Search

(257 words) Objective To determine changes of subchondral bone composition, micro-structure, bone marrow adiposity and micro-vascular perfusion in end-stage osteonecrosis of the femoral head (ONFH) compared to osteoarthritis (OA) using a combined in vivo and ex vivo approach. Design Male patients up to 70 years old referred for total hip replacement surgery for end-stage ONFH were included (n=14). Fifteen patients with OA were controls. Pre-operative MRI was used to assess bone perfusion (dynamic contrast-enhanced (DCE) sequences) and marrow fat content (chemical shift imaging). Three distinct zones of femoral head subchondral bone – necrotic, sclerotic, distant – were compared between groups. After surgery, plugs were sampled in these zones and Raman spectroscopy was applied to characterize bone mineral and organic components (old and newly-formed), and contrast-enhanced micro-computed tomography (CE-μCT) to determine bone micro-structural parameters and volume of bone marrow adipocytes, using conventional 2D histology as a reference. Results In the necrotic zone of ONFH patients compared to OA patients: i) the subchondral plate did not exhibit significant changes in composition nor structure; ii) the volume fraction of subchondral trabecular bone was significantly lower; iii) type-B carbonate substitution was less pronounced, iv) collagen maturity was more pronounced; and v) bone marrow adipocytes were significantly depleted. The sclerotic zone from the ONFH group showed greater trabecular thickness, and higher DCE-MRI AUC and Ktrans. Volume fraction of subchondral bone, trabecular number, and Kep were significantly lower in the distant zone of the ONFH group. Conclusions This study demonstrated alterations of subchondral bone microstructure, composition, perfusion and/or adipose content in all zones of the femoral head. Abstract (257 words) Objective To determine changes of subchondral bone composition, micro-structure, bone marrow adiposity and micro-vascular perfusion in end-stage osteonecrosis of the femoral head (ONFH) compared to osteoarthritis (OA) using a combined in vivo and ex vivo approach. Design Male patients up to 70 years old referred for total hip replacement surgery for end-stage ONFH were included (n=14). Fifteen patients with OA were controls. Pre-operative MRI was used to assess bone perfusion (dynamic contrast-enhanced (DCE) sequences) and marrow fat content (chemical shift imaging). Three distinct zones of femoral head subchondral bone – necrotic, sclerotic, distant – were compared between groups. After surgery, plugs were sampled in these zones and Raman spectroscopy was applied to characterize bone mineral and organic components (old and newly-formed), and contrast-enhanced micro-computed tomography (CE-μCT) to determine bone micro-structural parameters and volume of bone marrow adipocytes, using conventional 2D histology as a reference. Results In the necrotic zone of ONFH patients compared to OA patients: i) the subchondral plate did not exhibit significant changes in composition nor structure; ii) the volume fraction of subchondral trabecular bone was significantly lower; iii) type-B carbonate substitution was less pronounced, iv) collagen maturity was more pronounced; and v) bone marrow adipocytes were significantly depleted. The sclerotic zone from the ONFH group showed greater trabecular thickness, and higher DCE-MRI AUC and Ktrans. Volume fraction of subchondral bone, trabecular number, and Kep were significantly lower in the distant zone of the ONFH group. Conclusions This study demonstrated alterations of subchondral bone microstructure, composition, perfusion and/or adipose content in all zones of the femoral head. ispartof: Osteoarthritis and Cartilage vol:30 issue:8 pages:1103-1115 ispartof: location:England status: accepted

The purpose of this study was to assess the performance of our Fracture Liaison Service (FLS) over a period of 2 years. Osteoporosis medication was prescribed for 243 patients, and zoledronic acid was the main drug prescribed (60.2%).A Fracture Liaison Service (FLS) was implemented at Lille University Hospital in 2016. The main purpose of this study was to assess the performance of the FLS using criteria proposed by the International Osteoporosis Foundation (IOF).The criteria used were patient identification, patient evaluation, post-fracture assessment timing, vertebral-fracture identification, blood and bone mineral density (BMD) testing, falls prevention, multifaceted health and lifestyle risk-factor assessment, and medication initiation and review.Between January 2016 and January 2018, 736 patients (≥ 50 years old) with a recent history of fragility fracture (≤ 12 months) were identified. The identification rate for hip fractures was 74.2%. However, patient evaluation for all type of fractures was quite low (30.3%) since many patients failed to attend the FLS unit. The reasons for non-attendance were refusal, agreed but subsequently failed to attend, and still waiting to be seen. In all, 256 patients (76.6% female, mean (SD) age 74.3 (11.0) years) were seen at the FLS. Mean (SD) post-fracture assessment timing was 13.3 (9.3) weeks. Of the 139 patients seen for a non-vertebral fracture, 103 were assessed for vertebral fractures, and at least one new vertebral fracture was found in 45 of them (43.7%). Osteoporosis medication was prescribed for 243 (94.9%) patients. The main osteoporosis drug prescribed was zoledronic acid (60.2%).Secondary prevention of osteoporotic fractures has improved since the implementation of the FLS. However, patient identification, patient evaluation, and post-fracture assessment timing still need to be improved.

BackgroundSystemic inflammation is the main factor underlying secondary osteoporosis in patients with rheumatoid arthritis (RA). The JAK inhibitors, such as Tofacitinib (Tofa), can control systemic inflammation and have beneficial effects on bone in various models. This might be due to direct effects on the bone microenvironment and not exclusively based on their anti-inflammatory function. Bone marrow adipocytes (BMAds) are abundant in the bone microenvironment. The effect of JAK inhibitors on BMAds is unknown, but evidence suggests that there is competition between human bone marrow-derived stromal cell (hBMSCs) differentiation routes toward BMAds and osteoblasts (Ob) in osteoporosis.ObjectivesTo determine in various models whether Tofa influences directly bone marrow cell committment toward adipogenesis and osteoblastogenesis. Then, in a prospective pilot study, to investigate the potential effects of Tofa on bone marrow adiposity in patients with RA.MethodsTo study the effect of Tofa on cellular commitment, hBMSCs were cultured for 3 days in appropriate Ob- and BMAd- differentiation media (Ob-3d and BMAd-3d), together with Tofa at 200, 400 (equivalent to a therapeutic dose of 5 mg twice a day in RA patients) or 800 nM. To mimic inflammatory conditions, TNFα was added to the media at a dose of 1 ng/ml. This study was also conducted on mature BMAds and a similar treatment was applied for 6 days to mature BMAds at 14 days of differentiation (BMAd-20d). The impact of Tofa was determined by gene expression profile analysis, western-blot analysis and cell density monitoring. In parallel, in a pilot study of 9 RA patients treated with Tofa 5 mg twice a day (TOFAT study: NCT04175886), proton density fat fraction (PDFF) was measured by MRI (Dixon technique) at the lumbar spine at the start of treatment and at 6 months.ResultsIn non-inflammatory conditions, the gene expression of Runx2 decreased in Ob-3d treated with Tofa 400 and 800 nM(pConclusionOverall, in vitro and clinical results suggest a stimulatory effect of Tofa on BMAds commitment and differentiation, which does not support a positive effect of Tofa on boneDisclosure of InterestsJean-Guillaume Letarouilly Consultant of: Sêmeia, Grant/research support from: Pfizer, Julien Paccou: None declared, Sammy Badr: None declared, René-Marc Flipo Consultant of: member of the advisory board Pfizer, Christophe Chauveau: None declared, Bernard Cortet: None declared, Odile Broux: None declared, Aline Clabaut: None declared

Compared to healthy bone, the intrinsic bone materials properties in the pre-existing lamellar bone are altered in jaw bone sequesters of bisphosphonates (BP)-related osteonecrosis.The aim of this study was to evaluate the human jaw bone quality, especially intrinsic bone material properties among sequesters of osteonecrosis of the jaw (ONJ) induced by BP.Bone sequesters were obtained from 24 patients suffering from ONJ following a BP treatment. Within BP-exposed bone samples, benign-BP and malignant-BP groups were distinguished in relation to the underlying disease: osteoporosis and bone metastases or multiple myeloma, respectively. Healthy cadaveric cortical jaw bone samples were used as controls. The physicochemical parameters of bone samples - mineral/organic ratio, relative proteoglycan content, crystallinity, monohydrogen phosphate content, and type-B carbonate substitution - were evaluated by Raman microspectroscopy. Representative Raman spectral features of bones control and BP-exposed bone sequesters were identified with the Partial-Least-Square Discriminant Analysis (PLS-DA).BP-exposed bone sequesters are characterized by a significant increase of mineral to organic ratio (+12 %) and a significant decrease of relative proteoglycan content (-35 %), thus regulating initial collagen matrix mineral deposition. Structural changes on mineral components are revealed by a significant decrease of both crystallinity (-2 %) and mineral maturation (-41 %) in the BP-exposed bone sequesters compared to healthy bones. These modifications were also observed distinctly in both benign-BP and malignant-BP groups. In addition, a shift of the phosphate ν1 band was highlighted by PLS-DA between bones control and BP-exposed bone sequesters, revealing a disruption of the apatitic phosphate environment in the jaw bone sequesters.The present data show that jaw bone quality can be altered with an overmineralization and ultrastructural modifications of apatitic mineral in bone sequesters of BP-related ONJ.

Published also in Aging Clinical and Experimental Research, Vol.28, No.4, WOS: 000379034800030 Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest group on falls and fracture prevention of the European union geriatric medicine society (EUGMS), in collaboration with the International association of gerontology and geriatrics for the European region (IAGG-ER), the European union of medical specialists (EUMS), the Fragility fracture network (FFN), the International osteoporosis foundation (IOF) - European society for clinical and economic aspects of osteoporosis and osteoarthritis (ECCEO), outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people. (C) 2016 Published by Elsevier Masson SAS.

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX(®) ("Fracture Risk Assessment Tool") algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

The diagnosis of osteoporosis rests on areal bone mineral density (BMD) measurement using DXA. Cancellous bone microarchitecture is a key determinant of bone strength but cannot be measured using DXA. To meet the need for a clinical tool capable of assessing bone microarchitecture, the TBS was developed. The TBS is a texture parameter that evaluates pixel gray-level variations in DXA images of the lumbar spine. The TBS variations may reflect bone microarchitecture. We explain the general principles used to compute the TBS, and we report the correlations between TBS and microarchitectural parameters. Several limitations of the TBS as it is used now are pointed out. We discuss data from currently available clinical studies on the ability of the TBS to identify patients with fractures and to evaluate the fracture risk. We conclude that this new index emphasizes the failure of the BMD T-score to fully capture the fragility fracture risk. However, although microarchitecture may influence the TBS, today, to the best of our understanding, there is no sufficient evidence that a TBS measurement provides reliable information on the status of the bone microarchitecture for a given patient. The TBS depends on gray-level variations and in a projectional image obtained in vivo, these variations can have many causes. Nevertheless, as clinical studies suggest that the TBS predicts the risk of fracture even after adjustment for BMD, we are encouraged to learn more about this score. Additional studies will have to be performed to assess the advantages and limitations of the TBS, in order to ensure that it is used appropriately in clinical practice.

Introduction Le teriparatide est une PTH humaine recombinante indiquee dans le traitement de l’osteoporose severe chez des patients a risque fracturaire eleve. Parmi ses effets secondaires, une hypercalcemie legere transitoire peut etre observee. Nous rapportons le cas d’une hypercalcemie severe et persistante chez un patient traite par teriparatide. Observation Monsieur T., âge de 42 ans, est suivi pour un hypercorticisme ACTH-dependant en cours d’exploration, bien controle sous traitement medical. L’hypercorticisme a entraine une osteoporose severe (T-Score au niveau lombaire = −1,10 et au niveau du col femoral = −3,40) associee a plusieurs fractures vertebrales (de T10 a L4) necessitant l’introduction de teriparatide. Six semaines apres son introduction, il a presente une alteration de l’etat general, avec anorexie, nausees, vomissements et douleurs abdominales. Le bilan biologique montrait une hypercalcemie a 136 mg/L (contre 95 initialement) avec calcium ionise augmente a 1,64 mmol/L (1,17–1,30), phosphoremie a 34 mg/L, 25-OH-vitamine D et 1-25 OH vitamine D basses, et parathormone adaptee a 3 pg/mL (15–68). L’enzyme de conversion de l’angiotensine, la beta2microglobulinemie, le LDH et l’electrophorese des proteines plasmatiques etaient normaux. L’arret du teriparatide avec une hydratation efficace ont permis une normalisation progressive de la calcemie au bout de 10 jours a 97 mg/L. Discussion L’hypercalcemie sous teriparatide est observee dans 3 % des cas, habituellement legere et transitoire. Tres peu de cas dans la litterature rapportent la survenue d’une hypercalcemie severe et persistante sous teriparatide, d’ou la necessite d’une surveillance reguliere de la calcemie chez les patients sous ce traitement.

BackgroundCurrently, several effective anti-osteoporotic drugs areavailable, and their mechanisms of action are well known,albeit widely varying depending on the nature of the drugsinvolved. This paper addresses the following questions:Firstly, to what extent do these molecules and theirmechanisms of action accountfor their antifracture efficacy?Secondly, it is known that changes in the values ofintermediate parameters (BMD, bone remodelling markers)during treatment only partially account for the antifractureefficacy of these drugs.Various data suggest that the effect of anti-osteoporoticdrugs onbonemicroarchitecture is alsoan important factor totakeintoaccount.Recentfindingssuggestthattheeffectofthedrugs involved on bone ultrastructure plays a specific role.Thiseffectisoftenverydifferentdependingonthemechanismof action of the molecules in question (bone resorptioninhibitors, bone formation agents). The purpose of this paperis to evaluate the effect of bone anabolic agents on boneultrastructure. The effects of parathormone—both intactparathormone (PTH 1-84) and teriparatide (PTH 1-34)—andstrontium ranelateinparticularare considered.Asonlyalittledata is currently available in this field, we will be referring toanimalstudiesandtothefewstudiesundertakenusinghumanbone biopsies.IntroductionWith regards the ultrastructural characteristics of bonetissue, not only the mineral phase needs to be studied butalso the organic phase. Mineralisation process takes place attissue level whereas the study of bone mineral will help oneto assess the characteristics of the apatite crystal whichplays a strong role both in bone homeostasy and bonemetabolism.PTHThe increase in BMD observed in patients treated withteriparatide (TPT) accounts for no more than 40% of themolecule's antifracture efficacy [1]. It seems that TPT canalso modify some intrinsic properties of bone tissue, i.e.degree of bone mineralisation, mineral crystallinity and sizeand degree of maturation of collagen crystals. The latterproperty can be determined by measuring the ratio ofpyridinoline (pyr) to dehydro-dihydroxylysino-norleucine(deH-DHLNL).Paschalis et al. [2] analysed 61 pairs of bone biopsies(BB) taken from patients who had received either aplacebo or TPT. The interval between two biopsies was12 months in 21 cases and 18 months in the 40 remainingcases. The first group were as follows: placebo,n=8; TPT20μg, n=7; TPT 40μg, n=6. In the second group, 16patients received the placebo, 14 received a 20-μg/daydose of TPT and ten received a 40-μg/day dose of TPT.Biopsies from 15 patients from each group were selectedfor analysis using Fourier transformed infrared imaging(FTIRI). Seven biopsies were excluded due to insufficientquality. In all, 38 BB pairs were analysed using the FTIRImethod. The group of BB pairs were as follows: placebo

Les techniques percutanees ouvrent des perspectives therapeutiques palliatives dans le traitement des lesions osseuses metastatiques. Ces techniques s’utilisent seules ou en association entre elles et aux autres traitements conventionnels. Leurs indications doivent etre discutees au sein d’une equipe multidisciplinaire a laquelle participe le praticien interventionnel.

La regulacion de la calcemia depende principalmente de tres organos: el rinon, el tejido oseo y el intestino y de dos hormonas: la hormona paratiroidea y la vitamina D. Los mecanismos responsables principales de una hipercalcemia son la liberacion de gran cantidad de calcio por el tejido oseo, la disminucion de su excrecion renal y el aumento de su absorcion digestiva. La hipercalcemia de origen tumoral maligno y el hiperparatiroidismo primario son las causas mas frecuentes de la hipercalcemia del adulto y deben buscarse de forma sistematica una vez descartadas las falsas hipercalcemias. El tratamiento de la hipercalcemia consiste sobre todo en hidratacion con aportacion de sodio, prescripcion de bifosfonatos y tratamiento de la causa, si es posible. Este tratamiento se impone en la urgencia ante una hipercalcemia sintomatica y/o una concentracion serica de calcio superior a 120 mg/l.

A high prevalence of low bone mineralization is documented in adult patients with cystic fibrosis (CF). Osteopenia is present in as much as 85% of adult patients and osteoporosis in 13 to 57% of them. In children, studies are discordant probably because of different control database. Denutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity are well known risk factors for poor bone health. Puberty is a critical period and requires a careful follow-up for an optimal bone peak mass. This review is a consensus statement established by the national working group of the French Federation of CF Centers to develop practice guidelines for optimizing bone health in patients with CF. Recommendations for screening and for calcium, vitamin D and K supplementation are given. Further work is needed to define indications for treatment with biphosphonates and anabolic agents.

Resume Introduction Les rhumatismes inflammatoires sont des complications articulaires rares de la mucoviscidose. Nous decrivons 3 cas de polyarthrite rhumatoide (PR) chez des patients atteints de mucoviscidose. Cas cliniques Parmi les 100 patients suivis au CRCM adulte de Lille, 3 presentent egalement une PR. Celle-ci a debute a 17, 44 et 19 ans, le VEMS etait respectivement de 53, 42 et 94 %. Il s’agissait de 2 femmes et 1 homme, porteurs de la mutation deltaF508 (1 homozygote et 2 heterozygotes composites) avec test de la sueur positif. Il etaient colonises a Staphylococcus Aureus et le facteur rhumatoide et/ou les anti-CCP etaient positifs. L’apparition et les poussees de PR etaient associees a une exacerbation bronchique et a une degradation de la fonction respiratoire. Pour 2 d’entre eux, la PR est toujours evolutive malgre une approche therapeutique complexe comprenant successivement : corticoides a hautes doses, methotrexate (inefficaces) suivi du leflunomide (complique d’infection respiratoires recidivantes). Conclusion L’incidence de la PR parmi notre population atteinte de mucoviscidose est elevee. Les nouveaux marqueurs seriques de la PR dont les anti-CCP ont un interet diagnostique, l’evolution des 2 affections est liee et semble etre dependante du statut infectieux entrainant des difficultes therapeutiques.

Resumen Numerosas endocrinopatias pueden tener repercusiones sobre el tejido oseo por mecanismos diversos. El desarrollo de la densitometria osea ha permitido evaluar su impacto, de tal manera que una eventual disminucion de la masa osea, puede ser un criterio que debe tenerse en cuenta para orientar la decision terapeutica. Igualmente, la generalizacion de la determinacion de marcadores del recambio oseo ha contribuido a una mejor comprension de los mecanismos patogenicos incriminados en la afectacion osea de las endocrinopatias. Las afecciones hipofisarias mas clasicas estan representadas por la hiperprolactinemia, en la cual la disminucion de la masa osea aparece como consecuencia del hipogonadismo, la acromegalia, pero tambien los deficits de somatotropina cuya repercusion osea es tanto mas grave cuanto mas precozmente aparece el deficit. Los hipogonadismos congenitos (sindromes de Turner, Klinefelter o Kallmann) o adquiridos (anorexia nerviosa, actividad fisica intensa) tambien pueden dar origen a una desmineralizacion osea a veces responsable de complicaciones con fracturas reveladoras. Las afecciones suprarrenales incriminadas con mayor frecuencia son el sindrome o la enfermedad de Cushing, responsables de una osteoporosis de predominio trabecular debida a una disminucion en la formacion osea y tambien la enfermedad de Addison en la cual la patogenia de la repercusion osea es controvertida. La osteosis tiroidea se conoce desde hace mas de un siglo, aparece como consecuencia de una reestructuracion osea excesiva con aumento del reclutamiento espacial de nuevas unidades elementales de reestructuracion e incremento en su frecuencia de activacion. Dentro del mismo contexto, debe senalarse el posible efecto perjudicial sobre los huesos, de los tratamientos con hormonas tiroideas en dosis supresoras, prescritos para evitar el crecimiento anormal del tejido tiroideo. Por ultimo, la diabetes tipo I tambien puede originar una osteopenia, como consecuencia del deficit de insulina y de la disminucion de la sintesis del factor de crecimiento afin a la insulina (IGF) que provoca una reduccion de la formacion osea. Sin embargo, pese a que las referencias son poco abundantes, no parece existir un incremento en la incidencia de fracturas en el curso de la diabetes insulinodependiente.

Resume Propos Il est generalement reconnu que les glucocorticoides prescrits a doses moderees ou elevees entrainent une perte osseuse et une augmentation du risque de fractures. La perte osseuse est directement correlee a la dose cumulee de glucocorticoides et s'observe surtout durant les 3 a 6 premiers mois de traitement. Actualites et points forts Pour prevenir l'osteoporose cortico-induite, il est habituel d'essayer d'obtenir rapidement la plus petite dose minimale efficace. La prescription a jours alternes et l'utilisation de bolus n'ont pas demontre leur effet protecteur. L'association calcium et vitamine D constitue la base du traitement preventif. Les habitudes de vie doivent etre modifiees en arretant si possible le tabac, en limitant l'absorption d'alcool et en assurant une activite physique quotidienne de 30 minutes a 1 heure. Le regime pauvre en sel et les diuretiques thiazidiques sont parfois utiles lorsqu'existe une hypercalciurie importante sous glucocorticoides. Le traitement hormonal est systematiquement recommande chez la femme menopausee en l'absence de contre-indication, la contraception estroprogestative chez la femme jeune est utile lorsqu' existent des regles irregulieres. La maladie lupique reste encore classiquement une contre-indication aux estrogenes. Perspective et projets La densitometrie osseuse peut etre utile pour la prise en charge des patients a haut risque d'osteoporose cortico-induite permettant une mesure fiable de la densite minerale osseuse. L'etidronate a recemment demontre son efficacite dans la prevention de la perte osseuse, avec une reduction significative du nombre de fractures vertebrales chez les femmes menopausees.

Osteoporosis is a well-recognized adverse effect of corticosteroid therapy. This study aimed to investigate the effect of etidronate, intermittent cyclical therapy, in the prevention of corticosteroid-induced bone loss. Patients with various medical conditions starting high-dose corticosteroid therapy were enrolled in the study. The treatment had to be expected to continue for at least 12 months with the initial 90 days at a mean daily dose of at least 7.5 mg of prednisone, with subsequent treatment of at least 2.5 mg/day. One hundred seventeen patients were randomly assigned oral etidronate 400 mg/day, or placebo, for 14 days, followed by 76 days of oral calcium carbonate (500 mg elemental calcium), cycled over 12 months. The primary outcome measure was the difference in percent change from baseline in bone mineral density of the lumbar spine between the groups at the end of year 1. Secondary measures included changes in femur bone density and in biochemical markers of bone remodeling. The mean (+/- SEM) lumbar spine bone density changed 0.30 +/- 0.61% and -2.79 +/- 0.63% in the etidronate and placebo groups, respectively. The mean difference between groups after 1 yr was 3.0 +/- 0.84% (P = 0.004). The changes in the femoral neck and great trochanter were not different between the groups. There was a decrease in pyridinium crosslinks, significant from baseline at both 6 and 12 months, in the etidronate group. Osteocalcin increased in the placebo group, and difference between groups was -25.07 +/- 14.89% (P = 0.032) and -34.68 +/- 19.77% (P = 0.051), at 6 and 12 months respectively. There was no significant difference between the groups in number of adverse experiences, including gastrointestinal disorders. Etidronate intermittent cyclical therapy prevents lumbar vertebral bone loss in patients starting high-dose corticosteroid therapy.

Resume L'osteoporose de la grossesse est une pathologie rare. Les auteurs en rapportent deux nouvelles observations. Les deux patientes âgees de 31 ans et de 19 ans ont presente des tassements vertebraux non traumatiques se traduisant par des rachialgies aigues, l'une au cours du post-partum, l'autre au cours de la 34 e semaine d'amenorrhee. Chez la premiere, l'evolution a ete favorable avec une augmentation significative de la densite minerale lombaire chiffree a 15,2 % en 14 mois sous calcium et sous vitamine D. Avec un recul de 10 ans, l'etat de la seconde s'est aggrave malgre l'absence de nouvelle grossesse. Nos observations suggerent la possibilite de pathogenies differentes dans l'osteoporose de la grossesse.

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).

Androgen deprivation therapy represents an important part of the management of prostate cancer. However, epidemiological data have shown that it is a well-established cause of osteoporosis and increased risk of fracture. So far no consensus guidelines have been published regarding the screening and treatment of osteoporosis in men with prostate cancer. Here we report the design of a new questionnaire, derived from the FRAX(®) ("Fracture Risk Assessment Tool") algorithm, to evaluate the risk of fracture in those patients. In accordance with recent reviews and on the basis of their experience, our French board of experts recommends systematic screening for osteoporosis with dual energy x- ray absorptiometry scans, practice of exercise and calcium and vitamin D supplementation, and selective treatment with bisphosphonates in men at greatest osteoporotic risk.

The efficacy of low-dose cyclosporin-A (CyA) has been clearly demonstrated for rheumatoid arthritis. However, the long-term benefit-risk ratio remains to be investigated in patients with refractory RA. Thirty one patients were included in a prospective open study (24 females, seven males, mean age = 55 years). The mean duration of RA was 11 years and refractory RA was defined by the need of corticosteroid treatment in 26 patients and the previous failure of at least five second line drugs including methotrexate in 27 patients. Initial dosage of CyA was 3 mg/kg/d and could be progressively increased up to 5 mg/kg/d. The mean duration of the study was one year (3-39 months). At 3 months, clinically relevant improvement occurred in 22 patients (71%). Seven were withdrawn due to inefficacy. The main side-effects were hypertension (22 cases) and nephrotoxicity (18 cases) requiring the withdrawal from the study, respectively in one case and in four cases. Raised serum creatinine level had required reduction of the dosage with loss of efficacy in four cases. CyA appears to be an effective therapy for severe treatment refractory RA. Despite a high incidence of side-effects, the efficacy and the monthly management of the patients lead to a good benefit/risk ratio with a percentage of continuation of treatment of 42% at one year.

A high prevalence of low bone mineralization is documented in adult patients with cystic fibrosis (CF). Osteopenia is present in as much as 85% of adult patients and osteoporosis in 13 to 57% of them. In children, studies are discordant probably because of different control database. Denutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity are well known risk factors for poor bone health. Puberty is a critical period and requires a careful follow-up for an optimal bone peak mass. This review is a consensus statement established by the national working group of the French Federation of CF Centers to develop practice guidelines for optimizing bone health in patients with CF. Recommendations for screening and for calcium, vitamin D and K supplementation are given. Further work is needed to define indications for treatment with biphosphonates and anabolic agents.

Inflammatory arthropathies are rare complications of cystic fibrosis (CF). We describe three cases of rheumatoid arthritis (RA) occurring in patients with this disease.Among the 100 patients under the care of the adult CF centre in Lille 3 presented with RA. This developed at the ages of 17, 44 and 19 years with a FEV1 of 53%, 42% and 94% respectively. They were 2 women and 1 man, with CFTR gene mutation delta F508 (1 homozygote and 2 heterozygotes) and positive sweat tests. They were colonised with Staphylococcus aureus, and rheumatoid factor and/or anti CCP antibodies were positive. The appearance and progression of RA were associated with exacerbations of bronchial infection and deterioration of respiratory function. In 2 patients the RA was continuously progressive despite intensive treatment involving high dose cortico-steroids, methotrexate (ineffective) followed by leflunomide (complicated by intractable respiratory infection).There is an increased incidence of RA in our patient population with CF. The new serum markers of RA including anti CCP are of diagnostic interest. The evolution of the two diseases is related and seems to be dependent on the level of infection leading to therapeutic problems.

To assess the occurrence of bone loss in rheumatoid arthritis (RA) and to determine the factors influencing bone loss (particularly the usefulness of bone turnover markers) over an 18-month period.A total of 51 patients were studied, 6 men and 45 females (of whom 35 were menopausal). Their mean age was 56 +/- 10 years and the mean RA duration was 12 +/- 10 years. Twenty-eight (55%) were receiving corticosteroids (10 mg/day for a mean duration of 6 +/- 5 years). Several clinical and biological parameters reflecting disease activity or severity were recorded both at the 0 and 18-month investigations. Bone turnover was assessed at baseline by measuring the serum levels of 4 biological markers. Three of them reflected bone formation, i.e., procollagen type I C-terminal propepeptide (PICP), procollagen type I N-terminal propeptide (PINP) and osteocalcin (OC). The fourth, procollagen type I-C terminal telopeptide (ICTP), reflected bone resorption. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry both at the lumbar spine (LS) and femoral neck (FN) at baseline and 18 months later.Bone loss occurred both at the LS: 2.1%, [95% CI: 0.8%-3.4%, P0.005] and femoral neck: 3.1%, [95% CI: 1.1%-5.1%, P0.005]. Bone loss was markedly increased for postmenopausal women at the FN: 5.3% [95% CI: 2.9%-7.6%, P0.005]. Bone loss was not statistically significantly different between users and non-users of steroids. Bone loss at the LS was significantly correlated with both osteocalcin (r = 0.51, P0.01) and ICTP levels (r = 0.32, P0.05). FN bone loss was correlated with the osteocalcin level only (r = 0.34, P0.05). Fast losers (bone loss at the LS above the median) had higher OC (P0.01) and ESR (P0.05) levels at baseline as compared with slow losers (bone loss at the LS below the median).Bone loss occurs in RA particularly at the FN and seems to be influenced by increased bone turnover and high levels of inflammation.

The authors report a case of iliac muscle haematoma responsible for inguinal pain in a patient with Gaucher's disease type I. This exceptional cause of pain must now be considered side by side with the classical femoral head osteonecrosis and infectious coxitis. Magnetic resonance imaging appears to be the most sensitive and most specific examination for the aetiological diagnosis of hip pain in Gaucher's disease. In the absence of thrombocytopenia and franck abnormality of coagulation, the spontaneousness of the haematoma is discussed.

We report a new case of axial osteomalacia diagnosed in a 51-year-old white Caucasian male, made particular by its association with sacroiliitis, positive HLA-B27 antigen, and also moderate phosphate diabetes responsible for a decreased appendicular bone mass. The diagnosis was suspected when X-ray evaluation showed increased density and coarse trabeculation mainly involving the pelvis and spine. Dual energy X-ray absorptiometry confirmed the elevated bone density at the lumbar spine (T score: +1.92) contrasting with a decreased bone mass at the femoral neck (T score: -2.33). The diagnosis was confirmed by histomorphometry of the iliac crest showing marked thickening of the cortices (2190 microns +/- 0.574, N = 780 +/- 40) and an increased trabecular bone volume (33.24%, N = 14 +/- 3). Osteoid parameters were also markedly increased with an osteoid volume of 2.1% (N = 1.2 +/- 0.5) and a mean osteoid thickness of 28.7 microns (N = 13 +/- 2.5), with a normal bone fluoride content (0.082%, N0.10). Bone resorption as assessed on bone biopsy and by the measurement of markers of bone remodeling (serum procollagen type I C-terminal telopeptide and 24 hr urinary cross-laps to creatinine ratio) was increased. This latter finding was not necessarily due to axial osteomalacia and could be the consequence of moderate phosphate diabetes. The patient was treated with calcitriol which was promptly discontinued due to gastrointestinal symptoms and replaced by calcidiol without any significant effect on the low back pain.

Pachydermoperiostosis is manifested by finger clubbing, hypertrophic skin changes, and periosteal bone formation. We describe 5 cases revealed primarily by their rheumatologic manifestations. Also reported are preliminary experiences on the use of intravenous pamidronate as a treatment.This is a retrospective study including the analysis of clinical manifestations, laboratory results and morphological examinations gathered from patients' medical records. We evaluated efficacy of treatment with 1 mg/kg iv pamidronate in the 3 new cases.Before treatment with iv pamidronate, the patients' global assessment was poor (twice) and very poor (once). The physician's global assessment was poor in 3 patients. After treatment with iv pamidronate, 2 patients had significant improvement. Physician and patient global assessments were very good, good, and moderate. No side effects were observed. All biological variables were within normal ranges at 12 month followup visit.Pachydermoperiostosis must be recognized by the rheumatologist, since it can present symptomatically through articular manifestations. When conventional treatment modalities fail, iv pamidronate might be useful.

En bloc surgical excision of osteoid osteomas of the hip and femur is difficult because of problems with tumor boundary identification and the need to use internal fixation or bone grafting. We report our experience with seven cases treated by percutaneous drill-biopsy under computed tomography guidance.Six adults and one child with a mean age of 22 years treated since 1995. All seven patients reported insomnia due to pain during a mean of 10 months, improved by aspirin or other nonsteroidal anti-inflammatory agents. The tumor was seen on plain radiographs in four cases and on computed tomography scans in all seven cases. Magnetic resonance imaging was diagnostic in only two cases. The tumor was in the femoral neck in four patients, in the acetabulum in one, in the proximal femur in one, and at the distal diaphyseal-metaphyseal junction of the femur in one.A trephine was used to remove the tumor under computed tomography guidance during a short general anesthesia.No serious complications were recorded. Full weight bearing was allowed starting at the forty-eighth hour in six of the seven patients. Immediate pain relief and a full recovery were obtained in every case. Results were excellent in four patients and good in three after a follow-up of 14 to 44 months.Percutaneous drill-biopsy of osteoid osteomas is a valuable alternative to conventional surgery in patients with tumors at sites that are difficult to access. The technique allows early weight bearing and ensures a full recovery.