Pain Around Elbow: Not Always Tennis Elbow!

Elbow is a well-known body part of muscular strains and overuse syndromes. Patients presented to the orthopedic department with elbow pain or swelling often diagnosed with benign conditions such as tennis elbow, golfer’s elbow, or olecranon bursitis. It must be kept in mind that several tumoral conditions can be seen around the elbow and the patient must be carefully evaluated. In this study, we aimed to demonstrate rare cases of bone or soft tissue tumors around the elbow. Between 2004 and 2017, patients with a symptom of elbow pain or swelling are included in the study. Finally, the study consists of 53 patients. 20 patients were male and 33 were female. The mean age of the patients was 42.94 ± 15.3. There were 9 bone tumors, 16 soft tissue tumors, 9 non-classified benign cystic lesions, 3 metastasis, and 16 cases were non-tumoral conditions. 7 of 9 bone tumors were benign. The solitary bone cyst was the most common bone tumor seen around the elbow. 2 malignant bone tumor cases were diagnosed as Ewing Sarcoma and metastatic bone disease. Among the 16 soft tissue tumors, schwannomas are the most presented cases in the tumor council followed by lipoma (6 cases). Even in a multidisciplinary bone and soft tissue tumor council, almost one-third of the elbow pain patients were non-tumoral and the most commonly seen condition was myositis ossificans (6 cases), followed by infection or bursitis (5 cases). Elbow pain is commonly seen and evaluated by every orthopedic surgeon on outpatient’s clinic. It must be kept in mind that tumoral conditions around the elbow are rarely seen but deserve further examination in the presence of chronic pain.

1559. Methicillin Susceptible Staphylococcus aureus Is The Predominant Organism In Septic Bursitis With The Majority Involving The Olecranon Bursa: A Study Of 61 Cases

Background Bursae are fluid filled structures between mobile parts of the musculoskeletal system to reduce friction between surfaces by lubrication. The most frequently infected are the olecranon and prepatellar bursae. In reported studies there is male preponderance, a relationship to occupational or recreational activities, a mean age of about 50 years and the most frequent organism being Staphylococcus aureus. The frequency of methicillin resistance is not well documented. Methods We analyzed approximately 7000 Staphylococcus aureus isolates reported by the laboratory over a 3-year period in 10 of our network hospitals, 9 in Eastern Pennsylvania and one in adjacent Warren County, New Jersey and found 61 cases of S. aureus septic bursitis. Results Only 13/61 (21.3%) were caused by methicillin resistant S. aureus (MRSA), 8 olecranon (61.5%), 4 prepatellar (30.8%) and one subacromial (7.7%). Only one in MRSA group (olecranon bursitis) was female. The mean age of MRSA cases was 58.5. Methicillin susceptible S. aureus (MSSA) predominated with 34/48 (70.8%) olecranon bursitis (28M/6F), 11/48 (22.9%) prepatellar bursitis (10M/1F) and 3/48 (6.3%) sub acromial bursitis (1M/2F) with a mean age of 61.9. Overall (MRSA +MSSA), 51/61 (83.6%) were male and 10/61 (16.4%) were female. The olecranon bursa was involved in 42/61 (68.9%), prepatellar bursa 15/54 (24.6%) and subacromial bursa 4/54 (6.6%). The mean age for the entire group was 61.2 with the youngest 23 and the oldest 93. The occupational history was recorded only in a few patients e.g. roofer, floor worker, construction worker. Three in the MSSA group had bacteremia (2 subacromial bursitis and 1 olecranon bursitis). There was 1 death from gram negative sepsis which was unrelated. The majority were successfully treated with a combination of drainage and antibiotics. Conclusion In summary, our study shows a predominance of olecranon bursitis, with a higher incidence in males and majority caused by MSSA. The mean age around 61 was higher than the mean age in prior reports around 50 years. Elbows and knees accounted for 57/61 (93%) cases of septic bursitis. Avoidance of activities involving friction or repeated trauma to elbows and knees should help prevention of septic bursitis. As far as we are aware, this is the largest series of septic bursitis reported. Disclosures All Authors: No reported disclosures

AB0460 INTERLEUKIN-6 INHIBITION WITH TOCILIZUMAB FOR THE TREATMENT OF GIANT CELL ARTERITIS AND POLYMYALGIA RHEUMATICA IN PATIENTS WITH SERIOUS COMORBIDITIES

Background:Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related inflammatory conditions affecting people aged over 50 years.Objectives:We present our experience of using tocilizumab (TCZ) therapy for management of GCA/PMR aggravated by severe concurrent pathologies that potentially increase the risk of side effects of glucocorticoids (GCs).Methods:22 patients were recruited into the prospective study: six patients with GCA, 13- PMR, and three- with both GCA and PMR, 95.5% were females, mean age 72.8±6.5 years. Mean disease duration was 3.5 (0.5-19) months. All patients had active GCA/PMR with mean CRP 30.3±32.7 mg/l. Seven patients had visual ischemic complications, and another one- aortitis. All patients had serious comorbidities, 59% of patients had three and more severe concurrent diseases. All patients were administered TCZ i/v 2.3-8.8 mg/kg Q4W. 50% patients were also treated with prednisone at mean 20 (10-70) mg/day. The follow-up period was 24 (6-60) months.Results:All patients demonstrated good clinical response to TCZ i/v 2.3-8.8 mg/kg Q4W given for average 4,5 (2-11) months, achieving remission in 100% of cases. Some patients showed a very rapid improvement after initiation of treatment, including TCZ monotherapy. Prednisone dose was discontinued in 6/11, or was reduced to 2.5 (2.5-10) mg in 4/11. There was one relapse after TCZ discontinuation, although this patient managed to regain the remission after resumption of TCZ i/v 4 mg/kg. There was one (4.6%) serious complication (septic olecranon bursitis 1 month after TCZ discontinuation), one patient died of myocardial infarction 12 months later after TCZ discontinuation. Three remaining complications included one case of peripheral artery disease (claudication), one- psoriasis, and one- sural lipodermatosclerosis.Conclusion:Interleukin-6 inhibitors should be considered as potentially effective and relatively safe treatment for GCA/PMR patients with serious comorbidities, intolerance or contraindications to standard therapy. More data is necessary to identify the optimal dosing regimen and duration of TCZ therapy, as well as cost-effectiveness aspects.Disclosure of Interests:None declared

Epidermoid Cyst in an Infected Olecranon Bursa

Epidermoid cysts are common, benign cysts that form due to follicular epithelium implanting into the dermis. Although these cysts are often painless, they can incite an inflammatory process as well as abscess formation, especially if ruptured. Our case involves a 59-year-old woman with a history of remote elbow trauma diagnosed with septic olecranon bursitis with concomitant epidermoid cyst found on histology following incision and drainage (I&D). Due to the rare presentation and inadequate preoperative imaging, the diagnosis of epidermoid cyst was not made prior to surgery, resulting in incomplete enucleation.