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BILATERAL RUPTURE OF THE PATELLAR LIGAMENTS IN SYSTEMIC LUPUS ERYTHEMATOSUS
743 BILATERAL RUPTURE OF THE PATELLAR LIGAMENTS IN SYSTEMIC LUPUS ERYTHEMATOSUS SIR,-Recently we observed an unusual event in a patient with systemic lupus erythematosus (s.L.E.)-spontaneous rupture of both patellar ligaments. The patient was a woman born in 1906. Her disease began in 1952 with acute exudative pericarditis, bilateral exudative pleuritis, migratory polyarthralgia, tenosynovitis, and Raynaud’s phenomenon. Since then the rheumatic process has never ceased completely, and has resulted in multiple deformities of the fingers and hands caused by tendon contractures; no serious joint damage is demonstrable by clinical or radiological examination. She developed typical exanthema which recurred on several occasions. In 1966 she had an acute exacerbation, with ulcerating skin lesions, acute myocarditis, pulmonary
infiltration, and glomerulonephritis. The clinical picture was completed by high erythrocyte-sedimentation rate, secondary hypochromic anasmia, hypergammaglobuHnxmia, biological-false-positive reaction for syphilis, positive L.E.-cell test, and negative latex-fixation test for rheumatoid factor. In March, 1968, a new skin eruption appeared, accompanied by pulmonary infiltration, arthralgia, and fever. The daily dose of prednisone was increased to 15 mg. This improved her general condition and it was soon possible to return to the previous dose of 5 mg. per day. 4 weeks after the beginning of this exacerbation the patient was getting out of bed when she had a sudden severe pain in her right knee. Active extension of the joint became impossible and the knee became swollen. Nearly the same thing happened a week later in the left knee. The only difference was that there was no apparent precipitating cause (since the patient was immobilised in bed) and active extension of the joint recovered after some days. Examination of the anterior part of the right knee revealed a transverse groove. Palpation showed that this lay over the joint space. The patella was dislocated proximally and each contraction of quadriceps femoris shifted it further away. The diagnosis of complete rupture of the patellar ligament was confirmed radiologically. Because the patient was considerably disabled and conservative treatment (bandage) seemed unlikely to succeed, surgical treatment was attempted. Simple incision of the skin exposed the joint cavity. Just below the distal edge of the patella there was a large tear (3 x 3 cm.) in the patellar ligament. The texture and appearance of the ligament were distinctly abnormal. We succeeded in suturing the ligament to the anterior face of the patella by conventional sutures, and to the distal edge of the patella by a transosseous suture. The operation wound healed by first intention, and active extension of the knee completely recovered. The patient began to walk, and after 8 months still walks without difficulty. We wish to stress three points of interest. Firstly, spontaneous rupture of the patellar ligament in the course of S.L.E. seems to be extremely rare. (No published report has been discovered in a thorough search.) By contrast, tendon rupture has been described in 1 % of patients with
rheumatoid arthritis.1,2 What
was
the actual
cause
of the
rupture ? The possibility that the tendon was damaged by friction against bone protrusions (as can happen in rheumatoid arthritis) was ruled out during operation. On the other hand, it is highly probable that the structure of the patellar ligament was profoundly disturbed by glucocorticosteroid treatment, which had been administered almost without interruption for ten years, and which is known to inhibit the synthesis of collagen and other 1. 2.
Gamp, A., Schilling, A. Z. Rheumaforsch. 1966, 25, 42. Nalebuff, E. A., Potter, T. A. Clin. Orthop. 1968, 59, 147.
proteins. Nevertheless, the simultaneous rupture of both patellar ligaments suggests that the incident might have been connected with the preceding acute exacerbation of S.L.E. The success of the surgical treatment deserves attention, too, since the prospects of resuturing a pathologically altered tendon are usually regarded as poor. 1st Medical
2nd
Department
J. STREJČEK.
Clinic,
of Orthopædic
S. POPELKA.
Surgery,
Charles University, Prague, Czechoslovakia.
TURISTA IN TEHERAN in the paper by Professor Kean (Sept. 13, notice SIR,-I p. 583) that 19 out of 74 specialists in tropical diseases who replied to the questionary thought that water had been the cause of their own diarrhreal illness. It may therefore be useful to record that I happened to be visiting the watersupplies of the city during the week of the congresses. The city has a modern water-supply derived from distant impounding reservoirs and given comprehensive treatment including coagulation, sedimentation, filtration, and chlorination. Much of the plant was installed under the direction of British consulting engineers. The bacterial and chemical quality of the water is checked by the Water Department laboratory in Teheran. The hardness may be described as moderate and the salinity is low. The possibility that the outbreak in Teheran was due to drinkingwater appears as slight as it would be in an English citv. The Counties Public Health Laboratories, London W.C.1.
ROY C. HOATHER.
FLUORIDE AND TEA
SIR,-Professor Jenkins (Sept. 6, p. 542) is misreading my letter (Aug. 9, p. 329) when he supposes that the maximum fluoride intake in children " may be as much as 1-26 mg. daily ". This figure is the average intake by childrenfrom tea alone, and the intake averages 2.24 mg. daily in unfluoridated areas and 3-31 mg. daily in fluoridated areas. Fluoride intake of children in this survey from tea alone has varied from nil to as much as 4-7 mg. daily. Referring to the case of fluorosis reported by WebbPeploe and Bradley,! Dr. Bradley stated in a letter to me that they were careful not to incriminate any fluoride source because they could not be certain; and in an earlier letter he said he would be very interested to hear the outcome of an experiment to estimate the amount of fluoride actually in a cup of tea. Their paper also states, Suspicion therefore rested on his drinking water and diet. Our patient was a heavy tea drinker, but otherwise did not consume large amounts of food rich in fluoride." They were unable to show that he drank water high in fluoride, and water from a spring about a mile from the bricked-up well contained no detectable fluoride. Since the highest fluoride content of water in any part of Hampshire was stated to be 1 to 1-25 p.p.m., it is most unlikely that the bricked-up well contained any appreciable amount of fluoride, and the conclusion is therefore inevitable-that the patient’s only known exposure to fluoride was in the tea he drank. The case of the woman with mottled teeth2 from teafrom age 2 was confirmed as fluorosis, and not drinking " idiopathic ", by Prof. S. S. Jolly during a visit to this country. I have not seen it previously suggested that fluorotic mottling can only be determined by analysis (presumably requiring extraction). There is therefore no uncertainty in these two cases. 1. Webb-Peploe, M. M., Bradley, W. G. J. Neurol. Neurosurg. Psychiat. "
2.
1966, 29, 577. Cook, H. A. Pakistan dent.
Rev.
1968, 18, 100.
infiltration, and glomerulonephritis. The clinical picture was completed by high erythrocyte-sedimentation rate, secondary hypochromic anasmia, hypergammaglobuHnxmia, biological-false-positive reaction for syphilis, positive L.E.-cell test, and negative latex-fixation test for rheumatoid factor. In March, 1968, a new skin eruption appeared, accompanied by pulmonary infiltration, arthralgia, and fever. The daily dose of prednisone was increased to 15 mg. This improved her general condition and it was soon possible to return to the previous dose of 5 mg. per day. 4 weeks after the beginning of this exacerbation the patient was getting out of bed when she had a sudden severe pain in her right knee. Active extension of the joint became impossible and the knee became swollen. Nearly the same thing happened a week later in the left knee. The only difference was that there was no apparent precipitating cause (since the patient was immobilised in bed) and active extension of the joint recovered after some days. Examination of the anterior part of the right knee revealed a transverse groove. Palpation showed that this lay over the joint space. The patella was dislocated proximally and each contraction of quadriceps femoris shifted it further away. The diagnosis of complete rupture of the patellar ligament was confirmed radiologically. Because the patient was considerably disabled and conservative treatment (bandage) seemed unlikely to succeed, surgical treatment was attempted. Simple incision of the skin exposed the joint cavity. Just below the distal edge of the patella there was a large tear (3 x 3 cm.) in the patellar ligament. The texture and appearance of the ligament were distinctly abnormal. We succeeded in suturing the ligament to the anterior face of the patella by conventional sutures, and to the distal edge of the patella by a transosseous suture. The operation wound healed by first intention, and active extension of the knee completely recovered. The patient began to walk, and after 8 months still walks without difficulty. We wish to stress three points of interest. Firstly, spontaneous rupture of the patellar ligament in the course of S.L.E. seems to be extremely rare. (No published report has been discovered in a thorough search.) By contrast, tendon rupture has been described in 1 % of patients with
rheumatoid arthritis.1,2 What
was
the actual
cause
of the
rupture ? The possibility that the tendon was damaged by friction against bone protrusions (as can happen in rheumatoid arthritis) was ruled out during operation. On the other hand, it is highly probable that the structure of the patellar ligament was profoundly disturbed by glucocorticosteroid treatment, which had been administered almost without interruption for ten years, and which is known to inhibit the synthesis of collagen and other 1. 2.
Gamp, A., Schilling, A. Z. Rheumaforsch. 1966, 25, 42. Nalebuff, E. A., Potter, T. A. Clin. Orthop. 1968, 59, 147.
proteins. Nevertheless, the simultaneous rupture of both patellar ligaments suggests that the incident might have been connected with the preceding acute exacerbation of S.L.E. The success of the surgical treatment deserves attention, too, since the prospects of resuturing a pathologically altered tendon are usually regarded as poor. 1st Medical
2nd
Department
J. STREJČEK.
Clinic,
of Orthopædic
S. POPELKA.
Surgery,
Charles University, Prague, Czechoslovakia.
TURISTA IN TEHERAN in the paper by Professor Kean (Sept. 13, notice SIR,-I p. 583) that 19 out of 74 specialists in tropical diseases who replied to the questionary thought that water had been the cause of their own diarrhreal illness. It may therefore be useful to record that I happened to be visiting the watersupplies of the city during the week of the congresses. The city has a modern water-supply derived from distant impounding reservoirs and given comprehensive treatment including coagulation, sedimentation, filtration, and chlorination. Much of the plant was installed under the direction of British consulting engineers. The bacterial and chemical quality of the water is checked by the Water Department laboratory in Teheran. The hardness may be described as moderate and the salinity is low. The possibility that the outbreak in Teheran was due to drinkingwater appears as slight as it would be in an English citv. The Counties Public Health Laboratories, London W.C.1.
ROY C. HOATHER.
FLUORIDE AND TEA
SIR,-Professor Jenkins (Sept. 6, p. 542) is misreading my letter (Aug. 9, p. 329) when he supposes that the maximum fluoride intake in children " may be as much as 1-26 mg. daily ". This figure is the average intake by childrenfrom tea alone, and the intake averages 2.24 mg. daily in unfluoridated areas and 3-31 mg. daily in fluoridated areas. Fluoride intake of children in this survey from tea alone has varied from nil to as much as 4-7 mg. daily. Referring to the case of fluorosis reported by WebbPeploe and Bradley,! Dr. Bradley stated in a letter to me that they were careful not to incriminate any fluoride source because they could not be certain; and in an earlier letter he said he would be very interested to hear the outcome of an experiment to estimate the amount of fluoride actually in a cup of tea. Their paper also states, Suspicion therefore rested on his drinking water and diet. Our patient was a heavy tea drinker, but otherwise did not consume large amounts of food rich in fluoride." They were unable to show that he drank water high in fluoride, and water from a spring about a mile from the bricked-up well contained no detectable fluoride. Since the highest fluoride content of water in any part of Hampshire was stated to be 1 to 1-25 p.p.m., it is most unlikely that the bricked-up well contained any appreciable amount of fluoride, and the conclusion is therefore inevitable-that the patient’s only known exposure to fluoride was in the tea he drank. The case of the woman with mottled teeth2 from teafrom age 2 was confirmed as fluorosis, and not drinking " idiopathic ", by Prof. S. S. Jolly during a visit to this country. I have not seen it previously suggested that fluorotic mottling can only be determined by analysis (presumably requiring extraction). There is therefore no uncertainty in these two cases. 1. Webb-Peploe, M. M., Bradley, W. G. J. Neurol. Neurosurg. Psychiat. "
2.
1966, 29, 577. Cook, H. A. Pakistan dent.
Rev.
1968, 18, 100.