Denosumab use in bone fibrous dysplasia refractory to bisphosphonate: A retrospective multicentric study

INTRODUCTION

Increased RANKL expression is observed in the bone tissue of fibrous dysplasia of bone/McCune-Albright syndrome (FD/MAS). In one animal model of FD/MAS, the inhibition of RANKL reduced tumor volume. A beneficial effect of denosumab on pain in patients refractory to bisphosphonates has been reported, but without systematic quantification of pain improvement. This work describes the clinical experience of our group on the efficacy on pain of denosumab treatment, along with safety, in FD/MAS patients refractory to bisphosphonates.

MATERIALS AND METHODS

We have conducted a retrospective multicenter study in 6 academic rheumatology centers in France. We have collected patients and FD/MAS characteristics, duration of prior exposure to bisphosphonates, denosumab treatment modalities (dosage - administration regimen - number of courses); evolution of pain evaluated by Visual Analogic Scale (VAS).

RESULTS

13 patients were included (10 women and 3 men) 45 years on average, 5 MAS, 4 monostotic and 4 polyostotic forms. The average duration post-diagnosis of FD/MAS was 25 years and the mean duration of prior exposure to bisphosphonates was 4.7 years. Pain could be analyzed in 7 patients, showing a significant improvement from a mean VAS of 7.8 to 2.9 (-4.9 points, p = 0.003). In one patient with fronto-orbital FD/MAS, a 30 % decrease in lesional volume, assessed by MRI, was observed within 6 months of treatment, that was sustained over the following 12 months. Treatment regimens were heterogeneous. No hypercalcemia was observed after treatment cessation and the clinical tolerance was good.

DISCUSSION

This study suggests that denosumab reduces pain in patients with DF/MAS refractory to bisphosphonates, and quantifies this improvement for the first time in a multicenter study. In our cohort, no patients who discontinued denosumab developed hypercalcemia and clinical tolerance was overall good. This study also provides encouraging data regarding lesion volume control. Further controlled studies are required to determine the place and modalities of the denosumab treatment of FD/MAS.

CONCLUSION

Denosumab significantly decreased pain in FD/MAS refractory to bisphosphonate. This study paves the way for a randomized clinical trial to validate and standardize the prescription of denosumab in FD/MAS.

POS1333 STUDY OF THE RELATIONSHIP BETWEEN THE TREATMENT TYPE AND THE THERAPEUTIC RESPONSE ACCORDING TO THE SAPHO SYNDROME CLINICAL FORM IN ADULTS FROM A RETROSPECTIVELY ANALYSED MULTICENTER COHORT

Background

SAPHO syndrome (Synovitis, Acne, Palmoplantar Pustulosis, Hyperostosis and Osteitis) is a radio-clinical entity associating joint, bone and inflammatory skin disorders. The clinical presentation is very heterogeneous making the diagnosis difficult. The therapeutic strategy in SAPHO syndrome is poorly defined. The first-line treatment remains NSAIDs on demand, which are effective in treating painful flare-ups but rapidly become insufficient in 60% of cases during the course of the disease. TNF-αNF-O syndrome (S necrosis factor-alpha) are reserved for refractory forms and their efficacy is uncertain [1]. Bisphosphonates (BPs) seem to have potential interest [2].

Objectives

The main objective of this study was to investigate the response to treatment with BPs and/or immunosuppressive drugs (DMARDs - Disease modifying anti-rheumatic drugs), conventional synthetic cs-DMARDs or biologic (b-DMARDs), according to the clinical form of rheumatological SAPHO (bony predominantly versus articular or mixed predominantly.

Methods

All patients aged 18 years or older with SAPHO syndrome meeting Benhamou’s criteria whose clinical, biological and radiological data were available in the files and who received at least one DMARD or BP treatment for their disease were included in Rouen (thanks to the health data warehouse), Caen, Le Havre/Lillebonne and Dieppe Centres. Each imaging examination was reviewed blinded to the treatments by a radiologist with expertise in osteoarticular disease. Patients were classified into 2 groups (bony versus joint/mixed) according to imaging data and clinical history. The response to treatment was considered positive if symptoms were improved by at least 50% (cut-off used in the literature). An χ2 patients aged 18 years or older with SAPHO syndrome meeting Benhamou’s criteria whose clinical, biological and a Mann-Whitney test for quantitative variables using SPSS software.

Results

Thirty-four patients with SAPHO who had received DMARD or BP treatment were included and classified as follows: 13 in the bone group and 21 in the joint or mixed group. The 2 groups were comparable on demographics, duration of follow-up, previous chest involvement, existence of associated dermatological or inflammatory bowel disease, exposure to smoking, duration of exposure to a previous NSAID or antibiotic. Only the age of onset of symptoms differed between the two groups, with a younger onset of disease in the bone group (p=0.043). The prescribers’ therapeutic attitude differed significantly between the 2 groups (p=0.043) with a greater prescription of BPs as first line in the bone group (5/13 patients) and a DMARD in the joint/mixed group (19/21). Regarding treatment efficacy, 10/13 patients had effective treatment without escape during their follow-up in the bone group, which was not significantly different from the joint/mixed group (17/21). BPs achieved escape-free efficacy in significantly more cases in the bone group than DMARDs in the joint or mixed group (p= 0.002). The bone group used significantly fewer specific treatment lines (DMARDs or BP) than the joint/mixed group (1 specific line vs. at least 2) (p =0.046).

Conclusion

BPs appear to be more effective in SAPHO with predominantly bone involvement. This appears to be easier to treat compared to SAPHO with articular or mixed forms.

References

[1]Daoussis D, Konstantopoulou G, Kraniotis P, et al. Biologics in SAPHO syndrome: A systematic review. Seminars in Arthritis and Rheumatism 2019;48:618–25. doi:10.1016/j.semarthrit.2018.04.003

[2]Wu N, Zhao Y, Tao W, et al. A single cohort, open-label study of the efficacy of pamidronate for palmoplantar pustulosis in synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Clin Exp Rheumatol 2020;38:1263–4.

Disclosure of Interests

None declared

AB0663 Bicentric observational study on the therapeutic management of patients with rheumatoid arthritis and systemic sclerosis overlap syndrome

Background

The rheumatoid arthritis (RA)/systemic sclerosis (SSc) overlap syndrome is a rare and understudied association. It affects 5% of patients with SSc. Only open studies evaluating biological drugs (bDMARDs) have reported encouraging results, particularly on joint involvement. The management of these patients is therefore not codified.

Objectives

The objective was to analyze in real conditions the therapeutic strategy and the response to bDMARDs, with a focus on joint involvement.

Methods

We retrospectively analyzed over a 10-year period the clinical, biological, radiographic characteristics and therapeutic management of patients meeting the ACR/EULAR diagnostic criteria for RA and SSc in two academic centers. Response to bDMARDs was assessed according to EULAR and if unavailable according to therapeutic maintenance. The evolution of lung function test was also evaluated.

Results

Twenty-two patients were identified. Interstitial lung involvement was common (n=11). Only 7 patients were treated with csDMARD alone. The most commonly used drug was methotrexate. The use of bDMARDs was frequent (15/22), significantly greater in patients with rheumatoid factors (OR 26.7; p=0.004) and with a trend in patients with higher levels of anti-CCP (160 vs 15 IU; p=0.11) or diffuse interstitial lung disease (OR 10.6; p=0.063). Tocilizumab was the most selected therapy (n = 8) followed by rituximab (n = 5), abatacept, and anti-TNFs (n = 4 respectively). We evaluated 21 treatment sequences, 19 of which were evaluated according to EULAR response criteria. bDMARDS that inhibits the activation of lymphocytes (abatacept, rituximab) generally resulted in a good or moderate response (n = 9/10) with a significant decrease in DAS28 at 6 months (-1.75; p = 0.016). Cytokine inhibitors (tocilizumab, etanercept, infliximab) were less likely to achieve good or moderate control of joint involvement (n = 3/9) with a smaller decrease in DAS28 at 6 months (-0.79; p = 0.36). Two tocilizumab sequences were stopped early due to intolerance and could not be evaluated. One patient received tofacitinib with a good clinical response but was discontinued at 9 months for intolerance. Lung function test data did not change significantly on bDMARD.

Conclusion

In patients with rheumatoid arthritis (RA)/systemic sclerosis (SSc) overlap syndrome, bDMARDS that inhibits the activation of lymphocytes (abatacept, rituximab) resulted in more frequent and greater improvement in joint involvement than cytokine inhibitors (tocilizumab, etanercept, infliximab).

Disclosure of Interests

None declared

Management strategies for acutely decompensated aortic stenosis

Background

Uncertainty exists over the optimal treatment strategy for patients presenting with acutely decompensated severe aortic stenosis (AS). The available options include a bridging balloon aortic valvuloplasty (BAV) or a direct transcatheter aortic valve implantation (TAVI).

Purpose

Our study compares TAVI outcomes in patients treated with two different strategies in acutely decompensated severe AS: bridged TAVI vs direct TAVI.

Methods

In this observational study all patients admitted with decompensated severe AS who underwent balloon aortic balloon valvuloplasty (BAV) and/or TAVI on the index admission were included. Comparison was made between bridged TAVI group (defined as initial BAV followed by TAVI) and direct TAVI group (TAVI on the index admission without bridging BAV). For this analysis we excluded patients in cardiogenic shock. Baseline characteristics, echocardiographic and periprocedural data were recorded in hospital database. Major adverse cardiovascular events (MACE) were defined as death, major bleeding, rehospitalisation for heart failure, or stroke). The follow-up data was obtained by outpatient visits and/or telephone calls.

Results

178 patients with acutely decompensated AS were analysed: 58 bridged TAVI, 23 direct TAVI, 9 bridged SAVR and 88 destination BAV (defined as BAV non followed by a definite treatment). There was no statistically significant difference between bridged TAVI and direct TAVI group in mean age (83.6±6.6 vs 80.4±8.3 years), the prevalence major comorbidities (coronary, respiratory, neurological or peripheral vascular disease), renal function (eGFR 43.4±18.9 vs 45.2±20.9 ml/min/m2), the mean LV ejection fraction (53.4±13.8 vs 48.6±14.6%) or aortic valve gradient (39.4±13.0 vs 34.1±12.3mmHg), respectively. Direct TAVI patients had a higher mean surgical risk scores (STS 6.1±3.7 vs 9.1±7.0%, logES 18.8±11.5 vs 30.8±20.9%, p=0.01) and higher prevalence of significant aortic regurgitation (5% vs 43%, p=0.0001). The femoral TAVI access was used in 98% of bridged and 78% of direct TAVI patients (p=0.006). The estimated 1-year survival and 1-year MACE-free survival did not differ significantly between the bridged TAVI and direct TAVI groups (86.8% vs 78.3%, p=0.20 and 79.7% vs 64.2%, p=0.11, respectively).

Conclusions

A large proportion of patients admitted with acutely decompensated AS were not eligible for definite treatment. There is no difference in procedural success, 1-year all-cause mortality and 1-year major adverse cardiovascular events between the bridged TAVI or direct TAVI strategies in acute decompensated aortic stenosis allowing to personalize treatment strategy for individual patient.

Funding Acknowledgement

Type of funding sources: None. Table 1. Clinical and procedural data

FRI0095 SARILUMAB IMPROVED PATIENT-PERCEIVED IMPACT OF RHEUMATOID ARTHRITIS WHATEVER THE BASELINE DISEASE ACTIVITY: FIRST RESULTS FROM AN INTERVENTIONAL NON CONTROLLED STUDY: SARIPRO, IN MODERATE AND SEVERE RHEUMATOID ARTHRITIS PATIENTS

Background:

Sarilumab, an anti-IL-6R antibody, is approved for the treatment of moderate to severe RA and shown efficacy on disease activity and patient-reported outcomes (PROs). Detailed analyses of drug efficacy from the patient point of view is important. SariPRO is a pragmatic interventional study close to the daily practice.

Objectives:

To assess the effectiveness of sarilumab on several PROs using the RAID (Rheumatoid Arthritis Impact of Disease) score.

Methods:

The SariPRO study (NCT 03449758) was a French multicenter interventional study assessing the effects of sarilumab 200 mg on PROs in patients with moderately to severely active RA with an inadequate response or intolerance to conventional synthetic or biologic DMARDs. The primary endpoint was change in total RAID score from baseline to week 24 (RAID ranges 0-10 where 10 is maximal impact). Changes from baseline for RAID, DAS28-ESR and CDAI according to baseline disease activity were analyzed as secondary outcomes. Safety was assessed by monitoring adverse events (AE). All statistical analyses were descriptive, 95% CI was given when appropriate.

Results:

84 patients were included in 31 centers and 62 were evaluable and analyzed for effectiveness. They had similar characteristics to the 84 patients at baseline and were as expected for an RA population initiating a biologic: mean (SD) age: 59.9 (12.4) years, 71.0% female, disease duration 9.7 (10.3) years, rheumatoid factor positivity 82.5%, ACPA positivity 86.4%, and DAS28=4.9 (11). Total RAID score decreased significantly from 5.7 (2.0) at baseline to 3.3 (2.5) at W24; mean change was -2.4 [95% CI: -3.0; -1.8]. Furthermore, this improvement was noted both for highly and less active patients at baseline: for patients with DAS28-ESR < 5.1 (n=31), mean change was -1.56 [-2.28; -0.83] and for patients with DAS28-ESR≥5.1 (n=27), mean change was -1.98 [-2.91; -1.05]. Changes in DAS28-ESR and CDAI were significant (-2.8 [-3.2; -2.4] and -15.2 [-18.5; -11.8], respectively). AEs were consistent with the safety profile of anti-IL-6R antibodies and with results from RCTs (data not shown).

Conclusion:

In this real world study, treatment with sarilumab during 24 weeks in RA patients led to an improvement in the total RAID score irrespective of baseline levels of disease activity. This is the first time RAID score is used as the primary endpoint in a study.

References:

[1]Study was sponsored by Sanofi Genzyme

Disclosure of Interests:

Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, René-Marc Flipo Consultant of: Johnson and Johnson, MSD France, Novartis, Sanofi, Speakers bureau: Johnson and Johnson, MSD France, Novartis, Sanofi, Thierry Schaeverbeke: None declared, Christine Albert: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review, marie-Christophe Boissier: None declared, Cyrille Confavreux: None declared, Gregoire CORMIER: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Elisabeth Gervais Solau: None declared, Sophie Godot: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Slim Lassoued: None declared, Thierry Lequerre: None declared, Frederic Lioté Consultant of: CME: Nordic Pharma, Christian Marcelli: None declared, Yves Maugars: None declared, Minh Nguyen: None declared, Aleth Perdriger: None declared, Yves-Marie Pers: None declared, Edouard Pertuiset: None declared, Lucile Poiroux: None declared, Carole Rosenberg: None declared, Christian Roux: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Martin SOUBRIER: None declared, Pascale Vergne-Salle: None declared, Charles Zarnitsky: None declared, Eric Fakra Consultant of: Janssen, Lundbeck, Otsuka, Sanofi, Hubert MAROTTE Grant/research support from: Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Consultant of: AbbVie, Amgen, Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Paid instructor for: Sanofi-Aventis, Speakers bureau: Sanofi-Aventis, Florence E Lévy-Weil Employee of: Sanofi Genzyme employee

Hip fracture incidence and social deprivation: results from a French ecological study

The association between socioeconomic status (SES) and hip fracture (HF) incidence was analyzed in France in 2008. In men and women, a decrease in HF incidence was observed as the social deprivation index increased. This result may be partly due to the protective effect of increasing body weight against HF.

INTRODUCTION

Regional variations in hip fracture (HF) incidence exist worldwide. Reasons for these variations remain unknown. As regional variations have also been observed for socioeconomic status, we analyzed the association between socioeconomic deprivation (SED) and HF incidence in France in 2008.

METHODS

From the French Hospital National Database, we selected all HF encoded as primary diagnosis in persons aged 30 years and over. The recently published French version of the European Deprivation Index (EDI) was used for SED analysis, and an EDI score was measured for the year 2007 in each French local municipality. The EDI score was categorized in quintiles. Poisson regression was performed to examine the association between HF incidence and EDI adjusted for age and sex. The population attributable fraction (PAF) was measured to calculate the proportion of excess cases of HF associated with social affluence.

RESULTS

In 2008, 83,538 HF were reported in France of which 59,143 were included in this study. Among them, 44,401 fractures occurred in women (75%) and 14,742 in men (25%). In both men and women, there was a decrease in the HF incidence with increasing SED index. In Poisson regression, the interaction of age class and sex was significant (p < 0.0001) and the EDI in quintiles was significantly associated with the incidence of HF (p < 0.0001). A higher number of people living in affluent residential areas corresponded to a higher risk of HF. The risk of HF is 2.42 times higher for those living in the most affluent group compared to those living in the most underprivileged group. The value of the PAF was calculated at 27.1%.

CONCLUSION

Social disparities in HF incidence exist in France with the most deprived municipalities having the lowest incidence. Prior knowledge demonstrates the strong relationships between body weight and HF risk as well as between body weight and the SED. The link found in our study between EDI and HF incidence as well as regional and temporal variations in HF incidence may be partly due to the protective effect of increased body weight against HF.

Predictive risk factors of serious infections in patients with rheumatoid arthritis treated with abatacept in common practice: results from the Orencia and Rheumatoid Arthritis (ORA) registry

OBJECTIVES

Little data are available regarding the rate and predicting factors of serious infections in patients with rheumatoid arthritis (RA) treated with abatacept (ABA) in daily practice. We therefore addressed this issue using real-life data from the Orencia and Rheumatoid Arthritis (ORA) registry.

METHODS

ORA is an independent 5-year prospective registry promoted by the French Society of Rheumatology that includes patients with RA treated with ABA. At baseline, 3 months, 6 months and every 6 months or at disease relapse, during 5 years, standardised information is prospectively collected by trained clinical nurses. A serious infection was defined as an infection occurring during treatment with ABA or during the 3 months following withdrawal of ABA without any initiation of a new biologic and requiring hospitalisation and/or intravenous antibiotics and/or resulting in death.

RESULTS

Baseline characteristics and comorbidities: among the 976 patients included with a follow-up of at least 3 months (total follow-up of 1903 patient-years), 78 serious infections occurred in 69 patients (4.1/100 patient-years). Predicting factors of serious infections: on univariate analysis, an older age, history of previous serious or recurrent infections, diabetes and a lower number of previous anti-tumour necrosis factor were associated with a higher risk of serious infections. On multivariate analysis, only age (HR per 10-year increase 1.44, 95% CI 1.17 to 1.76, p=0.001) and history of previous serious or recurrent infections (HR 1.94, 95% CI 1.18 to 3.20, p=0.009) were significantly associated with a higher risk of serious infections.

CONCLUSIONS

In common practice, patients treated with ABA had more comorbidities than in clinical trials and serious infections were slightly more frequently observed. In the ORA registry, predictive risk factors of serious infections include age and history of serious infections.

Beneficial effects of vitamin D on falls and fractures: is cognition rather than bone or muscle behind these benefits?

The beneficial effect of vitamin D on bone tissue has long been attributed mainly to its positive effect on the intestinal absorption of calcium and on bone mineralization, which increases the bone mineral density (BMD) and thus decreases the risk of fracture. Recently, numerous extra osseous effects of vitamin D have been described, amongst them a positive effect on neuromuscular and cognitive functions. Several lines of evidence suggest that the beneficial effects of vitamin D on fall and fracture risk can be explained more by its action on the neuromuscular and cognitive functions than by its direct effect on bone metabolism. In this review, we first report on the relationships between vitamin D and osteoporotic fracture risk. Then, we present the data from the literature regarding the effects of vitamin D on risk factors such as fall risk and reduction in BMD, physical performance, and cognitive performance. Specific emphasis is put on the latter because there is evidence of a relationship between low concentration of serum 25-hydroxyvitamin D (the primary indicator of vitamin D status) and low cognitive abilities which have been shown to be a risk factor for falling. It can be further suggested that high risk of fracture in cognitively impaired adults could be explained by lower protective reaction when falling, which would result, for instance, from a lack of planning and foresight of the fall. Future studies are nonetheless needed to elucidate the associations between vitamin D and different risk factors, in particular the link between vitamin D and various cognitive functions.

Coracoacromial ligament section under ultrasonographic control: a cadaveric study on 20 cases

INTRODUCTION

The coracoacromial ligament is a complex anatomical structure involved in the development of subacromial impingement; treatment is founded on sectioning the ligament, with or without associated arthroscopic acromioplasty and debridement.

HYPOTHESIS

Complete coracoacromial ligament section can be performed under ultrasound, without lesion to surrounding structures.

MATERIALS AND METHODS

The coracoacromial ligament was sectioned on the coracoid side, under ultrasound navigation, in 10 cadavers donated to science: i.e. 20 shoulders. After ultrasound location of the shoulder structures, sectioning was performed with a skin incision at the level of the deltopectoral sulcus. Secondary surgical control checked conservation of the acromial branch of the thoracoacromial artery, and the quality of the procedure.

RESULTS

Mean surgery duration was 18.5 minutes (±5 min). Seventeen sections were complete (85%). Artery location was hampered by the impossibility of using Doppler on these cadavers, yet even so there were only 2 vascular lesions. There were no accidental rotator cuff or cartilaginous lesions.

CONCLUSION

This relatively non-invasive technique is quick and less heavy than open surgery, opening up new treatment perspectives. It could be indicated in coracoid and subacromial impingement before opting for surgery, or as a complement to surgery. It does, however, involve a learning curve and requires solid ultrasound skills.

Positivity for anti-cyclic citrullinated peptide is associated with a better response to abatacept: data from the 'Orencia and Rheumatoid Arthritis' registry

OBJECTIVES

Very limited data are available regarding the efficacy of abatacept (ABA) in real life. The aims of this study were to determine the efficacy of ABA in rheumatoid arthritis and predicting factors of efficacy in common practice.

METHODS

The Orencia and Rheumatoid Arthritis" (ORA) prospective registry, promoted by the French Society of Rheumatology, has included 1003 patients with RA.

RESULTS

773 patients had already fulfilled the 6-month follow-up visit. Only 21.3% of patients would have fulfilled inclusion criteria used in pivotal controlled trials. The European League Against Rheumatism (EULAR) response, was observed in 330 (59.1%) of the 558 assessed patients (good response: 20.4%, moderate response: 38.7%) and was similar in patients who did and in patients who did not fulfill inclusion criteria of controlled trials. Among EULAR responders, initial 28-joint disease activity score (5.4 (4.7-6.5) in responders vs 4.9 (4.0-6.0) in non responders, p< 0.0001), the proportion of rheumatoid factor (75.6% vs 66.7%, p= 0.03) and the proportion of anti-cyclic citrullinated peptide antibody (anti-CCP)-positivity (75.9% vs 62.2%, p= 0.001) were significantly higher. In multivariate analysis adjusted on initial 28-joint disease activity score and CRP, anti-CCP positivity was associated with EULAR response (OR=1.9;95% CI=1.2 to 2.9, p=0.007), but not rheumatoid factor (OR=1.0;95% CI=0.6 to 1.6, p=0.9). Anti-CCP positivity was also significantly associated with a higher ABA retention rate at 6 months.

CONCLUSIONS

Real life efficacy of ABA in the ORA registry was similar as that reported in clinical trials. Anti-CCP positivity was associated with a better response to ABA, independently from disease activity.

Efficacy of rituximab in primary Sjogren's syndrome with peripheral nervous system involvement: results from the AIR registry

OBJECTIVE

To evaluate rituximab (RTX) in primary Sjögren's syndrome (pSS) with peripheral nervous system (PNS) involvement.

METHODS

Patients with pSS and PNS involvement who were included in the French AIR registry were analysed.

RESULTS

17 patients (age 60 years (44-78 years); 14 were female) were analysed. Neurological improvement was noted in 11 patients (65%) at 3 months. Rankin scale decreased from 3 (1-5) to 2 (1-5), 2 (1-5) and 2 (1-6) after 3, 6 and 9 months (p=0.02). European Sjögren's Syndrome Disease Activity Index decreased from 18 (10-44) to 11 (5-20), 11 (5-29) and 12 (5-30) after 3, 6 and 9 months (p<0.05). RTX was effective in neurological involvement in 9/10 patients with vasculitis or cryoglobulinaemia (90%) (group 1) at 3 months and in 2/7 cases (29%) without cryoglobulinaemia and vasculitis (p=0.03). Rankin and European Sjögren's Syndrome Disease Activity Index scales decreased significantly in group 1.

CONCLUSION

RTX seems effective in cryoglobulinaemia or vasculitis-related PNS involvement in pSS.

[Can tumor necrosis factor inhibitors induce sclero-uveitis?]

We report three cases of female patients who presented a first episode of unilateral scleritis or acute anterior uveitis while they were treated for 12-16 months by TNF inhibitor: etanercept (Enbrel((R))) 25mg twice weekly for rheumatologic diseases (rheumatoid arthritis or ankylosing spondylitis). Ocular inflammation was resistant to the usual treatment. Some cases of scleritis and uveitis are known to be drug-induced. TNF inhibitors seem to be part of them. Ocular inflammation is usually the first episode. It appears generally in the first year of the treatment by TNF inhibitors and resists to usual treatment. The general disease is usually well stabilized. In our cases, inflammation decreased only when the etanercept was discontinued.

Anti-tumour necrosis factor treatment in patients with refractory systemic vasculitis associated with rheumatoid arthritis

OBJECTIVE

To assess anti-tumour necrosis factor (anti-TNF) agents in patients with refractory systemic rheumatoid vasculitis (SRV).

METHODS

1200 rheumatologists and internists were asked to provide medical files for patients with anti-TNF agents given as a second-line treatment for active SRV refractory to cyclophosphamide and glucocorticoids.

RESULTS

We identified nine cases in which anti-TNF drugs were given for active SRV, despite previous treatment with a mean cumulative dose of 8.4 g of cyclophosphamide in association with high-dose glucocorticoids. The mean prednisone dose before anti-TNF therapy was 29.6 mg/day. After 6 months, six patients were in remission (complete in five, partial in one). The treatment failed in one patient and two patients stopped taking the anti-TNF treatment due to side-effects. Mean prednisone dose was reduced to 11.2 mg/day. Severe infection occurred in three patients. Relapses were observed in two patients. Remission was re-established by reintroducing anti-TNF therapy in one case and increasing the dose in the other.

CONCLUSIONS

This study provides evidence of efficacy of anti-TNF therapy in adjunct to glucocorticoids for treating active refractory SRV. Remission was achieved in two-thirds of patients, with a significant decrease in prednisone dose, although there was a high rate of infection in these severely ill patients.

Inverse relationship between vertebral fractures and spine osteoarthritis in postmenopausal women with osteoporosis

BACKGROUND

Although the coexistence of osteoarthritis and osteoporosis is considered as uncommon, it has been suggested that, in postmenopausal women, disc space narrowing increases the risk of vertebral fracture. The aim of this study was to check this hypothesis in postmenopausal women with osteoporosis.

OBJECTIVE

We analysed the relationship between vertebral fractures and spine osteoarthritis in 410 postmenopausal women with osteoporosis: in this population both disc space narrowing and osteophytes are inversely related to vertebral fractures.

PATIENTS AND METHODS

This study is based on baseline data collected in a multicentre, prospective and 6-month longitudinal observational study. 410 postmenopausal women (74+/-5 years) were enrolled who had consulted for back pain, and had osteoporosis (according to WHO definition). Spine x-rays were performed according to standardised procedures. Vertebral fractures were evaluated from T4 to L4 using the Genant's semiquantitative method; osteoarthritis was evaluated by scoring osteophytes and disc space narrowing at all levels of the thoracic and lumbar spine, and by a qualitative assessment of facet joint arthritis.

RESULTS

The prevalence of vertebral fractures was 52.4%. At least one osteophyte, one disc space narrowing and one facet arthritis were present in 90.2, 64.6 and 77.8% of patients respectively. There was an inverse association between vertebral fractures and osteoarthritis: odds ratios adjusted for age and weight (95% CI) were 0.38 (0.17-0.86), p = 0.02 and 0.27 (0.16-0.46), p<10(-4) for the presence of at least one osteophyte, and of at least three disc space narrowings respectively. In a cluster analysis, it was possible to identify a subgroup of patients without any disc space narrowing, and another subgroup with all patients having at least one disc space narrowing; the proportion of patients having more than three vertebral fractures was 25.2 and 15.9% in these two clusters respectively.

CONCLUSIONS

Disc space narrowing and osteophytes are associated with a decreased vertebral fracture prevalence in postmenopausal women with osteoporosis.

Prevalence of vertebral fractures in French women older than 75 years from the EPIDOS study

The aim of this study was to ascertain the prevalence and severity of vertebral fractures in French elderly women. We used spinal radiographs collected during the baseline examination of the Epidémiologie de l'Ostéoporose (EPIDOS) study, a multicentric prospective study of risk factors for hip fracture. A total of 7598 ambulatory women volunteers were recruited in the EPIDOS cohort using large population-based listings such as voter-registration lists. A subsample of 770 participants were selected for spinal radiographs using a systematic selection procedure. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were reviewed by two trained rheumatologists using the semiquantitative (SQ) method described by Genant et al. [J. Bone Miner Res. 8 (1993) 1137]. Vertebral deformities that could be related to causes other than osteoporosis (i.e., Scheuermann's disease or osteoarthritis) were disregarded. The final analysis was made over 745 women after excluding 25 women whose spine radiographs were incomplete or of poor quality. The sample average age was 80.1 +/- 3.4 years. Vertebral fractures were found in 170 women: 22.8% (95% CI, 19.8-25.8%). A single, two, three, or more vertebral fractures were seen in 99 (58.2%), 43 (25.3%), and 28 (16.5%) of the 170 affected women, respectively. The prevalence of vertebral fractures increased with age from 19.0% (95% CI, 14.9-23.1%) among women 75-79 years old to 21.9% (95% CI, 17.3-26.5%) among those 80-84 years old and to 41.4%(95% CI, 31.0-51.7%) among those 85 years of age and over (Chi-square test for trend P < 0.00016). A significant correlation was found also between the number of vertebral fractures per woman and age (r = 0.108, P = 0.003) and between the spinal fracture index and age (r = 0.105, P = 0.004). We conclude that the prevalence of vertebral fractures is high in French ambulatory elderly women, which confirms the results of previous studies conducted in various Caucasian and Asian populations.

Distribution of bone mineral density at the proximal tibia in knee osteoarthritis

One hundred and thirteen knees with osteoarthritis (OA) were studied to assess the distribution of bone mineral density (BMD) in the proximal tibia and the potential relation between osteoarthritis and osteoporosis in evaluating hip BMD. All patients had severe knee pain and were diagnosed with Kellgren and Lawrence grade IV osteoarthritis. According to the magnitude of the axial deformity, four categories were created: varus>10 degrees ( 28.3%), varus 4-10 degrees (38.9%), aligned 180 +/- 3 degrees (13.3%), and valgus>4 degrees (19.5%). For each category, the medial and lateral proximal tibial density were assessed. BMD was measured at the femoral neck and at 14 regions of interest (ROI) in the proximal part of the tibia using dual X-ray absorptiometry. Based on the femoral neck BMD, patients were classified according to the World Health Organization (WHO) definition of osteoporosis. The mean knee BMD was positively correlated with the hip BMD value (knee BMD m = 0.38 + 0.73 x hip BMD, r = 0.60, P<0.001). The knee BMD distribution of the 113 patients was negatively correlated with the axial deformity (BMD MT-LT = 5.15 - 0.027 x HKA, r = 0.77, P<0.0001). In the varus deformity, BMD of the medial side was higher than that of the lateral side with an important asymmetry (0.587 g/cm2). This asymmetry was also found in the valgus deformity for the lateral side but was less important (-0.112 g/cm2). With equal deformity, the asymmetry of BMD was higher in varus deformity (0.587 g/cm2) than in valgus deformity (-0.112 g/cm2). Asymmetry of the knee BMD distribution revealed that progression of the deformity (either varus or valgus) with joint space narrowing led to an increase in the medio-lateral difference of the proximal tibia density. Lesser severity of Kellgren and Lawrence grades may reveal different results. Twenty patients with osteoporosis developed knee osteoarthritis (OA) and the relation between osteoporosis and knee OA remains unclear.

[Dual x-ray absorptiometry assessment of bone density of the proximal tibia in advanced-stage degenerative disease of the knee]

PURPOSE OF THE STUDY

Axial deformity secondary to degenerative joint disease of the knee can modify stress forces. Certain studies have reported an inversely proportional relationship between degenerative disease and osteoporosis. The aim of this prospective study was to quantify the horizontal linear distribution of bone density using dual x-ray absorptiometry (DXA) of the proximal tibia as a function of the femoral neck bone density in patients with knee osteoarthritis.

MATERIAL AND METHODS

Between September 1996 and March 1998, 90 cases of primary degenerative joint disease of the knee were programmed for total knee arthroplasty. Prior to the procedure, the patients were assessed clinically and radiologically according to the International Knee Society (IKS) criteria. The mechanical femorotibial angle was measured in all patients and the varus angles were recorded. Most of the patients were women (65 p. 100) with a mean age of 70 +/- 5 years. Valgus knees were excluded from this series. The mean mechanical femorotibial angle was 172 +/- 5 degrees. Fifteen patients had a normal axis (16 p. 100), 32 had a varus measuring 4 degrees to 10 degrees (35 p. 100) and 43 had a varus measuring 10 degrees or more (48 p. 100). The overall varus distance was 6.4 +/- 2 cm. All patients had two DXA explorations: femoral neck to determine the bone status according to the WHO criteria (normal, osteopenia, osteoporosis), knee to determine the linear distribution of bone density of the proximal tibia. A 7 mm high band including 7 regions of interest covering the width of the tibia were explored in the area where the tibial cut was to be made. These 7 regions of interest were: R1, R2 under the lateral compartment, R6, R7 under the medial compartment, and R3, R4, R5 on either side of the tibial spines. The level of significance was set at 5 p. 100.

RESULTS

The mean Z score (0.54 +/- 1) in the 90 patients showed a symmetrical distribution. These patients were representative of their age range. Their T score was - 1.40 +/- 1 (m +/- SD) and most had osteopenia (54 p. 100) according to the WHO criteria, although 16 p. 100 had osteoporosis. Mean bone density of the knee was 0.898 +/- 0.163 g/cm(3) and was correlated with that of the femoral neck (r=0.61, p=0.001). There were significant correlations between the differences in the bone densities of the knee compartments (R6-R2, R7-R1) and the mechanical femorotibial angle [(r=0.39, p=0.0001); (r=0.52, p=0.001)]. Irrespective of the overall bone density, there was a strong medial compartment overloading, which correlated with the degree of varus deformation.

CONCLUSION

DXA assessment of bone mineral density of the proximal tibia is a simple, reliable, precise and reproducible method. The distribution of bone density in the degenerative knee depends on the degree of deformation. The average level depends on the subject's general state of mineralization. Osteoporosis does not protect against degeneration of the knee joint since 16 p. 100 of our patients had osteoporosis according to the WHO criteria.

Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren

BACKGROUND

Nonspecific back pain in children is nearly as common as in adults but is associated with a number of age-specific risk factors including female gender, a family history of low back pain, a high level of physical activity, and prolonged sitting.

OBJECTIVE

To investigate potential school-related risk factors for back pain in children, most notably schoolbag weight expressed as a percentage of body weight (relative schoolbag weight), whether the schoolbag is carried by hand or by a shoulder harness, how the child travels to and from school, and sitting positions.

PATIENTS AND METHODS

123 eighth-graders, 58 girls and 65 boys, with a mean age of 14 +/- 0.6 years, completed an anonymous self-questionnaire during a school day involving six hours of classes. Their schoolbag was weighed on the same day.

RESULTS

Most respondents traveled to and from school in a vehicle (70%), made one trip in each direction each day (75%), and carried their schoolbag by the shoulder harness (92%). The prevalence of back pain on the study day was 27.6%, whereas the cumulative prevalence for the last 12 months was 82.9% with 16.3% of respondents reporting a single episode of pain, 57.7% recurrent pain, and 8.9% chronic pain. A need for a physician visit for back pain was reported in 18.7% of cases, and 14.6% of respondents had missed school and/or sporting activities because of back pain. Female gender was associated with current back pain (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.2-6.1). A relative schoolbag weight of 20% or more was associated with a history of back pain (OR, 3.1; 95% CI, 1.0-9.2), and this effect was larger in children who traveled to and from school on foot and in those who carried their schoolbag in their hand. Sitting on the edge of the chair while completing the questionnaire was significantly associated with a history of a physician visit for back pain (OR, 3.1; 95% CI, 1.0-9.5). Neither handedness nor the position of the questionnaire on the table were significantly associated with back pain in our study population.

CONCLUSIONS

The findings from this cross-sectional study indicate a need for a longitudinal prospective study designed to identify etiologic and prognostic factors of back pain in adolescents, with the goal of devising preventive strategies likely to reduce the risk of low back pain in adulthood.

Heritability of bone mineral density

OBJECTIVE

To evaluate the influence of genetic background as a determinant of peak bone mass.

PATIENTS AND METHODS

We compared lumbar spine bone mineral density in 175 girls with a bone age of 16 years or older and in their premenopausal mothers. We also investigated the influence of a family history of osteoporosis on lumbar spine bone mineral density in 275 women and their 559 daughters.

RESULTS

In the 175 mother-daughter pairs, heritability (h2) was significantly different from 0 (P < 0.0001) for lumbar spine bone mineral density (h2 = 53%; 95% confidence interval [95% CI] = 28.5-77.6%), bone mineral content (h2 = 62.3%; 95% CI = 37.7-86.8%), bone mineral density adjusted for body mass index (h2 = 56%; CI = 31.5-80.5%), and bone mineral content adjusted for body mass index (h2 = 68.2%; CI = 43.6-92.7%). However, the heritability estimations lacked accuracy, as shown by the wide 95% CIs. Osteopenia and osteoporosis were found in 16.4% and 1% of the mothers, respectively. In the subgroup defined by osteopenia or osteoporosis in the mother, lumbar spine bone mineral density was significantly higher in the daughters than in the mothers (0.994 +/- 0.095 g/cm2 versus 0.895 +/- 0.098 g/cm2; P < 0.0001), whereas the opposite was true in the subgroup defined by normal bone mass in the mothers (1.068 +/- 0.110 g/cm2 versus 1.109 +/- 0.098 g/cm2; P = 0.0003). Nevertheless, lumbar spine bone mineral density was significantly lower in the daughters of low-bone-mass women than in those of normal-bone-mass women (0.994 +/- 0.009 g/cm2 versus 1.069 +/- 0.012 g/cm2; P = 0.0006). These findings suggest a role of genetic factors inherited from the father and also indicate that bone mass gains during adulthood contribute to achievement of the optimal peak bone mass. In the family history study, bone mass was lower in the subjects with a family history of osteoporosis (123 of the 559 daughters, Z-scores normalized for height, weight, and pubertal status: bone mineral density Z-score, -0.054 +/- 1.104; bone mineral content Z-score, -0.014 +/- 1.079; 58 of the 275 mothers: bone mineral density, 1.048 +/- 0.107 g/cm2; bone mineral content, 43.3 +/- 6.8 g) than in those without a family history of osteoporosis (436 daughters, bone mineral density Z-score, 0.006 +/- 0.981; bone mineral content Z-score, -0.007 +/- 0.985; 217 mothers: bone mineral density, 1.070 +/- 0.127 g/cm2; bone mineral content, 43.8 +/- 6.7 g); however, none of these differences were statistically significant.

CONCLUSION

Our findings challenge the currently popular concept of marked bone mass heritability but are consistent with early genetic influences on lumbar spine bone mass. Thus, optimization of the peak bone mass acquired during growth may help to prevent osteoporosis.

[AA amyloidosis complicating sarcoidosis]

INTRODUCTION

Amyloidosis combined with sarcoidosis has been very rarely described.

EXEGESIS

We report the case of a 72-year-old man presenting with sarcoidosis and amyloidosis AA. The association of peripheral and retroperitoneal adenopathies accompanied by loss of weight and histopathological results conducted to the diagnosis of sarcoidosis, excluding other causes. Corticosteroid therapy led to a decrease in clinical manifestations and after 2 years, clinical signs of amyloidosis have not progressed.

CONCLUSION

According to results previously described in the literature and the description of the present case, we conclude that sarcoidosis can be complicated by amyloidosis AA, the presence of which may justify corticosteroid therapy.

Evolution of lumbar bone mineral content during adolescence and adulthood: a longitudinal study in 395 healthy females 10-24 years of age and 206 premenopausal women

In a longitudinal study of 395 normal 10- to 24-year-old female volunteers, 105 of whom were initially premenarcheal, lumbar bone mineral density (BMD) and content (BMC) were measured by dual-energy X-ray absorptiometry (DXA) at inclusion and after a 2-year interval. The mean age of menarche was 13.1 +/- 1.1 years (n = 395). In a multiple regression analysis the BMD and BMC relative gains were highly correlated with the height and weight relative gains and with the time since menarche (r = 0.91 and r = 0.93, respectively). The mean relative annual increments in body height, in L2-4 vertebral height, in BMD and in BMC peaked respectively at 1.5, 1.0, 0.6 and 0.7 years before menarche. The four perimenarcheal years, beginning with the first pubertal clinical signs, are essential for bone acquisition, since 46.7% of adult BMC is acquired during this period. Two years after menarche, BMC is 85% of the adult value. Seven years after menarche no further significant variation in BMC is observed. In 206 menstruating women 27-47 years old, a DXA lumbar measurement was also performed after a 4-year interval. There was a small but significant increase of 0.3%/year in BMD and 0.7%/year in BMC, contrasting with the results in the young population. This could be explained by a volumetric expansion with aging, which is supported by a small increase in L2-4 area (0.4%/year). In conclusion, this longitudinal study on the lumbar site emphasizes the importance of the pre- and perimenarcheal period, when half of lumbar adult BMC is acquired. This suggests that greater attention must be paid to this period regarding nutrition and physical activity.

Does spinal morphology influence the occurrence of low back pain? A retrospective clinical, anthropometric, and radiological study

OBJECTIVE

Insurance companies are showing considerable interest for measurement devices claimed to be effective in evaluating risks associated with occupational or sporting activities. The aim of this study was to evaluate the potential influence of spinal morphology on the risk of low back pain.

METHODS

1500 male construction work apprentices aged 16 to 23 years underwent spinal measurements at the Caen Teaching Hospital from 1991 to 1996. The 384 subjects with abnormal measurements or a history of spinal pain underwent plain radiography and a second set of spinal measurements done by a different examiner using a different device. The following radiological parameters were studied: incidence angle, junction couple, Ferguson's index, L1-L5 lordosis angle and L1-S1 lordosis angle.

RESULTS

In the 152 retrospectively studied subjects, no significant differences in static spinal parameters were found between subjects with and without a history of low back pain. The type of lordosis was correlated with the incidence angle but not with the junction couple.

CONCLUSION

In our population, spinal measurements were not correlated with a specific morphological pattern of the lumbar spine or pelvis, and neither was a history of low back pain correlated with a specific pattern of lumbar and pelvic balance.

Contribution of laboratory tests, scintigraphy, and histology to the diagnosis of lower limb joint replacement infection

OBJECTIVE

To evaluate the contribution of laboratory tests, histology and scintigraphy for diagnosing and monitoring the treatment of lower limb arthroplasty infection.

PATIENTS AND METHODS

37 lower limb arthroplasties, 20 at the hip and 17 at the knee, were studied. Investigations included laboratory tests for inflammation (erythrocyte sedimentation rate, C-reactive protein, haptoglobin, and orosomucoid), histology (presence of neutrophils) and scintigraphy (99m Tc-HMDP bone scan, colloidal sulfide bone marrow scan, and 99m Tc-HMPAO leukocyte scan). Follow-up was at least three years after treatment of the infection.

RESULTS

Acute phase reactants were more sensitive and more specific than the erythrocyte sedimentation rate. The full scintigraphy protocol had 100% sensitivity and 87% specificity. Recovery of neutrophils by aspiration or during surgery was 100% specific in the absence of hematomas or rheumatoid arthritis. Sensitivity of the presence of neutrophils varied with the collection technique.

Different morphometric and densitometric parameters predict cervical and trochanteric hip fracture: the EPIDOS Study

We used an experimental software measuring the hip axis length (HAL) and bone mineral density (BMD) in specific regions of the lower and upper part of the femoral neck on dual-energy X-ray absorptiometry scans. To determine whether these parameters were significant predictors of the type of hip fracture, we measured 167 healthy women (controls), 24 women with trochanteric, and 42 women with cervical hip fractures within the EPIDOS prospective cohort. EPIDOS is a multicenter prospective study on risk factors for hip fracture performed in 7575 elderly women living at home, aged 75-95 and conducted in five French centers (Amiens, Lyon, Montpellier, Paris, Toulouse). Measurements were performed on data acquired at baseline before the occurrence of fracture. In the cervical fracture group, HAL was significantly longer than in controls (94.2 vs. 92.3, p = 0.03), and the associated odds ratio (OR) adjusted for age, weight, and total femoral neck BMD was significant (OR = 1.64, 95% confidence interval [CI] 1.06-2.55). In contrast, HAL was not significantly different from controls in the trochanteric fracture group. Femoral neck diameter was not a predictor of fracture. The upper and lower femoral neck BMD was lower in the trochanteric fracture group than in controls, and both measurements predicted trochanteric femoral neck fracture. In contrast, the prediction of cervical femoral neck fracture was enhanced by measuring only the upper part of the femoral neck (OR = 2.79 vs. 1.97 for the total femoral neck) while BMD of the lower part was not different from controls. Hip axis length is a predictor of femoral neck fracture. Femoral neck BMD distribution is different between cervical and trochanteric fractures. These results support the hypothesis of a different pathophysiological mechanism between the two types of hip fractures.

Acute sacroiliitis as a manifestation of calcium pyrophosphate dihydrate crystal deposition disease. A report of two cases

Whereas radiographic lesions of the sacroiliac joints are common in patients with calcium pyrophosphate deposition crystal disease, they are rarely accompanied with clinical symptoms. We report two cases of acute sacroiliitis probably due to calcium pyrophosphate dihydrate deposition disease. The patients were a 53-year-old man and an 82-year-old woman with chondrocalcinosis in other joints and presence on computed tomography studies of the sacroiliac joints of sclerosis and irregularities of the joint margins with a thin linear calcific deposit within the joint. Both patients recovered fully under therapy with colchicine, analgesics and rest. These two cases suggest that acute sacroiliitis can be caused by calcium pyrophosphate dihydrate crystal deposition disease.

Cerebral vein thrombosis after an intrathecal glucocorticoid injection

We report two cases of cerebral venous thrombosis that occurred after an intrathecal glucocorticoid injection for common lumbosciatic syndrome. The patients were two females, aged 34 and 47 years, who developed typical post-lumbar puncture headache. The manifestations leading to the diagnosis of cerebral venous thrombosis were status epilepticus in one case and persistent headache in the other. Both patients were using oral contraceptives. Grynblat et al. (Rev Rhum [Engl Ed] 1995; 62: 691) recently reported two cases in young women of cerebral venous thrombosis after intrathecal administration of a glucocorticoid or an iodinated contrast agent. These cases are useful reminders that intrathecal glucocorticoid injections can be followed by cerebral venous thrombosis, and that younger women may be at increased risk for this complication.

Septic arthritis of lumbar facet joints. A review of six cases

Hematogenous infection of the facet joints by pyogenic organisms is exceedingly rare. We report six cases of lumbar facet joint septic arthritis due to hematogenous spread of a pyogenic organism. A review of the literature identified ten anecdotal reports of similar cases. An analysis of these 16 cases showed that the diagnosis was based mainly on imaging study findings and that clinical data failed to discriminate between facet joint septic arthritis and infectious discitis. Increased uptake on the radionuclide bone scan was an early finding and the pattern of uptake was different from that seen in discitis. Computed tomography was the investigation that best delineated the facet joint lesions. Magnetic resonance imaging of the lumbar spine was superior over computed tomography in demonstrating spread of the infection to the epidural space and/or soft tissues and in some instances demonstrated enhancement of the infected facet joint on T1 images after gadolinium injection. Aspiration of the facet joint under fluoroscopic guidance was required only when blood cultures were negative or when the diagnosis of the septic nature of the arthritis was in doubt. Blood cultures yielded a Staphylococcus aureus in the six cases in our series. Appropriate antimicrobial therapy was successful in most cases. In our series, four of the six patients had posterior epiduritis, pyomyositis, or an abscess in the paraspinal muscles or psoas muscle, suggesting that some epidural infections or psoas muscle abscesses believed heretofore to be primary may in fact be complications of facet joint septic arthritis. Facet joint septic arthritis is a new aspect of pyogenic spinal infections that deserves to be considered in patients with febrile spinal syndromes not explained by discitis.

[Fatigue fractures of the foot]

A stress fracture is a very localized change in bone remodeling occurring in a normal bone that is subjected to an unusual repeated cyclic loading. It is a common fracture in military recruits and recreational or competitive athletes. A typical medical history and a local bone tenderness at physical examination suggest the diagnosis that is confirmed by a local "hot" spot on the radionuclide bone scan. Radiographic signs are delayed and inconstant. Radiographs show the fracture line or a bone sclerosis as the result of fracture healing. Although every bone may be involved, depending on the type of the physical activity, metatarsals and calcaneus are the most frequent locations in the foot. The treatment of a stress fracture in the foot consists in a 4 to 6 nonweight-bearing immobilisation followed by a graduated return to march and sport.

Markers of bone resorption predict hip fracture in elderly women: the EPIDOS Prospective Study

Increased bone turnover has been suggested as a potential risk factor for osteoporotic fractures. We investigated this hypothesis in a prospective cohort study performed on 7598 healthy women more than 75 years of age. One hundred and twenty-six women (mean years 82.5) who sustained a hip fracture during a mean 22-month follow-up were age-matched with three controls who did not fracture. Baseline samples were collected prior to fracture for the measurement of two markers of bone formation and three urinary markers of bone resorption: type I collagen cross-linked N- (NTX) or C-telopeptide (CTX) and free deoxypyridinoline (free D-Pyr). Elderly women had increased bone formation and resorption compared with healthy premenopausal women. Urinary excretion of CTX and free D-Pyr, but not other markers, was higher in patients with hip fracture than in age-matched controls (p = 0.02 and 0.005, respectively). CTX and free D-Pyr excretion above the upper limit of the premenopausal range was associated with an increased hip fracture risk with an odds ratio (95% confidence interval) of 2.2 (1.3-3.6) and 1.9 (1.1-3.2), respectively, while markers of formation were not. Increased bone resorption predicted hip fracture independently of bone mass, i.e., after adjustment for femoral neck bone mineral density (BMD) and independently of mobility status assessed by the gait speed. Women with both a femoral BMD value of 2.5 SD or more below the mean of young adults and either high CTX or high free D-Pyr levels were at greater risk of hip fracture, with an odds ratio of 4.8 and 4.1, respectively, than those with only low BMD or high bone resorption. Elderly women are characterized by increased bone turnover, and some markers of bone resorption predict the subsequent risk of hip fracture independently of hip BMD. Combining the measurement of BMD and bone resorption may be useful to improve the assessment of the risk of hip fracture in elderly women.

[Epidural lipomatosis: complication of long-term corticotherapy. Apropos of 2 cases]

Spinal epidural lipomatosis (SEL) is defined as the deposition of loose fat tissue in the epidural space. Two cases are reported which illustrate the main features of this uncommon disease. Most frequently SEL is revealed by neurologic manifestations such as an acute chronic spinal cord compression. Corticosteroid therapy and obesity are the main factors able to induce the disease. The common location of the SEL at the thoracic spine is explained by the physiologic abundance of fat and by the relative narrowness of the spinal canal at this level. An osteoporotic vertebral crush fracture which reduces the diameter of the canal frequently reveals the SEL. MRI confirms the diagnosis of SEL and shows the extent in the spinal canal. The treatment of SEL is difficult. The decrease or the stop of corticosteroid therapy has allowed the recovery in a few cases with chronic neurologic symptoms. The risks of a surgical procedure are important in these patients and the medical or surgical treatment should be discussed taking into account the clinical symptoms of SEL, its location and extent, and the risks of recurrence if corticosteroid therapy must go on.