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Resume La prise en charge des spondylodiscites infectieuses est complexe et multidisciplinaire. Survenant chez des patients souvent âges et comorbides, elle necessite une bonne collaboration entre rhumatologues, infectiologues, bacteriologistes et chirurgiens pour assurer une prise en charge optimale. La pierre angulaire reste l’antibiotherapie qui sera dans l’ideal introduite apres l’identification du germe causal. L’evaluation clinique et radiologique initiale permettront de choisir au mieux la strategie d’immobilisation. Un lever le plus precoce possible sera entrepris pour eviter les complications de decubitus. La presence d’anomalies neurologiques initiales ou de collections importantes fera discuter une prise en charge chirurgicale. Enfin, le monitoring de l’efficacite et de la tolerance du traitement sur le court, moyen et long terme sera indispensable pour attester de la guerison de l’infection et detecter de potentielles sequelles. Dans cette revue, nous detaillerons un a un ces differents temps de la prise en charge.

Resume Objectif Proposer des recommandations pour une utilisation pertinente de l’echographie dans la polyarthrite rhumatoide (PR) en pratique quotidienne, fondees sur les donnees de la litterature et l’opinion d’experts en echographie osteo-articulaire. Methodes A partir d’une analyse systematique de la litterature, un comite scientifique a selectionne des thematiques et questions pertinentes pour elaborer une premiere version des recommandations. Celles-ci ont ete soumises a un groupe d’experts en echographie osteo-articulaire selon une procedure Delphi, permettant l’elaboration d’une version preliminaire des recommandations qui ont ensuite ete reformulees et validees par un groupe d’experts elargi en evaluant leur pertinence, leur comprehensibilite et leur exhaustivite, au cours d’une reunion presentielle. Le degre d’accord des experts et la faisabilite de ces recommandations en pratique ont ete precises. Resultats A l’issue de 2 tours de Delphi, un consensus a ete obtenu sur 3 principes generaux, incluant les definitions des sites articulaires, tendineux et osseux a evaluer, et 10 recommandations. Elles soulignent l’interet de l’echographie pour aider au diagnostic de PR devant des arthralgies inflammatoires ou une oligoarthrite inclassee et pour evaluer l’etendue de l’atteinte inflammatoire et structurale initialement. Elles positionnent cet examen au cours du suivi et une fois la remission clinique obtenue avant d’envisager la decroissance therapeutique. Elles precisent son interet pour aider a la realisation des gestes techniques. Conclusion Ces 10 recommandations consensuelles devraient permettre une homogeneisation ainsi qu’une optimisation des pratiques cliniques, conduisant a ameliorer la prise en charge des patients presentant une PR.

Resume Objectifs La plupart des etudes retrouvent une majoration du risque de fractures vertebrales chez les patients acromegales, malgre une densite minerale osseuse normale. Nous avons etudie la prevalence des fractures vertebrales chez les patients acromegales de moins de 80 ans suivis au CHU de Nantes. Methode Etude transversale monocentrique realisee au CHU de Nantes de 1988 a 2018. Cinquante patients (18 femmes, 32 hommes) d’un âge median de 52,3 ans (27 -78 ans) ont ete inclus. Les fractures vertebrales etaient evaluees sur des radiographies conventionnelles des rachis lombaire et thoracique de face et de profil, selon la methode semi-quantitative de Genant. Nous avons egalement etudie les deformations vertebrales autres que les fractures, en utilisant 3 criteres : presence d’osteophytes, presence de pincement discal et aspect cuneiforme des vertebres. Nous avons analyse la densite minerale osseuse par absorptiometrie bi-photonique et le statut hormonal. Resultats Trois patients (6 %) presentaient une fracture vertebrale : une fracture de grade 1 et 2 fractures de grade 2 selon la classification de Genant, chez deux patients osteoporotiques et un patient osteopenique. Leurs deficits ante-hypophysaires etaient substitues. En considerant les deformations franches (osteophyte ou pincement discal ≥ grade 2 ou aspect cuneiforme), le rachis dorsal etait deforme chez 22 patients (44 %) et le rachis lombaire chez 21 patients (42 %). Conclusions Les patients acromegales presentaient une faible prevalence de fractures vertebrales, mais un nombre important de deformations vertebrales. Nous supposons que cette forte prevalence de deformations franches pourrait expliquer la forte prevalence de fractures vertebrales rapportee precedemment.

OBJECTIVE The aim of this study was to assess the magnetic resonance imaging (MRI) features associated with microbial pathogen detection by computed tomography (CT)-guided biopsy in patients with suspected septic spondylodiscitis. METHODS For the last 10-year period, we analyzed the medical records of patients who underwent MRI and CT-guided biopsy for suspected septic spondylodiscitis. Clinical characteristics were recorded. The following MRI features were assessed: edema or contrast enhancement of the intervertebral disc, adjacent vertebrae, epidural and paravertebral space, presence of abscess, and paravertebral edema size. A positive biopsy was defined by pathogen identification on bacterial analysis or the presence of granuloma on histology. Predictors of a positive biopsy were assessed with a logistic regression model. RESULTS We analyzed data for 61 patients (34 [56%] male; mean age, 59.9 ± 18.0 years); for 35 patients (57%), CT-guided biopsy was positive for a pathogen. The 4 MRI findings significantly associated with a positive biopsy were epiduritis, greater than 50% vertebral endplate edema, loss of intradiscal cleft, and abscess. The size of paravertebral edema was greater with a positive than negative biopsy (median, 15.9 [interquartile range, 11.3-21.3] vs 7.3 [4.6-12.9] mm; p = 0.004). On multivariable analysis, epiduritis was the only independent predictor of a positive biopsy (adjusted odds ratio, 7.4 [95% confidence interval, 1.7-31.4]; p = 0.006). CONCLUSIONS Epiduritis and the size of paravertebral edema on MRI are associated with detection of a microbial pathogen in suspected septic spondylodiscitis. For patients without these MRI signs, the need for further investigations such as enriched or prolonged cultures, a second CT-guided biopsy, or even surgical biopsy need to be discussed.

Objectives Patients with acromegaly appear to be at increased risk of vertebral fractures despite normal bone mineral density. We investigated the prevalence of vertebral fractures in a cohort of acromegalic patients under 80 years of age. Methods Monocentric cross-sectional study performed at Nantes University Hospital from 1988 to 2018. Fifty patients (18 females, 32 males) with a median age of 52.3 years (range: 27–78) were included. Radiological vertebral fractures were evaluated on conventional lumbar and thoracic spine radiographs using Genant's semiquantitative fracture assessment. We studied qualitative abnormalities of the spine using three criteria: osteophytes, disc-space narrowing and wedge-shaped vertebrae. We analysed bone mineral density and endocrine status. Results Three patients (6%) had a vertebral fracture: one grade 1 and two grade 2 according to Genant's assessment, with two osteoporotic and one osteopenic patients. They had no unsubstituted pituitary deficiency. Considering the frank deformations (osteophyte or disc narrowing ≥ grade 2 or wedge-shaped), the thoracic spine was deformed in 22 patients (44%) and the lumbar spine in 21 patients (42%). Conclusion Acromegalic patients had a low prevalence of vertebral fractures but had a significant amount of vertebral deformations. We speculate that this high prevalence of frank deformations could explain the previously reported high prevalence of vertebral fractures.

Objective To report on the characteristics and long-term course of rheumatic manifestations in Schnitzler syndrome (SchS). Methods A retrospective cohort study of patients with SchS followed between 2000 and 2020. Inclusion criteria included a diagnosis of SchS (Strasbourg criteria). All available bone scans were reviewed and scored according to the intensity and number of pathological sites. The scintigraphic score was compared with the clinical activity score, CRP level, and treatments. Results Twenty-five patients were included. Median age at diagnosis was 68 years. Eighty patients (72%) had SchS-related rheumatic pain. Most patients had a long-standing isolated rash before constitutional and/or rheumatic symptoms appeared. The monoclonal component level was usually very low (IgMκ in 22/25). Rheumatic pain predominated around the knees. Bone scans revealed abnormal tracer uptake in 15/18 (85%). The scintigraphic score correlated with clinical activity (r = 0.4, p r = 0.47, p p Conclusions Rheumatic manifestations are very prevalent in SchS. However, bone pain can be misleading and contribute to misdiagnosis. Bone scan abnormalities are very prevalent and correlate with disease activity and treatments. IL1-Ra has a dramatic and durable efficacy but may not be required in every patient early on.

Resume Les tendinopathies calcifiantes de la coiffe sont une des causes les plus frequentes de douleurs chroniques de l’epaule, impactant generalement la vie quotidienne et professionnelle des patients. Apres l’echec du traitement de premiere intention associant antalgiques/AINS, kinesitherapie et infiltration de corticoides, un geste d’exerese de la calcification sous echographie est generalement propose. Cette revue reprend les differentes techniques utilisees : lavage a une ou deux aiguilles ou fragmentation seule, en detaillant leur mise en œuvre, leur efficacite et leurs complications. Les trois techniques ont une efficacite semblant equivalente bien que peu d’etudes comparatives soient disponibles. Les complications rapportees sont peu severes, essentiellement des malaises vagaux au cours du geste et une recrudescence des douleurs dans les 3 a 4 mois suivant le geste. De rares cas de bursites septiques ont ete rapportes (4 en tout). Enfin, bien que la technique soit quasi exclusivement etudiee au niveau de l’epaule, d’autres localisations (hanche, genou, coude) ont egalement ete traitees avec succes.

Compression of roots/nerves can disrupt some of their functions, but does not necessarily cause pain. This is illustrated by the frequency of nearly asymptomatic spinal stenosis or disc herniations. In fact, pain of radiculopathies (and nerve entrapments) may mostly be the consequence of intraneural oedema induced by microscopical venous stasis around roots/spinal ganglia (or nerves) not or poorly shown by imaging. This narrative review first lists arguments for a role of congestion of vasa-nervorum in the pathophysiology of radiculopathies, including those induced by disc herniation and spinal stenosis, but also other sources of overpressures in spinal venous plexuses (pregnancy, vena cava atresia and thrombosis, portal hypertension, epidural varices, arterio-venous fistula, vertebral hemangioma or hemangioblastoma). It also details sources of venous congestion around nerves outside the spine, from pelvis (May-Thurner syndrome, Nut-cracker syndrome) to buttocks (superior and inferior gluteal veins), and even thighs and legs. A better recognition of a preeminent role of venous congestion in radiculopathies, plexopathies, and nerve entrapments, should have major consequences: (i) discard the dogma that compression is mandatory to induce root/nerve suffering, since root/nerve adherences in two locations can impair blood flow in vasa-nervorum through root/nerve stretching; (ii) implementation of sensitive techniques to visualise impingement of blood flow around or within roots and nerves; (iii) better prevention of roots/nerves adherence, or arachnoiditis induced by extravascular fibrin deposition secondary to venous stasis.; (iv) optimizing treatments dampening clot formation and/or extravascular fibrin leakage in the intradural/peridural spaces, or around roots/nerves, like guided injection of tissue plasminogen activator.

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Resume Objectifs Cette etude, menee dans une population de patients atteints de LES, avait pour objectifs (1) de decrire les atteintes articulaires echographiques (US), (2) d’estimer la correlation du nombre d’articulations cliniquement gonflees (NAG-C) et du SLEDAI clinique (SLEDAI-C) avec le NAG echographique (NAG-US) et le SLEDAI echographique (SLEDAI-US), (3) de mettre en evidence les caracteristiques specifiques des patients lupiques selon les observations en mode Doppler puissance (DP). Methode Nous avons inclus dans cette etude transversale multicentrique 151 patients adultes consecutifs atteints de LES. L’evaluation comprenait un examen clinique standardise des articulations, une echographie en mode B et en mode Doppler puissance (DP) sur 40 articulations et 26 tendons, en aveugle des resultats de l’examen clinique. La correlation entre l’examen clinique et l’echographie en mode B a ete calculee au moyen du coefficient de correlation intra-classe (ICC [Intervalle de confiance a 95 %]). Resultats Un taux tres eleve d’anomalies infracliniques echographiques a ete observe chez les patients asymptomatiques : l’existence d’au moins une manifestation echographique a ete retrouvee chez 85 % des patients qui ne presentaient aucun symptome articulaire. Parmi eux, 46 patients (87 %) avaient un antecedent d’atteinte articulaire. L’epanchement articulaire (108 patients), l’hypertrophie synoviale (HS, 109 patients) et la synovite (61 patients) etaient les anomalies les plus frequemment retrouvees. Un signal DP positif des articulations ou des tendons (grade > 1) a ete retrouve dans 44 % des cas (67/151). Des synovites ont ete detectees principalement aux articulations MCP et des poignets. Malgre la faible correlation de l’examen clinique au NAG-US en mode B, une bonne correlation du SLEDAI clinique au SLEDAI echographique a ete retrouvee. La comparaison des patients atteints de LES avec et sans signal DP n’a pas mis en evidence de caracteristiques specifiques du LES. Conclusion L’echographie est une methode d’imagerie qui a prouve son utilite pour l’evaluation des atteintes articulaires dans le LES mais qui ne modifiait pas de maniere significative le score SLEDAI.

ObjectiveSteroid injections are common after an ultrasound-guided puncture and lavage (UGPL) of calcific tendonitis of the rotator cuff. However, steroids may prevent calcification resorption and negatively affect tendon healing. Our study was designed to determine whether saline solution was non-inferior to steroids in the prevention of acute pain reactions in the week following UGPL.MethodsThis was a randomised, double-blinded, controlled non-inferiority trial with 12-month follow-up. We included 132 patients (66 in each group) with symptomatic calcification measuring more than 5 mm. Patients received 1 mL of saline or steroid (methylprednisolone 40 mg) in the subacromial bursa at the end of UGPL. Primary outcome was the maximal pain during the week following the procedure with a prespecified non-inferiority margin of 10 mm (0–100 visual analogue scale). Secondary outcomes included pain at rest and during activity, function (disabilities of the arm, shoulder and hand score) and radiological evolution of the calcification over the 12-month follow-up.ResultsThe estimated mean difference in the first week’s maximal pain between these two groups was 11.76 (95% CI 3.78 to 19.75). Steroids significantly improved VAS pain at rest and during activities, as well as function at 7 days and 6 weeks. They did not change the rate of calcification resorption, which occurred in 83% and 74% of patients at 12 months in the saline and steroid groups.ConclusionNon-inferiority of saline when compared with steroids could not be established. However, steroid injection improved pain in the 6 weeks following the procedure, and function in the 3 months after, with no significant effect on calcification resorption.Trial registration numberNTC02403856.

The aim of our study was to describe spine immobilization in a multicentric cohort of vertebral osteomyelitis (VO), and evaluate its association with neurological complications during follow-up.We prospectively included patients from 2016 to 2019 in 11 centers. Immobilization, imaging, and neurological findings were specifically analyzed during a 6-month follow-up period.250 patients were included, mostly men (67.2%, n=168). Mean age was 66.7±15 years. Diagnosis delay was 25 days. The lumbo-sacral spine was most frequently involved (56.4%). At diagnosis, 25.6% patients (n=64) had minor neurological signs and 9.2% (n=23) had major ones. Rigid bracing was prescribed for 63.5% (n=162) of patients, for a median of 6 weeks, with variability between centers (P0.001). The presence of epidural inflammation and abscess on imaging was associated with higher rates of rigid bracing prescription (OR 2.33, P=0.01). Frailness and endocarditis were negatively associated with rigid bracing prescription (OR 0.65, P0.01, and OR 0.42, P0.05, respectively). During follow up, new minor or major neurological complications occurred in respectively 9.2% (n=23) and 6.8% (n=17) of patients, with similar distribution between immobilized and non-immobilized patients.Spine immobilization prescription during VO remains heterogeneous and seems associated inflammatory lesions on imaging but negatively associated with frailness and presence of endocarditis. Neurological complications can occur despite rigid bracing. Our data suggest that in absence of any factor associated with neurological complication spine bracing might not be systematically indicated. We suggest that spine immobilization should be discussed for each patient after carefully evaluating their clinical signs and imaging findings.

Resume Les tendinopathies calcifiantes de la coiffe des rotateurs sont dues a des depots d’apatite dans les tendons de l’epaule qui provoquent des douleurs chroniques invalidantes. Malgre la frequence de cette maladie qui concerne 10 a 42 % des epaules douloureuses, les mecanismes de cette mineralisation pathologique demeurent en grande partie inconnus. Dans les annees 1990, des etudes ont suggere un lien entre la formation de depots calciques et des cellules ayant l’aspect de chondrocytes identifiees a proximite des depots, dans une zone de fibrocartilage. On pensait a l’epoque que ces cellules etaient derivees des tenocytes, mais des cellules-souches de tendon capables de se differencier en chondrocytes ont ete isolees plus recemment. Les proprietes mineralisantes de ces cellules de type chondrocytaire, et notamment le role de la phosphatase alcaline, ne sont pas clairement etablis. Concernant la composition, ces depots contiennent de l’apatite carbonatee faiblement cristalline associee a des proteines, parmi lesquelles seule l’osteopontine a ete decrite comme un possible facteur de regulation. Lors de la resorption spontanee, la migration des cristaux d’apatite dans la bourse sous-acromiale provoque des douleurs severes et une limitation de mobilite. Des experiences in vivo et in vitro ont montre que les cristaux d’apatite pouvaient declencher un afflux de leucocytes et la secretion d’IL-1β et d’IL-18 en reponse a l’activation de l’inflammasome NLRP3. Neanmoins, les mecanismes conduisant a la resolution spontanee de cette inflammation et a la disparition de la calcification doivent encore etre elucides.

This review lists current evidences for a contribution of gut mycobiota to the pathogenesis of SpA and related conditions. Gut mycobiota has a small size as compared to bacterial microbiota, but an even greater inter- and intra-individual variability. Although most fungi (brought by food or air) are only transitory present, a core mycobiota of gut resident fungi exists, and interplays with bacteria in a complex manner. A dysbiosis of this gut mycobiota has been observed in Crohn's disease and sclerosing cholangitis, with decreased proportion of Saccharomyces cerevisiae and outgrowth of more pathogenic gut fungi. Fungal-induced lower number of commensal gut bacteria can promote translocation of some bacterial/fungal antigens through mucosae, and live fungi can also cross the epithelial border in Crohn's disease. This dysbiosis also lower the ability of bacteria to metabolize tryptophan into regulatory metabolites, consequently enhancing tryptophan metabolism within human cells, which might contribute to fatigue. Translocation of mycobiotal antigens like curdlan (beta-glucan), which plays a major role in the pathogenesis of SpA in the SGK mice, has been observed in humans. This translocation of fungal antigens in human SpA might account for the anti-Saccharomyces antibodies found in this setting. Contribution of fungal antigens to psoriasis and hidradenitis suppurativa would fit with the preferential homing of fungi in the skin area most involved in those conditions. Fungal antigens also possess autoimmune uveitis-promoting function. As genes associated with SpA (CARD9 and IL23R) strongly regulate the innate immune response against fungi, further studies on fungi contribution to SpA are needed.

Objectives The aim of this study was to show the usefulness of a mid-infrared fibre evanescent wave spectroscopy point of care device in the identification of septic arthritis patients in a multicentre cohort, and to apply this technology to clinical practice among physicians. Methods SF samples from 402 patients enrolled in a multicentre cohort were frozen for analysis by mid-infrared fibre evanescent wave spectroscopy. The calibration cohort was divided into two groups of patients (septic arthritis and non-septic arthritis) and relevant spectral variables were used for logistic regression model. Model performances were tested on an independent set of 86 freshly obtained SF samples from patients enrolled in a single-centre acute arthritis cohort and spectroscopic analyses performed at the patient’s bedside. Results The model set-up, using frozen–thawed SFs, provided good performances, with area under the curve 0.95, sensitivity 0.90, specificity 0.90, positive predictive value 0.41 and negative predictive value 0.99. Performances obtained in the validation cohort were area under the curve 0.90, sensitivity 0.92, specificity 0.81, positive predictive value 0.46 and negative predictive value 0.98. The septic arthritis probability has been translated into a risk score from 0 to 4 according to septic risk. For a risk score of 0, the probability of identifying a septic patient is very low (negative predictive value of 1), whereas a risk score of 4 indicates very high risk of septic arthritis (positive predictive value of 1). Conclusion Mid-infrared fibre evanescent wave spectroscopy could distinguish septic from non-septic synovial arthritis fluids with good performances, and showed particular usefulness in ruling out septic arthritis. Our data supports the possibility of technology transfer. Trial registration ClinicalTrials.gov, http://clinicaltrials.gov, NCT02860871.

Resume Les biofilms sont un mode de persistance, notamment a la surface des muqueuses, de 99,99 % des bacteries et levures, dans un etat metaboliquement peu actif. Elles y partagent au mieux les substrats, mais s’y controlent les unes les autres, via la secretion de peptides anti-microbiens. Elles y mutualisent aussi leur defense contre les menaces exterieures par la synthese d’un abri commun, traverse de fins canaux, fait d’un melange de glycoproteines (variables selon les especes de bacteries/levures), d’ADN extracellulaires bacteriens ou fongiques, et de molecules d’attachement, dont des molecules amyloides. Cette gangue et/ou l’etat dormant induit de certaines de ces bacteries/levures peut induire des faux negatifs des methodes de detection usuelle des agents infectieux, y compris PCR. Des bacteries peuvent aussi persister sous forme de biofilms intracellulaires au sein des macrophages et utiliser ces chevaux de Troie pour migrer des muqueuses aux articulations, dans lesquelles des biofilms extracellulaires peuvent se reformer grâce a la presence facilitante du liquide synovial. Certains biofilms peuvent induire un etat de phagocytose frustree des macrophages, source d’inflammation chronique, et/ou provoquer des phenomenes de NETose inefficace des polynucleaires. S’en suit une liberation d’ADN humain et de molecules citrullinees associees a des molecules amyloides bacteriennes, pouvant aboutir a une auto-immunisation a l’encontre de ces antigenes, cibles des auto-anticorps des rhumatismes inflammatoires. Les sels d’or, qui pouvaient induire des remissions tres durables des polyarthrites rhumatoides, sont ex vivo plus efficaces sur les biofilms que les antibiotiques. Des biofilms pourraient donc participer a l’initiation et/ou aux poussees des rhumatismes inflammatoires chroniques.

Resume L’interrogatoire et l’examen neurologique ne suffisent souvent pas au diagnostic de sciatique radiculaire, sur lequel repose surtout la reproduction de la douleur par la mise en tension des racines. Celle-ci est realisee d’ordinaire seulement par la manœuvre de Lasegue, dont le premier temps, jambe tendue, est denomme straight-leg-raising (SLR). Le test de Lasegue n’est toutefois pas parfait, ni toujours bien realise et interprete. La dorsiflexion de la cheville en fin de test (test de Braggard) peut etre plus sensible. Toutefois, ces deux tests peuvent etre parfois faussement negatifs, si bien que d’autres tests de mise en tension radiculaire peuvent aider a poser le diagnostic positif d’une souffrance sciatique en presence de douleurs atypiques d’un membre inferieur. Il s’agit premierement du signe de Christodoulides, qui correspond a la reproduction d’une douleur de topographie L5 lors de la realisation d’un test de Leri (femoral stretch test) ; deuxiemement, du signe de Slump, qui consiste sur un patient assis, a etendre la jambe douloureuse a l’horizontale puis a flechir passivement le cou (ou l’inverse) ; et troisiemement, du signe de la corde de l’arc, qui consiste lors de la manœuvre de Lasegue, une fois le genou un peu flechi apres avoir atteint le degre maximal d’elevation passive du membre douloureux, a appuyer sur le trajet des nerfs peroniers et tibiaux dans le creux poplite pour reproduire ou non la douleur connue du patient. La combinaison de tous ces tests pourrait beaucoup ameliorer tant la sensibilite que la specificite de l’examen clinique des sciatiques.

Resume Objectif L’articulation tibio-fibulaire proximale (TFP) est une articulation souvent oubliee, pourtant impliquee dans de nombreux processus pathologiques. Il n’existe pas a notre connaissance d’etude d’echo-anatomie descriptive permettant une standardisation des coupes echographiques de cette articulation. L’objectif de notre etude etait de decrire des coupes standardisees de l’articulation TFP en echographie en partant d’une etude anatomique puis en confirmant la faisabilite de ces coupes sur une serie de volontaires sains. Methodes Le premier temps de l’etude a consiste en la dissection d’articulations TFP sur 3 cadavres. Par la suite, 20 patients volontaires sains ont beneficie d’une echographie de l’articulation TFP, par un seul operateur. 3 coupes standardisees ont ete realisees : une coupe transversale anterieure oblique, une coupe coronale, et une coupe transversale posterieure oblique. Les elements musculo-ligamentaires environnants ont ete analyses. Resultats 20 volontaires sains d’âge median de 28 ans (minimum 21 ans, maximum 64 ans) ont beneficie d’une echographie de l’articulation TFP droite. L’interligne articulaire etait visualise dans 100 % des cas sur les 3 coupes. La coupe transversale anterieure oblique a permis d’analyser le ligament tibio-fibulaire proximal anterieur (LTFPA) dans 100 % des cas. La coupe coronale a permis d’identifier les arteres geniculees infero-laterales et recurrentes tibiales posterieures dans 90 et 85 % des cas, et l’insertion distale du ligament collateral fibulaire dans 100 % des cas. La coupe transversale posterieure oblique a permis de reperer le tendon poplite, le ligament arque et le ligament tibio-fibulaire proximal posterieur (LTFFP) chez 16 (80 %), 7 (35 %) et 2 (10 %) patients. Conclusion Nous avons realise une etude en 2 temps : une etude cadaverique puis une etude echographique sur volontaires sains, ayant permis de definir 3 coupes standardisees : une coupe transversale anterieure oblique, une coupe coronale et une coupe transversale posterieure oblique. Il s’agit de la premiere etude de ce genre a notre connaissance. La mise en place de coupes standardisees et la connaissance de l’aspect echographique de l’articulation tibio-fibulaire proximale en condition physiologique permet son utilisation en pratique clinique quotidienne.

Objective: \ud We undertook this study to examine microRNA (miRNA) expression across rheumatoid arthritis (RA) phenotypes, along with the effects and mechanisms of action of miRNA‐17‐5p (miR‐17).\ud \ud Methods: \ud A miRNA array was performed in synovial tissue biopsied from patients with naive erosive RA (n = 3) and patients with nonerosive RA (n = 3). MicroRNA‐17 lipoplex was delivered intraarticularly in the murine collagen‐induced arthritis model. Clinical, histologic, and structural effects were studied over the course of arthritis. In‐depth studies of the mechanisms of action of miR‐17 were performed in primary RA fibroblast‐like synoviocytes (FLS) isolated from synovial tissue.\ud \ud Results: \ud Fifty‐five miRNAs including miR‐17 were reduced in erosive RA. The miR‐17 transfection into arthritic paws reduced the clinical inflammation score between day 2 and day 7 (2.8 versus 1.9; P = 0.03). Synovial B cell, T cell, macrophage, and polynuclear neutrophil infiltration was significantly reduced. Structural damage was also decreased, as shown by a reduction in the number of osteoclasts detected using tartrate‐resistant acid phosphatase staining (osteoclast surface/bone surface 32% versus 18%; P = 0.005) and erosion score by computed tomography analysis (2.9 versus 1.7; P = 0.023). Proinflammatory cytokines from the interleukin‐6 (IL‐6) family and IL‐1β expression were also significantly reduced, but tumor necrosis factor was not. MicroRNA‐17 directly targeted the 3′‐untranslated regions of STAT3 and JAK1. STAT3 and JAK1 messenger RNA (mRNA) and protein expression were reduced in RA FLS following miR‐17 transfection. STAT3 and JAK1 mRNA and activation of STAT3, as assessed by immunohistochemistry, were also reduced in injected paws (% stained area 93% versus 62%; P = 0.035).\ud \ud Conclusion: \ud We demonstrate an antiinflammatory and antierosive role of miR‐17 in vivo. This effect involves the suppression of the IL‐6 family autocrine‐amplifying loop through the direct targeting of JAK1 and STAT3.

International audience; Lower lumbar radicular pain is a benign and frequent condition, mostly induced by disk herniation or osteoarthritis. The management of lower lumbar radicular pain is a public health problem, with multimodal management. Lumbar epidural steroid injections are considered as a treatment but their effectiveness remains controversial, with conflicting results. Injection via the caudal hiatus route (CH) under ultrasound (US) guidance has gained popularity because of accessibility or US equipment, absence of irradiation, feasibility and very few complications reported.A pragmatic prospective observational two-center (Rennes and Nantes University Hospitals) study was performed to evaluate the effectiveness of a single steroid (cortivazol) epidural injection delivered under US guidance via the CH on lower lumbar radicular pain. The primary outcome for success was achieving a numerical pain rating scale score (NPRS ≤ 3/10 at day 30 (D30) after epidural injection. The secondary endpoints were achieving a NPRS ≤ 3/10 at D30 without opiates and NSAIDs, level of analgesic and NSAIDs consumption, absence from work and occurrence of adverse events. Factors related to efficacy were not well established.

Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasegue test is the most popular method, which starts with the straight leg-raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognise lumbar root damage in patients with poorly defined pain in a lower extremity: firstly, the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; secondly, the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); and thirdly, the Bowstring test, which requires, at the end of the Lasegue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2 minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasegue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.

ObjectivesAnti-drug antibodies (ADA) are responsible for decreased adalimumab efficacy in axial spondyloarthritis (SpA). We aimed to evaluate the ability of methotrexate (MTX) to decrease adalimumab immunisation.MethodsA total of 110 patients eligible to receive adalimumab 40 mg subcutaneously (s.c.) every other week were randomised (1:1 ratio) to receive, 2 weeks before adalimumab (W-2) and weekly, MTX 10 mg s.c. (MTX+) or not (MTX−). ADA detection and adalimumab serum concentration were assessed at weeks 4 (W4), 8 (W8), 12 (W12) and 26 (W26) after starting adalimumab (W0). The primary outcome was the proportion of patients with ADA at W26. Four years after the study completion, we retrospectively analysed adalimumab maintenance in relation with MTX co-treatment duration.ResultsWe analysed data for 107 patients (MTX+; n=52; MTX-; n=55). ADA were detected at W26 in 39/107 (36.4%) patients: 13/52 (25%) in the MTX+ group and 26/55 (47.3%) in the MTX− group (p=0.03). Adalimumab concentration was significantly higher in the MTX+ than MTX− group at W4, W8, W12 and W26. The two groups did not differ in adverse events or efficacy. In the follow-up study, MTX co-treatment >W26 versus no MTX or ≤W26 was significantly associated with adalimumab long-term maintenance (p=0.04).ConclusionMTX reduces the immunogenicity and ameliorate the pharmacokinetics of adalimumab in axial SpA. A prolonged co-treatment of MTX>W26 seems to increase adalimumab long-term maintenance.

National audience; [No abstract available]

Objective.To investigate the uncommon co-occurrence of antisynthetase syndrome (AS) and sarcoidosis.Methods.From 2000 to 2015, patients with sarcoidosis were extracted from a retrospective multicentric cohort of 352 patients with AS.Results.Ten patients (2.8%; 6 men, 8 whites, 5 smokers, median age 50 yrs) had both AS and sarcoidosis. Most of the time, sarcoidosis and AS occurred simultaneously (n = 7). Antibody testing revealed anti-Jo1 (n = 5), anti-PL12 (n = 4), or anti-PL7 (n = 1). Finally, no patient had a worsening of muscular condition, 5 patients presented respiratory deterioration, 3 remained stable, and 2 showed improvement.Conclusion.Sarcoidosis may be underdiagnosed in patients with AS.

Objective The primary objective of this study was to compare the efficacy of local injection of a local anesthetic with a glucocorticoid versus a local anesthetic with saline to treat low back pain due to lumbosacral transitional vertebras (LSTV) with a pseudoarticulation. Methods A randomized placebo-controlled double-blind study was conducted in patients with unilateral low back pain ascribed clinically to LSTV. Patients were randomized to lidocaine plus saline (LS group) or lidocaine plus cortivazol (LC group) injected locally under computed tomography guidance. The primary outcome measure was the 24-hour mean visual analog scale (VAS) score for low back pain 4 weeks after the injection. Results Of 16 randomized patients, 15 were included in the analysis, 8 in the LS group and 7 in the LC group. The mean VAS pain score at week 4 was not significantly different between the two groups. In the two groups pooled, the mean VAS pain score decreased significantly from baseline to week 4, from 5.52 ± 0.99 to 3.86 ± 2.55 (P ≤ 0.05). The difference remained significant at week 12. Significant improvements occurred in the EIFEL disability index and items of the Dallas Pain Questionnaire. No adverse events were recorded. Conclusion In patients with chronic low back pain consistent with a symptomatic LSTV type II or IV in the Castellvi classification, a local injection of lidocaine with or without cortivazol may provide sustained improvements in pain and function. The underlying mechanism is unclear.

Resume Objectif L’objectif principal de cette etude etait de comparer l’efficacite des infiltrations anesthesie locale et corticoides versus anesthesie locale et serum physiologique dans le traitement des anomalies transitionnelles de la charniere lombosacree (ATLS). Methodes Les patients presentant une lombalgie unilaterale cliniquement liee a une ATLS ont ete randomises pour infiltration en double insu lidocaine et serum physiologique (LSP) versus lidocaine et cortivazole (LC) sous scanner. Le critere principal etudie etait l’evolution de l’EVA moyenne des 24 dernieres heures a 4 semaines. Resultats Seuls 16 patients ont ete randomises et 15 etudies (8 LSP et 7 LC). Il n’existait pas de difference significative entre les 2 groupes sur l’EVA moyenne a S4. Par contre si on regardait l’evolution de l’ensemble des patients, on notait une amelioration significative de l’EVA a S4 par rapport au baseline : EVA 5,52 ± 0,99 a S0 et 3,86 ± 2,55 a S4 ( p = Conclusion Dans les douleurs chroniques evoquant une origine ATLS avec neoarticulation de type II ou IV de la classification de Castellvi une infiltration peut etre proposee car elle peut ameliorer la douleur et la fonction durablement sans prejuger du mecanisme de l’amelioration.

Resume Les tendinopathies calcifiantes sont une cause frequence de douleurs d’epaule volontiers chroniques et invalidantes. Differentes options therapeutiques s’offrent a nous pour prendre en charge ces patients. Dans cette revue, les moyens et options strategiques dans cette pathologie sont discutes et permettent de degager certaines notions. Le traitement par kinesitherapie et anti-inflammatoires non steroidiens peut etre tente en premiere intention puisque le caractere symptomatique de la calcification peut etre un marqueur de l’evolution vers la resorption. Cependant, la duree necessaire a la disparition spontanee des symptomes peut etre longue et difficilement previsible. Ensuite, environ un tiers des patients pourront repondre sur le long terme a une infiltration de la bourse sous-acromio-deltoidienne, les autres recidivant souvent lorsque l’effet de la corticotherapie locale s’attenue. C’est a ce stade qu’une intensification du traitement peu se discuter. Les donnees actuelles semblent favoriser la ponction-lavage-fragmentation (PFL) de la calcification aux ondes de chocs. Cette derniere permet de maniere plus rapide et frequente la disparition de la calcification et de la douleur. Cette affirmation est a temperer au vu de la qualite et quantite de donnees disponibles. Le guidage de la PFL se fait maintenant sous echographie et avec une technique a une aiguille qui est equivalente au lavage a 2 aiguilles. Enfin, la chirurgie est clairement indiquee en cas d’echec d’une prise en charge medicale complete, n’ayant jamais montre sa superiorite par rapport aux autres therapeutiques.

International audience; Objective: To develop recommendations for the appropriate use of ultrasound in the management of rheumatoid arthritis (RA) in routine practice based on data from the literature and of experts opinion. Methods: Based on a systematic literature review, a scientific committee decided on themes and relevant questions to draw up an initial draft of recommendations. These recommendations were submitted to a group of experts in ultrasound in rheumatic and musculoskeletal diseases using a Delphi method, which produced preliminary recommendations. These were submitted to an expanded group of ultrasound experts for relevance, comprehensibility and comprehensiveness. The level of agreement of the experts were recorded during a face-to-face meeting. Results: Following two rounds of the Delphi, a consensus was reached on three overarching principles, including definitions of joints, tendons and articular sites to be examined, and 10 recommendations. These recommendations underline the benefit of ultrasound for the diagnosis of RA in cases of inflammatory arthralgia or undifferentiated arthritis as well as in assessing the extent of initial structural and inflammatory damage. They also define the role of ultrasound during follow-up or when considering treatment reduction once clinical remission has been achieved. Lastly, they illustrate the utility of ultrasound in facilitating technical procedures. Conclusion: These 10 consensus-based recommendations should harmonize and optimize clinical practice and thus improve the management of RA patients.

To describe the ultrasound abnormalities seen in septic arthritis and to assess their associations with clinical, biological, and radiological outcomes.We prospectively included 34 patients with septic arthritis of a native joint (knee, n=19; shoulder, n=6; hip, n=4; ankle, n=3; or wrist, n=2). Ultrasonography was performed to record synovial-membrane thickness and vascularity, joint effusion, and abnormalities of adjacent soft tissues, at baseline then 4days, 2weeks, and 3months later. Motion-range limitation of the affected joint was evaluated after 3months. Radiography was performed at inclusion and after 3months.Mean age was 63.7±17.6years. After 3months, 20 (58.8%) patients had motion-range limitation with worsening of the total radiological score (P0.001). The proportion of patients with synovitis was very high initially (96.4% at baseline, 96.3% after 4days, and 100% after 2weeks) then diminished to 77.8% after 3months (P=0.051). Synovial-membrane thickness was significantly higher after 4days and 2weeks compared to baseline (median, +17.3% and +20%, respectively; P=0.015) and was significantly lower after 3months compared to the earlier time points (median, -31.5%, P=0.015). A positive Doppler signal was common at baseline (n=18, 64.3%) then significantly less so after 3months (n=7, 25.9%; P=0.04). An unchanged or higher Doppler grade after 2weeks compared to baseline was associated with motion-range limitation at last follow-up (P=0.033).We report the first study on ultrasound evidence of synovitis, joint effusion, and soft tissue alterations at baseline and over time in patients with septic arthritis. Persistent synovitis and joint effusion 3months after starting antibiotic therapy was not associated with treatment failure. However, Doppler signal changes over the first 2weeks were associated with the 3-month functional outcome.

Resume L’echographie a pris ces dernieres annees une place importante dans la prise en charge des polyarthrites rhumatoides. De nombreuses publications ont confirme son interet dans le diagnostic de la maladie. Cet examen d’imagerie permet de detecter ou de confirmer des synovites infracliniques et ainsi de poser un diagnostic plus precoce de la maladie, introduire un traitement tot et eviter les dommages structuraux. Certains aspects typiques pouvant etre retrouves dans d’autres rhumatismes (psoriasique, microcristallins…) sont une aide dans le diagnostic differentiel d’une polyarthrite debutante. Son interet est egalement souligne comme aide dans la strategie therapeutique pour evaluer au mieux l’activite de la maladie. Dans ce contexte, la presence de signal Doppler parait l’anomalie la plus significative, capable de predire une evolution structurale future comme le risque de rechute chez les patients en remission. La remission echographique pourrait egalement etre un objectif pour guider l’intensification de nos traitements. Ces derniers points sont actuellement en cours d’investigation avec des resultats controverses. Des etudes de strategies incluant l’echographie dans l’adaptation des traitements seront donc necessaires dans les annees a venir pour mieux comprendre la place de l’echographie dans la prise en charge de la polyarthrite rhumatoide.

Resume La NETose suicidaire differe des autres morts cellulaires par l’expulsion d’ADN nucleaire melange a des proteines prealablement citrullinees par l’arginine deiminase 4 des neutrophiles. Ces « filets » (NETs) sont sertis de proteines des granules cytoplasmiques a activite bactericide. Lors de la NETose vitale, le neutrophile anuclee survit a cette expulsion et garde une capacite a migrer et a etre infecte par des bacteries vivantes. Lors des NEToses mitochondriales, seul les enzymes et de l’ADN mitochondrial oxydes sont ejectes. On retrouve au sein des NETs, les cibles de la plupart des auto-anticorps des polyarthrites rhumatoides (PR), lupus et vascularites. Les chevauchements cliniques et biologiques entre bronchectasies, PR, lupus et vascularites, designent la NETose comme un cofacteur inducteur probable de ces ruptures de tolerance. La NETose accroit la probabilite d’une association entre ces auto-antigenes et des antigenes infectieux au sein des biofilms, et d’une reaction auto-immune en cas de defaut de clairance de l’ensemble. La NETose aggrave le risque de lesions endotheliales et de thrombose. Cependant, la pathogenie des PR, lupus et vascularites ne se resume pas a ces auto-anticorps contre les NETs, et d’autres stimuli que les NETs pourraient aussi contribuer a leur induction, notamment d’autres circonstances d’hypercitrullination. La contribution d’infections intracellulaires a la rupture de tolerance aux NETs, pourrait etre plus etudiee, comme les infections « dormantes » qui favorisent aussi la citrullination pour entretenir leur dormance. La seule inhibition de la NETose pourrait en effet ne pas suffire a stopper les pathologies dysimmunitaires si des infections latentes persistent, dont au sein des neutrophiles.

Resume Objectifs L’objectif principal de cette etude etait de decrire les modifications echographiques observees au cours des arthrites septiques et leur relation avec l’evolution clinique, biologique et radiographique. Methodes Trente-quatre patients ayant une arthrite septique sur articulation native (19 genoux, 6 epaules, 4 hanches, 3 chevilles, 2 poignets) ont ete inclus de maniere prospective. Les donnees echographiques concernant la synovite (epaisseur, vascularisation), l’epanchement et les tissus mous adjacents etaient collectees a l’inclusion, 4 jours, 15 jours et 3 mois. La limitation articulaire etait evaluee a 3 mois. Une radiographie etait realisee a l’inclusion et a 3 mois. Resultats L’âge moyen etait de 63,7 ans (± 17,6). A 3 mois, 20 patients (58,8 %) avaient une limitation articulaire, associee a une aggravation du score radiologique total (p Conclusion Cette etude est la premiere evaluant, en echographie, la synovite, l’epanchement, l’atteinte des parties molles et leur evolution. La persistance d’une synovite et d’un epanchement articulaire a 3 mois n’est associee a un echec therapeutique. Cependant, l’evolution du signal doppler sur les 15 premiers jours etait associee au devenir fonctionnel a 3 mois.

Suicidal NETosis differs from other mechanisms of cell death by the release of a lattice, composed of DNA associated with proteins citrullinated by protein-arginine deiminase 4, from neutrophils. These 'NETs' are composed of granule-derived proteins with microbicidal activity. A similar type of release occurs during vital NETosis, in which anuclear neutrophils maintain their chemotactic ability and imprison live bacteria, even after NET extrusion. Mitochondrial NETosis is limited to the expulsion of oxidised mitochondrial DNA and cytoplasmic enzymes. NETs include the targets of most autoantibodies found in rheumatoid arthritis, lupus, and vasculitis. The clinical and biological overlaps sometimes observed between bronchectiasis and RA, RA and SLE, or SLE and vasculitis, implicate NETosis as a major triggering event common to these disorders. NETosis increases the possibility of association between autoantigens and infectious antigens in mucosal biofilms, impairing the clearance of pathogens and possibly triggering autoimmune reactions. NETosis aggravates these three conditions and increases endothelial damage and the risk of thrombosis. However, the pathogenesis of RA, SLE, and vasculitis is not confined to autoantibodies against NET components, and other mechanisms have been suggested to explain the breakdown of tolerance to NET autoantigens, such as hypercitrullination. The question of whether continuous presentation of autoantigens mixed with antigens from dormant intracellular pathogens (released following suicidal, vital, or mitochondrial NETosis) is required to induce and sustain autoimmunity must be addressed. Inhibiting NETois may not be sufficient to improve autoimmune disorders whereas such latent infections remain uncontrolled.

International audience; OBJECTIVES:Interleukin (IL)-38 is a newly characterised cytokine that belongs to the IL-1 family. This cytokine is expressed in the rheumatoid arthritis (RA) synovial tissue and IL-38 deficient mice have exacerbated arthritis. Here, we analysed the effect of IL-38 overexpression in the joints of arthritic mice, in human macrophages and synovial fibroblasts in vitro.METHODS:Articular injections of an adeno-associated virus (AAV) 2/8 encoding IL-38 were performed in collagen-induced arthritis (CIA), K/BxN serum transfer-induced arthritis (STIA) and antigen-induced arthritis (AIA) in mice. The effect of IL-38 overexpression was evaluated through clinical scores, immunohistochemistry, microCT, Luminex and RT-qPCR analysis. THP-1 macrophages were transduced with a lentiviral vector to overexpress IL-38.RESULTS:Clinical inflammatory scores were significantly decreased after AAV IL-38 injection in joints of mice with CIA and STIA, but not AIA. This decrease was accompanied by reduced macrophage infiltration and a decreased expression of Th17 cytokines (IL-17, IL-23, IL-22) and TNFα. However, IL-38 overexpression had no effect on cartilage or bone destruction. In vitro, the THP-1 monocytic cell line expressed less IL-6, TNFα and IL-23 after IL-38 overexpression. Conditioned media from these cells, containing released IL-38, also exert an anti-inflammatory effect on human primary macrophages and synovial fibroblasts from patients with RA.CONCLUSIONS:This study shows for the first time that IL-38 overexpression attenuates the severity of experimental arthritis. IL-38 may exert its anti-inflammatory effects by decreasing the production of proinflammatory cytokines by macrophages and synovial fibroblasts. This effect can lead to the development of novel treatment strategies in arthritis.

Resume L’echographie est couramment utilisee en rhumatologie pour etudier et guider les infiltrations des articulations peripheriques. Cette technique peut egalement fournir des informations utiles sur l’anatomie du rachis lombaire. Des etudes ont montre que l’examen echographique du rachis etait un outil efficace pour faciliter la realisation de l’anesthesie epidurale. L’objectif de cette etude etait de determiner si le choix du niveau optimal d’infiltration par echographie pouvait faciliter l’injection epidurale de corticoides dans les cas ou l’infiltration etait presumee difficile (IMC > 30 kg/m2, âge > 60 ans ou scoliose lombaire). Methodes Nous avons realise un essai comparatif randomise. Quatre-vingts patients ont ete randomises dans deux groupes : le groupe echographie (n = 40) qui a beneficie d’une echographie rachidienne prealable pour determiner le niveau lombaire optimal pour l’injection, ou le groupe de temoin (n = 40) chez qui le niveau d’injection a ete determine par palpation. Le critere d’evaluation principal etait la douleur ressentie durant la procedure, evaluee par l’echelle visuelle analogique (EVA). Resultats Nous avons constate une correlation positive entre la profondeur de l’espace epidural et l’IMC (p Conclusion L’echographie du rachis lombaire a pu etre realisee chez les patients presentant une affection lombaire, meme obeses et âges, et a permis de visualiser l’espace epidural. Toutefois, l’examen echographique prealable n’a pas permis d’attenuer la douleur lors de la procedure.