1196 BRITISH MEDICAL JOURNAL 17 m 1980

clearly the present state of affairs is unsatisfactory and urethritis without reactive arthritis, in whom antibodies may Br Med J: first published as 10.1136/bmj.280.6225.1196-a on 17 May 1980. Downloaded from dangerous and more stringent regulations are needed. also be present-though often in lower titres. In short, Koch's postulates remain unfulfilled for a "transmissible agent." oint Committee on the Use of Antibiotics in Animal Husbandry and Possession of the antigen HIA-B27 affects severity and Veterinary Medicine (Swann Report). Cmnd 4190. London: HMSO, 1969. prognosis, but reactive arthritis is not confined to persons 2 Threlfall BJ, Ward LR, Rowe B. Spread of multiresistant strains of with it. Keat el al found that rather more of their patients Salmonella typhimurium phage types 204 and 193 in Britain. Br MedJ7 1978;ii :997. with sexually acquired reactive arthritis presenting in the 3 Richmond MH, Linton KB. The use of tetracycline in the community rheumatology clinic carried B27 than those in the venereology and its possible relatiorn to the excretion of tetracycline-resistant clinic. bacteria. 7 Antimicrob Chemother 1980;6:33-41. The clear links between reactive arthritis and bacterial infection may provide useful clues to the mystery of rheumatoid arthritis and other connective tissue diseases. In some forms of reactive arthritis the mechanisms have been partially unravelled. Several forms of meningococcal arthritis occur with meningococcal meningitis, one being an aseptic or reactive arthritis in which meningococcal antigen and antibody Reactive arthritis are found in the blood and niay subsequently be shown Reactive arthritis is defined as an aseptic arthritis closely within polymorphs (together with complement) in affected related to an episode of infection elsewhere in the body. joints.7 That an aseptic or reactive arthritis may accompany Bacterial enteritis is one well-known cause, non-gonococcal proved gonococcal urethritis has long been known, and this urethritis with putative organisms is another; but in many form of non-bacterial "gonococcal" arthritis is more common cases no source of infection is identified. Reiter's syndrome in Britain than in the United States, where classical gonococcal is a particularly florid form with mucocutaneous and ocular arthritis is found as a complication of more severe and chronic lesions, but the use of this term has led to the inelegant gonococcal pelvic infection. A recent report by L Rosenthal "incomplete Reiter's syndrome" for the more common but and B Olhagen at the Fourth Congress of the South-east Asia less florid cases. The synovitis usually starts acutely and is and Pacific Area League against Rheumatism in 1980 frequently asymmetrical, with the knees and ankles most strengthened the view that some cases of postgonococcal commonly affected. Often there are also inflammatory lesions arthritis may be a true reactive arthritis rather than one of tendon sheaths and entheses, such as plantar fasciitis. A in which the sterile cultures of the joint fluid were merely careful examination will often elicit unsuspected pain and false-negative results. Careful prospective studies on the symmetrical limitation of movement of the lumbar spine. lines used by Greenwood7 in his studies of meningococcal Radiographs at this stage are often normal. The severity and arthritis may elucidate the mechanisms ofinduction in reactive duration of the acute episode are extremely variable, as is the and other forms of arthritis. Identification in affected joints likelihood of recurrence, but a prolonged and stormy course ofsome fragment or amino-acid sequence specific to chlamydias is more likely in individuals with certain histocompatibility or ureaplasmas might allow us to conclude that sexually http://www.bmj.com/ antigens, particularly HLA-B27.1 acquired reactive arthritis is in fact sexually acquired. Reactive arthritis often occurs in association with enteritis 1 Bitter T, ed. Reiter's syndrome. A symposium edited by T Bitter. caused by salmonellas and certain shigella strains2 and in Ann Rheum Dis 1979;38:suppl. Scandinavia particularly and occasionally in Britain with 2 Masi AT. Epidemiology of B27-associated diseases. Ann Rheum Dis 1979;38:suppl I 131-4. yersinia infections; some forms of campylobacter enteritis 9 Berden JHM, Muytjens HL, van de Putte LBA. Reactive arthritis may also induce the reaction.34 These forms of reactive associated with Campylobacter jejuni enteritis. Br Med J 1979;i :380-1. ' Urman JD, Zurier RB, Rothfield NF. Reiter's syndrome associated with arthritis may occur in prepubertal patients without sexual on 25 September 2021 by guest. Protected copyright. Campylobacter fetus infection. Ann Intern Med 1977;86:444-5. contact, and in males urethritis is a frequent component of ' Ford DK. Yersinia-induced arthritis and Reiter's syndrome. Ann Rheum these non-sexually acquired forms. A strong association of Dis 1979;38:suppl I 127-8. S Keat AC, Maini RN, Pegrum GD, Scott JT. The clinical features and promiscuous sexual contact surrounds reactive arthritis and HLA associations of reactive arthritis associated with non-gonococcal Reiter's syndrome, perhaps because urethritis is a common urethritis. Q J Med 1979;48:323-42. feature and cases occur most frequently in the sexually active 7 Greenwood BM, Whittle HC. In: Dumonde DC, ed. Infection and immunology in the rheumatic diseases 1976. Oxford: Blackwell, 1976: years, but the evidence is circumstantial. Even in patients 119-27. with recent sexual contacts other known causes of infection should be excluded before making a diagnosis of sexually acquired reactive arthritis. Sex and reactive arthritis may have become too closely associated in the minds of physicians. For example,5 a 28-year-old man developed dysuria, urethritis, and reactive arthritis after an episode of fever and diarrhoea, with appreciably raised serum concentrations of antibody to Patellar tendon rupture Yersinia enterocolitica; "he absolutely denied any recent sexual contacts." Little information on promiscuity is available in Traumatic rupture of the patellar tendon occurs in the young age-matched and sex-matched controls, and a recent study and is caused by sudden contraction of the quadriceps against of sexually acquired reactive arthritis failed to elicit a history resistance.' The lesion usually occurs at the point where the of recent contacts with new partners in 17% of the patients, patellar tendon (sometimes less properly called the patellar and not all urethral reinfections led to recurrences of reactive ligament) is attached to the lower pole of the patella, and less arthritis.6 Chlamydias and ureaplasmas may be isolated from commonly at its tibial attachment. Apart from injuries caused the urethra or cervix of patients with reactive arthritis and by cutting with sharp objects such as glass or metal (and in one antibodies to these organisms may be found, but the frequency instance a needle during diagnostic amniocentesis)2 a tear of isolation is not greatly different from that in patients with through the substance of a normal tendon does not occur.3 BRITISH MEDICAL JOURNAL 17 MAY 1980 1197 Rupture has, however, been recorded in patients with rheuma- 8 Wener JA, Schein AJ. Simultaneous bilateral rupture of the patellar tendon and quadriceps expansions in systemic lupus erythematosus. Br Med J: first published as 10.1136/bmj.280.6225.1196-a on 17 May 1980. Downloaded from toid arthritis,4 5 systemic lupus erythematosus,6-8 and renal J7 BoneJoint Surg (A) 1974;56A :823-4. disease.9 10 In some of these patients the tear occurred within 9 Cirincione RJ, Baker BE. Tendon ruptures with secondary hyperpara- thyroidism.J BoneJoint Surg (A) 1975;57A:852-3. the substance of the tendon.7 81112 In others the tendon 10 Hughes GN, Harder JA. Bilateral patellar tendon rupture associated with attachment had been avulsed,4 6 9 1 2-16 and in several chronic glomerulonephritis. CanJ Surg 1979;22:389. patients the lesion was bilateral.4-8 10 Infiltration ofthe tendon Ismail AM, Balakrishnan R, Rajakumar MK. Rupture of patellar ligament after steroid infiltration.J BoneJoint Surg (B) 1969;51B :503-5. fibres by injection of steroids after a sprain has led to rupture 12 Filipe G. Ruptures ofthe patellar tendon. Ann Chir 1977;31 :489-93. of the substance of the tendon.1' A tear in the absence of 13 Kelikian H, Riashi EM, Gleason J. Restoration of quadriceps function in appreciable trauma should alert the clinician to the possibility neglected tear of the patellar tendon. Surg Gynecol Obstet 1957;104: 200-4. ofassociated disease.9 14 Levin PD. Reconstruction of the patellar tendon using a Dacron Graft. The obvious diagnostic feature is loss of active extension of Clin Orthop 1976;118:70-2. than normal and a 15 Rao JP, Siwek KW. Bilateral spontaneous rupture of the patellar tendons. the knee joint. The patella may lie higher A new method oftreatment. Orthop Rev 1978;7:49-51. defect may be felt below it. A small fragment of bone may be 16 Ecker ML, Lotke PA, Glazer RM. Late reconstruction of the patellar displaced with the tendon from the lower pole of the patella, tendon.J Bone Joint Surg (A) 1979;61A:884-6. and unless the doctor appreciates the significance of this the injury may be dismissed as a minor fracture of little consequence. The treatment of choice is operative repair at the time of injury. The ligament is sutured back to the inferior pole of the patella with stainless steel wire'; and the lateral expansions, which are frequently torn as well, are also repaired. The liver and halothane- The knee is immobilised for six weeks before flexion is allowed. again Difficulty arises when the diagnosis is not made immediately after injury. In this event, or when the initial repair is un- The principle of Occam's razor'-that wherever possible satisfactory, the knee may require a reconstructive operation, phenomena should be assumed to have a single cause-has of which several kinds have been described. Kelikian12 and been one of the cornerstones of clinical science; but such an Filipe13 used the semitendinosus tendon as a substitute for the approach does not help in understanding multifactorial torn patellar tendon, and Levin14 carried out reconstruction syndromes such as liver failure or jaundice. Certainly the using a Dacron graft. Rao'5 reinforced the damaged tendon principle is a part explanation of the continuing controversy with fascia lata, and both he and Kelikian'3 emphasised the about the "cause" of liver damage after halothane.4 In the importance of a preliminary period of traction using a Stein- face of apparently irreconcilable pieces of evidence exponents man pin passed through the patella to approximate the bone to of any hypothesis have had to ignore or discount inconvenient its normal position before operation. Recently Ecker16 has observations, and publications on the topic are notable for reported four cases in which the reconstruction used the selective quotation. At last, however, some commentators are gracilis and semitendinosus tendons supplemented by heavy-

prepared to acknowledge the possibility that a combination of http://www.bmj.com/ gauge stainless steel wire. The wire was left in position for the mechanisms may sometimes operate.2 The next step is ex- first six weeks while healing occurred, and was then removed amination of the proposition that there must be at least two to prevent fragmentation before the patients started active mechanisms to encompass the experimental evidence and movements. They did not need preliminary traction as the clinical experience. patella could be mobilised during the operation and brought Fortunately, the practical problem facing the clinical down to its normal position. All four patients returned to their anaesthetist is a diminishing one. Though its design has been former level of activity, but none had been engaged in com- strongly criticised,3 5 a recent trial of repeated anaesthesia6 7 petitive sport. has shown that enflurane delivered from a calibrated vaporiser on 25 September 2021 by guest. Protected copyright. Disruption of the patellar tendon is an uncommon injury, is very unlikely to give rise to hepatic damage, probably but in most patients the diagnosis should not be difficult. because of its lesser amount of hepatic metabolism.8 Enflurane Immediate operative repair is the treatment of choice. When has physical properties that make it an acceptable clinical the diagnosis is delayed the patient may need a reconstructive alternative to halothane, so making it suitable for repeat procedure if he is to regain full active extension of the knee anaesthetics. Since, however, many years and many repeat joint. Disruption of the tendon in the absence of appreciable anaesthetics were needed before an association was recognised trauma should alert the clinician to the possibility of associated between halothane and liver damage anaesthetists would be disease. advised to keep an open mind about enflurane. And, apart from the use ofenflurane, there are other acceptable techniques not based on halogenated vapours, even though to employ them 1 Smillie IS. Injuries of the knee joint. 5th ed. Edinburgh: Churchill Livingstone, 1978. for a minor procedure may look like taking a sledgehammer to 2 Epley SL, Hanson JW, Cruikshank DP. Fetal injury with midtrimester crack a nut. diagnostic amniocentesis. Obstet Gynecol 1979;53 :77-80. Use of any routine alternative regimen, however, requires 3 McMaster PE. Tendon and muscle ruptures. Clinical and experimental studies on the causes and location of subcutaneous ruptures. Jf Bone that the overall mortality and morbidity from all causes J'oint Surg 1933;15:705-22. associated with it should be lower than with a repeat of 4 Razzano CD, Wilde AH, Phalen GS. Bilateral rupture of the infrapatellar who remain impressed with the tendon in rheumatoid arthritis. Clin Orthop 1973;91:158-61. halothane. Anaesthetists 5 Piero A, Ferrandis R, Garcia L, Alcazar E. Simultaneous and spontaneous overall safety of halothane will therefore want to consider bilateral rupture of the patellar tendon in rheumatoid arthritis. Acta whether there is any way to lessen the risk of hepatic damage Orthop Scand 1975;46:700-3. 6 Strejcek J, Popelka S. Bilateral rupture of the patellar ligaments in systemic after halothane or any marker to identify the patient who is lupus erythematosus. Lancet 1969 ;ii :743. particularly at risk. The clinical need for such advice is the 7 Rascher JJ, Morcolin L, James P. Bilateral, sequential rupture of the for a further review of the current evidence on patellar tendon in systemic lupus erythematosus. J Bone Joint Surg (A) justification 1974;56A :821-2. possible aetiological mechanisms. Animal models have been