Physical Examination Of Joints Research Articles

Forefoot inflammation in recent-onset ACPA-positive and ACPA-negative RA: clinically similar, but different in underlying inflamed tissues

ObjectivesAlthough joint swelling is traditionally interpreted as synovitis, recent imaging studies showed that there is also inflammation of tenosynovium and intermetatarsal bursae in the forefoot. We aimed to increase our...

Diagnostic error as a scientific and ethical challenge in establishing the activity of rheumatoid arthritis

The articular examination is an essential part of the physical examination of the patient with rheumatoid arthritis, since it gives information about the disease status at a given time and allows monitoring of its evolution over time. Despite the importance of the physical examination of the joints, it is noteworthy that there is no standardized technique. This paper aims to frame a discussion on whether standardization of the joint examination is justified, presenting arguments for and against. The paper raises several arguments about diagnostic error as a scientific and ethical challenge in establishing the activity of rheumatoid arthritis. It is time to adopt a standardized physical joint examination technique that allows better assessment of the inflammatory activity status of the disease, avoids risks resultant from poor disease status classification, adheres to ethical principles and does not incur unnecessary expenses. Failure to do so would have scientific, economic, ethical, and public health implications. El examen articular es una parte fundamental del examen físico del paciente con artritis reumatoide ya que permite obtener información sobre el estado de la enfermedad en un momento determinado, así como monitorizar su evolución en el tiempo. A pesar de la importancia del examen físico de las articulaciones, no existe una técnica estandarizada. Este ensayo tiene como objetivo desarrollar una discusión sobre si la estandarización del examen conjunto está justificada, para lo cual se presentan argumentos a favor y en contra. El ensayo plantea varios argumentos acerca del error diagnóstico como un desafío científico y ético cuando se trata de establecer la actividad de la artritis reumatoide. Es el momento de adoptar una técnica de exploración física conjunta y estandarizada, que permita una mejor valoración del estado de actividad inflamatoria de la artritis reumatoide, evite los riesgos derivados de una mala clasificación del estado de la enfermedad, respete los principios éticos y no incurra en gastos innecesarios. Dejar de hacerlo tendría implicaciones científicas, económicas, éticas y de salud pública.

Diagnostic error as a scientific and ethical challenge in establishing the activity of rheumatoid arthritis

The articular examination is an essential part of the physical examination of the patient with rheumatoid arthritis, since it gives information about the disease status at a given time and allows monitoring of its evolution over time. Despite the importance of the physical examination of the joints, it is noteworthy that there is no standardized technique. This paper aims to frame a discussion on whether standardization of the joint examination is justified, presenting arguments for and against. The paper raises several arguments about diagnostic error as a scientific and ethical challenge in establishing the activity of rheumatoid arthritis. It is time to adopt a standardized physical joint examination technique that allows better assessment of the inflammatory activity status of the disease, avoids risks resultant from poor disease status classification, adheres to ethical principles and does not incur unnecessary expenses. Failure to do so would have scientific, economic, ethical, and public health implications. El examen articular es una parte fundamental del examen físico del paciente con artritis reumatoide ya que permite obtener información sobre el estado de la enfermedad en un momento determinado, así como monitorizar su evolución en el tiempo. A pesar de la importancia del examen físico de las articulaciones, no existe una técnica estandarizada. Este ensayo tiene como objetivo desarrollar una discusión sobre si la estandarización del examen conjunto está justificada, para lo cual se presentan argumentos a favor y en contra. El ensayo plantea varios argumentos acerca del error diagnóstico como un desafío científico y ético cuando se trata de establecer la actividad de la artritis reumatoide. Es el momento de adoptar una técnica de exploración física conjunta y estandarizada, que permita una mejor valoración del estado de actividad inflamatoria de la artritis reumatoide, evite los riesgos derivados de una mala clasificación del estado de la enfermedad, respete los principios éticos y no incurra en gastos innecesarios. Dejar de hacerlo tendría implicaciones científicas, económicas, éticas y de salud pública.

POS0385 DURING DEVELOPMENT OF RHEUMATOID ARTHRITIS, INTERMETATARSAL BURSITIS MAY OCCUR BEFORE CLINICAL JOINT SWELLING: A LARGE MRI STUDY IN PATIENTS WITH CLINICALLY SUSPECT ARTHRALGIA

Background:Inflammation of the synovial lining is a hallmark of rheumatoid arthritis (RA). A synovial lining is not only present at synovial joints and tendon sheaths but also at bursae. Inflammation of the synovium-lined intermetatarsal bursae in the forefoot, intermetatarsal bursitis (IMB), was recently identified with MRI. It is specific for early RA and present in the majority of RA patients at diagnosis. During development of RA, MRI-detectable subclinical synovitis and tenosynovitis often occur before clinical arthritis presents. Whether IMB is also present in a pre-arthritis stage is unknown.Objectives:To assess the occurrence of IMB in patients with clinically suspect arthralgia (CSA) and its association with progression to clinical arthritis in a large MRI-study.Methods:We studied 524 consecutive patients presenting with CSA. CSA was defined as recent-onset arthralgia of small joints that is likely to progress to RA based on the clinical expertise of the rheumatologist. Participants underwent unilateral contrast-enhanced 1.5T MRI of the forefoot, metacarpophalangeal (MCP) joints and wrist at baseline. Thereafter patients were followed for detection of clinical arthritis, as identified at physical joint examination by the rheumatologist. Baseline MRIs were evaluated for IMB at all 4 intermetatarsal spaces. Also synovitis, tenosynovitis and osteitis were assessed in line with the RA MRI scoring system (summed as RAMRIS-inflammation). Both IMB and RAMRIS-inflammation were dichotomised into positive/negative using data from age-matched symptom-free controls as a reference. Cox regression analysed the association of IMB with progression to clinical arthritis; multivariable analyses were used to adjust for RAMRIS-inflammation which is known to associate with progression to clinical arthritis. Analyses were repeated stratified for ACPA-status, since ACPA-positive and ACPA-negative RA are considered separate entities with differences in pathophysiology.Results:The baseline MRIs showed ≥1 IMB in 35% of CSA-patients. Patients with IMB were more likely to also have synovitis (OR 2.5 (95%CI 1.2–4.9)) and tenosynovitis (8.9 (3.4–22.9)) on forefoot MRI, but not osteitis (0.9 (0.5–1.8)). Patients were followed for median 25 months (IQR 19–27). IMB-positive patients developed clinical arthritis more often than IMB-negative patients (HR 3.0 (1.9-4.8)). This association was independent of RAMRIS-inflammation (adjusted HR 2.2 (1.4–3.6)). In stratified analyses, IMB was more frequent in ACPA-positive than in ACPA-negative CSA (68% vs. 30%, p<0.001). Moreover IMB predicted clinical arthritis development in ACPA-positive CSA (HR 2.5 (1.1–5.7)) but not in ACPA-negative CSA patients (1.0 (0.5–2.2)).Conclusion:One-third of CSA patients have IMB. IMB is frequently present in conjunction with subclinical synovitis and tenosynovitis. It precedes the development of clinical arthritis, and in particular the development of ACPA-positive RA. These results reinforce the notion that not only intra- but also juxta-articular synovial inflammation is involved in the development of RA.Disclosure of Interests:None declared

Outcome measures in Haemophilia: Beyond ABR (Annualized Bleeding Rate).

Options for management of haemophilia are increasing rapidly with completely novel therapeutic approaches that cannot be compared using traditional factor assays. In addition, as prophylaxis regimens have improved, bleeding rates have decreased, and consequently, it is difficult to show an impact of novel therapies on rates of spontaneous bleeding. There is currently an urgent need for a panel of outcome measures to compare therapies that are dissimilar in many essential ways. Conventional objective outcome measures including joint physical examination and joint imaging continue to hold a central importance. Factor assays are essential for evaluation of products derived from native factor genes, but are not applicable to some extended half-life factors or non-factor bypassing agents. Global assays including thrombin generation and chromogenic assays of factor X activation are under investigation for their usefulness in haemophilia assessment. Bleeding rate is a conventional subjective patient-reported outcome that, while decreasing in frequency, is indispensable as an outcome given that the primary manifestation of haemophilia is bleeding. Other patient-reported outcomes such as pain intensity and interference, health-related quality of life and activities and participation are increasingly important to distinguish superior outcomes in comparative trials. This review of outcome measures for haemophilia presents examples of existing outcome measures with an emphasis on their strengths and limitations.

The value of inquiring about functional impairments for early identification of inflammatory arthritis: a large cross-sectional derivation and validation study from the Netherlands

ObjectivesHealthcare professionals other than rheumatologists experience difficulties in detecting early inflammatory arthritis (IA) by joint examination. Self-reported symptoms are increasingly considered as helpful and could be incorporated in online tools...

Young adult outcomes of childhood prophylaxis for severe hemophilia A: results of the Joint Outcome Continuation Study

The Joint Outcome Study (JOS), a randomized controlled trial, demonstrated that children with severe hemophilia A (HA) initiating prophylactic factor VIII (FVIII) prior to age 2.5 years had reduced joint damage at age 6 years compared with those treated with episodic FVIII for bleeding. The Joint Outcome Continuation Study (JOS-C) evaluated early vs delayed prophylaxis effects on long-term joint health, following JOS participants to age 18 years in an observational, partially retrospective study. Index joint magnetic resonance imaging (MRI) scores of osteochondral (OC) damage (primary outcome), joint physical examination scores, and annualized rates of joint/other bleeding episodes (secondary outcomes) were collected. Thirty-seven of 65 JOS participants enrolled in JOS-C, including 15 randomized to prophylaxis at mean age 1.3 years ("early prophylaxis"); 18 initially randomized to episodic treatment, starting "delayed prophylaxis" at mean age 7.5 years; and 4 with high-titer inhibitors. At JOS-C exit, MRI OC damage was found in 77% of those on delayed and 35% of those on early prophylaxis for an odds ratio of OC damage, in the delayed vs early prophylaxis group, of 6.3 (95% confidence interval, 1.3, 29.9; P = .02). Annualized bleeding rates were higher with delayed prophylaxis (mean plus or minus standard deviation, 10.6 ± 6.6 vs 3.5 ± 2.1; P < .001), including when only comparing time periods on prophylaxis (6.2 ± 5.3 vs 3.3 ± 1.9; P < .05). In severe HA, early initiation of prophylaxis provided continued protection against joint damage throughout childhood compared with delayed initiation, but early prophylaxis was not sufficient to fully prevent damage. This trial was registered at www.clinicaltrials.gov as #NCT01000844.

Functional Consequences of Joint Impairment at Age 79

A study of functional ability--in relation to joint impairment and disability--in 79-year-olds was performed on representative subsamples by interview (n = 134) and physical examination of joints (n = 89) as well as interview and functional tests regarding activities of daily living (ADL) (n = 84). Joint complaints of the lower extremities were more frequent than complaints of the upper extremities. Restricted knee motion had the highest correlation to disability of entering public transports. Previous sedentary workers were more disabled in ADL functions than those with a previous strenuous physical work. Correlation was found between low physical activity in the leisure time and impaired ADL functions. Low physical activity in the group with no definable disease was also correlated with greater social assistance. The reasons for commitment to institutional care were usually complex and, generally, not caused by joint impairment. Although disability had increased within the sample since age 70, at age 79 sixty per cent of the probands could still manage household tasks and personal care, and 69% did not require walking aids. The 79-year-olds thus display a high degree of musculoskeletal ability.

FRI0542 OBTAINING HIGH POSITIVE PREDICTIVE VALUES FOR THE DEVELOPMENT OF CLINICALLY APPARENT ARTHRITIS IN PATIENTS PRESENTING WITH CLINICALLY SUSPECT ARTHRALGIA; IS IT FEASIBLE?

Background:The hypothesis that initiation of DMARD-treatment before arthritis becomes apparent could permanently modulate the disease process, such that persistent RA is prevented, is being studied in several ongoing trials. Essential for such studies is the ability to accurately predict clinically apparent inflammatory arthritis (IA). However there are two hurdles: first, it is insufficiently known whether it is possible to obtain high positive predictive values (PPV) in patients presenting with clinically suspect arthralgia (CSA). Second, none of current predictive models is validated in independent cohorts. We here aimed to evaluate the first question, incorporating improved markers of MRI-detected subclinical inflammation that were recently identified but have not yet been combined with other known predictors.[1]Objectives:To assess the feasibility of achieving high PPVs in prediction of IA-development in patients with CSA by combining clinical, laboratory and imaging parameters.Methods:580 patients with CSA were consecutively included in the Clinically Suspect Arthralgia (CSA)-cohort and followed on the development of IA, determined by physical examination of joints. Unilateral contrast-enhanced 1.5 Tesla MRIs were made of MCP(2-5), wrist and MTP(1-5)-joints at baseline and scored in line with the RAMRIS. The number of locations with subclinical inflammation (0/1-2/≥3) and the presence of MCP peritendinitis were defined as described previously.[1] Other studied clinical and laboratory variables were based on the literature: initial localisation of complaints (small/large joints), functional disability (health assessment questionnaire (HAQ) ≥1), ACPA-positivity (Anti-CCP2), RF-positivity (IgM-RF) and elevated CRP.[2,3] LASSO Cox regression with a 10-fold cross-validated shrinkage parameter was used for predictor selection. Regression coefficients were rounded to the nearest number ending in .5 or .0 and multiplied by two, resulting in a weighted score. Kaplan Meijer curves were used to obtain PPVs of this weighted score and the area under the curve (AUC) was determined at 2-year follow-up.Results:Mean age was 44, 78% was female, and 18% progressed to IA within 2 years. The following parameters were selected with LASSO: RF-positivity, ACPA-positivity, HAQ≥1, &gt;2 locations of subclinical inflammation and presence of MCP-extensor peritendinitis. Based on the beta of LASSO-regression, patients were assigned 2 points for the risk-factors ACPA-positivity and &gt;2 locations of subclinical inflammation, 1 point for RF-positivity and presence of MCP-extensor peritendinitis and 0 points for HAQ≥1. Kaplan Meijer curves show PPVs of 8%, 9%, 30%, 54%, 73%, 79% and 86% at two years (Figure 1). This model yielded an AUC of 0.79.Figure 1.Kaplan Meijer curves on inflammatory arthritis development stratified for number of points based on LASSO regression. Legend: Points were based on the regression coefficients yielded by Cox LASSO-regression. 2 points were assigned for the risk factors ACPA-positivity and &gt;2 locations of subclinical inflammation and 1 point was assigned for RF-positivity and presence of MCP-extensor peritendinitis.Conclusion:High PPVs for IA-development can be achieved in patients with CSA by weighting a combination of known predictors. Although encouraging, these data are based on one observational cohort study and have not been validated in independent cohorts, limiting the relevance. To support future research in the field of arthralgia, it is needed that different research groups work together to come to risk estimations that are validated and accepted.

The relation between physical joint examination and MRI-depicted inflammation of metatarsophalangeal joints in early arthritis

BackgroundThe relationship between physical joint examination (PE) and MRI-detected inflammation in early inflammatory arthritis has mostly been studied in the hands. Physical examination of MTP joints is considered difficult, and for these joints, this relationship is unknown. Therefore, we studied the concordance of PE with MRI inflammation in MTP joints. Metacarpophalangeal (MCP) joints were included for comparison.MethodsOne thousand seven hundred fifty-nine MTP(2–5) and 1750 MCP(2–5) joints of 441 consecutive patients with early arthritis underwent PE (for joint swelling) and MRI, all evaluated by two assessors. MRI was scored for synovitis, tenosynovitis, and osteitis (summed MRI inflammation). Synovial intermetatarsal bursae may enlarge upon inflammation and become palpable and were therefore also assessed. Analyses (frequencies, GEE) were performed on joint level.ResultsPE and MRI were concordant in 79% of MTP joints. Of 1606 non-swollen MTP joints, 83% showed no MRI inflammation and 17% showed subclinical MRI inflammation. Of 153 swollen MTP joints, 48% had MRI inflammation and 52% (79 MTP joints) did not. Of these 79 swollen MTP joints without MRI inflammation, 31 showed intermetatarsal bursitis and 48 joints had none of these MRI abnormalities (this concerned 31% of swollen MTP joints). MTP swelling was statistically independently associated with tenosynovitis (OR 2.21, 95% CI 1.1–4.3) and intermetatarsal bursitis (OR 2.91, 95% CI 1.8–4.8).MTP joints showed subclinical inflammation less often than MCP joints (17% vs. 34%, P < 0.001). Swollen MTP joints showed MRI inflammation less often than swollen MCP joints (48% vs. 88%, P < 0.001).ConclusionsThe absence of swelling of MTP joints in early arthritis is mostly accompanied by the absence of MRI-detected inflammation. Swollen MTP joints are, in addition to synovitis, also explained by tenosynovitis and intermetatarsal bursitis and partly unexplained by MRI. Their clinical relevance must be determined in longitudinal studies.

Experience of musculoskeletal ultrasound scanning improves physicians' physical examination skills in assessment of synovitis.

Musculoskeletal ultrasound (US) is more sensitive than physical examination in detecting synovitis and helps physicians to understand its pathophysiology. In this study, we aimed to determine if the experience in musculoskeletal US scanning is independently associated with improved physical examination skills to detect synovitis. Seventy patients with rheumatoid arthritis and twenty-three physicians were enrolled. Patients were first assessed by multiple physicians with a range of clinical/sonographic experience for the swelling of the wrist, metacarpophalangeal and proximal interphalangeal (PIP) joints and next underwent US assessment performed by another physician experienced in musculoskeletal US. We then calculated the positive/negative predictive values (PPV/NPV) of joint swelling to identify US-detected synovial hypertrophy. Finally, the factors independently associated with the accuracy of clinical assessment were identified by using multivariate analyses. One thousand five hundred forty joints were assessed 6116 times in total for swelling. Overall, PPV and NPV of joint swelling were 51.7% and 88.3%, respectively. Multivariate analyses identified wrist joint, tenderness, male and greater patients' age as the factors significantly associated with higher PPV. In addition, there was a trend that longer experience in rheumatology clinical practice was associated with higher PPV (p = 0.058). On the other hand, longer experience in musculoskeletal US, PIP joint and positive rheumatoid factor were identified as the significant factors for higher NPV, while wrist joint, tenderness, presence of osteophyte and obesity as those for lower NPV. Our data suggest that the experience in musculoskeletal US improves physical examination skills particularly to avoid overestimation.Key Points• Physicians with longer US experience are less likely to overestimate synovitis by physical examination.• Musculoskeletal US is a useful tool for rheumatologists to improve their physical examination skill.• Presence of osteophytes, joint tenderness and obesity influence the accuracy of physical examination of joints.

Joint scores in hemophilic arthropathy in children: Developing country perspectives.

Hemophilia is a common X-linked recessive coagulopathy causing recurrent bleeding into the synovial joints and results in articular and periarticular abnormalities. To our knowledge, this is the first comprehensive study aimed at studying the clinico-radiological joint score evaluation in hemophilic arthropathy in children from a developing country and its possible impact on the quality of life. In this hospital-based, prospective, descriptive study, all children presenting to the pediatric rheumatology clinic were studied. The joint physical examination was scored using the Hemophilia Joint Health Score 2.1 (HJHS 2.1). The patients were then subjected to imaging of the most affected joint using ultrasonography (USG) and magnetic resonance imaging (MRI). Detailed USG and MRI radiological evaluation was recorded in the predesigned proforma using the Hemophilia Early Arthropathy Detection with Ultra Sound (HEAD-US) score and MRI DENVER score. The physical quality of life as per Functional Independence Score in Hemophilia (FISH) was noted. The clinical, radiological, and functional scores were analyzed with an appropriate statistical measure. The mean age at presentation was 7.4 years (interquartile range 4.9-10), with the knee being the most common joint involved. All of the USG score, MRI score, and FISH score have a significant correlation (p<0.05), with the HJHS 2.1 score with correlation coefficients of 0.7086, -0.8916, and 0.8607, respectively. USG and MRI had a correlation coefficient of -0.7145 and -0.8326 with FISH, respectively. The degree of association between HJHS 2.1 score was found to be maximum with HEAD-US score, whereas a negative correlation was seen evaluating FISH score with both HEAD-US and MRI DENVER scores. Use of these scores, specifically HEAD-US score, will result in consistent assessment of hemophilic joints, optimizing the management of the destructive changes.

Genetic biomarkers related to hemarthrosis, inflammation, and cartilage structure in pediatric patients with hemophilic arthropathy.

BackgroundThe pathophysiology of hemophilic arthropathy is complex and not completely understood. In this study, we aimed to identify biomarkers that can affect the hemophilic arthropathy severity.MethodsFifty patients were analyzed for biomarker frequencies; in 37 patients, articular symptoms were evaluated based on the physical joint examination score, and in 18, it was based on magnetic resonance imaging. Eight polymorphisms, namely FV 1691G>A, FII 20210G>A, MTHFR 677C>T and 1298A>C, TNFα‐308G>A and ‐238G>A, ACAN VNTR, and IL1RN*2‐VNTR were identified.ResultsPatients with the MTHFR 677TT genotype showed a higher number of affected joints (1.83 ± 0.9 vs. 0.55 ± 0.7 for CC; p = .023), whereas those with the MTHFR 1298AC genotype exhibited higher effusion according to two radiologists (0.90 ± 0.31/1.20 ± 0.63 vs. 0.38 ± 0.52/0.50 ± 0.53 for AA genotype; p = .043/0.036, respectively). In addition, patients with the TNFα‐308GA genotype had more subchondral cysts (0.75 ± 0.95 vs. 0.07 ± 0.26 for GG genotype; p = .041).ConclusionsThe distribution of risk genotypes for MTHFR and TNFα‐308GA suggests their association with clinical parameters of hemophilic arthropathy. Cohort studies are essential to verify these associations.

Developing a new scoring scheme for the Hemophilia Joint Health Score 2.1

BackgroundThe Hemophilia Joint Health Score (HJHS) is a validated outcome tool developed for the assessment of joint health in people with hemophilia. The ordinal joint score assesses 9 items in 6 index joints. It is recognized as an optimal measurement of arthropathy in children and young adults. The aim of this study was to develop an updated scoring system for the HJHS that may overcome the limitations of its current ordinal scoring structure.MethodsA survey was developed using 1000Minds decision‐making software. Respondents were provided with discrete choice tasks of ranking alternatives to determine the preference weight, or relative importance, placed on different criteria for each HJHS item. The survey was distributed to an anonymous sample of health care professionals with extensive experience in the physical examination of joints in people with hemophilia.ResultsA total of 64 musculoskeletal health care professionals participated; with a 64% survey completion rate. The HJHS item weights provide a sum to 1.0; the highest‐ranked item was extension loss (0.139) followed by swelling (0.121), whereas the lowest was duration of swelling (0.057) followed by muscle atrophy (0.08). Compared to the original, the relative efficiency of the new score was 5.4.ConclusionsObserved differences in preference weights for HJHS items highlight the potential under‐ or overestimation of true joint health using the current ordinal scoring system. An updated scoring system using weighted items may improve the precision of HJHS assessment, leading to improved clinical management of joint health, while providing a robust research tool.

OP0132 HOW ACCURATE IS PHYSICAL JOINT EXAMINATION OF THE MTP-JOINTS, AND WHAT CAN WE LEARN FROM ADDITIONAL MAGNETIC RESONANCE IMAGING ON FOREFOOT INVOLVEMENT IN EARLY ARTHRITIS?

Background Magnetic resonance imaging (MRI) is known to be more sensitive than physical examination in detecting inflammation, and has predominantly been studied in metacarpophalangeal-(MCP) and wrist-joints. Data on the concordance and discordance of physical examination and MRI-detected inflammation of metatarsophalangeal-(MTP)joints is scarce, which is surprising as physical examination of these joints is generally considered more challenging than of MCP-joints. Objectives We aimed to study the concordance and discordance of arthritis upon physical examination with MRI-detected inflammation of MTP-joints. Analyses on MCP-joints were included for comparison. Methods 1764 MTP(2-5)-joints and 1764 MCP(2-5)-joints of 441 consecutive patients presenting with early inflammatory arthritis (36% RA, 64% other inflammatory arthritides) underwent physical examination (PE) of joint swelling and 1.5T contrast-enhanced MRI of unilateral MCP- and MTP-joints. MRI-detected synovitis and bone marrow oedema were scored according to the RA MRI score (RAMRIS), and tenosynovitis according to Haavardsholm by two experienced readers (scores ranged 0-3). Analyses were done on joint level and joints were grouped as PE+MRI+, PE–MRI–, PE+MRI– and PE–MRI+. MRI-positivity required the presence of the same MRI-inflammatory feature on joint level that was scored by both readers≥1. In addition, to be classified as PE+MRI–, the joints required to have clinical swelling as objectified by two independent observers. After categorisation, the MRIs of the joints that were PE+MRI– were further studied by two other, independent observers among whom an experienced musculoskeletal radiologist, to investigate the presence of contrast-enhancement that was not scored according to RAMRIS guidelines. Results Physical examination of joints and MRI were concordant in 79% of MTP-joints (6% PE+MRI+, 74% PE–MRI–). For the MCP-joints this was 71% (15% and 56% respectively). Next discordance was studied. Subclinical joint inflammation (PE–MRI+) was present in 14% (n=248) of MTP-joints. This was less frequent than in MCP-joints, where subclinical inflammation was present in 27% joints (n=465, p Subsequently, the MRIs of the joints that were clinically inflamed and scored negative according to RAMRIS were studied for other MRI-abnormalities. Out of the 78 MTP-joints that were PE+MRI–, 54% (n=42) showed no MRI abnormalities, whereas in 46% (n=36) extra-articular contrast-enhanced lesions were observed that were predominantly identified as peri-arthritis and intermetatarsal bursitis. Within this category, extra articular inflammation was more prevalent in RA than in other inflammatory arthritides (58% vs 26%, p=0.005). At the MCPs no extra-articular inflammation was found. Conclusion Joint examination and MRI were mostly concordant in MTP- and MCP-joints. In MTP-joints MRI-detected subclinical joint inflammation was infrequent (14%), especially when compared to MCP-joints (27%). Clinical joint swelling without MRI-detected joint inflammation according to RAMRIS was also infrequent (5% of MTP-joints) and in part caused by extra-articular inflammation such as intermetatarsal bursitis. Further detailed imaging studies are needed to determine if extra-articular inflammation at the level of MTP-joints, with or without concomitant intra-articular inflammation, is a novel finding that is characteristic for early RA. Disclosure of Interests: Yousra Dakkak: None declared, Aleid Boer: None declared, Debbie Boeters: None declared, Monique Reijnierse Grant/research support from: Funding from the Dutch Arthritis Foundation. The funding source had no role in the design and conduct of the study., Annette van der Helm - van Mil Grant/research support from: The research leading to these results has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (Starting grant, agreement No 714312) and from the Dutch Arthritis Foundation. The funding source had no role in the design and conduct of the study.

Outcome of posterior wall blowout in anterior cruciate ligament (ACL) reconstruction via anteromedial portal approach: A retrospective research in 20 patients with 6 years follow-up

PurposeTo evaluate the clinical outcome in patients who received anterior cruciate ligament (ACL) reconstruction via anteromedial portal with or without posterior wall blowout.MethodsTwenty patients with ruptured ACL, who have received ACL reconstruction via anteromedial portal between Apr 2012 and Oct 2013 were enrolled. According to the conditions of posterior wall, the patients were divided into 2 groups: posterior wall blowout group (10 patients) and posterior wall intact group (10 patients). The median follow up time were 63 (range 19–75) months and 60.5 (range 25–64) months in the 2 groups respectively. The clinical outcome was evaluated by knee joint physical examination, magnetic resonance imaging (MRI), the International Knee Documentation Committee (IKDC) 2000 subjective score, Lysholm score, Tenger score, difference of thigh circumference, KT-2000 and Biodex isokinetic dynamometer system.ResultsNo significant differences were found in terms of the IKDC score, Lysholm score, Tegner score, Lachman test positive rate or Pivot Shift test positive rate between the two groups. In KT-2000 and Biodex isokinetic dynamometer tests, the difference of muscle strength between affected knees and unaffected knees in posterior wall blowout group was not significant less than that of posterior wall intact group (p > 0.05). In addition, there is no statistical difference between the two groups in signal/noise quotient (SNQ) of the graft (p > 0.05) in post operative MRI.ConclusionBlowout of posterior wall in ACL reconstruction via anteromedial portal does not affect the clinical outcome as long as reliable fixation has been taken intraoperatively.

Physiotherapy protocol during initial postoperative period of arthroscopy in horses

ABSTRACT: This study evaluated the effects of a physiotherapy protocol applied in joints with osteochondritis dissecans submitted to arthroscopy. Twelve horses totaling twenty joints were used and divided into two uniform groups, according to articular lesion grade. Treated Group (TG) received the physiotherapy protocol (cryotherapy, passive rage motion and controlled exercise) that initiate just after anesthetic recovery and extended for five days. Control Group (CG) remained resting in stall during the same period. Physical examination and synovial fluid analysis were used to evaluate the treatment. The synovial fluid examination consisted of physical analysis (color, aspect, and viscosity), mucin clot evaluation, Serum Amyloid A, Prostaglandin E2 and urea concentration. Synovial samples were collected by arthrocentesis at the beginning of the surgical procedure (D1), 48 hours (D3) and 96 hours (D5) after surgery. Before arthroscopy and daily during the postoperative period joints were evaluated by physical exam: superficial temperature (°C), range of motion (degrees) and circumference (centimeters). The joint physical examination showed no significant difference between groups and neither along the days for the same group. The parameters of synovial fluid showed difference over the moments in each group but didn’t have difference between groups. Color and aspect had the same patterns across moments, in CG fluid had significant change when compared D1 with D3 (color and aspect: p&lt;0.001) and D5 (color: p&lt;0.001; aspect: p&lt;0.05) becoming mostly bloody and cloudy in D3 and D5. However in TG the difference was significant just between D1 and D3 (color and aspect: p&lt;0.05), showing an improvement of synovial fluid in D5 (color and aspect: p&gt;0.05). Viscosity and mucin clot evaluation showed significant change in CG between D1 and D3 (viscosity: p&lt;0.01; mucin clot: p&lt;0.05) and between D1 and D5 (viscosity: p&lt;0.01;mucin clot: p&lt;0.01). In TG no significant difference of viscosity and mucin clot was observed over the moments, showing an early improvement of synovial fluid quality. The Serum Amyloid A concentration showed an extremely significant increase in CG (p&lt;0.001) when compared D1 (1217.13±664.47μg/mL) and D3 (42423.80±52309.31μg/mL). The comparison between D1 and D5 in CG, and across moments in TG, had no statistical difference. The PGE2 eicosanoid remained statistically unchanged all over the time. Urea showed significant increase in D3 when compared to D1 (p&lt;0.001) in CG, and had no variation in TG. The physiotherapy protocol minimized the inflammatory mediators and provided minor alterations in synovial fluid after arthroscopy.

Early Prophylaxis Provides Continued Joint Protection in Severe Hemophilia A: Results of the Joint Outcome Continuation Study

Early Prophylaxis Provides Continued Joint Protection in Severe Hemophilia A: Results of the Joint Outcome Continuation Study

Time-Driven Activity-Based Costing (TDABC) in Radiation Oncology: A Method for Implementation

Time-Driven Activity-Based Costing (TDABC) has gained popularity in the healthcare industry, but little information exists on the benefits and strategies for implementation within Radiation Oncology. Furthermore, the data may provide insight into opportunities for operational improvements. We sought to implement TDABC in a large academic radiation oncology practice using a customized approach and minimal resources. A multidisciplinary team was created to oversee and maintain the project scope, timeline and task list. Adaptability was noted as a key to project success, so a weekly schedule was established for team huddles. The data collection plan was divided into four phases: Process mapping, validation, resource allocation, and final validation. The resulting data were combined and organized into a functional tool allowing for scenario-specific analysis using treatment plan-specific variables (e.g. fractionation, complexity, on-treatment-visit volume, adaptive planning, verification simulation, etc.). The initiative required approximately 1.5 staff to manage over a 6 month period. Overall, 9 disease-site sections were considered. Between 16 and 18 workflow maps were produced within each section, resulting in approximately 44 unique cost profiles per section. Process maps for simulation, treatment planning, physics check and treatment delivery all contained cost profiles for each relevant treatment modality for each section. Initial analyses were performed on the Head and Neck (HN) and Genitourinary (GU) sections following the final phase of data collection. A 30 fraction (Fx) IMRT head and neck plan and a 39 Fx IMRT prostate plan were analyzed. 25% and 46% of total costs were accrued in the treatment delivery phase of the head and neck and prostate plans, respectively. The higher fractionation and additional time needed for patient set-up for the prostate plan were among multiple variables contributing to the difference in cost breakdown. Treatment delivery accounted for the largest proportion of total costs in both scenarios. On-Treatment-Visits (OTV) accounted for 16% and 20% of total costs for head and neck and prostate plans, respectively whereas Initial Consult Visits accounted for 13% and 12%, respectively. 15% of total costs in the head and neck scenario were attributed to head and neck section-specific processes such as joint physical examination and a minimum of one standard verification simulation during treatment. We conclude that TDABC can be implemented and sustained with the strategy outlined in our study. The data can provide insight into process variation and opportunities for operational improvement.

Long-Term Orthopedic Effects Of Delaying Prophylaxis In Severe Hemophilia A Until Age 6 Years: Results Of The Joint Outcome Study Continuation (JOSc)

Abstract The Joint Outcome Study (JOS) was a randomized controlled clinical trial in boys with severe factor VIII deficiency comparing prophylaxis consisting of 25 IU/kg factor VIII every other day begun prior to age 30 months with an enhanced episodic regimen given only in response to bleeding. At JOS exit at age 6 years, joint outcome by sensitive magnetic resonance image (MRI) and joint physical examination (PE) of 6 index joints (both ankles, knees and elbows) determined superiority of prophylaxis over episodic therapy (p &lt; 0.05). At JOS end, all parents were informed of the study results and boys in the episodic arm were counseled to initiate prophylaxis therapy; all but 1 JOS participant on episodic therapy switched to prophylaxis. The JOS Continuation Study is being performed to determine the results of early prophylaxis on joint development until the age of 18 years and to determine the impact of delaying prophylaxis initiation until age 6 years. All boys in the original JOS were eligible to enroll in the continuation study. Study data collected includes cumulative number of index joint and total hemorrhages, joint PE score of 6 index joints using the Colorado Pediatric Joint Assessment Scale as previously described (Haemophilia 6:649) and MRI soft tissue, osteochondral and total scores of 6 index joints using the expanded MRI 45 Scale as recently presented (ISTH OP Mon 7/1/13, 9 am). Additional data are collected on prophylaxis adherence, activities, surgeries, quality of life and replacement factor utilization. To date, results of 26 (40%) of the original 65 boys (16 on early and 10 on delayed prophylaxis) including 156 index joints are available for analysis. Results, expressed as a cumulative score for all 6 index joints, are shown in Table 1. While still enrolling, the JOS Continuation Study is documenting an ongoing disparity in joint outcome in children with initiation of prophylaxis delayed until age 6 years, compared with prophylaxis started before 30 months of age. Following delayed initiation of prophylaxis, adolescents manifest increased numbers of hemarthroses and increased MRI damage particularly affecting bone and cartilage. Joint PE is less sensitive than MRI in determination of joint outcome in hemophilia. Disclosures: Manco-Johnson: Bayer HealthCare: Membership on an entity’s Board of Directors or advisory committees, Research Funding; CSL Behring: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Baxter BioScience: Membership on an entity’s Board of Directors or advisory committees; Biogen Idec: Membership on an entity’s Board of Directors or advisory committees; NovoNordisk: Membership on an entity’s Board of Directors or advisory committees; Eisai: Research Funding. Manco-Johnson:Bayer HealthCare: Research Funding. Lane:Bayer HealthCare: Honoraria; Baxter BioScience: Paid travel to attend a meeting, Paid travel to attend a meeting Other. Shapiro:Bayer HealthCare: Research Funding; Baxter BioScience: Research Funding; Biogen Idec: Research Funding; Cangene: Research Funding. Valentino:Baxter BioScience: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Bayer HealthCare: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; CSL Behring: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; GTC Biotherapeutics: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Inspiration Bioscience: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; NovoNordisk: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding. Brown:Baxter BioScience: Research Funding; Biogen Idec: Research Funding; CSL Behring: Research Funding.