Evaluation of collected outcome measures in axial spondyloarthritis in daily-care rheumatology settings: the experience of the RHEVER network.

OBJECTIVES: Nowadays, the recommended measures for optimal monitoring of axial Spondyloarthritis (ax-SpA) disease activity are either BASDAI and CRP, or ASDAS-CRP. However, there could be a gap between recommendations and daily practice. We aimed to determine the measures collected by rheumatologists in an ax-SpA follow-up visit, and to determine the impact of a meeting (where rheumatologists reached a consensus on the measures to be collected) on the collection of such measures. METHODS: A consensual meeting of a local network of 32 rheumatologists proposed, four months later, to report at least the BASDAI score in the medical file of every ax-SpA patient at every follow-up visit. An independent investigator reviewed the medical files of 10 consecutive patients per rheumatologist, seen twice during the year (e.g. before and after the meeting). The most frequently collected measures were assessed, and then, the frequency of collection before and after the meeting was compared. RESULTS: A total of 456 medical files from 228 patients were reviewed. Treatment (>60%), CRP (51.3%) and total BASDAI (28.5%) were the most reported measures in medical files. Before/After the meeting, the frequencies of collected measures in medical files were 28.5%/51.7%, 51.3%/52.2%, 16.7%/31.6% and 0.9%/6.1% for BASDAI, CRP, BASDAI + CRP and ASDAS, respectively reaching a statistically significance for BASDAI, ASDAS and BASDAI+CRP (p<0.05). CONCLUSIONS: This study revealed a low rate of systematic report of the recommended outcome measures in ax-SpA. However, it suggests that a consensual meeting involving practicing rheumatologists might be relevant to improve the implementation of such recommendations.

[US evaluation of the hands and feet in rheumatoid arthritis]. / Comment je fais un bilan échographique des mains et des pieds dans la polyarthrite rhumatoïde?

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. Synovitis is usually found in the wrist, metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints. For these reasons, we believe that ultrasound with power doppler can be used for the detection and monitoring of synovitis with a simplified "hands and feet" protocol. In this article, we will describe this protocol used daily in our institution for early diagnosis and therapeutic management of this disease.

Chondroscopy: a new method for scoring chondropathy.

The purpose of this study was to evaluate the performance (simplicity, reproducibility, relevance) of chondroscopy as a method for evaluating cartilage damage. Chondroscopy consisted in endoscopic evaluation of the knee using a 2.7-mm Storz arthroscope under local anesthesia and recorded on videotape. Scoring of chondropathy was based on physician's overall assessment using a 100-mm-length visual analogue scale (VAS) and size and grade of cartilage lesions. Reproducibility was evaluated by variability (coefficient of variation [CV]) in the reading of chondroscopic evaluations of five patients five times by one physician and one time each by four different physicians. The correlations between scoring of chondropathy (VAS) and radiological articular joint space narrowing, demographic data (sex, age, weight), and disease characteristics (localization, etiology, activity) were studied in 84 outpatients fulfilling the American College of Rheumatology criteria for the diagnosis of osteoarthritis of the knee. The grade and size of the lesions were both correlated with the physician's overall assessment (r = 0.713 and r = 0.816, respectively). These two variables accounted for 72% of the variance of the VAS (multiple regression analysis). Intraobserver reproducibility was better than interobserver reproducibility (CV, 9% and 37%, respectively). There was a strong correlation between the scoring of chondropathy (VAS) and radiological joint space narrowing (r = .646, P < .0001). Moreover, in 17 of 33 patients without radiological joint space narrowing, VAS was > 20 mm. At variance, the body mass index was the single clinical variable found to correlate with the scoring of chondropathy (r = .282, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the responsiveness of symptomatic outcome measures in knee osteoarthritis.

OBJECTIVE: A number of international scientific societies have recommended a core set of domains to be systematically assessed in clinical research studies on osteoarthritis (OA), i.e., pain, function, and patient's overall assessment. This open, longitudinal, observational study compares the responsiveness of different symptomatic variables evaluating these 3 domains in knee OA. METHODS: Patients were individuals with painful knee OA. The collected data were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale (0-100) and WOMAC function subscale (0-100), Lequesne's index (0-100), pain after physical activities (visual analog scale [VAS] 100 mm), and patient's global assessment (VAS 100 mm). The procedure used was knee joint lovage. Time of collection was before and 1, 3, and 6 months after the lavage. Analysis was by comparison of the standardized response mean (mean of the changes/SD of the changes) in an intent-to-treat strategy after 1, 3, and 6 months using the jackknife method. RESULTS: Improvement in all dimensions of WOMAC subscale scores and VAS scores was observed at month 1. Lequesne's index was not responsive to change. The standardized response mean was moderate, ranging from 0.00 to 0.40. Comparison of the estimates of the standardized response means using the jackknife method showed a statistically significant difference between Lequesne's index and the WOMAC subscale for function, but not between VAS pain and the WOMAC subscale for pain. CONCLUSION: Most of the evaluated variables have a moderate responsiveness. In knee OA, the WOMAC function scale seems to be more sensitive than Lequesne's index for detecting changes after symptomatic therapy.

Injections in the treatment of osteoarthritis.

Injections, especially of corticosteroids but also of hyaluronan, are widely used in the treatment of osteoarthritis. The various joints - knee, hip, hand - affected by OA are accessible to these local treatments. This chapter concentrates on the evidence for efficacy of these treatments and attempts to delimit their respective indications and optimal doses. The side-effects of corticosteroid injections are reviewed, and the potential interest in post-injection rest is discussed. Finally, the potential structure-modifying effect of hyaluronan is investigated.

[Efficacy and role of topical treatment of gonarthrosis]. / Traitements locaux de la gonarthrose: efficacité et place.

INDICATIONS: To relieve pain in patients with knee osteoarthritis, local treatments can be effective both for episodes of acute congestion, characterized by inflammatory pain, intraarticular effusion and risk of acute chondrolysis, and for slowly progressive disease (with a characteristic lack of effusion). ACUTE CONGESTION: Local care is essential. Relief can be achieved by draining the effusion, associated with corticosteroid injections which may be repeated and followed by a 24 h rest. In case of failure or rapid development of chondrolysis, joint lavage (1 liter saline solution--two 2-mm needles) followed by cortico-steroid infiltration is indicated. Weight bearing should be avoided for 6 weeks (cane) until the effusion has been absorbed. In case of radiological evidence of chondrocalcinosis and chronic serous or bloody effusion, yttrium 90 synoviorthesis may be proposed as an alternative. SLOWLY PROGRESSIVE DISEASE: In patients with no effusion who continue to suffer despite physical and medical treatment, intraarticular injections of hyaluronic acid can be helpful. They are particularly effective in case of moderate disease. Hyaluronic acid is an interesting alternative to non-steroidal antiinflammatory drugs and is especially indicated after a rapidly progressive period of chondrolysis.

[Rapid chondrolysis after arthroscopic external meniscectomy. Apropos of 4 cases]. / Chondrolyse rapide après méniscectomie externe arthroscopique. A propos de 4 cas.

The authors report 4 cases of rapid lateral femoro-tibial chondrolysis following arthroscopic lateral meniscectomy. All patients were young athletes. At the time of meniscectomy, the cartilage of the lateral compartment was normal. Only one meniscectomy was done with the Ho Yag laser. Clinical symptoms were always identical: pain and important swelling, persisting despite intra articular injections of corticosteroids. A second-look arthroscopy was performed after a mean delay of 6 months (5 to 8), showing numerous cartilaginous debris floating in the joint (like in a chondromatosis disease) and a severe cartilaginous damage in the lateral compartment (grade 3 or 4). Swelling disappeared after arthroscopic lavage followed in two cases by a non weight bearing period of one to two months. But X-rays always demonstrated a narrowing of the lateral joint line on flexion-full weight bearing AP views. Rapid chondrolysis is a rare and severe complication of lateral meniscectomy. The etiology, which is mechanical, is not known. It probably represents an acute form of chronic, slow chondrolysis which is frequent after lateral meniscectomy. Rapid chondrolysis should be treated urgently by the following protocol: arthroscopic lavage, intra articular injections of corticosteroids and non weight bearing period.

[Vascular sarcomas of the ethmoid sinus (hemangioendothelioma)]. / Sarcomes vasculaires de l'ethmoïde (hémangio-endothéliome)

Vascular sarcomas (haemangio-endotheliomas) are tumours which are very rarely encountered in the facial mass. Only 10 cases have been found in the literature. Two cases are described: the first patient was operated on in 1968 for a localization in the left side of the ethmoid and presented 9 year later with a recurrence on the right side symmetrical with the first which remained apparently cured; a year later, there was a recurrence on the right then diffuse pulmonary metastases. The second case was that of a patient with an ethmoid localization cured by radiotherapy and surgery 20 years before, but presenting with a recurrence in the ganglia 10 years later and a parapharyngeal recurrence developing over the past 6 years. In connection with these two cases, the diagnostic difficulties involved in distinguishing these tumours from epitheliomas and sarcomas of the facial mass, which sometimes show considerable vascularization, from other vascular tumours, benign haemangioendotheliomas, glomus tumours and, in particular, haemangio-pericytomas, are described. The possibility of a long survival should be noted for some rare facial localizations: this is in contrast with the usually very rapid development of vascular sarcomas in other localizations.

[Chondroscopy: a new method for measuring osteoarthritis?]. / La chondroscopie: un nouvel intrument de mesure de l'arthrose?

Arthroscopy allows direct visual examination of joint cavity components and is useful for the diagnosis, treatment and evaluation of lesions. We investigated the contribution of arthroscopy to the evaluation of joint cartilage. The severity of cartilage lesions can be assessed using a total 100-mm visual analog scale (0 = no chondropathy; 100 = the worst possible lesions) or a more objective system based on the site, depth, and surface area of the lesions. This latter system was developed by the French Society for Arthroscopy (Société Française d'Arthroscopie) and provides a score and a class (SFA score and SFA grade). We investigated whether this system has the characteristics required of an evaluation tool, i.e., simplicity, reproducibility, clinical relevance, sensitivity to change, and discriminant capacity. Arthroscopy is an invasive procedure. However, we introduced several simplifications, including use of local rather than general anesthesia, performance on an outpatient basis, elimination of the tourniquet (to avoid muscular dysfunction), and use of a small arthroscope. This simplified technique is called chondroscopy. Intra-observer reproducibility is far better than inter-observer reproducibility. We found a good correlation between the two arthroscopy scales (visual analog scale and SFA scale). Chondroscopy and roentgenographic evaluations of cartilage lesions were closely correlated. Changes in the severity of cartilage lesions were correlated with changes in functional impairment. Chondroscopy proved capable of demonstrating statistically significant changes in cartilage lesions due to knee osteoarthritis between two evaluations done only one year apart, even in a small sample of patients (less than 20). A preliminary study of repeated hyaluronic acid injections suggested that chondroscopy may be capable of identifying truly chondromodulating agents.

[Evaluation of a quality of life scale (AIMS2) in rheumatology]. / Evaluation d'une échelle de qualité de vie (AIMS2) en rhumatologie.

OBJECTIVES: To evaluate the feasibility, relevance, and sensitivity of the French version of the revised Arthritis Impact Measurement Scale (AIMS2) in patients with rheumatoid arthritis or osteoarthritis of the hip. METHODS: translation of the English-language AIMS2 into French using the back-to-back technique; evaluation of feasibility on the basis of a) time needed to complete the AIMS2; b) percentage of questionnaires with at least one missing answer or one answer indicating that the question was misunderstood; evaluation of relevance on the basis of correlations between AIMS2 scores and conventional parameters for evaluating the activity of rheumatoid arthritis (85 patients); evaluation of sensitivity on the basis of total hip replacement-induced improvements in AIMS2 scores versus other conventional scores used to evaluate activity of osteoarthritis of the hip (48 patients). RESULTS: feasibility, mean time needed to complete the AIMS2 was 23 minutes in rheumatoid arthritis patients and 26 minutes in osteoarthritis patients. Forty per cent of patients failed to answer at least one question and 21% misunderstood at least one question; relevance: conventional parameters used in rheumatoid arthritis accounted for 51% of AIMS2 score variance, suggesting that the AIMS2 provided information not supplied by conventional parameters. SENSITIVITY: after total hip replacement for osteoarthritis, there were statistically significant decreases in all AIMS2 scores (with the exception of function and work). CONCLUSION: These data suggest that the AIMS2 score is not an easy evaluation tool but is both relevant and sensitive. These findings require confirmation by longitudinal studies.

Ultrasound-guided injection in osteoarticular pathologies: general principles and precautions.

In the past, needle aspirations or injections involving the motor system were always carried out either blind or guided by fluoroscopy. Over the last few years, sonography has begun to offer an interesting alternative. Its advantages are that it is a relatively inexpensive technique, while not emitting ionising radiation and being easily accessible. There has been a great deal of technical progress including high frequency transducers, which have led to performance improvements in terms of both diagnosis and treatment of pathologies of the motor system. Due to these technical advances and to sterile covers for the transducers, it is now possible to visualise and to aspirate or inject into a peripheral joint, a tendon sheath or a bursa with or without effusion. This technique does not require a contrast medium injection because the needle position can be checked directly. Minimally invasive, it allows a number of interventions to be carried out with a very low complication rate since the entire path of the needle is followed using sonography, which means that nerves, vessels and other structures can be avoided because they are visualised directly in real time.

Radiographic and microscopic anatomy of the mid-palatal suture in the elderly.

In a previous radiological study of the mid-palatal suture, it has been demonstrated that its obliteration was occurring during adult life and varied. In order to determine the histological status of mid-palatal suture in elderly men, 20 human palates aged more than 70 were examined by occlusal radiographs and histological study of the suture. In all palates the suture was ossified in the anterior thirds and made of conjunctive tissue in the posterior third. This particular evolution could be correlated to the mastication forces acting on the maxillary bones during the entire life.

Synovitis: a potential predictive factor of structural progression of medial tibiofemoral knee osteoarthritis -- results of a 1 year longitudinal arthroscopic study in 422 patients.

OBJECTIVE: To evaluate the prevalence of synovitis in painful medial tibiofemoral knee osteoarthritis (OA) and to evaluate correlation between synovitis and the structural severity and progression of tibiofemoral cartilage damage. STUDY: Multicenter, longitudinal, 1-year duration. PATIENTS: Primary painful knee OA (ACR criteria) of the medial tibiofemoral compartment, with pain of the signal knee on at least 30 days in the past 2 months, medial joint space width > or = 2mm, at least 10% of one cartilage surface of the medial compartment affected by superficial fibrillation or worse at baseline arthroscopy. ARTHROSCOPIC PARAMETERS: Knee arthroscopy under local anesthesia was performed and videorecorded at entry and after 1 year. Medial chondropathy was scored by using Societe Francaise d'Arthroscopie (SFA) score (0-100) and reader's overall assessment (VAS score, 100 mm). Progression of medial chondropathy was defined by a change in SFA and VAS scores over 4.5 and 8.0 mm after 1 year, respectively. Medial perimeniscal synovium was scored as normal (few translucent and slender villi, fine vascular network), reactive (proliferation of opaque villi), or inflammatory (hypervascularization and/or proliferation of hypertrophic and hyperemic villi). Medial chondropathy and synovitis were scored by a single reader blind to chronology of paired videotapes. RESULTS: Four hundred and twenty-two patients were enrolled (mean age: 61 years, females: 59%, body mass index: 31, mean disease duration: 4 years) and completed the 1-year study. Synovial abnormalities were present in 50% of the patients with reactive and inflammatory aspects in 29% and 21% of the patients, respectively. Patients with a reactive or inflammatory medial synovium had a more severe medial chondropathy. The worsening in medial chondropathy after 1 year was statistically more severe in the group of patients with an inflammatory perimeniscal synovial membrane at baseline compared to patients with normal and reactive aspects, with no difference between these two latter groups. The odds ratio for progression in VAS score after 1 year was 3.11 (95% CI [1.07, 5.69]) for patients with inflammatory synovium at baseline compared to patients with normal synovium. CONCLUSIONS: This study suggests that abnormalities of the medial perimeniscal synovium are a common feature of painful medial knee OA, associated with more severe medial chondropathy. It also suggests that an inflammatory aspect of the medial perimeniscal synovium could be considered as a predictive factor of subsequent increased degradation of medial chondropathy.