Rotura espontánea de los tendones extensores de la muñeca y la mano en pacientes con artritis reumatoide. Estudio retrospectivo / Spontaneous rupture of extensor tendons in the hands of patients with rheumatoid arthritis. A retrospective study

Fundamento: La rotura espontánea de los tendones extensores de la mano es una complicación relativamente frecuente en pacientes con artritis reumatoide (AR) de larga evolución. Por ello es importante conocer los factores locales predisponentes para la rotura espontánea, así como las posibilidades quirúrgicas, las complicaciones y los resultados de la reconstrucción de los tendones afectados. Material y métodos: Estudio retrospectivo de todos los pacientes con AR seguidos en nuestro hospital y diagnosticados de rotura espontánea de tendones extensores de la mano desde octubre de 1995 hasta diciembre de 2000. Se identificó un total de 18 pacientes intervenidos quirúrgicamente con un seguimiento adecuado de al menos un año. Se describen los factores locales predisponentes, el tiempo de evolución de la enfermedad desde el diagnóstico hasta que ocurrió la rotura, el tiempo de espera hasta la cirugía, las opciones quirúrgicas, las complicaciones y el resultado funcional (basado en el test de función de la mano de Jebsen). Resultados: Los factores locales predisponentes más frecuentes fueron la inestabilidad cubital distal y la tenosinovitis crónica de extensores (presentes en el 61% de los casos). El tiempo medio de evolución de la enfermedad hasta que ocurrió la rotura espontánea fue de 122 ± 73,19 meses, con un tiempo medio de espera desde el diagnóstico de la rotura hasta la cirugía reparadora de 2,38 ± 1,75 meses. La opción quirúrgica más frecuentemente realizada consistió en la transferencia del tendón extensor propio del índice al cabo roto y sutura término-lateral (en el 55,5% de los pacientes). Las complicaciones posquirúrgicas se observaron en 3 pacientes (16,6%). El resultado funcional fue excelente o bueno en 16 pacientes (89%) y se consideró regular en 2 pacientes (11%). Discusión: Es importante identificar a los pacientes con AR que presentan inestabilidad radiocubital distal y tenosinovitis crónica de extensores de la mano por el riesgo de rotura espontánea de dichos tendones. Una valoración conjunta y consensuada con un cirujano ortopédico y un rehabilitador con especial dedicación a enfermos con AR ayuda a una cirugía temprana y unos resultados favorables en la mayoría de los casos (AU)

Background: Spontaneous rupture of extensor tendons in the hand is a relatively frequent complication in patients with rheumatoid arthritis (RA). Consequently, it is important to consider local risk factors, treatment options, complications, and functional results after surgery. Material and methods:: A retrospective study of all the patients with RA diagnosed with spontaneous extensor tendon ruptures in the hand in our hospital between October 1995 and December 2000 was performed. Eighteen patients with a follow-up of at least one year after surgery were selected. The following data were analyzed: local risk factors, interval between diagnosis and rupture, time to reconstructive surgery, treatment options, and complications and functional results after surgery (according to Jebsen’s test of hand function). Results: The most common risk factors were distal ulnar instability and chronic dorsal tenosynovitis (61%). The mean disease duration until tendon rupture was 122 ± 73.19 months, whereas the mean period before surgery was 2.38 ± 1.75 months. The preferred surgical option was terminolateral suture and extensor indicis proprius transfer for ruptured tendon (55%). Postsurgical complications were observed in 3 patients (16.6%). Functional results were excellent or good in 16 patients (89%). Discussion: In patients with RA, distal ulnar instability and chronic dorsal tenosynovitis are significant risk factors for spontaneous tendon rupture in the hand. A multidisciplinary approach, involving the rheumatologist, orthopedic surgeon and therapist, is crucial for prompt surgery and good functional results (AU)

Radiología en la artritis reumatoide / Radiology in rheumatoid arthritis

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[An echocardiographic study of the aortic root in ankylosing spondylitis]. / Estudio ecocardiográfico de la raíz aórtica en la espondilitis anquilosante.

The inflammatory condition in ankylosing spondylitis (AS) may affect cardiac structures, being the aortic valve mostly studied. Several studies regard the existence of a subaortic ridging as specific for AS. Our objective was to assess abnormalities in the aortic root in AS using echocardiography and its relation to HLA B-27 and clinical parameters of the disease. Thirty patients with no clinical, radiographic or electrocardiographic evidence of cardiovascular disease were studied by monodimensional, bidimensional and Doppler echocardiography. After an initial ultrasound examination to detect subclinical cardiac abnormalities, aortic root dimensions were measured at the aortic annulus, at the tip of the cusps and 1 cm above the cusps. The existence of subaortic ridging was assessed using bidimensional echocardiography. As clinical parameters were estimated duration of AS, sacroiliac joint X-ray involvement and activity of disease. The results are compared with those in a control group of thirty healthy people with same age, sex and corporal surface. No statistical differences were observed in the mean values of aortic root dimensions between the two groups; in patients with AS were not seen significant differences in the echocardiographic measurements related to clinical parameters or HLA B-27. Only in one patient was observed the characteristic subaortic ridging (4%, NS compared to control group). We conclude, in contrast to other authors, that in patients with AS without cardiovascular disease echocardiographic examination of aortic root does not detect significant abnormalities.

Intestinal permeability in patients with ankylosing spondylitis and their healthy relatives.

Patients with AS were previously found to have increased intestinal permeability using the 51Cr-EDTA resorption test. In order to discover whether this alteration has taken place prior to, or as a consequence of the disease, we studied the intestinal permeability to 51Cr-EDTA in 20 patients with AS, 65 of their healthy relatives, and 25 normal volunteers. We also considered the HLA B27 antigen, the serum immunoglobulin A levels, the disease activity, the existence of peripheral arthritis, the ESR, the CRP values and the intake of drugs at the time of study. Gut permeability was found to have increased in the patients and their healthy relatives compared to the control group. No difference in gut permeability was found between patients and relatives regardless of whether they had the HLA B27 antigen or not. The increased intestinal permeability in the patients had no relation to the disease activity, to the presence of peripheral arthritis or to the intake of NSAIDs. Gut permeability was shown to bear no relation to IgA levels, ESR or CRP. Our findings suggest that the increase in gut permeability in AS patients and their relatives is a primary defect and may be an aetiologic factor in this disease.

[HLA DR7 as a protective factor against gold salt toxicity in rheumatoid arthritis]. / HLA DR7 como factor de protección frente a la toxicidad por sales de oro en la artritis reumatoide.

We performed a study of antigens HLA type I and II (specificity DR) in 90 patients with diagnosis of Rheumatoid Arthritis (RA) treated with Sodium Aurothiomalate (SATM) in order to detect the presence of an antigen HLA which could act as a protective factor against toxicity by SATM. Our results demonstrated a decrease in the frequency of the antigen DR7 in patients with toxicity by SATM, which suggests a protective factor of this antigen against the development of toxic reactions due to gold salts.

Mineral metabolism, osteoblastic function and bone mass in chronic alcoholism.

The role of ethanol as a risk factor for osteopenia was studied in alcoholic subjects without liver cirrhosis. The study was carried out in 58 male subjects classified into three groups: (1) 26 heavy drinkers, alcohol intake more than 100 g ethanol/day for more than 10 years; (2) 13 moderate drinkers, 60-100 g ethanol/day; (3) 19 healthy non-drinkers who served as control subjects. None of the drinkers had liver cirrhosis (normal clinical and biochemical data and/or liver biopsy). Mineral metabolism and serum bone Gla-protein (BGP) were studied while they were active drinkers and after they had abstained from ethanol for 7 days. Bone mineral density (BMD) was determined at the beginning of the study. Osteopenia was observed in 23% of the heavy drinkers. We found a significant inverse correlation between BMD and an index of cumulative alcohol intake. Heavy and moderate drinkers had significantly lower mean BGP values (1.6 +/- 0.4 and 1.9 +/- 0.3 ng/ml) (P < 0.01 for both) than controls (3.5 +/- 0.4 ng/ml); these values increased significantly (2.9 +/- 0.4 ng/ml; P < 0.01) after 7 days of abstinence. The data show that chronic ethanol ingestion can induce osteopenia regardless of the absence of liver cirrhosis, and that some relationship can be expected between the amount and duration of ethanol consumption and the degree of bone loss. The low serum BGP levels in drinkers are reversible upon withdrawal of ethanol, suggesting that reduction of osteoblastic activity is probably the main factor responsible for alcohol-associated bone disease.

[The study of zinc in osteonecrosis]. / Estudio del zinc en la osteonecrosis.

Plasmatic, urinary and intra-erythrocytic zinc levels did not modify in patients with head of femur aseptic osteonecrosis (HFAO), except for those patients with raised alkaline phosphatase who showed a diminution in zinc plasmatic levels, being found a negative correlation between plasmatic zinc levels and a raise in serum alkaline phosphatase. A raise on the latter would mean a raise on the osteoblastic activity in a repair intent from the bone of the small trabecular fractures and/or of the necrotic zone which is produced in HFAO. These results show the relationship of zinc with the increase on bone metabolic activity in patients with HFAO, but the scarce previous references force to study them in depth.

[Zinc and osteoporosis]. / Zinc y osteoporosis.

The relevant role of zinc in osteoporosis, its correlation with nutrient intake and the modifications of its urinary and serum levels, have been demonstrated. In this paper, we have studied the plasmatic, urinary and intraerythrocitary levels of zinc in a group of patients with extended primary osteoporosis, most of them women with postmenopausic osteoporosis. No significant differences were observed in zinc levels between osteoporotic patients and controls. We think that certain aspects regarding the correlation between zinc and bone mineral content still have to be defined, as well as zinc intake and osteoporosis.

[Clinical activity and serum immunoglobulin concentrations in patients with ankylosing spondylitis]. / Estudio de la actividad clínica y de las concentraciones séricas de inmunoglobulinas en pacientes con espondilitis anquilosante.

Several authors have suggested that immunoglobulin A plays a pathogenic role in ankylosing spondylitis. We have determined the levels of immunoglobulins in 30 patients, observing higher levels than in control patients (248 vs 176 mg/dl); p less than 0.01) and a relation between the increase of immunoglobulin A and the presence of clinical activity in the subgroup of patients B27-negative (163 vs 398 mg/dl, p less than 0.005), but not in B27-positive patients. We think that these e results support the hypothesis that ankylosing spondylitis is an heterogeneous disease, with different pathogenic mechanisms depending on the presence or absence of the serological marker HLA-B27.

[Zinc in arthrosis and microcrystalline arthritis]. / Estudio del zinc en la artrosis y en las artritis microcristalinas.

Plasma, urine, intra-erythrocytes and salivary zinc levels are not modified in Generalized Primary Arthrosis. In patients with microcrystalline arthritis (Gout and Joint Chondrocalcinosis), zinc levels do not vary in the absence of disease activity. In patients suffering gout with clinical activity, the lowest plasma zinc levels are observed. Zinc concentrations in patients presenting Chondrocalcinosis, since they belong to groups C and D ("pseudoarthrosis"), were not modified, similarly to the group of patients with arthrosis. The mechanisms of action of zinc in relation to the pathogenesis of the microcrystals induced inflammation are analyzed.

[Lymphocyte subpopulations in rheumatoid arthritis patients, their relatives and spouses]. / Subpoblaciones linfocitarias en pacientes con artritis reumatoide, sus familiares y cónyuges.

A study of lymphocytic sub-populations of patients with rheumatoid arthritis, their families and partners, is presented. The determination was carried out by means of monoclonal antibodies, analysing: T cells sub-population (CD3, CD4, CD8 and quotient CD4/CD8); B cells sub-population (B1); activated cells (OK1a); monocytes and NK cells (OKM1 and BMA 070). The results showed an increase of CD3 sub-population (T total lymphocytes) in patients with RA and their families. The meaning of these results is difficult to evaluate as lymphocyte sub-population is affected by several variables. The lack of modification of suppressor population, CD4/CD8 quotient and IKM1 cells in RA patients is probably due to the moderate activity of the disease.

[HLA antigens in patients with rheumatoid arthritis, their relatives, and spouses]. / Estudio de los antígenos HLA en pacientes con artritis reumatoide, sus familiares y cónyuges.

The results of the comparison between phenotypic frequency of HLA antigen classes I and II in patients afflicted with rheumatoid arthritis (RA) and their relatives (study carried out in the east of Andalusian), showed a significant increase of HLA A24, B51, B44, CW1 ans CW5 class I antigen in the group of relatives. We found a statistically significant DR4 antigen class II increase in both, patients and relative groups. The marriage parther of patients with RA did not have variations in class I or II HLA antigens compared to the control group. We concluded that RA is probably related to the following antigens: A24, B51, B44, CW1, CW5 and DR4.

[Plasma and intraerythrocytic zinc in rheumatoid arthritis and ankylosing spondylitis]. / Cinc plasmático e intraeritrocitario en la artritis reumatoide y espondilitis anquilosante.

The levels of plasmatic and intraerythrocyte zinc in our control group did not show differences in accordance with age or sex. Patients affected by rheumatoid arthritis showed a decrease of plasmatic levels of zinc and an increase of intraerythrocyte zinc level. The patients with ankylosing spondylitis did not show significant variations of zinc levels, even though the patient with increased SR after the first hour (25 mm) showed lower plasmatic zinc with statistical significance. Finally, patients with rheumatoid arthritis in treatment with NSAID, low dose of steroids, gold salts, D-penicilamin, did not show differences compared to the total group of patients with this disease.