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Rheumatology 2001; 40: 1141-1145
© 2001 British Society for Rheumatology

Original Papers

Radiographic joint space in rheumatoid elbow joints. A 15-year prospective follow-up study in 74 patients

J. T. Lehtinen, K. Kaarela, E. A. Belt, M. J. Kauppi, E. Skyttä, P. P. Kuusela, H. J. Kautiainen and M. U. K. Lehto1

Rheumatism Foundation Hospital, Heinola and
1 Tampere University Hospital, Tampere, Finland


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objective. To evaluate radiographically the humeroulnar (HU) and humeroradial (HR) joint spaces in patients with long-term rheumatoid arthritis (RA).

Methods. An inception cohort of 74 patients with RA were followed for 15 yr. At the end-point, 148 elbows were radiographed by a standard method. The HU and HR joint spaces were examined from the anteroposterior radiographs by measuring the shortest tangential distance in the middle of the joints. Destruction of the elbow joints, assessed with the Larsen method on a scale of 0–5, was studied in relation to the joint-space measurements.

Results. Mean (s.d.) HU joint space (n=148) in RA patients was 2.5 (1.1) mm, range 0–4 mm [2.9 (0.8) mm in men and 2.4 (1.1) mm in women]. Mean (s.d.) HR joint space (n=140) was 2.3 (0.9) mm, range 0–4 mm [2.5 (0.8) mm in men and 2.3 (1.0) mm in women]. HU and HR spaces of the affected joints (Larsen grades 2–5) [1.9 (s.d. 1.1) and 1.8 (0.9) mm respectively] were notably narrower than those of the unaffected (Larsen grades 0–1) joints [3.1 (0.7) and 2.9 (0.6) mm]. All the joints graded as Larsen 4 or 5 (n=13) had a value of 0 mm for both joint spaces. Both the HU and the HR joint-space narrowing was associated with increasing destruction (Larsen grading) of the joint. [r=-0.69 (95% CI -0.77 to -0.60) and r=-0.70 (-0.78 to -0.60)]. The monotonic narrowing was significantly increasing from unaffected (Larsen 0, 1), slightly (2), moderately (3) to severely (4, 5) affected joints (P<0.001). A step in this process occurred between Larsen grades 3 and 4, when the mean joint space diminished from 1.4 and 1.5 respectively to 0 mm.

Conclusions. Joint-space narrowing is a frequent consequence of rheumatoid affection of the elbow joint. HR joint space decreases together with HU joint space; however, the HR joint space is already slightly narrower at the start. The narrowing is a rather late phenomenon, occurring only after erosive destruction. This should be borne in mind when using the Larsen method to evaluate changes in the elbow joint.

KEY WORDS: Rheumatoid arthritis, Elbow joint, Joint space, Radiography, Larsen method.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Half of all patients with rheumatoid arthritis (RA) suffer from elbow destruction [1–3]. When investigating the cause of pain and following the course of the disease in RA, plain radiographs continue to be the primary diagnostic means of evaluating the elbow joint [4–6].

In RA, diminution of the elbow joint space is a common radiographic finding [4, 7–11]. The widely used Larsen grading for elbow joints is partly based on joint-space narrowing [12]. Joint-space narrowing has been proposed to be similar in the humeroradial (HR) and humeroulnar (HU) joints or to be greater in the HR joint, and to occur in various stages of the disease process [4, 7–11]. However, rheumatoid HR and HU joint-space measurements from radiographs have not been published to our knowledge, and the reported narrowing in rheumatoid elbow joints has been based on visual evaluation of radiographs [4, 7–11].

We studied the HU and HR joint space in a cohort of 74 patients with RA followed up for 15 yr.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
During 1973–75, a total of 121 patients with recent (<6 months) RA were studied at the Rheumatism Foundation Hospital in Heinola. The selection criteria, data collection strategy and details of the patients have been described elsewhere [13, 14]. At the 3-yr follow-up, 102 patients were positive for rheumatoid factor and had erosive RA. After the 3-yr check-up, 24 had died. Four patients failed to attend the 15-yr follow-up. Thus, 74 patients (18 males and 56 females) were the subjects of the present study. The age at the onset of disease ranged from 17 to 66 yr [mean 42 (S.D. 12) yr].

Anteroposterior (AP) and lateral radiographs of all 148 elbows were taken at the 15-yr check-up [mean 15 (S.D. 1) yr]. The following standard positioning was used for the AP view: patient sitting with shoulder in 90° flexion and elbow extended at 180° on the examination table, the hand supinated, the radius and the ulna in the same plane, palm facing upwards. The same radiographer confirmed correct positioning and took the radiographs using a standard technique. The straight AP projection (distance 0.95 m) was used with exposure factors of 45 kV and -50 mAs. The film (Agfa Scopix) format was 18x24 cm.

The HU and HR joint spaces were measured from the midpoint of the articular surfaces of the head of the radius and the coronoid process of the ulna to the corresponding articular surfaces of the capitellum and the trochlea of the humerus. In this AP projection, the joint spaces were measured as the shortest perpendicular distances between the articular surfaces (Fig. 1Go). When the original bony outlines had disappeared and the ulna or the radius protruded into the humerus, the joint space was evaluated as 0 mm.



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  		FIG. 1. HU and HR joint space measurement methods used in this study. See text for further details.

 
The elbow joints were classified according to the standard reference films of six Larsen grades from 0 to 5 [12]. Ten synovectomies and one excision arthroplasty had been performed in nine elbows of seven patients (two bilateral synovectomies). Excision of the head of the radius had been combined with synovectomy in eight elbows. One elbow had undergone resynovectomy and one elbow excision arthroplasty after synovectomy. No total elbow replacement had been done. The HR joint-space was not measured in the eight elbows with resection of the head of the radius.

Statistical comparison between elbows with different stages of destruction was performed using the Jonckheere test for ordered alternatives. Correlations were estimated with the Spearman correlation coefficient.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
There was no systematic right–left difference in either sex, and the measurements of the two sides were therefore pooled. Mean HU joint space (n=148) in RA patients was 2.5 (S.D. 1.1) mm, range 0–4 mm [2.9 (0.8) mm in men and 2.4 (1.1) mm in women]. Mean (S.D.) HR joint space (n=140) was 2.3 (0.9) mm, range 0–4 mm [2.5 (0.8) mm in men and 2.3 (1.0) mm in women]. The results of the measurements from different measuring sites for both men and women are presented separately for the right and left sides in Table 1Go. The Spearman correlation coefficients between right and left values were 0.54 [95% confidence interval (CI) 0.36 to 0.58] for the HU space and 0.61 (95% CI 0.44 to 0.74) for the HR space.


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  		TABLE 1. Elbow joint space at HU and HR joints [mm; mean (S.D.)]

 
The mean (S.D.) HU and HR spaces of the affected joints (Larsen grades 2–5) [1.9 (1.1) and 1.8 (0.9) mm respectively] were narrower than those [3.1 (0.7) and 2.9 (0.6) mm] of the unaffected (Larsen grades 0 and 1) joints. All the joints graded as Larsen 4 or 5 had a value of 0 mm for both joint spaces. Only one non-erosive (Larsen grade <2) but clearly osteoarthritic elbow had a joint space (both HU and HR) of 0 mm. Joint-space narrowing of both HU and HR was associated with increasing destruction (Larsen grading) of the joint [HU, r=-0.69 (95% CI -0.77 to-0.60); HR, r=-0.70 (95% CI -0.78 to -0.60)].

All the HU and HR joint-space values for Larsen grades for both men and women are shown in Fig. 2Go. The mean (S.D.) HU joint spaces for Larsen grades 0–5 were as follows: grade 0 (n=36), 3.2 (0.6) mm; grade 1 (n=37), 3.1 (0.8) mm; grade 2 (n=49)=2.5 (0.6) mm; grade 3 (n=13)=1.4 (0.5) mm; grade 4 (n=4)=0 (0) mm; grade 5 (n=9)=0 (0) mm. The mean (S.D.) HR joint spaces were as follows: grade 0 (n=36)=2.9 (0.5) mm; grade 1 (n=37)=2.8 (0.7) mm; grade 2 (n=48)=2.1 (0.6) mm; grade 3 (n=10)=1.5 (0.5) mm; grade 4 (n=3)=0 (0) mm; grade 5 (n=6)=0 (0) mm.



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  		FIG. 2. (a) Distribution of 148 HU joint space values according to the Larsen grading of the elbow for men and women. (b) Distribution of 140 HR joint space values according to the Larsen grading of the elbow for men and women.

 
The distribution of the elbow joints (n=148) according to Larsen grading and mean HU and HR joint spaces for each stage (none=0 to 1; slight=2; moderate=3; severe=4–5) of destruction are shown in Table 2Go. The monotonic decrease in joint space between different stages of destruction was statistically highly significant (P<0.001).


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  		TABLE 2. Radiographic assessement of 74 RA patients according to Larsen grading of elbow joints and HU and HR joint space [mm; mean (S.D.)]

 


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
The results of the present study confirm the visually observed joint-space narrowing in rheumatoid elbow joints [4, 7–11]. The mean joint spaces of affected rheumatoid elbows were noticeably narrower than those of the unaffected (Larsen grades 0 and 1) joints. We know of no published figures describing normal variation of the joint spaces of the elbow. However, if the mean HU space of the unaffected minus two standard deviations (i.e. 1.7 mm) and the corresponding mean HR space minus two standard deviations (i.e. 1.7 mm) are considered to be the limit for pathological narrowing, almost one in three of the affected (Larsen grades 2–5) elbows fulfilled the criteria. There was neither HU nor HR space left in any of the joints with Larsen grade 4 or 5 destruction, as a consequence of remarkable cartilage destruction. The one unaffected (Larsen grade 1) joint of a carpenter without any HU or HR space left suffered from severe osteoarthritic changes. There were no other non-erosive joints with a joint space less than 2 mm. Therefore, we suggest that joint space less than 2 mm can be considered pathological for both the HU and the HR joint.

Significant joint space reduction did not occur until Larsen grade 4 destruction. However, Larsen grading is partly based on joint-space narrowing [12]. Even unaffected (Larsen grade 1) joints may have slight joint-space narrowing according to Larsen's definition. On Larsen's standard reference films of the elbow, HR joint space is slightly narrowed at grade 1 and the HR and the HU spaces are both clearly narrowed at grade 2. Moreover, these joint spaces have almost disappeared at grade 3 [12]. According to our results, erosions of the elbow joint are followed, not preceded, by joint-space narrowing (Fig. 2Go). This finding is supported by the radiographic assessement for rheumatoid elbow destruction described by Souter [4, 15]. The elbow seems to follow a slower course of cartilage destruction than the weight-bearing hip and knee joints in RA [1, 16, 17]. We have suggested previously that the absence of body weight on the glenohumeral joint may protect the articular cartilage from early thinning, but not from erosions on the articular margin [18]. The same phenomenon has now been observed in the elbow, which supports our findings in the shoulder. Therefore, we suggest that grading of destruction in the non-weight-bearing elbow joint should also be based on erosive destruction, not on joint-space narrowing. Larsen also emphasizes that bony erosion and destruction are the main changes seen when assessing the grade of destruction for all joints [12]. Joint-space narrowing without erosion can be classified as Larsen grade 1, even 0, as this may be due to degeneration without any rheumatoid involvement. However, from grade 2 onwards the degree of erosion should be decisive. Joint-space narrowing is present at Larsen grade 3 (Fig. 3Go) and the space has disappeared at the late stage of destruction (Larsen grades 4 and 5).



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  		FIG. 3. Erosive destruction of the rheumatoid elbow. In spite of moderate erosions (Larsen grade 3), the joint spaces (HU 2 mm, HR 2 mm) are still within the normal range.

 
In the previous literature, which is based on visual observations, the site of joint-space narrowing in the rheumatoid elbow has remained controversial. Although most authors report joint-space narrowing in the rheumatoid elbow as a typical radiological finding, opinion is divided on which site is most affected and on the timing of this process in the course of elbow destruction. According to the present study, joint-space narrowing seems to be a symmetrical finding in both the HU and the HR joint, as described previously [7–9]. However, HR dominance has been reported by Resnick [11] and Stein et al. [19], which might be explained by the measurements on unaffected joints in our study. The HR joint space was already slightly narrower (2.9 vs 3.1 mm) than the HU space in the unaffected joints. However, at grade 3 the mean joint spaces were similar (1.5 and 1.4), before diminution to zero at grade 4. So HU joint destruction does not seem predominant either [10]. Symmetrical loss of both the joint spaces during the destructive process is supported by our observations; most of the destroyed joints had been radiographed previously when indicated clinically.

We conclude that joint-space narrowing in the rheumatoid elbow is an inevitable consequence of rheumatoid affection, and occurs equally in both the HU and the HR joints. The detection of rheumatoid involvement in the elbow joint should be based on erosions, not on joint-space narrowing on the radiograph. This should also be borne in mind when applying Larsen grading to the elbow joint.


   Notes
 
Correspondence to: K. Kaarela, Rheumatism Foundation Hospital, FIN-18120 Heinola, Finland Back


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. Ljung P, Jonsson K, Rydgren L, Rydholm U. The natural course of rheumatoid elbow arthritis: A radiographic and clinical five-year follow-up. J Orthop Rheumatol1995;8:32–6.
  2. Lehtinen JT, Kaarela K, Ikävalko M et al. Incidence of elbow involvement in rheumatoid arthritis. A 15 year endpoint study. J Rheumatol2001;28:70–4.[ISI][Medline]
  3. Gschwend N. Operations in the region of the elbow joint. In: Surgical treatment of rheumatoid arthritis. New York: Georg Thieme Verlag, 1980:45–66.
  4. Souter WA. Surgery of the rheumatoid elbow. Ann Rheum Dis1990;49:871–82.
  5. Kaye JJ. Arthritis: Roles of radiography and other imaging techniques in evaluation. Radiology1990;177:601–8.[Abstract/Free Full Text]
  6. Scutellari PN, Orzincolo C. Rheumatoid arthritis: sequences. Eur J Radiol1998;27:S31–5.
  7. De Sèse S, Debeyre N, Djian A, Manuel R. The elbow joint. In: Carter ME, ed. Radiological aspects of rheumatoid arthritis. Nijmegen: F. E. MacDonald, 1964:115–36.
  8. Berens DL, Ru-Kan L, eds. Elbow. In: Roentgen diagnosis of rheumatoid arthritis. Springfield: Charles C. Thomas, 1969:232–44.
  9. Forrester DM, Brown JC, eds. The elbow. In: Saunders monographs in clinical radiology. Radiology of joint disease. New York: W. B. Saunders, 1987:318–49.
  10. Hastings DE, Kwok J. Rheumatoid elbow deformity. J Bone Joint Surg1982;64B:634.[Free Full Text]
  11. Resnick D, ed. Diagnosis of bone and joint disorders, Rheumatoid arthritis. Philadelphia: W. B. Saunders, 1988:896.
  12. Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films. Acta Radiol Diagn1977;18:481–91.
  13. Kaarela K. Prognostic factors and diagnostic criteria in early rheumatoid arthritis. Scand J Rheumatol1985(Suppl. 57):1–54.
  14. Kaarela K, Kautiainen H. Continuous progression of radiological destruction in seropositive rheumatoid arthritis. J Rheumatol1997;24:1285–7.[Medline]
  15. Souter WA. Surgery for rheumatoid arthritis: Upper limb surgery of the elbow. Current Orthop1989;3:9–13.
  16. Duthie RB, Harris CM. A radiographic and clinical survey of the hip joint in sero-positive rheumatoid arthritis. Acta Orthop Scand1969;40:346–64.[ISI][Medline]
  17. Goldie I, Schlossmann D. Radiologic changes in rheumatoid knee joints before and after synovectomy. Clin Orthop1969;60:98–106.
  18. Lehtinen JT, Kaarela K, Kautiainen HJ, Belt E, Lehto MUK, Kauppi MJ. Radiographic joint space in rheumatoid glenohumeral joints. A 15 year prospective follow-up study in 74 patients. Rheumatology2000;39:288–92.[Abstract/Free Full Text]
  19. Stein H, Dickson RA, Bentley G. Rheumatoid arthritis of the elbow. Pattern of joint involvement, and results of synovectomy with excision of the radial head. Ann Rheum Dis1975;34:403–8.[Abstract/Free Full Text]
Submitted 25 September 2000; Accepted 9 May 2001


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