Indices of severity and disease activity for osteoarthritis.

Several indices have recently been constructed by rheumatologists for the assessment of clinical status in osteoarthritis of the extremities. These include the algofunctional indices for the hip and knee (Lequesne), the Western Ontario and McMasters Universities (WOMAC) index (Bellamy), patients and investigator's overall opinion (results of drug trials), global evaluation of change in handicap (self-assessment), and articular index of physical examination in nature (Doyle et al). Each of the above indices have been validated by their respective authors. Presently, we propose to further validate the disease-activity indices.

The osteoporosis of heparinotherapy and systemic mastocytosis.

Heparinotherapy and systemic mastocytosis are two unusual aetiologies of diffuse osteopenia, possibly linked by common pathophysiological factors. Osteoporosis related to heparinotherapy has only been observed in patients treated with doses higher than 10,000 units per day and for more than 4 months. Even in these, it is a rare disorder which has only been reported approximately 15 times in the world literature. Bone histomorphometry has demonstrated the occurrence of marked hyperresorption. In vitro, heparin appears to have resorptive and collagenolytic effects which could play a pathophysiological part in the disorder. Diagnosis of the osteopenic form of systemic mastocytosis may be difficult. Urticaria pigmentosa is a very important clue but may be misdiagnosed or even missing. Hepato or splenomegaly are inconstant. X-rays may show the coexistence of osteosclerotic lesions. Standard biochemical tests are of little help. The urinary excretions of the histamine metabolites methyl histamine and methyl imidazolacetic acid have been found increased when measured. Finally, the diagnosis is made by bone histology which must be performed without decalcification and read by a pathologist informed of the potential diagnosis. Toluidine blue stain shows that mastocytes are numerous in the bone marrow where they are grouped in foci. Histomorphometry demonstrates a high bone turnover with excessive resorption, which could be mediated by heparin or PG E 2 contained in mastocyte granules. Treatment is difficult and may involve cytostatic drugs and/or inhibitors of bone resorption: Clodronate has recently been reported to be at least transiently effective.

EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.

UNLABELLED: A task force for the EULAR standing committee for clinical trials determined the methodological and logistical approach required for the development of evidence-based guidelines for treatment of knee osteoarthirits (OA). METHODS: The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the databases of all European-language publications. All of the relevant studies were quality scored. The third stage involved determination of key clinical propositions by expert consensus employing a Delphi approach. The final stage involved ranking of these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus. RESULTS: 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 only certain clinical propositions are supported by substantial research-based evidence. There is thus an urgent need for future well-designed trials to address key clinical questions.

[Do 'chondroprotective agents' agents exist in osteoarthritis? Required proof]. / Y a-t-il des antiarthrosiques 'chondroprotecteurs'? Preuves exigibles.

The term 'chondroprotective agent' must be dropped in favour of that of structure-modifying drug which allows consideration of the global process of osteoarthritis (OA). A structure-modifying drug is defined as being able to prevent, retard, stabilize or even reverse all or a part of the lesions of bone and cartilage which form the structure of human OA. The demonstration of an eventual structure-modifying effect can only be provided by the proof of a favourable result on the anatomical lesions of OA. The measurement of joint-space narrowing by manual 'radiochondrometry' or performed by computer is presently the 'method of choice', but requires the strict respect of standardized rules during the radiographic procedure. MRI may allow, in the future, a satisfactory assessment of the volume of articular cartilage. Chondroscopy permits a direct evaluation of lesions but is an invasive technique. Molecular markers still lack reliability. Until now, no drug has been able to provide well-established proof of a real effect of structuromodulation.

[Clinical and radiographic status of patients in the ECHODIAH study who underwent THA Pertinence of the pain-function index for operative decision making]. / Statut clinique et radiologique des patients avec prothèse totale de hanche dans l'étude ECHODIAH.

DATA COLLECTION: The ECHODIAH study conducted to evaluate the chondromodulator effect of diacerein on the osteoarthritic hip joint has provided epidemiological data on patient symptoms at three-month intervals. Patients with degenerative hip joints evaluated their pain and handicap on visual analog scales. The Lequesne functional score was also determined. A radiographic study was performed every year. IMPROVED PREDICTIVE FACTORS: Among the 507 patients included in the study, 135 underwent total hip arthroplasty. Clinical and radiological evaluations of the operated patients demonstrated that the Lequesne functional score was the best predictive factor with an optimal cutoff at 12 points. The second best predictive factor was the radiographic measurement of the joint space.

[Tendinitis of the hip region]. / Tendinites de la région de la hanche.

Tendinitis and bursitis are less common around the hip than around the shoulder. Nevertheless, they must be recognized to avoid unnecessary and costly diagnostic errors. Their various clinical forms are studied in detail. Tendino-bursitis of the gluteus medius muscle is the most frequent in its subacute form, but it is rare in its acute, pseudo-gouty form. Calcification of the reflected tendon of the rectus femoris muscle often closely resembles arthritis of the hip. Synovial cysts of the psoas bursa and rupture of the gluteus medius tendon are rare but must be known. Local injections of corticosteroids play an important part in the treatment of these diseases.

Methodology issues in the evaluation of NSAID in inflammatory rheumatic diseases.

The characteristics required of tests used in trials of nonsteroidal antiinflammatory drugs in patients with inflammatory rheumatic diseases in order for such tests to provide meaningful results are reviewed. Those tests most widely used in trials of patients with rheumatoid arthritis or ankylosing spondylitis are assessed, and the ability of such tests to discriminate among the treatment effects of different agents is considered. Finally, several statistical and procedural issues important to clinical trial methodology are discussed.

Indices of severity in osteoarthritis for weight bearing joints.

Indices of severity for hip and knee diseases may be applied to any disabling disease of these joints, but were especially designed and validated for osteoarthritis (OA). With experience, a score could be obtained in 3-4 minutes and the reproducibility was satisfactory. Their discriminant power in a double blind crossover trial of a given nonsteroidal antiinflammatory drug versus placebo was, among other assessment tests, in the first rank concerning the hip OA index, in the 4th rank concerning the knee OA index. These indices allow longterm followup of OA, rationalization of decision for prosthesis, when the score reaches 8 to 12 points despite correct medical treatment.

Guidelines for testing slow acting drugs in osteoarthritis.

New compounds appear to improve symptoms of osteoarthritis (OA), and others are putative chondroprotective agents. We suggest experimental designs for studying the effects of these agents in subjects with hip and knee OA. The course of the articular cartilage lesion is the primary outcome measure to be assessed in putative chondroprotective agent trials. Serial radiographic studies suggest that the annual rate of joint space narrowing in patients with hip or knee OA is about 0.25 mm. Other approaches to quantitation of cartilage loss, e.g., radiographic measurement of the area of joint space, ultrasonography, magnetic resonance imaging and fiberoptic arthroscopy (for knee OA) are under investigation.

[Methods for evaluating chondroprotective agents]. / Méthodes d'évaluation des chondroprotecteurs.

A number of compounds have "chondroprotective" effects in animals or chondrocyte cultures. However, in humans, these drugs have not been convincingly shown to prevent, delay, arrest, or repair structural cartilage lesions due to osteoarthritis. In clinical trials, the main evaluation criterion should be the time-course of cartilage lesions. One parameter for assessing cartilage lesions is cartilage thickness, which can be measured at the site of greatest joint space loss using compasses and a magnifying glass. Alternatively, joint space surface area in the abnormal zone can be determined by automatic analysis of digitalized images. Use of echotomographic sections obtained using an intraarticular probe inserted during arthroscopy of the knee has been advocated. External measurements by magnetic resonance imaging or ultrasonography are technically difficult and most have been found inadequate during validation studies. Clinical trials should also include a clinical assessment of therapeutic benefits, without which chondroprotection would be pointless. Duration of these trials should be two to four years, since cartilage loss occurs slowly in osteoarthritis: mean values of 1/4 mm per year, with wide variations, have been reported at the hip and knee. A randomized, double-blind, placebo-controlled design should be used.

[Quality of life and functional indices in osteoarthritis]. / Les indices de qualité de vie et les indices fonctionnels dans l'arthrose.

The main Indices of Quality of Life used in rheumatology and their aims and applications are surveyed. Their use in osteoarthritis implies a few issues that are addressed in a critical manner. Indices of Quality of Life are useful to measure deficiency resulting from osteoarthritis by comparison with other rheumatic diseases, as rheumatoid arthritis, connective tissue diseases, fibromyalgia... They are sensitive enough for apraising the domains improved by a radical treatment such as joint replacement. However, their scores are only slightly changing in most of the drug trials, in which the more simple functional indices seem demonstrative enough. Last but no least, they are notably time consuming for both the patient and the physician.

[Post-traumatic coxarthrosis. Medicolegal conditions of the likelihood of fractures, luxations or contusions]. / La coxarthrose post-traumatique. Conditions médico-légales d'imputabilité à une fracture, une luxation ou une contusion.

Trauma is the cause of 5 to 10% of all cases of osteoarthritis of the hip. One third of patients with a dislocation or fracture-dislocation of the hip or an acetabular fracture develop osteoarthritis of the hip within one to 20 years. Symptoms may be minor or absent during the interval. In addition to severe injuries, simple contusions resulting for instance from a blow to the greater trochanter or knee or from forced abduction of the hip (e.g., splits) can also result in osteoarthritis of the hip. We developed a set of five imputability criteria, of which three are essential: 1) documentation of the exact nature of the trauma; 2) absence of osteoarthritis in the uninjured hip; 3) consistency between the estimated duration of osteoarthritis and the date of the injury. Causality assessment problems which arise when a trauma worsens or accelerates preexisting osteoarthritis are discussed on the basis of clinical and roentgenographic findings. Mechanical and biochemical factors involved in the pathophysiology of contusion-related osteoarthritis of the hip are briefly reviewed.

[Pigmented villonodular synovitis of the hip. Results of a national survey apropos of 58 cases]. / La synovite villo-nodulaire pigmentée de la hanche. Résultats d'une enquête nationale à propos de 58 observations.

Pigmented villonodular synovitis is an uncommon synovial disease which only rarely involves the hip. In a multicenter retrospective study, we identified 58 histologically-proven cases. There were 33 females and 25 males. Mean age at diagnosis was 38 years. In all but two cases, only one hip was involved; the right hip was affected somewhat more often (33 cases) than the left. Two patients probably had bilateral hip disease. Mean delay to diagnosis was four years. Pain was the presenting symptom in most cases. A palpable mass in the groin was found in six patients. Plain roentgenograms were considered normal in only three patients. Bony cysts were seen in 39 patients and kissing cysts in 19. Joint space narrowing was found in 40 patients and was diffuse in half the cases. Roentgenograms suggested pigmented villonodular synovitis in 63% of cases, osteoarthritis of the hip in 16%, and inflammatory hip disease in 14%. Additional imaging studies included opaque arthrography in 21 subjects, computed tomography in 23, magnetic resonance imaging in 11, and arthroscopy in 9. Initial treatment was osmic acid synoviorthesis in 14 patients, partial synovectomy in 9, and total synovectomy in 21; in addition, eight patients had insertion of a cup prosthesis and 13 had total arthroplasty of the hip. Treatment was successful in 65% of cases after a mean follow-up of three years; among the 35% of failures, there were seven recurrences (14%). Total hip arthroplasty was performed secondarily in nine patients. This study illustrates the diversity of roentgenological changes in pigmented villonodular synovitis of the hip and the high frequency of osteoarticular lesions precluding conservative treatment. Magnetic resonance imaging and/or arthroscopy should be used to establish the diagnosis at an early stage when conservative treatment with total synovectomy and synoviorthesis is most likely to be successful.

Clinical and MRI results in 67 patients operated for gluteus medius and minimus tendon tears with a median follow-up of 4.6 years.

INTRODUCTION: Although various techniques can be used to repair gluteal tendon tears, the long-term outcome is unclear and published studies typically involve only a small number of patients. The goals of this study were to determine (1) if functional improvement can be obtained, (2) if the repairs are continuous based on MRI, and (3) which factors determine success. HYPOTHESIS: Gluteus medius and minimus tears can be repaired effectively with an open double-row technique. MATERIAL AND METHODS: Seventy-three patients were operated on between 2003 and 2010. Of these patients, 67 (62 women, 5 men) were available for review consisting of functional clinical tests and MRI of the hip and pelvis. A double-row repair was performed on all tendon tears, no matter the type of injury. Age, body mass index (BMI), fatty degeneration and muscle atrophy were also evaluated to determine if these variables affected the outcome. RESULTS: The average follow-up was 4.6 years (range 1-8). The pre-operative scores had improved at the last follow-up: (1) pain (VAS): 8.7 ± 1.1 versus 1.7 ± 2.7 at the follow-up, (P<0.001), (2) Lequesne index: 12.3 ± 2.6 versus 4.0 ± 4.0 at the follow-up, (P<0.001), (3) Harris Hip Score: 50.5 ± 8 versus 87.9 ± 15.5 at the follow-up, (P<0.001). There were 11 failures (16%) including two repeat tears that were reoperated successfully. In the other 56 patients, the MRI showed no signs of the initial tear or bursitis. Of the four factors (age, BMI, fatty degeneration, muscle atrophy) that were potential predictors of the outcome, only muscle atrophy had a negative impact on functional outcome (P<0.05). CONCLUSION: Using an open double-row technique to repair gluteal tendon tears led to 85% of patients having good clinical results with significant improvement in symptoms and disappearance of abnormal findings on MRI. This technique can be used with all types of tendon tears, but should be performed before muscle atrophy sets in. LEVEL OF PROOF: Level IV-retrospective study.

Imaging data in a prospective series of adult hip pain in under-50 year-olds.

Two hundred and ninety-two patients under the age of 50 years, presenting with mechanical hip pain, were included in a prospective multicenter study. In 241 cases, imaging assessment included AP standing pelvic X-ray and Lequesne's false profile (LFP) and/or lateral neck (Ducroquet, Dunn or variant) hip X-ray. Cross-sectional arthroscan and/or arthro-MRI images were available in 81 cases. Exploration looked for acetabular and femoral head/neck dysplasia liable to induce cam or pincer anterior femoroacetabular impingement (AFAI), respectively. Labral and chondral lesions arise secondarily to hip osteoarthritis (HOA) and/or AFAI. Two-thirds of patients showed HOA. Only 6% showed a strictly normal aspect on imaging. More than half (52%) of cases had cam AFAI, half of these involving an osteophytic neck, associated in more than 90% of cases with large multifocal bone spurs of the head, neck and acetabula. These cases were considered ambiguous, due to the uncertainty as to the congenital nature of the cervico-cephalic dysmorphy; if they are excluded, only 23% of the series involved cam AFAI. Crossover sign on AP standing pelvic X-ray is the best assessment criterion for acetabular retroversion, the most frequent form of acetabular dysplasia underlying pincer AFAI, and should be explored for. Secondary neck lesions were visible only on lateral neck view in 42% of cases: this view should be included in standard radiologic work-up in under-50 year-olds. The alpha angle can be measured on this type of lateral view and on axial arthroscan and arthro-MR images; more than half of the cases in which it was pathological involved an osteophytic neck and thus a pseudo-cam effect.

Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.

Two hundred and ninety-two patients, aged between 16 and 50 years and presenting with mechanical hip pathology, were included in a prospective multicenter study. The descriptive study concerned the clinical examination and analysis of three X-ray views (AP pelvic, Lequesne false profile and lateral axial view). The series comprised 62% males, mean age 35 years, with 53% right side and 22% bilateral involvement. Initial trauma was reported in 19% of cases, and direct familial history of hip pathology in 20%. Seventy percent of the patients played sports, 30% were high-level athletes, and 17% played combat sports. The physical impingement sign was present in 18% to 65% of cases depending on the variant studied. On imaging (n=241), 62% of hips showed osteoarthritis, with 25% at the evolved stage. In the series, as a whole, there was a 35% rate of dysplasia, 63% of impingement and 5% of normal X-ray results. The radiologic impingement aspects were 58% cam-type, 19% pincer-type and 23% mixed. Twenty-two percent of dysplasia cases showed signs of associated impingement. Pain experienced exclusively in flexion/internal rotation/adduction on examination showed little sensitivity (20%) but considerable specificity (86%) for the main diagnosis of impingement. The links between impingement and dysplasia are discussed, and an integrative schema of all risk factors is put forward.