Arthritis & Rheumatism, Volume 60,
October 2009 Abstract Supplement

The 2009 ACR/ARHP Annual Scientific Meeting
Philadelphia October 16-21, 2009.


Ultrasonographic and Physical Examination of the Inflamed Knee: Intra and Inter Rater Reliability of the Sonographers and Clinical Examiners

Gogus1,  Feride, Hatemi2,  Gulen, Tascilar3,  Koray, Melikoglu2,  Melike, Yurdakul2,  Sebahattin, Kilic2,  Hasan, Yalim2,  Serkan

Gazi University, Faculty of Medicine, Ankara, Turkey,
Istanbul University, Cerrahpasa Faculty of Medicine, Istanbul, Turkey,
Numune Research and Teaching Hospital. Ankara, Turkey

Background:

We had previously shown in a pilot study that there was considerable inter observer variation in physical examination of the knee. The correlation with ultrasonographic (US) examination was also wanting (1).

Purpose:

i) To test intra and inter observer variability of the clinical examination of the knee among clinicians with different levels of rheumatology expertise. ii) To test the intra and inter observer variability of the ultrasonographic examination. iii) to investigate the concordance between the ultrasonographic and clinical examination of the knee.

Patients and Methods:

Twenty healthy volunteers and 21 patients with inflammatory arthritis of the knee were included in the study. A rheumatology nurse directed the clinical and ultrasonographic examination sequence in order to maintain blindness. Patients were asked to lie under sheets to conceal their identity and expose the knee joint areas only. 4 examiners (2 rheumatology attendings, 1 rheumatology fellow and 1 resident in internal medicine) examined 82 knee joints twice on the same day. Each examiner visually evaluated the presence of joint swelling, then performed clinical examination with a patellar tap and a sweep test. Two rheumatologists experienced in US and blinded to the clinical examination results did US examinations twice. Presence of effusion and synovial hypertrophy were checked at the suprapatellar, medial and lateral joint regions in standard longitudinal and transverse planes. A semiquantitative 0–3 scale was used for US evaluation for joint effusion and synovial hypertrophy. Data analysis was made by Kendall's coefficient of concordance and Kappa statistics for agreement.

Results:

Intra observer agreement between the rheumatology attendings was better than that of the rheumatology fellow and the medicine resident (k=0.57–1.00 and k= 0.25–0.77 respectively). On the other hand, the inter observer agreement among the four clinicians was poor in any of the two-way comparisons. Ultrasonographic inter observer agreement (k) varied between 0.73 and 0.91 in detecting synovial effusion and hypertrophy respectively. Intra observer agreement (k) at 6 US examination planes differed between 0.39–1.00.

Conclusion:

The inter observer variation in physical examination of the knee is considerably more than in US examination. The concordance of the physical examination findings is better among more experienced physicians.

Reference:

1.Gogus, F., Kitchen, J., Collins, R. & Kane, D.Reliability of physical knee examination for effusion: verification by musculoskeletal ultrasound. Annual ACR Meeting, San Francisco, 2008.

To cite this abstract, please use the following information:
Gogus, Feride, Hatemi, Gulen, Tascilar, Koray, Melikoglu, Melike, Yurdakul, Sebahattin, Kilic, Hasan, et al; Ultrasonographic and Physical Examination of the Inflamed Knee: Intra and Inter Rater Reliability of the Sonographers and Clinical Examiners [abstract]. Arthritis Rheum 2009;60 Suppl 10 :1465
DOI: 10.1002/art.26539

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