Sacroiliitis in Systemic Lupus Erythematosus Revisited

Objectives

This study aims to investigate the prevalence of inflammatory back pain (IBP) and sacroiliitis in a systemic lupus erythematosus (SLE) population as well as the association between IBP and the frequency of human leukocyte antigen B27 (HLA-B27).

Patients and methods

The study included 281 SLE patients (16 males, 265 females; mean age 39.9±11.9 years; range, 20 to 69 years) and 100 healthy controls (HCs) (2 males, 98 females; mean age 41.2±10.1 years; range, 19 to 64 years). Participants were administered a five-item Assessment of SpondyloArthritis international Society-IBP questionnaire. Patients and controls with IBP underwent detailed clinical and laboratory examinations to detect sacroiliitis. Radiographic evaluations were performed by a blinded rheumatologist and radiologist. Interobserver reliability was assessed with Cohen's kappa test.

Results

According to the questionnaire, IBP was present in 46 SLE patients (46/281; 16.3%) whereas none of the HC had IBP (p<0.001). In radiological assessment, 22 SLE patients (7.8%) had sacroiliitis detected by conventional X-ray and/or magnetic resonance imaging. Only one SLE patient with sacroiliitis had HLA-B27.

Conclusion

Our study showed that IBP is increased in SLE patients and IBP in SLE is not associated with HLA-B27.

A novel minimally invasive surgery combined with early exercise therapy promoting tendon regeneration in the treatment of spontaneous Achilles tendon rupture

OBJECTIVE

Acute closed spontaneous Achilles tendon rupture often occurs in elderly individuals and is usually accompanied with many complications. Conventional surgical approaches to remove the tendon lesions and enthesophytes are highly traumatic and cause complications. In this study, a previously established minimally invasive surgical approach was modified and combined with a Kazakh exercise therapy to reduce trauma, improve wound healing, and promote tendon regeneration in the management of acute closed spontaneous Achilles tendon rupture.

METHODS

Fifty-two patients with acute closed spontaneous Achilles tendon rupture were randomly classified into 2 groups. Group A included 23 patients that were treated with the novel approach. Group B included 29 patients that were treated with a continuous medial oblique surgical approach. Follow-up examinations were performed at post-operative weeks 12 and 24, and year 2. Outcomes were assessed by Achilles tendon rupture score (ATRS), a heel-rise endurance test, and ultrasonographic and multislice spiral computerized tomography.

RESULTS

Mean ATRS in Group A was 68.6 and 86.0 at post-operative week 12 and 24, respectively, significantly higher than that in Group B (55.9 and 72.0, respectively). Recovery of patients in Group A was significantly better compared to Group B (p < 0.01), allowing them to participate in early rehabilitating kinesiotherapy. Patients in Group A rarely experienced complications after surgery, such as infection and Achilles tendon exposure, while in Group B, the wound healing was slower, the inside flaps were prone to necrosis and infection, and Achilles tendon exposure occurred in 10% of patients.

CONCLUSIONS

The novel minimally invasive surgery is more advantageous in the treatment of acute closed spontaneous Achilles tendon rupture over previous approaches by promoting wound healing and tendon regeneration.

Bilateral sequential knee dislocation in a patient with connective tissue disorder: Report of an unusual case and lessons learnt

Tibiofemoral knee dislocation is a rare but serious limb-threatening injury. Without prompt recognition and management, amputation or long-term functional impairment may result. The authors present a case of bilateral sequential knee dislocation, secondary to low-energy trauma, in a patient with Systemic Lupus Erythematosus and antiphospholipid syndrome. Adequate stability was achieved on both occasions by reconstruction of the postero-lateral corner and MCL. During the first reconstruction, ipsi-lateral autograft, as well as hamstring tendons from the contra-lateral side, were used to strengthen the graft. For the second reconstruction, allografts were used. This case highlights that, a patient with soft-tissue disorder presenting with low-energy knee dislocation may be at risk of further dislocations. Treating surgeons should anticipate these issues and consider the role of allograft in ligamentous repair.

Long-term functional outcome of bilateral spontaneous and simultaneous Achilles tendon ruptures

Bilateral simultaneous ruptures are rare comprising less than 1% of all Achilles tendon ruptures. Risk factors for bilateral ruptures include chronic diseases and medications such as corticosteroids and fluoroquinolones. There is little in the literature on the long-term functional outcome of bilateral Achilles tendon ruptures. This article present a series of 3 cases of simultaneous and spontaneous bilateral Achilles tendon ruptures with a minimum of 5-year follow up suggesting a good functional outcome.

[Spontaneous Achilles tendon rupture as early manifestation of systemic lupus erythematosus]

Spontaneous tendon rupture is rare in the course of systemic lupus erythematosus (SLE). Its incidence rate remains unknown. The pathogenesis of this manifestation is complex and poorly understood. We report a 39-year-old woman who presented with a spontaneous Achilles tendon rupture as the presenting presentation of SLE, before any corticosteroid therapy. All the patients previously published were receiving corticosteroids and reported in some an associated traumatism. Risk factors are prolonged disease duration, chronic therapy with corticosteroids, deforming arthropathy of the hands, and inactive disease.

Spontaneous tendon rupture in systemic lupus erythematosus: association with Jaccoud’s arthropathy

Tendon rupture has rarely been described in patients with systemic lupus erythematosus. From observation of three cases of Jaccoud’s arthropathy with tendon rupture, and considering that this arthropathy is more related to an inflammatory process of the tendon sheath than to synovitis per se, the intention of this study was to review the cases of tendon rupture in patients with systemic lupus erythematosus, in the hope of determining the frequency of Jaccoud’s arthropathy associated with this complication. Systematic review using MEDLINE, Scielo and LILACS databases (1966 to 2009) and the following keywords: systemic lupus erythematosus, tendon rupture, Jaccoud’s arthropathy. Secondary references were additionally obtained. Additionally, three Brazilian systemic lupus erythematosus patients who developed tendon rupture are described. Only 40 articles obtained fulfilled the previously established criteria. They were all case reports; the number of cases reported was 52 which, together with the three cases presented herein add up to 55 cases. Forty-six patients were women aged between 19 and 71 years, with a mean age of 40.1 ± 12.4 years, and the average duration of the disease was 10 years. The most frequently observed rupture sites were the patellar and Achilles’ tendons. While almost all patients described were on various doses of corticosteroids, 16 patients concomitantly had Jaccoud’s arthropathy (29%). In conclusion, the association between Jaccoud’s arthropathy and tendon rupture in systemic lupus erythematosus has been underestimated. As almost one-third of the systemic lupus erythematosus patients with tendon rupture also have Jaccoud’s arthropathy, this arthropathy may be recognized as risk marker for tendon rupture. Lupus (2010) 19, 247—254.

Lupus arthritis

Arthritis in systemic lupus erythematosus (SLE) is one of the most common disease manifestations. Nearly all joints can be affected by SLE, but hand and knee involvement are the most typical. Periarticular structures can be inflamed leading to tendonitis, tenosynovitis and tendon rupture. Avascular necrosis (AVN) also occurs causing joint pain and disability, typically in larger joints such as the hip and knee. This article addresses the clinical features of arthritis in lupus and an approach to the differential diagnosis. Treatment strategies include nonsteroidal anti-inflammatories, corticosteroids, anti-malarials and a variety of immunosuppressive medications.