Cam deformity of the hip and personal identification of unidentified remains: two case reports of forensic anthropological interest

Cam-type deformities strongly predict total hip replacement within 5 years in those with early symptomatic OA: a prospective cohort study (check)

Figure: A lateral radiograph of the thoracic spine, left, shows bulky bridging osteophytes (arrowheads) along the anterior thoracic spine involving greater than 4 contiguous vertebral bodies compatible with DISH. A fracture along the inferior endplate of the T8 vertebral body is barely perceptible (arrow). A sagittal CT scan, center, of the thoracic spine shows an acute, minimally displaced fracture of the middle to inferior half of the T8 vertebral body which extends into and widens the disc space (arrow). Note the extent of DISH at levels above and below the fracture. A sagittal CT scan of the thoracic spine, right, further shows the extent of the fracture and intact bulky osteophytes above and below the fracture site (arrow).FigureFigureFigureA 66-year-old man was brought to the emergency department after being in a motor vehicle crash in which he was rear-ended with very low impact. He complained of point tenderness in the lower thoracic spine, and a trauma workup was performed according to routine protocol. Thoracic radiographs showed evidence of bulky bridging osteophytes consistent with DISH (diffuse idiopathic skeletal hyperostosis) but no evidence of a fracture at the site of pain. Further evaluation with CT showed a displaced fracture of the T8 vertebral body, which extended through the disc space. The patient was placed in a brace and managed for non-life-threatening injuries, and was then discharged home. DISH most commonly occurs in the thoracic spine, typically involving T7-T11 levels. Most patients with DISH are discovered incidentally on imaging because they are often asymptomatic. Occasionally, patients can present with pain, postural instability, neurological symptoms, or dysphagia. A DISH diagnosis is typically made on radiography, followed by cross-sectional imaging, namely CT or MRI. It is characterized by the presence of ‘‘flowing’’ bulky ossifications along the anterolateral margin of at least four contiguous vertebral bodies, preservation of the intervertebral disk height without any degenerative-related findings and absence of apophyseal joint ankyloses, or fusion at the costovertebral or sacroiliac joints. Imaging features are characteristic, but the differential diagnosis for DISH include seronegative spondyloarthropathies such as ankylosing spondylitis, reactive arthritis and psoriatic arthritis. Unlike ankylosing spondylitis, fusion of the sacroiliac, facet, and uncovertebral joints do not occur in DISH. Similarly, reactive arthritis has asymmetric sacroiliac joint involvement and psoriatic arthritis has a predilection for the cervical and lower lumbar spine, while DISH occurs most commonly in the thoracic spine. The fused spine in DISH or any preexisting fusion-type condition is more prone to fracture than a normal spine, and these fractures can involve multiple vertebral columns and can occur after even minor trauma. Patients with moderate to severe disease are more prone to fractures. The thoracic and cervical spine are most commonly involved. Hyperextension is the most common mechanism of injury resulting in DISH-related spinal fractures. Acute spinal fractures are not common, but can lead to neurological injury, nonunion, deformity, or death. DISH produces broad bridging osteophytes that encompass the anterior longitudinal ligament, annulus fibrosis, and paraspinal connective tissues. The bridging osteophytes are most robust at the intervertebral disk space, extending to the adjacent vertebral body. The proximal and distal thirds of a vertebral body, therefore, are typically covered by ossifications, leaving the mid-vertebral body above and below the site of attachment of the ossifications most vulnerable to fractures. Alternatively, fractures may occur at the end of a fused segment, involving the vertebral body at the junction of fused and unfused spine. Radiographs of the spine may be initially obtained if fractures are suspected following minor trauma. Fractures may not be easily detected with radiographs in the patients with DISH or any other spinal fusion because of overlapping bone and soft tissues and the presence of productive bone formation. It is therefore reasonable to conclude from this case that a low threshold must be used to order a CT scan of the spine if patients with spinal fusion sustain minor trauma. This will not only assist in making an early and accurate diagnosis but ensure appropriate and timely treatment for patients. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

A descriptive study of the association between diffuse idiopathic skeletal hyperostosis (DISH) and kyphosis. To investigate the association of DISH with Cobb angle of kyphosis in a large cohort of older subjects from the Health Aging and Body Composition Study. DISH and thoracic kyphosis are well-defined radiographical findings in spines of older individuals. Characteristics of DISH (ossifications between vertebral segments) reflect changes of spine anatomy and physiology that may be associated with Cobb angle of kyphosis. Using data from 1172 subjects aged 70 to 79 years, we measured DISH and Cobb angle of kyphosis from computed tomographic lateral scout scans. Characteristics of participants with and without DISH were assessed using the χ² and t tests. Association between DISH and Cobb angle was analyzed using linear regression. Cobb angle and DISH relationship was assessed at different spine levels (thoracic and lumbar). DISH was identified on computed tomographic scout scan in 152 subjects with 101 cases in only the thoracic spine and 51 in both thoracic and lumbar spine segments. The mean Cobb angle of kyphosis in the analytic sample was 31.3° (standard deviation = 11.2). The presence of DISH was associated with a greater Cobb angle of 9.1° and 95% confidence interval (95% CI) (5.6-12.6) among African Americans and a Cobb angle of 2.9° and 95% CI (0.5-5.2) among Caucasians compared with those with no DISH. DISH in the thoracic spine alone was associated with a greater Cobb angle of 10.6° and 95% CI (6.5-14.7) in African Americans and a Cobb angle of 3.8° and 95% CI (1.0-6.5) in Caucasians compared with those with no DISH. DISH is associated with greater Cobb angle of kyphosis, especially when present in the thoracic spine alone. The association of DISH with Cobb angle is stronger within the African American population.

This study compared Hounsfield unit (HU) values on computed tomography (CT) scans at fractured sites and each vertebral level of the whole spine among three groups: individuals with diffuse idiopathic skeletal hyperostosis (DISH), young individuals without DISH, and older individuals without DISH. A total of 71 patients with thoracolumbar fracture treated at our hospital from 2011 to 2022 were enrolled. Patients were divided into three groups: those with DISH (22 cases), young without DISH (Y non-DISH; age < 50 years, 24 cases), and older without DISH (O-non-DISH; age ≥ 50 years, 25 cases). The total spine HU values from C2 to S1 were measured from CT axial images, as follows: C2-C6, cervical spine; C7-T4, upper thoracic spine; T5-T9, lower thoracic spine; T10-L2, thoracolumbar spine; and L3-S1, lumbar spine. We compared (1) the HU values between fractured and non-fractured sites in each group (2) the HU values by site within each group, and (3) the HU values at each vertebral level of the whole spine between the three groups. In all groups, the mean HU values were significantly higher in the cervical spine than in the other regions (p < .05) and HU values increase at the fracture site (p < .05). The mean HU values for the lower thoracic, thoracolumbar, and lumbar spine were not significantly different in each group. The mean HU values below T6 were significantly lower in the DISH and O-non-DISH groups than in the Y-non-DISH group (p < .05). The mean HU values, except at T3, did not differ significantly between the DISH and O-non-DISH groups. Among patients with thoracolumbar injuries, spinal HU values were lower in older patients with and without DISH than in younger patients.

To determine the prevalence of cam-type deformities on hip magnetic resonance imaging (MRI) in young males. This was a population-based cross-sectional study in young asymptomatic male individuals who underwent clinical examination and completed a self-report questionnaire. A random sample of participants was invited for MRI of the hip. We graded the maximal offset at the femoral head-neck junction on radial sequences using grades from 0 to 3, where 0 = normal, 1 = possible, 2 = definite, and 3 = severe deformity. The prespecified main analyses were based on definite cam-type deformity grades 2 or 3. We estimated the prevalence of the cam-type deformity adjusted for the sampling process overall and according to the extent of internal rotation. Then we determined the location of the deformity on radial MRI sequences. A total of 1,080 subjects were included in the study and 244 asymptomatic males with a mean age of 19.9 years attended MRI. Sixty-seven definite cam-type deformities were detected. The adjusted overall prevalence was 24% (95% confidence interval [95% CI] 19-30%). The prevalence increased with decreasing internal rotation (P < 0.001 for trend). Among those with a clinically decreased internal rotation of < 30°, the estimated prevalence was 48% (95% CI 37-59%). Sixty-one of 67 cam-type deformities were located in an anterosuperior position. Cam-type deformities can be found on MRI in every fourth young asymptomatic male individual and in every second male with decreased internal rotation. The majority of deformities are located in an anterosuperior position.

ObjectivesAlthough diffuse idiopathic skeletal hyperostosis (DISH) is classically defined in the thoracic spine and the elderly population, there are case reports on the overlap between cervical DISH and spondyloarthritis (SpA).[1] We aimed to compare the frequency of cervical DISH in SpA vs controls to see whether there is a true increased frequency and if the presence of SpA impacts the onset age of DISH.MethodsThe SpA population included patients who were diagnosed with axial or peripheral SpA, followed at the Arthritis Centre and had cervical spine x-rays for screening purposes between 2016-2020. The control group included patients who presented to the Emergency Department and had a cervical spine x-ray for any reason. Four control patients for each SpA patient were age- and sex-matched. An investigator meeting on the definitions took place before the study, followed by an agreement exercise. Two radiologists independently scored the radiographs for the confidence level for the presence of DISH on a scale between 0-5. The ICC of the 2 radiologists were 0,935. For the study, the radiographs were read by 1 of the 2 radiologists, who distributed the cases and controls equally among the 2 radiologists. The confidence of Grade 3 was considered as DISH positive.ResultsOne-hundred-ninety-one SpA and 764 age- and sex-matched controls were included (Table). DISH was observed in 26 (13.6%) SpA patients and 108 (14.1%) controls, with similar frequencies (p=0.852). The age of DISH+ patients was statistically significantly lower in the SpA group than the control group (median (IQR); 54 (16) vs 59 (13); p=0.026). DISH was higher in males than females in both SpA (n:19/104 (18.3%) vs n:7/87 (8%); p=0.04) and control groups (n:74/416 (17.5%) vs n:35/348 (10.1%); p=0.003). There were 143 (74.9%) SpA patients with known HLA-B27 status. The frequency of DISH in HLA-B27(−) SpA patients was higher than HLA-B27(+) SpA patients numerically (n=14/65 (21.5%) vs n=8/78 (10.3%); p=0.063). Interestingly, HLA-B27 had different effects on the presence of DISH in subgroups: AxSpA patients (radiographic and non-radiographic combined) had more DISH if they were HLA-B27 positive (12.5% vs 8.7%), unlike the PsA, who had DISH exclusively if they were HLA-B27 negative (28.2% vs 0%).Table.Demographics and disease subgroupsConclusionThe frequency of DISH in SpA patients is similar to the general population. However, SpA patients develop DISH at an earlier age. Our observation of the differential impact of HLA-B27 on axSpA vs PsA may signal the different mechanisms impacting the spine in both diseases. [1.] Kuperus JS. Rheumatology (Oxford) 2018;57(12):2120-8.

Back-to-back: The co-occurrence of DISH and ankylosing spondylitis from early modern Poland

ObjectivesThe extension of diffuse idiopathic skeletal hyperostosis (DISH) from the low thoracic spine to the lumbar spine result in adjustment of spinal sagittal alignment in surgical patients. The aim of this study was to investigate changes in sagittal alignment and back pain in the thoracolumbar spine in nonsurgical DISH and control participants selected from a radiological database.MethodsParticipants in the DISH and the control group were selected by searching for “DISH or degenerative changes in the thoracic spine” in the radiology database of Taizhou Hospital between 2018 and 2021 using Resnick and Niwayama’s criteria. The subjects with spinal tumors, previous spinal surgery, vertebral fractures, inflammatory diseases, poor-quality radiographs, or loss of follow-up were excluded. Demographic and clinical characteristics were recorded retrospectively via the hospital information system and telephone follow-up. Segmental disc angles (SDAs), lumbar lordosis (LL), and bridge scores were analyzed using images of three-dimensional CT.ResultsThe final participants consisted of 51 individuals with DISH (DISH group) and 102 individuals without DISH (control group). Depending on the presence of thoracolumbar pain, the DISH group was divided into the DISH group with thoracolumbar pain (DISH+Pain) and the DISH group without thoracolumbar pain (DISH-Pain). The LL and SDAs of T11-T12 and T12-L1 were significantly greater in the DISH group than in the control group. In addition, the SDA of L1-L2 was significantly smaller in the DISH+Pain group than in the DISH-Pain group, whereas there was no significant difference in lumbar lordosis between the DISH+Pain group and the DISH-Pain group. The bridge scores in DISH+Pain group was larger in T10-T11 (p = 0.01) and L1-L2 (p < 0.01) spine segments than those in DISH-Pain group.ConclusionThe extension of DISH from thoracic to lumbar spine may increase lumbar lordosis and SDAs in the thoracolumbar spine. The DISH patients with more bony bridging and small L1-L2 SDA may be more likely have thoracolumbar pain. Adjustment of sagittal alignment of the spine in the development of DISH may be of clinical importance.

Background: This study investigated how diffuse idiopathic skeletal hyperostosis (DISH) influences clinical characteristics in patients with cervical ossification of the posterior longitudinal ligament (OPLL). Although DISH is considered unlikely to promote neurologic dysfunction, this relationship remains unclear. Methods: Patient data were prospectively collected from 16 Japanese institutions. In total, 239 patients with cervical OPLL were enrolled who had whole-spine computed tomography images available. The primary outcomes were visual analog scale pain scores and the results of other self-reported clinical questionnaires. Correlations were sought between clinical symptoms and DISH using the following grading system: 1, DISH at T3-T10; 2, DISH at both T3–10 and C6–T2 and/or T11–L2; and 3, DISH beyond the C5 and/or L3 levels. Results: DISH was absent in 132 cases, grade 1 in 23, grade 2 in 65, and grade 3 in 19. There were no significant correlations between DISH grade and clinical scores. However, there was a significant difference in the prevalence of neck pain (but not in back pain or low back pain) among the three grades. Interestingly, DISH localized in the thoracic spine (grade 1) may create overload at the cervical spine and lead to neck pain in patients with cervical OPLL. Conclusion: This study is the first prospective multicenter cross-sectional comparison of subjective outcomes in patients with cervical OPLL according to the presence or absence of DISH. The severity of DISH was partially associated with the prevalence of neck pain.

DISH is a common musculoskeletal disorder; however, the imaging features and disease continuum from early to advanced stages is poorly understood. The purpose of this study was to evaluate the prevalence of DISH and early-phase DISH in an American population and to assess the extent and pattern of ectopic mineralization across the thoracic spine. Data were retrieved in collaboration with the Rochester Epidemiology Project. We conducted a retrospective image evaluation of a sample of individuals over 19 years of age with CT of the thoracic spine from a Northern US catchment area. Stratified random sampling by age and sex was used to populate the study. We examined the prevalence and extent of ectopic mineralization along the thoracic spine using previously established criteria. A total of 1536 unique images (766 female and 770 male individuals) including 16 710 motion segments were evaluated for imaging features of the continuum of DISH. Collectively, 40.5% of all motion segments evaluated displayed evidence of ectopic mineralization in the thoracic spine. The prevalence of early-phase DISH was 13.2% (10.4% of female and 15.8% of male individuals). The prevalence of established DISH was 14.2% (7.4% of female and 20.9% of male individuals). Remarkable heterogeneity was detected in individuals within each disease classification, based on the extent of the thoracic spine affected and degree of mineralization. The continuum of imaging features associated with DISH is detected in more than one in four adults and both sexes in an American population.

Background Degenerative intervertebral disease (DID) is an exclusion criterion in the Resnick and Niwayama radiographic classification for diffuse idiopathic skeletal hyperostosis (DISH). However, although DID was previously described in DISH, no systematic computed tomography (CT) analysis has been reported so far. Purpose To assess for the presence and prevalence of such changes on CT examinations of the thoracic spine of individuals with DISH. Material and Methods Intervertebral space (D1-L1) on chest CT examinations of DISH patients was retrospectively evaluated for the presence of DID. Parameters evaluated were disc space height, disc protrusion, subchondral cysts/sclerosis, Schmorl nodes, vacuum phenomenon, and posterior elements including costovertebral and facet joints. Parameters were compared with two age- and gender-matched control groups of individuals whose entire spine CT lacked evidence of DISH (Control 1 individuals < 2 flowing osteophytes, Control 2 individuals < 4 and ≥ 2 flowing osteophytes). Results A total of 158 participants (DISH/Control 1/Control 2 = 54/54/50; 106 men, 52 women; average age = 70.6 years) were evaluated. Average intervertebral disc height was significantly lower in the DISH group compared with both control groups (DISH/Control 1/Control 2 = 4.55/5.13/5.01 mm, P < 0.001). Costovertebral degenerative changes were more prevalent in DISH patients ( P < 0.05) and, except for vacuum phenomenon (more prevalent in controls), other DID changes were as prevalent in DISH as in controls. Conclusion The presence of degenerative intervertebral changes on thoracic CT should not deter from diagnosing DISH. Thus, the radiographic Resnick and Niwayama DISH criteria cannot be directly adapted to CT.

Diffuse idiopathic skeletal hyperostosis (DISH) is a common disease in older adults that causes extensive spinal ankylosis. However, its impact on quality of life (QOL) and locomotive syndrome (LS) remains unknown. Thus, we aimed to evaluate the DISH effect on QOL and LS in community-dwelling middle-aged and older adults. Data of community volunteers who attended a health checkup in 2018–2019 were assessed. A total of 455 subjects were included. Whole spine lateral radiographs were obtained to detect DISH according to the Resnik criteria. QOL was evaluated using SF-36 and EQ5D HUSV. LS was evaluated using the stand-up and two-step tests and GLFS-25. Multivariate regression analysis was performed, adjusting for sex, age, body mass index, and knee osteoarthritis. Additionally, a sex-stratified analysis was performed. DISH was detected in 83 (18.2%) participants. Multivariate analysis demonstrated that DISH was significantly associated with low EQ5D HSUV. Multivariate analysis in men demonstrated that DISH was associated with low PCS, low EQ5D HSUV, high LS stage. Multivariate analysis in women demonstrated that DISH was not associated with any QOL or LS. DISH may be associated with a poor QOL. Additionally, DISH is more common and produces a greater clinical impact in men than in women.

Background: S-RANKL (Receptor activator of nuclear factor Кappa-B ligand) is a member of the TNF/TNF receptor superfamily. RANKL has been identified to control bone regeneration and remodeling. S-RANKL is secreted by osteoblasts and binds to the RANK receptor on osteoclast precursor and mature osteoclast cells. Variation in concentration levels of S-RANKL throughout several organs reconfirms the importance of RANKL in bone growth. S-RANKL is ability to stimulate osteoclast formation and activity.Methods: S-RANKL is estimated on 55 patients with Diffuse Idiopathic Skeletal Hyperostosis (DISH), 25 patients with Ankylosing Spondilitis (AS), 50 patients with spondylosis and 15 particularly healthy people aged 55-65. All patients were treated and monitored in University Clinic of Rheumatology, UMHAT “Sveti Georgi”, Plovdiv, Bulgaria. The measuring of the S-RANKL is done by ЕLISA-method with reader (Sitio-Microplate reader, Seac, Itаlу), ƛ 450 nm, with a kits of eBioscience, Austria. The statistic processing is done with SPSS 23 programme (p&lt;0.01).Results:The average measurements of s-RANKL of patients with DISH were 197,00±35,90 pg/ml, in patients with AS 190,86±18,54 pg/ml. S-RANKL in patients with spondilosis were 20,60±66,16 pg/ml, and in old control group were 23,33±15,07 pg/ml. The average measurements of s-RANKL in patients with DISH and AS were significant higher in comparison with the results of patients with spondylosis and healthy people, regardless of their age (p&lt;0.05).Conclusion: S-RANKL is significantly increased in patients with DISH and spondylosis in comparison with the results of patients with AS and healthy old people. Hypothetically, this might be a result as a sequence of events, based on stimulation of inflammatory proteins, on-going osteoporosis and compresion fractures in patients with DISH and spondylitis. The endurance of the vertebrae is decreased and the body increases the production of proteins from the osteoblasts to form compensatory more bone substance. The overproduction of S-RANKL is implicated in new bones formation in patients with DISH. Blocked up at S-RANK might have an important role in the suppression of pathological processes in this diseases. The results indicate a possible common pathogenic connection between inflammatory joint disease (AS) and degenerative joint disease(DISH).

Diffuse idiopathic skeletal hyperostosis (DISH) is difficult to distinguish from various forms of inflammatory arthritis, including psoriatic arthritis (PsA), rheumatoid arthritis, and ankylosing spondylitis. A 67-year-old Japanese male had been treated for psoriasis vulgaris for 13 years. Numbness of his right arm and lower limbs and spinal stiffening had developed 7 years prior to his initial evaluation at our facility. He noticed pain mainly while exercising. There were symmetrical marginal syndesmophytes in the spine, from the thoracic vertebrae to the upper lumbar vertebrae, on radiological examinations. We therefore suspected DISH. Furthermore, ossifications of the posterior and anterior longitudinal ligaments were noted in the cervical spine. Laboratory examinations revealed a normal peripheral white blood cell count, serum C-reactive protein, and erythrocyte sedimentation rate, and he was negative for rheumatoid factor. We detected human leukocyte antigen B39 but not B27. All distal interphalangeal joints were swollen but without pain. X-ray imaging showed narrowing of the joint space, and the consolidation of the joint was recognized, but there was no new juxta-articular bone formation. Based on clinical and radiological findings, we concluded that he had DISH and not PsA. DISH was indicated by marked radiological features of the axial skeleton, particularly the thoracic spine, but may also have involved the peripheral joints. DISH is one of the entheseal disorders, and 10% of Japanese middle-aged and elderly men have DISH. Therefore, the differentiation of DISH from PsA is necessary in psoriasis patients with spinal involvement.

We aimed to assess the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) and its association with lumbar spondylosis (LS) and knee osteoarthritis (KOA) using a population-based cohort study entitled Research on Osteoarthritis/osteoporosis Against Disability (ROAD). In the baseline ROAD study, which was performed between 2005 and 2007, 1,690 participants in mountainous and coastal areas underwent anthropometric measurements and radiographic examinations of the whole spine (cervical, thoracic, and lumbar) and both knees. They also completed an interviewer-administered questionnaire. Presence of DISH was diagnosed according to Resnick criteria, and LS and KOA were defined as Kellgren-Lawrence (KL) grade ≥3. Among the 1,690 participants, whole-spine radiographs of 1,647 individuals (97.5%; 573 men, 1,074 women; mean age, 65.3 years) were evaluated. Prevalence of DISH was 10.8% (men 22.0%, women 4.8%), and was significantly higher in older participants (presence of DISH 72.3 years, absence of DISH 64.4 years) and mainly distributed at the thoracic spine (88.7%). Logistic regression analysis revealed that presence of DISH was significantly associated with older age [+1 year, odds ratio (OR): 1.06, 95% confidence interval (CI): 1.03-1.14], male sex (OR: 5.55, 95% CI: 3.57-8.63), higher body mass index (+1 kg/m(2), OR: 1.08, 95% CI: 1.02-1.14), presence of LS (KL2 vs KL0: 1, OR: 5.50, 95% CI: 2.81-10.8) (KL ≥3 vs KL0: 1, OR: 4.09, 95% CI: 2.08-8.03), and presence of KOA (KL ≥3 vs KL0: 1, OR: 1.89, 95% CI: 1.14-3.10) after adjusting for smoking, alcohol consumption, and residential area (mountainous vs coastal). This cross-sectional population-based study clarified the prevalence of DISH in general inhabitants and its significant association with LS and severe KOA.