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Protecting joints with a water-filled glove.

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1437
LETTERS
bandages, administration of an epidural anesthetic, and daily
intravenous injections of lidocaine have also been tried in
such patients (1,6,7).
The surgical procedure of removing excess deposits
of fat by suction has been variously termed suction lipectomy, suction lipoplasty, liposuction, and suction lipexeresis.
Pioneered as a form of sharp curettage, to which suction was
added, the technique has evolved to the current practice of
passing a cannula through a surgical incision of the skin at
the site of accumulation and suctioning the deposits by use
of a vacuum pump (8).
Since fat suction has proved to be useful in reconstructive surgery (9,10), we believed that good results could
be expected from use of this procedure in the treatment of
juxtaarticular adiposis dolorosa. Indeed, our patient has
experienced complete and prolonged relief of the knee pain.
Although it is a relatively new procedure and not completely
without complications, we believe that fat suction should be
considered as an alternative mode of therapy for juxtaarticular adiposis dolorosa, particularly in severe cases.
Morton A. Scheinberg, MD, PhD
Ricardo Diniz
Jorge Diamant
lnstituto Arnaldo Vieira
S6o Paulo, Brazil
Figure 1. The patient’s knees A, before liposuction, showing swelling of the medial aspect of both knees and B, after aspiration of the
fat deposits.
was ambulatory and completely asymptomatic (Figure 1).
One: year after the procedure, she remained symptom-free.
The variety of names used to describe painful swelling (offat around the knees has led to a confusion of different
clinicopathologic entities (2-5). The condition has been
classified as extraarticular, such as Dercum’s syndrome and
juxtaarticular adiposis dolorosa, and as intraarticular, such
as IHoffa’s disease and premenstrual water-retention syndrome. Fat legs and orthostatic edema are considered to
represent different medical conditions (1).
Various modes of treatment have been previously
prolposed, but none has been completely satisfactory. Administration of analgesics or nonsteroidal antiinflammatory
drugs and local physical measures are the usual approaches
to treatment of this condition. Application of compression
1. Eisman J, Swezey RL: Juxta-articular adiposis dolorosa: what
is it? Report of 2 cases. Ann Rheum Dis 38:479-482, 1979
2. Steiger WA, Litvin H, Lasche EM, Durant TM: Adiposis
dolorosa (Dercum’s disease). N Engl J Med 247:393-396, 1952
3. Kling DH: Juxta-articular adiposis dolorosa: its significance and
relation to Dercum’s disease and osteoarthritis. Arch Surg
34t.599-630, 1937
4. Hoffa A: The influence of the adipose tissue with regard to the
pathology of the knee joint. JAMA 43:795-796, 1904
5 . Des Marchais J, Gagnon PA: Maladie d’Hoffa (liposynovitis
infrapatellaris, inflammation infrapatellar fat-pad). Union Med
Can 102:1313-1315, 1973
6. Blonistrand R, Juhlin L, Nordestan H, Ohlsson R, Werner B,
Engstron J: Adiposis dolorosa associated with defects of lipid
metabolism. Acta Derm Venerol (Stockh) 51:243-250, 1971
7. Iwane T, Maruyama M, Matsuki M, Ito Y, Shimoji K: Management of intractable pain in adiposis dolorosa with intravenous
administration of lidocaine. Anesth Analg 55:257-259, 1976
8. Grajer F: Suction-assisted lipectomy, lipolysis and lipexeresis.
Plast Reconstr Sur 72:620-623, 1983
9. Editorial: Fat suction. Lancet II:192, 1985
10. IIloun YG: Body contouring by lipolysis: a 5 year experience
with over 3000 cases. Plast Reconstr Surg 72591-597, 1983
Protecting joints with a water-filled glove
To the Editor:
A rolling platform-walker can be used by patients
with rheumatoid arthritis (RA) for support and stability while
walking. The forearm attachments used with this aid decrease the pressure on the hand and wrist joints, which are
frequently involved in RA. Unfortunately, the attachments
increase the load to the shoulder and elbow joints (Slack D,
Levine P, Banwell B, Utsinger PD: Physical medicine and
rehabilitation, Rheumatoid Arthritis: Etiology, Diagnosis,
LETTERS
1438
After she was discharged from the hospital, she improved on
the invention by using a water-filled rubber balloon inside
the rubber glove. She found this to be more effective and
secure (Figure 1).
For patients who use the platform-walker with the
forearm attachments, the water-filled rubber glove is a
simple and inexpensive way to redistribute the pressure on
painful elbow joints or rheumatoid nodules. Such items may
be applicable for other situations in which joint protection is
similarly needed.
Meika A. Fang, MD
Esther Torch
Harold Paulus, MD
UCLA Center for the Health Sciences
Los Angeles, CA
Comment on the article by Cairns et a1
Figure 1. A, A rubber glove containing a water-filled balloon secured
to the top of the forearm attachment of a rolling platform-walker. B,
Cushioning for the elbow joints and a redistribution of pressure are
benefits to the person who must use the walker.
Management. Edited by PD Utsinger, NJ Zvaifler, GE
Ehrlich. Philadelphia, JB Lippincott, 1985, pp 728-729).
Thus, for the RA patient with bilateral elbow involvement,
use of the rolling platform-walker often produces pain.
We describe here a novel and effective way of
reducing the pressure on the elbows. This device was
suggested by an RA patient with bilateral elbow arthritis and
epicondylitis, who had just undergone hip surgery. Although
she put sheepskin over the forearm attachments on a rolling
platform-walker, it did not reduce the pain in her elbows,
and she could not use the walker. She got a pair of rubber
gloves, partially filled them with water, tied the ends closed,
and put them under the sheepskin. She noted a marked
decrease in elbow pain, and was able to use the walker.
To the Editor:
We were most interested to read the article by Cairns
et al (I), which demonstrated very clearly that human
hybridoma-derived autoantibodies from an individual without autoimmune disease may share antigen-binding profiles
with monoclonal autoantibodies from patients with systemic
lupus erythematosus (SLE). We were, however, puzzled by
the assertion of those authors, in reference to an article we
published (21, that cross-reactive idiotypes of SLE monoclonal antibodies are not shared with the serum antibodies of
normal individuals. In fact, we stated that raised levels of
idiotype 16/6 (first identified on a human monoclonal antiDNA antibody derived from a patient with SLE) were
present in 4 of 96 normal sera that we used to establish a
normal range (2). Recently, using more sophisticated methods, Madaio et al (3) found 16/6 idiotype activity in titers
>1:2,700 in 9 of 32 healthy individuals tested.
Much more information has been published about the
16/6 idiotype. For example, it has been identified in the
serum of more than 20% of healthy first-degree relatives of
patients with SLE (4), and in 23 (8.7%) of 265 patients with
monoclonal gammopathies (5). Datta and colleagues (6) have
also shown that cultured, pokeweed mitogen-stimulated
lymphocytes from 6 normal subjects all produced antibodies
bearing the 16/6 idiotype, though interestingly, these antibodies did not bind to DNA. Our own studies have confirmed this finding and have also indicated a preferential
production of 1616 idiotype-bearing antibodies in response to
stimulation with Klebsiella pneumoniae (7). This observation complements the description of notable similarities in
amino acid sequences, antigen-binding profiles, and idiotypic (1616) determinants between monoclonal anti-DNA
antibodies and monoclonal antibodies from patients with
Waldenstrom's macroglobulinemia that reacted with Klebsiella polysaccharides (8).
Taken together, these observations actually enhance
the findings of Cairns et a1 ( l ) , by showing even greater
similarities between antibodies derived from those with and
those without autoimmune disorders. It is now clear that the
production of autoantibodies is insufficient to induce autoim-
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