Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a randomized double-blind controlled study.

INTRODUCTION: We performed a randomized, double-blind, controlled clinical trial comparing intravenous pamidronate and placebo for pain relief in recent osteoporotic vertebral compression fractures (VCF). METHODS: Patients suffered from recent (<21 days), painful, osteoporosis-related VCF. They were randomized to receive daily intravenous infusions of either placebo or 30 mg pamidronate for three consecutive days (total pamidronate: 90 mg). The main criterion for efficacy was improvement in standing pain on a 100-mm visual analogical scale (VAS) at day 7. Secondary criteria were standing pain at days 3 and 30; supine pain at days 3, 7, and 30; patients' overall assessment of improvement; mobility index; and number of "20% responders" and "50% responders" (respectively, 20% and 50% improvement in standing pain at days 7 and 30). Statistical analysis with non-parametric tests was carried out on an intention to treat basis. RESULTS: Thirty-two patients were enrolled in the study; 16 were given placebo and 16 pamidronate. Thirty-one patients were evaluated at day 7 and 26 patients at day 30. VAS pain decreased significantly in both groups at day 7 (placebo -23 mm, pamidronate -42 mm, p<0.01). The difference in pain scores between groups was -23.25 mm (confidence interval (CI) [-42.3; -4.2], p=0.018) at day 7 and -26 mm at day 30 (p=0.03), in favor of pamidronate. At day 7, there were 4 versus 12 "50% responders," respectively, in the placebo and in the pamidronate groups (likelihood ratio: 8.372; p=0.004) and 9 versus 14 "20% responders" (likelihood ratio: 4.038; p=0.044). At day 30, there were 5 versus 10 "50% responders," respectively, in the placebo and in the pamidronate groups, and 7 versus 11 "20% responders." Patients' overall assessment of improvement at day 7 was 37+/-26 mm in the placebo group and 59+/-30 mm in the pamidronate group (p=0.019), and 42+/-26 mm and 72+/-21 mm at day 30 (p=0.07). The two groups did not differ significantly at days 7 and 30 for supine pain, Schober index, or finger-ground distance. No significant adverse reaction related to treatment occurred. CONCLUSION: Pamidronate provides rapid and sustained pain relief in patients with acute painful osteoporotic VCF and is well tolerated. Further investigations are needed to better define the place of pamidronate in the management of painful recent osteoporotic collapse.

Placement of intra-articular injection verified by the backflow technique.

OBJECTIVE: To develop and to assess a simple, inexpensive method for ascertaining, without any imaging procedure, the intra-articular placement of the needle in the knee for intra-articular injections. METHODS: Outpatients referred for intra-articular treatment with "dry" symptomatic knee osteoarthritis were included in this prospective study. "Dry" knee disease was defined as a knee without any clinically detectable effusion. Once intra-articular positioning of the needle considered adequate using the backflow technique, contrast solution was injected using the same needle without changing its position and immediately afterwards lateral and anterior-posterior X-rays were taken to assess the needle position. RESULTS: Of the 32 of 33 cases with obtained backflow, the needle was correctly placed in all cases. In the remaining case, the needle was extra-articularly positioned. The concordance between the two techniques using the Cohen's Kappa was 1 [CI 95%: 0.22-1]. CONCLUSION: The backflow technique allows to accurate the intra-articular placement of the needle for "dry" knee joints injection. This technique can be proposed as a learning tool as well as a daily practice technique to ascertaining intra-articular knee injections without using fluoroscopy with injection of contrast material. Further studies are needed to assess the technique for other joint injections.

Diagnostic value of serum and synovial procalcitonin in acute arthritis: a prospective study of 42 patients.

OBJECTIVE: To determine the diagnostic value of serum and synovial procalcitonin (PCT) for bacterial arthritis and to determine the cellular origin of synovial PCT. METHODS: A prospective study enrolled 42 patients with acute arthritis including 11 bacterial arthritis, 18 rheumatoid arthritis and 13 crystal induced arthritis. Diagnostic values of serum and synovial PCT levels were determined by a immunoluminometric assay (Lumitest PCT) and compared to those of classical inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, synovial fluid cellularity and both serum and synovial IL-6 and TNF alpha). Using fibroblast-like synoviocyte (FLS) cultures derived from rheumatoid arthritis (n = 4) and osteo-arthritis (n = 3) synovium, with or without stimulation by lipopolysaccharid or recombinant streptococcal protein 1/II, we attempted to determine whether synovial cells could be a source of PCT. RESULTS: Serum PCT was the best parameter to distinguish patients with acute bacterial arthritis from patients with crystal induced arthritis or rheumatoid arthritis. In setting of an acute arthritis serum PCT (> 0.5 ng/mL) achieved 55% sensitivity and 94% specificity for the diagnosis of bacterial arthritis, while CRP (> 50 mg/L) had 100% sensitivity but poor specificity (40%). Serum PCT appeared to be higher in patients with septic arthritis resulting from "systemic infection" than in cases resulting from direct inoculation. Synovial PCT was not useful to discriminate between infectious and non infectious arthritis in clinical practice. PCT could not be detected at significant levels in the conditioned medium from fibroblast-like synoviocyte cultures. CONCLUSION: Serum PCT is a poorly sensitive but specific marker of bacterial arthritis. Use of serum PCT in association with CRP could nevertheless be useful in an emergency situation for the diagnosis of bacterial arthritis.

Uveitis, an under-recognized adverse effect of pamidronate. Case report and literature review.

Ophthalmologic adverse effects of bisphosphonate therapy are infrequent and of unclear pathogenesis. The most common has been anterior uveitis, of which 18 cases have been reported. Onset was within 24 to 48 hours after infusion initiation, and both eyes were affected in most patients. The outcome was favorable within a few days after bisphosphonate discontinuation and topical glucocorticoid therapy, although rechallenge was frequently followed by a recurrence. Bisphosphonates are being used successfully in an increasingly broad range of disorders. We report a case of pamidronate-induced anterior uveitis and present a review of the relevant literature.

[Differential diagnosis of infective spondylodiscitis and erosive degenerative disk disease]. / Diagnostic différentiel entre spondylodiscite infectieuse et discopathie dégénérative erosive.

PURPOSE: To assess the value of imaging in the differential diagnosis of erosive intervertebral osteochondrosis (EIVO) versus infectious discitis (ID). MATERIALS AND METHODS: Twelve cases of EIVO and 30 cases of ID were reviewed to define the usefull signs for differential diagnosis on plain films, CT, and MR. RESULTS: No single sign is sufficient, but the association of several signs is suggestive of EIVO: discal vacuum phenomenom, well-defined sclerosis and erosions of vertebral endplates, high signal strip surrounding low signal of vertebral endplates on T1-weighted images. CONCLUSION: Imaging is helpful in difficult differential diagnosis of EIVO versus ID.

Contribution of arthroscopy and magnetic resonance imaging to the evaluation of painful knee osteoarthritis.

In knee osteoarthritis, arthroscopy provides valuable information that suggests an original approach to the disease. In combination with recent imaging study data, this information can be used to develop a novel concept of the evaluation of knee osteoarthritis. The main mechanisms responsible for flares of the disease seem to be synovitis, degenerative meniscal disease, and subchondral bone lesions. Treatments targeted at each of these mechanisms can be used as appropriate. Determination of the exact nature of the lesions can be difficult and relies at present on sophisticated investigations not readily available in everyday practice. Further work is needed to determine how a finer analysis of symptoms and signs in combination with simple investigations can differentiate between the various pathological patterns of knee osteoarthritis.

Painful swelling of the thigh in a diabetic patient: diabetic muscle infarction.

A 44-year-old woman with a 5-year history of poorly controlled Type 1 diabetes mellitus presented with a painful, firm and warm swelling in her right thigh. Pain was severe but the patient was not febrile, and had no history of trauma or abnormal exercise. Laboratory tests showed ketoacidosis, major inflammation (erythrocyte sedimentation rate (ESR) = 83 mm/h), normal white blood cell count and normal creatine kinase level. Plain radiographs were normal, and there were no signs of thrombophlebitis at Doppler ultrasound. Magnetic resonance imaging (MRI) showed diffuse enlargement and an oedematous pattern of the adductors, vastus medialis, vastus intermedius and sartorius of the right thigh. The patient's symptoms improved dramatically, making biopsy unnecessary, and a diagnosis of diabetic muscular infarction was reached. Idiopathic muscular infarction is a rare and specific complication of diabetes mellitus, typically presenting as a severely painful mass in a lower limb, with high ESR. The diabetes involved is generally poorly controlled longstanding Type 1 diabetes with established microangiopathy. Differential diagnoses include deep vein thrombosis, acute exertional compartment syndrome, muscle rupture, soft tissue abscess, haematoma, sarcoma, inflammatory or calcifying myositis and pyomyositis. In fact, physician awareness should allow early diagnosis on the basis of clinical presentation, routine laboratory tests and MRI, thereby avoiding biopsy and its potential complications as well as unnecessary investigations. Rest, symptomatic pain relief and adequate control of diabetes usually ensure progressive total recovery within a few weeks. Recurrences may occur in the same or contralateral limb.

Fibrous dysplasia with intramuscular myxoma (Mazabraud's syndrome). Report of a case and review of the literature.

About 30 cases of fibrous dysplasia associated with one or more myxomas (Mazabraud's syndrome) have been reported since 1926. We report a new case in a woman with polyostotic fibrous dysplasia and a myxoma in the left femoral muscle. She also had a history of precocious sexual development and café au lait spots, two manifestations whose association with polyostotic fibrous dysplasia defines McCune-Albright syndrome.

Anteroposterior atlantoaxial subluxation in cervical spine osteoarthritis: case reports and review of the literature.

Nontraumatic anteroposterior atlantoaxial subluxation (AAS) has been described in several rheumatic or inherited disorders, especially rheumatoid arthritis and to a lesser extent the inflammatory spondyloarthropathies. We describe AAS secondary to osteoarthritis (OA) of the cervical spine in a 76-year-old man and a 73-year-old woman with severe cervical OA, symptomatic C1-C2 facet joints, and signs of generalized OA. Only 6 similar cases exist in the literature. OA should be added to the causes of AAS, and conversely AAS should be assessed in cases with severe OA of the upper cervical spine.

The intravertebral vacuum phenomenon ("vertebral osteonecrosis"). Migration of intradiscal gas in a fractured vertebral body?

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To compare the prevalence of the association between contiguous intervertebral disc and vertebral collapses with or without an intravertebral vacuum phenomenon. SUMMARY OF BACKGROUND DATA: The mechanism of occasional gas accumulation within some vertebral collapses is poorly known. The current hypothesis is that this phenomenon is indicative of bone ischemia. In fact, avascular necrosis as the main pathologic event remains speculative, and should not explain per se the presence of gas within a vertebral body. METHODS: Comparison of the prevalence of intervertebral disc vacuum phenomenon adjacent to the affected vertebral body in 23 cases of intravertebral vacuum phenomenon in 19 patients (intravertebral vacuum phenomenon group) and in 708 osteoporotic collapses without intravertebral vacuum phenomenon in 199 patients (control group). RESULTS: There were no differences in sex and age between the two groups, and all the patients in the intravertebral vacuum phenomenon group had signs of underlying osteoporosis. A vacuum phenomenon in at least one intervertebral disc adjacent to the collapses on radiographs, conventional tomography, computed tomography, or magnetic resonance imaging was found in 19 cases (83%) in the intravertebral vacuum phenomenon group, compared with 13% in the control group (P < 0.0001). Considering plain radiographs only, this association was found in 50% of the intravertebral vacuum phenomenon group and in 9.7% of the control group (P < 0.0001). The intervertebral and intravertebral gaseous collections were connected through a fractured endplate in six cases. CONCLUSIONS: The high prevalence of the association of contiguous intervertebral and intravertebral vacuum phenomenon could have implications in the pathogenesis of the intravertebral vacuum phenomenon. We hypothesize that the intravertebral vacuum phenomenon could simply be the result of migration of an intradiscal-gaseous collection through the fractured endplate of some osteoporotic collapses.

Bone insufficiency fractures as an inaugural manifestation of primary hyperparathyroidism.

Primary hyperparathyroidism causes excessive bone resorption with a decrease in bone mineral density. Fractures of the vertebras and appendicular bones, however, seem uncommon, even in the long term. We report three patients who presented with bone insufficiency fractures as the inaugural symptom of primary hyperparathyroidism. The three patients were women, aged 62, 65 and 86 years, respectively, who presented with fractures of the medial tibial plateau, femoral neck of femoral neck and tarsus. Laboratory tests showed hypercalcemia, hypophosphatemia and elevated parathyroid hormone levels. Apart from confusion in the 86-year-old patient, there were no clinical manifestations. A bone biopsy obtained in one patient showed increased resorption parameters with no loss of bone trabecular volume; the two other patients underwent absorptiometry, which disclosed a marked decrease in bone mineral density at the spine and femoral neck. There were no risk factors for osteopenia apart from advanced age and female gender. A parathyroid adenoma was removed surgically in all three cases. Vitamin D deficiency was a concomitant abnormality that probably exacerbated the adverse effects of hyperparathyroidism on the skeleton.

Insufficiency fractures of the medial femoral condyle.

We report six cases of insufficiency fractures of the medial femoral condyle responsible for severe mechanical pain in the medial knee compartment in the absence of any identifiable precipitating factor. Suggestive changes were seen on initial roentgenograms in only one case, whereas increased radionuclide uptake was a consistent finding on the bone scan. The diagnosis was established only by magnetic resonance imaging in five cases. All six patients were women and four were older than 75 years. Two patients had a history of osteoporotic fractures, one had laboratory test evidence of osteomalacia and one had recurrent insufficiency fractures mistakenly ascribed for several years to migratory transient osteoporosis. Bone density was subnormal in five of the six patients. Rest and standard analgesics consistently ensured a favorable outcome within three to four weeks. To our knowledge there have been no previous reports of stress fractures of the medial femoral condyle. These lesions may be underdiagnosed since they are easily mistaken for primary osteonecrosis in the absence of magnetic resonance imaging. Primary osteonecrosis of the femoral condyle shares several features with insufficiency fractures, including predominance in elderly women with factors responsible for mechanical stress (varum, obesity, trivial trauma), mechanical pain, and increased radionuclide uptake. Because some cases of primary osteonecrosis may be secondary to undiagnosed stress-related microfractures, early diagnosis and elimination of weight bearing are essential.

Intervertebral disk vacuum phenomenon secondary to vertebral collapse: prevalence and significance.

PURPOSE: To evaluate the prevalence of the intervertebral vacuum phenomenon in disks adjacent to vertebral collapses of various causes. MATERIALS AND METHODS: The authors retrospectively studied 310 consecutive patients who had at least one vertebral collapse. The vacuum phenomena were divided into collapse-related (ie, adjacent to a collapse) and degenerative (ie, not associated with a vertebral fracture) ones. Plain radiography was performed in all patients, and, in addition, conventional tomography, computed tomography, and/or magnetic resonance imaging was performed in 175 patients. RESULTS: Collapse-related vacuum phenomena were seen in 15% of patients with plain radiography and in 21% when all of the imaging modalities were considered. They occurred in association with all of the causes of collapse (ie, osteoporosis, multiple myeloma, metastasis, acute trauma, and vertebral osteomyelitis), although the prevalence was lower in association with metastasis or trauma (P = .008). The occurrence of collapse-related vacuum phenomenon was correlated with age (P = .001) and with the coexistence of degenerative disk-related vacuum phenomenon in the same patient (P = .0002). CONCLUSION: Occurrence of a vacuum cleft in disks adjacent to a vertebral collapse is common and appears as the second cause of vacuum phenomenon after degenerative disk disease.

An unexpected, benign cause of increased muscular uptake at bone scintigraphy.

Bone scintigraphy was performed in a healthy 30-year-old man because of post-traumatic heel pain. The scintigraphy displayed a bilateral increased uptake of 99mTc-MDP in the pectoral muscles and triceps brachii. Further extensive investigations including muscle biopsy were normal and excluded diagnoses such as polymyositis, myositis ossificans or amyloidosis. The abnormalities were in fact explained by physical exercise performed a few hours prior to the radionuclide scan. This was confirmed by the absence of these changes on a second bone scan performed 3 months later. This case shows that muscle exercise should be kept in mind as a cause of skeletal muscle uptake of bone-seeking agents, with the view to avoid unnecessary investigations.

[New methods of analysis of gait in the evaluation of the action of anti-inflammatory drugs. Apropos of naproxen]. / Méthodes nouvelles d'analyse de la marche dans l'évaluation de l'action des anti-inflammatoires. A propos du naproxène.

Two nontraumatizing and reproducible tools for quantitative gait analysis as part of the objective evaluation of nonsteroidal antiinflammatory drugs are reported. The Bessou gait analyzer is a simple mechanical device which measures spatiotemporal and kinematic parameters (stride length; duration of stride, weight-bearing, and forward swing; speed and peak speed of swing; and overall speed of walking). The ELITE system is a considerably more complex instrument for analyzing three-dimensional motions through high-speed shape recognition. Computerized data management allows not only to determine the spatiotemporal parameters listed above but also to study displacements of selected landmarks in several planes and to derive joint angles and angular speeds. Coupling of the ELITE system to a force platform and to telemetric transmission surface electromyography substantially expands the range of data provided. The mechanical gait analyzer was used to evaluate the effects of naproxen in 11 patients with osteoarthritis of the knee; another similar study in 13 patients with osteoarthritis of the hip is ongoing. Gait was recorded before and after daily administration of naproxen for seven days. After treatment, walking speed was significantly increased as a result of increased stride length and decreased stride duration. Durations of monopodal and bipodal weight-bearing decreased concomitantly with the increase in speed, whereas duration of forward swing remained unchanged. These data demonstrating improved kinematic gait parameters show that naproxen is effective in reducing the adverse mechanical effects of pain. This study also demonstrates the usefulness of gait analysis for evaluating drugs.

[Camptocormia in the elderly patient: myopathy or muscular dystonia?]. / La camptocormie du sujet agé: myopathie ou dystonie musculaire?

Two cases of camptocormia in elderly patients are reported. Both patients presented with an anterior curvature of the trunk which disappeared in the decubitus position. Computed tomography demonstrated hypodensity of the muscles which preceded atrophy. Histological changes were of low specificity and diverse with irregular and a trophic muscle fibers and occasionally endomysial fat or mitochondrial abnormalities. These findings suggest that camptocormia may be the consequence of a disease of spinal muscles. Pathophysiological hypotheses include neurogenic atrophy of spinal muscles, spinal amyotrophy, and delayed primary myopathy. None of these hypotheses was consistent with findings in our two patients. The terms "muscular dystrophy" and "mitochondrial myopathy" occasionally used seem inappropriate in view of the lack of specificity of the lesions. A better term may be "muscular insufficiency", the mechanism of which is still unclear.

[Inflammatory myalgic syndrome and muscular mitochondrial abnormalities: 4 cases]. / Syndromes myalgiques inflammatoires et anomalies mitochondriales musculaires: 4 cas.

Histologic and biochemical anomalies of muscle mitochondria were identified in four patients with predominantly rhizomelic myalgia clinically suggestive of an inflammatory disease but inconsistent biologic evidence of inflammation. This clinical pattern was initially suggestive of atypical polymyalgia rheumatica and could not be ascribed to any other disease. To explain this combination of anomalies, several hypotheses can be put forward, including coincidence, aging, and nonspecific mitochondrial anomalies resulting from immunologic or inflammatory disease. The speculation that these patients have an autonomous syndrome cannot be outruled but should be considered with caution. A therapeutic trial with coenzyme Q is under way.

[Aspects and role of spinal MRI in the assessment of solitary plasmacytoma and multiple myeloma. Apropos of 11 cases]. / Aspects et rôle de l'irm du rachis au cours de l'exploration du plasmocytome solitaire et du myélome multiple. A propos de 11 observations.

Spinal MRI was performed in 9 multiple myeloma and 2 solitary plasmacytoma, using sagittal, T 1-weighted (TR: 350-550 ms/TE: 15-26 ms) and T 2-weighted (TR: 2,000-2,500 ms/TE: 60-120 ms) sequences, with additional gadolinium injection in 3 cases. MRI features were the following: 1) round, patchy lesions with low T 1 signal highlighted by gadolinium and bright T 2 signal were present in 10 of the 11 patients: all osteolytic lesions seen on plain X-rays corresponded to such lesions and biopsy performed in 4 cases showed massive marrow replacement by plasma cells. 2) overall marrow signal was dramatically decreased in 3 patients (2 of whom had a high tumoral mass). 3) extra-dural compression was present in 4 cases. 4) 25 vertebral compression fractures (10 of whom with a "benign" appearance) and focal fat deposition were seen. 5) postradiation treatment examination seemed predictive of the outcome in the 2 solitary plasmacytomas. MRI proved to be more sensitive than plain X-rays or bone scintigraphy. Number and size of focal tumor-like lesions did not correlate with the low marrow signal appearance. Both correlated poorly with overall tumoral mass but diffuse abnormalities were associated with rapidly fatal outcome in three cases. These features might reflect qualitative rather than quantitative patterns of the disease (nodular or diffuse macroscopic marrow replacement). These findings are in agreement with those of the few previous studies. MRI is valuable for spinal cord damage assessment. It appears less accurate in benign versus malignant vertebral compression fracture determination than it does in bone metastasis. Its prognostic value is still questionable.