Inter- and intra-observer reliability of arthroscopic quantification of chondropathy in horses with

Transkript

1 Inter- and intra-observer reliability of arthroscopic quantification of chondropathy in horses with osteochondral fragments in the tibiotarsal joint using different scoring systems. Jon Vedding Nielsen Dyrlæge

2 Årsag til studie Artroskopi hyppigt indgreb Diagnostisk ved haltheder Terapeutisk ved ekstirpation af fragmenter Salgsvurdering/forsikringsvurdering Utilstrækkeligt scoringssystem Kategorisk Kun dybde ikke størrelse og placering Ingen etablering og validering af scoringsystemer equint (dog Brommer et al men ikke ved OCD)

3 Ultimative scoring system Dybde, størrelse og lokalisation af brusk defekt Synovium, intra-artikulære ligamenter, menisk Høj intra- og inter-observatør korrelation Påvise forandringer over tid Anvendelig ved OCD læsioner

4 Scorings systemer Equin Grad I-IV Beguin and Locker SFA Grading System valideret (Brommer 2004) Human SFA Grading System SFA Scoring System Overall assessment of chondropathy (VAS - Visual Analogue Scale) Overall assessment of degeneration (VAS) ACR Scoring System

5 Scorings systemer Grad I-IV Beguin and Locker Grad I: Blødt og hævet brusk med intakt overflade Grad II: Overfladiske fissurer Grad III: Dybe fissurer ned til subkondral knogle eller erosioner uden eksponeret knogle Grad IV:Erosioner ned til subkondral knogle SFA Grading System (Société Francaise d Arthroscopie) SFA grad 0: 100%. SFA grad IV: Grad IV 1% og grad 0<65% (Beguin and Locker) Obs. ikke anvendelig ved OCD, da disse kan falde uden for kategori

6 Scoring Systems Overall assessment of chondropathy VAS - Visual Analogue Scale 0-100, 0 ingen chondropati 100 mest udpræget chondropati Gennemsnit af VAS for hver ledflade Distal dorsolateral tibia Lateral trochlea Intermediærkam Medial trochlea Medial malleoli Overall assessment of degeneration Dannelsen af osteofytter indgår

7 Scoring systemer SFA scoring system Graderne I-IV (Beguin and Locker) vurderes i % af total ledflade og SFA scoren beregnes: SFA score = A+B+C+D, hvor A = størrelse (%) af grad I x 0,14 B = størrelse (%) af grad II x 0,34 C = størrelse (%) af grad III x 0,65 D = størrelse (%) af grad IV x 1,00 Grad I-IV Beguin and Locker Grad I: Blødt og hævet brusk med intakt overflade Grad II: Overfladiske fissurer Grad III: Dybe fissurer ned til subkondral knogle eller erosioner uden eksponeret knogle Grad IV: Erosioner ned til subkondral knogle Kontinuerlig skala fra 0-100

8 Scoring systemer ACR scoring system Graderne I-III (Klashman et al) vurderes i % af total ledflade og ACR scoren beregnes: ACR score = A+B+C+D+E+F, hvor A = størrelse (%) af grad Ia x 1 B = størrelse (%) af grad Ib x 1,5 C = størrelse (%) af grad IIa x 2,0 D = størrelse (%) af grad IIb x 2,5 E = størrelse (%) af grad IIIa x 3,0 F = størrelse (%) af grad IIIb x 3,5 Grad I-III Klashman et al. Grad Ia: Intakt men tør brusk Grad Ib: Blødt og hævet brusk med intakt overflade Grad IIa: Superficielle fissurer Grad IIb: Dybe fissurer eller dybe erosioner Grad IIIa: Eksponeret knogle uden kavitet Grad IIIb: Eksponeret knogle med kavitet Kontinuerlig skala fra 0-350

9 Scorings systemer Øvrige vurderinger: Overall assessment of synovial structures (0-100) Overall assessment of Osteoarthritis (chondropathy, osteophytes and synovial structures) (0-100) Størrelse af fragment (mm/1-3) OCD læsion større end fragment Assessment of osteoarthritis (1-3) Prognose (God, reserveret, dårlig, slet)

10 Materiale og metode Population på 200 heste over en 6 mdr. Periode der undergik artroskopi på Ansager Dyrehospital Udvalgt heste med osteochondrose dissicans i tibiotarsalled Inden ekstirpation optoges en intra-artikulær digital videosekvens af haseleddet Herfra udvalgtes 10 heste, der repræsenterede forskellige grader af chondropati Optagelserne blev vurderet post-operativt af 3 kirurger

11 Materiale og metode Operation Hesten placeret i rygleje Noteret galle, fibrøs fortykket ledkapsel Artroskopi via dorsomedial portal (McIlwraith et al. 2005) 4 mm, 30 graders artroskop Vurdering/optagelse fra lateral til medialt

12 Materiale og metode

13 Materiale og metode Eksempel på optagelse

14 Studie-design Præ-træning vurdering (1 uge præ-træning) Kort introduktion til scorings systemer og vurderingsskema Ingen anbefaling vedr. selve vurderingen Uafhængig vurdering baseret på kirurgens erfaring med artroskopi Træning/konsensus vurdering Interaktiv vurderingssession med de tre kirurger samlet til diskussion Forskellige vurderinger blev diskuteret til opnåelse af konsensus MIA/CD-RAP artroskopivurderinger Post-træning vurdering (8 uger post-træning) Uafhængig vurdering uden umiddelbar påvirkning fra tidligere vurderinger

15 Vurdering

16 Anvendt statistik Variansanalyse (ANOVA) to faktor med gentagelse H 0 : ingen forskel mellem grupper, P<0,05 Forklarende variabler: Kirurg Præ-, træning, post-træning Responsvariabler (kontinuerte): VAS average VAS chondropathy, osteophytes VAS chondropathy, osteophytes, synovium SFA ACR Fragment, læsion størrelse VAS synovium

17 Anvendt statistik Liniær regressions analyse Y = a + bx, hvor a (skæringspunkt med Y-aksen er sat til 0) H 0 : b=0 (ingen sammenhæng mellem Y og X, P<0,05) H 0 : R=0 (tilfældig fordeling, F<0,05) Kirurg præ og træning post og træning præ og post

18 Resu ultater Table 1: Means, +/-standard deviation and (minimum-maximum) of the different output variables Pre-training #1 #2 #3 #4 #5 #6 #7 #8 VAS average 64+/ / /-6 23+/ /-6 14+/-12 9+/-8 13+/-9 (52-78) (33-72) (30-40) (6-34) (8-20) (1-24) (4-18) (4-22) VAS chondropathy, osteophytes 77+/-6 73+/-6 43+/ / /-6 12+/-15 8+/-3 22+/-25 (70-80) (70-80) (30-70) (15-50) (10-20) (2-30) (5-10) (5-50) VAS chondropathy, osteophytes 73+/ / / / /-8 16+/ /-6 15+/-9 and synovium (60-80) (50-80) (40-70) (5-60) (5-20) (2-30) (10-20) (5-20) SFA score 60+/ /-13 9+/-7 9+/-6 11+/-13 3+/-2 3+/-1 5+/-5 (38-76) (5-27) (2-17) (3-15) (2-25) (1-4) (2-3) (1-11) ACR score 263+/ / / / / / / /-51 ( ) ( ) (60-165) (24-205) (30-130) (18-110) (23-160) (9-110) Fragment size in mm 9+/-2 28+/-8 7+/-0 22+/-13 7+/-3 13+/-6 7+/-2 9+/-1 (6-10) (20-32) (7-7) (10-35) (5-10) (10-20) (5-8) (8-10) Lesion size in mm 9+/-2 28+/-8 18+/-3 22+/-13 7+/-3 13+/-6 7+/-2 8+/-0 (6-10) (20-35) (15-20) (10-35) (5-10) (10-20) (5-8) (8-8) VAS synovium 73+/ / /-0 23+/ /-27 3+/-2 5+/-5 33+/-23 (60-80) (10-30) (20-20) (10-30) (3-50) (2-5) (0-10) (20-60) OCD graduated from (2-3) (1-1) (2-3) (1-2) (2-3) (1-3) (3-3) (2-3) Pathology graduated from (1-1) (1-2) (1-2) (1-3) (2-3) (2-3) (3-3) (3-3) Prognosis Poor Fair Fair Good Good Good Good Good Post-training #1 #2 #3 #4 #5 #6 #7 #8 VAS average 63+/ / / / / / /44 40+/-41 (44-78) (30-72) (31-80) (13-78) (18-88) (9-88) (12-88) 8-86) VAS chondropathy, osteophytes 67+/ /-0 67+/-6 57+/ / / / /-43 (40-80) (80-80) (60-70) (40-80) (30-90) (10-90) (20-90) (5-90) VAS chondropathy, osteophytes 87+/-6 42+/ / / / / / /-43 and synovium (80-90) (1-85) (70-90) (40-90) (20-90) (10-90) (10-90) (5-90) SFA score 64+/ /-8 31+/ / /-9 8+/-7 3+/-2 1+/-1 (32-81) (5-21) (13-46) (5-23) (3-21) (3-16) (1-6) (0-3) ACR score 259+/ / / / / / / /-88 ( ) (35-148) (45-177) (25-95) (10-148) (10-95) (10-55) (10-170) Fragment size in mm 10+/-9 27+/ / / / /16 12+/ /-8 (4-20) (15-45) (4-30) (6-40) (3-30) (4-35) (3-25) (5-20) Lesion size in mm 11+/-8 28+/ / / / /16 13+/ /-8 (4-20) (15-45) (4-40) (6-40) (3-35) (4-35) (3-25) (5-20) VAS synovium 63+/ / / / / / / /-6 (40-80) (2-60) (50-80) (30-90) (20-90) (20-90) (5-90) (70-80) OCD graduated from /-1 1+/-1 2+/-1 1+/-1 3+/-1 2+/-1 3+/-1 2+/-1 (2-3) (0-1) (2-3) (1-2) (2-3) (1-3) (2-3) (2-3) Pathology graduated from /-1 2+/-1 2+/-1 2+/-1 3+/-0 3+/-0 3+/-0 3+/-0 (1-2) (1-3) (1-3) (2-3) (3-3) (3-3) (3-3) (3-3) Prognosis Poor Fair Fair Good Good Good Good Good Table 1: Means, +/-standard deviation and (minimum-maximum) of the different output variables.

19 Resultater Table 2: Mean, p value of outcome variables stratified by pre- and post-training Significant difference Surgeons pretraining Surgeos post-training n=8 Surgeon 1 Surgeon 2 Surgeon 3 P-value Surgeon 1 Surgeon 2 Surgeon 3 P-value Outcome variable n=8 n=8 n=8 n=8 n=8 n=8 VAS average VAS chondropathy, osteophytes SFA score 11, ACR score Size of fragment in mm Size of lesion in mm VAS synovium VAS chondropathy, osteophytes, synovium OCD graduated Pathology graduated Prognosis Excellent Fair Reserved Poor Primary change Intermediate ridge Intermediate ridge, medial malleolus Medial malleolus Secondary change Lateral trochlea Medial trochlea No synovium abnormality Petechiation Hyperemia Edema Hyperplasi Adhesion Haemosiderin Area Difuse Localised

20 Resu ultater Table 3 a. b and c. Correlation between the surgeons pre-/post-training and the training assessment. R is the correlation coefficient with F indicating its significance. B describes the association between the surgeons assessment and the training assessment. Correlation coefficients not different from zero. Confidence intervals of b not containing 1 - significant difference between assessments. Correlation between pre-training and training assessment Pre-training=x Surgeon r F b Confidence interval P value < < VAS average < < < < VAS chondropathy and osteophytes < < < < SFA score < < < < ACR score VAS synovium < < < < < VAS chondropathy. osteophytes and synovium < < a b c Correlation between post-training and training assessment Post-training=x Surgeon r F b Confidence interval P value VAS average VAS chondropathy and osteophytes < < < < SFA score < < < ACR score VAS synovium VAS chondropathy. osteophytes and synovium < < Correlation between pre- and post-training assessment Post-training=x Surgeon r F Coefficient Confidence interval P value VAS average < < < < VAS chondropathy and osteophytes < < SFA score < ACR score < < VAS synovium VAS chondropathy. osteophytes and synovium < <0.0001

21 Diskussion Forskellige selektionskriterier mellem humane og equine patienter (rheumatoid arthritis kontra osteochondrose) Højst sandsynligt mere udprægede forandringer ved humane artroskopier generelt Alle scoringssystemer kunne påvise forskel mellem de forskellige heste (udvalgt til at repræsentere forskellige grader af kondropati) Ikke muligt at påvise forskel i scoring og prognose ved nogen scorings systemer obs. den begrænsede population God korrelation (0,70-0,97) på nær Kirurg 1 post-træning ACR misforståelse ved kirurg 2 Signifikant højere værdier ved post-træning Som følge af træningssession - studiedesignet

22 Konklusion Indikation for brug af SFA score, VAS average og VAS (chondropathy, osteophytes and synovium) Krav om yderligere undersøgelser Større inter-observatør undersøgelse Etablering af nøglevurderinger Inter-observatør undersøgelser af andre led Longitudinelle studier påvise ændringer over tid Korrelation med kliniske symptomer Korrelation med makroskopiske fund

23 Summary Summary Reasons for performing study: Arthroscopic evaluation of joints is a well established diagnostic procedure but establishment and validation of different intra-articular scoring systems have not been performed in equine practice. Objectives: To investigate the intra- and inter-observer reliability of different scoring systems and to evaluate the effect of a training session on the inter-observer reliability. Methods: Ten horses were selected from a population of horses that underwent arthroscopic removal of OCD in the tibiotarsal joint with simultaneous video digital recording. The ten horses were selected for findings that represent different stages of severity of chondropathy in the tibiotarsal joint. The arthroscopic recordings were evaluated in a pre-training assessment, a training session and post-training assessment. Results: There were no significant differences in all the scoring systems between the surgeons at the pre-training assessment. All scoring systems except the SFA score showed significant difference between the surgeons in the post-training assessment. This study showed acceptable reliability of the SFA score, VAS average and VAS (chondropathy, osteophytes and synovium). Conclusions and potential relevance: This study indicates a possible use of the SFA score, VAS average and VAS (chondropathy, osteophytes and synovium).

24 Rettelser side 6 different lesion grades (grade I to IV) are evaluated on a 100 mm VAS in which 0 indicates absence of chondropathy and 100 the most severe chondropathy. The ACR score is obtained as follows: A = size (mm) of grade Ia lesions x 1 B = size (mm) of grade Ib lesions x 1.5 C = size (mm) of grade IIa lesions x 2.0 D = size (mm) of grade IIb lesions x 2.5 E = size (mm) of grade IIIa lesions x 3.0 F = size (mm) of grade IIIb lesions x 3.5 ACR score = A+B+C+D+E+F The ACR score is a continuous variable ranging from 0 to 350, where 0 indicates no chondropathy and 350 indicates the most severe chondropathy with total exposure of bone. 5) Overall Assessment of Synovial structures of the tibiotarsal joint of using a 100 mm VAS. This assessment does not include chondropathy. 6) Overall Assessment of Osteoarthritis in the tibiotarsal joint of using a 100 mm VAS. This assessment includes chondropathy, osteophytes and synovial structures. 7) Size of the osteochondral fragment was assessed using description in mm and a categorical variable ranging from 1-3 with 1 being the largest fragment. 8) Osteochondral lesions in the cartilage bigger than the fragment was assessed using description in mm. 9) An Assesment of Osteoarthritis of the tibiotarsal joint with a categorical variable ranging from 1-3 with 1 being the highest degree of changes. 10) Finally the prognosis for recovery to complete athletic use was evaluated as excellent, fair, reserved or poor.