The effect of etanercept on osteoclast precursor frequency and enhancing bone marrow oedema in patients with psoriatic arthritis.

OBJECTIVE: The frequency of osteoclast precursors (OCPF) and the presence of bone marrow oedema (BMO) are potential response biomarkers in psoriatic arthritis (PsA). Previous studies suggest a central role for tumour necrosis factor (TNF) in the formation of osteoclast precursors. To better understand this association, the effect of etanercept on OCPF and BMO was analysed in PsA patients with erosive arthritis. METHODS: A total of 20 PsA patients with active erosive PsA were enrolled. Etanercept was administered twice weekly for 24 weeks. OCPF was measured and clinical assessments were performed at baseline, 2, 12 and 24 weeks. Gadolinium enhanced MR images were obtained at baseline and 24 weeks. RESULTS: Significant improvements in joint score (p<0.001), HAQ scores (p<0.001) and SF-36 parameters were observed after 6 months of therapy with etanercept compared to baseline. The median OCPF decreased from 24.5 to 9 (p = 0.04) and to 7 (p = 0.006) after 3 months and 6 months of treatment, respectively. MR images were available for 13 patients. The BMO volume decreased in 47 and increased in 31 sites at 6 months. No correlation was noted between OCPF, BMO and clinical parameters. CONCLUSION: The rapid decline in OCPF and overall improvement in BMO after anti-TNFalpha therapy provides one mechanism to explain the anti-erosive effects of TNF blockade in PsA. Persistence of BMO after etanercept treatment, despite a marked clinical response, was unexpected, and suggests ongoing subchondral inflammation or altered remodelling in PsA bone.

Juvenile dermatomyositis and polymyositis: a follow-up study of long-term sequelae.

BACKGROUND: Juvenile dermatomyositis/polymyositis (DMS/PM) are childhood inflammatory myopathies that normally affect children between 2 and 15 years of age. The disease is manifested as severe proximal muscle weakness and, in JDMS, as a characteristic cutaneous eruption. It is difficult to predict the course of the disease. This study is aimed at objectively assessing the long-term morbidity of dermatomyositis/polymyositis in children. METHODS: Twelve cases of JDMS/PM identified through chart review were evaluated by physical and dermatologic examination, muscle testing, ultrasonography, and magnetic resonance imaging (MRI). RESULTS: The patient population included 6 male and 6 female patients with a mean age of 18.8 years (standard deviation 12.4). The mean age at onset of JDMS/PM was 5.8 years (SD 2.8), and the mean time from onset of symptoms to beginning of the study was 10.1 years (SD 9.3). The mean duration of corticosteroid therapy was 53.1 months (SD 40.5), with patients reporting an average of 1.7 relapses (SD 1.5). Patients compared their own activity level with that of healthy control subjects, and on a scale of 1 to 5 with 5 being normal, their mean score was 3.9 (SD 0.9). Fifty-eight percent of the patients had at least one residual finding on physical examination, and 78% of those with JDMS had residual dermatologic sequelae. Despite these findings, the mean grade for the group was 4.6 (SD 0.6) for muscle strength, using a scale of 0 to 5 with 0 being no muscle resistance and 5 being normal. In 60% of patients examined by ultrasonography, increased echogenicity indicated possible residual fibrotic change in at least one muscle group. Although MRI showed no active disease process in four patients, scattered intramuscular calcification was found in one patient. CONCLUSIONS: Multiple physical and dermatologic sequelae are commonly present in patients with JDMS/PM on long-term follow-up, but these do not preclude a productive life. Ultrasonography and MRI provide additional noninvasive means of analysis, but because of the current high cost, MRI is not routinely recommended.

A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST).

OBJECTIVE: To determine the effects of structured exercise programs on self-reported disability in older adults with knee osteoarthritis. SETTING AND DESIGN: A randomized, single-blind clinical trial lasting 18 months conducted at 2 academic medical centers. PARTICIPANTS: A total of 439 community-dwelling adults, aged 60 years or older, with radiographically evident knee osteoarthritis, pain, and self-reported physical disability. INTERVENTIONS: An aerobic exercise program, a resistance exercise program, and a health education program. MAIN OUTCOME MEASURES: The primary outcome was self-reported disability score (range, 1-5). The secondary outcomes were knee pain score (range, 1-6), performance measures of physical function, x-ray score, aerobic capacity, and knee muscle strength. RESULTS: A total of 365 (83%) participants completed the trial. Overall compliance with the exercise prescription was 68% in the aerobic training group and 70% in the resistance training group. Postrandomization, participants in the aerobic exercise group had a 10% lower adjusted mean (+/- SE) score on the physical disability questionnaire (1.71 +/- 0.03 vs 1.90 +/- 0.04 units; P<.001), a 12% lower score on the knee pain questionnaire (2.1 +/- 0.05 vs 2.4 +/- 0.05 units; P=.001), and performed better (mean [+/- SE]) on the 6-minute walk test (1507 +/- 16 vs 1349 +/- 16 ft; P<.001), mean (+/-SE) time to climb and descend stairs (12.7 +/- 0.4 vs 13.9 +/- 0.4 seconds; P=.05), time to lift and carry 10 pounds (9.1 +/- 0.2 vs 10.0 +/- 0.1 seconds; P<.001), and mean (+/-SE) time to get in and out of a car (8.7 +/- 0.3 vs 10.6 +/- 0.3 seconds; P<.001) than the health education group. The resistance exercise group had an 8% lower score on the physical disability questionnaire (1.74 +/- 0.04 vs 1.90 +/- 0.03 units; P=.003), 8% lower pain score (2.2 +/- 0.06 vs 2.4 +/- 0.05 units; P=.02), greater distance on the 6-minute walk (1406 +/- 17 vs 1349 +/- 16 ft; P=.02), faster times on the lifting and carrying task (9.3 +/- 0.1 vs 10.0 +/- 0.16 seconds; P=.001), and the car task (9.0 +/- 0.3 vs 10.6 +/- 0.3 seconds; P=.003) than the health education group. There were no differences in x-ray scores between either exercise group and the health education group. CONCLUSIONS: Older disabled persons with osteoarthritis of the knee had modest improvements in measures of disability, physical performance, and pain from participating in either an aerobic or a resistance exercise program. These data suggest that exercise should be prescribed as part of the treatment for knee osteoarthritis.

Intraosseous pneumatocyst of the iliac bone.

Intraosseous pneumatocyst of the iliac bone is usually an innocuous incidental finding with characteristic radiographic features. Because this entity is uncommon and has not been described in the orthopaedic literature, many orthopaedic surgeons are unfamiliar with the entity. Three cases of intraosseous pneumatocyst of the iliac bone are presented to illustrate some of the imaging features to assist in recognizing it for what it is: an innocuous incidental finding that should not prompt invasive procedures such as a biopsy.

Magnetic resonance imaging of the musculoskeletal system. Part 4. The knee.

Since its introduction to musculoskeletal imaging in the early 1980s, magnetic resonance imaging has proven to be an excellent technique for evaluating patients with knee problems. Studies have shown it to be accurate in the identification of abnormalities of the menisci, ligaments, patellofemoral joints, and other soft tissue and osseous structures in the knee. The main advantages of magnetic resonance imaging are its noninvasive nature and its high accuracy and negative predictive value in evaluating the menisci and anterior cruciate ligament. Magnetic resonance imaging has been shown to be useful in the detection and diagnosis of various traumatic and nontraumatic knee abnormalities. It has also proved useful in the diagnosis of occult or unsuspected bone lesions. Magnetic resonance imaging can therefore help in the selection of those patients who need therapeutic arthroscopy. There is evidence that magnetic resonance imaging of the knee is a cost effective screening technique when used in conjunction with the clinical findings in patients who are candidates for arthroscopy. Magnetic resonance imaging of the knee is still a relatively expensive modality.

Synovial osteochondromatosis.

Primary or idiopathic synovial osteochondromatosis is an uncommon condition probably caused by synovial metaplasia and typically resulting in multiple calcified periarticular bodies. Synovial osteochondromatosis also may occur secondary to other joint disorders. This article reviews the pathogenesis, pathologic features, clinical features, and radiologic imaging of synovial osteochondromatosis. The differentiation of synovial osteochondromatosis from other conditions associated with periarticular calcified bodies is discussed.

Low-grade chondrosarcoma in a 12-year-old boy.

We present a case of a rare central chondrosarcoma in a 12-year-old boy and discuss its radiographic and magnetic resonance appearance.

The evaluation of pain in patients with knee osteoarthritis: the knee pain scale.

OBJECTIVE: To develop and validate a knee pain scale (KPS) for use with osteoarthritis (OA) of the knee. METHODS: Patients with documented evidence of knee OA completed the KPS and a test battery including measures of physical functioning, physical performance, and depression. Analyses were conducted to confirm the 4-factor structure of the measure, determine alpha reliabilities, assess the test-retest reliability, and examine the construct validity of the KPS. RESULTS: Confirmatory factor analysis revealed that the KPS has 4 subscales, including frequency and intensity of pain experienced during both ambulation/climbing and transfer activities. All reliabilities were in excess of 0.80 and the subscales of the KPS shared expected variance with both self-reported and objective indices of dysfunction. CONCLUSION: The KPS has good psychometric properties for assessing pain experienced in conjunction with the performance of activities of daily living. Although at present it is a research tool, with further study it should prove valuable in clinical practice as well.

Three-dimensional MRI of the glenoid labrum.

The objective of this study was to assess the accuracy of three-dimensional (3D) magnetic resonance imaging (MRI) reformation in the evaluation of tears of the glenoid labrum complex (GLC). Fifty-five shoulders were evaluated by MRI using standard spin-echo sequences. Gradient-refocused-echo axial projections were used to assess the GLC on the two-dimensional (2D) studies. Three-dimensional Fourier transform multiplanar gradient-recalled imaging with a resolution of 0.7 mm was also performed in all patients. Independent analyses of the anterior and posterior labra were performed in a blinded manner for both the 2D and 3D studies by three experienced musculoskeletal radiologists. Observations of the imaging studies were compared with the videoarthroscopic findings. The appearance of the GLC was rated on a scale of 0 to 4 (0-2 = normal, 3, 4 = abnormal or torn). The diagnostic confidence was averaged from the three reader's scores. Anterior labral tears were effectively detected with sensitivities of 89% and 96% and specificities of 96% and 100% (P < 0.0001) for the 2D and 3D studies, respectively. For posterior labral tears, the sensitivity and specificity of the 2D method were 47% and 98%, respectively. The sensitivity and specificity of the 3D volume sequence were 53% and 98%, respectively. The lower sensitivity of both imaging methods for detecting posterior labral tears may be influenced by the smaller number (n = 5) of arthroscopically confirmed cases in our study and reflects the difficulty of visualizing the posteroinferior borders of the GLC with present MRI techniques.

Type 4 acromion: a new classification.

The three types of acromial processes previously described in the literature include type 1, in which the undersurface is straight, and types 2 and 3, in which the undersurface is concave. In this report, a fourth type of acromion is described in which the undersurface is convex near its distal end. The frequency of a type 4 acromion in the normal population is discussed based on a retrospective review of the MR examinations of 30 patients that originally were read as normal.

MR diagnosis of superior labral anterior posterior (SLAP) injuries of the glenoid labrum: value of routine imaging without intraarticular injection of contrast material.

OBJECTIVE: Superior labral anterior posterior (SLAP) lesions are peculiar types of tears that involve the superior and anterior aspects of the glenoid labrum and extend posteriorly. The biceps tendon may also be involved in the injury. There have been conflicting reports in the literature about the value of MR imaging in depicting these injuries. Some authors have advocated imaging in special planes and, more recently, the use of intraarticular injection of contrast material to facilitate the diagnosis of SLAP injuries. Symptoms of SLAP injury of the glenoid labrum are nonspecific, and patients are often imaged according to routine imaging protocols that include images in axial, oblique coronal, and oblique sagittal planes using spin-echo pulse sequences. Intraarticular injection of contrast material is not part of routine MR imaging of the shoulder. We sought to determine the value of routine MR imaging without intraarticular contrast enhancement in the diagnosis of SLAP injuries of the glenoid labrum. MATERIALS AND METHODS: The MR images of eight patients with arthroscopically proved SLAP lesions were selected for this study. The MR imaging appearance of the glenoid labrum, biceps tendon attachment, and rotator cuff tendons were retrospectively evaluated in the axial, oblique coronal, and oblique sagittal planes in each case. The findings were correlated with the surgical observations. RESULTS: All eight patients showed an abnormal labrum on the coronal MR images, on 88% of the axial images, and on 50% of the sagittal images. An oblique or horizontal linear focus of increased signal was seen to traverse the labrum in 50% of the cases on sagittal images. Fifty percent of the cases also showed an intraarticular body, presumably representing the displaced fragment of a bucket-handle tear, on all imaging planes (the MR "Cheerio" sign). CONCLUSION: Routine MR imaging of the shoulder without intraarticular injection of contrast material is useful in the diagnosis of SLAP injuries of the glenoid labrum.

Comparison of axial T1 spin-echo and T1 fat-saturation magnetic resonance imaging techniques in the diagnosis of chondromalacia patellae.

To test the diagnostic value of T1 spin-echo and T1 fat-saturated magnetic resonance images (MRIs), we reviewed axial T1-weighted images with and without fat saturation in 20 patients with clinically suspected chondromalacia of the patella. All scans were obtained on 1.5-MR units. The scans were randomly ordered and reviewed independently at different times by two radiologists without knowledge of the arthroscopy results. The sensitivity of the individual techniques for detecting grade 3 or 4 chondromalacia patellae was 92% for fat-saturated axial T1-weighted images alone, and 67% for axial T1-weighted images without fat saturation. The sensitivity of the combined techniques was 100% for grades 3 and 4 and 90% for all grades (0 to 4). Chondromalacia patellae is diagnosed more accurately by using T1 fat saturation than by using T1 spin-echo images. With a combination of the two techniques, accuracy is 90% to 100%.

Isolated subacromial bursal fluid on MRI of the shoulder in symptomatic patients: correlation with arthroscopic findings.

Fluid in the subacromial bursa (SAB) is a common finding on magnetic resonance (MR) images of the shoulder, and the implications of this finding have not been clarified. We retrospectively reviewed and correlated the MR features with arthroscopic findings in 21 symptomatic patients who had fluid in the SAB on MR imaging without demonstrable rotator cuff tear. Rotator cuff impingement was the most frequent surgical finding (42.9%). Other frequent surgical observations were glenoid labrum abnormality (28.6%), bursitis (19%), and supraspinatus tendinitis (14.3%). Distribution of acromial types was similar to that reported by Bigliani et al., and impingement was evenly distributed among acromial types in our study population. We conclude that in our patient population group the MR finding of isolated SAB fluid in symptomatic patients is highly likely to be associated with the finding of other abnormalities in the shoulder joint at surgery.

Dermatomyositis with normal muscle enzyme concentrations. A single-blind study of the diagnostic value of magnetic resonance imaging and ultrasound.

BACKGROUND AND METHODS: It is well documented that the cutaneous lesions of dermatomyositis may precede clinical myositis or may occur in the absence of any muscle disease detectable by current diagnostic criteria. In this single-blind study, we used magnetic resonance imaging (MRI) and ultrasound to evaluate five patients who presented with classical clinicopathologic dermatomyositis, but with normal levels of serum muscle enzymes. This patients group has not been previously studied with these techniques. Patients who served as positive and negative control subjects were also examined. RESULTS: Ultrasonography revealed hyperechogenicity, and MRI revealed high signals on T2-weighted images in several muscle groups of the patient with active myositis (positive control). Increased echogenicity was also noted in the deltoid region of one patient who had previously had a normal muscle biopsy finding. In the same patient, MRI revealed inflammatory changes in the lumbar paraspinal muscles. Another patient, with all previous study results being normal, had MRI evidence of T2 high signals in the gluteus minimus. CONCLUSIONS: Noninvasive examinations such as MRI and ultrasound are beneficial as adjunctive means of examination in the evaluation of patients with dermatomyositis sine myositis or dermatomyositis. Future studies may suggest additional uses for these tests, including serial evaluation of patients, noninvasive confirmation of diagnosis in pediatric patients, or in directing muscle biopsy, thus increasing sensitivity. Ultrasound appears to be the more cost-effective and simple test; but MRI, although more expensive, may be more sensitive and specific.