Unilateral neuropathic arthropathy of the shoulder secondary to syringomyelia: Diagnostic challenges

Neuropathic arthropathy of the shoulder is a rare disorder characterized by joint degeneration, and is associated with loss of sensory innervation. Syringomyelia is a disease in which fluid-containing cavities(syrinxes) form within the spinal cord. Here, we report a case of neuropathic arthropathy of the shoulder secondary to syringomyelia in a 40-year-old woman. X-rays of the left shoulder revealed damage to bone and joint architecture. Blood tests indicated vitamin D deficiency and secondary hyperparathyroidism. Magnetic resonance imaging of the cervical spine showed a large syrinx from the second cervical spine to the second dorsal spine. Although neuropathic arthropathy is uncommon, it should be considered in cases of unexplained pain, discomfort, or limited range of motion of the affected joint. Symptoms related to the affected joint may precede or overshadow neurological deficits. Appropriate radiological examinations and diagnoses are imperative to prevent misdiagnosis or undetected bone and joint disorders.

Prevention and management of post-instability glenohumeral arthropathy

Post-instability arthropathy may commonly develop in high-risk patients with a history of recurrent glenohumeral instability,both with and without surgical stabilization.Classically related to anterior shoulder instability,the incidence and rates of arthritic progression may vary widely.Radiographic arthritic changes may be present in up to two-thirds of patients after primary Bankart repair and 30%after Latarjet procedure,with increasing rates associated with recurrent dislocation history,prominent implant position,non-anatomic reconstruction,and/or lateralized bone graft placement.However,the presence radiographic arthrosis does not predict poor patient-reported function.After exhausting conservative measures,both joint-preserving and arthroplasty surgical options may be considered depending on a combination of patient-specific and anatomic factors.Arthroscopic procedures are optimally indicated for individuals with focal disease and may yield superior symptomatic relief when combined with treatment of combined shoulder pathology.For more advanced secondary arthropathy,total shoulder arthroplasty remains the most reliable option,although the clinical outcomes,wear characteristics,and implant survivorship remains a concern among active,young patients.

One-stage revision arthroplasty in a patient with ochronotic arthropathy accompanied by joint infection:A case report

BACKGROUND Ochronotic arthropathy(OcA)is a rare disease,which is caused by the accumulation of homogentisic acid in the joint.Patients with OcA have obvious joint pain and the disease progresses rapidly,eventually resulting in disability.Arthroplasty is an efficacious treatment in patients with OcA.However,when OcA patients have joint infection,is joint replacement an option?In the present report,we performed total knee arthroplasty in a patient with OcA and knee infection under the guidance of one-stage revision theory.CASE SUMMARY A 64-year-old male was referred to our hospital due to severe left knee pain with limited mobility for 2 years.On physical examination,the patient was found to have dark brown pigmentation of the sclera and auricle.Laboratory test results showed elevations in C-reactive protein level(65.79 mg/L)and erythrocyte sedimentation rate(90.00 mm/h).The patient underwent debridement of the left knee joint,during which the cartilage surface of the knee joint was found to be black-brown in color.Bacterial culture of synovial fluid revealed Achromobacter xylosoxidans.We then carried out arthroplasty under the guidance of the theory of one-stage revision.After surgery,the patient’s left knee joint pain disappeared and function recovered without joint infection.CONCLUSION OcA accompanied by joint infection is rare.One-stage revision arthroplasty may be a treatment option for this disease.

Rotator Cuff Reconstruction and Humeral Head Replacement Using Smaller Humeral Prostheses in Cuff Tear Arthropathy Patients under 70 Years of Age

Background: Most reverse shoulder arthroplasty (RSA) studies have shown good improvement in arm elevation without improvements in external rotation (ER). In addition, high rates of complications after long-term RSA have been reported, suggesting that RSA should be limited to elderly patients, especially those who are older than 70 years old. Since 2001, we have developed a strategy of rotator cuff reconstruction with muscle transfer and humeral head replacement (HHR), using smaller humeral prostheses, in cuff tear arthropathy patients. The aim of the present study was to investigate the clinical outcome of our strategy in patients under 70 years of age who had irreparable rotator cuff tears and osteoarthritis. Materials and Methods: A total of 25 shoulders of 25 patients under 70 years of age (males, 15;females, 10) with irreparable cuff tears were treated with HHR and cuff reconstruction. The average age at the time of surgery was 64.3 years (range, 55 - 69) and the average follow-up period was 38.7 months (range, 24 - 72). The cuff defect was repaired using a partial subscapularis transfer in 14 shoulders;nine shoulders required a latissimus dorsi transfer, one required a pectoralis major transfer, and one required both a latissimus dorsi and a pectoralis major transfer. Clinical outcomes were assessed with the range of motion (ROM), UCLA score, Japanese Orthopaedic Association (JOA) score and postsurgical complications. Results: Shoulder pain was diminished in all patients after surgery. The preoperative UCLA and JOA scores were 13.1 and 47.0 respectively, improving to 28.6 and 81.5 respectively after surgery. Active forward flexion has improved from an average of 89.0° to 138.8°, and the ER improved from an average of 16.2° to 33.2°. No complications occurred after surgery. Conclusion: Anatomical reconstruction using smaller head humeral prostheses yielded favorable results and less complication, compared with RSA. Considering another advantage of ability to retain glenoid bone stock, the current procedure can be a useful option for irreparable rotator cuff tears with OA in patients under 70 years old.

Neuropathic arthropathy of the shoulder: Two cases of syringomyelia with cocaine use

Neuropathic arthropathy (NA) is a progressive, degenerative disorder associated with decreased sensory innervation of the involved joints. The shoulder joint is an uncommon presentation for NA, although syringomyelia is the most common cause for this joint. Two cases are presented of NA of the shoulder, with both patients having a history of syringomyelia and cocaine use. In both cases a work up for malignancy was negative, but imaging was consistent with NA. Although syringomyelia has been linked with this presentation in prior publications, the role of cocaine use may not be incidental, with complex biochemical interactions in bone metabolism. Cocaine has been shown to involve the Leptin, Neuromedin U (NmU), cocaine and amphetamine-regulated transcript (CART), and Receptor activator of nuclear factor kappa-B ligand (RANKL) pathways of bone remodeling. Treatment can be challenging, involving concurrent use of pharmacotherapy, surgical correction, and protective bracing.

Evaluation of Charcot Neuroarthropathy in Diabetic Foot Disease Patients at Tertiary Hospital

Purpose: To evaluate Charcot neuroarthropathy in diabetic foot patients at tertiary hospital. Methods and Material: It is a retrospective study from 2005 to 2015 of Charcot foot patients in diabetic patients admitted in King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Sixty-four patients were admitted as diabetic foot disease and were studied by reviewing patients records of demography, pain, discharge, duration of disease, duration and types of diabetes IDDM [Insulin Dependant Diabetes Mellitus] NIDDM [Non Insulin Dependent Diabetes Mellitus], history of trauma, peripheral vascular disease, obesity, hypertension, co-morbid conditions, previous surgery, involvement of fore foot/midfoot/hindfoot, deformity, ulcer and treatment like casts, offloading devices, pharmacological like biphosphonates, debridement, osteotomy, arthrodesis, exostectomy, and amputation. Results: Majority of patients were males (81.2%). Mean age was 61.75 years. Pain was reported in 25% of patients, numbness in 12.5%, foot deformity in 23.4%, pus discharge in 73.4%, difficulty in walking in 12.5%, and 10.9% had history of trauma. Majority of patients were NIDDM 68.8%, IDDM 31.3%, (62.5% had DM more than 10 years and 36.9% had DM less than 10 years), controlled DM in 21.9% and uncontrolled DM in 73.4%, nephropathy in 46.3%, neuropathy in 59.4%, retinopathy in 40.6%, cardiomyopathy in 48.4% and vasculopathy in 56.3%. Charcot arthropathy was in 28.1% of cases and forefoot was involved in 65.5%, midfoot in 4.7% and hindfoot/ankle in 21.9%. It was forefoot which was mainly involved in Charcot joint disease. It was demonstrated by X-rays which showed subluxation in 40.6%, dislocation in 54.7%, disorganized foot joints in 42.2%, bone resorption in 23.4%, osteomyelitis in 14.1%, fractures in 50%, joint collapse in 39.1% and destruction of articular surfaces in 37.5%. Debridement was done in 25% of cases while 75% of patients underwent some sort of amputation. 14.1% of patients underwent above knee amputation, 10.9% below knee amputation, 10.9% transmetatarsal and 39.1% toe amputation. Debridement and amputation were the main treatment offered. Conclusions: Diabetic patients with Charcot joint disease pose great challenge in management. Emphasis should be given for early detection, investigations and prompt treatment. Treatment should be tailored according to stage of disease and patient occupation.

Long-term clinical outcomes following total knee arthroplasty in patients with hemophilic arthropathy:a single-surgeon cohort after a 10-to 17-year follow-up

Background:Total knee arthroplasty(TKA)can reduce severe joint pain and improve functional disability in hemophilia.However,the long-term outcomes have rarely been reported in China.Therefore,this study aimed to evaluate the long-term outcomes and complications of TKA in Chinese patients with hemophilic arthropathy.Methods:We retrospectively reviewed patients with hemophilia who underwent TKA between 2003 and 2020,with at least 10 years of follow-up.The clinical results,patellar scores,patients’overall satisfaction ratings,and radiological findings were evaluated.Revision surgery for implants during the follow-up period was recorded.Results:Twenty-six patients with 36 TKAs were successfully followed up for an average of 12.4 years.Their Hospital for Special Surgery Knee Score improved from an average of 45.8 to 85.9.The average flexion contracture statistically significantly decreased from 18.1°to 4.2°.The range of motion(ROM)improved from 60.6°to 84.8°.All the patients accepted patelloplasty,and the patients’patellar score improved from 7.8 preoperatively to 24.9 at the last follow-up.There was no statistically significant difference in clinical outcomes between the unilateral and bilateral procedures,except for a better ROM at follow-up in the unilateral group.Mild and enduring anterior knee pain was reported in seven knees(19%).The annual bleeding event was 2.7 times/year at the last follow-up.A total of 25 patients with 35 TKAs were satisfied with the procedure(97%).Revision surgery was performed in seven knees,with 10-and 15-year prosthesis survival rates of 85.8%and 75.7%,respectively.Conclusions:TKA is an effective procedure for patients with end-stage hemophilic arthropathy,which relieves pain,improves knee functions,decreases flexion contracture,and provides a high rate of satisfaction after more than ten years of follow-up.

Short-term outcome of total knee replacement in a patient with hemophilia:A case report and review of literature

BACKGROUND Hemophilia A is a rare inherited bleeding disorder caused by mutations in the factor Ⅷ gene. This clotting factor plays an intrinsic role in the blood coagulation pathway. Patients with hemophilia may develop orthopedic manifestations such as hemarthrosis, but multiple malunion of fractures over the knee is rare and difficult to treat.CASE SUMMARY We report a patient with hemophilia A who developed severe knee osteoarthritis along with fracture malunion and nonunion. Total knee replacement was performed using a custom-made modular hinged knee prosthesis(cemented) equipped with extended distal and proximal stems. At 3 years’ follow-up, the patient exhibited excellent clinical function and remained satisfied with the surgical outcome. Surgical intervention was accompanied by rigorous coagulation factor replacement.CONCLUSION This case highlights various unique scenarios specific to individuals with hemophilia and fracture deformity.

Outcomes of gout in patients with cirrhosis:A national inpatient sample-based study

BACKGROUND Hyperuricemia is a prerequisite for the development of gout.Elevated serum uric acid(UA)levels result from either overproduction or decreased excretion.A positive correlation between serum UA levels,cirrhosis-related complications and the incidence of nonalcoholic fatty liver disease has been established,but it is unknown whether hyperuricemia results in worsening cirrhosis outcomes.We hypothesize that patients with cirrhosis will have poorer gout outcomes.AIM To explore the link between cirrhosis and the incidence of gout-related complications.METHODS This was a cross-sectional study.The national inpatient sample was used to identify patients hospitalized with gout,stratified based on a history of cirrhosis,from 2001 to 2013 via the International Classification of Diseases,Ninth Revision,Clinical Modification codes.Primary outcomes were mortality,gout complications and joint interventions.Theχ^(2)test and independent t-test were performed to assess categorical and continuous data,respectively.Multiple logistic regression was used to control for confounding variables.RESULTS Patients without cirrhosis were older(70.37±13.53 years vs 66.21±12.325 years;P<0.05).Most patients were male(74.63%in the cirrhosis group vs 66.83%;adjusted P<0.05).Patients with cirrhosis had greater rates of mortality(5.49%vs 2.03%;adjusted P<0.05),gout flare(2.89%vs 2.77%;adjusted P<0.05)and tophi(0.97%vs 0.75%;adjusted P=0.677).Patients without cirrhosis had higher rates of arthrocentesis(2.45%vs 2.21%;adjusted P<0.05)and joint injections(0.72%vs 0.52%;adjusted P<0.05).CONCLUSION Gout complications were more common in cirrhosis.Those without cirrhosis had higher rates of interventions,possibly due to hesitancy with performing these interventions given the higher complication risk in cirrhosis.

Minimally Invasive Hind-Foot Fusion in Charcot Patients

Background: Hindfoot fusion, is a fusion of the talonavicular, talocalcaneal, and calcaneocuboid joints and is commonly performed for patients complaining of pain, chronic instability and gross deformity as a result of hindfoot pathology. Objective: This study aimed to assess the functional outcomes of the patients underwent hindfoot fusion, the post-operative complications and patient’s satisfaction. Methodology: This study is a prospective cohort study was conducted in Future hospital, in Khartoum, Sudan. It involved 30 patients from July 2015-July 2022. Data was collected by the primary researcher using data collection sheet, then it was cleaned and entered into Microsoft excel data sheet and was analysed using SPSS version 28 software. Results: 33.3% of the patients are aged 51 - 60 years, and >60 years. Male: Female equals 1:1. 56.7% are for the left side, only 23.3% developed complications. 63.3% patients are fully satisfied. There is a significant correlation between the AOFAS score before and after the operation. Also, a significant correlation between the means of AOFAS score after with the complications and the satisfaction of the patients. Conclusion: Minimally invasive tibio-talo-calcaneal is an alternative procedure for the treatment of severe Charcot arthropathy of the ankle. The expected functional outcome is impressive and comparable with the open surgery. However, the post-operative complications are prevalent in 23.3% of patients. Most candidates are fully satisfied with the procedure.

Reverse polarity shoulder replacement: Current concepts and review of literature

Shoulder replacement in cuff tear arthropathy(CTA)is an unsolved challenge.CTA poses a soft tissue deficiency in an arthritic glenohumeral joint which the anatomical total shoulder replacement and hemiarthroplasty cannot reliably provide stability,range of movement,function or satisfactory long term outcome.In the past two decades since the introduction of the reverse shoulder replacement,the prosthesis has evolved and has shown promising results.It is a partially constraint joint by virtue of its design features.The reversal of the concavity and convexity of the joint to the proximal humerus and the glenoid,respectively,also shifts and improves its center of rotation onto the osseous surface of the glenoid with less exposure to shear stress.It is a successful pain relieving procedure,offering good outcome in patients with irreparable massive rotator cuff tear with or without osteoarthritis.Consequently,this has led to wider use and expansion of its indication to include more complex elective and trauma cases.Whereas originally used in the more elderly patients,there is increasingly more demand in the younger patients.It is important to have good quality long term data to support these increasing indications.Therefore,we review the literature on the concepts of reverseshoulder replacement and the contemporary evidence.

Bone marrow mononuclear cells for joint therapy: The role of macrophages in inflammation resolution and tissue repair

Osteoarthritis(OA)is the most prevalent joint disease causing major disability and medical expenditures.Synovitis is a central feature of OA and is primarily driven by macrophages.Synovial macrophages not only drive inflammation but also its resolution,through a coordinated,simultaneous expression of pro-and anti-inflammatory mechanisms that are essential to counteract damage and recover homeostasis.Current OA therapies are largely based on anti-inflammatory principles and therefore block pro-inflammatory mechanisms such as prostaglandin E2 and Nuclear factor-kappa B signaling pathways.However,such mechanisms are also innately required for mounting a pro-resolving response,and their blockage often results in chronic low-grade inflammation.Following minor injury,macrophages shield the damaged area and drive tissue repair.If the damage is more extensive,macrophages incite inflammation recruiting more macrophages from the bone marrow to maximize tissue repair and ultimately resolve inflammation.However,sustained damage and inflammation often overwhelms pro-resolving mechanisms of synovial macrophages leading to the chronic inflammation and related tissue degeneration observed in OA.Recently,experimental and clinical studies have shown that joint injection with autologous bone marrow mononuclear cells replenishes inflamed joints with macrophage and hematopoietic progenitors,enhancing mechanisms of inflammation resolution,providing remarkable and long-lasting effects.Besides creating an ideal environment for resolution with high concentrations of interleukin-10 and anabolic growth factors,macrophage progenitors also have a direct role in tissue repair.Macrophages constitute a large part of the early granulation tissue,and further transdifferentiate from myeloid into a mesenchymal phenotype.These cells,characterized as fibrocytes,are essential for repairing osteochondral defects.Ongoing“omics”studies focused on identifying key drivers of macrophagemediated resolution of joint inflammation and those required for efficient osteochondral repair,have the potential to uncover ways for developing engineered macrophages or off-the-shelf pro-resolving therapies that can benefit patients suffering from many types of arthropaties,not only OA.

Value of Contrast-enhanced Ultrasound in Evaluating Synovitis and Predicting Recurrent Joint Bleeding of Hemophilia

Objective Contrast-enhanced ultrasound(CEUS)is advantageous for evaluating microcirculation,and has been applied to assess arthritis in previous studies.However,CEUS examinations have not been studied for hemophilia arthritis.Hemophilia arthritis is different from other arthritis,because it is induced by spontaneous joint bleeding.Hence,CEUS may have special value in evaluating hemophilia arthritis.The present study assessed the value of CEUS in evaluating synovial hypertrophy and predicting recurrent joint bleeding in severe hemophilia A patients.Methods From August 2016 to January 2017,81 severe hemophilia A patients,who were referred to our hospital for ultrasound joint assessment with conventional ultrasound,were enrolled.Among these 81 patients,46 patients consented for CEUS examinations on the same day.Results Compared to color Doppler flow imaging(CDFI),four more joints presented with a blood flow signal under CEUS mode.In addition,the synovial hypertrophy measured by CEUS was thicker than that measured by conventional ultrasound.The ultrasound scores(including the total grey-scale ultrasound score,joint effusion/hemarthrosis,synovial hypertrophy,CDFI semi-quantitative score,and CEUS semi-quantitative score)were significantly higher in the joint bleeding group than in the no joint bleeding group(P<0.05).Furthermore,these ultrasound scores were positively correlated with the joint bleeding frequency,and had the highest correlation with the CEUS score(r=0.620,P<0.05).Conclusion CEUS can more accurately assess the degree of synovial hypertrophy and vascularization,and diagnose synovitis,when compared to conventional ultrasound.In addition,CEUS appears to be essential for evaluating the possibility of recurrent joint bleeding,and providing more reliable evidence for individualized treatment.

Orthotic approach to prevention and management of diabetic foot:A narrative review

Diabetic foot is a common complication affecting more than one-fifth of patients with diabetes.If not treated in time,it may lead to diabetic foot ulcers or Charcot arthropathy.For the management of diabetic foot,shoe modifications and orthoses can be used to reduce pressure on the affected foot or provide the foot with increased stability.In addition,the shoe modifications and orthotic devices can relieve patient discomfort during walking.Appropriate shoe modifications include changing the insole material,modifying the heel height,adding a steel shank or rocker sole,and using in-depth shoes.Alternatively,a walking brace or ankle-foot orthosis can be used to reduce the pressure on the affected foot.The purpose of this narrative review was to provide a reference guide to support clinicians in prescribing shoe modifications and foot orthoses to treat diabetic foot ulcers and Charcot arthropathy.

Initial joint bleed volume in a delayed on-demand treatment setup correlates with subsequent synovial changes in hemophilic mice

Background: Hemophilic arthropathy is a debilitating morbidity of hemophilia caused by recurrent joint bleeds. We investigated if the joint bleed volume, before initiation of treatment, was linked to the subsequent degree of histopathological changes and the development of bone pathology in a mouse model of hemophilic arthropathy.Methods: FVIII knock-out(F8-KO) mice were dosed with a micro-CT blood pool agent prior to induction of hemarthrosis. Eight hours after induction, the bleed volume was quantified with micro computed tomography(micro-CT) and recombinant FVIII treatment initiated. On Day 8, inflammation in the knees was characterized by fluorescence molecular tomography. On Day 14, knee pathology was characterized by micro-CT and histopathology. In a second study, contrast agent was injected into the knee of wild-type(WT) mice, followed by histopathological evaluation on Day 14.Results: The average joint bleed volume before treatment was 3.9 mm3. The inflammation-related fluorescent intensities in the injured knees were significantly increased on Day 8. The injured knees had significantly increased synovitis scores, vessel counts, and areas of hemosiderin compared to un-injured knees. However, no cartilage-or bone pathology was observed. The bleed volume before initiation of treatment correlated with the degree of synovitis and was associated with high fluorescent intensity on Day 8. In F8-KO and WT mice, persistence of contrast agent in the joint elicited morphological changes.Conclusion: When applying a delayed on-demand treatment regimen to hemophilic mice subjected to an induced knee hemarthrosis, the degree of histopathological changes on Day 14 reflected the bleed volume prior to initiation of treatment.

Frequency and Etiology of Viral Arthropathies in West African Patients

Aim: To determine the frequency and etiology of viral arthritis in West African patients at the National Hospital University Hubert Koutoukou Maga of Cotonou. Patients and Methods: It was a cross-sectional descriptive study carried out from January 2010 to July 2014 on patients received in rheumatology, hepato-gastroenterology, pediatric and internal medicine units. The selected patients had viral arthropathy. The diagnosis of viral arthritis was based on the presence of arthralgia or arthritis in the context of a viral infection. Patients with insufficiently explored records were excluded. Results: Among 4361 patients consulted, 49 (1.12%) had a viral arthropathy. The mean age of the patients was 49.13 ± 17.1 [15 - 68] years. The sex ratio was 0.58 (31 F/18 H). 38 patients were from Benin, 5 from Nigeria, 3 from Togo, 2 from Mali and 1 from Cote d’Ivoire. Joint symptoms were dominated by polyarthritis (n = 24 cases) and polyarthrlagias (n = 18 cases). Extra-articular signs present were dominated by fever (100%), skin signs (n = 37 cases), flu symptoms (n = 23 cases) and liver disorder (n = 19 cases). Viruses diagnosed were dominated by hepatitis B (n = 17), varicella-zona (n = 8) and HIV (n = 14). Conclusion: Viral arthropathy diagnosis is relatively common in West African patients especially with the HIV. This occurs as arthralgias or arthritis. The diagnosis is difficult in our working condition.

Differential Diagnosis of Post-Procedural Skin Lesions: A Case Report

Skin reactions caused by interventional pain procedures are well documented in literature, ranging from fistula formation to urticarial allergic reactions and infections. Burn lesions may also occur, however far less common;and as pain physician we must be cognizant of this possible complication and its etiologies. This is difficult in an outpatient setting where a patient cannot be regularly monitored, their adherence to prescribed therapies is unclear, and reporting is often done via phone, ancillary staff, and outside facility records. These compounding factors require clinicians to consider a broad differential and be comfortable with instituting myriad therapies or appropriately involve outside consultation for thorough patient care.

One-Stage Bilateral Total Hip Arthroplasty for Hemophilic Spontaneous Ankylotic Hip: A Case Report

Total hip arthroplastys (THAs) for hemophilic spontaneous ankylotic hips are rare. We performed one-stage bilateral THA for hemophilic patient and I would like to report the results of the case. A 61-year-old male had been diagnosed with mild hemophilia A as a neonate. He had severe pain in both hips and moderate pain in both knees. His hips were ankylotic and had no mobility. Uncemented simultaneous bilateral THAs were performed under general anesthesia. This case suggests that one-stage THA can be a good option for hemophilic hips, provided that sufficient substitution therapy is used.

Combined therapeutic approach:Inflammatory bowel diseases and peripheral or axial arthritis

Inflammatory bowel diseases(IBDs), particularly Crohn's disease(CD) and ulcerative colitis(UC), are associated with a variety of extra-intestinal manifestations(EIMs).About 36% of IBD patients have at least one EIM, which most frequently affect the joints, skin, eyes and the biliary tract.The EIMs associated with IBD have a negative impact on patients with UC and CD, and the resolution of most of them parallels that of the active IBD in terms of timing and required therapy;however, the clinical course of EIMs such as axial arthritis, pyoderma gangrenosum, uveitis, and primary sclerosing cholangitis is independent of IBD activity.The peripheral and axial arthritis associated with IBD have traditionally been treated with simple analgesics, non-steroidal anti-inflammatory drugs, steroids, sulfasalazine, methotrexate, local steroid injections and physiotherapy, but the introduction of biological response modifi ers such as tumor necrosis factor-α blockers, has led to further improvements.