Belt E A, Kaarela K, Mäenpää H, Kauppi M J, Lehtinen J T, Lehto M U
Rheumatism Foundation Hospital, Heinola, Finland.
Joint Bone Spine. 2001 Mar;68(2):154-7. doi: 10.1016/s1297-319x(00)00242-6.
In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA).
An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzick's test.
At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick's test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients.
The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.
在本研究中，我们评估了类风湿关节炎（RA）患者踝关节的影像学受累情况及其与距下关节破坏的关系。
对103例血清阳性RA患者的起始队列进行了20年的随访。在入组后发病时、1年、3年、8年、15年和20年进行随访检查。共有83例患者参加了15年随访，68例患者参加了20年随访。使用负重位踝关节侧位X线片进行影像学评估。对胫距关节采用简化分级，将踝关节（患者）分为三组：无变化、轻度变化和重度变化。在终点分析中采用最后一张X线片。记录距下关节破坏情况（Larsen分级≥2级）。使用手部和足部的Larsen评分0 - 100评估不同组中RA的严重程度。使用Cuzick检验评估患者组之间的差异。
在终点时，仅7例患者（7%）踝关节出现重度变化，17例患者（16%）出现轻度变化。2例患者在3年随访时首次出现踝关节轻度受累。2例患者的3个踝关节在15年随访时首次出现重度变化。所有出现重度变化的踝关节中，距下关节病变均先于胫距关节。在17例出现轻度变化的患者中，除2个踝关节外，其余所有踝关节均同时出现距下关节病变，而在21个踝关节中的13个，距下关节病变在影像学上先于胫距关节受累。0 - 100的Larsen评分均值在三个踝关节分级组中分别为40、54和63。Cuzick趋势检验具有高度显著性（P < 0.001）。随访期间踝关节未进行重建手术，而12例患者累计进行了距下关节融合术。
踝关节在RA晚期受累，通常仅在重症患者中受到影响。距下关节病变几乎总是先于胫距关节的变化出现。
