Alastair G. Mowat

Hematologic abnormalities in rheumatoid arthritis

Abstract A moderate anemia due chiefly to reduction of red blood cell count with a modest reduction in MCHC is common in rheumatoid arthritis and contributes to the disability and morbidity produced by the disease. This anemia has features in common with that found in other chronic disease states, and its cause is multifactorial. Mild degrees of hemodilution and hemolysis occur, and there is some impairment of iron absorption from the gastrointestinal tract. Blood loss from the gastrointestinal tract is probably not important in most cases. More important causes are the abnormal storage of iron in the reticuloendothelial system and synovial tissue and the failure of bone marrow to respond to anemia. Most of these abnormalities are related to the activity of the disease and return to normal when this is controlled. Interest has been expressed in the possible cause of iron storage in the synovial tissue and whether the iron has any local action. It is yet undetermined whether iron enters the synovial cells by an active or passive process and whether it has a local action on lysosomal membranes. It is possible that iron has a beneficial effect by acting in a manner similar to gold, but the effect of iron on lysosomal systems requires investigation. The possibility of megaloblastic anemia in rheumatoid arthritis must always be borne in mind, especially in those cases in which the degree of anemia is not proportional to the activity of the disease. Further population surveys are required to establish the true incidence of pernicious anemia in association with rheumatoid arthritis, but these are time-consuming because multiple investigations of vitamin B 12 metabolism are required. Although folate deficiency is apparently common in rheumatoid arthritis on the basis of serum folate values, it requires bone marrow examination and erythrocyte folate values for its true diagnosis. The latter is not yet a routine laboratory procedure. Although many of the abnormalities in folate metabolism return to normal when the activity of the disease is controlled, some patients will require folate supplements on a long-term basis. Many of the pathways of folate metabolism in patients with rheumatoid arthritis, particularly with regard to dietary requirements, cell proliferation, protein abnormalities, and deficiency of iron and pyridoxine, require further investigation. The existence of Feltys syndrome as a distinct disease entity has been questioned, and the value of splenectomy in this disease has been examined. More detailed reports of the effect of splenectomy on the incidence of bacterial infection are required. It is suggested that in these patients greater attention be directed toward the measurement of white cell function than toward actual white cell count.

The effect of heel pads on the treatment of Achilles tendinitis: A double blind trial

Thirty-three subjects entered a blind-observer, random, prospective study of three forms of conservative treat ment of sports-induced Achilles tendinitis, results being assessed by clinical and biomechanical parameters. Two patient groups received heel pads, ultrasound, and exercises, while the third received only ultrasound and exercises. All three groups showed some improve ment at both 10 day and 2 month assessment, but the claimed benefit of viscoelastic pads widely used by athletes was not substantiated. The more striking bene fit from ultrasound and exercises alone occurred in patients with a shorter history; a comparison of duration of injury in all three groups suggested this was an important factor influencing outcome. The study has highlighted the need for biomechanical outcome measures as well as for more objective clinical outcome measures in the assessment of physical ther apy.

WOUND HEALING AFTER OPERATIONS ON PATIENTS WITH RHEUMATOID ARTHRITIS

1. The incidence of failure of wound healing by primary intention due to infection, haematoma and gaping of wound edges, has been compared in 100 patients with rheumatoid arthritis and in 100 matched controls following a variety of orthopaedic operations. 2. There were thirty-one cases of failure of wound healing in the patients with rheumatoid arthritis and sixteen in the controls (P 3. The problems of wound healing were minor since there was no difference in the mean number of days ±1 standard deviation to wound healing between the patients: l6·6±7·5 days; and the controls: 15·2±7·9 days. 4. There was no correlation between duration or severity of rheumatoid disease and wound healing. 5. There was no difference in wound healing between patients with sero-positive and seronegative disease. 6. Forty-nine patients received corticosteroid therapy in small dosage. This was associated with an increased incidence of wound infection. Treatment for more than three years was associated with a significant increase in the mean number of days to wound healing. 7. The results are discussed in the light of the increased incidence of infection in several sites in patients with rheumatoid arthritis and of the effect of corticosteroid therapy on wound healing in man and experimental animals. It is suggested that more marked abnormalities might have been expected, and that these findings may need to be considered in the future surgical management of such patients.

Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement.

The results of total elbow replacement (TER) in 45 elbows of 38 patients with rheumatoid arthritis were compared with results of radial head excision with synovectomy (RHES) in 45 age-matched patients treated in the same unit. The groups were similar with respect to duration of disease and preoperative clinical status, although pain was of longer duration and slightly more severe in the TER group. Failure was defined as the onset of moderate or severe pain after surgery or revision surgery for any reason. Reduction in pain was greater after TER than after RHES (P < .05). Recurrence of pain was common after RHES but was not seen after TER. Movement increased by a similar amount in each group. Complications were more frequent and more serious after TER (4 dislocations, 4 ulnar nerve dysfunctions, 1 significant wound breakdown) than after RHES (2 ulnar nerve dysfunctions, 1 transient wound discharge). Complications after TER were most common in patients who had previous RHES. On survival analysis, TER results were better than RHES results in each successive year. Cumulative survival rates at 10 years were 85% for TER and 69% for RHES, but the difference in rates was not statistically significant. In the medium term, TER relieves pain more reliably than RHES and its use is justified despite the greater risk of complications. In view of the paucity of long-term results for TER, RHES may retain a role in younger patients or in those whose symptoms are related mainly to the radiohumeral joint.

Posterior interosseous nerve palsy in rheumatoid arthritis

Bilateral posterior interosseous nerve palsy in a rheumatoid patient is described. Six previous case reports and our experience indicate that steroid injection into the elbow may not produce lasting recovery and may lead to unacceptable delay before surgical decompression. An anterolateral approach for division of the arcade of Frohse is effective in cases with diffuse synovitis; where there is a local cystic swelling a posterolateral approach provides better access. Good recovery of nerve function can be expected after early operation.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis: Predictive factors and long-term outcome

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

SYNOVECTOMY OF THE ELBOW AND RADIAL HEAD EXCISION IN RHEUMATOID ARTHRITIS

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Reiter's Syndrome in a 73-Year-Old Man with Bronchiectasis

We report the case of what we believe to be the oldest person to develop Reiters Syndrome. There was no evidence of preceding gastro-intestinal or genito-urinary infection but the patient had post-tuberculous bronchiectasis and the role that this might have played is examined.