Coracoclavicular involvement--an atypical manifestation in rheumatoid arthritis

An inception cohort of 74 patients with seropositive and erosive RA were followed up for 15 years. All 148 shoulders were radiographed with a standard method at the 15-year follow-up. The coracoclavicular region was evaluated from each radiograph. In addition, the distance between the processus coracoideus and the superior margin of the clavicle was measured. Only one clavicle had elongated, shallow erosion on the undersurface at the insertion area of the coracoclavicular ligaments. In this case the distance between the coracoid process and clavicle was 25 mm, whereas the mean distance of all shoulders (n = 148) was 17.4 mm (range 9 25 mm). We conclude that resorption on the undersurface of the distal clavicle is an atypical manifestation in rheumatoid arthritis. The origin of this atypical lesion is a not diminished distance between the processus coracoideus and the clavicle. Inflammation of the coracoclavicular ligaments is most likely the reason for this lesion.

Conventional monotherapy compared to a "sawtooth" treatment strategy in the radiographic progression of rheumatoid arthritis over the first eight years

OBJECTIVE

To describe the treatment with disease-modifying antirheumatic drugs (DMARDs) in two inception cohorts of rheumatoid arthritis (RA) patients and to compare their radiographic outcomes.

METHODS

A recent onset RA cohort was collected in Heinola in 1973-1975, and another in Jyväskylä in 1983-1989. The cohorts were followed up prospectively and treated with available DMARDs. The radiographic outcomes of 103 and 85 seropositive cohort patients from Heinola and Jyväskylä respectively were assigned Larsen scores (0-100) for their wrist, hand and foot radiographs in years 0, 1, 3, and 8, and compared with each other.

RESULTS

In this study it was seen that DMARD treatment for RA became more extensive over time. The earlier cohort patients were treated with gold sodium thiomalate, chloroquine and D-penicillamine, while 8 additional DMARDs and various DMARD combinations were used for the later cohort patients. At the 8 year visit, 23%, 33%, and 2% of the Heinola patients, and 6%, 45%, and 21% of the Jyväskylä patients respectively were being treated with chloroquine, other single DMARDs, or DMARD combinations. Destruction in the peripheral joints remained lower in the more extensively treated cohort; from 0 to 8 years the median Larsen score increased from 1 to 25.5 and from 0 to 12 (p = 0.001) for the Heinola and the Jyväskylä patients, respectively.

CONCLUSION

Our result supports a role of DMARDs in preventing joint destruction in RA in the long-term.

Secondary amyloidosis has decreased in patients with inflammatory joint disease in Finland

We studied whether the high incidence of secondary amyloidosis (SA) is a consistent finding in patients with inflammatory joint disease. A total of 4508 biopsies of patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis were studied at the Rheumatism Foundation Hospital during 1987-1997. The results show that the annual number of findings of SA was reduced from 68 to less than 10. We suggest that a change in medication towards more frequent use of cytostatic agents is the reason for the reduction in incidence of SA.

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

OBJECTIVE

To evaluate the incidence of involvement and nature of destruction of acromioclavicular joints (AC) in a prospectively followed cohort of 74 patients with rheumatoid factor positive and erosive rheumatoid arthritis (RA).

METHODS

At the 15 year followup, radiographs of 148 AC joints were evaluated, and the grade of destruction was assessed by the Larsen method.

RESULTS

No surgical procedures had been performed on the AC joints. Rheumatoid involvement (Larsen Grade > or = 2) was observed in 87/148 (59%) of the AC joints in 50/74 (68%) patients: 37 bilaterally and 13 unilaterally. Incidence of mild erosions (Larsen Grade 2) was 39%, and of severe (Larsen 3-5) 20%. Erosions were most often observed on the inferior edge of the clavicular joint margin. Degenerative features without rheumatoid changes were present in 11 joints. Larsen score (0-100) of peripheral joints correlated well with the AC joint Larsen Grade in both sides: right, r = 0.56 (95% CI 0.38 to 0.70), left, r = 0.49 (95% CI 0.30 to 0.65).

CONCLUSION

After 15 years two-thirds of the patients with RA showed involvement of the AC joints. Erosions were located most often on the inferior margin of the joint.

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

OBJECTIVES

To evaluate patients with mutilans-like hand deformities in chronic inflammatory joint diseases and to determine radiographic scoring systems for arthritis mutilans (AM).

METHODS

A total of 52 patients with severe hand deformities were collected during 1997. A Larsen hand score of 0-110 was formed to describe destruction of the hand joints. Secondly, each ray of the hand was assessed individually by summing the Larsen grade of the wrist and the grades of the MCP and PIP joints. When the sum of these grades was > or = 13, the finger was considered to be mutilated. A mutilans hand score of 0-10 was formed according to the number of mutilans fingers. Surgical treatment and spontaneous fusions were recorded.

RESULTS

The study consisted of 22 patients with juvenile rheumatoid arthritis (JRA), nine with rheumatoid factor (RF) positive and 13 with RF negative arthritis, 27 patients with RF positive RA, and three adult patients with other diagnoses. The mean age of patients with adult rheumatic diseases was 27 years at the onset of arthritis. The mean disease duration in all patients was 30 years. The mean Larsen hand score was 93. Four patients had no mutilans fingers and in 15 patients all 10 fingers were mutilated. The Larsen hand score of 0-110 and the mutilans hand score of 0-10 correlated well (rs = 0.90). Fourteen patients showed spontaneous fusions in the peripheral joints. A total of 457 operations were performed on 48 patients.

CONCLUSION

Both the Larsen hand score of 0-110 and the mutilans hand score of 0-10 improve accuracy in evaluating mutilans-like hand deformities, but in unevenly distributed hand deformities the mutilans hand score is better in describing deformation of individual fingers.

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

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

Hip involvement in seropositive rheumatoid arthritis. Survivorship analysis with a 15-year follow-up

In a prospective survey of recent arthritis 96 patients had erosive and seropositive rheumatoid arthritis (RA). Severe radiological changes in the hipjoint (Larsen grade 3-5) were observed in 31 (32%) and acetabular protrusion in five (5%) patients 15 years after the onset of arthritis. At the end of follow-up Larsen score 0-100 of peripheral joints (p < 0.015), HAQ (p < 0.001), ESR (p < 0.001), and CRP (p < 0.01) were significantly higher in patients with hip joint destruction than in those without. Secondary amyloidosis was found in eight patients with and in three patients without hip involvement (p = 0.002). In survivorship analysis (the Larsen 0-2 grade hips) an overall predicted rate of survival was 80% after 14 years of rheumatoid arthritis. When analyzed according to HLA-B27 the rate of radiological survival for the patients with a positive test was 62% and 87% for the others (p = 0.02). In conclusion, RA patients with high number of destructive peripheral joints (Larsen score) and high ESR or CRP should be carefully monitored due to the increased risk of hip destruction.

Serum C-reactive protein is rarely lost into urine in patients with secondary amyloidosis and proteinuria

We studied whether the low serum C-reactive protein (S-CRP) level in patients with inflammatory arthritis and proteinuria was due to the loss of CRP into urine. In 19 patients with secondary amyloidosis (14 with rheumatoid arthritis and five with juvenile chronic arthritis), S-CRP was measured with both immunoturbidimetric and radioimmunoassays. The concentration of urinary CRP was measured with a double-antibody radioimmunoassay. One patient with the most extensive proteinuria (12 g/24 h) excreted CRP at 14 mg/24 h, while in 18 of 19 patients only negligible, if any, amounts of CRP were found in 24-h urine samples. Proteinuria of < 8 g/24 h did not reduce the S-CRP level. Proteinuria exceeding this level may result in increased excretion of CRP into urine and consequently may result in a reduced S-CRP level.

Destruction and arthroplasties of the metatarsophalangeal joints in seropositive rheumatoid arthritis. A 20-year follow-up study

Destruction and arthroplasties of the metatarsophalangeal (MTP)joints and interphalangeal (IP) joint of the big toe were evaluated in 103 seropositive rheumatoid arthritis (RA) patients in a prospective follow-up study at onset and at 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year follow-up and 68 attended the 20-year follow-up. Data on the forefoot synovectomies and reconstructions performed were obtained from patient documents and radiographs. The radiographs were assigned by the Larsen method; in the end point analysis the last or preoperative radiograph was used. Erosions of Larsen grade > or =2 were present in 6%/ of the investigated 1236 joints at onset and after 20 years in 62%, respectively. At the end point, 24% of the joints were severely damaged (Larsen grade 4-5). The MTP I and IP joints showed the lowest grade of destruction during follow-up, and MTP V the worst destruction. Synovectomies were performed in 24 MTP joints; a total of 75% of these joints were later resected. MTP II-V head resections were performed in 21% and the Keller procedure in 12% of the MTP I joints. Erosive changes occur early in the MTP joints, and their grade of destruction is high; therefore they should be included in radiographic criteria and scores. MTP synovectomies are insufficient treatments for RA without concomitant immunosuppression of the disease.

When does subluxation of the first carpometacarpal joint cause swan-neck deformity of the thumb in rheumatoid arthritis: a 20-year follow-up study

The aim of our study was to assess the incidence of subluxation of the first carpometacarpal joint (CMC I) and to evaluate which degree of subluxation produces swan-neck deformity of the thumb in rheumatoid arthritis (RA) occurring over 20 years. The hands of 83 rheumatoid factor (RF)-positive RA patients with recent (< or = 6 months) arthritis were evaluated radiographically at onset and at 1, 3, 8 and 15 years; 68 patients were evaluated at 20 years from entry. Subluxation was assessed in millimetres and compared with the MCP-I angle measurement to evaluate the thumb deformity. A statistical end-point analysis was performed between two different grades of subluxation. Subluxation of 2-3 mm was non-specific and only one third of these thumbs showed swan-neck deformity. At the end-point, subluxation of > or = 4mm was present in 17% of the thumbs, 81% of which had the swan-neck deformity; only five thumbs did not show this deformity, but presented deformed and unstable MCP I and interphalangeal joints. The frequency of swan-neck deformity was highly significantly (p < 0.0001) increased in the thumbs with severe CMC I subluxation (> or = 4 mm) compared with lesser subluxation (< 4 mm). When subluxation of the CMC I exceeds 4 mm, the swan-neck deformity of the thumb is a common consequence. This deformity is often progressive, and the hand function of such patients should be followed up carefully, both clinically and radiographically.

Destruction and reconstruction of hand joints in rheumatoid arthritis. A 20 year followup study

OBJECTIVE

To examine the radiographic endpoint changes and performed joint fusions and arthroplasties in hand joints in rheumatoid arthritis (RA) occurring over a 20 year period.

METHODS

In 83 patients with recent (< 6 months) rheumatoid factor positive RA, radiographs were taken at 15 and 20 years from entry. The Larsen grades for 12 hand joints were evaluated, as well as the preoperative grades for reconstructed joints. Data of the performed hand joint fusions and arthroplasties were obtained.

RESULTS

At 15 year followup the mean Larsen grade of wrist joints was 2.5, metacarpophalangeal (MCP) I-V 1.0-1.8, and interphalangeal I and proximal interphalangeal (PIP) II-V 0.7-0.9. At the endpoint the mean grades were: wrist joint 2.7, MCP I 1.1, MCP II 2.2, MCP III 1.9, MCP IV 1.3, MCP V 1.5, IP I and PIP II-V 0.7-1.0. Modified Larsen grade for carpometacarpal I was 1.6 and 2.0 at 15 year followup and endpoint, respectively. Reconstructive surgery was performed in 33/83 patients. The number of operations was 83, and 38 of them were wrist fusions.

CONCLUSION

In this inception cohort, wrist joints had the highest destruction and the need for reconstructive surgery; the grade of destruction was lower in MCP and PIP joints, in this order. Possibilities of reconstructive surgery are discussed.

Antibody to stratum corneum (antikeratin antibody) and antiperinuclear factor: markers for progressive rheumatoid arthritis

The purpose of this study was to examine the relationship between circulating antibodies to stratum corneum (AKA) and antiperinuclear factors (APF) on one hand, and the x-ray progression of joint damage in chronic poly/oligoarthritis on the other hand. The analysis involved 133 patients with either rheumatoid or nonspecific arthritis derived from a cohort of 442 patients with recent onset arthritis. The patients were followed up for eight years with regular clinical, laboratory, and radiological evaluations. Radiographic evidence of joint destruction was quantitated by a radiographic index based on the Larsen grading. AKA and APF were detected, either at entry or at follow-up, in 26 and 54 patients, respectively. Seventy-six of the 133 patients had developed erosions. All AKA-positive patients had a rheumatoid factor-positive erosive poly-arthritis. The presence of APF was also associated with a progressive arthritis although four APF-positive patients had a non-erosive disease. Neither AKA nor APF were able to distinguish a particularly severe form of progressive RA.

Destruction of the first carpometacarpal joint behaves differently from that of the entire carpus in rheumatoid arthritis. A 20-year follow-up study

The aim of our study was to examine the radiographic changes of the wrist and the first carpometacarpal (CMC I) joints in rheumatoid arthritis (RA) occurring over 20 years. The wrists of 83 RF positive RA patients with recent (< or = 6 months) arthritis were evaluated radiographically at onset, at 1, 3, 8, and 15 years and of 68 patients 20 years from entry. In hands where wrist fusion was performed, follow-up continued until the arthrodesis. Larsen grading for the wrist joints and modified grades for the ipsilateral CMC I joints were compared. Larsen grades of both wrists differed highly significantly (p < 0.001) from the grades of the ipsilateral CMC I joints after 3 years and up to end of the study. In conclusion destruction of the CMC I does not proceed uniformly with destruction of the entire carpus and it would be beneficial to classify it separately.

A 20-year follow-up study of subtalar changes in rheumatoid arthritis

The destruction of the subtalar joints in 103 seropositive RA patients with recent (< or = 6 months) disease was evaluated radiographically in a prospective follow-up study at onset and at 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year follow-up and 68 the 20-year follow-up. The Larsen grades of the joints were evaluated and the need for surgical treatment considered. At the 15-year follow-up the mean Larsen grade was 1.2 (median 0) and at the 20-year follow-up 1.3 (median 0); at the 20-year follow-up 77 subtalar joints were still assessed as Larsen grade 0. In this series, subtalar fusions were performed in 12 patients only. Spontaneous fusions occurred in 5 hindfeet in 3 patients. The destruction rate of the subtalar joint was lower than in previous retrospective or cross-sectional studies. The need for routine radiographs of ankles in RA patients is questioned.

Does wrist fusion cause destruction of the first carpometacarpal joint in rheumatoid arthritis? 18 patients followed for 2-6 years

We evaluated radiographic destruction of the first carpometacarpal joint (CMC I) in 18 hands with wrist fusions and compared it with the unoperated contralateral hands preoperatively and after a follow-up of a mean of 4.4 (2-6) years. Patients were obtained from a prospective 20-year follow-up study of 103 patients with seropositive rheumatoid arthritis. The degree of destruction in the CMC I-joints was evaluated with Larsen grades. The mean value of Larsen indices for CMC I was 0.9 before wrist fusion and 2.5 (p < 0.001) at the follow-up, compared to 0.8 and 1.3 (p = 0.06) in the control hands, respectively. No preoperative difference was found between the hands to be fused and the control hands, but the difference was significant (p = 0.009) after the follow-up.

Continuous progression of radiological destruction in seropositive rheumatoid arthritis

OBJECTIVE

To examine the radiographic changes in rheumatoid arthritis (RA) occurring over a 20 year period.

METHODS

In 103 patients with recent (< 6 months) seropositive RA, radiographs were taken at onset and at 1, 3, 8, 15, and 20 years from entry. Larsen grades for wrist and subtalar joints were first multiplied by 5, and these together with Larsen grades for the 1st to 5th metacarpophalangeal (MCP) joints, the 1st interphalangeal, and the 2nd to 5th metatarsophalangeal (MTP) joints of the feet (24 joints) were added to form a Larsen score of 0-200. Larsen grades for the 1st to 5th MCP, wrists, and 2nd to 5th MTP (20 joints) were added to form a Larsen score of 0-100.

RESULTS

The means of the 0-200 Larsen score were 4.3, 12.9, 26.9, 55.7, 77.5, and 86.4, and of the 0-100 Larsen score 2.5, 7.0, 13.9, 28.2, 39.4, and 44.5.

CONCLUSION

Seropositive RA is a chronic disease still leading to continuous progression of joint damage 20 years after onset.

The value of the ACR 1987 criteria in very early rheumatoid arthritis

We assessed the sensitivity and specificity of the ACR 1987 revised criteria for rheumatoid arthritis (RA) in 121 patients with recent-onset (< or = 6 months) RA, 68 with reactive arthritis (ReA), 19 with ankylosing spondylitis (AS), and 13 with psoriatic arthritis (PsA). The sensitivity of each single criterion ranged 8.3-90.9% and specificity 52.0-100%. The sensitivity of four fulfilled criteria was 83.5% and specificity 86.0%. In ReA 11.8%, AS 5.3%, and PsA 38.5% of patients fulfilled four criteria respectively. Thus at the beginning of RA, 83% of patients could be diagnosed correctly by using the ACR 1987 criteria, and the remaining 17% had seropositive and/or erosive arthritis at the onset. The suitability of the radiographic ACR criteria is discussed.

Correlations between clinical facets of outcome in rheumatoid arthritis

At 8-year follow-up of 103 patients with rheumatoid arthritis, an X-ray index based on Larsen's score for the hands, wrists, ankles and feet showed a high correlation with the joint score (0.75 by Spearman's rank correlation), the function score (0.68), ESR (0.61), and CRP (0.64). These results suggest that Larsen's method of scoring both the hands and feet is a valid single method to assess long-term outcome in rheumatoid arthritis.

How often is seropositive rheumatoid arthritis an erosive disease? A 17-year followup study

OBJECTIVE

The frequency of erosiveness was studied in rheumatoid arthritis (RA) by longterm followup.

METHODS

A community based cohort of 263 patients with recent onset (< or = 6 months) arthritis were followed in Heinola. At 8-year followup examination 113 cases were found to have rheumatoid factor positive (seropositive) nonspecific arthritis, and 15 were nonerosive in the radiographs. The 15 patients were reexamined in 1992 (17-year followup).

RESULTS

Eleven of 15 were found to have erosive disease, and of these, 6 had putative psoriatic arthritis, 4 RA, and one monoarthritis of the knee. Of the remaining 4 seropositive nonerosive cases only one fulfilled the 1987 American College of Rheumatology (ARA) criteria for RA.

CONCLUSION

In patients with seropositive RA with 4 1987 ARA criteria, 99% developed erosive disease.

Predictive value of synovial fluid analysis in rheumatoid arthritis. A 7.5-year follow-up study

OBJECTIVES

To evaluate the prognostic value of some synovial fluid variables in patients with rheumatoid arthritis.

METHODS

Twenty-nine patients with erosive rheumatoid arthritis and hydropsy in a knee joint were followed for 7.5 years in a prospective study. At the start of the study the knee joints were aspirated and 15 synovial fluid variables were analyzed. The patients were divided into two groups according to whether or not there had been progress of radiologically detected destruction in the knee joints during the follow-up.

RESULTS

Of the synovial fluid variables at the start, only C3 (p = 0.030) and acid phosphatase (p = 0.047) differed significantly between the groups, the former being lower and the latter higher in patients with deterioration of knee joints.

CONCLUSIONS

These preliminary results may indicate that low synovial fluid C3 and high acid phosphatase predict poor prognosis in a joint affected by rheumatoid arthritis.

Amyloidosis--incidence and early risk factors in patients with rheumatoid arthritis

In a 15-year follow-up examination, reactive secondary amyloidosis (RSA) was found by subcutaneous fat biopsy in six out of 74 still living patients (8.1%) of an original population of 102 with erosive and seropositive rheumatoid arthritis (RA). Five of the 24 deceased patients had had RSA. Thus the 15-year incidence of RSA in RA was at least 10.9% (11/102). To study early prognostic aspects of RSA, comparison was made of 14 entry variables and the initial treatment in the RSA group (n = 11) and the control group (n = 81) respectively. At onset (< or = 6 months) of RA only serum orosomucoid, but after three years morning stiffness, ESR, serum CRP and orosomucoid were significantly worse in patients whom later developed RSA. Three out of 48 patients treated with gold sodium thiomalate and seven out of 30 treated with chloroquine developed RSA (p = 0.04). It is concluded that continuously active disease was the risk factor underlying RSA. The role of early chloroquine therapy is discussed.

HLA typing and seropositivity in Finnish and in Polish patients with rheumatoid arthritis and amyloidosis

We determined HLA-A, -B, -C and -DR antigens in 83 patients with rheumatoid arthritis (RA) and reactive secondary amyloidosis (RSA), 60 in Finland and 23 in Poland, and compared the results with control RA patients and blood donors. There were no significant differences in the frequencies of HLA between the RA patients with and those without RSA in either Finland or Poland, and no significant differences between the Finnish and Polish patients with RSA. All the RSA patients from Finland and 70% of the RSA patients from Poland were seropositive. In the development of RSA, the prolonged period of inflammatory stimuli may play a more important role than genetic factors.