Prevalence of symptomatic hip and knee osteoarthritis: a two-phase population-based survey

OBJECTIVE

Osteoarthritis (OA) epidemiologic data are scarce in Europe. To estimate the prevalence of symptomatic knee and hip OA in a multiregional sample in France.

DESIGN

A two-phase population-based survey was conducted in six regions in 2007-2009. On initial phone contact using random-digit dialing, subjects 40-75 years old were screened with a validated questionnaire. Subjects screened positive were invited for ascertainment: physical examination and hip and/or knee radiography (Kellgren-Lawrence grade≥2). Multiple imputation for data missing not-at-random was used to account for refusals.

RESULTS

Of 63,232 homes contacted, 27,632 were eligible, 9621 subjects screened positive, 3707 participated fully in the ascertainment phase, and 1010 had symptomatic OA: 317 hip, 756 knee. Hip OA prevalence according to age class ranged from 0.9% to 3.9% for men and 0.7-5.1% for women. Knee OA ranged from 2.1% to 10.1% for men and 1.6-14.9% for women. Both differed by geographical region. The hip and knee standardized prevalence was 1.9% and 4.7% for men and 2.5% and 6.6% for women, respectively.

CONCLUSIONS

This confirmed the feasibility of using a screening questionnaire for eliciting population-based estimates of OA. In France, it increases with age and is greater among women above the age of 50. The geographical disparity of hip and knee OA parallels the distribution of obesity. Study registration ID number 906297 at http://www.clinicaltrials.gov/.

Multiple intraosseous meningiomas

In our knowledge, we are the first to report an observation on multiple osteomeningioma.

EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To develop evidence based recommendations for the management of hip osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale.

RESULTS

Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

OBJECTIVES

To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

METHODS

The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

RESULTS

497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

CONCLUSION

The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered.

Sex differences in hip osteoarthritis: results of a longitudinal study in 508 patients

OBJECTIVE

To evaluate sex differences in the clinical and structural presentation, and natural history of hip OA.

METHODS

A multicentre, prospective, longitudinal, five year follow up study of 508 patients (302 women, 206 men, mean age 63 (7) years) with painful hip OA. Data collected were baseline demographics, symptomatic, therapeutic, and structural variables; symptomatic variables and changes in joint space width (JSW) during the first year's follow up; requirement for total hip arthroplasty (THA) between the end of the first and fifth years.

STATISTICAL ANALYSIS

evaluation of sex differences (a) at baseline, in the main characteristics of hip OA using multivariate logistic regression; (b) during the first year of follow up, in the radiological progression of the disease; (c) during the five years of follow up, in the requirement for THA using Kaplan-Meier curves and the log rank test, and of the parameters related to THA, using a multivariate Cox analysis.

RESULTS

At entry, women presented more frequently than men with polyarticular OA (mean (SD) articular score 306 (162) v 235 (127)), and superomedial migration of the femoral head (40% v 19%), and had more severe symptomatic disease (patient's overall assessment 46 (23) v 40 (26)). The change in JSW did not differ between women and men after one year, but a greater proportion of women had rapid structural progression (OR=2.34, 95% CI 1.1 to 5.2). THA was performed more often in women. Multivariate analysis suggested that the decision to perform surgery was related more closely to the symptomatic and structural severity of the disease than to the sex of the patient.

CONCLUSION

Hip OA in women is more frequently part of a polyarticular OA, and displays greater symptomatic and structural severity.

Chondroitin sulfate in osteoarthritis of the knee: a prospective, double blind, placebo controlled multicenter clinical study

OBJECTIVE

To assess the efficacy and safety of chondroitin sulfate (CS) 1 g/day per os compared to placebo, in a double blind, randomized, parallel group study, with 3 months treatment followed by a 3 month posttreatment period, in patients with femorotibial osteoarthritis (OA).

METHODS

The main criterion was the functional handicap assessed by Lequesne's algofunctional index (AFI). Secondary efficacy criteria were: self-assessed pain with activity and at rest, self-assessed impact of OA on daily living, patient and physician assessed overall change in patient state since the previous visit, and daily NSAID and analgesic consumption, all evaluated monthly. The main analysis was performed on the intent-to-treat (ITT) population at treatment endpoint compared to baseline (Day 0).

RESULTS

The ITT efficacy data set comprised 130 patients (63 in CS group and 67 in placebo group). At treatment endpoint, the AFI showed greater but nonsignificant improvement in the CS than in the placebo group. Improvement became significant (p = 0.02) in the completer population (n = 114). In the ITT population, all variables tended towards greater improvement in the CS than the placebo group. In the completer population, pain at rest also significantly decreased in the CS group compared to the placebo group (p = 0.03), and, one month after treatment, CS had a significantly higher persistent effect than placebo on the AFI (p = 0.01), pain with activity (p = 0.001), physician assessed patient state (p = 0.05), and most other efficacy criteria. Adverse event rates did not differ significantly.

CONCLUSION

We observed a trend towards efficacy of CS 1 g/day compared to placebo with good tolerability after 3 month treatment, and persistent efficacy one month posttreatment. Further investigations are required to confirm this trend.

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

BACKGROUND

Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee.

METHODS

The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach.

RESULTS

Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted.

CONCLUSIONS

These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.

Requirement for total hip arthroplasty: an outcome measure of hip osteoarthritis?

OBJECTIVE

To assess if total hip arthroplasty (THA) is a valid outcome measure of hip osteoarthritis (OA), in respect to clinical and radiological assessments.

METHODS

A prospective 3 year study of patients who had painful hip OA with an initial radiographic joint space width > or =1 mm at the narrowest point. Dependent variable was THA. Patient data including body mass index, OA structural severity by radiograph, OA symptomatic severity (pain, function), and OA localization were recorded at entry. Pelvic radiographs were obtained before THA, when available, and once yearly during the study.

RESULTS

During the study 106 of 506 patients underwent THA. Risk was estimated (Kaplan-Meier method) to be 8+/-1, 16+/-2, and 23+/-2% after 1, 2, and 3 years, respectively. Factors predisposing to requirement for surgery were: age > or =70 years, female sex, superolateral migration of the femoral head, joint space width <2 mm, Kellgren-Lawrence grade > or =3, pain (visual analog scale) > or =50 mm, and Lequesne index > or =10 with a relative risk of 1.65, 1.71, 1.96, 1.85, 1.89, 1.86, and 2.59, respectively. Mean change in joint space width was 0.22+/-0.50 vs 0.97+/-1.35 mm/year in patients without and with THA, respectively (p<0.0001). Changes in radiological joint space width during the first year were highly predictive of requirement for THA during the 2 following years (risk of 5, 13, 25, and 79% in patients with a radiological joint space width worsening during the first year of 0, < or =25, >25 and < or =50, and >50%, respectively).

CONCLUSION

These data suggest that THA could be considered as a valid outcome measure in OA. However, further studies should be conducted in other countries with different health care systems to evaluate the inter-country reliability of this measurement.

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial

OBJECTIVE

To evaluate the efficacy of joint lavage and intraarticular steroid injection, alone and in combination, in the treatment of patients with symptomatic knee osteoarthritis (OA).

METHODS

Ninety-eight patients with painful tibiofemoral OA were enrolled in a prospective, randomized, controlled, 2 x 2 factorial-design trial of 6 months' duration. The 4 treatment groups consisted of 1) intraarticular placebo (1.5 ml of 0.9% normal saline), 2) intraarticular corticosteroids (3.75 mg of cortivazol in 1.5 ml), 3) joint lavage and intraarticular placebo, and 4) joint lavage and intraarticular corticosteroid. Outcome measures evaluated at baseline, week 1, week 4, week 12, and week 24 included severity of pain (100-mm visual analog scale [VAS]), global status (100-mm VAS), and Lequesne's functional index.

RESULTS

No interaction between steroid injection and joint lavage was demonstrated. Patients who had undergone joint lavage had significantly improved pain VAS scores at week 24 (P = 0.020). In contrast, corticosteroid injection had no long-term effect (P = 0.313); corticosteroid injection was associated with a decrease in pain only at week 1 (P = 0.003) and week 4 (P = 0.020). After week 4, Lequesne's functional index was not significantly improved regardless of the assigned treatment.

CONCLUSION

Compared with placebo, both treatments significantly relieved pain but did not improve functional impairment. The effects of the 2 treatments were additive. Cortivazol provided short-term relief of pain (up to week 4). The effects of joint lavage persisted up to week 24.

Bone and joint involvement in adults with Werner's syndrome

A 45-year-old man with Werner's syndrome had large asymptomatic calcium deposits about the elbows, hips, and shoulders. During the four-year follow-up, he developed insufficiency fractures of the pelvis, both ulnas, one radius and one metatarsal, all of which failed to heal. Bone mineral densities evaluated by dual-energy X-ray absorptiometry were at the lower end of the normal range, but a histomorphometric study showed a reduction in trabecular bone volume and marked decreases in osteoid parameters with a calcification rate of zero. Serum assays of 25 hydroxy vitamin D3, 1,25 dihydroxy vitamin D3, osteocalcin and alkaline phosphatase were normal. The nonunions in this patient may have been caused by impaired osteoblast function associated with Werner's syndrome and/or by decreased activity of growth factors involved in bone repair.

Osteoporotic vertebral fractures in a man under high-dose inhaled glucocorticoid therapy. A case-report with a review of the literature

A 65-year-old man had surgery in June 1995 for femoral neuralgia. The plain films of the spine were normal at the time. In September of the same year, when he was beginning to walk gradually longer distances, he started experiencing back pain. Crush fractures of T8 and L2 were seen on plain films. His pain worsened, and he was admitted in December 1995. A third set of plain films disclosed fractures of all the vertebral bodies from T8 through L5, with increased density of the endplates of the same vertebras. Serum and urinary levels of calcium and phosphate were normal. Dual-energy X-ray absorptiometry demonstrated osteoporosis predominating in the trabecular bone. Evidence of increased bone resorption was seen on the histomorphometric study. Large amounts of dihydroxypyridinoline were found in the urine. Investigations for the classical causes of osteoporosis in males were unrewarding. Careful questioning revealed that the patient had been taking inhaled beclomethasone for seven years to treat chronic obstructive lung disease. Serum levels of cortisol and ACTH were low, consistent with a diagnosis of treatment-induced hypercorticism. To our knowledge, this is the first reported case of osteoporotic vertebral fractures in a male due to inhaled glucocorticoid therapy. Inhaled glucocorticoids are generally believed to induce only minimal systemic effects. However, decreased serum osteocalcin levels and increased urinary excretion of bone resorption markers have been reported in patients under inhaled beclomethasone therapy. Low spinal bone mineral density values correlated with the degree of pituitary-adrenal gland suppression as evaluated using the ACTH test have also been found in several groups of patients treated with inhaled glucocorticoids.

Inflammatory rheumatism and nasal polyposis

We report five cases of seronegative inflammatory rheumatism associated with nasal polyposis. The patients were four women and one man, mean age 49.5 years (range 42-59 yrs.). Two patients had polyarthralgia predominating in the hands, wrists and knees and two patients had symmetrical acromelic polyarthritis. The fifth patient, a woman, had oligoarticular arthritis. In a single female patient, X-rays showed moderate erosions of both tarsometatarsal bones. The inflammatory syndrome was moderate with mean ESR 23 (12-38) and immunological investigations were negative except for the presence of pANCA (50-200 U) in three patients. HLA-A1, B8, and Bw35 antigens were found in three of the five patients. In all cases, nasal and sinus polyposis (NSP) preceded rheumatism and the joint symptoms were accompanied by worsening of the ENT symptoms. NSP was confirmed by CT scan of the nasal fossae and sinuses. Polyps were surgically removed in four patients and the histology showed neither granuloma nor vasculitis. In four patients the joint symptoms, which responded poorly to nonsteroidal anti-inflammatory drugs (NSAIDs), improved markedly after ENT treatment (surgery and topical steroids) and synthetic antimalarials. The concomitant course of the joint and ENT symptoms suggests there may be a link between inflammatory rheumatism and NSP.

Phosphate excretion in reflex sympathetic dystrophy syndrome before and after a single infusion of pamidronate

To clarify the relations between reflex sympathetic dystrophy syndrome and moderate phosphate diabetes, we prospectively determined urinary phosphate excretion parameters (clearance, renal tubular reabsorption of phosphate and threshold of tubular reabsorption of phosphate) in 37 patients with reflex sympathetic dystrophy syndrome before and after treatment with 60 mg of pamidronate (n = 23) and in 35 age- and sex-matched controls. Urinary phosphate excretion parameters were identical in cases and in controls. Fourteen of the 23 cases treated by pamidronate were improved after one to two months. Pamidronate had no effect on phosphate excretion. Four cases versus only one control had phosphate diabetes (X2 = 0.18). Three of the four cases with phosphate diabetes failed to respond to pamidronate therapy but improved under phosphate and 1,25-diOH vitamin D3 therapy.

An X-ray absorptiometry study of reflex sympathetic dystrophy syndrome

X-ray absorptiometry (Lunar DPX) was performed before and after treatment to determine bone mineral content and density, as well as fat-free mass and body fat, in 28 males and 11 females with a mean age of 37 years who met Doury's criteria for reflex sympathetic dystrophy syndrome. Mean disease duration was eight months. Before treatment, as compared to the unaffected limb, bone mineral content was decreased by 8.8%, bone mineral density by 9.6%, and fat-free mass by 6.2%, whereas body fat was increased by 6%. These differences were largest in those patients with the longest disease durations. The severity of bone loss was not correlated with the outcome, the severity of roentgenographic lesions, or whether the patient was evaluated at the warm or cold stage of the disease process. Study parameters were unchanged after three months both in patients who were and were not improved. After nine to 12 months, increases in bone and fat-free mass were seen in those patients whose clinical manifestations had subsided.

Comparative study of 4 diagnosis criteria sets for mixed connective tissue disease in patients with anti-RNP antibodies. Autoimmunity Group of the Hospitals of Toulouse

OBJECTIVE

To evaluate the performances of 4 sets of criteria proposed to define mixed connective tissue disease (MCTD): the criteria of Sharp, Alarcón-Segovia, Kasukawa, and Kahn. As anti-U1-RNP antibodies appear indispensable to establish the diagnosis of MCTD, we wished to reevaluate these sets of criteria in patients who all had anti-U1-RNP antibodies.

METHODS

We analyzed clinical and biological data to find which diagnostic criteria were met by 45 patients with anti-U1-RNP antibodies. We tested criteria for rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, polymyositis, Sjögren's syndrome, and 4 sets of criteria for MCTD.

RESULTS

The criteria that best identified patients with MCTD were those proposed by Alarcón-Segovia, with 62.5% sensitivity and 86.2% specificity, comparable to Kahn's criteria. The overlap with other connective tissue diseases was found to be 16%. These results could be improved by using the term "myalgia" instead of "myositis" in the definition. This increased sensitivity to 81.3%, with no decrease in specificity.

CONCLUSION

Alarcón-Segovia's and Kahn's criteria are the best classification criteria to define MCTD.

Radiological progression of hip osteoarthritis: definition, risk factors and correlations with clinical status

OBJECTIVES

To determine a cut off value for changes in radiological joint space width that allowed definition of radiological progression of hip osteoarthritis not related to measurement method errors and, thereafter, to determine factors predictive of radiological progression of hip osteoarthritis and to evaluate the correlations between clinical and radiological parameters.

METHODS

A prospective, longitudinal (one year duration), multicentre study was made of patients with osteoarthritis of the hip (American College of Rheumatology criteria). Data on clinical activity (pain, functional impairment), demographic data (age, gender, body mass index), and femoral head migration (superolateral, superomedial, concentric) were collected when the patient entered the study; radiological grade (joint space width in millimetres at the narrowest point using a 0.1 mm graduated magnifying glass, evaluated by a single observer unaware of the chronology of the films) was recorded at the patient's entry to the study and after one year.

RESULTS

Analysis of the means of the differences between two analyses performed by a single observer of 30 pairs of radiographs (one performed after an interval of one year) (0.06 (SD 0.23)) suggested that a change of more than 0.56 mm (2 SD) after a one year follow up could define progression of osteoarthritis of the hip. Of the 508 patients recruited, 461 (91%) completed the one year follow up and radiological progression was observed in 102 (22%). The factors predictive of radiological progression that were identified in the multivariate analysis were: radiological joint space width at entry < or = 2 mm, superolateral migration of the femoral head, female gender, Lequesne's functional index > 10, age at entry > 65 years (odds ratios 2.11, 4.25, 2.51, 2.66, 1.90, respectively). The level of clinical parameters (pain, functional impairment) and the amount of symptomatic treatment required (non-steroidal anti-inflammatory drugs and analgesic intake) accounted for 20% (p < 0.0001) of the variability of the changes in radiological joint space width over the one year study period.

CONCLUSION

These data suggest that radiological progression of hip osteoarthritis could be defined by a change in joint space width of at least 0.6 mm after a one year follow up period, is correlated with the changes in clinical status of the patients, and is related not only to demographic data (age, gender), but also to some specific characteristics of osteoarthritis (localisation, radiological severity, clinical activity).

[Medical treatment of osteoarthritis]

Immediate symptom relief, long-term symptom relief and chondroprotection comprise the basis of medical treatment of degenerative joint disease. Nonsteroid anti-inflammatory agents, antalgics and intra-articular infiltrations with corticosteroids provide rapid relief. A more delayed long-term effect can be obtained with a large number of drugs. Chondroprotectors are currently the focus of therapeutic research. Advances in our knowledge of the pathophysiological processes involved in the development of the degenerative process, a critical analysis of current medical therapies and rigorous methodology in clinical trials will soon provide a better range of treatments for patients suffering from degenerative joint disease.

Pamidronate infusions for the treatment of Paget's disease of bone

Effective pamidronate dosages in Paget's disease of bone have not yet been determined. We prospectively compared two pamidronate dosages (60 mg and 120 mg) in 26 patients whose baseline alkaline phosphatase level was at least two-fold the upper limit of normal. Pamidronate was given as three-hour infusions of 60 mg each. Follow-up was two years. The two groups were comparable at baseline except for higher alkaline phosphatase and hydroxyproline levels in the group treated with 120 mg pamidronate. Efficacy on laboratory parameters was greater in the higher dosage group. Osteocalcin levels showed little change. In both dosage groups, alkaline phosphatase levels fell significantly versus baseline, and the difference persisted throughout the two-year follow-up. Urinary hydroxyproline excretion remained significantly reduced versus baseline during the first 12 months and rose subsequently. A return to normal of the two study parameters six months after treatment was associated with longer duration of the biologic treatment response. A survival curve analysis confirmed this finding and suggested that a return to normal of laboratory parameters was predictive of clinical remission. The drug was well tolerated. Adverse effects were mild and similar to those recorded during earlier studies.

Effect of ovariectomy on intraosseous vascularization and bone remodelling in rats: action of tiludronate

In order to study the action of tiludronate on the changes in intraosseous vascularization induced by ovariectomy, and to link these effects to those observed in bone remodelling, 30 female Sprague-Dawley rats (age 40 weeks) were studied. Ten rats were shamoperated and treated by vehicle, 10 rats were ovariectomized and treated by vehicle, and 10 rats were ovariectomized and treated orally with tiludronate, 0.16 mmol/kg/per day, 3 days a week for 16 weeks, from the day following ovariectomy. The rats were killed after 4 months, and a histomorphometric study and quantification of intraosseous vessels carried out on the sixth lumbar vertebra. The area of the intraosseous sinusoidal capillaries increased after ovariectomy, which also induced a moderate increase in resorption surfaces and osteoid surfaces leading to a decrease of 40% in the trabecular bone volume at the lumbar spine level. This bone mineral loss was completely prevented by tiludronate, which normalized the bone turnover. However, tiludronate was without any effect on intraosseous vascularization. These results indicate that the surface area of the intraosseous sinusoidal capillaries was correlated positively with resorption surfaces and negatively with trabecular bone volume and the number of bone trabeculae. In these experimental conditions, an inhibitor of bone resorption can exert its positive effect on bone mass without normalization of vascularization.

Lactose intolerance and osteoporosis in men

Three men with osteoporotic fractures were found to have lactase deficiency and low dietary calcium intakes, decreased urinary calcium, and moderately increased serum osteocalcin and parathyroid hormone levels. Histomorphometric studies demonstrated increases in osteoid parameters and resorption surfaces. The few studies of the links between osteoporosis and lactase deficiency have yielded discordant results. A low calcium intake due to aversion to dairy products caused by the lactase deficiency may promote the development of osteoporosis.

Tubular excretion of phosphate in Paget's disease of bone. Effect of pamidronate

Two recent reports of phosphate diabetes in pagetic patients prompted us to evaluate urinary phosphate and its variations under pamidronate therapy in Paget's disease of bone. We also investigated whether Paget's disease is associated with phosphate diabetes. Urinary phosphate excretion was determined in 75 pagetic patients with a mean age of 72 years. None of the patients had received treatment during the six months preceding the evaluation. The 30 patients with clinical, laboratory test, and/or roentgenographic evidence of active Paget's disease were given intravenous pamidronate in a dosage of 60 or 120 mg. The control group was composed of thirty-seven age- and sex-matched subjects selected among patients admitted for degenerative bone or joint diseases. Phosphate and calcium levels were determined in blood and urine on two consecutive days in both cases and controls. The same assays were repeated six months after pamidronate therapy in the 30 patients with active Paget's disease. Phosphate diabetes was defined as a phosphate clearance above 20 ml/mn, a rate for tubular reabsorption of phosphate above 80%, and a ratio of the maximal rate for tubular reabsorption of phosphorus over the glomerular filtration rate (TmP04/GFR) below 0.80 mmol/l. As compared with controls, untreated cases had a nonsignificant increase in phosphate clearance (16.78 +/- 10.40 ml/mn versus 14.81 +/- 7.20 ml/mn), a significant decrease in tubular reabsorption of phosphate (83.41 +/- 5.57% versus 86.70 +/- 5.30%; p < 0.05), and a nonsignificant decrease in the TmP04/GFR ratio (0.93 +/- 0.14 mmol/l versus 0.98 +/- 0.15 mmol/l).(ABSTRACT TRUNCATED AT 250 WORDS)

Etiologic factors in finger osteoarthritis

Etiological factors in finger osteoarthritis are both local (single injury or repetitive joint use) and general. Epidemiological studies, twin studies, and studies of the ethnic influence have established that genetic factors play a role. The disease is more common in postmenopausal women, suggesting an influence of hormonal factors. Findings from studies of associations between finger osteoarthritis and osteoarthritis at other sites (spine, hips, knees), hyperostosis, and obesity, as well as the fact that the disease is less common in patients with osteoporosis and absent in hemiplegia, suggest that the concept of "osteoarthritic disease" is relevant.

Is camptocormia a primary muscular disease?

STUDY DESIGN

This study analyzed computed tomographic scans, magnetic resonance images, and biopsies of the paravertebral muscles of patients with camptocormia and age-matched patients with lumbar interapophyseal osteoarthritis or lumbar vertebral stenosis.

OBJECTIVES

To define the muscular lesions and clarify their nature in this particular disorder.

SUMMARY OF BACKGROUND DATA

Progressive lumbar kyphosis or camptocormia, a rare disease of the elderly characterized by inability to immobilize the lumbar spine in relation to the pelvis appears to be a result of weakness of the paraspinal muscles. The features presented by these patients do not correspond to any myopathy previously described.

METHODS

Twenty-seven patients (5 men and 22 women) mean age 69 years, with camptocormia were compared to fifteen age-matched patients without camptocormia but with posterior interapophyseal osteoarthritis and to nine elderly patients operated for narrowing of lumbar canal. Computed tomographic scans, magnetic resonance images, light microscopy, histochemistry, and electron microscopy of paraspinal muscles were obtained in both groups.

RESULTS

In patients with camptocormia, computed tomographic scans and magnetic resonance imaging showed heterogeneous appearance of the spinal muscles with areas of low density. These features were distinct from those of patients with interapophyseal osteoarthritis and were similar to the features described in primary muscular dystrophies. The main microscopic change in camptocormia was the increase of fibrous tissue, frequently with a lobular pattern, not seen in osteoarthritic patients. Familial history of the disorder was frequent (20 out of the 27 patients).

CONCLUSION

Camptocormia, disappearing in the recumbent position, is thus very probably linked to muscle involvement. That there is often a family history of such disorder is in favor of a genetically transmitted condition. Magnetic resonance images and computed tomographic scan appearance seems to be in favor of primary muscular disease, restricted to the spinal muscles.

Abnormal T cell receptor V beta gene expression in the peripheral blood and synovial fluid of rheumatoid arthritis patients

OBJECTIVE

The aim of this study was to assess T cell receptor V beta-gene expression in the peripheral blood and synovial fluid of rheumatoid arthritis patients.

METHODS

Cytometric analysis was performed on peripheral blood and synovial fluid lymphocytes from 12 patients using a restricted set of V beta-specific monoclonal antibodies (to V beta 5.1-3, V beta 6.7 and V beta 8). In 5 patients the expression of the V beta 1 through V beta 20 gene families was also analysed, using a recently described method based on a one-side-specificity polymerase chain reaction coupled to reverse dot hybridization.

RESULTS

Cytometric analysis failed to show any consistent difference in the expression of V beta 5, 6 and 8 between the two compartments on the one hand, or between the peripheral blood of normal individuals and patients on the other hand. The PCR/dot hybridization method did not demonstrate a significant difference in the V beta repertoires between peripheral blood and synovial fluid samples from arthritis patients. However, in all patients the V beta 6, 13 and/or 14 families were expressed to a high level, so that these families frequently represented over 40% of the V beta 1-20 repertoire in both compartments, instead of the approximately 20% seen in normal peripheral blood samples.

CONCLUSION

We conclude that V beta 6, 13 and 14 are overexpressed in both the peripheral blood and synovial fluid of rheumatoid arthritis patients compared to normal samples.

Comparison of the bone mineral content of the lower limbs in men with ischaemic atherosclerotic disease

In a previous study, the authors demonstrated that in 17 men with ischaemic atherosclerotic disease the bone mineral density (BMD) of the femoral neck was lower than in matched control subjects. The patients with arterial disease were thinner and were heavier smokers than the controls. Osteoporosis and arterial disease of the lower limbs were perhaps due to common risk factors: tobacco consumption and a low body build index. In order to demonstrate the direct effect of atherosclerosis on bone mineral content (BMC), the authors studied by dual-energy X-ray absorptiometry the BMC of both legs in 18 men presenting symptomatic arterial disease of the lower limbs quantified by measurement of distal systolic indexes by doppler ultrasonography. The mean BMC of the leg more severely affected by arterial disease was significantly lower than the mean BMC of the leg less affected by arterial disease (512 +/- 76 g versus 495 +/- 80 g: p = 0.003). In 13 of the 18 patients, the BMC was lower in the leg more severely affected by arterial disease; in 4 of 18 the difference between the BMC of the left and right legs was less than 1%, and in a single patient the BMC was higher in the leg more affected by arterial disease. Arterial disease of the lower limbs could lead to bone mineral loss.

Renal tubular disorders and arteriopathy of the lower limbs: risk factors for osteoporosis in men?

In order to clarify the risk-factors for men with vertebral fractures due to osteoporosis, we carried out a study of 51 cases. Twenty-five percent of patients had an endocrine disorder (hyperparathyroidism, hypogonadism, hyperthyroidism) or had received corticosteroids. These patients were compared with 26 age-matched controls. Eleven patients compared with 2 of the 26 control subjects had arteriopathy of the lower limbs; 11 patients had hypercalciuria or hyperphosphaturia compared with 3 of the control subjects. Arteriopathy appears to be associated with osteoporosis in older patients (mean age 71 years), whereas renal tubular disorders were found in younger patients (mean age 45 years).

Breast granuloma and C.R.S.T. syndrome

One case of CRST syndrome with breast granuloma is presented. The presumed diagnosis were infectious or neoplastic diseases. High doses of corticosteroids led to improvement in breast nodules.

Clonality of T lymphocytes expanded with IL-2 from rheumatoid arthritis peripheral blood, synovial fluid and synovial membrane

The association of rheumatoid arthritis (RA) with particular MHC class II genes suggests that autoantigen-specific T cell clones present in joints could be central to the pathogenesis of the disease. Previous investigations on the clonal diversity of T cells infiltrating the rheumatoid synovial membrane have yielded conflicting results. With the use of Southern blot analysis, we investigated the clonality of rheumatoid T cell lines expanded from peripheral blood, synovial fluid and synovial tissue. From peripheral blood lymphocyte (PBL) of RA patients and healthy normal controls, we also checked the consequences of two different culture conditions on the clonality of these cell lines. From control PBL, we found that in vitro non-specific expansion of non-clonal T cell populations does not create artefactual clonal selection. However, growing T cells in vitro with IL-2 seems to be able to lead to preferential expansion of cells bearing IL-2 receptor (IL-2R). We identified such in vivo activated IL-2-sensitive T cell clones frequently in RA synovial tissue (8/13) and more rarely in synovial fluid and peripheral blood (3/12). One patient presents the same T cell receptor gene rearrangements in synovial membrane of two affected joints. In RA synovial tissue, the frequency of these IL-2-responsive T cells is most prevalent among actively inflamed membranes removed early in the disease process. The role and the relevance to the disease of these IL-2-responsive T cells remain to be elucidated.

Lumbar and cervical stenosis. Frequency of the association, role of the ankylosing hyperostosis

The authors report a study of 47 patients admitted for cervical myelopathy (N = 17) or symptomatic lumbar spinal stenosis (N = 30). Nine patients had clinical evidence of coexisting cervical myelopathy and lumbar spinal stenosis. Ten out of the 17 patients having cervical myelopathy had lumbar spinal stenosis as evidenced by sagittal tomography and/or computerized tomography. Nine out of the 30 patients admitted for symptomatic lumbar spinal stenosis had coexisting cervical canal stenosis as evidenced by sagittal tomography. Thirteen out of these 19 patients with both cervical and lumbar canal stenosis had also ankylosing spinal hyperostosis.

Stenosis of the lumbar spinal canal in vertebral ankylosing hyperostosis

Certain morphologic features frequently observed in radiography or computed tomography (CT) scan in patients with hyperostosis led us to study the association between a narrowed spinal canal and vertebral hyperostosis. Twenty-eight items were selected and studied by three different investigators (two rheumatologists and one radiologist) in radiographs and CT scans of 100 patients with acquired stenosis of the lumbar canal, with or without hyperostosis (46 and 54 cases, respectively). The most distinctive points that we suggest can be used as diagnostic criteria of the hyperostotic narrowed lumbar canal are anterior or posterior lateral marginal somatic osseous proliferations, proliferations of the nonarticular aspects of the posterior apophyses, and ossifications of the posterior articular capsule and of the ligaments (yellow ligament, posterior longitudinal ligament, and the supraspinal ligament). Four of these six criteria should be present to establish the diagnosis of hyperostotic lumbar stenosis. The appearance of lumbar hyperostosis on X-ray or CT scans differs from that of simple degenerative changes due to arthrosis, and the hyperostosis can be held responsible for dural compression.

Intensive combined therapy for previously untreated aggressive myeloma

A trial was initiated to determine the feasibility and efficacy of a three-phase treatment including: (1) induction chemotherapy (IC); (2) high-dose melphalan with total body irradiation supported by unpurged autologous bone marrow transplantation (ABMT); and (3) interferon (IFN) alpha maintenance treatment, in previously untreated aggressive myeloma. Thirty-five consecutive patients, ages under 65 years, were enrolled. Initial induction therapy was randomized between the VAD regimen (vincristine, doxorubicin, dexamethasone) or the VMCP regimen (vincristine, melphalan, cyclophosphamide, prednisone) that were found to give similar results as IC. Thirty-one of 35 (89%) patients, with good performance status and normal renal function after IC, received ABMT. IFN alpha was started soon after ABMT and was well tolerated. Fifteen of 35 (43%) patients achieved complete response (CR) and 14 of 35 (40%) achieved partial response (PR). Low pretreatment beta 2 microglobulin was the only predictive factor for accomplishing CR. The duration of response was significantly affected by the magnitude of response. The 33-month, post-ABMT probability of progression-free survival was 85% for patients in CR versus 24% for patients in PR. The 42-month, post-diagnosis probability of survival was 81%. This overall strategy may represent an advance in the management of multiple myeloma. Furthermore, the high rate and long duration of CR that we observed in patients with low beta 2 microglobulin suggest that such patients may preferentially benefit from this strategy.

Increased concentrations of endogenous 13-cis- and all-trans-retinoic acids in diffuse idiopathic skeletal hyperostosis, as demonstrated by HPLC

Endogenous 13-cis- and all-trans-retinoic acids have been quantitated in human serum using a solvent extraction procedure followed by isocratic reversed phase high performance liquid chromatography and UV detection. In healthy adults, after an overnight fasting period, the concentrations of 13-cis- and all-trans-retinoic acids yielded 5.3 +/- 2.43 nmol/l and 11.8 +/- 3.3 nmol/l, respectively (mean +/- SD). The method has been successfully applied to the analysis of both isomers in serum from patients with idiopathic skeletal hyperostosis in whom, the 13-cis- as well as all-trans-retinoic acid levels were raised as compared to the control group.

Maintenance treatment with recombinant alpha interferon after autologous bone marrow transplantation for aggressive myeloma in first remission after conventional induction chemotherapy

Twenty patients (median age 57 years) with high tumor mass myeloma in first remission after conventional chemotherapy received a two-phase treatment: autologous bone marrow transplantation (ABMT) using a preparative regimen of high dose melphalan plus total body irradiation followed by maintenance treatment with recombinant alpha interferon. Before ABMT all patients were in partial remission, while after ABMT 10 (50%) achieved complete remission, and 10 remained in partial remission (with a 90% decrease in measurable paraprotein in 7/10). With a median follow-up of 19.8 months (12.2-33.5) after diagnosis and 13 months (4-25) after ABMT, the Kaplan-Meier 2-year post-ABMT probability of progression-free survival was 85% (95% CI = 58.7-95.8%). None of the 10 patients in complete remission has relapsed. No toxic death occurred. Alpha interferon was introduced early after ABMT (2.7 months) and was well tolerated. This strategy may represent an advance in the management of aggressive myeloma.

Phosphate diabetes associated with bone metastases of oat cell lung cancer

Although the link between phosphate diabetes and neoplasm or benign mesenchymal tumors has been well documented, the nature of the phosphaturia factor remains unknown. We describe two cases of phosphate diabetes associated with bronchogenic cancer. In these case reports, we suggest that fibroblasts or osteoblasts synthesize a phosphate eliminating substance.

Unusual stress fracture on the roof of the acetabulum: magnetic resonance imaging

We describe a case of stress fracture of the roof of the acetabulum, in a woman with osteoporosis. Magnetic resonance imaging gave abnormally low signals in T1 weighted images and high signals in T2 weighted images.

Osteonecrosis of the femoral and humeral heads after intraarticular corticosteroid injections

Two cases of multifocal osteonecroses are described. Two hips were affected in one case, 2 hips and 2 shoulders in the other. In both cases osteonecroses developed after intraarticular instillations of long-acting corticosteroids.

Treatment of Paget's disease of bone with (4-chloro-phenyl) thiomethylene bisphosphonate

Introduction of antiosteoclastic drugs, calcitonin and etidronate, has profoundly changed the treatment of active Paget's disease of bone. Nevertheless, the use of these drugs is limited in some patients by the occurrence of side-effects or by a resistance to therapy. We report the results of an open, nonrandomized study with a new bisphosphonate, (chloro-4 phenyl) thiomethylene bisphosphonate (Cl-TMBP), given orally to 35 patients with active Paget's disease of bone. At two different dosages this new bisphosphonate induced a significant decrease in disease activity. Patients receiving a mean dosage of 5 mg/kg/d (n = 14) showed a significant reduction of serum alkaline phosphatase levels to 43% of pretherapeutic values (from 499 +/- 91 to 214 +/- 41 IU/l) while hydroxyproline/creatinine ratio decreased to 43% of baseline (from 93 +/- 21 to 40 +/- 11). A second group of patients (n = 21) receiving a mean dosage of 11 mg/kg/d exhibited a similar response: serum alkaline phosphatase activity was reduced to 42% of initial values (from 1384 +/- 209 to 584 +/- 111 IU/l) while hydroxyproline/creatinine ratio fell to 48% of baseline (from 144 +/- 27 to 69 +/- 15). This was accompanied by a reduction in radionuclide uptake in pagetic areas. A prolonged beneficial effect was observed in most patients. In patients receiving the highest dosage significant reduction in serum calcium and rise in parathyroid hormone were observed. Otherwise no clinical or biological side-effect occurred throughout the study.

The transsynovial lymphocytic ratio. Characterization of blood and synovial fluid lymphocytes from patients with arthritic diseases

Monoclonal antibodies and flow cytometry techniques were used to analyze and compare the distribution of lymphocyte subpopulations of peripheral blood and synovial fluid (SF) from 70 patients, 43 with rheumatoid arthritis (RA), 10 with ankylosing spondylitis (AS) or reactive synovitis, 10 with psoriatic arthritis and 7 with other inflammatory arthritic diseases. Patients with RA had significantly reduced number of CD8+ T cells and greater CD4/CD8 ratios in peripheral blood, a greater number of CD4+ T cells and lower CD4/CD8 ratio in SF. No significant difference was found between the groups with AS, reactive synovitis and psoriatic arthritis. The simultaneous analysis of peripheral blood and SF lymphocyte subpopulations allowed us to establish a transsynovial lymphocytic ratio which reflects CD4/CD8 variations on both peripheral blood and SF, 2 easily accessible compartments for physicians. This new ratio may distinguish RA from other inflammatory arthritic diseases.