Incidence of glenohumeral joint involvement in seropositive rheumatoid arthritis. A 15 year endpoint study

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of glenohumeral (GH) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup radiographs of 148 GH joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 71/148 (48%) GH joints in 41/74 (55%) patients; 30 patients had bilateral and 11 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 401148 (27%), and of severe (Larsen 3-5) 31/148 (21%). The 11 most severely involved (Larsen grade 5) joints were seen in 6 (8%) patients. Erosions were most often (61/71 joints) observed on the superolateral articular surface of the humerus. Glenoidal involvement was less common (28/71 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the GH joint Larsen grade on both sides (p < 0.001). CONCLUSION: After 15 years more than half the patients with RA showed definite involvement and 1 in 4 had severe destruction of the GH joint. The greatest destruction was almost always bilateral.     

Incidence of acromioclavicular joint involvement in rheumatoid arthritis: a 15 year endpoint study.

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of acromioclavicular joints (AC) in a prospectively followed cohort of 74 patients with rheumatoid factor positive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup, radiographs of 148 AC joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: No surgical procedures had been performed on the AC joints. Rheumatoid involvement (Larsen Grade > or = 2) was observed in 87/148 (59%) of the AC joints in 50/74 (68%) patients: 37 bilaterally and 13 unilaterally. Incidence of mild erosions (Larsen Grade 2) was 39%, and of severe (Larsen 3-5) 20%. Erosions were most often observed on the inferior edge of the clavicular joint margin. Degenerative features without rheumatoid changes were present in 11 joints. Larsen score (0-100) of peripheral joints correlated well with the AC joint Larsen Grade in both sides: right, r = 0.56 (95% CI 0.38 to 0.70), left, r = 0.49 (95% CI 0.30 to 0.65). CONCLUSION: After 15 years two-thirds of the patients with RA showed involvement of the AC joints. Erosions were located most often on the inferior margin of the joint.     

Acute destruction of the hip joints and rapid resorption of femoral head in patients with rheumatoid arthritis

We report three rheumatoid arthritis (RA) cases with acute destruction of hip joint and rapid resorption of femoral head. The condition occurred in less than 6 months and closely resembled rapid destructive coxarthrosis. All three patients were postmenopausal women with active RA who had been taking steroids. Two of the patients were taking prednisolone (PSL) of over 20 mg as maximum dose per day, and all patients were resistant to disease-modifying anti-rheumatic drugs (DMARDs). Other than the problems of their hip joints, one had a giant bursitis around the pathological side of the hip joint, another had multiple rheumatoid nodules and skin infarction, and the other suffered from insufficiency fracture of the contralateral femoral subcapital lesion. As a result, all of them had total hip arthroplasty. We recommend taking repetitive radiographs for RA patients with continuing severe hip pain.     

Acute destruction of the hip joints and rapid resorption of femoral head in patients with rheumatoid arthritis

Abstract

We report three rheumatoid arthritis (RA) cases with acute destruction of hip joint and rapid resorption of femoral head. The condition occurred in less than 6 months and closely resembled rapid destructive coxarthrosis. All three patients were postmenopausal women with active RA who had been taking steroids. Two of the patients were taking prednisolone (PSL) of over 20?mg as maximum dose per day, and all patients were resistant to disease-modifying anti-rheumatic drugs (DMARDs). Other than the problems of their hip joints, one had a giant bursitis around the pathological side of the hip joint, another had multiple rheumatoid nodules and skin infarction, and the other suffered from insufficiency fracture of the contralateral femoral subcapital lesion. As a result, all of them had total hip arthroplasty. We recommend taking repetitive radiographs for RA patients with continuing severe hip pain.     

Assessment of mutilans-like hand deformities in chronic inflammatory joint diseases. A radiographic study of 52 patients

OBJECTIVES: To evaluate patients with mutilans-like hand deformities in chronic inflammatory joint diseases and to determine radiographic scoring systems for arthritis mutilans (AM). METHODS: A total of 52 patients with severe hand deformities were collected during 1997. A Larsen hand score of 0-110 was formed to describe destruction of the hand joints. Secondly, each ray of the hand was assessed individually by summing the Larsen grade of the wrist and the grades of the MCP and PIP joints. When the sum of these grades was > or = 13, the finger was considered to be mutilated. A mutilans hand score of 0-10 was formed according to the number of mutilans fingers. Surgical treatment and spontaneous fusions were recorded. RESULTS: The study consisted of 22 patients with juvenile rheumatoid arthritis (JRA), nine with rheumatoid factor (RF) positive and 13 with RF negative arthritis, 27 patients with RF positive RA, and three adult patients with other diagnoses. The mean age of patients with adult rheumatic diseases was 27 years at the onset of arthritis. The mean disease duration in all patients was 30 years. The mean Larsen hand score was 93. Four patients had no mutilans fingers and in 15 patients all 10 fingers were mutilated. The Larsen hand score of 0-110 and the mutilans hand score of 0-10 correlated well (rs = 0.90). Fourteen patients showed spontaneous fusions in the peripheral joints. A total of 457 operations were performed on 48 patients. CONCLUSION: Both the Larsen hand score of 0-110 and the mutilans hand score of 0-10 improve accuracy in evaluating mutilans-like hand deformities, but in unevenly distributed hand deformities the mutilans hand score is better in describing deformation of individual fingers.     

Long-term prognosis of monoarthritis. A follow-up study

During 1973-75, a total of 446 patients with recent arthritis were examined. The diagnosis in 32 cases was non-classified monoarthritis. After the 3-9 years' follow-up of these 32 patients, two seropositive, definite rheumatoid arthritis cases (6%), and one ankylosing spondylitis case were noted. In the remaining patients the diagnosis was still non-specific arthritis. Of the 31 patients tested, 39% were HLA-B27-positive. The difference between this and the HLA-B27-positivity in the normal Finnish population (14%) is statistically significant (p less than 0.005). At the end of the follow-up the good prognosis of monoarthritis was confirmed: only one erosion developed in one patient's hands or feet.     

Incidence of elbow involvement in rheumatoid arthritis. A 15 year endpoint study

OBJECTIVE: To evaluate the incidence of involvement and cause of destruction of humeroulnar (HU) and humeroradial (HR) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 75/148 (51%) elbows in 45/74 (61%) patients; 30 patients had bilateral and 15 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 49/148 (33%), and severe erosions (Larsen 3-5) 26/148 (18%). The 13 most severely involved (Larsen grade 4-5) joints were seen in 8 (11%) patients. Erosions were most often observed on the capitellum (64 joints) and the lateral epicondyle (58 joints) of the humerus (AP view) or on the olecranon of the ulna (52 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the elbow joint Larsen grade on both sides: right, r = 0.53 (95% CI 0.34 to 0.68); left, r = 0.53 (95% CI 0.34 to 0.68). CONCLUSION: After 15 years more than half of the elbows and almost 2 of 3 patients with RA showed definite involvement of the elbow joint. Erosions were most often located on the capitellum and the lateral epicondyle of the humerus or the olecranon of the ulna. Severe destruction was most often bilateral.     

Cementless total hip arthroplasty in patients with rheumatoid arthritis using a tapered designed titanium hip stem minimum: 10-year results

The results of cementless tapered designed femoral stem were studied at a minimum 10-year follow-up in a non-selected, consecutive group of 27 patients (39 hips) with rheumatoid arthritis. Clinical and radiological analyses were performed in 27 hips, 17 patients (mean age at surgery 45 years) after a mean of 12 years. The postoperative Harris hip score was excellent for 14 hips, 9 hips were rated as good and 4 hips were fair or poor. No stem had to be revised for aseptic loosening. Proximal stress shielding was observed in 26 hips (96%); heterotopic ossification was present in 11 hips (41%). Six hips required revision of the acetabular component. With uncemented tapered femoral fixation excellent 12-year results are achieved in patients with rheumatoid arthritis.     

Amyloid deposition in rheumatoid arthritis of the hip

The aim of this study was to examine the frequency of amyloid deposition in patients with end-stage rheumatoid arthritis (RA) of the hip. The impact on the clinical situation and the RA severity regarding the inflammation was analyzed. Fifty patients with RA who consecutively underwent total hip replacement were prospectively evaluated. X-rays of the patients were analyzed radiologically (Larsen score) to quantify the radiological changes. A clinical score (Harris Hip Score) was preoperatively calculated from every patient. A laboratory set of inflammation markers (erythrocyte sedimentation rate, CRP, serum amyloid A-SAA, electrophoresis) was measured in every patient the day before the operation. Specimens of bone and cartilage from the femoral head and of the capsule were obtained from every patient intraoperatively for histological evaluation. A histological grading was performed. In patients with amyloid deposits, the subtypes were characterized immunohistologically. Ninety-two percent of the patients had raised SAA in the blood samples, but the only amyloid subtype was ATTR. No correlation was found for any other measured item, such as inflammation signs in the blood samples, the histological grading, the radiological or the clinical score. Amyloid plays a role in inflammatory joint destruction processes in RA with raised SAA values, but the amyloid deposits in the joint are of a different subtype. Thus, these amyloid deposits can be considered as minor pathologic significance. A correlation to the radiological and histological changes was ruled out by our study. As in degenerative arthritis, ATTR amyloid deposits may be an incidental finding in aged joints.     

Prevalence of mutilans-like hand deformities in patients with seropositive rheumatoid arthritis. A prospective 20-year study

This study examined radiographically the prevalence of arthritis mutilans hand deformities in an inception cohort of 68 rheumatoid arthritis (RA) patients. Hand deformities of 103 RF-positive RA patients were evaluated after 8 years, 83 patients after 15 years and 68 patients 20 years after entry. The grade of destruction in the hand joints was assessed by the Larsen method and Larsen scores of 0-50 were determined for both PIP (+IP) and MCP joints. At the end point, 3 patients had Larsen scores > or =40 for both PIP and MCP joints. These three patients had severe resorption in most of the finger joints, but did not demonstrate classical opera-glass hand. The prevalence of mutilans-like hand deformities with RA was 3/68 (4.4%) in a prospective 20-year study.     

Chondrocalcinosis and rapid destruction of the hip

The frequency and significance of articular chondrocalcinosis was studied in 86 cases of osteoarthritis (OA) with rapid destruction of the hip that underwent total arthroplasty. The occurrence of articular chondrocalcinosis was 3 times more frequent than in a matched control population without rheumatic complaints (32.5% vs 10.5%). In a matched group of control patients operated on for common OA of the hip, the frequency of articular chondrocalcinosis (18.6%) was higher than in the control patients but significantly lower than in the patients with rapid destruction of the hip. Fifty-five patients in each of the 3 groups were aged 70 years or more, and the frequency of articular chondrocalcinosis in those patients with rapid destruction of the hip rose to 45.4% compared to 13.7% for the control group (p less than 0.01) and 27.2% for the group with common OA of the hip (p less than 0.05).     

Immunogenetic markers and seropositivity predict radiological progression in early rheumatoid arthritis independent of disease activity

OBJECTIVE: A prospective clinical study of patients with recent onset rheumatoid arthritis (RA) to examine the relationship between inflammatory disease activity and joint destruction in a 4 year followup, and to evaluate prognostic markers for severe joint erosions early in the disease. METHODS: Eighty-seven patients with RA according to the American College of Rheumatology criteria and a disease duration < 2 years were followed for an observation time of 2 to 4 years (mean 3.1 yrs). Variables of clinical and laboratory disease activity were monitored, and HLA-DRB1 alleles were determined. Hand and foot radiographs were taken every 6 months. RESULTS: Multivariate analysis of independent contributions of covariates to progression of joint destruction resulted in a mixed effect regression model with significant influences for the presence of a shared epitope (SE) positive DR4 allele (SE+ DR4+; p = 0.007), rheumatoid factor (RF) IgA (p = 0.01), and sex (p = 0.059), but not for clinical variables or acute phase reactants. The odds ratio to reach a Larsen score above 32 during the observation period of 4 years was increased in patients positive for RF IgM (OR 2.7, p = 0.019), for the shared epitope on a DR4 allele (OR 8.6, p < 0.005), and in patients with erosions already at study entry (OR 11.9, p = 0.001). The highest sensitivity and specificity for the prediction of severe bone destruction (84% and 79%) were found when the presence of either a SE+ DR4 allele or of early erosions was used as a prognostic marker (OR 20.4, p < 0.0001). CONCLUSION: Our results show the pace of joint destruction in RA to be influenced by the presence of SE+ DR4 alleles, RF production, and sex and by the presence of erosive disease at presentation. Those prognostic markers exert their influence independently from the inflammatory disease activity.     

A new method for the detection of hidden IgM rheumatoid factor in patients with juvenile rheumatoid arthritis

The sera of 56 children with active seronegative juvenile rheumatoid arthritis were examined for the presence of hidden IgM rheumatoid factors (RF) by use of a rapid new method consisting of ion exchange chromatography and an ELISA assay. Elevated hidden IgM-RF levels were detected in 57% of all patients (median value 0.6 IU/ml, p less than 0.01), in 67% of patients with polyarticular disease (1.1 IU/ml, p less than 0.005), in 62% of the group with monoarticular disease (0.6 IU/ml, p less than 0.02), and in 60% of the group with systemic disease (0.6 IU/ml, NS). Whereas hidden IgM-RF plays no role in HLA-B27 positive disease, we found raised titers in 86% of B27 negative patients (0.8 IU/ml, p less than 0.001).     

Relation of glenohumeral and acromioclavicular joint destruction in rheumatoid shoulder. A 15 year follow up study

OBJECTIVES: To evaluate the relation of glenohumeral (GH) and acromioclavicular (AC) joint involvement in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up radiographs of 148 shoulders were evaluated, and the grade of destruction of GH and AC joints were assessed by the Larsen method. One GH joint arthroplasty had been performed after 13 years of the disease onset and the preoperative radiograph was evaluated. RESULTS: Erosive involvement (Larsen grade >/= 2) was observed in 96 of 148 (65%) of the shoulders. Both GH and AC joints were affected in 62 of 148 (42%) shoulders. GH joint alone was involved in nine (6%) shoulders and only AC joint was affected in 25 (17%) shoulders. AC joint destruction correlated with the GH joint destruction, r=0.74 (95% confidence intervals (CI) 0.65 to 0.80 ). CONCLUSION: In RA AC joint is affected more often than the GH joint, but in half of the patients both joints are involved. This should be remembered when treating painful rheumatoid shoulder.     

Stable occurrence of knee and hip total joint replacement in Central Finland between 1986 and 2003: an indication of improved long-term outcomes of rheumatoid arthritis

BACKGROUND: Total joint replacement (TJR) surgery is an important severe long-term outcome of rheumatoid arthritis, but relatively little is known about changes of its incidence in patients with rheumatoid arthritis over the past two decades. METHODS: A population-based, retrospective, incidence case review was conducted to analyse the frequency of primary TJR surgery of the knee and hip in all patients, and specifically in patients with rheumatoid arthritis in Central Finland between 1986 and 2003. Patients with TJR surgery of the knee and hip were identified in hospital databases over the 18-year period. Age-standardised incidence rate ratios for the primary TJR of the knee and hip were calculated, stratified to sex and diagnosis, with 1986 as the reference value. RESULTS: In patients without rheumatoid arthritis the age-adjusted incidence rate ratios (with 95% CI) for TJR of the knee increased 9.8-fold from 1986 to 2003 in women and men, and for TJR of the hip 1.8-fold in women and 2-fold in men. By contrast, no meaningful change was seen over this period, in age-adjusted incidence rate ratios for TJR of the knee or hip in patients with rheumatoid arthritis, ranging from 0.7 to 1.2 in 2003 compared with 1986. CONCLUSION: The prevalence of TJR surgery has increased 2-10-fold in patients without rheumatoid arthritis patients, associated with an ageing population, but has not increased in patients with rheumatoid arthritis between 1986 and 2003. These data are consistent with emerging evidence that long-term outcomes of rheumatoid arthritis have improved substantially, even before the availability of biological agents.     

Clinical and radiological results of non-cement impaction bone-graft method of total hip arthroplasty for rheumatoid arthritis

We performed total hip arthroplasty using the non-cement impaction auto-bone-grafting method with the resected femoral head for acetabular protrusion that is not combined with the destruction of acetabular rim or dysplasia of the hip joint. Ten patients (eight women and two men) with rheumatoid arthritis who showed acetabular protrusion underwent total hip arthroplasty using this method. All patients were able to walk with full weight within 5 days after surgery. The short-term results of our cases were very good. The postoperative periods of the radiographic-bone incorporation of the grafting bone were 2 months after surgery in four joints, 3 months after surgery in four joints, and 4 months after surgery in three joints. There were no cases that showed any migration or radiolucency around the acetabular component at the time of follow-up. Our operative technique is simple and easy, and it is a useful method for the treatment of protrusion in patients with rheumatoid arthritis.     

Anpassungsformen des rheumatischen Karpus nach radiolunärer Arthrodese

OBJECTIVE: The aim of this study was the analysis of long-term carpal changes after radiolunate arthrodesis. METHODS: Pre- and postoperative X-rays of 91 wrists in 78 patients with rheumatoid arthritis, who were treated for carpal instability with a radiolunate arthrodesis, were examined concerning the midcarpal joint and the Larsen grade. The mean follow-up was 60 months. RESULTS: After radiolunate arthrodesis the midcarpal joint space remained unchanged in 28%. In 35% secondary arthritis and in 37% further arthritic destruction occurred. The mean Larsen grade increased from 3.2 to 3.8. Six wrists needed complete arthrodesis 25 to 87 months after the primary procedure and one was treated by total wrist replacement. Adaptive changes of the carpus during progressive disease and in secondary arthritis were recognized. Three types of joint lines could be identified: in 35% of the wrists a "perilunar", in 22% a "radio-midcarpal" and in 3% a purely "midcarpal" joint line. In 40% no specific joint line could be identified. CONCLUSION: After radiolunate arthrodesis the carpus remains unchanged in the long run in nearly a third of cases. But even if secondary arthritis or further arthritic destruction occurs as in the remaining cases, the carpus shows an amazing capacity for adaptation. A new intracarpal joint line may develop or the midcarpal joint re-establishes itself.     

Knee and/or hip joint destruction in rheumatoid arthritis is associated with HLA-DRB1*0405 in Japanese patients

To determine the prognostic factors for knee and/or hip joint destruction in rheumatoid arthritis (RA) patients, we typed 379 RA patients for HLA-DRB1 alleles and analysed the antigen frequencies. The DRB1^*0405 antigen frequency in RA patients who underwent total knee replacement and/or total hip replacement was significantly higher than in those who did not have replacements, which meant that DRB1^*0405 was associated with knee and/or hip joint destruction. This finding may be of value for predicting knee and/or hip joint destruction in RA.     

Radiographic joint space in rheumatoid glenohumeral joints. A 15-year prospective follow-up study in 74 patients

OBJECTIVE: To evaluate radiographically the glenohumeral (GH) joint space in patients with long-term rheumatoid arthritis (RA). METHODS: A cohort of 74 patients with RA were followed prospectively for 15 yr. At the end point, 148 shoulders were radiographed using a standard method. The GH joint space was examined from the radiographs using a method developed previously for population studies; the joint space was measured at three different sites and the average of the three measurements, the integral space, was calculated. Destruction of the GH joints was assessed with the Larsen method on a scale of 0-5 and compared with the joint space measurements. RESULTS: The mean GH joint space in RA patients was 3. 1 (S.D. 3.3), range -17.3 to 5.7 mm; 2.7 mm (S.D. 4.5) in men and 3. 2 mm (S.D. 2.8) in women. The mean of the affected joints (Larsen grades 2-5), 1.7 mm (S.D. 4.5), was notably narrower than the mean 4. 4 mm (S.D. 0.6) of the non-affected (Larsen grades 0-1) joints. Pathological GH joint space, less than 2 mm, was found in five (15%) of 36 joints in men and in 14 (13%) of 112 joints in women. All the joints graded as Larsen 4 and 5 (n = 17) fulfilled this pathological criterion. Joint space narrowing was associated [r = - 0.66, 95% confidence interval (CI): -0.56 to -0.75] with increasing destruction (Larsen grading) of the joint. The narrowing was significant between non- (Larsen 0, 1), moderately (Larsen 2, 3) and severely (Larsen 4, 5) affected joints (P < 0.001). However, a remarkable step in this process occurred between Larsen grades 3 and 4 when the mean joint space diminished from 3.1 to 0.3 mm. CONCLUSIONS: Joint space narrowing is a frequent consequence of GH joint rheumatoid affection. However, joint space narrowing is a late phenomenon occurring not until after marked erosive destruction, which should be noted when using the Larsen method for GH joints.     

Clinical and radiological results of non-cement impaction bone-graft method of total hip arthroplasty for rheumatoid arthritis

Abstract

We performed total hip arthroplasty using the non-cement impaction auto-bone-grafting method with the resected femoral head for acetabular protrusion that is not combined with the destruction of acetabular rim or dysplasia of the hip joint. Ten patients (eight women and two men) with rheumatoid arthritis who showed acetabular protrusion underwent total hip arthroplasty using this method. All patients were able to walk with full weight within 5 days after surgery. The short-term results of our cases were very good. The postoperative periods of the radiographic-bone incorporation of the grafting bone were 2 months after surgery in four joints, 3 months after surgery in four joints, and 4 months after surgery in three joints. There were no cases that showed any migration or radiolucency around the acetabular component at the time of follow-up. Our operative technique is simple and easy, and it is a useful method for the treatment of protrusion in patients with rheumatoid arthritis.