Classifications for rheumatoid arthritis

15.1 Variations in Involvement in rheumatoid arthritis [102]*

Low-grade, intermediate, and severe involvement. There is a great deal about rheumatoid arthritis that is poorly understood. We do not know its cause or have a specific diagnostic test. In our present state of ignorance, it is helpful in making clinical decisions to classify the disease as low-grade, intermediate, or severe.

Post-operative rehabilitation is much easier in those with mild disease. Bone loss is apt to occur more slowly, and they may develop marginal osteophytes similar to those seen in osteoarthritis.

In the more severe form of rheumatoid arthritis, there may be rapid destruction of the joint surfaces with early ascent of the humerus and involvement of the rotator cuff. If shoulder arthroplasties are postponed unnecessarily, severe bone loss and rotator cuff damage can occur needlessly. In one major rheumatoid hospital in the United States, patients underwent an average of four other major arthroplasties (hips, knees or elbows) prior to the first shoulder arthroplasty. The delays in performing shoulder arthroplasty undoubtedly contributed to their very high incidence of rotator cuff defects and severe glenoid bone loss.

Dry, wet, and resorptive. In addition to the variations in severity of the disease as discussed above, there are three clinical types of this condition. As illustrated in Fig. 63 A to C. In the dry form there is sclerosis, subchondral cysts, and loss of joint space. Minimal margin erosion is seen, and marginal osteophytes may form similar to those characteristic of osteoarthritis. The joints tend to be stiffer than in the other types of this disease. Muscle wasting may be intense in patients with juvenile rheumatoid arthritis with this type of disease; however, muscles are usually in better condition in adults. When only a few joints are in-

Fig. 63. Variations in involvement in rheumatoid arthritis. A Dry form with stiffness, sclerosis, and marginal osteophytes similar to those seen in osteoarthritis. B Wet form with inflammation and abundant marginal erosion of the articular surfaces by the destructive granulation. C End-stage bone destruction with complete loss of glenoid and head after years of involvement

Fig. 63. Variations in involvement in rheumatoid arthritis. A Dry form with stiffness, sclerosis, and marginal osteophytes similar to those seen in osteoarthritis. B Wet form with inflammation and abundant marginal erosion of the articular surfaces by the destructive granulation. C End-stage bone destruction with complete loss of glenoid and head after years of involvement volved, many terms have been used, which probably apply to this condition: "inflammatory osteoarthritis", "low-grade rheumatoid arthritis," and "mixed arthritis".

In the wet form there are exuberant granulations with marginal erosion, which causes the ends of the bone to become pointed. Severe destruction of the glenoid may occur not only because of granulation erosion and disuse osteopenia but also because the pointed end of the humerus causes pressure erosion of the glenoid.

There is a wet and resorptive form of rheumatoid arthritis associated with severe bone loss and central migration of the humerus that Neer has termed "centralization".

Centralization: severe loss of bone is associated with loss of the contour of the shoulder. The point of the shoulder becomes flattened and resembles a Burgundy wine bottle without the shoulders of a Bordeaux bottle, a finding that if looked far can easily be seen. This finding is significant in revealing marked bone loss and the probability of difficulty in implanting a glenoid component.

Glenoid Arthritis
Fig. 64. Assessing glenoid water in rheumatoid arthritis on true AP view: stage 1, subcondral bone intact or minimally deformed; stage 2, wear reaching the foot of the coracoid; and stage 3, wear beyond the foot of the coracoid

15.2 Staging of glenoid wear in rheumatoid arthritis according to Levigne and Franceschi [76]*

Glenoid wear was graded as stage 1 when the subcondral bone was intact or minimally deformed, as stage 2 when the wear reached the foot of the coracoid and as stage 3 when it went beyond the foot of the coracoid (Fig. 64).

15.3 Staging of humeral head wear in rheumatoid arthritis according to Levigne and Franceschi [76]*

Wear of the humeral head was graded as stage 1 when the subchondral bone was intact or had micro-geodes, as stage 2 when the anatomical neck was deformed by a notch greater than 10 mm and as stage 3 when the head had lost its spherical form (Fig. 65).

Greater Tuberosity Geode
Fig. 65. Assessing humeral head wear in rheumatoid arthritis on true AP view: stage 1, microgeodes; stage 2, notch in the greater tuberosity; stage 3, loss of spherical form

15.4 Radiological classification of rheumatoid arthritis according to Levigne and Franceschi [76]*

By examining the different preoperative radiographic appearances and particularly by analysing the radiographic history of the many patients followed regularly since their initial diagnosis, the authors were able to distinguish three radiographic forms as defined on two criteria: the sphericity of the humeral head and upward migration of the head in relation to the glenoid (Fig. 66).

■ The "ascending" form. This was the most frequent occurring in 41% in their series. It is characterised by upward migration of the humeral head which precedes glenoid wear. The head retains its sphericity throughout the evolution. Narrowing of the joint space occurs at the superior pole of the glenoid followed by localised wear at this level, which progressively destroys the subchondral bone and gives the glenoid a sinusoidal appearance on the AP radiograph. The humeral head retains its sphericity but migrates upwards, inwards and backwards under the spine of the scapula. It ascends and medialises. At more evolved stage the surgical neck of the humerus comes into contact with the inferior border of the glenoid which leaves an imprint and creates the classical notch on the medial surface of the surgical neck (Fig. 66 a).

a iff Fig. 66. Radiological classification of rheumatoid arthritis, a The ascending form of rheumatoid arthritis. b The centred form of rheumatoid arthritis. c The destructive form of rheumatoid arthritis. (From [76])

■ The "centred" form. This was almost as frequent, occurring in 36% in their series. It is characterised by the absence of upward migration of the humeral head and a progress, uniform wear of he glenoid throughout its height. The humeral head retains its sphericity but pushes into the glenoid like an "egg into an egg-cup". This form is reminiscent of the appearance seen in osteoarthritis and may be accompanied by marginal osteophytes at the superior and inferior poles of the glenoid. The progressive medialisation of the humeral head is followed in time by a reduction in the acromio-humeral distance (Fig. 66b).

■ The "destructive" form. This is less frequent occurring in 19%. It is characterised by destruction of the humeral head which loses its sphericity. Wear occurs at the level of the anatomical neck producing a characteristic notch which progressively wears away at the circum

Larsen Dale Eek

iff Fig. 66. Radiological classification of rheumatoid arthritis, a The ascending form of rheumatoid arthritis. b The centred form of rheumatoid arthritis. c The destructive form of rheumatoid arthritis. (From [76])

Larsen Dale Eek

ference of the neck to give it a "champagne cork" appearance. This very aggressive form of rheumatoid arthritis destroys the glenoid simultaneously. Some of the cases did not display a loss of joint space due to the articular incongruity (Fig. 66 c).

15.5 Radiologic classification of rheumatoid arthritis according to Larsen, Dale, Eek [75]*

The system offers a possibility to reproduce radiographic evaluation of arthritis in the essential joints of the extremities. The reproducibility has been tested several times, with the general result that different observers uniformly graded 90% of films of rheumatoid arthritis. The validity of the radiographic criteria is based on the joint pathology. This system is not specific for rheumatoid arthritis. When new bone formation is not predominant it is possible the evaluate extremity joints in other chronic inflammatory conditions, such as ankylosing spondylitis and psoriatic arthropathy, which are known to present many common features in joint pathology. However, the system is not suited for evaluating juvenile rheumatoid arthritis or arthropathies in childhood with abnormal epiphyseal development. Osteoarthritis may cause abnormalities comparable with grade I, or even more severe grades, particularly in the interphalangeal joint of the finger (erosive, osteoarthritis), in the hips and in the knees. Osteoarthrosis is usually differential diagnosis without considering the clinical and laboratory data, as well as the result of radiography of the spine and sacroiliac joints.

The present system is a purely radiographic evaluation method for arthritis. It should not be considered as a general measure of the severity of the disease:

■ Grade 0. Normal conditions. Abnormalities not related to arthritis, such as marginal bone deposition, may be present.

■ Grade I. Slight abnormality. One or more of the following lesions are present: periarticular soft tissue swelling, periarticular osteoporosis and slight joint space narrowing. When possible, use for comparison a normal contralateral or a previous film of the joint in the same patient. Soft tissue swelling and osteoporosis may be reversible. This stage represents an early uncertain phase of arthritis or a later phase without destruction. Compatible appearances may occur without arthritis in old age, traumatic conditions, Sudeck's atrophy etc.

■ Grade II. Definite early abnormality. Erosion and joint space narrowing corresponding to the standards. Erosion is obligatory except in the weight-bearing joints.

■ Grade III. Medium destructive abnormality. Erosion and joint space narrowing corresponding to the standards. Erosion is obligatory in all joints.

■ Grade IV. Severe destructive abnormality. Erosion and joint space narrowing corresponding to the standards. Bone deformation is present in the weight-bearing joints.

■ Grade V. Mutilating abnormality. The original articular surfaces have disappeared. Gross bone deformation is present in the weight-bearing joints. Dislocation and bony ankylosis, being late and secondary, should not be considered in the grading; if present, the grading should be made according to the concomitant bone destruction or deformation.

There may sometimes, especially in the erosive phase of arthritis, be some disparity between the degree of erosion and the narrowing of the joint space, because loosening of joint ligaments and the presence of excess joint fluid may cause widening of the joint space. If so, the degree of erosion should be the decisive factor when using the present grading system.

This system is recommended for the following purposes:

1. In diagnostic radiology for numerical evaluation of arthritis and for recording of spontaneous variations of the disease.

2. In therapeutic connections, for evaluating disease progression. The system is applicable both in trials of drugs and in synovectomy.

3. In epidemiology of arthritis for exact recording of lesions in individual joints.

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