Specific bioactivities of monocyte-derived interleukin 1 alpha and interleukin 1 beta are similar to each other on cultured murine thymocytes and on cultured human connective tissue cells.

In this report we compare the bioactivities of pure, human monocyte-derived interleukin 1 (IL-1) alpha and beta in the standard murine thymocyte proliferation assay, a human dermal fibroblast proliferation assay, and in an assay measuring stimulation of prostaglandin E2 (PGE2) release from human rheumatoid synoviocytes. In each case the different species of IL-1 produced saturable stimulation and gave similar dose response curves. Half-maximal stimulation was observed at average IL-1 concentrations of 29 pM in the thymocyte assay, 2 pM in the dermal fibroblast proliferation assay, and 5 pM in the synovial cell assay. Our results show that native, monocyte-derived IL-1 alpha and IL-1 beta are both potent stimulators of connective tissue cells and that the specific bioactivities of these molecules are similar to each other in tests on human connective tissue cells, as well as on murine lymphoid cells.

The press-fit condylar modular total knee system with a posterior cruciate-substituting design. A concise follow-up of a previous report.

The purpose of the present study was to determine the long-term results of a series of 150 consecutive primary posterior stabilized modular knee arthroplasties that had been performed in 118 patients with use of a circumferential tibial insert capture as described in a previous report, published in 1997. The patients were evaluated with use of a patient-administered questionnaire; Knee Society clinical, functional, and radiographic scoring systems; and Kaplan-Meier survivorship analysis. A good to excellent result was confirmed in seventy-six (90%) of the eighty-four patients (105 knees) with a mean duration of follow-up of twelve years (range, ten to thirteen years). At twelve years, the survival rate was 94.6% +/- 4.0% with failure for any reason as the end point and 98.3% +/- 2.4% with mechanical failure as the end point. Revision surgery was performed in five knees because of infection (two knees), dislocation (one knee), and substantial polyethylene wear with femoral osteolysis (two knees). We concluded that, while fixation failure is rare, polyethylene wear and osteolysis are emerging as important causes of failure.

Surgical management of the rheumatoid hip.

Total hip arthroplasty (THA) has improved significantly in the last 30 years since the popularization of the procedure by John Charnley in the late 1960s. The significant advances in THA in the last 20 years have been that it is highly reproducible and durable, has high quality of function and low morbidity, patient satisfaction is high, and salvage is possible when necessary. The main object of this article is to discuss the surgical management of patients who have RA of the hip joint, dealing with indications, surgical techniques, results, and complications.

Effect of posterior cruciate sacrificing on durability of the cement-bone interface: a nine-year survivorship study of 100 total condylar knee arthroplasties.

This paper presents a survivorship analysis of the second group of 100 consecutive primary total-condylar knee arthroplasties carried out in 75 patients between 1979-80 with a maximum follow-up of 9 years. With this type of knee arthroplasty the posterior cruciate ligament is routinely sacrificed. Survivorship results revealed that 98.9% of the knees had a good outcome at 9 years of follow-up, using revision surgery for aseptic and septic loosening, and radiographic evidence of global radiolucency or shift of the component as the end point. Radiographic survivorship analysis showed well-fixed components in 87% of implants using endpoint criteria of appearance and progression of radiolucency under the tibial component. Sacrificing the posterior cruciate ligament does not adversely affect the durability of fixation of total-condylar knee arthroplasty. Bone cement provides an excellent fixation of the total knee implant.

Survivorship analysis of total hip replacements. Results in a series of active patients who were less than fifty-five years old.

Between 1971 and 1980, the senior one of us (C.S.R.) performed 101 primary total hip replacements in eighty-five consecutive patients who were less than fifty-five years old. All of the patients had degenerative joint disease. Survivorship analysis was used to calculate a predicted cumulative rate of success for this series of total hip replacements over ten years of follow-up. This method of analysis of the data was chosen because it provides a prediction of the expected durability of a total hip arthroplasty in any individual patient. The need for revision because of loosening or infection or else radiographic evidence of migration of a component was the criterion for failure. Two revisions were performed for aseptic loosening of the acetabular component. One infection necessitated revision, and radiographic evidence of loss of fixation was seen in one additional acetabular component and one femoral stem. Life-table calculations predicted that the survivorship of all of the total hip replacements in this series would be 87.6 per cent at ten years of follow-up. Based on the results of the application of this method of analysis to the current series, we concluded that a primary cemented total hip replacement, when performed for coxarthrosis, can be expected to function durably in an active middle-aged patient.

The osteo-anconeus flap. An approach for total elbow arthroplasty.

Twenty-seven consecutive primary total elbow arthroplasties were done with a technique that preserved the continuity of the attachment of the triceps brachii muscle with a wafer of bone from the reflected extra-articular portion of the olecranon and with the lateral fascia of muscles of the forearm. During closure, the wafer was reattached to the broad cancellous surface of the olecranon with sutures through the bone. The elbows were immobilized for an average of sixteen days postoperatively. The patients who were available for follow-up were re-examined at an average of 3.9 years, and the strength of the triceps muscle was checked. No extensor lag or avulsion of the triceps occurred, and mild extensor weakness was seen in only two elbows. No patient had early or late drainage of the wound or infection. The average range of motion compared favorably with that in other reported series. This osteo-anconeus posterior approach is advocated for total elbow arthroplasty because it provides rapid and wide exposure, it is associated with a low rate of complications related to the wound, and it preserves the strength of the triceps.

The total condylar knee prosthesis. A report of two hundred and twenty cases.

The total condylar knee prosthesis is a non-hinged surface replacement which can be used for almost all knee deformities. This report discusses the first consecutive 220 arthroplasties in 183 patients. Follow-up time was three to five years. Before operation eighty-six knees had more than 10 degrees of fixed varus deformity and thirty-one knees had more than 10 degrees of fixed valgus deformity. All patients were assessed using The Hospital for Special Surgery scoring system. Of the total of 220 knees, 137 (62%) were rated excellent; sixty-one (28%), good; ten (4.5%), fair; and twelve (5.5%), poor. Of 139 osteoarthritic knees, 93% were rated excellent or good. Complications included three deep infections and four cases of posterior subluxation. The over-all reoperation rate was 3.6%.

Madelung's deformity. An end-result study of surgical treatment.

A long-term follow-up (average, eight years) of surgical treatment of thirteen cases of Madelung's deformity in eight patients showed that the Darrach procedure was successful when there was mild deformity and that biplane osteotomy of the radius combined with the Darrach procedure was needed for severe deformity. Subluxation of the lunate bone ulnarward occurred after the Darrach procedure but was not clinically symptomatic.

Total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis.

Thirty-five total hip arthroplasties done in twenty-five patients with protrusio acetabuli secondary to rheumatoid arthritis were reviewed. There was an average follow-up of 4.3 years, with a range of three to seven years. The results were rated as excellent or good in 66 per cent, fair in 26 per cent, and poor in 8 per cent. Although 100 per cent demonstrated cementbone interface demarcation around the acetabular component, only 10 per cent showed progression of the line of demarcation to two millimeters and one had acetabular loosening with migration. Eight per cent showed femoral loosening or subsidence; 8 per cent, calcar resorption; and 6 per cent, a receding cortex with cystic changes. Twenty-three per cent had nonunion of the greater torchanter after trochanteric osteotomy. Type-III cement-bone interface demarcation was present around the acetabular component was positioned one centimeter superiorly or medially beyond the anatomical position, as estimated by the method described. In thirteen hips in which the acetabular component was positioned within five millimeters of the anatomical position, no Type-III demarcation was present. Better fixation and position of the acetabular component is achieved by the use of a bone graft or a special titanium perforated-sheet mesh, or both, or by an acetabular shell. The use of three wires improved trochanteric fixation.

Total hip replacement in congenital dislocation and dysplasia of the hip.

The results of thirty-one total hip replacements in twenty-four patients with either severe congenital dysplasia or dislocation, after an average follow-up of four years, were excellent in eleven, good in sixteen, fair in one, and poor in one. The operative technique included superolateral bone grafts to increase the acetabular coverage in six hips. Twenty-seven hips required smaller and straighter femoral components than normal. The incidence of major complications was 19 per cent.

Joint replacement surgery in patients under thirty.

Forty-five patients, twenty-six of them with juvenile rheumatoid arthritis, had sixty-seven total hip arthroplasties. The patients' ages ranged from twelve to twenty-nine years. An over-all good result was demonstrated in 93 per cent of the patients had a poor result, in 6.9 per cent. The average follow-up period was 32.5 months. Careful planning in severely dysplastic joints should be done.

Total ankle replacement in rheumatoid arthritis.

The indications for total ankle-replacement arthroplasty are controversial. Some preliminary experience with its use in patients with rheumatoid arthritis has been disappointing. However, in our fifteen single-axis arthroplasties, fourteen of the Mayo and one of the Buchholz type, after an average follow-up of thirty-nine months seven ankles were rated excellent and eight, good. The relief of pain was gratifying in all of the patients, only four patients having residual slight pain with starting activity. The average gain in the range of motion was 9 degrees. No patient had loosening that required reoperation, although radiolucent lines were seen in eleven ankles. Thirteen of the fifteen ankles had moderate to severe arthritic changes in the talonavicular, subtalar, or other intertarsal joints.

A comparison of four models of total knee-replacement prostheses.

Twenty-nine knees with unicondylar, sixty-four with duocondylar, fifty with Guepar, and fifty with geometric prostheses were studied. The follow-up ranged from two to three and one-half years. The unicondylar prosthesis was used in the mildest cases and gave the least complications, but the quality of results was not superior to that achieved with the other prostheses. The duocondylar model was best suited for knees with rheumatoid arthritis and mild deformity. The geometric prosthesis was the best condylar prosthesis for osteoarthritis with moderate to severe deformity, but gave the worst results in knees with rheumatoid arthritis. The Guepar prosthesis was used in the worst knees and gave the best results, but it had the highest infection rate and was the most difficult to salvage. A radiolucency was observed in about 60 per cent of the condylar replacements around the tibial component and in 45 per cent of the Geupar replacements around the femoral component. The significance of this cannot yet be determined but it suggest that the fixation may not be ideal. In all types, residual pain was most frequently attributed to the patellar compartment. Patellectomy was not a solution.

Total hip replacement in patients with ankylosing spondylitis with involvement of the hip.

Twenty-three patients with ankylosing spondylitis underwent thirty-four total hip arthroplasties with an average follow-up of 42.5 months. The over-all results were rated good in all but two patients. Significant benefit was obtained in posture and function so that these patients could be gainfully employed. Improvement in the sum total range of motion was 96.1 degrees in patients with bone ankylosis and 150 degrees in those with fibrous ankylosis. The preoperative sum total range of motion was maintained or improved in hips with a painful arc of motion. Most of the limited motion in patients with ankylosed hips was due to myositis ossificans.

The press-fit condylar modular total knee system. Four-to-six-year results with a posterior-cruciate-substituting design.

One hundred and eighteen patients who had had 150 consecutive primary total knee replacements (sixteen bilateral procedures) between February 1988 and February 1990, with insertion of the press-fit condylar modular total knee system with cement, were enrolled in a prospective study. Ninety-six patients (125 knees) were followed for an adequate interval (mean, 4.8 years; range, 3.8 to 6.2 years). Thirteen patients (fifteen knees) died, and nine patients (ten knees) were lost to follow-up. The mean age of the patients at the time of the index arthroplasty was seventy years (range, twenty-nine to eighty-five years). The patients were evaluated clinically and radiographically, according to the scoring system of the Knee Society, and the results on a self-administered questionnaire were used to evaluate pain, function, satisfaction, and patellofemoral symptoms. A Kaplan-Meier survivorship analysis was performed with a revision operation as the end point. The mean functional and clinical scores, according to the system of the Knee Society, were 78 and 93 points, respectively, at the most recent follow-up examination. The result was excellent for 103 knees, good for thirteen, fair for three, and poor for six. Three revision operations were necessary: two because of infection and one because of instability. The over-all rate of patellofemoral symptoms was 8 per cent (ten knees). Three knees had tibiofemoral instability; subsequent modification of the design of the tibial cam decreased the prevalence of this problem. Non-progressive radiolucent lines were present at the cement-bone interface in 39 per cent (thirty-nine) of the ninety-nine knees that had complete radiographic follow-up. No prosthesis had loosened by the time of the most recent follow-up examination. The rate of survival of the implant was 97 per cent at six years, and the standard error of the mean was 1.6 per cent. In the present series, total knee arthroplasties with the press-fit condylar modular knee system resulted in excellent relief of pain, an excellent range of motion, and restoration of function. They were also associated with a low prevalence of patellofemoral problems.

Long-term results of total hip arthroplasty in congenital dislocation and dysplasia of the hip. A follow-up note.

Twenty-three of twenty-nine hips that were previously reported on were studied at an average of fourteen years (range, eight to 16.5 years) after total hip arthroplasty with cement. The original arthroplasties had been performed between November 1971 and January 1976. In all hips, there was dislocation or severe dysplasia. In six hips, superolateral bone grafts were used to increase acetabular coverage. At the latest follow-up examination, seven hips were rated excellent; nine, good; and one, fair. There were six failures (26 per cent) that were revised: four hips (17 per cent) had a fractured Trapezoidal-28 stem, one had loose femoral and acetabular components, and one had loosening of only the acetabular component. Radiographic analysis of the remaining hips revealed that one had progressive acetabular radiolucencies. This patient had an excellent clinical result. Two-thirds of the failures were due to a fractured stem.

Total hip arthroplasty in juvenile rheumatoid arthritis. Two to eleven-year results.

From 1971 to 1980, forty-five patients with juvenile rheumatoid arthritis had eighty-three cemented total hip replacements at The Hospital for Special Surgery and North Carolina Memorial Hospital. Thirty-four of these patients, with sixty-two involved hips, returned for examination and radiographs. The average age of these thirty-four patients at the time of surgery was twenty-six years, and twenty-seven of them, with forty-nine involved hips, were thirty years old or less. The average length of follow-up was six years (range, two to eleven years), with forty-one hips having been followed for five to eleven years. According to The Hospital for Special Surgery hip-rating system, thirty hips were rated excellent; nineteen, good; nine, fair; and four, poor. Of the four hips with a poor result, two (in the same patient) had severe heterotopic ossification with ankylosis postoperatively, and two had required revision: one for acetabular loosening six years after replacement and the other for a broken stem of the femoral component ten years postoperatively. Radiographic review of the sixty-two hips demonstrated progressive radiolucencies or migration of 26 per cent of the acetabular components and 8 per cent of the femoral components. The frequency of acetabular migration or progressive radiolucencies was related to the postoperative position of the component relative to the position of the true acetabulum. These results were somewhat better than those in other reports on cemented total hip replacement in young patients. The difference is probably related to the lower average weight and decreased activity level of patients with juvenile rheumatoid arthritis.

A self-administered hip-rating questionnaire for the assessment of outcome after total hip replacement.

The hip-rating questionnaire was developed for the assessment of the outcome of total hip replacement. The purpose of this study was to evaluate its reproducibility, validity, and responsiveness. The questionnaire uses a 100-point scale in which equal weight is given to the domains of global or over-all impact of arthritis, pain, walking, and function. Ninety-eight patients were enrolled in the prospective study and have been followed for at least three months; sixty-two patients have been followed for six months; and forty-two patients have been followed for one year. Reproducibility was tested with the use of the kappa statistic in fifty patients whose condition was stable clinically, and it was found to be good or excellent both for individual questions and for the total score. The validity of the questionnaire was assessed by comparison with the scores from a six-minute walking-distance test and arthritis impact-measurement scales. The result of the six-minute walking-distance test correlated with the patient's response concerning walking distance on the hip-rating questionnaire. The score for pain from the hip-rating questionnaire correlated well with the score for pain from the arthritis impact-measurement scales, and the total score from the hip-rating questionnaire correlated well with the total score from the arthritis impact-measurement scales. The score on the hip-rating questionnaire was responsive to the change in the clinical condition of the patient, as indicated by a favorable index of responsiveness. The results of the questionnaire were sensitive enough to demonstrate differences among treatment groups with relatively small sample sizes. This questionnaire has the characteristics of a useful instrument for assessment of outcomes, such as that after an operation.

Cervical spine fusion in rheumatoid arthritis.

Spinal fusion for deformity of the cervical spine was done in thirty-three patients with rheumatoid arthritis. The average follow-up was three years. The deformities present were atlano-axial subluxation, superior migration of the odontoid process into the foramen magnum, and subaxial subluxation of the vertebral bodies. We devised a classification of the pain and the neural involvement in these patients and a new method of measuring superior migration. The surgical procedures for treating instability, intractable pain, or neural involvement, or a combination of the three, were: (1) a Gallie fusion of the first and second cervical vertebrae for atlanto-axial subluxation, (2) a fusion of the occiput and the second cervical vertebra for superior migration of the odontoid process, and (3) a posterior fusion for subaxial subluxation. The occiput was included in the fusion if superior migration of the odontoid process was demonstrated. The results show that four of five patients who had an anterior fusion had no improvement. Twenty-five patients had posterior fusion; in seventeen the condition was improved, in five there was improvement, and in three the condition was worse. Of nineteen patients with neural involvement, the condition was improved in eight, it was unchanged in seven, and it was made worse in two. There were three postoperative deaths and six additional unrelated deaths within two years of surgery. There were five pseudarthroses.

Conventional total hip arthroplasty for degenerative joint disease in patients between the ages of forty and sixty years.

We analyzed the records of 103 conventional hip arthroplasties in seventy-five active patients who were between the ages of forty and sixty years. After five to ten years of follow-up, an excellent or good clinical result was evident in 90 per cent. The radiographic appearance of the cement-bone interface of the acetabular component was stable in those hips, and no progressive acetabular radiolucency was found in 80 per cent of the hips. Of twenty hips with a complete acetabular radiolucency (Grade III or IV), only three had a secondary revision operation, two in conjunction with a fracture of the stem of the prosthesis and one for migration (Grade IV). Eight additional hips showed migration. Seventy per cent of the femoral components were well fixed, without radiographic evidence of loosening. A fracture of the femoral stem occurred in eight hips, all of which had a revision operation. One revision operation was done for loosening of the femoral stem. Seven femoral stems showed either shift or subsidence. An isolated radiolucency in the superolateral zone was present in four hips and an isolated lucency in other zones, measuring one millimeter or less, was present in ten hips. Thus, radiographic evidence of loosening, including the hips with a fractured stem, was present in 29.9 per cent. One additional revision, making ten in all, was done for symptomatic acetabular loosening. Based on this study, we concluded that conventional hip arthroplasty is a highly successful treatment in active patients between forty and sixty years old who have osteoarthritis of the hip.