Spinal changes in association with sternocostoclavicular hyperostosis.

A case of sternocostoclavicular hyperostosis was reported in a 63-year-old woman who had been followed for 15 years. Radiographic changes in the claviculo-sternal area were typical of this condition, and biopsy revealed abnormalities in the right clavicle and in the sternum compatible with infection. Radiographic changes in the thoracic and lumbar spine revealed findings compatible with infective spondylitis and a seronegative spondylarthropathy, respectively. The nature of these spinal changes as compared with those of diffuse idiopathic skeletal hyperostosis and seronegative spondylarthropathy is discussed.

Synovial fluid hydroxyapatite crystals: detection thresholds of two methods.

A method of synovial fluid preparation giving optimal hydroxyapatite detection as well as definitions of the threshold masses of hydroxyapatite in viscous synovial fluid detectable by x ray diffraction and scanning electron microscopy with energy dispersive analysis is reported. Use of an equal volume of 100% hydrazine with the synovial fluid optimised detection of hydroxyapatite. By x ray diffraction the threshold mass of hydroxyapatite was 500 micrograms and by scanning electron microscopy with associated energy dispersive analysis 5 micrograms.

Rapidly progressive hip osteoarthrosis--an unusual presentation of ochronosis.

A case of rapidly evolving osteoarthrosis of the right hip in a 65 year-old woman, as the presenting feature of ochronosis is described and literature reviewed. This unusual presentation may have been precipitated by an acute mechanical overload.

Degenerative spondylolisthesis, synovial cyst of the zygapophyseal joints, and sciatic syndrome: report of two cases and review of the literature.

Two cases of sciatica secondary to nerve root compression by a "synovial cyst" of a zygapophyseal joint are described. In light of these 2 cases and on reviewing the literature, it appears that zygapophyseal joint osteoarthritis with degenerative (or articular) spondylolisthesis can be a predisposing factor to the formation of such synovial expansions and, consequently, the cause of nerve root compression. The coexistence of a lumbar degenerative spondylolisthesis with a radicular syndrome should therefore encourage early investigation by computed tomography scan, so that conservative treatment would not be unnecessarily prolonged.

Coexisting rheumatoid arthritis and ankylosing spondylitis.

Since the second publication by some of the present authors in which 10 patients with coexisting rheumatoid arthritis (RA) and ankylosing spondylitis (AS) were described, 7 new cases have been found. For accuracy, all cases of the original study still available were reexamined. Of the total of 17 cases, 13 were male and 4 female. All had positive tests for rheumatoid factor and 6 had subcutaneous nodules. The male predominance and the frequency of nodules are consistent with other publications. In addition, our study demonstrates the strong association of each of these 2 diseases with its genetic marker: the antigen HLA-DR4 was present in 8 of 12 cases tested and the antigen HLA-B27 was present in 16 of the 17 cases. The coexistence of these 2 classical rheumatological entities in the same patient appears to occur by chance and is probably often overlooked.

Periarticular hand hydroxyapatite deposition after corticosteroid injections.

Four cases of periarticular calcifications chronologically related to deposteroid injections of small joints of the hands are presented. The calcifications were excised and documented to contain hydroxyapatite by x-ray diffraction analysis.

Sternocostoclavicular hyperostosis (SCCHO) with palmoplantar pustulosis (PPP).

Three cases of sternocostoclavicular hyperostosis (SCCHO) or pustulotic arthro-osteitis (PAO) associated with plantar pustulosis are presented. Two of them were associated with psoriasis vulgaris although the pustulosis was of a different histological type in each case. Anatomo-pathological study of two of these three cases shows that this hyperostosis is secondary to an inflammatory osteomedulloperiosteal remodelling suggesting an infectious origin which remains to be proven. The relationship of this syndrome with some seronegative spondylarthropathies cannot, however, be excluded.

Sternocostoclavicular hyperostosis. Radiological and pathological study of a specimen with ununited clavicular fracture.

Anatomico-radiological study of a sternocostoclavicular mass taken post-mortem from a man whose clinical history had shown bilateral sternocostoclavicular hyperostosis (SCCH) with plantar pustulosis for 27 years. The clavicle showed an ununited fracture attributable to a trauma sustained five years earlier. Both clavicular segments showed active remodelling with intraosseous granulation tissue and periosteal metaplastic ossification. The sternocostoclavicular region was fused in a bony block in which there were no signs of remodelling activity. The first rib and the distal extremity of the clavicle were histologically normal. These observations support the conclusions of a previous study of another case of SCCH. The condition might be due to a bone infection caused by an--as yet--unknown germ. Bone remodelling would explain the periosteal hyperostosis and the fragility of the underlying bone. Furthermore, the possibility that the condition might also be a joint disease related to the group of rheumatic diseases called spondyloarthropathies should be considered.

Pyrophosphate arthropathy in the carpal and metacarpophalangeal joints.

The hand x-rays of group of patients with generalised osteoarthrosis alone were compared with those patients with generalised osteoarthrosis and chondrocalcinosis (CC). An arthropathy seemingly specific for CC could be identified in the metacarpophalangeal (MCP) and carpal joints. In the MCP joints it was characterised by subchondral rarefactions, deviation of the joint axis, joint space narrowing, and osteophytosis. Usually only the second and/or third MCP joints are affected. In the carpal joints similar subchondral cysts, sometimes associated with joint space narrowing, were found much more frequently in the group with CC. There was no direct relation with the presence of calcification.

[Chondrocalcinosis]. / La chondrocalcinose.

Chondrocalcinosis is an arthropathy caused by deposits of calcium pyrophosphate-dihydrate microcrystals (CPPD) in the joints and occasionally in the tendons and ligaments. In our region it is almost always seen in its sporadic form in elderly subjects. The patients can be without symptoms or present four different clinical entities: an acute arthritis which can resemble and even be mistaken for an attack of gout or a septic arthritis; an inflammatory polyarthritis suggesting a rheumatoid arthritis; most frequently it appears as a benign polyarthrosis; sometimes it runs a destructive course capable of seriously damaging one or several joints. In certain cases chondrocalcinosis is associated with another metabolic disease. Familial forms have been described in some countries. Factors which induce the formation of the deposits of CPPD in the articular cartilages, fibrocartilages, the synovium and occasionally in the tendons and ligaments remain obscure. In contrast to urate gout, chondrocalcinosis appears to be due to a disturbance of pyrophosphate metabolism localized almost exclusively in the articular region. Its association with polyarthrosis rather frequently leads to destructive arthropathies. No etiological treatment for chondrocalcinosis exists at the present time. Therapy is limited to the administration of nonsteroidal antiinflammatory drugs and physiotherapy.

Measurement of soluble pyrophosphate in plasma and synovial fluid of patients with various rheumatic diseases.

Soluble pyrophosphate was measured in the plasma and synovial fluid of various groups of patients and in the plasma of two control groups. The two control groups consisted of 13 healthy subjects and 19 patients suffering from benign lumbar back pain. The other group of patients had rheumatoid arthritis (RA) (14 plasma and 19 synovial fluid examinations), osteoarthrosis (OA) (19 plasma and 26 synovial fluids) and articular chondrocalcinosis (ACC) (27 plasma and 43 synovial fluids). The level of soluble pyrophosphate in the plasma was 3.5 mumol/l in healthy subjects, 4.0 mumol/l in patients with lumbar back pain, 4.1 mumol/l in individuals having OA and 3.5 mumol/l in the group suffering from RA as well as for those with ACC. The differences between these values are not significant statistically. In the synovial fluid the values were 4.6 mumol/l for the group with RA, 12.7 mumol/l for those with OA and 34.2 mumol/l in the group having ACC. If a normal distribution of these values is assumed and the average values and standard deviations recalculated for each group after elimination of cases more than 3 standard deviations above the mean, then we obtain 9.8 mumol/l for the group with OA and 23.8 mumol/l for those with ACC. The difference between the group with RA and that with OA is highly significant (p greater than 0.0001). Even more significant is the difference between the group with RA and ACC (p less than 0.0005). The difference between the OA and the ACC is also highly significant (p less than 0.001). On the basis of these observations various mechanisms leading to the pyrophosphage crystal deposition disease are discussed.

Erosive spondylopathy.

Seven patients with chronic dorsolumbar pain, stiffness and some restriction of spinal movements are described. Multiple lesions of the vertebral bodies were present. The lesions occurred at various levels and all had similar radiological characteristics, often returning to normal after several years. Vertebral changes of this type may be seen in patients with ankylosing spondylitis but for a variety of cogent reasons presented in this report our patients did not readily fall into this diagnostic group. The aetiology of these vertebral lesions is unknown but available evidence indicates that they should not be attributed to an infectious or neoplastic process.

[Arthropathies due to calcium pyrophosphates]. / Les arthropathies aux pyrophosphates de calcium.

Articular chondrocalcinosis results from the deposits of calcium pyrophosphate microcrystals in the articular hyalin and fibrocartilages, the synovium and at times the tendons. In our area it is seen most frequently as isolated cases in the elderly and may be asymptomatic. When the affected joints present clinical manifestations, they vary from acute to subacute or chronic recurrent arthritis. A marked articular destruction can be observed in some cases. There is a classical radiological picture: linear opacities are most frequently seen localized in the mid-zone layer of the hyalin cartilage running parallel to but at a certain distance from the bone cortex. A part of our research has shown that in contrast to urate gout, articular chondrocalcinosis results from a metabolic disturbance of the calcium pyrophosphate localized almost exclusively in the same articular structures. Precise information is lacking at the present time to explain why calcium pyrophosphate mycrocrystals accumulate in the cartilage, the synovium and at times at the tendons; nor do we understand the precise role played by the pyrophosphate in bone and cartilage destruction.

A double-blind study of erbium169 synoviorthesis in rheumatoid digital joints. Results after one year.

A double-blind study was made on the effectivenss of erbium169 synoviorthesis in the digital joints of 7 patients with erosive, seropositive rheumatoid arthritis. The study involved 70 joints observed over a 12-month period: 20 pairs of metacarpophalangeal joints (MCP) and 15 pairs of proximal interphalangeal joints (PIP) were injected with erbium169 in one joint and saline in the other one. All joints had radiological lesions corresponding to State I and II of the Steinbroker classification. Six months after synoviorthesis, good and excellent results were observed in 71% of the articulations treated with erbium169 and in only 40% of those injected with saline (placebo) (p less than 0.01). Good and excellent results were noted in 79% of the joints treated with the isotope after one year, compared with only 50% injected with the placebo (p less than 0.05). The beneficial effect of erbium169 synoviorthesis on the pain and inflammatory phenomena of rheumatoid digital joints is therefore proven. Occasionally the isotope causes a slight decrease in the range of movement of the treated joint.

Talalgia. A review of 30 severe cases.

Seronegative spondyloarthritides (Reiter's syndrome, ankylosing spondylitis, or psoriatic arthritis) was diagnosed in 24 of 30 patients with severe heel pain. Most of the patients were carriers of the antigen HLA B27. Talalgia was frequently the first symptom of disease. Heel surgery is contra-indicated during the inflammation phase, since it may cause local aggravation and risk of ankylosis of the talocalcaneal articulation. Other causes of heel pain include tendon chondrocalcinosis, local tuberculous infection, and nodular tendinitis caused by a partial rupture of the tendon. On the other hand, severe talagia was rarely found in rheumatoid arthritis, and no case was related to the presence of tophi or xanthomas of the Achilles tendon.

[Synoviorthesis of finger joints using erbium-169. Parameters influencing the clinical results at middle-term]. / La synoviothése des articulations digitales de la main à l'erbium 169. Paramètres influençant les résultats cliniques à moyen terme.

Synoviorthesis of the finger joint with erbium-169 is a beneficial therapeutic procedure which produces reduction of articular pain and swelling in 2/3 of cases. The effect is lasting and shows only slight regression during the first 24 months. However, if the rheumatoid disease is very active, or if the articular lesions are primarily erosive, the results are poorer. No correlation was found between therapeutic results and the radiological findings prior to 169E treatment. Erbium-169 reduces inflammation and leads to progressive articular fibrosis. Any chronic synovitis of interdigital joints resistant to appropriate conventional anti-inflammatory treatment may benefit from radio-synoviorthesis with erbium-169. Erbium-169 synoviorthesis is is technically easy to perform and free of side effects. It is a palliative measure which the authors consider a valuable complement to the classical treatment of rheumatoid arthritis.