Long-term clinical and radiographic results of cementless total hip arthroplasty for patients with rheumatoid arthritis: minimal 10-year follow-up

Abstract

Objectives. The aim of this study was to clarify the long-term clinical and radiographic results of cementless total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA).

Methods. Twenty-eight total hip arthroplasties in 24 patients with a diagnosis of RA were performed from October 1992 to October 1996. All components were titanium alloy with a circumferential porous coating. Six patients (six hips) died before the 10-year follow-up, and one patient (one hip) was lost to follow-up, leaving 21 joints of 17 patients for review at a minimum 10-year follow-up after surgery. There were 3 men and 14 women with an average age of 55.0 years. The average duration of RA at the time of the operation was 12.6 years, and the average follow-up period was 12.2 years. We evaluated the Japanese Orthopaedic Association (JOA) hip scores, radiographic changes and survivor rates of components.

Results. Compared with the preoperative JOA hip scores, there was significant improvement in the postoperative scores. Spot welds consistent with bone ingrowth were identified in 95.0% of the femoral components. No femoral components showed radiographic loosening or required revision for aseptic loosening, but two acetabular revisions were performed because of aseptic loosening. The 14-year survivor rates of the stem and cup with the end point of loosening were 100% and 88.2%, respectively.

Conclusions. Cementless THA with this component design in patients with RA appears to be a promising treatment.     

Total hip arthroplasty with bone graft for acetabular protrusion in rheumatoid arthritis

 Twenty-five hips in 19 rheumatoid arthritis (RA) patients with protrusio acetabuli were followed up, both clinically and radiographically, for more than 9 years after total hip arthroplasty (THA), that was performed with a bone graft to reinforce the medial acetabular wall. Radiographs were taken preoperatively and every 6 months postoperatively. Clinical assessments of pain, gait, and range of motion of the hips were obtained preoperatively and every year postoperatively using the Japanese Orthopaedic Association hip-scoring system. Radiographs showed that bony union had occurred in all cases. Six acetabular components were loose, but no femoral components became loose during the 9-year period. The clinical evaluation showed that relief of pain was very significant. The range of motion of the hip joints also improved from 12 points to 16.6 points after 9 years. Walking ability improved, but is becoming worse as time goes by. The radiographic results were compared with the results of a THA group with RA that had not had a bone graft. The rate of loosening of the THA without a bone graft was significantly higher than that of THA with a bone graft. We concluded that bone grafting for protrusio acetabuli was a very useful procedure. Received: September 21, 2001 / Accepted: February 1, 2002 Correspondence to: K. Kondo     

Radiographic patterns and response to corticosteroid hip injection

OBJECTIVES—A prospective, open study of corticosteroid hip injection (CHI) was performed to determine if different radiological patterns of arthritis vary in their response.
METHODS—Forty five patients (15 with rheumatoid arthritis, 27 with osteoarthritis, and three with anklyosing spondylitis) underwent hip injection with 80 mg methyl- prednisolone and lignocaine under x ray control. Outcome was assessed at two, 12, and 26 weeks for pain, range of hip movement, and graded functional questionnaire. Patients estimated their pain in four components, night pain, rest pain, weight bearing, and referred pain, each measured by 10 cm visual analogue score and summed to give a total score out of 40 cm. Hip radiographs were evaluated blindly for pattern and severity of arthritis, as well as for progression between 0 and 26 weeks.
RESULTS—Median total pain score decreased from 29 cm at baseline to 22 cm at two weeks (p=0.0001), 24 cm at 12 weeks (p=0.03), but had returned nearly to baseline by 26 weeks (25 cm, p=0.3). Greatest improvement was seen for night pain. Mean range of internal rotation increased from 16 to 28 degrees at two weeks (p=0.03) and 23 degrees at 12 weeks (p=0.06). Functional ability did not change. Hips with an atrophic pattern of arthritis on plain radiography gained negligible pain relief at two weeks compared with hips with a hypertrophic or mixed bone response (p=0.04). The degree of pain relief was similar in patients with OA and RA, and was not influenced by radiographic severity or by the direction of migration of the femoral head.
CONCLUSION—Pain and internal rotation improve for up to 12 weeks after CHI. CHI offers a useful and safe therapeutic option for patients with hip arthritis, with the exception of those with a purely atrophic radiological pattern.

     

Total hip replacement in children with arthritis

Fourteen children with juvenile rheumatoid arthritis and two with ankylosing spondylitis received 29 total hip replacements (THR). The ages at THR were 12 to 18 years, the median duration of prior hip disease was 7.1 years, and the minimum followup was one year (range 1–4 years, median 2.2 years). The primary indication for THR was pain in 5 hips and severe malposition or flexion contractures in 24 hips. (Sixteen of these also had some degree of pain.) All 29 hips demonstrated improved postoperative range of motion, and all were free of pain. In children, active rheumatic disease in other joints, prosthesis longevity, and possible lack of adequate motivation all merit special consideration prior to THR, but the results are encouraging.     

Incidence of hip involvement and need for total hip replacement in rheumatoid arthritis. An eight-year follow-up study

In an 8-year follow-up of a prospective study of recent arthritis, 103 patients were found to have erosive and 97% seropositive rheumatoid arthritis. A 20% incidence of hip joint involvement was observed among them. Moderate radiological changes could be seen in 10%, severe destruction (Larsen 4 or 5) in 3%, and acetabular protrusion in 1% of the patients. It was estimated that the minimum annual need of total hip replacement in rheumatoid arthritis in Finland would be 470. This is about 100 per million in the overall population. At the end of the follow-up the Larsen X-ray index was highly significantly (p less than 0.001), ESR significantly (p less than 0.005), and CRP clearly (p less than 0.03) higher in the 13 patients with radiologically confirmed hip changes than in the 90 without them. Thus their hip destruction is attributable to a more severe disease condition and not to the glucocorticoids administered. Furthermore, HLA-B27 was positive in 69% of the above-mentioned 13 patients compared with 27% of the rest, and this difference (p less than 0.005) may also explain the poor prognosis for true rheumatoid arthritis patients.     

Very recent onset arthritis: the value of initial rheumatologist evaluation and anti-cyclic citrullinated peptide antibodies in the diagnosis of rheumatoid arthritis

The objective of this study is to identify baseline factors associated with rheumatoid arthritis (RA) diagnosis at the end of 1-year follow-up in a cohort of patients with very recent onset arthritis. Incident cases with self-reported arthritis (≤12 weeks) referred by primary care physicians were assessed by a designated rheumatologist who predicted in those with ≥1 swollen joint the diagnosis of RA at the end of follow-up. Patients were regularly seen and diagnosed through follow-up by staff rheumatologists who were blind to diagnostic prediction. Of 119 referrals, 78 (65.5%; age 35.5 ± 13.5 years; 69 females) were diagnosed at baseline as very recent onset arthritis (median duration 6 weeks (0–12 weeks)); of 75 patients completing 1-year follow-up, 51 (66.5%) were classified as RA; 12 (16%) had self-limited arthritis; and 13 (17.5%) other diagnoses. The characteristics of patients with RA as final diagnosis were polyarthritis, morning stiffness ≥1 h, high counts of swollen joints, and low frequency of systemic symptoms. Rheumatologist prediction of RA and anti-cyclic citrullinated peptide (anti-CCP) antibodies was strongly associated with RA as a final diagnosis in the logistic regression analysis. Sensitivity and specificity of the rheumatologist prediction were 94% and 74%, for anti-CCP antibodies, 56% and 96%; the combination of both variables had a specificity of 100% and a sensitivity of 53%, and a positive predictive value of 98%. The combination of RA as predicted diagnosis by a rheumatologist and anti-CCP antibodies is highly specific for RA diagnosis in patients with very early arthritis.     

The effects of shockwave on systemic concentrations of nitric oxide level, angiogenesis and osteogenesis factors in hip necrosis

This study investigated the effects of shockwave on systemic concentrations of nitric oxide (NO) level, angiogenic and osteogenic and anti-inflammatory factors in hips with osteonecrosis of the femoral head (ONFH). Thirty-five patients (47 hips) with ONFH were enrolled in this study. Each hip was treated with 6,000 impulses of shockwave at 28 kV in a single session. Ten milliliters of peripheral blood was obtained for the measurements of serum NO level, angiogenic factors (VEGF, vWF, FGF basic and TGF-β1); osteogenic factors (BMP-2, osteocalcin, alkaline phosphatase, DKK-1 and IGF); and anti-inflammation markers (sICAM and sVCAM) before treatment and at 1, 3, 6 and 12 months after treatment. The hips were evaluated with clinical assessment, serial radiograph and MRI. At 12 months, the overall results showed 83% improved and 17% un-improved. Total hip was performed in 4 cases (8.5%). Serum NO3 level showed significant elevation at 1 month after treatment, but the changes at 3, 6 and 12 months were not significant. For angiogenesis, significant elevations of VEGF, vWF and FGF basic and a decrease in TGF-β1 were observed at 1 month, but the changes at 3, 6 and 12 months were non-significant. For osteogenesis, BMP-2, osteocalcin, alkaline phosphatase and IGF were significantly elevated, while DKK-1 was decreased at 1 month, but the changes at 3, 6 and 12 months were not significant. For anti-inflammation markers, significant decreases in sICAM and sVCAM were noted at 1 month after treatment, but the changes at 3, 6 and 12 months were non-significant. Local ESWT application results in significant elevations of serum NO level, angiogenic and osteogenic and anti-inflammatory factors in ONFH.     

Outcome of total hip replacement for avascular necrosis in systemic lupus erythematosus

OBJECTIVE: To describe the short and medium term results of total hip arthroplasty (THA) for avascular necrosis in patients with systemic lupus erythematosus (SLE). METHODS: Nineteen patients with SLE and avascular necrosis of the femoral head (AVNFH), who underwent 26 THA were retrospectively reviewed with a minimum followup of 2 years. To determine whether these patients had results similar to those of patients with other conditions, we formed a control group of 19 patients who had 29 THA. They were matched for age, sex, and followup to the patients with SLE. Controls had THA for juvenile rheumatoid arthritis (n = 7), osteoarthritis (5), adult onset rheumatoid arthritis (8), developmental dysplasia of the hip (4), and other diagnoses (5). Outcome measures included a 10 point visual analog scale (VAS) for pain, the Harris hip score, and the SF-36 self-administered health outcome questionnaire. We used the methods of Delee, Harris, and Engh for radiological assessment. RESULTS: Mean age at surgery was 46 years (range 21-71 years) and average followup was 4 years, 7 months (range 1 yr 9 mo to 9 yrs 6 mo), similar in both groups. Technical problems, mostly consisting of small, nonpropagating cracks of the calcar in uncemented stems, were encountered in 4 SLE hips and 1 control hip. Six complications were noted in the SLE group, including 2 early, nonrecurrent dislocations, 1 patient with thigh pain for 1 year, 1 pericarditis, 1 sick-sinus syndrome, and 1 urinary tract infection. There was one case of urinary tract infection in the control group. One SLE patient developed a low grade prosthetic infection and underwent successful revision 2 years after primary surgery. Clinical outcome measures had similar scores in the 2 groups: average VAS pain score = 2.00 in SLE hips (maximum 10) and 1.97 in control hips; mean Harris hip score = 86.7 in SLE patients (maximum 100) and 81.9 in controls; average SF-36 score = 63.4 in SLE patients (maximum 100) and 60.5 in controls. There was no radiological evidence of implant loosening in controls; there was 1 asymptomatic cup migration in the SLE group. CONCLUSION: In the short and medium term, patients with SLE and AVN had good results after THA. Results were similar in patients who had hip replacement for other diagnoses. Less favorable clinical outcomes of hip replacement have been reported in young patients who have AVN of other etiology (e.g., alcoholic, post-traumatic), but this was not the case in our young patients who had AVN and SLE. Thus, AVNFH and SLE should not constitute a contraindication to hip replacement.     

Hand bone loss in early undifferentiated arthritis: evaluating bone mineral density loss before the development of rheumatoid arthritis

OBJECTIVES: (1) To examine the change in regional bone mineral density (BMD), including the hands, and assess its role as a predictor of outcome in patients presenting with an early undifferentiated inflammatory arthritis; (2) to examine for associations with the changes in hand BMD. METHODS: 74 patients with undifferentiated hand arthritis of less than 12 months' duration were examined at baseline and then at three, six, and 12 months follow up, including BMD measurement of the femoral neck, spine (L2-4), and the whole hands using dual energy absorptiometry (DXA). RESULTS: During the study, 13 patients were diagnosed as having rheumatoid arthritis, 19 as having inflammatory non-rheumatoid joint disorders, and 42 as having non-inflammatory joint disorders. At the femoral neck and lumbar spine no significant bone loss was seen in any of the three subgroups. At the 12 months follow up the mean (95% confidence interval) hand BMD loss in the patients with rheumatoid arthritis was -4.27% (-1.41 to -7.13); in the inflammatory non-rheumatoid group, -0.49% (-1.33 to +0.35); and in the non-inflammatory joint disorder group, -0.87% (-1.51 to -0.23). In a multivariate linear regression model (including age, rheumatoid factor, mean C reactive protein, mean HAQ score, and cumulative glucocorticoid dose), only mean C reactive protein (p<0.001) and rheumatoid factor (p = 0.04) were independently associated with change in hand BMD during follow up. CONCLUSIONS: Hand DXA provides a very sensitive tool for measuring bone loss in early rheumatoid arthritis and may be useful in identifying patients at high risk of developing progressive disease. Further studies are needed to evaluate the role of hand bone loss as a prognostic factor and outcome measure in rheumatoid arthritis.     

Clinical and radiological results of GSB III total elbow arthroplasty in patients with rheumatoid arthritis

Total elbow arthroplasty (TEA) with the GSB III prosthesis was performed in 32 patients (36 elbows) with rheumatoid arthritis between 2001 and 2009. At final follow-up, 31 patients (35 TEAs) were available for clinical and radiological evaluation. The mean follow-up period was 6.3 (2.0–10.3) years, with a minimum follow-up of 2 years. The mean Mayo elbow performance score was significantly improved from 48 points preoperatively to 83 points at final follow-up. The radiographic loosening rate was 14.3% for humeral components and 5.7% for ulnar components. There were 4 cases of intraoperative fracture and 1 case of humeral shaft fracture at 4 months after surgery. The rates for loosening and fracture were relatively low when compared with those in other studies of linked TEA. There were 2 cases of ulnar nerve palsy, but there was no deep infection or triceps disruption. The clinical results of TEA using the GSB III prosthesis in patients with rheumatoid arthritis were found to be satisfactory.     

Cementless large-head metal-on-metal total hip arthroplasty in patients younger than 60 years-a multicenter early result

Large-head metal-on-metal total hip arthroplasty has the theoretical advantages of less wear and better range of motion than traditional polyethylene bearings and seems to be a better choice for young and active patients. We conducted a retrospective study and reported the early results of using such prostheses in 59 patients (70 hips) with a mean age of 43.1 years (range, 23-59 years) at the time of surgery. Osteonecrosis of the femoral head accounted for most diagnoses. Harris Hip Scores and hip range of motion both significantly improved (p<0.001) at an average follow-up of 32.6 months (range, 24-48 months). Only one intraoperative calcar fissure was encountered, and it was fixated by cerclage wiring; there was no infection, dislocation, or osteolysis around either the cup or the stem at the latest follow-up. A postoperative gap in the acetabular component was noted in 24 hips, with a mean depth of 1.11 mm, but this was not correlated with the functional score (p=0.291). Transient thigh pain, which resolved after 6 months, was observed in six patients but was not related to either the postoperative gap or cup inclination (p=1.000 and p=0.664, respectively). All patients resumed their original jobs and recreational activities with little discomfort. Thus far, large-head metal-on-metal total hip arthroplasty has shown excellent early results. The long-term results and the effects of metal debris and potentially elevated serum metal ion levels require further observation.     

Rheumatoid arthritis among Nigerians: the first 200 patients from a rheumatology clinic

Rheumatoid arthritis has uncommonly been reported among Africans and rarely among West Africans. Most of the reported cases have been from Southern Africa. A recent awareness of increased reports of RA among Nigerians necessitated this study. The objective of this retrospective study was to identify the clinical presentations, laboratory characteristics as well as treatment regimens of Nigerians presenting with rheumatoid arthritis to a private rheumatology clinic in Lagos, Nigeria. This is a retrospective study of consecutive rheumatoid arthritis patients seen over a period covering 7 years and 10 months diagnosed using the ARA Criteria for RA. Laboratory tests and radiographic investigations were carried out. Treatment was with NSAIDs, prednisolone, disease modifying anti-rheumatic drugs (DMARDs), and biologics. RA accounted for 12.3% of a total of 1,623 patients presenting to the clinic with rheumatologic complaints over the study period. Females were mostly affected (F:M—2.4:1) and mean age is 46.9 years. Duration of symptoms before presentation was 4–264 months with a mean of 63.4 months. The proximal interphalangeal joints were mostly involved. Subcutaneous nodules were seen in 29.5% of the cases while rheumatoid factor was found in 38.5% of the subjects. ESR was mostly elevated and radiographic changes were mostly mild with 29.2% showing erosive changes on radiographs of the hands. Treatment was variously with non-steroidal antiinflammatory drugs (NSAIDs), prednisolone, and DMARDs. Rheumatoid arthritis is not uncommon among Nigerian; and clinical, serologic acumen are necessary for early diagnosis and appropriate referral.     

Long term prognosis of reactive salmonella arthritis

OBJECTIVES—Reactive joint complications triggered by salmonella gastroenteritis are increasingly reported, but the outcome and long term prognosis of the patients is incompletely known. This study looked at the prognosis of salmonella arthritis in patients hospitalised in 1970-1986.
METHODS—Hospital records from two hospitals in southern Finland were screened for patients with the discharge diagnosis of salmonellosis or reactive, postinfectious arthritis or Reiter's disease. For the patients with confirmed diagnosis of reactive salmonella arthritis, data about the acute disease were collected from the hospital records. A follow up study was performed.
RESULTS—There were 63 patients (28 women, 35 men, mean age 36.5 years) with salmonella arthritis. Urethritis occurred in 27%, eye inflammation in 13%, and low back pain in 44% of the patients. HLA-B27 was present in 88%. More men than women were HLA-B27 positive. HLA-B27 positive patients had higher erythrocyte sedimentation rate (mean 80.9 v 46.5 mm 1st h, p = 0.0180). Also, extra-articular features and radiological sacroiliitis were seen only in HLA-B27 positive patients. A follow up study was performed on 50 patients mean 11.0 (range 5-22 years) later. Twenty patients had recovered completely. Ten patients had mild joint symptoms, 11 patients had had a new acute transient arthritis, and five acute iritis. Eight patients had developed chronic spondyloarthropathy. Radiological sacroiliitis was seen in six of 44 patients, more frequently in male than in female patients (32% v 0%; p = 0.0289). Recurrent or chronic arthritis, iritis or radiological sacroiliitis developed only in HLA-B27 positive patients.
CONCLUSION—Joint symptoms are common after reactive salmonella arthritis. HLA-B27 contributes to the severity of acute disease and to the late prognosis.

     

Longterm followup of hip and knee soft tissue release in juvenile chronic arthritis.

Longterm results of soft tissue release for hip and knee flexion deformity in 27 patients with juvenile chronic arthritis (JCA) were evaluated. A total of 53 tenotomies were reviewed: 22 hips and 31 knees. Mean age at surgery was 12.1 years, with a mean underlying disease duration of 6.3 years and a postoperative followup of 5 years. Patients were evaluated at 3-6 months, then at one, 3 and 5 years. Results showed a marked drop in flexion contracture and an improvement in joint range up to the first 3 years postsurgery, but beyond this period benefits achieved were gradually partially lost. Only 37% of patients were able to walk before surgery. At one year followup, 81% were able to do so. Soft tissue release thus seems a beneficial therapeutic alternative to preserve both alignment and function in hip and knee flexion deformity affecting patients with JCA.     

Histopathology of femoral head osteonecrosis in rheumatoid arthritis: the relationship between steroid therapy and lipid degeneration in the osteocyte

Summary To investigate the pathology of osteonecrosis of the femoral head (ON) in patients with rheumatoid arthritis (RA), we examined 26 hips clinically and histologically. In this study, we diagnosed ON by both the radiological evidence of femoral head collapse, with or without narrowing of the joint space, and by histological evidence of extensive areas of bone necrosis with surrounding reparative new bone. Thus 14 hips were diagnosed as ON, and 12 hips were not. All of the patients with ON had a history of steroid medication. The frequency of lipid-containing osteocytes observed in the subchondral area of the femoral head significantly correlated with the occurrence of ON (P<0.05). In electron micrographs, these osteocytes showed degenerative features, with their nuclei pressed towards one side of the cell by plump fatty droplets (fatty degeneration). In patients with RA, there was a significant correlation between the appearance of lipid-containing osteocytes and steroid medication (P<0.05). No relationship existed between the severity of RA synovitis and the occurrence of ON. These data suggest that ON in rheumatoid hips may relate to the administration of a steroid and the fatty degeneration of osteocytes.     

Seronegative oligoarthritis: a 23-year follow-up study

The aim of the study was to investigate the long-term outcome of non-specific seronegative oligoarthritis in adults. The study included 64 adult patients with recent (<6 months) seronegative oligoarthritis (rheumatoid factor negative, number of swollen joints 1–4 during the first 6 months). Follow-up examinations were carried out at onset and at 1, 3 and 8 years from entry. A total of 47 patients attended the 23-year follow-up. The endpoint outcome was good. Seven had mild erosions in the hands or feet. Only one patient with HLA-B27 developed bilateral sacroiliitis. Three patients had retired from work because of joint disease. The functional outcome of the patients analysed by HAQ was very good after 23 years: 0 in 33 and 0.1–0.9 in 12 of the 47 patients. Reclassification revealed a certain heterogeneity: one case each of rheumatoid arthritis, SLE and ankylosing spondylitis, two cases of post-traumatic arthritis, four of osteoarthrosis, and six of possible reactive arthritis. Out of the remaining 49 patients 15 were HLA-B27 positive and 16 had at least one of the psoriasis-related HLA antigens (HLA-B13, 17, w16). In conclusion, our 23-year prospective follow-up study of patients with seronegative oligoarthritis confirms their favourable outcome. The reason is that the endpoint diagnoses seemed to be similar to those of mild spondylarthropathies. Received: 23 August 2001 / Accepted: 6 March 2002     

Role of MRI in evaluation of hip joint involvement in juvenile idiopathic arthritis

Aim of the WorkTo evaluate the role of MRI in diagnosing hip arthritis and correlating it with clinical and laboratory assessments in juvenile idiopathic arthritis (JIA).Patients and MethodsThe study included 30 patients with JIA with mean age of 13.5 ± 4.5. Disease activity was evaluated by DAS28 score, physician’s global assessment (PGA–VAS), patient’s global assessment (VASglobal) and the assessment of functional ability by (CHAQ). Hip joint evaluation was assessed by hip pain on movement and the degree of limitation of motion (score 0–3). Plain radiography and MRI of the hip joint were performed for all patients. MRI score was done.ResultsMRI of hips was abnormal in 12 (40%) of all patients: 2/8 (25%) of the oligoarticular group, 4/13 (30.8%) of the polyarticular group, 5/7 (71.4%) of the systemic onset group and 1/2(50%) of the enthesitis related group. Comparing mean values of MR scores of the four clinical subsets showed significant difference (p < 0.001). Patients with active disease showed higher MR scores (3.7 ± 1.5) than those with inactive disease (2.1 ± .9) [p < 0.002]. Presence of effusion and gadolinium enhancement were significantly higher in active hips (p < 0.01 and p < 0.001 respectively). VAS–PGA and ESR were significantly correlated with MRI score (p < 0.02 and <0.05 respectively).ConclusionMRI of the hip plays an important role in the study of patients with JIA as it reveals early joint involvement and evaluates the extent of joint disease. This permits intervention at an appropriate time with suitable treatment. Clinical and laboratory findings are inadequate diagnostic tools for the assessment of hip arthritis when comparing with MRI.     

ASEPTIC NECROSIS OF THE FEMORAL HEAD IN SICKLE-CELL DISEASE

Aseptic necrosis of the femoral head accounted for 75 (28.2%)of the 266 major skeletal complications seen in 207 patientswith sickle-cell disease in a 66-month period. Forty-five (60%)of the 75 patients were males. The onset of symptoms occurredbetween the ages of 10 and 29 years in 60 (80.0%) of the patients,and the mean age at onset was 20.8 (range 8–54) years.There were 37 patients with sickle-cell anaemia (SS) with 46hips affected by necrosis, and 38 patients with sickle-cellhaemoglobin C with 40 affected hips. Perthes-like changes occurredin 40 hips, osteochondritis dissecans-like lesion in one hipand severe hip deformity in 45 hips. Four of the five hips withPerthes-like necrosis which were treated by rotation upper femoralosteotomy had partial reconstitution of the femoral head, andall five were symptom-free. The other hips were treated conservativelywith generally poor results. KEY WORDS: Femoral head necrosis, Osteonecrosis, Anaemia, sickle-cell     

HLA-B27 antigen and rheumatoid factor negative (seronegative) peripheral arthritis : Studies in younger patients with early-diagnosed arthritis

HLA-B27, a valuable genetic marker for spondyloarthritis, offers a means for improved definition of rheumatoid factor negative (seronegative) peripheral arthritis. A group of 109 early-diagnosed patients with seronegative peripheral arthritis, who were under 45 years of age at the onset of disease, were studied prospectively. HLA-B27 prevalence was 23 per cent in the total group (25 of 109) and in those initially diagnosed as having rheumatoid arthritis (seven of 30) as compared to 7 per cent in normal subjects (six of 91). The age at onset of B27-associated arthritis was significantly concentrated in those 12 to 24 years of age (p < 0.005), especially in black males. The 25 patients who had the B27 antigen were matched on selected entry variables with 25 patients who did not. Clinical features and laboratory results were highly similar at entry to study and after three years average follow-up, with one exception found at the last examination. A striking prevalence of 83 per cent roentgenologic sacroiliitis was found in patients who had HLA-B27 compared to 21 per cent in those who did not, despite a paucity of spinal manifestations in both groups. These data emphasize the predominance of roentgenologic sacroiliitis in a varied spectrum of B27-associated arthritis, i.e., peripheral as well as spinal. The spectrum of seronegative peripheral arthritis includes an important subgroup who have B27, especially those with onset in adolescence or the early twenties. Clinical manifestations are often indistinguishable from matched patients without B27 and they may be frequently diagnosed as having seronegative rheumatoid arthritis during the early course of disease.