Best Practice & Research Clinical Rheumatology
Volume 23, Issue 2 , Pages 161-192 , April 2009

Joint aspiration and injection and synovial fluid analysis

  • Philip Courtney, MD, FRCP (Consultant Rheumatologist)
    • ,
  • Michael Doherty, MA, MD, FRCP (Professor of Rheumatology)

      Affiliations

    • Corresponding Author InformationCorresponding author. Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK. Tel.: +115 823 1756; Fax: +115 823 1757.

References 

  1. Pascual E, Doherty M. Aspiration of normal or asymptomatic pathological joints for diagnosis and research indications, technique and success rate. Ann Rheum Dis. 2009;68:3–7
  2. Pal B, Nash EJ, Oppenheim B, et al. Routine synovial culture: is it necessary? Lessons from an audit. Br J Rheumatol. 1997;36:1116–1117
  3. Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following intra-articular steroid injection of the knee – a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol. 2003;22:386–390
  4. Yood RA. Use of gloves for rheumatology procedures. Arthritis Rheum. 1993;36:575
  5. Cawley PJ, Morris IM. A study to compare the efficacy of two methods of skin preparation prior to joint injection. Br J Rheumatol. 1992;31:847–848
  6. Seror P, Pluvinage P, Leqoc d'Andrade F, et al. Frequency of sepsis after local corticosteroid injections (an enquiry on 1,160,000 injections in rheumatological private practice in France). Rheumatology. 1999;38:1272–1274
  7. Weston VC, Jones AC, Bradbury N, et al. Clinical features and outcome of septic arthritis in a single UK Health district. Ann Rheum Dis. 1999;58:214–219
  8. Sibbitt WL, Sibbitt RR, Michael AA, et al. Physician control of needle and syringe during aspiration-injection procedure with new reciprocating syringe. J Rheumatol. 2006;33:771–778
  9. Weitoft T, Uddenfeldt P. Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. Ann Rheum Dis. 2000;59:233–235
  10. Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ. 1993;307:1329–1330
  11. Bliddal H. Placement of intra-articular knee injections verified by mini air-arthrography. Ann Rheum Dis. 1999;58:641–646
  12. Kang MN, Rizio L, Prybiaen M, et al. The accuracy of subacromial corticosteroid injections: a comparison of multiple methods. J Shoulder Elbow Surg. 2008;17:61S–68S
  13. O'Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis. 2000;59:918–919
  14. Cassidy JT, Bole GG. Cutaneous atrophy secondary to intra-articular corticosteroid. Ann Intern Med. 1966;65:1008–1018
  15. Sparling M, Malleson P, Wood B, Petty R. Radiographic follow-up of joints injected with triamcinolone hexacetonide for the management of childhood arthritis. Arthritis Rheum. 1990;33:821–826
  16. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injection in osteoarthritis of the knee: a randomised placebo-controlled trial. Arthritis Rheum. 2003;48:370–377
  17. Laaksonen AL, Sunnell JE, Westeren H, Mulder J. Adrenocortical function in children with juvenile rheumatoid arthritis and other connective tissue disorders. Scand J Rheumatol. 1974;3:137–144
  18. Emkey RD, Lindsay R, Lyssy J, et al. The systemic effect of intra-articular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis. Arthritis Rheum. 1996;39:277–282
  19. McDonald AG, Land DV, Sturrock RD. Microwave thermography as a non invasive assessment of disease activity in inflammatory arthritis. Clin Rheumatol. 1994;13:589–592
  20. Winifield J, Crawley JCW, Hudson EA, et al. Evaluation of two regimens to immobilise the knee after injections of yttrium 90. BMJ. 1979;I:986–987
  21. Chakravarty K, Pharoah PDP, Scott DGI. A randomised controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol. 1994;33:464–468
  22. Chatham W, Williams G, Moreland L, et al. Intra-articular corticosteroid injections: should we rest the joints?. Arthritis Care Res. 1989;2:70–74
  23. Hollander JL, Brown EM, Jessar RA, et al. Hydrocortisone and cortisone injected into arthritic joints. Comparative effects of and use of hydrocortisone as a local anti-arthritic agent. JAMA. 1951;147:1629–1635
  24. McCarty D. Treatment of rheumatoid joint inflammation with triamcinolone hexacetonide. Arthritis Rheum. 1972;15:157–173
  25. Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Ann Rheum Dis. 1996;55:829–832
  26. Blyth T, Hunter JA, Stirling A. Pain relief in the rheumatoid knee after steroid injection: a single-blind comparison of hydrocortisone succinate, and triamcinolone acetonide or hexacetonide. Br J Rheumatol. 1994;33:461–463
  27. Padeh S, Passwell JH. Intra-articular corticosteroid injection in the management of children with chronic arthritis. Arthritis Rheum. 1998;41:1210–1214
  28. Luukkiainen R, Hakala M, Sajanti E, et al. Predictive value of synovial fluid analysis in estimating the efficacy of intra-articular corticosteroid injections in patients with rheumatoid arthritis. Ann Rheum Dis. 1992;51:874–876
  29. Furtado RN, Oliveira LM, Natour J. Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study. J Rheumatol. 2005;32:1691–1698
  30. Von Reiss G, Swensson A. Intra-articular injection of osmic acid in painful joint affections. Acta Med Scand Suppl. 1951;259:27–32
  31. Bessant R, Steuer A, Rigby S, Gumpel M. Osmic acid revisited: factors that predict a favorable response. Rheumatol. 2003;42:1036–1043
  32. Berglof FE. Osmic acid in arthritis therapy. Acta Rheumatol Scand. 1959;5:70–74
  33. Nissila M, Isomaki H, Koota K, et al. Osmic acid in rheumatoid synovitis. A controlled study. Scand J Rheumatol. 1977;6:158–160
  34. Sheppeard H, Aldin A, Ward DJ. Osmic acid versus yttrium-90 in rheumatoid synovitis of the knee. Scand J Rheumatol. 1981;10:234–236
  35. Nissila M, Anttila P, Hamalainen M, Jalava S. Comparison of chemical, radiation and surgical synovectomy for knee joint synovitis. Scand J Rheumatol. 1978;7:225–228
  36. O'Duffy EK, Ell PJ. The practice of medical and surgical synovectomy: a UK survey. Nucl Med Commun. 1999;20:21–24
  37. Bridgman JF, Bruckner F, Eisen V, et al. Irradiation of the synovium in the treatment of rheumatoid arthritis. Q J Med. 1973;42:357–367
  38. Doherty M, Dieppe PA. Effect of intra-articular yttrium-90 on chronic pyrophosphate arthropathy of the knee. Lancet. 1981;2:1243–1246
  39. Fernandez-Palazzi F, Caviglia H. On the safety of synoviorthesis in haemophilia. Haemophilia. 2001;7(Suppl):50–53
  40. Heuft-Dorenbosch LLJ, de Vet CW, van der Linden S. Yttrium radiosynoviorthesis in the treatment of knee arthritis in rheumatoid arthritis: a systematic review. Ann Rheum Dis. 2000;59:583–586
  41. Jones G. Yttrium synovectomy: a meta-analysis of the literature. Aust N Z J Med. 1993;23:272–275
  42. Taylor WJ, Corkill MM, Rajapaske CN. A retrospective review of yttrium-90 synovectomy in the treatment of knee arthritis. Br J Rheumatol. 1997;36:1100–1105
  43. Grant EN, Bellamy N, Fryday-Field K, et al. Double-blind randomized controlled trial and six year open follow up of yttrium-90 radiosynovectomy versus triamcinolone hexacetonide in persistent rheumatoid knee synovitis. Inflamopharmacology. 1992;1:231–238
  44. Jahangier ZN, Jacobs JW, van Isselt JW, Bijlsma JW. Persistent synovitis treated with radiation synovectomy using yttrium-90: a retrospective evaluation of 83 procedures for 45. patients. Br J Rheumatol. 1997;36:861–869
  45. Ghosh P. The role of hyaluronic acid in health and disease:interactions with cells, cartilage and components of the synovial fluid. Clin Exp Rheumatol. 1996;12:75–82
  46. Balazs EA, Watson D, Duff IF, Roseman S. Hyaluronic acid in synovial fluid. 1. Molecular parameters of hyaluronic acid in normal and arthritis human fluids. Arthritis Rheum. 1967;10:357–376
  47. Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol. 1993;39:S3
  48. Brandt KD, Smith GN, Simon LS. Intraarticular injection of hyaluronan as treatment of knee osteoarthritis. What is the evidence?. Arthritis Rheum. 2000;43:1192–1203
  49. Hochberg MC. Role of intraarticular hyaluronic acid preparations in the medical management of osteoarthritis of the knee. Sem Arthritis Rheum. 2000;30:2–10
  50. Kawkak CE, Frisbie DD, Trotter GW, et al. Effect of intravenous administration of sodium hyaluronate on carpal joints in exercising horses after arthroscopic surgery and osteochondral fragmentation. Am J Vet Res. 1997;58:1132–1140
  51. Karlsson J, Sjogren LS, Lohmander S. Comparison of two hyaluronan drugs and placebo in patients with knee osteoarthritis. A controlled, randomised, double-blind parallel-design multicentre study. Rheumatology. 2002;41:1240–1248
  52. Listrat V, Ayral X, Patarnello F, et al. Arthroscopic evaluation of potential structure modifying effect of hyaluronan (Hylgan) in osteoarthritis of the knee. Osteoarthritis Cartilage. 1997;5:153–160
  53. Lussier A, Cividino AA, McFarlane CA, et al. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 1996;23:1579–1585
  54. Berg P, Olsson U. Intra-articular injection of non-animal stabilized hyaluronic acid (NASHA) for osteoarthritis of the hip: a pilot study. Clin Exp Rheumatol. 2004;22:300–306
  55. Bliddal H, Terslev L, Ovistgaard E. A randomized, controlled study of a single intra-articular injection of etanercept or glucocorticoids in patients with rheumatoid arthritis. Scand J Rheumatol. 2006;35:341–345
  56. Mayer JH. Carpometacarpal osteoarthritis of the thumb. Lancet. 1970;2:270
  57. Niedel J, Boehnke M, Kuster RM. The efficacy and safety of intra-articular corticosteroid therapy for coxitis in juvenile rheumatoid arthritis. Arthritis Rheum. 2002;46:1620–1628
  58. Flanagan J, Casale FF, Thomas TL, Desai KB. Intra-articular injection for pain relief in patients awaiting hip replacement. Ann R Coll Surg Engl. 1988;70:156–157
  59. Plant MJ, Borg AA, Dziedzic K, et al. Radiographic patterns and response to corticosteroid hip injection. Ann Rheum Dis. 1997;56:476–480
  60. Margules KR. Fluroscopically directed steroid installation in the treatment of hip osteoarthritis:safety and efficacy in 510 cases. Arthritis Rheum. 2001;44:2449–2450
  61. Leopold SS, Battista V, Oliverio JA. Safety and efficacy of intraarticular hip injection using anatomic landmarks. Clin Orthop. 2001 Oct;391:192–197
  62. Karabacakoglu A, Karakose S, Ozerbil OM, Odev K. Fluoroscopy-guided intraarticular corticosteroid injection into the sacroiliac joints in patients with ankylosing spondylitis. Acta Radiol. 2002;43:425–427
  63. Pereira PL, Gunaydin I, Remy CT, et al. Interventional MR imaging for injection of sacroiliac joints in patients with sacroiliitis. A J Roentgenol. 2000;175:265–266
  64. Hanly JG, Mitchell M, MacMillan L, et al. Efficacy of sacroiliac corticosteroid injections in patients with inflammatory spondyloarthropathy:results of a 6 month controlled study. J Rheumatol. 2000;27:719–722
  65. Mooney V, Robertson J. The facet syndrome. Clin Orthop. 1976;115:149–156
  66. Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Eng J Med. 1991;325:1002–1007
  67. Lilius G, Laasonen EM, Myllynen P, et al. Lumbar facet joint syndrome. A randomized clinical trial. J Bone Joint Surg. 1989;71B:681–684
  68. Dolan AL, Ryan PJ, Arden NK, et al. The value of SPECT scans in identifying backpain likely to benefit from facet joint injection. Br J Rheumatol. 1996;35:1269–1273
  69. Hasselbacher P. The structure of the synovial membrane. Clin Rheum Dis. 1981;7:57–69
  70. Gatter RA. In:  Gatter RA editors. A practical handbook of joint fluid analysis. Philadelphia, PA: Lea and Febiger; 1984;p. 1–6
  71. Mc Cutchen CW. Joint lubrication. Clin Rheum Dis. 1981;7:241–257
  72. Román J, Pascual E, De Juán J, et al. Vascular congestion and involvement of the sympathetic nervous system in the synovial membrane adjacent to meniscal tears. Br J Rheumatol. 1990;29(Suppl. 2):31
  73. Cohen AS, Goldenberg D. Synovial fluid. In:  Cohen AS editors. Laboratory diagnostic procedures in the rheumatic diseases. Orlando, FL: Grune and Stratton; 1985;p. 40–53
  74. Gatter RA. Gross synovianalysis at the bedside. In:  Gatter RA editors. A practical handbook of joint fluid analysis. Philadelphia, PA: Lea and Febiger; 1984;p. 15–20
  75. Kitridou R, Schumacher HR, Sbarbaro JR, Hollander J. Recurrent hemarthrosis after knee arthroplasty: identification of metal particles in synovial fluid. Arthritis Rheum. 1969;12:520–524
  76. Hunter T, Gordon DA, Ogryzlo MA. The ground pepper sign of synovial fluid. A new diagnostic feature of ochronosis. J Rheumatol. 1974;1:45–49
  77. Popert AJ, Scott DL, Wainwright AC. Frequency of occurrence, mode of development, and significance of rice bodies in rheumatoid arthritis. Ann Rheum Dis. 1982;41:109
  78. Atanes A, Fernandez V, Nun˜ez R, et al. Idiopathic eosinophilic synovitis. Case report and review of the literature. Scand J Rheumatol. 1996;25:183–185
  79. Spriggs AI, Doddington MM, Mowat AG. Joint fluid cytology in Reiter's disease. Ann Rheum Dis. 1978;37:557–560
  80. Hasselbacher P. Synovial fluid analysis. In:  Utsinger PD,  Zvaifler NJ,  Ehrlich EE editor. Rheumatoid arthritis, etiology, diagnosis and management. Philadelphia, PA: J.B. Lippincott Company; 1985;p. 193–208
  81. Gratacos J, Vila J, Moya F, et al. D-lactic acid in synovial fluid. A rapid diagnostic test for bacterial synovitis. J Rheumatol. 1995;22:1504–1508
  82. Kortekangas P, Peltola O, Toivanen A, Aro HT. Synovial fluidL-lactic acid in acute arthritis of the adult knee joint. Scand J Rheumatol. 1995;24:98–101
  83. McCarty DJ, Hollander JL. Identification of urate crystals in gouty synovial fluid. Ann Intern Med. 1961;54:452–460
  84. Kohn NN, Hughes RE, McCarty DJ, Faires JS. The significance of calcium pyrophosphate crystals in the synovial fluid of arthritic patients: the ‘pseudogout syndrome’. II. Identification of crystals. Ann Intern Med. 1962;56:738–745
  85. Pascual E, Batlle-Gualda E, Martínez A, et al. Synovial fluid analysis for diagnosis of intercritical gout. Ann Intern Med. 1999;131:756–759
  86. Pascual E. Persistence of monosodium urate crystals, and low grade inflammation, in the synovial fluid of untreated gout. Arthritis Rheum. 1991;34:141–145
  87. Bomalaski JS, Lluberas G, Schumacher HR. Monosodium urate crystals in the knee joints of patients with asymptomatic non-tophaceous gout. Arthritis Rheum. 1986;29:1480–1484
  88. Martínez A, Pascual E. Intra and extracellular CPPD crystals are regularly found in the synovial fuid of uninflamed joints of CPPD related arthropathy. Arthritis Rheum. 1995;38:S246
  89. Sivera F, Aragon R, Pascual E. First metatarsophalangeal joint aspiration using a 29-gauge needle. Ann Rheum Dis. 2008;67:273–275
  90. Rothschild BM. Identification of calcium pyrophosphate dihydrate crystals. Clin Exp Rheumatol. 1993;11:216–217
  91. Swan A, Amer H, Dieppe P. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis. 2002;61:493–498
  92. Hasselbacher P. Variation in synovial fluid analysis by hospital laboratories. Arthritis Rheum. 1987;30:637–642
  93. Schumacher HR, Sieck MS, Rothfuss C, et al. Reproducibility of synovial fluid analyses; a study among our laboratories. Arthritis Rheum. 1986;29:770–774
  94. Von Essen R, Holtta AMH. Quality control of the laboratory diagnosis of gout by synovial fluid microscopy. Scand J Rheumatol. 1990;19:232–234
  95. Von Essen R, Holtta AMH, Pikkarainen R. Quality control of synovial fluid crystal identification. Ann Rheum Dis. 1998;57:107–109
  96. Petrocelli A, Wong AL, Sweezy RL. Identification of pathological synovial fluid crystals on Gram stain. J Clin Rheumatol. 1998;4:103–105
  97. Gordon C, Swan A, Dieppe P. Detection of crystals in SF by light microscopy; sensitivity and reliability. Ann Rheum Dis. 1989;48:737–742
  98. Lumbreras B, Pascual E, Frasquet J, et al. Analysis for crystals in synovial fluid: training of the analysts results in high consistency. Ann Rheum Dis. 2005;64:612–615
  99. Galvez J, Saiz E, Linares LF, et al. Delayed examination of synovial fluid by ordinary and polarized light microscopy to detect and identify crystals. Ann Rheum Dis. 2002;61:444–447
  100. Ivorra J, Rosas J, Pascual E. Most calcium pyrophosphate crystals appear as non-birefringent. Ann Rheum Dis. 1999;58:581–584
  101. McCarty D, Kohn NH, Faires JS. The significance of calcium phosphate crystals in the synovial fluid of arthritic patients: the pseudogout syndrome. I. Clinical aspects. Ann Intern Med. 1962;56:711–737
  102. Ryan LM, McCarty DJ. Calcium pyrophosphate crystal deposition disease. Pseudogout and articular chondrocalcinosis. In:  Koopman WJ editors. Arthritis and allied conditions. Baltimore, MD: Williams and Wilkins; 1997;
  103. Schumacher HR, Reginato A. Calcium phosphate dihydrate crystals. In:  Schumacher HR,  Reginato A editor. Atlas of synovial fluid analysis and crystal identification. Philadelphia, PA: Lea and Febiger; 1991;
  104. McGill NW, York HF. Reproducibility of synovial fluid examination for crystals. Aust N Z J Med. 1991;21:710–713
  105. Pascual E, Tovar J, Ruiz MT. The ordinary light microscope: an appropriate tool for the detection and identification of crystals in synovial fluid. Ann Rheum Dis. 1989;48:983–985
  106. Pascual E, Jovanı V. A quantitative study of the phagocytosis of urate crystals in the synovial fluid of asymptomatic joints of patients with gout. Br J Rheumatol. 1995;34:724–726
  107. Swan A, Chapman B, Heap P, et al. Submicroscopic crystals in osteoarthritic synovial fluids. Ann Rheum Dis. 1994;53:467–470
  108. McCarty DJ, Lehr JR, Halverson PB. Crystal population in human synovial fluid. Arthritis Rheum. 1983;26:1220–1224
  109. Halverson PB, Cheung HS, McCarty DJ, et al. Milkwakee shoulder: association of michrospheroids containing hydroxyapatite crystals, active collagenase and neutral protease with rotator cuff defects. Synovial fluid studies. Arthritis Rheum. 1981;24:474–483
  110. Dieppe PA, Doherty M, McFarlane DG, et al. Apatite associated destructive arthritis. Br J Rheumatol. 1984;23:84–91
  111. Schumacher HR, Somlyo AD, Tse RI, Maurer K. Arthritis associated with apatite crystals. Ann Intern Med. 1977;87:411–416
  112. Gerster JL, Lagier R. Acute synovitis with intrarticular apatite deposits in a osteoarthritic metacarpophalangeal joint. Ann Rheum Dis. 1985;44:207–210
  113. Schumacher HR, Schimmer B, Godon GV. Articular manifestations of polymyositis and dermatomyo-sitis. Am J Med. 1979;67:287–292
  114. Nalbant S, Martinez JA, Kitumnuaypong T, et al. Synovial fluid features and their relations to osteoarthritis severity: new findings from sequential studies. Osteoarthritis Cartilage. 2003;11:50–54
  115. Gibilisco PA, Schumacher HR, Hollander JL, Soper KA. Synovial fluid crystals in osteoarthritis. Arthritis Rheum. 1985;28:511–515
  116. Bardin T, Bucki B, Lansaman J, et al. Alizarin red staining of articular fluids. Comparison of the results with electron microscopy and clinical data. Rev Rhum Mal Osteoartic. 1987;54:149–154
  117. Hamilton E, Pattrick M, Hornby J, et al. Synovial fluid calcium pyrophosphate dihydrate crystals and alizarin red positivity: analysis of 3000 samples. Br J Rheumatol. 1990;29:101–104
  118. Fawthrop F, Hornby J, Swan A, et al. A comparison of normal and pathological synovial fluid. Br J Rheumatol. 1985;24:61–69
  119. Paul H, Reginato AJ, Schumacher HR. Alizarin red S staining as a screening test to detect calcium compounds in synovial fluid. Arthritis Rheum. 1983;26:191–200
  120. Reginato AJ, Ferrero Seoane JL, Barbazán Alvarez C, et al. Arthropathy and cutaneous calcinosis in hemodialysis oxalosis. Arthritis Rheum. 1986;29:1397–1398
  121. Riordan JW, Dieppe PA. Cholesterol crystals in shoulder synovial fluid. Br J Rheumatol. 1987;26:430–432
  122. Fam AG, Pritzker KP, Cheng PT, Little AH. Cholesterol crystals in osteoarthritic joint effusions. J Rheumatol. 1981;8:273–280
  123. Pritzker KP, Fam AG, Omar SA, Gertzbein SD. Experimental cholesterol crystal arthropathy. J Rheumatol. 1981;8:281–290
  124. Ettinger RE, Hunder GG. Synovial effusions containing cholesterol crystals: report of 12 patients and review. Mayo Clin Proc. 1979;54:336–340
  125. Lazarevic MB, Skosey JL, Vitic J, et al. Cholesterol crystals in synovial and bursal fluid. Semin Arthritis Rheum. 1993;23:99–103
  126. McCarty DJ, Hogan JM. Inflamatory reaction after intrasynovial injection of microcrystalline adrenocorticosteroid esthers. Arthritis Rheum. 1964;7:359–367
  127. Kahn CB, Hollander JL, Schumacher HR. Corticosteroid crystals in synovial fluid. J Am Med Assoc. 1970;211:807–809
  128. Reginato AJ, Schumacher HR, Allan DA, Rabinowitz JL. Acute monoarthritis associated with lipid liquid crystals. Ann Rheum Dis. 1985;44:537–543
  129. Smukler NM, Schumacher HR, Pascual E, et al. Synovial fat necrosis associated with ischemic pancreatic disease. Arthritis Rheum. 1979;22:547–553
  130. Lawrence C, Seife B. Bone marrow in joint fluid: a clue to fracture. Ann Intern Med. 1971;74:740–743

PII: S1521-6942(09)00004-7

doi: 10.1016/j.berh.2009.01.003

Best Practice & Research Clinical Rheumatology
Volume 23, Issue 2 , Pages 161-192 , April 2009

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