Cross cultural adaptation and psychometric properties of the Finnish version of Western Ontario shoulder instability index (WOSI).

BACKGROUND: Western Ontario shoulder instability index (WOSI) is a widely used disease-specific self-assessment measurement tool for patients with shoulder instability. The main aim of this study was to translate and cross culturally adapt the WOSI into Finnish language and to test its measurement properties. METHODS: WOSI was translated in Finnish and adapted into an electronic user interface. 62 male patients with traumatic anteroinferior shoulder instability, programmed for stabilizing shoulder surgery, answered the questionnaire twice preoperatively (2 and 0 weeks), and twice postoperatively (3 and 12 months). Additional scoring tools, such as satisfaction to treatment outcome, subjective shoulder value (SSV), Oxford shoulder instability index (OSIS) and Constant score (CS), were used as comparators. The reliability, validity and responsiveness of WOSI were investigated through statistical analysis. RESULTS: Preoperative test-retest results were available for 49 patients, and 54 patients were available at final follow up. The mean WOSI was 57.8 (SD 20.3), 70.4 (SD 18.9), and 85.9 (SD 15.5), at baseline, 3, and 12 months, respectively. There was a statistically significant mean improvement of 28.8 (SD 24.5) in WOSI between baseline and 12 months (p < 0.0001). The intraclass correlation coefficient for the preoperative WOSI was excellent 0.91. At 12 months WOSI had an excellent Pearson's correlation coefficient both with SSV (0.69), OSIS (-0.81), and poor with CS (0.25) scores, confirming our a priori hypothesis. There were no detected floor nor ceiling effects for WOSI pre- or postoperatively. The calculated minimal detectable change was 9.2 and the estimated minimal clinically important difference 13.4 to 18.1. CONCLUSION: Finnish version of WOSI is a reliable and valid tool for assessing health state and improvement after operative treatment of shoulder instability in young male patients.

Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years.

AIMS: Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. PATIENTS AND METHODS: This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. RESULTS: A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. CONCLUSION: The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799-805.

Use of the de la Caffinière prosthesis in rheumatoid trapeziometacarpal destruction.

This study evaluated the outcome of the de la Caffinière prosthesis in patients with an inflammatory arthropathy affecting the trapeziometacarpal joint. The procedure was performed in 57 thumbs for rheumatoid arthritis (41 cases), juvenile chronic arthritis (ten cases), psoriatic arthritis (four cases) and other inflammatory joint diseases (two cases). Survival analysis with a revision procedure or radiographic implant failure as end points was performed. Five loosened cups and two permanently dislocated prostheses underwent revision surgery. These were managed with a bone graft and tendon interposition technique. Radiographic follow-up yielded four additional implant failures (two loosened cups, one loosened metacarpal stem and one permanent dislocation). The implant survival rate based on revision operation was 87% (95% CI 73-94) at 10 years, and the total radiographic and implant failure rate based on radiographic findings was 15% (95% CI 7-29) at 10 years.

Previous synovectomy or epiphyseal stapling and the influence on knee replacement in juvenile chronic arthritis.

Seventy-seven anatomically graduated components (AGC) total knee arthroplasties (TKA) were performed on 52 patients with juvenile chronic arthritis. According to the nature of previous surgery on the knee, the patients were subdivided into three groups. The mean age at onset of disease in 23 patients with previous synovectomy of the knee was 11 (1.5-16) years, the mean age at the time of synovectomy was 20 (4-42) and the mean age when arthroplasty was performed was 31 (18-45) years. In nine patients with previous epiphyseal stapling, the mean age at disease onset was 4 (1.5-8) years, at stapling 8 (4-16) years, and at arthroplasty 23 (18-30) years. In patients with no previous surgery, the mean age at disease onset in this group was 7 (1.5-16) years and the mean age at arthroplasty 34 (16-64) years. Patients with need for epiphyseal arrest had an early disease onset and knee replacement in early adulthood. The mean age at knee replacements was highest in the group with no prior surgery.

Atlantoaxial disorders in rheumatoid arthritis associate with the destruction of peripheral and shoulder joints, and decreased bone mineral density.

OBJECTIVE: To evaluate whether cervical spine changes are associated with the destruction of shoulder or peripheral joints and with bone mineral density (BMD) in patients with long-term RA. METHODS: An inception cohort of 67 patients with seropositive and erosive RA were followed up for 20 years. Cervical spine, shoulder, hand and foot radiographs, and the BMD of the lumbar spine and femoral neck were evaluated. RESULTS: A positive relationship was detected between the occurrence of atlantoaxial disorders and the destruction of both shoulder (p < 0.001) and peripheral (p = 0.001) joints. In addition, the severity of anterior atlantoaxial subluxation and atlantoaxial impaction positively correlated with the grade of destruction in the evaluated joints. Furthermore, patients with atlantoaxial disorders presented decreased BMD of the femoral neck (p = 0.019). The occurrences of subaxial subluxations (SAS) and subaxial disc space narrowings only associated with higher onset age of RA. CONCLUSIONS: Patients with severe RA and osteoporosis have an increased risk for atlantoaxial disorders. The co-existence of shoulder destruction and cervical spine disorders makes the differential diagnosis of shoulder and neck pain challenging.

Radiographic joint space in rheumatoid elbow joints. A 15-year prospective follow-up study in 74 patients.

OBJECTIVE: To evaluate radiographically the humeroulnar (HU) and humeroradial (HR) joint spaces in patients with long-term rheumatoid arthritis (RA). METHODS: An inception cohort of 74 patients with RA were followed for 15 yr. At the end-point, 148 elbows were radiographed by a standard method. The HU and HR joint spaces were examined from the anteroposterior radiographs by measuring the shortest tangential distance in the middle of the joints. Destruction of the elbow joints, assessed with the Larsen method on a scale of 0-5, was studied in relation to the joint-space measurements. RESULTS: Mean (s.d.) HU joint space (n=148) in RA patients was 2.5 (1.1) mm, range 0-4 mm [2.9 (0.8) mm in men and 2.4 (1.1) mm in women]. Mean (s.d.) HR joint space (n=140) was 2.3 (0.9) mm, range 0-4 mm [2.5 (0.8) mm in men and 2.3 (1.0) mm in women]. HU and HR spaces of the affected joints (Larsen grades 2-5) [1.9 (s.d. 1.1) and 1.8 (0.9) mm respectively] were notably narrower than those of the unaffected (Larsen grades 0-1) joints [3.1 (0.7) and 2.9 (0.6) mm]. All the joints graded as Larsen 4 or 5 (n=13) had a value of 0 mm for both joint spaces. Both the HU and the HR joint-space narrowing was associated with increasing destruction (Larsen grading) of the joint. [r= -0.69 (95% CI -0.77 to -0.60) and r= -0.70 (-0.78 to -0.60)]. The monotonic narrowing was significantly increasing from unaffected (Larsen 0, 1), slightly (2), moderately (3) to severely (4, 5) affected joints (P<0.001). A step in this process occurred between Larsen grades 3 and 4, when the mean joint space diminished from 1.4 and 1.5 respectively to 0 mm. CONCLUSIONS: Joint-space narrowing is a frequent consequence of rheumatoid affection of the elbow joint. HR joint space decreases together with HU joint space; however, the HR joint space is already slightly narrower at the start. The narrowing is a rather late phenomenon, occurring only after erosive destruction. This should be borne in mind when using the Larsen method to evaluate changes in the elbow joint.

Valgus deformity and proximal subluxation of the rheumatoid elbow: a radiographic 15 year follow up study of 148 elbows.

OBJECTIVE: To evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated. The mediolateral HU angle of the elbow was measured from anteroposterior radiographs. The proximal subluxation of the HU joint was measured from lateral radiographs as the distance between the posterior aspect of the olecranon process and the posterior surface of the humerus. The anteroposterior subluxation of the HR joint was measured from lateral radiographs as the relation of the midpoint of head of the radius to the midpoint of the capitellum of the humerus. Destruction of the elbow joints was assessed with the Larsen method on a scale of 0 to 5 and compared with the measurements. RESULTS: Mean HU angle in 148 elbows of patients with RA was 11.5 degrees (SD 6.1), range -21 degrees (varus) to 34 degrees (valgus); 9.9 degrees (SD 4.3) in men and 12.0 degrees (SD 6.4) in women. The mean HU angle, 14.4 degrees (SD 6.0) of the affected joints (Larsen grades 2-4), showed more valgus than the mean 9.8 degrees (SD 2.5) of the non-affected (Larsen grades 0 to 1) joints; totally destroyed and unstable Larsen 5 joints were excluded. Mean HU and HR subluxations, 2.0 mm (SD 3.8) and 0.8 mm, of the affected joints (Larsen 2-5) were greater than the means, -1.1 mm (SD 1.5) and -0.4 mm (SD 0.9), of the non-affected joints. Both the HU proximal subluxation and the HR anterior subluxation correlated, r(s)=0.64 (95% CI 0.53 to 0.73 ) and r(s)=0.48 (95% CI 0.34 to 0.60), with the destruction of the elbow joint. CONCLUSIONS: The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis. A 20-year follow-up study.

AIMS: In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). METHODS: An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzick's test. RESULTS: At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick's test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. CONCLUSIONS: The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

Bone destruction, upward migration, and medialisation of rheumatoid shoulder: a 15 year follow up study.

OBJECTIVE: To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively. METHODS: At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space. RESULTS: Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=-0.49 (95% CI -0.36 to -0.60) and r=-0.58 (95% CI -0.46 to -0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5. CONCLUSIONS: Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.

Incidence of elbow involvement in rheumatoid arthritis. A 15 year endpoint study.

OBJECTIVE: To evaluate the incidence of involvement and cause of destruction of humeroulnar (HU) and humeroradial (HR) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 75/148 (51%) elbows in 45/74 (61%) patients; 30 patients had bilateral and 15 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 49/148 (33%), and severe erosions (Larsen 3-5) 26/148 (18%). The 13 most severely involved (Larsen grade 4-5) joints were seen in 8 (11%) patients. Erosions were most often observed on the capitellum (64 joints) and the lateral epicondyle (58 joints) of the humerus (AP view) or on the olecranon of the ulna (52 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the elbow joint Larsen grade on both sides: right, r = 0.53 (95% CI 0.34 to 0.68); left, r = 0.53 (95% CI 0.34 to 0.68). CONCLUSION: After 15 years more than half of the elbows and almost 2 of 3 patients with RA showed definite involvement of the elbow joint. Erosions were most often located on the capitellum and the lateral epicondyle of the humerus or the olecranon of the ulna. Severe destruction was most often bilateral.

Subacromial space in the rheumatoid shoulder: a radiographic 15-year follow-up study of 148 shoulders.

A cohort of 74 patients with rheumatoid arthritis was monitored prospectively for 15 years. At the end of the study 148 shoulders were radiographed with a standard method. The subacromial space was examined from the radiographs with a method where the acromiohumeral interval was measured from the dense cortical bone marking the inferior aspect of the acromion to a point directly above the head of the humerus. The smallest distance was recorded, and negative values were used when the original articular surface of the humerus exceeded the inferior surface of the acromion. Destruction of the glenohumeral (GH) joints was assessed by the Larsen method on a scale of 0 to 5. The relation of subacromial space measurement to the grade of destruction of GH joints was examined. The mean subacromial space was 6.7 (SD 4.4), range from -13 to 12 mm: 6.1 mm (SD 5.6) in men and 6.9 mm (SD 4.0) in women. The mean of nonaffected (Larsen grade 0 or 1) shoulders (n = 77) was 8.6 mm (SD 1.5), and the corresponding mean of the affected (Larsen grade > or =2) shoulders (n = 71) was 4.6 mm (SD 5.5). Previously reported pathologic criterion (<6 mm) indicating rotator cuff involvement was fulfilled in 30 (20%) of 148 shoulders: in 8 (22%) of 36 shoulders in men and in 22 (20%) of 112 shoulders in women. All the shoulders with severe rheumatoid destruction (Larsen grade 4 or 5) fulfilled the pathologic limit. The subacromial space had a significant negative correlation with the GH joint destruction (Larsen grade) in both sides: right r = -.63 (95% CI -.75 to -.47), left r = -.71 (95% CI -.81 to -.58). Progressive upward migration is an inevitable consequence of rheumatoid destruction in the GH joint. A significant step in this process occurred between the Larsen grades of 3 and 4, where the mean distance turned negative, indicating rotator cuff disease. A patient with rheumatoid arthritis and painful shoulder and upward migration of the humerus on the shoulder radiograph should be evaluated by an orthopaedic surgeon. In indistinct cases with subacromial space diminution, imaging techniques like ultrasonography or magnetic resonance imaging may be required to determine the exact pathologic condition of the rotator cuff and to select optimal treatment.

Radiographic joint space in rheumatoid glenohumeral joints. A 15-year prospective follow-up study in 74 patients.

OBJECTIVE: To evaluate radiographically the glenohumeral (GH) joint space in patients with long-term rheumatoid arthritis (RA). METHODS: A cohort of 74 patients with RA were followed prospectively for 15 yr. At the end point, 148 shoulders were radiographed using a standard method. The GH joint space was examined from the radiographs using a method developed previously for population studies; the joint space was measured at three different sites and the average of the three measurements, the integral space, was calculated. Destruction of the GH joints was assessed with the Larsen method on a scale of 0-5 and compared with the joint space measurements. RESULTS: The mean GH joint space in RA patients was 3. 1 (S.D. 3.3), range -17.3 to 5.7 mm; 2.7 mm (S.D. 4.5) in men and 3. 2 mm (S.D. 2.8) in women. The mean of the affected joints (Larsen grades 2-5), 1.7 mm (S.D. 4.5), was notably narrower than the mean 4. 4 mm (S.D. 0.6) of the non-affected (Larsen grades 0-1) joints. Pathological GH joint space, less than 2 mm, was found in five (15%) of 36 joints in men and in 14 (13%) of 112 joints in women. All the joints graded as Larsen 4 and 5 (n = 17) fulfilled this pathological criterion. Joint space narrowing was associated [r = - 0.66, 95% confidence interval (CI): -0.56 to -0.75] with increasing destruction (Larsen grading) of the joint. The narrowing was significant between non- (Larsen 0, 1), moderately (Larsen 2, 3) and severely (Larsen 4, 5) affected joints (P < 0.001). However, a remarkable step in this process occurred between Larsen grades 3 and 4 when the mean joint space diminished from 3.1 to 0.3 mm. CONCLUSIONS: Joint space narrowing is a frequent consequence of GH joint rheumatoid affection. However, joint space narrowing is a late phenomenon occurring not until after marked erosive destruction, which should be noted when using the Larsen method for GH joints.

Relation of glenohumeral and acromioclavicular joint destruction in rheumatoid shoulder. A 15 year follow up study.

OBJECTIVES: To evaluate the relation of glenohumeral (GH) and acromioclavicular (AC) joint involvement in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up radiographs of 148 shoulders were evaluated, and the grade of destruction of GH and AC joints were assessed by the Larsen method. One GH joint arthroplasty had been performed after 13 years of the disease onset and the preoperative radiograph was evaluated. RESULTS: Erosive involvement (Larsen grade >/= 2) was observed in 96 of 148 (65%) of the shoulders. Both GH and AC joints were affected in 62 of 148 (42%) shoulders. GH joint alone was involved in nine (6%) shoulders and only AC joint was affected in 25 (17%) shoulders. AC joint destruction correlated with the GH joint destruction, r=0.74 (95% confidence intervals (CI) 0.65 to 0.80 ). CONCLUSION: In RA AC joint is affected more often than the GH joint, but in half of the patients both joints are involved. This should be remembered when treating painful rheumatoid shoulder.

Incidence of glenohumeral joint involvement in seropositive rheumatoid arthritis. A 15 year endpoint study.

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of glenohumeral (GH) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup radiographs of 148 GH joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 71/148 (48%) GH joints in 41/74 (55%) patients; 30 patients had bilateral and 11 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 401148 (27%), and of severe (Larsen 3-5) 31/148 (21%). The 11 most severely involved (Larsen grade 5) joints were seen in 6 (8%) patients. Erosions were most often (61/71 joints) observed on the superolateral articular surface of the humerus. Glenoidal involvement was less common (28/71 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the GH joint Larsen grade on both sides (p < 0.001). CONCLUSION: After 15 years more than half the patients with RA showed definite involvement and 1 in 4 had severe destruction of the GH joint. The greatest destruction was almost always bilateral.

Radiographic joint space in rheumatoid acromioclavicular joints: a 15 year prospective follow-up study in 74 patients.

OBJECTIVE: To evaluate radiographically the acromioclavicular joint space in patients with long-term rheumatoid arthritis (RA). METHODS: A cohort of 74 patients with RA was followed prospectively for 15 yr. At the end point, 148 shoulders were radiographed with a standard method. The acromioclavicular (AC) joint space was examined from the radiographs with a method developed previously for population studies; the joint space was measured at its superior and inferior border, and the average of the two measurements, the integral space, calculated. RESULTS: Mean AC joint space in RA patients was 4.9 (S.D. 3.7), range 0-20.5 mm; 6.2 mm (S.D. 5.1) in men and 4.5 mm (S.D. 3. 0) in women. An AC joint space wider than 7 mm in men was found in 11 (31%) out of 36 joints and wider than 6 mm in women in 17 (15%) out of 112 joints. Joint space widening was associated (r=0.87, 95% CI 0.82-0.90) with increasing destruction (Larsen grading) of the joint and it seems to be an inevitable consequence of AC joint affection in RA. Joint space widening is more progressive on the caudal side because of the nature of the erosive destruction. Degeneration with joint space narrowing was observed in 8 (11%) patients (11 joints, 7%; three bilateral). CONCLUSIONS: The largest value of the joint space may be used when evaluating rheumatoid AC joint space. In RA patients, a joint space of >7 mm in men and >5 mm in women is a sign of destructive AC joint affection.

Larsen grades in evaluating the first carpometacarpal joint.

OBJECTIVE: To illustrate different Larsen grades for CMC I. METHODS: In the Heinola Follow-up Survey of Arthritis 103 seropositive patients with rheumatoid arthritis (RA) were followed prospectively over 20 years. Hand radiographs were taken at onset and at 1, 3, 8, 15, and 20 years from entry. One female patient was selected to demonstrate Larsen grades for CMC I, as she presented all the different grades of destruction during the progression of RA. Interobserver and intraobserver errors in grading of CMC I were tested. RESULTS: Radiographs of the different grades with schematic presentation are illustrated. Interobserver and intraobserver errors were in the Weighted Kappa test 0.75 and 0.82, respectively. CONCLUSION: We emphasise the importance of following the destruction of CMC I separate from the entire carpus during the course of RA.

Acromioclavicular joint subluxation is rare in rheumatoid arthritis. A radiographic 15-year study.

AIM: To conduct a radiographic assessment of the occurrence of the acromioclavicular joint subluxation in patients with long-standing rheumatoid arthritis. METHODS: A cohort of 74 patients with seropositive rheumatoid arthritis was followed prospectively for 15 years. At the 15-year visit, plain radiographs of both shoulders (n = 148) were obtained using a standard method. Acromioclavicular joint destruction was evaluated using Larsen's method, and radiographic subluxation was measured on the radiographs using two different methods. In one of these methods (method A), the distance between the upper edge of the coracoid process and the upper surface of the clavicle was measured. The other method (method B) involved measurement of the alignment of the upper joint margins of the acromion and clavicle. RESULTS AND CONCLUSION: Two of the 148 acromioclavicular joints fulfilled criteria for subluxation with method B. Neither measurement A nor measurement B differed significantly between unaffected joints (Larsen's grade 0 or 1) and affected joints (Larsen's grade > or = 2). In addition, neither measurement was correlated with the stage of acromioclavicular joint destruction (r < 0.10 for both measurements). Measurements A and B were significantly correlated to each other (r = 0.23; 95% CI, 0.07 to 0.38). The two subluxations (one upward and one downward) occurred among the nine joints with the most severe destructive lesions (Larsen's grade 5). In conclusion, acromioclavicular joint subluxation is rare in rheumatoid arthritis, occurring only when destruction of the joint is severe. The method B used in this study may prove useful for both population studies and routine clinical work.

Coracoclavicular involvement--an atypical manifestation in rheumatoid arthritis.

An inception cohort of 74 patients with seropositive and erosive RA were followed up for 15 years. All 148 shoulders were radiographed with a standard method at the 15-year follow-up. The coracoclavicular region was evaluated from each radiograph. In addition, the distance between the processus coracoideus and the superior margin of the clavicle was measured. Only one clavicle had elongated, shallow erosion on the undersurface at the insertion area of the coracoclavicular ligaments. In this case the distance between the coracoid process and clavicle was 25 mm, whereas the mean distance of all shoulders (n = 148) was 17.4 mm (range 9 25 mm). We conclude that resorption on the undersurface of the distal clavicle is an atypical manifestation in rheumatoid arthritis. The origin of this atypical lesion is a not diminished distance between the processus coracoideus and the clavicle. Inflammation of the coracoclavicular ligaments is most likely the reason for this lesion.

Incidence of acromioclavicular joint involvement in rheumatoid arthritis: a 15 year endpoint study.

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of acromioclavicular joints (AC) in a prospectively followed cohort of 74 patients with rheumatoid factor positive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup, radiographs of 148 AC joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: No surgical procedures had been performed on the AC joints. Rheumatoid involvement (Larsen Grade > or = 2) was observed in 87/148 (59%) of the AC joints in 50/74 (68%) patients: 37 bilaterally and 13 unilaterally. Incidence of mild erosions (Larsen Grade 2) was 39%, and of severe (Larsen 3-5) 20%. Erosions were most often observed on the inferior edge of the clavicular joint margin. Degenerative features without rheumatoid changes were present in 11 joints. Larsen score (0-100) of peripheral joints correlated well with the AC joint Larsen Grade in both sides: right, r = 0.56 (95% CI 0.38 to 0.70), left, r = 0.49 (95% CI 0.30 to 0.65). CONCLUSION: After 15 years two-thirds of the patients with RA showed involvement of the AC joints. Erosions were located most often on the inferior margin of the joint.