Enthesitis and ankylosis in spondyloarthropathy: What is the target of the immune response?

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Abstract
A report from a symposium held at Klinikum Benjamin Franklin, Free University, Berlin, Germany, 25–26 February 2000 This symposium was organised by J Braun and J Sieper (Free University, Berlin) to review the current knowledge of the anatomical, inflammatory, microbiological, and immunological events in enthesitis. The term “enthesopathy” is relatively new and its medical history short, but some important contributions can be listed (boxFB1). Figure FB1 History of “enthesopathy” • 1966 Enthesopathy first used by Niepel • 1970 Entheses centrally affected in ankylosing spondylitis, in contrast with rheumatoid arthritis (RA; Heberden oration lecture by Ball) • 1975 Some enthesitis in sacroiliitis (François) • 1983 Syndrome of seronegative enthesopathy and arthropathy in children (Rosenberg) • 1982 Sacroiliitis starts in the subchondral bone (Shichikawa) • 1991 Enthesopathy discriminative feature of spondyloarthropathy (SpA; European Spondyloarthropathy Study Group criteria, Dougados) • 1998 Entheses more commonly affected in arthritis in SpA compared with RA (McGonagle) The spondyloarthropathies are among the most common inflammatory rheumatic diseases.1 In addition to the strong genetic predisposition, partly due to HLA-B27,2 there are characteristic clinical features of SpA3: inflammatory back pain often due to sacroiliitis4 and enthesitis occurring mostly at various well defined locations, predominantly of the legs, such as the Achilles tendon, the plantar aponeurosis, the knee, the trochanter regions of the femur, and several pelvic sites.5 Thus entheses are ubiquitous, resulting in a diversity of associated pathological manifestations. Sacroiliitis is the most common early sign of SpA.6Whether or not ligamentous and entheseal structures are affected in sacroiliac inflammation has not yet been entirely clarified. To answer some of the most critical questions an expert symposium on enthesitis was organised:

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