Aims. Insufficient treatment response in rheumatoid arthritis (RA) patients requires novel treatment strategies to halt disease progression. The potential benefit of combination of cytokine-inhibitors in RA is still unclear and needs further investigation. To explore the impact of combined deficiency of two major cytokines, namely interleukin (IL)-1 and IL-6, in this study double deficient mice for IL-1αβ and IL-6 were investigated in different tumour necrosis factor (TNF)-driven inflammatory bone disorders, namely peripheral arthritis and sacroiliitis, as well as systemic bone loss. Methods. Disease course, histopathological features of arthritis, and micro-CT (µCT) bone analysis of local and systemic bone loss were assessed in 15-week-old IL1-/-IL6-/-hTNFtg in comparison to IL1-/-hTNFtg, IL6-/-hTNFtg, and hTNFtg mice. µCT bone analysis of single deficient and wild-type mice was also performed. Results. Combined deficiency of IL-1/IL-6 markedly ameliorated TNF-mediated arthritis and bilateral sacroiliitis, but without additive benefits compared to single IL-1 deficiency. This finding confirms the important role of IL-1 and the marginal role of IL-6 in TNF-driven pathways of local joint damage, but questions the efficacy of potential combinatorial therapies of IL-1 and IL-6 in treatment of RA. In contrast, combined deficiency of IL-1/IL-6 led to an additive protective effect on TNF-driven systemic bone loss compared to single IL-1 and IL-6 deficiency. This finding clearly indicates a common contribution of both IL-1 and IL-6 in TNF-driven systemic bone loss, and points to a discrepancy of cytokine dependency in local and systemic TNF-driven mechanisms of inflammatory arthritis. Conclusion. Combinatorial treatments in RA might provide different benefits to inflammatory local arthritis and systemic comorbidities. Cite this article: Bone Joint Res 2022;11(7):484–493

We report the management of an adult patient with septic sacroiliitis. This is an uncommon condition. Debridement, decompression and spontaneous fusion are the treatment of choice when symptoms do not resolve with routine initial intravenous antibiotic therapy. A percutaneous technique is described, using the principles of sacroiliac screw insertion commonly used for pelvic reconstruction surgery. After successful evacuation of the infected joint, fusion was observed in our patient

We report four patients with unilateral postpartum sacroiliitis presenting with agonising unilateral pain, an elevated ESR, elevated alkaline phosphatase levels, leucocytosis and positive bone scans. The diagnosis of a non-infectious inflammatory cause was supported by the postpartum onset, the response to non-steroidal anti-inflammatory drugs, negative aspiration cultures in two cases and the lack of changes in the sacroiliac joints on long-term follow-up radiographs

Purpose and background:. Sacroiliitis identified by MRI is considered as a keystone in the diagnosis of spondyloarthritis. To reduce the number of unnecessary MRI scans it would be ideal if sacroiliac (SI) joint pain provocation tests could be used to identify patients at risk of having sacroiliitis. The aim of the current study was to investigate the diagnostic value of three pain provocation SI-joint tests for sacroiliitis identified by MRI. Methods:. Patients (n=454, mean age 32 years, 54% women) without clinical signs of nerve root compression were selected from a cohort consisting of patients with persistent low back pain referred to an outpatient spine clinic. Data from the Gaenslen's Test, Thigh Thrust Test and Long Dorsal Sacroiliac Ligaments Test and sacroiliitis identified by MRI were analysed. Results:. The prevalence of SI-joints with sacroiliitis was 5%. In the whole study group, only the Thigh Trust Test was associated with sacroiliitis, ROC area 0.58 (95% CI 0.51–0.65), sensitivity 31% (18–47) and specificity 85% (82–87). In men, sacroiliitis was associated with all three SI joint tests and multitest regimens, with the greatest ROC area found for ≥ 1 positive out of 3 tests, (0.68 (0.56–0.80)), sensitivity 56% (31–79) and specificity 81% (77–85). In women, no significant associations were observed between the assessed SI joint tests and sacroiliitis. Conclusions:. Only in men were the performed SI-joint tests found to be associated with sacroiliitis identified by MRI. Although, the diagnostic value was limited, the results indicate that the use of SI joint tests for sacroiliitis may be optimised by gender-separated analyses

The use of ultrasound-guided wire localisation of lesions is not well described in the orthopaedic literature. We describe a case of an impalpable schwannoma of the femoral nerve and another of sacroiliitis with an associated pelvic abscess. In both, surgical localisation was difficult. Peri-operative ultrasound-guided wire localisation was used to guide surgery and minimise tissue damage, thereby optimising the results and recovery of the patient

Purpose and Background:. The spread of upright MRi scanning is a relatively new development in the UK. However, there is a lack of information about whether weight bearing scans confer any additional useful information for low back conditions. Methods and Results:. Forty-five patient referrals to the upright MRI Department at the AECC for weight bearing lumbar spine scans between November 1. st. 2014 and June 30. th. 2015, and the resulting radiologists' reports were reviewed. Age, gender, clinical history, summary of findings, type of weight bearing scanning performed (sitting, standing, flexion, extension) were abstracted. All patients were scanned in a 0.5T Paramed MRopen scanner and all also received supine lumbar spine sagittal and axial scans. The patients comprised 18 females and 27 males, mean age 52 years, (SD 15.5). Thirty had leg pain, 6 of which was bilateral. In 15, a stenotic lesion was suspected. Other reasons for referral were; possible malignancy (1), effects of degenerative change (4), spondylolisthesis (2), fracture, (1), previous surgery (3), trauma (1), sacroiliitis (1) and instability (3). In 12/45 cases, reportable findings were more prominent, and sometimes only identifiable, on weight bearing scans, while in a further 4, the reverse was true. All but one of these involved disruption of the spinal or root canals. Eight of them also involved positional alignment. Conclusion:. In this case series nearly a third of referred patients had reportable findings relating to the spinal or nerve root canals that were differentiated by upright MRI scans

Pyogenic sacroiliitis (PS) is one of the less frequent localizations among joint infections, near the 1,5%. A late diagnosis generally exists. So we decided to analyze its behaviour in our uniit. A retrospective study of 39 records was carried out, 32 with diagnosis of entrance of PS and 7 with another pathology's diagnosis that turned out to be a PS, among the years 1999 and 2014 in our unit. 27 only fulfilled the requirements to be classified as PS (Clinic features of infection and sacroiliac localization, laboratory exams and Tc-99 bone scintigraphy alterations). 20 males and 7 females (74% males), 52% right sacroiliac joint, only 7 had clinically predisposing conditions (trauma), aged between 3 and 14 years (average 9.6 years). The half time of clinical evolution foresaw to diagnosis was of 4,7 days (6,7 days between 1999–2005 and 3,5 between 2006–2014) (range between 1 and 10 days). The main symptom that motivates the consultation was fever (96%) accompanied by FABER test positive (70%) by buttock pain (52%) and by limping (48%). Laboratory exams: WBC count was normal in 11 cases and elevated in 16 cases too and only in 5 cases with left deviation (PMNs elevated); CRP higher than 55 mg/dl in 23 patients (100% over 20mg/dl), ERS with value average of 72 mmHg/hour (27–111). Blood cultures were positive in 70% and the Staphylococcus aureus was the main bacteria founded (89%). No radiological alterations were found initially. The TC-99 bone scintigraphy was positive in all cases after the third day. All patients had a 5 to 12 days course of intravenous antibiotics (oxacillin + amikacin in 96% of patients) and then completed 4 weeks with oral oxacillin. All patients recovered without sequel. Blood cultures may be obtained prior the antibiotics’ administration. The Staphylococcus aureus is by far the most frequent germ involved in this process, and it may guide the empiric antibiotic therapy. The precocious antibiotic treatment solves the case without sequels. The PS is an uncommon pathology in children that makes it often not recognized initially. Wrong diagnosis such as appendicitis, transient synovitis of the hip, discitis, etc. can be avoided if PS is sought in a systematic way

Aims

To investigate the correlations among cytokines and regulatory T cells (T-regs) in ankylosing spondylitis (AS) patients, and their changes after anti-tumour necrosis factor-α (TNF-α) treatment.

Athletes are prone to iterated traumatic straining of sacroiliac joints and insertion of muscles in pelvic bones. The aim of our study was to show the connection between iterated trauma and staphylococcal infection in athletes. A compilation of data concerning 22 patients, all high-ranking athletes in Sweden, with pelvic skeletal infection (symphysitis, sacroiliitis and acetabular necrosis) is presented. Most of them were ball-players, 2 females and 20 males with an average age of 21 years. The onset was acute or subacute and the disease was commonly misinterpreted, mainly as an acute abdominal disease. Four patients erroneously underwent laparotomy for suspected appendicitis. Eight patients had skin lesions (5 purulent and 3 uninfected) at the onset and thus had a portal for possible entry for a bacterial impact in the pelvic skeleton. The only verified bacterial aetiology was Staphylococcus aureus in 19 cases (culture of blood and/or aspirated samples in 18 and serology only in 1). An early scintigraphy was of greater value than X-ray for diagnosis and was positive in 8/10 evaluable cases. In all, 12/18 had early positive plain radiological findings. Another patient (#22) had, except skeletal infection, a psoas abscess, diagnosed by Magnetic Resonance Imaging (MRI). Antistaphylococcal drugs administered parenterally for 1–2 weeks followed by oral drugs for a few months comprised a successful treatment and no patient had serious sequelae or relapse. The occurrence of abdominal and/or lower back pains concomitant to fever in young persons engaged in elite team sports should lead to a suspicion of pelvic pyogenic infection. Early scintigraphy and cultures of blood and aspirated material from the infection site was essential for the diagnosis. MRI has also been shown to be valuable

Aims

Osteoporosis is characterized by decreased trabecular bone volume, and microarchitectural deterioration in the medullary cavity. Interleukin-19 (IL-19), a member of the IL-10 family, is an anti-inflammatory cytokine produced primarily by macrophages. The aim of our study was to investigate the effect of IL-19 on osteoporosis.

Purpose: To evaluate the diagnostic parameters for detection of pelvic bone infections and to present the results of conservative and operative treatment. Materials-methods: 17 children with acute osteomyelitis of the pelvis or septic sacroiliitis were treated from 1992 to 2000. They were followed-up for 1,5 to 8 years. 10 patients presented with leukocytosis. In 15 patients ESR exceeded 40 mm and in 10 patients CRP exceeded 20 mg%. Blood cultures yielded Staphylococcus aureus in 6 cases and Streptococcus in one. In only 2 cases were plain X-Rays suggestive of infection. Every patient had a positive Tc99m MDP bone scan (increased absorption), which permitted localization of the infection. Furthermore, MRI was performed on 12 patients, yielding abnormal findings in all cases. All patients received antistaphylococcal antibiotics intravenously for 10–14 days, followed by a further 3–8 week course per os, depending upon the response to treatment. Treatment started with considerable delay for 3 patients; they all were submitted to surgical drainage and debridement. Results: All patients were normal at clinical follow-up by the end of treatment. By the end of follow-up no signs of osteomyelitis or residual deformity appeared. Conclusions: The usual laboratory and radiological investigations can be misleading. Tc99m MDP bone scan and MRI permit prompt diagnosis and localization of the infection. With the appropriate antibiotics the clinical results are usually excellent, provided that the disease is diagnosed without delay. Surgical drainage and debridement is necessary in cases of delayed or missed diagnosis

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

The April 2013 Spine Roundup³⁶⁰ looks at: smuggling spinal implants; local bone graft and PLIF; predicting disability with slipped discs; mortality and spinal surgery; spondyloarthropathy; brachytherapy; and fibrin mesh and BMP.

The February 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip dislocation in children with CTEV: two decades of experience; Population-based prevention of DDH in cerebral palsy: 20 years’ experience; Shoulder derotation in congenital plexus palsy; Back pain in the paediatric population: could MRI be the answer?; Intercondylar fracture of the humerus in children; The Dunn osteotomy in SUFE; Radiocapitellar line a myth!; Do ‘flatfooted’ children suffer?

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Resurfacing arthroplasties of the hip are being undertaken with increasing frequency and the complications associated with this procedure are well documented. We have encountered a further problem with a fracture of the centralising peg of the femoral component in a prosthesis which had been in situ for three years.