Luc Lateur

Proliferative myositis in a child

Abstract A case of proliferative myositis in the lumbar paraspinal muscles in a 14-year-old boy is presented. Imaging investigations including plain radiograph, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), bone scan and positron emission tomography (PET) were suggestive of an inflammatory process such as myositis ossificans. The diagnosis was made by incisional biopsy. More pronounced edema, more muscle fiber necrosis and a higher cellularity were found compared to adult cases. The karyotype of the lesion was normal. Clinically, the mass disappeared spontaneously. After 24 months, asymptomatic bridging ossification between the third and fourth lumbar vertebrae was noted.

Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum

Background: Osteoporosis is an increasing problem attributed to the greater longevity of the population and the incidence of fractures related to osteoporosis. The presence of osteoporotic bone, comorbidities, and functional status of the patient require adequate solutions to improve the clinical outcome of sacral insufficiency fractures. Conservative treatment by means of prolonged bed rest and analgesics are associated with increased risks and complications. A sacroplasty significantly improves the functional outcome. We describe the trans-iliac-sacral-iliac-bar (TISIB) procedure and our clinical experience to treat insufficiency fractures of the sacrum. Materials and Methods: The records of 19 consecutive patients with a mean age of 71.7 years (range: 57-82 years) who had been managed with a TISIB procedure from 2005 till 2007 were reviewed retrospectively. There were 15 females and 4 males. Predisposing factors for sacral insufficiency fractures were osteoporosis (n = 12, 63%), radiotherapy (n = 6, 32%), and rheumatoid arthritis (n =1). Diagnosis with a mean delay of 3.7 months was mainly made by CT. All patients were preoperatively and at follow-up assessed by means of the visual analogue score (VAS), analgesic consumption, and the ability to perform activities of daily living (ADLs) using a 5-point pain scale: 1, without pain; 2, mild pain; 3, moderate pain; 4, severe pain and, 5 unable to perform ADLs because of pain. Results: The average duration of postoperative follow-up was 9 months (range: 3–24.5 months). No neurological complications occurred during the surgery. A postoperative radiographic study showed a well-positioned bar in every case. The mean VAS improved 44.7 mm (preoperative: 67.8; at follow-up: 23.2). Fifteen patients (79%) consumed narcotic analgesics before surgery, and only one (5%) at follow-up; two patients (10%) consumed NSAIDS before surgery and three (15%) after. Two patients (10%) consumed minor analgesics before, and 11 (58%) after the procedure. Finally, four patients (21%) were not taking any analgesics at follow-up. Before surgery, 9 patients (47%) were able to perform ADLs with a pain score of 4; 6 (32%) with a score of 3, and 4 (21%) a score of 2. At follow-up 1 (5%) did have a score of 4; 1 (5%) a score of 3, 8 (42%) a score of 2 and 9 (47%) a pain score of 1. Conclusion: A TISIB procedure relies on the principles of fracture treatment: fracture stabilisation and compression. The incapacitating problem of an insufficiency fracture of the sacrum can be elegantly solved by means of this minimally invasive procedure. A near-immediate improvement is noticed when looking at the VAS score, analgesics consumption, and the ability to perform ADLs.

Effectiveness of initial treatment allocation based on expert opinion for prevention of rapid radiographic progression in daily practice of an early RA cohort

Objectives To evaluate expert treatment selection for early rheumatoid arthritis and to validate a prediction model for rapid radiographic progression (RRP) in daily practice. Methods Patients received initial combination therapy with steroids (ICTS) or disease-modifying antirheumatic drug monotherapy (IMT) after informal evaluation of prognostic factors, followed by a tight control strategy. Changes in Sharp/van der Heijde score (total Sharp score (TSS)) of >5 units over 1 year (=RRP) were documented. The mean change in TSS and proportion with RRP were compared between groups. Based on the 28 swollen joint count, rheumatoid factor titre and C reactive protein/erythrocyte sedimentation rate, patients were placed in the ASPIRE prediction matrix, yielding a RRP risk. Numbers needed to treat (NNT) intensively to avoid one RRP after 1 year were calculated. Results The mean change in TSS after 1 year and the proportion with RRP was lower in the ICTS group (n=37) than in the IMT group (n=43). The mean calculated risk of RRP was higher in patients with radiographic progression. The mean NNT intensively to prevent RRP was lower in the ICTS group than in the IMT group. The positive predictive value of NNT for RRP prevention was 12.6%, but the negative predictive value reached 100%. Conclusion ICTS seems more effective in preventing RRP than IMT. The predictive matrix model could be helpful in preventing overtreatment in practice.

Tumour-induced rickets: A case report and review of the literature

Hypophosphataemic rickets was diagnosed in a 6-year-old boy with a negative family history. After 16 years of medical treatment he developed a malignant sarcoma of the right distal thigh. Removal of the tumour by high amputation of the leg resulted in disappearance of the phosphate leak. In spite of surgery and chemotherapy, the patient died due to extensive lung metastases. Retrospective analysis of the initial X-ray films showed a benign lesion on the lateral side of the right distal femur. This lesion is believed to be at the origin of the rickets. This is the first paediatric case reported with malignant degeneration of a benign tumour causing rickets.ConclusionPatients with the classical hallmarks of X-linked, familial hypophosphataemic rickets but no affected family members should have a careful periodic search for a tumour, even years after onset of the disorder.

Case report 842

Fig. 2. Angiography demonstrates the internal iliac artery. The hypervascular tumor is fed by a hypertrophic branch of the left superior gluteal artery and the inferior gluteal artery Fig. 3A-C. The following magnetic resonance sequences were performed: T2weighted images (TE = 120 ms, TR = 2700 ms) and Tl-weighted images (TE = 15 ms, TR = 650 ms) before and after administration of gadolinium. A On the T2weighted image the mass is hypointense with dispersed hyperintense septae. Hypointense tubular structures are visible in the wall of the mass. B The mass shows a hyperintense signal on Tl-weighted images with infiltration in the adjacent muscles. C After administration of gadolinium the mass becomes more hyperintense on T1weighted images, without contrast enhancement of the muscles surrounding the mass

Case report 762

Correspondence to: Prof. Dr. A.L. Baert, Department of Radiology, University Hospitals K.U. Leuven, Herestraat 49, B-3000 Leuven, Belgium Fig. 2. A plain film of the upper lumbar spine shows generalized osteopenia and degenerative changes. Slight decrease in height of the corpus of L2 with increased lucency of its anterior part is noted. Observe bulging of the anterior margin (arrows) of the vertebral body

Localisation and diagnosis of osteoid osteoma of the carpal area by angiography

Three patients are reported in whom the existence and exact localisation of an osteoid osteoma in the carpal area was established only by angiography. In each case demonstration of the lesion by conventional roentgenograms, including fine-section tomograms, had failed. This failure, together with initially atypical clinical symptoms, significantly delayed diagnosis, to such an extent that one patient was referred for a psychiatric opinion. The first valid diagnostic clue was provided in two cases by bone scanning, but with inadequate detail to show precisely the position of the lesion. This study re-emphasizes the value of angiography when an osteoid osteoma presents no characteristic radiological stigmata.

THU0144 Two Year Radiological Follow-Up of Early Rheumatoid Arthritis Patients Treated with Initial Step Up Monotherapy or Initial Step Down Therapy with Glucocorticoids, Followed by a Tight Control Approach

Background Combination therapy with disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids(GCs) or biological agents is superior in achieving clinical response and preventing joint damage compared to DMARD monotherapy in patients with early rheumatoid arthritis (RA). Objectives To compare initial DMARD combination therapy with steroids (ICTS) with DMARD monotherapy (IMT) on the radiologic evolution of patients with early RA over a 2 year treatment period, applying tight control (TC) in daily practice. Methods 74 DMARD-naïve early RA patients received ICTS or IMT in a TC setting, based on the expert opinion of their rheumatologist (n=2) after informal evaluation of prognostic factors. Demographics were registered at baseline and the following clinical characteristics were obtained at baseline, year 1 and year 2: swollen/tender joint counts (TJC, SJC, TJC28 and SJC28), global assessment scores ( PGA, PhGA, pain and fatigue), Health assessment questionnaire ( HAQ), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) status. Disease activity score based on CRP status (DAS 28(CRP)), EULAR DAS response, clinically meaningful HAQ response, DAS change and HAQ change were calculated from these parameters. Remission was defined as a DAS28 (CRP) score below 2,6. Baseline, year 1 and year 2 X-rays of hands and feet were scored according to Sharp/van der Heijde by 3 readers in consensus: 2 experienced musculoskeletal radiologists (LL and GVDS) and 1 clinical researcher (DDC). Rapid radiographic progression (RRP) was defined as total Sharp score (TSS) of >5 units/year. The mean change in TSS and proportion with RRP were compared between groups. Results At baseline, joint scores and PhGA were significantly higher in the ICTS group. Thus ICTS patients were perceived to have a higher level of RA severity compared with IMT patients. At year 1, both treatment groups achieved 50% remission. At year 2, 37% of IMT and 60% of ICTS patients were in remission, despite ICTS patients having a more severe RA profile at baseline. RRP was found in 4/74 patients at year 1: 3 IMT and 1 ICTS patient. Remarkably, 3 of these 4 patients had no radiographic progression in the second year. 5 Other patients had RRP in the second year: 4 IMT and 1 ICTS patient. 4 Notably young female IMT patients were initially treated with SSZ monotherapy, 2 of which because of pregnancy wish. These patients developed RRP in the second year. Conclusions In a TC setting, ICTS appears to be more effective than IMT in achieving remission and preventing RRP in the daily practice of a Belgian academic hospital over 2 years. Furthermore, risk on RRP is underestimated in certain patient groups which is translated in conservative therapy choices. References Verschueren P, Esselens G, Westhovens R. (2008) Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis. Rheumatology (Oxford) 47(1):59-64 Disclosure of Interest None Declared

Chance-type fracture of L1 with entrapment of the cauda equina

A patient is presented who sustained a motor vehicle accident while wearing a seat belt. Due to life-threatening intraabdominal lesions, a Chance-type fracture of L1 and a subluxation of C6/C7 were diagnosed and treated surgically with a certain delay. The retention of urine and fecal incontinence could be explained as being due to a partial entrapment of the cauda equina at the level of the fractured pedicle of L1 on the right side with an associated injury of the conus medullaris.