Markku Kauppi

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.

The rheumatoid cervical spine

The cervical spine contains 31 joints and moves about 600 times per hour. This makes it a site with a predilection for synovitis, ligamentous inflammation and mechanical stress in all types of chronic arthritis. Accordingly, eight different atlantoaxial or subaxial sublaxations and numerous other pathologic conditions occur in this area. The vital structures contained in this area impart particular significance to this involvement. Because there are practically no similarities between the structure and function of the lumbar spine and cervical spine, no parallels can be drawn between these two anatomically separate sites. Therefore, the anatomy, physiology, pathology, clinical syndromes, and treatment of the rheumatoid cervical spine have to be understood and dealt with on their own. This review article contains an update of topics of utmost importance in patient care, in light of the most recent basic and clinical science studies. Particular attention has been paid to new imaging and neurophysiologic techniques and their relevance to clinical design and treatment decisions, and modes of treatment in light of new advances in surgical technique and in our understanding of the long-term effects of active expectance and surgical intervention.

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 (≤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 ≥4 mm 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 (≥4 mm) compared with lesser subluxation (<4 mm). When subluxation of the CMC I exceeds 4 mm, the swanneck 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.

Cervical Spine Disorders in Patients with Rheumatoid Arthritis and Amyloidosis

Abstract: The aim of this radiographic study was to ascertain the extent of inflammatory cervical spine disorders in patients with rheumatoid arthritis (RA) complicated by secondary amyloidosis (SA). The study involved 147 patients with RA and SA, whose cervical spine radiographs were available. They were treated at the Rheumatism Foundation Hospital, Heinola, during the period 1989–2000 and had had RA for a mean of 24 years. The inflammatory abnormalities of the cervical spine were studied from radiographs taken at or after the diagnosis of SA during flexion and extension. One-hundred and eleven (76%) patients had subluxations, impaction or apophyseal joint ankylosis. Atlantoaxial impaction (AAI) was seen in 76 (52%) patients and anterior atlantoaxial subluxation (AAS) in 59 (40%). Apophyseal joint ankylosis was the third most frequent finding, seen in 34 (23%) cases. A combination of AAI and apophyseal joint ankylosis was noted in 26 (18%) patients. Eight (5%) patients had undergone surgery on the cervical spine. In conclusion, inflammatory and destructive changes are frequent in the cervical spine of patients with RA and SA. Characteristic changes are AAI and AAS. RA patients with SA have more severe disease than those in epidemiological studies when cervical spine disorders are concerned.

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.

Atlantoaxial laxity in rheumatoid arthritis

We found that 14 of 162 rheumatoid arthritis patients with chronic occipitocervical pain had anterior atlantoaxial instability in the absence of any corresponding radiographic changes in the joint cartilage or subchondral bone. Our findings suggest that ligamentous instability is a prerequisite for this type of change. At the time of the detection of the instability, the median duration of disease was 12 (6-28) years. Rheumatoid occipitocervical pain may be initially caused by facet-joint arthritis or inflammation in the ligaments, and at a later stage also by irritation of the C2 nerve roots.

A Retrospective Clinical and Neuroimmunohistochemical Study of Rheumatoid Arthritic Patients with Atlanto-Axial Subluxation

In a retrospective study of 87 RA patients with radiographically documented anterior atlanto-axial subluxation (AAS) in flexion-extension radiographs, 40 had been studied radiographically before they developed AAS. Of these 40 patients, 34 had had occipitocervical pain already before the subluxation. This shows that pain early in the course of the rheumatoid cervical spine is not caused by or associated with AAS itself. In a separate operatively treated group of 5 patients, ligament neuroanatomy in AAS was more closely studied, using specific heteroantisera to cytoskeletal neurofilaments and various transmitter neuropeptides as neural markers and the highly sensitive avidin-biotin-peroxidase complex (ABC) immunohistochemical staining procedure. These specimens were obtained from the ligamentous structures between the posterior arch of the atlas and the spinous process of C2, corresponding to the C1-C2 interspinal non-inflammatory ligament, during atlanto-axial stabilizing operations. This ligamentous tissue contained, in addition to focal inflammatory cell infiltrates, neurofilament and/or neuropeptide immunoreactive neural elements. This finding may suggest that pain early in anterior AAS could be caused not only by synovitis, for example, but also by local ligamentary involvement leading to irritation of local neural elements. This phenomenon may have contributed to the local occipitocervical pain experienced by 34/40 patients who later developed AAS.

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.

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.

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.