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.

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.

[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.

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.

DNA microarray allows molecular profiling of rheumatoid arthritis and identification of pathophysiological targets.

This study was undertaken to evaluate the possibility to obtain a molecular signature of rheumatoid arthritis (RA) comparatively osteoarthritis (OA), and to lay the bases to develop new diagnostic tools and identify new targets. Microarray technology was used for such an analysis. The gene expression profiles of synovial tissues from patients with confirmed RA, and patients with OA were established and compared. A set of 63 genes was selected, based, more specifically, on their overexpression or underexpression in RA samples compared to OA. Results for six of these genes have been verified by quantitative PCR using both samples identical to those used in the microarray experiments and entirely separate samples. Expression profile of the 48 known genes allowed the correct classification of additional RA and OA patients. Furthermore, the distinct expression of three of the selected genes was also studied by quantitative RT-PCR in cultured synovial cells. Detailed analysis of the expression profile of the selected genes provided evidence for dysregulated biological pathways, pointed out to chromosomal location and revealed novel genes potentially involved in RA. It is proposed that such an approach allows valuable diagnosis/prognostics tools in RA to be established and potential targets for combating the disease to be identified.

Assessment of progression in knee osteoarthritis: results of a 1 year study comparing arthroscopy and MRI.

OBJECTIVE: The objectives of this study were to determine the sensitivity to change of magnetic resonance imaging (MRI) quantification of chondropathy after 1 year in osteoarthritis of the medial tibiofemoral compartment and to assess the predictive value of subchondral bone marrow edema and bone abnormalities on progression of chondropathy. DESIGN: Twenty patients with symptomatic knee osteoarthritis of the medial compartment underwent a prospective, longitudinal study. All patients were evaluated the same day at entry and after 1 year by plain weight-bearing radiographs, MRI with a three-dimensional gradient-echo sequence, using a 0.2-T dedicated MR unit, and arthroscopy. The medial tibiofemoral chondropathy was quantified blindly with MRI and arthroscopy using the French Society of Arthroscopy (SFA) score. Presence of subchondral bone marrow edema and bone abnormalities on initial MRI was recorded in order to evaluate their influence on both unchanged and worsened chondropathy after 1 year. RESULTS: After 1 year, no statistically significant changes were observed with plain radiographs and arthroscopy. At variance, a statistically significant worsening of chondropathy was found with MRI using the SFA-MR score (P=0.01). SFA-MR score was the most responsive outcome. Absence of subchondral bone abnormalities and bone marrow edema on initial MR assessment predicted absence of worsening of chondropathy after 1 year. CONCLUSION: MRI appears promising for evaluating progression of knee osteoarthritis.

Influence of medial meniscectomy on tibiofemoral joint space width.

OBJECTIVE: The aim of this study was to evaluate the influence of partial medial meniscectomy on tibiofemoral joint space width (JSW). DESIGN: Thirty-seven patients (mean age: 51 years), suffering from medial meniscal lesions, (post-traumatic (n=22) or degenerative (n=15)), and requiring arthroscopic partial meniscectomy, were enrolled in a prospective, controlled study. Bilateral weight-bearing radiographs in extended and flexed position were performed in the same Radiology Unit just before and 2 days after meniscectomy. During arthroscopy, the extent of meniscectomy was evaluated in percentage and medial chondropathy was quantified using the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Medial chondropathy was absent or mild (mean SFA score: 8+/-13). Meniscectomy removed an average of 61% of the posterior third of the medial meniscus, 51% of the middle third and 22% of the anterior third. Radiographs, before and after meniscectomy, were read singly and were analyzed by a single reader unaware of patient identity and date of radiographs. Medial JSW was measured at the narrowest point of the medial compartment using a 0.1mm graduated magnifying glass. RESULTS: Comparison of JSW before and after meniscectomy did not show any statistically significant difference (mm): 0.01+/-0.43 (p=0.83) and -0.05+/-0.56 (p=0.66) in the extended and flexed views, respectively. CONCLUSION: This preliminary study suggests that partial medial meniscectomy does not influence tibiofemoral JSW on weight-bearing X-rays. Consequently, joint space narrowing appearing after partial meniscectomy should lead to seeking postmeniscectomy cartilage degradation rather than being attributed to removal of the meniscus.

Arthroscopic evaluation of potential structure-modifying drug in osteoarthritis of the knee. A multicenter, randomized, double-blind comparison of tenidap sodium vs piroxicam.

OBJECTIVE: To test the hypothesis that tenidap has a structure-modifying effect in human knee osteoarthritis. STUDY: multicenter, prospective, randomized, double blind, 1 year duration. PATIENTS: primary painful knee osteoarthritis (ACR criteria) of the medial tibiofemoral compartment, 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. STUDY MEDICATION: once daily dosage of either tenidap 40 mg, tenidap 120 mg or piroxicam 20mg. STUDY ENDPOINTS: bilateral extended weight-bearing X-rays and knee arthroscopy under local anaesthesia were done at entry and after 1 year. Joint space width was measured in millimeters at the narrowest point of the medial compartment. Chondropathy was scored by using reader's overall assessment (VAS score, 100mm) and Société Française d'Arthroscopie (SFA) score (0-100). RESULTS: Patients (665) were randomized and 494 completed the study. After 1 year, intra-group radiological changes and radiological difference between both tenidap groups and the piroxicam group did not reach statistical significance. The intra-group arthroscopic deterioration of chondropathy was low, but statistically significant in the three study groups. However, there was no statistically significant difference between both tenidap groups and the piroxicam group. CONCLUSIONS: This study failed to demonstrate any difference between the treatment arms with regard to the structural progression of medial knee osteoarthritis as measured by radiography and arthroscopy. Arthroscopy did, however, appears to be more sensitive in detecting disease progression than the weight-bearing radiographs with fully extended knees. This study shows that it is possible to complete a large international trial using arthroscopy as an outcome measure of articular cartilage.

A hyaluronan preparation (500-730 kDa) in the treatment of osteoarthritis: a review of clinical trials with Hyalgan.

The purpose of this paper is to review the intra-articular treatment of osteoarthritis (OA) of the knee with the hyaluronan preparation 500-730 kDa (Hyalgan). Reviewing the results of 24 clinical trials, it can be concluded that 3-5 weekly injections of Hyalgan significantly improve the pain and functional status of patients with OA. Although the onset of improvement is delayed by 3-4 weeks, the effect can last at least six months and up to one year after treatment cessation. The benefits of Hyalgan compared with intra-articular corticosteroids are also addressed. The potential for Hyalgan to have a structure-modifying action by retarding stuctural progression in OA of the knee is considered. However, further studies of Hyalgan in OA in other joints, and in damaged joints in rheumatoid arthritis, are needed.

Chemical synoviorthesis with osmic acid in haemophilia.

Based on previous experience in inflammatory arthritis, a small number of open studies have evaluated the usefulness of chemical synoviorthesis with osmic acid in haemophilia, with various assessment criteria and a wide range of follow-up periods. Based on these studies, the efficacy of osmic acid seems modest, with 30-44% of good clinical and radiological results, but with fair or poor clinical results in other patients with a possible deleterious effect on cartilage. Osmic acid was found inferior to Yttrium-90 in one retrospective study. Synoviorthesis with osmic acid seems particularly indicated in haemophilic arthritis with no or mild radiological deterioration in children between 8 and 15 years of age. However, prospective randomized studies are clearly required to evaluate the symptomatic and structural effects of chemical and radioactive synoviorthesis in haemophilic arthritis.

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.

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.

[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.

Arthroscopic evaluation of post-traumatic patellofemoral chondropathy.

OBJECTIVE: To evaluate clinically and arthroscopically post-traumatic patellofemoral chondropathy. METHODS: Fifty-nine patients with post-traumatic patellofemoral chondropathy were included in a cross sectional study and 46 of them completed a 6 month longitudinal study. Evaluation of the disease, performed once in the cross sectional study and twice (at entry and after 6 months) in the longitudinal study, included clinical and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator using a visual analog scale, and by the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Synovitis was assessed by the "synovitis score," which represents a composite index taking into account intensity, extent and location of synovial abnormalities. RESULTS: In the cross sectional study, severity of chondropathy correlated with age, body mass index, disease duration, functional impairment (Lequesne's index and maximum number of steps descended), patellofemoral crepitus on active motion, limitation of flexion, and presence and amount of synovitis. Knee effusion correlated with the presence of synovitis, but no correlation was found between pain or functional impairment and presence or amount of synovitis. In the longitudinal study, no statistically significant change in chondropathy was observed after 6 months followup despite a statistically significant improvement in pain, function, and knee effusion after this period. However, a statistically significant correlation was found between the progression of patellofemoral chondropathy and the presence and amount of synovitis at baseline. Synovitis was present at baseline in 10 patients. Changes in SFA scores were 1.2 +/- 1.6 and -0.1 +/- 1.0 in the groups of patients with and without synovitis, respectively (p = 0.0062). CONCLUSION: These data suggest that synovitis might have a deleterious effect on the evolution of post-traumatic patellofemoral chondropathy or might be a marker for active cartilage breakdown.

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial.

OBJECTIVE: To evaluate the efficacy of joint lavage and intraarticular steroid injection, alone and in combination, in the treatment of patients with symptomatic knee osteoarthritis (OA). METHODS: Ninety-eight patients with painful tibiofemoral OA were enrolled in a prospective, randomized, controlled, 2 x 2 factorial-design trial of 6 months' duration. The 4 treatment groups consisted of 1) intraarticular placebo (1.5 ml of 0.9% normal saline), 2) intraarticular corticosteroids (3.75 mg of cortivazol in 1.5 ml), 3) joint lavage and intraarticular placebo, and 4) joint lavage and intraarticular corticosteroid. Outcome measures evaluated at baseline, week 1, week 4, week 12, and week 24 included severity of pain (100-mm visual analog scale [VAS]), global status (100-mm VAS), and Lequesne's functional index. RESULTS: No interaction between steroid injection and joint lavage was demonstrated. Patients who had undergone joint lavage had significantly improved pain VAS scores at week 24 (P = 0.020). In contrast, corticosteroid injection had no long-term effect (P = 0.313); corticosteroid injection was associated with a decrease in pain only at week 1 (P = 0.003) and week 4 (P = 0.020). After week 4, Lequesne's functional index was not significantly improved regardless of the assigned treatment. CONCLUSION: Compared with placebo, both treatments significantly relieved pain but did not improve functional impairment. The effects of the 2 treatments were additive. Cortivazol provided short-term relief of pain (up to week 4). The effects of joint lavage persisted up to week 24.

Piroxicam therapy: a double blind, randomized, multicenter study comparing 2 versus 4 week treatment in patients with painful knee osteoarthritis with effusion.

OBJECTIVE: To compare the efficacy and safety of piroxicam 20 mg once a day for 14 or 28 days in patients with knee osteoarthritis (OA) and synovial effusion. METHODS: We conducted a multicenter, randomized, double blind study in 1905 outpatients. Efficacy was assessed by changes in synovial effusion, pain on a 100 mm visual analog scale (VAS), and impairment using Lequesne's functional index. Patients were classified at Day 28 as improved (defined as VAS and Lequesne index decrease of at least 30% from Day 14), worsened (defined as VAS and Lequesne index increase of at least 30% from Day 14), or unchanged. Safety was assessed on the basis of adverse events reported by the patients. RESULTS: After 14 days, changes in pain, synovial effusion, and functional impairment significantly decreased from baseline within each group (p < 0.001, respectively), but did not differ between the groups. Between 14 and 28 days, outcome measure changes were significantly better in the 28 day group, p = 0.01, 0.0001, and 0.0001, respectively. In the 28 day and 14 day groups, improvement with regard to pain was observed for 339 (52.4%) and 280 (29.4%) patients, respectively, (p < 0.0001), and with regard to functional impairment for 298 (31.5%) and 233 (24.3%) patients (p < 0.0001). Adverse events accounted for 7.5 and 6.7% of withdrawals in the 28 day and 14 day groups, respectively. CONCLUSION: When administration of piroxicam 20 mg is prolonged to 28 days, continuing benefit is observed for some patients with knee OA with painful synovial effusion without a significant difference in safety.

Osteoarthritis of the hip: agreement between joint space width measurements on standing and supine conventional radiographs.

OBJECTIVE: To assess the effect of standing position on joint space width (JSW) measurements of the hips with and without osteoarthritis (OA) on pelvic radiographs. METHODS: Adult patients aged 18 or more had pelvic anteroposterior conventional radiographs standing and supine performed by a single radiologist in the same radiology unit according to standardised guidelines. JSW measurements in mm were made by a single reader blind to patients' identity and type of view, using a 0.1 mm graduated magnifying glass directly laid over the radiograph, at the narrowest point for OA hips or at the vertical joint space for non-OA hips. Agreement of JSW between both views was assessed using the Bland and Altman graphical analysis. RESULTS: JSW was greater on standing than supine radiographs, for example, 7.1% for OA hips. Mean (SD) differences and limits of agreement (mm) between both views were 0.08 (0.27) and -0.46 to 0.62 for the 70 non-OA hips, 0.02 (0.31) and -0.60 to 0.64 for the 46 OA hips. Corresponding 95% confidence intervals of mean difference were 0.02, -0.14 mm and -0.07, -0.11 mm. CONCLUSIONS: Measurements of JSW of the hip on pelvic standing and supine radiographs are concordant. Changes less than or equal to 0.64 mm between the two views are similar or inferior to radiological progression of OA.