Defining enthesitis in spondyloarthritis by ultrasound: Results of a delphi process and of a reliability reading exercise

Maria Antonietta D'Agostino, L. Terslev, E. Naredo, A. Iagnocco, P. V. Balint, R. J. Wakefield, P. Aegerter, S. Z. Aydin, A. Bachta, H. B. Hammer, G. A.W. Bruyn, E. Filippucci, F. Gandjbakhch, P. Mandl, C. Pineda, W. A. Schmidt, M. A. D'Agostino

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Objective To standardize ultrasound (US) in enthesitis. Methods An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability. Results Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63). Conclusion This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work. © 2014, American College of Rheumatology.
Original languageEnglish
Pages (from-to)741-748
Number of pages8
Publication statusPublished - 2014


  • Arthritis, Juvenile
  • Humans
  • Reproducibility of Results
  • Spondylarthritis
  • Reading
  • Ultrasonography
  • Delphi Technique
  • Physician's Role
  • Surveys and Questionnaires

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