Appropriate Distraction Strength For Metatarsophalangeal Joint Arthroscopy

This study is to investigate the natural metatasophalangeal joint (MTP) distance, the appropriate degree of distraction and the associated factors including age, gender, body mass index(BMI). Regarding natural MTP joint space size, the MTP-2 joint had the largest joint size (2.39 ± 0.37 mm). The MTP-5 joint had the smallest joint size (1.59 ± 0.34 mm). In MTP joint arthroscopy, traction power of 10 lbs is sufficient for appropriate distraction for all MTP joints while traction power of 5 lbs is an appropriate power for distraction of the MTP-2 joint. Manual traction is generally not appropriate for distraction because it is not consistent or sufficient. Less distraction power is required for males than for females, especially for MTP-1, MTP-3, and MTP-4 joints.

Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy of the Lesser Toes: Clinical, Radiologic, and Pedobarographic Outcomes

Background: The minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) is a percutaneous operative technique with the aim to relieve the symptoms of metatarsalgia. To our knowledge, no previous research has analyzed both pre- and postoperative pedobarographic data including the changes in plantar pressure. Methods: Thirty patients (31 feet) were operated on with a DMMO and included in a prospective study. Clinical, radiologic, and pedobarographic outcomes were evaluated in comparison with the preoperative parameters. The American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, the Foot Function Index (FFI), the Foot and Ankle Outcome Score (FAOS), and a visual analog scale (VAS) for pain were used in order to assess clinical parameters. Radiographs were taken to compare metatarsal lengths. The pedobarographic analysis served to determine plantar peak pressure (PPP) beneath the metatarsophalangeal (MTP) joints. Results: All scores indicated a significant mean pre- to postoperative improvement (AOFAS = 31.9 points, FAOS = 16.3%, FFI = 24.3%, VAS pain = 4.1 points, VAS general limitation = 3.3 points) ( P < .05). PPP was substantially reduced in the relevant area (M6 [plantar area beneath the second and third MTP joint] had a mean pre to post PPP = 14.15 N/cm2) and concurrently higher in the lateral and medial MTP joint areas (M5 mean pre to post = +14.37, M7 pre to post = +7.11). Our mean metatarsal shortening was 6.6 mm. However, our findings do not demonstrate a significant correlation between metatarsal length relationships and the prevalence of metatarsalgia. Conclusion: Our results demonstrate a significant improvement in clinical scores and PPP. A statistically significant relation between metatarsal length and the prevalence of metatarsalgia was not found in this prospective case series Level of Evidence: Level IV, case series.

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet; 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD < 5 mm; grade 2, 5 ≤ MOD < 10 mm; and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.

Acute gout flare of bilateral first metatarsophalangeal joints due to ibrutinib use in chronic lymphocytic leukemia

Introduction Bruton tyrosine kinase inhibitors represent important tools in the therapeutic armamentarium against chronic lymphocytic leukemia (CLL) and other B-lymphoproliferative disorders. Case Report We describe herein a unique 65-year-old patient who presented with bilateral foot pain four months after starting treatment with ibrutinib for CLL. Of note, the patient had previously been diagnosed with gout, and was taking allopurinol prophylactically at the time of the event. Compliance with allopurinol was in excess of 99%. Yet, he was diagnosed with acute gout flare of bilateral first metatarsophalangeal (MTP) joints. Management & Outcome: Ibrutinib dose was reduced by one third, and the patient’s gout flare up was treated with ibuprofen as needed. After symptoms abated, ibrutinib was continued at 2/3rds of the dose, with an excellent CLL control. The patient tolerated this dose without any further adverse effects. Discussion/Conclusions: We have reported a unique side effect of acute bilateral first MTP joint gout flare likely triggered by ibrutinib use for CLL while the patient was taking a xanthine oxidase inhibitor. The mechanism by which ibrutinib caused this phenomenon remains to be elucidated.

OP0146 TENOSYNOVITIS, SYNOVIAL HYPERTROPHY AND FEET BURSITIS ARE USEFUL ULTRASOUND BIOMARKERS FOR PREDICTING ARTHRITIS DEVELOPMENT IN A POPULATION AT-RISK FOR RHEUMATOID ARTHRITIS

Background:Musculoskeletal ultrasound (MSUS) evaluation of individuals at risk for developing rheumatoid arthritis (RA) having Anti-Citrullinated Protein Antibody (ACPA) positivity and musculoskeletal complaints, may play an important role in the very early detection of RA.Objectives:We aimed to identify which ultrasound markers could predict arthritis development.Methods:Individuals with musculoskeletal complaints with a positive anti-CCP2 test were referred to the rheumatology department for a detailed clinical (68 joint count) and MSUS examination of the hands, feet and any symptomatic joints. Only those without clinical and/or MSUS detected arthritis were included in the RISK RA prospective cohort and followed-up over 3 years/ or until arthritis onset. Using EULAR-OMERACT guidelines1, MSUS markers for synovial hypertrophy (SH) and hyperemia (Doppler activity) were documented for each visit. Finger and wrist tendons were screened for any signs of tenosynovitis (TS), and between metatarsal joints for bursitis. Association of MSUS biomarkers with arthritis development was tested (comparing proportions) using Chi-Squared or Fisher’s exact tests.Results:288 individuals were included from January 2014 to October 2019 (79% female, 35% RF positive, median age 48 years: IQR: 36-58). Within a median of 38 months (IQR: 1-72) since recruitment, 84 individuals (28%) developed an arthritis diagnosis.Prior to obtaining any diagnosis (at inclusion and/or follow-up visit), 95 of the 288 individuals (33%) had at least one type of MSUS anatomical modification present (around the tendons, joint synovium and/or within bursal cavities), and 56% (53/95) of these individuals eventually developed arthritis. Of the remaining 193 that did not present with any obvious MSUS changes, 16% progressed towards arthritis development.The presence of tenosynovitis was detected in 64 of 288 individuals scanned prior to diagnosis and were more frequent in those developing arthritis (44%, 37/84) as compared to those with TS not developing arthritis (13%, 27/204), p<0.0001. The extensor carpi ulnaris wrist tendons were mostly involved. Sonographic changes within the synovium were noted in 11% (32/288) of all individuals, mostly affecting the metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. There was a higher incidence of synovial hypertrophy detected in those developing arthritis (22%, 18/24), as compared to those that remained arthritis free (7%, 14/204), p<0.0001. The MCP joints with synovial hypertrophy were more prone to arthritis development as compared to the MTP’s. Furthermore, we observed a higher frequency of bursitis between the MTP joints in individuals developing arthritis, as compared to individuals having a bursitis who did not develop arthritis (13%, 11/84 versus 7%, 14/204, p=0.009).Conclusion:Ultrasound biomarkers such as tenosynovitis of the extensor carpi ulnaris, synovial hypertrophy of the MCP joints and feet bursitis have good potential to predict arthritis development in a population at-risk for rheumatoid arthritis.References:[1]Maria-Antonietta D’Agostino et al. RMD Open 2017;3:e 000428Acknowledgements:All study participants and patients, including researchers that are part of the multidisciplinary laboratory, clinical and academic teams of the RISK RA study group, as well as all assisting this research in one form or the other are greatly acknowledged.Disclosure of Interests:None declared

AB0124 STRUCTURAL DAMAGE IN THE FOOT IN RHEUMATOID ARTHRITIS: DON’T MISS THE OTHER METATARSOPHALANGEAL JOINTS

Background:The foot involvement in rheumatoid arthritis (RA) affects the functionality and the quality of life in patients. Despite this, the clinicians do not give enough care to the foot in RA patients, especially if asymptomatic, resulting in joint damage, deformity, and disability. The distribution of erosions of the other MTP joints (excluding the 5th) has not previously been studied.Objectives:This study aimed to investigate the distribution of erosions in MTP joints and their clinical implications.Methods:We conducted a retrospective study including patients with RA according to the American college of rheumatology/ the European league against rheumatism classification criteria. Sociodemographic data, as well as disease activity related characteristics, were recorded.Posterior–anterior radiographs of the hands and feet of each patient were assessed for erosions.All patients were assessed by Ultrasonography (US) of the hands. US erosions were scored 0-3 according to Szkudlarek [1]. We divided patients into two groups (G1 without MTPs erosions and G2 with MTPs erosions).Results:We enrolled forty-two females and eleven males in our studies. The mean age was 58.6 years ±12.7 [23-77], and the mean disease duration was 8.4 years [1-47]. Rheumatoid factor or cyclic citrullinated peptide antibodies (Anti-CCP) were positive in 62.3% of cases. The mean DAS28ESR score was 5.1±1.16 [2.5-7.7]. Half of the patients had the active disease (52.8%). Hand erosions evaluated with plain radiographs and the US were found in 43.1% and 50.9% of cases, respectively. The distribution of foot erosions (15.1%) was at follows: 5th right MTP (7.5%), the 5th right IPP (2%), the 1st left MTP (2%), 3th left MTP (3.8%), 4th left MTP (5.7%) and the 5th left MTP (9.4%). Erosions on MTPs with the exclusion of the 5th MTP were present in 9.4% of cases. The presence of MTPs erosion was more frequent in males (p=0.01) but was not associated with age (p=0.6) or disease duration (p=0.2). Seropositivity was similar between the two groups (p=0.06). Similarly, the inflammatory markers (ESR and CRP), as well as DAS28 ESR, did not differ between the two groups (p>0.05). MTPs erosion was not associated with the presence of hand erosions on a plain radiograph (p=0.445). However, MTPs erosion was significantly more frequent in patients with less erosive hands-on US (p=0.034).Conclusion:Our study showed that screening of other MTPs (excluding the 5th) is mandatory in RA diagnosis. Interestingly, in our result, MTPs erosion is more frequent in males with less erosive hands.Disclosure of Interests:None declared

Distal Metatarsal Segmental Shortening for the Treatment of Chronic Metatarsophalangeal Dislocation of Lesser Toes

Background: This retrospective study aimed to describe the techniques and results of distal metatarsal segmental shortening (DMSS) for the treatment of chronic irreducible metatarsophalangeal (MTP) dislocation of lesser toes. Methods: We retrospectively reviewed patients who underwent DMSS for chronic dislocation of MTP joints of lesser toes between January 2010 and December 2017 with follow-up of at least 24 months. Demographic data, radiographic measurements, functional outcomes, and complications were analyzed. Furthermore, the results of patients with short segment of shortening (group I, <10 mm) were compared to those with long segment of shortening (group II, ≥10 mm). A total of 43 MTP joints of 30 patients with an average age of 70.4 years were included. Results: Union was observed in 42 metatarsals (97.7%). Mean American Orthopaedic Foot & Ankle Society scale scores improved significantly from 42.2 (range, 15-65) preoperatively to 79.1 (range, 52-90) ( P < .001). Mean visual analog scale pain score improved significantly from 5.0 (range, 1-9) preoperatively to 1.8 (range, 0-6) ( P < .001). Complications included 1 nonunion, 1 osteonecrosis, 3 metatarsal angulation, 4 recurrent instability, 4 symptomatic osteoarthritis, 3 transfer metatarsalgia, and 1 floating toe. Group I included 23 MTP joints and group II included 20 MTP joints. There was no significant difference in clinical outcomes and complications between the 2 groups. Conclusion: DMSS was a reliable procedure for the treatment of chronic irreducible dislocated MTP joint of lesser toes. It provided satisfactory surgical outcomes and a low rate of postoperative complications, regardless of length of metatarsal shortening. Level of Evidence: Level III, retrospective comparative study.

Comparing racing performance following arthroscopic surgery of metacarpophalangeal/metatarsophalangeal and carpal joints in Thoroughbred racehorses rehabilitated using conventional and underwater treadmill therapies

BackgroundRehabilitation of horses using underwater treadmill therapy has been shown to improve joint range of motion, joint mobility, stride length and proprioceptive parameters with experimental studies. However, studies investigating the prognosis and return to function following rehabilitation are lacking.MethodsA retrospective study of Thoroughbred racehorses treated with arthroscopic surgery for osteochondral fragments of the metacarpophalangeal (MCP) or metatarsophalangeal (MTP) joints or carpal joints undergoing conventional rehabilitation or underwater treadmill assisted rehabilitation at the same facility were included. The objective of the current study was to investigate if underwater treadmill assisted rehabilitation following arthroscopy in the Thoroughbred racehorse was positively associated with returning to racing, time to return to racing and postoperative racing performance including Beyer Speed Figures.ResultsSurgery was performed on 165 horses on 174 surgical occasions; 70 (40.2 per cent) underwent underwater treadmill rehabilitation, with the remainder undergoing conventional rehabilitation. The time to return to racing was a median of 227 (IQR 185–281) days and 239 (IQR 205–303) days for underwater treadmill and conventional rehabilitation, respectively (P=0.16). Of the horses that raced presurgery, 83 per cent (58/70) of underwater treadmill rehabilitated horses and 61 per cent (63/104) of horses undergoing conventional rehabilitation returned to racing following surgery (P=0.02).ConclusionUnderwater treadmill rehabilitation is superior in returning a Thoroughbred racehorse to racing following arthroscopic surgery of the carpus and/or MCP/MTP joints.

AB1128 ULTRASOUND SYNOVITIS AND SQUEEZE TEST: IS THERE A RELATIONSHIP?

Background:The squeeze test or the Gaenslen’s test is an easy and rapid method to identify arthritis in metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints. It’s characterized by tenderness upon lateral compression of MCP or MTP joints. This is a useful clinical exam for the early diagnosis of Rheumatoid Arthritis (RA).Objectives:The aim of our study is to assess the real value of that test and its association with synovitis.Methods:A prospective study including RA patients (2010 ACR/EULAR criteria) was conducted at the Rheumatology Department of Mongi Slim Hospital Tunis.US examination was performed by an experimented rheumatologist blinded to clinical data using a machine type Esaote MyLAb 60 with a linear probe of 6-18 MHz. MCP joints were assessed in dorsal longitudinal view, in mode B and Power Doppler.Synovitis was defined and Flexor digitorum Tenosynovitis was defined according to OMERACT.A p<0.05 was considered statistically significant.Results:Forty-three cases of RA were included. The mean age was 58.92 years [27 - 81]. The sex ratio was 0.16. Among our patients, 46.5% of cases were receiving methotrexate with a mean dose of 15,875 mg / week [7.5 - 22.5]. Corticosteroids were used in 55.8% of our patients with a mean dose of 8.65 mg / day [2.5 - 30]. Moreover, 23.25% of the patients were on biologics.The mean value of morning stiffness was 37 min [0 - 150], the mean value of the global assessment of the disease by the patient was 5/10 [1 - 8]. The Gaenslen’s test was positive bilaterally in 25,6% of cases, in the right hand and in the left one in respectively 39.5% and 27.9% of the patients. Tenosynovitis of the flexors were found clinically in 11.6% case.The mean CRP was 29.7 mg / L [0.2 - 275] and the mean ESR was 65 mm [3 - 120]. The mean value of DAS28 and DAS28CRPwere respectively 5.20 ± 1.43 [2.69 – 9.00] and 4.33 ± 1.43 [1.35 – 8.32]. Overall, 430 joints and 430 flexor tendons were assessed by Ultrasound. Ninety-one synovitis were detected with a mean of 2.56 synovitis in MCP per patient [0 - 10]. Flexor tenosynovitis was found in 53.5% of patients.A statistically significant correlation was found between the squeeze test and presence of ultrasound synovitis of the MCP whatever the site of the synovitis; on the right side (r = 0.507; p < 10-3), or the left one (r = 0.607; p < 10-3) but no correlation between the clinically detected tenosynovitis and the ultrasound tenosynovitis (p = 0.364). We found a significant correlation between the Gleason test and ultrasound tenosynovitis on both side with r = 0.368 and p = 0.015 on the right hand and r = 0.441 and p = 0.003 on the left one.Conclusion:The squeeze test seems to be a very useful and practical clinical examination to easily detect synovitis and aid in the early diagnosis of RADisclosure of Interests:None declared

AB1258 THE VALUE OF THE SQUEEZE TEST FOR DETECTION OF SUBCLINICAL SYNOVITIS IN PATIENTS WITH ARTHRALGIA SUSPICIOUS FOR PROGRESSION TO RA

Background:The squeeze test (or compression test) is often used to quickly screen for arthritis in metacarpophalangeal (MCP)- and metatarsophalangeal (MTP)-joints. A positive test is traditionally assumed to indicate presence of synovitis. Previous studies in early arthritis indeed showed that a positive squeeze test was associated with presence of swollen MCP- and MTP-joints, as well as with local MRI-detected inflammation. The sensitivity of the test, with MRI-detected synovitis as reference, was 31-33%. The field is moving towards identifying patients at risk for rheumatoid arthritis (RA) in the phase of arthralgia. However, it is unclear if the squeeze test in the phase of clinically suspect arthralgia (CSA) is associated with subclinical inflammation, which can be detected with MRI.Objectives:We aimed to assess if a positive squeeze test in patients with CSA is associated with MRI-detected subclinical inflammation, especially with subclinical synovitis and tenosynovitis (the latter is recently identified as a strong predictor for RA-development).Methods:315 patients with recent-onset (<1 year) arthralgia of small joints and a clinical suspicion for progression to RA were consecutively included in our CSA-cohort. At baseline the squeeze test (compression across the knuckles of MCP- and MTP-joints with the force of a firm handshake) and unilateral contrast-enhanced 1.5T MRI of MCP(2-5)- and MTP(1-5)-joints was performed and scored according to RAMRIS. MRI-scores were dichotomized with data from age-matched symptom-free controls as reference. Follow-up ended when patients developed clinically apparent inflammatory arthritis (IA), or else after 2 years. Associations of the squeeze test and MRI-data were studied with generalized estimating equations, associations with IA-development with cox regression.Results:51% of CSA-patients had a positive squeeze test in MCP- or MTP-joints. In univariable analyses a positive test was associated with MRI-detected subclinical synovitis (OR 2.10 (95%CI 1.30-3.40)) and tenosynovitis (OR 1.68 (1.05-2.68)). In multivariable analyses including both inflammatory features only synovitis remained significant (OR 1.90 (1.16-3.13)). Thus, a positive squeeze test is a measure of subclinical synovitis, with a sensitivity of 44% (95%CI 33-55) and specificity of 72% (68-76).A positive squeeze test in CSA was not associated with IA-development in cox regression adjusted for age, gender, CRP and ACPA-status (HR 1.57 (0.77-3.19). This was consistent with the finding that subclinical synovitis was not associated with IA-development in multivariable analysis adjusted for age, gender, CRP, ACPA-status and tenosynovitis (HR 1.40 (0.59-3.31), whilst tenosynovitis was associated (HR 4.94 (2.03-12.06).Conclusion:The squeeze test is a simple test that, when positive in CSA, doubles the probability of presence of subclinical synovitis.Disclosure of Interests:None declared