Ultrasound detection of subclinical synovitis in rheumatoid arthritis patients in clinical remission: a new reduced-joint assessment in 3 target joints.

OBJECTIVES: The ability of ultrasound (US) to identify subclinical joint inflammation in rheumatoid arthritis (RA) patients in remission has been already reported. Nonetheless, current studies present a lack of homogeneity in patient's characteristics and number of joints assessed by US. The aim of this study was to identify a reduced set of target joints to be scanned in RA patients in clinical remission in order to detect subclinical synovitis. METHODS: Forty RA patients in clinical remission (DAS28 ≤2.6) for at least 3 months underwent an US examination of 18 joints: wrist, II-III-IV-V metacarpophalangeal (MCP) and II-III-IV-V metatarsophalangeal joints bilaterally. The presence of synovial hypertrophy (SH) and power-Doppler (PD) signal was registered following the OMERACT definitions and was graded according to a 4-point scale (0-3). Then, by applying a process of data reduction based on the frequency of joint involvement, a reduced assessment was obtained. RESULTS: Twenty (50%) subjects had at least one joint affected by active synovitis; 17.5% presented grade 1 PD and 32.5% grade 2 PD. The joints most frequently affected by active synovitis were the wrists (75%) and the II MCP joints (55%). After data reduction, the evaluation of 3 joints (both wrists and the II MCP of the dominant hand) obtained a sensitivity of 90% for the detection of subclinical synovitis. CONCLUSIONS: The US scan of 3 target joints showed a high sensitivity in detecting subclinical active synovitis in RA patients in clinical remission and can be feasible in the routine assessment of these patients.

Incarcerated Plantar Dislocation of the First Metatarsophalangeal Joint: Reduction Using Intra-articular Saline Injection.

Plantar dislocation of the first metatarsophalangeal (MTP) joint is exceedingly rare, and in prior reported cases, simple closed manipulation easily enabled reduction. We present here the first reported plantar dislocation that failed closed manipulation. We also report a technique involving injection of saline into the joint to facilitate reduction. The saline insufflation likely relieves buttonholing of the metatarsal head through the dorsal joint capsule. For first MTP joint plantar dislocations that fail reduction with manipulation, we recommend attempting injection of the joint with saline prior to subjecting the patient to open reduction. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Are ultrasound features at the first metatarsophalangeal joint associated with clinically-assessed pain and function? A study of people with gout, asymptomatic hyperuricaemia and normouricaemia.

BACKGROUND: The first metatatarsophalangeal joint (1st MTP joint) is a common location for sonographic evidence of urate deposition in people with gout and asymptomatic hyperuricaemia. However, it is unclear whether these are related to clinically-assessed pain and function. This study aimed to determine the association between ultrasound features and clinical characteristics of the 1st MTP joint in people with gout, asymptomatic hyperuricaemia and age- and sex-matched normouricaemic individuals. METHODS: Twenty-three people with gout, 29 with asymptomatic hyperuricaemia and 34 with normouricaemia participated in a cross-sectional study. No participant had clinical evidence of acute inflammatory arthritis at the time of assessment. Four sonographic features at the 1st MTP joint were analysed: double contour sign, tophus, bone erosion and synovitis. Clinical characteristics included in the analysis were 1st MTP joint pain, overall foot pain and disability, 1st MTP joint temperature, 1st MTP joint range of motion and gait velocity. Statistical analyses adjusted for the diagnostic group of the participant. RESULTS: After accounting for the diagnostic group, double contour sign was associated with higher foot pain and disability scores (P < 0.001). Ultrasound tophus was associated with higher foot pain and disability scores (P < 0.001), increased temperature (P = 0.005), and reduced walking velocity (P = 0.001). No associations were observed between ultrasound synovitis or erosion and the clinical characteristics. CONCLUSIONS: Ultrasound features of urate crystal deposition, rather than soft tissue inflammation or bone erosion, are associated with clinical measures of foot-related functional impairment and disability even in the absence of clinical evidence of current acute inflammatory arthritis. This association persisted regardless of the diagnosis of the participant as having gout or asymptomatic hyperuricaemia.

Usefulness of plain radiography for assessing hypouricemic treatment response in patients with tophaceous gout.

AIM: To investigate whether plain radiography is useful for assessing the changes in gouty tophi size following hypouricemic therapy. METHODS: Gout was diagnosed according to the American College of Rheumatology criteria. Before and after hypouricemic treatment, serum uric acid level was measured, and plain radiography was performed to measure gouty tophi size. The tophi were graded by measuring the maximum vertical and horizontal diameters, and they were scored by adding up the scores of the grades. The vertical diameter was measured on both sides of the proximal phalanges (PPs). The horizontal diameter was measured on the lateral side of the PPs. The maximum vertical diameter measurement was graded 0-4. The maximum horizontal diameter measurement was graded 0-3. RESULTS: Seven hundred first metatarsal phalangeal joints (MTPJ) of 350 patients with gout were assessed for gouty tophi. Tophi were observed using plain radiography in 174 MTPJs (24.9%) of 109 patients (31.1%). Follow-up plain radiography was performed in 60 of these patients. Before the treatment, the average serum uric acid level of these patients was 8.3 ± 1.9 mg/dL, and the average tophi score was 3.7 ± 2.5. After hypouricemic treatment, the uric acid level decreased to 5.9 ± 1.6 mg/dL (P < 0.05), and the average tophi score decreased to 1.5 ± 1.8 (P < 0.05). CONCLUSIONS: This new method for measuring gouty tophi using plain radiography may be useful for evaluating changes in gouty tophi size following hypouricemic treatment.

Sonography of the first metatarsophalangeal joint and sonographically guided intraarticular injection of corticosteroid in acute gout attack.

OBJECTIVE: The aims of this study were to identify the characteristic ultrasound (US) findings of the first metatarsophalangeal joint (MTPJ1) in acute gout attack and to evaluate the efficacy and safety of US-guided intraarticular corticosteroid injection of the MTPJ1. METHODS: We enrolled 21 patients with acute gout attack involving the MTPJ1 unilaterally. US evaluation of each affected MTPJ1 was compared with radiographic features. US-guided intraarticular corticosteroid (0.5 ml [20 mg] of triamcinolone mixed with 0.5 ml of 2% lidocaine) was injected into the affected MTPJ1s. Pain, general disability, and walking disability were assessed at baseline, 24 hours, 48 hours, and 7 days after injection with visual analog scales. RESULTS: The characteristic US findings of MTPJ1 were erosion, joint effusion, synovial hypertrophy, tophus-like lesion, double contour, hyperechoic spots, and increased power Doppler signal in acute gout attack. US was more sensitive than conventional radiograph in detecting erosion and tophus-like lesion. The reductions of mean visual analog scale scores in pain, general disability, and walking disability were 48 mm (SD, 27), 35 mm (SD, 26) and 39 mm (SD, 26), respectively, 48 hours after US-guided intraarticular corticosteroid injection. There were no adverse events. CONCLUSIONS: US is a sensitive tool to evaluate joint abnormality of the MTPJ1 in acute gout attack and US-guided intraarticular corticosteroid injection to this joint is effective and safe.

Patterns of magnetic resonance imaging of the foot in rheumatoid arthritis: which joints are most frequently involved?

To investigate patterns of inflammatory MRI pathologies of the fore- and midfoot in rheumatoid arthritis (RA) and early RA (ERA) and their changes under therapy. In this prospective study, MRI data of the foot of 39 RA patients (29 female, 10 male; age: 54 ± 13 years; disease duration: 35 ± 37 months; baseline DAS28: 3.0 ± 2.0; medication: 29 DMARD, 1 biological, 9 symptomatic or non-specific treatment) were evaluated for synovitis in 314 joints, bone marrow edema and erosions according to RAMRIS criteria in a total of 585 joints. The change in joint pathology intensity was evaluated on follow-up MRI (time of follow-up: 8 ± 4 months) in 25 patients. Inflammation was generally more frequent in the metatarsophalangeal (MTP) joints (221/292; 76 %) than in the proximal metatarsal (47/292; 16 %) and tarsal bones (24/292; 8 %). The overall most frequently involved joints of the foot were MTP 5 (51/292; 18 %) and 1 (49/292; 17 %). Change under therapy was most frequently seen in the MTP 1 joint. Progress of inflammation in the MTP 1 was more frequently found in ERA patients than in patients with established RA (disease duration >12 months) (p = 0.002). In RA, the MTP joints, primarily MTP 5 and 1, are the predominant sites of inflammatory MRI pathologies of the foot. A change of inflammatory activity under therapy can be most frequently noted in the MTP 1 joint. This information might be helpful to improve effectiveness of MRI-controlled therapy approaches and clinical trials.

Characteristics of patients with rheumatoid arthritis in clinical remission: the many aspects of DAS28 remission.

OBJECTIVES: The aim of this study was to observe the clinical characteristics, including the extent of foot and ankle involvement, of Korean patients with rheumatoid arthritis (RA) in remission, defined as Disease Activity Score in 28 joints (DAS28) <2.6. METHODS: Data from a registry of RA patients who visited a rheumatology clinic of a university-affiliated hospital and who were regularly evaluated with DAS28, including the ankle and foot metatarsophalangeal (MTP) joints were enrolled. Patients who were treated with disease-modifying anti-rheumatic drugs for at least three months and who were in DAS28 remission were included in this study. RESULTS: Two hundred and thirteen episodes of DAS28 remission were observed in 147 patients. The mean DAS28 value at the time of remission was 1.84 (range, 0.14-2.59). The mean numbers of swollen joints and tender joints (of the 28 joints examined for DAS28) at the time of remission was 0.4 (range, 0-6) and 1.5 (range, 0-13), respectively. Overall, 11.7% and 38% of the patients in clinical remission had foot MTP/ankle swollen and tender joints, respectively. Additionally, 7% and 8.9%, respectively, of the patients in clinical remission had foot MTP/ankle swollen and tender joints without any involvement of the 28 joints included in the DAS28. CONCLUSIONS: Our results show that RA patients in DAS28 remission frequently have residual disease activity in the ankle and foot joints. Given that fore-foot disease activity can lead to joint damage and disability with respect to weight-bearing activities, these joints should be included in the clinical examination.

Monoclonal anti-HMGB1 (high mobility group box chromosomal protein 1) antibody protection in two experimental arthritis models.

High mobility group box chromosomal protein 1 (HMGB1) is a DNA-binding nuclear protein that can be released from dying cells and activated myeloid cells. Extracellularly, HMGB1 promotes inflammation. Experimental studies demonstrate HMGB1 to be a pathogenic factor in many inflammatory conditions including arthritis. HMGB1-blocking therapies in arthritis models alleviate disease and confer significant protection against cartilage and bone destruction. So far, the most successful HMGB1-targeted therapies have been demonstrated with HMGB1-specific polyclonal antibodies and with recombinant A box protein, a fragment of HMGB1. The present study is the first to evaluate the potential of a monoclonal anti-HMGB1 antibody (2G7, mouse IgG2b) to ameliorate arthritis. Effects of repeated injections of this antibody have now been studied in two conceptually different models of arthritis: collagen type II-induced arthritis (CIA) in DBA/1 mice and in a spontaneous arthritis disease in mice with combined deficiencies for genes encoding for the enzyme DNase type II and interferon type I receptors. These mice are unable to degrade phagocytozed DNA in macrophages and develop chronic, destructive polyarthritis. Therapeutic intervention in CIA and prophylactic administration of anti-HMGB1 monoclonal antibody (mAb) in the spontaneous arthritis model significantly ameliorated the clinical courses. Anti-HMGB1 mAb therapy also partially prevented joint destruction, as demonstrated by histological examination. The beneficial antiarthritic effects by the anti-HMGB1 mAb in two diverse models of arthritis represent additional proof-of-concept, indicating that HMGB1 may be a valid target molecule to consider for development of future clinical therapy.

Silicone granulomatous reactions after first metatarsophalangeal hemiarthroplasty.

We reviewed 55 patients (78 feet) who had undergone silicone hemiarthroplasty of the first metatarsophalangeal joint for hallux valgus (40) or hallux rigidus (38). At a mean period of 4.5 years (1 to 11), 56 feet had radiological evidence suggestive of silicone granulomatous disease. The frequency and severity of the changes increased with time from the operation. Histological material from three revisions confirmed the presence of silicone granulomata. We recommend that the operation of silicone hemiarthroplasty for hallux valgus and hallux rigidus be abandoned.

[Erbium 169 synoviortheses and infiltrations of triamcinolone hexacetonide in metatarsophalangeal arthritis of chronic inflammatory rheumatism]. / Synoviorthèses à l'erbium 169 et infiltrations d'hexacétonide de triamcinolone dans les arthrites métatarsophalangiennes des rhumatismes inflammatoires chroniques.

The authors report their experience in the treatment of metatarsophalangeal arthritis of chronic inflammatory rheumatism by Erbium 169 synoviortheses (112 joints treated) and by infiltrations of triamcinolone hexacetonide (53 joints treated). The steroid appears to have a marked early superiority as it gives 85% good results compared to 61.6% for Erbium 169 after a period of one to three months. However, its results then deteriorate more rapidly and after 6 months, the proportion of good results is greater with the radioactive treatment (64% compared to 46.7%). The authors consider it reasonable to use triamcinolone hexacetonide as the first line treatment as it is easier to manage and less expensive, reserving the radioactive synoviortheses for later with the prospect of more lasting results.

A study of the anti-inflammatory effect of Voltaren in patients with rheumatoid arthritis.

In a double-blind, crossover study conducted in ten hospitalised patients suffering from active rheumatoid arthritis, the anti-inflammatory effect of diclofenac sodium (Voltaren) in a daily dosage of 125 mg was compared with that of placebo under strictly standardised conditions. Changes in reversible articular swelling were determined by measuring the circumference of involved wrist, knee, metacarpophalangeal, interphalangeal, and metatarosphalangeal joints. A consistent decrease in joint swelling occurred in response to treatment with diclofenac sodium, as compared with a consistent increase following placebo medication. This difference was significant at the 5% level for all except the interphalangeal joints. Similarly, in response to diclofenac sodium a greater improvement was noted in duration of morning stiffness and grip strength and a greater reduction in the total number of painful and swollen joints. The status of the rheumatoid condition improved in nine patients following treatment with diclofenac sodium, but in none following placebo medication. Two patients reported unwanted effects, consisting of a sensation of fullness during treatment with diclofenac sodium in one case and of heartburn during both treatment periods in the other. No laboratory abnormalities were noted.