Ultrasound detects synovitis in replaced and other surgically operated joints in rheumatoid arthritis patients

Evan A Choate, Gurjit S Kaeley, Jenny Brook, Roy D Altman, John D FitzGerald, Astrid R Floegel-Shetty, David A Elashoff, Veena K Ranganath, Evan A Choate, Gurjit S Kaeley, Jenny Brook, Roy D Altman, John D FitzGerald, Astrid R Floegel-Shetty, David A Elashoff, Veena K Ranganath

Abstract

Background: Joint replacements continue to occur during a rheumatoid arthritis (RA) patient's lifetime despite significant advances in available treatment options. The purpose of this study was to examine and quantify synovitis in surgically operated joints by ultrasound (US) in RA patients starting a new therapeutic agent.

Methods: RA subjects were enrolled in either tocilizumab or tofacitinib open-label, investigator-initiated trials and were assessed by ultrasound. In a subset of RA patients with joint replacements and/or operations of joint areas (OJA; e.g. joint arthroscopies, fusions, and synovectomies), joint-level scores of synovitis were compared between replaced joints, OJAs, and native joints. Joint-level synovitis was measured by grayscale (GSUS (0-3)) and power Doppler (PDUS (0-3)) at baseline and follow-up (3-6 months). McNemar's test or Wilcoxon signed rank test utilized the mixed effects ordinal logistic regression models.

Results: Twenty RA patients had a total of 25 replaced joints and 24 OJA. All replaced joints had GSUS> 1 and 92% had PDUS> 1 at baseline, while OJA and native joints had lower evidence of GSUS> 1 (37.5, 38% respectively) and PDUS> 1 (45.8, 62% respectively). GSUS and PDUS semiquantitative scores improved significantly with treatment in replaced joints (p = 0.01, p = 0.007), and native joints (p < 0.001 both), but not OJA.

Conclusions: In RA, joint replacement does not eliminate or prevent ultrasound measured synovitis, where all replaced joints have some evidence of US synovitis. US can also act as a potential marker of response to therapy in replaced joints. Scoring US synovitis in replaced joints should be considered in ultrasound RA clinical trials.

Trial registration: ClinicalTrials.gov NCT01717859 (registered 10/31/2012); ClinicalTrials.gov NCT02321930 (registered 12/22/2014).

Keywords: Arthritis, rheumatoid; Joints; Response; Surgical procedures operative; Synovitis; Ultrasonography.

Conflict of interest statement

Competing interestsEAC: none reported; GSK: none reported; JB: none reported; RDA serves as a consultant for Ferring, Flexion, GSK, Novartis, Olatec, and Pfizer; JF: none reported; ARFS: none reported; DAE: none reported; VKR has received research support and grants from Genentech (IST grant), Pfizer (IST grant), Mallinkrodt (IST grant), BMS (ad board), and Amgen (DSMB).

© The Author(s) 2020.

Figures

Fig. 1
Fig. 1
Synovitis detectable by ultrasound of the lateral knee. Left column, Power Doppler ultrasound (PDUS) and grayscale ultrasound (GSUS) of replaced joint, Grade 3 (severe synovitis). Middle column, PDUS and GSUS of native joint, Grade 0 (no synovitis). Right column, PDUS and GSUS of native joint, Grade 3 (severe synovitis). Yellow star indicates the location of the prosthesis
Fig. 2
Fig. 2
Mean synovitis scores for replaced joints, operated joint areas (OJA), and native joints. From baseline to final visit (N = 16 patients). Panel (a) measures the change in mean Power Doppler ultrasound (PDUS) scores over time. Panel (b) depicts the change in mean grayscale ultrasound (GSUS) scores over time. Legend: replaced joints (••■••), OJA (—▲—), and native joints (—●—)

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