Rheumatoid Knee Joint Research Articles

Thermal imaging in rheumatoid arthritis knee joints and its correlation with power Doppler ultrasound

BackgroundPower Doppler ultrasound (PDUS) is an established non-invasive modalities for quantification of inflammation, which has a bearing on the assessment of disease activity in rheumatoid arthritis (RA). However, PDUS has several disadvantages including cost of equipment, steep learning curve and inter-observer variability. Thermal imaging has emerged as a simple, powerful tool for mapping the heat distribution pattern and has the potential to document and quantify disease activity in RA. The objective was to study the thermal imaging pattern of inflamed knee joints in cases of RA and its correlation with PDUS. MethodsThis pilot case-control study was carried out at the rheumatology centre in India including 100 subjects (50 controls and 50 RA patients). All participants underwent thermal imaging and PDUS for the knee joints. The mean temperatures in area of interest in knee, thigh and knee–thigh differential were analysed in comparison with PDUS findings. ResultsRA subjects had significantly higher mean knee temperature and mean knee–thigh temperature differential compared with controls (p value < 0.00001). PDUS documented inflammation strongly correlated with knee–thigh temperature differential. ConclusionThere was a statistically significant difference in mean knee temperature as well as mean knee–thigh temperature differential of inflamed versus control knees. Thermal imaging has the potential to become simple, objective, cost-effective and reliable tool for diagnosis and assessment of disease activity in inflammatory arthritis.

Pathology of bone epiphyses and frequency of various damage degree cases in patients with rheumatoid arthritis complicated by knee joint frontal deformities

Aim: based on several semi-quantitative morphometric indices, which represent pathological changes in femoral and tibial condyles, to determine pathological changes occurrence frequencies of damaged knee joints, complicated by frontal deformations. Materials and methods. Resected femoral and tibial condyles, obtained during knee replacement in 38 patients with rheumatoid arthritis and deformations of knee joints in frontal plane, served as material of current study. The following research methods were used: clinical examination, histological with semi-quantitative morphometric indices determination; statistical with determination of mean parameters, frequency of occurrence of cases with different gradations of indicators expression and their differences. Results. Groups of rheumatoid arthritis patients with lesions of knee joints complicated by deformities in frontal plane of different forms (valgus – varus), had significant differences by several clinical and clinical-visual indices. Pathological changes of epiphyses which are reflected by such morphometric parameters as “pannus structure and inflammation”, “inflammatory activity in subchondral spongiosa” and “stage of dystrophic-destructive changes of the joint surface” with different frequency and severity occur in the tissues of all rheumatoid arthritis patients with knee injuries, complicated by frontal deformations. In condyles from bones of one type, that form knee joint, compared in varus and valgus deformities, occurrence frequency of varying severity cases of separate morphometric indices varies in condyles according to different degree of compression. In condyles from bones of one type, which form knee joint, compared in different bones (femur and tibia) in cases of valgus deformity there was higher occurrence frequency of cases with more expressed indicator of “pannus structure and inflammation” in tibial condyles, in cases of varus deformity – in femoral condyles (independent of degree of compression). Conclusions. Results of study showed that degree of both clinical and morphometric indices of tibia and femur condyles condition in patients with rheumatoid arthritis and knee joint frontal deformities has no constant, unambiguous tendencies, and occurrence frequencies of cases with high and low degrees vary in wide limits.

Widening of the narrow rheumatoid knee joint space associated with combination of methotrexate and abatacept therapy

Widening of the narrow rheumatoid knee joint space associated with combination of methotrexate and abatacept therapy

Dynamic gadolinium-enhanced magnetic resonance imaging allows accurate assessment of the synovial inflammatory activity in rheumatoid arthritis knee joints: a comparison with synovial histology

Objective: To determine whether dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) evaluated using semi-automatic image processing software can accurately assess synovial inflammation in rheumatoid arthritis (RA) knee joints.Methods: In 17 RA patients undergoing knee surgery, the average grade of histological synovial inflammation was determined from four biopsies obtained during surgery. A preoperative series of T1-weighted dynamic fast low-angle shot (FLASH) MR images was obtained. Parameters characterizing contrast uptake dynamics, including the initial rate of enhancement (IRE), were generated by the software in three different areas: (I) the entire slice (Whole slice); (II) a manually outlined region of interest (ROI) drawn quickly around the joint, omitting large artefacts such as blood vessels (Quick ROI); and (III) a manually outlined ROI following the synovial capsule of the knee joint (Precise ROI). Intra- and inter-reader agreement was assessed using the intra-class correlation coefficient (ICC).Results: The IRE from the Quick ROI and the Precise ROI revealed high correlations to the grade of histological inflammation (Spearman’s correlation coefficient (rho) = 0.70, p = 0.001 and rho = 0.74, p = 0.001, respectively). Intra- and inter-reader ICCs were very high (0.93–1.00). No Whole slice parameters were correlated to histology.Conclusion: DCE-MRI provides fast and accurate assessment of synovial inflammation in RA patients. Manual outlining of the joint to omit large artefacts is necessary.

Clinical Results of Arthroscopic Synovectomy for Rheumatoid Knee Joint

Clinical Results of Arthroscopic Synovectomy for Rheumatoid Knee Joint

Arthroscopic Synovectomy of the Knee Joint in Rheumatoid Arthritis: Surgical Steps for Complete Synovectomy

For successful arthroscopic total synovectomy in rheumatoid arthritis of the knee, proper sequential steps are required. First, we resect hypertrophied synovial villi on the intercondylar notch to make a gateway for the posterior compartments. We also perform synovectomy at the posterolateral chamber because of the narrower space of the chamber than that of the posteromedial chamber and the intra-articular crowding due to swollen synovial villi with the passage of operation time. Special care should be taken not to overlook both posterior back corners and roofs, which cannot be seen through the transnotch view, even with a 70° arthroscope. The posterior back corners and roofs can be visualized by using the trans-septal approach technique. In this approach, we prefer to perforate the posterior septum in the posterolateral-to-posteromedial direction to avoid damaging the neurovascular structures because the structures are located just behind and lateral to the midline septum and the posteromedial capsule bulges a bit more posteriorly than the posterolateral capsule. Attention is then directed to the medial, lateral, and suprapatellar compartments, and finally the retropatellar compartment. Our surgical steps are safe and effective for complete synovectomy of the rheumatoid arthritic knee joint and other synovial disorders.

Clinical evaluation of high molecular hyaluronic acid (HA) on rheumatoid arthritic knees

It has been reported that the injection of hyaluronic acids (HA) provided the effective therapy for osteoarthritic knee joints. Recently HA was accepted the therapy for rheumatoid arthritic knee joints. We tried to clearly the effects of HA injection of RA (rheumatoid arthritis) Knees from the aspect of clinical results, using clinical assessment. It is clearly concluded that HA was very effective therapy for the rheumatoid arthritic knee with pain, swelling without hydrarthrosis and reduced the times of injection corticosteroid and the interval of its injection on rheumatoid arthritic knee with hydrarthrosis.

脂肪抑制造影ＭＲＩを用いたＲＡ患者膝における滑膜増殖度の数値化の試み

To assess the synovial proliferation in rheumatoid knee joints, a new method by means of MRI was designed. Coronal slices of fat-suppressed Gd-enhanced MRI were divided into 5mm widths laterally. In each area, high intensity synovial membrane was scored as no membrane (0), partial (1), and full (2). Calculating these scores, synovial proliferation of the knee joint was assessed in 7 knees (RA and operated, 3; RA and not operaed 3; non-RA, 1). All three knee joints operated on with TKR had high scores, and the non-RA had a low score. By using this method, synovial proliferation of RA knee join was assessed more objectively.

Hydroxyl radical generation by rheumatoid blood and knee joint synovial fluid.

To demonstrate directly that highly reactive hydroxyl radicals (OH.) can be generated in patients with rheumatoid arthritis and contribute to joint damage, and to examine the ability of blood to cause OH. generation. The sensitive and specific technique of hydroxylation of aromatic compounds (salicylate and phenylalanine) was used to measure OH.. Synovial fluid and blood from patients with active rheumatoid arthritis were aspirated and immediately added to tubes containing salicylate and phenylalanine as detectors of OH., or to tubes containing saline as a control. Levels of specific products of attack of OH. upon salicylate (2,3- and 2,5-dihydroxybenzoates) and phenylalanine (ortho- and meta-tyrosines) were measured by high performance liquid chromatography. Synovial fluid samples aspirated into saline never contained ortho- or meta-tyrosines or 2,3-dihydroxybenzoate. Of 53 patients examined, synovial fluid and blood from 36 caused formation of ortho- and meta-tyrosines when aspirated into solutions containing phenylalanine. Repeated sampling from three "positive" patients showed consistent evidence of these hydroxylation products. Similarly, of 22 patients examined, synovial fluid and blood from 18 caused formation of 2,3- and 2,5-dihydroxybenzoates when aspirated into salicylate solutions. Further evidence for the role of OH. was provided by inhibition of the hydroxylation by the specific OH. scavengers mannitol and sodium formate. Aspirated knee joint fluids and blood from rheumatoid arthritis patients can generate OH., consistent with current views on the importance of this radical as a cytotoxic agent in rheumatoid disease. The ability of body fluids to cause OH. formation is not correlated with simple laboratory indices of disease activity, but is reproducible on sequential sampling from the same patients. The mechanism and significance of the phenomenon in rheumatoid arthritis pathology remain to be established.

慢性関節リウマチ患者に発生した膝か嚢腫破裂の４例

Inflammatory arthritic conditions affecting the rheumatoid knee joint may be complicated by the development of popliteal cysts. We describe 4 RA patients who presented with ruptured cysts. Patients were 2 males and 2 females. All were outpatients and their ages at the time of rupture ranged from 43 to 61 years. Duration of RA ranged from 7 to 31 years. They presented with acute pain and swelling around the knee in accordance with increasing inflammatory indices. All patients were treated conservatively at the begining. One patient's is popliteal complaint improved following an intra-articular corticosteroid injection. The other patients remained symptomatic and underwent surgery. One patient with a markedly degenerated knee joint underwent total knee arthroplasty. We performed cystectomy and anterior synovectomy on the other 2 patients. There were no relapses of popliteal cysts in any patients. It is important to treat ruptured popliteal cysts in RA to control synovitis. If resistant to nonsurgical treatment, cystectomy with further anterior synovectomy should be performed.

Prospective sonographic and arthroscopic evaluation of proliferative knee joint synovitis.

The objective of this study was to verify the accuracy of ultrasonography in assessing the topography, morphology, and extent of synovial proliferation in rheumatoid and psoriatic knee joint synovitis. Findings were compared to those obtained using prospective arthroscopy as the gold standard; in addition, topographically defined sonographic findings before and after arthroscopic synovectomy were compared. Sonographic examination was performed in 12 patients with rheumatoid arthritis (13 knees) and 13 patients with psoriatic arthritis (14 knees) who had synovitis of the knee using an electronic linear transducer (7.5 MHz) or a mechanical sector transducer (10 MHz). This examination was followed within 1 week by arthroscopy, to compare the topography (intra-articular localization) and the morphology (sonographic patterns) of synovial proliferation. In 15 knees undergoing arthroscopic synovectomy, preoperative sonographic measurement of synovial thickness in the suprapatellar, medial parapatellar, and lateral parapatellar recesses was compared with arthroscopic visualization of synovial proliferation; 13 knees were reevaluated 2 months after arthroscopic synovectomy by sonography at the same sites. Three distinct sonographic patterns of synovial proliferation were confirmed by arthroscopic examination: a villonodular aspect in 12 knees; uniform thickening in eight knees, and overlapping layers in seven knees. About 50% of the knees showed more than one sonographic pattern, with no differences in pattern distribution between rheumatoid arthritis and psoriatic arthritis patients. A significant correlation was found between sonographic and arthroscopic evaluations of synovial thickness in the suprapatellar (P < 0.02) and medial parapateoffr recesses (P < 0.02), the sites of maximal synovial proliferation in our patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlative histologic and arthroscopic evaluation in rheumatoid knee joints

The correlation between arthroscopic observations and histologic changes in rheumatoid arthritis is still controversial. Synovial samples of 21 knee joints in rheumatoid arthritis patients were comparatively investigated by endoscopy and histology. Biopsies were scored by an endoscopist and subsequently dissected. Different histochemical and immunocytochemical staining techniques were used to define inflammatory activity. Arthroscopic and histological values were compared by rating scales and variance analysis. Our study indicates that synovial biopsy is of diagnostic value in rheumatoid arthritis. However, its usefulness depends on the histochemical methods used. The results revealed highly significant correlations of endoscopic features with the number of neutrophilic granulocytes, intravascular leukocytes, and peroxidase-positive macrophages. However, no relationship was found between the detection of lymphocytes or resident macrophages and inflammatory scores. The close correlation between endoscopic and histological findings suggests that arthroscopic evaluation allows a valuable classification of the inflammatory activity in rheumatoid synovitis.

Radiolabelled white blood cell imaging in arthritis. Is it a blood pool effect?

The aim of this study is to determine whether white blood cell imaging in inflammatory conditions is due to a blood pool effect as a result of an increased vascularity and vascular permeability, or whether cellular migration is the major contributing factor. It will be shown that white cell uptake is a specific phenomenon in the rheumatoid knee joint and not just a blood pool effect.

慢性関節リウマチ膝関節における骨・軟骨移行部の病態に関する研究

Destruction of articular cartilage of rheumatoid knee joints proceeds by erosion with pannus from periarticular tissues. The subchondral changes, however, are not understood well. In the present study, cartilage with subchondral bone of the patello-femoral joints from 20 rheumatoid knees taken during total knee replacement was examined in sections stained with hematoxylin-eosin and safranin-O, as well as by immunohistochemical techniques (peroxidase anti-peroxidase method).Alterations of the articular cartilage and subchondral bone plate were graded into 4 stages: A) Partial destruction of the subchondral bone plate, presence of intramedullary granulation tissue, and concomitant decrease in cartilage matrix staining. B) Numerous erosion sites at the osteochondral junction arising from intramedullary granulation tissue. C) Widespread and multiple invasion by the granulation tissue, but cartilage still remaining. D) Almost total loss of cartilage, replaced with granulation tissue.The osteochondral junction was destroyed by invasion by granulation tissue which proceeded in parallel from both articular cartilage and the intramedullary bone space. Lysozyme was positive on monocytes and fibroblasts at the osteolytic area of the osteochondral junction. S-100 protein was positive on monocytes corresponding to chondrocytes in the same area, where they may take account for lytic function.It was also confirmed histologically that the subchondral bone has high turnover changes.

Radiological findings in the rheumatoid knee joint in a seventeen-year follow-up.

In 1967 a population survey of rheumatoid arthritis (RA) was carried out in Stockholm. In a sample of 15,268 subjects, 239 were found to have RA. In 1983, i.e. 17 years later, all the 127 subjects still living could be traced, 109 of them were re-examined and 98 radiographed. Whole-leg weight-bearing radiographs of the 168 knee joints were available for determination of the HKA (Hip-knee-ankle) angle and of the articular space. In this sample, which represented the epidemiological spectrum of RA, disease activity could be associated with radiologic changes in the knee joint, e.g., erosions, cysts and sclerosis. These radiologic findings were predictable owing to the fact that New York criterion no. 3 or 4 for RA had been fulfilled 17 years earlier. In 52% of those with active RA at the follow-up, the articular space was seen to be narrowed. A certain varus angulation (2.2 degrees) was ascertained in the joints of subjects with inactive RA, while this angulation was less pronounced (0.7 degrees) in knee joints of subjects with an active disease.

Experimental cryo-irrigation of the knee joint.

Experiments have been carried out to test the feasibility of using cryo-irrigation as a means of ablating the synovium in the rheumatoid knee joint. Cryo-irrigation was performed by a cooling machine and pump, which circulated cold 200/10 centistoke (cSt) silicone through the knee joint of rabbits anaesthetised with intravenous (IV) 'Saffan'. Fluid left the joint at -5 to -10 degrees C. Sixteen normal New Zealand rabbits received cryo-irrigation of one knee joint for 10-20 minutes and were killed at one day, and one, two, and 12 weeks thereafter. Judged by radioactive sulphate incorporation there was no impairment of chondrocyte function in the articular cartilage of irrigated joints. Histological examination showed mild synovitis and some loss of staining of superficial cartilage in 6/16 irrigated joints (v 1/16 control joints). Similar treatment of rabbit joints in which the Glynn model of synovitis had been induced showed marked reduction of synovitis 14-45 days after silicone treatment. Nine of 26 animals in which synovitis was induced in both knees and cryo-irrigation performed in one knee died either immediately postoperatively or during the next week. These deaths remain unexplained. A single dog received cryo-irrigation of one knee (-6 to -9 degrees C for 22 min) and remained perfectly well up to sacrifice at six months, when the joint appeared histologically completely normal.

Some aspects of knee joint kinematics in rheumatoid arthritis as studied with roentgen stereophotogrammetry.

Kinematic studies of the rheumatoid knee joint with the aid of roentgen stereophotogrammetry were performed in 4 patients (6 knees). Three kinds of experiments were carried out. The screw axis of rotation between various flexion angles was determined. The displacement of the screw axis indicated pathological function in all cases. Using different treatment techniques the effect of traction was studied. A separation between the femur and the tibia of 1.3-3.8 mm was found in 3 knees which were slightly flexed during the traction. The compression effect of isometric knee extension was determined in 4 knees. Compression of 0.5 mm at a medial point and of 0.3 mm at a lateral point of the femoral condyle were found in one knee. The present study indicates that roentgen stereophotogrammetric analysis may give additional information on the development of internal derangement of the rheumatoid knee joint.

Bidirectional erosion of cartilage in the rheumatoid knee joint.

Specimens of cartilage with contiguous bone and overlying synovial pannus were obtained from 22 rheumatoid knee joints and examined histologically using specific histochemical staining techniques. All showed significant erosions of cartilage by synovial cells, but seven specimens also showed substantial cartilage erosion by cells from the subchondral bone region. This bidirectional attack on rheumatoid knee cartilage did not represent an 'underpinning' of cartilage by synovial pannus, as judged by serial sectioning and the identification of specific cells. Whereas cartilage-pannus junctions had mainly macrophagic or fibroblastic cells, cartilage-bone lesions were usually characterised by chondroclasts and blood vessels. Lymphocytes were generally absent from all sites of cartilage erosion. The bidirectional attack on articular knee cartilage suggests that changes have occurred within the cartilage that make it vulnerable to cellular invasion and erosion. Such changes might reflect a deficiency in 'anti-invasion factors', or the exposure of hidden epitopes and subsequent immunogenicity, or a combination of both.

Chondroclasts and osteoclasts at subchondral sites of erosion in the rheumatoid joint

Histochemical and ultrastructural studies of bone-cartilage junctions from 21 rheumatoid knee joints have demonstrated the presence of both osteoclasts and chondroclasts. Significant erosions of bone and mineralized cartilage were observed in 15 specimens, and 6 showed localized erosions of unmineralized (hyaline) cartilage. Chondroclasts, defined by their close association with both mineralized and unmineralized cartilage, were morphologically and histochemically similar to osteoclasts. Our observations suggest that these multinucleate cells play a crucial role in subchondral tissue destruction, but that erosion of unmineralized cartilage is primarily the result of synovial pannus tissue.

Arthrographic study of the rheumatoid knee. Part 1. Synovial proliferation.

The improved method of double-contrast arthrography for the knee joint, which can give extensive information on the intra-articular components, was undertaken in 131 knee joints with classical rheumatoid arthritis. Synovial proliferation was classified by its localisation into 6 types: nonproliferated (NP); localised, subdivided into suprapatellar pouch (SPP), proper articular (PA), and posterior (POST); panarticular (PAN); and burned out type (BO). These types are intimately related to the radiological stage and pathological changes of the articular cartilage and menisci. By following the dynamic changes of synovial proliferation by arthrography the clinical course of the rheumatoid knee joint may be predicted. While in the NP and SPP types destruction of the joint is minimal, it is relatively rapid and severe in the PA and PAN types. Thus the proliferation in the joint proper has a stronger influence on joint destruction than does the suprapatellar pouch. From these results synovectomy to resect proliferated synovial tissues of the joint proper completely, and to resect those of the suprapatellar pouch only superficially in the early stage, was undertaken in 21 rheumatoid arthritic joints, giving excellent results in 80.9%. The advantages of this method are discussed.