Contemporary outcomes of primary total hip arthroplasty in patients with inflammatory arthritis.

Aims: Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods: We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m2 (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results: The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion: Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis.

Arthroscopic synovectomy versus intra-articular injection of corticosteroids for the management of refractory psoriatic or rheumatoid arthritis of the wrist: study protocol for a randomized controlled trial (ARCTIC trial).

BACKGROUND: Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are inflammatory diseases that often affect the wrist and, when affected, can lead to impaired wrist function and progressive joint destruction if inadequately treated. Standard care consists primarily of disease-modifying anti-rheumatic drugs (DMARDs), often supported by systemic corticosteroids or intra-articular corticosteroid injections (IACSI). IACSI, despite their use worldwide, show poor response in a substantial group of patients. Arthroscopic synovectomy of the wrist is the surgical removal of synovitis with the goal to relieve pain and improve wrist function. The primary objective of this study is to evaluate wrist function following arthroscopic synovectomy compared to IACSI in therapy-resistant patients with rheumatoid or psoriatic arthritis. Secondary objectives include radiologic progress, disease activity, health-related quality of life, work participation and cost-effectiveness during a 1-year follow-up. METHODS: This protocol describes a prospective, randomized controlled trial. RA and PsA patients are eligible with prominent wrist synovitis objectified by a rheumatologist, not responding to at least 3 months of conventional DMARDs and naïve to biological DMARDs. For 90% power, an expected loss to follow-up of 5%, an expected difference in mean Patient-Rated Wrist Evaluation score (PRWE, range 0-100) of 11 and α = 0.05, a total sample size of 80 patients will be sufficient to detect an effect size. Patients are randomized in a 1:1 ratio for arthroscopic synovectomy with deposition of corticosteroids or for IACSI. Removed synovial tissue will be stored for an ancillary study on disease profiling. The primary outcome is wrist function, measured with the PRWE score after 3 months. Secondary outcomes include wrist mobility and grip strength, pain scores, DAS28, EQ-5D-5L, disease progression on ultrasound and radiographs, complications and secondary treatment. Additionally, a cost-effectiveness analysis will be performed, based on healthcare costs (iMCQ questionnaire) and productivity loss (iPCQ questionnaire). Follow-up will be scheduled at 3, 6 and 12 months. Patient burden is minimized by combining study visits with regular follow-ups. DISCUSSION: Persistent wrist arthritis continues to be a problem for patients with rheumatic joint disease leading to disability. This is the first randomized controlled trial to evaluate the effect, safety and feasibility of arthroscopic synovectomy of the wrist in these patients compared to IACSI. TRIAL REGISTRATION: Dutch trial registry (CCMO), NL74744.100.20. Registered on 30 November 2020. CLINICALTRIALS: gov NCT04755127. Registered after the start of inclusion on 15 February 2021.

Musculoskeletal Surgery in Psoriatic Arthritis: Prevalence and Risk Factors.

OBJECTIVE: Despite medical therapy, damage occurs in patients with psoriatic arthritis (PsA) requiring musculoskeletal (MSK) surgery. We aimed to describe MSK surgery in patients with PsA and identify risk factors for undergoing first MSK surgery attributable to PsA. METHODS: A single-center cohort identified patients with PsA fulfilling Classification Criteria for Psoriatic Arthritis who had MSK surgery between January 1978 and December 2019 inclusive. Charts were reviewed to confirm surgeries were MSK-related and attributable to PsA. Descriptive statistics determined MSK surgery prevalence and types. Cox proportional hazards models evaluated clinical variables for undergoing first MSK surgery using time-dependent covariates. Using a dataset with 1-to-1 matching on markers of PsA disease severity, a Cox proportional hazards model evaluated the effect of targeted therapies, namely biologics on time to first MSK surgery. RESULTS: Of 1574 patients, 185 patients had 379 MSK surgeries related to PsA. The total number of damaged joints (hazard ratio [HR] 1.03, P < 0.001), tender/swollen joints (HR 1.04, P = 0.01), presence of nail lesions (HR 2.08, P < 0.01), higher Health Assessment Questionnaire scores (HR 2.01, P < 0.001), elevated erythrocyte sedimentation rate (HR 2.37, P = 0.02), and HLA-B27 positivity (HR 2.22, P = 0.048) were associated with increased risk of surgery, whereas higher Psoriasis Area Severity Index (HR 0.88, P < 0.002) conferred a protective effect in a multivariate model. The effect of biologics did not reach statistical significance. CONCLUSION: MSK surgery attributable to PsA is not rare, affecting 11.8% of patients. Markers of cumulative disease activity and damage are associated with a greater risk of requiring surgery.

Concise report: a minimal-invasive method to retrieve and identify entheseal tissue from psoriatic arthritis patients.

OBJECTIVES: To establish a minimally invasive biopsy technique for the analysis of entheseal tissue in patients with psoriatic arthritis (PsA). METHODS: Human cadavers were used for establishing the technique to retrieve tissue from the lateral humeral epicondyle enthesis (cadaveric biopsies). After biopsy, the entire enthesis was surgically resected (cadaveric resections). Biopsies and resections were assessed by label-free second harmonic generation (SHG) microscopy. The same technique was then applied in patients with PsA with definition of entheseal tissue by SHG, staining of CD45+immune cells and RNA extraction. RESULTS: Entheseal biopsies from five cadavers allowed the retrieval of entheseal tissue as validated by the analysis of resection material. Microscopy of biopsy and resection sections allowed differentiation of entheseal, tendon and muscle tissue by SHG and definition of specific intensity thresholds for entheseal tissue. In subsequent entheseal biopsies of 10 PsA patients: the fraction of entheseal tissue was high (65%) and comparable to cadaveric biopsies (68%) as assessed by SHG microscopy. Furthermore, PsA biopsies showed immune cell infiltration and sufficient retrieval of RNA for further molecular analysis. CONCLUSION: Entheseal biopsy of the lateral epicondyle is feasible in patients with PsA allowing reliable retrieval of entheseal tissue and its identification by SHG microscopy.

Major differences in medical and surgical treatment of psoriatic arthritis and rheumatoid arthritis: a comparison of two historic cohorts.

OBJECTIVES: Substantial changes in the handling of patients with inflammatory arthritis have occurred during the past half century. Polyarticular psoriatic arthritis (PsA) has been treated with the same synthetic disease-modifying anti-rheumatic drugs (DMARDs) as rheumatoid arthritis (RA), but for PsA there is less documentation regarding their effect. For biologic DMARDs, evidence of effect is more convincing. We have previously investigated the risk of orthopaedic surgery in patients with RA and PsA to see whether the change in treatment over time has improved the long-term outcome of inflammatory arthritis. For RA, patients diagnosed from 1999 onwards had a lower risk of surgery than patients diagnosed in earlier years. For PsA, the risk of surgery did not change similarly. We wished to compare RA patients to PsA patients with regard to medical and surgical treatment. METHOD: We compared a historic cohort of 1010 RA patients diagnosed in 1972-2009 to a historic cohort of 590 PsA patients diagnosed in 1954-2011. RESULTS: PsA patients received significantly less medical treatment both in the first year of disease and during the disease course. Risk of surgery during the disease course was lower for PsA than for RA (20% vs 31%). The risk of surgery in RA patients diagnosed from 1999 onwards was similar to that of PsA patients. CONCLUSIONS: PsA patients received less intensive treatment than RA patients. Their prognosis, regarding orthopaedic surgery, was also less severe. Contrary to RA, the change in treatment did not have beneficial effects regarding the risk of orthopaedic surgery.

Incidence and time trends of joint surgery in patients with psoriatic arthritis: a register-based time series and cohort study from Denmark.

OBJECTIVE: To investigate time-trends and cumulative incidence of joint surgery among patients with psoriatic arthritis (PsA) compared with the general population. METHODS: In this nationwide register-based cohort study, The Danish National Patient Registry was used to identify incident PsA patients. The 5-year incidence rates (IR) and incidence rate ratios (IRR) of joint surgery were calculated in four calendar-period defined cohorts. Each patient was matched with ten non-PsA individuals from the general population cohort (GPC). The cumulative incidences of any joint and joint-sacrificing surgery, respectively, were estimated using the Aalen-Johansen method. RESULTS: From 1996 to 2017, 11 960 PsA patients (mean age 50 years; 57% female) were registered. The IRR of any joint surgery was twice as high for PsA patients compared with GPCs across all calendar periods. Among patients with PsA, 2, 10 and 29% required joint surgery at 5, 10 and 15 years after diagnosis. The risk of surgery in PsA patients diagnosed at 18-40 years was higher (22%) than in GPC 60+ year old (20%) after 15 years of follow-up. CONCLUSIONS: The use of joint surgery among PsA patients remained around twofold higher from 1996 to 2012 compared with GPC. After 15 years of follow-up, nearly 30% of the PsA patients had received any surgery, and even a person diagnosed with PsA at the age of 18-40 years had a higher risk of surgery than GPCs of 60+ year old. Thus, the high surgical rates represent an unmet need in the current treatment of PsA.

Treatment of end stage temporomandibular joint disorder using a temporomandibular joint total prosthesis: The Slovenian experience.

PURPOSE: The aim of this study was to analyse treatment results after alloplastic temporomandibular joint replacement surgery. MATERIALS AND METHODS: Twelve patients who met the inclusion criteria underwent operation between the years 2012 and 2016 at the Department of Maxillofacial and Oral Surgery of the University Medical Centre Ljubljana, Slovenia. Seven patients had posttraumatic sequelae, 4 osteoarthritis and 1 psoriatic arthritis. We inserted 12 temporomandibular joint prostheses (Biomet- Lorenz). A retrograde analysis of the patients, subjective assessment of the pre- and postoperative temporomandibular pain, opening the mouth, the ability to chew food, and quality of life (VAS scale, 0-10) was performed. Additionally, we evaluated the inter-incisal distance pre- and postoperatively. Complications that occurred were also included in our evaluation. RESULTS: During final examinations, at least 15 months after the surgery (on average 39.5 months), we observed an improved ability to open the mouth in all patients. The average preoperative inter-incisal distance was 22 mm (15-30 mm); the average postoperative distance was 37.5 mm (32.3-1.8 mm), (p < 0.001). The analysis of pain and other subjective variables (opening the mouth, the ability to chew, quality of life) showed a statistically significant improvement (p < 0.001). CONCLUSION: According to our initial experience, replacement of the temporomandibular joint with a total prosthesis is a safe and effective treatment method.

Increasing Rates of Arthroplasty for Psoriatic Arthritis in the United Kingdom Between 1995 and 2010.

OBJECTIVE: Arthroplasty requirements among patients with psoriatic arthritis (PsA) are not well known. This information is important to clinical and policy stakeholders for health-system planning and may serve as a surrogate for estimation of the efficacy of disease-modifying therapy. METHODS: We utilized The Health Improvement Network (THIN), a large general practice medical records database in the UK, to assess rates of primary total arthroplasty among patients with PsA and the general population between the years 1995 and 2010. Linear regression was used to estimate arthroplasty rates for the 2 cohorts during the study period, and Poisson regression was used to determine age- and sex-adjusted incidence rate ratios (IRRs) between the PsA and general population cohorts. RESULTS: We identified 5,619 patients with incident PsA and 5,090,814 eligible patients from the general population between 1995 and 2010. In total, 187 primary total arthroplasties were documented in patients with PsA, and 80,163 primary total arthroplasties were documented in the general population. A trend of increasing arthroplasty rates was observed for both the PsA (R2 = 0.809; P < 0.0001) and general population (R2 = 0.890; P < 0.0001) cohorts during the study period. After adjustment for age and sex, patients with PsA had a first arthroplasty incidence rate that was twice that of the general population (IRR 2.01 [95% confidence interval 1.73-2.34]; P < 0.0001), notably beyond the year 2003 when biologic therapies were introduced. CONCLUSION: Both the general population and patients with PsA have experienced increasing rates of first arthroplasty from 1995 to 2010, although the overall incidence rate was significantly higher for those with PsA.

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis.

OBJECTIVE: To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery. METHODS: We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital's administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery. RESULTS: There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30-59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954-1985 vs 1999-2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time. CONCLUSION: There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

[Total hip arthroplasty in patients with Psoriatic arthritis].

Objective: To evaluate the clinical efficacy of Total hip arthroplasty (THA) in treating the hip joint involvement of Psoriatic arthritis (PsA). Methods: From January 2005 to December 2016, a total of 15 PsA patients (20 hip joints) underwent THA in Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. All the patients had obvious restriction in daily life before operation. The mean Harris score was 25.2 averagely and the mean total range of the hip joint movement was 39.6° before surgery. All the prosthesis were biotype and ceramic to ceramic. Results: All patients were followed up with an average of 35.7 months and could take care of themselves. The Harris score of hip joint was 83.2 averagely, including 15 hips excellent, 3 good, and 2 passable, with an excellent and good rate of 90%. The mean total range of the hip joint movement was 175° after surgery. There was no infection, nerve injury or loosening of the prosthesis. 1 hip appeared avulsion fracture of greater trochanter of femur, and the joint function was satisfying at the last time of follow-up. Conclusion: THA is an effective method in treating affected hip joint of PsA. It can restore the hip function and improve the life quality of the PsA patients.

From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis.

Treatment with systemic immunomodulatory agents is indicated for patients with moderate to severe plaque psoriasis and psoriatic arthritis. In these patients, surgery may confer an increased risk of infectious or surgical complications. We conducted a literature review to examine studies addressing the use of methotrexate, cyclosporine, and targeted immunomodulatory agents (tumor necrosis factor-alfa inhibitors, interleukin [IL]-12/23 inhibitors, IL-17 inhibitors) in patients undergoing surgery. We examined 46 total studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. One study in patients with psoriasis and psoriatic arthritis reviewed 77 procedures and did not find an elevated risk of postoperative complications with tumor necrosis factor-alfa and IL-12/23 inhibitors even with major surgeries. Based on level III evidence, infliximab, adalimumab, etanercept, methotrexate, and cyclosporine can be safely continued through low-risk operations in patients with psoriasis and psoriatic arthritis. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient's individual risk factors and comorbidities.

Short-Term Total Hip Arthroplasty Outcomes in Patients With Psoriatic Arthritis or Psoriatic Skin Disease Compared to Patients With Osteoarthritis.

OBJECTIVE: Outcomes of total hip arthroplasty (THA) in patients with psoriasis have been poorly studied. This study was undertaken to assess whether patients with psoriatic arthritis (PsA) or those with cutaneous psoriasis (PsC) without evidence of inflammatory joint disease are at an increased risk for worse outcomes after THA as compared to patients with osteoarthritis (OA). METHODS: Among subjects in a prospective THA registry, PsA and PsC cases were identified by International Classification of Diseases, Ninth Revision codes, and all cases were matched with patients with OA as controls. Analyses were performed to identify predictors of poor postoperative pain or function. RESULTS: Of the 289 potential cases of PsA or PsC, 63 with PsA and 153 with PsC were validated. Self-report data were available postoperatively from 75% of PsA patients, 69% of PsC patients, and 94% of OA controls. In total, 51% of PsA patients and 56% of PsC patients were male, compared to 45% of OA controls (P = 0.04). Body mass index was higher in those with PsA or PsC (P = 0.002 versus controls). There were no differences in race or education between the 3 groups. PsA patients and PsC patients had more comorbidities than OA controls. PsA patients were more likely than PsC patients and OA controls to be current or previous smokers. Moreover, 54% of PsA patients were being treated with biologics or nonbiologic disease-modifying antirheumatic drugs, compared to 8% of PsC patients. There were no significant differences in pre- or postoperative Western Ontario and McMaster Universities OA Index scores for pain or function between the 3 groups. Short-Form 36 mental component summary scores were significantly better in the OA controls, both pre- and postoperatively (P = 0.006 and P < 0.001, respectively, versus PsA or PsC). EuroQol 5-domain health-related quality of life scores were significantly worse postoperatively for those with PsA or PsC (P < 0.0001 versus OA controls). In regression analyses, neither PsA nor PsC were risk factors for worse THA outcomes. Satisfaction with the outcomes of THA was similarly high among all 3 groups (P = 0.54). CONCLUSION: Neither PsA nor PsC are risk factors for poor outcomes after THA. This is important information to convey to patients with either PsA or PsC who are contemplating surgical intervention with THA.

Management of the temporomandibular joint in rheumatoid disorders.

This article summarises the rheumatoid diseases that particularly affect the temporomandibular joint (TMJ): psoriatic arthropathy, ankylosing spondylitis, and rheumatoid arthritis. Management is by a joint approach between rheumatologists and maxillofacial surgeons with a specific interest in diseases of the TMJ who give early surgical advice. Steroid injections, whilst useful in the short term, are not useful for long term or repeated treatment, and may lead to collapse of the joint and development of a deformed anterior open bite. These disorders should be managed primarily using standard conservative regimens, and failure to respond should lead to diagnostic or therapeutic arthroscopy and appropriate surgical treatment. When ankylosis develops or the joint collapses, a replacement joint should be considered and patients should be referred to an appropriately trained surgeon.

Replacement with silicone wrist implant after failed silicone wrist arthroplasty: 3 case reports in inflammatory arthritis.

Revision surgery after failed silicone wrist arthroplasty is often challenging. In particular, in cases of inflammatory arthritis there is a high incidence of extensive bone loss which leads to a high complication rate in wrist fusion as a salvage procedure. Sometimes the surgeon may be faced with a patient in poor overall medical condition, who is very low demand so that the complexities of wrist fusion after a failed silicone arthroplasty may be contraindicated. For that situation, revision with a silicone prosthesis is a easy method in cases of severe osseous destruction in low demand patients with a long history of inflammatory arthritis.With 3 case reports will describe the topic of replacement with silicone wrist implant after failed silicone wrist arthroplasty.

Heparin-induced thrombocytopenia after total knee arthroplasty, with subsequent adrenal hemorrhage.

Heparin-induced thrombocytopenia (HIT) is a life-threatening immune-mediated adverse effect of chemoprophylaxis for venous thromboembolic events. We present the case of a 44-year-old man who developed bilateral adrenal hemorrhage (BAH) as a sequela of HIT after bilateral total knee arthroplasty. In our review of clinical management of HIT-induced BAH, we discuss the 21 published cases of this phenomenon, 14 of which occurred after orthopedic surgery. Given the potentially fatal consequences and the importance of early intervention, physicians should be on the alert for recognizing HIT-induced BAH in patients experiencing shock unresponsive to fluid resuscitation. In addition, chemoprophylaxis with alternative agents such as a synthetic pentasaccharide factor Xa inhibitor and oral direct thrombin inhibitors that are associated with lower risks of HIT in orthopedic patients merits exploration.

Radiolunate and radioscapholunate arthrodeses as treatments for rheumatoid and psoriatic arthritis: long-term follow-up.

PURPOSE: We evaluated long-term results for radiolunate and radioscapholunate arthrodeses for patients with rheumatoid or psoriatic arthritis to determine the durability and efficacy of the procedures. The results are described and compared with those in the literature. METHODS: We carried out arthrodesis of the radiolunate joint (33 wrists) and the radioscapholunate joint (13 wrists) to achieve pain reduction and ulnar translation of the carpus in patients with rheumatoid (42 wrists) or psoriatic arthritis (4 wrists). At follow-up, 11 patients (13 wrists) had died, 2 patients (4 wrists) were lost to follow-up, and in 6 wrists an additional midcarpal arthrodesis had been performed. We evaluated the remaining 23 wrists (19 radiolunate and 4 radioscapholunate, and 1 psoriatic arthritic wrist) after a mean of 11 years. RESULTS: Clinical outcome was good, with a mean visual analog score of 2 out of 10 for pain, mean grip strength of 13 kg, and mean range of flexion-extension of 60°. Outcomes as measured by questionnaires were good. Radiographs demonstrated deterioration of all intracarpal joints as noted by an increased Larsen score and evidence of carpal translation. We noted no significant change in carpal height. CONCLUSIONS: Despite radiographic progression, radiolunate and radioscapholunate arthrodeses yield good clinical results at long-term follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Psoriatic arthritis.

Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of patients with psoriasis. Arthritis is not correlated with the extent of skin disease. Classic radiographic findings of the involved joint include erosion, ankylosis, and fluffy periostitis. Site-specific characteristic deformities such as pencil-in-cup deformity of the phalanges also may be present. The disease typically follows a moderate course, but up to 47% of cases develop into destructive arthritis in which the inflammatory process leads to bony erosion and loss of joint architecture. The mainstay of treatment is biologic therapy (eg, tumor necrosis factor-α inhibitors) in conjunction with disease-modifying antirheumatic drugs. Patients with end-stage joint destruction may require surgery to alleviate pain and restore function. Orthopaedic surgeons should be cognizant of the risk factors (eg, increased risk of cardiovascular disease) and potential complications (eg, poor wound healing and increased risk of infection) associated with psoriatic arthritis.

Universal total wrist arthroplasty: midterm follow-up study.

PURPOSE: We reviewed 21 consecutive patients who underwent a total wrist arthroplasty as a primary procedure between October 2001 and February 2007. The purposes of the present study were to communicate our midterm results and to compare them with previously published series. METHODS: We evaluated all patients clinically and radiologically. We used the Patient-Related Wrist Evaluation a primary outcome measure. The mean follow-up was 5.5 years (range, 3-8 years). A total of 14 patients had rheumatoid arthritis, including 1 with juvenile arthritis, and 1 each had psoriatic arthritis, systemic lupus erythematosus, and undifferentiated spondyloarthropathy. Of the remaining 4 patients, 2 had grade IV Kienböck disease, 1 had degenerative arthrosis, and 1 had chondrocalcinosis. RESULTS: Postoperative Patient-Related Wrist Evaluation scores averaged 24 points (SD, 21 pints) out of 100 (worst score). When the patients were specifically asked about pain and function of the arthroplasty, 20 claimed to be satisfied or very satisfied with the procedure. Two early and 3 late complications occurred. One patient had a wound hematoma and another had a superficial wound infection, both of which resolved with no further complications during the immediate postoperative period. In 2 patients, there was some osteolysis around the screw inserted into the medullary canal of the index metacarpal, but not in the trapezoid bone. One patient had a slight loosening of the distal component with subsidence on the ulnar side of the carpus. There have been no dislocations or surgical revisions of the components. CONCLUSIONS: Based on our study, a total wrist arthroplasty should be considered as a good alternative to arthrodesis for patients who wish to preserve some degree of mobility of the wrist. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of psoriatic arthritis.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that can be progressive and may be associated with permanent joint damage and disability. Early identification of PsA will enable these patients with progressive disease to be treated early and aggressively. Due to lack of consistent diagnostic or classification criteria in the past, PsA was considered as uncommon. Overall it affects 6-10% of all psoriasis patients during the course of their disease. Both dermatologists and rheumatologists should be involved in the diagnosis and management of this disorder. Interest in PsA has greatly enhanced over the past several years due to many factors including a better understanding of disease mechanisms, improved investigational tools, better clinical trial design and perhaps most importantly, the availability of newer therapeutic agents. Mild forms of PsA can initially be treated with nonsteroidal antiinflammatory drugs (NSAID). In acute as well as oligo- to polyarticular joint involvement, disease-modifying anti-rheumatic drugs (DMARD) are indicated for PsA. The biologics particularly tumor necrosis factor alpha (TNF-α) antagonists are gaining increasing significance as second-line therapy. Treatment choice should also take into consideration the extent of skin involvement.

Possible association between NOD2 variants and joint surgery in psoriatic arthritis.

BACKGROUND: Psoriatic arthritis (PsA) has been inconsistently associated with common NOD2 gene variants, although some of these studies did not include patient stratification by clinical phenotype. OBJECTIVES: To analyse the association between the three common NOD2 variants (R702W, G908R and L1007fs) and clinical phenotypes of PsA, particularly with surrogate markers of severe joint destruction. PATIENTS AND METHODS: A total of 183 unrelated PsA patients and 187 controls were included. Demographic, clinical, biological and immunological characteristics were collected. Genotypes for the three common NOD2 gene variants were obtained by PCR and direct sequencing. RESULTS: NOD2 variants in PsA patients (7.6%) are just as prevalent as in healthy controls (7.5%). 18.5% of PsA patients carrying at least one NOD2 variant underwent joint surgery compared with 4.5% of those without these variants (p=0.019). Multivariate analysis confirmed this finding (OR 8.82, CI 1.7-46.3). There was no requirement for early surgery in patients carrying the NOD2 variants but there was an increased possibility of requiring surgery at similar times of disease duration. No other association with clinical features and NOD2 status carrier was found. CONCLUSIONS: Common NOD2 gene variants are not associated with PsA, but might increase the risk of undergoing joint replacement surgery, suggesting that this autoinflammatory-associated gene could act as a phenotypic modifier gene in PsA patients by increasing the risk of joint destruction. Given the small number of PsA patients with joint surgery included, we consider our findings a new hypothesis that will need further testing.