Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty.

OBJECTIVE: To determine the relationship between frequent intraarticular corticosteroid injection and subsequent joint replacement surgery. METHODS: A 1987 database of patients with rheumatic diseases was reviewed to find patients with rheumatoid arthritis (RA) who had received 4 or more intraarticular injections in an asymmetric pattern in a single year. RESULTS: A subset of 13 patients with an average of 7.4 years of followup was established as the cohort of a 5 year prospective study. In this highly selected cohort of patients with RA in a university practice who received 1622 injections, joint replacement surgery was not significantly more common in the heavily injected joints. CONCLUSIONS: A strategy of frequent intraarticular steroid injection does not greatly increase, through added risk of joint replacement, the risk inherent in continued disease activity for patients with established RA. Frequent corticosteroid injection may offer some chondroprotection when the alternative is continuous disease activity.

Dry taps and what to do about them: a pictorial essay on failed arthrocentesis of the knee.

PURPOSE: To determine and illustrate the causes of unproductive arthrocentesis of the knee. PATIENTS AND METHODS: Consecutive patients were studied who had inflammatory (rheumatoid or psoriatic) arthritis affecting the knees and experienced unproductive arthrocentesis during a randomized, controlled trial. Magnetic resonance imaging (MRI) was used, supplemented first by intravenous gadolinium contrast and subsequently by manual mixing of the diffused contrast to outline the furthest possible penetration of contrast within the joint cavity. RESULTS: In 4 out of 5 patients studied, failed arthrocentesis was due to combinations of inspirated joint fluid too viscous to be withdrawn or to mix with contrast, adipose tissue, and lipoma arborescens (thickened synovium with fat replacement). One MRI exam was normal. More free synovial fluid was imaged on the lateral side. CONCLUSIONS: Failure to aspirate synovial fluid from the knee is explicable to anatomic terms; in particular, fluid viscosity and lipoma arborescens play a role in chronic effusions. Although surface anatomic landmarks for knee arthrocentesis may be more visible medially, the lateral approach is more likely to yield fluid for synovial analysis in difficult cases. Internal medicine trainees should be taught the lateral approach.

Acute rheumatic fever: is it returning to Virginia?

In summary, rheumatic fever seems to be on the rise in the United States. It remains to be seen whether this case is an example of a resurgence of ARF in adults in Virginia, but it probably does, since there are a number of cases being seen in the pediatric population.

Erosive arthritis in Cronkhite-Canada syndrome.

A patient with Cronkhite-Canada syndrome and an erosive arthritis whose course correlated with the activity of his bowel disease is described. We found no previous description of articular manifestations in any patients with this syndrome. Cronkhite-Canada syndrome should be added to the differential diagnosis of erosive arthritis in the appropriate clinical setting.

The benign hypermobile joint syndrome.

Benign hypermobility as defined by a modification of the Carter-Wilkinson criteria was found in 31 of 637 healthy blood donors, a prevalence of 5%. No increased prevalence of arthritis/arthralgia or characteristics suggestive of Ehlers-Danlos syndrome other than a possible familial predisposition were found when these 31 hypermobile subjects were compared to an age and sex matched two-for-one control group. Cardiac evaluation by auscultation, electrocardiogram, and echocardiogram showed no increased occurrence of mitral valve prolapse in hypermobile subjects. Thus the benign hypermobile joint syndrome appears to be one extreme of the range of normal joint motion and not a systemic connective tissue disorder.