Radiographic features predictive of radiographic progression of hip osteoarthritis

OBJECTIVES

To evaluate potential radiographic predictors of hip osteoarthritis progression.

PATIENTS AND METHODS

A prospective, longitudinal two-year study was conducted in patients meeting American College of Rheumatology criteria for hip osteoarthritis. Hip osteoarthritis progression was defined as a greater than 0.5-mm decrease in joint space width measured using a magnifying glass marked at intervals of 0.1 mm, at the site of maximum joint space narrowing, by a single investigator who was blinded to the chronological order of the radiographs. Radiographic parameters determined at study entry were as follows: presence of osteophytes, osteosclerosis, and subchondral cysts; femoral head migration (superolateral, superomedial, concentric); and severity (joint space width in mm, Kellgren and Lawrence grade, subjective evaluation of joint space narrowing).

RESULTS

In the 463 study patients, joint space width decreased from 2.2 +/- 0.8 at baseline to 1.7 +/- 1.0 mm after two years (P < 0.0001). Radiographic progression was seen in 148 patients (32%). Radiologic parameters predictive of disease progression in the multivariate analyses were as follows:

CONCLUSION

Our data suggest that a number of baseline radiological features including distribution of joint space loss, subchondral bone production, and severity of joint space loss are predictive of progression of hip osteoarthritis.

Medical treatment of reflex sympathetic dystrophy

The treatment of reflex sympathetic dystrophy is not delineated clearly, and there are few controlled studies regarding rehabilitation as medicine. Analgesics, nonsteroidal anti-inflammatory drugs, and intra-articular steroids are used widely, but especially in Europe, calcitonin is the primary treatment at early stages of the disease. Local intravenous injections are used currently in case of failure of the previous treatments. Physical therapy and rehabilitation are needed also to decrease pain and to improve stiffness.

No link between avascular necrosis of the femoral head and antiphospholipid antibodies

The rate of occurrence of antiphospholipid antibodies was compared in 47 patients with avascular necrosis of the femoral head and in 47 controls matched on age and sex. Antiphospholipid antibodies were looked for using three techniques in each patient, namely the VDRL test, an ELISA for anticardiolipin, and a circulating anticoagulant detection procedure involving three different tests. The VDRL and the tests for circulating anticoagulants were negative in all the patients and controls. No significant between-group difference was found for the ELISA, which was positive in three patients and two controls.

Histological appearance of the intra-osseous vessels of the femoral head in aseptic osteonecrosis of the hip, with or without antiphospholipid antibodies

It has been suggested that in some patients non-traumatic aseptic osteonecrosis of the hip (AOH) could be the result of the intra-osseous thrombosis. Antiphospholipid antibodies (APL) have been associated with venous and arterial occlusive events and the association between AOH and APL syndrome has been reported.

OBJECTIVES

To compare bone vessels of the femoral head in patients operated on for AOH with or without APL.

PATIENTS

Twenty patients (mean age 47 yrs) with AOH were included: in eight patients APL (IgG-ELISA) were negative (< 8 GPL units), in nine patients APL were doubtful (8-15 GPL units), and in three patients APL were positive (> 15 GPL units).

METHODS

Bone vessels were examined: arteriosclerotic lesions, i.e. fibrosis or thickening of the media and rupture of the internal elastic lamina, thrombosis or vasculitis were sought in the femoral heads after total hip replacement or core decompression.

RESULTS

Bone vessel lesions were the same in the three groups.

Hyperparathyroidism during lithium therapy. Two new cases

We report two new cases of hyperparathyroidism during lithium therapy. The patients were a 50-year-old male and a 48-year-old female under lithium for bipolar disease. Both developed osteoporosis without fractures and laboratory test abnormalities consistent with moderate hyperparathyroidism. Although only 30 or so cases of lithium-associated hyperparathyroidism have been reported, as many as 10 to 15% of lithium-treated patients may have laboratory test evidence of hyperparathyroidism. Typically, urinary calcium excretion is normal, serum phosphate levels are moderately decreased and cyclic AMP levels are normal. An adenoma is the most common lesion. Surgery is usually required in patients whose clinical and laboratory test abnormalities persist despite discontinuation of the drug. Lithium-associated hyperparathyroidism may be due to dysregulation of the caliostat, a feedback loop that subordinates parathyroid hormone secretion to serum calcium levels. Little is known about lithium-induced osteoporosis. Trabecular bone was predominantly affected in one of our patients and cortical bone in another.

[Gonarthroses]

Osteoarthritis of the knee joint can affect femoro-tibial as femoro-patellar compartments. It is a frequent and disabling location of the disease which may induce pain at motion and stiffness. Swelling of the knee is very frequent and synovial fluid is easy to puncture. Roentgenologically, the AP view, in standing position, with a 30 degree flexion is useful to depict mild narrowings of the femoro-tibial joint space. Knee is the main joint used for clinical trials in osteoarthritis because: 1. it is frequent location of the disease; 2. its handicap is relevant; 3. validated assessment criteria are available. As knee joint is superficial, femoro-tibial osteoarthritis may benefit by local treatments in addition to general usual management.

Persistence of dominant T cell clones in synovial tissues during rheumatoid arthritis

In a previous study, we showed that the T cell repertoire is biased in the synovial membrane (SM) compared with peripheral blood during rheumatoid arthritis (RA). The same bias was observed in different joints from the same patient and seems to be the same over time. To discover whether this bias was due to expansion of a clonal subset resulting from activation by conventional Ag(s) or to polygonal stimulation by superantigen(s), we sequenced more than 650 TCRBV-D-J junctional regions from freshly isolated SM and peripheral blood of two DR4-RA patients. From each patient, two SM were obtained on the same day, and a third was obtained later. Several dominant clones were found in SM but not in peripheral blood. Some of them were found only at the first time point in anatomically different SM, the majority persisted over time, and others were detected only at the second time point. Analysis of the complementarity-determining region 3 (CDR3) showed a bias in TCRBD and amino acid usage. Valine, encoded by randomly inserted N nucleotides, was used by 45% of dominant clones compared with 18% in the control population (p less than 0.001). In addition, GXXG and TSG motifs were frequently observed in the CDR3 of these dominant clones. These data indicate a dynamic TCR selection process during the perpetuation phase of RA. The dynamic changes of dominant clones also suggest a determinant spreading mechanism during RA.

Persistence of dominant T cell clones in synovial tissues during rheumatoid arthritis

In a previous study, we showed that the T cell repertoire is biased in the synovial membrane (SM) compared with peripheral blood during rheumatoid arthritis (RA). The same bias was observed in different joints from the same patient and seems to be the same over time. To discover whether this bias was due to expansion of a clonal subset resulting from activation by conventional Ag(s) or to polygonal stimulation by superantigen(s), we sequenced more than 650 TCRBV-D-J junctional regions from freshly isolated SM and peripheral blood of two DR4-RA patients. From each patient, two SM were obtained on the same day, and a third was obtained later. Several dominant clones were found in SM but not in peripheral blood. Some of them were found only at the first time point in anatomically different SM, the majority persisted over time, and others were detected only at the second time point. Analysis of the complementarity-determining region 3 (CDR3) showed a bias in TCRBD and amino acid usage. Valine, encoded by randomly inserted N nucleotides, was used by 45% of dominant clones compared with 18% in the control population (p less than 0.001). In addition, GXXG and TSG motifs were frequently observed in the CDR3 of these dominant clones. These data indicate a dynamic TCR selection process during the perpetuation phase of RA. The dynamic changes of dominant clones also suggest a determinant spreading mechanism during RA.

Membranoproliferative glomerulonephritis, p-antineutrophil cytoplasmic antibodies, and rheumatoid arthritis. Report of a case

Many rheumatoid arthritis patients have renal dysfunction induced either by the drugs used to treat their joint disease or by the chronic inflammation. A case of rheumatoid arthritis with p-antineutrophil cytoplasmic antibodies and mesangial glomerulonephritis that progressed to type I membranoproliferative glomerulonephritis is reported. The glomerular abnormalities were diagnosed by two renal biopsies done at a one-year interval. Reasons for the first and second renal biopsies were renal dysfunction with hematuria and impure nephrotic syndrome, respectively. Unusual features in this case include the succession of two histologic forms of glomerular disease in a patient with rheumatoid arthritis, the correlation between p-antineutrophil cytoplasmic antibody titers and activity of the renal disease. In addition, type I membranoproliferative glomerulonephritis is exceedingly rare in rheumatoid arthritis patients.

[Increase of CA 19.9 in dysimmune inflammatory rheumatism. Apropos of 6 cases]

CA 19.9 is a marker for several cancers, including ductal adenocarcinomas of the pancreas. CA 19.9 elevation is rarely found in patients without benign or malignant digestive system disease. We studied serum CA 19.9 levels in patients with a variety of inflammatory joint diseases, including rheumatoid arthritis (n = 20), lupus, Sjögren's syndrome or U1RNP-associated connective tissue syndrome (Sharp's syndrome) (n = 11), dermatopolymyositis (n = 8), and giant cell arteritis or polymyalgia rheumatica (n = 8). The mean CA 19.9 level in each of these groups was not significantly different from the value seen in a group of patients with osteoporosis. Six patients had persistent marked elevation in serum CA 19.9 levels. Two had Sjögren's syndrome, two had Sharp's syndrome and two had dermatopolymyositis. None of these six patients had evidence of tumoral disease despite a follow-up of several years. Likely explanations for the CA 19.9 elevation were chronic pancreatitis in one case and lung disease in the other five. In patients with lung involvement due to inflammatory joint disease, CA 19.9 elevation may indicate severe disease and may be of use for monitoring the lung condition.

[Osteocalcin and smoking]

Smoking is a risk factor for osteoporosis. Nicotine and nonnicotine tobacco smoke components have been shown to depress osteoblast activity in a number of in vitro and animal studies. To determine whether smoking is associated with depressed osteoblast activity in humans, we measured serum osteocalcin levels (using a radioimmunological method based on an antibody to human osteocalcin) in 24 male or female smokers and 24 matched nonsmokers. Overall, osteocalcin levels were significantly lower in smokers (15 +/- 6.95 ng/ml) than in nonsmokers (21.27 +/- 8.34 ng/ml) (p = 0.007). The difference between smokers and nonsmokers was significant in males (15.3 +/- 4.5 vs 23.27 +/- 9.7; p = 0.02) but not in females (16.27 +/- 8.9 vs 19.45 +/- 6.7; p = 0.2). These data suggest that smoking may induce osteoblast depression, either directly or via hormonal changes.

[Rheumatic manifestations of chronic hepatitis C and response to the treatment with interferon alpha-2b]

Chronic hepatitis C can be responsible for a broad range of autoimmune manifestations, including cryoglobulinemia and Sjögren's syndrome. We report our experience with six patients (five women and one man; mean age 55.6 years) in whom hepatitis C was diagnosed during evaluation of joint symptoms. Polyarthralgia was the main symptom and was often accompanied with myalgia; a polyalgic syndrome was seen in some patients. Isolated cytolysis was consistently found, although, in some instances, liver enzyme elevations were moderate and postdated the onset of the clinical symptoms. The diagnosis of hepatitis C was confirmed by recombinant immunoblot assay (RIBA) in every case. The polymerase chain reaction (PCR) detected hepatitis C virus RNA in five of the six patients. Histological findings were characteristic of chronic hepatitis. All six patients had immunological test abnormalities, which included presence of rheumatoid factors (2 of 6), positive antinuclear antibodies without anti-DNA antibodies (3 of 6) and low serum complement levels (3 of 6). A cryoprecipitate was found in four of the six patients. Four patients reported symptoms of sicca syndrome and two had Chisholm grade III lesions upon examination of salivary gland biopsy specimens. Four patients were given a six-month course of interferon alpha. In three of these four patients, evaluation at the end of the treatment showed abatement or resolution of symptoms, normal liver function tests, unchanged or diminished antinuclear antibody titers, and normal serum complement levels. In the remaining patient, no changes in symptoms or transaminase levels occurred during interferon alpha treatment. In conclusion, rheumatic symptoms can be the most prominent manifestation of chronic hepatitis C.(ABSTRACT TRUNCATED AT 250 WORDS)

Absence of Epstein-Barr virus carrying cells in synovial membranes and subcutaneous nodules of patients with rheumatoid arthritis

OBJECTIVES

To determine whether the Epstein-Barr virus is present in synovial membranes and subcutaneous nodules of patients with rheumatoid arthritis.

METHODS

A sensitive in situ hybridisation technique was applied to tissue sections of 11 synovial membranes and five rheumatoid nodules.

RESULTS

Cells carrying the Epstein-Barr virus were not detected using EBER and BHLF1 oligonucleotides in the tissue samples investigated here.

CONCLUSIONS

Although it has been suggested that the Epstein-Barr virus could play a part in the aetiology of rheumatoid arthritis, it was not detected in synovial membranes and subcutaneous lesions in this study.

[Diacetylrhein on a postcontusion model of experimental osteoarthritis in the rabbit]

The "chondroprotective" activity of a drug must be tested not only in vitro but also in vivo. Because this would require several years in humans, animal models of osteoarthritis are used. A closed contusion of the patella caused by the impact of a 1-kg weight dropped from a height of one meter results in osteoarthritis. Twenty-three adult New Zealand rabbits were sacrificed 49 days after the contusion. Cartilages of both condyles and the patella were studied on 6-mu hematoxylin-eosin-stained serial sections. The morphologic osteoarthritis score (sum of gross and microscopic scores) was determined. Mean score was the mean value of scores for both condyles and the patella, whereas total score was the sum of scores at the three sites. The 23 rabbits were divided into four groups: controls (n = 6), controls + diacerhein (n = 5), contusion (n = 6), and contusion + diacerhein (n = 6). Diacetylrhein was given orally (3.5 mg/kg/d) throughout the 49-day interval between contusion and sacrifice. Mean and total scores showed no significant differences between the control, diacerhein, and diacerhein + contusion groups. Scores were significantly lower in the control group as compared with the contusion group (p < 0.03) and in the diacerhein + contusion group as compared with the contusion group (p < 0.05). Diacetylrhein given in as prophylactic treatment under the experimental conditions used prevented contusion-induced cartilage destruction and exhibited a "chondro-protective" effect.

Skeletal manifestations of moderate phosphate diabetes

Six patients, with vertebral osteoporosis and reflex sympathetic algodystrophy syndrome of the lower limbs, due to moderate diabetes, are presented. Osteoporosis was documented by low CT scan bone density and moderate decrease of bone trabecular volume. Histomorphometric studies found a mild increase of resorption areas. All patients had unremarkable serum phosphorus level (mean: 0.91 +/- 0.13) but increase of urinary phosphorus excretion was documented by phosphate clearance higher than 20ml/mm, phosphate tubular reabsorption lower than 80% and TmPo4/GFR lower than 0.8mmol/l. Phosphate clearance and phosphate tubular reabsorption are studied in two control groups. Mild phosphate diabetes, of unknown incidence and prevalence (need for prospective studies) may be the vector of osteoporosis, vertebral and peripheral. The diagnosis of PD requires determination of phosphate clearance, phosphate tubular reabsorption, TmPo4/GFR and these tests may be useful in the diagnostic work up of bone demineralization disorders. We thought that osteoporosis could be the result of progressive dissolution of bone apatite crystals necessary to maintain normal or sub-normal blood phosphate level in spite of the phosphate diabetes.

Histopathology of the vessels of the femoral heads in specimens of osteonecrosis, osteoarthritis and algodystrophy

The authors studied by light microscopy the vessels of the femoral head and neck in 38 well preserved specimens from core biopsy. There were 17 cases of osteonecrosis (ON), 11 cases of osteoarthrosis (OA) and 10 cases of reflex sympathetic dystrophy, so called algodystrophy (AD). Mean age of the patients was respectively 44, 45 and 42 years. The sex ratio, M/F, was respectively 12/5, 6/5 and 9/1. Types of staining used were hematoxylin-eosin, Masson Trichrome, P.A.S. and Verhoeff. In counting, thick-walled and thin-walled vessels were distinguished. There was a significant reduction in the number of the thick- and thin-walled vessels, in the ON group, by comparison with the OA and AD groups. An increased number of thin-walled vessels in the AD group were also observed. Morphological study showed an abnormal frequency of fibrosis of the media in the arteries of the ON group, i.e. arteriosclerosis. These data were compared with the few other histopathological studies previously published. The authors recommend further studies in order to precise their frequency and their significance.