Berna Goker

Bone mineral density in the proximal tibia varies as a function of static alignment and knee adduction angular momentum in individuals with medial knee osteoarthritis

Based on the premise that bone mass and bone geometry are related to load history and that subchondral bone may play a role in osteoarthritis (OA), we sought to determine if static and dynamic markers of knee joint loads explain variance in the medial-to-lateral ratio of proximal tibial bone mineral density (BMD) in subjects with mild and moderate medial knee OA. We utilized two surrogate markers of dynamic load, the peak knee adduction moment and the knee adduction angular momentum, the latter being the time integral of the frontal plane knee joint moment. BMD for medial and lateral regions of the proximal tibial plateau and one distal region in the tibial shaft was measured in 84 symptomatic subjects with Kellgren and Lawrence radiographic OA grades of 2 or 3. Utilizing gait analysis, the peak knee adduction moment (the external adduction moment of greatest magnitude) and the time integral of the frontal plane knee joint moment (the angular momentum) over the entire stance phase as well as for each of the four subdivisions of stance were calculated. The BMD ratio was not significantly different in grade 2 (1.32 +/- 0.27) and grade 3 knees (1.47 +/- 0.40) (P = 0.215). BMD of the tibial shaft was not correlated with any loading parameter or static alignment. Of all the surrogate gait markers of dynamic load, the knee adduction angular momentum in terminal stance explained the most variance (20%) in the medial-to-lateral BMD ratio (adjusted r(2) = 0.196, P < 0.001). The knee adduction angular momentum for the entire stance phase explained 18% of the variance in the BMD ratio (adjusted r(2) = 0.178, P < 0.001), 10% more variance than explained by the overall peak knee adduction moment (adjusted r(2) = 0.081, P < 0.001). 18% of the variance in the BMD ratio was also explained by the knee alignment angle (adjusted r(2) = 0.183, P < 0.001), and the total explanatory power was increased to 22% when the knee adduction angular momentum in terminal stance was added (change in r(2) = 0.041, P < 0.05, total adjusted r(2) = 0.215, P < 0.001). The BMD ratio and its relationship to dynamic and static markers of loading were independent of height, weight, and the body mass index, demonstrating that both dynamic markers of knee loading as well as knee alignment explained variance in the tibial BMD ratio independent of body size.

Quantification of progressive joint space narrowing in osteoarthritis of the hip: Longitudinal analysis of the contralateral hip after total hip arthroplasty

OBJECTIVE The rate of progressive joint space narrowing in the contralateral hip after total hip arthroplasty (THA) for osteoarthritis (OA) and the factors which may predispose patients to more aggressive joint space narrowing remain undefined. The current study sought to evaluate the rate and pattern of, and risk factors for, progressive joint space narrowing in the contralateral hip after THA for OA. METHODS Each patient who underwent THA for OA in 1984-1985 was followed up longitudinally, and annual anteroposterior (AP) pelvis radiographs were obtained. The radiographic joint space width (JSW) of each contralateral hip joint was quantified, and the rates of JSW narrowing were determined. Evaluation of potential risk factors for accelerated progression of joint space narrowing included age, sex, side of surgery, weight, height, body mass index (BMI), hip pain, etiology of OA, and Kellgren/Lawrence radiographic grade. RESULTS Ninety-nine patients and 619 AP pelvis radiographs were evaluated. The median initial JSW was 3.48 mm (interquartile range 1.55). JSW declined in a linear manner at a median rate of 0.10 mm/year. The rate of decline between baseline and followup in 20 months was predictive of the overall slope. Two subpopulations were identified. Eighty-five percent of patients maintained a slow decline in JSW (< or =0.2 mm/year), and 15% exhibited an accelerated decline in JSW (>0.2 mm/year). Kellgren/ Lawrence radiographic grade > or =2 and a diagnosis of primary OA were each associated with a more rapid decline in JSW (P = 0.006 and P = 0.02, respectively). Initial JSW, age, sex, weight, height, BMI, and hip pain were not risk factors for rapid decline in JSW. CONCLUSION Radiographic hip JSW may be reliably quantified and followed up longitudinally using standard AP radiographs. Progression of JSW narrowing in the contralateral hip after THA for OA proceeds in a linear manner over several years. A subpopulation of patients with accelerated narrowing of contralateral JSW may be identified within 20 months, and may represent a suitable population with which to assess the potential efficacy of new disease-modifying agents.

The radiographic joint space width in clinically normal hips: effects of age, gender and physical parameters

OBJECTIVE The aim of the study was to assess the relationship of the radiographic joint space width (JSW) in the hip with age and a variety of physical parameters in a clinically non-arthritic population in order to identify potential age-related changes. DESIGN One hundred and eighteen patients (58F/60M, age range 20-79 years) who underwent supine abdominal radiography for non-rheumatological indications and had no hip pain were evaluated. Height, weight and leg lengths were measured. JSW was quantified manually by a dial caliper, and femoral head diameters were determined for each hip. RESULTS Overall, JSW was 3.61mm+/-0.58 (mean+/-SD) in the right (R) and 3.63mm+/-0.59 in the left (L) hip (range 2.34-6.1mm). There was no age-related decline in the JSW, either by decade (P=0.5 and 0.6, for R and L hips, respectively), or by individual age (Spearmans rho=-0.108 and 0.057, P=0.3 and 0.5 for R and L hips, respectively); similarly, no age-related changes were observed when each gender was analyzed separately. Women had significantly narrower hip JSW than men (P=0.001 and 0.01, R and L hips, respectively). However, gender was no longer significant after height was taken into account (P=0.26 and 0.45, for R and L hips, respectively). JSW correlated significantly with height, weight (which also correlated with height) (r=0.31/0.27 and 0.29/0.28 for height and weight R/L, respectively, P<0.004 for each), but not with body mass index (P=0.62 and 0.57, R and L, respectively). Hip JSW significantly correlated also with femoral head diameter and leg length (r=0.38/0.29 and 0.25/0.19 for femoral head and leg length, R/L, respectively). CONCLUSIONS No effect of aging was detected on the radiographic JSW of the hip among normal individuals even at advanced ages. In contrast, height, femoral head diameter and leg length were directly related to JSW.

The Association Between Neutrophil/Lymphocyte Ratio and Disease Activity in Rheumatoid Arthritis and Ankylosing Spondylitis

Elevated neutrophil count is associated with poor prognosis and increased mortality in many conditions. Neutrophil to lymphocyte ratio (NLR) has emerged as a marker of inflammation in neoplastic and cardiovascular disorders. Herein, we investigated utility of this simple tool in rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

Improved precision in quantifying knee alignment angle.

Knee alignment angle, a measure of mechanical axis, has been reported to correlate with severity and progression of knee osteoarthritis. However, quantification of knee alignment often results in unacceptable reproducibility because of poor definition of landmarks and imprecise measurement techniques. We describe and validate a reproducible, sensitive method. Fourteen patients (28 knees) with symptomatic knee osteoarthritis who had full-limb radiography were evaluated. Knee alignment angle, defined as the angle formed between the mechanical axis of the femur and that of the tibia, was determined using a conventional manual technique and compared with a novel digital method using freely available Image J software to designate landmarks digitally and to determine the angles formed by the femoral and tibial axes. We found agreement between the manual and digital methods. All assessments were performed in duplicate on separate days. Using the manual method, the limits of agreement were +1.65° to -1.55°, yielding a minimal detectable change of approximately 1.6°. However, the digital method provided limits of agreement of +0.43° to -0.37° resulting in a minimally detectable change of 0.4°. We describe a method to reliably determine mechanical axis with precision permitting detection of differences less than 1°.Level of Evidence: Level I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Real-time sonoelastography of Achilles tendon in patients with ankylosing spondylitis.

ObjectiveReal-time sonoelastography (SE) is a new ultrasound-based imaging technique that provides information on tissue elasticity and stiffness. We determined the efficacy of SE for assessing Achilles tendon abnormalities in patients with ankylosing spondylitis (AS).Materials and methodsForty-one consecutive AS patients and 32 asymptomatic healthy subjects were enrolled. Achillodynia was scored on a 0- to 100-mm visual analog scale. A high-resolution ultrasound machine equipped with an elastography-compatible linear probe was used to perform bilateral B-mode ultrasound, Doppler ultrasound, and SE examinations of Achilles tendons. Tendons were divided into proximal, middle, and distal segments. B-mode examinations included tendon thicknesses, echotextures, and enthesopathic findings. SE using color-coded images was performed in the same areas. Normal consistent tendon structures were coded as blue or green, and moderately (yellow) or severely (red) softened areas were considered pathological.ResultsThe distal third of the Achilles tendons was the most commonly affected part in the AS patients compared with healthy subjects (p = 0.001), whose middle third was more commonly affected. Achillodynia intensity tended to be higher in patients with pathological B-mode or SE examination findings (p = 0.09 and p = 0.07 respectively). Softening detected by SE in the distal third was associated with enthesopathy findings such as calcaneal bone erosions (Fisher’s X2, p = 0.07) and tendinous enlargement (Fisher’s X2, p = 0.001). B-mode and SE findings had moderate to good correlation in the assessment of Achilles tendon abnormalities.ConclusionsSonoelastography may be useful for the evaluation of tendon abnormalities in patients with AS; in addition; it may be useful for the evaluation of other inflammatory rheumatic conditions.

Radiographic osteoarthritis of the hip joint in Turkey

Abstract. The prevalence of hip osteoarthritis (OA) varies greatly across different geographic areas. Limited data exist about the prevalence of radiographic hip OA in the Turkish population. The aim of this study was to estimate the prevalence of radiographic hip OA in Turkey utilizing a random sample. That sample consisted of radiographs filed at the Department of Urology, Gazi University Hospital, Ankara, and included patients aged 25 years and older (range 25–97 years). Plain supine abdominal radiographs and intravenous pyelographies were evaluated using the Kellgren and Lawrence (K&L) grading system. Evaluations were made of 1,248 hips in 682 patients (205 women and 477 men). Overall, 8.8% of the hips evaluated had radiographic hip OA (K&L grade 2 or higher). Both hips were visible in 566 patients. Of those patients 11.7% had radiographic hip OA in either one or both hips (9.4% of women and 12.6% of men), and 51.5% of whom had bilateral findings. Prevalence increased with age and was 1.9%, 16.1%, and 21.5% for age ranges 25–39, 40–54, and 55 years and older, respectively. Patients aged 40 years and older had significantly more radiographic hip OA than those younger than 40 years (P<0.001). Men had a higher frequency than women after the age of 40 years, but this did not reach statistical significance. In most patients radiographic findings indicated only mild disease. Three patients had grade 3 disease and only one patient (aged 68 years) had grade 4 disease. Among patients aged 40 years or older, 1.1% had grade 3 or 4 disease. These findings suggest that K&L grade 2 OA changes emphasizing osteophytes at hip joints are not uncommon in the Turkish population, especially among those aged 40 years and older. However, frequency of moderate or severe radiographic hip OA may be low.

Idiopathic Hypoparathyroidism Mimicking Diffuse Idiopathic Skeletal Hyperostosis

Idiopathic hypoparathyroidism is an uncommon disease caused by insufficient secretion of parathyroid hormone. Idiopathic hypoparathyroidism may cause various musculoskeletal findings, including diffuse ligamentous and entheseal ossifications. Diffuse idiopathic skeletal hyperostosis is a disorder of the elderly characterized by ossification of the anterior longitudinal ligament of the spine and various extraspinal ligaments. We present a 50-year-old man with idiopathic hypoparathyroidism who had been diagnosed as having DISH at 40 years of age. Resistant neck, left shoulder, and left hip pain did not improve with calcium and calcitriol treatment after diagnosis of idiopathic hypoparathyroidism.

Rapid resolution of protracted febrile myalgia syndrome with anakinra: Report of two cases

Protracted febrile myalgia syndrome (PFMS) is a very rare but severe manifestation of familial Mediterranean fever (FMF) which is characterized by severe debilitating pain in large muscle groups that may last for several weeks. Colchicine is ineffective and treatment is largely supportive. Demonstration of crucial role of interleukin-1 (IL-1) in the pathogenesis of FMF has increased the use of IL-1 blockers in colchicine resistant or intolerant patients. Herein, we reported successful use of an IL-1 inhibitor, anakinra, in treatment of two patients with PFMS.

Localized Castleman's disease and nephrotic syndrome not responsive to resection plus colchicine therapy

Abstract. We describe one patient with localized Castlemans disease (CD) of the mixed hyaline vascular and plasma cell type located at the mesentery of the small bowel, associated with systemic amyloidosis and nephrotic syndrome. A true nephrotic syndrome has rarely been reported in patients with CD. In the literature, it has been suggested that clinical and laboratory manifestations generally improved after surgical resection of the tumor. However, in our case, clinical and laboratory findings did not regress after operation followed by colchicine therapy.