Comparison between resection arthroplasty alone and resection arthroplasty with arthrodesis of the first MTP joint for rheumatoid forefoot deformities

It has been reported that nearly 90% of patients with rheumatoid arthritis (RA) have problems with their feet. Several methods of treating hallux valgus deformity in RA have previously been reported, including arthrodesis and joint resection, and good results have been observed with surgical procedures. In this report, we compare the clinical and radiological outcomes of resection arthroplasty alone (the first method) and resection arthroplasty with arthrodesis of the first MTP joint (the second method) for the treatment of forefoot deformities of RA patients. On clinical assessment, the American Orthopaedic Foot and Ankle Society (AOFAS) scale score significantly improved in both methods; however, the second method gave better results than the first method in relation to the footwear and alignment components. On radiographic assessment, in the first method there were no significant changes in the valgus angle (H–V angle) and the fifth metatarsal bone (M1/5) angle between preoperation and last follow-up. In contrast, these angles were decreased in the second method. One of the most important issues in the treatment of forefoot deformities in RA patients is to correct splaying foot deformity. We believe that the second method, which can correct splaying foot deformity, is currently the most reliable treatment method.     

Comparison between resection arthroplasty alone and resection arthroplasty with arthrodesis of the first MTP joint for rheumatoid forefoot deformities

Abstract

It has been reported that nearly 90% of patients with rheumatoid arthritis (RA) have problems with their feet. Several methods of treating hallux valgus deformity in RA have previously been reported, including arthrodesis and joint resection, and good results have been observed with surgical procedures. In this report, we compare the clinical and radiological outcomes of resection arthroplasty alone (the first method) and resection arthroplasty with arthrodesis of the first MTP joint (the second method) for the treatment of forefoot deformities of RA patients. On clinical assessment, the American Orthopaedic Foot and Ankle Society (AOFAS) scale score significantly improved in both methods; however, the second method gave better results than the first method in relation to the footwear and alignment components. On radiographic assessment, in the first method there were no significant changes in the valgus angle (H–V angle) and the fifth metatarsal bone (M1/5) angle between preoperation and last follow-up. In contrast, these angles were decreased in the second method. One of the most important issues in the treatment of forefoot deformities in RA patients is to correct splaying foot deformity. We believe that the second method, which can correct splaying foot deformity, is currently the most reliable treatment method.     

Development of large pseudocysts adjacent to the knee joint in rheumatoid arthritis. Assessment of radiological and histopathological approaches

Abstract

?This study examined the pathogenesis of large pseudocysts adjacent to knee joints in rheumatoid arthritis (RA). The radiological and histopathological features of 17 large subarticular pseudocysts in 12 knee joints of 10 patients were analyzed. Nine of the 10 patients were classified as class 2 according to Steinbrocker's functional class. Eight large pseudocysts were located at the lateral femoral condyle, seven were at the proximal part of the tibia, one was at the medial femoral condyle, and one was at the patella. The large pseudocysts were divided into two groups according to whether they did or did not connect with the joint cavity. Serial radiographs revealed that all large pseudocysts in communication with the joint cavity had enlarged gradually over the past several months. They extended from the subarticular area toward the bone marrow. Histopathological findings confirmed that holes allowing communication were located at a transitional zone between the ligament and the hyaline cartilage, and that rheumatoid granulation tissue invaded the large pseudocyst through these holes. The results of this study indicate that large pseudocysts are formed by the extension of articular inflammation. Moreover, repeated extrinsic mechanical stress due to walking and the aggressive inflammatory nature of rheumatoid arthritis play important roles in the formation of large pseudocysts.     

Correlation between knee and hindfoot alignment in patients with rheumatoid arthritis: The effects of subtalar joint destruction

Abstract

Objectives. Compensatory hindfoot alignment for deformities at the knee level has been demonstrated in patients with knee osteoarthritis. However, this phenomenon has not been elucidated in patients with rheumatoid arthritis (RA). The aim of this study is to investigate the relationship between knee deformity and hindfoot alignment and the effect of subtalar joint destruction in patients with RA.

Methods. We retrospectively investigated RA patients (110 patients, 205 limbs) using radiographs in the standing anteroposterior knee, standing lateral foot, and hindfoot alignment views. The grade of destruction at the knee and subtalar joints was assigned using Larsen's grading system. The correlation between the femorotibial and tibiocalcaneal angles and the effect of joint destruction on this correlation were analyzed using Pearson's correlation coefficients.

Results. There was moderate correlation between the femorotibial and tibiocalcaneal angles in a group of knees with a Larsen grade of ≥ 4 (r = 0.544, p = 0.0239). This correlation was stronger in a group with less damaged subtalar joints with a Larsen grade of ≤ 3 (r = 0.705, p = 0.0049).

Conclusion. These findings emphasized the importance of examining foot and ankles in patients with RA who undergo total knee arthroplasty.     

Development of large pseudocysts adjacent to the knee joint in rheumatoid arthritis. Assessment of radiological and histopathological approaches

 This study examined the pathogenesis of large pseudocysts adjacent to knee joints in rheumatoid arthritis (RA). The radiological and histopathological features of 17 large subarticular pseudocysts in 12 knee joints of 10 patients were analyzed. Nine of the 10 patients were classified as class 2 according to Steinbrocker's functional class. Eight large pseudocysts were located at the lateral femoral condyle, seven were at the proximal part of the tibia, one was at the medial femoral condyle, and one was at the patella. The large pseudocysts were divided into two groups according to whether they did or did not connect with the joint cavity. Serial radiographs revealed that all large pseudocysts in communication with the joint cavity had enlarged gradually over the past several months. They extended from the subarticular area toward the bone marrow. Histopathological findings confirmed that holes allowing communication were located at a transitional zone between the ligament and the hyaline cartilage, and that rheumatoid granulation tissue invaded the large pseudocyst through these holes. The results of this study indicate that large pseudocysts are formed by the extension of articular inflammation. Moreover, repeated extrinsic mechanical stress due to walking and the aggressive inflammatory nature of rheumatoid arthritis play important roles in the formation of large pseudocysts. Received: April 16, 2001 / Accepted: September 21, 2001     

Reliability and validity of the Turkish version short-form McGill pain questionnaire in patients with rheumatoid arthritis

The translation of existing pain measurement scales is considered important in producing internationally comparable measures for evidence based practice. In measuring the pain experience, the short-form of McGill's pain questionnaire (SF-MPQ) is one of the most widely used and translated instruments. The purpose of this study was to examine whether the Turkish version of the SF-MPQ is a valid and reliable tool to assess pain and to be used as a clinical and research instrument. Translation retranslation of the English version of the SF-MPQ was done blindly and independently by four individuals and adapted by a team. Eighty-nine rheumatological patients awaiting control by a rheumatologist were assessed by the Turkish version of the SF-MPQ in the morning and in the afternoon of the same day. Internal consistency was found adequate at both assessments with Cronbach's alpha 0.705 for test and 0.713 for retest. For reliability of the total, sensory, affective, and evaluative total pain intensity, high intraclass correlations were demonstrated (0.891, 0.868, 0.716, and 0.796, respectively). Correlation of total, sensory and affective score with the numeric rating scale was tested for construct validity demonstrating r = 0.637 (p < 0.001) for test and r = 0.700 (p < 0.001) for retest. Correlation with erythrocycte sedimentation rates for concurrent validity was found to be r = 0.518 (p < 0.001) for test and r = 0.497 (p < 0.001) for retest. The results of this study indicate that the Turkish version of the SF-MPQ is a reliable and valid instrument for the measurement of pain in Turkish speaking patients with rheumatoid arthritis.     

Management of cervical spinal lesions in rheumatoid arthritis

We review the management of cervical spinal lesions in rheumatoid arthritis. Surgical treatment for cervical lesions presents several potential problems, such as spinal cord injury during surgery, prolonged and painful postoperative immobilization, poor outcome incompatible with surgical invasiveness, and a high failure rate of arthrodesis. The introduction of spinal instrumentation techniques to surgery for cervical lesions has solved some of these problems. Rigid spinal fixation using screws, rods, and wires has made surgery more reliable, and has freed patients from painful postoperative immobilization methods such as the Halo vest. However, the effects of surgical treatment have not been clearly examined using methods of evidence-based medicine. There is a need for clinical studies of treatment for cervical lesions, in order to help establish better methods for the management of cervical spinal lesions.     

Management of cervical spinal lesions in rheumatoid arthritis

Abstract

We review the management of cervical spinal lesions in rheumatoid arthritis. Surgical treatment for cervical lesions presents several potential problems, such as spinal cord injury during surgery, prolonged and painful postoperative immobilization, poor outcome incompatible with surgical invasiveness, and a high failure rate of arthrodesis. The introduction of spinal instrumentation techniques to surgery for cervical lesions has solved some of these problems. Rigid spinal fixation using screws, rods, and wires has made surgery more reliable, and has freed patients from painful postoperative immobilization methods such as the Halo vest. However, the effects of surgical treatment have not been clearly examined using methods of evidence-based medicine. There is a need for clinical studies of treatment for cervical lesions, in order to help establish better methods for the management of cervical spinal lesions.     

Bone resorption of the facet joint in rheumatoid arthritis as a predictor of lower cervical myelopathy

The purpose of the present study was to identify the risk factors to predict instability of the subaxial cervical spine and cervical myelopathy based on plain radiographs. The study was performed on 99 patients with mutilating rheumatoid arthritis (RA). From plain lateral radiographs of the cervical spine over time, rheumatoid cervical spine lesions were investigated and evaluation was made on the possibility to develop cervical myelopathy. The incidence of subaxial cervical spine lesions in the patients with mutilating RA was as high as 98%. In particular, resorption of the superior facet suggests high risk to develop cervical myelopathy. The presence of spinous process erosion is also likely to reveal such a possibility. There was no statistically significant difference in the anteroposterior diameter of cervical spinal canal between the cases with cervical myelopathy and those without it. Resorption of the superior facet is the most important factor for the development of cervical myelopathy. In the cases with rheumatoid cervical spine lesions, it is necessary to take special notice of the superior facet.     

Bone resorption of the facet joint in rheumatoid arthritis as a predictor of lower cervical myelopathy

Abstract

The purpose of the present study was to identify the risk factors to predict instability of the subaxial cervical spine and cervical myelopathy based on plain radiographs. The study was performed on 99 patients with mutilating rheumatoid arthritis (RA). From plain lateral radiographs of the cervical spine over time, rheumatoid cervical spine lesions were investigated and evaluation was made on the possibility to develop cervical myelopathy. The incidence of subaxial cervical spine lesions in the patients with mutilating RA was as high as 98%. In particular, resorption of the superior facet suggests high risk to develop cervical myelopathy. The presence of spinous process erosion is also likely to reveal such a possibility. There was no statistically significant difference in the anteroposterior diameter of cervical spinal canal between the cases with cervical myelopathy and those without it. Resorption of the superior facet is the most important factor for the development of cervical myelopathy. In the cases with rheumatoid cervical spine lesions, it is necessary to take special notice of the superior facet.     

Total ankle arthroplasty for deformity of the foot in patients with rheumatoid arthritis using the TNK ankle system: clinical results of 21 cases

Abstract

We report the results of total ankle arthroplasty (TAA) of 21 ankle joints performed on 19 patients with rheumatoid arthritis (RA) using the Japanese TNK ankle system. The clinical evaluation for an average follow-up period of 33.8 months was based on the ankle analysis system. The total score, pain score, range of motion, and walking ability significantly improved postoperatively compared with the preoperative period. These parameters also showed significantly different values between the preoperative and the follow-up periods. However, the range of motion significantly improved postoperatively. In the evaluation of TAA using the TNK ankle system, a radiolucent line of about 1?mm was detected, but there was no dislocation or sinking of the tibial and talar prostheses. There were no severe complications except for two cases with a delayed wound healing and one with a deep infection. These results suggest that if the talocrural joint only was destroyed and the neighboring joints (subtalar or talonavicular) had fibrous fusion, or the patient had relatively fewer activities in daily life or was an elderly person, TAA using the TNK ankle system was effective for the treatment of painful and disabling ankle joints in patients with RA in the middle of the follow-up period.     

Diagnosis and therapy of rheumatoid arthritis in the future

Abstract

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic disease characterized by joint pain and destruction. We describe the importance of early diagnosis, recording magnetic resonance images images at an early stage, monitoring disease progression using gliostatin purified in our laboratory, and sugar-chain analysis of RA serum IgG. For treatment of RA, cyclooxygenase-2-selective inhibitors, disease-modifying antirheumatic drugs, biological products, and the possibility of gene therapy are discussed. The development of therapeutic methods based on the elucidation of the pathology of RA has progressed markedly in the past decade, and further progress and the development of an early diagnostic method are expected.     

Diagnosis and therapy of rheumatoid arthritis in the future

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic disease characterized by joint pain and destruction. We describe the importance of early diagnosis, recording magnetic resonance images images at an early stage, monitoring disease progression using gliostatin purified in our laboratory, and sugar-chain analysis of RA serum IgG. For treatment of RA, cyclooxygenase-2-selective inhibitors, disease-modifying antirheumatic drugs, biological products, and the possibility of gene therapy are discussed. The development of therapeutic methods based on the elucidation of the pathology of RA has progressed markedly in the past decade, and further progress and the development of an early diagnostic method are expected.     

Total knee arthroplasty with a long-stemmed component for fractures adjacent to the knee in rheumatoid arthritis: a report of four cases

Abstract

Four rheumatoid arthritis patients with fractures adjacent to the knee were treated by total knee arthroplasty with a long-stemmed component. All four fractures healed; joint reconstruction and limb realignment were achieved simultaneously. Total knee arthroplasty with a long-stemmed component was useful in stabilizing the fracture and rapidly restoring function in the joint and the limb.     

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.     

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.     

Ultrasonographic evaluation of synovial effusion and synovial proliferation pattern in the knee joints of patients with rheumatoid arthritis

In the present study, 49 knee joints of 26 patients with rheumatoid arthritis and 17 knee joints of 17 healthy subjects were ultrasonographically examined. Lateral, superior, and medial aspects of the patella were scanned using an ultrasonograph with a 7.5-MHz annular array transducer to evaluate the thickness of synovial effusion and the synovial proliferation pattern. The overall mean thickness of synovial effusion (mean of all three sites) in the knee joints was 4.9 ± 3.4 mm for rheumatoid arthritis patients and 1.4 ± 0.5 mm for healthy subjects. In rheumatoid arthritis patients, the mean thickness of synovial effusion at the superior aspect of the patella (6.5 ± 4.1 mm) was significantly greater than that at the lateral aspect (4.5 ± 4.8 mm) (P < 0.05) and the medial aspect (4.0 ± 3.1 mm) (P < 0.01). Patients with the villonodular pattern of synovial proliferation had a shorter duration of disease than those with uniform thickening or an overlapping pattern. Received: May 1, 2001 / Accepted: August 6, 2001     

Cartilage oligomeric matrix protein in serum and synovial fluid of rheumatoid arthritis: potential use as a marker for joint cartilage damage

This study examined the serum and synovial fluid concentrations of cartilage oligomeric matrix protein (COMP) in relation to the evolution of joint cartilage damage and the requirement for surgery in 125 patients with rheumatoid arthritis (RA). We compared the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and matrix metalloproteinase-3 (MMP-3) levels with COMP levels determined by specific enzyme-linked immunosorbent assay (ELISA). Patients were divided into three groups: (1) patients with least erosive disease (LES); (2) patients with more erosive disease (MES); and (3) patients with mutilating disease (MUD). In addition, synovial fluid samples were collected from patients undergoing arthroscopic synovectomy of the knee joint (ASS) and total knee arthroplasty (TKA). Serum COMP levels correlated with the ESR (P < 0.0001, r = 0.374, n = 125) and the CRP level (P = 0.0014, r = 0.281, n = 125). COMP levels did not correlate with the MMP-3 level (P = 0.182, r = 0.114, n = 125). The COMP levels of the LES group were significantly lower than those of the MES or MUD groups. Lastly, synovial fluid COMP levels in the TKA group were higher than in the ASS group. Therefore, these findings suggest that serum and synovial fluid COMP levels in patients with RA may reflect cartilage destruction and are correlated with the ESR and the CRP level, which are indicators of the acute-phase response.     

Cartilage oligomeric matrix protein in serum and synovial fluid of rheumatoid arthritis: potential use as a marker for joint cartilage damage

Abstract

This study examined the serum and synovial fluid concentrations of cartilage oligomeric matrix protein (COMP) in relation to the evolution of joint cartilage damage and the requirement for surgery in 125 patients with rheumatoid arthritis (RA). We compared the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and matrix metalloproteinase-3 (MMP-3) levels with COMP levels determined by specific enzyme-linked immunosorbent assay (ELISA). Patients were divided into three groups: (1) patients with least erosive disease (LES); (2) patients with more erosive disease (MES); and (3) patients with mutilating disease (MUD). In addition, synovial fluid samples were collected from patients undergoing arthroscopic synovectomy of the knee joint (ASS) and total knee arthroplasty (TKA). Serum COMP levels correlated with the ESR (P < 0.0001, r = 0.374, n = 125) and the CRP level (P = 0.0014, r = 0.281, n = 125). COMP levels did not correlate with the MMP-3 level (P = 0.182, r = 0.114, n = 125). The COMP levels of the LES group were significantly lower than those of the MES or MUD groups. Lastly, synovial fluid COMP levels in the TKA group were higher than in the ASS group. Therefore, these findings suggest that serum and synovial fluid COMP levels in patients with RA may reflect cartilage destruction and are correlated with the ESR and the CRP level, which are indicators of the acute-phase response.