Need and sequence of large joint replacements in rheumatoid arthritis. A 25-year follow-up study

OBJECTIVE

The aim of the present study was to evaluate the number and sequence of large joint replacements (LJR) performed in long-term rheumatoid arthritis (RA) from an inception cohort of 103 patients with rheumatoid factor (RF)-positive RA followed over 25 years.

METHODS

A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Patient documents and radiographs were evaluated in the beginning of 2001 and a complementary interview was arranged to assess the number and sequence (timing) of LJRs performed.

RESULTS

The cumulative number of LJRs performed for 22 patients (19 women) during the 25 years of follow-up was 41. Seventeen total hip joint replacements (THR) (42% of the total number of 41 LURs) were performed on 13 patients, median time from the diagnosis to the operation being 14 years; 14 total knee replacements (TKR) (34%) on 11 patients (after a median time of 17 years); 3 total shoulder replacements (TSR) (7%) on 3 patients (median time of 18 years); and 7 total elbow replacements (TER) (17%) on 4 patients (median time of 21 years), respectively. Six patients had undergone three or more LJRs during the follow-up period.

CONCLUSION

During our 25 years of follow-up, in 27% of RA patients LUR was needed, and 41% of them needed more than one replacement.

Differences in understanding and application of 1987 ACR criteria for rheumatoid arthritis and 1991 ESSG criteria for spondylarthropathy. A pilot survey

OBJECTIVES

To determine areas of agreement and disagreement among experts in the interpretation of the published criteria for RA (ACR) and spondylarthropathies ( ESSG).

METHODS

Thirty-two experts (16 from France and 16 from 10 other countries) replied anonymously to a mailed questionnaire.

RESULTS

Tenosynovitis and 'sausage-like' painless swelling of the toes were considered as criteria for RA by 18 and 14 experts, respectively. The definition of symmetry differed widely among experts (symmetry of only one group of joints was sufficient for 13). Twenty-five experts considered erosions of other joints than the wrists and fingers as a criterion for RA, 17 thought that fulfilment of criteria could be achieved cumulatively, and 19 would appreciate clarifications of the current criteria. Among possible clarifications for RA, it was frequently recommended that morning stiffness and nodules be eliminated and that new marker antibodies, X-rays of the feet, and exclusion criteria be added. Twenty-three of the 29 experts who gave an opinion (79%) agreed with the notion of SP in the absence of axial signs and sacroiliitis, 26/31 (84%) indicated that a patient can have both RA and SP, and 19/30 (63%) thought that RA and SP could be regarded as syndromes more than diseases. Only 5/32 experts relied more on the criteria than on their clinical judgement in diagnosing RA.

CONCLUSIONS

There would seem to be a needfor the optimisation of RA and ESSG criteria, particularly within the context of early arthritis.

Apolipoprotein E phenotypes in rheumatoid arthritis with or without amyloidosis

The role of apolipoprotein (apo) E in the pathogenesis of reactive amyloidosis is unclear. Here we evaluated the apoE phenotype distribution and apolipoprotein e allele frequencies in 55 adult patients with seropositive, erosive RA with amyloid and compared them with 55 matched RA patients without amyloid The apoE isotypes were determined by isoelectric focusing and immunoblotting. RA patients without amyloid had more often the apoE 3/3 phenotype (71%) than the RA+A patients (49%, P<0.05) or Finnish control subjects (47%, P<0.01) and the frequency of the apo epsilon3 allele was significantly higher among the RA patients without amyloid than among RA+A patients (P<0.05) or control subjects (P<0.01). The prevalence of the apoE3/4 phenotype among the RA+A patients, although higher, did not significantly differ from the RA patients without amyloid (40% and 26%, respectively, NS) or Finnish control subjects (40% and 35%, respectively, NS). The frequency of the apo epsilon4 allele among the RA+A patients did not signficantly differ from that of RA patients without amyloid (0.23 and 0.13, respectively, NS) or Finnish control subjects (both 0.23). However, the apo epsilon4 frequency of 0.13 among the RA patients without amyloid was significantly lower than that of Finnish control subjects (0.23, P<0.05). We conclude that the prevalence of the apoE4 isotype is not increased in patients with RA complicated by amyloidosis when compared with Finnish control subjects. Since the frequency of the apo epsilon4 allele is significantly decreased in RA patients without amyloid when compared with Finnish control subjects, the presence of the apoE4 in a patient with RA could, though, represent a relative risk factor for developing reactive amyloidosis.

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

OBJECTIVE

To evaluate radiographically the humeroulnar (HU) and humeroradial (HR) joint spaces in patients with long-term rheumatoid arthritis (RA).

METHODS

An inception cohort of 74 patients with RA were followed for 15 yr. At the end-point, 148 elbows were radiographed by a standard method. The HU and HR joint spaces were examined from the anteroposterior radiographs by measuring the shortest tangential distance in the middle of the joints. Destruction of the elbow joints, assessed with the Larsen method on a scale of 0-5, was studied in relation to the joint-space measurements.

RESULTS

Mean (s.d.) HU joint space (n=148) in RA patients was 2.5 (1.1) mm, range 0-4 mm [2.9 (0.8) mm in men and 2.4 (1.1) mm in women]. Mean (s.d.) HR joint space (n=140) was 2.3 (0.9) mm, range 0-4 mm [2.5 (0.8) mm in men and 2.3 (1.0) mm in women]. HU and HR spaces of the affected joints (Larsen grades 2-5) [1.9 (s.d. 1.1) and 1.8 (0.9) mm respectively] were notably narrower than those of the unaffected (Larsen grades 0-1) joints [3.1 (0.7) and 2.9 (0.6) mm]. All the joints graded as Larsen 4 or 5 (n=13) had a value of 0 mm for both joint spaces. Both the HU and the HR joint-space narrowing was associated with increasing destruction (Larsen grading) of the joint. [r= -0.69 (95% CI -0.77 to -0.60) and r= -0.70 (-0.78 to -0.60)]. The monotonic narrowing was significantly increasing from unaffected (Larsen 0, 1), slightly (2), moderately (3) to severely (4, 5) affected joints (P<0.001). A step in this process occurred between Larsen grades 3 and 4, when the mean joint space diminished from 1.4 and 1.5 respectively to 0 mm.

CONCLUSIONS

Joint-space narrowing is a frequent consequence of rheumatoid affection of the elbow joint. HR joint space decreases together with HU joint space; however, the HR joint space is already slightly narrower at the start. The narrowing is a rather late phenomenon, occurring only after erosive destruction. This should be borne in mind when using the Larsen method to evaluate changes in the elbow joint.

Radiographic remission in seropositive rheumatoid arthritis. A 20-year follow-up study

OBJECTIVE

Rheumatoid arthritis (RA) is in most instances a progressive disease. Very little information is available on halting of the radiographic damage, particularly in later phases of the disease. We studied radiographic remission of RA lasting to the end of follow-up, covering the period 1973-96.

METHODS

Radiographs of hands and feet were taken at onset and at 1, 3, 8, 15 and 20 years from entry in 102 cases of recent onset (< 6 months) seropositive and erosive RA. A Larsen score of 0-100 was formed for 20 joints of hands and feet. If the score did not worsen by more than one point between one of the above time points and the end of the study, the patient was considered to be in remission.

RESULTS

Remission was confirmed in 27 (26%) of the patients. In 3 cases the remission was from the 1-year check-up, in 5 from the 3-year check-up, in 6 from the 8-year check-up and in 13 cases from the 15-year check-up. Some of the remission cases had a mild disease from the outset, but there were cases in which the disease process had led to marked joint destruction before slowing down.

CONCLUSION

This data may serve as a basis for comparison with subsequent cohort studies on new treatments-of-choice.

Valgus deformity and proximal subluxation of the rheumatoid elbow: a radiographic 15 year follow up study of 148 elbows

OBJECTIVE

To evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively.

METHODS

At the 15 year follow up standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated. The mediolateral HU angle of the elbow was measured from anteroposterior radiographs. The proximal subluxation of the HU joint was measured from lateral radiographs as the distance between the posterior aspect of the olecranon process and the posterior surface of the humerus. The anteroposterior subluxation of the HR joint was measured from lateral radiographs as the relation of the midpoint of head of the radius to the midpoint of the capitellum of the humerus. Destruction of the elbow joints was assessed with the Larsen method on a scale of 0 to 5 and compared with the measurements.

RESULTS

Mean HU angle in 148 elbows of patients with RA was 11.5 degrees (SD 6.1), range -21 degrees (varus) to 34 degrees (valgus); 9.9 degrees (SD 4.3) in men and 12.0 degrees (SD 6.4) in women. The mean HU angle, 14.4 degrees (SD 6.0) of the affected joints (Larsen grades 2-4), showed more valgus than the mean 9.8 degrees (SD 2.5) of the non-affected (Larsen grades 0 to 1) joints; totally destroyed and unstable Larsen 5 joints were excluded. Mean HU and HR subluxations, 2.0 mm (SD 3.8) and 0.8 mm, of the affected joints (Larsen 2-5) were greater than the means, -1.1 mm (SD 1.5) and -0.4 mm (SD 0.9), of the non-affected joints. Both the HU proximal subluxation and the HR anterior subluxation correlated, r(s)=0.64 (95% CI 0.53 to 0.73 ) and r(s)=0.48 (95% CI 0.34 to 0.60), with the destruction of the elbow joint.

CONCLUSIONS

The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement.

Lessons from an international survey of paper cases of 10 real patients from an early arthritis clinic. CRI (Club Rhumatismes et Inflammation) Group

OBJECTIVE

To determine how experts would classify 10 early-arthritis cases (7 atypical) and to study discrepancies in diagnoses relative to ACR criteria for rheumatoid arthritis (RA) or ESSG criteria for spondyloarthropathy (SpA).

METHODS

Ten real cases (5 met ACR criteria for RA, 6 ESSG criteria for SpA, 3 both and 2 neither) followed for 28.5 +/- 4.8 months were sent as paper cases to 20 international and 12 French experts. Each expert selected a diagnosis among 8 possible choices and rated it on a 0-10 confidence scale. For each case, 3 analog scales (0-100 mm) were used to indicate the probability of RA, SpA or undifferentiated arthritis (UA).

RESULTS

Experts often disagreed about diagnoses (up to 5 different diagnoses for a given case, with a mean of 3.9 per case). Similarly, expert opinions on probabilities for RA and SpA differed widely, with great overlap between confidence for RA, SpA and UA. Fulfilment of ACR or ESSG criteria was poorly related to the experts' diagnosis and evaluation of probabilities for RA and SpA. However, UA was a relatively infrequent choice (19%).

CONCLUSIONS

There was no general consensus about the nosology of early RA and SpA. Classification of atypical early arthritis was not resolved by currently available criteria for RA and SpA. This may have implications for therapy in early disease.

Bone destruction, upward migration, and medialisation of rheumatoid shoulder: a 15 year follow up study

OBJECTIVE

To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively.

METHODS

At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space.

RESULTS

Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=-0.49 (95% CI -0.36 to -0.60) and r=-0.58 (95% CI -0.46 to -0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5.

CONCLUSIONS

Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.

Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis

OBJECTIVE

Serum C reactive protein (CRP) concentration was evaluated in patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) to ascertain the postoperative CRP response.

METHODS

Thirty seven consecutive patients with RA who had undergone THA or TKA were included in the study. The CRP concentration was measured in every patient once preoperatively and every other day for one week postoperatively.

RESULTS

The peak median CRP concentration (94 mg/l) was achieved on the first and second day postoperatively and was seven times higher than the median preoperative concentration (13 mg/l). CRP declined to the preoperative concentration in about one week. The rise of the CRP concentration was significant (p< 0.001). No infection was encountered in this series.

CONCLUSION

A rapid rise in the postoperative CRP concentration is normal in patients with RA treated by THA or TKA. The CRP concentration decreases to the preoperative value in about one week. Serial CRP measurements, including at least one preoperative measurement, are needed when the clinical significance of the postoperative CRP values is evaluated. When the postoperative CRP concentration remains raised for several days compared with the preoperative value, or even rises, it may indicate the presence of a complication in these patients.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis. A 20-year follow-up study

AIMS

In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA).

METHODS

An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzick's test.

RESULTS

At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick's test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients.

CONCLUSIONS

The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

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.

Development rate of mutilans fingers in patients with rheumatic disease

OBJECTIVE

To describe arthritis mutilans (AM) deformity during the progression of rheumatic disease.

METHODS

The development of mutilans-like hand deformities in 2 patients with juvenile chronic arthritis (JCA) and in 2 patients with adult onset rheumatoid arthritis (RA) are presented. The hands of these patients were evaluated at least at two time points during the course of disease using two different scoring methods based on differently summed Larsen grades of the hand joints.

RESULTS

Two patients (one with JCA and one with RA) showed AM changes after a disease period of less than 10 years and 2 not until after 30 years. The patients with adult onset disease were young at the onset of joint disease. Early wrist fusions were performed on both patients showing a slow development rate.

CONCLUSIONS

The development rate of AM is very variable, even in patients with the same diagnoses. Wrist fusion prevents shortening of the carpus and may decrease the development rate of AM.

Subacromial space in the rheumatoid shoulder: a radiographic 15-year follow-up study of 148 shoulders

A cohort of 74 patients with rheumatoid arthritis was monitored prospectively for 15 years. At the end of the study 148 shoulders were radiographed with a standard method. The subacromial space was examined from the radiographs with a method where the acromiohumeral interval was measured from the dense cortical bone marking the inferior aspect of the acromion to a point directly above the head of the humerus. The smallest distance was recorded, and negative values were used when the original articular surface of the humerus exceeded the inferior surface of the acromion. Destruction of the glenohumeral (GH) joints was assessed by the Larsen method on a scale of 0 to 5. The relation of subacromial space measurement to the grade of destruction of GH joints was examined. The mean subacromial space was 6.7 (SD 4.4), range from -13 to 12 mm: 6.1 mm (SD 5.6) in men and 6.9 mm (SD 4.0) in women. The mean of nonaffected (Larsen grade 0 or 1) shoulders (n = 77) was 8.6 mm (SD 1.5), and the corresponding mean of the affected (Larsen grade > or =2) shoulders (n = 71) was 4.6 mm (SD 5.5). Previously reported pathologic criterion (<6 mm) indicating rotator cuff involvement was fulfilled in 30 (20%) of 148 shoulders: in 8 (22%) of 36 shoulders in men and in 22 (20%) of 112 shoulders in women. All the shoulders with severe rheumatoid destruction (Larsen grade 4 or 5) fulfilled the pathologic limit. The subacromial space had a significant negative correlation with the GH joint destruction (Larsen grade) in both sides: right r = -.63 (95% CI -.75 to -.47), left r = -.71 (95% CI -.81 to -.58). Progressive upward migration is an inevitable consequence of rheumatoid destruction in the GH joint. A significant step in this process occurred between the Larsen grades of 3 and 4, where the mean distance turned negative, indicating rotator cuff disease. A patient with rheumatoid arthritis and painful shoulder and upward migration of the humerus on the shoulder radiograph should be evaluated by an orthopaedic surgeon. In indistinct cases with subacromial space diminution, imaging techniques like ultrasonography or magnetic resonance imaging may be required to determine the exact pathologic condition of the rotator cuff and to select optimal treatment.

Prediction of 20-year outcome at onset of seropositive rheumatoid arthritis

OBJECTIVE

With the advent of new and expensive antirheumatic treatments with potentially serious side effects, it would be essential to identify as early as possible those rheumatoid arthritis (RA) patients who have a poor prognosis. Here study was made of the prognostic value of different markers recorded at the onset of RA.

METHODS

At the 20-year follow-up of our prospective study, 66 patients had rheumatoid factor-positive (RF+) RA. At commencement of follow-up (disease duration < 6 months), the prognostic value of 19 demographic, laboratory, clinical and radiographic variables was tested to explain the 20-year Larsen score for peripheral joints and the Health Assessment Questionnaire (HAQ) index using Somers'd for asymmetrical associations.

RESULTS

An association was observed between onset blood platelets (0.17), serum IgG (0.18), the onset Larsen score (0.33) and the 20-year Larsen score. Old age (0.30), serum orosomucoid (0.17), the function score (0.28), morning stiffness (0.28), and grip strength (0.24) were associated with the 20-year HAQ.

CONCLUSION

The correlation between the investigated entry variables and end-point outcome was poor. In our discussion we conclude that the most important prognostic factor in RF + RA is the treatment.

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.

The links between joint damage and disability in rheumatoid arthritis

OBJECTIVE

The characteristic joint damage and disability of rheumatoid arthritis (RA) increase slowly over 10-20 yr. Although it is generally believed that persisting inflammatory synovitis causes joint damage and subsequent disability, the strength of their relationship has not been systematically evaluated. This review describes their progression and interrelationship in treated RA.

METHODS

MEDLINE and Current Contents databases were searched for the combined terms of rheumatoid arthritis AND X-rays, Health Assessment Questionnaire, slow-acting anti-rheumatic drugs and all identifiable synonyms. This search identified 1303 articles and from these we evaluated in detail 23 reports on the progression of joint damage, 12 reports on the progression of disability and 25 reports dealing with their interrelationship. Additional information was obtained from four data sets comprising 725 RA patients studied cross-sectionally and 33-126 cases followed prospectively for 1-5 yr. X-ray damage was primarily assessed by Larsen and Sharp indices, and disability by the Health Assessment Questionnaire (HAQ).

RESULTS

Joint damage and disability both increase throughout the duration of RA. Although disability (HAQ score) is correlated with disease duration (correlation coefficients between 0.27 and 0.30), the link between X-ray damage and disability is stronger (correlation coefficients between 0.30 and 0.70). In the earliest phases of RA, X-ray damage and HAQ scores are not related. By 5-8 yr, there are significant correlations with correlation coefficients between 0.30 and 0.50. In late RA (>8 yr), most studies show highly significant correlations between 0.30 and 0.70.

CONCLUSIONS

Joint damage progresses constantly over the first 20 yr of RA. It accounts for approximately 25% of disability in established RA. The link between damage and disability is strongest in late (>8 yr) RA. However, avoiding or reducing joint damage in both early and established/late RA is likely to maintain function.

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.

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.

Prevalence of radiological changes in the cervical spine--a cross sectional study after 20 years from presentation of rheumatoid arthritis

OBJECTIVE

To evaluate the prevalence of cervical spine changes in patients with rheumatoid factor (RF) positive rheumatoid arthritis (RA) followed prospectively for 20 years.

METHODS

An inception cohort of 103 patients with RF positive RA have been followed at the Rheumatism Foundation Hospital, Heinola. A total of 68 patients attended for the 20 year followup. An additional 28 patients died and 7 were not able to attend due to severe disease or old age. The plain cervical spine radiographs of 69 patients (68 and one received from another hospital) taken after 20 years of RA were evaluated.

RESULTS

Anterior atlantoaxial subluxation was found in 16 cases (23%), while 18 patients (26%) had atlantoaxial impaction as judged by the Sakaguchi-Kauppi method. Subaxial subluxations and lateral atlantoaxial subluxations were found in 13 cases (19%) and 3/52 cases (6%), respectively, while 45 patients (65%) had subaxial disc space narrowing.

CONCLUSION

Cervical spine changes are common in patients with long lasting RA. They should be diagnosed and treated early to avoid complications. In our patient group no cervical spine surgery was performed, but at least 7 patients (10%) required further evaluation for possible surgery.

Larsen grades in evaluating the first carpometacarpal joint

OBJECTIVE

To illustrate different Larsen grades for CMC I.

METHODS

In the Heinola Follow-up Survey of Arthritis 103 seropositive patients with rheumatoid arthritis (RA) were followed prospectively over 20 years. Hand radiographs were taken at onset and at 1, 3, 8, 15, and 20 years from entry. One female patient was selected to demonstrate Larsen grades for CMC I, as she presented all the different grades of destruction during the progression of RA. Interobserver and intraobserver errors in grading of CMC I were tested.

RESULTS

Radiographs of the different grades with schematic presentation are illustrated. Interobserver and intraobserver errors were in the Weighted Kappa test 0.75 and 0.82, respectively.

CONCLUSION

We emphasise the importance of following the destruction of CMC I separate from the entire carpus during the course of RA.

Work disability in an inception cohort of patients with seropositive rheumatoid arthritis: a 20 year study

OBJECTIVE

Information from successive inception cohorts is needed to monitor the long-term prognosis of rheumatoid arthritis (RA) and the effect of treatment on it. We studied work disability and its association with the Health Assessment Questionnaire (HAQ) index and the Larsen score of radiographic damage.

METHODS

Work disability was recorded at onset and at 1, 3, 8, 15 and 20 yr from entry among 103 patients with recent-onset (<6 months) seropositive RA.

RESULTS

Work disability due to RA was already 31% [95% confidence interval (CI) 21-40] after 1 yr among patients of working age. It increased gradually and the cumulative rate reached 80% (95% CI 70-89) by the 20 yr check-up. The mean HAQ index was 0.96 at the 20 yr check-up and the mean Larsen score 45% of the maximum value.

CONCLUSION

The data serve as a basis of comparison for later cohort studies.

Radiographic joint space in rheumatoid acromioclavicular joints: a 15 year prospective follow-up study in 74 patients

OBJECTIVE

To evaluate radiographically the acromioclavicular joint space in patients with long-term rheumatoid arthritis (RA).

METHODS

A cohort of 74 patients with RA was followed prospectively for 15 yr. At the end point, 148 shoulders were radiographed with a standard method. The acromioclavicular (AC) joint space was examined from the radiographs with a method developed previously for population studies; the joint space was measured at its superior and inferior border, and the average of the two measurements, the integral space, calculated.

RESULTS

Mean AC joint space in RA patients was 4.9 (S.D. 3.7), range 0-20.5 mm; 6.2 mm (S.D. 5.1) in men and 4.5 mm (S.D. 3. 0) in women. An AC joint space wider than 7 mm in men was found in 11 (31%) out of 36 joints and wider than 6 mm in women in 17 (15%) out of 112 joints. Joint space widening was associated (r=0.87, 95% CI 0.82-0.90) with increasing destruction (Larsen grading) of the joint and it seems to be an inevitable consequence of AC joint affection in RA. Joint space widening is more progressive on the caudal side because of the nature of the erosive destruction. Degeneration with joint space narrowing was observed in 8 (11%) patients (11 joints, 7%; three bilateral).

CONCLUSIONS

The largest value of the joint space may be used when evaluating rheumatoid AC joint space. In RA patients, a joint space of >7 mm in men and >5 mm in women is a sign of destructive AC joint affection.

Acromioclavicular joint subluxation is rare in rheumatoid arthritis. A radiographic 15-year study

AIM

To conduct a radiographic assessment of the occurrence of the acromioclavicular joint subluxation in patients with long-standing rheumatoid arthritis.

METHODS

A cohort of 74 patients with seropositive rheumatoid arthritis was followed prospectively for 15 years. At the 15-year visit, plain radiographs of both shoulders (n = 148) were obtained using a standard method. Acromioclavicular joint destruction was evaluated using Larsen's method, and radiographic subluxation was measured on the radiographs using two different methods. In one of these methods (method A), the distance between the upper edge of the coracoid process and the upper surface of the clavicle was measured. The other method (method B) involved measurement of the alignment of the upper joint margins of the acromion and clavicle.

RESULTS AND CONCLUSION

Two of the 148 acromioclavicular joints fulfilled criteria for subluxation with method B. Neither measurement A nor measurement B differed significantly between unaffected joints (Larsen's grade 0 or 1) and affected joints (Larsen's grade > or = 2). In addition, neither measurement was correlated with the stage of acromioclavicular joint destruction (r < 0.10 for both measurements). Measurements A and B were significantly correlated to each other (r = 0.23; 95% CI, 0.07 to 0.38). The two subluxations (one upward and one downward) occurred among the nine joints with the most severe destructive lesions (Larsen's grade 5). In conclusion, acromioclavicular joint subluxation is rare in rheumatoid arthritis, occurring only when destruction of the joint is severe. The method B used in this study may prove useful for both population studies and routine clinical work.