Charley J. Smyth

Synovectomy and Débridement of the Knee in Rheumatoid Arthritis

1. The results of twenty-eight synovectomies and debridements in adults and three synovectomies in children are discussed. Eighty-five per cent of the procedures in adults were performed in late stages of destruction. All adult patients had classic rheumatoid arthritis with multiple joint involvement. Seventy-nine per cent of the knees were rated improved by the patient as compared with 65 per cent rated improved by the examiner. In 46.5 per cent definite or probable recurrence was found. 2. The results and the incidence of recurrence were found to be time dependent and proportional to the general activity of the disease as well as to the extent of damage present at the time of operation. When synovectomy was done bilaterally at an identical stage of the disease, the results were comparable. 3. Scoring of a patients disability and local disease activity were found to be very useful in order to evaluate the results quantitatively. 4. Joint instability and joint narrowing were used as the criteria of the extent of joint damage and were found to be reliable in predicting the chances of success of synovectomy in a patient with low or moderate disease activity. 5. Angular deformity, antedating rheumatoid involvement, tends to progress rapidly with the onset of arthritis and should probably be corrected early. 6. Recurrence does not always become apparent during the first few months after synovectomy. 7. In advanced stages of destruction the objective of synovectomy is temporary relief of pain and functional improvement. Synovectomy alone is not indicated when there is severe instability and loss of articular cartilage. 8. Synovectomy is strongly indicated for a knee which has shown persistent involvement of short duration when there is advanced joint destruction of the opposite knee. 9. With early mobilization, the range of motion is not significantly affected and does not correlate with the final subjective and objective result in most patients. 10. Only two complications occurred: one a separation of the patellar tendon and the other, thrombophlebitis.

A Visual, Histological, and Enzymatic Study of Regenerating Rheumatoid Synovium in the Synovectomized Knee

In the knees of twenty-five patients with rheumatoid arthritis who had had synovectomy an average of thirty-one months previously (range one to 120), arthroscopy, aspiration, and biopsy were done. The findings were that the regenerated synovium became histologically indistinguishable from that found in patients not operated on—grossly and microscopically active areas alternated with inactive ones, lysosomal glycosidases were elevated and rose with time, and the synovium of eighteen of twenty-one of the patients two years after synovectomy met the criteria for rheumatoid disease.

Therapy of rheumatoid arthritis. A pyramidal plan.

Two questions are often asked about treatment of rheumatoid arthritis: What do you use? When do you use specific measures? Because the problems differ so widely from case to case, optimal management is problem-oriented. A pyramidal plan of therapy is set forth which may help in realistic planning. At the base of the pyramid are heat, exercise, rest, salicylates and education. Depending on the severity of disease and the response to the basic program, one may or may not move up the pyramid, using steroids, orthopedic devices, gold salts, hospitalization for intensive care, and surgery.

Phenylbutazone in rheumatoid arthritis

Abstract 1. 1. The long-term therapeutic value of phenylbutazone (Butazolidin) has been studied in 93 patients with rheumatoid arthritis and objective measurements of therapeutic effectiveness have been made over a shorter period on 20 patients. 2. 2. A method for measuring the degree of joint inflammation has been presented. 3. 3. Of 49 patients treated for periods of 2 to 5 years, 19 (39 per cent) have found this drug to be a satisfactory long-term therapeutic agent in terms of maintaining functional capacity. 4. 4. In a double-blind comparative study, phenylbutazone and cortisone were found to be superior to aspirin in suppression of inflammation and maintenance of functional capacity. Large doses of cortisone were superior to phenylbutazone but the differences were not striking. 5. 5. The natural course of the pathologic process of rheumatoid arthritis as reflected in the joint destruction shown in serial roentgenograms was not arrested by phenylbutazone. 6. 6. The toxic reactions in 222 patients who received phenylbutazone for a variety of rheumatic disorders have been analyzed. In no case was it established that phenylbutazone caused any permanent harm to the patients in this series.

A Method for Measuring Swelling of Hands and Feet: Part I Normal Variations and Applications in Inflammatory Joint Diseases

SummaryThe size of the hands and wrists and of the feet and ankles can be accurately and quickly determined by a simple apparatus using the principle of water displacement. The measurements of the hands and wrists of 36 normal active individuals taken both in the morning and in the afternoon of the same day showed a difference in volume of less than 1 %. Variations of the normal hands and wrists between the morning and afternoon during five successive days showed a mean coefficient of variation of 1.5 %. The accuracy of hand-volume apparatus was tested in ten normal subjects. Ten determinations of the hand size made in rapid succession in each of these ten normal individuals showed a variation of less than 1 %.The volume of the feet varied more from hour to hour and from day to day than did the volume of the hands. For this reason, it is recommended that measurements of the feet be taken early in the morning and at the same time of the day. Under these conditions the normal variation from day to day has b...

Effect on Joint Permeability of Adrenal Cortex Extract, ACTH, Cortisone Hydroxy-phenyl Cinchoninic Acid and Hyaluronidase

Summary and conclusions 1. Permeability studies were conducted on rabbits by injection of PSP into (the joint and recovery of the dye from the urine. 2. Cortisone, ACTH, adrenal cortex extract and hydroxyphenylcinchoninic acid (HPC) given to normal rabbits failed to cause any significant alteration of synavial permeability. 3. ACTH given parenterally exhibited a significant antihyaluronidase effect. 4. We agree that the permeability of the joint membrane to PSP is not necessarily a measure of its permeability to normal body substances.

Newer Drugs For Arthritis

An intensive search continues for effective, nontoxic drugs for rheumatoid arthritis and other inflammatory diseases. Of the newer drugs, indomethacin appears of most value so far. Other agents, such as dimethylsulfoxide, an indomethacin analogue, cytotoxic drugs, immunosuppressive agents and anthranilic acid derivatives, are still experimental. Older drugs still have a definite place. In certain cases of gout, both indomethacin and allopurinol have proved useful.

Mild disease in a highly motivated patient

Selected illustrative cases are reported, followed by “instant consultations” with appropriate specialists. The psychologic and socioeconomic effects of arthritis are inseparable from the direct physical effects of the disease. Even in mild disease a good deal of motivation is necessary to successful management. The best source of this stimulation is the patients personal physician.

severe disease complicated by osteoporosis

In this illustrative case, rheumatoid disease changed an active, self-supporting woman into a disabled, dependent and depressed person. When disease activity is continuous, early efforts to prevent severe deformity take on great urgency. It is also important to alleviate the psychosocial impact of the disease, which may well be more than even a highly motivated patient can handle alone.

Unremitting disease in a young mother.

In this case the psychosocial impact of arthritis was superimposed on an already precarious home environment. When the disease began, the patient was still a teen-ager and was pregnant. Three years later she was an abandoned wife, was unable fully to care for her baby or herself, and did not have enough money for food.