Background:Hip osteoarthritis (HOA) is a severe outcome of juvenile idiopathic arthritis (JIA) itself and also can be result of corticosteroid (CS) treatment, if it was used. Total hip arthroplasty (THA) is the last step in JIA treatment and indicates ineffectiveness of conservative treatment.Objectives:We aimed to evaluate risk factors which lead to THA in JIA patients with HOA.Methods:753 patients aged 2-17 years were included in our retrospective study during the last 10 years. Diagnosis was made according to ILAR criteria. Clinical, laboratory and radial examinations were evaluated. Diagnosis of HOA was made on MRI, CT and planar radiograms and confirmed by morphological examination of removed femoral heads.Results:Total 153/753 (20.3%) patients with JIA had hip involvement. HOA developed in 48/153 (31.4%) of JIA patients and 16/48 (33.3%) of them had THA was undergone. Prevalence of HOA and THA (%) in JIA subtypes: in polyarticular (5/32 (15.6%) and 8/16 (50%), systemic (6/32 (18.7%) and 5/16 (31.2%)), enthesitis-related (19/32 (59.4%) and 3/16 (18.8%)) and psoriatic (2/32 (6.7%) and 0/16) subtypes respectively, р=0,0000001. Patients who underwent THA initially had higher level of inflammation: elevated ESR (33 vs 5 mm/h, p=0.002) and CRP (14.7 vs 1.9 mg/l, p=0.03), more active joint, and especially involvement of joints of upper limbs: elbows (p=0.004) and proximal interphalangeal joints (p=0.001), arthritis of subtalar joint (p=0.02). Delayed biologic treatment (7.5 vs 3.4 years, p=0.043) and delayed achievement of remission (9.2 vs 5.6 years, p=0.047) were main predictors of THA. Patients with HOA without biologics had increased cumulative probability of THA: HR=1.99 (1.01; 3.98), p=0.049 (Figure 1). Patients with THA received corticosteroids (93.7 vs 50%, p=0.003) more often including high dose pulse-therapy regimes, but differences in the cumulative doses were not observed (5000 vs 4500 mg, p=0.54) between groups, CS administration was independent risk factor of HOA and THA.Figure 1.Cumulative probability of THA in JIA patients with hip osteoarthritis.Conclusion:the main risk factors of THA are systemic and polyarticular course because of their activity, systemic CS and delayed biologic treatment. Corticosteroids should be avoided in those group of patients because of risk of avascular pathway HOA formation.This work supported by the Russian Foundation for Basic Research (grant № 18-515-57001).Table 1.The features of JIA patients with hip osteoarthritis depending onJIA featuresTHA, (n=16)HOA without THA, (n=32)pTime to THA, years5.2 (3.6; 10.2)4.6 (2.2; 8.7)0.4Onset age, years7.95 (3.5; 11.1)8.3 (4.3; 13.1)0.5JIA duration, years8.5 (6.5; 13.2)5.43 (2.8; 11.1)0.07Polyarticular JIA, n (%)8 (50.0)5 (15.6)0.037Systemic JIA, n (%)5 (31.3)6 (7.0)0.037ANA, n (%)3/8 (37.5)5/16 (31.3)0.760HLA B27, n (%)3/6 (50)9/19 (47.4)0.911RF, n (%)0/9 (0)1/15 (6.7)0.429Uveitis, n (%)1/16 (6.3)3/24 (12.5)0.519ESR, mm/h33 (13; 54)5 (3; 27)0.002CRP, mg/l14.7 (2.9; 72.3)1.9 (0.3; 12.7)0.03Active joints, n21.5 (8.5; 52.5)9 (5; 16)0.02Elbows, n (%)11 (68.7)8 (25.0)0.004Proximal interphalangeal joints, n (%)10 (62.5)5 (15.6)0.001Subtalar, n(%)4 (25.0)1 (3.1)0.02Pulse-therapy GCS, n(%)11 (68.7)10 (31.3)0.014Cumulative GCS dose, mg5000 (3000; 14000)4500 (500; 20000)0.54Time to biologic, years7.6 (4.3; 11.4)3.4 (1.9; 8.6)0.04Achievement of remission, years9.2 (6.6; 15.4)5.6 (3.3; 11.4)0.047Disclosure of Interests:None declared

Обоснование. Гравитационная эритема-редкое патологическое состояние, которое характеризуется аномальной сосудистой реакцией на изменение венозного давления. Заболевание является доброкачественным, входит в круг дифференциальной диагностики васкулитов, васкулопатий, нейропатий и не требует лечения. В некоторых случаях может потребоваться применение компрессионного трикотажа. Описание клинического случая. Приведено описание случая гравитационной эритемы у пациента 13 лет. Заболевание характеризовалось появлением эритематозной мозаичной сыпи на коже нижних конечностей через 4-6 мин после перехода в положение стоя, максимально на уровне голеней, сопровождавшейся пятнами с синеватым оттенком, исчезающими при надавливании. Элементы сыпи носили зудящий характер, сопровождались появлением боли в дистальных отделах стоп. Элементы сыпи купировались при ходьбе, перемене положения конечности. Отмечен положительный компрессионный тест. Заключение. Дифференциальная диагностика гравитационной эритемы с другими клинически схожими состояниями сохраняет актуальность. Редкость диагностики гравитационной эритемы и низкая осведомленность врачей приводит к ошибочному диагнозу, неоднократному дорогостоящему обследованию и неэффективному лечению.

Background:Hip osteoarthritis (HOA) is a severe irreversible complication of patients with juvenile idiopathic arthritis (JIA) leads to intensive pain, disability and required total hip arthroplasty (THA) in childhood or in the young adults.Objectives:the aim of our study was to evaluate risk factors of HOA in JIA patients.Methods:we analyzed 753 patients with JIA for last 10 years. In each patient we observed if the HOA developed or no. We evaluated the main clinical JIA measurements, such a JIA category, CRP, ESR, WBC, PLT, active joints, initial or delayed hip involvement, ANA, HLA B27, onset age, JIA duration, time before HOA and before THA, bone metabolic markers, treatment, particularly glucocorticosteroids (GCS), their cumulative doses, route of administration (oral, intra-articular, pulse therapy). HOA was confirmed with radiological assessment (MRI and CT). For comparison analysis used nonparamentric statistics. Each possible variable was evaluated with univariate regression analysis and further multiple regression analysis was applied.Results:the comparative study between 2 groups shown in the table 1. HOA was detected in 48 (6.4%), in oligoarthritis-0%, in polyarthritis - 4.9%, in psoriatic arthritis - 5.0%, in enthesitis-related arthritis -11.8%, in systemic arthritis 19% (p=0.0000001), THA was performed in 16 (2.1%). Hip involvement at onset of JIA was similar in both groups (49.5% vs 41.7%, p=0.367).Table 1.Characteristics of JIA patients, depends on HOA development.ParameterHOA (n=48)No HOA (n=705)pOnset age, y8.0 (4.0; 12.5)5.9 (3.0; 10.7)0.045HLA B27, n (%)13/25 (52.0)88/283 (31.1)0.033JIA duration, y7.5 (3.2; 12.1)4.2 (1.8; 7.2)0.00007CRP, mg\l2.8 (0.8; 20.9)1.3 (0; 7.1)0.006Active joints, n11.0 (6.0; 27.0)6.0 (3.0; 12.0)0.000001Oral GCS, n(%)21 (43.8)131/704 (18.6)0.00003GCS pulse-therapy, n (%)21 (43.8)114/702 (16.2)0.000002GCS, cumulative doses, mg5000 (3000; 16000)2000 (1000; 4000)0.001Biologics, n (%)43 (89.6)308 (43.7)0.0000001Remission, n (%)24 (50.0)461 (65.4)0.03Time, before remission, y7.4 (3.9; 12.3)3.0 (1.4; 6.2)0.0000001Alkaline phosphatase, U\l129.3 (84; 244)223 (147; 386)0.00001Delayed hip involvement, n (%)28 (58.3)24/87 (27.6)0.00004We calculated cut-off and OR of variables, associated with HOA development (table 2). After selection of 26 clinically meaningful and statistical significant risk factors only 22 pass the univariate regression analysis. In multiple regression analysis the main independent risk factors of HOA development were: HLA b27 (p=0.001), oral GCS/pulse therapy GCS (p=0.03) and alkaline phosphatase≤165 U/l (p=0.00006).Table 2.Cutt-offs, odds ratio for HOA risk factors in JIA patients.ParameterSeSpOR (95%CI)pActive joints > 489,642,06,2 (2,4-15,9)0,000002Alkaline phosphatase ≤ 165 U/l65,970,84,7 (2,4-9,2)0,000001GCS > 2700 mg82,658,16,6 (2,1-20,6)0,0004Time before remission>5 years66,778,97,5 (3,1-18,0)0,0000001Time before biologics >7,8 years44,286,75,2 (2,6-10,2)0,0000001Conclusion:the main risk factors of HOA were increased inflammatory activity, systemic arthritis, HLA B27, systemic corticosteroids, delayed remission and biologics, decreased bone metabolism. Delayed hip involvement underline the possible non-inflammatory mechanism of HOA, such as avascular necrosis.Disclosure of Interests:None declared

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Systemic corticosteroids are continued to be administered in juvenile idiopathic arthritis (JIA) patients, especially in systemic JIA (sJIA), despite the ability of biologic therapy. One of the complications of long-term CS treatment is delayed hip arthritis development with risk of secondary hip osteoarthritis formation and total hip arthroplasty (THA).We compared different types of hip joint lesions in JIA, especially, secondary hip osteoarthritis development and THA rates in systemic and non-systemic JIA, and evaluate systemic corticosteroids contribution to those complications.The study included 753 JIA patients. They were divided into 2 groups: patients with sJIA and non-systemic JIA (nsJIA). Clinical and demographic characteristics, CS treatment regimens were compared.Results. Hip arthritis was found equally often in both groups, but both secondary hip osteoarthritis (19% vs 5,3%) and THA (8.6% vs 1.6%) prevailed in the sJIA. Patients with sJIA had delayed hip involvement (57.9% vs 30.6%; p=0.019), earlier secondary hip osteoarthritis development (4.5 vs 5.1 years after the JIA onset) with younger age of secondary hip osteoarthritis achievement (13.7 vs 15.2 years; р=0.045), they also had higher inflammatory activity, greater systemic corticosteroids administration (94.8% vs 56.1%; р=0.0000001) and higher cumulative systemic corticosteroids dose (3085 mg vs 2000 mg; p=0,005). More than half patients (56.1%) with nsJIA had systemic corticosteroids treatment and impaired calcium-phosphorus metabolism.Conclusion. Systemic corticosteroid treatment and delayed hip involvement are independent predictors of secondary hip osteoarthritis in all JIA categories. Calcium and phosphate metabolism disturbances are additional predictor for secondary hip osteoarthritis in non-systemic JIA categories