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Inflammatory osteoarthritis of the hand

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Inflammatory or erosive are terms used interchangeably to define a clinical subset of osteoarthritis of the hand (HOA), targeting interphalangeal joints and characterised by an abrupt onset, marked pain and functional impairment, inflammatory symptoms and signs, including stiffness, soft tissue swelling, erythema, paraesthesiae, mildly elevated C-reactive protein and a worse outcome than non-erosive HOA. This subset is defined radiographically by subchondral erosion, cortical destruction and subsequent reparative change, which may include bony ankylosis. Although the presence of both clinical and radiographic aspects are very suggestive for the diagnosis in most cases, doubts have been recently raised from some studies which, by means of sensitive imaging techniques such as magnetic resonance imaging (MRI) and sonography, had found erosive changes in most patients with HOA, including those without signs of erosions at conventional radiography. However, many findings suggest that subjects with erosive HOA exhibit more inflammatory features than those with non-erosive HOA in different ways, including clinical, laboratory and sonographic aspects. Thus, it is probably preferable to use the double term inflammatory/erosive to better define this particular subset of HOA.

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Inflammatory/erosive HOA: the difficult to search an identity

There is still no general consensus on the definition of IE-HOA. In time, its identity has been discussed and variously proposed as a subset of HOA [11], *[12], *[13], variant of HOA [14], severe form of HOA [15], inflammatory phase of HOA [16] and an entity distinct from OA [17]. These doubts have influenced many aspects of research in this particular field of HOA, therefore, leading to many difficulties in the interpretation of available data.

Since 1961, Crain underlined the existence of “a

Epidemiological and clinical features of inflammatory/erosive HOA

In absence of a true disease definition, no exact epidemiological data are available, especially concerning prevalence. Therefore, there are some discrepancies among old studies suggesting that IE-HOA was a rare disease and those, more recent, claiming that this variant is very frequent. Pattrick et al. found 10 cases of erosive HOA among 67 patients attending their Rheumatology Unit with polyarticular HOA [24]. In a prospective study of 500 consecutive patients attending a rheumatology clinic

Radiography

Although the main hallmark of IE-HOA is the presence of erosion at CR, the precise definition of erosion in IE-HOA is still a matter for debate. Classically, as stated in the EULAR recommendations, erosive HOA is defined radiographically by subchondral erosion, cortical destruction and subsequent reparative change, which may include bony ankylosis [13]. These apparently simple observations need to be carefully specified.

The erosions in HOA are seen in DIPs and PIPs and may occur within both the

The inflammation of inflammatory/erosive HOA

Besides clinical features, signs of inflammation in IE-HOA subset may also be evident by other ways (Table 2). In a recent US study performed in IE-HOA using a power Doppler, the findings of synovial membrane thickening and increased vascularity indicative of active synovitis were found in the vast majority of patients with erosive HOA, thus consistent with the term “inflammatory form of OA” that has been attributed to erosive HOA [23]. The percentages of DIPs and PIPs with active synovitis on

Pathogenetic hypotheses concerning the role of inflammation in erosive/inflammatory HOA

The first attempt to investigate the pathogenesis of IE-HOA was by Utsinger et al. to evaluate the possibility that immune mechanisms may have a role [46]. They compared some immunologic parameters in erosive HOA and RA. Changes in levels of IgG, lymphocytotoxic antibodies and cryoglobulins were found almost exclusively in RA [46]. In another study, the same authors observed that synovial fluid and synovial membrane from patients with erosive HOA, similarly to RA, had increased number of Ia+ T

Therapy: is an anti-inflammatory therapy justified?

Treatment of IE-HOA remains still unsatisfactory. In contrast to non-IE-HOA, paracetamol and even non-steroidal anti-inflammatory drugs (NSAIDs) are ineffective in a significant number of cases of IE-HOA [11], *[12], [46], *[51]. Intra-articular injections of corticosteroids seem to be more effective in controlling symptoms, although there is no demonstration that they are able to reduce the development of erosions or accelerate their healing [46]. Thus, other substances have been proposed, not

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