The remainder of Dr. Toth’s talk was devoted to eight case studies, which demonstrated the collaboration between sports medicine and pediatric rheumatology at Duke. For instance, a 14-year-old basketball player with a history of bilateral anterior uveitis and morning joint stiffness, taking methotrexate 25 mg SQ weekly, presented with a 3rd metatarsal stress fracture. The dominant philosophy, said Dr. Toth, is that “inactivity is not good, even in someone with inflammatory arthritis.” Thus, using a custom “clamshell” brace of fiberglass and ethyl vinyl acetate, a modified orthotic, and a carbon fiber shank in the shoe, the treatment team was able to unload the metatarsal and allow the young man to continue to play.
In one cautionary case, Dr. Toth and her team performed a revision tibial tubercle osteotomy in a girl with juvenile spondyloarthritis. The first surgery had resulted in a nonunion and wound infection when the girl returned to soccer practice and to her immunosuppressant medications too soon after surgery. After the revision surgery, physicians held off on restarting her adalimumab and MTX. The case points out, said Dr. Toth, that rheumatologists should make sure their orthopedic colleagues are aware of their patients’ special issues, since they differ from those of the general orthopedist’s population.
Rheumatologists can access the expertise of their sports medicine colleagues to devise strategies for treating their patients, either through appropriate bracing and orthotics or with timely and expert surgical repairs. Surgical consultations should be considered for refractory synovitis, mechanical entrapment (such as “hourglass biceps”), AVN (the joint can be salvaged before resorting to total knee replacement), joint malalignment, and chondral pathology. These young people need not be denied the positive benefits of sports participation, believes Dr. Toth.
If you want to view this session, download it (and more than 70 other sessions) from the ACR/ARHP Annual Scientific Meeting via ACR SessionSelect at www.rheumatology.org/SessionSelect.
