Surgical management of tibia refracture with a bent intramedullary nail: A case report and review of the literature

Intramedullary nailing is the gold standard for long bone fractures in the lower limbs. Fractures of the tibia with bending of the intramedullary nail is a very uncommon complication. Removing a bent nail is an unpredictable and challenging procedure for any trauma surgeon. We report the case of a 34-year-old man presenting a refractured tibia with a bent intramedullary nail following a motor vehicle accident. We describe the management of this patient as well as a substantial review of the literature to depict the peculiarities of this entity compared to its more commonly reported femoral counterpart. When approaching a deformed tibia nail, standard extraction techniques should be attempted and are more likely to be successful than in deformed femoral nails.

Sternoclavicular septic arthritis in a healthy adult: A case report and a review of the literature

Sternoclavicular joint septic arthritis is rare and commonly associated with specific risk factors. We report the case of a 58-year-old female with no previous medical or surgical history who presented complaining of a warm, indurated mass overlying the right sternoclavicular joint. Computed tomography of the chest showed erosion of the sternal end of the clavicle and the manubrium sternum associated with thickening of the synovium and a sternoclavicular joint space narrowing, suggestive of an infective process. Intraoperative finds a purulent collection extending both over the clavicle and the sternum. Limited destruction of small parts of the sternoclavicular joint was noted. The abscess was drained. Simple debridement and limited curettage were preferred to en bloc resection given the limited size of necrotic tissues. Sternoclavicular joint septic arthritis is a condition with significant morbidity and potential mortality. All medical practitioners must maintain a high degree of suspicion, even in healthy patients, as it can lead to serious complications.

Extraspinal osteoarticular tuberculosis: A diagnostic and therapeutic challenge

Tuberculosis (TB) is a major cause of morbidity and mortality, representing a challenge for health-care providers worldwide. Extraspinal osteoarticular tuberculosis (ESOTB) represents a rare location of TB. We aim to describe ESOTB focusing on clinical, diagnostic, and therapeutic characteristics of this entity. We report a retrospective case series of patients diagnosed with ESOTB, treated, and followed up between 2015 and 2022. The diagnosis was based either on bacteriological results (culture and polymerase chain reaction [PCR]) or histological analysis. Five patients with confirmed ESOTB, three women and two men, with a mean age of 46.4 (16-72), were enrolled in study. The affected sites were the elbow (one case), the shoulder (one case), the greater trochanter (one case), the second metatarsal (one case), and the distal interphalangeal joint (one case). The mean delay to diagnosis was 5.8 months (3-10)]. The most common symptoms on presentation were pain (all cases), swelling (all cases), and limited joint range of motion (all cases). One case presented with a draining sinus (20%). Radiological findings were soft tissue swelling (two cases) and periarticular bone destruction (all cases). Four patients presented with pathognomonic histology. PCR was performed in two patients and was positive in both of them. All cases were cured after 9-12 months of oral TB treatment without relapse for the 12-18 months of follow-up. Only one patient underwent surgery for abscess drainage to gain local infection control. ESOTB is a mysterious condition that must not be overlooked and should be suspected in cases of long-standing bone and joint pain and swelling.

AB1253 DISEASE PERCEPTION ASSESSMENT IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS AND THEIR PARENTS

Background

Juvenile Idiopathic Arthritis (JIA) has an impact on the quality of life of the patient and his family. Parent/patient reported outcomes have shown an increasing interest in the management of JIA because it reflects the perception of the disease course and the effectiveness of the therapeutic interventions.

Objectives

To determine the level of agreement between patients with JIA and their parents for the five quantitative items in Juvenile Arthritis Multidimensional Assessment Report (JAMAR) questionnaire.

Methods

We included children aged between 7 and 18 years old with AJI (ILAR criteria) and their parents. Demographic data and disease related parameters were collected. We asked both parent and child to complete the five quantitative items of JAMAR questionnaire. Were measured on a 21-numbered circle visual analogue scale (VAS) for pain (0 =no pain; 10 =very severe pain), disease activity (DA): (0 =no activity; 10 =maximum activity) and well-being (WB): (0 =very well; 10 =very poorly). Physical function was assessed by Juvenile Arthritis Functional Score (JAFS) [0-45] and health-related quality of life (HRQoL) [0-30] through the Physical Health (PhH) and Psychosocial Health (PsH) subscales. We calculated children and parents median scores for the five items. Intra class correlation coefficient ICC was used for analysis (ICC below 0.50: poor; between 0.50 and 0.75: moderate; between 0.75 and 0.90: good; above 0.90: excellent).

Results

A total of 21 patients/parent (12 girls and 9 boys) were included in the study. Forty percent belong to rural enviroment. Majority of patients were in secondary school (77%), 23% were in primary school. Seven patients had oligoarticular JIA, 13 had polyarticular JIA and one had systemic JIA. Median age at diagnosis was 11.4 ± 1.2 years [6-13]. Median age at disease onset was 9.5 ± 1.9 years [2-13]. Median disease duration was 4.3 years [0-7]. Median JADAS was 10 [8-18]. Uveitis was noted in 30% of cases. Comparison of parent proxy-reported and child self-reported data revealed a striking similarity for all items (p<0.001). The results of the five quantitative items of JAMAR questionnaire are represented in Table1. Good correlation was noted in JAFS, DA VAS, well-being VAS and HRQoL. Excellent correlation was noted in VAS pain.

Table 1.

Assessement of quantitative items of Juvenile Arthritis Multidimensional Assessment Report by patients and parents.

ItemsPatientsParentsICCMean pain VAS (0-10)4.2 [4-6]4.3[4-6]0.97Mean disease activity VAS (0-10)4.1 [4-5]4.2 [4-5]0.81Mean well-being VAS (0-10)4.4 [4-6]4.3 [4-5]0.9Mean Juvenile Arthritis Functional Score (JAFS)10.0 [1-20]10.2 [2-21]0.81Mean HRQoL score14.1 [7-17]14.8 [6-14]0.88

ICC: Intraclass Correlation Coefficient; HRQoL: Health-Related Quality of Life; VAS: Visual Analogue Scale.

Conclusion

Our study showed high level of agreement between patients and parents. The JAMAR provides a promising approach to quantitative measurement in standard pediatric rheumatology care. Availability of this new instrument may enhance regular use of parent/patient questionnaires in routine practice and improve disease management.

Disclosure of Interests

None declared

AB0321 ADHERENCE TO MEDITERRANEAN DIET AND PREVALENCE OF CARDIOVASCULAR RISK FACTORS IN RHEUMATIC DISEASES

Background

Rheumatic diseases (RD) are autoimmune inflammatory arthritis. However involvement to other organs can occur and leads to atherosclerosis and cardiovascular (CV) risk factors. Mediterranean diet (MD) has attracted considerable interest because it seems to offer significant benefits to that end.

Objectives

To evaluate the role of MD in the development of the cardiovascular risk factors in RD.

Methods

We conducted a cross-sectional study including patients with RA (ACR-EULAR 2010 criteria) or with SA (ASAS 2009 criteria), in remission or in low activity disease and with no history of cardio vascular risk factors before the diagnosis of their RD. Sociodemographic and disease related data were collected: Disease Activity Score (DAS28-CRP), Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) and medication. We asked the patients to complete the 14-items MD adherence questionnary. We evaluated the association of adhrence to MD with cardiovascular risk factors: obesity, type-2 diabetes, hyperlipidemia and hypertension. We estimated odds ratios for each cardiovascular risk factors and their 95% confidence intervals. In all analyses, the high adherence category of MD adherence score [10–14) was considered the reference category.

Results

We included 61 patients (40 women and 21 men) with a mean age of 42.2 ± 1.1 years old [20-66]. Among them, 32.7% belong to urban environment and 26.2% were professionally active. The mean disease duration was 83.2 months [9-180]. The mean DAS28-CRP was 1.2 [0.8-1.9] and the mean ASDAS-CRP was 1.8 [1.1-2.01]. Methotrexate was used by 52.4%, either as monotherapy or combination and biological in 47.6 %. Thirty patients had high adherence to MD (H-MD) and thirty-one had medium or low adherence to MD (L-MD). We found that higher adherence to the MD is inversely associated with the prevalence of each of the four cardiovascular risk factors, results are shown in Table 1.

Table 1.

Prevalence of cardiovascular risk factors and odds ratio in high adhrence to Mediterranean diet in rheumatic diseases.

Prevalence %Odds ratio95% confidence intervalsObesity57.40.017[0.03-0.93]Type-2 diabetes50.80.01[0-0.019]Hyperlipidemia50.80.126[0.04-0.3]Hypertension42.60.13[0.43-0.4]

Conclusion

Our results suggest that the healthy effects of the MD observed in epidemiologic studies are exerted partly through plausible mechanisms: low prevalence of obesity, of type2 diabetes, of hyperlipidemia and of hypertension. Interventional studies may eventually provide stronger evidence. In the meantime, an increasing of knowledge supports the Mediterranean diet as a useful tool in managing individuals with RD, who are at high risk ofcardiovascular diseases.

Disclosure of Interests

None declared

AB1572-PARE VIEWPOINTS OF YOUNG TUNISIAN WOMEN WITH RHEUMATOID ARTHRITIS REGARDING THE IMPACT OF THE DISEASE ON FERTILITY: ARE THEY AWARE ENOUGH?

Background

Rheumatoid Arthritis (RA) is one of the most common chronic inflammatory disease in women in reproductive age. It seems difficult to acheive parenthood in RA, therefore, reproductive health in these patients is an important issue. Many factors may interfere with procreation such as high disease activity and medication. Female perception and behavior towards fertility are not often assessed.

Objectives

We aimed to evaluate the fertility perceptions and related behavior among young women with RA.

Methods

We conducted a cross sectional study involving young female patients with RA (2010 ACR-EULAR criteria). Sociodemographic data and the following disease-related parameters were collected: diseases activity score (DAS28CRP) and NSAID (Non steroidal Anti-inflammatory Drugs), prednisone and DMARDs being used. We asked the patients about their knowledge about the risk of infertility due to the disease itself, the activity of RA and medication.

Results

Sixty-two females patients were included. The average age was 26.1 ±2.1 years [20-35]. The majority of patients, 54 women, live in rural enviroment and 8 women live in urban enviroment. Forty-two women (67%) were illiterate, ten women (16%) had primary or secondary school level and ten women (16%) had university school level. Only twenty percent (20%) were employed. There were no smokers included. Sixty-six percent (66%) were married. Forty-one women (66%) aimed to have children: 35 women got pregnant and 6 still didn’t get pregnant. The average of gestity was 1.6 [0-4]. The average of parity was of 1.2 [0-3]. The average of time to pregnancy (TTP) was 12 months ± 2 [6-24]. Pregnancy resulted in a live-born baby in 30 women (73%), 4 women (9%) miscarried and there was one intra-uterine fetal death (2%). Ten pregnant women had had fertility treatment to get pregnant. The mean duration of the RA was 3.1 years ± 1.2 [2-10]. The mean DAS28CRP were 3.1 ± 1.25[2-3.9]. Both rheumatoid factor and anti-citrullinated peptides antibodies were positive in 58 women (93%). RA was erosive in 48 cases (76.1%) and deformed in 2 cases (3%). Half of patient were using NSAID daily and 60% were using prednisone with an average daily dose of 5.1 mg/day [2.5-7.5]. Sixty-one percent (61%) of patients were using Methotrexate with an average weekly dose of 15.1 mg/week [10-22.5], 10% Leflunomide, 10% Sulfasalazine, and 45% biotherapy. About half of patient think that RA may cause fertility problems, infertility in 60% and abortion in 40% and they had this information in 60% from media, 30% from siblings and only 10.1% from their rheumatologist. None of patients think that disease activity may interfere with pregnancy and that they should strive low disease activity before trying to conceive. None of patients think that NSAID or COX2 inhibitor or prednisone may interfere with fertility and about 10 women used NSAID in pregnancy. About 24% think that DMARDs may interfere with procreation especially infertility (100%) with respectively: MTX (70%), Leflunomide (3%), Sulfasalazine (5%), biotherapy (20%). Women who didn’t get pregnant accused their impaired fertility to their DMARDs and eight women stopped their DMARDs in pregnancy for fear that it affected their baby. Only 5 women (8%) saw a rheumatologist in the preconception period.

Conclusion

The relationship between RA and fertility seems to be misunderstood in young women with RA. Clinicians must routinely discuss this issue with these young patients to preserve their fertility by learning them the mechanisms by which RA may affects their fertility: the disease itself and medication. Appropriate information about fertility can help women in productive age reach and carry a healthy pregnancy.

Disclosure of Interests

None declared

POS0294 PROFILE OF SPINAL TUMORS IN RHEUMATOLOGY DEPARTMENTS

Background:

Spine tumors remain a hot topic because of their associated morbidity by affecting motor and sensory function. Contrary to metastatic spine disease (MSD), extremely prevalent, rise within or surrounding the spinal cord and/or vertebral column, primary spinal tumors are rare, 5% of all primary skeletal tumors and frequently benign (20%). The diagnostic delay of these tumors, even when benign, is associated with a poor prognosis. Establishing the correct diagnosis is heavily reliant on magnetic resonance imaging and histological confirmation.

Objectives:

to provide an overview of the epidemiology, radiological and histopathological of spinal tumors diagnosed in a rheumatology department.

Methods:

A retrospective study consisting of clinical characteristics analysis, laboratory and x-ray examinations, was performed on 40 patients who were hospitalised for a spinal tumor, in a rheumatology department, over 5-year period from 2015 to 2020.

Results:

A total of 40 patients with a mean age of 66 ± 13.5 years [18-93] and a sex-ratio of 1.1, were included. The most common initial complaints were inflammatory back pain (67.5%) and fatigue (52.5%), with a median duration of 5 months. Physical examination abnormalities included lumbar stiffness (32.5%), radicular signs (18.7%), hepatomegaly (12.5%), and lymphadenopathy (17.5%). Neurological deficit was found in only 3 patients (7.5%). Hypercalcemia (corrected serum calcium > 105 mg/l), and anemia (hemoglobin (Hb) < 100 g/l in female, Hb <110g/l in male) were present initially in respectively 47.5% and 46.3% patients, while biological inflammatory syndrome was present in 89.7% patients (median C-reactive protein of 44.7). Tumor markers were performed in 12 patients and they were positive in 9 of them.

Plain radiographs findings were vertebral compression fractures (43.6%), osteolytic lesions (30.8%) and osteoblastic lesions (12.5%). Lumbar spine was the most affected (57.5%), followed by the dorsal spine (45%). Magnetic resonance imaging (MRI) was performed in 55%, and the most common lesion was low signal intensity on T1-weighted sequences and high signal intensity on T2-weighted sequences (68.1%).

In our study, only one patient was diagnosed for a myxopapillary ependymoma, a benign primary spinal tumor characterised by a metastatic dissemination risk. For the rest (39 patients), the diagnosis of bone metastasis, multiple myeloma (57.7%), and of solid tumor cancers (40%), were established. Primary cancers were mainly prostate cancer (37.5%), lung cancer (18.7%) and kidney cancer (18.7%). By a median follow-up time of 25 months, overall survival rate was 30%.

Conclusion:

Extradural lesions are the most common, and are typically metastatic. Special attention should be pain to the patient’s medical history and laboratory abnormalities. In fact, an early diagnosis requires a high index of clinical suspicion.

Disclosure of Interests:

None declared