Intermalleolar Distance Research Articles

Comparative analysis of the frequency of comorbid diseases in axial psoriatic arthritis and other variants of axial spondyloarthritis. Data from a hospital cohort

Objective: to compare the frequency of comorbid diseases in axial psoriatic arthritis (axSpA) and in other variants (OV) of axial spondyloarthritis (axSpA).Material and methods. We studied 60 patients, 30 with axPsA (15 men and 15 women, mean age – 49.1±10.4 years, disease duration – 12.6±6.9 years) and 30 with OV axSpA (16 men and 14 women, mean age – 42.9±9.7 years, disease duration – 16.30±8.3 years). All patients underwent a standard rheumatological examination. The diagnosis of comorbid diseases was confirmed using ICD-10 codes. The Cumulative Illness Rating Scale (CIRS), Charlson comorbidity index (CCI) and the weighted version of Functional Comorbidity Index (w-FCI) were used to assess comorbidity.Results and discussion. Comparative analysis of the two groups revealed that axPsA patients were older than OV axSpA patients (p <0.05). Occurrence of back pain before the age of 40 was observed in 60% of axPsA cases, compared to 86.7% in OV axSpA (p<0.05). The limitation of spinal and hip mobility was less severe in axPSA than in OV axSpA. The median side flexion was 12.3 [10; 15] and 9.5 [8; 11] cm, the Schober test was 4.2 [3; 5] and 3.0 [2; 4] cm and intermalleolar distance was 95.9 [86; 102] and 83.0 [75; 100] cm, respectively (p<0.05). Patients with axPsA were more likely to have peripheral arthritis compared to patients with OV axSpA: 27 (90%) and 11 (36.7%) cases, respectively (p<0.05) and higher laboratory indices of activity: median ESR, 31.9 [10; 38] and 20.4 [5; 14] mm/h, and CRP, 20.5 [2.8; 20.7] and 13.6 [0.9; 12.0] mg/L, respectively (p<0.05). In the axPsA and OV axSpA groups, circulatory system diseases were found in 50 and 50% of patients, metabolic disorders in 76.6 and 76.6%, and gastrointestinal diseases in 46.7 and 70 %. Obesity was more common in axPsA than in OV axSpA – in 40 and 16.7% of patients, respectively (p<0.05).Conclusion. A high frequency of comorbidities, mainly cardiovascular and metabolic diseases, was found in both groups. These data should be considered in the choice of therapy and optimization of existing treatment algorithms.

Baseline and 2-year differences in spinal symptoms and spinal and hip mobility in early axial spondyloarthritis and non-axial spondyloarthritis chronic back pain patients

ObjectiveTo compare spinal symptoms and spinal/hip mobility at baseline and 2 years in early axial spondyloarthritis (axSpA) and non-axSpA chronic back pain (BP) patients.MethodsBaseline and 2 years data of the...

CT-based comprehensive scoring system for assessing hip arthropathy in ankylosing spondylitis: feasibility study with clinical correlation.

To develop a CT-based scoring system for assessment of hip arthropathy in AS. All AS patients were prospectively recruited, consented, and underwent whole-body stereoradiographs and pelvis CT, which were assessed by two independent radiologists. Stereoradiographs were assessed according to Kellgreen-Lawrence and BASRI-h. For the Hip arthropathy CT score in AS (HACTSAS), joints were divided into 7 segments and scored for joint space, osteophytes, subchondral cysts/erosions. Patients were clinically assessed for range of motion (ROM), pain, and clinical scores (BASMI, BASFI, ASQol, BASDAI and ASDAS). Radiological scores correlations with clinical parameters were compared. ROM sensitivity and specificity for hip arthropathy (BASRI-h ≥ 2) were calculated. Sample included 112 patients, with 36/112 females and 76/112 males. Average age was 51.0 ± 11.2 years and mean duration of AS was 20.9 ± 9.6 years. ICC for HACTSAS, Kellgreen-Lawrence and BASRI-h were 0.89, 0.89 and 0.82 respectively. HACTSAS showed moderate absolute correlation with ROM (ρ=-0.41) and BASMI (ρ = 0.45), and weak with pain (ρ = 0.18) and BASFI (ρ = 0.25). BASRI-h and Kellgreen-Lawrence exhibited moderate correlation with ROM (ρ=-0.44 and ρ=-0.40, respectively), weak with pain (ρ=-.27and ρ=-0.23, respectively) and BASFI (ρ=-0.16 and ρ=-0.18, respectively), but only weak with BASMI (ρ=-0.34 and ρ=-0.36, respectively). Internal rotation <15°, abduction <31°, and intermalleolar distance <75cm were, respectively, 73%, 70% and 73% sensitivity and 81%, 65% and 68% specific for hip arthropathy. HACTSAS exhibited higher correlation with BASMI and BASFI when compared with BASRI-h, but less correlation with pain and ROM. Internal rotation was the best clinical discriminator for hip arthropathy.

The Effect of Wushu on Balance, Anthropometric Properties and Some Performance Parameters

Objective: In this study, it was aimed to determine the effects of Wushu on balance, anthropometric characteristics and some performance parameters.&#x0D; &#x0D; Methods: An experimental model, which is one of the quantitative research types, was chosen for the research model. The study group of the research consisted of 20 athletes between the ages of 14-17 who practice Wushu in the Bidam Fight Club Sports Club in Düzce. Before starting the 8-week training program and at the end of the 8-week training, balance measurements, anthropometric measurements and performance measurements were taken from the athletes. In this context, bipedal, left foot and right foot balance, shoulder anterior-posterior distance, thigh circumference, calf circumference, biceps circumference, hip diameter, intermalleolar distance, interstiloidal distance, interpicondylar distance and intercondylar distance, right paw strength, left paw strength, push-ups, sit-ups and long jump measurements were made. The analysis of the data was done by applying quantitative analysis methods using SPSS 25.0 package program. All analyzes were evaluated at 95% confidence interval and p

The relationship between body mass index and lower extremity biomechanics in children aged 10-12 years: a comprehensive analysis

Childhood obesity has emerged as a global health concern leading to complications, such as bones and muscles misalignment of knees, flat feet and changes in walking patterns. Although some studies have individually linked these conditions to body mass index (BMI), the relationship between these variables needs to be explored. This study aimed to investigate the associations between BMI and knee position, foot position and plantar footprint in children aged 10 to 12 years. Data were collected from 59 children by measuring their BMI, knee alignment, foot position and plantar footprint. Spearman’s correlation coefficient was used to examine the relationship between BMI and inter-malleolar distance (DIM), foot position and plantar footprint. The Mann- Whitney U test was used to compare these variables between boys and girls (p-value &lt; 0.05). Higher BMI values were associated with higher DIM in both boys and girls. Furthermore, we observed that genu valgum was positively correlated with foot pronation and a flattened plantar footprint. No significant differences were found in relation to BMI, variations in foot position or footprint types. Our research provides evidence that there is a connection, between BMI and genu valgum in children between the ages of 10 and 12. We have also found a correlation between genu valgum and foot pronation among children in this age group. These findings highlight the significance of addressing childhood obesity to prevent any health issues.

The Coronal Alignment of Lower Limbs in the Adolescent Football and Ice Hockey Players

BackgroundTo investigate the influence of sport-specific activities on coronal axial alignment of the lower limbs in adolescent football and ice hockey players.MethodsThis cross-sectional study targeted healthy adolescent male football and ice hockey players with at least 3 years of sports participation. 90 football and 38 ice hockey players aged 12–16 years were divided into five age-matched subgroups. Coronal alignment of the lower limbs was determined by measuring the players' intercondylar or intermalleolar (ICD-IMD) distance with a custom-made calliper. In addition, their sports history was recorded. An age-matched comparison between the two sports groups was performed using the two-way model ANOVA and a multiple regression model for ICD-IMD was constructed. Results were additionally compared with age-matched data from the general population published in recent literature.ResultsA statistically significant increase in ICD-IMD values (p < 0.05) was found between 12 (football 0 mm; ice hockey − 64 mm) and 16 years (football 340 mm; ice hockey 310 mm) in both sports groups. Results of regression analysis of pooled group data showed that ICD-IMD has low positive correlation (r = 0.407; r2 = 0.168; p < 0.05) with time of participation in sport, but no association with age of athletes at the start of their sport participation (r = − 0.018; r2 = 0.000; p > 0.05). There were no statistically significant differences between the two groups at any time point. Both sports groups showed a significant increase in ICD-IMD values (mean 198 mm) after the age of 14 compared to the general population.ConclusionsParticipation in football and ice hockey is associated with a similar increase in ICD-IMD in the adolescent years in male athletes. The observed increase was higher in both groups of athletes than in their peers who do not regularly participate in sports.Level of EvidenceLevel 4 (case series).

Preliminary Results of Measurements of Frontal Plane Knee Alignment Using a Standardized, Sonographic-Assisted Digital Photograph—A Reliable and Accurate Alternative to a Full-Leg Radiograph?

(1) Clinical alternatives to the full-leg radiograph (FLR) for determining frontal plane lower limb alignment have shown mixed results so far concerning reliability and accuracy. In addition, intercondylar respectively intermalleolar distance (ICD/IMD) measurement is limited in the interpretation of its results. The purpose of the study is to present a standardized, sonographic-assisted photographic measurement (SPM) of the leg axis in the frontal plane using a digital photograph and compare it with the gold standard of the anterior–posterior FLR. (2) Adults who had recently received an FLR were included in the study. After determining the center of the hip joint and knee joint gap in a standing position via ultrasound, a standardized digital photograph was taken. Subsequently, the hip–knee–ankle angle (HKA) was measured using an image editing program for SPM and FLRs. Mean deviation (MD), Pearson’s correlation coefficient and the clinical method’s interclass correlation coefficient (ICC) were calculated. (3) Of 18 subjects (8 male and 10 female), respectively, 34 lower extremities have been included in the study. Their mean BMI was 25.5 kg/m2. The correlation between the two measurement methods for subjects with BMI &lt; 30 kg/m2 was reliably high (r = 0.93, p &lt; 0.001). The HKAs derived from SPM and FLRs showed a mean deviation (MD) of 2.4° (range 0.1–6.0°) for subjects with BMI &lt; 30 kg/m2. The average ICC among all examiners conducting the SPM was 0.99 (CI 0.95–0.99, p &lt; 0.001). The MD for subjects ≥ 30 kg/m2 increased significantly (MD = 5.5°; n = 10, p &lt; 0.001). (4) SPM of the leg axis in the frontal plane allows sufficiently accurate results in patients with a BMI lower than 30 kg/m2. The methodology is limited in cases of increased BMI and needs well-trained examiners. Nevertheless, as a screening method in the field of children and adolescents, this method can be recommended in clinical daily routine.

Frontal Plane Angular Knee Deformities in School Children in Kribi, South Region of Cameroon

Bone problems such as angular deformities of the knee are common in children in Africa. The aim of this survey was to study epidemiologic aspects of frontal plane angular knee deformities in school children in Kribi. A total of 860 school children in Kribi aged 3 to 18 years were surveyed in a cross-sectional descriptive study from December 2019 to March 2020. Each child was examined. Intercodylar distances, intermalleolar distances and the tibiofemoral angles were assessed. The type of knee deformity in the frontal plane was determined from the children`s tibiofemoral angles and compared with reference values of normal children in the same age ranges. One hundred and fourty two (142, 16.5%) children surveyed presented with frontal plane knee deformities, with genu varum representing 68.0% (96 cases) of the deformities. The prevalence of these deformities in school children in Kribi varied significantly with age. We did not find any significant difference in the variation of these deformities with gender or ethnic groups. We identified some frontal plane angular knee deformities, including bilateral deformities being predominant 90.71% (127 cases). The mean body mass index was higher than those of normal children. 15.5% (22) of them presented with associated deformity in the sagital plane, dominated by bilateral genu recurvatum and 33.8% (48) of them presented with associated rotational knee deformities, dominated by bilateral medial rotation. Frontal plane knee angular deformities are common amongst school children in Kribi. Their prevalence is 16.51% (142 cases). This prevalence varies with ages. Sagittal plane and rotational plane deformities are equally present in children presenting with these deformities. Keywords: Bone, Children, Deformities, Cameroon.

Treatment of Severe Genu Valgum Deformity Secondary to Renal Osteodystrophy by Medial Close Wedge Osteotomy using an Innovative Trigonometric Technique of Wedge Calculation

Genu valgum is one of the most common deformity of the knee in which the knee bend toward the midline with increase in the intermalleolar distance. It is often treated surgically with the osteotomy or by growth modulation techniques such as hemiepiphysiodesis using bone staplers. We, hereby, present a case of 16-year-old female with severe genu valgum deformity of bilateral lower limbs secondary to renal osteodystrophy causing pain in her bilateral lower limbs and inability to walk. She was treated by McEwan’s close wedge osteotomy using an innovative trigonometric-based technique for calculation of wedge size which resulted in accurate correction of deformity. Keywords: Genu valgum, Renal osteodystrophy, Medial close wedge osteotomy, Trigonometric method of wedge calculation.

Knock knee deformity and body mass index among the male school students of 9 to 13 years old of chandigarh, India

Abstract Study aim: To study knock knee deformity and the body mass index among male school students of Chandigarh, India. The study also intended to evaluate the association of knock knee deformity with BMI. Material and method: In total, 900 school students were selected, and out of these 300 each were from private, government model and government schools in slum areas. Convenient sampling was employed. The age of the subjects ranged from 9 to 13 years. Height, weight, BMI and intermalleolar distance of selected subjects were assessed. Descriptive statistics, ANOVA and correlation were employed. Results: The highest percentages of obese (11.3%) and overweight (15.3%) students were found in the private schools. The highest percentages of severe knock knee deformity (10.7%) were found in the students of the private schools, whereas 16.7% of students in the government model schools had moderate knock knee deformity. Height, weight and BMI were significantly correlated with knock knee deformity. Conclusion: Body weight among the school students might be associated with the school type, as the problem of obesity and underweight was pervasive in private and government schools. Knock knee deformity was related to the school type and body weight status.

Results of Wedgeless Distal Femoral Osteotomy for the Treatment of Genu Valgus Deformity.

Coronal plane knee deformities are common disorders affecting adolescents. Valgus deformities (tibiofemoral angle (TFA) > 12-15 degrees and intermalleolar distance (IMD) > 10 cm) often require corrective osteotomy and a wedgeless "V" distal femoral osteotomy is a good treatment option for such deformities. Thirty adolescent patients (13-17 years) with valgus deformitieswere included. Patients with severe collateral ligament instability, subluxation, and sagittal plane deformity > 15 degrees or genu valgum due to tibial deformity were excluded. Preoperativeclinical(Bostman's knee score, IMD, and knee-flexion test) and radiological evaluations weredone. The surgery (wedgeless distal femoral V osteotomy) was performedand stabilized with two Kirschner wires (K-wires). Postoperative clinical and radiological parameters were recorded including complications. The preoperative TFA was 20.23 ± 3.63 degrees, which reduced to 5.5 ± 0.73 at six months postoperatively. The preoperative IMD was 12.45 ± 2.2 cm, which reduced to 1.63 ± 0.32 cm at six months. The mean mechanical axis deviation (MAD) and lateral distal femoral angle (LDFA)were recorded as 2.8 ± 0.39 and 87.7 ± 0.83, respectively, and the differences were statistically significant from preoperative values. The Bostman score was 26.2 ± 1.79 at three months and 29.47 ± 0.9 at six months. The complications included infection in two patients, a hypertrophic scar in one patient, and common peroneal neuropraxia in one patient. Wedgeless distal femoral osteotomywith K-wire fixation is a viable option for correction of genu valgus deformity with potential advantages of minimal blood loss, no leg length discrepancy, non-rigid fixation, and early union as compared to other treatment options.

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy

Category: Ankle Arthritis; Ankle Introduction/Purpose: We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy. Methods: We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into two groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the two groups. Results: There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the two groups (all, P&gt;.05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P&lt;.05). Among patients with TT &gt;=8 degrees, a greater decrease in TT (+1.0 degrees vs. -2.8 degrees) and TCA was observed in the DS group, while the PS group demonstrated greater increases in TCA and intermalleolar distance (all, P&lt;.01). Conclusion: In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis.

How does Spinal Mobility Affect Balance and Postural Control in Patients with Ankylosing Spondylitis? A Cross-Sectional Study

Abstract Purpose Alterations in spinal mobility lead to impaired postural control and balance, an increased risk of falls and a decrease in quality of life. The purposes of this study were to investigate the relationship between spinal mobility, postural control and balance and to compare spinal mobility and balance with a view to disease severity in patients with ankylosing spondylitis (AS). Methods 137 patients with AS were divided into 2 groups by tragus-to-wall distance (TWD): (Group I=mild AS, n=51), (Group II=moderate AS, n=86). Balance was assessed with the Single-Leg Balance Test, the Timed Up and Go Test (TUG) and the Berg Balance Scale (BBS). Spinal mobility was measured by BASMI Index [TWD, cervical rotation (CR), Modified Schober Test (MST), lumbar lateral flexion (LLF), intermalleolar distance (IMD) and thoracic expansion (TE)] and was compared between the groups. The association with balance was investigated. Results Spinal mobility and BBS scores in Group II were worse than in Group I (p&lt;0.05). Static balance and TUG of the groups were similar (p&gt;0.05). Dynamic balance was weakly correlated with MST, LLF and IMM and moderately correlated with CR, TE and BASMI. Static balance was weakly correlated with spinal mobility (p&lt;0.05). There was no correlation between TWD and any balance domains (p&gt;0.05). Conclusions In patients with AS, spinal mobility and dynamic balance worsen as the disease progresses, whereas static balance does not change. Such changes in mobility and balance can negatively affect patients’ participation in daily life and increase their risk of falls. Therefore, detailed evaluation of balance, balance training and fall prevention approaches need to be implemented in the rehabilitation programs of patients with AS.

Back-Carrying in Children Is Related to Lower Limb Development.

Back-carrying of children is a culturally accepted method of transport and safekeeping of babies in many cultures. Developmental consequences related to back-carrying practices have not been directly investigated. This study determined the relationship between frontal and transverse plane lower limb (LL) development, and back-carrying practices, in black Setswana-speaking children. In 691 2- to 9-year-old Setswana-speaking children, the tibiofemoral angle, intermalleolar distance, femoral anteversion angle (AVA) and tibial torsion angle (TTA), were measured to determine LL development. Back-carrying practices were recorded with a questionnaire and Classification and Regression Tree (CART) was used for the analyses. Significant (p < 0.001) relationships, between back-carrying practices and LL development, were discovered. Statistically significant greater genu valgum (F(5, 690) = 7.2, p < 0.001), greater internal TTAs (F(9, 684) = 17.8, p < 0.001), and smaller AVAs (F(13, 685) = 5.1, p < 0.001) were observed in children back-carried more frequently than children back-carried less frequently. There are relationships between back-carrying practices and LL development in both the frontal and transverse plane. However, the genu valgum, internal TTA and smaller AVA noted in more frequently back-carried children is still within normal limits, thus no educational intervention in back-carrying methods or durations is required. Further research should determine the exact back-carrying practice factors (age until which the child is back-carried) impacting lower limb development the greatest.

Wedge-less oblique supracondylar femoral osteotomy and casting for genu valgum in older children and young adults

BackgroundGenu valgum is one of the commonest deformities seen by the orthopaedicians. The most common cause is idiopathic but genu valgum secondary to nutritional deficiency is also fairly common in developing and third world countries. Supracondylar osteotomy and internal fixation with plate and screws, is the treatment of choice in older children and young adults, which is costly, requires a wide exposure, a second surgery for implant removal and risk of infection is more. This study was undertaken to measure the outcome of simple oblique percutaneous wedge-less metaphyseal supracondylar osteotomy of the distal femur and casting in older children and adolescents with Genu Valgum in a small centre catering mostly to patients from middle and low income households. Patients and methodsPatients aged between 12 and 22 years with genu valgum deformity with a tibiofemoral angle ≥15°, and an intermalleolar distance of more than 7 cm in unilateral and more than 10 cm in bilateral cases, who are not amenable to be treated with guided growth techniques, were included. Patients having knee instability, restriction of knee range of motion, genu recurvatum, tibial deformity component, open physis, were excluded from the study. The correction was undertaken by a simple supracondylar wedge-less metaphyseal short oblique osteotomy of the distal femur followed by immobilization with a long leg plaster of Paris cast. Functional outcome was assessed using Böstman et al. score. Results46 limbs in 29 patients with a mean age of 14.5 years were operated. The mean follow-up of patients was 6 months. The preoperative radiological tibiofemoral angle (TFA) had a mean value of 19.89° which improved to a mean of 5.31° postoperatively. Intermalleolar distance (IMD) improved from a mean of 13.81 cm to 3.15 cm post-correction. Mean Lateral distal femoral angle (LDFA) improved from 77.11° to 87.20°. Knee score was excellent in all patients at 3 months and 6 months post intervention. There were no serious complications except superficial plaster sores in 4 patients, which healed uneventfully and temporary restriction of knee range of motion in 5 patients. All patients achieved a full range of knee motion after physical therapy. ConclusionSupracondylar wedge-less short oblique metaphyseal distal femoral osteotomy and immobilization with plaster of Paris cast is a simple, cheap, safe & viable option for the correction of genu valgum deformity originating from distal femur, with minimal complications in older children and adolescents with limited growth potential, especially in low income countries and small centres.

P24 Ankylosing spondylitis &amp; uveitis - challenges in management

Case report - IntroductionAnkylosing spondylitis is a chronic inflammatory condition involving spine, chest and sacroiliac joints. It can be associated with extra spinal manifestations which include uveitis and enthesitis, as well as other features of an inflammatory spondyloarthropathy including psoriasis and inflammatory bowel disease. It is characterised by the presence of inflammatory back pain, limited range of spinal movement, sacroiliitis on imaging, excess spinal bone formation and a high prevalence of HLA-B27. The main aims of treatment are to improve symptoms and retain function as well as to prevent disease complications.Case report - Case descriptionA 49-year-old male diagnosed with ankylosing spondylitis at the age of 23 (HLA-B27 positive, classical radiographic features on plain radiographs and MRI), with background of meningitis and subsequent epilepsy (not on treatment since the age of 13), severe hip osteoarthritis and osteoporosis. He has peripheral elbow and knee synovitis. At the age of 27 he developed sight-threatening bilateral recurrent anterior uveitis complicated by cystoid macular oedema (causing central vision loss). Initial management included anti-inflammatories and steroids. He progressed to biologics but developed a rash on adalimumab. He was switched to infliximab in 2010. In 2015 it was switched due to reduced response to golimumab which was non-beneficial. Subsequently he was switched to etanercept but after 3 months it was discontinued due to eye flare. The patient’s therapy was switched to certolizumab, which was non-beneficial for spine and discontinued. In 2016, infliximab was retried as the patient thought it worked best. Unfortunately, in 2018 patient developed Infliximab antibodies and treatment was changed to secukinumab. After 9 months this was stopped owing to ongoing active eye and spine disease. Adalimumab was re-tried; however, it was discontinued as it was showing no benefit. In 2020 Eeanercept (Benepali) was re-tried; however, only for 4 months because of severe flare of joint and eye disease. Tofacitinib was commenced but was non-beneficial and hence it was discontinued. Currently he continues on ixekizumab, oral prednisolone and also receives steroid eye and joint injections. On commencing biologics he was on methotrexate; however, the patient stopped. He was switched to mycophenolate mofetil which he remained on for 10 years. It was switched to methotrexate to try and control peripheral inflammatory joint disease better (re-tried for the second time) which the patient has recently discontinued as he felt it was non-beneficial.Case report - DiscussionThe case is very challenging. The patient’s disease continues to flare despite changing therapies. He continues to get flares in his back disease, eye disease and peripheral synovitis. His latest BASDI was 5.1 and VAS was 9/10. Measurements: intermalleolar distance 15cm, modified Schober’s 4cm, right lateral flexion 3.8cm and left lateral flexion 11cm. His latest MRI of whole spine and SI joints (in 2020) showed signs of previously active seronegative spondyloarthropathy with established cervical and thoracic ankyloses as well as bilateral sacroiliac joint ankylosis. There is a need for repeated steroid injections to the knees as well as the eyes. He continues on oral prednisolone which was first started in 2006. This is associated with multiple side effects, i.e., osteoporosis. The patient has already completed 8 years of bisphosphonate therapy. He is under regular review with the osteoporosis clinic. His bone density scan showed worsening bone mineral density and bisphosphonates had to be restarted. The patient adjusted medications depending on his symptoms. Recently he also discontinued methotrexate as he felt it was of no benefit to him at all. We are very limited at present to find combined medications to manage both the patient’s inflammatory back disease and inflammatory eye disease.Case report - Key learning pointsThis patient was diagnosed with ankylosing spondylitis 26 years ago. To date he has tried 5 different anti-TNF agents (two of which have also been re-tried at a different time point). This failed to control his disease as he continued to experience flares in either inflammatory back or eye disease. The biologic classes were also changed – he has tried one IL-17A agent as well as a JAK-I. Unfortunately, they both failed to control his disease. He currently continues on a second IL-17A; however, he still requires steroid eye and joint injections as well as systemic steroids. Throughout the years he has tried different DMARDs – most recently methotrexate. Unfortunately, the patient decided to discontinue it as he felt it was of no benefit to him. All of the above indicates that there is still a need to find a collaborative treatment option that will control the patient’s inflammatory back disease, inflammatory eye disease and peripheral synovitis. The aim would be, if possible, to decrease the steroid dose as well (currently on prednisolone 15mg daily) in order to prevent the steroid-associated side effects.

Genu valgum bilatéral pathologique dans un contexte d’hyperparathyroïdie secondaire à une maladie rénale chronique

Mineral bone disorders are common in patients with chronic kidney disease, particularly in hemodialysis patients. We report the case of a 21-year-old patient who has been chronically hemodialysed for 5 years for end-stage renal disease. While the initial nephropathy is undetermined, the patient has developped for the past 3 years, a progresssively worsening genu valgum with an inter-malleolar distance of 10 cm. Standard radiography of the lower limbs showed bone demineralization. There were no calcifications on blood vessels. Cardiac Doppler and supra-aortic trunk Doppler showed valvular and vascular calcifications. The biological check-up found secondary hyperparathyroidism with an intact parathormone at 910 pg/mL. A subtotal para-thyroidectomy was performed in January 2019. Pathological examination showed glandular hyperplasia. The evolution has been favorable and orthopedic management may be considered to correct the genu valgum. This is a rare case of late osteo-articular deformation in association with hyperparathyroidism secondary to renal failure. Etiological management was performed after the deformation was installed. Hence, this complication shows the interest of pre-emptive management of patients with chronic kidney disease. Received: April 29th, 2021 Accepted: June 18th, 2021

Radiographic Outcomes of Proximal vs Distal Syndesmotic Low Tibial Osteotomy.

We aimed to determine whether the location of tibial osteotomy affects the outcome during low tibial osteotomy (LTO) with fibular osteotomy for varus ankle arthritis by comparing proximal syndesmotic (PS) and distal syndesmotic (DS) tibial osteotomy. We retrospectively reviewed the radiographic findings of 50 cases (among 47 patients) who underwent LTO with fibular osteotomy for varus ankle arthritis. The enrolled patients were divided into 2 groups according to the location of the tibial osteotomy: the PS group (25 cases, 24 patients) and the DS group (25 cases, 23 patients). Radiographic parameters were compared between the 2 groups. There were no significant differences in tibial anterior and lateral surface angles, tibiomedial malleolar angle, talar center migration, and intermalleolar distance correction between the 2 groups (all P > .05). However, the decreases in talar tilt (TT) and talocrural angle (TCA) were more pronounced in the DS group than in the PS group (both P < .05). Among patients with TT ≥8 degrees, a greater decrease in TT (+1.0 degrees vs -2.8 degrees) and TCA was observed in the DS group, whereas the PS group demonstrated greater increases in TCA and intermalleolar distance (all P < .01). In this series, DS tibial osteotomy combined with fibular osteotomy was a more effective operative option than PS tibial osteotomy to correct both extra- and intra-articular deformity for varus ankle arthritis. Level III, retrospective comparative study.

Development of Garments with Elastic Straps and Pressure Applicator (GESPA) and "GVcorrect" App to Follow the Changes in Lower-Extremity Alignment (Genu Valgum)-A Pilot Study.

Background: There are non-invasive methods of correcting genu valgum (GV), but to date, there is no method to evaluate mechanotherapeutic intervention that does not restrict child’s natural movements while the process is on-going so that timely decisions could be made on effectiveness of intervention. The aim of study was to develop and assess the comfortability of garments with elastic straps and pressure applicator (GESPA) and the reliability and user-friendliness of “GVcorrect” app, which aims to catch the elastic straps’ pressure level (mN). Methods: 6 children (5–7 y) with intermalleolar distance ≥5 cm wore GESPA daily for 3 months. Anthropometrical and goniometrical measurements were done according to standard technique; tone and biomechanical parameters of skeletal muscles determined with MyotonPRO; feedback about GESPA and “GVcorrect” collected via questionnaire. Results: Based on feedback from children and parents, new, more comfortable and user-friendly GESPA were designed; several updates were made to “GVcorrect” app; new goals were set for the next phase of the study. Conclusions: GESPA and the “GVcorrect” app serve their purpose, but there are still a number of important limitations that need to be removed before the product can be marketed. The study continues with product development until a medical device certificate is obtained.

Genetic and clinical analysis of X-linked hypophosphatemic rickets

Objective: To investigate the clinical and genetic features, and treatment of X-linked hypophosphatemic rickets (XLH). Methods: In this retrospective study, we reviewed the medical records of 25 pediatric patients with XLH who were admitted to Department of Endocrinology Genetics and Metabolism,Beijing Children's Hospital from January 2010 to January 2020. The clinical characteristics, PHEX gene variants, as well as clinical outcome of the patients were summarized. To analyze the correlation between genotype and phenotype, the patients were divided into different subgroups according to the location of the variants, including N-terminal-located vs. C-terminal-located variant, and Zn-binding domain exon 17 or 19 variant vs. non-exon 17 or 19 variant. The age at onset, height standard deviation score (HtSDS), intercondylar or intermalleolar distance, fasting serum phosphorus, and HtSDS and intercondylar or intermalleolar distance at the final follow-up were compared by rank sum test or t text. Results: Among the 25 children with XLH, 8 were boys and 17 were girls. The median age of onset was 1.2 (1.0, 1.8) years, and the median age of diagnosis was 2.5 (1.5, 4.3) years. The main clinical manifestations were abnormal gait and lower limb deformity. The HtSDS was -2.0(-3.2, -0.8), and the intercondylar or intermalleolar distance was 4.5 (3.0, 6.0) cm. The fasting serum phosphorus level was 0.8 (0.7, 0.9) mmol/L, while the serum alkaline phosphatase level was (721±41) U/L and the serum calcium level was (2.5±0.1) mmol/L. Three patients (12%) had parathyroid hormone levels above the upper limit of the normal range. Twenty-five patients (100%) showed radiographic changes of active rickets. Nephrocalcinosis was found in 2 cases (9%). Twenty-four different PHEX variations were detected in 25 patients, among whom 11 (44%) had not been reported previously. No hot spot variation was found. No statistical differences (all P>0.05) were identified in clinical features and outcomes either in comparing patients with N-terminal (21 cases) and C-terminal (4 cases) variants, or in comparing patients with variant located in exon 17 or 19 (4 cases) or not (21 cases). Twenty-four cases (96%) were treated regularly with phosphate supplements and active vitamin D. After 2.7 (1.6, 5.0) years of follow-up, clinical symptoms were relieved in 96% (24/25) of the patients. The HtSDS after treatment had no significant difference compared to that before treatment (-2.0(-3.2, -0.8) vs.-2.0(-2.8, -1.1),Z =-0.156, P>0.05), while the intercondylar or intermalleolar distance after treatment was significantly reduced compared to that before treatment (4.5(3.0, 6.0) vs. 1.5(0, 3.3) cm, Z =-3.043, P<0.05). Bone X-rays were reexamined in 17 cases after treatment, and radiographic signs of rickets were improved. Eighteen cases had secondary hyperparathyroidism and 7 cases had nephrocalcinosis. Conclusions: The main clinical manifestations of XLH are abnormal gait, lower limb deformity and short stature. A high proportion of novel variations of PHEX gene but no hot spot variation neither genotype-phenotype correlation are found. Regular treatment with phosphate supplements and active vitamin D can significantly improve the symptoms except for the height. However, the rate of adverse events including secondary hyperparathyroidism and nephrocalcinosis seems to be high.