Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise

OBJECTIVE

To standardize ultrasound (US) in enthesitis.

METHODS

An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability.

RESULTS

Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63).

CONCLUSION

This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.

Vertebral involvement in calcium pyrophosphate dihydrate crystal deposition disease. Radiographic-pathological correlation

The authors conducted a comprehensive radiographic and pathological investigation of more than 1,000 postmortem spinal specimens and documented many examples of calcium pyrophosphate dihydrate crystal deposition disease (CPPD/CDD) in a variety of vertebral structures, including not only the intervertebral disk but also the apophyseal and sacroiliac joints, posterior longitudinal ligament, interspinous and supraspinous ligaments, ligamentum flavum, interosseous sacroiliac ligament, transverse atlas ligament, and posterior median atlanto-axial joint. Such crystal accumulation supports previous reports of abnormal calcification and structural damage on radiographs of the axial skeleton in patients with CPPD/CDD and may explain not only the associated spinal symptoms and signs but also spinal stenosis, spondylolisthesis, and atlanto-axial subluxation.

Noninvasive cerebrovascular assessment of Takayasu arteritis

BACKGROUND AND PURPOSE

Despite prominent neurological symptoms reported in Takayasu arteritis (TA), a complete evaluation of the cerebral circulation has not been consistently performed. The purpose of this study is to describe MR angiography (MRA), color Doppler flow imaging, and transcranial Doppler (TCD) findings in the extracranial and intracranial cerebral arteries in TA.

METHODS

MRA, color Doppler flow imaging, and TCD were performed in 21 patients with TA. Intima-media thickness was measured in the common carotid artery. The correlation between noninvasive studies and panaorto-arteriography was examined for supraortic vessels. Cerebral angiography findings were compared with the noninvasive methods in 7 patients. Intracranial hemodynamic changes detected by TCD were compared with extracranial circulation lesions assessed by panaorto-arteriography.

RESULTS

Noninvasive vascular techniques showed at least 1 abnormality in the extracranial and/or intracranial cerebral arteries in 20 of 21 patients (95%). Both MRA and color Doppler flow imaging showed a substantial correlation in the ability to detect obstructive lesions in supra-aortic vessels compared with panaorto-arteriography. High-resolution ultrasonography displayed common carotid artery wall thickening in 5 vessels that were considered normal by arteriography. In 24% of patients, MRA and TCD showed abnormalities consistent with stenosis of the basal cerebral arteries. In 10 patients with severe extracranial circulation involvement (detected by arteriography), TCD displayed intracranial hemodynamic changes consisting of dampened or blunted waveforms with low pulsatility.

CONCLUSIONS

The comprehensive assessment of cerebral circulation in TA patients by noninvasive methods allowed the detection of a high rate of diverse vascular abnormalities in both extracranial and intracranial circulation.

Primary hypertrophic osteoarthropathy

We describe seven patients with primary HOA and review 125 cases reported in the English, French, and German literature. The salient clinical features of primary HOA are: a bimodal distribution of disease onset with one peak during the first year of life and the other at age 15, a male predominance (nine to one), uncommon benign joint effusion, and a variety of skin abnormalities resulting from cutaneous hypertrophy or glandular dysfunction. We concluded that HOA is not a synovial disease. It is suggested that synovial effusions, when present, are perhaps a sympathetic reaction to the neighboring periostitis. Proposed diagnostic criteria for HOA, including digital clubbing and radiographic periostitis, appear 86% sensitive. The clinical features, age of onset, and sex distribution suggest that a genetically controlled growth promoting factor, different from growth hormone, plays a role in the pathogenesis of this syndrome.

Osteoarthritis of the glenohumeral joint: a radiologic-pathologic study

Cadaveric specimens and patient radiographs were examined in order to establish the pattern and the distribution of degenerative alterations of the glenohumeral joint. Characteristic osseous changes occur in response to alterations in the articular cartilage and rotator cuff. The extent of these changes is underestimated by plain-film radiography. A strong association was found between the changes of osteoarthritis (OA) and those related to deterioration of the rotator cuff. Idiopathic OA of the glenohumeral joint was discovered in 10 (20%) of 50 symptomatic patients age 60 years and over. Theories regarding the pathomechanics and interrelations between glenohumeral joint OA and rotator cuff deterioration are discussed.

Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis

OBJECTIVE

To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.

METHODS

A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.

RESULTS

Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver kappa was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, -0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver kappa for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.

CONCLUSIONS

US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

Validity of ultrasonography and measures of adult shoulder function and reliability of ultrasonography in detecting shoulder synovitis in patients with rheumatoid arthritis using magnetic resonance imaging as a gold standard

OBJECTIVE

To assess the intra- and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard.

METHODS

Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI.

RESULTS

The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant.

CONCLUSION

Overall agreements between gray-scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.

Glycosylphosphatidylinositol-specific phospholipase D is expressed by macrophages in human atherosclerosis and colocalizes with oxidation epitopes

BACKGROUND

Glycosylphosphatidylinositol-specific phospholipase D (GPI-PLD) may play an important role in inflammation, because it can hydrolyze the GPI anchors of several inflammatory membrane proteins (eg, CD106, CD55, and CD59) and its hydrolytic products upregulate macrophage cytokine expression (eg, interleukin-1 and tumor necrosis factor-alpha). Because of its potential regulatory role in inflammatory reactions, we hypothesized that GPI-PLD might be expressed in atherosclerosis.

METHODS AND RESULTS

Immunohistochemistry using human GPI-PLD-specific rabbit polyclonal antiserum was performed on a total of 83 nonatherosclerotic and atherosclerotic human coronary arteries from 23 patients. Macrophages, smooth muscle cells, apoA-I, and oxidation epitopes also were identified immunohistochemically. Cell-associated GPI-PLD was detected in 95% of atherosclerotic segments, primarily on a subset of macrophages. Extracellular GPI-PLD was present in only 30% of atherosclerotic segments and localized to regions with extracellular apoA-I. In contrast, GPI-PLD was not detected in nonatherosclerotic segments. Expression of GPI-PLD mRNA by human macrophages was confirmed in vitro by reverse transcription/polymerase chain reaction. Further studies demonstrated that GPI-PLD-positive plaque macrophages contained oxidation epitopes, suggesting a link between oxidant stress and GPI-PLD expression. This possibility was supported by studies in which exposure of a macrophage cell line to H2O2 led to a 50+/-3% increase in steady-state GPI-PLD mRNA levels.

CONCLUSIONS

Collectively, these results suggest that oxidative processes may regulate GPI-PLD expression and suggest a role for GPI-PLD in inflammation and in the pathogenesis of atherosclerosis.

Influence of feeding status, time of the day, and season on baseline adrenocorticotropic hormone and the response to thyrotropin releasing hormone-stimulation test in healthy horses

Equine pituitary pars intermedia function can be assessed by the measurement of baseline and thyrotropin releasing hormone (TRH)-induced concentrations of adrenocorticotropic hormone (ACTH); however, these measurements may be affected by the environment. Therefore, a prospective observational study evaluated the influence of feeding, time of the day, and season on baseline and TRH-induced concentrations of ACTH in healthy horses. Baseline ACTH was measured in 50 horses before and 2 h after feeding. Six research horses were subjected to a crossover study in which 6 TRH tests were performed in 2 different seasons, March-April (MA) and July-September (JS), at 2 different times of the day, 8 AM and 8 PM, and, under 2 different conditions relative to feeding status, fasted and 2 h after feeding. Differences between fasted and fed horses were found in baseline ACTH, 17.1 ± 1.8 versus 46.1 ± 7.6 pg/mL (P = 0.003) and TRH-stimulated ACTH: 124.1 ± 21.3 versus 192.6 ± 33.1 pg/mL (P = 0.029) at 10 min, and 40.1 ± 4.9 versus 73.2 ± 13.4 pg/mL (P = 0.018) at 30 min post TRH injection. No differences were found between tests performed at different times of the day. Basal ACTH concentrations were greater in JS than in MA, 17.1 ± 1.8 versus 11.9 ± 0.6 pg/mL (P = 0.006). A seasonal influence was also found in stimulated ACTH values, which were much greater in JS 122.7 ± 36.7 versus 31.2 ± 7.4 pg/mL, at 10 min (P = 0.03) and 39.0 ± 7.2 versus 19.8 ± 3.1 pg/mL, at 30 min (P = 0.03). In addition to season, feeding is a potential confounding factor when measuring baseline or stimulated ACTH in horses. In conclusion, feeding status should be standardized for the diagnosis of equine pituitary pars intermedia dysfunction.

Concurrent cisplatin/gemcitabine chemotherapy along with radiotherapy in locally advanced cervical carcinoma: A phase II trial

OBJECTIVE

To evaluate the efficacy and safety of a concurrent regimen of gemcitabine/cisplatin and radiotherapy in women with locally advanced cervical carcinoma (LACC).

METHODS

From April 2001 to June 2002, we enrolled women diagnosed with histologically proven LACC (FIGO stages IIA through IIIB), for treatment with concurrent regimen of chemo-radiotherapy. The treatment consisted of: cisplatin 40 mg/m(2), followed by gemcitabine 125 mg/m(2), once weekly, given about 1 to 2 h before radiotherapy. External beam radiation was delivered 5 days/week to entire pelvic radiation field for a total of 50 Gy in 25 fractions over 5 weeks. After completion of external radiation, patients received brachytherapy with cesium-137 via standard Fletcher-suit applicators delivering 30 Gy to point A.

RESULTS

Of the 23 enrolled patients (mean age 47 years), 20 completed the treatment and were evaluable for response and safety. The complete response rate was 90% (18/20), and partial response rate was 10% (2 patients with persistent disease after therapy). Toxicity was moderate: 2 patients required blood transfusions; 5% patients had grade 2 leukopenia or thrombocytopenia; 40% had grade 1-2 nausea-vomiting, and 50% had grade 1 diarrhea. At a median follow-up of 12 months, all patients are alive, and 16/20 (80%) are disease-free.

CONCLUSIONS

The gemcitabine/cisplatin combination administered concurrently with radiotherapy is highly active in locally advanced cervical carcinoma. The tolerable toxicity and synergistic activity of this concurrent chemoradiation regimen are consistent with prior reports. Definitive results are awaited from an on-going large, randomized trial comparing this regimen with standard treatment.

Computerized tomography of proximal femoral trabecular patterns

A comprehensive imaging and pathologic investigation utilizing patients and cadaver material was performed in order to identify the normal trabecular pattern of the proximal femur and to assess alterations in this pattern in various disorders. Patients and specimens were studied with computed tomography (CT), including three-dimensional CT image reconstruction in selected cases and plain film radiography. The CT imaging of the proximal femur provides insight into the dynamic state of bone in this region. Despite limited resolution, three-dimensional CT image reconstruction is capable of portraying the concentration and orientation of major trabeculae in the proximal femur. Increased trabecular spacing occurs in osteoporosis and is well depicted by CT. Proliferation and thickening of the most superior subchondral primary compressive trabeculae is an early sign of osteoarthritis. In the region of the calcar femorale, crossing trabeculae, similar to the appearance of an enchondroma or bone infarct, have been described in osteoporosis and osteoarthritis and probably represent unmasking of normally present reinforcing trabeculae. In ischemic necrosis, CT should be considered a useful modality for detection of early or mild alterations and may be valuable in treatment planning.

Evidence of hypertrophic osteoarthropathy in human skeletal remains from pre-Hispanic Mesoamerica

Hypertrophic osteoarthropathy is one of the earliest recognized disease entities in the history of medicine. It has a peculiar periosteal proliferation distinctive from other bone diseases. In its advanced stage, it leaves an indelible mark on the skeleton. It has been recently shown that digital clubbing is accompanied by a bone remodeling process of the underlying phalanges. Thus, theoretically, this entity can be recognized in ancient human skeletal remains. We studied part of the collection of skeletal remains from pre-Hispanic Mesoamerica preserved at the National Museum of Anthropology of Mexico City. We examined 1000 specimens and found 2 skeletons with widespread, bilateral, symmetric periosteal proliferation of the tubular bones in addition to the bone remodeling changes of the distal phalanges. One of the specimens was from the Formative period (2000 B.C. to 100 A.D.). We conclude that hypertrophic osteoarthropathy can be recognized in ancient human skeletal remains and that this disease was present in Mesoamerica near the time of the original description of clubbing by Hippocrates about 2500 years ago.

Digital arthrography of the wrist: a radiographic-pathologic investigation

An analysis of digital arthrography of the wrist was accomplished in 10 cadaveric specimens. In each case, images were obtained during a 30-sec period in which a small amount of contrast material was introduced into the radiocarpal compartment; films were reviewed with and without subtraction technique. Pathologic examination of the sectioned specimens documented the accuracy of this arthrographic method. The sequence of contrast opacification of the various compartments of the wrist and the location and size of the defects within ligamentous and cartilaginous structures were ideally seen with digital arthrography. A previously unemphasized pattern of communication, that between the midcarpal and pisiform-triquetral compartments, was seen in two instances. Digital wrist arthrography seems to represent an excellent method to evaluate the patient with suspected soft-tissue injury.

Effect of levosimendan on myocardial contractility, coronary and peripheral blood flow, and arrhythmias during coronary artery ligation and reperfusion in the in vivo pig model

OBJECTIVE

To determine whether levosimendan, a calcium sensitiser that facilitates the activation of the contractile apparatus by calcium, improves myocardial contractile function during severe ischaemia and reperfusion without exacerbating the incidence of arrhythmias.

DESIGN

Pigs were pretreated orally twice daily for 10 days with 0.08 mg/kg levosimendan or placebo. On day 11 the left main coronary artery was ligated for 30 minutes, followed by 30 minutes of reperfusion. A bolus dose of levosimendan, 11.2 microg/kg intravenously, or placebo was given 30 minutes before coronary ligation, followed by a continuous infusion of 0.2 microg/kg/min levosimendan or placebo for the remainder of the experiment.

RESULTS

During the ischaemic period, cardiac output was higher in the levosimendan group than in the placebo group (mean (SD): 2.6 (0.5) v 2.0 (0.2) l/min, p < 0.05) and systemic vascular resistance was lower (2024 (188) v 2669 (424) dyne.s(-1).cm(-5), p < 0.005). During reperfusion, cardiac output and contractility (LV(max)dP/dt (pos), 956 (118) v 784 (130) mm Hg/s, p < 0.05) were increased by levosimendan. The incidence of ischaemic ventricular fibrillation and tachycardia was similar in the two groups but there were more arrhythmic events (ventricular tachycardia and ventricular fibrillation) in the levosimendan treated group (8/12 levosimendan v 1/9 control p = 0.05).

CONCLUSIONS

Levosimendan improved cardiac output and myocardial contractility during coronary artery ligation and reperfusion. However, it increased the number of arrhythmic events during ischaemia in this model of in vivo regional ischaemia.

Plantar compartmental infection in the diabetic foot. The role of computed tomography

This review discusses the role of computed tomography (CT) in the evaluation of extent of plantar soft tissue infection in the diabetic foot. CT abnormalities are correlated with conventional radiography, results of preoperative aspiration cultures, intraoperative assessment, and bone, gallium, and 111In-leukocyte scan findings. Plantar soft tissue disease respects compartmental boundaries in general, with transcompartmental spread possible along musculotendinous units that normally transgress the intervening fascial septae. CT correlates well with the extent of infection as determined by other modalities, but cannot precisely predict its proximal boundary due to gradual transition between unequivocally abnormal and normal tissue. CT may be useful in establishing an appropriate level for contemplated amputation and can detect extension of superficial diabetic foot infections at an earlier stage than existing clinical methods, potentially resulting in less extensive surgical procedures.

Feline parathyroid hormone: validation of hormonal assays and dynamics of secretion

Validated assays for quantification of intact parathyroid hormone (I-PTH) are no longer available. Moreover, the third-generation PTH assay that only detects the whole PTH molecule (W-PTH) has never been tested in cats. The work presented here is aimed to validate a commercially available assay for measurement of I-PTH and W-PTH in cats and to study the dynamics of PTH secretion in healthy cats. Our results show that both assays are reliable for the measurement of feline PTH. In healthy adult cats W-PTH concentration (15.1 ± 1.6 pg/mL) was greater (P < 0.001) than I-PTH concentration (9.1 ± 0.7 pg/mL). The dynamics of PTH secretion in response to changes in extracellular calcium (Ca(2+)) were investigated in 13 cats by studying PTH-Ca(2+) curves. PTH-Ca(2+) curves were obtained by intravenous infusion of disodium ethylenediaminetetraacetic acid and CaCl(2). PTH was measured using both I-PTH and W-PTH assays. During hypocalcemia a sigmoidal curve that was similar when measured with I-PTH or W-PTH was obtained. The maximal PTH concentration in response to hypocalcemia was greater with W-PTH (179.6 ± 41.9 pg/mL) than with I-PTH (67.6 ± 10.5 pg/mL; P = 0.01). However, hypercalcemia resulted in an equivalent PTH inhibition, with both assays yielding PTH concentrations as follows: W-PTH = 4.0 ± 0.4 pg/mL and I-PTH = 4.9 ± 0.3 pg/mL (NS). Parameters of the feline PTH-Ca(2+) curve are similar to what has been previously reported in dogs.

Vitamin E protection of obesity-enhanced vascular calcification in uremic rats

This study aimed to determine the extent of extraskeletal calcification in uremic Zucker rats, by comparing obese and lean phenotypes, and to evaluate the influence of vitamin E (VitE) on the development of calcifications in both uremic rats and human vascular smooth muscle cells (HVSMCs) cultured in vitro. Zucker rats of lean and obese phenotypes with normal renal function [control (C); C-lean and C-obese groups] and with uremia [5/6 nephrectomy (Nx); Nx-lean and Nx-obese groups] and uremic rats treated with VitE (Nx-lean + VitE and Nx-obese + VitE groups) were studied. Uremic groups were subjected to Nx, fed a 0.9% phosphorus diet, and treated with calcitriol (80 ng/kg ip). The aortic calcium concentration was significantly higher ( P < 0.05) in Nx-obese rats (10.0 ± 2.1 mg/g tissue) than in Nx-lean rats (3.6 ± 1.3 mg/g tissue). A decrease in plasma glutathione peroxidase activity was observed in Nx-obese rats compared with Nx-lean rats (217.2 ± 18.2 vs. 382.3 ± 15.5 nmol·min−1·ml−1, P < 0.05). Treatment with VitE restored glutathione peroxidase activity and reduced the aortic calcium concentration to 4.6 ± 1.3 mg/g tissue. The differences in mineral deposition between Nx-lean, Nx-obese, Nx-lean + VitE, and Nx-obese + VitE rats were also evidenced in other soft tissues. In HVSMCs incubated with high phosphate, VitE also prevented oxidative stress and reduced calcium content, bone alkaline phosphatase, and gene expression of core-binding factor-α1. In conclusion, uremic obese rats develop more severe calcifications than uremic lean rats and VitE reduces oxidative stress and vascular calcifications in both rats and cultures of HVSMCs.

Hand radiographic changes in patients with primary and secondary Sjögren's syndrome

Unselected hand radiographs from 37 primary Sjögren's syndrome patients (pSS), 19 patients with rheumatoid arthritis (RA) and Sjögren's syndrome (secondary SS) and 29 patients with RA only were evaluated blind by osteoradiologists, using reference radiographs for scoring joint space narrowing and erosion at the proximal interphalangeal joints, the metacarpophalangeal joints and the wrists. A history of arthralgias and/or arthritis of the above joints was taken from the patients charts. It is shown that pSS patients suffer from transient episodes of arthralgias and/or arthritis, while both secondary SS and RA patients had a history of chronic arthritis of the small joints of the hand. Evaluation of the hand radiographs showed that pSS patients exhibited mild joint space narrowing but no erosions, whereas the other two groups of patients presented with more severe joint space narrowing and varying degrees of erosions. Finally, RA patients without SS had more advanced radiographic changes than secondary SS patients. Thus hand X-rays can be used in addition to the previously described clinical differences in the differentiation of primary and secondary SS.

Ochronotic arthropathy as a paradigm of metabolically induced degenerative joint disease. A case-based review

Alkaptonuria is a rare, hereditary metabolic disorder in which a deficiency in the homogentisate 1,2-dioxygenase enzyme results in an accumulation of homogentisic acid. Deposition of excess homogentisic acid in different intra- and extra-articular structures with high content of connective tissue causes brownish-black pigmentation and weakening, ultimately resulting in tissue degeneration and finally osteoarthritis. Ochronotic arthropathy is considered a rapidly progressive, disabling condition in which weight-bearing joints and the thoracolumbar spine are predominantly affected. Patients often require multiple joint replacements, such as in the case of the patient presented here. At present, there is no definitive cure for ochronosis, and management is predominantly symptomatic.

Development of a radiographic index to assess the tarsal involvement in patients with spondyloarthropathies

OBJECTIVE

To develop and test an index to evaluate the radiographic changes that occur in the tarsus and adjacent areas of the foot in patients with spondyloarthropathies (SpA).

METHODS

The spondyloarthropathy tarsal radiographic index (SpA-TRI) was developed in three consecutive steps: (a) detection of descriptors after reviewing 70 radiographic files; (b) descriptor gradation and subsequent modifications performed by a consensus committee, and (c) interobserver variability assessed by three blinded and independent observers on 272 radiographs: anteroposterior 118, lateral 90, oblique 64 from 121 patients with SpA, and intraobserver variability on 75 radiographs from 25 patients with SpA. Statistical analysis included percentage of agreement and kappa test. SpA-TRI score ranges from 0 to 4 (0=normal; 1=osteopenia or suspicious findings; 2=definite joint space narrowing, bony erosion(s), periosteal whiskering, or enthesophyte(s) in the plantar fascia or Achilleal tendon attachments; 3=para-articular enthesophyte(s); 4=bony ankylosis (joint space fusion or complete bridging)).

RESULTS

Complete agreement for every evaluation was >40%, and discordance >1 grade was <15%. The kappa scores among the three observers were acceptable for all the single projections: oblique (0.52, 0.36, 0.35), lateral (0.50, 0.42, 0.56), and anteroposterior (0.40, 0.41, 0.21) views. The combination of lateral and oblique views achieved the highest concordance rates (0.72, 0.33, 0.66), surpassing that of the three projections altogether (0.34, 0.58, 0.37). In every case the concordance was comparable with that of sacroiliac joints (0.47, 0.41, 0.34); intraobserver concordance showed a similar trend.

CONCLUSION

The SpA-TRI is an index that includes the most prominent features of tarsal disease and adjacent areas of the foot in SpA and grades them accordingly, it has an adequate reproducibility, and is suitable for use with two or more projections, preferably the combination of oblique and lateral.

Detection of intra-articular osteochondral bodies in the knee using computed arthrotomography

A new technique using air arthrography followed by computed tomography enables identification of free osteocartilaginous fragments in the knee joint. Clinical examples with useful diagnostic information are presented, and potential pitfalls in the interpretation of this information are discussed.