Unveiling Novel Drug Targets and Emerging Therapies for Rheumatoid Arthritis: A Comprehensive Review

Rheumatoid arthritis (RA) is a chronic debilitating autoimmune disease, that causes joint damage, deformities, and decreased functionality. In addition, RA can also impact organs like the skin, lungs, eyes, and blood vessels. This autoimmune condition arises when the immune system erroneously targets the joint synovial membrane, resulting in synovitis, pannus formation, and cartilage damage. RA treatment is often holistic, integrating medication, physical therapy, and lifestyle modifications. Its main objective is to achieve remission or low disease activity by utilizing a "treat-to-target" approach that optimizes drug usage and dose adjustments based on clinical response and disease activity markers. The primary RA treatment uses disease-modifying antirheumatic drugs (DMARDs) that help to interrupt the inflammatory process. When there is an inadequate response, a combination of biologicals and DMARDs is recommended. Biological therapies target inflammatory pathways and have shown promising results in managing RA symptoms. Close monitoring for adverse effects and disease progression is critical to ensure optimal treatment outcomes. A deeper understanding of the pathways and mechanisms will allow new treatment strategies that minimize adverse effects and maintain quality of life. This review discusses the potential targets that can be used for designing and implementing precision medicine in RA treatment, spotlighting the latest breakthroughs in biologics, JAK inhibitors, IL-6 receptor antagonists, TNF blockers, and disease-modifying noncoding RNAs.

Diagnosis of Inflammatory Bowel Disease-Associated Peripheral Arthritis: A Systematic Review

BACKGROUND

Inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA) decreases quality of life and remains poorly understood. Given the prevalence of this condition and its negative impact, it is surprising that evidence-based disease definitions and diagnostic strategies are lacking. This systematic review summarizes available data to facilitate development and validation of diagnostics, patient-reported outcomes, and imaging indices specific to this condition.

METHODS

A literature search was conducted. Consensus or classification criteria, case series, cross-sectional studies, cohort studies, and randomized controlled trials related to diagnosis were included.

RESULTS

A total of 44 studies reporting data on approximately 1500 patients with pSpA were eligible for analysis. Data quality across studies was only graded as fair to good. Due to large heterogeneity, meta-analysis was not possible. The majority of studies incorporated patient-reported outcomes and a physical examination. A total of 13 studies proposed or validated screening tools, consensus, classification, or consensus criteria. A total of 28 studies assessed the role of laboratory tests, none of which were considered sufficiently accurate for use in diagnosis. A total of 17 studies assessed the role of imaging, with the available literature insufficient to fully endorse any imaging modality as a robust diagnostic tool.

CONCLUSIONS

This review highlights existing inconsistency and lack of a clear diagnostic approach for IBD-associated pSpA. Given the absence of an evidence-based approach, a combination of existing criteria and physician assessment should be utilized. To address this issue comprehensively, our future efforts will be directed toward pursuit of a multidisciplinary approach aimed at standardizing evaluation and diagnosis of IBD-associated pSpA.

Do Patients With Insulin-Dependent and Non-Insulin-Dependent Diabetes Have Different Risks for Complications After Total Ankle Arthroplasty?

BACKGROUND

Patients with diabetes undergoing total ankle arthroplasty tend to be at greater risk for complications than those without diabetes. However, the effect of diabetes severity and how it impacts the risk for perioperative complications is less clear. The purpose of this study was to compare (1) complications, (2) length of hospital stay, and (3) readmissions within 30 days for total ankle arthroplasty (TAA) patients without diabetes, patients with non-insulin-dependent diabetes, and patients with insulin-dependent diabetes.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a total of 1803 patients undergoing TAA between 2007 and 2019 were collected. The relationship between diabetes status (no diabetes [n = 1,589], insulin-dependent [n = 169], and non-insulin-dependent [n = 45]) and outcomes were compared. Multivariate linear regression models were used to adjust for confounding variables such as age, sex, race, body mass index, smoking, steroid use, hypertension, chronic obstructive pulmonary disease, anesthesia type, dyspnea, and outpatient status. Statistical significance was set at P <.05.

RESULTS

Insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days (odds ratio 6.47, 95% CI 0.79-33.66; P = .043). Hospital length of stay was also increased in patients with non-insulin-dependent diabetes (β = 0.21, 95% CI 0.02-0.40; P = .031) and insulin-dependent diabetes (β = 0.40, 95% CI 0.04-0.76; P = .028). However, neither diabetic state demonstrated a statistically significant increase in readmissions or wound complications within 30 days.

CONCLUSION

Patients with insulin-dependent diabetes included in this cohort were at increased risk of having an infection within 30 days after TAA. Additionally, patients with diabetes status had an increased hospital length of stay. These results can inform patients on their potential outcomes after total ankle arthroplasty based on their diabetes status.

Comprehensive insights into rheumatoid arthritis: Pathophysiology, current therapies and herbal alternatives for effective disease management

Rheumatoid arthritis is a chronic autoimmune inflammatory disease characterized by immune response overexpression, causing pain and swelling in the synovial joints. This condition is caused by auto-reactive antibodies that attack self-antigens due to their incapacity to distinguish between self and foreign molecules. Dysregulated activity within numerous signalling and immunological pathways supports the disease's development and progression, elevating its complexity. While current treatments provide some alleviation, their effectiveness is accompanied by a variety of adverse effects that are inherent in conventional medications. As a result, there is a deep-rooted necessity to investigate alternate therapeutic strategies capable of neutralizing these disadvantages. Medicinal herbs display a variety of potent bioactive phytochemicals that are effective in the complementary management of disease, thus generating an enormous potency for the researchers to delve deep into the development of novel phytomedicine against autoimmune diseases, although additional evidence and understanding are required in terms of their efficacy and pharmacodynamic mechanisms. This literature-based review highlights the dysregulation of immune tolerance in rheumatoid arthritis, analyses the pathophysiology, elucidates relevant signalling pathways involved, evaluates present and future therapy options and underscores the therapeutic attributes of a diverse array of medicinal herbs in addressing this severe disease.

Classifying Self-Reported Rheumatoid Arthritis Flares Using Daily Patient-Generated Data From a Smartphone App: Exploratory Analysis Applying Machine Learning Approaches

BACKGROUND

The ability to predict rheumatoid arthritis (RA) flares between clinic visits based on real-time, longitudinal patient-generated data could potentially allow for timely interventions to avoid disease worsening.

OBJECTIVE

This exploratory study aims to investigate the feasibility of using machine learning methods to classify self-reported RA flares based on a small data set of daily symptom data collected on a smartphone app.

METHODS

Daily symptoms and weekly flares reported on the Remote Monitoring of Rheumatoid Arthritis (REMORA) smartphone app from 20 patients with RA over 3 months were used. Predictors were several summary features of the daily symptom scores (eg, pain and fatigue) collected in the week leading up to the flare question. We fitted 3 binary classifiers: logistic regression with and without elastic net regularization, a random forest, and naive Bayes. Performance was evaluated according to the area under the curve (AUC) of the receiver operating characteristic curve. For the best-performing model, we considered sensitivity and specificity for different thresholds in order to illustrate different ways in which the predictive model could behave in a clinical setting.

RESULTS

The data comprised an average of 60.6 daily reports and 10.5 weekly reports per participant. Participants reported a median of 2 (IQR 0.75-4.25) flares each over a median follow-up time of 81 (IQR 79-82) days. AUCs were broadly similar between models, but logistic regression with elastic net regularization had the highest AUC of 0.82. At a cutoff requiring specificity to be 0.80, the corresponding sensitivity to detect flares was 0.60 for this model. The positive predictive value (PPV) in this population was 53%, and the negative predictive value (NPV) was 85%. Given the prevalence of flares, the best PPV achieved meant only around 2 of every 3 positive predictions were correct (PPV 0.65). By prioritizing a higher NPV, the model correctly predicted over 9 in every 10 non-flare weeks, but the accuracy of predicted flares fell to only 1 in 2 being correct (NPV and PPV of 0.92 and 0.51, respectively).

CONCLUSIONS

Predicting self-reported flares based on daily symptom scorings in the preceding week using machine learning methods was feasible. The observed predictive accuracy might improve as we obtain more data, and these exploratory results need to be validated in an external cohort. In the future, analysis of frequently collected patient-generated data may allow us to predict flares before they unfold, opening opportunities for just-in-time adaptative interventions. Depending on the nature and implication of an intervention, different cutoff values for an intervention decision need to be considered, as well as the level of predictive certainty required.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty

BACKGROUND

There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider.

METHODS

We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio.

RESULTS

During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187).

CONCLUSIONS

There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Effects of walking speeds on lower extremity kinematic synergy in toe vertical position control: An experimental study

BACKGROUND

This study aimed to investigate whether lower limb joints mutually compensate for each other, resulting in motor synergy that suppresses toe vertical position fluctuation, and whether walking speeds affect lower limb synergy.

METHODS

Seventeen male university students walked at slow (0.85 ± 0.04 m/s), medium (1.43 ± 0.05 m/s) and fast (1.99 ± 0.06 m/s) speeds on a 15-m walkway while lower limb kinematic data were collected. Uncontrolled manifold analysis was used to quantify the strength of synergy. Two-way (speed × phase) repeated-measures analysis of variance was used to analyze all dependent variables.

RESULTS

A significant speed-by-phase interaction was observed in the synergy index (SI) (P  < .001). At slow walking speeds, subjects had greater SI during mid-swing (P  < .001), while at fast walking speeds, they had greater SI during early-swing (P  < .001). During the entire swing phase, fast walking exhibited lower SI values than medium (P  = .005) and slow walking (P  = .027).

CONCLUSION

Kinematic synergy plays a crucial role in controlling toe vertical position during the swing phase, and fast walking exhibits less synergy than medium and slow walking. These findings contribute to a better understanding of the role of kinematic synergy in gait stability and have implications for the development of interventions aimed at improving gait stability and reducing the risk of falls.

Cytoplasmic PPARγ Significantly Correlates With P53 Immunohistochemical Expression and Tumor Size in Localized Tenosynovial Giant Cell Tumor

BACKGROUND

Tenosynovial giant cell tumor (TGCT) is a monoarticular fibrohistiocytic benign or locally aggressive soft tissue tumor that originates from the synovium of joints, bursae, and tendon sheaths. It has an inflammatory neoplastic nature, with a clinical presentation ranging from pain, swelling, stiffness, and limited range of movement to joint instability and blockage. Its uncommon incidence leads to a poorly understood pathogenesis. Localized forms of TGCT (LTGCT) can cause significant morbidity, interfere with daily patient activities, and decrease the patient's quality of life in challenging cases. This study aimed to investigate the immunohistochemical expression of PPARγ (peroxisome proliferator-activated receptor gamma) and P53 in LTGCT to understand the disease better and offer potential therapeutic targets.

METHODS

The study is cross-sectional, in which 27 LTGCT cases were collected from the Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt. Solitary and multiple LTGCT cases retrieved between January 2018 and December 2022 were included, and immunohistochemically stained with anti-PPARγ and P53 antibodies. The TGCT samples were excluded if they were insufficient for sectioning, processing, and interpretation, over-fixed, had process artifacts, or were of the diffuse TGCT type. Scoring of stain expression was performed by ImageJ (National Institutes of Health, Bethesda, MD) analysis using the threshold method and was expressed in percent area/high power field. Clinicopathological correlations were analyzed.

RESULTS

All the 27 collected LTGCT cases were located in the small joints of patients' hands. Cases with solitary LGTCTs constituted 55.6% (n = 15), while 44.4% (n = 12) had multiple LTGCTs related to one affected site/case (e.g., multiple tumors in one finger). PPARγ was expressed in the cytoplasm of mononuclear and multinucleated tumor cells and foamy histiocytes, while P53 expression was mainly in mononuclear cells' nuclei. PPARγ significantly correlated with P53 expression (r = 0.9 and P = 0.000). PPARγ (r = 0.4 and P = 0.02) and P53 (r = 0.5 and P = 0.01) were positively correlated with tumor size. Only P53 expression was positively correlated with tumor multiplicity (r = 0.4 and P = 0.03). Using the receiver operating characteristic curve test, the P53 cutoff score detecting the multiplicity of TGCTs was ≥20.5%, with a 75% sensitivity and 80% specificity.

CONCLUSION

PPARγ and P53 have a significant role in LTGCT growth, while P53 plays a role in tumor multiplicity. They can be possible targets in LTGCTs unfit for excision.

Estimation of the forces exerted on the limb long bones of a white rhinoceros (Ceratotherium simum) using musculoskeletal modelling and simulation

Heavy animals incur large forces on their limb bones, due to the transmission of body weight and ground reaction forces, and the contractions of the various muscles of the limbs. This is particularly true for rhinoceroses, the heaviest extant animals capable of galloping. Several studies have examined their musculoskeletal system and the forces their bones incur, but no detailed quantification has ever been attempted. Such quantification could help understand better the link between form and function in giant land animals. Here we constructed three-dimensional musculoskeletal models of the forelimb and hindlimb of Ceratotherium simum, the heaviest extant rhino species, and used static optimisation (inverse) simulations to estimate the forces applied on the bones when standing at rest, including magnitudes and directions. Overall, unsurprisingly, the most active muscles were antigravity muscles, which generate moments opposing body weight (thereby incurring the ground reaction force), and thus keep the joints extended, avoiding joint collapse via flexion. Some muscles have an antigravity action around several joints, and thus were found to be highly active, likely specialised in body weight support (ulnaris lateralis; digital flexors). The humerus was subjected to the greatest amount of forces in terms of total magnitude; forces on the humerus furthermore came from a great variety of directions. The radius was mainly subject to high-magnitude compressive joint reaction forces, but to little muscular tension, whereas the opposite pattern was observed for the ulna. The femur had a pattern similar to that of the humerus, and the tibia's pattern was intermediate, being subject to great compression in its caudal side but to great tension in its cranial side (i.e. bending). The fibula was subject to by far the lowest force magnitude. Overall, the forces estimated were consistent with the documented morphofunctional adaptations of C. simum's long bones, which have larger insertion areas for several muscles and a greater robusticity overall than those of lighter rhinos, likely reflecting the intense forces we estimated here. Our estimates of muscle and bone (joint) loading regimes for this giant tetrapod improve the understanding of the links between form and function in supportive tissues and could be extended to other aspects of bone morphology, such as microanatomy.

A review of modification methods, joints and self-healing methods of adhesive for aerospace

In recent years, the adhesive technology has been widely used in the production of high-strength joins and precise positioning of various materials, such as metals, glass and composite materials. The adhesive technology has become a promising assembly process in the aerospace field due to its versatility, low creep and high damage tolerance. However, the reliability and predictability of adhesive bonding still require further development due to the complex operating conditions involved. Therefore, this article reviews and discusses the latest advances in aerospace adhesive technology, such as methods for improving bonding performance, bonding techniques (including joints structure and failure modes) and self-healing adhesive layers. Additionally, the current research results are summarised, and possible development trends and research directions in the field of adhesive bonding are prospected.

Expert United Kingdom consensus on the preservation of joint health in people with moderate and severe haemophilia A: A modified Delphi panel

AIM

For people with haemophilia A (PwHA), bleeding in the joints leads to joint damage and haemophilia-related arthropathy, impacting range of motion and life expectancy. Existing guidelines for managing haemophilia A support healthcare professionals (HCPs) and PwHA in their efforts to preserve joint health. However, such guidance should be reviewed, considering emerging evidence and consensus as presented in this manuscript.

METHODS

Fifteen HCPs experienced in the management of PwHA in the UK participated in a three-round Delphi panel. Consensus was defined at ≥70% of panellists agreeing or disagreeing for Likert-scale questions, and ≥70% selecting the same option for multiple- or single-choice questions. Questions not reaching consensus were revised for the next round.

RESULTS

26.8% (11/41), 44.8% (13/29) and 93.3% (14/15) of statements reached consensus in Rounds 1, 2 and 3, respectively. HCPs agreed that prophylaxis should be offered to patients with a baseline factor VIII (FVIII) level of ≤5 IU/dL and that, where there is no treatment burden, the aim of prophylaxis should be to achieve a trough FVIII level ≥15 IU/dL and maintain a longer period with FVIII levels of ≥20-30 IU/dL to provide better bleed protection. The aspirational goal for PwHA is to prevent all joint bleeds, which may be achieved by maintaining normalised (50-150 IU/dL) FVIII levels.

CONCLUSION

The panel of experts were largely aligned on approaches to preserving joint health in PwHA, and this consensus may help guide HCPs.

The assessment of Spondyloarthritis International Society Health Index (ASAS HI) in patients with spondyloarthritis - a single centre experience

Aim The Assessment of Spondyloarthritis International Society Health Index (ASAS HI) Croatian version was used to assess health and functioning of patients with spondyloarthritis (SpA) covering aspects of physical, emotional and social functioning. Methods A cross sectional study was conducted at the Clinic for Internal Diseases Tuzla from January to June 2021. Inclusion criteria: fulfilled the ASAS diagnostic criteria for SpA. Exclusion criteria: failure to fulfil the diagnostic criteria, acute infection, the use of antibiotics in the past month, malignancy, associated disorders, psychiatric disorders, pregnancy, patient's refusal to take part in the study. The Disease Activity Score with C reactive protein values (ASDAS-CRP) was assessed. Results Eighty three patients (43 male and 40 female) fulfilled the study criteria with median age of 54 years. The median value of ASDAS-CRP was 2.15, since ASAS HI had the median of 8 (interquartile range; IQR: 2-13) points. Patients with inactivity and with low disease activity had the ASAS HI median of 2 (IQR: 0-6) and 5 (IQR: 1-9) points, respectively. Significantly higher values of ASAS HI were found in patients with moderate and high disease activity, males (13.5 and 16) and females (13 and 14), respectively. The correlation between ASDAS-CRP and ASAS HI, (r=0.62; p<0.0009) was positive, statistically significant. However, the significant correlation between disease duration and ASAS HI values was not found (r=0.11; p=0.28). Conclusion The ASAS HI, Croatian version, is valid and reliable disease specific questionnaire for the assessment of health status in patients with SpA in the Bosnian speaking area.

Ultrasound evaluation of hemophilic arthropathy: a proposal of definitions in a changing landscape

The advent of novel effective treatments and the identification of the need to achieve a higher trough level for persons with hemophilia A and B have changed the landscape of management of these patients, allowing to change the target from survival and prevention of life-threatening complications to prevention of musculoskeletal complications and improvement of quality of life. Point-of-care musculoskeletal ultrasound imaging has also improved the early recognition of joint bleeding and the differential diagnosis of acute joint pain. In addition, joint ultrasound allows the evaluation of the severity of hemophilic arthropathy in terms of synovitis and cartilage and bone damage. However, a lack of standardization in the definition of ultrasound elementary lesions of hemophilic arthropathy may lead to confusion and an incorrect evaluation of the presence and progression of joint damage. Here, we propose to start a standardization and validation process for ultrasound definitions of hemophilic arthropathy that has been planned to become a project within the Factor VIII/IX Standardization Subcommittee of the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee.

Pediatric Psoriasis with or without Arthritis: Does It Make a Difference?

BACKGROUND

Psoriasis and psoriatic arthritis can present simultaneously or separately in children and may pose a diagnostic challenge.

OBJECTIVE

To compare the dermatological manifestations in pediatric psoriatic patients with and without arthritis.

METHODS

A retrospective case-control study of psoriatic patients ≤ 18 years old at Sheba Medical Center was conducted between 2011 and 2021. Patients with psoriatic arthritis versus psoriasis-only were compared according to body surface area (BSA) involvement, cutaneous distribution, severity of skin disease, response to treatment and related side effects.

RESULTS

The study cohort included 29 psoriatic arthritis and 64 psoriasis-only patients matched by age and sex. The psoriasis-only group had a significantly higher mean BSA (19.7%, SD ± 18.7) than the psoriatic arthritis group (6.1%, SD ± 11.4), (p = 0.029). The skin distribution differed with the psoriasis group showing more involvement of the extremities, scalp, trunk, and genitals. Both groups primarily experienced partial responses to methotrexate, whereas the psoriasis group mainly saw complete responses to biologics. Adverse events were rare, with a higher incidence in the psoriasis group.

CONCLUSION

This retrospective study highlights the differences in cutaneous disease characteristics, severity, and treatment response in pediatric patients with psoriasis and psoriatic arthritis, providing valuable insights for diagnosis and disease course in the pediatric population.

Ultrasound in anti-CCP+ at-risk individuals without clinical synovitis: development of a novel 6-joint protocol for feasible risk prediction

OBJECTIVES

To investigate, in anti-cyclic citrullinated peptide antibody positive individuals with musculoskeletal symptoms but no clinical synovitis (CCP+ at-risk), the additional value of ultrasound (US) for the prediction of inflammatory arthritis (IA). Furthermore, to define a concise US protocol for feasible risk prediction.

METHODS

Demographic and clinical data were collected in 417 CCP+ at-risk (Leeds CCP cohort) with a baseline US scan assessing synovitis and bone erosions in 36 joints, and a follow-up duration ≥24 months. Multivariable binary regression models for IA development at 24 months evaluated routine clinical variables associated with IA alone ("clinical" model) and combined with a 36-joint US scanning protocol ("clinical-US extended" model). A "clinical-US short" model was developed.

RESULTS

At 24 months, 92/417 (22.1%) CCP+ at-risk developed IA (median time: 7 months, IQR : 3-12). The "clinical-US extended" model performed better than the "clinical" model (AUC 0.788 vs AUC 0.731 respectively, p< 0.001) with an odds ratio for IA development of 3.18 (95% IC 1.80-5.63) for US synovitis and 2.54 (95% IC 1.21-5.37) for bone erosions. The "clinical-US short" model, which retained the wrists, knees and MTP5 joints, performed better (AUC 0.782) than the "clinical" model (p< 0.001) and similarly (difference in Akaike information criteria <2) to the "clinical-US extended" model.

CONCLUSIONS

US provides valuable information for predicting progression to IA in CCP+ individuals both alone and in addition to clinical variables. US synovitis was associated with a threefold increase risk of IA development. A concise US protocol of 6 joints provides clinically feasible risk prediction in CCP+ at-risk.

Rheumatoid Arthritis Has Won the Battle but Not the War: How Many Joints Will We Save Tomorrow?

Rheumatoid arthritis refers to joint diseases of unclear etiology whose final stages can lead to unbearable pain and complete immobility of the affected joints. As one of the most widely known diseases of the joints, it serves as a study target for a large number of research groups and pharmaceutical companies. Modern treatment with anti-inflammatory drugs, including janus kinase (JAK) inhibitors, monoclonal antibodies, and botanicals (polyphenols, glycosides, alkaloids, etc.) has achieved some success and hope for improving the course of the disease. However, existing drugs against RA have a number of side effects which push researchers to elaborate on more selective and effective drug candidates. The avant-garde of research, which aims to develop treatment of rheumatoid arthritis using antisense oligonucleotides along with nonsteroidal drugs and corticosteroids against inflammation, increases the chances of success and expands the arsenal of drugs. The primary goal in the treatment of this disease is to find therapies that allow patients with rheumatoid arthritis to move their joints without pain. The main purpose of this review is to show the victories and challenges for the treatment of rheumatoid arthritis and the tortuous but promising path of research that aims to help patients experience the joy of freely moving joints without pain.

Surgical accuracy of image-free versus image-based robotic-assisted total knee arthroplasty

BACKGROUND

This study investigated the accuracy in achieving proper lower limb alignment and component positions after total knee replacement (TKR) with image-free and image-based robotic-assisted TKR.

METHODS

A total of 129 patients (166 knees) suffering from end-stage knee arthritis who underwent TKA operated by robotic-assisted surgery between the years 2018 and mid-2021 were recruited. Radiological outcomes were compared between image-free and image-based robotic-assisted surgical systems.

RESULTS

There were significant differences between the two robotic systems when comparing the mean planned component alignment and the mean measured alignment on radiographs, in which the image-free robotic-assisted system was more varus, whereas the image-based robotic-assisted system was more valgus for both the mean femoral and tibial component coronal alignment (p < 0.001). For tibial component sagittal alignment, the image-based group had a larger deviation from the planned posterior slope (p < 0.001).

CONCLUSION

Image-free and image-based robotic assisted TKR had differing accuracy in femoral and tibial alignment.

LincRNA-EPS Alleviates Inflammation in TMJ Osteoarthritis by Binding to SRSF3

Temporomandibular joint osteoarthritis (TMJOA) is a common inflammatory disease that can cause pain, cartilage degradation, and subchondral bone loss. However, the key regulatory factors and new targets for the treatment of TMJOA have yet to be determined. Long noncoding RNAs (lncRNAs) have shown remarkable potential in regulating tissue homeostasis and disease development. The long intergenic RNA-erythroid prosurvival (lincRNA-EPS) is reported to be an effective inhibitor of inflammation, but its role in TMJOA is unexplored. Here, we found that lincRNA-EPS is downregulated and negatively correlated with inflammatory factors in the condyles of TMJOA mice. LincRNA-EPS knockout aggravated inflammation and tissue destruction after TMJOA modeling. The in vitro studies confirmed that loss of lincRNA-EPS facilitated inflammatory factor expression in condylar chondrocytes, while recovered expression of lincRNA-EPS showed anti-inflammatory effects. Mechanistically, RNA sequencing revealed that the inflammatory response pathway nuclear factor-kappa B (NF-κB) was mostly affected by lincRNA-EPS deficiency. Moreover, lincRNA-EPS was proved to effectively bind to serine/arginine-rich splicing factor 3 (SRSF3) and inhibit its function in pyruvate kinase isoform M2 (PKM2) formation, thus restraining the PKM2/NF-κB pathway and the expression of inflammatory factors. In addition, local injection of the lincRNA-EPS overexpression lentivirus significantly alleviated inflammation, cartilage degradation, and subchondral bone loss in TMJOA mice. Overall, lincRNA-EPS regulated the inflammatory process of condylar chondrocytes by binding to SRSF3 and showed translational application potential in the treatment of TMJOA.

Prophylaxis with a recombinant factor VIII Fc in hemophilia A: long-term follow-up on joint health, efficacy, and safety from phase 3 studies in children and adults

Background

Recurrent joint bleeds are a major cause of morbidity in severe hemophilia. Prophylaxis with efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, [rFVIIIFc]) has demonstrated benefits beyond bleed control, including joint health maintenance.

Objectives

To assess long-term efficacy and safety of rFVIIIFc prophylaxis in severe hemophilia A in phase 3 pivotal (A-LONG/Kids A-LONG) and extension (ASPIRE) studies.

Methods

Longitudinal analysis included pooled data from A-LONG/Kids A-LONG and ASPIRE. Subgroup analyses investigated outcomes in modified Hemophilia Joint Health Score or Hemophilia Joint Health Score and target joints in subjects with 4 to 5 years follow-up on individualized prophylaxis (IP), and those with the highest annualized bleeding rate (ABR) quartile during Year 1 of IP.

Results

Overall, rFVIIIFc consumption remained stable and low ABRs were maintained, with a median treatment duration of 4.2/3.4 years in subjects from A-LONG/Kids A-LONG, respectively. Median overall ABR also remained low (1.0-2.0) in subjects on IP for 4 to 5 years. Sustained improvements in modified Hemophilia Joint Health Score or Hemophilia Joint Health Score were demonstrated over a median follow-up of 3.7 years. In subjects from A-LONG/Kids A-LONG, 99.6% (n = 234)/100% (n = 9) of evaluable baseline target joints were resolved, with no recurrence in 95%/100% of target joints. In IP subjects within the highest ABR quartile in Year 1, continued improvements were observed over a median follow-up of 4.3 years in ABR and joint health, without increased factor consumption. No inhibitors or treatment-related serious adverse events were reported.

Conclusion

Previously treated subjects of all ages receiving long-term prophylaxis with rFVIIIFc had sustained clinical benefits, including improved joint health and low ABR.

T2 mapping magnetic resonance imaging of cartilage in hemophilia

Background

In hemophilia, recurrent hemarthrosis may lead to irreversible arthropathy. T2 mapping MRI may reflect cartilage changes at an earlier reversible stage of arthropathy as opposed to structural MRI.

Objectives

To evaluate interval changes of T2 mapping compared with the International Prophylaxis Study Group (IPSG) structural MRI scores of ankle cartilage in boys with hemophilia receiving prophylaxis.

Methods

Eight boys with hemophilia A (median age, 13; range, 9-17 years), 7 age- and sex-matched healthy boys (controls, median age, 15; range, 7-16 years). A multiecho spin-echo T2-weighted MRI sequence at 3.0T was used to obtain T2 maps of cartilage of boys with hemophilia and controls. Structural joint status was evaluated using the IPSG MRI score.

Results

T2 relaxation times of ankle cartilage increased significantly over time in both persons with hemophilia and controls (P = .002 and P = .00009, respectively). Changes in T2 relaxation time strongly correlated with changes in IPSG cartilage scores (rs = 0.93 to rs = 0.78 [P = .0007 to P = .023]), but not with changes in age (P = .304 to P = .840). Responsiveness of T2 relaxation times were higher than that of IPSG cartilage scores, with standardized response means >1.4 for T2 mapping in all regions-of-interest compared with 0.84 for IPSG cartilage scores. Baseline T2 relaxation time strongly correlated with timepoint 2 IPSG cartilage score (rs = 0.93 to rs = 0.82 [P = .001 to P = .012]) and T2 relaxation time (rs = 0.98 to rs = 0.88 [P = .00003 to P = .004]) changes in most regions-of-interest.

Conclusion

T2 mapping shows sensitivity to biochemical changes in cartilage prior to detectable damage using conventional MRI, offering potential for early detection of bleed-related cartilage damage in boys with hemophilia.

Transforming Orthopedic Joint Surgeries: The Role of Artificial Intelligence (AI) and Robotics

The landscape of orthopedic joint surgeries, specifically total hip arthroplasty (THA) and total knee arthroplasty (TKA), is rapidly changing, and artificial intelligence (AI) along with robotics is at the helm of this transformation. These technologies, working synergistically, have introduced unprecedented levels of precision and personalization to surgical procedures, thereby significantly enhancing patient outcomes. In this editorial, we explore the changing perspectives of orthopedic surgeons toward AI and robotics and dissect the incorporation of these technologies in surgeries, their associated advantages, their inherent limitations, and potential future prospects. We draw from a host of recent studies to provide a comprehensive understanding of how these transformative technologies can augment surgical performance and patient care.

Dalbavancin in Bone and Joint Infections: A Systematic Review

BACKGROUND

Approved for acute bacterial skin and skin structure infections, dalbavancin (DBV) has gradually acquired over the years a role as an off-label treatment for several infections caused by Gram-positive bacteria even in other anatomical sites. Osteoarticular (OA) infections are one of the most difficult-to-treat infections and, since the absence of recommendations, clinicians use different and heterogenic DBV dosing schedule regimens for the off-label treatment of osteomyelitis, spondylodiscitis, and septic arthritis. Our aim is to systematically review the current literature to describe DBV administration schedules and their outcome in OA infections.

METHODS

According to the 2020 updated PRISMA guidelines, all peer-reviewed articles regarding the use of DBV in OA infections were included. We conducted a literature search on PubMed and Cochrane Controlled Trials.

RESULTS

A total of 23 studies and 450 patients were included, prevalently male (144/195, 73.8%) and diabetic (53/163, 32.5%). Overall, 280 (280/388, 72.2%) osteomyelitis, 79 (79/388, 20.4%) spondylodiscitis, and 29 (29/388, 7.5%) septic arthritis were considered. Staphylococcus aureus (164/243, 67.5%) was the most common pathogen isolated. A previous treatment failure (45/96, 46.9%) was the main reason for a switch to a long-acting antibiotic. Most patients were successfully cured with DBV (318/401, 79.3%). A source control was performed in most patients with a favourable outcome (80.4%), while MRSA was prevalently isolated in people with an unfavourable outcome (57%). While a higher percentage of success was found in people who received three doses of DBV 1 week apart (92.3%), a higher rate of treatment failure was recorded in cases of when the DBV cycle was composed of less than two or more than four doses (27.8%).

CONCLUSIONS

DBV has shown to be effective as a treatment for OA infections. The most favourable outcome was found in patients receiving three doses of DBV and with an adequate surgical management prior to antibiotic treatment. Although a rigorous administration schedule does not exist, DBV is a viable treatment option in the management of OA infections.

Economic Evaluations of Digital Health Interventions for the Management of Musculoskeletal Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Musculoskeletal disorders (MSDs) are widespread in many countries and their huge burden on the society has necessitated innovative approaches such as digital health interventions. However, no study has evaluated the findings of cost-effectiveness of these interventions.

OBJECTIVE

This study aims to synthesize the cost-effectiveness of digital health interventions for people with MSDs.

METHODS

Electronic databases including MEDLINE, AMED, CIHAHL, PsycINFO, Scopus, Web of Science, and Centre for Review and Dissemination were searched for cost-effectiveness of digital health published between inception and June 2022 following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. References of all retrieved articles were checked for relevant studies. Quality appraisal of the included studies was performed using the Quality of Health Economic Studies (QHES) instrument. Results were presented using a narrative synthesis and random effects meta-analysis.

RESULTS

A total of 10 studies from 6 countries met the inclusion criteria. Using the QHES instrument, we found that the mean score of the overall quality of the included studies was 82.5. Included studies were on nonspecific chronic low back pain (n=4), chronic pain (n=2), knee and hip osteoarthritis (n=3), and fibromyalgia (n=1). The economic perspectives adopted in the included studies were societal (n=4), societal and health care (n=3), and health care (n=3). Of the 10 included studies, 5 (50%) used quality-adjusted life-years as the outcome measures. Except 1 study, all the included studies reported that digital health interventions were cost-effective compared with the control group. In a random effects meta-analysis (n=2), the pooled disability and quality-adjusted life-years were -0.176 (95% CI -0.317 to -0.035; P=.01) and 3.855 (95% CI 2.023 to 5.687; P<.001), respectively. The meta-analysis (n=2) for the costs was in favor of the digital health intervention compared with control: US $417.52 (95% CI -522.01 to -313.03).

CONCLUSIONS

Studies indicate that digital health interventions are cost-effective for people with MSDs. Our findings suggest that digital health intervention could help improve access to treatment for patients with MSDs and as a result improve their health outcomes. Clinicians and policy makers should consider the use of these interventions for patients with MSDs.

TRIAL REGISTRATION

PROSPERO CRD42021253221; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=253221.

Poor correlation between biomarkers and MRI-detected joint damage in a cross-sectional study of persons with nonsevere hemophilia A (DYNAMO study)

BACKGROUND

Persons with nonsevere hemophilia A (NSHA) experience less frequent joint bleeding than persons with severe hemophilia A, but may still develop joint damage. Biomarkers of cartilage and synovial remodeling can reflect ongoing pathologic processes that may precede or coincide with damage on joint imaging. If so, biomarkers may be an important diagnostic tool for joint damage in NSHA.

OBJECTIVE

To assess the correlation between biomarkers and MRI-detected joint damage in persons with NSHA.

METHODS

In a cross-sectional study, men with NSHA (factor VIII [FVIII], 2-35 IU/dL) were included. Participants underwent magnetic resonance imaging of elbows, knees, and ankles and blood and urine sampling for biomarker analysis on a single visit. The following biomarker(s) were analyzed in urine: CTX-II or serum: cartilage oligomeric matrix protein, chondroitin sulfate 846, vascular cell adhesion molecule 1, osteopontin (OPN), neo-epitope of MMP -mediated degradation of type II collagen, N-terminal propeptide of type II collagen, collagen type IV M, and propetide of type IV collagen. Spearman's rank correlations were calculated between these biomarkers and the total International Prophylaxis Study group (IPSG) score, soft-tissue subscore, and osteochondral subscore.

RESULTS

In total, 48 persons with NSHA were included. Median age was 43 years (range, 24-55 years) and median FVIII was 10 IU/dL (IQR, 4-16 IU/dL). The median IPSG score was 4 (IQR, 2-9). Median IPSG soft-tissue subscores were 3 (IQR, 2-4) and osteochondral subscores were 0 (IQR, 0-4). No strong correlations were found between the studied biomarkers, total IPSG score, subsequent soft-tissue, and osteochondral subscores.

CONCLUSIONS

In this study, selected biomarkers indicative of different aspects of hemophilic arthropathy showed no consistent correlation with IPSG scores. This suggests that systemically measured biomarkers are currently not suitable for identifying milder joint damage in NSHA, as observed on magnetic resonance imaging.

Accuracy of Intraarticular Injections: Blind vs. Image Guided Techniques-A Review of Literature

Intra-articular injections are widely used for diagnostic and therapeutic purposes of joint pathologies throughout the body. These injections can be performed blind by utilizing anatomical landmarks or with the use of imaging modalities to directly visualize the joint space during injections. This review of the literature aims to comprehensively identify differences in the accuracy of intra-articular injections via palpation vs. image guidance in the most commonly injected joints in the upper and lower extremities. To our knowledge, there are no such comprehensive reviews available. A narrative literature review was performed using PubMed and Google Scholar databases to identify studies focusing on the accuracy of blind or image-guided intra-articular injections for each joint. A total of 75 articles was included in this review, with blind and image-guided strategies being discussed for the most commonly injected joints of the upper and lower extremities. Varying ranges of accuracy with blind and image-guided modalities were found throughout the literature, though an improvement in accuracy was seen in nearly all joints when using image guidance. Differences are pronounced, particularly in deep joints such as the hip or in the small joints such as those in the hand or foot. Image guidance is a useful adjunct for most intra-articular injections, if available. Though there is an increase in accuracy in nearly all joints, minor differences in accuracy seen in large, easily accessed joints, such as the knee, may not warrant image guidance.