Metabolic and molecular imaging in inflammatory arthritis.

It is known that metabolic shifts and tissue remodelling precede the development of visible inflammation and structural organ damage in inflammatory rheumatic diseases such as the inflammatory arthritides. As such, visualising and measuring metabolic tissue activity could be useful to identify biomarkers of disease activity already in a very early phase. Recent advances in imaging have led to the development of so-called 'metabolic imaging' tools that can detect these changes in metabolism in an increasingly accurate manner and non-invasively.Nuclear imaging techniques such as 18F-D-glucose and fibroblast activation protein inhibitor-labelled positron emission tomography are increasingly used and have yielded impressing results in the visualisation (including whole-body staging) of inflammatory changes in both early and established arthritis. Furthermore, optical imaging-based bedside techniques such as multispectral optoacoustic tomography and fluorescence optical imaging are advancing our understanding of arthritis by identifying intra-articular metabolic changes that correlate with the onset of inflammation with high precision and without the need of ionising radiation.Metabolic imaging holds great potential for improving the management of patients with inflammatory arthritis by contributing to early disease interception and improving diagnostic accuracy, thereby paving the way for a more personalised approach to therapy strategies including preventive strategies. In this narrative review, we discuss state-of-the-art metabolic imaging methods used in the assessment of arthritis and inflammation, and we advocate for more extensive research endeavours to elucidate their full field of application in rheumatology.

Revision to the musculoskeletal domain of the BILAG-2004 index to incorporate ultrasound findings.

OBJECTIVES: To improve the definitions of inflammatory arthritis within the musculoskeletal (MSK) domain of the BILAG-2004 index by incorporating imaging findings and clinical features predictive of response to treatment. METHODS: The BILAG MSK Subcommittee proposed revisions to the BILAG-2004 index definitions of inflammatory arthritis, based on review of evidence in two recent studies. Data from these studies were pooled and analysed to determine the impact of the proposed changes on the severity grading of inflammatory arthritis. RESULTS: The revised definition for severe inflammatory arthritis includes definition of 'basic activities of daily living'. For moderate inflammatory arthritis, it now includes synovitis, defined by either observed joint swelling or MSK US evidence of inflammation in joints and surrounding structures. For mild inflammatory arthritis, the definition now includes reference to symmetrical distribution of affected joints and guidance on how US may help re-classify patients as moderate or no inflammatory arthritis. Data from two recent SLE trials were analysed (219 patients). A total of 119 (54.3%) were graded as having mild inflammatory arthritis (BILAG-2004 Grade C). Of these, 53 (44.5%) had evidence of joint inflammation (synovitis or tenosynovitis) on US. Applying the new definition increased the number of patients classified as moderate inflammatory arthritis from 72 (32.9%) to 125 (57.1%), while patients with normal US (n = 66/119) could be recategorized as BILAG-2004 Grade D (inactive disease). CONCLUSIONS: Proposed changes to the definitions of inflammatory arthritis in the BILAG-2004 index will result in more accurate classification of patients who are more or less likely to respond to treatment.

Comparison of different fibula procedures in tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a mid-term retrospective study.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for severe tibiotalar and talocalcaneal arthritis has a high fusion rate; however, no studies have focused on how to handle the fibula intraoperatively to achieve better results. This study aimed to compare the efficacies of various fibular procedures. METHODS: We retrospectively reviewed the cases of severe tibiotalar and talocalcaneal arthritis in adults treated with TTC arthrodesis using a retrograde intramedullary nail between January 2012 and July 2017. The patients were divided into three groups according to different fibular procedures: Fibular osteotomy (FO), fibular strut (FS), and fibular preservation (FP). Functional outcomes and pain were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score and visual analog scales (VAS), respectively. The operation time, fusion time, radiographic evaluation, and complications were also recorded. RESULTS: Fifty-eight patients with an average age of 53.2 (range, 32-69) years were enrolled in the final analysis. The numbers of patients enrolled in the three groups were 21, 19, and 18 in the FO, FS, and FP groups, respectively. The mean postoperative follow-up time was 66.0 (range, 60-78) months. All groups showed a high fusion rate (90.5% for FO, 94.7% for FS, and 94.4% for FP) and significant improvement in AOFAS ankle and hindfoot scores and VAS scores at the latest follow-up. There were no significant differences in these parameters among the three groups. The mean operation time of FS (131.3 ± 17.1 min) was longer than that of FO (119.3 ± 11.7 min) and FS (112.2 ± 12.6 min), but the fusion time was shorter (15.1 ± 2.8 weeks for FS, 17.2 ± 1.9 weeks for FO, and 16.8 ± 1.9 weeks for FP). Statistically significant differences were observed in these parameters. CONCLUSIONS: TTC arthrodesis using a retrograde intramedullary nail is an effective procedure with a high rate of fusion to treat severe tibiotalar and talocalcaneal arthritis in adults; however, FSs can shorten fusion time when compared with FO and FP. LEVEL OF CLINICAL EVIDENCE: Level 3.

Posttraumatic arthritis and functional outcomes of nonoperatively treated distal radius fractures after 3 years.

Recent studies have shown that distal radius fractures (DRFs) in elderly patients can be treated nonoperatively with good functional results after 1 year. However, scientific evidence regarding longer follow-up to assess posttraumatic arthritis (PA), complications, and functional outcomes is scarce. This prospective case series aimed to evaluate these outcomes in a cohort of patients ≥ 65-year-old with nonoperatively treated DRFs after a minimum of 3 years. The primary outcome was PA. Secondary outcomes were complications, Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure (QuickDASH), Patient-Rated Wrist/Hand Evaluation (PRWHE), pain, range of motion and grip strength. The full data of 32 patients with a mean follow-up of 3.3 years were available: 10/32 patients had radiological signs of PA, but only 2 of these patients reported pain. A total of 11/32 fractures healed in malunion (> 10° dorsal angulation). There was no significant difference in QuickDASH or PRWHE from 1 year to the latest follow-up after more than 3 years. This study thus adds to the literature stating that radiological signs, including PA and malunion, do not necessarily result in symptoms. Moreover, it underpins that nonoperative treatment of these patients results in good functional outcomes after 1 and 3 years.

EXPLORing Arthritis with Total-body Positron Emission Tomography.

Arthritis has significant adverse consequences on musculoskeletal tissues and often other organs of the body. Current methods for clinical evaluation of arthritis are suboptimal, and biomarkers that are objective and measurable indicators for monitoring of arthritis disease activity are in critical demand. Recently, total-body positron emission tomography (PET) has been developed that can collect imaging signals synchronously from the entire body at ultra-low doses and reduced scan times. These scanners have increased signal collection efficiency that overcomes several limitations of standard PET scanners in the evaluation of arthritis, and they may potentially provide biomarkers to assess local and systemic impact of the arthritis disease process. This article reviews current results from using total-body PET in the assessment of common arthritic conditions, and it outlines future opportunities and challenges.

The Role of Supramalleolar Osteotomies in Ankle Arthritis.

The supramalleolar osteotomy (SMO) is a joint-preserving surgical procedure that allows realignment of the ankle joint in severe deformity secondary to arthritis. This osteotomy realigns the mechanical axis to provide better weight distribution through the ankle joint. With an aligned mechanical axis, the overloaded asymmetric ankle joint will shift toward the preserved joint area in a valgus or varus ankle joint. The SMO also can be used via a staged approach to correct severe deformity in an end-stage arthritic ankle before total ankle arthroplasty to optimize the implant's longevity and improve overall functional outcomes.

Percutaneous fixation of displaced intraarticular fractures of the calcaneus. A retrospective case series study and a review of the literature.

PURPOSE: To evaluate the outcome of displaced intraarticular calcaneal fractures (DIACFs) of a case series of patients who were treated with a percutaneous fixation technique. MATERIALS AND METHODS: Eight patients were operated for DIACFs and they were evaluated for the outcome and complications in a mean follow up of 9 months (range: 6 - 12 months). At the last follow up the AOFAS score, the Boehlers' angle and the presence of any complication were noted. The time from injury to surgery was also reported. The correlation of the AOFAS score and the development of post traumatic subtalar arthritis to the type of fracture, to the post operative Boehler's angle and to the time from injury to surgery were investigated. RESULTS: The overall mean AOFAS (Americal Orthopaedic Foot and Ankle Society) score was 84,625 (Range: 73 - 96). The mean AOFAS score of type II and type III fractures was 87,667 and 75,500 respectively. The mean AOFAS score for fractures with a postoperative Boehler's angle of less than 10° and more or equal to 10° was 76,750 and 92,500 respectively. This difference was found to be statistically significant. The mean AOFAS score for fractures who were treated less or equal to six days and more than six days post injury was 91,250 and 78 respectively. Two out of four patients with a post operative Boehler's angle less than 10° developed post traumatic subtalar arthritis. No patient out of four for whom a Boehler's angle of more than 10° has been achieved, developed subtalar arthritis. No infection occurred in any of the patients. CONCLUSION: Percutaneous fixation is a safe and effective way of treating DIACFs. The outcome is directly related to the quality of reduction, which is significantly dependent to the timing of surgery. The earlier the fracture is operated the better the reduction by closed means is.

Seeing is believing: Smart use of musculoskeletal ultrasound in rheumatology practice.

Musculoskeletal ultrasonography has become an increasingly valuable tool as a complement to the physical exam in rheumatology practice. Its point-of-care access, low cost, safety, portability, and reliability in trained hands, make this technique especially useful in patients with inflammatory arthritis. Growing evidence has demonstrated the value of musculoskeletal ultrasound in the detection of inflammatory and structural changes in patients with joint pain without obvious joint swelling, in differentiating various inflammatory diagnoses, in the monitoring of inflammatory arthritis, and interventional procedures. The potential role of ultrasound guiding treat-to-target strategies or tapering treatment in inflammatory arthritis requires further research. However, musculoskeletal ultrasound can also have pitfalls and limitations that a clinician should be aware of.

Quantitative 3-D CT Demonstrates Distal Row Pronation and Translation and Radiolunate Arthritis in the SNAC Wrist.

BACKGROUND: In scaphoid nonunion advanced collapse (SNAC) wrist arthritis, we analyzed the 3-dimensional (3-D) deformity patterns of carpal alignment secondary to scaphoid nonunion and quantified subchondral arthritis by investigating alterations in bone density. METHODS: We constructed 3-D models of the carpal bones and radius from 51 patients with scaphoid nonunion (nonunion group) and 50 healthy controls (control group). We quantified the differences in 3-D geometric position of the distal carpal row relative to the distal radius in SNAC wrists versus controls. In addition, we assessed the bone density of anatomic regions of interest in the radiocarpal and capitolunate joints relative to the pisiform bone density to characterize degenerative changes in SNAC wrists. RESULTS: The distal carpal row pronated by a difference of 14° (7.2° versus -6.7°; p < 0.001), deviated ulnarly by a difference of 19° (7.7° versus -11.2°; p < 0.001), shifted dorsally by a difference of 17% of the dorsovolar width of the distal radius (21.0% versus 4.4%; p < 0.001), shifted radially by a difference of 8% of the radioulnar width of the distal radius (13.2% versus 5.3%; p < 0.001), and migrated proximally by a difference of 12% of the lunate height (96.3% versus 108.8%; p < 0.001) in the nonunion group compared with the control group. Additionally, it was found that bone density was greater at the capitolunate joint (capitate head: 140.4% versus 123.7%; p < 0.001; distal lunate: 159.9% versus 146.3%; p < 0.001), the radial styloid (157.0% versus 136.3%; p < 0.001), and the radiolunate joint (proximal lunate: 134.8% versus 122.7%; p < 0.001; lunate fossa: 158.6% versus 148.1%; p = 0.005) in the nonunion group compared with the control group. CONCLUSIONS: Scaphoid nonunion exhibited a unique deformity pattern and alteration in bone-density distributions. The distal carpal row not only shifted dorsally and migrated proximally but also pronated, deviated ulnarly, and shifted radially. Bone density was greater at the capitolunate joint, the radial styloid, and surprisingly, the radiolunate joint. Our findings give insight into the natural history and progression of arthritis of the SNAC wrist. Additionally, future studies may give insight into whether successful treatment of scaphoid nonunion arrests the progression of arthritis. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Best practices for ultrasound-guided synovial biopsy in the United States.

The target organ in many forms of inflammatory arthritis is the synovium. However, synovial tissue has historically been perceived as either difficult to obtain or of little practical value. Ultrasound-guided synovial biopsy [UGSB] is a safe and well-tolerated bedside procedure that is established in Europe and rapidly growing in popularity in the United States. The technique can be mastered by rheumatologists who are already experienced in ultrasound-guided procedures such as joint aspirations. The USGB procedure allows the proceduralist to access small, medium, and large joints and is inexpensive and less invasive compared to surgical alternatives. The relative ease of obtaining this tissue, along with recent research suggesting that synovium may have more clinical and investigational utility than previously thought, has led clinicians and researchers to a new appreciation of the role of synovial biopsy in both the clinical and research setting. In this manuscript, the authors present recommendations on best practices for ultrasound-guided synovial biopsy in the United States, based on our initial training with well-established experts overseas and our own subsequent collective experience in performing numerous synovial biopsies in the United States over the past 7 years for both clinical and research indications. We envision a future where UGSB is more frequently incorporated in the standard diagnostic workup of arthritis and drives novel research initiatives.

An Automatic 3-D Ultrasound and Photoacoustic Combined Imaging System for Human Inflammatory Arthritis.

Aiming at a point-of-care device for rheumatology clinics, we developed an automatic 3-D imaging system combining the emerging photoacoustic (PA) imaging with conventional Doppler ultrasound (US) for detecting human inflammatory arthritis. This system is based on a commercial-grade GE HealthCare (GEHC, Chicago, IL, USA) Vivid E95 US machine and a Universal Robot UR3 robotic arm. This system automatically locates the patient's finger joints from a photograph taken by an overhead camera powered by an automatic hand joint identification method, followed by the robotic arm moving the imaging probe to the targeted joint to scan and obtain 3-D PA and Doppler US images. The GEHC US machine was modified to enable high-speed, high-resolution PA imaging while maintaining the features available on the system. The commercial-grade image quality and the high sensitivity in detecting inflammation in peripheral joints via PA technology hold great potential to significantly benefit clinical care of inflammatory arthritis in a novel way.

Combined surgical and anti-infective therapy for brucella arthritis of the knee in players: a case report

In some rural areas of northern China, brucellosis is an endemic zoonotic infection caused by a bacteria of the genus Brucella. As a result of brucellosis, osteoarticular involvement is the most common complication. Here, we report the case of a 50-year-old male who presented with severe swelling and pain in the right knee in players. Brucella arthritis was diagnosed based on his contact history, clinical manifestations, and results of serological tests, synovial fluid cultures, and radiological imaging. As part of the treatment plan, surgery including an arthrotomy, debridement, and irrigation of the joint cavity was carried out. In the weeks following surgery, the patient reported significant improvement in his right knee joint's function and a significant reduction in the intensity of his joint pain in players. (AU)

Proximal Interphalangeal Joint Arthrodesis of the Hand Utilising a Rigid Intramedullary Device.

The proximal interphalangeal joint (PIPJ) is critical for proper finger and hand function. Arthritis of this joint can lead to significant pain and functional impairment. The APEX IP® Extremity Medical fusion device (Extremity Medical, Parsippany, New Jersey, USA) is an interlocking intramedullary screw device that provides a reliable method of hand PIPJ arthrodesis with good patient outcomes. We describe an easily reproducible surgical technique guide for using this device. Level of Evidence: Level V (Therapeutic).

Change in Height Following Tibiotalocalcaneal Arthrodesis: Retrospective Radiographic Analysis.

Tibiotalocalcaneal arthrodesis (TTCA) with an intramedullary rod is a viable treatment option for a myriad of pathologies involving the foot and ankle. While the current literature has focused on fixation techniques, deformity correction, and clinical outcomes, we are unaware of any studies specifically examining change in height following a TTCA. In the present study, we retrospectively analyzed radiographs with novel radiographic techniques to determine the change in height from preoperative to postoperative radiographs following TTCA. Patients were divided into 3 categories: Charcot, arthritis, and pes planus as the indication for surgical intervention. We found that Charcot and arthritis had an average decrease in height on anterior and posterior measurements of the height from the distal tibia to the calcaneus, while pes planus had an increase in height. The average Charcot change in height was -12.0 ± 24.4 mm anteriorly and -7.6 ± 15.5 mm posteriorly. The average change in height for the arthritis group was -6.9 ± 6.7 mm anteriorly and -3.8 ± 5.8 mm posteriorly. The pes planus group was found to have an average increase in height 0.5 ± 8.0 mm anteriorly and 2.9 ± 5.8 mm posteriorly. Overall, we found a statistically significant difference in height change between the 3 groups in anterior measurements (p = .012) and posterior measurement (p = .006). We recommend surgeons who perform this procedure to be aware of the potential change in height to better tailor surgical and postoperative care.

Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls.

BACKGROUND: While it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis. METHODS: A retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years). RESULTS: The valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031). CONCLUSION: Our findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.

Does ankle arthrodesis induce satisfactory changes in the medial longitudinal arch height of the foot for severe varus ankle arthritis?

PURPOSE: We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA). METHODS: We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2 mm or < 2 mm). RESULTS: A post-operative MCH decrease of ≥ 2 mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2 mm than in those with < 2 mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172). CONCLUSION: Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.