Joint hypermobility

Joint hypermobility is an area of neglect in rheumatology. That is not to say it is overlooked by rheumatologists. It is spotted when sought, but for many unfortunate patients, here the story ends. The act of recognition becomes the goal in itself rather than the medium through which effective therapy can be provided. This chapter serves to reinforce the clinical and epidemiological importance of a common disorder whose significance is under-appreciated and impact largely ignored. In contradistinction to our earlier chapter, published in 2000, which took for its remit the heritable disorders of connective tissue in general, the current one focuses on the commonly encountered (so-called benign) joint hypermobility syndrome, its recognition, epidemiology, clinical features and management according to the most recent literature.     

Joint hypermobility

Patients with joint hypermobility, perhaps the mildest of the various inherited abnormalities of connective tissue, may present to a rheumatologist or general practitioner although a large proportion are recognized by health professionals, particularly physiotherapists. Hypermobility may be generalized or extreme at a small number of joints. Sometimes it is associated with involvement of other organs because of abnormal inherited collagen structure elsewhere. A small proportion of patients will have one of the more serious conditions such as Ehlers-Danlos syndrome, Marfan's syndrome or osteogenesis imperfecta. Management is multidisciplinary requiring a team including physicians, physiotherapists, occupational therapists and podiatrists, among others. Patients often wait a long time before receiving their definitive diagnosis and are sometimes dismissed as malingerers. Patients often have a lot of queries about their condition unrelated to their joints. Among these are whether there will be problems in pregnancy, whether the condition will be passed on to their children, whether symptoms arising from organs other than the joints are related and whether they might have been incorrectly accused of battering their children.     

Prosthetic Joint Infections

Prosthetic joint infections represent a major therapeutic challenge for both healthcare providers and patients. This article reviews the predisposing factors, pathogenesis, microbiology, diagnosis, treatment, and prophylaxis of prosthetic joint infection. The most optimal management strategy should be identified on the basis of a number of considerations, including type and duration of infection, antimicrobial susceptibility of the infecting pathogen, condition of infected tissues and bone stock, patient wishes, and functional status.     

Joint aspiration and injection

Joint aspiration/injection is an invaluable procedure for the diagnosis and treatment of joint disease. The knee is the commonest site to require aspiration although any non-axial joint is accessible for obtaining synovial fluid. Septic arthritis and crystal arthritis can be readily diagnosed by aspirating synovial fluid. Intra-articular injection of long-acting insoluble corticosteroids produces rapid resolution of inflammation in most injected joints and is a well established procedure in rheumatological practice. The technique involves only a knowledge of basic anatomy and should not be unduly painful for the patient. Provided sterile equipment and a sensible, aseptic approach are used it is a safe procedure. This chapter addresses the indications, technical principals, expected benefits and risks of intra-articular corticosteroid injection. The use of other intra-articular injections including osmic acid, radioisotopes and hyaluronic acid, which are less universally utilised than intra-articular corticosteroid, will also be addressed.     

Joint manifestations in sarcoidosis

The commonest type of joint involvement in sarcoidosis is the acute arthritis of the L ofgren syndrome. This usually precedes the erythema nodosum and regresses in a few weeks. Arthritis without erythema nodosum is less common and has a much more variable presentation. Chronic sarcoid polyarthritis is very rare and does not usually cause bone erosion or deformation. It is usually associated with involvement of other organs. In children, sarcoid polyarthritis may resemble Still's disease. The entity of sarcoid sacro iliitis is discussed. Rare cases of sarcoid spondylodiscitis simulating bacterial spondylodiscitis have been described.