High frequency of inflammatory back pain and other features of spondyloarthritis in patients with rheumatoid arthritis.

The aim of this study was to investigate the frequency of patients with rheumatoid arthritis (RA) who have inflammatory back pain (IBP) and meet the existing classification criteria for ankylosing spondylitis (AS) and spondyloarthritis (SpA). We included 167 patients fulfilling the ACR 1987 revised criteria for RA. After obtaining a medical history and performing a physical examination, standard pelvic X-rays for examination of the sacroiliac joints (SIJ) were ordered in all patients. A computed tomography (CT) or magnetic resonance imaging (MRI) of SIJ was performed in patients with suspected radiographic sacroiliitis and MRI of SIJ in those who have IBP but no radiographic sacroiliitis. IBP was defined according to both Calin and experts' criteria. The modified New York (mNY) criteria were used to classify AS, both ESSG and Amor criteria for SpA and ASAS classification criteria for axial SpA. There were 135 female and 32 male patients with a mean age of 54.8 years. The mean disease duration was 9.8 years. RF was positive in 128 patients (79.2 %) and anti-CCP in 120 patients (81.1 %). Twenty-eight patients with RA (16.8 %) had IBP (Calin criteria), and four (2.4 %) had radiographic sacroiliitis of bilateral grade 3. Three patients (1.8 %) fulfilled the mNY criteria for AS, 31 (18.6 %) ESSG and 26 (15.6 %) Amor criteria for SpA. Nine patients (five with MRI sacroiliitis) (5.3 %) were classified as having axial SpA according to new ASAS classification criteria. This study suggests that the prevalence of SpA features in patients with RA may be much higher than expected.

Regional migratory osteoporosis: case report of a patient with neuropathic pain.

Regional migratory osteoporosis (RMO) is an idiopathic disorder characterized by severe periarticular pain, transient and migratory arthralgia, and osteoporosis. Osteoporosis in this disease may appear in the form of local regional osteoporosis and bone marrow edema or generalized osteoporosis. It occurs most commonly in middle-aged men and late second or third trimester pregnant women. The laboratory findings of the disease are usually normal and do not demonstrate apparent anomalies. The presence of bone marrow edema on MRI is its characteristic finding. RMO can only be separated from transient osteoporosis of hip and avascular necrosis with migration to other joints. Clinically, RMO progresses in three stages: increasing pain and disability, radiological findings (osteopenia), maximalization of symptoms, and finally, the regression of the disease and radiological changes. In this case report, we present a 29-year-old woman whose symptoms had first appeared at the second trimester of pregnancy and migrated both to the other joints in the proximo-distal direction and to the adjacent bones within the same joint. She also had symptoms such as hyperalgesia, hyperesthesia and hypertrichosis along with neuropathic pain, which she described as a burning, biting, and prickling type of pain at the right leg. The neuropathic pain of the patient was resistant to medical treatment. We believe that this case was worth reporting because of the obstinate clinical course of the patient's disease and her severe neuropathic pain that was resistant to treatment.

The efficacy of conservative treatment in patients with full-thickness rotator cuff tears.

Rotator cuff tears are a common cause of shoulder pain and disability. Although many studies have reported about the surgical results of full-thickness tears of the rotator cuff, there are few studies about the efficacy of conservative treatment. The aim of this study was to investigate the efficacy of conservative treatment in patients with full-thickness rotator cuff tears by using objective and subjective measurements. Twenty patients with full-thickness rotator cuff tears were included in the study. Outcome measures were range of motion, pain and function according to the shoulder index of the American Shoulder and Elbow Surgeons (ASES), Constant score, Short-Form 36 Health Survey (SF-36), isokinetic shoulder strength, and patient response. Patients were assessed at baseline and after 6 months. In addition, patients were contacted by telephone at 1 year and at 3 years for functional assessment according to ASES, and patient response. The treatment protocol included activity modification, oral nonsteroidal antiinflammatory medications, physical modalities, and a specific exercise program. Statistically significant improvements were obtained in range of motion, pain and function scores according to ASES, Constant score, SF-36 scores, and isokinetic strength (P < 0.05). At the 6-month evaluation, 11 patients (55%) reported that they were "much better", and 9 patients (45%) "better". Conservative treatment of full-thickness rotator cuff tears yields satisfactory results both subjectively and objectively.

Prevalence of spondyloarthritis in Turkish patients with inflammatory bowel disease.

Rheumatic manifestations are the most common extraintestinal findings of inflammatory bowel disease (IBD), although there are wide variations among different studies. The only previous Turkish study reported a rather high prevalence of spondyloarthritis (SpA) in patients with IBD. We aimed to determine the frequency of SpA and ankylosing spondylitis (AS) in patients with IBD attending a gastroenterology clinic from a referral centre. The study was conducted in 122 patients with established diagnosis of IBD [28 with Crohn's disease (CD) and 94 with ulcerative colitis (UC)]. A detailed medical history was obtained and a complete physical examination was performed in all the patients. Standard pelvic X-rays for examination of the sacroiliac joints were performed only when clinically indicated. The X-rays were read blindly by an experienced rheumatologist and reported according to the established grading system. The modified New York criteria were used to classify AS, and the European Spondyloarthropathy Study Group criteria for SpA. The prevalence of AS and SpA in patients with IBD was 8.2 and 28.7%, respectively. SpA was found to be significantly more common in the patients with CD compared to patients with UC, but the frequency of AS was not different between these two groups. There was no correlation between localisation or extent of the intestinal inflammation and presence of AS and SpA. A higher frequency of women was observed in patients diagnosed as SpA. Almost half of the patients with SpA (45.7%) had not been diagnosed before the study, although they had a history of IBP and/or peripheral arthritis. This study suggests that the prevalences of SpA and AS in Turkish patients with IBD are similar to those in many other populations. There may be a significant female predominance of SpA among patients with IBD.

Anatomical and biomechanical evaluation of the tension band technique in patellar fractures.

Tension band wiring for patellar fractures is common, but some recent reports refer to disadvantages of this approach. Our anatomical and biomechanical study focused on use of tension band techniques in patellar fractures. The anatomy of the patella and tendon insertion was examined with knee magnetic resonance imaging (MRI) and correlated with the technical requirements of the tension band. Tension band wiring over tendinous tissue was simulated and calculated with a cyclic biomechanical test on cow patellae. According to tension band templating on the MRI section, Kirschner wire insertion was needed for the tension band to turn over the tendinous tissue. The tension band became more stable while turning over less tendinous tissue and more adjacent bone surface. Nevertheless, cyclic loading tests indicate that all tension band applications in this study lose their initial stability. Excessive initial compression by the tension band resulted in bending of the Kirschner wire and thus reduction failure. For optimum stabilisation, tension force transfer should be done directly on bone or at least material that protects the tendon would be useful.

Effects of three- or four-cortex syndesmotic fixation in ankle fractures.

BACKGROUND: There is no study comparing how Weber type C ankle fractures treated with either three- or four-cortex syndesmotic fixation affects the structure of the syndesmosis. METHODS: In a retrospective study, 46 patients were separated into two groups: 22 patients with three-cortex fixation and 24 patients with four-cortex fixation. All of the patients were evaluated clinically and radiographically at least 1 year after removal of the syndesmosis screws. RESULTS: There were three types of joint space obliteration: type 1, synostosis on plain radiographs; type 2, an incomplete bony bridge on magnetic resonance imaging with normal plain radiographs; and type 3, fibrous obliteration of the joint space. Although obliteration of the joint space was significant (P < .005) after four-cortex fixation, radiologic results did not affect the clinical outcome. CONCLUSION: Four-cortex fixation for diastasis after an ankle fracture should not be a routine procedure. We advocate three-cortex fixation because the clinical results are no different and there is less syndesmotic space obliteration postoperatively.

Shoulder proprioception in patients with subacromial impingement syndrome.

BACKGROUND: Recently, proprioception deficits of the rotator cuff and the deltoid muscles have been suggested to play a pivotal role in the subacromial impingement syndrome (SIS). To date, there are no study has been found where the kinesthesia and joint position senses have been evaluated together in SIS. OBJECTIVE: To investigate the shoulder proprioception in patients with SIS. METHODS: Sixty-one patients with SIS and 30 healthy controls, aging between 25 and 65 years, were included in the study. Main outcome measure was proprioception, assessed with an isokinetic dynamometer. Kinesthesia, active and passive joint repositioning senses were tested at 0° and 10° external rotation. All tests were repeated 4 times and the mean of angular errors were obtained. RESULTS: The mean age was 49.14 ± 10.27 and 48.80 ± 11.09 years in patient group and in control group respectively. No significant difference was found between two groups in terms of age, gender and dominance. When involved and uninvolved shoulders of the patient group were compared, kinesthesia, active and passive joint position senses were significantly impaired in involved shoulders at all angles (P < 0.05). When involved shoulders of the patient group were compared to the control group, kinesthesia, active and passive joint position senses were significantly impaired in involved shoulders in patient group at all angles (P < 0.05) except active position sense at 0°. When uninvolved shoulders of the patient group were compared to the control group, kinesthesia at 10° was significantly impaired (P < 0.05). CONCLUSION: This study showed that shoulder proprioception was impaired in patients with SIS. This proprioceptive impairment was found not only in involved shoulders but also in uninvolved shoulders in patients with SIS.

Hypermobility syndrome increases the risk for low bone mass.

Few studies on the benign joint hypermobility syndrome suggest a tendency toward osteopenia, but there are conflicting results. We assessed bone mineral density in pre-menopausal women with hypermobility. Twenty-five consecutive Caucasian women diagnosed with benign hypermobility syndrome by Beighton score and 23 age- and sex-matched controls were included in the study. Age, menarch age, number of pregnancies, duration of lactation, physical activity and calcium intake were questioned according to European Vertebral Osteoporosis Study Group (EVOS) form. All subjects were pre-menopausal and none of them were on treatment with any drugs effecting bone metabolism or had any other systemic disease. No statistically significant difference was found for body mass index, menarch age, number of pregnancies, duration of lactation, calcium intake, calcium score and physical activity score between the two groups. Total femoral and trochanteric bone mineral density and t and z scores were significantly lower in hypermobile patients compared to the control group. Ward's triangle and femoral neck z scores were also found to be significantly low in hypermobile patients (p<0.05). Significant negative correlations were found between the Beighton scores and trochanteric BMD, t and z scores (r=-0.29, r=-0.30, and r=-0.32) in hypermobility patients. Low bone mass was more frequently found among subjects with hypermobility (p=0.03). Hypermobility was found to increase the risk for low bone mass by 1.8 times (95% confidence interval 1.01-3.38). Our study suggests that pre-menopausal women with joint hypermobility have lower bone mineral density when compared to the controls and hypermobility increases the risk for low bone mass.

Efficacy of Proprioceptive Exercises in Patients with Subacromial Impingement Syndrome: A Single-Blinded Randomized Controlled Study.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of proprioceptive exercises on shoulder proprioception, range of motion, pain, muscle strength, and function in patients with subacromial impingement syndrome. DESIGN: Sixty-one patients with subacromial impingement syndrome participated in this prospective, single-blind randomized controlled trial. All patients were randomly divided into two groups: control group (conventional physiotherapy, n = 30) and intervention group (proprioceptive exercise and conventional physiotherapy, n = 31). The primary outcome measures were sense of kinesthesia and active and passive repositioning for proprioception at 0 degrees and 10 degrees external rotation at 12 wks. The secondary outcome measures were pain at rest, at night, and during activities of daily living with the visual analog scale (0-10 cm), the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons index, range of motion, and isometric muscle strength at both 6 and 12 wks. RESULTS: After treatment, significant improvement was found in range of motion, pain, isometric muscle strength, kinesthesia at 0 degrees external rotation, and functional tests in both groups. The intervention group showed a significant improvement in kinesthesia at 10 degrees external rotation and active and passive repositioning at 10 degrees external rotation. When groups were compared, there were no statistically significant differences in any of the parameters at 12 wks. CONCLUSIONS: Although proprioceptive exercises may provide better proprioceptive acuity, no additional positive effect on other clinical parameters was observed.

Factors affecting reduction in low-grade lumbosacral spondylolisthesis.

OBJECT: Lumbosacral spondylolisthesis (LSS) is a common disorder that often requires a stabilization and fusion procedure. The aim of this study was to determine the early neuroimaging-detected results of instrumentation-assisted (in situ) fusion with no attempt at surgical reduction of the deformity in patients with low-grade LSS. The neuroimaging results were evaluated to determine the extent of reduction and its correlation with different parameters. METHODS: Thirty patients with low-grade LSS underwent short-segment transpedicular screw fixation; surgical reduction was not attempted. All patients underwent plain anteroposterior and lateral lumbar radiography, flexion-extension lateral lumbar radiography, and computerized tomography and magnetic resonance imaging of the lumbar spine before and after surgery. Postoperative measurements were determined on the late (9 to 12-month) postoperative radiographs. The findings were recorded and grouped. Correlation analysis was performed among the radiological findings, body mass index, age, and sex. Paired-sample t-tests were performed for each paired group to determine statistically significant differences. There was no significant difference in extent of deformity reduction in patients with different lordotic angles, sagittal-plane rotation angles, and intervertebral disc heights. The extent of reduction was statistically significant at the L4-5 level (p < 0.05), in patients younger than 50 years of age (p < 0.05), and in those in whom the facet joint angle was increased (p < 0.05). CONCLUSIONS: The authors found that in cases of low-grade LSS, short-segment posterior stabilization (in situ fusion and fixation) does not require surgical reduction and in fact is associated with a measurable reduction when used as the sole treatment.

Congenital anterior dislocation of the radial head: a case with radiographic findings identical to traumatic dislocation.

Differentiation of congenital unilateral dislocation of the radial head from a traumatic dislocation depends mainly on the radiographic findings. Here, we report a case of congenital unilateral anterior radial head dislocation with radiographic findings identical to traumatic dislocation.

Lung parenchyma changes in ankylosing spondylitis: demonstration with high resolution CT and correlation with disease duration.

OBJECTIVE: To analyze the spectrum of the lung parenchyma changes in ankylosing spondylitis (AS) with high resolution computed tomography (HRCT) and correlate the findings with disease duration. MATERIAL AND METHODS: Twenty patients (18 male, 2 female) with the diagnosis of AS according to New York criteria were included in the study. None of the patients had history of tuberculosis, prolonged inorganic dust exposure and hospitalization for pneumonia. Seven of the patients were smokers, three patients were ex-smokers, and 10 patients were nonsmokers. The patients were assigned to three groups depending on disease duration. Group 1: patients with disease duration or=6 years but or=11 years (N: 12 patients). HRCT and pulmonary function tests (PFT) were performed in all patients. RESULTS: HRCT demonstrated pathology in 17 patients (85%). Two patients in group 1, 4 patients in group 2 and 11 patients in group 3 had pulmonary parenchyma changes. Emphysema (9/20), septal thickening (9/20) and pleural thickening (9/20) were the most common changes followed by nodule (8/20) and subpleural band formation (7/20). Three patients had apical fibrosis (AF). Septal and pleural thickening (both 4/10) were the most common changes when only nonsmokers were considered. Among nine patients with emphysema three were nonsmokers. CONCLUSION: There is a wide spectrum in pulmonary parenchyma changes in AS. These changes begin in early stages of the disease and increase with disease duration. Although smoking complicates the spectrum of changes in pulmonary parenchyma, they are predominately in the form of interstitial inflammation.

Extraarticular pigmented villonodular synovitis of the hip.

Pigmented villonodular synovitis of any joint in the extraarticular region is very rare. Its clinical and radiological differential diagnosis is difficult due to exhibiting findings of any soft tissue tumor. Here we report an extrarticular pigmented villonodular synovitis case of the hip of a five-year-old boy, with its radiological and histopathological aspects. The mass was completely extraarticular and was identified histologically and radiologically as pigmented villonodular synovitis. Six months after marginal excision, the lesion recurred. The physicians can face such cases of pigmented villonodular synovitis presenting with unusual extraarticular location, and the preferred excision should be wide to avoid possible recurrences.

Evaluation of physical findings in acute wrist trauma in the emergency department.

OBJECTIVE: The aim of the study was to evaluate the value of physical findings to predict fracture in patients with acute wrist trauma. METHODS: This prospective clinical study was conducted over a period of four months from December 1998. The patients who were older than 18 years and presenting with acute wrist trauma within 24 hours of the time of injury were included in the study. Magnetic resonance imaging (MRI) was done for the patients who had inconsistency between clinical and radiographic diagnosis. RESULTS: Fifty-five patients were included in the study. Four fractures were diagnosed on the MRI of eight patients who have contradiction between clinical diagnosis and X-ray studies. The positive predictive values of edema, localized tenderness, pain on active and passive motion, pain with grip and pain in supination were found as 95.2%, 67.3%, 77.3%, 91,7%, 89.3%, and 96%, respectively. Physical findings having high sensitivity were found as localized tenderness (94.3%), pain on the active and passive motion (97.1%, 94.3%, respectively). Pain on the active and passive motion were determined as physical findings with highest negative predictive values (%90.9, %89.5, respectively). CONCLUSION: Edema, pain on grip and supination, and especially pain on passive and active motion and localized tenderness can be valuable to predict or rule out fracture in acute wrist trauma cases who have no deformity.

The effect of hip rotation on bone mineral density of the proximal femur measured by dual energy X-ray absorptiometry.

OBJECTIVES: The aim of this study was to compare the effect of lower extremity position changes on hip bone mineral density measured by dual energy X-ray absorptiometry. PATIENTS AND METHODS: Sixty-nine healthy university students (30 men, 39 women; mean age 21.9+/-1.6; range 20 to 25 years) participated in this study. Participants were evaluated in two groups as male and female. A special positioning device was produced and used during bone mineral density measurements. Measurements were performed in positions of external 30 degrees , external 15 degrees , neutral 0 degrees , internal 15 degrees , and internal 30 degrees of hip rotations. Measurements were evaluated at shaft, wards and trochanteric region of proximal femur. Differences between positions at shaft, wards, trochanter and total values were compared using repeated measures of analysis of variance. RESULTS: External rotation significantly increased bone mineral density values measured by dual energy X-ray absorptiometry in both male and female. The lowest bone mineral density value was measured at 30 degrees internal rotation in both sexes. There were slight differences between neutral, 15 degrees and 30 degrees internal rotation positions, but these differences were not statistically significant. CONCLUSION: Our findings suggest that position differences are important in adult healthy male and female during bone mineral density measurements of proximal femur using dual energy X-ray absorptiometry.

Axial sarcoidosis mimicking radiographic sacroiliitis.

Involvement of the axial skeleton in sarcoidosis is a rare condition. Herein we report a case with an extensive axial sarcoidosis whose plain radiographs were non-informative. The present case suggested that osseous lesions on sacrum and iliac bones might cause misdiagnosis of sacroiliitis in plain radiographs and advanced imaging may be necessary to make an accurate diagnosis. Our case also underscores the importance of magnetic resonance imaging in selection of a suitable biopsy site to establish diagnosis.

Prevalence of ankylosing spondylitis and related spondyloarthritides in an urban area of Izmir, Turkey.

OBJECTIVE: To determine the prevalence of ankylosing spondylitis (AS) and related spondyloarthritides (SpA) in an adult urban population of Izmir, Turkey. METHODS: A survey was conducted of 2887 subjects aged 20 years or over, selected by cluster sampling. Those who responded positively to the screening questions were contacted by 2 rheumatologists and evaluated in detail to establish presence of AS (modified New York criteria) or related SpA (ESSG criteria). RESULTS: In the initial screening, 2835 subjects participated; 422 were considered screening-positive and a telephone interview was done with 328 (78%). Based on their clinical history, 145 subjects were invited to the hospital and 120 (83%) agreed to do so. After detailed evaluation, 31 subjects were classified as having SpA (including 14 with AS). The age- and sex-adjusted prevalence was estimated to be 0.49% for AS (95% CI 0.26-0.85), and 1.05% for SpA (95% CI 0.70-1.50). The prevalence of AS was 0.54% in men (95% CI 0.19-1.20) and 0.44% in women (95% CI 0.19-0.88), and that of SpA was 0.88% in men (95% CI 0.42-1.59) and 1.22% in women (95% CI 0.73-1.89). CONCLUSION: This epidemiological study suggests a high prevalence (0.49%) of AS in an adult urban population from western Turkey, which equals that of rheumatoid arthritis in the same population. The overall prevalence of SpA, including AS, was 1.05%. A minimal male predominance was noted among AS patients, which disappeared among the whole group of patients with SpA.

Does scapular elevation accompany glenohumeral abduction in healthy subjects?

INTRODUCTION: Although it is used in clinical practice, there are no data concerning scapular elevation during glenohumeral abduction. MATERIALS AND METHODS: Scapular elevation of 30 healthy volunteers in supine and sitting positions were measured at 90-180 deg of glenohumeral abduction by two examiners. In addition, radiographs of the ten subjects were taken in supine position at 0-180 deg of glenohumeral abduction, and the scapular elevation measurements were repeated. Also, the movements of five anatomical landmarks (acromioclavicular joint, center of glenoid cavity, scapular notch, angulus superior and inferior) were measured with regard to transverse and vertical axes. RESULTS: The values obtained for scapular elevation during 90, 120, 150, and 180 deg of glenohumeral abduction were (mean and SD) 26.63 and 3.96, 31.77 and 4.36, 35.97 and 5.15, 40.10 and 5.18 deg, respectively. There were no significant differences with regard to side, gender, and position of the subject. No correlation was found between the clinical and radiological measurements. Movements of certain points did not reveal progressive upward motion. CONCLUSION: There is no scapular elevation but rather rotation during glenohumeral joint abduction. Normal values given in the present study can be used in clinical examinations.

A case with recurrent calf pain and swelling: recurrent spontaneous calf haematoma.

The differential diagnosis of unilateral calf swelling and pain includes deep venous thrombosis, haematoma, ruptured popliteal cyst, infection, lymph oedema, and sarcoma. It is important to distinguish between these entities, as the treatment of each is different. We present a case of recurrent calf swelling due to spontaneous calf haematoma diagnosed with ultrasound and MRI and subsequently treated conservatively.