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Vol. 9. Issue 1.
Pages 38-41 (January - February 2013)
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Vol. 9. Issue 1.
Pages 38-41 (January - February 2013)
Brief Report
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Mutilating/Resorptive Arthritis. A Study of 24 Patients in a Series of 360 Patients With Psoriatic Arthritis
Artritis mutilante/resortiva. Estudio de 24 pacientes de una serie de 360 artritis psoriásicas
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Jesús Rodriguez-Morenoa,��
Corresponding author
, Maria Bonetb, Jordi Del Blanco-Barnusellc, Carmen Castañod, Teresa Clavaguerae, Lourdes Mateo-Soriaf, Daniel Roig-Vilasecag, Jose M. Ruiz-Martinh
a Servicio de Reumatología, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
b Unidad de Reumatología, Hospital Comarcal de l’Alt Penedès, Vilafranca del Penedés, Barcelona, Spain
c Unidad de Reumatología, Hospital Sant Jaume de Calella, Calella de Mar, Barcelona, Spain
d Unidad de Reumatología, Hospital Municipal de Badalona, Badalona, Barcelona, Spain
e Unidad de Reumatología, Hospital de Palamós, Palamós, Girona, Spain
f Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
g Unidad de Reumatología, CAE Cornellà, Cornellà de Llobregat, Cornellà de Llobregat, Barcelona, Spain
h Unidad de Reumatología, Hospital de Viladecans, Viladecans, Barcelona, Spain
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Tables (2)
Table 1. Comparison Between Groups of Affected Patients With PsA With and Without Juxtaarticular Bone Resorption.
Table 2. Description of 24 Patients Affected With Arthritis Mutilans/Resorptive Arthropathy.
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Abstract
Objective

To describe a large series of patients with mutilans/resorptive arthritis (AM) of a representative population of patients with psoriatic arthritis (PsA) and analyze the associated variables.

Methods

Multicenter cross-sectional study of consecutive patients affected by PsA in 8 centers. In patients with swelling or deformity of the hands or feet we performed an anteroposterior rx. The patient was affected by AM if erosive disorder affecting both articular surfaces completely was present.

Results

Of the 360 patients studied, 24 had PsA and AM (6.7%). The duration of their disease was significantly higher, and they exhibited a worse functional capacity as well as more DIP joint affection (p<.05). 30% had radiological changes indistinguishable from nodular osteoarthritis.

Conclusions

AM in PA is associated with a worse functional capacity. Its possible association with nodular hand osteoarthritis deserves further study.

Keywords:
Psoriatic arthritis
Arthritis mutilating
Resorptive arthropathy
Resumen
Objetivo

Describir una serie amplia de pacientes con artritis mutilante/resortiva (AM) de una población representativa de pacientes con artritis psoriásica (APs) y analizar las variables asociadas.

Métodos

Estudio transversal multicéntrico que incluyó de forma consecutiva a los pacientes afectados de APs de 8 centros. A aquellos pacientes con tumefacción o deformidad de manos o pies sospechosa de se les realizó una radiografía antero-posterior. Se consideró que el paciente estaba afectado de AM si presentaba un trastorno erosivo que afectaba totalmente ambas superficies articulares.

Resultados

De los 360 pacientes con APs estudiados, 24 presentaban AM (6,7%). La duración de la enfermedad fue significativamente mayor y presentaban una peor capacidad funcional, así como una mayor afección de IFD (p<0,05). En un 30% se detectaron cambios radiológicos indistinguibles de una osteoartritis nodular.

Conclusiones

La AM en la APs se asocia a una peor capacidad funcional. Su posible asociación con la osteoartritis nodular de manos merece más estudios.

Palabras clave:
Artritis psoriásica
Artritis mutilante
Artropatía resortiva
Full Text
Introduction

In the first descriptions of psoriatic arthritis (PsA),1,2 Wright described a subtype of patients who had involvement of the distal interphalangeal joints with erosion and resorption of the joint ends and a characteristic shortening of the fingers that he called mutilating arthritis (MA). Apart from the first PsA series published by Wright,1,2 few studies3–6 have mentioned these mutilating forms. In the largest series PsA published to date,4,7–11 the prevalence varies enormously, ranging between 2% and 23%.

There is some confusion in the terminology used (“opera-glass hand syndrome,”12, “main in lorgnette,”13 “arthritis mutilans” or “resorptive arthropathy”5).

The objective of this study was to describe the frequency of MA and study its relationship with other variants of PsA.

Patients and Methods

This was an observational, cross-sectional multicenter PsA study performed in 8 rheumatology centers. All patients met CASPAR14 criteria. The recorded variables are shown in Table 1. We performed an anteroposterior X-ray of the hands and feet in those patients with clinical deformity indicative of MA (shortened fingers) or clinical signs of inflammatory activity in these locations. The patient was considered as having resorptive arthropathy if hands and feet radiographs showed at least one joint with both bone ends shortened without osteophytes.

Table 1.

Comparison Between Groups of Affected Patients With PsA With and Without Juxtaarticular Bone Resorption.

Variable  Arthritis Mutilans/Resorptive Arthropathy (n=24)  No Arthritis Mutilans/Resorptive Arthropathy (n=336)  P 
Age  56.3±12.5  53±13.9  .262 
Age at onset of arthritis  38.9±13  41.5±14.3  .411 
Age at onset of psoriasis  35.6±14.8  34.9±16  .828 
Gender (male/female)  12/12 (50)  166/170 (49.4)  .955 
Duration of arthritis (years)  17.7±9.9  11.5±9.3  .002 
Duration of psoriasis (years)  20.8±11.8  18.3±12.6  .334 
Spondylitis  5 (21.7)  53 (17)  .566 
History of dactilytis  14 (58.3)  137 (44.1)  .175 
Affection of distal interphalangeal joints  17 (70.8)  97 (31.7)  .000 
Nail disease  10 (55.5)  161 (55.5)  .997 
CRP (mg/l)  15.7±13.6  11.5±13.1  .179 
ESR  29±20.1  22.3±15.5  .055 
Painful joints  6.7±7.8  4.6±6.2  .138 
Swollen joints  1.1±1.6  1.6±3.4  .442 
Positive HLA B27  4 (19)  50 (17)  .856 
Treatment with low dose steroid  6 (25)  72 (21.4)  .682 
mHAQ  1.3±0.8  0.6±0.6  .001 
Functional scale (ACR)
I+II  17 (80.9)  300 (93.7)  .05 
III+IV  4 (19.1)  20 (6.3)   
Statistics

We used the chi-square or Fisher's exact test for categorical variables. For quantitative variables we used and Student t and Mann–Whitney nonparametric tests.

We performed a multivariate logistic regression analysis by the “forward stepwise” method, which showed a tight association of the duration of arthritis, and distal interphalangeal and mHAQ condition variables.

Results

Twenty-four patients (6.7%) were diagnosed with MA. The description of the patients is shown in Table 2. The analysis of the different variables in the subgroup of patients with bone resorption and the rest of the patients in the PsA series are shown in Table 1. The duration of arthritis was significantly greater (p<.05) in patients with bone resorption. The distal interphalangeal involvement was significantly more common in patients with resorptive changes (p=.00).

Table 2.

Description of 24 Patients Affected With Arthritis Mutilans/Resorptive Arthropathy.

Patient  Sex  Age  Age at Onset of Psoriasis  Duration Psoriasis  Age at Onset of Arthritis  Duration Arthritis  Pattern of Peripheral Arthritis  Resorption<3 Digits  Single Resorption  “Opera glass hand”  Solo Pies  X-ray Signs of Nodular OA  Distal Interphalangeal  Axial Affection  HLA B27+  Steroids 
EBM  Male  52  17  35  29  23  Polyart           
JCV  Male  30  10  20  13  17  Polyart               
JCT  Male  54  29  25  41  13  Oligoart             
MPP  Female  51  14  37  28  23  Polyart             
CCF  Female  45  24  21  27  18  Polyart                 
EGC  Female  48  14  34  28  20  Polyart           
MTR  Female  65  50  15  49  16  Polyart             
RRT  Female  71  47  24  46  25  Polyart               
PRM  Male  63  51  12  48  15  Polyart               
AGC  Female  64  25  39  48  16  Polyart                 
PLM  Female  49  35  14  35  14  Oligoart             
DPO  Female  77  33  44  63  14  Polyart           
RRS  Female  45  20  25  22  23  Polyart           
JMR  Male  47  35  12  33  14  Polyart             
RBQ  Male  75  41  34  46  29  Polyart               
AVR  Male  65  52  13  58  Polyart           
MCB  Female  45  31  14  33  12  Polyart           
ARM  Male  65  64  58  Polyart           
FCA  Female  56  36  24  39  24  Polyart               
ABP  Female  53  44  27  26  Polyart             
JAGF  Male  46  40  40  Oligoart             
CLS  Male  60  50  10  56  Polyart               
AHC  Male  46  40  39  Polyart             
ARA  Female  80  54  26  29  51  Polyart               

OA: nodular osteoarthritis; Oligoart: oligoarticular; Polyart: Polyarticular.

Functional capacity was worse in this subset of patients, both in the case of that perceived by the physician as well as that according to the ACR scale (p=.05) and self-perceived by the patient in the self-administered mHAQ questionnaire (p=.001). We observed a higher concentration of MA in tertiary health centers (p=.015).

Multivariate analysis showed an association between independent variables of duration of arthritis, distal interphalangeal condition and mHAQ with regard to the dependent variable (presence or absence of MA).

Discussion

The term “arthritis mutilans” generally refers to severe deformities and recalls the “opera glass syndrome” appearance of multiple shortened fingers. But sometimes the resorptive process is not as marked as we have shown in this study, because one third of our patients had less than 3 affected fingers. When the process is limited to the feet it may go unnoticed and 20% in our series had a resorption process limited to the feet. For this reason, we believe that the term “resorptive arthropathy”, based on the X-ray image and coined by Swezey et al.5 better reflects the nature of the process. The “opera glass hand” deformity would be the final stage for some patients where juxtaarticular bone resorption is more severe.

The exact prevalence of MA/resorptive arthropathy in PsA shows very different results that we believe are due to the very heterogeneous definitions used in published series. Our prevalence is slightly higher than other series (6.7%) because we believe that we have included milder forms manifested only in X-rays. When only considering the “opera glass syndrome”, the prevalence in our series is 1.94% and if we take into consideration only those patients who are clinically shown to have shortening of any finger, the frequency of hand or foot affection is 4.4%. When compared with larger and recent ones,4 which use expert opinion consensus or the CASPAR definition of ‘arthritis mutilans’, prevalence is 3.7%.

Most of the joint pattern involved is polyarticular and symmetrical, as we and other authors4 have shown. We have to note that 12.5% of our patients with MA/resorptive arthropathy have an oligoarticular form.

We also observed an association with a longer duration of arthritis, distal interphalangeal involvement and a worse functional capacity measured by the HAQ score and ACR functional scale. CASPAR4 study data also show an association with increased duration of arthritis, but instead do not show a worse functional capacity according to the HAQ score. The fact that it is associated with a longer duration of arthritis can lead one to believe that MA/resorptive arthropathy is a consequence of the inflammatory process in time longer.

One of the incidental findings that was striking in our study is the high frequency (30%) of the association findings of MA and nodular osteoarthritis. The prevalence of nodular osteoarthritis in normal population over 40 years is less than 8.5%.15 We have not found any publication describing this association.

Ethical AspectsProtection of Persons and Animals

The authors declare that the procedures performed conformed to the ethical rules of the human experimentation committee and were in accordance with the World Medical Association and the Helsinki declaration.

Data Confidentiality

The authors declare that all protocols for publication of patient data in their center were followed and all patients included in the study received sufficient information and gave their informed consent in writing in order to participate in the study.

Right to Privacy and Informed Consent

The authors obtained informed consent of the patients and/or subjects referred to in the article. This corresponding author is in possession of this document.

Conflict of Interest

The authors have no conflict of interest to make.

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Please, cite this article as: Rodriguez-Moreno J, et al. Artritis mutilante/resortiva. Estudio de 24 pacientes de una serie de 360 artritis psoriásicas. Reumatol Clin. 2013;9:38–41.

Copyright © 2012. Elsevier España, S.L.. All rights reserved
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