[Dynamic magnetic resonance tomography of the sacroiliac joint: diagnosis of the early stages of a sacroiliitis].
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A 19-year-old woman sustained a vertical shear type pelvic fracture. Sacroiliac fixation using computed tomography (CT)-guided cannulated screws was performed for a left sacroiliac dislocation fracture, and a satisfactory result was obtained over time. Patients who have posterior instability of the lateral compression or vertical shear type do not obtain adequate stability by fixation of the anterior part alone; and they often have persistent residual pain, necessitating internal fixation of the posterior part later. Advantages of CT-guided sacroiliac screw fixation include precise evaluation of the degree of reduction and absence of nerve and vascular damage during the time the screw is inserted into the sacral body. This procedure is a useful, safe method owing to its minimal invasiveness in patients with unstable pelvic fractures that are reducible by manual manipulation or traction.
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Scintigraphic and radiometric investigation with 99mTc-pyrophosphate was carried out on the sacro-iliac joints of 79 patients: 48 with positive form of Behterev disease, 26 -- with probable form of the disease, 2 -- with Reiter syndrome and 2 -- with rheumatoid arthritis. Scintigraphy was combined with radiometric investigation (determination of sacro-iliac -- sacral index) with a view to obtaining quantitative information about the degree of accumulation of pyrophosphate in sacro-iliac joints. The data from the scintigraphic and radiometric investigations were juxaposed to clinical laboratory and X-ray investigations. Forty of the patients examined were HLA-B27 positive and 38 of them-HLA-B27 negative. Sacro-iliac index, determined in 13 healthy subjects (26 sacro-iliac joints) was within the limits of 1.18 +/- 0.094. The average value of the index of the 78 patients examined was 1.41 +/- 0.20. The index, during the first and second X-ray stage was 1.43 +/- 0.13 and 1.45 +/- 0.19 resp. The values decreased to 1.39 +/- 0.18 during the third X-ray stage, whereas in the fourth stage with completely ankylosis of the joints, the index was 1.20 +/- 0.07, being close to that of the control group of healthy subjects.
We treated a 62-year-old man with intermittent polyarthritis whose neck pain was prominent. Progressive deformities, limited neck motion, and the appearance of subcutaneous nodules prompted his admission to the hospital. The diagnosis of gout was established; the erosive and destructive changes in C6-7 were believed to be due to gout as well. Cervical spine involvement, although rare, can occur in gout.
A photogrammetric method was used to measure the range of motion of the iliosacral joint in a two-dimensional in-vitro model. The results were compared with values reported in the literature. The influence of morphological and histopathological parameters was simultaneously studied on the same objects. This method which does not use radiation or metal implants leads to comparable values. Three-dimensional in-vivo studies using similar photogrammetric methods can achieve the required accuracy in a less invasive way.
The sacro-iliac joint of a patient who had been ill with ankylosing spondylitis for half a year was investigated histologically at necropsy. Two basic histological phenomena were apparent: inflammation and aggressive proliferating chondroid metaplasia at the chondro-osseous junction and in the subchondrium. Joint cartilage degeneration, joint cartilage fusion, capsule ossification and subchondral bone apposition were observed as epiphenomena at the sacro-iliac joint. Both basic morphological phenomena are due to the same cause which has not yet been clarified. They progress independently of each other with varying intensity. This assumption explains differing opinions and the relation of inflammation and pathological ossification of the skeletal axis as well as the unsatisfactory objective results of treatment. Only a combination therapy directed against both morphological basic phenomena will result in an objective therapeutic success and not only in a symptomatic improvement of ankylosing spondylitis.
PURPOSE: The purpose of this study was to evaluate the pattern of tumour spread across the SI articulation, correlating with cadaveric anatomic observations, in order to better understand the local spread of tumour and to assist in the assessment of local staging. MATERIAL AND METHODS: Twenty-four consecutive patients (14 male, 10 female; age range 22-89 years, mean 52 years) with primary bone tumours of the iliac bone or sacrum abutting the SI joint, in whom surgical resection of the SI joint was performed, were studied following institutional ethics approval. In all patients, preoperative magnetic resonance (MR) imaging studies of the pelvis and SI joint were reviewed for imaging evidence of transarticular extension across the SI joint. Gross pathologic and histologic assessment of possible transarticular SI joint tumour extension was performed in all patients. Nine cadaveric pelvic specimens without pelvic neoplastic disease (4 male, 5 female; age range 20-84 years, mean 59 years, median 58 years) were anatomically dissected and the articular anatomy of the SI joint examined macroscopically. RESULTS: Twelve of the twenty-four patients demonstrated imaging and histological evidence of transarticular SI joint invasion. Eight tumours infiltrated only the interosseous ligamentous aspect of the SI joint. In the remaining four cases, extensive tumour infiltrated both the cartilaginous and ligamentous aspects of the joint. No case showed tumour involvement isolated to the cartilaginous aspect of the joint. Among the cadaveric specimens studied, degenerative changes were found involving the majority of cases (6/9), with cartilage thinning and fibrillation and antero-superior marginal osteophytes seen involving the cartilaginous portion of the SI joint articulation. Four of the nine specimens demonstrated central ossification bridging the iliac and sacral aspects of the ligamentous (interosseous) SI joint. CONCLUSION: Tumour invasion across the SI articulation favours its interosseous ligamentous portion. Factors influencing transarticular tumour extension and its preferential course across the interosseous component of the articulation have been discussed. It is particularly important to assess the interosseous ligamentous portion of the SI articulation when locally staging primary pelvic bone tumours subjacent to the SI articulation, as this will have a significant impact on planning surgical management.
Using a quantitative method, scintigraphy of SI joints was performed by means of 99m technetium pyrophosphate in 21 patients with definite ankylosing spondylitis, in 17 control patients, and in 26 patients 'at risk', i.e. patients with complaints of back pain of the inflammatory type where on clinical grounds there was a possibility of sacroiliitis developing but with normal x-ray findings of the SI joints. Radioisotope uptake was higher in the ankylosing spondylitis group than in the other two groups, although the difference was not statistically significant with regard to the group 'at risk'. The high variance in the three groups considerably reduces the diagnostic value of the examination. In the ankylosing spondylitis group no correlation was found between radioisotope uptake and age, duration of disease, erythrocyte sedimentation rate, or radiological stage of scaroiliitis. Since the specificity and sensitivity of scintiscanning are lower than that of clinical and radiological diagnosis of the disease, we conclude that scintigraphy is not very helpful in the early diagnosis of sacroiliitis, at least by the techniques used here.
During a two year period, sagittal fractures of the wing of the ilium were diagnosed in 10 Thoroughbred horses. All were spontaneous fractures sustained during normal exercise in training and racing, with no history of inciting trauma. When ultrasound scans of the surface of the pelvis were performed, the fracture was clearly visible as a discontinuity of the sacral wing of the ilium. In 3 horses, an irregular contour suggestive of periosteal callus was seen in the vicinity of the acute fracture. All horses examined by gamma scintigraphy had a focal increase in uptake of isotope just lateral to the tuber sacrale. Nine of the horses were treated conservatively by rest. The other horse had bilateral fractures and was subjected to euthanasia at the time of the injury. Six horses returned to full training, and 2 subsequently won, without recurrence of lameness.
Scintillation counting of the sacro-iliac bones using technetium pyrophosphate or diphosphate is a simple examination without danger. The uptake opposite each sacro-iliac bone is assessed by reference to that of the lumbar spine visible on the film. A study of a control group of 81 subjects permits one to determine the existence of variations in relation to age: the fixation is high in subjects under the age of 20 years and reduced in adults aged over 50 years. The 44 controls from 20 to 50 years, permit one to retain as reference value, the ratio 1.14 for the right sarco-iliac bone and 1.11 for the left sarco-iliac bone with a confidence interval of 0.13. There was noted a significantly high uptake during arthritis. Whether this was the axial form (40 cases) or the peripheral from (7 cases) and during Reiter's syndrome (15 cases). This hyperfixation was more frequent and more important when the sacro-iliac involvements (whether accompanied or not by radiological signs) were the cause of inflammatory pain. Increased uptake was also noted during other forms of chronic inflammatory rheumatism: rheumatoid arthritis (10 cases). Chronic inflammatory rheumatism (unclassifiable) 20 cases. It thus seems that one may retain in many cases the existence of sacro-iliac inflammatory changes without the latter being necessarily accompanied by clinical or radiological signs. The discovery of hyperfixation of the sacro-iliacs during chronic inflammatory rheumatism is further evidence in favour of the diagnosis of sacro-iliac arthritis but should be interpretated in the light of the general context.
Many cartilage matrix proteins or domains such as collagen types II, IX, and XI, GP39, AG1, VG1, and LP are potential antigens that might induce polyarthritis in susceptible animals (Table 1). Ordinarily, spondylitis is not a feature of polyarthritis induced with collagen types II, IX, and XI, GP39, cartilage matrix protein (matrilin-1) and cartilage LP. It seems that only the proteoglycans aggrecan and versican are capable of inducing sacroiliitis and spondylitis. Both molecules are structural proteins in intervertebral discs. Moreover, the arthritogenic or spondylitogenic epitopes of both molecules have been localized to the homologous N-terminal G1 globular domains. This region of versican and aggrecan is highly conserved, with 52% identity of amino acids. The homology is seen exclusively in the G1 domain and is concentrated between residues 115 and 332 (AG1 numbering) near the natural cleavage DIPEN site of aggrecan [84, 85]. Extra-articular pathology is often seen in rheumatic diseases, especially in AS. Other tissues, such as the sclera of the eye [86] and the media of the arteries [86, 87], also contain type II collagen, AG1, VG1, and LP, and versican is present in the central and peripheral nervous systems. Thus, there is the potential for an immune response against cartilage G1 and LP to be directed against related structures in extra-articular tissues. The presence of versican in the tendon and trochlea of the human superior oblique muscle might account for the occurrence of transient attacks of acquired Brown syndrome in patients with juvenile and adult forms of chronic RA [88]. Thus, it will be interesting to determine whether or not extra-articular expression of these cartilage proteins is closely related to extra-articular pathogenic expression in rheumatic diseases. Uveitis develops in VG1-immunized BALB/c mice, which is not seen in AG1-, and LP-treated animals. There is evidence that aggrecan and LP are also localized at these sites in the eye, but only immunity to versican can induce uveitis. In sacroiliitis and enthesitis of AS patients, the inflammation is associated with chondrometaplasia. In versican-induced sacroiliitis, replacement of cartilage by bone is seen with relatively little inflammation, somewhat resembling the situation in AS (Fig. 2). Versican can also stimulate chondrocyte proliferation [43]. Three conserved domains of human cartilage matrix molecules, namely VG1, AG1, and LP, show considerable homology [77, 79, 80, 89], and each is capable of inducing a unique inflammatory arthritis in BALB/c mice, with VG1 inducing only spondylitis [65], LP inducing peripheral arthritis with no spondylitis [90], and AG1 inducing axial and peripheral arthritis [66, 91]. It remains a mystery why such similar molecules cause different pathology in different target tissues. The exact immunopathogenic mechanisms deserve further study.
Most traumatic injuries of the sigmoid colon are penetrating, such as those due to stab and bullet wounds, but an occasional patient may have a perforated colon as a result of a pelvic fracture. Such lesions may be occult, resulting in delayed diagnosis, with substantial morbidity. Injury to the sigmoid colon in association with sacroiliac fracture has apparently not been described in the English-language literature. This paper reports such a case and describes the mechanism of injury and its recognition.