Associations of HLA-DR4 with rheumatoid factor and radiographic severity in rheumatoid arthritis.

Possible associations between HLA-DR4 and laboratory, radiographic, joint count, functional, and demographic measures of clinical status were analyzed in 154 white patients with rheumatoid arthritis. Overall, 65 percent of the patients were HLA-DR4 positive, similar to other series. HLA-DR4 was associated significantly with the presence of rheumatoid factor and more severe radiographic changes. HLA-DR4 was not associated with significant differences in demographic, joint count, or functional measures of clinical status. HLA-DR1 was not associated significantly with differences in the presence of rheumatoid factor, radiographic changes, or other measures of clinical status. Selective associations of HLA-DR4 with rheumatoid factor and radiographic scores were more marked in men than in women. Patients who were putatively homozygous for HLA-DR4 were all seropositive and had more severe radiographic changes than patients who were heterozygous for HLA-DR4.

Bony ankylosis in rheumatoid arthritis. Associations with longer duration and greater severity of disease.

Hand and wrist radiographs of 203 patients with rheumatoid arthritis were examined for bony ankylosis. Forty-eight patients (23.6%) showed ankylosis, including 34 with more than one joint fused. The distribution of ankylosed joints was 32.4% midcarpal, 29.5% common carpometacarpal, 15.8% radiocarpal, 15.8% proximal interphalangeal, and 6.5% metacarpophalangeal. Patients with ankylosis had significantly higher radiographic erosion, joint space narrowing, and malalignment scores than those without ankylosis (all P less than .001). Patients with ankylosis had significantly longer duration of disease (P less than .001) and physical examinations showed more limited motion and deformity (both P less than .001). More patients with ankylosis had subcutaneous nodules (P less than .05). Functional testing with grip strength and the button test revealed poorer performance in patients with ankylosis (both P less than .001). Questionnaires revealed patients with ankylosis had more difficulty with activities of daily living (P less than .001) and had more limited activity (P less than .01); physicians estimated more limited functional capacity (P less than .001). Thus, radiographic bony ankylosis was a relatively common feature of rheumatoid arthritis, and a marker of patients whose disease was clinically, radiographically, and functionally more severe.

Problems with the Steinbrocker staging system for radiographic assessment of the rheumatoid hand and wrist.

Hand and wrist radiographs of 202 patients with rheumatoid arthritis were graded with the classical Steinbrocker Staging System, and were also assigned quantitative scores for joint space narrowing, erosion, and malalignment according to a detailed scoring method. Steinbrocker Stage scores were correlated significantly with total detailed scores (r = 0.60 to 0.66, P less than 0.001). However, the ranges of detailed total and subtotal scores among the various Steinbrocker Stage scores were broad, with considerable overlap. Practical problems in applying the Steinbrocker staging method were identified in 26.5% of the hands graded with the Steinbrocker method. Additionally, analysis of scoring data showed discrepancies between the scoring methods in 25.2% of the hands examined; one-half of these discrepancies were felt to result from the global or overall approach of the Steinbrocker method in contrast to individual joint analysis. Asymmetry in assigned stages between right and left hands was found in 15.8% of patients. The detailed scoring method, although more time-consuming, appears superior to the Steinbrocker Stage for quantitative assessment of patient radiographic status in rheumatoid arthritis.

Observer variation in quantitative assessment of rheumatoid arthritis. Part I. Scoring erosions and joint space narrowing.

Six observers, including two bone and joint radiologists, two general radiologists, and two senior radiology residents, compared scores to quantitate radiographic findings in the hands and wrists of patients with rheumatoid arthritis. In the scoring system used, erosions and joint-space narrowing are graded separately. This scoring system differs from other methods in that equivocal findings are not scored, while ankylosis, subluxation, and dislocation are scored, and data from postoperative joints are included. Total radiographic scores were highly significantly correlated for all observers (R = .908-.958, P less than .001), as were subtotal scores for erosions (R = .723-.931, P less than .001) and joint-space narrowing (R = 0.843-0.966, P less than .001). Analysis of proximal interphalangeal, metacarpophalangeal, and wrist-joint scores showed highly significant correlations for all observers in each location. Highly significant correlations were found among three separate readings of two bone and joint radiologists (R = .950-.961, P less than .001). This scoring system provides highly consistent and reproducible results, even in the hands of less experienced observers.

Observer variation in quantitative assessment of rheumatoid arthritis Part II. A simplified scoring system.

A new and more comprehensive simplified scoring system to provide quantitative assessment of radiographic findings in rheumatoid arthritis was studied by six observers with different levels of expertise. Since the observers, film set, and joints scored were the same as in a prior study of a more detailed scoring method, a precise comparison of the results was made. Interobserver variation with the simplified scoring system was small; there were highly significant correlations of the total radiographic scores for all observers (R = .898-.978, P less than .001). There were highly significant correlations between scores obtained with the simplified scoring system and those obtained with the more detailed method (R = .920-.955, P less than .001). When the same joints were evaluated by the two methods, a significantly greater number of possible observations could be scored with the simplified scoring system than with the more detailed method (X2 = 131.07, P less than .001). The simplified scoring system required 2.3 times less time to use in the hands of experienced observers.

Vicarious excretion of contrast medium in patients without azotemia.

Although excretion of urographic iodinated contrast agents via the biliary and gastrointestinal tract is not uncommon in patients with renal insufficiency, such vicarious excretion is unusual in the presence of normal renal function. The observation of such vicarious excretion in 2 patients with acute unilateral ureteral obstruction and no azotemia is reported in conjunction with review of the appropriate literature and suggestion of possible etiologies.

Measures of activity and damage in rheumatoid arthritis: depiction of changes and prediction of mortality over five years.

OBJECTIVE: To analyze various quantitative measures of inflammatory activity and joint damage, including articular, radiographic, laboratory, questionnaire, and physical function measures, in regard to changes in status in surviving patients and prediction of mortality in non-survivors over 5 years in a cohort of patients with rheumatoid arthritis (RA) monitored in the mid-1980s and early 1990s. METHODS: A comprehensive evaluation, which included a complete joint count, radiograph, laboratory tests, physical measures of function, and self-report questionnaire scales, was performed at baseline and 5 years later in 210 consecutive patients with RA. RESULTS: Five years after baseline, 206 of the 210 patients were accounted for: 37 had died, 130 had a comprehensive repeat assessment, and 39 had a more limited repeat assessment. In surviving patients, most measures of activity were generally unchanged or somewhat better, including joint tenderness, pain on motion, and swelling; erythrocyte sedimentation rate and rheumatoid factor; as well as questionnaire scores for pain, global status, helplessness, and difficulty in performing 8 activities of daily living (ADL) according to a modified Health Assessment Questionnaire (MHAQ). By contrast, measures of damage, including joint deformity, grip strength, walk time, and radiographic scores, indicated worse status. Mortality over 5 years was predicted significantly in univariable analyses by American College of Rheumatology (formerly the American Rheumatism Association) Functional Class, limited joint motion, scores for MHAQ, global status, helplessness, grip strength, walk time, button time, and number of comorbidities and duration of diseases, as well as the sociodemographic measures of age and formal education. In multivariable Cox regressions, age, comorbidities, MHAQ, and other measures of functional status were the most effective predictors of 5-year mortality. CONCLUSION: In patients with RA, most measures of inflammatory activity were unchanged and sometimes better, while measures of damage indicated worse status in the same patients over 5 years. Measures indicating functional disability, as well as age and comorbidities, predict 5-year mortality more effectively than radiographic and laboratory data. Measures of inflammatory activity may underestimate long-term outcomes in RA, and long-term studies should include measures of damage.

Meniscal abnormalities in knee arthrography.

When carefully performed, arthrography is a safe, simple, and accurate method for the evaluation of meniscal abnormalities. Accuracy depends on an understanding of the various tear types, their arthrographic appearances, and their expected locations. The arthrographer must also be aware of other abnormalities, such as meniscal cysts and discoid menisci, which may be accompanied by meniscal tears. With careful attention to detail in positioning, filming, and interpretation, a diagnostic accuracy of 90 per cent or better can be expected in the evaluation of meniscal abnormalities by double-contrast knee arthrography.

Imaging of the temporomandibular joint.

Both arthrography and MR imaging are of proven value in the evaluation of internal derangements of the TMJ. Arthrography provides the advantages of a dynamic display of joint mechanics and the easy detection of disc perforation. Its disadvantages include its technical difficulty and its poor visualization of the disc in the medial-lateral plane. MR imaging of the TMJ provides excellent soft-tissue detail and more readily demonstrates medial and lateral displacements of the disc. Unfortunately, perforations of the disc or ligaments are not usually visualized, and bony detail is not seen as well as on plain radiographs or computed tomography. In addition, real-time dynamic imaging of joint mechanics is not readily available. Currently, the choice of imaging modality is based on the specific diagnostic question, and availability of arthrography and MR imaging.

Thoracic and lumbar spine trauma.

The frequency and distribution of fractures of the thoracic and lumbar spine are reviewed. Classifications of thoracolumbar spine injuries are considered. Compression or wedge fractures, burst fractures, lap seat-belt-type injuries, and fracture-dislocations are considered with discussion of findings on conventional radiography and computed tomography. The concepts of stability and instability are briefly discussed and the relative advantages of computed tomographic imaging are reviewed.

Cervical spine trauma.

The conventional radiographic examination remains as the single best initial study in patients with potential cervical spine injury. Computed tomography is the best, most readily available second study. Specific cervical spine injuries are presented as they follow a classification based on mechanism of injury.

Pain in the athlete's knee.

When the athlete develops knee pain, conventional radiographs are often helpful to establish the correct diagnosis. Knee arthrography may provide additional information when conventional radiography shows no specific abnormality. A number of causes of knee pain in the athlete are illustrated.

Juxta-articular calcifications in secondary hyperparathyroidism: resorption after parathyroidectomy.

Soft-tissue calcification in chronic renal failure has been described, but little is understood about its pathogenesis or progression. Our patient's case is a dramatic example of complete resorption of soft-tissue juxta-articular calcification in secondary hyperparathyroidism after removal of parathyroid gland tissue. This resolution is most likely due to normalization of the calcium-phosphate ion product.

Insufficiency fractures of the femoral neck in association with chronic renal failure.

The femoral neck is a relatively uncommon location for stress fractures. As with other stress fractures, those occurring in the femoral neck can be divided into fatigue and insufficiency fractures. Chronic renal failure (CRF) is an underlying condition that can predispose patients to insufficiency fractures of the femoral neck. We report 12 such fractures occurring in eight patients with CRF; half had bilateral fractures. In addition, 50% of the fractures were of the tensile (transverse) type, which may progress to complete fracture.

The opisthion on the lateral radiograph of the cervical spine.

Ten adult dry skulls were radiographed in the lateral projection to evaluate the appearance of the opisthion, the posterior margin of the foramen magnum. The opisthion was seen on all 10 skulls and its position was confirmed by outlining it with barium paste. In cross section, it is a teardrop-shaped structure continuous with the internal occipital crest. A beak-shaped shadow anterior to the opisthion was also examined with the barium technique. It is an overlap shdow formed by the interior margin of the foramen magnum and the inferior border of the occipital bone on the same side. In a review of 50 random radiographs of the cervical spine, the opisthion was identified on 42 (84%) and the beak-shaped overlap shadow was seen on 28 (56%). The spinolaminal line, which delineates the posterior margin of the cervical spinal canal, was an unreliable indicator of the position of the opisthion in 17 (40%) of the 42 cases in which the opisthion could be identified.

Volar plate fractures.

Rupture of the volar plate of the proximal interphalangeal joint, usually secondary to hyper-extension injury, may be accompanied by a radiographically evident avulsion fracture at the base of the middle phalanx. Findings were reviewed in 55 patients with 58 cases of volar plate fracture. This fracture should be specifically looked for in a patient with the typical history, since it may be the only radiographic evidence of a potentially disabling injury.

Rheumatoid arthritis: explanatory power of specific radiographic findings for patient clinical status.

Radiographs of the hands and wrists of 201 patients with rheumatoid arthritis (RA) were scored for erosion, joint space narrowing, and malalignment. The explanatory power of these findings for measures of clinical status was studied with stepwise multiple linear regression analyses. Radiographic scores explained 59.2% of variation in physical joint count deformity scores, 58.5% of variation in limited motion scores, 22.5% of variation in grip strength scores, 20.5% of variation in button test scores, and 13.5% of variation for the American Rheumatism Association (ARA) Functional Class. Malalignment scores best explained variation in physical deformity, limited motion, and button test scores; joint-space-narrowing scores best explained variation in grip strength; erosion scores best explained variation in ARA Functional Class. When age, duration of disease, erythrocyte sedimentation rate, and rheumatoid factor titer were included in the regression analyses, results were similar to those without these variables. Therefore quantitative scores of specific radiographic findings are in themselves explanatory for measures of clinical status.

Evidence of significant radiographic damage in rheumatoid arthritis within the first 2 years of disease.

Quantitative radiographic scores for joint space narrowing erosion, and malalignment in the hands and wrists of 200 patients with rheumatoid arthritis (RA) were significantly correlated with duration of disease. Nonetheless, most of the 42 patients who reported disease for less than 2 years had evidence of radiographic damage, including 35 with joint space narrowing, 28 with erosions but only one with malalignment. Significant radiographic damage in the absence of malalignment may be seen in many patients within the first 2 years after presentation of RA.

Sequential indium-labeled leukocyte and bone scans to diagnose prosthetic joint infection.

Previous studies suggest that sequential technetium-99-hydroxymethyl diphosphonate bone scanning and indium-111 leukocyte scintigraphy may play a role during revision arthroplasty. Preoperative sequential imaging was compared with joint aspiration and clinical assessment during revision knee or hip arthroplasty. Scans were considered positive if indium-111 leukocyte uptake was incongruent or focally more intense than that of technetium-99-hydroxymethyl diphosphonate uptake. Of 166 cases, 22 were infected. Sequential technetium-99-hydroxymethyl diphosphonate and indium-111 leukocyte imaging was 64% sensitive and 78% specific. Fever, physical findings, or sedimentation rate did not identify infection reliably, and preoperative aspirate culture was only 28% sensitive. Positive scintigraphy increased the likelihood of finding infection intraoperatively from 14% to 30%, although negative scintigraphy decreased this likelihood to 7%. Based on the current study, the routine use of sequential technetium-99-hydroxymethyl diphosphonate and indium-111 leukocyte imaging cannot be advocated for differentiating occult infection from mechanical failure in painful, loose total joint arthroplasties.