Reachout Orthopedics - Issue 2

Heijde/Sharp methods showed that both demonstrated a similar performance [52] (Fig. 3). Ratingen Score (1998) A new scoring method, derived from the Larsen score, was developed by Rau and Herborn. A notable difference is the inclusion of a quantitative appraisal of the percentage of loss of the joint surface. This method is known as a “Ratingen score” [53]. The amount of joint surface destruction is defined by the length of the clearly visible interruption of the corti- cal plate in relation to the total joint surface. In this method, the stages are described as a quantitative measure of the destroyed joint surface area and can, therefore, be applied more easily. These modifications also enhance sensitivity and increase reliability. Simplified Erosion and Narrowing Score (SENS) (1999) The SENS was developed by van der Heijde [54] and is a simplified method by summing the number of eroded and narrowed joints on selected joints on hand and foot radiographs. It exploits the same joints of hands and feet, but as opposed to applying a semiquantitative scale of 0–4 for JSN and 0–5 for erosions, the SENS simply dichotomizes (bimodal answer modality) whether an erosion is absent (score 0) or present (score 1) and whether JSN is absent (score 0) or present (score 1). The SENS showed a good intra- and inter-reader reliability and is sensitive to change [55]. Another important issue is the absence of a clear ceiling effect. Its decisive advantage is its feasibility in clinical practice [56]. It has been demonstrated that the carpal joints may be omitted from SENS without noticeable repercussion for its responsiveness and discriminant validity [57] (Fig. 4). Feasibility of The Scoring Methods in Clinical Practice An important disadvantage of the scoring methods for clinical trials is the fact that they require significant training and that scoring according to these methods is time-consum- ing, making these techniques unfeasible for routine clinical practice. Several authors cal- culated the time needed to score radiographs with different methods in RA. The time to score seven radiographs of hands and feet was Fig. 1: van der Heijde-modified Sharp scoring method representation with figure and grading. a Joints selected in each hand for erosions: 4 PIP, 5 MCP, IP, scaphoid, lunate, distal ulna, distal radius, the two components of the CMC joints of the thumb are evaluated separately (PMC and trapezium–trapezoid). The maximum score for both hands is 160. b Joints selected in each foot for erosions: the proximal and distal articular components of the MTP and IP are evaluated separately resulting in a 0–10 score for each joint. The maximum score considering both feet is 120. c Joints selected in the hand: the CMC 3, CMC 4, CMC 5 are scored separately, the IP is not included, only the radio-scaphoid part of the radiocarpal joint is evaluated. The maximum score for both hands is 120. d Joints selected for JSN in each foot. The maximum score for both feet is 48. CMC carpometacarpal, CS capitate–scaphoid, IP interphalangeal joint, Lun lunate, MCP metacarpophalangeal joint, MTP metatarsophalangeal joint, PIP proximal interphalangeal joint, PMC proximal metacarpal, Rad radius, RC radio-scaphoid, Sc scaphoid, ST scaphoid–trapezium, T–T trapezium–trapezoid, Ul ulna Fig. 2: Modified Larsen method represented with figure and grading. a Joints evaluated in each hand: 4 PIP, 4 MCP, the wrist is subdivided into four quadrants that are scored separately. The maximum score for both hands is 120. b Joints selected in each foot: in this method, the MTP and the IP of the big toe are not considered. The maximum score considering both feet is 40. IP interphalangeal joint, MCP metacarpophalangeal joint, MTP metatarsophalangeal joint, PIP proximal interphalangeal joint 5 reachOut Orthopedics