Effect of a treat-to-target strategy based on methotrexate and intra-articular betamethasone with or without additional cyclosporin on MRI-assessed synovitis, osteitis, tenosynovitis, bone erosion, and joint space narrowing in early rheumatoid arthritis: results from a 2-year randomized double-blind placebo-controlled trial (CIMESTRA).

OBJECTIVES: To investigate whether a treat-to-target strategy based on methotrexate (MTX) and intra-articular (IA) betamethasone suppresses magnetic resonance imaging (MRI)-determined measures of disease activity and reduces joint destruction in early rheumatoid arthritis (eRA) patients, and to investigate whether concomitant cyclosporin A (CyA) provides an additional effect. METHOD: In the 2-year randomized, double-blind, treat-to-target trial CIMESTRA, 160 patients with eRA (< 6 months) were randomized to MTX, intra-articular betamethasone and CyA, or placebo CyA. A total of 129 patients participated in the MRI substudy, and had contrast-enhanced MR images of the non-dominant hand at months 0, 6, 12, and 24. MR images were evaluated for osteitis, synovitis, tenosynovitis, bone erosion, and joint space narrowing (JSN), using validated scoring methods. RESULTS: Significant reductions were seen at 6 months in all inflammatory parameters [synovitis, mean change -1.6 (p < 0.001, Wilcoxon), tenosynovitis, -3.5 (p < 0.001), and osteitis, -1.3 (p < 0.05)] and at 12/24 months in synovitis and tenosynovitis [-1.6/-2.2 and -3.6/-3.8, respectively; all p < 0.001]. MRI signs of inflammation were not fully eliminated, and increases in erosion and JSN scores were observed at 6 months [0.4 (p < 0.01)/0.1 (p < 0.05)], 12 months [0.8 (p < 0.001)/0.3 (p < 0.01)], and 24 months [1.0 (p < 0.001)/0.4 (p < 0.001)]. Clinical measures decreased significantly (p < 0.001) at all time points. There were no consistent statistically significant differences between treatment groups. CONCLUSIONS: In this eRA treat-to-target trial, MTX and intra-articular glucocorticoids markedly reduced, but did not eliminate, MRI osteitis, synovitis, and tenosynovitis. Accordingly, minimal but statistically significant increases in bone erosion and JSN were observed. No additional effect of CyA was demonstrated.

Increased anterior pelvic tilt in patients with acetabular retroversion compared to the general population: A radiographic and prevalence study.

INTRODUCTION: The prevalence of acetabular retroversion is sparsely investigated. It may be associated with increased anterior pelvic tilt. The purpose of this study was to investigate whether patients with symptomatic and radiographically verified acetabular retroversion demonstrated increased anterior pelvic tilt compared to a control group, and furthermore to evaluate the prevalence of acetabular retroversion in the general population. METHODS: Anteroposterior pelvic radiographs in standing position of 111 patients with acetabular retroversion prior to anteverting periacetabular osteotomy (PAO) and 132 matched controls from the general Danish population were assessed. Pelvic tilt was assessed by the sacrococcygeal joint-symphysis distance and pelvic-tilt-ratio. Acetabular retroversion was defined as positive cross-over sign and posterior wall sign. Prior to assessments, interrater reliability analysis was performed. Measurements were agreed by two independent assessors. A nonparametric regression model was used to test between-group differences in median pelvic tilt. The prevalence was calculated as the ratio of subjects and hips with acetabular retroversion, respectively. RESULTS: The patient group had significantly larger median anterior pelvic tilt of 14.3 mm in sacrococcygeal joint-symphysis distance and -0.08 in pelvic-tilt-ratio, compared to controls. The prevalence of subjects in the general population with either unilateral or bilateral acetabular retroversion was 24% and 18% for all hips. CONCLUSION: Our data demonstrated that patients with symptomatic acetabular retroversion have increased anterior pelvic tilt compared to the general population. Radiographic sign of acetabular retroversion was highly prevalent in the general population. IMPLICATION FOR PRACTICE: Increased anterior pelvic tilt should be considered when diagnosing and treating patients with hip pain, as symptoms may be related to the functional position of the pelvis and not necessarily solely come from the radiographic verified acetabular retroversion.

MRI bone oedema is the strongest predictor of subsequent radiographic progression in early rheumatoid arthritis. Results from a 2-year randomised controlled trial (CIMESTRA).

OBJECTIVE: To identify predictors of radiographic progression in a 2-year randomised, double-blind, clinical study (CIMESTRA) of patients with early rheumatoid arthritis (RA). METHODS: Patients with early RA (n = 130) were treated with methotrexate, intra-articular betamethasone and ciclosporin/placebo-ciclosporin. Baseline magnetic resonance imaging (MRI) of the wrist (wrist-only group, n = 130) or MRI of wrist and metacarpophalangeal (MCP) joints (wrist+MCP group, n = 89) (OMERACT RAMRIS), x-ray examination of hands, wrists and forefeet (Sharp/van der Heijde Score (TSS)), Disease Activity Score (DAS28), anti-cyclic citrullinated peptide antibodies (anti-CCP), HLA-DRB1-shared epitope (SE) and smoking status were assessed. Multiple regression analysis was performed with delta-TSS (0-2 years) as dependent variable and baseline DAS28, TSS, MRI bone oedema score, MRI synovitis score, MRI erosion score, anti-CCP, smoking, SE, age and gender as explanatory variables. RESULTS: Baseline values: median DAS28 5.6 (range 2.4-8.0); anti-CCP positive 61%; radiographic erosions 56%. At 2 years: DAS28 2.0 (0.5-5.7), in DAS remission: 56%, radiographic progression 26% (wrist+MCP group, similar for wrist-only group). MRI bone oedema score was the only independent predictor of delta-TSS (wrist+MCP group: coefficient = 0.75 (95% CI 0.55 to 0.94), p<0.001; wrist-only group: coefficient = 0.59 (95% CI 0.40 to 0.77), p<0.001). Bone oedema score explained 41% of the variation in the progression of TSS (wrist+MCP group), 25% in wrist-only group (Pearson's r = 0.64 and r = 0.50, respectively). Results were confirmed by sensitivity analyses. CONCLUSION: In a randomised controlled trial aiming at remission in patients with early RA, baseline RAMRIS MRI bone oedema score of MCP and wrist joints (and of wrist only) was the strongest independent predictor of radiographic progression in hands, wrists and forefeet after 2 years. MRI synovitis score, MRI erosion score, DAS28, anti-CCP, SE, smoking, age and gender were not independent risk factors. TRIAL REGISTRATION NUMBER: NCT00209859.

Radiographic signs of acetabular retroversion using a low-dose slot-scanning radiographic system (EOS®).

INTRODUCTION: Acetabular retroversion is assessed using pelvic X-ray. Cross-over-sign (COS), posterior-wall-sign (PWS) and ischial-spine-sign (ISS) are important radiographic signs of the condition. The pelvic area is sensitive to radiation and thus, possibilities to reduce dose should be considered. The purpose was to compare radiographic signs of acetabular retroversion on conventional pelvic anteroposterior (AP) X-rays with a low-dose slot-scanning system (EOS) in a sample of patients with retroversion of the acetabulum and to compare the radiation doses. METHODS: 34 participants with radiographic signs of acetabular retroversion in one or both hips on conventional pelvic X-ray were consecutively recruited. Pelvic EOS-images were acquired in each patient and COS, PWS, ISS, COS-ratio and PWS-ratio was assessed. Radiation dose comparison of X-ray vs. EOS was performed using Dose-Area Products. RESULTS: Retroversion was present in 57 out of 68 hips. The absolute agreement was 91%, 84% and 76% for COS, PWS and ISS, respectively. No statistically significant differences were present between COS-ratio and PWS-ratio in either modality and Bland-Altman limits of agreement were narrow. The mean radiation dose was 1053 mGy*cm2 in X-ray and 593 mGy*cm2 in EOS (p = 0.003). CONCLUSION: The results indicate that pelvic EOS provides diagnostic qualities similar to conventional X-ray using 44% less radiation when radiographic signs of acetabular retroversion are assessed.

Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur.

OBJECTIVE: To estimate sensitivity and specificity of CT and MRI examinations in patients with fractures of the proximal femur. To determine the interobserver agreement of the modalities among a senior consulting radiologist, a resident in radiology and a resident in orthopaedics surgery. MATERIALS AND METHODS: 67 patients (27 males, 40 females, mean age 80.5) seen in the emergency room with hip pain after fall, inability to stand and a primary X-ray without fracture were evaluated with both CT and MRI. The images were analysed by a senior consulting musculoskeletal radiologist, a resident in radiology and a resident in orthopaedic surgery. Sensitivity and specificity were estimated with MRI as the golden standard. Kappa value was used to assess level of agreement in both MRI and CT finding. RESULTS: 15 fractures of the proximal femur were found (7 intertrochanteric-, 3 femoral neck and 5 fractures of the greater trochanter). Two fractures were not identified by CT and four changed fracture location. Among those, three patients underwent surgery. Sensitivity of CT was 0.87; 95% CI [0.60; 0.98]. Kappa for interobserver agreement for CT were 0.46; 95% CI [0.23; 0.76] and 0.67; 95% CI [0.42; 0.90]. For MRI 0.67; 95% CI [0.43; 0.91] and 0.69; 95% CI [0.45; 0.92]. CONCLUSION: MRI was observed to have a higher diagnostic accuracy than CT in detecting occult fractures of the hip. Interobserver analysis showed high kappa values corresponding substantial agreement in both CT and MRI.

[Ultrasonographic scanning of patients with severe abdominal injuries]. / UL-scanning af abdomen hos hårdt kvaestede patienter.

INTRODUCTION: The aim of this study was to describe our experiences with ultrasonography (US) of severely traumatised patients, and to show whether it is a safe and fast procedure when screening for intra-abdominal lesions. MATERIAL AND METHODS: In a period from 1996 to 1999, 876 patients were received by the trauma team. The number of patients with an injury severity score (ISS) > 15, was constant during the period. Seventy-five per cent of the patients were men. One hundred and fifty-five patients (18%) died, 111 before US was carried out. RESULTS: Over the four-year period, the number of patients received by the trauma team increased from 150 in 1996 to 365 in 1999. The number of US examinations increased from 61 (1996) till 303 (1999). The number of pathological US scans was constantly about 20 per year, where as the number of pathological CT scans was between ten and 20 per year. The number of patients that went on to explorative laparotomy was between seven and 17 per year and 49 in the whole period. The sensitivity of US to detect abdominal lesions is 0.74 and the specificity 0.97, whereas that to detect free abdominal fluid is 0.88 and the specificity 0.99. DISCUSSION: US of the abdomen is a fast and safe procedure to carry out on the severely traumatised patient. An algorithm for diagnosis is suggested.

The role of acetabulum geometry and femoral head-neck ratio in the development of osteoarthritis in young men.

We studied the role of acetabulum geometry and head neck ratio in the development of osteoarthritis of the hip in young men. Contrary to previous studies we evaluated the significance of the anterior, posterior and total coverage of the femoral head, the influence of the femoral neck and the consequence of acetabular retroversion on standardized x-rays. Men aged 26-55 years who earlier had a total hip arthroplasty were included in the case group. This group was compared to a control-group of men treated as trauma patients. The study indicates that acetabular dysplasia and retroversion and a relative decreased head neck ratio are associated with osteoarthritis of the hip in young men.

Cerebral infarct following carotid endarterectomy. Frequency, clinical and hemodynamic significance evaluated by MRI and TCD.

The purpose of this study was to disclose the frequency of new infarcts after Carotid Endarterectomy (CEA) by MRI and Transcranial Doppler examinations (TCD), and to evaluate the clinical and pathological significance. Of a consecutive series of 41 patients with a symptomatic carotid stenosis exceeding 69%, 33 had MRI and TCD examinations performed before and after the CEA. Pre-operative MRIs revealed Focal High Signal Intensity (FHSI) in 21 patients (64%) on the side of the stenosis, ranging in number from 2 to more than 20 and in size from 0.5 cm to more than 3 cm. After the operation 8 patients (24%) each had acquired from 1-4 new FHSIs, but only 3 patients (9%) suffered from clinical symptoms. In 2 patients, who had had a stroke, the FHSIs were more than 3 cm. In 1 patient, who experienced a Transient Ischemic Attack (TIA), the FHSI was 1-2 cm. The TCD disclosed low Pulsatility Index (PI) values in 2 of the 3 patients who had new FHSIs and clinical symptoms. In all the patients who did not show new FHSIs after the operation, the PI was normal in the MCA of the symptomatic hemisphere after CEA. So new cerebral FHSIs were rather frequent after a CEA, but only FHSIs >1 cm were accompanied by a TIA or stroke, and a low PI in the MCA of the relevant hemisphere was found before or in connection with the operation in 2 of the 3 patients who developed clinical symptoms.