The Hand and Wrist in Juvenile Rheumatoid Arthritis

Angular assessment of joints in juvenile idiopathic arthritis

Background

Joint deformities in juvenile idiopathic arthritis (JIA) are most common in children, are not defined in term of angular measurements. The study was aimed to evaluate the joint deformities in angular deviation of the afected joints in JIA patients.

Methods

This cross-sectional study was conducted at Pediatric Rheumatology Clinic, North Bengal Medical College, West Bengal. The children aged 2-16 years diagnosed with JIA according to the International League of Associations for Rheumatology (ILAR) criteria were included in the study. Patients with co-morbid disease, hemodynamic instability, and other acute conditions were excluded. Angular measurements were performed using goniometer.

Results

The mean age of children was (8.05 ± 3.20) years of which 57.5% was male and the disease duration associated with the deformities in JIA. The prevalent subtypes of JIA were Oligoarticular JIA (oligoJIA)(40%), followed by polyarticular JIA (pJIA) (35%) and systemic-onset JIA (sJIA) (12.5%). The commonly involved joint were knee (40%), followed by small joint of hand (32.5%), ankle (30%), wrist and foot (17.5% each), elbow (12.5%) and cervical joint (7.5%). In pJIA, duration of disease significantly (P = 0.017) associated with the number of affected joints. Mostly, wrist, knee and ankle deformities were observed in oligoJIA, pJIA and sJIA. The angular deviation (mean ± SD) of right and left knee were (2° ± 4.16°) and (1.87° ± 5.12°) in oligoJIA, (13.36° ± 17.03°) and (12.5° ± 15.08°) in pJIA and (3° ± 6.71°) and (2.4° ± 5.37°) in sJIA. Right ankle angular deviation were (2.62° ± 5.06), (5.43° ± 8.21°) and 4° ± 8.94° respectively in oligoJIA, pJIA and sJIA. The angular deviation of right and left wrist were (1.25° ± 3.41°) and (0.94° ± 3.75°) in oligoJIA, (4.07° ± 8.93°) and (4.14° ± 9.36°) in pJIA and (2.45° ± 5.37°) and (2° ± 4.47°) in sJIA.

Conclusion

This study is the first study from India to quantify the angular deviation of deformed joints in JIA. Angular deviation could serve as a valuable parameter for monitoring disease progression across various JIA subtypes.

Treatment of Juvenile Idiopathic Arthritis

This review outlines the natural history, diagnosis, and management of juvenile idiopathic arthritis involving the hand and wrist. The discussion of management considers both nonoperative and surgical management to preserve functionality and mitigate long-term articular damage in children and adolescents. The review describes the current literature and identifies areas for further study.

Clinical and laboratory features of juvenile idiopathic arthritis with wrist involvement: Results of a retrospective cohort study

BACKGROUND

Previous studies in the pre-biological era showed an association of wrist inflammation in juvenile idiopathic arthritis (JIA) with progressive disease course, polyarticular involvement and failure of methotrexate treatment.

AIM

To describe features of JIA, associated with wrist arthritis.

METHODS

Data from about 753 JIA patients were included in this retrospective cohort study. The clinical and laboratory features of patients with and without wrist involvement were analyzed.

RESULTS

Wrist involvement was found in oligoarthritis (5.8%), RF(-)/RF(+) polyarthritis (44.9%/15.0%), enthesitis-related arthritis (17.7%), and systemic (58.6%) JIA categories. Unilateral wrist involvement was typical for oligoarthritis patients, bilateral involvement was either equal to that of unilateral involvement or was more frequent in other categories. Wrist arthritis was found to be associated with female sex, a low incidence of uveitis, and more indications of systemic inflammation, including elevated levels of C-reactive protein, erythrocyte sedimentation rate, and platelets, as well as involvement of the cervical spine, temporomandibular, shoulder, elbow, metacarpophalangeal, proximal interphalangeal, distal interphalangeal, hip, ankle, and tarsus arthritis. The number of patients with hip osteoarthritis and hip replacement was also higher. Wrist arthritis was associated with a lower probability of achieving remission [hazard ratio (HR) = 1.3 (95%CI: 1.0-1.7), P = 0.055], and a higher probability of being treated with biologics [HR = 1.7 (95%CI: 1.3-2.10, P = 0.00009)].

CONCLUSION

Wrist arthritis in JIA patients is a marker of a severe disease course, characterized by more intensive inflammation, unfavorable outcomes, and. requiring more intensive treatment with early administration of biologics. Close monitoring of wrist inflammation with ultrasound and MR assessment with early biological treatment might improve the outcomes.

Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis

Background and Purposes  The wrist is the fourth most common joint to be involved in juvenile inflammatory arthritis (JIA), which is a common rheumatological condition affecting children. Wrist arthroscopy is well established in rheumatoid arthritis, but remains unexplored in JIA. The aim of this study is to investigate the role of wrist arthroscopy in JIA, with focus on those who are refractory to medical management. Methods  This is a prospective observational study, including consecutive patients with JIA undergoing arthroscopy between January 2016 and December 2020. Those over the age of 18 years and those with other rheumatological diagnoses were excluded. Data including pre-, intra-, and postoperative variables, demographics, and patient-reported outcomes were collated and are reported using standard measures. Results  A total of 15 patients underwent arthroscopy ( n  = 20 wrists). Synovitis was noted in all wrists on arthroscopy and synovectomy was performed in all cases. Other procedures were performed as indicated during the procedure. The median follow-up duration was 11.3 (interquartile range [IQR] 8.1-24.2) months. Median reduction of 4 (IQR 2.25-6) points on the Visual Analogue Score for pain on loading was noted postoperatively. Grip strength was improved in n  = 11/20 wrists and functional improvement was noted in n  = 18/20 wrists. Restriction of range of motion was achieved with a shrinkage procedure in patients with hypermobile joints. There were no postoperative complications, and no patients were lost to follow-up. Conclusion  In experienced hands, wrist arthroscopy is feasible, safe, and efficacious in the management of JIA, among patients who are refractory to medical management. Level of Evidence  This is a Level II study.

Late-infantile GM1 gangliosidosis: A case report

RATIONALE

Monosialotetrahexosylganglioside (GM1) gangliosidosis is a rare lysosomal storage disorder caused by the deficiency of ß-galactosidase. Because clinical symptoms of GM1 gangliosidosis overlap with other neurodevelopmental disorders, the diagnosis of this disease is not easy, specifically in late infantile GM1 gangliosidosis. This report described a case of late-infantile GM1 gangliosidosis mistaken for juvenile idiopathic arthritis.

PATIENT CONCERNS

A 16-year-old girl was referred to our hospital due to persistent multiple joint deformities and mental retardation, which could not be explained by juvenile idiopathic arthritis.

DIAGNOSIS

We made a diagnosis of late infantile GM1 gangliosidosis through enzyme assays and genetic testing after a skeletal survey.

INTERVENTIONS

The patient underwent cervical domeplasty and laminectomy for cord compression and received rehabilitation treatment.

OUTCOMES

The patient is receiving multidisciplinary care at a tertiary center for variable skeletal disease and conditions associated with GM1 gangliosidosis.

LESSONS

Late infantile GM1 gangliosidosis should be considered in the differential diagnosis of progressive neurologic decline and skeletal dysostosis.

Inflammatory conditions of the pediatric hand and non-inflammatory mimics

Hand involvement can assume an outsized role in the perception and presentation of disease as a result of functional impairment, visual conspicuity and susceptibility to early structural damage. Rheumatologic referral for inflammatory conditions can be delayed because of assumptions of a traumatic, infectious or neoplastic etiology; conversely, initial rheumatologic evaluation might be pursued for many of the same non-inflammatory causes. This pictorial essay highlights inflammatory conditions affecting the pediatric hand, including juvenile idiopathic arthritis, infectious arthritis, systemic connective tissue disorders, and a variety of less common inflammatory diseases, as well as non-inflammatory congenital, vascular, neoplastic and metabolic differential considerations.

Validity and reliability of "Shriners Hospital for Children Upper Extremity Evaluation" in children with rheumatic diseases

INTRODUCTION/OBJECTIVES

The aim of this study was to investigate the validity and reliability of "Shriners Hospital for Children Upper Extremity Evaluation (SHUEE)" for children with rheumatic diseases.

METHODS

The study was carried out after obtaining the necessary permissions and retrospectively registered. The psychometric properties evaluated were reliability and concurrent validity. Reliability was determined by intra- and inter-observer agreement. Concurrent validity was performed using the Jebsen Taylor Hand Function Test (JTHFT), Abilhand-Rheumatoid Arthritis (Abilhand-RA), and Children Health Assessment Questionnaire (CHAQ). The validity and reliability of the evaluation were determined after the retest 1 week later.

RESULTS

Twenty children with rheumatic diseases were participated in to study. Intraclass coefficients ranged from 0.82 to 0.97 and the intraobserver reliability for SHUEE total and subscales were considered "excellent." Interobserver reliability was considered "excellent" for the SHUUE total score, spontaneous functional analysis and dynamic positional analysis, and "moderate" for grasp-release. A moderate negative correlation was determined between Spontaneous Functional Analysis and JTHFT (r =  - 0.63; p = 0.003).

CONCLUSION

SHUEE is a valid and reliable evaluation for children with rheumatic diseases. ClinicalTrials.org NCT04685434/21.12.2020 Key Points • SHUEE tends to be appropriate and acceptable to children with rheumatic diseases. • SHUEE can be used safely in the pediatric rheumatology group and it is beneficial in the clinical decision-making process. • SHUEE is a pioneering performance test that evaluates the quality of movement in pediatric rheumatology on a joint basis.

Wrist Arthroscopy in Juvenile Idiopathic Arthritis: A Review of Current Literature and Future Implications

Introduction  Juvenile Idiopathic Arthritis (JIA) is the most common rheumatological condition in children and frequently affects the wrist. The roles for wrist arthroscopy and arthroscopic synovectomy (AS) in JIA are unclear. Our aim was to find the current evidence supporting its use. Methods  Systematic literature review of relevant publications from 1990 to present in the Cochrane Library, Clinical Knowledge Summaries, DynaMed, PEMSoft, NICE Guidance, MEDLINE, EMBASE, and PubMed. Results  We found no publications detailing the use of arthroscopy or AS specifically in patients with JIA involving the wrist. There is evidence that AS reduces pain, improves function, and induces remission in patients with rheumatoid arthritis resistant to medical management. Discussion and Conclusion  Although there is paucity in evidence for the use of AS in the wrists of patients with JIA, studies suggest it to be safe and effective, and could be applied to patients with refractive JIA. It is possible that early identification of patients suffering from JIA with extensive joint destruction and little symptoms could benefit from AS, delaying joint destruction and preserving function.