Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study

OBJECTIVE

To evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease (CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard.

METHODS

Consecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0-3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other's findings.

RESULTS

11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%-sensitivity of 91% (range 71%-87% in single sites) and specificity of 59% (range 68%-92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation.

CONCLUSION

Ultrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

OP0317 ACCURACY OF THE OMERACT DEFINITIONS FOR IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS WITH ULTRASOUND: FINAL RESULTS OF THE OMERACT US IN CPPD SUB-TASK FORCE STUDY

Background:

The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].

Objectives:

Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.

Methods:

Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.

Results:

101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1

Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86

Conclusion:

Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.

References:

[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542

Disclosure of Interests:

Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Macroscopic and microscopic findings in avascular necrosis of the femoral head

The avascular necrosis of the femoral head is an illness induced by the cutoff of blood flow to the femoral head and it affects mostly young adults between the ages of 30 and 50 years, raising therapeutic and diagnostic issues. Many risk factors are incriminated in the development of avascular necrosis of the femoral head like: trauma, chronic alcohol consumption, smoking, administration of corticosteroid drugs, most of the cases are considered to be idiopathic. The main goal of our paper is to describe the macroscopic and microscopic variations of the bone structure, which occur in patients with avascular necrosis of the femoral head.

MATERIALS AND METHODS

The biological material needed for our study was obtained following hip arthroplasty surgery in 26 patients between the ages of 29 and 59 years, which previously were diagnosed with avascular necrosis of the femoral head and admitted in the Orthopedics Department of the Emergency County Hospital of Craiova (Romania) between 2010 and 2011. From a macroscopic point of view, we found well defined areas of necrosis, most of which were neatly demarcated of the adjacent viable tissue by hyperemic areas, loss of shape and contour of the femoral head and transformations of the articular cartilage above the area of necrosis. When examined under the microscope, we found vast areas of fibrosis, narrow bone trabeculae, obstructed blood vessels or blood vessels with clots inside, hypertrophic fat cells, bone sequestration but also small cells and pyknotic nuclei. The microscopic and macroscopic findings on the femoral head sections varied with the patients and the stage of the disease.

Power Doppler sonography, a non-invasive method of assessment of the synovial inflammation in patients with early rheumatoid arthritis

OBJECTIVE

To detect synovitis is important in both the diagnosis and outcome assessment of early rheumatoid arthritis. This study was meant to assess the validity and reproducibility of ultrasonography (US) as a mean of detection for the knee synovitis, by comparing US findings with clinical examination and histopathological findings in synovial membrane.

METHODS

The study group included 65 patients with early rheumatoid arthritis - below 12 months from the debut, naive for DMARDs, in whom demographic data - gender, age, disease duration, the number of tender and swollen joints, HAQ score (Health Assessment Questionnaire) and serum samples for CRP, RF, anti-CCP2 antibodies (ELISA, QUANTA LiteTM, CCP IgG, INOVA Diagnostics Inc, USA), VEGF (ELISA, VEGF2, DRG International, IRC, USA) determination were recorded. Disease Activity Score for 28 joints (DAS28) was calculated. PDS signal was scored from 0 to 3 according to the overall expression of PDS findings at the knees. A sample of synovial tissue was obtained in 35 patients during the arthroscopy, and the vascularisation of the synovial tissue was evaluated by immunohistochemistry and was analyzed qualitatively by a pathologist who was unaware of the PDS findings. Written, informed consent was obtained from each patient before entering the study. They all had active synovitis of the knee, ultrasonographically confirmed, with the identification of the target biopsy sites. The study was approved by the Ethics Committee of the University of Medicine and Pharmacy of Craiova.

RESULTS

Angiogenesis was evaluated and quantified by immunohistochemical evaluation of synovial VEGF, one of the most specific endothelial growing factors, that proved to correlate significantly with the serum levels of VEGF, DAS28 as well as with the power Doppler sonography (PDS) score.

CONCLUSIONS

The statistical analysis of the data showed that PDS could be used as non-invasive marker with predictive value regarding synovial inflammation and disease progression in early forms of the disease as well as a useful method in the assessment of the therapeutic response.

The arthroscopy-histological criterion link in the result's estimation of the endoscopic treatment by resection of the knee's meniscus lesions

The authors present the results of a statistical, clinical, imaging X-ray and optical microscopic studies of some lesions of knee's meniscus, the arthroscopy allowing this structure's biopsy during the endoscopic procedures of resection. These histological criterions are very important estimation factors of long-term results of these techniques, often the microstructure looking different to the appearing normal macroscopic aspect.

A multidisciplinary approach in patients with femoral neck fracture on an osteoporotic basis

INTRODUCTION

Osteoporosis is a common affection characterized by a reduction of bone mass that affects mostly women after menopause. It currently leads to fractures, especially of the spine and hip thus enhancing the costs of medical care. There are many factors that contribute to its development, leading to various strategy lines to deal with it.

AIM

The present study aims at showing how a multidisciplinary, multifactorial approach can be effective in treating and preventing new osteoporotic fractures.

MATERIAL AND METHODS

The study included 17 patients that had replacement arthroplasty for femoral neck fractures. Bone tissue fragments were obtained from all of them and analyzed by pathology specialists. A dual-energy X-ray absorptiometry exam was also performed on each patient. In the end, the data was collected and processed by rehabilitation experts in order to establish proper therapy.

RESULTS

The hip fracture incidence was two times more frequent in women than in men, higher in the 71-80-year-old group. By analyzing the bone fragments atrophy could be seen, especially in the femoral neck as well as lamellae and osteon reduction and bone architecture alterations.

CONCLUSIONS

Surgical or pharmacological treatments alone are not sufficient for handling osteoporosis. Strategies such as preventing falls, a proper diet, treating associated conditions and a well-established exercise program need to be considered. Specialists from several areas such as pathology, orthopedics, endocrinology, internal medicine and rehabilitation should work together to design the best approach to deal with osteoporosis.

Numerical simulations of human tibia osteosynthesis using modular plates based on Nitinol staples

The shape memory alloys exhibit a number of remarkable properties, which open new possibilities in engineering and more specifically in biomedical engineering. The most important alloy used in biomedical applications is NiTi. This alloy combines the characteristics of the shape memory effect and superelasticity with excellent corrosion resistance, wear characteristics, mechanical properties and a good biocompatibility. These properties make it an ideal biological engineering material, especially in orthopedic surgery and orthodontics. In this work, modular plates for the osteosynthesis of the long bones fractures are presented. The proposed modular plates are realized from identical modules, completely interchangeable, made of titanium or stainless steel having as connecting elements U-shaped staples made of Nitinol. Using computed tomography (CT) images to provide three-dimensional geometric details and SolidWorks software package, the three dimensional virtual models of the tibia bone and of the modular plates are obtained. The finite element models of the tibia bone and of the modular plate are generated. For numerical simulation, VisualNastran software is used. Finally, displacements diagram, von Misses strain diagram, for the modular plate and for the fractured tibia and modular plate ensemble are obtained.

Numerical simulations of the 3D virtual model of the human hip joint, using finite element method

In this paper, we present a three-dimensional mathematical model for a normal hip joint. The three-dimensional finite element model has been constructed based on Computer Tomograph scans of the bones. The obtained 3D model is studied using the finite element method, taking into consideration the real structure of the bone and the mechanical characteristics of cortical and spongy. The FE model of hip joint, the material properties used to simulate the behavior of the cortical and trabecular bone (of femur and coxal bone) and the cartilage, as well as the boundary conditions are presented. The distribution map of the axial and global movements on the global model and the distribution map of the axial and von Misses strain in the cartilaginous surface of the femur are presented.

Hypothesis of microfractures by buckling theory of bone's trabeculas from vertebral bodies affected by osteoporosis

Osteoporosis has become in recent years a public health problem considered a true "silent epidemic", by increasing the number of osteoporosis fractures in the world as a result of increased number of persons 3rd group of age by increasing life expectancy and reducing physical effort and the emergence of sedentary occupations, increasing incidence of obesity, diabetes, liver disease and kidney by applying widely corticosteroid therapy. Starting from the macroscopic and microscopic aspects of the bone spongy tissue affected by osteoporosis, from vertebral bodies, we try to explain the modality of damaging the bone micro-structure by buckling phenomenon, knowing that the bone tissue has at trabecular level, an elasticity degree and supports high levels of mechanical forces.

The arthroscopy-histological criterion link in endoscopic "repair" treatment of chondral and chondralbone lesions of the knee

The authors present the results of optical microscopic studies of some lesions of cartilage and subchondral bone of the knee, the arthroscopy allowing this structure's biopsy during the endoscopic procedures. These histological criteria are very important estimation factors of long term results of these "repair" techniques, the microstructure showing the real biological status of these specific tissues.

CAD method for three-dimensional model of the tibia bone and study of stresses using the finite element method

In the real life, the leg and its skeleton are exposed at the most diverse stresses. It is known that the human bone is one of the most important natural composite materials. The paper presents a method of study and the steps to obtain the virtual bones of the human body, method applied to tibia bone. For that purpose was used a CAD parametric software which permits to define models with a high level of complexity. To obtain the bone cross sections of the tibia bone a Computer Tomograph was used. The obtained 3D model is studied using the finite element method, taking into consideration the real structure of the bone and the mechanical characteristics of cortical and spongy, and we can obtain the stresses distribution for different solicitation.

The virtual model of the prosthetic tibial components

The paper presents a method of study and the steps to obtain the virtual tibial component of the human knee joint prosthesis. For that purpose CAD parametric software was used which allows the construction of a high definition model. The obtained 3D model was studied using the finite element method and the stress and displacements distribution was obtained for different solicitations of the prosthetic and non-prosthetic tibial component of the virtual knee joint.

Histological study [correction of styudy] of the femural head and neck microscopic architecture in persons with senile osteoporosis

For our study were available fragments of bony tissue from 24 patients (15 females and 9 males) aged between 55-82 which needed hip arthroplasty after they had undergone femural neck fractures. Biologic pieces have been fixed, then decalcified and processed by wax embedding. We noted that the spongious osseous tissue appeared as rarefied after the remoulding processes; osseous traveas grew unplainly thinner, with their large areolar cavities filled of bony yellow marrow. The osseous cortex presented deformed osteomas with large irregular Havers ducts. The osteocytes appeared rarefied, of small size with a picnotic and hyperchrome nucleus.

[Lower limb varicosity in patients, with indication for total knee arthroplasty]

Preoperative treatment of the peripheral venous pathology in patients with indication for total knee arthroplasty (TKA) would reduce the risk of postoperative deep venous thrombosis (DVT). Between 1997 and 2004, 110 patients were evaluated for TKA. 35 had also varicose veins in the lower limbs. 4 patients were excluded because of absolute contraindications for surgery. 31 patients presented varicose disease, in different stages according with CEAP. The patients were treated surgically (Babcock or Muller technique), phlebotomy drugs and mechanical contention. In a single case the TKA was done without any preoperative treatment of the varicosities. TKA was done after 8-12 weeks. DVT prophylactic measures were undertaken in all 95 cases. Results were good except 2 cases of DVT and 1 case or pulmonary embolism in patients with preoperative treatment of the venous disease. The patient with no preoperative treatment of its varicose veins developed DVT with chronic, persistent oedema. Preoperative treatment of the varicose veins in the lower limb is mandatory for a successful TKA.

The generation of the three-dimensional model of the human knee joint

In this paper we analyze the anatomic elements that compose the human knee joint. Also, we build the spatial model of the human knee joint components. This study is necessary for the design of prosthesis elements and for the establishment of the necessary prosthesis technique.