The French multicentre elevated bone mass study: prevalence and causes.

The purpose of this multicentric study was to evaluate the prevalence and causes of Elevated Bone Mass (EBM) in patients who underwent DXA scanning over a 10-year period. The prevalence of EBM was 1 in 100. The main causes of EBM were degenerative spine disorders and renal osteodystrophy. INTRODUCTION: Reports of elevated bone mass (EBM) on routine dual energy X-Ray absorptiometry (DXA) scanning are not infrequent. However, epidemiological studies of EBM are few and definition thresholds are variable. The purpose of this French multicentric study was to evaluate the prevalence and causes of EBM in adult patients who underwent DXA scanning over a 10-year period. METHODS: This multicentric, retrospective study was conducted in six French regional bone centres. DXA databases were initially searched for individuals with a bone mineral density (BMD) Z-score ≥ +4 at any site in the lumbar spine or hip from April 1st, 2008 to April 30st, 2018. RESULTS: In all, 72,225 patients with at least one DXA scan were identified. Of these, 909 (322 men and 587 women) had a Z-score ≥ + 4, i.e. a prevalence of 1.26% [1.18-1.34%]. The DXA scan reports and imagery and medical records of the 909 EBM patients were reviewed and 936 causes were found. In 42 patients (4%), no cause could be determined due to unavailability of data. Artefactual causes of EBM were found in 752 patients (80%), in whom the predominant cause was degenerative disease of the spine (613 patients, 65%). Acquired causes of focal EBM-including Paget's disease (n = 7)-were found in 12 patients (1%), and acquired causes of generalized EBM-including renal osteodystrophy (n = 32), haematological disorders (n = 20) and hypoparathyroidism (n = 15)-in 84 patients (9%). Other causes were rare hereditary diseases and unknown EBM in 19 (2%) and 27 (3%) cases respectively. CONCLUSIONS: The prevalence of EBM was approximately 1 in 100. These findings suggest that degenerative disease of the spine is the main cause of EBM, but that acquired or hereditary diseases are also causal factors.

[A review of avascular necrosis, of the hip and beyond]. / Ostéonécroses aseptiques, une revue générale des ostéonécroses de la hanche, et au-delà.

Avascular necrosis is an ischemic or cytotoxic necrosis of epiphyseal bone, responsible for joint pain, altered life quality and frequently affecting young patients. Avascular necrosis can be unifocal or multifocal, underlining the possibility of a systemic origin. Avascular necrosis involves the femoral head in more than 75% of cases. Although avascular necrosis is irreversible, many risk factors must be sought, including corticosteroid treatment, hypercholesterolemia, sickle cell disease or alcohol abuse. MRI imaging is the main exploration for the diagnostic and staging of the disease, and should be performed in unexplained hip pain in young patients with normal X-rays. In the earlier stages of the disease (stage I and II of the Arlet and Ficat classification), joint surface is preserved, and conservative treatment is recommended. In the more advanced stages (III and IV of the Arlet and Ficat classification), the articular surface collapses and joint arthroplasty is the main treatment. However, there are some recent therapeutic advances, based on mesenchymal stem cells, which may contribute, in the future, to improve the bad functional prognosis of the disease.

Vertebral fractures cascade: potential causes and risk factors.

We performed a study to identify potential causes and risk factors of vertebral fracture cascade. Vertebral fracture cascade is a severe clinical event in patients with bone fragility. Only half of patients have an identified cause of secondary osteoporosis. INTRODUCTION: Vertebral fracture (VF) is the most common osteoporotic fracture, and a strong risk factor of subsequent VFs leading to VF cascade (VFC). We prompted a study to identify potential causes and risk factors of VFC. METHODS: VFC observations were collected retrospectively between January 2016 and April 2017. VFC was defined as an occurrence of at least three VFs within 1 year. RESULTS: We included in 10 centers a total of 113 patients with VFC (79.6% of women, median age 73, median number of VFs in the cascade, 5). We observed 40.5% and 30.9% of patients with previous major fractures and a previous VF, respectively, and 68.6% with densitometric osteoporosis; 18.9% of patients were currently receiving oral glucocorticoids and 37.1% in the past. VFC was attributed by the physician to postmenopausal osteoporosis in 54% of patients. A secondary osteoporosis associated with the VFC was diagnosed in 52 patients: glucocorticoid-induced osteoporosis (25.7%), non-malignant hemopathies (6.2%), alcoholism (4.4%), use of aromatase inhibitors (3.6%), primary hyperparathyroidism (2.7%), hypercorticism (2.7%), anorexia nervosa (2.7%), and pregnancy and lactation-associated osteoporosis (1.8%). A total of 11.8% of cases were reported following a vertebroplasty procedure. A total of 31.5% patients previously received an anti-osteoporotic treatment. In six patients, VFC occurred early after discontinuation of an anti-osteoporotic treatment, in the year after the last dose effect was depleted: five after denosumab and one after odanacatib. CONCLUSION: The results of this retrospective study showed that only half of VFC occurred in patients with a secondary cause of osteoporosis. Prospective studies are needed to further explore the determinants of this severe complication of osteoporosis.

Type 1 primary hyperoxaluria: A case report and focus on bone impairment of systemic oxalosis.

Primary hyperoxaluria is a rare genetic disorder characterized by oxalate overproduction, leading to kidney failure due to nephrocalcinosis, and is eventually responsible for systemic oxalosis. Bone impairment, secondary to oxalate deposits, is one of the many complications that may occur. Skeletal involvement can be difficult to diagnose because of lack of clinical symptoms and therefore needs to be confirmed by invasive testing, such as transiliac bone biopsy. If confirmed, bone oxalosis is the proof of disease severity and that combined liver-kidney transplantation should be performed.

[Discontinuation or tapering strategies of biologics in rheumatoid arthritis in remission]. / Stratégies d'arrêt ou de réduction des biomédicaments dans la polyarthrite rhumatoïde en rémission.

The arrival of new drugs and new therapeutic strategies allowed to reach sustained remission in an increasing number of patients with rheumatoid arthritis. The study of biologic disease-modifying anti-rheumatic drugs (bDMARDs) adaptation strategies is a need to optimize the benefit/risk balance and cost/effectiveness ratio of these molecules. Current recommendations such as EULAR 2016 propose tapering bDMARDs, especially when combined with a csDMARD, when the patient is in remission after stopping persistent glucocorticoids. The analysis of literature comprising 22 studies shows that a bDMARD adaptation is possible in established rheumatoid arthritis when clinico-biological and ultrasound remission is maintained over six months. Priority should be given to a progressive tapering strategy doses controlled by disease activity while maintaining "tight control" to identify and effectively treat a relapse, a retreatment being usually favorable.

How to determine the bone mineral density of the distal humerus with radiographic tools?

INTRODUCTION: The aim of this study was to investigate three methods of prediction of the bone quality of the distal humerus: dual-energy X-ray absorptiometry (DEXA), Ct-Scan and plain radiographs. MATERIALS AND METHODS: The bone mineral density (BMD) of 21 cadaveric distal humerus was determined using DEXA at two levels. Then a CT-scan and anteroposterior radiographs were taken. The cancellous density was estimated with the CT-scan. The cortico-medullar index (CMI) was calculated as cortical thickness divided by total bone thickness on AP views. RESULTS: A significant positive correlation was found between the BMD of the epiphysis and the CMI of r = 0.61. The mean BMD of the distal humerus was 0.559 g/cm(2). Male specimens showed a significantly higher BMD than females. The mean CMI of diaphysis was 1.431 and the mean BMD of the metaphysis region was 0.444 g/cm(2). DISCUSSION: More than a direct evaluation of the bone density with a CT-scan, the CMI of the distal humerus diaphysis is a predictor of the bone quality of the distal humerus. This should be of great help for the surgeon's decision making in case of fracture of the distal humerus, as open Reduction and Internal Fixation (ORIF) of fractures of the distal humerus can lead to failure due to poor bone quality. LEVEL OF EVIDENCE: Basic Science Study, Anatomic Cadaver Study.

Persistent hyperparathyroidism is a major risk factor for fractures in the five years after kidney transplantation.

The risk of fractures after kidney transplantation is high. Hyperparathyroidism frequently persists after successful kidney transplantation and contributes to bone loss, but its impact on fracture has not been demonstrated. This longitudinal study was designed to evaluate hyperparathyroidism and its associations with mineral disorders and fractures in the 5 posttransplant years. We retrospectively analyzed 143 consecutive patients who underwent kidney transplantation between August 2004 and April 2006. The biochemical parameters were determined at transplantation and at 3, 12 and 60 months posttransplantation, and fractures were recorded. The median intact parathyroid hormone (PTH) level was 334 ng/L (interquartile 151-642) at the time of transplantation and 123 ng/L (interquartile 75-224) at 3 months. Thirty fractures occurred in 22 patients. The receiver operating characteristic (ROC) curve analysis for PTH at 3 months (area under the ROC curve = 0.711, p = 0.002) showed that a good threshold for predicting fractures was 130 ng/L (sensitivity = 81%, specificity = 57%). In a multivariable analysis, independent risk factors for fracture were PTH >130 ng/L at 3 months (adjusted hazard ratio [AHR] = 7.5, 95% CI 2.18-25.50), and pretransplant osteopenia (AHR = 2.7, 95% CI 1.07-7.26). In summary, this study demonstrates for the first time that persistent hyperparathyroidism is an independent risk factor for fractures after kidney transplantation.

Vertebral fractures in Gaucher disease type I: data from the French "Observatoire" on Gaucher disease (FROG).

UNLABELLED: Gaucher disease type 1 (GD1), results in a range of skeletal complications including osteopenia, osteoporosis, and osteonecrosis, but there is little published information regarding vertebral fractures. Findings from this observational study indicated that the prevalence of vertebral fractures in a cohort of adult French GD1 patients is approximately 15%. INTRODUCTION: The aim of the study was to assess the prevalence and characteristics of vertebral fractures in a cohort of adult patients with GD1. METHODS: This study was performed in adult patients with GD1 based on a detailed and complete clinical examination. For all patients for whom vertebral fractures were reported, a specific questionnaire was sent to physicians, and imaging data were collected, when available, for centralized analysis. RESULTS: Data were collected from a total of 105 adult GD1 patients. Bone complications were reported in 85% of patients, among whom vertebral fractures were diagnosed in 16 (15%); seven women and nine men (mean age, 45 years). We observed five patients with multiple vertebral fractures and one patient in whom the T3 vertebra was fractured. Most of these patients did not report fracture-related back pain. CONCLUSIONS: The prevalence of vertebral fractures in this cohort of adult patients with GD1 was 15%. Greater awareness of the natural history of vertebral fractures in GD1, and rigorous monitoring of bone fragility and spine involvement in affected patients, should allow earlier detection and initiation of treatment tailored toward improving bone status.

The neurological manifestations of Gaucher disease type 1: the French Observatoire on Gaucher disease (FROG).

BACKGROUND: Gaucher disease (GD), the most prevalent inherited lysosomal storage disorder, is caused by deficient glucocerebrosidase activity. Type 1 GD (GD1), the most common variant, is classically considered non-neuronopathic. METHODS: We performed a national cross-sectional observational survey-the French Observatoire on Gaucher Disease (FROG)-in patients with GD1 between March 2005 and September 2006. The study included all patients over 18 years of age with confirmed GD1 who attended participating centers for regular follow-up. RESULTS: One hundred and five patients were included, in whom we studied the prevalence and characteristics of relevant neurological symptoms associated with the neuraxis. Of these, 51 (49%) GD1 patients presented at least one neurological symptom. Four patients (4%) had Parkinson disease and 22 (21%) presented with at least one parkinsonian sign or at least one sign frequently associated with Parkinson disease. Five patients (5%) had a previous diagnosis of peripheral neuropathy. Other central nervous system symptoms were recorded in 20 (19%) patients and other peripheral nervous system symptoms in 39 (37%) patients. CONCLUSIONS: These data challenge the current classification of GD, and suggest that the three forms of GD each involve a different profile of neurological manifestations.

Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies.

The aim of this study was to review the evidence supporting the use of anti-depressants in painful rheumatological conditions. A systematic review of papers published between 1966 and 2007, in five European languages, on anti-depressants in rheumatological conditions was performed. Papers were scored using Jadad method and analgesic ES was calculated. We selected 78 clinical studies and 12 meta-analyses, from 140 papers. The strongest evidence of an analgesic effect of anti-depressants has been obtained for fibromyalgia. A weak analgesic effect is observed for chronic low back pain, with an efficacy level close to that of analgesics. In RA and AS, there is no analgesic effect of anti-depressants, but these drugs may help to manage fatigue and sleep disorders. There is no clear evidence of an analgesic effect inOA, but studies have poor methodological quality. Analgesic effects of anti-depressants are independent of their anti-depressant effects. Tricyclic anti-depressants (TCAs), even at low doses, have analgesic effects equivalent to those of serotonin and noradrenalin reuptake inhibitors (SNRIs), but are less well tolerated. Selective serotonin reuptake inhibitors (SSRIs) have modest analgesic effects, but higher doses are required to achieve analgesia. Anti-depressant drugs, particularly TCAs and SNRIs, have analgesic effects in chronic rheumatic painful states in which analgesics and NSAIDs are not very efficient, such as fibromyalgia and chronic low back pain. In inflammatory rheumatic diseases, anti-depressants may be useful for managing fatigue and sleep disorders. Further studies are required to compare anti-depressants with other analgesics in the management of chronic painful rheumatological conditions.

[Secondary screening for osteoporosis in patients admitted for hip fracture to a rehabilitation center. Results of a survey]. / Dépistage de l'ostéoporose après fracture de hanche en milieu de rééducation. Résultats d'une enquête.

GOALS: To determine prevalence, risk factors and treatment of osteoporosis in patients with hip fracture observed in a rehabilitation ward. BACKGROUND: Hip fractures are associated with up to 20% excess mortality in the first year after fracture and cause functional disability in most survivors. Despite available risk indices and physician information, osteoporosis is still underdiagnosed and undertreated. METHOD: We obtained history, clinical and biological data, and bone density (BD) data in 41 patients admitted with hip fracture to a rehabilitation care centre. RESULTS: Only 3 patients had known osteoporosis. Although 50% had at least 1 clinical risk factor, all patients showed osteopenic BD scores and 68% had osteoporotic scores; only one was correctly treated. DISCUSSION: As with international studies, our study shows that osteoporosis is underdiagnosed. Risk assessment tools allow for routine screening and preventive measures incorporated into standard care practice. The prevention of osteoporotic fracture can be promoted in rehabilitation centres.

[Ankylosing spondylitis and osteoporosis]. / Spondylarthrite ankylosante et ostéoporose.

PURPOSE: Ankylosing Spondylitis (AS) is an inflammatory rheumatism characterized by its disease course with flares leading to progressive ankylosis of the spine related to paravertebral ligamentous and discal structures ossification. AS patients suffer significantly more vertebral fractures than control groups. These fractures could affect cervical spine. They are due to either ankylosis-related flawed spine compliance or AS-induced osteoporosis. CURRENT KNOWLEDGE AND KEY POINTS: The physiopathology of this osteoporosis is multi-factorial, but essentially linked to AS-related inflammatory phenomenons. It is marked by reduced bone density (at lumbar spine and femoral neck), increased bone turnover (with increased urinary C-telopeptide cross-linked collagen type 1), but without any significant change in phosphocalcic blood parameters. Histological features are depressed bone formation, with either maintained or increased resorption. FUTURE PROSPECTS: The screening of this osteoporosis is based upon investigating people at risk (progressive inflammatory AS) using dual-energy x-ray absorptiometry and biochemical markers of bone turnover. Treatment is based upon a modulation of both inflammatory phenomenons and bone remodelling using bisphosphonates and anti-TNF alpha.

[Spinal extradural meningiomas: MRI findings in two cases]. / LES MENINGIOMES RACHIDIENS EXTRADURAUX: DONNEES IRM A PROPOS DE DEUX OBSERVATIONS.

Spinal extradural meningiomas are rare and may be easily confused with malignant neoplasms. We report two unusual cases of epidural spinal meningioma one within the left C6-C7 foramen and the other within the left posterolateral epidural space at the T3-T4 level. Low signal intensity of the tumor on T2-wi, thickening and enhancement of the dura with only the possibility of bone erosion are the most characteristic MR findings.

[Locomotor handicap and obesity]. / Handicap locomoteur et obésité

Obesity and osteoarthritis are frequently associated, particularly in older patients. Obesity increases the relative risk to develop knee or hip osteoarthritis, mainly in case of early obesity. This relative risk to develop osteoarthritis increases with body mass index, particularly in women. Early management of obesity, even a moderate weight loss, decreases the risk to develop knee osteoarthritis. Therapeutic management of obese patients is not different from those of non-obese patients; however, it is essential to integrate weight loss within the therapeutic project. Obesity should not be a contraindication to total knee or hip replacement, but weight loss has to be part of the pre- and post surgical management program of the obese patient.

Fatal Aspergillus fumigatus Myositis in an immunocompetent patient.

A 69-year old farmer developed Aspergillus myositis in the right psoas and paravertebral muscles extending to the retroperitoneum and the fifth lumbar vertebra. The infection appeared after two local instillations of steroid for back pain. Although the patient was not immunocompromised, surgical drainage and antifungal therapy failed to cure him; he died of a bacterial pulmonary superinfection while cultures of the abscess drainage fluid grew Aspergillus. The likely portal of entry in this patient was direct inoculation during infiltration of the steroid; the steroid probably caused a local impairment in host defenses. Only six cases of Aspergillus myositis have been reported previously. All of them occurred in severely immunosuppressed patients and the outcome was fatal in all cases.

Rapid chondrolysis after an intra-articular leak of bone cement in treatment of a benign acetabular subchondral cyst: an unusual complication of percutaneous injection of acrylic cement.

Percutaneous injection of methylmethacrylate is now increasingly employed to treat bone lesions, both malignant and benign. However, the risks of this procedure are still to be fully established. In this report, we describe a case of rapid chondrolysis appearing after the intra-articular leakage of cement during injection of an acetabular subchondral cyst, resulting in hip replacement. Although the mechanism of such chondrolysis is unknown, this event suggests a chondrolytic effect of the acrylic cement. Thus, it is essential to systematically search for the presence of an intra-articular passage before injecting bone cement into a peri-articular cyst. This unusual complication highlights the need for rigorous evaluation of the benefits and risks of percutaneous injection of acrylic cement in the treatment of benign lesions, especially close to an articulation.

Leukocyturia in women with diabetes and its clinical implications.

BACKGROUND: Urinalysis is one of the most common studies performed on the diabetic patient at every visit. The presence of leukocyturia is relatively common but it is not clear what the attitude of the physician toward this particular finding should be. The main objective of the present study was to investigate the clinical significance of leukocyturia in diabetic women. METHODS: Ninety-eight diabetic women (84.7% type 2) aged 57 +/- 13 years who were being seen at the diabetic out-patient clinic were randomly selected. All patients underwent a clinical and gynecologic examination and a urinalysis. A Papanicolaou smear and a urine culture were also obtained. RESULTS: The overall prevalence of leukocyturia (>5 cells/high power field (hpf)) was 46.5%. Patients with urinary tract infections (UTI) were 7.5 times more likely to have leukocyturia, while a leukocyte count <5cells/hpf predicted the absence of UTI in 96% of the women. In the comparison of patients with and without leukocyturia, we found that proteinuria (p = 0.06) and bacteriuria (p <0.002) were more common in the women with leukocyturia. A significant association with leukorrhea was not demonstrated. The empirical use of antibiotics was 12 times more frequent in the patients with leukocyturia. CONCLUSIONS: A urinary culture should be requested in all diabetic patients with leukocyturia. The possibility of a UTI is remote when leukocyturia is absent.

A case of intracranial dural arteriovenous fistula draining into the spinal medullary veins.

Intracranial dural arteriovenous fistulas draining into the spinal medullary veins (ICDAVFMs) are exceedingly rare lesions. Their diagnosis is difficult and is often made late. About twenty well documented cases have been published. We report a case in a 55-year-old woman who presented with persistent interscapular pain and neurological evidence of ascending myelopathy after therapy for cervicobrachial neuralgia. ICDAVFM should be considered by rheumatologists in patients with clinical and radiological findings suggestive of spinal cord disease, particularly if these findings indicate involvement of the medulla oblongata or cervical spinal cord.