The effectiveness of corticosteroid injection and splint in diabetic de Quervain's tenosynovitis patients: A single-blind, randomized clinical consort study.

BACKGROUND: There is no clear information on the efficacy of corticosteroids, and splints in the treatment of patients with diabetes mellitus (DM). The aim of this study was to compare the outcomes of isolated corticosteroid injection therapy with splint treatment with corticosteroid injection in patients with and without DM. METHODS: 84 diabetics, and 84 healthy patients with a diagnosis of de Quervain's tenosynovitis were included in our study. The patients were randomly distributed into four subgroups with and without DM. Groups 1 and group 2 consisted of diabetic patients, while group 3 and group 4 consisted of healthy patients. Corticosteroid injections were administered to groups 1 and 3, and corticosteroid injection and splint treatment were administered to groups 2 and 4. RESULTS: There was no significant difference in terms of age, gender, dominant/non-dominant hand, pre-treatment Quick Disabilities of the Arm, Shoulder and Hand score and visual analog scale scores score between the four groups. Quick Disabilities of the Arm, Shoulder and Hand and visual analog scale scores in the four groups were found to be significantly better than pre-treatment at the 12th month. Finkelstein test results were positive in 37.5% of the patients in the first group, 35% of the patients in the second group, 20% of the patients in the third group and 9.5% of the patients in the fourth group. Groups 1 and 2 and, groups 3 and 4 were compared to evaluate the effect of the splint. While forearm-based thumb splint affected the results positively in healthy individuals, it was determined that it had no effect on the results in diabetic patients. CONCLUSION: Although corticosteroid treatment is effective in the treatment of de Quervain's tenosynovitis in healthy and diabetic individuals, the results are worse in diabetic patients than in healthy patients. In addition, the use of splint with corticosteroid injection in healthy individuals positively affects the results, while it does not affect the results in diabetic patients.

Role of ultrasound for assessment of psoriatic arthritis patients with fibromyalgia.

OBJECTIVE: To investigate whether ultrasonography (US), as an objective imaging modality, can optimise the evaluation of disease activity in psoriatic arthritis (PsA) patients with concomitant fibromyalgia syndrome (FMS). METHODS: The study population included 156 consecutive PsA patients who were recruited prospectively and fulfilled the ClASsification criteria for Psoriatic ARthritis criteria. The patients underwent complete clinical evaluation including assessment of fulfilment of the 2016 fibromyalgia classification criteria. All of the patients underwent US evaluation including 52 joints, 40 tendons and 14 entheses. The US score was based on the summation of a semiquantitative score (including synovitis, tenosynovitis and enthesitis). Scoring was performed by a sonographer blinded to the clinical data. Spearman's correlation coefficient and multivariate linear regression models were used to examine the association of FMS with clinical and the US scores. RESULTS: Forty-two patients (26.9%) with coexisting PsA and FMS were compared with 114 (73.1%) PsA patients without FMS. Patients with PsA and FMS had significantly increased scores for clinical composite indices, including non-Minimal Disease Activity, Composite Psoriatic Disease Activity Index (CPDAI), Disease Activity for Psoriatic Arthritis (DAPSA) and Psoriatic Arthritis Disease Activity Score (PASDAS) (p<0.001). In contrast, the total US score and its subcategories were similar for those with and without FMS. The total US score significantly correlated with CPDAI, DAPSA and PASDAS (p<0.001) in the PsA without FMS but not in the PsA with FMS group. FMS was significantly associated with higher clinical scores (p<0.001) but not with the US score (multivariable linear regression models). CONCLUSIONS: US has significantly greater value than composite clinical scores in the assessment of disease activity in PsA patients with FMS.

Are Patient Expectations and Illness Perception Associated with Patient-reported Outcomes from Surgical Decompression in de Quervain's Tenosynovitis?

BACKGROUND: Psychological factors such as depression, pain catastrophizing, kinesiophobia, pain anxiety, and more negative illness perceptions are associated with worse pain and function in patients at the start of treatment for de Quervain's tenosynovitis. Longitudinal studies have found symptoms of depression and pain catastrophizing at baseline were associated with worse pain after treatment. It is important to study patients opting for surgery for their condition because patients should choose surgical treatment based on their values rather than misconceptions. Psychological factors associated with worse patient-reported outcomes from surgery for de Quervain's tenosynovitis should be identified and addressed preoperatively so surgeons can correct any misunderstandings about the condition. QUESTION/PURPOSE: What preoperative psychosocial factors (depression, anxiety, pain catastrophizing, illness perception, and patient expectations) are associated with pain and function 3 months after surgical treatment of de Quervain's tenosynovitis after controlling for demographic characteristics? METHODS: This was a prospective cohort study of 164 patients who underwent surgery for de Quervain's tenosynovitis between September 2017 and October 2018 performed by 20 hand surgeons at 18 centers. Our database included 326 patients who underwent surgery for de Quervain's tenosynovitis during the study period. Of these, 62% (201 of 326) completed all baseline questionnaires and 50% (164 of 326) also completed patient-reported outcomes at 3 months postoperatively. We found no difference between those included and those not analyzed in terms of age, sex, duration of symptoms, smoking status, and workload. The mean ± SD age of the patients was 52 ± 14 years, 86% (141 of 164) were women, and the mean duration of symptoms was 13 ± 19 months. Patients completed the Patient-Rated Wrist Evaluation (PRWE), the VAS for pain and function, the Patient Health Questionnaire for symptoms of anxiety and depression, the Pain Catastrophizing Scale, the Credibility/Expectations Questionnaire, and the Brief Illness Perceptions questionnaire at baseline. Patients also completed the PRWE and VAS for pain and function at 3 months postoperatively. We used a hierarchical multivariable linear regression model to investigate the relative contribution of patient demographics and psychosocial factors to the pain and functional outcome at 3 months postoperatively. RESULTS: After adjusting for demographic characteristics, psychosocial factors, and baseline PRWE score, we found that only the patient's expectations of treatment and how long their illness would last were associated with the total PRWE score at 3 months postoperatively. More positive patient expectations of treatment were associated with better patient-reported pain and function at 3 months postoperatively (ß = -2.0; p < 0.01), while more negative patient perceptions of how long their condition would last were associated with worse patient-reported pain and function (timeline ß = 2.7; p < 0.01). The final model accounted for 31% of the variance in the patient-reported outcome at 3 months postoperatively. CONCLUSION: Patient expectations and illness perceptions are associated with patient-reported pain and functional outcomes after surgical decompression for de Quervain's tenosynovitis. Addressing misconceptions about de Quervain's tenosynovitis in terms of the consequences for patients and how long their symptoms will last should allow patients to make informed decisions about the treatment that best matches their values. Prospective studies are needed to investigate whether addressing patient expectations and illness perceptions, with decision aids for example, can improve patient-reported pain and function postoperatively in those patients who still choose surgery for de Quervain's tenosynovitis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison Between Clinical and Ultrasound Assessment of the Ankle Region in Children With Juvenile Idiopathic Arthritis.

OBJECTIVE: To compare the frequency of joint and tendon disease on ultrasound (US) and clinical examination, and to investigate agreement between US and clinical evaluation in ankles with clinically active juvenile idiopathic arthritis (JIA). METHODS: US and clinical evaluation were performed independently in the joint and tendon compartments of 105 ankles. Gray-scale (GS) US and power Doppler (PD) US joint abnormalities were scored on a 4-point semiquantitative scale. A joint with a GS score ≥2 and/or a PD score ≥1 was defined as active on US. Agreement was tested using kappa statistics. RESULTS: A total of 163 joints in 89 ankles had active synovitis on US. The tibiotalar (TT) joint was the most commonly affected joint on US and on clinical evaluation. The intertarsal (IT) joint and the subtalar (ST) joint were the second in frequency on US and on clinical evaluation, respectively. Tenosynovitis was found more commonly on US than on clinical evaluation (70.5% and 32.4%, respectively), and was more frequent in the medial and lateral than in the anterior tendon compartment. Isolated tenosynovitis was detected on US in 12 of 105 ankles. Agreement between US and clinical evaluation for detection of active synovitis and tenosynovitis was less than acceptable (κ <0.4). No correlation was found between any feature of active disease recorded on clinical evaluation (joint swelling, tenderness/pain on motion, and restricted motion) and active synovitis on US in the TT joint, ST joint, and IT joint. CONCLUSION: Coupling clinical evaluation with US aids in correctly localizing pathology. US training of practitioners is recommended to manage ankle disease in JIA.

Differing time-orders of inflammation decrease between ACPA subsets in RA patients suggest differences in underlying inflammatory pathways.

OBJECTIVES: Advanced imaging modalities have shown that not only joints but also bones and tendon sheaths can be inflamed at diagnosis of RA. We aimed to better understand the time-order in which the inflamed tissues respond to DMARD treatment. Also, because ACPA status may reflect a different pathophysiology, differences in time-order of inflammation decrease were hypothesized between these disease types. METHODS: A total of 216 consecutive patients presenting with RA (n = 176) or undifferentiated arthritis (n = 40), who all started with conventional synthetic DMARD treatment, were studied. 1.5T contrast-enhanced hand and foot MRIs were performed before treatment and after 4, 12 and 24 months. Cross-lagged models evaluated the influence of two time patterns: a simultaneous pattern ('change in one inflammatory feature associated with change in another feature') and a subsequent pattern ('change in one inflammatory feature preceded change in another feature'). ACPA stratification was performed. RESULTS: The median symptom duration at presentation was 13 weeks. Forty-four percent of patients was ACPA-positive. All pairs of inflammatory features decreased simultaneously in all time intervals (0-4/4-12/12-24 months; P < 0.05). Moreover, time-orders were identified: synovitis decrease preceded tenosynovitis decrease (0-4 to >4-12 months; P = 0.02 and 4-12 to >12-24 months; P = 0.03). Largely similar results were obtained in both ACPA subgroups. Additionally, in ACPA-positive but not ACPA-negative patients, synovitis decrease preceded osteitis decrease (4-12 to >12-24 moths; P = 0.002). CONCLUSION: This study increased the understanding of the response to treatment on the tissue level. In addition to simultaneous decrease of inflammation, synovitis decrease preceded tenosynovitis decrease. Differences in time-order of inflammation decrease between ACPA subgroups suggest differences in underlying inflammatory pathways.

Hand dominance in early and established rheumatoid arthritis: evaluation by dynamometer, Ritchie index and musculoskeletal ultrasound: a cross sectional study.

Rheumatoid arthritis (RA) usually occurs as a symmetrical disease, which mainly affects the small joints of the hands and feet. The correlation of handedness with radiological changes shows significantly greater radiological changes in the dominant hand than in the non-dominant one. Additionally, the dominant hand is more severely affected in terms of strength, function and deformity. Our objective is to evaluate the influence of handedness on musculoskeletal ultrasound (US), Ritchie articular index (RAI) and digital dynamometer findings in patients with active RA (early, group B, vs. established, group A). A total number of 113 patients with established RA and 44 patients with early RA with active disease (DAS28-ESR >3.2) were included in the study. US assessments of both hands were performed to assess synovitis, tenosynovitis, and erosions. RAI was used to evaluate three joint groups in each hand. Handgrip strength was measured with a digital dynamometer. The US5 score showed that the dominant hand was more affected than the non-dominant one. This was significant in group A for the synovitis Power Doppler (PD) mode (p=0.032) and tenosynovitis PD (p=0.005) scores, and in group B for synovitis Grey Scale (GS) mode (p<0.001), synovitis PD (p=0.037) and erosions (p=0.027) scores. RAI was significantly higher in the dominant hand (p=0.013) in group A and even greater in group B (p=0.011). The dominant hand was stronger than the non-dominant hand in both groups. The dominant hand is generally affected in early RA. Subsequently, the disease tends to become more symmetrical with disease progression.

Contribution of tenosynovitis of small joints to the symptom morning stiffness in patients presenting with undifferentiated and rheumatoid arthritis.

Objective: Morning stiffness (MS) is characteristic of rheumatoid arthritis (RA). Despite its association with functional disability, the extent to which local inflammatory processes contribute to this symptom is unknown. Magnetic resonance imaging (MRI)-detected tenosynovitis of small joints is recognized as an early feature of RA, which is also associated with functional impairments. It has been proposed that tenosynovitis contributes to MS. Therefore, we assessed the relationship between MS and MRI-detected inflammation, in particular tenosynovitis.Method: In total, 286 consecutive patients newly presenting with undifferentiated arthritis and RA underwent contrast-enhanced 1.5 T MRI of (2-5) metacarpophalangeal, wrist, and (1-5) metatarsophalangeal joints. Scans were scored for tenosynovitis according to Haavardsholm, and for synovitis by Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS). MS was dichotomized as ≥ 60 min or not. Associations between MS and tenosynovitis/synovitis were tested with logistic regression, data were categorized (solitary or simultaneous presence of synovitis/tenosynovitis), and the presence of an additive interaction was assessed.Results: MS was present in 40% of patients. Tenosynovitis was more often present in patients with MS than without MS [80% vs 65%, odds ratio (OR) 2.11, 95% confidence interval (1.21;3.69)]. Synovitis was more often present in patients with MS [58% vs 44%, OR 1.79 (1.11;2.91)]. In categorized analyses, concurrent synovitis and tenosynovitis had the largest association [OR 2.43 (1.30;4.54)], in contrast to solitary synovitis [OR 0.85 (0.21;3.47)]. The additive interaction was non-significant. The variance explained in all analyses was small (range 4-5%).Conclusion: Tenosynovitis, combined with synovitis, at small joints is associated with MS and contributes to the pathophysiology of MS.

Idiopathic tenosynovitis with rice bodies.

PURPOSE: Idiopathic tenosynovitis with rice bodies is a rare disease and its non-association with rheumatic diseases, tuberculosis infection or trauma is reported only in few cases in literature. PATIENTS, MATERIALS AND METHODS: Our study presents a series of five patients diagnosed with tenosynovitis with rice bodies at the flexor tendons of the upper limb. Medical history revealed no associated disease or trauma. Disease duration ranged between two months and four years, two patients presenting symptoms of acute carpal tunnel and three patients tumor mass. In one case, the tumor measured 210 mm in length and a tendon rupture was suspected. Laboratory and imaging investigations could not establish a specific associated pathology and a preoperative diagnosis. Surgical treatment consisting of synovectomy was performed in all patients. RESULTS: In all five cases, intraoperative appearance could easily determine the presence of rice bodies. Histopathological examination revealed typical aspect for rice bodies and make the diagnosis possible without the need for other more laborious processing (immunohistochemistry). The amount of rice bodies was directly proportional to disease duration. In all cases, the recovery was complete. After a median 30.4-month follow-up, no recurrence was detected. Subsequently performed laboratory investigations and specific tests did not reveal tuberculosis infection, rheumatic disease, or other diseases. CONCLUSIONS: This is the largest series of patients with idiopathic tenosynovitis with rice bodies and the bigger tumor mass reported to date. Synovectomy with removal of all rice bodies represents the optimal treatment. A longer disease course may be associated with a larger number of rice bodies, which may be associated with tendon rupture. The etiopathogenesis remains unclear, further studies being necessary to establish it.

Predominant ultrasonographic extracapsular changes in symptomatic psoriatic dactylitis: results from a multicenter cross-sectional study comparing symptomatic and asymptomatic hand dactylitis.

OBJECTIVE: Despite diffuse digital swelling, dactylitis may sometimes be asymptomatic. The objective of this study was to compare the clinical and ultrasonographic features of symptomatic with asymptomatic psoriatic arthritis (PsA) dactylitis. METHODS: One hundred and twenty-five hand dactylitis were evaluated in a multicenter cross-sectional study for the presence of pain, subjective functional limitation, and tenderness (4-points scale) with the calculation of a Leeds Dactylitis Index (LDI) score. Fingers were subsequently investigated using high-frequency ultrasound (US) both in gray-scale (GS) and power Doppler (PD), for the presence and grading of flexor tenosynovitis, soft tissue edema, subcutaneous PD signal (PDUS), extensor tendon involvement, and joints synovitis. Clinical and US characteristics of symptomatic dactylitic fingers were compared with the asymptomatic dactylitic ones. RESULTS: Symptomatic fingers (n = 80) had a significantly lower dactylitis duration compared to asymptomatic fingers (n = 36) (p < 0.001). Values of LDI, patient VAS-pain, and VAS-functional score were significantly higher in fingers with symptomatic dactylitis (p < 0.001 and p = 0.010, respectively). Symptomatic dactylitis had a higher prevalence of flexor tenosynovitis of grade > 2, soft tissue edema and subcutaneous PDUS signal (p < 0.001). Asymptomatic dactylitis showed a greater prevalence of joint synovitis (both in GS and in PD) than symptomatic dactylitis (p < 0.001). CONCLUSIONS: Digital tenderness and pain are linked to US tenosynovitis of grade > 2 and extra synovial abnormalities and conversely asymptomatic dactylitis is associated with joint-based synovitis.Key Points• Digital tenderness and local pain in psoriatic arthritis dactylitis are strongly associated with flexor tenosynovitis of grade> 2, soft tissue edema, and subcutaneous PD signal.• In psoriatic arthritis, asymptomatic dactylitis showed a greater prevalence of joint synovitis than symptomatic dactylitis.• In psoriatic arthritis, ultrasound inflammatory abnormalities are present in about 70% of cold dactylitis which is linked for disease chronicity.• In psoriatic arthritis, the flexor tendon and adjacent soft tissues play a significant role in symptomatic dactylitis.

Enthesitis and its relationship with disease activity, functional status, and quality of life in psoriatic arthritis: a multi-center study.

Psoriatic arthritis (PsA) is an inflammatory arthritis with distinct phenotypic subtypes. Enthesitis is assigned as a hallmark of the disease, given its significant relations to disease activity and quality of life. Our objective is to evaluate the prevalence of enthesitis and its association with some clinical parameters, particularly quality of life, using data from a national registry. Patients with PsA meeting ClASsification criteria for Psoriatic Arthritis (CASPAR) were enrolled by means of a multi-centre Turkish League Against Rheumatism (TLAR) Network Project. The following information was recorded in web-based case report forms: demographic, clinical and radiographic data; physical examination findings, including tender and swollen joint counts (TJC and SJC); nail and skin involvement; Disease Activity Score-28 for Rheumatoid Arthritis with Erythrocyte Sedimentation Rate (DAS 28-ESR); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); Maastricht Ankylosing Spondylitis Enthesitis Score (MASES); Psoriasis Area Severity Index (PASI); Bath Ankylosing Spondylitis Radiology Index for the spine (BASRI-s); Health Assessment Questionnaire (HAQ); Bath Ankylosing Spondylitis Functional Index (BASFI); Health Assessment Questionnaire for the spondyloarthropathies (HAQ-s); Psoriatic arthritis quality of Life scale (PsAQoL); Short Form 36 (SF-36); Hospital Anxiety Depression Scale (HADS); Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F); and Fibromyalgia Rapid Screening Tool (FiRST) scores. The patients were divided into two groups, namely with and without enthesitis, based on the triple Likert-type physician-reported statement of 'active enthesitis', 'history of enthesitis' or 'none' in the case report forms. Patients with active enthesitis were compared to others in terms of these clinical parameters. A total of 1130 patients were enrolled in this observational study. Of these patients, 251 (22.2%) had active enthesitis according to the clinical assessment. TJC, HAQ-s, BASDAI, FiRST and PsAQoL were significantly higher whereas the SF-36 scores were lower in patients with enthesitis (p < 0.05). Chronic back pain, dactylitis, and tenosynovitis were more frequent in the enthesopathy group (59.4%/39%, 13.1%/6.5% and 24.7%/3.4%, respectively). Significant positive correlations between the MASES score and the TJC, HAQ, DAS 28-ESR, BASDAI, FiRST and PsAQoL scores, and a negative correlation with the SF-36 score were found. When linear regression analysis was performed, the SF-36 MCS and PCS scores decreased by - 9.740 and - 11.795 units, and the FiRST scores increased by 1.223 units in patients with enthesitis. Enthesitis is an important involvement of PsA with significant relations to quality of life determined with PsAQoL and SF-36 scores. Our study found higher frequency of dactylitis and chronic back pain, and worse quality of life determined with SF-36 and PsAQoL scores in patients with enthesitis.

Imaging detected tenosynovitis of metacarpophalangeal and wrist joints: an increasingly recognised characteristic of rheumatoid arthritis.

Tenosynovitis is traditionally recognised at physical examination in patients with inflammatory rheumatic diseases, such as, e.g. psoriatic arthritis and (longstanding) rheumatoid arthritis (RA). The increasing use of sensitive imaging techniques (ultrasound, magnetic resonance imaging (MRI)) has recently revealed that subclinical tenosynovitis is prevalent in early RA and in patients in different phases of RA development (asymptomatic state, arthralgia, early arthritis). In this review, the recent findings on MRI-detected tenosynovitis and associations with RA development are highlighted, and an overview of the most reported inflamed tendon locations within the hand and wrist of patients in different disease phases is provided. The data presented show that tenosynovitis is one of the earliest inflammatory features in patients with imminent RA and associated with impairment of activities in daily life. The value of tenosynovitis as an outcome measure in RA is also discussed.

Does patients' opinion of remission in rheumatoid arthritis overlap ultrasound "true" remission? - a pilot study.

AIM: Patients describe rheumatoid arthritis (RA) remission as the absence of any symptoms or return to normality. Residual ultrasound (US) synovitis was frequently described in remission cohorts in previous studies. US tenosynovitis evaluation and scoring seems to better follow clinical remission scores compared with synovitis in RA. Our objective was to verify the presence of US findings suggestive of persistent inflammation in a cohort of patients in remission according to their own opinion. MATERIALS AND METHODS: Forty-three RA patients were prospectively enrolled in this pilot study between 2015-2017 according to their positive answer to the question "Are you feeling free of symptoms, just like before your RA symptomsstarted?". Clinical evaluation of tender and swollen joints was performed in the same day with US evaluation of 24 joints and 26 tendon sites and lab C-reactive protein (CRP) evaluation. DAS28-CRP and SDAI were calculated. RESULTS: A total of 72.9% (35 of 43) of patients were in remission per DAS28 criteria. Except for CRP value, no other variables were significantly different in the 35 of 43. PD scoring in tenosynovitis of the ankle and feet was 100% overlapping remission felt by patients. PD tenosynovitis in both upper and lower limbs was found in less than 10% of patients, and only grade 1 (minimal). CONCLUSION:  A combination of patients' opinion and PDUS evaluation could be a starting point for RA treatment tapering.

Carpal Tunnel Syndrome and Trigger Wrist Caused by Localized Amyloidosis: A Case Report.

We report a case of carpal tunnel syndrome and trigger wrist caused by localized amyloidosis. A 37-year-old man, who worked as a manufacturer, presented with a 5-month history of tingling sensation in the three radial fingers of the left hand and a painful click at the volar aspect of the wrist during digital motion. We divided the transverse carpal ligament and detected diffuse tenosynovitis that was especially severe around the flexor digitorum profundus tendons. Histological findings led to a diagnosis of amyloidosis. Localized amyloidosis could thus be a cause of trigger wrist. Systemic amyloidosis may develop in patients with localized amyloidosis; therefore, patients with trigger wrist caused by flexor tenosynovitis should be investigated for the existence of localized amyloidosis, with biopsy of the flexor tenosynovium.

Distal intersection syndrome progressing to extensor pollicis longus tendon rupture: a case report with sonographic findings.

The purpose of this case report is to describe the value of musculoskeletal ultrasound (US) in diagnosing both distal intersection syndrome (DIS) and rupture of the extensor pollicis longus (EPL) tendon in the same patient. A 38-year-old female presented for evaluation of a painful bump of unknown etiology on the dorsolateral aspect of her non-dominant wrist. US demonstrated tenosynovitis distal to Lister's tubercle of the EPL and extensor carpi radialis tendon sheaths, consistent with DIS. Immobilization therapy was employed, during which time the patient suffered rupture of the EPL tendon. Follow-up US examination confirmed this additional diagnosis. Characteristic US findings of DIS and EPL tendon rupture were observed. Surgical intervention was required and the patient recovered without complication. Although EPL rupture is relatively common in the literature, DIS is rare. This is the first known case of imaging-proven DIS progressing to EPL tendon rupture. This case underscores the value of US as a widely available, cost effective, and dynamic imaging modality for evaluation of wrist complaints.

Flexor Tenosynovitis.

For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.

Ankle pathologies in patients with inflammatory rheumatic diseases: a clinical and ultrasonographic study.

AIM: We determined ankle pathologies in patients with different types of inflammatory rheumatic diseases using high-resolution ultrasonographic (US) images, and compared the findings among the different patient groups. METHODS: The study included 142 randomly selected inflammatory rheumatic disease patients with clinically swollen or painful ankle joints; 69 patients had rheumatoid arthritis (RA), 58 had spondyloarthropathies (SpA) and 15 had gout. Ankle assessment on US included all of the important anatomical structures. The foot function of patients was evaluated using the Foot Function Index (FFI). RESULTS: Among all the patients, 98.6% of joints were tender and 72.9% were swollen; 82.1% joints were pathological on US. Tibiotalar joint synovitis was observed significantly more frequently in the SpA and gout patients (P < 0.05). Tibialis posterior (TP) tenosynovitis was significantly more common in the RA group than in the other groups (P < 0.001). Subtalar and talonavicular joint synovitis were observed more frequently in the early RA group compared to the other groups (P < 0.05). Tibiotalar joint synovitis was observed more frequently > 1 year after RA diagnosis (P < 0.05). Subtalar joint synovitis, TP tenosynovitis, and peroneus tenosynovitis were the best predictors of higher FFI scores in patients with RA (R2 c = 0.360, F = 11.83, P < 0.000). CONCLUSION: Tendon involvement in our RA patients was observed more frequently than has been previously estimated. TP tenosynovitis appears to be more specific for RA, while Achilles tendinitis is more frequent in axial SpA and reactive arthritis. Tibiotalar joint involvement exhibits a time-dependent significant increase in frequency in patients with RA.

Relationship between clinical evaluation and ultrasound assessment of rheumatoid arthritis patients using a 12 joint score.

AIM: To identify if the use of a systematic ultrasound (US) evaluation has relevance in the determination of disease activity in rheumatoid arthritis patients on biological disease-modifying anti-rheumatic drug treatment. METHODS: A 12 joint US assessment was performed on the same day of the routine clinical examination. Both Grey-scale (GS) and Power Doppler (PD) were graded semi-quantitatively (0-3 scale). RESULTS: Forty-one patients were included. GS or PD > 0 were found in 24% and 3% of the ankles, 21% and 17% of the wrists, 19% and 9% of the second metacarpophalangeal joints (MCP), 7% and 2% of the third MCP, 6% and 0% of the knees and 5% and 0% of the elbows, respectively; tenosynovitis of the tibialis posterior was found in 19% of the ankles. Eight of the patients with Disease Activity Score of 28 joints (DAS28) ≤ 2.6 (n = 15) had an US score of 0. Twenty-seven joints (6.7%) had US evidence of synovitis but were not considered to be swollen; 10 (2.5%) were considered to be swollen but had no US evidence of synovitis. CONCLUSIONS: Using a 12 joint US assessment, a high proportion of patients with DAS28 < 2.6 were found to have inflammatory US activity, and a significant proportion of patients had evidence of tenosynovitis of the tibialis posterior, which may be difficult to clinically detect. A regular and standardized US assessment of RA patients is therefore warranted to complement clinical evaluation and better define disease activity.

Severity and Diurnal Improvement of Morning Stiffness Independently Associate with Tenosynovitis in Patients with Rheumatoid Arthritis.

BACKGROUND AND OBJECTIVES: Although morning stiffness has long been recognized as a characteristic feature of rheumatoid arthritis (RA), it is no more included in the 2010 ACR/EULAR Classification Criteria or in the current major instruments for evaluating disease activity of RA. In this cross-sectional study, we aimed to determine the independent value and the optimal measurement of morning stiffness by clarifying the associations between morning stiffness and synovial inflammation. PATIENTS AND METHODS: We enrolled 76 consecutive RA patients who underwent musculoskeletal ultrasound examination and agreed to participate in the study. In addition to asking the duration of morning stiffness, we asked patients to complete a diagram which represents the time course of their morning stiffness in the dominant hand. Based on this diagram, we calculated the severity and the diurnal improvement of morning stiffness. We also determined the activity of intra-articular synovitis in 11 joints and tenosynovitis in 8 tendons/tendon compartments in the same hand by using power Doppler (PD) ultrasound with a semiquantitative score (0-3). RESULTS: For intra-articular synovitis, swollen/tender joint counts more strongly correlated with total PD scores (ρ = 0.379-0.561, p ≤ 0.001) than did any parameters of morning stiffness (ρ = 0.217-0.314, p = 0.006-0.021). For tenosynovitis, however, the severity on awakening and the improvement of morning stiffness more strongly correlated with total PD scores (ρ = 0.503-0.561, p < 0.001) than did swollen/tender joint counts (ρ = 0.276-0.388, p = 0.001-0.016). Multivariate analyses identified the severity on awakening and the improvement but not the duration of morning stiffness as factors that independently associate with the total tenosynovial PD score. CONCLUSIONS: Our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and also give an insight into the optimal measurement of morning stiffness. Our data support an independent value of evaluating morning stiffness in the management of RA.

Magnetic resonance imaging-detected inflammation is associated with functional disability in early arthritis-results of a cross-sectional study.

OBJECTIVES: MRI sensitively detects inflammation, but the clinical relevance of MRI-detected inflammation is undetermined in early arthritis. Therefore, the aim of this cross-sectional study was to investigate the association between MRI-detected inflammation of hands and feet and functional disability in early arthritis. METHODS: Five hundred and fourteen early arthritis patients, consecutively included in the Leiden Early Arthritis Clinic, were studied. At baseline a unilateral 1.5 T MRI of the wrist, MCP and MTP joints was performed and functional disability was measured using the HAQ. MRIs were scored for tenosynovitis, synovitis and bone marrow oedema (BME) by two readers. The sum of these types of MRI-detected inflammation yielded the total MRI-inflammation score. Linear and nonlinear regression analyses were performed with HAQ as outcome. RESULTS: The total MRI-inflammation score was associated with the HAQ score (ß = 0.014, P < 0.001), as were tenosynovitis (ß = 0.046, P < 0.001), synovitis (ß = 0.039, P < 0.001) and bone marrow oedema scores (ß = 0.015, P < 0.001) separately. Analysing these three types of MRI-detected inflammation in one multivariable model revealed that only tenosynovitis was independently associated with the HAQ score (ß = 0.039, P < 0.001). Also after correction for age, gender, joint counts, CRP and auto-antibodies, this association remained significant (ß = 0.034, P < 0.001). MRI-detected inflammation at wrists or MCP joints associated significantly with impairments in hand functioning (e.g. difficulties with opening milk cartons or jars). Exploring the relation between MRI-detected inflammation and HAQ scores showed no evidence of a floor effect, suggesting that even low scores of MRI-detected inflammation are functionally relevant. CONCLUSION: MRI-detected inflammation, and tenosynovitis in particular, is associated with functional disability. This demonstrates the functional relevance of MRI-detected inflammation in early arthritis.