Differing time-orders of inflammation decrease between ACPA subsets in RA patients suggest differences in underlying inflammatory pathways.

OBJECTIVES: Advanced imaging modalities have shown that not only joints but also bones and tendon sheaths can be inflamed at diagnosis of RA. We aimed to better understand the time-order in which the inflamed tissues respond to DMARD treatment. Also, because ACPA status may reflect a different pathophysiology, differences in time-order of inflammation decrease were hypothesized between these disease types. METHODS: A total of 216 consecutive patients presenting with RA (n = 176) or undifferentiated arthritis (n = 40), who all started with conventional synthetic DMARD treatment, were studied. 1.5T contrast-enhanced hand and foot MRIs were performed before treatment and after 4, 12 and 24 months. Cross-lagged models evaluated the influence of two time patterns: a simultaneous pattern ('change in one inflammatory feature associated with change in another feature') and a subsequent pattern ('change in one inflammatory feature preceded change in another feature'). ACPA stratification was performed. RESULTS: The median symptom duration at presentation was 13 weeks. Forty-four percent of patients was ACPA-positive. All pairs of inflammatory features decreased simultaneously in all time intervals (0-4/4-12/12-24 months; P < 0.05). Moreover, time-orders were identified: synovitis decrease preceded tenosynovitis decrease (0-4 to >4-12 months; P = 0.02 and 4-12 to >12-24 months; P = 0.03). Largely similar results were obtained in both ACPA subgroups. Additionally, in ACPA-positive but not ACPA-negative patients, synovitis decrease preceded osteitis decrease (4-12 to >12-24 moths; P = 0.002). CONCLUSION: This study increased the understanding of the response to treatment on the tissue level. In addition to simultaneous decrease of inflammation, synovitis decrease preceded tenosynovitis decrease. Differences in time-order of inflammation decrease between ACPA subgroups suggest differences in underlying inflammatory pathways.

Osteitis condensans ilii: current knowledge and diagnostic approach.

Osteitis condensans ilii is a noninflammatory condition of an uncertain etiology, characterized by sclerotic bone lesions located mainly in the iliac region of the sacroiliac joints. In many patients, osteitis condensans ilii remains an incidental imaging finding; however, it has been associated with lower back pain and may mimic inflammatory rheumatic conditions such as axial spondyloarthritis. The diagnosis is based on the presence of the characteristic sclerotic lesions on radiographs and the exclusion of other conditions that are associated with back pain. Management is usually conservative with the use of physical therapy and analgesics, and it is associated with a favorable prognosis. Herein, we conducted a narrative literature review using the terms osteitis condensans ilii, and we identified case reports, case series, reviews, and original studies associated with the condition. The aim of this article is to raise the awareness of this underrecognized clinicoradiological condition and to enable the health-care providers to recognize clinical and radiological features that should raise suspicion of the osteitis condensans illi, and to describe the treatment options.

Clinical Manifestations, Management, and Outcomes of Osteitis/Osteomyelitis Caused by Mycobacterium bovis Bacillus Calmette-Guérin in Children: Comparison by Site(s) of Affected Bones.

OBJECTIVE: To evaluate the clinical manifestations, management, and outcomes of Mycobacterium bovis Bacillus Calmette-Guérin (BCG) osteitis/osteomyelitis. STUDY DESIGN: We reviewed 71 cases of BCG osteitis/osteomyelitis registered in Taiwan's vaccine injury compensation program (VICP) in 1998-2014. Demographic, clinical, laboratory, treatment, and outcome data were compared according to site(s) of infection. RESULTS: Involvement of a long bone of the lower extremity was present in 36.6% of the children, followed by foot bone (23.9%), rib or sternum (15.5%), upper extremity long bone (9.9%), hand bone (7%), multiple bones (4.2%), and vertebrae (2.8%). Children with lower extremity long bone involvement had a longer interval from receipt of BCG vaccine to presentation (median, 16.0 months; P = .02), and those with foot bone infection had higher rates of swelling (94.1%; P = .02) and local tenderness (76.5%; P = .004). Surgical intervention was performed in 70 children, with no significant difference in the number of procedures by site (median, 1.0 procedure per patient). Among the 70 children who received antimicrobial therapy, those with vertebral and multifocal infections had a longer duration of treatment (P < .001) and/or second-line antituberculosis medications (P = .002). Three children with vertebral and multifocal infections had major sequelae with kyphosis or leg length discrepancy. Outcomes were good for children with involvement of the ribs, sternum, and peripheral bones without multifocal involvement. The average time for functional recovery was 6.2 ± 3.9 months. CONCLUSION: Children with BCG osteitis/osteomyelitis in different bones had distinct presentations and outcomes. Pediatricians should consider BCG bone infection in young vaccinated children with insidious onset of signs and symptoms, and consider affected site(s) in the management plan.

Axial sesamoiditis in the horse: A review.

Axial sesamoiditis or osteitis of the proximal sesamoid bones (PSBs) in the horse is described as a rare condition. The cause remains unknown and speculative, with vascular, infectious, and traumatic aetiologies implicated. It is specifically associated with injury of the palmar or plantar ligament (PL), also known as the intersesamoidean ligament. Imaging findings are generally rewarding and radiological changes are typical, if not pathognomonic, for the condition. Lesions consist of bone lysis at the apical to mid-body axial margins of the PSBs, with variable degrees of joint effusion. Radiographic technique warrants careful attention to make a diagnosis, and exposure factors may need to be adjusted. Perineural, intra-articular and intra-thecal anaesthesia does not seem to provide consistent improvement of lameness in these cases, with literature reporting inconsistent findings. Ultrasonographic findings include digital flexor sheath effusion, loss of the normal fibre structure of the PL at its attachment to the PSBs, abnormal echogenicity or change in thickness of the PL, and irregular hyperechoic cortical margins of the axial margins of the PSBs. Scintigraphy, computed tomography and magnetic resonance imaging, although not necessary to make a diagnosis, may add valuable information regarding the location and extent of lesions. The prognosis remains guarded to poor for return to athletic function. The focus of this paper is a comprehensive review of the proposed aetiopathogenesis of the condition, the prognosis, and a summary of the literature findings with focus on the notable diagnostic imaging features, including radiography, ultrasonography, scintigraphy, computed tomography and magnetic resonance imaging.

Role of 18-fluoro-2-deoxyglucose positron emission tomography in detecting acute inflammatory lesions of non-bacterial osteitis in patients with a fever of unknown origin: A comparative study of 18-fluoro-2-deoxyglucose positron emission tomography, bone scan, and magnetic resonance imaging.

We report three patients with non-bacterial osteitis (NBO) who had fever of unknown origin (FUO) as an initial symptom. 18-Fluoro-2-deoxyglucose positron emission tomography (18F-FDG-PET) can be used to detect acute inflammatory lesions. There seems to be variation among the results of 18F-FDG-PET, a bone scan, and magnetic resonance imaging (MRI). Therefore, it would be useful to perform a bone scan to detect all lesions, combined with MRI to confirm the diagnosis of NBO, followed by 18F-FDG-PET.

Active synovitis in the presence of osteitis predicts residual synovitis in patients with rheumatoid arthritis with a clinical response to treatment.

AIM: To clarify the relationship between active synovitis/osteitis and subsequent residual synovitis (R-synovitis) in patients with rheumatoid arthritis (RA). METHODS: Three hundred and twenty finger joints of 16 patients with active RA at baseline (Disease Activity Score with 28 joints - erythrocyte sedimentation rate > 3.2) who subsequently achieved clinical low disease activity or remission afterwards were analyzed. Synovial vascularity (SV) was assessed according to a semi-quantitative ultrasound score (grades 0-3). Active synovitis was defined by SV positivity at baseline. R-synovitis was defined by the presence of grade > 2 SV at the 24th week. Osteitis was detected by magnetic resonance imaging (MRI) at baseline as trabecular bone lesions with water content and indistinct margins. RESULTS: Ultrasonography detected active synovitis in 116 joints at baseline. Forty-seven joints had R-synovitis at the 24th week. MRI detected osteitis in 12 joints at baseline. The presence of active synovitis with osteitis at baseline was significantly correlated with R-synovitis at the 24th week. CONCLUSIONS: Active synovitis in the presence of osteitis predicted R-synovitis regardless of whether there was a clinical improvement in RA.

Role of the gene Slc11a1 and selected genotypes for minimum and maximum inflammatory reactivity in the process of alveolar bone healing in mice / Papel do gene Slc11a1 e de genótipos selecionados para mínima e máxima reatividade inflamatória no processo de reparo ósseo alveolar em camundongos

The process of alveolar bone healing can be influenced by several local and systemic factors, which include the immune system and healing related genes. However, the exact role of host inflammatory responsiveness and genetic background in bone healing process remains unclear. In this context, we evaluated the influence inflammation in alveolar bone healing taking advantage of mice strains genetically selected for maximum (AIRmax) or minimum (AIRmin) acute inflammatory response, as well AIR strains homozygous for RR/SS Slc11a1 genotypes. Experimental groups (N=5/time/group) comprised 8-week-old male or female AIRmax and AIRmin; and substrains AIRminRR, AIRminSS and AIRmaxRR and AIRmaxSS; submitted to extraction of upper right incisor and evaluated at 0, 3, 7, 14 and 21 days after upper incision extraction by micro-computed tomography (CT), histomorphometry, birefringence, immunohistochemistry and molecular (PCRArray) analysis. Initially, our results demonstrated that AIRmin mice presented an early increase (p<0.05) in bone volume, hyperdense regions, density of bone matrix and osteoblasts, increased (p<0.05) expressed of BMP4, BMP7 and RUNX2 when compared to AIRmax strain. AIRmin mice also presented lower counts of GR1+ and CD80+ cells, and higher counts of F4/80+ and CD206+ cells, in parallel with higher mRNA expression of CX3CL1, CCL5, CCR5 and ARG when compared to AIRmax animals. In late repair stages, the AIRmin strain presented a decreased (p<0.05) density of osteoclast and blood vessels than AIRmax, along lower RANKL and Catepk and higher PHEX and SOST mRNA expression, but the healing outcome at the endpoint was similar in AIRmin and AIRmax strains. When analyzed the effect of RR/SS Slc11a1 genotypes was evaluated in parallel with the influence AIRmin/AIRmax background, we initially observed that the AIRmax strain, associated with both RR and SS Slc11a1 genotypes, presented a more effective bone healing, characterized by increased (p<0.05) of bone volume and predominance of red fiber in analysis in contrast to AIRmin strains. AIRmaxRR presented increased (p<0.05) F4/80+ and decreased CD80+ e CD206+ cells count, while AIRmaxSS presented increased (p<0.05) GR1+, F4/80+ and CD80+ and decreased CD206+ cells. When the analysis was performed in order to address the influence Slc11a1 variants, AIRmaxSS strain presented a bone healing delay when compared to AIRmaxRR; characterized by decreased (p<0.05) of bone volume, trabecular number and red collagen fibers, increased (p<0.05) GR1+ and CD80+ and decreased F4/80+ and CD206+. Conversely, AIRminSS presented a more effective healing when compared with AIRminRR mice; characterized by increased (p<0.05) of bone volume, trabecular number/separation and red birefringence, increased GR1+ and decreased CD206+ cells count. In conclusion, while AIRmin and AIRmax strains presents a similar healing outcome at the endpoint, the early repair in AIRmin strain was associated with decreased presence of neutrophils and M1 macrophages, and increased M2 macrophages. Additionally, our while results showed that AIRmax inflammatory background was associated to a more effective bone healing process irrespective of the presence of RR/SS Slc11a1 genotypes, RR genotype favors the healing in AIRmax background and SS genotype was found to favor the healing in the AIRmin background.(AU)

O processo de reparo ósseo alveolar pode ser influenciado por vários fatores locais e sistêmicos, que incluem o sistema imunológico e os genes relacionados ao reparo. No entanto, o exato papel da resposta inflamatória do hospedeiro e genético background no processo de reparo ósseo ainda não está claro. Neste contexto, avaliamos a influência da inflamação no reparo óssea alveolar, em camundongos selecionadas geneticamente para uma resposta inflamatória aguda máxima (AIRmax) ou mínima (AIRmin), como também em camundongos AIR homozigoto para os alelos RR/SS do gene Slc11a1.Neste estudo foram utilizados camundongos machos e fêmeas (N=5/tempo/grupo), das linhagens selecionados para máxima e mínima (AIRmax e AIRmin) reação inflamatória, e também as sublinhagens AIRminRR, AIRminSS, AIRmaxRR e AIRmaxSS com idade aproximada de 8 semanas. Todos foram submetidos à extração do incisivo superior direito e avaliados nos períodos de 0, 3, 7, 14 e 21 dias pós extração, seguido pela análise tomografia computadorizada (CT), análise histomorfometria, análise de birrefringência, análise imuno-histoquímica e análise molecular (PCRArray). Inicialmente, nossos resultados demonstraram que a linhagem AIRmin, no período inicial, apresentou um aumento (p<0.05) no volume ósseo, nas regiões hiperdensas, na densidade de matriz óssea e osteoblastos, seguido pelo aumento (p<0.05) na expressão de BMP4, BMP7 e RUNX2 quando comparado a linhagem AIRmax. Camundongos AIRmin também apresentou uma menor contagem de células GR1+ e CD80+ e aumento da contagem de células F4/80+ e CD206+, em paralelo com aumento da expressão de mRNA de CX3CL1, CCL5, CCR5 e ARG quando comparado aos camundongos AIRmax. Nos períodos tardios, a linhagem AIRmin apresentou uma diminuição (p<0.05) na densidade de osteoclastos e vasos sanguíneos em comparação AIRmax, seguido por uma diminuição na expressão de mRNA de RANKL e Catepk e aumento de PHEX e SOST, mas o processo de reparo ósseo alveolar, no período final foi semelhante entres as linhagens AIRmin e AIRmax. Quando analisamos o efeito dos alelos RR/SS do gene Slc11a1 em paralelo com a influência do background AIRmin/AIRmax, nós inicialmente observamos que a linhagem AIRmax associada com ambos os alelos RR/SS do gene Slc11a1 apresentaram um processo de reparo mais efetivo, caracterizado pelo aumento (p<0.05) volume ósseo e predominância de fibras vermelhas em comparação com a linhagem AIRmin. Camundongos AIRmaxRR apresentaram aumento (p<0.05) na contagem de células F4/80+ e diminuição na contagem de células CD80+ e CD206+, enquanto, camundongos AIRmaxSS apresentou um aumento (p<0.05) na contagem de células GR1+, F4/80+, CD80+ e diminuição na contagem de células CD206+. Quando analisamos a influência dos alelos do gene Slc11a1, a linhagem AIRmaxSS apresentaram um atraso no reparo óssea quando comparado ao AIRmaxRR; caracterizado pela diminuição (p<0.05) do volume ósseo, número trabecular e fibras colágenas vermelhas, seguido pelo aumento (p<0.05) da contagem de células GR1+ e CD80+ e diminuição de células F4/80+ e CD206+. Por outro lado, camundongos AIRminSS apresentaram um reparo ósseo mais efetivo quando comparada com AIRminRR; caracterizada pelo aumento (p<0.05) do volume ósseo, número / separação trabecular e birrefringência das fibras colágenas no espectro vermelho, seguido pelo aumento da contagem de células GR1+ e diminuição das células CD206+. Diante disso, os nossos resultados demonstraram que as linhagens AIRmin e AIRmax apresentaram um processo de reparo ósseo alveolar semelhantes no período final do reparo, enquanto no reparo inicial a linhagem AIRmin estava associada com a diminuição de neutrófilos e macrófagos M1 e aumento dos macrófagos M2. Além disso, nossos resultados demonstraram que background AIRmax estava associado a um processo de reparo mais efetivo, independentemente da presença de genótipos RR/SS Slc11a1, o genótipo RR favorece o reparo no background AIRmax e o genótipo SS favoreceu a reparo no background AIRmin.(AU)

Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome.

BACKGROUND AND PURPOSE: Osteitis pubis (OP), a common pathology in elite athletes, is an aseptic inflammatory process of the pubic symphysis bone, and may involve surrounding soft tissues, tendons and muscles. OP is typically characterized by (often recurring) groin pain and is an important cause of time-off from sports activity in athletes. Aim of this retrospective study was to analyze magnetic resonance imaging (MRI) findings in professional football players with clinical diagnosis of OP and to correlate MRI findings with clinical outcome. MATERIAL AND METHODS: All professional football players (23 males, 1 female; mean age: 21±3.7years; range: 16-30 years) with groin pain and clinical diagnosis of OP, who underwent pelvic MRI in our institution were retrospectively analyzed. The MR images were analyzed regarding the presence of bone marrow edema and its extension, whether fluid in the symphysis pubis or periarticular soft tissue edema with a rim-like periosteal distribution or edema in the muscles located around the symphyseal joint were present, whether degenerative changes of the symphysis pubis and of signs of symphyseal instability were encountered. A quantitative measurement of the signal intensity in bone marrow edema on 3T STIR sequences was performed, normalizing these values to the mean signal intensity values in the ipsilateral iliopsoas muscle. All patients were classified according to a 3-point grading scale. For each patient, both the symptoms 18 months after the initial MRI examination, the duration of time off from playing football and the kind of treatment applied were evaluated. RESULTS: Among all professional athletes, in 20/24 (83.3%) MRI showed signs of OP with bone marrow edema at the pubic bone. 12 of these patients showed complete clinical recovery without any symptoms after 18 months, while in 8 patients partial recovery with persistence of groin pain during higher sports activity was observed. Patients with edema in periarticular soft tissues or in the muscles around the symphyseal joint on MRI at the beginning of symptoms presented significantly more often with a partial recovery after returning to high sports activity (p=0.042 and p=0.036, respectively). A partial recovery was also significantly associated with higher normalized mean signal intensity values in bone marrow edema on STIR sequences at the beginning of symptoms (mean=4.77±1.63 in the group with partial recovery vs. mean=2.86±0.45 in the group with complete recovery; p=0.0019). No significant association was noticed between MRI findings and time of abstinence from high sports activity, as well as between the 3-point grading scale and the time off from high sport activity and recovery at 18 months. CONCLUSIONS: Edema in periarticular soft tissues, edema with extension to the muscles located around the symphyseal joint, as well as higher normalized signal intensity values in bone marrow edema on STIR sequences in the pubic bones at the beginning of groin pain are the most reliable MRI findings of a poor clinical long-term outcome of OP in professional football players and should be regarded as negative prognostic factors.

Biofilm and Osteitis in Refractory Chronic Rhinosinusitis.

Our understanding of chronic rhinosinusitis (CRS) show biofilm and osteitis play a role in the disease's pathogenesis and refractory. Studies point to its role in pathogenesis and poor prognosis. Outside the research laboratory, biofilm detection remains difficult and specific treatment remains elusive. It is believed that osteitis is a nidus of inflammation and occurs more commonly in patients with refractory CRS. However, osteitis may be exacerbated by surgery and a marker of refractory disease, not a causative agent. Surgery remains the mainstay treatment for biofilm and osteitis with mechanical disruption and removal of disease load providing the most effective treatment.

Sports Hernia and Extra-Articular Causes of Groin Pain in the Athlete.

Groin pain is a common complaint in athletes that use the musculature of the lower abdomen and proximal thigh. The complex anatomy of the groin region and broad differential diagnosis presents the sports medicine specialist with unique diagnostic and treatment challenges. Sports hernia, osteitis pubis, and adductor dysfunction are common extra-articular musculoskeletal causes of groin pain in athletes. The current paper reviews the pathogenesis, history and physical examination, imaging, non-operative treatment, surgical techniques, and outcomes for these conditions. Treatment algorithms are presented for management of patients with sports hernia, osteitis pubis, and adductor dysfunction.

Dysregulated osteoclastogenesis is related to natural killer T cell dysfunction in rheumatoid arthritis.

OBJECTIVE: To investigate the role played by natural killer T (NKT) cells in osteoclastogenesis and their effects on inflammatory bone destruction. METHODS: Patients with rheumatoid arthritis (RA) (n = 25) and healthy controls (n = 12) were enrolled in this study. In vitro osteoclastogenesis experiments were performed using peripheral blood mononuclear cells (PBMCs) in the presence of macrophage colony-stimulating factor and RANKL. PBMCs were cultured in vitro with α-galactosylceramide (αGalCer), and proliferation indices of NKT cells were estimated by flow cytometry. In vivo effects of αGalCer-stimulated NKT cells on inflammation and bone destruction were determined in mice with collagen-induced arthritis. RESULTS: In vitro osteoclastogenesis was found to be significantly inhibited by αGalCer in healthy controls but not in RA patients. Proliferative responses of NKT cells and STAT-1 phosphorylation in monocytes in response to αGalCer were impaired in RA patients. Notably, αGalCer-stimulated NKT cells inhibited osteoclastogenesis mainly via interferon-γ production in a cytokine-dependent manner (not by cell-cell contact) and down-regulated osteoclast-associated genes. Mice treated with αGalCer showed less severe arthritis and reduced bone destruction. Moreover, proinflammatory cytokine expression in arthritic joints was found to be reduced by αGalCer treatment. CONCLUSION: This study primarily demonstrates that αGalCer-stimulated NKT cells have a regulatory effect on osteoclastogenesis and a protective effect against inflammatory bone destruction. However, it also shows that these effects of αGalCer are diminished in RA patients and that this is related to NKT cell dysfunction. These findings provide important information for those searching for novel therapeutic strategies to prevent bone destruction in RA.

Paciente con artritis en rodillas y pustulosis palmoplantar / Patient with arthritis knee and palmoplantar pustulosis

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Musculoskeletal etiologies of pelvic pain.

Several musculoskeletal diagnoses are frequently concomitant with pelvic floor pathology and pain. The definition of pelvic pain itself often depends on the medical specialist evaluating the patient. Because there is variability among disorders associated with pelvic pain, patients may seek treatment for extended periods as various treatment options are attempted. Further, health care providers should recognize that there may not be a single source of dysfunction. This article discusses the musculoskeletal disorders of the pelvic girdle (structures within the bony pelvis) and their association with lumbar spine and hip disorders.

Pooled analysis of non-union, re-operation, infection, and approach related complications after anterior odontoid screw fixation.

BACKGROUND: Anterior odontoid screw fixation (AOSF) has been one of the most popular treatments for odontoid fractures. However, the true efficacy of AOSF remains unclear. In this study, we aimed to provide the pooled rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures. METHODS: We searched studies that discussed complications after AOSF for type II or type III odontoid fractures. A proportion meta-analysis was done and potential sources of heterogeneity were explored by meta-regression analysis. RESULTS: Of 972 references initially identified, 63 were eligible for inclusion. 54 studies provided data regarding non-union. The pooled non-union rate was 10% (95% CI: 7%-3%). 48 citations provided re-operation information with a pooled proportion of 5% (95% CI: 3%-7%). Infection was described in 20 studies with an overall rate of 0.2% (95% CI: 0%-1.2%). The main approach related complication is postoperative dysphagia with a pooled rate of 10% (95% CI: 4%-17%). Proportions for the other approach related complications such as postoperative hoarseness (1.2%, 95% CI: 0%-3.7%), esophageal/retropharyngeal injury (0%, 95% CI: 0%-1.1%), wound hematomas (0.2%, 95% CI: 0%-1.8%), and spinal cord injury (0%, 95% CI: 0%-0.2%) were very low. Significant heterogeneities were detected when we combined the rates of non-union, re-operation, and dysphagia. Multivariate meta-regression analysis showed that old age was significantly predictive of non-union. Subgroup comparisons showed significant higher non-union rates in age ≥ 70 than that in age ≤ 40 and in age 40 to <50. Meta-regression analysis did not reveal any examined variables influencing the re-operation rate. Meta-regression analysis showed age had a significant effect on the dysphagia rate. CONCLUSIONS/SIGNIFICANCES: This study summarized the rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures. Elderly patients were more likely to experience non-union and dysphagia.

Isokinetic imbalance of hip muscles in soccer players with osteitis pubis.

In this study, we compared the isokinetic torques of hip flexors/extensors and abductors/adductors in soccer players suffering from osteitis pubis (OP), with normal soccer players. Twenty soccer male athletes with OP and 20 normal soccer athletes were included in this study. Peak torque/body weight (PT/BW) was recorded from hip flexor/extensor and abductor/adductor muscles during isokinetic concentric contraction modes at angular velocity of 2.1 rad · s(-1), for both groups. The results showed a significant difference between the normal and OP groups for hip flexors (P < 0.05). The normal group had significant, lower PT/BW value than the OP group for their hip flexors (P < 0.05). The hip flexor/extensor PT ratio of OP affected and non-affected limbs was significantly different from that of normal dominant and non-dominant limbs. There were no significant differences between the normal and OP groups for hip extensor, adductor and abductor muscles (P > 0.05). Regarding the hip adductor/abductor PT ratio, there was no significant difference between the normal and OP groups of athletes (P > 0.05). The OP group displayed increase in hip flexor strength that disturbed the hip flexor/extensor torque ratio of OP. Therefore, increasing the hip extensor strength should be part of rehabilitation programmes of patients with OP.

New insights into pustular dermatoses in pediatric patients.

Pustular eruptions are common in the pediatric population. The focus of this review is to highlight entities that present with pustules, signs and symptoms of systemic inflammation, and other organ involvement. Although these conditions are rare, awareness of them should facilitate early recognition, faster evaluation (including genetic testing, if appropriate), and adequate treatment.

Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up.

INTRODUCTION AND OBJECTIVES: Chronic groin pain (athletic pubalgia) is a common problem in sports such as football, hockey, cricket, baseball and athletics. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with athletic pubalgia. These manoeuvres place large forces across the bony pelvis and its soft tissue supports, accounting for the usual clinical presentation of multiple symptomatic abnormalities forming one pattern of injury. RESULTS: The diagnoses encountered in this series of 100 patients included rectus abdominis muscle atrophy/asymmetry (22), conjoint tendinopathy (16), sports (occult, incipient) hernia (16), groin disruption injury (16), classical hernia (11) traumatic osteitis pubis (5), and avulsion fracture of the pubic bone (4). Surgical management was generally undertaken only after failed conservative therapy of 3-6 months, but some professionals who have physiotherapy during the football season went directly to surgery at the end of the football season. A variety of operations were performed including groin reconstruction (15), open hernia repair with or without mesh (11), sports hernia repair (Gilmore) (7) laparoscopic repair (3), conjoint tendon repair (3) and adductor tenotomy (3). Sixty-six patients were available for follow at an average of 13 years after initial consultation and the combined success rate for both conservative treatment and surgery was 94%. CONCLUSION: The authors believe that athletic pubalgia or sports hernia should be considered as a 'groin disruption injury', the result of functional instability of the pelvis. The surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis.