Effect of glucosamine hydrochloride in the treatment of pain of osteoarthritis of the knee.

OBJECTIVE: Glucosamine products have been used extensively for the management of pain in osteoarthritis (OA). We investigated the efficacy of the hydrochloride salt of glucosamine on pain and disability in knee OA. METHODS: At Week -2, subjects were examined, randomized, and instructed to take only prescribed acetaminophen for pain. At Week 0 patients were examined, prescribed acetaminophen, and either placebo or glucosamine hydrochloride (glucosamine). At Week 4 the prescriptions for acetaminophen and placebo or glucosamine were renewed. At Weeks 4 and 8, patients returned diaries and unused medications, and were examined. The WOMAC questionnaire was administered at Weeks -2, 0, and 8. After completing the randomized 8 week trial, subjects were offered known glucosamine hydrochloride capsules in an 8 week open label trial, with followup telephone survey after the 8 week open label trial. RESULTS: The primary endpoint (statistically significant difference in WOMAC pain score between Week 0 and Week 8) was not met. However, positive trends were noted for the glucosamine group in 23 of 24 WOMAC questions. A significant difference was noted from Week 5 through Week 8 in the knee examination (p = 0.026) and in the response to a daily diary pain question (p = 0.018). However, responding to the question, "Are you better than at the start of the trial?", 40% of placebo and only 49% of glucosamine subjects answered in the affirmative (p = 0.58). At the end of the randomized trial, 34% of placebo and 47% of glucosamine subjects believed that they had been given glucosamine. After the end of the 8 week open label trial, 77% of the subjects were still taking glucosamine, although now obliged to pay for commercially available products. CONCLUSION: There was no significant difference in pain reduction between the glucosamine hydrochloride and placebo groups as measured by WOMAC. However, the secondary endpoints of cumulative pain reduction as measured by daily diary and knee examination were favorable, suggesting that glucosamine hydrochloride benefits some patients with knee OA.

Accelerated nodulosis in a patient with psoriasis and arthritis during treatment with methotrexate.

A 66-year-old woman with longstanding psoriasis involving the skin presented with asymmetrical polyarthritis. Methotrexate (MTX) was given initially intramuscularly and orally. Intramuscular MTX was discontinued, and a few months after she had been taking only oral MTX she developed nodules, first in surgical incisions, and subsequently in her buttocks, thighs, legs, and arms. Reduction of the dose of oral MTX was followed by gradual diminution in size of the nodules and then total disappearance.

The molecular weight of therapeutic hyaluronan (sodium hyaluronate): how significant is it?

Various molecular weight hyaluronic acid (HA) preparations have been injected into joints for the treatment of human and equine osteoarthritis. A therapeutic advantage has been claimed for commercial products with a molecular weight in the range found in normal synovial fluid (SF), compared to lower molecular weight products. But a correlation between molecular weight and efficacy is not borne out by an analysis of the available literature on clinical results. SF viscosity, HA concentration, HA molecular weight and rate of synthesis in joint disease. It is proposed that the beneficial effect of injected HA in joint disease may be due to pharmacological rather than to physical properties.

Charcot's arthropathy of the shoulder following intraarticular corticosteroid injections.

We describe a case of inflammatory and degenerative arthritis treated with intraarticular corticosteroid injections. This led to rapid subjective relief of symptoms, but inappropriate repeated injections led to the development of Charcot's arthropathy and rapid destruction of the shoulder joint.

Parotid gland enlargement in HIV infection: clinical/imaging findings.

Parotid gland enlargement with or without facial paralysis may be the presenting clinical manifestation of AIDS. Submandibular involvement may occur as well. Failure to recognize this association may lead to inappropriate or unnecessary intervention in the investigation and treatment of the salivary gland enlargement. In this paper, we discuss the role of imaging techniques in the investigation of salivary gland enlargement, and identify the specific radiologic signs found in HIV infection. Demonstration of intraparotid or submandibular gland cysts with focal intraparotid mass lesion(s) on imaging may help to differentiate parotid gland enlargement due to HIV infection from the many other causes of parotid enlargement.

An evaluation of rheumatology education at Canadian medical schools.

The present study uses data from a nationally administered multiple choice examination (MCE) to assess the performance of Canadian medical students in rheumatology. An average of 1722 medical students undertook to write the Medical Council of Canada (MCC) examination each year between 1978-82. Between 17 and 29 of the 516 MCE questions were of a rheumatological nature and the success rate of students from the 16 Canadian medical schools varied between 65.5 and 78.5% in any given year. No direct correlation was noted between the students' MCE performance and the amount of rheumatology education given at an individual university. Analysis of Arthritis Society Undergraduate Statistics indicated that the average medical student in Canada receives 17.5 h of didactic lectures, 10.4 h of clinical bedside demonstration and 8.9 h of direct supervision of rheumatologic patients by rheumatologists.

Pyogenic vertebral osteomyelitis: diagnosis and management.

Vertebral osteomyelitis represents a diagnostic challenge to the clinician. Two cases of pyogenic vertebral osteomyelitis occurring weeks to months after a urinary tract infection with Escherichia coli are described. The rarity and subtle clinical presentation of this condition, the presence of pre-existing degenerative arthritic changes, and delayed appearance of radiologic signs of progression to destructive osteomyelitis contributed to a significant delay in diagnosis. Increased awareness of vertebral osteomyelitis as a clinical entity combined with information from radionuclide scanning may permit earlier detection of this condition.

Radionuclide evaluation of spontaneous femoral osteonecrosis.

Spontaneous osteonecrosis of the femoral condyle in 40 knees was followed by sequential radiographs and three-phase bone scans using 99mTc-methylene diphosphonate. The characteristic bone scan appearance of focal increased uptake by the medial femoral condyle in blood flow, blood pool, and delayed images helped to make the specific diagnosis in 11 knees that had no characteristic radiographic findings at the time of presentation. The three phases of the bone scan demonstrated a pattern that was useful in determining the activity of the process. There was a gradual loss of hyperemia as healing progressed. Late bone scans were normal or showed nonspecific findings. Radionuclide bone scans were able to confirm or exclude this disease and were superior to radiographs in demonstrating the disease in the acute phase.

Spontaneous osteonecrosis of the medial tibial plateau.

Spontaneous osteonecrosis (ON) of the medial tibial plateau was diagnosed in 15 elderly patients (21 knees). The onset was characterized by sudden severe medial knee pain, usually with an effusion. Radiographic changes suggestive of ON occurred medial to the weight bearing area of the medial tibial plateau in 9 knees and were normal in 12. The disease entity was documented most clearly by intense radionuclide bone uptake in the medial tibial plateau in all knees. It could be distinguished clinically and radiologically from medial femoral ON, tibial stress fractures and primary osteoarthritis (OA). Tibial ON did not appear to accelerate the development or progression of OA of the knee and most patients were better in less than 1 year.

Avulsion of the quadriceps tendons in a patient with an unusual deforming arthritis and varied skin lesions.

Spontaneous avulsion of both quadriceps tendons occurred in a young woman who had been treated with corticosteroids for progressive severely deforming seronegative arthritis and recurring skin lesions clinically and histologically suggestive of cutaneous vasculitis and pyoderma gangrenosum. We postulate that recurrent minor trauma to tendons previously damaged by vasculitis and inhibition of tendon repair by oral corticosteroids were predisposing factors to the bilateral tendon avulsions.

Apatite-associated arthropathy: a clinical study of 14 cases and of 2 patients with calcific bursitis.

Fourteen cases of acute calcific periarthritis and 2 cases of acute calcific bursitis are described. All patients had radiologic periarticular calcific deposits. Synovial fluid was available from 8 patients. Hydroxyapatite crystals were positively identified in 1 by x-ray diffraction analysis and by scanning and transmission electron microscopy. Apatite-associated arthropathy likely represents a form of crystal-induced inflammation. Three articular syndromes can be recognized; acute calcific periarthritis, acute (calcific) arthritis and a subacute-to-chronic arthritis resembling osteoarthritis. To improve patient classification, diagnostic criteria are proposed.

The ultrastructure of urate crystals in gout.

Using correlative scanning and transmission electron microscopic techniques, we studied the ultrastructure of natural and synthetic monosodium urate crystals. The internal architecture of both natural and synthetic urates consists of an interconnecting electron lucent network. This network is different in crystals from tophi, suggesting crystal formation about an electron lucent nidal matrix. Urate crystals from articular cartilage surfaces have smooth faces supporting the hypothesis that acute goat is a two phase process involving first the precipitation of urate crystals in the synovial fluid and second the adherence to the crystals of proteins and cells with the consequent inflammatory response.

Articular cartilage transplantation.

This report describes the biopsy findings in four of 30 patients treated with cadaver osteochondral shell allografts for osteoarthritis in the knee. This study demonstrates that graft cartilage cells can survive in excess of 25 months, and that host bone can completely replace graft bone by creeping substitution. An inflammatory reaction in synovium and bone marrow was found in only one of four cases. Graft failure was related to prolonged down time of donor cartilage in one case and mechanical factors related to osteoarthritis in the apposing femoral surface in other cases. The clinical success of these grafts is attributed to the prolonged viability of cartilage cells, the capacity of host bone to join graft cartilage without histologic reaction, and the host's immunologic tolerance, which obviates the need for immunosuppressive therapy.

Pseudotumor of temporomandibular joint: destructive calcium pyrophosphate dihydrate arthropathy.

The clinical and pathological features of a tumor of the temporamandibular joint occurring in a 55 year old man, and subsequently identified as a calcium pyrophosphate dihydrate (CPPD) arthropathy, are reported. Crystalline deposits were identified by compensated light microscopy and confirmed with X-ray diffraction, transmission, and scanning electron microscopy. The relationship of this unique case to other clinical presentations of CPPD deposition disease and the implications of the histological features to the pathogenesis of pseudogout are discussed. This case demonstrates that CPPD arthropathy should be included in the differential diagnosis of an arthrosis or of a tumor involving the temporomandibular joint.