[Update in non-union treatment]. / Actualités dans le traitement des pseudarthroses aseptiques.

Non-union of long bones is still a dreadfull complication. Depending on the type and location of the non-union, we describe current treatment options including various types of bone fixation, isolated or vascularised bone grafts, biophysical enhancement and newer developments with biological bone inducers (BMP).

A prospective randomised multicentre study comparing continuous and intermittent treatment with celecoxib in patients with osteoarthritis of the knee or hip.

OBJECTIVE: To compare the effects of continuous and intermittent celecoxib treatment in patients with knee or hip osteoarthritis in flare. METHODS: In this 24-week, prospective, randomised, double-blind, placebo-controlled study, patients were randomly assigned to receive continuous (n = 62) or intermittent (n = 61) treatment with celecoxib 200 mg once daily. The primary efficacy end point was the area under the curve (AUC) of the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores between baseline and week 24 divided by the time interval. Secondary end points included the percentage of days with intake of the flare drug, the AUC of the change in the WOMAC total scores, the mean change from baseline in the WOMAC scores, and the patient's and physician's global assessment of osteoarthritis. RESULTS: There were no significant differences between patients randomised to continuous or intermittent treatment in the primary end point or most of the secondary end points, although a consistent trend supporting continuous treatment was observed. The percentage of days with intake of the flare drug was significantly lower (p = 0.031) in the group receiving continuous versus intermittent celecoxib. Both treatment regimens were well tolerated. CONCLUSION: The results of this pilot study indicate a potential clinical difference between continuous and intermittent treatment with celecoxib, and may be useful in designing future trials. A larger trial on both efficacy and safety outcomes is required for conclusive evidence in favour of either continuous or intermittent treatment.

Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium kansasii.

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

Comparison between clinical evaluation and ultrasonography in detecting hydrarthrosis of the knee.

OBJECTIVE: To assess the validity of the clinical detection of knee hydrarthrosis compared to ultrasonography (US). To assess the differences of results for both clinical and US tests when they are done by independent investigators. To assess the effect of a previous clinical evaluation on the US diagnosis. METHOD: The clinical and US examinations were scored using a 3 point scale. In 50 symptomatic patients, 82 knees underwent clinical and US evaluations by the same physician. Two independent observers clinically and echographically tested 22 other knees (11 patients). Finally, in another series of 20 knees (10 patients), the first investigator performed clinical testing before the US evaluation, while the other did the US with no previous clinical evaluation. RESULTS: Between the clinical and US evaluations, agreement was moderate (kappa = 0.508), but statistically significant (p<0.001). The relationship between the 2 investigators for clinical evaluation was slightly weaker (kappa = 0.446, p = 0.032). Possible (score 1) or definite (score 2) clinical knee hydrarthrosis sensitivity was 79/100% and specificity 25/78%, respectively. In contrast, US studies from 2 independent observers were strongly related (kappa = 0.902) and were not modified by a previous clinical evaluation. CONCLUSION: Clinical knee hydrarthrosis detection is less accurate and reproducible than US detection.

Articular aspergillosis: two case reports and review of the literature.

We report two cases of septic arthritis of the knee caused by Aspergillus: one by Aspergillus terreus in a cirrhotic patient and the other by Aspergillus fumigatus after vascular graft infection. The recovery of these organisms in synovial fluid should be considered as pathogenic, particularly in immunocompromised hosts. The pathogenic mechanism is discussed and the literature is reviewed.

[Role of conservative treatment in impingement syndromes of the shoulder]. / Place du traitement conservateur dans les syndromes de conflit au niveau de l'épaule.

The impingement syndrome of the shoulder could be primary when the origin is abnormalities of the coracoacromial arch, or secondary when the problem concerns the tendons, the hyperlaxity of the joint or an imbalance between the different muscles. In every case, the treatment has to be first of all conservative, including analgesics, anti inflammatory drugs and rehabilitation. A review of these therapeutic procedures is done.

Relationship between magnetic resonance imaging and histologic findings by bone biopsy in nontraumatic osteonecrosis of the femoral head.

To attest the validity of magnetic resonance imaging (MRI) to evaluate the pathophysiology in nontraumatic osteonecrosis (ON) of the femoral head, we attempted to correlate the different MRI patterns with the histology in cases of early stages. We used not only the T1 and T2 pulse sequences, but also the T1 sequence after gadolinium-DTPA to demonstrate the presence of vascularization. Studying 24 core biopsies from 16 hips (9 patients), we explored the MRI presentations that corresponded to the main histologic findings of the different trabecular bone and bone marrow conditions. Histologic findings including trabecular bone necrosis and bone marrow necrosis represented by amorphous eosinophilic debris presented a low T1 signal intensity without enhancement after intravenous gadolinium injection and a low T2 signal intensity. Trabecular bone necrosis associated with mummified fat cells presented a normal T1 and T2 signal intensity. Trabecular bone necrosis with fibrosis filling the intertrabecular spaces had a low T1 signal intensity that was enhanced by gadolinium and had an intermediate T2 signal intensity. Bands of fibrosis without trabecular bone as seen in fracture zones showed a low T1 signal intensity that was enhanced by gadolinium with a high T2 signal intensity. Thickened trabecular bone with fibrosis as found in creeping substitution areas had also a low T1 signal enhanced by gadolinium, but the T2 signal intensity was low. Farther from the necrotic area, despite normal trabecular bone, we found some patchy necrosis of the bone marrow without any modification of the normal T1 and T2 MRI patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Study of magnetic resonance imaging in transient osteoporosis of the hip.

To better define the magnetic resonance imaging (MRI) features during transient osteoporosis of the hip, we carried out sequential MRI of 8 patients with transient osteoporosis of the hip showing the typical radiographic pattern of diffuse osteoporosis of the femoral head. These cases displayed the same MRI changes in the femoral head and neck characterized by low signal intensity on the T1 weighted images and high signal intensity on the T2 weighted images. The MRI signal became normal within 11 months, but surprisingly, migration of the MRI abnormalities was observed during the course of the disease in 5 cases: abnormal MRI signals were first observed in the anterior area, then migrated to the posterior part, while a normal MRI signal reappeared in the anterior part. We conclude that MRI seems to show some particular features in transient osteoporosis of the hip, which normalize after a few months of evolution; this could represent a migration of MRI abnormalities. Such findings could help in the differential diagnosis of hip diseases such as aseptic bone necrosis.

Enkephalinase: a physiologic neuroimmunomodulator detected in the synovial fluid.

Enkephalinase (endopeptidase 24.11) is a metallopeptidase that is able to cleave not only neuropeptides and hormones but also immune mediators. The enzyme was quantified in synovial fluid obtained from 36 swollen joints. Its concentration correlated with the synovial fluid cell count, mainly the polymorphonuclear cells and lymphocytes, and with the erythrocyte sedimentation rate. No statistically significant difference in enkephalinase levels was demonstrated between the groups of patients with rheumatoid arthritis, seronegative spondylarthropathy, microcrystalline arthritis, or osteoarthritis. The presence of enkephalinase in the synovial fluid could reflect the intensity of the inflammatory process, or it could represent a physiologic regulator of inflammation and pain within the joint.

Medullary impairment at early stage of non-traumatic osteonecrosis of the femoral head.

We found that a painful hip without radiological changes presented a modification of the magnetic resonance image of the femoral head and neck with diffuse low T1 weighted and high T2 weighted signal. Core biopsy showed that the bone marrow was replaced from the neck to the head of the femur by fibroblastic tissue and edema without detectable trabecular bone impairment. Classical radiographic, CT, and MRI abnormalities of osteonecrosis of the femoral head were present 14 months later. This report suggested that diffuse femoral head and neck medullary impairment with fat cell replacement by fibroblastic tissue without evidence of trabecular bone necrosis can be found at the early stages of idiopathic osteonecrosis.

Chronic acquired immunodeficiency syndrome-associated arthritis: a synovial ultrastructural study.

We describe a patient who developed acquired immunodeficiency syndrome-related complex, complicated by chronic, symmetric polyarthritis. Synovial biopsy showed large areas of plasma cell infiltration subjacent to the synovial lining. Ultrastructural study demonstrated tubuloreticular structures within endothelial cells, crystal-like inclusions in plasma cells, and virus-like particles located around synoviocyte fragments. Although immunologic and morphologic studies did not permit classification of these virus-like structures, the role of these possible virions in the pathogenesis of the observed synovitis remains to be determined. Surprisingly, the patient's chronic arthritis resolved with anti-retroviral treatment (azidothymidine: AZT).

The diagnostic value of magnetic resonance imaging in non-traumatic osteonecrosis of the femoral head.

To assess the effectiveness of nuclear magnetic-resonance imaging in the detection of osteonecrosis of the femoral head, we studied the cases of twenty-five patients (forty-nine hips) in whom necrosis of the femoral head was suspected on the basis of plain radiographs, computed tomographic scans, radionuclide bone scans, and magnetic resonance-imaging scans. The results of these investigations were compared, for all except one patient, with the pathological findings of transtrochanteric core biopsies of the femoral head and neck of both hips. Of the forty-nine hips, thirty-three had histological proof of osteonecrosis. Twenty-two (67 per cent) of these hips showed definite necrosis on the plain radiographs; eighteen (62 per cent), on the twenty-nine available computed tomographic scans; twenty-four (77 per cent), on the thirty-one available radionuclide bone scans; and all of the hips, on the magnetic resonance-imaging studies. In six additional hips, there were histological changes (marrow necrosis, edema, hemorrhage, and fibrosis) in the medullary spaces without detectable osteonecrosis. The plain radiographs and computed tomographic scans of these six hips were normal except for the computed tomographic scan of one, and the radionuclide uptake on bone-scanning was abnormal in four of the six, as were the magnetic resonance-imaging studies. In the two hips that had normal magnetic resonance-imaging studies, the biopsies showed only destruction of fat cells in the medullary spaces, with no edema or fibroblastic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind, placebo-controlled study of OM-8980 in rheumatoid arthritis.

A total of 95 patients suffering from active rheumatoid arthritis were included in this double-blind, placebo-controlled study of the immunomodulator OM-8980. Treatment was one capsule daily of OM-8980 or placebo for 6 months. A significant improvement was observed in the OM-8980 group in comparison with the placebo group as regards the Ritchie index (P = 0.002), grip strength (P = 0.02) and pain (P = 0.03). The number of swollen joints, duration of morning stiffness and erythrocyte sedimentation rate decreased more markedly under OM-8980 than under the placebo, without reaching the level of statistical significance. A significant difference in favour of OM-8980 was observed in the intake of non-steroidal anti-inflammatory drugs and oral corticosteroids. Clinical tolerance was on the whole good (10 cases with side effects out of 49 in the OM-8980 group and 7 out of 46 in the placebo group, ns), with the majority of the side effects concerning the gastrointestinal system. The global assessment of the therapeutic efficacy both by the physician and the patient showed a highly significant superiority of OM-8980 over the placebo (P = 0.001).

Bilateral non-traumatic aseptic osteonecrosis in the femoral head. An experimental study of incidence.

Thirty-five patients who were seen with non-traumatic aseptic osteonecrosis of the femoral head were included in a study of the contralateral hip to evaluate the incidence of bilateral disease. We used not only conventional radiography and scintigraphy but also measurement of intramedullary pressure and core biopsy. Pain was caused by 14.3 per cent of the contralateral hips, a lesion was demonstrated on plain radiographs in 51.4 per cent, and increased isotopic uptake was seen in 31.4 per cent. Histological study of specimens obtained by osteomedullary biopsy (after special procedure) showed bilateral necrosis in 88.5 per cent of the patients. After a mean follow-up of thirty-four months, only one of nine hips that were painless and had negative radiographic and isotopic findings, but had positive findings on biopsy, became painful and radiographically positive. The intramedullary pressure in the intertrochanteric area was recorded in each hip, and no correlation was found with the radiographic stage or with pain.

Diagnosis of aseptic osteonecrosis of the femoral head by percutaneous transtrochanterian needle biopsy.

A technique is described whereby aseptic osteonecrosis of the femoral head can be investigated before definite radiological signs do develop. Qualitative and quantitative data are presented supporting the generalisation of this method and its implications are discussed.

The use of CT scanning for the study of posterior lumbar intervertebral articulations.

The spine is composed of three articular axes: one discal, two facetal. The slightest alteration in one of these axes affects the others. CT is particularly effective in demonstrating biochemical alternations due to architectural pathologies of the column. A judicious therapeutic approach is suggested.