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 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.

Rheumatoid synovial cell proliferation, transformation and fibronectin secretion in culture.

OBJECTIVE: There is some experimental evidence that patients with rheumatoid arthritis (RA) have a defect in the control of cellular proliferation. To examine this further, synovial cells from patients with RA and osteoarthritis controls (OA) were studied for phenotypic characteristics of transformation and proliferation. METHODS: Synovial cells grown in vitro were studied to determine the extent of proliferation, anchorage-independent growth, growth under reduced serum conditions, fibronectin secretion, and the presence of cell proliferation antigens. RESULTS: RA synovial cell proliferation was less than that recorded for normal skin fibroblasts and was not increased compared to OA synovial cells. Studies of growth in soft agarose showed no colony formation by RA or OA synovial cells after 28 days, indicating that anchorage-independent growth does not occur. At low serum concentrations RA and OA synovial cells showed similar growth. Fibronectin was constant for each cell line studied, irrespective of the cell number or diagnosis. RA cells did not show an increased rate of fibronectin secretion. RA cells did not show an increased expression of proliferating cell antigens. CONCLUSION: These studies do not support the concept that defective proliferation of synovial cells is a major factor in the pathogenesis of RA.

Ileal pouch arthritis.

The association between arthritis and intestinal inflammation is well established, but the pathogenesis of the inflammatory joint disease remains speculative. We report six patients who developed a polyarthritis following restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) for extensive ulcerative colitis between 1983 and 1990. Six patients were identified with no complaint of joint symptoms before surgery. The average time to onset of arthritis following surgery was 8 months (1 week-yr). The typical features were of an acute symmetrical polyarthritis involving the peripheral and axial skeleton. Early morning stiffness was pronounced in two and minimal in the rest. Three patients were treated with a course of prednisolone and remain in remission (1-4 yr). We believe that this is a novel form of arthritis clearly linked to pouch surgery which may provide important clues to the role of gastrointestinal antigens in rheumatic diseases.