POS0034 RADIOGRAPHIC ENTHESEAL LESIONS AT HIP AND PELVIC REGION ARE ASSOCIATED WITH LONGER DISEASE DURATION, HIGHER BMI AND MORE SEVERE SPINAL AND HIP RADIOGRAPHIC DAMAGE IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:Enthesitis is an important feature of ankylosing spondylitis (AS) and structural and inflammatory entheseal lesions (EL) are frequently present on ultrasound. Plain radiographs also provide good imaging of structural entheseal involvement1. Until now, little is known about the presence of structural EL at the hip and pelvic region and the association with patient characteristics in AS.Objectives:Our aim was to investigate the prevalence of radiographic EL at the hip and pelvic region in AS patients compared to age and sex matched control subjects and to explore the relation with AS patient characteristics.Methods:AS patients from the Groningen Leeuwarden Axial SpA (GLAS) cohort, included between November 2004 and December 2010, with available anteroposterior (AP) pelvis radiographs at baseline were included. All patients fulfilled the modified New York criteria for AS. Additionally, 100 randomly selected AP pelvis radiographs from age and sex matched control subjects were obtained from the radiology department of the University Medical Center Groningen. The sacroiliac joints of all radiographs were blinded and radiographs were scored independently by two trained observers unaware of patient characteristics and treatment. The entheseal sites scored were: trochanter major, trochanter minor, os ischium, crista iliaca, both left and right side. The following 3 EL were scored: erosion/cortical irregularity, calcification and enthesophyte. Only lesions with absolute agreement between both observers were used for analyses. Radiographic spinal involvement was scored according to the modified Stoke AS Spine Score (mSASSS; range 0-72) and radiographic hip involvement according to the Bath AS Radiology Index (BASRI)-hip (range 0-4). Independent samples t test, Mann-Whitney U test, Chi-Square test, and Fisher Exact test were used to compare patient characteristics between patients with and without radiographic EL.Results:Of the 167 included AS patients, 117 (70%) were male, mean age was 43 ± 11 years, 133 (80%) were HLA-B27 positive and median symptom duration was 16 years (range 1-53). 127 (76%) AS patients and 58 (58%) controls showed EL, with 501 lesions in total of which 377 (75%) in AS patients. AS patients showed significantly more lesions than controls at all 5 locations. Os ischii showed the most lesions in both AS patients and controls (66% vs 53%, p<0.05). The most prevalent type of lesion in both groups was erosion/cortical irregularity (72% vs 51%, p<0.005). Enthesophytes were also more often observed in AS patients than in controls (31% vs 21%, p=0.07). Prevalence of calcifications was low in both groups and not significantly different (5% vs 2%, p=0.22). AS patients with EL were significantly older (mean 45.2 vs 35.1 yrs, p<0.005) and had longer symptom duration (median 18 vs 7.5 yrs, p<0.005) than patients without EL. Furthermore, patients with BMI >25 had significantly more often enthesophytes (42% vs 16%, p<0.05) than patients with a normal BMI. Additionally, AS patients with EL had significantly more often radiographic spinal damage than patients without EL with median mSASSS total score 8.7 vs 1.0 (p<0.005) and a trend toward significance for radiographic hip involvement (BASRI-hip score ≥2; p=0.06).Conclusion:Radiographic EL at hip and pelvic region are significantly more prevalent in AS patients than in age and sex matched controls. AS patients with EL were significantly older, had longer symptom duration and more spinal radiographic damage than patient without EL. Furthermore, BMI >25 was associated with a higher prevalence of enthesophytes. These new findings contribute to the knowledge of entheseal involvement in AS.References:[1]Voudouris et al. J Musculoskelet Neuronal Interact. 2003;3(1):89-100.Disclosure of Interests:Freke Wink Consultant of: Abbvie, Thomas Diemel: None declared, Suzanne Arends: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, and Novartis, Grant/research support from: Abbvie, Pfizer, UCB and Novartis.

Reliability of a Novel Scoring System for MRI Assessment of Severity in Gluteal Tendinopathy: The Melbourne Hip MRI Score

Background: Gluteal tendinopathy is commonly reported in the literature, but there is a need for a validated magnetic resonance imaging (MRI)-based scoring system to grade the severity of the tendinopathy. Purpose: To use intra- and interobserver reliability to validate a new scoring system, the Melbourne Hip MRI (MHIP) score, for assessing the severity of gluteal tendinopathy. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The MHIP score assesses gluteal tendinopathy according to each 1 of 5 categories: (1) extent of tendon pathology (maximum 5 points); (2) muscle atrophy (maximum 4 points); (3) trochanteric bursitis (maximum 4 points); (4) cortical irregularity (maximum 3 points); and (5) bone marrow edema (maximum 1 point), with an overall range of 0 to 17 (most severe). A total of 41 deidentified MRI scans from 40 patients diagnosed with gluteal tendinopathy (mean baseline age, 57.44 ± 25.26 years; 4 male, 36 female) were read and graded according to MHIP criteria by 2 experienced musculoskeletal radiologists. The radiologists were blinded to previous reports, and the scans were read twice within a 2-month period. Statistical analysis using the intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reliability and mean/range for the MHIP scores. Results: Of a total of 123 readings, the mean MHIP score (±SD) was 3.93 ± 2.24 (range, 0-17 points). The MHIP score demonstrated excellent reliability for determining the severity of gluteal tendinopathy on MRI. The ICC for intra- and interobserver reliability was 0.81 (95% CI, 0.67-0.89) and 0.78 (95% CI, 0.62-0.87), respectively. Conclusion: The MHIP score had excellent intra- and interobserver reliability in scoring gluteal tendinopathy. This score allows gluteal tendon pathology to be graded prior to treatment and to be used for standardized comparisons between results in future research undertaking radiological review of gluteal tendinopathy.

Evidence of osteomyelitis in Cuban aborigines

Paleopathology is the branch of science that is responsible for the study of diseases suffered by our ancestors, in Cuba some studies have been carried out on pathologies suffered by the aborigines. The objective is to present a specimen of human diaphyseal bone found in the funerary site of the "Cueva de los Chivos" in the Sumidero de Jibacoa Valley, Guamuhaya mountain massif, municipality of Manicaragua, Villa Clara province, Cuba in excavations carried out between the years 2000 and 2002 by the archeology group of the Center for Environmental Studies and Services of CITMA in Villa Clara. Presentation: It is a tibia fragment due to its thickness and triangular shape with periosteal thickening, cortical irregularity and a large number of crypts, whose radiography shows the presence of bone sequestration with the corresponding involvement and signs of periostitis. The skeletal remains found show evidence of having suffered from chronic osteomyelitis. Based on the archaeological materials found at the funerary site, it was determined that these belonged to pre-agricultural pottery groups that populated the island between 2000 and 6000 years ago. Conclusions: The Cuban aboriginal groups had elementary knowledge of orthopedic conditions such as bone infections and their treatment in all probability, evidenced by the chronicity of osteomyelitis presented in this specimen which survived for a period of time.

Mesenchymal Chondrosarcoma: A Rare Aggressive Variant of Chondrosarcoma

A 15-year-old boy reported a 2-month history of severe left thigh pain Physical examination revealed left thigh swelling measuring 6x5 cm. X-ray of the region showed mixed lytic and sclerotic lesion involving the femoral head and neck. A Computed Tomography scan showed mixed lytic and sclerotic lesion involving the femoral head and neck with cortical irregularity and mild periosteal reaction with associated soft tissue in the anterior aspect. Magnetic resonance imaging demonstrated heterogeneous signal intensity lesion with areas of sclerosis involving the femoral head and neck. The large associated soft tissue in the anterior aspect appears predominantly hyperintense on T2W images. On post-contrast axial and sagittal images, heterogeneous enhancement with areas of necrosis involving soft tissue was seen. A presumptive radiological differential diagnosis of Ewing Sarcoma and Osteosarcoma was made. However, on histopathology, it was a case of mesenchymal chondrosarcoma.

Inferior Glenohumeral Ligament (IGHL) Injuries: A Case Series of Magnetic Resonance (MR) Imaging Findings and Arthroscopic Correlation

The inferior glenohumeral ligament (IGHL) complex is commonly assessed by both magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrogram. Our study aimed to compare the accuracy of MR arthrogram compared to MRI using arthroscopic correlation as the gold standard. A retrospective review of cases reporting an IGHL injury was performed. 77 cases met inclusion criteria, while 5 had arthroscopic reports that directly confirmed or refuted the presence of IGHL injury. Two arthroscopic reports confirmed concordant IGHL injuries, while 3 arthroscopic reports mentioned discordant findings compared to MR. Interestingly, all three discordant cases involved MR arthrogram. Findings included soft tissue edema, fraying of the axillary pouch fibers, and cortical irregularity of the humeral neck. Of the two concordant cases, one was diagnosed by MRI, revealing an avulsion of the anterior band, while the second was diagnosed by MR arthrogram showing ill-defined anterior band fibers. Many cases involved rotator cuff or labral tears, which may have been the focus of care for providers, given their importance for shoulder stability. Additionally, a lack of diagnostic confidence in MR reports may have influenced surgeons in the degree to which they assessed the IGHL complex during arthroscopy. In conclusion, radiologists seemed more likely to make note of IGHL injuries when MR arthrograms were performed; meanwhile, all three discordant cases involved MR arthrogram reads. Therefore, additional larger studies are needed with arthroscopic correlation to better elucidate MR findings that confidently suggest injury to the IGHL complex, in order to avoid false positive radiology reports.

Case report (precis): Atypical delayed presentation of cervical spinal epidural abscess

Background: Older patients with spinal epidural abscesses (SEA) may present in an atypical fashion, failing to exhibit the classical triad of pain, fever, and a neurological deficit. Rather, they may be less aware of pain, fail to develop a fever, and attribute their neurological deficit to “old age.” Further, their laboratory studies may not be abnormal, and critical findings on MR (i.e., more so than CT studies) may be overlooked. Here, we present an elderly patient with severe upper extremity monoparesis whose cervical SEA was overlooked for months. Case Description: Over 10 months, and 6 months ago respectively, the patient had two successive MR scans ordered due to falls; both were interpreted as normal. Within the past few months, a third cervical MR, and an initial CT scan were performed; they both showed “questionable” changes (e.g. cortical irregularity/epidural air) that were largely ignored. When the patient presented to a spine surgeon with severe upper extremity monoparesis, the fourth MR clearly demonstrated a high cervical SEA. Of interest, laboratory findings were normal (e.g. white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)). The patient successfully underwent an anterior cervical discectomy/and fusion (ACDF); cultures grew Staphylococcus aureus, and he was appropriately managed with intravenous antibiotic therapy. Conclusion: This case report (precis) highlights three “teaching” points. First, elderly immunologically compromised patients may not develop the classical SEA triad of pain, fever, and a neurological deficit. Second, laboratory studies may remain normal. Third, it may take longer for abnormal findings to develop on MR/CT studies consistent with SEA in immunocompromised older patients, thus resulting in very delayed surgery.

Plasma Cell Rich Osteomyelitis: A Rare Entity

Plasma cell rich osteomyelitis is a rare finding characterised by a plethora of plasma cells localised in the affected bone without the typical clinical features of infection. It usually affects the metaphysis of long bones with a radiological appearance as a dense thickening of bone without sequestrum formation. We present an atypical case of plasma cell osteomyelitis with a lesion in the metaphysis as well as the diaphysis of the humerus without sclerosis but with sequestrum formation. An 11-year-old girl was brought to OutPatient Department (OPD) with complaints of post-traumatic pain and swelling at left shoulder and proximal arm since one and a half months with aggravation of symptoms since last 10 days. Patient had also been treated for Urinary Tract Infection (UTI) by a paediatrician who prescribed antibiotics and antipyretics because of which fever subsided but the pain persisted. The x-ray of left shoulder with arm revealed a fracture of surgical neck of humerus with cortical irregularity noted in the mid-shaft of humerus along with lamellated periosteal reaction suggestive of post-traumatic osteomyelitis with a pathological fracture. Clinicoradiologic diagnosis of pathological fracture of left neck of humerus was made with an underlying neoplastic or infective aetiology. An open biopsy was taken from left proximal humerus. Histopathological examination showed plasma cells in sheets having abundant basophilic cytoplasm, round to eccentric nuclei and perinuclear hoff along with lymphocytes and few polymorphs with surrounding area showing fibrosis, oedema and hyperemia. A diagnosis of chronic plasma cell osteomyelitis was rendered, which is an uncommon condition without specific clinical findings and an ambigious cause. Histopathology is the definitive tool for obtaining an accurate diagnosis and we strongly recommend a meticulous histopathological examination correlated with clinico-radiological description for a correct diagnosis in order to avoid an increased frequency of diagnosis of neoplastic plasma cell lesion as well as for advocating the correct treatment. This case is discussed for presentation of plasma cell osteomyelitis and also to report a case of chronic primary plasma cell rich osteomyelitis with atypical clinical features.

Enthesopathy and involvement of synovio-entheseal complex in systemic sclerosis: an ultrasound pilot study

Objectives SSc is a chronic autoimmune disease characterized by inflammation of the skin and multiple internal organs. Articular involvement is one of the main features of SSc, and typical hallmarks of SpA have been found in SSc patients. The aim of the present study was to estimate the prevalence of entheseal and synovio-entheseal complex (SEC) alterations in a cohort of SSc patients. Methods One hundred SSc patients and 25 healthy subjects were included in this cross-sectional study. The enthesis sites of lateral epicondylar common extensor tendons (CET) and the enthesis of the Glasgow Ultrasound Enthesis Scoring System were evaluated. SEC involvement was evaluated only at CET enthesis. Results In SSc, the Glasgow Ultrasound Enthesis Scoring System score was significantly higher (median 4.0, interquartile range 2.0–7.0) than in controls (median 1.0, interquartile range 0.0–3.0) (P < 0.0001). CET enthesis of SSc patients showed more frequent US B-mode alterations than that of controls (χ2 = 11.47, P = 0.0007 for size; χ2 = 13.79, P = 0.0002 for cortical irregularity, χ2 = 5.24, P = 0.022 for calcification/enthesophytes). Power Doppler US signal at CET enthesis was significantly more frequent in SSc patients than in healthy controls (χ2 = 9.11, P = 0.0025), as was the concomitant SEC involvement (χ2 = 8.52, P = 0.0035). Conclusion These data show that SSc patients frequently present US features of enthesopathy. Moreover, CET enthesopathy was correlated with SEC inflammation, suggesting that entheseal inflammation in SSc may share the same micro-anatomical targets as found in SpA.

Garre’s Osteomyelitis

Our case involved an 8 year girl who presented with a painful swelling Right lower jaw, with difficulty in deglutition, there was no fever. Earlier treatment by Dentists & ENT Specialists had provided no relief. Relevant investigations were within normal limits. The OPG was normal. MDCT scan of the face/orbit showed cortical irregularity and erosions in the Right hemi-mandible with a significant periosteal reaction & multiple irregular lytic areas in the marrow along with soft tissue changes suggestive of osteomyelitis. The significant periosteal reaction combined with osteomyelitis was suggestive of Garre’s osteomyelitis. No bone biopsies were considered due to the typical clinical & radiological features. With 4 weeks of antibiotic treatment the patient was completely relieved of her symptoms, with a major correction in the facial asymmetry. Regular follow up demonstrated a remodeling of the mandible with normal results on bone scanning