Articular Involvement Research Articles

Clinical profile of patients with fractures of distal end of radius

Introduction: Smith in 1854 described a volar angulated fracture of the distal radius with a ‘Garden Spade’ deformity. In the reverse Colle’s fracture the hand and wrist are displaced volarly with respect to forearm. This fracture pattern included both extra articular as well as intra articular involvement and also formed part of the fracture dislocation of the wrist. Methodology: Routine examination of blood was done for hemoglobin percentage, total and differential WBC counts, fasting blood sugar, blood urea, serum creatinine, bleeding and clotting time, HIV and Hbs Ag. Examination of urine was done for presence of albumin and sugar. Blood pressure and ECG were recorded in all patients. Preparation of the part was done on the day of surgery. Tetanus toxoid injection and intravenous antibiotic were given to all patients pre-operatively. Results: Most of the fractures are sustained due to RTA and fall on the out stretched hand and are usually intra articular displaced. Conclusion: Fractures occur in older individuals as a result of a trivial trauma /fall owing to the lack of bone density.

Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease

Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy. Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs. The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.

A Rare Association of Rheumatoid Arthritis with Crohn’s Disease

Crohn’s disease (CD) is an chronic autoimmune inflammatory bowel disease (IBD) which may involve any part of the gastrointestinal system (GIS) (1). Although the rellationships among autoimmune diseases are known, association of rheumatoid arthritis (RA) and CD is an extremely rare condition (2,3). A 50-year-old male patient who had the diagnosis of seropositive RA for 5 years, presented with the complaints of bloody diarrhea and abdominal pain. The RA treatment had been regulated as a combination of methotrexate, sulfasalazine and hydroxychloroquine, and the patient reported that he was regularly taking the medical therapy. In joint examination, metacarpophalangeal joint arthritis were found bilateral. No hand deformity was observed. In physical examination, there were no findings except tenderness in the lower abdominal quadrants. There was not any bacterial growth in the stool culture. The results of the colonoscopy, found inflammation in the ileum (Figure 1a, 1b). Histopathologic examination was compatible with CD. Anteroposterior hand radiography revealed narrowing in 3rd and 4th proximal interphalengeal joints (Figure 1c). Genu varum deformity was found in the knee and magnetic resonance imaging (MRI) revealed synovial hypertrophy. Biochemical analysis yielded sedimentation rate as 22 mm/h (Reference range: 0-20 mm/h), C-reactive protein 1.21 mg/dL (reference range: 0-0.5 mg/dL), rheumatoid factor (+) and anti cyclic citrullinated peptide (CCP) (+). Mesalazine and azathioprine were added to his treatment protocol. At follow-up, complaints of the patiens gradually regressed within 4 months. Articular system involvement is commonly seen in IBD such as ulcerative colitis (UC) and CD. Axial and peripheral articular findings may commence before, concurrently or after the diagnosis of IBD. Peripheral arthritis is generally in form the oligoarticular involvement of the large joints. However, in a small portion of IBDs, an arthritis form may be seen, resembling rheumatoid arthritis and often affecting the small joints of the hand symmetrically and polyarticularly (4). Peripheral arthritis is reported in CD by 10-20% which is more frequent compared to UC (5). Our patient was diagnosed with CD, suggesting us the joint findings may be occured due to this condition. However, IBD arthritis is seronegative and never or rarely causes joint destruction compared to RA (5). In our patient, arthritis had begun about 5 years before GIS symptoms. According to 2010 American College of Rheumatology/European League Against Rheumatism criteria, positivity of anti CCP, RF antibodies, marked synovial hypertrophy in the knees on MRI and narrowing of the joint spacing found in our patient confirmed the diagnosis of RA. Our patient who could not describe an association between the exacerbation of CD and arthritis gave positive response to RA treatment. Hatice Resorlu, Erdem Akbal*, Ferhat Gokmen, Yilmaz Savas

Mallet Fractures of the Thumb Compared With Mallet Fractures of the Fingers

The purpose of this study was to look for differences in mechanism, radiographic findings, and treatment between mallet fractures of the thumb and mallet fractures of the index through small fingers. This retrospective study included 24 mallet fractures of the thumb and 392 mallet fractures of other digits. We compared demographics, injury factors (side, dominant hand, time between injury and first visit, and injury mechanism), subluxation, fragment size, treatment, and time from injury to final evaluation between the 2 groups. Mallet fractures of the thumb presented for treatment sooner after injury (2.9 vs 13 days on average), had less fragment displacement (27% vs 33%), and less articular involvement (39% vs 46% on average). None of the mallet fractures of the thumb had radiographic evidence of subluxation, whereas 25% of mallet fractures of other fingers had initial or later subluxation. Mallet fractures of the thumb are not likely to subluxate.

Factors associated with subluxation in mallet fracture.

IV.

Functional and radiological outcomes of distal femur intra articular fractures treated with locking compression plate

Introduction: The treatment of distal intra articular femur fractures has been a controversial topic and it has recently evolved towards indirect reduction and minimally invasive techniques. The goal is to strike a balance between the mechanical stability of the fragments and the biological viability. For intraarticular femur fractures, periarticular locking plates have been rapidly adopted as an alternative to intramedullary nails, blade plates, and nonlocking condylar screws. However, there is a paucity of data to assess the results when these implants are used in the presence of intra articular involvement and comminution. The aim of this study is to assess the functional and radiological outcomes following fixation of intra articular distal femur fractures with locking compression plate (LCP). Material and methods: The study period, dated from June 2013 to Dec 2015, included a total of 27 cases of distal femur fracture ( AO/OTA classification type C2 and C3) treated with locking compression plate .The patients’ age ranged from 20 to 77 years and all patients were followed up according to post-operative follow up protocol. The minimum follow up period was 1 year and patients were assessed for functional outcome and radiological signs of fracture healing every month in the outpatient department. Results: Of the 27 patients treated with distal LCP, 24 Patients (90%) showed radiological union within 20 weeks. 3 patients had delayed union and implant failure. Average time for union was 16.1 weeks. (excluding the cases of implant failure). Average flexion in this study was 113 degree with more than 20 patients having knee range of motion more than 90 degrees. Out of these 20 patients, 10 had a range more than 110 degrees. The functional outcome was measured using Neer’s scoring system, with 59% of the study group having excellent results The complications encountered during the study period involved one superficial skin infection treated by debridement, shortening of 0.5 – 2 cms in three patients which was associated with the extensive communition at the fracture site. There were two patients who at the end of year of follow up showed varus angulation of 7 degrees. 3 patients had an implant failure treated with bone grafting and re application of LCP. 1 patient developed fat embolism. The results showed a better functional and radiological outcomes when compared to other published studies done on these intra articular fractures using other implant options namely, distal femoral nail, dynamic condylar screw and less invasive stabilisation system (LISS) Conclusions: The locking compression plates with option of locked screws has provided the means to increase the rigidity of fixation in intraarticular distal femoral fractures. However this is a technically demanding procedure considering the severity of these injuries. We conclude that this method of fixation is especially suited for fractures where achieving congruency of the articular surface would be difficult with less invasive modalities like retrograde nailing and LISS.

INSULIN RESISTANCE AND ENDOTHELIAL DYSFUNCTION IN RHEUMATOID ARTHRITIS

Rheumatoid arthritis is a chronic inflammatory disease, in which, besides articular involvement, cardiovascular complications due to premature and accelerated atherosclerosis represent a serious problem. Endothelial dysfunction is the first step in the atherosclerosis development. Rheumatoid arthritis associated inflammation contributes to endothelial dysfunction through direct action of cytokines on endothelium, or via increased insulin resistance. The aim of this study was represented by the assessment of endothelial dysfunction in rheumatoid arthritis patients, and correlation of this with impaired insulin sensitivity. Material and methods. The study was performed on a group of 35 patients with newly diagnosed rheumatoid arthritis. In all patients were assessed: rheumatoid arthritis activity (DAS28), insulin resistance (HOMA-IR) and endothelial dysfunction by means of flow-mediated dilation (FMD). Results. Inflammation was present in all patients, and the disease activity was high (DAS28: 6.41 ± 0.94). The studied patients showed high insulin resistance (HOMA-IR 5.97 ± 1.89) and endothelial dysfunction (FMD 7.94 ± 0.91%). There were significant correlations between endothelial dysfunction and insulin resistance (p = 0.0174), respective disease activity (p = 0.0201). On the other hand, it was shown a correlation between insulin resistance and the disease activity (p = 0.0290). Conclusion. Endothelial dysfunction was present even in newly diagnosed rheumatoid arthritis patients, contributing to the development of later atherosclerotic cardiovascular disease. Insulin resistance represented an important factor involved in endothelial dysfunction appearance.

Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment

Foot and ankle fractures represent 12% of all pediatric fractures. Malleolar fractures are the most frequent injuries of the lower limbs. Hindfoot and midfoot fractures are rare, but inadequate treatment for these fractures may results in compartment syndrome, three-dimensional deformities, avascular necrosis and early post-traumatic arthritis, which have a significant impact on overall foot and ankle function. Therefore, the challenges in treating these injuries in children are to achieve adequate diagnosis and precise treatment, while avoiding complications. The objective of the treatment is to restore normal anatomy and the correct articular relationship between the bones in this region. Moreover, the treatment needs to be planned according to articular involvement, lower-limb alignment, ligament stability and age. This article provides a review on this topic and presents the scientific evidence for appropriate treatment of these lesions.

Post-Reduction Stability of the Proximal Interphalangeal Joint after Dorsal Fracture Dislocation-A Cadaveric Study.

Proximal interphalangeal joint (PIPJ) dorsal fracture dislocations (DFD) are challenging injuries. Treatment aims to achieve stability of the PIPJ after reduction so that early motion can be initiated. We studied how increasing articular destruction would affect post reduction stability and investigate the amount of traction and PIPJ flexion needed to maintain the reduction. Increasing amounts (20%, 40% and 60%) of damage to the volar lip of the middle phalanx in cadaveric specimens were created to represent PIPJ DFD that were stable, of tenuous stability and frankly unstable. Traction forces and PIPJ flexion needed to maintain the reduction were then measured. The PIPJ DFD with 20% damage were stable and did not subluxe while the one with 40% articular involvement was stable after reduction. For unstable the PIPJ with 60% involvement, the more the PIPJ was flexed, the less traction force was needed to hold the joint in reduction. For PIPJ flexion of 20 degrees, a minimum 4.4N of force is needed to maintain reduction while PIPJ flexion of 10 degrees required a minimum 5.0N of force. No amount of force could maintain PIPJ reduction if traction was performed in full extension. In our model, PIPJ DFD with less than 30% articular damage are stable while those with 30% to 50% of involvement have tenuous stability. For the unstable PIPJ DFD, traction obviates the need for excessive flexion of the PIPJ to maintain joint reduction. This information should be considered in treatment modalities for PIPJ DFD, as well in the design of external traction devices for the treatment of PIPJ DFD.

Treatment of distal tibia fractures: plating versus intramedullary nailing

<p class="abstract"><strong>Background:</strong> Distal tibia shaft fractures pose significant challenge to treating surgeons. Giving more importance to anatomical reduction and ignoring often injured soft tissues has led to poor outcomes and high complication rates. Although multiple options are described to treat these fractures, there is no consensus on the best method of treatment. We hereby want to study the results of distal tibia fractures treated by expert tibia nailing and distal tibia plating.</p><p class="abstract"><strong>Methods:</strong> This study was undertaken in patients who were operated in between January 2012 to March 2015 at M S Ramaiah Teaching Hospital, which is a tertiary care hospital in Bangalore. Study included 52 patients with distal tibia fracture treated by surgery. All the fractures were closed distal diaphyseal fractures without articular involvement. Thirty two patients underwent expert tibia nailing whereas 20 patients were treated with open reduction and internal fixation with locking plates. Patients were followed up at 6 weeks, 3 months, 6 months and 1 year.<strong></strong></p><p class="abstract"><strong>Results:</strong> Fifty two patients included in study and they were divided into two groups as nailing group and plating group. Plating group included 20 patients whereas nailing group included 32 patients. The mode of injury was road traffic injury in 32 cases , followed by self-fall in 17 cases and sports related injury in 3 cases. Distal tibia fracture was associated with in 29 patients (87%) of nailing group whereas in 17 patients (80) of plating group. Average distance of fracture from pilon was 6 cm in nailing group and 3cm in plating group. The average duration of surgery in nailing was group was 88 minutes (range, 65-130 minutes) whereas average duration of surgery in plating group was group was 92 minutes (range, 70-130 minutes). The average time for union was 16 weeks for nailing group and for plating group it was 18 weeks. </p><p class="abstract"><strong>Conclusions:</strong> Both intramedullary nailing and plating are the optimal methods of treatment. Plating is preferred in cases where fracture is close to pilon whereas intramedullary nailing is preferred for fractures away from tibial pilon. There is no significant difference between union and complication rates.</p>

Involvement of the Lesser Sigmoid Notch in Elbow Fracture Dislocations

Purpose: To address the primary null hypothesis that there is no difference in the articular surface area of the lesser sigmoid notch involved among Mayo classes. Second, we analyzed the fracture line location and the pattern of lesser sigmoid notch articular surface involvement among Mayo classes. Methods: Using quantitative 3-dimentional computed tomography, we reconstructed and analyzed fractures involving the lesser sigmoid notch articular surface in 52 patients. Furthermore, we assessed the surface area involved in the fracture, the number of fracture fragments, and the location and direction of the fracture lines. Coronoid fractures were classified according to Mayo types. Results: There was no significant difference between Mayo types 1 and 2 in any characteristic of the involvement of the lesser sigmoid notch articular surface, whereas Mayo type 3 was significantly different from both Mayo types 1 and 2 in the area involved in the fracture (42% in Mayo type III vs 9% in Mayo types I and II), the number of articular fragments (>3 fragments in type III vs 2 fragments in types I and II), and the direction of fracture line (both horizontal and vertical lines in type III vs only horizontal line in types I and II). Conclusion: Mayo type III results in a more complex fracture, which might need to be addressed directly or indirectly during open reduction internal fixation of the olecranon fracture dislocations because changes in the geometry of lesser sigmoid notch may affect the radioulnar joint if it remains incongruent.

The Septic Hand

Aim of the Study: To compare our septic hand cases from 2002 with the septic hand cases from 2012 due to the fact that we have the impression that the number and pathology of septic hand conditions has changed in the last few years. Material and Method: We have retrospectively compared, using the available medical documentation, the surgically treated septic hand conditions from 2002 to 2012: number of patients, localization and extension of the septic process, type of tissue affected (skin, subcutaneous tissue, bone, articulation), and the type of the pathogenic germ. Also, number of days from the first symptoms to surgery, length of hospitalization, and number of days needed for return to work were evaluated. Results: In 2002, in total, 52 septic hand cases were operated in our unit compared with 98 in 2012. The most frequently affected was the index finger on the left hand in both periods. Of all, 60% of the patients were male and 40% female in both periods. In 2002, the most frequently affected tissue was the subcutaneous tissue in 63%, and in 2012, the small joints of the hand in 65%. The pathogenic germs remained unchanged. The number of digital amputations grew from 11% to 16%. The time elapsed from the first symptoms to surgery was in average 12 days for both periods. Number of days spent in hospital decreased from 9 to 7 days, but the final healing occurred in average after 44 days in 2012 compared with 30 days in 2002. Conclusions: The number of septic hand conditions has doubled in 10 years. Interestingly, neither the number of affected fingers nor the pathogenic germs had changed. Localization changed from the subcutaneous tissue to the joints level. This was reflected in the increase of number of amputations and the 30% longer period needed for the final healing. It seems obvious that bigger attention should be addressed to early stages of hand infections to prevent articular involvement and unwanted mutilating outcome.

The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study.

BackgroundTibial plateau fractures are of great challenge to treat with open reduction and internal fixation, because fractures vary from simple to complex, with little or extensive articular involvement. Hence, recognition and comprehension of the fracture features will help orthopedic surgeons understand the injury mechanism better and manage these fractures by planning optimal surgical procedures. This study aimed to evaluate the morphological characteristics of tibial plateau fractures based on the Schatzker classification.MethodsA total of 186 patients with 188 tibial plateau fractures from 2010 to 2014 in our hospital were reviewed using a computed tomography scan and three-dimensional (3D) reconstruction. The main fracture line angles (FLA) of Schatzker types I, II, and IV were measured. For each fracture, depression depth was measured, and the depression zone was also located. Depression zones were overlapped to obtain a frequency diagram.ResultsSchatzker type I and II fractures had three subtypes: single anterolateral fracture, single posterolateral fracture, and complex fracture (the anterolateral and posterolateral parts). Schatzker type IV fractures were also divided into three subtypes: single posteromedial fracture, single anteromedial fracture, and the whole medial fracture. For various Schatzker types and subtypes of fracture, fracture depression clustered and occurred at different locations of the tibial plateau. A significant difference was observed in the depression depth among the different Schatzker types (P < 0.01, Kruskal-Wallis test), especially between Schatzker type III and other types (Nemenyi test). There was no difference in the depression depth among the subtypes of Schatzker type II, whereas the difference was significant between the two subtypes of Schatzker type IV.ConclusionsSchatzker type I, II, and IV fractures could be divided into three corresponding subtypes by FLA. Various Schatzker types of fractures differed in location and depth of depression. A proper operative approach should be made based on the morphological characteristics of individual types of tibial plateau fractures.

Functional Outcome of Various Modalities of Management of Distal Tibial Fractures

INTRODUCTION: Distal tibial fractures remain a challenge to orthopaedic surgeons. They usually occur as a result of high energy trauma in young patients, but in the elderly they can result from a simple fall. In the elderly, the problem is compounded by poor bone-stock, their limited ability to partially weight bear and co-morbid conditions. The main challenges: 1.The compromised skin and soft tissue envelope as in open fractures lead to a high incidence of complications following open reduction and internal fixation. 2. In the metaphysis, fixation is less rigid and early loosening is a frequent event as the cancellous bone is open and ‘cell- like’ and therefore ill equipped to support a screw thread. 3. Comminuted fracture patterns, which create difficulty in achieving rigid fixation since the purchase in trabecular bone is less than optimal to permit weight bearing or even start early joint mobilization.These conditions that restrict mobility lead to decubitus ulcers, deep vein thrombosis, joint stiffness and secondary osteoarthritis. 4. These high energy fractures may be associated with extremely damaged soft tissue envelope, as well as comminuted metaphyseal region and articular surface making anatomical reduction difficult. AIM OF THE STUDY: To analyze and individualize the choice of fixation in the management of distal tibial fractures. MATERIALS AND METHODS: The present study deals with the analysis of out come of various modalities of treatment of distal tibial fractures depending on the type of fracture, location of the fracture and the status of the soft tissue envelope. The Study was conducted in Government Royapettah Hospital, Kilpauk Medical College between 2004 – 2006. Patients admitted with distal tibial fractures with or without intra articular extension and those having closed or open injuries were considered for this study. All patients having distal third tibial fractures were admitted and evaluated for co-morbid conditions. Routine investigations are done for anesthetic fitness and also to rule out systemic illness. Associated medical conditions were treated by corresponding specialists. The patients were maintained in POP and calcaneal pin traction in the case of compound fractures. Patients with compound fractures were treated with broad spectrum antibiotics. The time of surgery varied from 5 days to 25 days. There were 10 open injuries, of which there were 6 – Grade1; 3 – Grade 2 and 1-grade 3 open injuries. Those 5 patients who were not willing to undergo surgical procedures were treated conservatively by applying POP after 3 weeks of pin traction and check x-ray. RESULTS: The outcome of treatment of distal tibial fractures, is most affected by the severity of injury, management of the fracture and occurrence of certain complications. There are no uniformly accepted criteria for rating results. A number of factors are important for assessing results of tibial shaft fractures. Most reports omit one (or) more of them. For example Anderson et al., used only shortening and angulation to classify results of treatment into categories of excellent, good, fair, and poor. He rejected range of motion of the ankle joint as a criteria. However Horne and Colleagues with Hutching found ankle motion was a major determinant of functions. CONCLUSION: A short series of results of various modalities of management of distal tibial fractures were analyzed and the overall results including quality of reduction, functional recovery and the presence or absence of complications have led to us to individualise the option of treatment according to the status of the soft tissue, fracture location; fracture pattern and articular involvement. We are aware of the fact that the number of patients and duration of study may not give us the liberty to conclusively arrive at a protocol and might need a more elaborate study for standardization of the different methods available for the management of fractures of distal tibia.

Morphological Characteristics of the Posterior Malleolus Fragment According to the Ankle Fracture Patterns by Lauge-Hansen

Category: Trauma Introduction/Purpose: The posterior malleolus fragment (PMF) of an ankle fracture occurs in various shapes with regard to injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the posterior malleolus fragment according to the ankle fracture pattern by Lauge-Hansen classification using computer tomographic images. Methods: We retrospectively analyzed computer tomography data of 107 patients (107 ankles) who underwent surgery for tri- malleolus fracture from January 2012 to December 2014. A total of 76 ankles belong to Supination-Exorotation stage IV (SER group), 31 belong to Pronation- Exorotation stage IV (PER group). The type of PMF of two groups was respectively assessed by Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle and fragment height (FH) were measured as morphologic assessments. Results: The PMF type in SER group had mainly the posterolateral shape, while that in PER group had mainly the psotermedial two parts or large, posterolateral triangular shape (P= 0.02). The average cross angle (α) was no significant difference between two groups (SER group = 19.4°, PER group = 17.6°). The fragment length ratio and fragment height in PER group were significantly larger than that in SER group (P= 0.024, P=0.006). The fragment in PER group was significantly more vertical than that in SER group (P= 0.017). Conclusion: Morphological characteristics of the posterior malleolus fragment are different between SER group and PER group in trimalleolar ankle fracture. The SER type fractures are associated with smaller “rotational” fragment, while the PER type fractures are associated with larger “rotational and vertical” fragment with regard to the fragment volume and articular involvement.

Paradoxical articular manifestations in patients with inflammatory bowel diseases treated with infliximab.

Articular involvement is the most common extraintestinal manifestation associated with inflammatory bowel diseases (IBDs). Manifestations are 'paradoxical' when they occur during treatment, notably with anti-tumor necrosis factor (anti-TNF) drugs, which are expected to prevent or treat them. The aim of this study was to assess the frequency, characteristics, and associated factors of paradoxical articular manifestations in patients with IBD treated with anti-TNF. In this prospective single-center study, an examination by a rheumatologist was systematically offered to all patients with IBD treated with infliximab (IFX) to assess the prevalence of articular manifestations and distinguish between those related to treatment and those associated with intestinal disease. Paradoxical manifestations were defined as the occurrence of articular manifestations (excluding induced lupus and hypersensitivity reactions) during anti-TNF therapy in patients with intestinal remission. Measures of biological inflammatory, immunological markers, HLA-B27 allele, IFX trough levels, and anti-IFX antibody (Ab) were performed for all patients. Between May 2013 and April 2014, 65 patients with Crohn's disease and 15 with patients ulcerative colitis treated with IFX were included. The median duration of anti-TNF therapy was 66 months [quartile (Q)1=23 months-Q3=81 months]. Articular manifestations were observed in 50 (62%) patients treated with IFX. Eleven percent (n=9) were considered to be associated with IBD and 16% (n=13) to be associated with anti-TNF therapy. Among articular manifestations associated with anti-TNF therapy, nine (11%) patients were considered paradoxical, two (2%) as drug-induced lupus, and two (2%) as a hypersensitivity reaction. Among the nine patients with paradoxical manifestations, all had Crohn's disease in clinical remission, three patients presented a spondyloarthropathy, and three developed associated paradoxical psoriasis. No patient discontinued anti-TNF because of the articular manifestations. Methotrexate was effective on articular symptoms in two of the three treated patients with paradoxical manifestations. No clinical or biological factors, including IFX trough levels, were associated with the occurrence of paradoxical manifestations. Paradoxical articular manifestations in IBD patients treated by anti-TNF are common, affecting more than 10% of patients. These events are generally mild and do not need discontinuation of anti-TNF therapy.

Auditory involvement in Behcet's disease: relationship with demographic, clinical, and therapeutic characteristics.

The study objective was to evaluate the occurrence of sensorineural hearing loss (SNHL) in patients with Behcet's disease (BD), looking at potential correlations with specific demographic, clinical, and therapeutic features. Forty-four consecutive patients (15 males, 29 females) fulfilling the International Study Group (ISG) and/or the International Criteria for Behçet's Disease (ICBD) were enrolled. The endpoints of the study consisted in identifying a deflection of at least 25dB on pure-tone audiometry and performing statistical analysis to evaluate demographic, clinical, or therapeutic differences between patients with and without SNHL. Our patients showed a mean age ± SD of 45.43±14.05years; a mean age at disease onset ± SD of 31.54±15.53years; a disease duration ± SD of 13.89±9.15years. SNHL was highlighted in 28 (63%) patients representing the fourth most frequent clinical manifestation in our group of patients. Otologic involvement was significantly more frequent among subjects fulfilling ISG criteria than in patients fulfilling ICBD criteria (p=0.04). Regarding correlations with BD manifestations, SNHL was significantly associated with cutaneous plus articular involvement (p=0.013). Conversely, detached analysis of articular and skin manifestations led to no significant differences (p=0.085 and p=0.067). No further significant correlations were found between SNHL and BD clinical features or previous or concomitant treatments. Hearing loss was the fourth most common clinical feature in our patients and probably represents an underrated aspect of BD. Hearing impairment was significantly associated with cutaneous plus articular involvement, suggesting the importance of an otologic evaluation in such patients.

Repetitive Stresses Generate Osteochondral Lesions in Skeletally Immature Rabbits

Background: The origin of juvenile osteochondritis dissecans (OCD) is unknown. Existing experimental animal models of OCD most frequently involve surgically created lesions but do not examine repetitive stress as a possible cause of OCD. Hypothesis: Repetitive stresses can cause OCD-like lesions in immature animals. Study Design: Controlled laboratory study. Methods: Six juvenile rabbits were subjected to repetitive loading forces of approximately 160% body weight to the right hindlimb during five 45-minute sessions per week for 5 weeks. The contralateral limb was the unloaded control. After 5 weeks, rabbits were euthanized and examined with radiographs, micro–computed tomography, and gross and histopathologic analysis. Results: All 6 rabbits developed osteochondral lesions in loaded limbs on the medial and lateral femoral condyles, while contralateral unloaded limbs did not demonstrate lesions. Loaded limbs developed relative osteopenia in the femoral epiphysis and tibial metaphysis with associated decreased trabecular density. Loaded limbs also demonstrated increased femoral subchondral bone thickness near the lesions. Lesions did not have grossly apparent extensive articular cartilage damage; however, cartilage thickness increased on histology with reduced ossification. Loaded knees demonstrated abundant chondrocyte cloning, limited cartilage fissuring, and a focal loss of cellularity at the articular surface. Conclusion: Low-grade lesions in human OCD have little gross articular cartilage involvement despite substantial changes to the subchondral bone as shown on magnetic resonance imaging and radiographs. Histopathology findings in this study included cartilage thickening and chondrocyte cloning resembling those of recently published human OCD biopsy studies. Our animal model supports the hypothesis that repetitive stress to immature knees may contribute to the development of human OCD. This model may be useful in understanding the pathophysiology and healing of human OCD. Clinical Relevance: Repetitive physiologic stress generated changes to the subchondral bone in immature animals without causing extensive articular damage. The similarities of these lesions in gross and histologic appearance with human OCD support repetitive stress as the likely the cause for human OCD.

Fractures of the tibial plateau involve similar energies as the tibial pilon but greater articular surface involvement.

Patients with tibial pilon fractures have a higher incidence of post-traumatic osteoarthritis than those with fractures of the tibial plateau. This may indicate that pilon fractures present a greater mechanical insult to the joint than do plateau fractures. We tested the hypothesis that fracture energy and articular fracture edge length, two independent indicators of severity, are higher in pilon than plateau fractures. We also evaluated whether clinical fracture classification systems accurately reflect severity. Seventy-five tibial plateau fractures and 52 tibial pilon fractures from a multi-institutional study were selected to span the spectrum of severity. Fracture severity measures were calculated using objective CT-based image analysis methods. The ranges of fracture energies measured for tibial plateau and pilon fractures were 3.2-33.2 Joules (J) and 3.6-32.2 J, respectively, and articular fracture edge lengths were 68.0-493.0 mm and 56.1-288.6 mm, respectively. There were no differences in the fracture energies between the two fracture types, but plateau fractures had greater articular fracture edge lengths (p < 0.001). The clinical fracture classifications generally reflected severity, but there was substantial overlap of fracture severity measures between different classes. Similar fracture energies with different degrees of articular surface involvement suggest a possible explanation for dissimilar rates of post-traumatic osteoarthritis for fractures of the tibial plateau compared to the tibial pilon. The substantial overlap of severity measures between different fracture classes may well have confounded prior clinical studies relying on fracture classification as a surrogate for severity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:618-624, 2017.

Efficacy of abatacept in systemic lupus erythematosus: a retrospective analysis of 11 patients with refractory disease.

Objective The objective of this study was to assess the safety and efficacy of abatacept in patients with SLE refractory to conventional treatment in routine clinical practice. Methods This retrospective study included 11 SLE patients treated with abatacept for an active and refractory disease. The primary endpoint was the change in SLE Disease Activity Index (SLEDAI) score at six months. Response was defined as a decrease of SLEDAI ≥4 in a patient continuing abatacept. Results Indications of abatacept treatment were articular ( n=8), renal ( n=1) and cutaneous ( n=1) involvement and autoimmune thrombocytopenia ( n=1). Abatacept was discontinued before six months in two patients, because of adverse event ( n=1) and/or lupus flare ( n=2). The median SLEDAI decreased from 6 (2-20) to 4 (0-20) ( p=0.031). Decrease of SLEDAI ≥4 was observed in 6/11 patients (55%) and response to treatment according to the physician's judgement in 8/11 (73%) patients. Improvement of articular involvement was observed in 7/8 (87.5%) patients. Four adverse events were observed in three patients, but no severe infection occurred. Conclusion This study suggests some efficacy of abatacept in patients with refractory disease in routine clinical practice, particularly in the case of articular manifestations, with an acceptable safety profile. These data support conducting new controlled trials of abatacept in SLE patients.