FROM T H E DEPARTMENT (DIRECTOR:

PROF.

OF RADIOLOGY (DIRECTOR: P R O F . P . VIRTAMA) A N D MEDICINE

L. KALLIOMAKl),

TURKU

UNIVERSITY

HOSPITAL,

SF-20520

TURKU,

FINLAND.

SOFT TISSUE RADIOGRAPHY FOR EVALUATING CLINICAL ACTIVITY OF RHEUMATOID ARTHRITIS P. M A K E L A a n d M . HAATAJA

T h e a c t i v i t y of r h e u m a t o i d a r t h r i t i s is a t e r m w h i c h refers t o t h e r e v e r s i b l e a n d p r e d o m i n a n t l y i n f l a m m a t o r y f e a t u r e s of t h e d i s e a s e . T h e g r e a t v a r i a t i o n i n t h e c l i n i c a l c o u r s e a n d s y m p t o m s t o g e t h e r w i t h t h e f a c t t h a t t h e e t i o l o g y a n d p a t h o g e n e s i s of t h e d i s e a s e still r e m a i n u n k n o w n n e c e s s i t a t e s t h e u s e of v a r i o u s signs a n d i t e m s w h e n evaluating t h e host response t o t h e disease process. N u m e r o u s criteria have been f o u n d t o b e q u a n t i f i a b l e a n d t o c o r r e l a t e sufficiently well w i t h t h e d i s e a s e a c t i v i t y . A s s e m b l i n g t h o s e v a r i o u s i t e m s t o d e f i n e t h e i n t e n s i t y of t h e w h o l e p r o c e s s r e q u i r e s t h e u s e of s o m e n u m e r i c a l s y s t e m . O n e s u c h a c t i v i t y i n d e x h a s b e e n s u g g e s t e d b y L A N S B U R Y ( 1 9 6 6 ) , a n d is o f t e n

used.

J o i n t p a t h o l o g y h a s a l w a y s b e e n c o n s i d e r e d of p r i m a r y i m p o r t a n c e w h e n a s s e s s i n g t h e a c t i v i t y of t h e d i s e a s e . T h e t r a d i t i o n a l c h a r a c t e r i s t i c s of i n f l a m m a t i o n a r e p a i n , swelling, h e a t a n d r e d n e s s , a n d l o s s of f u n c t i o n . A l t h o u g h c l i n i c a l o b s e r v a t i o n of t h e s e f e a t u r e s is s i m p l e , t h e i r q u a n t i f i c a t i o n is m o r e difficult. P a l p o m e t e r s h a v e b e e n d e v e l o p e d f o r q u a n t i f i c a t i o n of j o i n t t e n d e r n e s s a n d g o n i o m e t e r s f o r e s t i m a t i o n of j o i n t m o t i l i t y . T h e t e m p e r a t u r e of t h e j o i n t s m a y b e e s t i m a t e d b y t h e r m o g r a p h y ( B O A S 1 9 5 4 ) . S e v e r a l m e t h o d s h a v e b e e n s u g g e s t e d f o r t h e m e a s u r e m e n t of j o i n t swelling, b u t n o n e h a s b e e n g e n e r a l l y a c c e p t e d . H A R T & C L A R K ( 1 9 5 1 ) r e c o m m e n d e d t h e u s e of a r i n g series, E C C L E S ( 1 9 5 6 ) a n d S M Y T H e t c o l l . ( 1 9 6 3 ) m e a s u r e d t h e s w e l l i n g

of t h e h a n d s a n d feet o n t h e b a s i s of t h e a m o u n t of fluid t h e y s u p p l a n t e d . Submitted for publication 18 March 1977. Acta Radiologica Diagnosis 19 (1978) Fasc. 2

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389

P . M A K E L A A N D M. H A A T A J A

390

Fig. 1. Female, aged 46, with 3rd proximal interphalangeal proximal interphalangeal and proximal interphalangeal and

a 3-year history of rheumatoid arthritis. Grade 2 swelling in 2nd and and metacarpophalangeal joints. Grade 1 swelling in 4th and 5th 5th melacorpophalangeal joints. Grade 2 superficial erosions in 5th 2nd and 3rd metacarpophalangeal joints.

T h e e a r l i e s t r o e n t g e n o g r a p h i c l e s i o n s in r h e u m a t o i d a r t h r i t i s a p p e a r in t h e soft t i s s u e s of t h e j o i n t s , a n d a r e a t least p a r t l y r e v e r s i b l e . R a d i o l o g i c a l l y i d e n t i f i a b l e a r e f u s i f o r m t h i c k e n i n g a n d swelling of t h e j o i n t c a p s u l e , a n d p e r i a r t i c u l a r o e d e m a w h i c h a p p e a r s a s a b l u r r i n g of t h e o u t l i n e of t h e j o i n t c a p s u l e a n d a s a s o m e w h a t m o t t l e d s t r u c t u r e in t h e j o i n t s u r r o u n d i n g s . S e v e r a l a u t h o r s h a v e e m p h a s i z e d t h e i m p o r t a n c e of t h e soft t i s s u e a p p e a r a n c e in t h e e a r l y d i a g n o s i s of r h e u m a t o i d a r t h r i t i s . It h a s a l s o b e e n f o u n d t h a t m a s s i v e j o i n t swelling a n d p e r i a r t i c u l a r o e d e m a a r e i n d i c a t i v e of t h e a c t i v e s t a g e of t h e d i s e a s e ( L O C K I E 1 9 5 3 , S O I L A 1 9 5 8 , B E R E N S e t c o l l . 1 9 6 4 , STEINBACH & JENSEN 1 9 7 5 ) .

A d v a n c e s in t h e field of soft t i s s u e r a d i o g r a p h y h a v e i m p r o v e d t h e d e m o n s t r a t i o n of t h e s e l e s i o n s p a r t i c u l a r l y in t h e h a n d s a n d feet ( F I S C H E R 1 9 7 3 , R E I C H M A N N et c o l l . 1974).

I n c r e a s e d b l o o d flow in t h e i n f l a m m a t o r y j o i n t t i s s u e m a y b e m e a s u r e d , isotopes. In recent years the isotope most frequently employed has been " T c

m

using either

a s p e r t e c h n e t a t e o r a s " T c - t a g g e d a l b u m i n ( O K A et coll. 1 9 7 0 , M A X F I E L D e t coll. m

1972,

G O M E Z et coll. 1 9 7 4 ) . Significant correlations h a v e been found between the

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Fig. 2. Male, aged 35. a) Grade 3 swelling and periarticular oedema in 2nd and 3rd proximal interphalangeal joints, b) Six months later. Grade 2 swelling and no periarticular oedema. Clinical activity (Lansbury index) decreased at the same time from 85 to 55.

a c c u m u l a t i o n of t h e i s o t o p e in t h e j o i n t t i s s u e a n d t h e e s t i m a t e d d e g r e e of a c t i v i t y of t h e d i s e a s e ( O K A e t coll. 1 9 7 3 , H A A T A J A 1 9 7 5 ) . A T c - i n d e x b a s e d o n t h e i s o t o p e a c ­ c u m u l a t i o n in t h e j o i n t s h a d a highly significant c o r r e l a t i o n t o t h e L a n s b u r y i n d e x of t h e p a t i e n t s ( O K A et coll. 1 9 7 3 ) . T h e r a d i o l o g i c a p p e a r a n c e s of t h e soft tissues of t h e h a n d s w e r e c o r r e l a t e d w i t h t h e clinical a c t i v i t y of t h e d i s e a s e a s e v a l u a t e d w i t h t h e L a n s b u r y i n d e x . C o r r e l a t i o n s b e t w e e n local i s o t o p e a c c u m u l a t i o n in t h e h a n d s a n d soft tissue l e s i o n s c o r e s w e r e also investigated. T h e results are n o w reported.

M a t e r i a l and M e t h o d s T h e m a t e r i a l c o m p r i s e d 6 7 p a t i e n t s u n d e r t r e a t m e n t a t t h i s d e p a r t m e n t of m e d i c i n e . T h e d i a g n o s i s of r h e u m a t o i d a r t h r i t i s w a s c o n f i r m e d t h r o u g h t h e clinical, l a b o r a t o r y a n d r a d i o g r a p h i c fulfilment of t h e c r i t e r i a for classical o r definite d i s e a s e a s d e f i n e d by t h e A m e r i c a n R h e u m a t i s m A s s o c i a t i o n ( R O P E S et coll. 1 9 5 9 ) . T h e p a t i e n t s , 5 0 females a n d 1 7 m a l e s r a n g i n g f r o m 2 6 t o 4 7 y e a r s of a g e ( m e a n 5 0 . 5 y e a r s ) , w e r e classified i n t o 3 g r o u p s a c c o r d i n g t o t h e d u r a t i o n of t h e d i s e a s e :

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392

P. MAKELA A N D M. HAATAJA

Fig. 3. Female, aged 65, with rheumatoid arthritis for more than 10 years. Grade 3 swelling and periarticular oedema in 2nd proximal interphalangeal joint.

less t h a n o n e y e a r in 17 p a t i e n t s , m o r e t h a n o n e y e a r b u t less t h a n 3 y e a r s in 9 p a t i e n t s , a n d m o r e t h a n 3 y e a r s in 4 0 p a t i e n t s . T h e clinical a c t i v i t y of t h e d i s e a s e w a s e s t i m a t e d a c c o r d i n g t o t h e L a n s b u r y a c t i v i t y i n d e x , b a s e d o n t h e f o l l o w i n g six c r i t e r i a : (1) D u r a t i o n of m o r n i n g stiffness, (2) t h e t i m e i n t e r v a l b e t w e e n g e t t i n g o u t of bed a n d t h e o n s e t of f a t i g u e , (3) t h e d a i l y n e e d for a n a l g e s i c s c a l c u l a t e d t o a n e q u i v a l e n t a m o u n t of acetylsalicylic a c i d , (4) g r i p s t r e n g t h m e a s u r e d b y

sphygmomanometer,

(5) j o i n t i n d e x b a s e d o n j o i n t t e n d e r n e s s t o p r e s s u r e o r p a s s i v e m o v e m e n t a n d t h e size of t h e j o i n t s i n v o l v e d , a n d (6) e r y t h r o c y t e s e d i m e n t a t i o n r a t e . Soft t i s s u e r a d i o g r a p h y of t h e h a n d s w a s p e r f o r m e d molybdenum

using a combination

t a r g e t e q u i p m e n t f o r m a m m a r y r a d i o g r a p h y a n d i m m e r s i o n of

of the

h a n d s in a 2.5 c m l a y e r of 1 : 1 e t h a n o l - w a t e r s o l u t i o n ( M A K E L A & H A A T A J A 1976). T h e radiologic abnormalities were scored as follows: 1) All p r o x i m a l i n t e r p h a l a n g e a l a n d m e t a c a r p o p h a l a n g e a l j o i n t s a n d t h e r a d i a l a n d u l n a r p a r t s of t h e w r i s t w e r e e x a m i n e d for t h e p r e s e n c e of e r o s i o n s a n d s c o r e d a s follows: 0 = n o erosion, 1 = subperiosteal osteolytic region representing a pre-erosive lesion, 2 = o n e pocketed erosion or surface erosion, 3 = t w o or m o r e erosions. T h e t o t a l m a x i m u m s c o r e for e r o s i o n s w a s 6 6 .

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SOFT TISSUE R A D I O G R A P H Y

393

Fig. 4. Same case as in Fig. 3. One year later. Grade I swelling in 2nd proximal interphalangeal joint; grade 3 swelling and periarticular oedema in 4th and 5th proximal interphalangeal joints. Deteriorating erosive lesions especially in 2nd proximal interphalangeal joint.

2) T h e s a m e r e g i o n s w e r e a l s o e x a m i n e d f o r e v i d e n c e of j o i n t c a p s u l e t h i c k e n i n g a n d swelling a n d s c o r e d a s f o l l o w s : 0 = n o s w e l l i n g , 1 = slight t h i c k e n i n g , 2 = d e f i n i t e swelling, 3 = m a s s i v e swelling. T h e h i g h e s t p o s s i b l e j o i n t s w e l l i n g s c o r e w a s t h u s 6 6 . 3) T h e s a m e j o i n t s w e r e a l s o i n v e s t i g a t e d for e v i d e n c e of p e r i a r t i c u l a r o e d e m a a s s u g g e s t e d b y b l u r r i n g of t h e o u t l i n e of t h e j o i n t c a p s u l e o r t h e p r e s e n c e of a slightly m o t t l e d s t r u c t u r e a r o u n d t h e j o i n t . D i l a t e d vessels p r o x i m a l t o a j o i n t w e r e a l s o c o n ­ s i d e r e d e v i d e n c e of p e r i a r t i c u l a r o e d e m a . T h e n u m b e r of j o i n t s t h u s affected

was

c o u n t e d , a n d t h e m a x i m u m s c o r e for j o i n t o e d e m a w a s 2 2 . I n 33 p a t i e n t s m e a s u r e m e n t of r a d i o a c t i v e " T c

m

a c c u m u l a t i o n in t h e h a n d

and

w r i s t w a s p e r f o r m e d u s i n g a m o d i f i c a t i o n of t h e m e t h o d d e s c r i b e d b y O K A e t c o l l . ( 1 9 7 3 ) . T h i r t y m i n u t e s after i n t r a v e n o u s injection of o n e m C i of " T c - p e r t e c h n e t a t e , m

a c t i v i t y d i s t r i b u t i o n w a s r e c o r d e d by a Single C h a n n e l A n a l y s e r A S - 1 1 ( W a l l a c e O y , F i n l a n d ) . A c t i v i t y w a s m e a s u r e d for a t o t a l of 30 s e c o n d s o v e r b o t h h a n d a n d w r i s t u s i n g a 30 c m d e t e c t o r - s k i n d i s t a n c e . T h e c e n t r e of t h e field w a s f o c u s e d

midway

b e t w e e n t h e m e t a c a r p o p h a l a n g e a l j o i n t s a n d t h e w r i s t o n t h e d o r s u m of t h e h a n d w i t h t h e fist c l e n c h e d . F o r b a c k g r o u n d a c t i v i t y , p u l s e s o v e r t h e h e a r t a n d b l a d d e r

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394

P . MAKELA A N D M. HAATAJA

Fig. 5. Female, aged 55, with rheumatoid arthritis for over 6 years. Mainly degenerative joint changes without erosion or periarticular oedema, and with some joint capsule thickening in proximal interphalangeal joints and 5th metacarpophalangeal joint. The rheumatoid arthritis was not clinically active.

w e r e a l s o r e c o r d e d for 3 0 s. T h e T c - i n d e x for t h e h a n d w a s c a l c u l a t e d b y d i v i d i n g t h e v a l u e of t h e p u l s e s o b t a i n e d o v e r t h e h a n d by t h e m e a n v a l u e of t h e p u l s e s o v e r t h e h e a r t a n d b l a d d e r . In t h e s e 33 p a t i e n t s s c o r e s for e r o s i o n s , j o i n t swelling a n d p e r i a r t i c u l a r o e d e m a w e r e e s t i m a t e d f o r t h e r i g h t a n d t h e left h a n d s e p a r a t e l y . C o ­ efficients f o r l i n e a r c o r r e l a t i o n b e t w e e n v a r i a b l e s w e r e e s t i m a t e d a c c o r d i n g t o t h e P e a r s o n m e t h o d . C o r r e s p o n d i n g p - v a l u e s w e r e o b t a i n e d f r o m t h e statistical t a b l e s of D o c u m e n t a G e i g y ( 1 9 6 0 ) . E x a m p l e s of soft t i s s u e r a d i o g r a p h y r e s u l t s , a n d c o r r e ­ s p o n d i n g s c o r e s , a r e given in F i g s 1 t o 5.

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SOFT TISSUE R A D I O G R A P H Y

Table Mean, range and standard deviation of Lansbury indices and radiologic scores (ft = 67)

Lansbury activity index Erosion score Joint swelling score Periarticular oedema score

Mean

Range

SD

68.99 17.18 14.10 3.90

8-125 0-48 0-37 0-14

31.36 9.44 13.47 3.25

Results T h e m e a n , range a n d s t a n d a r d deviation for L a n s b u r y indices, scores for erosions, j o i n t c a p s u l e swelling a n d o e d e m a a r e e x p r e s s e d i n t h e T a b l e . F i g s 6 t o 8 r e p r e s e n t s c a t t e r d i a g r a m s for t h e a s s o c i a t i o n b e t w e e n d i f f e r e n t r a d i o l o g i c s c o r e s a n d t h e c o r ­ r e s p o n d i n g L a n s b u r y i n d e x v a l u e s . T h e y a l s o s h o w t h e coefficients f o r r e g r e s s i o n ( + S D ) a n d coefficients f o r c o r r e l a t i o n . T h e s e a r e all h i g h l y s i g n i f i c a n t ( p < 0 . 0 0 1 ) . T h e h i g h e s t c o r r e l a t i o n coefficient is o b t a i n e d b e t w e e n t h e s c o r e f o r o e d e m a

and

L a n s b u r y i n d e x (r = 0.654) a n d t h e l o w e s t b e t w e e n t h e s c o r e f o r e r o s i o n s a n d t h e L a n s b u r y i n d e x (r = 0.486). N o significant c o r r e l a t i o n w a s f o u n d b e t w e e n L a n s b u r y i n d e x a n d t h e a g e of t h e p a t i e n t s o r t h e d u r a t i o n of t h e d i s e a s e . C o r r e l a t i o n s b e t w e e n t h e s c o r e s f o r d i f f e r e n t l e s i o n s w e r e all h i g h l y significant, t h e c l o s e s t c o r r e l a t i o n b e i n g t h a t b e t w e e n s c o r e s for swelling a n d o e d e m a (r = 0 . 7 3 2 ) . C o r r e l a t i o n coefficients b e t w e e n s c o r e s f o r e r o ­ s i o n s a n d s c o r e s for j o i n t s w e l l i n g a n d b e t w e e n s c o r e s f o r e r o s i o n s a n d s c o r e s f o r o e d e m a w e r e r = 0.689 a n d r = 0 . 4 6 3 , r e s p e c t i v e l y . T h e n u m b e r of e r o s i o n s w a s a l s o o b s e r v e d t o c o r r e l a t e t o t h e d u r a t i o n of t h e d i s e a s e , b u t t h i s w a s n o t s o f o r s w e l l i n g a n d o e d e m a . T h i s o b s e r v a t i o n s u p p o r t s t h e c o n c e p t of t h e p a r t l y r e v e r s i b l e n a t u r e of j o i n t swelling a n d o e d e m a . m

T h e " T c - i n d i c e s o b t a i n e d f r o m 6 6 h a n d s of 33 p a t i e n t s r a n g e d f r o m 0 . 3 3 t o 0 . 0 6 ( m e a n 0.17, S D 0.06). A h i g h l y s i g n i f i c a n t c o r r e l a t i o n e x i s t e d b e t w e e n t h e L a n s b u r y m

i n d e x a n d t h e " T c - i n d e x of t h e h a n d s (r = 0 . 4 0 3 ) . F i g s 9 a n d 10 give t h e c o r r e l a t i o n b e t w e e n s c o r e s for j o i n t swelling a n d T c - i n d e x a n d b e t w e e n s c o r e s f o r p e r i a r t i c u l a r o e d e m a a n d T c - i n d e x in c o r r e s p o n d i n g h a n d s . T h e s e c o r r e l a t i o n coefficients

are

b o t h significant ( p < 0 . 0 1 ) . Discussion A n a c c u r a t e d e t e r m i n a t i o n of t h e a c t i v i t y of t h e r h e u m a t o i d a r t h r i t i s is m a n d a t o r y in t h e a s s e s s m e n t of t h e effectiveness of v a r i o u s t r e a t m e n t s . S i g n s a n d s y m p t o m s a s well a s l a b o r a t o r y f i n d i n g s h a v e often b e e n u s e d in m e a s u r i n g t h e i m p r o v e m e n t i n t h e p a t i e n t ' s c o n d i t i o n w h i l e s t r u c t u r a l c h a n g e s (as d e m o n s t r a t e d , f o r e x a m p l e , b y r a d i o l o g y ) h a v e b e e n g i v e n less a t t e n t i o n .

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396

P . MAKELA A N D M. HAATAJA Erosion

score

5 On

40

30-

20

Fig. 6. Scatter diagram of erosion score and Lansbury activity indices. b = 0.20819 + 0.0464***. r = 0.486***. n = 67. 10

Joint

20

swelling

30

40

50

60

70

50

60

70

90

100 110 120 130 L a n s b u r y index

90

100 110 120 130 Lansbury index

score

40 i

30

20

Fig. 7. Scatter diagram of joint swelling score and Lansbury activity indices, b = 0.1729 + 0.0305***. r = 0.574***. n = 67.

10

10

20

30

40

Periarticular o e d e m a 15

80

score

n

10-

Fig. 8. Scatter diagram of peri­ articular oedema score and Lansbury activity indices. b = 0.067741+0.0097***. r = 0.654***. n = 67.

1 0 2 0

30

40

50

60

70

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80

90

100 110 120 130 Lansbury index

397

SOFT TISSUE R A D I O G R A P H Y Joint

swelling

Periarticular o e d e m a score

score

10i

20n

15

O o

10

00 e

o

o

o o

e

OO OO 0 o ©

00

o o°°P 3 o

o o o O O oo

oo

o

e

o

o OO

»

o 20

10

o

30

oo

Oo oo o

10

40

o 20

m

"Tc -index

40 m

Tc -index

Fig. 10

Fig. 9 Fig. 9. Scatter diagram of joint swelling score and " T c n = 66.

30 9 9

m

indices. b = 27.1335+ 8.69**. r - 0 . 3 6 3 * * .

Fig. 10. Scatter diagram of periarticular oedema score and " T c r = 0.361**. n = 66.

m

indices. b = 12.325 + 3.9861**.

Analgesics a n d anti-inflammatory drugs are t h o u g h t to have a t e m p o r a r y

effect

o n s e v e r a l signs w i t h o u t h a v i n g a n y effect o n t h e c o u r s e a n d p r o g n o s i s of t h e d i s e a s e . I t h a s b e e n s u g g e s t e d t h a t serial d e t e r m i n a t i o n s of E S R a n d C - r e a c t i v e p r o t e i n t o ­ g e t h e r w i t h a n i n c r e a s e of e r o s i o n s d e m o n s t r a t e d a t r a d i o g r a p h y is m o r e ( A M O S et coll.

useful

1977).

S i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s h a v e b e e n f o u n d b e t w e e n t h e e x t e n t of r a d i o ­ g r a p h i c a b n o r m a l i t i e s o r t h e r a t e of p r o g r e s s i o n of r a d i o g r a p h i c l e s i o n s a n d s e v e r a l clinical a n d l a b o r a t o r y m a n i f e s t a t i o n s ( S H A R P e t c o l l . 1 9 7 1 ) . I n t h e l a t t e r

report,

n a r r o w i n g of t h e j o i n t s p a c e a n d t h e n u m b e r of e r o s i o n s w e r e s c o r e d . H o w e v e r , t h e s e l e s i o n s a r e i r r e v e r s i b l e , a n d t h e a c t u a l a c t i v i t y of t h e d i s e a s e p r o c e s s c a n n o t

be

m e a s u r e d . By u s i n g a h i g h r e s o l u t i o n r a d i o g r a p h i c t e c h n i q u e i n c r e a s e of e r o s i o n s can be demonstrated even within a three m o n t h follow-up period ( M A K E L A & H A A T A J A ) . H o w e v e r , i n c r e a s e of e r o s i o n s a n d j o i n t s p a c e n a r r o w i n g is s o m e t i m e s d e m ­ o n s t r a t e d i n p a t i e n t s w i t h o u t clinical e v i d e n c e of a c t i v e d i s e a s e ( K A R T E N e t c o l l . 1972).

L i t t l e i n f o r m a t i o n is a v a i l a b l e a b o u t m o r p h o l o g i c c h a n g e s i n t h e e a r l i e s t p h a s e of the disease. Biopsies h a v e n o t been p e r f o r m e d until several days after the a p p a r e n t o n s e t of a n a c u t e a t t a c k . K U L K A ( 1 9 5 9 ) s u g g e s t e d t h a t v e n u l i t i s is t h e c a r d i n a l p r i m a r y p a t h o l o g i c e v e n t i n t h e d i s e a s e p r o c e s s . C O O P E R ( 1 9 6 8 ) r e g a r d e d t h e a g g r e g a t i o n of

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398

P. MAKELA A N D M. HAATAJA

i n f l a m m a t o r y cells a r o u n d d i l a t e d v e n u l e s a s a p r e l u d e t o m i g r a t i o n of t h e s e b l o o d b o r n e cells. T h e s y n o v i a l m e m b r a n e is g e n e r a l l y a g r e e d t o b e t h e site of o r i g i n of t h e p r o c e s s . E x u d a t i o n a n d o e d e m a a r e t h e m o s t s t r i k i n g f e a t u r e s in t h e e a r l y s t a g e ( G A R D N E R 1972). J o i n t effusion r e s u l t s a s a s e c o n d a r y p h e n o m e n o n f r o m t h e s p r e a d of t h e s e i n f l a m m a t o r y c o m p o n e n t s f r o m t h e s y n o v i a l m e m b r a n e . I n t h e a c u t e p h a s e s w e l l i n g a n d t h i c k e n i n g of t h e j o i n t c a p s u l e a r e p a r t l y d u e t o e x t e n s i o n of t h e s y n o v i a l oedema. I n t h e l a t e r s t a g e of t h e d i s e a s e t h i s t h i c k e n i n g m a i n l y r e s u l t s f r o m s c a r f o r m a t i o n a n d t h u s r e s e m b l e s t h e i r r e v e r s i b l e b o n e a n d j o i n t a b n o r m a l i t i e s ( C O O P E R ) . T h i s is in a c c o r d a n c e w i t h t h e r e s u l t s of t h e p r e s e n t i n v e s t i g a t i o n a n d p e r i a r t i c u l a r o e d e m a a p p e a r s t o b e t h e l e s i o n w h i c h h a s t h e c l o s e s t c o r r e l a t i o n t o t h e clinical a c t i v i t y i n d i c e s r e f l e c t i n g t h e a c u t e i n f l a m m a t o r y r e a c t i o n . T h e v a l u e of o b s e r v i n g t h e o e d e m a i n l o n g - t e r m e v a l u a t i o n n e e d s c l o s e r i n v e s t i g a t i o n . I n t h e p r e s e n t series o n l y a few patients were followed for a long period. A c l o s e c o r r e l a t i o n w i t h t h e r e s u l t s of j o i n t s c i n t i g r a p h y p r o v e s t h a t i n c r e a s e d b l o o d f l o w in j o i n t r e g i o n s , j o i n t s w e l l i n g a n d o e d e m a all i n d i c a t e a c t i v e s y n o v i t i s . V a s c u l a r d i l a t a t i o n is o f t e n s e e n i n soft t i s s u e h a n d films p r o x i m a l t o a s y n o v i t i c j o i n t ( F I S C H E R & B R A U N 1973). T h e r m o g r a p h y h a s a l s o b e e n u s e d f o r d e m o n s t r a t i o n of a c t i v e s y n o v i t i s b u t a p p e a r s t o b e i n f e r i o r t o j o i n t s c i n t i g r a p h y ( M A X F I E L D et coll.). O n e m a j o r d i s a d v a n t a g e of t h i s soft t i s s u e r a d i o g r a p h i c m e t h o d is t h e c o n s i d e r a b l e l o c a l s k i n r a d i a t i o n d o s e w h i c h w o u l d a p p e a r t o l i m i t its u s e in s t a n d a r d e x a m i n a t i o n s , p a r t i c u l a r l y i n t h e c a s e of c h i l d r e n . T h e u s e of l o w - d o s e m a m m a r y

radiography

techniques possibly provides o n e solution t o this p r o b l e m .

SUMMARY T h e value of soft tissue r a d i o g r a p h y in assessing t h e activity of r h e u m a t o i d arthritis was investigated in 67 patients a n d correlated t o the clinical activity of t h e disease. Soft tissue r a d i o g r a p h y using a technique for m a m m a r y r a d i o g r a p h y was combined with immersion. Radiologically d e m o n s t r a t e d periarticular o e d e m a was m o s t closely correlated t o clinical activity. A close correlation also existed between soft tissue r a d i o g r a p h i c lesions a n d " T c a c c u m u l a t i o n in h a n d s . m

ZUSAMMENFASSUNG D e r W e r t der rontgenologischen Weichteildiagnostik zur Feststellung der Aktivitat einer r h e u m a t i s c h e n Arthritis w u r d e bei 67 Patienten untersucht u n d zur klinischen Aktivitat der E r k r a n k u n g korreliert. D i e Weichstrahlaufnahmen, wie sie fiir Brustuntersuchung verwendet werden, w u r d e n mit einer I m m e r s i o n k o m b i n i e r t . D a s rdntgenologisch nachweisbare periartikulare O d e m w a r a m engsten zur klinischen Aktivitat korreliert. Eine enge K o r r e l a t i o n bestand a u c h zwischen den rontgenologisch nachweisbaren WeichteilV e r a n d e r u n g e n u n d der " T c A u f n a h m e in d e n H a n d e n . m

RESUME Les auteurs o n t etudie l'interet d e la r a d i o g r a p h i c des tissus m o u s p o u r juger l'activite de la polyarthrite rhumato'ide sur 67 malades et l'ont correlee a l'activite clinique de la maladie. L a r a d i o g r a p h i c des parties molles utilisant u n e technique d e radiographic m a m m a i r e a ete

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SOFT TISSUE R A D I O G R A P H Y

399

associee avec r i m m e r s i o n . L ' o e d e m e periarticulaire m o n t r e p a r la r a d i o g r a p h i e est e n rela­ tion tres etroite avec l'activite clinique. 11 y a aussi u n e correlation etroite entre les lesions r a d i o g r a p h i q u e s des tissues m o u s et la fixation d u " T c d a n s les m a i n s . m

R E F E R E N C E S A M O S R . S., CONSTABLE T. J . , C R O C K S O N R . A . , C R O C K S O N A . P . a n d M C C O N K E Y B . : R h e u ­

m a t o i d arthritis. Relation of serum C-reactive protein a n d erythrocyte s e d i m e n t a t i o n rates t o r a d i o g r a p h i c changes. Brit. m e d . J . 1 (1977), 195. BERENS D . L., L O C K I E L . M . , L I N R . a n d N O R C R O S S B . M . : R o e n t g e n changes in early

r h e u m a t o i d arthritis. Radiology 82 (1964), 645. BOAS N . F . : T h e r m o g r a p h y in r h e u m a t o i d arthritis. A n n . N . Y . A c a d . Sci. 121 (1964), 2 2 3 . COOPER N . S.: P a t h o l o g y of r h e u m a t o i d arthritis. M e d . Clin. N . A m e r . 52 (1968), 607. D o c u m e n t a Geigy Wissenschaftliche Tabellen: 6. Auflage J . R . Geigy A . G . , Basel 1960. ECCLES M . : H a n d volumetrics. Brit. J . phys. M e d . 19 (1956), 5. FISCHER E.: D i e rontgenologische Weichteildiagnostik d e r rheumatischen Arthritis. (Weichstrahlaufnahmen der H a n d . ) In: Klinisch-Radiologisches Seminar, B a n d 3, p . 17. G e o r g Thieme Verlag, Stuttgart 1973. — u n d B R A U N J . : N e u e diagnostische Moglichkeiten a n d e n E x t r e m i t a t e n d u r c h Weichstrahlaufnahmen m i t M a m m o g r a p h i e g e r a t e n . Electromedica 3 (1973), 90. G A R D N E R D . : Articular tissues. G r o s s a n d microscopic pathology. In: T h e p a t h o l o g y of r h e u m a t o i d arthritis, p . 7. E d w a r d A r n o l d Publishers, L o n d o n 1972. G O M E Z E., G R E E N F . A . a n d H A Y S M . T . : N e w t e c h n i q u e s for identification of synovitis

a n d evalutation of joint disease. Bull, r h e u m . D i s . 25 (1974), 786. HAATAJA M . : E v a l u a t i o n of t h e activity of r h e u m a t o i d arthritis. Scand. J . R h e u m . 4 (1975) Suppl. N o . 7. H A R T F . a n d C L A R K C : M e a s u r e m e n t of digital swelling in r h e u m a t o i d arthritis. L a n c e t 1 (1951), 775. K A R T E N I . , O ' B R I E N W . M . , B E C K E R M . H . a n d M C E V E N C : A r t i c u l a r erosions in r h e u m a ­

toid arthritis. J . c h r o n . D i s . 25 (1972), 449. K U L K A J . P . : T h e pathogenesis of r h e u m a t o i d arthritis. J . c h r o n . D i s . 10 (1959), 388. LANSBURY J . : M e t h o d s for evaluating r h e u m a t o i d arthritis. In: Arthritis a n d allied c o n d i ­ tions, p . 269. Edited by J . Hollander. L e a & Febiger, Philadelphia 1966. L O C K I E L . M . : T r e a t m e n t of t h e c o m m o n forms of arthritis. Ariz. M e d . 10 (1953), 2 2 1 . M A K E L A P . a n d HAATAJA M . : Soft tissue r a d i o g r a p h y of t h e h a n d s in t h e r h e u m a t o i d arthri­ tis. Scand. J . R h e u m . 5 (1976), 113. MAXFIELD W . S., W E I S S T . E . a n d SHULER S. E . : Synovial m e m b r a n e scanning in arthritic disease. Sem. nucl. M e d . 2 (1972), 50. O K A M . , R E N K O N E N A . a n d R U O T S I A . : Technetium-99m in t h e study of r h e u m a t i c joints. Acta r h e u m , scand. 16 (1970), 2 7 1 . and K U I K K A J . : M e a s u r e m e n t of systemic inflammatory activity in r h e u m a t o i d arthritis by the Tc-99m m e t h o d . Scand. J . R h e u m . 2 (1973), 101. R E I C H M A N N S., D E I C H G R A B E R E., S T R I D F . , H E Y M A N F . a n d S T R A N D T . : Soft tissue r a d i o ­

g r a p h y of finger joints. A c t a radiol. Diagnosis 15 (1974), 439. R O P E S M . , B E N N E T G., C O B B S., J A C O X R . a n d JESSAR R . : 1958 revision of d i a g n o s t i c criteria

for r h e u m a t o i d arthritis. A r t h r . a n d R h e u m . 2 (1959), 16. S H A R P J . T., L I D S K Y M . D . , C O L L I N S L . C . a n d M O R E L A N D J . : M e t h o d s for s c o r i n g t h e

progression of radiologic changes in r h e u m a t o i d arthritis. C o r r e l a t i o n of radiologic, clinical a n d l a b o r a t o r y abnormalities. A r t h r . a n d R h e u m . 14 (1971), 706.

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S M Y T H C , V E L A Y O S E . a n d H L A D C . : A m e t h o d for m e a s u r i n g swelling of h a n d s a n d feet.

A c t a r h e u m , scand. 9 (1963), 293. STEINBACH H . L . a n d JENSEN P . S.: R o e n t g e n o g r a p h s changes in t h e arthritides. P a r t 1. Sem. A r t h r . R h e u m . 5 (1975), 167. SOILA P . : R o e n t g e n manifestations of adult r h e u m a t o i d arthritis. W i t h special regard to t h e early changes. A c t a r h e u m , scand. (1958). Suppl. N o . 1.

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Soft tissue radiography for evaluating clinical activity of rheumatoid arthritis.

FROM T H E DEPARTMENT (DIRECTOR: PROF. OF RADIOLOGY (DIRECTOR: P R O F . P . VIRTAMA) A N D MEDICINE L. KALLIOMAKl), TURKU UNIVERSITY HOSPITAL,...
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