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The objective of our study was to evaluate the aseptic technique used in interventional rheumatology by Moroccan and Tunisian rheumatologists. We performed an online survey among rheumatologists from Morocco and Tunisia. The questionnaire included 15 questions with single and multiple-choice answers and three open sections for freetext comments. An online survey was prepared and sent to 380 rheumatologists. One hundred and four rheumatologists (27.36%) replied to the survey. More than half of the participants (56.7%) were from Tunisia and 43.3% were from Morocco. Interventional procedures on superficial joints were performed by all participants. Ultrasonography was used by 41.3% of respondents to guide interventional procedures. Regarding the aseptic precautions taken to avoid infection, the majority of participants used povidone iodine to clean the skin and only 8.7% wore a mask. Hand washing alone without gloves wearing was done by 19.2% of participants. 2.9% of participants reported a history of iatrogenic septic arthritis and the duration of practice was the only factor associated with its occurrence (P=0.007). Our study showed that aseptic technique used during interventional rheumatologic procedures is heterogeneous. However, the majority of participants were aware of its necessity to avoid iatrogenic septic arthritis.

La rhumatologie interventionnelle est en plein essor. Elle comporte des aspects de plus en plus à la fois éthiques et médico-légaux, et techniques avec des gestes de plus en plus guidés, notamment grâce à l'échographie. Les aspects éthiques font débat, et si la grande positivité de la balance bénéfices/risques des gestes interventionnels en rhumatologie ne fait guère de doute, il y a quand même un mouvement pour, d'une part, être de plus en plus efficace, avec des études d'établissement de preuves d'efficacité de plus en plus nombreuses, et une précision du geste apportées par le guidage, et d'autre part, de diminuer encore les risques, avec là encore le guidage, mais également avec des mesures adaptées en fonction de la gravité et de la fréquence de ces risques. Les aspects médico-légaux ont fait l'objet d'une loi en 2002 qui satisfait la plupart des médecins et des patients, en distinguant bien ce qui est de l'ordre de la faute médicale de ce qui est de l'ordre de l'aléa thérapeutique, avec un fonds spécial dédié pour ces derniers patients lorsque le taux d'incapacité permanente est de plus de 25 %. L'environnement nécessaire à la pratique de l'interventionnel ne fait pas encore l'objet de réglementation en France, mais des réunions sont en cours pour pallier ce manque. Pour la très grande majorité des gestes courants en rhumatologie interventionnelle, il n'y aura a priori pas de mesures autres que d'adapter une salle de consultation à la bonne pratique des gestes interventionnels, possibles en externe. Enfin, l'asepsie a fait l'objet de recommandations consensuelles de la section SIRIS de la Société française de rhumatologie, qui insiste surtout sur la nécessité de procédures et de protocoles d'asepsie bien établis, qui permettent de garder ce risque infectieux à des taux extrêmement bas, de l'ordre de 1/38 000, malgré la technicité du guidage. Même à l'époque des biothérapies, que ce soit pour les pathologies inflammatoires, mais également pour les pathologies mécaniques, la place de la rhumatologie interventionnelle reste et restera très importante, avec plus de 2 millions de gestes réalisés par an en France, et plus de 90 % de patients satisfaits. Interventional rheumatology is booming. It includes more and more aspects that are both ethical and medico-legal, and technical with more and more guided injections, notably with ultrasound technique. The ethical aspects are debated, and if the great positivity of the benefit/risk balance of interventional gestures in rheumatology makes no doubt, there is still a dynamics to offer a more and more effectiveness, with studies assessments of more and more evidence, and a precision of the gestures provided by the guidance, and on the other hand to further reduce the risks, again with the guidance, but also with measures adapted according to the severity and the frequency of these risks. The medico-legal aspects were the subject of a law in 2002 which satisfied most doctors and patients, with a clear distinction between what is of the order of medical malpractice and what is of the order of therapeutic hazard, with a special dedicated fund for these latter patients when the rate of permanent disability is more than 25 %. The environment necessary for the practice of interventional rheumatology is not yet the subject of regulations in France, but discussions are underway to remedy this lack. For the vast majority of common gestures in interventional rheumatology, a priori there will be no measures other than adapting a consultation room to the good practices of interventional gestures, possible externally. Finally, asepsis was the subject of consensus recommendations of the SIRIS section of the French Rheumatology Society, which insists above all on the need for well-established asepsis procedures and protocols, which allow this infectious risk to be kept at extremely low rate, of the order of 1/38,000, despite the technicality of the guidance. Even at the time of biotherapies, whether for inflammatory pathologies, but also for mechanical pathologies, the place of interventional rheumatology remains and will remain very important, with more than 2 million gestures performed per year in France, and more than 90 % of patients satisfied. [ABSTRACT FROM AUTHOR]

L'échographie en rhumatologie s'est développée à partir des années 1990, à la fois pour le diagnostic et le suivi thérapeutique, mais aussi dans le développement de techniques infiltratives échoguidées. Depuis, son utilisation fait partie du quotidien du rhumatologue. Ce chapitre permet de passer en revue les différents aspects des gestes échoguidés en rhumatologie : les principales indications, les contre-indications et les effets indésirables à connaître, ainsi que les modalités pratiques : l'aspect technique et les voies d'abord et le choix du matériel (dérivés cortisonés, aiguilles, sondes). Since the 1990s, ultrasonography has been used in rheumatology practice for diagnostic and therapeutic purposes, especially with ultra-sound guided procedures. It is now used in every-day practice. This chapter aims at reviewing the different aspects of interventional ultrasound in rheumatology. We will describe the main indications and contra-indications, as well as the potential side effects. More technical aspects will explain the main techniques used in ultrasound-guided procedures, with the different materials that can be used (local corticosteroids, needles, probes). [ABSTRACT FROM AUTHOR]

La radioprotection a fait l'objet d'une réévaluation par l'autorité de sûreté nucléaire (ASN) suite à une enquête de pratiques sur le terrain montrant d'importantes insuffisances de précautions, et pour se mettre en accord avec les nouvelles directives européennes. Les rhumatologues sont de moins en moins impliqués avec le choix de la nouvelle génération de jeunes rhumatologues de privilégier l'approche échographique, tant à visée diagnostique qu'interventionnelle. Cependant, les rayonnements X resteront de mise pour visualiser le tissu osseux et pratiquer des gestes interventionnels à ce niveau, et l'absorptiométrie, bien qu'extrêmement peu irradiante, est également concernée, tout comme la pratique de synoviorthèses isotopiques. Enfin, les rhumatologues restent des prescripteurs d'examens ou d'actes interventionnels réalisés sous contrôle visuel grâce aux rayonnements X. Ceux qui seront exposés aux rayonnements ionisants devront respecter les nouvelles réglementations, acquérir un matériel adéquat, respecter des procédures préétablies, et valider une formation de radioprotection vis-à-vis des patients d'une journée tous les 7 ans en France. Radiation protection is being re-evaluated by the nuclear safety authority (ASN) following an investigation of practices showing significant inadequacies in precautions, and in order to comply with the new European directives. Rheumatologists are less and less involved with the choice of the new generation of young rheumatologists to favor the ultrasound approach, both diagnostic and interventional. However, X-rays will still be required to visualize the bone tissue and to practice interventional gestures at this level, and absorptiometry, although extremely non-irradiating, is also concerned, as is the practice of isotopic synoviortheses. Finally, rheumatologists remain prescribers of exams or interventional procedures carried out under visual control with X-rays. Those who will be exposed to ionizing radiation will have to comply with the new regulations, acquire an adequate equipment, respect pre-established procedures, and validate radiation protection training for patients, 1 day every 7 years in France. [ABSTRACT FROM AUTHOR]

Le rhumatologue interventionnel se doit de maîtriser les différents gestes techniques nécessaires à son activité diagnostique en particulier les biopsies disco-vertébrales percutanées. Leurs aspects techniques, mais aussi les complications et les aspects médico-légaux doivent être connues. Leurs indications seront confirmées dans le cadre d'une réunion de concertation médico- chirurgicale pluridisciplinaire : biopsie diagnostique afin de caractériser la nature d'une lésion osseuse, recherche de germes pathogènes dans le cadre d'une infection disco vertébrale. La rentabilité diagnostique reste sujet à débat mais quelques précautions techniques et le respect de certaines recommandations lors de leur réalisation permettront de l'augmenter. Les biopsies disco-vertébrales percutanées resteront dans le domaine de compétence du rhumatologue s'il accepte d'acquérir la formation adéquate en milieu spécialisé. The interventional rheumatologist must master the various technical procedures necessary for his diagnostic activity, in particular percutaneous disco-vertebral biopsies. Their technical aspects, but also the complications and forensic aspects must be known. Their indications will be confirmed in the context of a multidisciplinary medical-surgical consultation meeting: diagnostic biopsy to characterize the nature of a bone lesion, search for pathogenic germs in the context of a vertebral disk infection. The diagnostic profitability remains a subject of debate but some technical precautions and the respect of certain recommendations during their realization will make it possible to increase it. Percutaneous disco-vertebral biopsies will remain in the area of competence of the rheumatologist if he agrees to acquire the appropriate training in a specialized environment. [ABSTRACT FROM AUTHOR]

Objectives: To decrease radiation exposure of patients undergoing interventional rheumatology procedures, without adversely affecting quality of care.Methods: The radiation dose received, assessed by the dose-area product (DAP), was measured during 283 intraarticular injections performed under fluoroscopic guidance between May and July 2013. Then, three steps were taken to decrease patients' radiation exposure: a copper filter was added, the anti-scatter grid was removed, and exposure cell sensitivity was set at the highest value. DAP was measured during 158 intraarticular injections performed in 2014 with these measures in place.Results: Mean DAP before optimization was 175μGray·m2 during facet joint injections (n=4) and 43μGray·m2 during hip injections but was less than 20μGray·m2 for injections into the shoulders (15.7μGray·m2), ankles (7.7μGray·m2), wrists (3.7μGray·m2), and fingers (3.3μGray·m2). After optimization, DAP decreased markedly for all injection sites, by 52% (shoulders) to 87% (facet joints, 22.7μGray·m2). Decreases occurred at all three steps of the procedure, i.e., patient installation, injection, and last image hold. Exposure during facet joint injections varied from 84 (54.5-108.5) μGray·m2 when body mass index (BMI) was <25kg/m2 to 228.9 (161.3-340.4)μGray·m2 when BMI was>30kg/m2.Conclusion: Simple technical changes translate into large decreases in patient radiation exposure during fluoroscopically-guided injections, particularly at the facet joints and in obese patients. [ABSTRACT FROM AUTHOR]

Arthroscopy is an important diagnostic procedure which can be used in rheumatology practice to provide direct visualization of the joint cavity, permitting macroscopic evaluation of the synovium, sampling for histopathologic and microbiologic examination and the potential therapeutic benefit of lavage. The term 'medical arthroscopy' is used here to refer to arthroscopy performed by rheumatologists for these purposes. This term differentiates arthroscopy performed by orthopedic surgeons for structural interventions such as meniscal debridement and ligament repair. Medical arthroscopy finds a place in rheumatology as an aid to diagnosis, to confirm the presence of synovitis when not expected, to provide histologic or microbiologic diagnosis, and potential stratification for therapy, for example in rheumatoid arthritis, as well as a range of other research purposes. It is performed with local anesthetic using a small bore arthroscope, most usually inserted into the knee, although the wrist and metacarpophalangeal joints may also be inspected in this way. In experienced hands it is well tolerated, safe and complications are comparable to those reported by orthopedic surgeons. [ABSTRACT FROM AUTHOR]

Résumé L’échographie interventionnelle ostéo-articulaire prend une place de plus en plus grande en rhumatologie. Le maniement simultané de la sonde et de l’aiguille pourrait laisser penser qu’il faut prendre des mesures de précaution d’asepsie plus grandes par rapport aux gestes réalisés habituellement sous repérage anatomique. Sont-elles justifiées ? Nous n’avons aucune donnée allant en ce sens et une étude randomisée est impossible du fait de la grande rareté des événements. Nous passons en revue les différents éléments de l’asepsie, concernant le patient (essentiellement la désinfection de la peau), le médecin (essentiellement le port de gants stériles ou non) et le matériel (protection de la sonde échographique et distance par rapport à l’aiguille). La procédure est probablement au moins aussi importante que les moyens. L’attention doit se porter surtout sur l’intégrité de l’asepsie de l’aiguille. Il ne faut pas piquer dans le gel sous peine d’apporter des polyacrylates non biodégradables ou du propylène glycol dans les tissus. Nous ne pouvons conclure à une justification de l’inflation des moyens d’asepsie mis en œuvre lors d’un geste ostéo-articulaire échoguidé. Certes, pour certains gestes plus complexes et agressifs, sur certains terrains fragilisés, et en fonction du lieu de pratique, on peut considérer des mesures d’asepsie plus importantes, mais de la même manière que pour un geste habituel. Seul un observatoire des pratiques, non seulement des procédures de réparation du dommage corporel administrées par les assurances, mais surtout prospectivement et sur une très grande échelle au niveau national, pourra nous apporter des réponses plus précises. Osteoarticular interventional injections guided with ultrasound are playing an increasingly role in Rheumatology. The simultaneous handling of the probe and the needle might suggest the need to take greater aseptic precautions with respect to actions usually performed in anatomical injections. Are they justified? We have no data going in this direction, and a randomized study is impossible because of the rarity of events. We review the different parameters of the aseptic procedure, about the patient (primarily skin disinfection), about the practitioner (mainly wearing sterile gloves or not) and material (protection of ultrasound probe and distance to the needle). The procedure is probably at least as important as the material. Attention needs to be focused on the integrity of the asepsis of the needle. We may not prick into the gel because we can bring non-biodegradable polyacrylate or propylene glycol in tissues. We cannot conclude that the inflation of aseptic measures implemented during a musculoskeletal ultrasound guided gesture is justified. Nevertheless, for some more complex and aggressive gestures, for some fragile patients, and according to the place of practice, we can consider more important infection control procedures, but in the same way as a usual gestures. Only practices observatory, not only by the number of repair procedures administered by the physical damage insurance, but prospectively and on a very large scale at a national level to bring us more precise answers. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the quality of patient information about fluoroscopy-guided rheumatologic procedures, and to look for an impact on the patient's experience of the procedure.Methods: One hundred and nineteen patients completed questionnaires before and after undergoing fluoroscopy-guided interventions. We looked for associations between the information supplied by the rheumatologist who recommended the procedure and pain, anxiety, awareness of potential complications, and the match between patient expectations and actual experience.Results: 62.8% of patients reported receiving information about the procedure. Only 20.5% reported receiving specific information about potential adverse events, although 80.9% felt this information would have been useful. Most patients (74.8%) would have liked to receive additional information. Only 10.1% patients were given written information. Mean (+/-SD) anticipated pain severity as assessed in the waiting room before the procedure on a 0-10 scale was 4.5+/-2.4 in women and 4.2+/-2.3) in men. Actual pain severity during the procedure as assessed on the same scale was 2.7+/-2.6 in women and 2.2+/-1.6 in men. The level of information about the procedure did not influence anticipated or actual pain severity. Anxiety was reported by 59.8% patients and was more common in women (P<0.001), in patients given written information (P=0.05), and in patients undergoing their first intervention (P=0.05). Information was perceived as alleviating anxiety by 69.9% patients, and 77.3% of patients felt they would experience less anxiety if they had the procedure a second time. Only 21.2% patients were able to name a potential adverse event, and this proportion was not influenced by receiving written information. A mismatch between expectations about the procedure or its duration and actual experience was reported by 17 (17/69, 24.6%) and 34 (34/98, 34.7%) patients, respectively, with no significant differences across study subgroups.Conclusion: Information about interventional rheumatology procedures is required for ethical principles and legislation. Patients increasingly expect detailed information, which may increase the likelihood that the procedure unfolds smoothly. Our results indicate a need for optimizing patient information. Standardized written material deserves to be evaluated as a means of better meeting the informational needs of patients. [ABSTRACT FROM AUTHOR]