Development of a standardized method of assessment of radiographs and radiographic change in juvenile idiopathic arthritis: Introduction of the Dijkstra composite score

Abstract

Objective. To evaluate the sensitivity to change of a newly developed radiologic assessment tool, the Dijkstra score, and to develop a numeric composite score and progressor classification scheme to apply in juvenile idiopathic arthritis (JIA) trials.Methods. A placebo-controlled trial of sulfasalazine (SSZ) in patients with oligoarticular-and polyarticular-onset JIA yielded the data for this study. Data were obtained from 418 sets of radiographs of the clinically involved and contralateral joints (at study entry and at 6 months' followup) from 66 JIA patients. The Dijkstra score assesses the presence or absence of swelling, osteopenia, joint space narrowing, growth abnormalities, subchondral bone cysts, erosions, and malalignment. These signs were combined in the Dijkstra composite score, to assess inflammation (DI), growth (DG), and damage (DD). Progression was defined as an increase in either the DG or the DD score. Scores were evaluated among all radiographs, a standard set of films (hand, foot, and knee), and per patient. All scores were used to explore differences between the 2 treatment groups.Results. Over time, 58% of joints remained normal, 23% remained abnormal but stable, 14% showed an increase in signs, and 5% showed a decrease in signs. Of the 66 JIA patients, 12% had normal radiographic findings throughout followup, 27% showed abnormalities at some sites without change, and 61% showed change in at least 1 site. Changes in the DI, DG, and DD scores varied considerably per type of joint and occurred most frequently in joints of the standard set. DI and DG scores changed most often in the knees, while DD scores changed primarily in the hands and feet. The disease course in 8% of joints was classified as progressive. Films of SSZ-treated patients, versus the placebo group, showed less deterioration by the DD scores (P ‫؍‬ 0.04), and the disease course was more often classified as nonprogressive in the SSZ group (P ‫؍‬ 0.037). When progressors were defined as those who had at least one 1 Marion A. J. van Rossum, MD: Emma Children's Hospital AMC and Jan van Breemen Instituut,

Use of the sharp and larsen scoring methods in the assessment of radiographic progression in juvenile idiopathic arthritis

“…* The letters A through F correspond to the specific radiographs in Figure 4. Little information exists on the use of standardized scoring systems of joint radiographs in JIA (5)(6)(7)(8)(9)(10)(11). Recent studies have shown that the Poznanski method is a reliable and sensitive instrument for assessing radiographic progression in clinical and research settings and in therapeutic trials (6,7,9).…”

“…A number of scoring systems are available to quantify radiographic changes in adults with rheumatoid arthritis (3,4). However, little information exists on standardized measurement of radiographic damage in the investigation of disease outcome in children with juvenile idiopathic arthritis (JIA) (5)(6)(7)(8)(9)(10)(11). Furthermore, the assessment of radiographic progression has never been included in controlled trials of second-line agents in JIA.…”

EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice

“…Other studies describing radiological features of JIA found most CR changes in the hands (57%), knees (47%), ankles (27%) and feet (36%), with erosions mainly in hands (18%) and feet (25%) 56. The hands and feet were the area most likely to show CR damage progression at 6 months and 5 years 57 58…”

Choosing Wisely: The American College of Rheumatology's Top 5 for Pediatric Rheumatology

“…Radiation exposure is a potential risk. In the absence of data to support clear benefit, radiographs should be obtained by the pediatric rheumatologist only when history and physical examination raise clinical concern about joint damage or decline in function (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35).…”