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Sharp van der Heijde Score

Tutorial Sharp

1) How to take radiographs

2) How to score radiographs with the Sharp/van der Heijde (SvH) scoring method

3) SENS, a simplified alternative to the SvH scoring method

4) Testing your skills with actual radiographs

 


1) How to take radiographs

This section contains general instructions on collecting the x-ray images in order to obtain a sufficient quality of radiographs to correctly determine the Sharp/van der Heijde score.

 

1) If you are using film, be sure to use high resolution or fine detail film.

 

2) Ask single films of each hand and foot. Taking both hands or foot on the same cassette increases the odds to observe artefacts, such as an ulnar deviation of the wrists or the MCP (parallax problems).

 

3) Positioning the arm and hand or foot should be well standardized. Ask the technician to review the previous films before taking the follow-up. This is more important when some deformity has developed during the course of the RA so that the hand or foot is hard to position the same as in the earlier exam.

 

4) The x-ray tube should be 40 inches or 100 centimeters from the cassette. The x-ray beam should be centered on the 3rd metacarpal in the hand or the 3rd MTP joint in the foot.

 

5) HAND RADIOGRAPHS: The general rule for positioning the hand is to have the elbow in the same plane as the hand and to have the 3rd metacarpal on a line with the forearm, or at most with less than 10 degrees of ulnar deviation. The fingers should be flat on the table or cassette, or as flat as the patient can comfortably tolerate if there is a flexion contracture. Moreover, if you would like to visualize a few centimeters of the radius and ulna, ask the technician to include the wrist on the x-ray.

 

6) FOOT RADIOGRAPHS: The foot’s x-ray is taken with the patient applying some pressure of the whole foot on the cassette so the foot is completely flat. The patient doesn’t have to apply enough pressure to be painful, but just enough to keep the foot flat. The “standard” foot film is an excellent image for the evaluation of the mid-foot BUT it is not optimal to evaluate the MTP joints, because it frequently causes a too dark film (little penetrated). Using the term FOREFOOT FILMS to order the image reminds the technician that what you want is different from the “standard” foot film, and usually solves this problem. If you still have problems, emphasize that you want to see the toes clearly, and in particular the MTP joints.

 

2) How to score radiographs with the Sharp/van der Heijde (SvH) scoring method

SCORING SHEETS (Printable)

Scoring sheets in PDF format, that can be used to score radiographs of hand and feet, are available by clicking this link.

 

THE SHARP/van der HEIJDE scoring method

The Sharp method for scoring radiographs of hands and feet in rheumatoid arthritis, modified by Dr. Désirée van der Heijde (the Sharp/van der Heijde or SvH scoring method), is now a reference method used in a majority of clinical trials and longitudinal observational studies.

Description of the scoring method is largely adapted from the paper by Désirée van der Heijde "How to read radiographs according to the Sharp/van der Heijde method" Journal of Rheumatology 2000; 27:261-3.

The SvH method includes, in each hand, 16 areas for erosions and 15 areas for joint space narrowing, and, in each foot, 6 areas for erosions and 6 areas for joint space narrowing (see printable Scoring sheets in the previous section).

 

SCORING THE HANDS

 

The erosion score per joint of the hands can range from 0 to 5. Erosions are scored 1 if they are discrete but clearly present and 2 or 3 if they are larger, depending on the surface area of the joint involved. A score of 3 is given if the erosion is large and extends over the imaginary middle of the bone. A score of 5 is given if a complete collapse of the joint is present or if the full surface of the joint is affected. In each joint, individual erosions are summed up to a maximum of 5. The maximal erosion score for each hand is thus 80, considering the16 areas for erosions per hand.

We present a number of examples of the different scores in the teaching section.

 

Joint space narrowing and joint subluxation or luxation are combined in a single score with a range of 0 to 4. A normal joint space is scored 0. A score of 2 is allowed to a focal narrowing of the joint or to a joint space not sufficiently narrowed to be scored 2. The score of 1 should not be used when the reader is unsure whether there is joint space narrowing. A generalized narrowing leaving more than 50% of the original joint space present is scored 2. A generalized narrowing leaving less than 50% of the original joint space present is scored 3, and a subluxation of a joint is also scored 3. A bony ankylosis or a complete luxation of the joint is scored 4. The maximal narrowing/(sub)luxation score for each hand is thus 60.

 

SCORING THE FEET

 

The erosion score per joint can range from 0 to 10, with each side of the joint independently scored from 0 to 5. The maximal erosion score per foot is thus 60.

 

The joint space narrowing and joint (sub)luxation are combined in a single score with a range of 0 to 4. Criteria for scoring are identical to those of the hands. The maximal narrowing/(sub)luxation score per foot is thus 24.

 

In all cases, erosions (and joint space narrowing/(sub)luxation) are always scored and no judgment should be made on whether they are due to rheumatoid process or to osteoarthritic lesions.

 

The total replacement of a joint or the chirurgical fusion of it automatically assigns a maximal erosion and narrowing/(sub)luxation score to this joint.

 

Ideally, two independent readers should establish a score for each radiograph. The average of the scores of the two evaluators is the score assigned to the radiograph. It is although possible to have only one reader when that person can frequently refer to score examples.

 

There is a debate to know if the radiographs should be read haphazardly or in time sequence.

 

When the time sequence is known to the reader, it becomes possible to take into account small technical changes such as positioning or film quality, and thus to decrease measurement error. The Smallest Detectable Difference (SDD) is then usually from 3 to 5. If a joint Thus, if a joint lesion was present on a previous radiograph and is no more present on later radiographs, and if this improvement appears to the reader to be independent of technical variations, a lower grade can be attributed to the lesion. However, if a joint cannot be scored because it is not visible on the radiograph or because of prior joint surgery, the last observation carried forward method is applied to ensure that a score cannot decrease in these situations.

 

When the radiographs are haphazardly read (without time sequence), the “normal” tendency to identify an erosion on a radiograph because it was present on earlier radiographs is eliminated. The evaluation obtained is more objective, but at the price of a more important imprecision of the measurement. The SDD is thus from 5 to 8.

 

Regardless of the technical used, it is important to locally evaluate the SDD.

 

SUMMING OF SCORES

 

Maximal total erosion score of the hands is thus 160. Maximal total erosion score of the feet is 120. Maximal total erosion score (hands and feet) is 280.

 

Maximal total narrowing/(sub)luxation score in the hands is 120. Maximal total narrowing/(sub)luxation score in the feet is 48. Maximal total narrowing/(sub)luxation score (hands and feet) is 168.

 

Maximal total Sharp/van der Heijde score is 448.

 

Scoring sheets in PDF format, that can be used to score radiographs of hand and feet, are available by clicking this link.

 

3) SENS, a simplified alternative to the SvH scoring method

THE Simple Erosion Narrowing Score (SENS) METHOD

 

The SENS method was derived from the Sharp/van der Heijde method as an easier, quicker and quite reliable to score joint lesions, especially in the first few years of disease (van der Heijde D, Dankert T, Nieman F, Rau R, Boers M. Reliability and sensitivity to change of a simplification of the Sharp/van der Heijde radiological assessment in rheumatoid arthritis. Rheumatology (Oxford) 1999; 38:941-7). The joints evaluated are the same than those evaluated in the SvH score. In each hand, For erosions, there are thus 16 areas valuable in each hand and 6 in each foot. For joint space narrowing, there are 15 areas valuable in each hand and 6 in each foot.

 

SENS gives a score of 1 if at least one joint erosion is noted.

 

In the same way, SENS gives a score of 1 if there is any narrowing in the joint, no matter the importance of the lesion noted.

 

In the hands, the maximal erosion score is 32, and 30 for narrowing/(sub)luxation. In the feet, the maximal erosion score is 12, and 12 for narrowing/(sub)luxation. As a consequence, the range of the SENS method is from 0 to 86.

 

4) Testing your skills with actual radiographs

In the left margin, click on the "Tutorial Sharp" tag, and the select "Evaluate extremities" or "Evaluate patients". Have fun!