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Axial Spondyloarthritis
Published in Jason Liebowitz, Philip Seo, David Hellmann, Michael Zeide, Clinical Innovation in Rheumatology, 2023
Imaging modalities have been extensively applied to the conundrum of enthesitis. In particular, ultrasound, with its portability and ready availability at bedside, has shown significant promise in the detection of enthesitis.15 In 2018, the Outcome Measures in Rheumatology Clinical Trials group proposed the following definition, which resulted in good reliability: “Hypoechoic and/or thickened insertion of the tendon close to the bone (within 2mm from the bony cortex) which exhibits Doppler signal if active and which may show erosions and enthesophytes/calcifications as a sign of structural damage.”79 As of this textbook’s publication, however, definitions of enthesitis on ultrasound have yet to be standardized and widely adopted, although this process of standardization is ongoing.80 Thus, significant variability persists between ultrasonographers.
Foot and ankle radiology
Published in Maneesh Bhatia, Essentials of Foot and Ankle Surgery, 2021
Anterior ankle impingement occurs as a result of chronic repetitive trauma. This results in enthesophyte formation along the anterior margin of the tibial plafond and the talar neck, leading to restricted dorsiflexion of the ankle joint. MRI demonstrates joint effusion with localised synovitis within the anterior recess of the ankle joint. There is usually associated capsular thickening/scarring demonstrated by thickened synovial lining of the anterior ankle joint.
Psoriatic arthritis
Published in Biju Vasudevan, Rajesh Verma, Dermatological Emergencies, 2019
There is a marked heterogeneity of bone phenotypes in PsA ranging from extensive bone damage in the form of erosions and mutilans variety, to spinal ankyloses and formation of enthesophytes. In psoriatic synovium, there is marked upregulation of the receptor activator of NF-κB (RANK) ligand (RANKL), and low expression of its antagonist, osteoprotegerin, in the adjacent synovial lining. The RANKL cytokine binds to RANK on the surface of osteoclast precursors that are derived from circulating CD14+ monocytes. This ligand-receptor interaction triggers proliferation of the osteoclast precursors and their differentiation into multinucleated osteoclasts, which resorb bone [22]. There is also increased TNF-α, and together with RANK, there is increased osteoclastogenesis and bone erosions.
Dickkopf-1 directs periosteal bone formation in two murine models of inflammatory arthritis
Published in Scandinavian Journal of Rheumatology, 2022
AT Shaw, J Yan, SA Kuhstoss, JF Charles, EM Gravallese
The periosteal bone observed in the flare variant of AIA occurred specifically at tendon and ligament insertion sites in arthritic knees, resulting in enthesophytes. Notably, these enthesial sites are also areas of mechanical stress, which has been identified as a contributory factor in bone formation in SpA (18). Thus, the formation of new bone evident in the control rat IgG and PBS treatment groups was not unexpected. However, mice treated with the anti-DKK1 antibody developed strikingly more bone, presumably because of the relief of antagonism of the Wnt pathway, resulting in increased Wnt signalling and osteoblast differentiation. Conversely, Dkk1 Tg mice developed less new bone around the wrists compared to controls. This new bone was confined to the periosteal surfaces and did not develop from entheses, suggesting that modulating DKK1 function can affect inflammatory new bone formation at multiple locations.
Ultrasound Doppler enthesitis shows sensitivity to change after biological therapy in spondyloarthritis and psoriatic arthritis patients
Published in Scandinavian Journal of Rheumatology, 2022
J Molina Collada, C Macía-Villa, C Plasencia-Rodríguez, JM Álvaro-Gracia, E de Miguel
However, while there is consensus about the relevance of enthesitis in SpA and PsA, our results showed that the MASES was not associated with other outcomes of disease activity. This is in agreement with the finding that enthesitis assessment by physical examination has low sensitivity, specificity, and reliability (5). Therefore, the inclusion of imaging modalities is a challenge for evaluating this domain. US has demonstrated greater sensitivity and specificity in detecting inflammatory activity and structural lesions at the entheses than physical examination (5). In recent years, several US enthesitis scoring systems have been published (6, 20–23), although no consensus has been reached regarding the best score. In 2018, a consensus definition of US enthesitis was proposed by the OMERACT US Working Group, which states that enthesitis is a hypoechoic and/or thickened insertion of the tendon within 2 mm of the bony cortex, which exhibits a PD signal if active, with possible erosions and enthesophytes/calcifications as signs of structural damage (8). However, there is ongoing debate over which PD enthesitis definition best reflects the pathophysiological process underlying the inflammation of the enthesis if the OMERACT ‘< 2 mm of cortical bone profile’ concept or the GRAPPA ‘full synovioentheseal complex’ hypothesis (24) is included in the MASEI score.
Role of the IL-23 pathway in the pathogenesis and treatment of enthesitis in psoriatic arthritis
Published in Expert Opinion on Biological Therapy, 2020
Maurizio Rossini, Oscar Massimiliano Epis, Ilaria Tinazzi, Rosa Daniela Grembiale, Annamaria Iagnocco
Another cytokine which acts on osteoblasts downstream of the IL-23 signaling pathway is IL-22. This cytokine is associated with bone formation and is found to be elevated in the synovial fluid of PsA patients compared with patients with osteoarthritis. In this context, systemic overexpression of IL-23 leads to new entheseal bone formation and osteoblast expansion via upregulation of IL-22, which induces osteoblast-related genes in the enthesis. Similar to IL-23, overexpression of IL-22 leads to new periosteal bone formation through STAT3 activation and increased expression of genes that regulate bone formation, including the Wnt family members [9]. Recent in vitro studies demonstrated that IL-22 can enhance osteogenic differentiation in human mesenchymal stem cells [100]. IL-23 has also been reported to directly regulate osteoblast formation, as its binding to the IL-23 R on human mesenchymal stem cells leads to increased expression of osteoblast-related genes and formation of osteoblasts in vitro [101]. The role of IL-23 in the pathogenesis of enthesitis and enthesophytes is shown in Figure 1.