Case series: Monoarticular rheumatoid arthritis

Incidental Arthroscopic Finding of Rheumatoid Arthritis in a Post-traumatic Ligamentous Injury to Knee Joint

Introduction

The relationship between physical trauma and subsequent symptoms of rheumatoid arthritis (RA) has been described in the past though onset of newer disease of RA in apparently normal patient is doubtful. Trauma can cause precipitation of RA symptoms. Such trauma includes fractures, joint injuries, road traffic accidents, and also surgeries and deliveries. Although post-traumatic osteoarthritis following anterior cruciate ligament (ACL) injury is more common pathology, association of RA following ACL injury has not been reported in the literature. This case report highlights on one rare incidental diagnosis of RA postoperatively in a patient with traumatic ACL tear with previously no features of RA and how patient was managed successfully both by surgical and by medical management.

Case Report

A 30-year-old male patient presented to us with complaints of pain over right knee associated with recurrent swelling, instability, clicking sounds, and occasional locking episodes since 6 months following twisting injury with no other symptoms in other joints of the body. Based on clinicoradiological workup, the diagnosis of traumatic complete ACL tear with medial meniscus bucket handle tear of body and posterior horn with early osteoarthritic changes was made. The patient was operated with ACL reconstruction with quadrupled hamstring graft, partial medial meniscectomy and debridement + microfracture for cartilage defects. The patient was worked up for inflammatory arthritis post operatively considering unusual synovitis of knee. Based on histopathological and serological investigations (rheumatoid factor and anticitrullinated protein antibody), the patient was put on disease modifying antirheumatoid drugs for 1 year. At 1-year follow-up, the patient was back to his normal activities with full range of movements with Lysholm Knee Score of 89.

Conclusion

Traumatic ACL tear can result in onset of RA following trauma and needs to be worked up further when there are findings of unusual synovitis or cartilage damage arthroscopically. Such association is rare and concomitant diagnosis of RA or other inflammatory arthritis can be easily missed out if not addressed properly.

Five cases of seronegative persistent inflammatory monoarthritis improved with biological therapy

Persistent inflammatory monoarthritis is defined as inflammation of one joint that continues for longer than 3 months. Most cases remain as nonspecific arthritis after several years. Persistent inflammatory monoarthritis is difficult to diagnose and treat in the early stage because there are no criteria for diagnosis and treatment. We report five seronegative persistent inflammatory monoarthritis cases that affected the left knee, right knee, left knee, left ankle, and right knee. All patients underwent joint punctures; two patients received steroid injections in the affected joint. The bacterial and mycobacterial culture were negative in all patients. Two patients received oral steroids, and two patients were administered nonsteroidal anti-inflammatory drugs; however, their symptoms did not improve, and one patient experienced progression of joint destruction. We investigated the usefulness of biological disease-modifying antirheumatic drugs for the treatment of seronegative persistent inflammatory monoarthritis. We obtained a remarkable improvement effect and prevented the advance of joint destruction.

Genicular nerve block in juvenile idiopathic arthritis: a randomized clinical trial

OBJECTIVES

This study aimed at evaluating the effect of genicular nerve block (GNB) in juvenile idiopathic arthritis (JIA) patients with persistent unilateral knee arthritis on pain, inflammatory parameters, function, and range of motion.

METHODS

A total of 104 JIA patients were diagnosed according to the International League Against Rheumatism (ILAR) criteria with persistent unilateral knee arthritis. They were allocated randomly into 2 groups: group 1 treated with GNB, while group 2 was treated with intra-articular triamcinolone (TA) only. Visual analogue scale (VAS) on pain, sonography of large joints in rheumatology (SOLAR) scoring system, and Lysholm scores were assessed at 0-, 2-, and 12-week intervals. Swelling and tenderness were clinically evaluated semi-quantitatively (0-3) at the same time intervals.

RESULTS

VAS pain, tenderness, swelling, and SOLAR grey scale (GS) and power Doppler (PD) scores were significantly reduced after 2 weeks in both groups (p < 0.05). This was greater in the GNB group regarding VAS and tenderness, while SOLAR and swelling were stronger reduced in TA group. After 12 weeks, all outcome measures showed lower values in the GNB group compared to TA, and this was significant regarding VAS pain. Moreover, Lysholm functional score was significantly increased in both groups at both intervals; and higher values were seen in the TA group compared to GNB after 2 weeks.

CONCLUSION

GNB was able to control pain and improve function and inflammation of the knee joint in JIA patients. Though steroid attained better results after 2 weeks, GNB achieved an equivalent longer-term improvement after 12 weeks.

TRIAL REGISTRATION IDENTIFYING NUMBER

NCT04687930. Key Points • Persistent knee arthritis treatment in JIA is always challenging. • GNB was approved for treatment of pain in knee osteoarthritis. • GNB in the present study succeeded to control active knee arthritis and this effect was comparable to intra-articular steroid injection.

Monarticular rheumatoid arthritis of the elbow

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterised by symmetric inflammatory polyarthritis. However, RA limited to a single joint is extremely rare. Here, we report a middle-aged woman who presented with insidious right elbow arthritis. She had no other peripheral joint pain, tenderness or swelling. She had high-positive anti-cyclic citrullinated peptide antibodies. An MRI of the right elbow showed capsular distension, joint effusion and bone marrow oedema. Synovial biopsy revealed hyperplasia with lymphoplasmacytic infiltrate consistent with RA. Therapy with methotrexate 7.5 mg orally weekly was effective to control her inflammatory arthritis. This case highlights the relevance of synovial tissue analysis for patients presenting with chronic inflammatory monarthritis when the cause is not clinically evident, and the importance of considering RA even in the absence of polyarticular involvement. Delayed diagnosis and treatment of inflammatory monarthritis can lead to joint destruction and disability.

Genicular nerve block in rheumatoid arthritis: a randomized clinical trial

OBJECTIVE

This study highlights the effect of a genicular nerve block (GNB) on pain, function, and inflammation outcome measures in rheumatoid arthritis (RA) knees.

METHODS

A total of sixty-four patients diagnosed with RA using ACR/EULAR 2010 criteria with unilateral persistent knee arthritis were recruited to the study. They were randomly assigned into two groups: group 1 received GNB and group 2 received intra-articular triamcinolone. Both groups were examined by the SOLAR scoring system, visual analog scale (VAS), and Lysholm score at 0, 2, and 12 weeks. A semi-quantitative score was used to assess the tenderness and swelling at the same intervals.

RESULTS

Function and inflammation improved significantly in group 2 at a 2-week interval as compared to group 1, whereas pain improved in both groups with non-significant differences. After 12 weeks, group 1 showed significant improvement as compared with group 2 for the three outcome measures. Neither the disease activity nor the current medication was related to the GNB effect. Disease duration was negatively related to GNB-induced improvement.

CONCLUSION

GNB is a new promising local therapy for RA to control pain, improve function, and alleviate inflammation of the knee joint. Although it has a relatively short-term effect, yet it has outperformed the steroid effect. Key Points • Knee monoarthritis treatment in rheumatoid arthritis is always challenging • GNB has been approved for the treatment of pain in knee osteoarthritis • GNB in this study was able to control active knee arthritis and this effect persisted longer thane intra-articular steroid injection.

Unilateral knee effusion in an elderly patient: an unusual presentation of rheumatoid arthritis

Unilateral atraumatic knee effusion is a relatively common presenting complaint among geriatric patients in primary care and musculoskeletal speciality clinics. Gout, pseudogout, degenerative joint diseases and reactive arthritis are the most common causes of the atraumatic knee effusions. Rheumatoid arthritis very rarely presents as arthritis of one or two large joints. Arthrocentesis, plain radiography and screening blood tests should be performed to help narrow the differential diagnosis. In some cases, advanced imaging modalities such as MRI may be indicated. This study reports a case of rheumatoid arthritis in a 75-year-old gentleman with oligoarthropathy of two large joints as the presenting symptoms.

Surgical Management of Monoarticular Rheumatoid Arthritis of the Fifth Metatarsophalangeal Joint

OBJECTIVE

To investigate the clinical and radiological outcomes in patients with monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint after Weil osteotomy.

METHODS

From July 2011 to September 2015, 18 feet of 16 rheumatoid arthritis patients who underwent Weil osteotomy of the fifth metatarsal toe with a mean age at the time of surgery of 48.8 ± 7.4 years were reviewed retrospectively. The mean disease duration was 44.6 ± 6.8 months, and the follow-up period was 36 months. Clinical outcomes were evaluated according to the American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal interphalangeal scale (AOFAS), 10-item SF-36 physical functioning and 2-item SF-36 bodily pain, Visual Analogue Scale (VAS), and satisfaction scores. In the radiologic evaluation, fifth metatarsophalangeal angle (MTP-5), lateral deviation angle (LDA), and longitudinal axes of the fifth metatarsal were measured on anterior-posterior (AP) weight-bearing radiographs preoperative and at the last follow-up.

RESULTS

Clinical assessment showed that the total average of AOFAS was significantly increased from preoperative 53.6 ± 9.0 to 98.7 ± 2.0 points, and the VAS score was significantly decreased from preoperative 4.1 ± 1.5 to 1.1 ± 0.8 points at the last follow-up (P < 0.001). The total averages of SF-36 physical functioning and SF-36 bodily pain were significantly increased from preoperative 48.9 ± 9.0 to 99. ± 2.1 and from 61.4 ± 12.1 to 99.4 ± 2.4 points, respectively, at the last follow-up (P < 0.001). Subjectively, the excellent outcome of the surgery results were rated by 13 patients (81.3%) that underwent surgery and three patients (18.7%) were rated as good. Regarding radiographic parameters, the mean MTP-5 significantly decreased from 21.5° ± 1.2° preoperatively to 10.2° ± 1.2°, the mean LDA significantly decreased from 7.1° ± 1.2° preoperatively to -2.4° ± 1.0°, and the mean length of the fifth metatarsal was significantly shortened from 71.5 ± 1.4 preoperatively to 67.8 ± 1.5 mm at the final follow-up visit (P < 0.001). No malunion, nonunion, necrosis, pseudoarthrosis, or fracture of the fifth metatarsal was found. No exuberant bone growth, perforation of the screw, subluxation, or dislocation was observed. No indications of modification, revision or repeat surgery, or delayed wound healing were observed during follow-up period.

CONCLUSION

Surgical management of the monoarticular rheumatoid arthritis of the fifth metatarsophalangeal joint can achieve good clinical and radiological outcomes, with pain relief and dislocation reduction, as well as high satisfaction and improvement without recurrence or progression during the follow-up period.