[Clinical presentation imaging and treatment of digital osteoarthritis]. / Présentation clinique, imagerie et traitement de l'arthrose digitale.

Digital osteoarthritis relates to primarily the distal interphalangeal (DIP) and first carpometacarpal (CMC-I) joints. Heberden's nodes often accompany osteoarthritis of the DIP joints. Osteoarthritis of the PIP joints can be more painful and more inflammatory. It can be at the origin of Bouchard's nodes. The DIP and the PIP joints can be the seat of erosive lesions. Osteoarthritis of the MCP joints is rare. Osteoarthritis of the CMC-I joint is sometimes at the origin of a deformity of the thumb impairing its function and an atrophy of the thenar muscles. Treatment includes non-pharmacological and pharmacological modalities. Surgery is proposed after failure of the conservative approach.

[Rotator cuff tear of the hip]. / Rupture de la coiffe des rotateurs de la hanche.

We report the observations of two women with a recurrent periarthritis of the hip complicated by a spontaneous rupture of the tendons of the gluteus medius and minimus. These patients usually complain from an acute lateral hip pain and show a Trendelenburg gait. When the rupture is complete, clinical evaluation reveals a drop of the pelvis on the non-stance side and resisted rotation starting from the extreme external rotation position is weak. MRI plays a key role in the diagnosis and the evaluation of a possible surgical repair. Hip rotator-cuff rupture is probably insufficiently diagnosed by ignorance. Nonetheless, optimized handling could relieve the pain of most these patients and improve the disability of some of them.

Candida glabrata spinal osteomyelitis involving two contiguous lumbar vertebrae: a case report and review of the literature.

Due to the increase of the immunocompromised population, mucosal and systemic infections caused by Candida glabrata, formerly known as Torulopsis glabrata, have shown a recent significant increase. We present a case of C. glabrata vertebral osteomyelitis which required repeated surgical therapy, a complete L2 and L3 corporectomy and more than one year of hospitalisation to complete healing. We compare this case to eight previously reported cases outlining the features of C. glabrata spinal osteomyelitis, including symptoms, diagnosis, treatment, evolution and outcome. According to the case presented and in review of the literature, we believe that in the absence of abscess and neurologic symptoms, medical treatment should be initiated with close clinical, laboratory and radiologic follow-up. An unfavorable evolution of these parameters should be an indication for aggressive and, if necessary, repeated surgical intervention in association with an antifungal treatment.

Rotator cuff repair. Long-term results.

OBJECTIVES: To evaluate the results of rotator cuff repair and to look for preoperative and/or intraoperative predictors of long-term outcomes. PATIENTS AND METHODS: All patients who underwent open rotator cuff repair surgery for a full-thickness tear between 1990 and 1996 and who were subsequently followed-up for at least 4 years were contacted. The surgical technique and postoperative rehabilitation program were standardized. We recorded factors potentially associated with outcomes (age, sex, dominant hand, pain, symptom duration, and active range-of-motion limitation). RESULTS: Of the 56 patients identified, 26 men and 24 women with a mean age of 58.52 years were included in the study. Mean symptom duration was 12 months (range, 3-48 months). Before surgery, mean active range of motion of the shoulder was 144.6 degrees for forward elevation, 135.2 degrees for abduction, and 39.4 degrees for lateral rotation with the elbow at the side. The size of the tear measured during surgery was 1-5 cm. Mean time to recovery of shoulder power (75% of the value before the tear) as assessed by the patients was 10 months. After a mean follow-up of 6 years, a significant reduction in pain was noted (from 2.18/3 to 0.98/3; P < 0.001), although two-thirds of the patients reported occasional pain. Six patients were dissatisfied. Range of motion had improved in one-fourth of the patients. Constant's score after surgery was 65/100. Persistent difficulty in taking objects down from high shelves was noted. None of the preoperative or intraoperative factors studied predicted the long-term outcomes. CONCLUSION: In this series of patients, rotator cuff repair reduced pain severity. Nearly a year was needed to achieve the final result. Only a minority of patients experienced an improvement in range of motion.

Methotrexate in chronic-recurrent calcium pyrophosphate deposition disease: no significant effect in a randomized crossover trial.

INTRODUCTION: Calcium pyrophosphate deposition (CPPD) may cause severe arthropathy, major joint destruction and treatment options are limited. The aim of this study was to test the therapeutic efficacy of methotrexate (MTX) in chronic or recurrent CPPD arthropathy. METHODS: Patients with CPPD arthropathy were randomized to receive either weekly subcutaneous injections of 15 mg/week of MTX or placebo (PBO) for three months, in a double-blind, crossover randomized controlled trial. Inclusion criteria comprised definite CPPD disease, recurrent arthritis or persistent polyarthritis, and an insufficient response to NSAIDs, glucocorticoids or colchicine. The primary outcome was an improvement in the disease activity scores based on 44 joints (DAS44). The analysis was performed on an intent-to-treat basis. RESULTS: We randomized 26 patients, and compared 25 treatment periods on MTX with 21 treatment periods on PBO. Baseline characteristics were balanced between the groups. The evolution of the DAS44 was not statistically significantly different between groups (median DAS44 decreased by -0.08 on MTX versus -0.13 on PBO, after three months, P = 0.44). Furthermore, pain levels remained stable in both groups (median change in VAS Pain -1 unit on MTX and 0 on PBO, P = 0.43), and none of the secondary outcomes was significantly different between the two groups. Minor adverse events (AE) did not differ in frequency between the groups, but the only serious AE occurred on MTX (bicytopenia). CONCLUSIONS: The results of this trial with MTX in this older population with chronic or recurrent CPPD arthropathy suggest no strong effect of MTX on disease activity. TRIAL REGISTRATION: EudraCT No: 2007-003479-37. Registered 26 April 2008.

Pathogenic role of basic calcium phosphate crystals in destructive arthropathies.

BACKGROUND: basic calcium phosphate (BCP) crystals are commonly found in osteoarthritis (OA) and are associated with cartilage destruction. BCP crystals induce in vitro catabolic responses with the production of metalloproteases and inflammatory cytokines such as interleukin-1 (IL-1). In vivo, IL-1 production induced by BCP crystals is both dependant and independent of NLRP3 inflammasome. We aimed to clarify 1/ the role of BCP crystals in cartilage destruction and 2/ the role of IL-1 and NLRP3 inflammasome in cartilage degradation related to BCP crystals. METHODOLOGY PRINCIPAL FINDINGS: synovial membranes isolated from OA knees were analysed by alizarin Red and FTIR. Pyrogen free BCP crystals were injected into right knees of WT, NLRP3 -/-, ASC -/-, IL-1α -/- and IL-1ß-/- mice and PBS was injected into left knees. To assess the role of IL-1, WT mice were treated by intra-peritoneal injections of anakinra, the IL-1Ra recombinant protein, or PBS. Articular destruction was studied at d4, d17 and d30 assessing synovial inflammation, proteoglycan loss and chondrocyte apoptosis. BCP crystals were frequently found in OA synovial membranes including low grade OA. BCP crystals injected into murine knee joints provoked synovial inflammation characterized by synovial macrophage infiltration that persisted at day 30, cartilage degradation as evidenced by loss of proteoglycan staining by Safranin-O and concomitant expression of VDIPEN epitopes, and increased chondrocyte apoptosis. BCP crystal-induced synovitis was totally independent of IL-1α and IL-1ß signalling and no alterations of inflammation were observed in mice deficient for components of the NLRP3-inflammasome, IL-1α or IL-1ß. Similarly, treatment with anakinra did not prevent BCP crystal effects. In vitro, BCP crystals elicited enhanced transcription of matrix degrading and pro-inflammatory genes in macrophages. CONCLUSIONS SIGNIFICANCE: intra-articular BCP crystals can elicit synovial inflammation and cartilage degradation suggesting that BCP crystals have a direct pathogenic role in OA. The effects are independent of IL-1 and NLRP3 inflammasome.

[The humeroradial impingement]. / L'enclavement huméroradial.

Lateral pain of the elbow is frequently reported. Impingement of the humeroradial fold or a synovial fringe is a seldom evoked cause, sometimes ignored. Nonetheless, this etiology should be remembered in young adults performing sport activities and in heavy workers. Pain can be acute and inflammatory. Elective pain is usually elicited by the pressure on the humeroradial joint space, beneath the lateral epicondyle. Snapping, locking and restricted mobility can be observed. MRI-arthrogram is the best radiological examination to perform. Symptoms can be improved by conservative treatment but may warrant an arthroscopical resection.

Miller-Fisher syndrome in a patient with rheumatoid arthritis treated with adalimumab.

Adalimumab is a frequently prescribed TNFalpha inhibitor for treatment of rheumatoid arthritis. We report on a patient who probably developed a Miller-Fisher syndrome after the second injection of adalimumab.

Suspected gouty tophus in a woman's breast.

A postmenopausal woman treated with diuretics for hypertension and who underwent surgery for a previous fibroadenoma of the left breast presented, in December 2003, with a sudden bloody discharge of the left nipple with local swelling, redness, and pain. Radiologic investigations revealed a well-delimited tumor under the areola. Needle aspiration disclosed many histiocytes but no bacteria. Despite improvement with antibiotics, the tumor was removed. Pathological examination shows features suggesting the tumor was a gouty tophus. Birefringent crystals were retrospectively found on the smears of the aspirated material. To our knowledge, only 3 similar cases have been reported in the literature.

[Slow-acting anti-rheumatic agents: recent developments]. / Les médicaments anti-arthrosiques d'action lente. Développements récents.

Until recently, treatment of osteoarthritis targeted the pain and the disability of the involved joints. It consisted in a mix of analgesics, anti-inflammatory drugs, steroid infiltrations and physical therapies. Usefulness of slow but long acting substances is increasing not only by their action on the symptoms but also because they positively influence the evolution of the disease. Some of them seem to induce a structural effect on the cartilage confirmed by a slow down of the joint space narrowing on successive radiographs of the knees. Presently, only basic matricial precursors such as chondroitin sulfate, glucosamine sulfate and hyaluronic acid are available in the clinic. They act by reducing cartilage destruction and enhancing chondrocyte anabolism. These preliminary results should be confirmed by further studies based on magnetic resonance imaging and surrogate markers of the cartilage matrix. Recent developments in the understanding of the physiopathology of osteoarthritis, including the key role of some cytokines, should allow new therapic ways, individually or in combination.

[A practical approach to diagnosing and managing post-menopausal osteoporosis]. / De l'ostéopénie à l'ostéoporose: une approche pragmatique en Rhumatologie.

Postmenopausal osteoporosis is a major challenge in Medicine. From a simple 10 points questionnaire allowing the detection of the main risks of the disease, different treatment options, based on mineral density, are now available. Treatment should be adapted to age and way of life of the patient.

The cervical spine in calcium pyrophosphate dihydrate deposition disease. A prevalent case-control study.

OBJECTIVE: To test the hypothesis that calcium pyrophosphate dihydrate (CPPD) deposition disease is a risk factor for neck pain. METHODS: A prevalent case-control study was conducted to assess cervical calcifications and neck pain between patients with and without known peripheral CPPD deposition disease. CPPD cases were included if diagnosed with CPPD deposition disease of peripheral joints, and excluded if their chief complaint was neck pain. Controls were randomly selected among consecutive patients, hospitalized for conditions unrelated to CPPD deposition disease or neck pain, and matched to CPPD cases by age and sex. Cervical calcifications were assessed by lateral cervical radiographs and computed tomography scans of the upper cervical spine; neck pain and cervical function were appraised by a validated questionnaire. RESULTS: Cervical calcifications were found in 24 out of 35 patients (69%) in the CPPD group compared to 4 out of 35 patients (11%) in the control group (p < 0.001). Patients with CPPD deposition disease reported significantly more neck pain and discomfort than controls (p < 0.001), and were 5 times more likely to report any neck pain (odds ratio 5.5; 95% confidence interval: 1.9, 21.9). Among male patients, more extensive cervical calcified deposits correlated with more severe neck pain (rs = 0.58, p = 0.03). CONCLUSION: These results suggest that CPPD deposition disease frequently involves the cervical spine and may be associated with the development of neck pain.