Limited Joint Motion Research Articles

PTEN knockout using retrogradely transported AAVs transiently restores locomotor abilities in both acute and chronic spinal cord injury

Restoring function in chronic stages of spinal cord injury (SCI) has often been met with failure or reduced efficacy when regenerative strategies are delayed past the acute or sub-acute stages of injury. Restoring function in the chronically injured spinal cord remains a critical challenge. We found that a single injection of retrogradely transported adeno-associated viruses (AAVrg) to knockout the phosphatase and tensin homolog protein (PTEN) in chronic SCI can effectively target both damaged and spared axons and transiently restore locomotor functions in near-complete injury models. AAVrg's were injected to deliver cre recombinase and/or a red fluorescent protein (RFP) under the human Synapsin 1 promoter (hSyn1) into the spinal cords of C57BL/6 PTENFloxΔ/Δ mice to knockout PTEN (PTEN-KO) in a severe thoracic SCI crush model at both acute and chronic time points. PTEN-KO improved locomotor abilities in both acute and chronic SCI conditions over a 9-week period. Regardless of whether treatment was initiated at the time of injury (acute), or three months after SCI (chronic), mice with limited hindlimb joint movement gained hindlimb weight support after treatment. Interestingly, functional improvements were not sustained beyond 9 weeks coincident with a loss of RFP reporter-gene expression and a near-complete loss of treatment-associated functional recovery by 6 months post-treatment. Treatment effects were also specific to severely injured mice; animals with weight support at the time of treatment lost function over a 6-month period. Retrograde tracing with Fluorogold revealed viable neurons throughout the motor cortex despite a loss of RFP expression at 9 weeks post-PTEN-KO. However, few Fluorogold labeled neurons were detected within the motor cortex at 6 months post-treatment. BDA labeling from the motor cortex revealed a dense corticospinal tract (CST) bundle in all groups except chronically treated PTEN-KO mice, indicating a potential long-term toxic effect of PTEN-KO to neurons in the motor cortex which was corroborated by a loss of β-tubulin III labeling above the lesion within spinal cords after PTEN-KO. PTEN-KO mice had significantly more β-tubulin III labeled axons within the lesion when treatment was delivered acutely, but not chronically post-SCI. In conclusion, we have found that using AAVrg's to knockout PTEN is an effective manipulation capable of restoring motor functions in chronic SCI and can enhance axon growth of currently unidentified axon populations when delivered acutely after injury. However, the long-term consequences of PTEN-KO on neuronal health and viability should be further explored.

Case 316: Progressive Pseudorheumatoid Dysplasia.

A 10-year-old North Indian boy presented with swelling of multiple joints in his hands for the past 3 years. This swelling involved the small joints of his hands and some restriction of joint movement, without any associated tenderness or morning stiffness. No other joints were symptomatically involved. Prior to visiting our hospital, he had received disease-modifying antirheumatoid drugs for suspected juvenile idiopathic arthritis, without any clinical benefit. On examination, the metacarpophalangeal and interphalangeal joints were nontender but had swelling and flexion deformities. He also had a short stature (below the third centile) for his age. Inflammatory markers, including erythrocyte sedimentation rate (7 mm per hour; normal range, 0-22 mm per hour) and C-reactive protein level (1.5 mg/L; normal level, <10 mg/L), were normal, and the rheumatoid factor test result was negative. A skeletal survey of the patient was performed.

MANAGEMENT OF ASTHI-MAJJAGATA VATA VYADHI : A CASE STUDY

Asthimajjagata Vata is a Vatavyadhi in which vitiated Vata accumulate in Asthivaha and Majjavaha Srotasa where already Kha Vaigunya has been developed due to etiological factors. In Brihattrayee symptoms of Asthigata Vata and Majjagata Vata described together as they are closely related to each other. In Charak Samhita and Ashtang Hridaya, Acharya stated that Asthimajjagata Vata can be cured by internal and external application of Sneha. Basti is one of the ways of internal administration of Sneha. Spondylosis is one of the most common forms of joint disease. Most of the time it falls under the concept of Vatavyadhi mainly due to vitiating Vatdosha further results in Dhatukshaya. Basically, this disease contains Asthi and Majja Dhatu. This disease limits our daily activities such as walking, running, standing, dressing, cycling, bathing, etc., which makes the patient sick or disabled. It is Kashtasadhya Vatavyadhi due to intense pain and limited joint movements. Here we discuss the case report of Asthimajjgat Vatavyaddhi which is the best treated with Ayurvedic concepts as described by Acharyas in Vatavyadhi Chikitsa Adhyaya.

Poster 120: Understanding the Biological Basis of Contracture Using a Mouse Model of Single Hindlimb Immobilization-Induced Fibrosis

Poster 120: Understanding the Biological Basis of Contracture Using a Mouse Model of Single Hindlimb Immobilization-Induced Fibrosis

E026 Hypertrophic pulmonary osteoarthropathy, rheumatoid arthritis mimic: don’t distract with immunology

Abstract Background/Aims Hypertrophic pulmonary osteoarthropathy is a para-neoplastic syndrome characterized by periosteal bone proliferation, clubbing, swelling of soft tissues and joints which is frequently associated with adenocarcinoma of lung. We hereby present a case series of two very interesting cases who were initially thought to have seropositive inflammatory arthritis, but later on investigation confirmed an underlying lung malignancy-associated secondary hypertrophic pulmonary osteoarthropathy. Methods Case 1:A 62-year-old female with previous history of leucoclastic vasculitis and hypertension, presented to rheumatology with 6 months history of widespread polyarthralgia associated with prolonged early morning stiffness. She had been smoking 10 cigarettes a day for 30 years. Clinical examination revealed no synovitis or restriction of joint movements. C-reactive protein was raised, rheumatoid factor was 284 (Normal 0-15), anti-CCP antibodies were 1 (0-6). She was diagnosed of inflammatory arthritis and started on hydroxychloroquine, with no response. Review at 4 months confirmed new swelling over the fingertips associated with weight loss, loss of appetite and persistent mild cough. Examination confirmed tenderness over the distal radius and proximal tibia with pronounced grade 3 to 4 clubbing in fingers and toes, no clinically detectable active synovitis noted. CT scan showed a large left upper lobe mass, and spinal metastases and biopsy confirmed adenocarcinoma. Results Case 2: A 74-year-old gentleman with 50 pack year history of smoking and past medical history of paroxysmal atrial fibrillation, peripheral vascular disease and Type 2 diabetes mellitus, initially presented with 10 months history of constant pain only in left big toe joint, associated with significant weight loss and on-going shortness of breath for past few months. Investigations revealed rheumatoid factor 1300 (0-15) and anti-CCP antibodies &amp;gt;340 (0-6), C-reactive protein was 54. On examination digital clubbing was noted, no synovitis or restriction of joint movements. Chest X-ray demonstrated right middle zone mass. CT Thorax abdomen &amp; pelvis confirmed malignancy. Conclusion Rheumatoid Factor has a pooled sensitivity of 69% and a specificity of 85%. Sensitivity and specificity of anti-CCP antibodies are 66% and 90.4%, respectively. Both are useful in the diagnosis of rheumatoid arthritis, but can be false positive, and can sometimes be misleading. Studies have shown a direct relation between rheumatoid factor, anti-CCP antibodies and smoking. Titres were significantly higher in heavy smokers. This case series reminds us that hypertrophic pulmonary osteoarthropathy can mimic rheumatoid arthritis. Where clinical features are not convincing of inflammatory arthritis, and red flags like history of smoking and digital clubbing are present, a high index of suspicion is required to rule out a paraneoplastic condition. Disclosure A.B. Awan: None. F. Javaid: None. A. Moorthy: None. K. Sunmboye: None.

The influence of induced gait asymmetry on joint reaction forces

Chronic injury- or disease-induced joint impairments result in asymmetric gait deviations that may precipitate changes in joint loading associated with pain and osteoarthritis. Understanding the impact of gait deviations on joint reaction forces (JRFs) is challenging because of concurrent neurological and/or anatomical changes and because measuring JRFs requires medically invasive instrumented implants. Instead, we investigated the impact of joint motion limitations and induced asymmetry on JRFs by simulating data recorded as 8 unimpaired participants walked with bracing to unilaterally and bilaterally restrict ankle, knee, and simultaneous ankle + knee motion. Personalized models, calculated kinematics, and ground reaction forces (GRFs) were input into a computed muscle control tool to determine lower limb JRFs and simulated muscle activations guided by electromyography-driven timing constraints. Unilateral knee restriction increased GRF peak and loading rate ipsilaterally but peak values decreased contralaterally when compared to walking without joint restriction. GRF peak and loading rate increased with bilateral restriction compared to the contralateral limb of unilaterally restricted conditions. Despite changes in GRFs, JRFs were relatively unchanged due to reduced muscle forces during loading response. Thus, while joint restriction results in increased limb loading, reductions in muscle forces counteract changes in limb loading such that JRFs were relatively unchanged.

Case 316

A 10-year-old North Indian boy presented with swelling of multiple joints in his hands for the past 3 years. This swelling involved the small joints of his hands and some restriction of joint movement, without any associated tenderness or morning stiffness. No other joints were symptomatically involved. Prior to visiting our hospital, he had received disease-modifying antirheumatoid drugs for suspected juvenile idiopathic arthritis, without any clinical benefit. On examination, the metacarpophalangeal and interphalangeal joints were nontender but had swelling and flexion deformities. He also had a short stature (below the third centile) for his age. Inflammatory markers, including erythrocyte sedimentation rate (7 mm per hour; normal range, 0-22 mm per hour) and C-reactive protein level (1.5 mg/L; normal level, <10 mg/L), were normal, and the rheumatoid factor test result was negative. A skeletal survey of the patient was performed and is shown in Figures 1-6.

Postrenal transplant tuberculosis of the ankle joint

Tuberculosis (TB) is one of the common infections after renal transplantation in developing countries. Patients who receive kidney grafts are at an increased risk for the development of mycobacterial disease than the general population, because of uremia and the immunosuppressants used in the posttransplant period, all of which interfere with T-cell function. Extrapulmonary TB is more common in renal allograft recipients and may present with dissemination or atypical features. Although extrapulmonary TB occurs frequently, isolated ankle joint TB is a rare form of extrapulmonary TB infection. We report here a renal allograft recipient with ankle joint TB presenting 6 months after transplantation with persistent pain in the left ankle joint associated with swelling and mild restriction of joint movement. He was diagnosed to be having an osteomyelitis of the talus bone extending to the navicular and anterior part of the calcaneus. He underwent open debridement and CB-NAAT of the tissue, which showed mycobacterium TB and rifampicin resistance was not detected. He was started on antituberculous treatment. This report highlights the need for a high index of suspicion for diagnosing TB early among renal transplant recipients and diagnostic difficulties of the TB disease due to insidious and nonspecific clinical presentation. Also, the treatment has to be monitored closely due to drug interaction between immunosuppressants and anti-TB drugs.

A RARE CLINICAL CASE SERIES OF LEIOMYOSARCOMA OF BONE WITH REVIEW OF LITERATURE

Introduction: Leiomyosarcoma is a rare malignant sarcoma which occurs in different anatomic sites including bone with similar histological characteristics but heterogenous clinical behaviour and prognosis. Primary LMS of bone is a rare aggressive sarcoma which presents as a high grade destructive tumour with poor prognosis and limited treatment options. Final diagnosis of LMS includes a combination of histomorphological features along with immunohistochemistry. Due to rarity of disease there is limited understanding of its pathology , prognosis and treatment . Objective: Due to rarity of this disease a case series of primary LMS of bone is prepared to understand its behaviour and management in accordance with the current literature. Material And Methods: 3 cases of primary LMS of Bone is documented in this case series along with history, imaging , diagnosis and treatment. 1] LMS Left Fibula :- A 55 year old male patient reported with pain and partial limitation of motion of the left knee joint. Patient managed with Surgery and Radiotherapy. 2] LMS Right Shoulder :- A 40 year old female patient reported with complaints of lump over right back with associated pain and restriction of joint movements. Patient managed with Surgery, Radiotherapy and Chemotherapy. 3] LMS Right Hip :- A 50 year old male patient reported with lump over right hip with pus discharge. Patient managed with Chemotherapy , Surgery and Radiotherapy . Conclusion: Due to rarity of LMS Bone cases little is known about its clinical behaviour and treatment outcomes. A multidisciplinary approach is needed for the optimal management of the disease. Surgery with a curative intent is the corner stone of treatment of localised disease along with the combination of neoadjuvant or adjuvant chemotherapy and radiotherapy. Further research is needed to identify more effective outcomes.

Migrated K-wire in the urinary bladder not causing symptoms: A rare case report

Kirschner wires (K-wires) are commonly used implants in the treatment of bony fracture. The migration of K-wire has been reported in the literature, but such migration into the urinary bladder is extremely rare. We report a case of an asymptomatic patient with a migrating K-wire in the urinary bladder, who came to our follow-up clinic after treatment of a hip fracture. The patient was absolutely fine but follow-up image showed K-wire in the urinary bladder. In view to prevent further migration and injuries, the laparotomy was planned and wire has been removed under the C-arm image guidance. Postoperative period was uneventful and patient was discharged. The aim of reporting this case was to spread the awareness about mandatory follow-up after K-wire placement, its migration, and the recommendation to remove it at earliest. As per my best knowledge, this is the first and unique case of K-wire migration into the urinary bladder, detected on follow-up image without symptoms. Bending the end of the K-wires after insertion, the restriction of joint movement, and removal of migrated K-wires at earliest are the key points in a patients with K-wire insertion. The mandatory follow-up in cases of K-wire placement for treatment of bone fracture, and early diagnosis prevent the potentially fatal complications.

Hematogenous septic arthritis after second degree burn and rational use of antibiotics

A 51-month-old female patient, who has meningomyelocele, presented with complaints of pain, fever, and inability to move her left leg from the hip while receiving antibiotic treatment after a localized second degree burn (9%). Physical findings, radiographic findings, and aspiration fluid from the hip joint were consistent with septic arthritis (SA). Methicillin-sensitive staphylococcus aureus growth was observed in wound culture, blood culture and synovial fluid culture sent after the operation. As the clinical condition of the patient with hematogenous spread was stable, treatment with ampicillin-sulbacsite was started. In burn patients, SA should be suspected in cases with fever and joint movement limitation, and it should be predicted that infections related to the burn may be pathogenic for SA. A rational antibiotic approach should be adopted in order to prevent resistance. Cases occurring after the development of large surface burns are available in the literature, and our case is the first pediatric case to develop septic arthritis after small surface area burn.

A case of tumoral calcinosis in hemodialysis

Dear Editor, Tumoral calcinosis is a rare syndrome which presents as painless, firm, tumor-like masses around the joints leading to pain, and limitation of joint movements. Commonly affected joints are shoulders, elbows, and hip joints. Spinal, temporomandibular joint, metacarpals, and metatarsal involvement have also been described. A 50-year-old female on twice weekly maintenance hemodialysis for the last 3 years presented with complaints of pain and restriction of movements at right hip joint and knee. On examination, range of movements was restricted at the hip joint. On palpation, there were subcutaneous hard nodules in the right hip region. Plain radiographic images of the pelvis were obtained and they showed irregular periarticular masses [Figure 1a]. Plain radiographs of hand, skull, and shoulder joins showed similar lesions [refer to adjoining Figure 1b-d]. On metabolic work, she had parathyroid hormone level of 162 pg/mL, phosphorus of 8.5 mg/dL, calcium of 9.8 mg/dL, albumin of 3.5 g/dL, and Vitamin D level of 29 ng/mL. She was poorly compliant with dietary restrictions and taking phosphate-binding medications. Diagnosis of secondary tumoral calcinosis was made. The patient was managed with phosphate-restricted diet, phosphate-binding medication, and increasing the dialysis frequency from twice weekly to thrice weekly.Figure 1: X-ray images showing (a) irregular peri articular masses around the hip joint. Similar findings were seen in X-ray images of (b) hand (c) skull and (d) shoulder joints as wellTeutschlaender initially described this disease in his studies in 1930’s and it came to be known as Teutschlaender disease.[1] The term tumoral calcinosis was coined by Inclan in 1943.[2] Smack et al. retrospectively studied 122 cases of tumoral calcinosis and proposed a classification system.[3] They classified it as (1) primary normophosphatemic type, (2) primary hyperphosphatemic type, and (3) secondary tumoral calcinosis. Secondary causes include renal insufficiency, hyperparathyroidism, or hypervitaminosis D, with renal insufficiency being the most common identifiable condition. Even though soft-tissue calcifications are common in hemodialysis patients, the prevalence of periarticular masses is low. Most of cases in chronic kidney disease are thought to occur due to the presence of hyperparathyroidism although it may occur in its absence as well. The calcification process results from elevated calcium–phosphorus product with hyperphosphatemia being the most important component. Diagnosis is based on characteristic imaging findings. Imaging typically shows amorphous, cystic, and multi-lobulated deposits in periarticular areas.[4] Computed tomography may show cystic loculi with fluid levels giving rise to sedimentation signs. Treatment of secondary tumoral calcinosis in the setting of renal failure is predominantly medical therapy. Calcium- and phosphate-restricted diets and phosphate binders are used as first-line management. Intravenous pamidronate is also shown to be effective.[5] Partial or total parathyroidectomy can be considered in refractory cases in case hyperparathyroidism is the cause.[6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Developments in Research on the Relationship Between Matrix Metalloproteinases and Osteoarthritis

Matrix metalloproteinases (MMPs) acquired their names because they depend on metal ions such as Ca 2+ and Zn 2+ as their cofactors. Members of this family of proteins share a similar structure consisting of five functionally distinct structural domains. MMPs, including MMP-1, MMP-3, MMP-9, and MMP-13, are key substances that promote cartilage matrix degradation and play an important role in the occurrence and progression of osteoarthritis (OA). MMPs boost the development of OA through the degradation of extracellular matrix proteins of chondrocytes, the promotion of inflammation, and other mechanisms, and are hence attracting extensive and increasing attention from the medical community. OA is a common degenerative disease that occurs in the joints and is associated with aging, metabolism, infections, genetics, exercise, and other predisposing factors. The pathological changes it causes can lead to a series of clinical symptoms such as joint pain, morning stiffness, and restricted joint movement, severely affecting patients' quality of life. The pathogenic mechanism of this highly prevalent disease is still unclear. At present, there is no effective treatment available for disease improvement. In the future, selective inhibition of MMPs, the key enzymes, may become an effective therapeutic approach. Focusing on the pathogenic effects of MMPs in OA, we herein reviewed the latest findings on the role of MMPs in the occurrence and progression of OA.

Nontuberculous Mycobacterial Tenosynovitis of the Hand: A 10-Year Experience at Two Centers in South Korea.

The aim of this study was to investigate the clinical characteristics of nontuberculous mycobacterial tenosynovitis and to report the process of diagnosis and the outcomes of surgical debridement and drug administration in South Korea. Between 2010 and 2019, 23 patients (10 men and 13 women) with nontuberculous tenosynovitis of the hand were treated at two centers. Their average age was 64 years, and the average duration of symptoms was 8 months (range, 1-36 months). Eight patients had a history of trauma or surgery. The average number of corticosteroid injections before diagnosis was 2.6 for 7 patients. All 23 patients were treated with a combination of extensive tenosynovectomy and antibiotics. Of the 23 patients, 20 were available for the final follow-up (1, lost to follow-up; 1, transferred to another hospital; and 1, died from a comorbidity). The most common species was Mycobacterium intracellulare (70%), followed by Mycobacterium abscessus (10%). The frequency of involvement of the extensor/flexor tendon was similar to that of the wrist/finger. The mean number of surgical debridement operations was 2.2. The average duration of antibiotic administration was 9.8 months. At the last follow-up, 3 patients were symptom-free with full range of motion at the involved site, 1 patient complained of localized swelling or pain with full range of motion, 1 patient was found to have a recurrence of infection in a finger, and 15 complained of restricted joint motion. The most common species noted in patients with nontuberculous mycobacterial tenosynovitis was M. intracellulare. Patients with only 1 finger involved showed good range of motion at the final follow-up. Most patients experienced delayed wound healing and adverse effects from drug therapy during treatment and limited joint motion at the final follow-up.

Total Hip Arthroplasty in Patients with Hemophilia: What Do We know?

Total hip arthroplasty (THA) is the mainstay therapy for terminally hemophilic arthropathy patients. Hemophilic patients have distinguishing characteristics, including the increased likelihood of bleeding, younger age, restricted pre-operative joint motion, disrupted anatomy, and more post-operative side effects. The present study aimed to assess the THA sequels in hemophilic patients from various perspectives, including indications, challenges, factor replacement post-operative outcomes, and other complications.

Rat Model of Quadriceps Contracture by Joint Immobilization.

Muscle contracture is an abnormal pathologic process resulting in fibrosis and muscle atrophy, which can lead to limitation of joint motion. To establish a diagnostic method to detect muscle contracture and a method to control its progression, we investigated an appropriate method to create an animal model of quadriceps contracture using rats. Eighteen Wistar rats were divided into three groups, and bilateral hindlimbs were immobilized with either a cast (Group I), a Velcro hook-and-loop fastener (Group V), or steel wire (Group S) with the knee and ankle joints in extension position for two weeks. Five rats in a control group (Group C) were not immobilized. After two weeks, the progression of quadriceps contracture was assessed by measuring the range of joint motion and pathohistological changes. Muscle atrophy and fibrosis were observed in all immobilization groups. The knee joint range of motion, quadriceps muscle weight, and muscle fiber size decreased only in Group S compared to the other immobilization groups. Stress on rats due to immobilization was less in Group S. These results indicate that Group S is the superior quadriceps contracture model. This model aids research investigating diagnostic and therapeutic methods for muscle contracture in humans and animals.

Clinical and Genetic Analysis of Multiple Osteochondromas in A Cohort of Argentine Patients.

Multiple Osteochondromatosis (MO, MIM 133700 & 133701), an autosomal dominant O-glycosylation disorder (EXT1/EXT2-CDG), can be associated with a reduction in skeletal growth, bony deformity, restricted joint motion, shortened stature and pathogenic variants in two tumor suppressor genes, EXT1 and EXT2. In this work, we report a cross-sectional study including 35 index patients and 20 affected family members. Clinical phenotyping of all 55 affected cases was obtained, but genetic studies were performed only in 35 indexes. Of these, a total of 40% (n = 14) had a family history of MO. Clinical severity scores were class I in 34% (n:18), class II in 24.5% (n:13) and class III in 41.5% (n:22). Pathogenic variants were identified in 83% (29/35) probands. We detected 18 (62%) in EXT1 and 11 (38%) in EXT2. Patients with EXT1 variants showed a height z-score of 1.03 SD lower than those with EXT2 variants and greater clinical severity (II-III vs. I). Interestingly, three patients showed intellectual impairment, two patients showed a dual diagnosis, one Turner Syndrome and one hypochondroplasia. This study improves knowledge of MO, reporting new pathogenic variants and forwarding the worldwide collaboration necessary to promote the inclusion of patients into future biologically based therapeutics.

Association of a femoral neck T score with knee joint osteophyte formation but not with skeletal muscle mass.

Osteophyte formation is an important radiographic sign of osteoarthritis (OA) and limited joint motion in knee osteoarthritis patients. Some studies revealed relationships of osteophyte formation with a high bone mineral density and a high muscle mass, while others showed no correlations. The aim of this study was to identify relationships of osteophyte formation with bone mineral density and muscle mass. A cross sectional study of knee osteoarthritis was conducted. Cases were classified as patients with osteophyte formation, while controls were those without osteophytes. All subjects underwent a knee x-ray and bone mineral density and body composition evaluation. General patient characteristics, covariates, and the results of biochemical analyses were also recorded. Statistical analysis was conducted using SPSS Version 22.0. Logistic regression and the chi-square test were utilized to analyze the relationships between the presence of knee osteophytes and the study variables. A total of 228 patients were enrolled, including 78 with osteophytes in the knee joint and 150 without. A total of 162/228 are females; knee OA is commonly explained among females. (p = 0.001). The mean age was 73.23 ± 11.10years in the osteophyte group and 71.86 ± 12.23 in the no osteophyte group (p = 0.409). The mean body mass index was 24.15 ± 3.27kg/m2 in the osteophyte group and 23.37 ± 3.48kg/m2 in the no osteophyte group (p = 0.433). More patients in the osteophyte group had hypertension (p = 0.002), so the age group 73years expected to have OA and hypertension along other metabolic diseases, and the femoral neck T score was higher in the osteophyte group (p = 0.044). Logistic regression analysis showed that the male gender was associated with less osteophyte formation (p = 0.001, odds ratio (OR) 0.11 (0.03-0.37)), and hypertension was associated with increased muscle loss (p = 0.005). Femoral neck T score was associated with the presence of osteophyte formation (p = 0.011, OR 1.98 (1.17-3.36)). The results demonstrated an association of knee osteophyte formation with the femoral neck T score and hypertension, but no association with muscle mass. We speculated that in patients with osteophytosis and increased bone mass, metabolic factors such as hypertension should be considered. Further study of the molecular mechanisms regulating these processes is needed in the future. Key Points • Associations of knee osteophyte formation with the femoral neck T score, but not with muscle mass. • Those with osteophytosis and an increased bone mass and metabolic factors such as hypertension need to be assessed.

PSAT182 Dilemmas in the Diagnosis and Management of Osteoporosis in a patient with Alkaptonuria: Successful Treatment with Teriparatide

Abstract Introduction Diagnosis and management of osteoporosis in patients with alkaptonuria can be challenging. Coexisting arthritis involving the lumbar spine (LS) and hips can falsely elevate bone density making DXA interpretation difficult. We report a patient with alkaptonuria who was successfully treated with teriparatide in addition to bisphosphonate therapy. Case History A 69-year-old female presented for evaluation of osteoporosis. She was diagnosed with alkaptonuria at age 29 when she reported bilateral conjunctival hyperpigmentation. She was also diagnosed with arthritis requiring left knee joint replacement at the age of 57 years. Subsequently, she underwent left hip, right knee, right hip, and left shoulder joint replacement surgeries. She also sustained fragility fractures in the foot and a 2-inches height loss. Physical examination: normal vital signs. Examination of eyes and ears: bluish black discoloration of the conjunctiva and ear lobes. Heart examination showed normal S1, split S2, and IV/VI systolic murmur over the right parasternal border; the rest of the physical examination revealed limited joint movements of thoracic and lumbar spines, wrists, ankles, knees and hip joints. Laboratory: serum PTH 33 pg./mL, 25-OH vitamins 28 ng/mL, 1,25 (OH)2 vitamin D 43 pg/mL, osteocalcin 11.6 mg/mL (ref 9.4-47.4), collagen cross-linked C-telopeptide 318 pg/mL (ref 104-1008), tyrosine 79.1 umol/L (ref 31.1-118.1), 24 hours urine homogentisic acid 4.2 gms (ref 20-30 mg). Genetic testing: compound heterozygous mutation for the HGD C. 496T2T&amp;gt;C and HGD C.1102A &amp;lt; G (p.mev368Va) variants, consistent with a diagnosis of alkaptonuria. DXA scan done at the age of 56 years showed osteoporosis (T score -2.7 femoral neck, 1.8 total hip, 2.5 LS). Patient was started on alendronate 70mg PO weekly for 5 years in addition to nitisinone. While on alendronate, she sustained fragility fractures of the right radius and left ankle. After 5 years of alendronate, the patient was transitioned to teriparatide 20-mcg subcutaneously (SC) daily for 2 years followed by annual intravenous zoledronic acid. For the subsequent 7 years, the patient led a healthy, active life with no fractures. Follow-up DXA showed improvement to the osteopenic range at the radius site as degenerative arthritis made interpretation of other sites impossible.This case illustrates the challenges in the diagnosis and treatment of osteoporosis in patients with alkaptonuria. DXA can be ineffective in this condition due to the hip and LS arthritis. Measurement of trabecular bone scoreS and CT of the LS may be better alternate choices. Bisphosphonates alone are typically not effective in preventing fragility fractures in this population but use of teriparatide may be an effective treatment. Further studies are needed to assess the effectiveness of teriparatide in this population but our case shows promise that this treatment result in BMD improvement and fracture prevention. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation

The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions. A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed. Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°). In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up. Therapeutic V.