Faculty Bibliography

Purpose: We have previously shown that carriage of an IL1RN haplotype (CTA) was associated with substantially lower odds of radiographic severity (KL score, joint space width [JSW]) (Ann Rheum Dis. 2010). In this 24 month prospective study we assessed whether IL1-RN haplotypes predicted disease progression in patients with symptomatic knee OA. Methods: Ninety-seven (N=97) patients from NYUHJD who met ACR criteria for symptomatic knee OA were genotyped for single nucleotide polymorphisms (SNPs) in the IL-1b and IL-1RN genes. Standardized fixed-flexion radiographs were taken on all patients at baseline and 24 months. Radiographic progression of signal (more painful) knee OA was determined by change in JSW over 24 months. To account for variations in baseline JSW, we defined progression as greater than 30% joint space narrowing (JSN) of the diseased compartment over 24 months, rather than in change in absolute JSW in millimeters. Results: Decreases in JSW ranged from zero to 3.7 mm over the 24 months; 19 of 97 patients exhibited < 30% JSN. (Figure presented) Patients with the IL-1RN (rs419598/rs315952/9005) TTG haplotype exhibited increased radiographic knee OA severity at baseline compared to those without TTG (p>0.08). These TTG patients exhibited increased risk for radiographic progression at 24 months that approached significance based on <=30% JSN [OR = 2.85; 95%CI=0.68-11.67; p>0.15]. In contrast, OA patients with IL-1RN CTA haplotype showed decreased risk for JSN over 24 months in the signal knee [OR= 0.33; 95%CI=0.170-1.014; p>0.05]. Differences in reported VAS pain between the CTA and TTG group were significant at 24 months (p> 0.01), indicating that while these patients were not distinguishable by radiograph or symptoms at onset, IL1RN haplotype predicted symptomatic differences at two years. Finally, the TTG haplotype group of patients expressed relatively increased IL-1b gene expression [15.683 +/- 9.407 (p>0.0001)] as assessed by TaqMan QPCR in peripheral blood leukocytes. The TTG patients also exhibited decreased sIL-1Ra [283.64 +/- 36.4 pg/ml (p>0.001) in plasma samples compared to IL-1RN CTA haplotype protective groups [IL-1b (fold change), 5.444 +/- 10.083; sIL-1Ra, 370.35 +/- 43.3pg/ml] of patients respectively. Conclusion: IL-1RN gene family polymorphisms, which appear to affect host production of IL-1Ra, merit evaluation as biomarkers that predict the risk of progression in patients with symptomatic knee OA

Purpose: There is insufficient understanding regarding how generalized OA involving the hand and knee differs from isolated knee OA, which may result from other factors such as obesity or trauma. The purpose of these studies is to determine whether the presence of hand OA involving interphalangeal (IP) and first carpometacarpal (CMC) joints, alone or in combination, predicts progression of patients with symptomatic knee OA. Methods: Hand radiographs were obtained on 94 patients at NYUHJD who met ACR criteria for symptomatic knee OA, and who were enrolled in a two-year NIH-sponsored prospective study. The patients completed standardized fixed-flexion knee radiographs at baseline and 24 months, with progression the signal (more painful) knee OA determined by change in joint space width (JSW) and KL score. For these analyses, the patients were separated into two groups by results on their signal knee: 17 progressors, defined by at least 30% decreased JSW over 24 months, and 77 non-progressors. For each set of hand x-rays, 2 radiologists evaluated 18 IP joints and 2 CMC joints for joint space narrowing and/or osteophytes, and whether or not there was erosive change at the IP joints; we averaged the scores from the two readers. Results: Kappa scores between the two scoring radiologists for the IP and CMC joints, and for the presence of erosive IP disease, were 0.79, 0.87 and 0.96, respectively. The overall mean IP score was 5.6 and 1st CMC score was 0.9, while medians were 5 and 1.0, respectively. The 17 progressors had a higher average IP (but not CMC) score than the non-progressors, 7.2+/- 5.4 vs. 5.0+/-4.6, p=0.13. Since the IP scores were not normally distributed, we further analyzed data by dichotomizing the study populations into two groups using the median IP total (5) as the cutoff point. When so analyzed, the presence of hand OA increased the odds ratio of knee OA progression to 2.8 (p=0.096). Of interest, the severity of knee OA correlated with hand OA scores: the average total hand OA scores (out of 20 joints) increased with baseline KL score, with mean scores of 3.8+/-5.5, 6.1+/-6.1 and 7.2+/-5.6 for KL 1 to 3 (p=0.06). There is also an increasing trend of total hand OA joint scores by KL score (p=0.042) when dichotomized around the median (5 joints), and with IP scores alone (p=0.026). The 8 patients with radiographic evidence of erosive IP disease, as compared with the 31 non-erosive IP OA patients (>5 IP joints) and the 54 without IP OA, demonstrated faster knee OA progression over 2 years by average KL increases (1.00, 0.35, 0.30) and decreases in joint space width (0.65, 0.56, 0.36), although perhaps given small numbers, this was not statistically significant (p=0.839). Conclusions: In cross-sectional analysis, the quantitative burden of hand OA correlates with the radiographic severity of knee OA (KL). Moreover, radiographic hand OA at the IP joints, but not at the 1st CMC joint, predicts more rapid progression of knee OA. Erosive IP disease may be an even stronger predictor than non-erosive IP disease of accelerated progression of knee OA

Osteoblastoma is an extremely rare entity that represents less than 1% of all bone tumors, and affects twice as many males as females with peak incidence between 15 and 20 years. Osteoblastomas commonly affect axial bones, long bones, bones of the foot and hand, and less commonly the pelvis, scapula, ribs, and clavicle. Osteoblastoma does not have a classic presentation, but can vary with the location and size of the tumor. The main complaint is often progressive pain localized at the tumor site. Osteoblastoma is a benign tumor with an aggressive behavior. The treatment is wide surgical resection, otherwise it continues to enlarge and destroy the bone and surrounding structures. We report a 32-year-old male with an osteoblastoma of this sternum who was treated with an en-bloc resection and reconstruction with Marlex((R)) and a methylmethacrylate plate

Objective: To evaluate the relationship of quantitative assessment of Bone Marrow Lesions (BML) with knee OA severity by radiographic findings. Methods: 58 OA patients (mean age 62+/-10, mean BMI 27+/-3, 59% female) underwent standardized nonfluoroscopic fixed-flexion knee radiographs. Two radiologists read the X-rays for KL grade, joint space width (JSW), and, using the OARSI atlas, joint space narrowing (JSN) and osteophytes; interreader agreement was assessed using Kappas and concordance correlation coefficients. Linear and logistic regression analysis was performed to assess associations while controlling the effects of age, sex and BMI. 3T-MRI included sagittal T2-weighted fat saturated spin-echo images (TR/TE=4000ms/75ms, FOV=15cm, matrix=256x128, slice thickness=3.0mm, receiver bandwidth 130Hz/pixel) and in/out of phase of FLASH images. Compartment-wise (medial tibial, lateral tibial, medial femur, lateral femur) BML volumes were quantified with T2-weighted fat saturated images and in/out of phase images respectively. BML volumes were dichotomized for statistical analysis. Results: KL score was a significant predictor of total BML volume (OR = 8.41, p = 0.0235). Medial tibial JSW, OARSI medial JSN, and medial tibial plateau osteophytes approached significance as predictors of BML volume at the medial tibia (OR = 0.71, p = 0.0551; OR = 2.16, p = 0.0597; and OR = 2.68, p = 0.0875, respectively). OARSI lateral JSN was a significant predictor of BML volume at the lateral tibia (OR = 3.62, p = 0.0169). Lateral tibial plateau osteophytes were predictors of total BML volume (OR = 4.58, p = 0.0299) and of BML volume at the lateral tibia (OR = 2.31, p = 0.0685). Lateral femoral condyle osteophytes approached significance as a predictor for BML at the lateral femur (OR = 2.25, p = 0.0651). Furthermore, quantitative BML volume strongly correlated with total quantitative synovial volume measured on MRI (beta= 0.22, p = 0.0003). Conclusions: Our data indicate that BML volume on MRI is a characteristic feature of progressive stages of OA, which not only correlates with JSN and osteophytes, but does so in a compartment-specific way. The data suggest that the altered mechanical forces that promote compartmental disease in OA lead to BML, JSN and osteophyte formation. Whether BML further contribute to cartilage loss, and are therefore targets of therapeutic intervention, remains to be determined

Thermal ablation of tumors is a rapidly growing field that has found various applications in the musculoskeletal system. Radiofrequency ablation (RFA) has become the reference standard for treatment of most osteoid osteomas. More recently, RFA has been applied to several other forms of primary tumors and in the treatment and palliation of osseous metastases. Cryoablation using new closed systems has also become available for the percutaneous treatment of both primary and metastatic lesions, and the initial results have been promising

PURPOSE: To demonstrate that radiofrequency (RF) ablation can be used safely and effectively to treat selected cases of chondroblastoma. MATERIALS AND METHODS: Approval was obtained from institutional review boards, research was in compliance with HIPAA protocol. The need to obtain informed consent was waived for retrospective review of patient records. The records of patients with biopsy-proved chondroblastoma who were treated with RF ablation at two academic centers from July 1995 to July 2007 were reviewed. RF ablation was performed with a single-tip electrode by using computed tomography for guidance. Lesion characteristics were determined from imaging studies obtained at the time of the procedure. Symptoms were assessed before and 1 day after the procedure. Longer-term follow-up was obtained from medical records. RESULTS: Thirteen male and four female patients were treated (mean age, 17.3 years). The lesions were located in the proximal humerus (n = 7), proximal tibia (n = 4), proximal femur (n = 3), and distal femur (n = 3). The mean volume of the lesions was 2.46 mL. All patients reported relief of symptoms on postprocedure day 1. Three patients were lost to follow-up. Of the 14 patients for whom longer-term (mean, 41.3 months; range, 4-134 months) follow-up was available, 12 had complete relief of symptoms with no need for medications and full return to all activities. The patient who had the largest lesion of the study required surgical intervention because of collapse of the articular surface in the treatment area. Residual viable tumor was found at surgery. Another patient experienced mechanical problems that were thought to be unrelated to the RF ablation and was rendered pain-free after subsequent surgical treatment. CONCLUSION: Percutaneous RF ablation is an alternative to surgery for treatment of selected chondroblastomas. Larger lesions beneath weight-bearing surfaces should be approached with caution due to an increased risk of articular collapse and recurrence

OBJECTIVE: Femoroacetabular impingement is an important entity with well-described radiographic findings. One of the criteria of the cam type of femoroacetabular impingement is femoral head-neck dysplasia, denoted mathematically as the 'alpha angle.' Several observers have reported that direct measurement of the angle may not be necessary because subjective appraisal may yield similar results. We sought to scientifically determine the accuracy of a subjective assessment, using the calculated angle as the gold standard. MATERIALS AND METHODS: At 1.5 T, 50 consecutive patients' hips were evaluated on sets of oblique axial images. Two musculoskeletal radiologists recorded their subjective opinion as to the alpha angle using a confidence scale of 1-5. Direct mathematic measurement of the alpha angle was done by a third independent observer and correlated with the subjective results. Correlations between the subjective and measured angles and interobserver variation were calculated. RESULTS: Statistically, significant variability was seen in the subjective assessment of the alpha angle. When the alpha angle was > 55 degrees, the area under the receiver operating characteristic curve (AUC) was 0.606, indicating that visual assessment is a poor predictor of a wide alpha angle. Even in patients with a measured normal alpha angle (< 55 degrees), slightly fewer than half were subjectively thought to possibly, likely, or definitely have abnormal angles. Similarly, more than half of the abnormal cases (alpha angles > 55 degrees) were subjectively thought to possibly or probably be normal. CONCLUSION: Subjective assessment of alpha angles is suboptimal unless one is quite confident of a bone abnormality