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Acromegalic Arthropathy

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Acromegalic Arthropathy Ann. rheum. Dis. (1971), 30, 243 Ann Rheum Dis: first published as 10.1136/ard.30.3.243 on 1 May 1971. Downloaded from Acromegalic arthropathy R. BLUESTONE*, E. G. L. BYWATERS, M. HARTOG, P. J. L. HOLT, AND S. HYDE From the Department of Medicine, Royal Postgraduate Medical School, London Introduction comparable age-range. X rays were obtained of the peripheral joints and of the total spines in most patients. Spinal and peripheral joint abnormalities in patients with acromegaly, which have been recognized since Results (Table, overleaf) the original description was published by Marie (1886), may be severely disabling. However, the PERIPHERAL JOINTS nature of the arthropathy is not clear, and only Sixteen patients (9 men and 7 women) gave a history very limited morphological information is available of intermittent and long-lasting pain with episodes (Erdheim, 1931; Waine, Bennett, and Bauer, 1945; lasting weeks or months, usually of the shoulders, Keligren, Ball, and Tutton, 1952). Furthermore, knees, hands, or hips, but generalized in five and present day pituitary gland ablation, together with associated with widespread morning stiffness in more accurate assessment of treatment, should allow two. the reversibility of the arthropathy to be gauged. Peripheral joint abnormalities were detected in We have systematically characterized the loco- 26 patients of both sexes and all age groups. Joint motor system disorders in a group of patients swelling, other than simple bone-end enlargement, copyright. with acromegaly. Detailed studies of joint mor- was found in nine patients. This was usually a phology have been undertaken in three patients; painful knee swelling, sometimes due to effusion and we have correlated the arthropathy with the but more usually thickened synovial or periarticular duration and severity of the acromegaly. structures. A prominent prepatellar bursa was a common finding. Painless swelling of proximal interphalangeal, metacarpophalangeal, or carpo- Patients studied and methods metacarpal joints was also noted, and a dorsal http://ard.bmj.com/ expansion of the bases of the middle phalanges A series of 42 consecutive patients admitted to hospital (producing a bony ridge just distal to the proximal for assessment and treatment of adult-onset acromegaly interphalangeal joints) was present in twelve patients. was studied. There were 25 men (age range 22 to 66 years: Painful of movement was in mean 46) and 17 women (age range 26 to 68 years: limitation joint found mean 49). The approximate duration, severity, and eight patients, being generalized in three and activity of their pituitary disease was assessed in all but particularly affecting the shoulders. Significant two patients. This assessment (by MH) was based on the coarse crepitus throughout the full range of joint on September 26, 2021 by guest. Protected clinical state, x-ray changes, and plasma growth hormone movement was detected in over half the patients. levels. It was most marked in the knees and shoulders All patients were directly questioned about symptoms but was usually symptomless. referable to their joints. Peripheral joints were examined, A history characteristic of carpal tunnel syndrome and total spinal movement was measured as the difference was given by 22 patients, bilateral in all but two, in centimetres between the 7th cervical vertebral spine and the sacro-coccygeal junction when the spine and hip but without noticeable wasting of the hand muscles were fully flexed and fully extended. Overall spine and Ten patients described symptons suggestive of mild hip mobility was assessed by measuring the minimum Raynaud's phenomenon. distance (cm.) between the outstretched finger-tips and the floor in the straight-leg, bent-forward position ('finger- SPINE floor distance'). Contact with the floor was recorded as Twenty patients (12 men and 8 women) gave a zero and the amount of digital contact with the floor history of non-traumatic backache, usually of the beyond zero was recorded as a minus value. As controls, lumbo-sacral spine but occasionally involving the total spinal movement and overall mobility was measured thoracic and cervical spine. in ninety unselected hospital patients of both sexes and Mean total spinal movement was not significantly Accepted for publication November 23, 1970 * Present address: VA Wadsworth Hospital, Los Angeles, California 90073, U.S.A. 244 Annals of the Pheumatic Diseases Ann Rheum Dis: first published as 10.1136/ard.30.3.243 on 1 May 1971. Downloaded from Table Acromegaly: clinical and radiological findings in locomotor system in 42 cases -~~~~~~~~~~~~~~~~~~~~~~~e jpea jon Patient Age Sex Duration Severity Carpal PeripheralpinS no. (yrs) of of tunnel swelling and/or limitation disease * disease syndrome H K A S E Ha 1 26 M L 2 40 F L ±+ * 3 47 F L ++ + 4 58 M L ++ 5 26 F L ++ 6 28 M L 7 42 M VL +++ ± * 8 57 F L ++ + * 9 62 F VL ++ + * 10 66 M VL ++ 11 51 M VL + 12 34 M L ++ + * * 13 44 F L +++ + 14 55 F VL ++ + 15 46 M L 16 53 M L ++ 17 35 M L ++ 18 51 M VL ++ * * 19 61 M L + * 20 35 F VL ++ * $ * 21 60 F VL + * * * 22 * * * * 67 F VL ++ + * 23 68 F L +++ * 24 40 M L * * 25 42 M Sh ++ * * 26 60 M VL ++ copyright. 27 51 M VL 28 51 F VL 29 22 M L ++ 30 41 M VL ++ 31 45 M VL ++ 32 48 M VL +++ 33 58 M L + 34 43 F L +++ 35 58 F Sh ++ http://ard.bmj.com/ 36 24 M L ++ 37 34 M L ++ 38 35 F L ++ 39 44 F L + 40 64 M 41 59 M L 42 47 F L + Duration: VL very long; L - long; Sh - short; - = not recorded. Joints: H hip; K = klee; A = ankle; S = shoulder; E = elbow; Ha = hands. on September 26, 2021 by guest. Protected Severity of disease, backache, and x-ray changes classified as severe + + +; moderate + +; mild +. reduced in the patient group (15 -3 cm.) as compared phalanges, resulting in sclerotic-looking hooks. to the control subjects (16-3 cm.), regardless of Associated with this were small round areas of the presence or absence of backache (Fig. 1). joint capsule calcification or ossification at the Mean overall spine and hip mobility (measured as middle and terminal interphalangeal joints, present finger-floor distance) was 3 2 cm. for the patients in nearly half of the films examined (Fig. 3a, over- compared to 6 - 8 cm. for the controls (P = < 0 01), leaf). suggesting increased mobility in patients with head exostoses at the sites of ligament acromegaly (Fig. 2). This was particularly marked Metacarpal attachment led to of the bone ends. in some older patients, despite backache. squaring Remodelling of the phalanges leading to loss of the RADIOLOGY waists in the distal parts of the shafts was always Hand present (Fig. 4, overleaf). Sesamoid bones over flexor The main features were the well-recognized increased surfaces ofjoints were large and prominent, particu- cartilage thickness and the heavy ungual tufting. larly over the first metacarpophalangeal joint. The Other changes included extension of joint margins joint surfaces were smooth, without sclerosis, to form bony lips especially at the bases of terminal erosions, or malalignment. Acromegatic arthropathy 245 Ann Rheum Dis: first published as 10.1136/ard.30.3.243 on 1 May 1971. Downloaded from Joints affected Spinal movement Backache Joints affiected Spinal movement Backache Spinal x-ray changes by crepitus (cm.) K A S Finger-floor Total Cervical Thoracic Lumbar * -18 255 + * * -11 5 25-5 ++ * -6-5 24 + * -12-5 21-5 + ++ ++ * 10 20-5 +++ -4 20 5 + + + _ * * -7.5 20-5 + * * -9 19 + * * -20-5 19 ++ + ++ +++ * * 5 15 + + + * * 15 12-5 + - + ++ * 15 11P5 + * * -5 11-5 + ++ * * -7.5 11-5 + + ++ * 16-5 12-5 + +++ + * * _+ - ++ ++ $ + * * ++ - ++ + -O + * * * -18 23 ++ + * &65 12-5 + + + * * -15 15 + *__ ++ * * 0 19 ++ +++ ++ copyright. * * -12-5 18 - + + * * 4 12 - ++ + * * -7.5 25-5 * *__ * * 10 15 - ++ * 4 14 *__ + ++ *__ _ ++ ++ * -7.5 +++ ++ http://ard.bmj.com/ -20 5 15 + 6 5 14-5 14 16 + + +++ +++ ++ ++ 24 11-5 + on September 26, 2021 by guest. Protected 30- A _*0 A A A 5000 A A ' * A 20- * c A A 2 00- * V *:0 *- * A* E A AA V A 0 A 0 E O's *- .1 *. C 10 *-0 . _ 0 * OL ± I .II .I I I I I C P C P C P C P C P C P C P C P C P C P 20 30 40 50 60 70 20 30 40 50 60 1 70 Age (yrs) Age (yrs) FIG. 1 Spinal movement (see text) FIG. 2 Finger-floor distance (see text). C = Control subjects P = Patients; A = Patients with backache; A = Patients without backache. No sex difference detected. 246 Annals of the Rheumatic Diseases Ann Rheum Dis: first published as 10.1136/ard.30.3.243 on 1 May 1971. Downloaded from ow k.... "I'A. I...t. .X" ?. -,., ':,, .i 3b FIG. 3a and b Right 4thfinger, Patient 230 (a) Postero-anterior and lateral x rays (b) Histology of distal interphalangeal joint, showing hypertrophied cartilage, marginal fibrocartilage calcific- ation of capsular insertion, and on the other side ossific- ation ofthis. Haematoxylin and eosin. x 6. copyright. http://ard.bmj.com/ 3a Knees Unusually wide joint spaces, indicative of thickened cartilage, were common both between the tibia and femur and behind the patellar. Some patients had osteophytosis of the joint margins and intracondylar on September 26, 2021 by guest. Protected notch. Cartilage calcification, resembling chondro- calcinosis, was noted in several patients but was never gross. More discrete areas of capsular ossifi- cation, some having the appearance of intra-articulai foreign bodies, were also seen. Hips Widened cartilage spaces were prominent.
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