Arthroscopic release for the severely stiff elbow.

BACKGROUND: Arthroscopic release for the stiff elbow has been widely used, but there are no reports limited to severe stiffness. The purpose of this study was to investigate the outcomes of severe cases. MATERIALS AND METHODS: Ten patients with 10 severely stiff elbows defined by a limited arc of ≤ 60° underwent this arthroscopic release. Causes of stiffness were post-traumatic stiffness (one patient), osteoarthritis (three patients), and rheumatoid arthritis (six patients). Using arthroscopy, the capsule contracture and the intra-articular fibrosis were removed and the impinging osteophyte and part of the radial head were resected. For four patients with preoperative ulnar nerve symptoms or contracture of the posterior oblique ligament of the medial collateral ligament, mini-open ulnar nerve neurolysis and release of the posterior oblique ligament were performed. Patients were followed up for an average of 24 months. RESULTS: Arthroscopic release could be performed without any intraoperative complications. Range of motion for the elbow significantly improved from 95° of flexion and - 55° of extension to 109° of flexion and - 32° of extension. The Mayo Elbow Performance Score also improved from 56 points to 80 points. Two patients underwent a second arthroscopic surgery and gained further arc of motion. One patient showed osteophyte reformation and needed revision open surgery 1 year after the initial surgery. CONCLUSIONS: Arthroscopic release for the severely stiff elbow could improve range of motion. Careful attention should be given during surgery to avoid complications such as intramuscular bleeding or nerve damage.

Changes in axial alignment of the ipsilateral hip and knee after total hip arthroplasty.

AIMS: We investigated changes in the axial alignment of the ipsilateral hip and knee after total hip arthroplasty (THA). PATIENTS AND METHODS: We reviewed 152 patients undergoing primary THA (163 hips; 22 hips in men, 141 hips in women) without a pre-operative flexion contracture. The mean age was 64 years (30 to 88). The diagnosis was osteoarthritis (OA) in 151 hips (primary in 18 hips, and secondary to dysplasia in 133) and non-OA in 12 hips. A posterolateral approach with repair of the external rotators was used in 134 hips and an anterior approach in 29 hips. We measured changes in leg length and offset on radiographs, and femoral anteversion, internal rotation of the hip and lateral patellar tilt on CT scans, pre- and post-operatively. RESULTS: The mean internal rotation increased by 11° (-15° to 46°) and was associated with underlying disease (OA), pre-operative range of internal rotation, gender, surgical approach, leg lengthening, and change of femoral anteversion (adjusted R(2) : 0.253, p < 0.001). The mean lateral patellar tilt increased by 4° (-5° to 14°) and was associated with age, leg lengthening, and increment of hip internal rotation (adjusted R(2): 0.193, p < 0.001). CONCLUSION: Both internal rotation of the hip at rest and lateral patellar tilt are increased after THA. Changes in rotation after THA may affect gait, daily activities, the rate of dislocation of the hip, and ipsilateral knee pain. TAKE HOME MESSAGE: Internal rotation of the hip at rest and lateral patellar tilt increase after THA.

Eight-year preservation of knee function with radiographic healing phenomena after anti-tumor necrosis factor-α therapy for a severely erosive knee in a young patient with rheumatoid arthritis.

A 23-year-old woman developed rheumatoid arthritis (RA). The pain in her right knee was aggravated and anti-tumor necrosis factor (TNF)-α therapy was selected at the age of 35. The range of motion and Larsen grade were 5º to 120º and 4, respectively. Infliximab and etanercept therapies were quite effective and the pain of the right knee improved. An X-ray at 1 year showed radiographic healing phenomena that included reappearance of a clear visible cortical plane, partial filling-in of erosions and cysts, and sclerosis of the subchondral bone. An X-ray at the age of 43 showed that the radiographic healing phenomena were still preserved after 7 years. The right knee remained pain-free although the Larsen grade was still 4, and the knee function was preserved for 8 years. In conclusion, anti-TNF-α therapy may preserve knee function with radiographic healing phenomena and prevent total arthroplasty of severely erosive knees in young RA patients.

Foot deformities in rheumatoid arthritis and relevance of disease severity.

OBJECTIVE: To investigate foot deformities in rheumatoid arthritis (RA) in relation to the disease severity. METHODS: Radiographs of 100 weight bearing feet of 50 patients who had had RA for >10 years (mean 13.5 years) were studied. The patients were classified into 2 study groups according to the severity of disease. We measured hallux valgus angle (HVA), intermetatarsal angle between first and 2nd (M1/2), and intermetatarsal angle between first and 5th (M1/5) on anteroposterior (AP) radiographs, as well as calcaneal pitch (CP) and first metatarsal pitch (MP) on lateral radiographs. The differences in these angles between the 2 groups (Inter-group study) and the correlations among angles within each group (Intra-group study) were examined. RESULTS: Inter-group study showed significant differences between the 2 groups for all variables. Intra-group study, on the other hand, showed no correlation between variables of the 2 deformities, i.e., splaying of forefoot (M1/2 and M1/5) and flattening of longitudinal arch (CP and MP). Only HVA correlated with the splaying (M1/2 and M1/5) in both study groups. CONCLUSION: Disease severity is related to the progression of foot deformities in RA, but the flattening and the splaying are not correlated with each other. We believe that foot deformities should be treated properly and early, especially for patients who are expected to have severe disease.

A long-term follow-up study of cervical lesions in rheumatoid arthritis.

To determine the natural history of cervical lesions in rheumatoid arthritis, 161 patients who had been followed for a minimum of 5 years were enrolled in this study. The average follow-up period was 10.2 years (range, 5 to 20 years). The severity of the rheumatoid arthritis was classified into three types based on the multiplicity of peripheral joint rheumatoid involvement: a least erosive subset, a more erosive subset, and a mutilating disease subset. Ninety-two patients (57%) had upper cervical involvement, which progressed in the order of anterior atlantoaxial subluxation, anterior atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Subaxial subluxation was found in 18 patients (11%). In 17 of these 18 patients, upper cervical lesions were also noted. The incidence of cervical involvement in each disease subset was 39% in the least erosive group, 83% in the more erosive group, and 100% in the mutilating disease group. Fifty percent of the patients with cervical involvement had neck pain, and the remaining patients were asymptomatic. Neural involvement occurred in 10 patients. In 7 of these 10 patients, vertical subluxation of the atlas was responsible for the neural deficit. Six patients required surgical intervention because of progressive myelopathy.

Cervical lesions related to the systemic progression in rheumatoid arthritis.

STUDY DESIGN: Cross-sectional study of cervical involvement in rheumatoid arthritis. OBJECTIVES: To clarify the correlation between the deterioration of cervical lesions and the systemic progression of rheumatoid arthritis. SUMMARY OF BACKGROUND DATA: The natural course of cervical lesions varies. To date, no systemic parameter has been clarified to predict the progression. METHODS: One hundred seventy-three patients with rheumatoid arthritis participated in this study. The authors studied the progression of cervical lesions and investigated the relation between the types of cervical subluxation at the end of study and the following four variables: the serum level of C-reactive protein, the number of joints with erosion, carpal height ratio, and disease subset (least erosive subset, more erosive subset, and mutilating disease subset). RESULTS: Of the 173 patients, 55 already had cervical subluxation before entering the study. During the follow-up period, 44 patients deteriorated radiographically, and 77 (45%) had cervical involvement, including involvement of upper cervical lesions in 65 patients, upper lesions combined with subaxial subluxation in 10, and subaxial subluxation alone in 2. The upper cervical subluxation progressed in the order of anterior atlantoaxial subluxation, atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Deterioration of upper cervical lesion and occurrence of subaxial subluxation were closely correlated with an elevation of serum C-reactive protein level, an increase in the number of joints with erosion, and a decrease in the carpal height ratio. The incidence of cervical involvement and the extent of deterioration were different among the disease subsets. CONCLUSIONS: The serum level of C-reactive protein, the number of joints with erosion, and the carpal height ratio correlated closely with the extent of the cervical subluxation. The average C-reactive protein values during the follow-up period correlated with progression of the cervical lesions. The classification of rheumatoid disease subset was useful for predicting the terminal feature of the cervical lesions.

Pathological fracture of a lumbar vertebra caused by rheumatoid arthritis--a case report.

We describe a case of rheumatoid arthritis (RA) with collapse of the L3 lumbar vertebra for which surgery was performed. The pathogenesis of lumbar lesions affected by RA is discussed and the literature reviewed.

[A case of basilar impression treated with mandible splitting transoral approach].

We report a case of basilar impression treated with mandible splitting transoral approach surgery. A 39-year-old man presented a ten-year history of gait disturbance. He had experienced acceleration of his spastic paraparesis for the past few years. Neurological examination on admission demonstrated tetraparesis (MMT4/5), severe hyperreflexia in his arms and legs, severe sensory loss below C2, urinary retention and inability to open his mouth widely. Radiological findings showed the dens and the body of C2 are deeply invaginated to the atlas and the foramen magnum and medulla and upper cervical cord were markedly compressed by this basilar invagination. After carrying out posterior decompression and occipito-cervical fixation, we attempted to remove the invaginated dens and the C2 vertebral body using a conventional transoral approach. But limitation of mouth opening made operative fields narrow. Consequently because of insufficient anterior decompression his neurological deficits could not be alleviated. Employment of mandible splitting procedure brought about a wide operative view so that complete removal of the residual dens and 70% drilling out of the C2 body was made possible. Postoperative complications were negligible. Finally, great alleviation of his deficits was achieved. Mandible splitting procedure is effective for obtaining a wide operative field on the anterior approach to the craniocervical junction.

Bone marrow stromal cells contribute to synovial cell proliferation in rats with collagen induced arthritis.

OBJECTIVE: To observe the migration of bone marrow stromal cells into the joint cavity and the contribution of such cells to synovial proliferation in rats with collagen induced arthritis (CIA). METHODS: After bone marrow stromal cells preliminarily labeled with fluorescent dye or 3H thymidine accumulated in the bone marrow of splenectomized rats by intraperitoneal injection, the migration of labeled stromal cells in rats with CIA was analyzed by liquid scintillation counting, autoradiography, and fluorography. RESULTS: In splenectomized control rats, labeled bone marrow stromal cells were mostly found in the bone marrow and not in the synovium. Over 2 weeks after immunization, labeled stromal cells were microscopically found migrating directly into the joint cavity through the area between the articular margin and the synovial insertion (the bare zone). Labeled stromal cells were mainly found in the sublining layers of proliferating synovial tissue. CONCLUSION: At the onset of CIA, bone marrow stromal cells migrated from the bone marrow into the affected joint cavity and seemed to contribute to synovial proliferation.

The MEK kinase activity of the catalytic domain of RAF-1 is regulated independently of Ras binding in T cells.

Deletion of the amino-terminal domain of Raf-1, which contains the Ras-binding region, results in the constitutive activation of the liberated Raf-1 catalytic domain in fibroblast cell lines. We demonstrate that the MEK kinase activity of the isolated Raf-1 catalytic domain, Raf-BXB, is not constitutively active, but is regulated in Jurkat T cells. Raf-BXB is activated by engaging the antigen receptor-CD3 complex, or treating cells with phorbol myristate acetate or okadaic acid. Increasing intracellular cAMP inhibits Raf-1 activation stimulated by phorbol myristate acetate, but not the activation of Raf-BXB. Serine 621, but not serine 499, is essential for Raf-BXB MEK kinase activity. Because Raf-BXB does not bind Ras, the data establishes a Ras-independent signal in directly regulating the activity of the Raf-1 catalytic domain.

Phenotypic characteristics of bone marrow cells in patients with rheumatoid arthritis.

OBJECTIVE: Our previous study showed the presence of abnormal myeloid lineage cells in the epiphyseal bone marrow adjacent to joints affected with severe rheumatoid arthritis (RA). Now, we investigated whether there were any changes of other marrow cell populations related to RA, and whether there were any pathologically characteristic changes in the iliac bone marrow, which is one of the major systemic hematopoietic organs. METHODS: 2-Color flow cytometry was carried out to analyze the phenotypes of mononuclear cells (MNC) fractions in bone marrow aspirates and venous blood from 56 patients with RA and 7 non-RA controls. RESULTS: The absolute number of MNC in the iliac bone marrow was increased by 3-fold in the RA patients compared with the non-RA controls. In contrast, no significant increase of MNC was observed in the tibial epiphyseal bone marrow or peripheral blood. The ratio of each MNC fraction in the iliac bone marrow did not differ significantly between the RA patients and the non-RA controls. In lymphocyte subsets, the percentage of HLA-DR+CD8+ cells to all CD8 cells in the iliac bone marrow increased significantly in the RA patients compared with the non-RA controls. Abnormal myeloid cells (MX-GA+MY4+ cells), specific to severe RA, were found to be more concentrated in the iliac bone marrow than in the tibial epiphyseal bone marrow. CONCLUSION: Characteristic pathologic changes of the iliac bone marrow suggest an important role of systemic bone marrow in the progression of RA.

Therapeutic effect of intradermal injections with difucosyl lactosamine (dimeric Lex) on patients with rheumatoid arthritis.

As reported by us, a new myeloid cell population with an oncofetal membrane marker, dimeric Lex (di-Lex; III3FucV3 FucnLc6), was found in the epiphyseal bone marrow adjacent to the involved joints of patients with severe rheumatoid arthritis (RA). Patients with RA received intradermal (id) injections of di-Lex incorporated in liposome or of high molecular weight glycoprotein, or tumor associated carbohydrate antigen (TCA), containing the same carbohydrate epitope as di-Lex. The epiphyseal myeloid cells were reduced or sometimes eliminated during id injection. In random trials of id injection, observation under clinical and laboratory conditions showed improvement in 63% (17/27) of the patients treated for 6 months with appropriate doses of di-Lex (III3FucnLc4), and in 72% (31/43) of those treated with an identical protocol for TCA. However, id injection with monomeric Lex had no effect.

Raf-1 is required for T cell IL2 production.

Engagement of the T cell receptor/CD3 complex activates the serine/threonine kinase, Raf-1, but the physiologic consequences of its activation have not been determined. The effects of Raf-1 on interleukin 2 (IL2) production in T cells were examined using activated and inhibitory forms of Raf-1. A truncated active form of Raf-1 was expressed constitutively from the metallothionein promoter in a malignant T cell line, Jurkat. Treatment of the cells with zinc and cadmium greatly increased active Raf-1 expression. This increase in Raf-1 expression allowed antibodies to CD3 and to CD28 to stimulate IL2 production in the absence of phorbol myristate acetate (PMA) and enhanced IL2 production stimulated by these antibodies in the presence of PMA. The action of active Raf-1 was to increase IL2 gene transcription as it enhanced transcription of a reporter gene linked to IL2 promoter. Finally, the dominant negative form of Raf-1 inhibited transcription directed by the IL2 promoter that was induced by the mitogen phytohemagglutinin (PHA) and PMA. We conclude that Raf-1 activity is necessary for IL2 gene transcription and secretion. These data indicate a role for Raf-1 in the immune response.

Regulation and properties of extracellular signal-regulated protein kinases 1 and 2 in vitro.

Extracellular signal-regulated protein kinases (ERK) 1 and 2 and mutants of each were expressed in bacteria with a hexahistidine tag and purified using nickel-chelate chromatography. Basal activity of wild type ERK2 was approximately 2 nmol/min/mg. Self-catalyzed phosphorylation occurred in vitro on the major physiological site of tyrosine phosphorylation in an intramolecular reaction. Rabbit muscle ERK activator activated ERK2 500-1000-fold up to a specific activity (approximately 2 mumol/min/mg) approximating that of ERK1 purified from stimulated cells (Boulton, T.G., Gregory, J.S., and Cobb, M.H. (1991) Biochemistry 30, 278-286). ERK1 could also be activated by the ERK activator to the same extent. Mutants lacking the major site of tyrosine phosphorylation were autophosphorylated at a greatly reduced rate and were no longer highly activated by the ERK kinase. Mutants lacking the major site of threonine phosphorylation were autophosphorylated at the same or an enhanced rate, but the kinase activity of these mutants depended on the residue used to replace the threonine. Replacement by glutamate rendered the kinase capable of being activated by ERK activator, while replacement by alanine did not. Thus, the carboxyl group of glutamate can provide at least some of the features introduced by phosphothreonine in activated ERKs.

Extracellular signal-regulated kinases in T cells: characterization of human ERK1 and ERK2 cDNAs.

Extracellular signal-regulated kinases 1 and 2 are growth factor-sensitive serine/threonine kinases. cDNAs for both human kinases were isolated and sequenced. The nucleic acid and deduced protein sequences of human extracellular signal-regulated kinase 1 were 88% and 96% identical, respectively, to the homologous rat sequences. The nucleic acid and deduced protein sequences of human extracellular signal-regulated kinase 2 were 90% and 98% identical, respectively, to the corresponding rat sequences. A human extracellular signal-regulated kinase 2 specific probe was used to demonstrate that the mRNA for this kinase was present in T cells and did not change with activation. The deduced protein sequences of both human kinases were greater than 95% identical to two Xenopus kinase sequences, indicating that these enzymes are highly conserved across species.

Bone marrow changes in adjuvant-induced and collagen-induced arthritis. Interleukin-1 and interleukin-6 activity and abnormal myelopoiesis.

OBJECTIVE: To investigate the role of bone marrow in arthritis. METHODS: Bone marrow changes over time were investigated in rats with adjuvant-induced and collagen-induced arthritis, using bioassay techniques and histologic analysis. RESULTS: In both animal models, bone marrow interleukin-1 and interleukin-6 activity began to rise before the onset of arthritis and increased in relation to the progression of arthritis. Enhanced myelopoiesis in the bone marrow was noted in conjunction with the increased cytokine activity. CONCLUSION: Bone marrow changes such as those demonstrated in this study may be common to various models of induced arthritis and may have an important role in the pathogenesis of this disease.

Effect of early synovectomy on the course of rheumatoid arthritis.

Ninety-one patients with rheumatoid arthritis were retrospectively assigned to 3 subsets according to the number of joints with erosion (NJE). The subsets were least erosive (LES); more erosive (MES); most erosive involving multilating disease (MUD). In the early stages of disease the subsets were distinct (p less than 0.001) regarding mean values of annual reduction of carpal height (delta CHR) and serum Clq levels. Patient assessment (radiographic and clinical) continued to deteriorate in the MES and MUD subsets over the 1-5 year interval after synovectomy. Apparent stabilization of knee disease in the LES subset may be a feature of this subset rather than a result of synovectomy. Although synovectomy may offer short term symptomatic relief, we found no evidence that it retards the bony destruction or the disease process.

Facs analysis of myeloid differentiation stages in epiphyseal bone marrow, adjacent to joints affected with rheumatoid arthritis.

To analyze the differentiation stages of myeloids statistically, we adopted a two-color FACS system and used appropriate monoclonal antibodies belonging to CD15, CD16 and CD11b. By using HL60 treated with DMSO or human bone marrow MNCs from patients with rheumatoid arthritis, it was proved that with this system, myeloids could be clearly separated according to differentiation stages. Furthermore, the number of myeloids at certain stages of differentiation in the epiphyseal bone marrow of patients with RA or OA was measured. Nine of 15 samples from RA patients showed immature and relatively mature myeloids, while none of the 8 OA samples did. When the proportions of myeloids in epiphyseal bone marrow MNCs were compared with the clinical features, disease subsets in RA and the degree of synovitis, seemed to be important factors for abnormal myelopoiesis.

[Repair of rabbit articular surfaces with allografts of chondrocytes embedded in collagen gels].

In an attempt to restore articular cartilage, allogeneic articular chondrocytes embedded in collagen gels were transplanted onto full-thickness defects in rabbit articular cartilage. Within 24 weeks after the transplantation, the defects were filled with hyaline cartilage, specifically synthesizing type II collagen. These chondrocytes were autoradiographically proven to be originated from the originally transplanted chondrocytes. As histologically assessed, success rate was about 80%, a marked improvement over the results (40% success rate) in previous studies reporting chondrocyte transplantation without collagen gels. On the other hand, the defects without chondrocyte transplantation healed with fibrocartilaginous tissue more than 24 weeks after treatment. Immunological enhancement induced by transplanted allogeneic chondrocytes or collagen was not significant for eight weeks after treatment, so far as shown by both direct and indirect blastformation reactions. Thus, allogeneic transplantation of isolated chondrocytes embedded in collagen gels appears to be one of the most promising methods for the restoration of articular cartilage.