<< Monoarticular Arthritis Update: Current Evidence For Diagnosis And Treatment In The Emergency Department


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Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.


  1. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation — United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2010;59(39):1261-1265. (Prospective trial)
  2. Cisternas MG, Yelin EH, Foreman AJ, Pasta DJ, Helmick CG. Trends in medical care expenditures of US adults with arthritis and other rheumatic conditions 1997 to 2005. J Rheumatol. 2009;36(11):2531-2538. (Randomized clinical trial)
  3. Robinson E-G. Evaluation of the Patient: History and Physical Examination. Primer on the Rheumatic Diseases, 13th ed. 2008:6. (Prospective trial)
  4. Sun HB. Mechanical loading, cartilage degradation, and arthritis. Ann N Y Acad Sci. 2010;1211:37-50. (Review)
  5. Flannery CR ZR, Corcoran C, Jones AR, Root A, Rivera-Bermúdez MA, Blanchet T, Gleghorn JP, Bonassar LJ, Bendele AM, Morris EA, Glasson SS. Prevention of cartilage degeneration in a rat model of osteoarthritis by intraarticular treatment with recombinant lubricin. Arthritis Rheum. 2009;60(3):840-847. (Prospective trial)
  6. Jay GD TJ, Warman ML, Laderer MC, Breuer KS. The role of lubricin in the mechanical behavior of synovial fluid. Proc Natl Acad Sci USA. 2007;104(15):6194-6199. (Comparison study)
  7. Dubost JJ, Soubrier M, De Champs C, Ristori JM, Bussiere JL, Sauvezie B. No changes in the distribution of organisms responsible for septic arthritis over a 20 year period. Ann Rheum Dis. 2002;61(3):267-269. (Retrospective study)
  8. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ. 2008;336(7639):309-312. (Prospective cohort study)
  9. Singh JA, Reddy SG, Kundukulam J. Risk factors for gout and prevention: a systematic review of the literature. Curr Opin Rheumatol. 2011;23(2):192-202. (Systematic review)
  10. Berenbaum F. Osteoarthritis: Epidemiology, Pathology, and Pathogenesis. Atlanta: Arthritis Foundation; 2001. (Medical encyclopedia)
  11. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006;43(9):1089-1134. (Practice guideline)
  12. Bacon RM, Kugeler KJ, Mead PS, Centers for Disease C, Prevention. Surveillance for Lyme disease--United States, 1992-2006. MMWR. Surveill Summ. 2008;57(10):1-9. (United States government surveillance summary)
  13. Till SH, Snaith ML. Assessment, investigation, and management of acute monoarthritis. J Accid Emerg Med. 1999;16(5):355-361. (Review)
  14. * Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488. (Systematic review)
  15. Imboden J. Laboratory diagnosis. In: Imboden J, Hellman D, Stone J, eds. Current Rheumatology Diagnosis and Treatment. New York: McGraw-Hill; 2007:22. (Textbook)
  16. * Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. Rheumatology. 2006;45(8):1039-1041. (Practice guideline)
  17. Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA. 2008;299(7):806-813. (Systematic review)
  18. Nawaz A, Torigian DA, Siegelman ES, et al. Diagnostic performance of FDG-PET, MRI, and plain film radiography (PFR) for the diagnosis of osteomyelitis in the diabetic foot. Mol Imaging Biol. 2010;12(3):335-342. (Prospective trial)
  19. * Punzi L, Oliviero F. Arthrocentesis and synovial fluid analysis in clinical practice: value of sonography in difficult cases. Ann N Y Acad Sci. 2009;1154:152-158. (Review)
  20. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum. 1996;39(1):1-8. (Practice guidelines)
  21. Thumboo J, O’Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum. 1998;41(4):736-739. (Prospective trial)
  22. Campo MM, Kerkhoffs GM, Sierevelt IN, et al. A randomised controlled trial for the effectiveness of intra-articular Ropivacaine and Bupivacaine on pain after knee arthroscopy: the DUPRA (DUtch Pain Relief after Arthroscopy)-trial. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):239-244. (Randomized clinical trial)
  23. Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92(3):599-608. (Prospective trial)
  24. Abdullah S, Young-Min SA, Hudson SJ, et al. Gross synovial fluid analysis in the differential diagnosis of joint effusion. J Clin Pathol. 2007;60(10):1144-1147. (Evaluation study)
  25. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 5th Ed. New York: Saunders, 2009.
  26. Tallia AF, Cardone DA. Diagnostic and therapeutic injection of the shoulder region. Am Fam Physician. 2003;67(6):1271-1278.
  27. Reichman EF, Waddell R. Arthrocentesis. In: Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York: McGraw-Hill; 2003: 570-572.
  28. * Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based diagnostics: adult septic arthritis. Acad Emerg Med. 2011;18(8):781-796. (Systematic review)
  29. Goldenberg DL, Cohen AS. Acute infectious arthritis. A review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med. 1976;60(3):369-377. (Review)
  30. Sexually transmitted disease surveillance, 2010. 2011; Government research document. Available at: http://www.cdc.gov/std/stats10/default.htm. Accessed March 1, 2012. (United Stated government report)
  31. Dalla Vestra M, Rettore C, Sartore P, et al. Acute septic arthritis: remember gonorrhea. Rheumatol Int. 2008;29(1):81-85. (Case report)
  32. Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. 2005;19(4):853-861.
  33. Hook EW, Handsfield HH. Gonococcal Infections in Adults. 2nd edition ed. New York: Churchill Livingstone; 1990. (Textbook)
  34. Handsfield H. Neisseria Gonorrhoeae. 3rd edition ed. New York: Churchill Livingstone; 1990. (Textbook)
  35. Gandhi M, Jacobs R. Septic arthritis and disseminated gonococcal infection. In: Imboden J, Hellman D, Stone J, eds. Current Rheumatology Diagnosis and Treatment. New York: McGraw-Hill; 2007:359. (Textbook)
  36. O’Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore). 1983;62(6):395-406. (Review)
  37. O’Malley A, Svinos H. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 3: Is the white cell count of the joint aspirate sufficiently sensitive/specific to rule in/out septic arthritis? Emerg Med J. 2009;26(6):435-437. (Review)
  38. Shmerling RH, Delbanco TL, Tosteson AN, Trentham DE. Synovial fluid tests. What should be ordered? JAMA. 1990;264(8):1009-1014. (Prospective case review)
  39. Kortekangas P, Aro HT, Tuominen J, et al. Synovial fluid leukocytosis in bacterial arthritis vs reactive arthritis and rheumatoid arthritis in the adult knee. Scan J Rheumatol. 1992;21:283-288.
  40. Yang S, Ramachandran P, Hardick A, et al. Rapid PCR-based diagnosis of septic arthritis by early Gram-type classification and pathogen identification. J Clin Microbiol. 2008;46(4):1386-1390. (Evaluation study)
  41. Ho G. Infectious disorders: septic arthritis. In: Klippel JH, ed. Primer on the Rheumatic Diseases, 13th ed. Atlanta, GA: Arthritis Foundation; 2008:271. (Textbook)
  42. Sukswai P, Kovitvanitcha D, Thumkunanon V, Chotpitayasunondh T, Sangtawesin V, Jeerathanyasakun Y. Acute hematogenous osteomyelitis and septic arthritis in children: clinical characteristics and outcomes study. J Med Assoc Thai. 2011;94 Suppl 3:S209-216. (Retrospective case review)
  43. Al-Nammari SS, Bobak P, Venkatesh R. Methicillin resistant Staphylococcus aureus versus methicillin sensitive Staphylococcus aureus adult haematogenous septic arthritis. Arch Orthop Trauma Surg. 2007;127(7):537-542. (Retrospective review)
  44. Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982-1991. Ann Rheum Dis. 1999;58(4):214-219. (Retrospective chart review)
  45. Eggebeen AT. Gout: an update. Am Fam Physician. 2007;76:801-808. (Review)
  46. Schumacher HR, Jr., Boice JA, Daikh DI, et al. Randomised double blind trial of etoricoxib and indometacin in treatment of acute gouty arthritis. BMJ 2002;324(7352):1488-1492. (Randomized control trial)
  47. Kesselheim AS, Solomon DH. Incentives for drug development--the curious case of colchicine. N Engl J Med. 2010;362(22):2045-2047. (Historical article)
  48. Zhang W, Doherty M, Bardin T, et al. EULAR recommendations for calcium pyrophosphate deposition. Part II: management. Ann Rheum Dis. 2006;65(10):1212-1324. (Practice guidelines, review)
  49. Sussman JS, Brozena SC, Skop N, et al. Accidental intravenous colchicine poisoning. Ther Drug Monitor. 2004;26(6):688-692. (Case report)
  50. Winzenberg T, Buchbinder R. Cochrane Musculoskeletal Group review: acute gout. Steroids or NSAIDs? Let this overview from the Cochrane Group help you decide what’s best for your patient. J Fam Prac. 2009;58(7):E1-E4. (Review)
  51. 51.* Terkeltaub RA, Furst DE, Bennett K, et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum. 2010;62(4):1060-1068. (Randomized controlled trial)
  52. Ibuprofen: Drug information. In: UpToDate, Lexicomp, UpToDate, Waltham, MA, 2012. (Online database)
  53. Colchicine: Drug information. In: UpToDate, Lexicomp, UpToDate, Waltham, MA, 2012. (Online database)
  54. * Man CY, Cheung ITF, Cameron PA, Rainer TH. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial. Ann Emerg Med. 2007;49(5):670-677. (Randomized controlled trial)
  55. Axelrod D, Preston S. Comparison of parenteral adrenocorticotropic hormone with oral indomethacin in the treatment of acute gout. Arthritis Rheum. 1988;31(6):803-805. (Prospective trial)
  56. Ritter J, Kerr LD, Valeriano-Marcet J, et al. ACTH revisited: effective treatment for acute crystal induced synovitis in patients with multiple medical problems. J Rheumatol.1994;21(4):696-699. (Retrospective chart review)
  57. Schlesinger N. Overview of the management of acute gout and the role of adrenocorticotropic hormone. Drugs. 2008;68(4):407-415. (Review)
  58. Keith MP, Gilliland WR. Updates in the management of gout. Am J Med. 2007;120(3):221-224. (Review)
  59. Felson DT, Anderson JJ, Naimark A, Kannel W, Meenan RF. The prevalence of chondrocalcinosis in the elderly and its association with knee osteoarthritis: the Framingham Study. J Rheumatol. 1989;16(9):1241-1245. (Retrospective cohort study)
  60. Sanders S WR. Pseudogout: Calcium Pyrophosphate Dihydrate Crystal Deposition Disease. New York: McGraw-Hill; 2007. (Textbook)
  61. McCarthy G. Calcium Pyrophosphate Dihydrate, Hydroxyapatite, and Miscellaneous Crystals. 13th ed. Atlanta: Arthritis Foundation; 2008. (Textbook)
  62. Werlen D, Gabay C, Vischer TL. Corticosteroid therapy for the treatment of acute attacks of crystal-induced arthritis: an effective alternative to nonsteroidal antiinflammatory drugs. Rev Rhum Engl Ed.1996;63(4):248-254. (Comparative study, prospective trial)
  63. Hochberg MC. Osteoarthritis: clinical features. 12th edition ed. Atlanta, GA: Arthritis Foundation; 2001. (Textbook)
  64. Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007;66(3):377-388. (Practice guidelines)
  65. Towheed TE, Maxwell L, Judd MG, Catton M, Hochberg MC, Wells G. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev. 2006(1):CD004257. (Review)
  66. Avouac J, Gossec L, Dougados M. Efficacy and safety of opioids for osteoarthritis: a meta-analysis of randomized controlled trials, Osteoarthritis Cartilage 2007: 15; 957–965.
  67. Wandel S, Juni P, Tendal B, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. 2010;341:c4675. (Meta-analysis)
  68. McCleane G. The analgesic efficacy of topical capsaicin is enhanced by glyceryl trinitrate in painful osteoarthritis: a randomized, double blind, placebo controlled study. Eur J Pain. 2000;4(4):355-360. (Randomized controlled trial)
  69. Barthel HR, Haselwood D, Longley S, 3rd, Gold MS, Altman RD. Randomized controlled trial of diclofenac sodium gel in knee osteoarthritis. Semin Arthritis Rheum. 2009;39(3):203-212. (Randomized controlled trial)
  70. Barthel HR, Axford-Gatley RA. Topical nonsteroidal anti-inflammatory drugs for osteoarthritis. Postgrad Med. 2010;122(6):98-106.
  71. Bannuru RR, Natov NS, Obadan IE, et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum. 2009;61(12):1704-1711. (Meta-analysis, systematic review)
  72. Petrella MJ, Cogliano A, Petrella RJ. Original research: long-term efficacy and safety of periarticular hyaluronic acid in acute ankle sprain. Phys Sportsmed. 2009;37(1):64-70. (Randomized controlled trial)
  73. Arrich J, Piribauer F, Mad P, Schmid D, Klaushofer K, Mullner M. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ. 2005;172(8):1039-1043. (Meta-analysis, systematic review)
  74. Hu L. Lyme arthritis. Infect Dis Clin North Am. 2005;19(4):947-961. (Review)
  75. Feder HM Jr, Abeles M, Bernstein M, et al. Diagnosis, treatment, and prognosis of erythema migrans and Lyme arthritis. Clin Dermatol. 2006;24(6):509-520. (Case reports)
  76. Carter JD. Reactive arthritis: defined etiologies, emerging pathophysiology, and unresolved treatment. Infect Dis Clin North Am. 2006;20(4):827-847. (Review)
  77. Kim PS, Klausmeier TL, Orr DP. Reactive arthritis: a review. J Adolesc Health. 2009;44(4):309-315. (Review)
  78. Panush RS, Wallace DJ, Dorff RE, et al. Retraction of the suggestion to use the term “Reiter’s syndrome” sixty-five years later: the legacy of Reiter, a war criminal, should not be eponymic honor but rather condemnation. Arthritis Rheum. 2007;56(2):693-694. (Historical article)
  79. Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993;75(6):945-949. (Prospective study)
  80. Casteleyn PP, Handelberg F, Opdecam P. Traumatic haemarthrosis of the knee. The J Bone Joint Surg Br. 1988;70(3):404-406. (Prospective review)
  81. Glazebrook KN, Guimaraes LS, Murthy NS, et al. Identification of intraarticular and periarticular uric acid crystals with dual-energy CT: initial evaluation. Radiology. 2011;261(2):516-524. (Prospective study)
  82. Rapley JH, Beavis RC, Barber FA. Glenohumeral chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion. Arthroscopy. 2009;25(12):1367-1373.
  83. Goyal M, Pines JM, Drumheller BC, Gaieski DF. Point-of-care testing at triage decreases time to lactate level in septic patients. J Emerg Med. 2010;38(5):578-581. (Prospective trial)
  84. Shapiro NI, Fisher C, Donnino M, et al. The feasibility and accuracy of point-of-care lactate measurement in emergency department patients with suspected infection. J Emerg Med. 2010;39(1):89-94. (Prospective cohort study)
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Nicholas Genes; Makini Chisolm-Straker

Publication Date

May 2, 2012

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