“OUTCOME ANALYSIS OF TIMELY CONSERVATIVE MANAGEMENT OF HAEMOPHILIC KNEE ARTHROPATHY WITH FACTOR REPLACEMENT AND PHYSIOTHERAPY.”

INTRODUCTION: Haemophilia is a disorder of the initiation of coagulation, and is due to reductions in the concentrations of, or the presence of a less active version of, one of two coagulation factors, factor VIII and factor IX. There are several orthopaedic problems linked to haemophilia including recurrent hemarthroses, chronic synovitis, exion deformities, hypertrophy of the growth epiphyses, damage to the articular cartilage and hemophilic arthropathy MATERIALS AND METHODS : 290 patients of all age group of haemophilia A and B coming to orthopaedic OPD with Knee Haemarthosis between October 2018 to May 2020 were included in our study. These patients were prospectively analyzed for complications and severity. HJHS Scoring system were used to assess the severity of joint disease. RESULTS : . out of 290 patients it was found that haemophilia was more prevalent in rural population (53.10%) as compared to urban population (46.90%). In our study it was found that majority of the patients with haemophilia had single joint involved (57.94%) as compared to 42.06% who had multiple joint involved. It was revealed that in majority right knee was involved (52.41%) followed by left joint in 47.58% patients with haemophilia. It was found that most common complication in patients of knee haemarthrosis was recurrent haemarthrosis (57.24%) followed by synovitis (27.93%). arthropathy (9.31%) . It was found that most common complication in patients of knee haemarthrosis was recurrent haemarthrosis (57.24%) followed by synovitis (27.93%). arthropathy (9.31%) . It was found that out of 290 patients with haemophilia, majority were performing regular physiotherapy (57.59%) followed by 42.41% of the patients who were occasional in physiotherapy. It was found that mean HJHS score was increasing with increasing the severity of the disease. Mean HJHS score for mild cases was 10.53±4.495 as compared to 13.06±7.575 of moderate cases and 17.82±7.991 of severe cases. CONCLUSION In present study haemophilia was more prevalent in rural population. Majority of the patients with haemophilia had single joint and in majority right knee was involved. Most common complication in patients of haemophilia was recurrent haemarthrosis followed by synovitis and arthropathy. Majority of our patients were having severe form of the disease. Adequate factor replacement along with good active physiotherapy early detection and prompt treatment with active life style makes muscles and joints healthier and stronger reduces tendancy of bleeding and further damage of joint. reduce the frequency and longterm complications of knee haemarthrosis like recurrent haemarthosis , synovitis ,arthropathy, fracture and deformity. Prophylactic factor replacement is having denitely positive role as per available literature over western countries, unfortunately it needs more specic clinical trial to know about longterm good results in India.

A case report on Rheumatoid Arthritis with sickle cell trait

A female patient aged 6 years, a suspected case of sickle cell trait (SCT) having symptoms of Rheumatoid arthritis (RA), while evaluating joint complaints in adult sickle cell disease (SCD) patients, a number of sickle cell-based entities come to mind such as avascular necrosis, osteomyelitis, bone infarcts, and septic arthritis. RA is a chronic systemic inflammatory disease, many reports highlighted the occurrence of RA in SCD presenting as diagnostic challenges for cases with chronic inflammatory arthritis, SCT also have appeared to persist in some populations at a perplexingly high rate given the degree of early mortality of homozygosity of SCD, our case report showed that not only SCD but if a patient has SCT they can develop RA as complication. Our case report concludes that during the evaluation of a SCT patient who presents with chronic synovitis, one should strongly consider the possibility of coexistence of RA and SCT.

Dynamics of Quality of Life Indicators in Patients with Chronic Synovitis of the Knee Joint after Arthroscopic Laser Double-mode Synovectomy

Background: The treatment of patients with chronic synovitis of the knee joint is a challenge faced by many doctors all around the world. Treatment of this pathology is often a difficult task. Aim. The aim of the study was improving the results of treatment of patients with chronic synovitis of the knee joint by applying two wavelengths of radiation. Material and methods. The treatment results of 50 patients with chronic synovitis of the knee joint aged 23 to 67 years with stage II-IV osteoarthritis according to the Kellgren-Lawrence classification were analyzed. All patients underwent arthroscopic sanation, partial laser synovectomy using LSP-IRE-Polus apparatus, wavelength 0,97 microns in pulse-periodic mode (pulse 100 ms, pause 50 ms) with power 5 W and wavelength 1,56 microns in continuous mode with power 5 W. Morphological examination of the synovial membrane and capsule was performed. Preoperative, 3, 6 and 12 month postoperative questionnaires were administered using the following scales and questionnaires: VAS, Leken index, WOMAC and KOOS. Results. Mean age (M) was 45.32±131, BMI 28.63±4.72kg/m2, duration of synovitis 2.26±1.91 years. A statistically significant improvement on the VAS, WOMAC, Leken, KOOS scales was noted by the 3rd month of postoperative follow-up. By the 6th month postoperatively, the results had further improved. The achieved results were preserved up to 12 months after surgery (P <0.05). Conclusion. The results suggest that the proposed technique may be introduced into clinical practice.

From Bed to Bench and Back: TNF-α, IL-23/IL-17A, and JAK-Dependent Inflammation in the Pathogenesis of Psoriatic Synovitis

Psoriatic arthritis (PsA) is a chronic inflammatory immune-mediated disease with a burdensome impact on quality of life and substantial healthcare costs. To date, pharmacological interventions with different mechanisms of action, including conventional synthetic (cs), biological (b), and targeted synthetic (ts) disease-modifying antirheumatic drugs (DMARDs), have been proven efficacious, despite a relevant proportion of failures. The current approach in clinical practice and research is typically “predictive”: the expected response is based on stratification according to clinical, imaging, and laboratory data, with a “heuristic” approach based on “trial and error”. Several available therapeutic options target the TNF-α pathway, while others are directed against the IL-23/IL-17A axis. Janus kinase inhibitors (JAKis), instead, simultaneously block different pathways, endowing these drugs with a potentially “broad-spectrum” mechanism of action. It is not clear, however, whether targeting a specific pathway (e.g., TNF-α or the IL-23/IL-17 axis) could result in discordant effects over other approaches. In particular, in the case of “refractory to a treatment” patients, other pathways might be hyperactivated, with opposing, synergistic, or redundant biological significance. On the contrary, refractory states could be purely resistant to treatment as a whole. Since chronic synovitis is one of the primary targets of inflammation in PsA, synovial biomarkers could be useful in depicting specific biological characteristics of the inflammatory burden at the single-patient level, and despite not yet being implemented in clinical practice, these biomarkers might help in selecting the proper treatment. In this narrative review, we will provide an up-to-date overview of the knowledge in the field of psoriatic synovitis regarding studies investigating the relationships among different activated proinflammatory processes suitable for targeting by different available drugs. The final objective is to clarify the state of the art in the field of personalized medicine for psoriatic disease, aiming at moving beyond the current treatment schedules toward a patient-centered approach.

The Expression of Non-Coding RNAs and Their Target Molecules in Rheumatoid Arthritis: A Molecular Basis for Rheumatoid Pathogenesis and Its Potential Clinical Applications

Rheumatoid arthritis (RA) is a typical autoimmune-mediated rheumatic disease presenting as a chronic synovitis in the joint. The chronic synovial inflammation is characterized by hyper-vascularity and extravasation of various immune-related cells to form lymphoid aggregates where an intimate cross-talk among innate and adaptive immune cells takes place. These interactions facilitate production of abundant proinflammatory cytokines, chemokines and growth factors for the proliferation/maturation/differentiation of B lymphocytes to become plasma cells. Finally, the autoantibodies against denatured immunoglobulin G (rheumatoid factors), EB virus nuclear antigens (EBNAs) and citrullinated protein (ACPAs) are produced to trigger the development of RA. Furthermore, it is documented that gene mutations, abnormal epigenetic regulation of peptidylarginine deiminase genes 2 and 4 (PADI2 and PADI4), and thereby the induced autoantibodies against PAD2 and PAD4 are implicated in ACPA production in RA patients. The aberrant expressions of non-coding RNAs (ncRNAs) including microRNAs (miRs) and long non-coding RNAs (lncRNAs) in the immune system undoubtedly derange the mRNA expressions of cytokines/chemokines/growth factors. In the present review, we will discuss in detail the expression of these ncRNAs and their target molecules participating in developing RA, and the potential biomarkers for the disease, its diagnosis, cardiovascular complications and therapeutic response. Finally, we propose some prospective investigations for unraveling the conundrums of rheumatoid pathogenesis.

Outcomes in rheumatoid arthritis patients treated with abatacept: a UK multi-centre observational study

Background Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes chronic synovitis, resulting in progressive joint destruction and functional disability and affects approximately 400,000 people in the UK. This real-world study aimed to describe the characteristics, treatment patterns and clinical outcomes of patients who received abatacept in UK clinical practice. Methods This was a multi-centre, retrospective, observational study of patients with RA treated with abatacept at four UK centres between 01 January 2013 and 31 December 2017. Data were collected from medical records of each patient from the index date (date of first bDMARD initiation) until the most recent visit, death or end of study (31 December 2017). Results In total, 213 patients were included in the study. Patients received up to eight lines of therapy (LOTs). Treatment with abatacept, or any other bDMARD, was associated with reductions in DAS28-ESR and DAS28-CRP scores at 6 and 12 months. The distribution of EULAR responses (good/moderate/no response) tended to be more favourable for patients when receiving abatacept than when receiving other bDMARDs (22.8%/41.3%/35.9% versus 16.6%/41.4%/42.1% at 6 months, and 27.9%/36.1%/36.1% versus 21.2%/34.5%/44.2% at 12 months). Patients receiving abatacept at LOT1 (n = 68) spent significantly longer on treatment compared with patients receiving other bDMARDs (53.4 vs. 17.4 months; p< 0.01); a similar trend was observed for LOT2. Among patients who discontinued after 6 months, a greater proportion experienced infection requiring antibiotics when receiving other bDMARDs compared to those receiving abatacept. Conclusions RA patients who received bDMARDs, including abatacept, experienced reduced disease activity. When receiving abatacept as first or second line of therapy, patients persisted with treatment significantly longer than those receiving other bDMARDs.

Retained Foreign Body Which Should be Suspected as a Cause of Retractable Chronic Hand Inflammation and Diagnostic Capacity of Ultrasonography

Background: Foreign bodies in the hand are common but easily and often missed in the initial evaluation of injury. Diagnosing retained foreign bodies is difficult due to radiolucent foreign bodies. Purpose of this study is to emphasize the need of consideration of foreign bodies in patients with chronic synovitis in hand. Methods: Twenty-five patients who had retained foreign body in soft tissue of hand with chronic inflammation symptoms were included. Ultrasonography was conducted in all of the patients. Patient age, sex, localization of foreign body, duration of symptom, history of injury, follow up period, complication, and biopsy results were recorded and reviewed. Also, patients’ demographics and clinical results were retrospectively reviewed. Results: Nine of the 25 patients diagnosed with a foreign body in the hand did not remember the initial presentation of injury. The average symptom duration (from injury to hospitalization) was 10.5 months (range 1–96 months). The middle finger and the proximal interphalangeal joint were the most common site of a retained foreign body (10 patients). All patients were diagnosed via ultrasonography and underwent surgery. Biopsy results showed mainly chronic inflammation, fibrosis, granuloma, and foreign bodies. Conclusions: Patient with symptoms of cellulitis, osteomyelitis, and palpable mass in hand for over a month without a diagnosis should be suspected of retained FBs.

The Hip in Juvenile Idiopathic Arthritis

The hip joint is commonly affected in Juvenile Idiopathic Arthritis (JIA), especially in cases of systemic polyarticular disease. Chronic synovitis of the hip leads to joint destruction, therefore, systemic and local control of the disease is of paramount importance. Non-steroidal anti-inflammatory drugs, Disease Modifying Anti-Rheumatic Drugs (DMARDs), biologics, intra-articular corticosteroid injections, and physical therapy are the mainstay for controlling ongoing inflammation and hip joint contractures. Synovectomy with soft tissue releases is useful in the early stages of the disease, when the joint cartilage is largely preserved. Total joint arthroplasty (THA) is successful in relieving pain, and improving function, ambulation and range of motion in end-stage degenerative arthritis. With improved designs of smaller prostheses and modern bearing couples, it is hoped that the longevity of THA will facilitate a more normal and enduring lifestyle.