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Osteoarthritis.

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NEUWfl#ROPHIC ARTHROPATHY, OSTEOARTHRITIS
Recurrent hemorrhage, progressive loss of joint
function, and intractable pain have led to synovectomy
with total p i n t replacement (L168,M81). Other successful operative procedures included: 1) supracondylar
correction of knock-knee, 2) intertrochanteric correction of coxa valga, and 3) evacuation of iliacus hematoma in patients with paralysis of the femoral nerve
(H155). Lower limb joint arthrodeses for pain, recurrent
hemarthrosis, gross deformity, instability, and recurring
calf bleeds have been performed in knees and ankles
(H195). The mean time to union was 5 % months for
knees and 4 months for ankles. All arthrodeses finally
united but there were 3 cases of delayed union.
Hemarthrosis of the knee followed minor trauma
and presented as a synovial rupture with excessive
bruising of the ankle (C 142); this complication followed
223
minor trauma in a patient taking sodium warfarin (523).
Two additional cases were unassociated with trauma.
All patients tolerated synovial aspiration to substantiate
the diagnosis.
Lipohemarthrosis of the knee is highly suggestive of a fracture causing communication of the joint
space with fat-containing bone marrow. Recognition of
this condition on standard vertical beam knee radiographs may alert the radiologist to obtain additional
confirmatory films when the fracture is not initially recognized ( S 5 ) . This is analogous to the demonstration of
an elbow joint effusion secondary to subtle, initially unrecognized fracture of the head of the radius, and it is
superior to observation of the posterior fat pad as a specific sign of elbow trauma (Y23).
NEUROTROPHIC ARTHROPATHY
Syringomyelia tarda postparaplegia with secondary neuropathic arthrosis of the shoulder, described in 2
paraplegic patients, emphasized the need for early
awareness of any neurologic changes in the upper extremities of a paraplegic patient which could point to
recognition of the syringomyelic process and portend a
tendency toward neuropathic arthrosis of the shoulder
(T102). This would require a high index of suspicion
and subsequently a preventative protective orthopedic
approach to minimize the usual functional deformity
that occurs when this neuropathy involves the shoulder.
The second reported case of the rare entity of Charcot
arthropathy involving the elbow was unassociated with
any recognizable neurologic syndrome (B 168). However, syringomyelia, tabes dorsalis, diabetic neuropathy,
congenital insensitivity to pain, Charcot-Marie-Tooth
disease, and calcium pyrophosphate dihydrate crystal
deposition disease had to be ruled out.
Extensive periarticular calcification is characteristic of Charcot joints. Fragmentation of the articular
margins of bone contributes to the bony detritus, but
the majority forms de novo in the joint capsule. It is not
known why occasionally the calcific debris is seen far
removed from the joint. The pattern of soft tissue calcification suggested that the debris around a Charcot joint
may break out of the periarticular space and dissect
along muscle planes (H69). Arthrography demonstrated
continuity of the joint space and distant calcifications
(F83).
OSTEOARTHRITIS
An overview of degenerative joint disease
It was suggested that division of degenerative
joint disease (DJD) into idiopathic and secondary types
of disease was not valid (M264). Instead, it was proposed that DJD be classified by cause under the following general categories: 1) abnormal concentrations of
force on normal articular cartilage matrix, 2) normal
concentrations of force on abnormal cartilage matrix, 3)
normal concentrations of force on normal cartilage supported by stiffened subchondral bone, and 4) normal
concentrations of force on normal cartilage matrix supported by weakened subchondral bone.
The commonness of osteoarthritis was reflected
in an epidemiologic study showing that 29% of the individuals over 40 years of age in Greenland had some
form of osteoarthritis (A98). Differences in prevalance
rates in these population groups might reflect differ-
224
ences in occupation or genetic susceptibility. Many brief
reviews appeared describing developing trends in concepts of the nature and treatment of osteoarthritis
(C111,G119,H201,M312). Attention continued to be focused on cartilage as the site of primary disturbance in
osteoarthrosis, with the articular lesion resulting from
combinations of aging, mechanical factors, or leakage
of degradative enzymes from neighboring synovial lining cells. Others suggested that osteoarthrosis results
from an imbalance between enzymes leaking from the
synovial cells and native inhibitors present in the synovial fluid. The development of detailed information
concerning the chemical anatomy of the proteoglycan
aggregate has focused attention on this component of
cartilage matrix as a site for the early abnormalities of
DJD.
Pathology of osteoarthritis
It was stated that the articular cartilage in the
American knee resists wear and tear of a normal life
span remarkably well and infrequently undergoes progressive degradation (C55). This welcome news was derived from a study of 300 cadaver knees whose average
age was 70 years; a much lower prevalence of degenerative lesions of cartilage was demonstrated than had been
anticipated. The patella was normal or nearly normal in
62% and the weight-bearing areas were abnormal in
only 23%. Eighty-two percent of the menisci were essentially normal, as were 96% of the cruciate ligaments.
The synovial changes in posttraumatic synovitis and the
findings in osteoarthritis were again emphasized (S290).
Synovial cells showed little hyperplasia and hypertrophy, and fibrosis of the subsynovial tissue and sclerosis of associated blood vessels were frequent. Inflammatory cell infiltrates were thought to be less common
in the posttraumatic synovial reaction.
Another study demonstrated a correlation between degenerative cartilage changes and bony abnormalities determined by marrow content and morphometric analysis (R45).The order of occurrence or
relationship between these lesions was unclear. Horizontal splitting of articular cartilage at the uncalcifiedcalcified interface occurred in 3/5 of the left patellae examined from 50 necropsy subjects ranging from 18 to 96
years of age (M169). These splits represented in vivo
microfractures. A topographic study of articular cartilage from osteoarthritic femoral heads revealed torn or
frayed collagen bundles with a pattern distinct from
that seen in RA (M260).
OSTEOARTHRITIS
Biochemical studies of cartilage
A careful histologic and biochemical study of
osteoarthrotic femoral heads emphasized the focal nature of the changes in cartilage and found no indication
of elevation in sulfate incorporation by the abnormal
cartilage components (B3 11). In another study, a reduced ratio of chondroitin sulfate to keratin sulfate in
articular cartilage was found to be related to age (B162).
No change in hyaluronic acid concentration occurred
with advancing age in osteoarthritis. This report implied
that general qualitative changes in glycosaminoglycan
(GAG) content of cartilage occur around the age of 50
in all parts of the cartilage surface. At sites predisposed
to develop osteoarthritis, the changes were more pronounced and paralleled a reduction of all GAGs. A
study of the collagen and GAG content of human lumbar intervertebral discs over an age spectrum led to the
conclusion that differences in mechanical function may
be reflected by differences in the chemical composition
of the discs (A24). Thus, mechanical failure might result
from variations in chemical composition. The collagen
content of the disc annuli increased as one moved along
the spinal levels, type I1 collagen being most prominent
in the nucleus, and type I predominant in the annulus.
The similarities between the natural human and
experimental canine osteoarthritis were again reviewed
(M325). It was thought that initial changes in osteoarthritis involve major changes in the metabolism of the
entire cartilage, thought to be set in motion by an early
increase in hydration of the tissue, with degenerative
changes becoming obvious only at advanced stages of
the process. One study argued that enzymatic degradation was unlikely to be the sole or major factor in the
pathogenesis of progressive osteoarthrosis. Biochemical
changes were compatible with collagen and matrix disruption due to focal overloading in one part of the joint
and attempted repair elsewhere (S422). This report
demonstrated several varieties of change in GAG, including zones depleted of carbohydrate, altered ratio of
keratin sulfate to chondroitin sulfate, fewer proteoglycan aggregates, and decreased hyaluronic acid
content.
Other studies emphasized the distinction between degenerative changes in cartilage and those related to aging (V35). Osteoarthritic cartilage showed a
trend toward increasing hydration and loss of GAGs,
whereas the reverse was true in relation to aging. It was
pointed out that in intact cartilage, the swelling pressure
OSTEOARTHRITIS
gradient related to water binding by GAGs must be balanced by tension in the collagen network. Once the collagen network is broken, water will distribute itself in
proportion to the local swelling pressures (V36). Since
the surface of cartilage loses its GAGs earlier than
deeper levels, it shows little tendency to swell, but the
middle zone with its relatively high GAG content will
imbibe more water as soon as the restraining force of its
fiber network is diminished.
Morphologically normal hip cartilage from aged
humans was studied with respect to the macromolecular
organization of its constituent proteoglycans (P89). The
proteoglycan molecule did not appear to interact with
hyaluronic acid, and a deficiency of link glycoproteins
was demonstrated. Canine cartilage exposed to diphosphonate drugs revealed reversible inhibition of GAG
synthesis and decreased size of proteoglycan aggregates
(P16). The latter abnormality was thought to result from
an abnormality in the hyaluronate binding region of the
proteoglycan core protein. One reveiwer pointed out
that the function of proteoglycan aggregation is really
unknown, but speculated that the aggregation might
help to immobilize the proteoglycans within the collagen network and might protect them from the effects of
proteinases, since controlled partial degradation of proteoglycan was possible only with aggregated proteoglycans, whereas monomers were degraded rapidly
(M326). Among the connective tissue matrix components, only hyaluronic acid appears to be specific in
influencing proteoglycan synthesis. Hyaluronate, even
in low molecular weight forms, was said to decrease
proteoglycan formation by embryonic chondrocytes in
vitro.
Uptake of "SO, was measured in cultured cartilage slices from osteoarthritic individuals and from
asymptomatic hip joints of individuals of similar age
(M154). GAG metabolism measured by this method in
these samples appeared to be similar and was found to
be depressed by sodium salicylate in the osteoarthritic
cartilage. The latter observation again raised the question concerning the role of salicylates in the management of osteoarthritis.
Cartilage from femoral heads obtained at postmortem and from total hip replacement procedures was
used to study the kinetics of cartilage swelling (M82).
With these materials, it was found that water was freely
exchangeable in both normal and degenerative specimens, and it was again concluded that the swelling of
degenerative tissue related to the failure of the damaged
collagen network to oppose the swelling pressure of the
proteoglycans. Further, the pathologic findings could be
225
mimicked by treating normal cartilage specimens with
collagenase.
The hydroxylysine/hydroxyproline ratios were
similar in osteoarthritic and normal tissue, militating
against the possibility that in osteoarthritis the chondrocyte shifts from the synthesis of type I1 to type I collagen (L 152). Evidence was presented that osteoarthritic
cartilage contained a collagenase bound to a trypsin
degradable inhibitor (E31). Very small amounts of a
similar enzyme were thought to be present in normal
cartilage. Cartilage collagenase apparently is unmasked
late in the course of osteoarthritis, since the greatest
concentrations were detected when the osteoarthritic
process was moderate or severe (E30). The characteristics of low molecular weight metalloproteases which
might diffuse through cartilage matrix and digest proteoglycans at neutral pH were described (W164).
Arylsulfatase A and B activities were reduced in
human chondrocyte cultures in the presence of ascorbic
acid in both normal and osteoarthritic cell strains
(S 123). Increased sulfated proteoglycan synthesis by
cartilage cells in the presence of ascorbate was again
confirmed. The possibility that the increased net synthesis of sulfated proteoglycans might result from reduction of lysosomal enzymes involved in the breakdown of intracellular matrix was considered. Damaged
cartilage was shown to be capable of inducing platelet
aggregation, and the possibility was raised that one consequence of aggregation might be release of factors able
to induce cartilage cell participation in the repair of cartilage lesions (Z19). Organ culture experiments provided evidence that the pig synovial membrane had a
direct, presumably enzymatic, effect on the matrix of
both living and dead cartilage (F26). It was additionally
postulated that there might be an indirect effect acting
through chondrocytes and cells. Study of cartilage from
fetal calves, calves, and steers revealed that the hyaluronate content of cartilage increased with maturation in
healthy tissues, particularly in areas of maximum contact (T57). Hyaluronate was said to be decreased in
amount in human osteoarthritic cartilage.
Dopamine beta-hydroxylase (DBH) is the enzyme that catalyzes the conversion of dopamine to
noradrenaline in synaptic vesicles of sympathetic neurones. This enzyme was easily detected in normal joint
fluid and found in substantially greater quantities in the
synovial fluid removed from patients with osteoarthritis
(S20). The possibility that this finding might reflect unsuspected neuroregulatory control of the secretory function of articular cells was one interesting conjecture
arising from this study.
226
Physiologic studies
Ferrography is an industrial technique for separating particulate matter from samples of lubricating solutions which has been applied to the extraction of wear
particles from synovial fluid. By combining bichromatic
polarized microscopy and scanning electron microscopy
with ferrographic techniques, it was possible to identify
and characterize the metallic, polyethylene, and acrylic
wear particles from arthroplastic joints, as well as biologic wear fragments of bone, cartilage, meniscus, and
synovium from osteoarthritic joints (M173).
A miniaturized latex-glass test system was devised to test the boundary lubricating ability of synovial
fluid (D37). This study suggested that DJD was not associated with defective synovial lubrication.
Instrumentation was developed to generate information concerning the consequences of impacting
forces on living articular tissue studied in vitro (F50). It
is now possible to obtain stress/strain, energy absorp-,
tion, and chondrocyte viability data for cartilage from
the tibia1 plateau of humans and dogs subjected to controlled impacts. Repetitive impulse loading of rabbit
legs was associated with increased subchondral bone
stiffening which was associated with the earliest metabolic changes of cartilage damage (R3). When bone
stiffening returned to normal, the effects on cartilage
were partially reduced. These studies suggested that
subchondral bone stiffening accompanies the earliest
metabolic changes in osetoarthritic chondrocytes and
that trabecular microfracture may occur very early in
this process. Similar experiments were interpreted
slightly differently by other workers who thought that
the mechanical models supported the view that cartilage
degeneration was directly effected by repetitive mechanical compression (i.e., fatigue) and the decrease in mechanical support of subchondral bone (S 155).
In another set of experiments designed to examine the effect on joint cartilage of overuse and peak
overloading of rabbit knees, progressive articular cartilage damage was shown in association with an increase
in prostaglandin E in the synovial fluid, and reduction
in the cyclic AMP in the subchondral bone (D64). The
data suggested that cartilage damage and chemical
changes in subchondral bone were nearly simultaneous,
and both may be responsible for degenerative changes.
Studies on the degenerative effects of medial
meniscectomy and medial meniscus tears in dogs' knees
were extrapolated to humans, and it was suggested that
a meniscus should be removed only when abnormal and
interfering with the normal biomechanics of the knee
0S TEOARTHRITIS
joint (C216). Data collected from 369 cadaver knees
and 100 consecutive unselected knees examined by
arthroscopy also failed to support the impression that a
tom meniscus is a primary cause of unicompartmental
osteoarthritis ((36). It was suggested that a commonsense attitude toward treating meniscal derangements
dictated that torn menisci be removed only where true
joint locking was present. The late consequences of joint
hypermobility were examined in a small group of patients (B154). The findings ranged from no evidence of
osteoarthritis to widespread radiologic findings of osteoarthritis.
Ninety-five patients with rheumatoid arthritis
(RA) and DJD were studied in a gait laboratory and
compared with a group of 29 normal subjects (S350).
Gait abnormalities of the patient groups were significant and related more to functional status of the knee
than to patient age, sex, or diagnosis. Knee joint disease
produced an inefficient gait that seemed designed to reduce pain.
Experimental models of osteoarthritis
Rapidly progressing joint disease resembling
osteoarthritis was produced in rabbit knee joints by intraarticular injection of concentrated papain (H85).
Metabolic changes characteristic of osteoarthritis, including GAG depletion and increased uptake of "sulfate, were found in rabbits whose right knees were immobilized in plastic splints (E63). An experimental model
was again described for causing osteoarthritis in mature
dogs by sectioning the anterior cruciate ligament
(M138). The careful study of DJD in an inbred strain of
mice was carried out using routine histology, radiology,
and scanning electron microscopy (W22,23,25). Destruction of cartilaginous homografts in dogs was studied by histologic and isotopic techniques (Yl). The
mechanism for destruction of the foreign cartilage appears to reside in a hyperplastic synovial membrane
which closely resembled rheumatoid pannus.
In a rabbit model for osteoarthritis (induced by
partial menisectomy) salicylates did not retard degenerative changes, whereas chloroquine and a cartilagebone marrow extract had a temporary preventative effect (M3 14). Autologous osteochondral grafting proved
feasible in rabbits (L20). Such grafts maintained their
structural, biochemical, and functional integrity for as
long as 12 months, and the subchondral bone in these
autographs was rapidly replaced to preserve the supportive function of the underlying bone. The use of hydroxyapatite implants as a biomaterial for restoration of
OSTEOARTHRITIS
articular surfaces in rabbits showed consistent regenerative healing of hyaline cartilage from the margins of the
defects (C112). Restoration with TiO, and aAl,O, was
less successful. Experiments were performed on rabbits
in which isolated epiphyseal chondrocytes were transplanted as allografts into drill holes in the tibial articular surface (B105). Factors affecting survival of such
chondrocyte allografts clearly require further study.
Clinical considerations in osteoarthritis
Tolmetin, 300 mg 3 times daily, was as effective
in the mangement of osteoarthritis of the knee as 4.5
grams of aspirin daily (M328). Side effects were significantly less with tolmetin than with acetylsalicylic acid.
Further experience with the use of naproxen in the
treatment of osteoarthritis suggested that it is a useful
agent, and that 250 mg, 2 or 3 times a day is as helpful
as conventional salicylate therapy with the likelihood of
reduced frequency of side effects (B173,M119,191).
Ibuprofen, like aspirin, exerted a statistically significant
effect on the symptoms of osteoarthritis compared with
placebo (G73). Although both drugs were superior to
placebo, they were not distinguishable from each other
except that the incidence of gastrointestinal complaints
with ibuprofen was less than with aspirin.
X-ray evidence suggested that 4 of 20 patients
treated for osteoarthritis of the hip with an extract of
bone marrow and cartilage (Rumalon R) exhibited
substantial restoration of cartilage and clinical improvement (D71,72). The use of this agent was without significant toxicity. Alpha-tocopherol (vitamin E) was used in
a dose of 600 mg per day for 10 days to treat osteoarthritis in a single-blind cross-over study (M5).Fiftytwo percent of patients completing the study showed a
good analgesic effect thought to be statistically significant in comparison with placebo.
An interesting discussion appeared in which Heberden’s nodes were described as a part of a hereditary,
hypophyseally induced constitutional anomaly designated as a form of “involutional” acromegaly (032). In
a mouse model of osteoarthritis, there was no positive
correlation between obesity and osteoarthrosis (W24).
This was in agreement with previous studies on mice
and is contrary to the common belief that human obesity predisposes to osteoarthrosis. Digital mucinous
pseudocysts were again described as fluctuant, smooth
lesions, usually on a finger, and usually near a fingernail (G 146). Transillumination confirms the diagnosis,
and treatment usually consists of injection of the lesion.
The influence of patterns of usage on the structure and function of the hands of 3 groups of female
227
textile workers was examined critically (H8). Highly significant task-related differences were demonstrated related to usage pattern as measured by osteophyte formation, radiographic measurement, and range of
motion studies. The pathogenesis of hallux rigidus was
explored in a clinical and radiologic study (M160).
Characteristic chondral and osteochondral lesions were
detected at a specific site on the metatarsal head which
limited dorsiflexion, and histologic evidence indicated
that the etiology was probably traumatic.
A cost effective method for educating geriatric
patients with respect to important aspects of osteoarthritis was developed and successfully tested (S398).
Careful analysis was made of an effort to develop outcome criteria and standards for the assessment of quality of care among patients with osteoarthrosis (G213).
An optimistic report appeared concerning the
fate of osteochondral allografts used for the treatment
of osteoarthritis of the knee (P163). The success of these
grafts was attributed to the prolonged viability of the
cartilage cells, the capacity of host bone to join graft
cartilage without histologic reaction, and the host’s immunologic tolerance, which obviates the need for immunosuppressive therapy. The surgical experience with
tibial (single) and tibiofemoral (double) osteotomy for
osteoarthrosis and RA was reported (130). The authors
concluded that the double osteotomies tended to have a
higher incidence of complications and had no advantages over the single osteotomy with respect to pain relief. In a study of patellectomy for osteoarthritis, in
which there were no controls, it was found that a good
result was achieved in 53% of the patients, a fair result
in 26%, and poor result in 21% (A19). The authors concluded that this survey favors a conservative approach,
in view of possible subsequent total joint replacement as
a form of therapy.
Arthroplasty of the temporomandibular joint
with a v i t a h m condyle prosthesis was carried out in 3
patients (S207). The deformed arthritic condyle was removed and replaced by vitallium prosthesis and results
were said to be gratifying at followup studies 2 to 3
years after the operation.
Preliminary experience with implant arthroplasty for the distal interphalangeal joint of the finger in
osteoarthritis was reported (S272). Seven joints managed in this fashion apparently have done well. A 12year experience with fusion of the first metacarpotrapezial joint for degenerative arthritis was reported for
some 30 operated thumbs (S339). The long-term results
were said to be gratifying, with patients having painless,
stable thumbs with excellent strength.
Computed tomography of the chest shows that
228
right-sided unilateral thoracic osteophytosis is a common phenomenon (G 132). Cross-sectional images also
support the thesis that aortic pulsations have a preventive effect on the formation of left-sided osteophytes.
A method was described for measuring the rotational
instability of the knee joint radiographically, and it was
suggested that the method might be useful in selection
of appropriate surgical measures (L84). The diagnostic
value of buttressing of the femoral neck was reviewed
(M94). This finding was present radiologically in 33 of
73 patients with idiopathic osteoarthritis, 24 of 32 hips
with osteonecrosis of the femoral head, and was thought
to be less common in RA and ankylosing spondylitis. A
method for measuring the joint space in normal hip radiographs was described (F 101). Vertical joint space in
the hip commonly measures approximately 4.5 mm
while the horizontal joint space averages from 8 to 9
mm. The value of arthrography in nonmeniscal abnormalities of the knee was discussed (H 117). Anatomic
abnormalities of the synovial membrane, including
Baker’s cyst, and cartilaginous abnormalities such as
osteoarthritis, osteochondritis dissecans, osteonecrosis,
and osteocondylar fractures might be recognized by arthrography.
An excellent review stressed the differential diagnosis of arthritis of the temporomandibular joint with
emphasis on the contrast between arthritis and other facial pain syndromes of nonarticular origin (M64). The
possibility that frustration contributes to temporomandibular joint pain was investigated through the use of
electromyographic recordings (G8). No relationship to
frustration was identified and the authors cautioned
against psychologically oriented explanations of this
problem. Other authors concluded that the majority of
patients with myofascial pain-dysfunction syndromes
associated with temporomandibular joint symptoms
have this difficulty primarily on a psychologic basis
leading to tension, creating spasm in the masticatory apparatus and resultant occlusal disharmony (G254).
Another review dealt with ear symptoms that
may be associated with temporomandibular joint disturbances (568). Temporomandibular joint arthrography was found helpful in selecting patients for surgery
when severe temporomandibular joint dysfunction was
present (L208). Ankylosed temporomandibular joints
were replaced in 3 patients by chrome-cobalt prostheses
with satisfactory short-term results (K182). Another approach to the surgical management of temporomandibular joint arthritis involved the use of a Silastic cap
adapted to the condylar neck (S21).
For temporomandibular joint syndrome associated with excessive mobility, it was suggested that
OSTEOARTHRITIS
shortening of the temporalis tendon might be effective
(G183). In 7 patients where this procedure was carried
out, only 1 escaped complications. Other workers emphasized the multifactorial nature of the temporomandibular joint syndrome (23). Treatment measures suggested include patient counseling, analgesics and
sedatives, occlusal adjustment, bite-plane treatment,
jaw exercises, use of topical and/or local anesthetics,
and mandibular immobilization with interdental wiring.
The natural history of osteoarthritis in 94 knee
joints was followed over a period of 10 to 18 years
(H 120). Radiographic changes progressed over the
years, but the changes remained limited to the compartment first affected. A survey of the knees and ankles
in sport and veteran military parachutists indicated that
as a group they did not show increased prevalence of radiologic osteoarthrosis of the knee or ankle (M354).
Postmeniscectomy degenerative joint disease of the
knee was thought to be correlated with a failure of meniscal regeneration via a fibrous semilunar mold (E63). A
case report described osteoarthritis in the shoulder of a
72-year-old woman (D141). A mixture of hydroxyapatite and calcium pyrophosphate dihydrate crystals
was identified in the joint tissues using electron microscopy and infrared spectroscopy. Eighty-four patients
with osteoarthritis of the knee were examined at an
early stage in the disease and followed up 10 to 18 years
later (H119). On the second examination, 23% of the
joints had radiographic evidence of chondrocalcinosis.
The authors stressed that this might implicate chondrocalcinosis as a secondary finding late in the course of
primary osteoarthritis and not necessarily as a separate
metabolic disorder. An informative and extensive series
of observations was reported concerning osteoarthrosis
of the hip (B3 12). Pain localization in osteoarthrosis of
the hip was described in 89 patients (W202). Areas commonly involved included the greater trochanteric area,
the anterior knee, the anterior thigh, groin, shin, and the
medial buttock near the sacroiliac area. It was usual for
the pain to be referred to more than one site with the
combination of greater trochanter, thigh, and knee
being the most common.
A helpful review of the association between diseases of the cervical spine and headaches appeared
(E13). It was concluded that headaches caused by cervical spine diseases are uncommon in comparison with
migraine or tension headaches, but that they do occur.
Headaches may be a symptom of cervical spondylosis,
trauma, RA, ankylosing spondylitis, craniovertebral
anomalies, and high cervical and foramen magnum tumors. Clinical features were identified which tended to
point to the cervical origin of certain headache syn-
BACKACHE
229
dromes. Cervical myeloradiculopathy was shown to be
caused by hypertrophy of the posterior facets and laminae in 5 patients (E58). Clearly this possibility needs
to be considered along with cervical stenosis when confronted with patients exhibiting cervical myeloradiculopathy. The Brown-Sequard syndrome was described as a consequence of cervical spondylosis in a
group of 6 patients (Jl). In 5 of the 6 patients, the cervical spine findings were primarily those of osteoarthritis, whereas 1 patient showed a congenitally small
canal. Four patients were described with spasticity and
fasciculations in the upper and lower extremities due to
cervical spondylosis (K36). This emphasized that
spondylosis and motor system disease may appear in a
similar manner with upper and lower motor neuron
signs. Another patient was reported with severe dysphagia caused by cervical osteophytes (K58).Surgical
excision of the osteophyte led to a complete recovery.
The mechanical response of the lumbar inter-
vertebral joint under physiologic loading was studied in
vitro (L122). These studies disclosed that when a
healthy specimen is subjected to complex loading,
“yielding or failure” occurs in the vertebral body and
not in the annulus fibrosus of the disc. A positive correlation was demonstrated between pseudospondylolisthesis and arthrosis of the hands (M340).
Severe degenerative joint disease was described
in patients with hemophilia A (G84). The pathogenesis
of this arthropathy is thought to be multifactorial and
may result from repeated joint hemorrhage that is unrecognized and inadequately treated. The clinical picture of diabetic osteoarthropathy was reviewed (F8 1).
The authors emphasized that the pathologic presentation usually occurred in middle aged or elderly diabetic
patients who had exhibited diabetes of long duration
and poor control. Frequently, neurologic symptoms
were prominent as well as bone destruction, loose joints,
and articular swelling.
BACKACHE
Back pain was the topic of a special issue of the
Clinics in Rheumatic Diseases (G191). It contained chapters on 11 key areas of research critical to an understanding of etiology, pathogenesis, treatment, and prevention. A symposium on low back pain that stressed
the paucity of basic research efforts on the subjects appeared (A42). The introductory paper was an unedited
lecture delivered in 1961 by Dr. Joseph S. Barr (Professor of Orthopedic Surgery, Harvard Medical School,
1947-1964) in which he describes the events surrounding his 1931 disclosure associating low back pain and
sciatic pain with disc herniation (B41).
Epidemiology and pathogenesis
Eight million people in the United States have
back impairment (B116). Injury while at work accounted
for approximately one-half million of those so impaired;
a controlled prospective study of acute low back pain
in industry appeared (B 115). The course (duration) of
acute low back pain in 217 patients was categorized.
There was complete recovery within a month in 33% of
patients, within 2 months in 70%, and within 3 months
in 86%. An association between the onset of back pain
and lifting, bending, or sudden movement was reported
by 45% of subjects. Most patients (67%) believed their
pain to be intense and to be aggravated by bending forward or sitting. The initial episode of pain was prolonged among patients who reported: 1) frequent bending and twisting movements or fixed postures during
work, 2) repetitive and monotonous work, 3) daily back
fatigue and tiredness after work, and 4) dissatisfaction
with work.
The causes of low back pain in children were assessed (H174). Sprain was the most frequent cause,
while herniated disc was rare. Backache in the elderly
was appraised (S31) and categorized (B24). Emphasis
was placed on classifying back discomfort as mechanical or pathologic on the basis of the history, clinical examination, x-rays, and the erythrocyte sedimentation
rate (S3 1). The major causes of back pain in the elderly
were classified as degenerative (spondylosis, osteoarthritis, ankylosing hyperostosis), neoplastic (multiple
myeloma, metastases from malignancy), and metabolic
(osteoporosis, osteomalacia, chondrocalcinosis, Paget’s
disease) (B24).
Over a 2-year period, the data on all patients in a
general practice with back and leg pain were recorded
(B3 1). Two broad categories were distinguished among
the 175 patients evaluated: those with low back pain
syndromes and those with back and leg pain syndromes.
Only 2 patients with low back syndromes required hos-
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