. Sensitivity and specificity of the Z-Score (based on joint space widths differentiated for each peripheral finger joint) were evaluated to reveal the potential for the occurrence of erosions. Additionally, the potential of the Z-Score regarding the differentiation of therapeutic effects on joint space widths in patients under a therapy of methotrexate versus leflunomide was performed.

RESULTS

The Z-Scores of finger articulations in patients with RA were generally decreased. Metacarpal-phalangeal (MCP) joint articulations showed a continuous significant decline of -1.65±0.30 standard deviations dependent on the Sharp Score. The proximal-interphalangeal joints also revealed a significant reduction of the Z-Score (-0.96±0.31 standard deviations). The sensitivity and specificity of MCP joint space distance for the detection of erosions were 85.4% versus 55.2%. The Sharp Score for joint space narrowing was not able to detect different treatments, whereas an accentuated stabilization of joint space narrowing could be identified for the Z-Score of the MCP joints in patients treated with leflunomide and methotrexate.

CONCLUSION

The Z-Scoring method based on computer-aided analysis of joint space widths was able to reliably quantify severity-dependent joint space narrowing in RA patients. In the future, calculation of a Z-Score based on gender-specific and age-specific reference data shows the potential for a surrogate marker of RA progression that comprehends the early identification of patients with RA, and in particular those with erosive course of the disease, enabling a timely therapeutic strategy for cartilage protection.

Validity of joint space width measurements in hand osteoarthritis

OBJECTIVE

To investigate the validity of joint space width (JSW) measurements in millimeters (mm) in hand osteoarthritis (OA) patients by comparison to controls, grading of joint space narrowing (JSN), and clinical features.

METHODS

Hand radiographs of 235 hand OA patients (mean age 65 years, 83% women) and 471 controls were used. JSW was measured with semi-automated image analysis software in the distal, proximal interphalangeal and metacarpal joints (DIPJs, PIPJs and MCPJs). JSN (grade 0-3) was assessed using the osteoarthritis research society international (OARSI) atlas. Associations between the two methods and clinical determinants (presence of pain, nodes and/or erosions, decreased mobility) were assessed using Generalized Estimating Equations with adjustments for age, sex, body mass index (BMI) and mean width of proximal phalanx.

RESULTS

JSW was measured in 5631 joints with a mean JSW of 0.98 mm (standard deviation (SD) 0.21), being the smallest for DIPJs (0.70 (SD 0.25)) and largest for MCPJs (1.40 (SD 0.25)). The JSN=0 group had a mean JSW of 1.28 mm (SD 0.34), the JSN=3 group 0.17 mm (SD 0.23). Controls had larger JSW than hand OA patients (P-value<0.001). In hand OA, females had smaller JSW than men (β -0.08, (95% confidence interval (95% CI) -0.15 to -0.01)) and lower JSW was associated with the presence of pain, nodes, erosions and decreased mobility (adjusted β -0.21 (95% CI -0.27, -0.16), -0.37 (-0.40, -0.34), -0.61 (-0.68, -0.54) and -0.46 (-0.68, -0.24) respectively). These associations were similar for JSN in grades.

CONCLUSION

In hand OA the quantitative JSW measurement is a valid method to measure joint space and shows a good relation with clinical features.

Feasibility study of semi-automated measurements of finger joint space widths

The purpose of this study is to evaluate technical feasibility based on image capturing conditions (film-focus distance (FFD), film sensitivity, film brand, exposure level and tube voltage) that potentially alter radiographs and consequently may influence the semi-automated measurement of joint space distance (JSD) by computer-aided joint space analysis (CAJSA) in rheumatoid arthritis and osteoarthritis. The radiographs of a left hand (deceased man) were acquired under systematically changing image capturing conditions (exposure level: 4-8 mAs; FFD: 90-130 cm; film sensitivity: 200/400 and tube voltage: 40-52 kV with different image modalities: conventional radiographs, original digital radiographs, digital print-outs). All JSD-measurements were performed with the CAJSA-technology (Radiogrammetry Kit, Version 1.3.6; Sectra; Sweden) at the metacarpal-phalangeal articulation. JSD-analysis was not influenced by changes of FFD, exposure level, film sensitivity or film brand. JSD showed significant variation caused by tube voltage (conventional: CV = 1.913% for Agfa and CV = 2.448% for Kodak; digital: CV = 0.741% for Philips print-outs and CV = 0.620% with original digital images versus CV = 2.185% for Siemens print-outs and 0.951% with original digital images). Computer-aided joint space analysis for JSD-measurements is unaffected by the following image capturing parameters: film-focus distance, film sensitivity, film brand and exposure level. An influence of tube voltage was detected in a lesser extent for original digital images compared to the printed digital as well as conventional versions. Consequently, a standardized tube voltage is essential for accurate reproductions of CAJSA-measurements in rheumatoid arthritis and osteoarthritis.

Prevalence and risk factors of vertebral fractures in women with rheumatoid arthritis using vertebral fracture assessment

OBJECTIVE

To study the prevalence and risk factors of vertebral fractures (VFs) in a large cohort of patients with RA using VF assessment (VFA).

METHODS

We enrolled 172 women with RA, none of whom were taking osteoporosis medications. Patients underwent dual X-ray absorptiometry at the hip and spine and VFA, and completed a questionnaire. Radiological status was assessed by the modified Sharp erosion and narrowing score. VFA was classified using a combination of Genant semi-quantitative approach and morphometry.

RESULTS

Patients had a mean (s.d.) disease duration of 8.4 (5.2) years. VFs were detected in 36% (62/172). This group of women had a statistically significant lower weight, height and lumbar spine and total hip BMD and T-scores than those without a VFA-identified VF. They also had more long-standing and severe disease and a greater consumption of corticosteroids. Stepwise regression analysis showed that the presence of VFs was independently associated with low weight and total hip T-score and long disease duration, CRP and Sharp erosion score.

CONCLUSION

RA is a risk factor on its own for the development of osteoporosis and VFs and this risk increases more with low weight, disease duration and severe course of disease. These findings may suggest that to prevent the development of VFs, precautions should be taken immediately to suppress the disease activity and correct the weight loss in patients with RA.