Prospective study of a cementless, mobile-bearing, third generation total ankle prosthesis.

BACKGROUND: The SALTO total ankle prosthesis is a noncemented mobile bearing anatomic design characterized by dual Ti-HA coating. This study reviews our results with this prosthesis. MATERIALS AND METHODS: Between 2001 and 2007, 413 consecutive SALTO prostheses were implanted in our institution in 215 women and 198 men, aged 57.1 +/- 11.9 years. At the last visit, 401 implants (47% in the left ankle) were available with a mean followup of 29 (range, 1 to 84) months. RESULTS: Based on the results of the 218 patients with at least 2 years of postoperative followup, the 5-year estimated survivorship, with the primary end-point being implant removal, was 86.6% and ranged from 85.1% in patients with post-traumatic osteoarthritis to 95.6% in those with rheumatoid arthritis. The AOFAS score increased from 50.9 +/- 16.8 points preoperatively to 82.2 +/- 14 points at followup (mean difference, 31.1 +/- 1.4, 95% confidence interval (C.I.) for the difference, 28.3 to 33.8, p < 0.001). Visual analog scale for pain decreased from 7.4 +/- 1.1 preoperatively to 2.0 +/- 2.0 postoperatively (mean difference, -5.4 +/- 0.7, 95% C.I. for the difference, -5.6 to -5.2, p < 0.001). Flexion/extension ROM increased from 25.2 +/- 14.1 degrees to 33.1 +/- 13.6 degrees at the last followup visit (mean difference, 7.9 +/- 0.5 degrees, 95% C.I. for the difference, 4.3 to 7.2, p < 0.001), while pronation/supination ROM increased from 23.8 +/- 13.7 degrees to 25.4 +/- 14.5 degrees (mean difference, 1.6 +/- 0.7 degrees, 95% C.I. for the difference, 0.9 to 2.2, p = 0.005). CONCLUSION: The SALTO prosthesis provided good clinical and functional results and we believe helps validate the concept of anatomic replacement.

Altered neuromuscular control of a hand muscle in chronic rotator cuff tears.

INTRODUCTION: Previous EMG studies have shown that chronic rotator cuff tears (RCT) may be associated with an altered activation of adjacent shoulder muscles. The effect of RCT on central neuromuscular control mechanisms of hand muscles has as yet not been studied in detail. This study investigated the cortico-motor excitability of the first dorsal interosseus muscle (FDI) in patients with RCT. MATERIALS AND METHODS: The resting motor threshold (RMT) of the FDI on both sides were obtained from patients with unilateral chronic RCT and compared with healthy control subjects without any shoulder pathologies with transcranial magnetic stimulation. Analysis of variance for repeated measures was performed to detect possible differences in RMT of the FDI in patients and healthy controls. RESULTS: The RMT of FDI in patients on the affected side was lower when compared to the non-affected side (p = 0.015) and to both sides in control subjects (p = 0.041, F = 4.8). CONCLUSIONS: The reduced RMT of FDI in patients with unilateral RCT may be related to alterations in the sensory output from the shoulder and points toward a complete sensimotor restriction of the involved upper limb. These findings seem to be assigned to adaptive changes in the motor cortex as a consequence of chronic RCT.

Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair.

BACKGROUND: The surgical treatment of massive rotator cuff tears (RCT) is still controversial and can be based on a variety of different surgical repair methods. This study investigated the effectiveness of arthroscopic debridement or arthroscopic partial repair in patients with massive RCT. MATERIALS AND METHODS: This prospective, randomized study involved forty-two patients with massive RCT (fatty infiltration stage 3 or 4) treated with either arthroscopic partial repair or arthroscopic debridement were selected to detect possible differences in functional outcome. Both groups were matched according to age and gender. Patients were examined before, and 16 +/- 3 and 24 +/- 2 months after surgery. The status of the rotator cuff repair was determined using ultrasonographic evaluation. RESULTS: Regardless of the treatment group, postoperative results demonstrated highly significant improvements compared with preoperative values in most parameters. The overall Constant score in the partial repair group was superior to the outcome in the debridement group (P < 0.01, F = 8.561), according to better results in abduction (P < 0.01, F = 13.249), activity (P < 0.01, F = 21.391) and motion (P < 0.01, F = 4.967). All treatment groups had similar pain relief (P = 0.172, F = 1.802) and satisfaction, reflected in equal values of disabilities of the arm, shoulder and hand (DASH) score (P = 0.948, F = 0.004). Ultrasonography revealed structural failure of the partial rotator cuff repair in 52% at final follow-up. CONCLUSIONS: During the follow-up period all patients in our series had good or satisfactory outcome after rotator cuff surgery. Regardless of high rates of structural failure of the partial rotator cuff repair, the results of arthroscopic partial rotator cuff repair demonstrated slightly better functional outcome than debridement.

[Mini-subvastus approach for total knee replacement]. / Mini-Subvastus-Zugang bei der Implantation von Knieendoprothesen.

OBJECTIVE: Total knee replacement in minimally invasive technique without any trauma to the extensor apparatus and with soft-tissue-referenced bone resections. Only the subvastus approach preserves the integrity of the extensor apparatus and has therefore been modified to become a minimally invasive technique with a shorter skin incision and lateralization instead of eversion of the patella. Soft-tissue balancing is done through this direct anterior approach. INDICATIONS: Mild to moderate varus osteoarthritis of the knee up to 15 degrees of malalignment, mild and passively correctable valgus osteoarthritis of the knee up to 10 degrees of malalignment. CONTRAINDICATIONS: Severe, contract varus osteoarthritis of the knee, severe and moderate, contract valgus osteoarthritis of the knee, severe obesity, exceptionally muscular patients, decreased skin perfusion. SURGICAL TECHNIQUE: Central skin incision from the superior pole of the patella to the tibial tubercle. Exposure of the medial retinaculum and mobilization of the vastus medialis muscle subcutaneously. Incision of the medial retinaculum and blunt separation of the vastus medialis muscle from the intermuscular septum. Lateralization of the patella and flexion of the knee joint. Resection of the tibia perpendicular to the diaphysis. Adjustment of the anteroposterior (AP) resection block at the level of the anterior femoral cortex and of rotation by applying equal tension to the collateral ligaments. Balancing of soft-tissue tension in flexion gap by release, if necessary. After AP resection fixation of distal resection block in planned valgus angle. Balancing of soft-tissue tension in extension gap by release, if necessary. After distal femur resection facet resection, adaptation of posterior femoral condyles, and implantation of prosthesis. Check on stability and range of motion. Wound closure. POSTOPERATIVE MANAGEMENT: Full weight bearing from the 1st postoperative day, CPM (continuous passive motion) with up to 90 degrees flexion with peridural anesthesia as tolerated, stair climbing starting on the 7th postoperative day. RESULTS: 100 patients were randomized to total knee replacement via a parapatellar or subvastus approach. Radiologically, there were no differences in operative precision or leg alignment. Patients treated minimally invasively suffered less pain and achieved a higher flexion of 110 degrees versus 95 degrees 6 weeks postoperatively. However, there were two cases of delayed wound healing in this group. The surgical technique is demanding and the operating time is longer. Long-term results are still missing.

Long-term results after arthroscopic treatment of synovial chondromatosis of the shoulder.

PURPOSE: The purpose of this study was to document the results of arthroscopic treatment for synovial chondromatosis of the shoulder with loose body removal and partial synovectomy. METHODS: Five cases of shoulder arthroscopy performed for synovial chondromatosis were reviewed. Removal of loose bodies and partial synovectomy was performed in all cases. Follow-up of 4 to 9 years was obtained on these 5 patients. RESULTS: The clinical result was very good for all patients. Radiologic signs of chondroma were observed in two patients. Revision surgery was not necessary in either case. CONCLUSIONS: The clinical results referring to the Constant and Murley score and subjective assessment were very good at 4 to 9 years following surgery. However, in two out of five subjects, radiographs revealed evidence of persisting or recurrent synovial chondroma at follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Navigated minimally invasive unicompartmental knee arthroplasty.

Unicompartmental knee arthroplasty (UKA) is an alternative procedure to high tibial osteotomy. This study assessed the procedure using computer navigation to improve implantation accuracy and presents early radiological results of a group of patients implanted with the univation UKA (B. Braun Aesculap, Tuttlingen, Germany) with navigation instrumentation and a minimally invasive approach. The authors concluded that navigated implantation of a UKA using a nonimage-based system improved radiologic accuracy implantation without significant inconvenience and minimal change in the conventional operating technique.

Arthroscopic anterior cruciate ligament reconstruction using the double press- fit technique: an alternative to interference screw fixation.

PURPOSE: Patellar tendon autograft fixation in arthroscopic anterior cruciate ligament reconstruction is commonly accomplished using interference screws. However, improper insertion of the screws may reduce primary stability, injure the posterior femoral cortex, or displace hardware into the joint. Even if placed properly, metallic screws interfere with postoperative magnetic resonance imaging. In case of revision surgery, removing screws may be difficult and leaves bone defects. TYPE OF STUDY: Retrospective study. METHODS: An arthroscopic technique was developed that achieves patellar tendon autograft fixation by press-fit without any supplemental internal fixation. Forty patients were examined clinically and by KT-1000 arthrometer 28.7 months (range, 22 to 40 months) postoperatively. RESULTS: The mean difference in side-to-side laxity was 1.3 mm (SD 2.2) and the results according to the IKDC score were as follows: 7 A, 28 B, 5 C, and 0 D. CONCLUSIONS: The double press-fit technique we present avoids all complications related to the use of interference screws and creates an ideal environment for osseous integration of the bone-patellar tendon-bone autograft. Concurrently, it achieves a stable fixation of the autograft and allows early functional rehabilitation. However, fixation strength depends on bone quality and the arthroscopic procedure is demanding.

Percutaneous repair of acute Achilles tendon rupture.

Various studies have shown that the operative treatment of a freshly ruptured Achilles tendon is generally considered to be more appropriate than a nonoperative regimen. However, complications in open reconstructions are reported to occur in 11-29%. The method used in this study reduced the risk of complications arising from operation, but simultaneously allowed early postoperative mobilization and functional treatment. It was a percutaneous repair of the Achilles tendon, using two Lengemann extension wires for coadaptation of the ruptured tendon. To fix the rupture site, the authors used a fibrin sealant. The spikes of the wire were hooked in at the fascia of the soleus muscle. Via a big, curved needle, the wire was placed in the distal stumps of the ruptured tendon and guided out laterally and medially above the calcaneus. After blocking the wires distally, the fibrin sealant was applied at the rupture site. The current report describes this method of treatment in 66 patients. The postoperative observation period was 1 year. Sixty-four patients were male and two were female. Their average age was 42 years. The Achilles tendon ruptures occurred during sporting activities and were treated by operation within 22 hours on average. The outcome was very good in 98%. One patient (2%) suffered a rerupture due to trauma. There were no other complications.

[Shoulder metastasis as the initial manifestation of hepatocellular carcinoma (HCC)]. / Schultermetastase als Erstmanifestation eines hepatozellulären Karzinoms (HCC).

BACKGROUND: Primary diagnosis of hepatocellular carcinoma (HCC) by a shoulder metastasis is a rare event. HISTORY AND CLINICAL FINDINGS: A 68-year-old man was admitted with swelling of his left shoulder. No further clinical symptoms. Alcohol consumption: 1 l beer/day. On ultrasound, the clinically impressing tumor of the left shoulder showed calcifications. INVESTIGATIONS: Histologic examination of the tumor of the shoulder showed a well-differentiated, trabecular carcinoma consistent with the metastasis of an HCC. Subsequent ultrasound of the abdomen gave evidence of liver cirrhosis. In addition, an infiltrating mass was found, which encompassed 75% of the right liver lobe and was subsequently shown by histology to be a well-differentiated HCC with identical features of the tumor of the shoulder. Further metastases with pathologic rib fractures were found on CT scan of the thorax. DIAGNOSIS: Based on clinical findings, laboratory investigations and imaging studies, the patient suffered from an HCC owing to ethyl-toxic liver cirrhosis stage Child C, and initially presented with a shoulder metastasis. THERAPY: Due to the advanced tumor stage, no curative or palliative therapy was administered. CONCLUSION: This is an interesting case of an atypical primary diagnosis of HCC. The most important information was given by the pathologists who raised the suspicion of a metastasizing HCC by examining the tumor of the shoulder.

Blinded-read of bone scintigraphy: the impact on diagnosis and healing time for stress injuries with emphasis on the foot.

AIM: This study evaluated the use of bone scintigraphy (BS) for the diagnosis of stress fractures in athletes and its validity for the prediction of healing time, with a focus on foot injuries. METHODS: In our retrospective study, 84 athletes with a total of 93 suspected stress fractures (foot, n = 66; others, n = 27) were included. A blinded-read of BS was performed by 3 observers. The standard of reference was established by an interdisciplinary truth-panel using all imaging data (scintigraphic, radiographic, and magnetic resonance imaging) and follow-up data (>12 month). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosing stress fractures were calculated. Stress injuries were rated according to a 5-point grading score (0-4) and associated to the healing time. RESULTS: For the diagnosis of stress injuries (n = 50/93), mean sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 97.3%, 67.4%, 77.7%, 95.6%, and 83.5%, respectively. Interobserver analysis showed a high agreement between all 3 readers (mean κ = 0.83). In univariate analysis healing time of grade 3 to 4 stress injuries was significantly higher (median, 87 days; interquartile range, 69-132 days) compared with grade 1 to 2 lesions (median, 63 days; interquartile range, 43-95 days; P = 0.0067). Moreover, healing time of scintigraphic high grade stress injuries was significantly longer in a general linear model with adjustment for cofactors (grade, 3-4 vs. 1-2; P = 0.033). CONCLUSIONS: BS is a sensitive and reliable method for the diagnosis of stress injuries. In addition, the simplified classification for mild and severe stress injuries allows an estimation of healing time.

[Reconstruction of the acetabulum with structured bone graft in press-fit technique]. / Rekonstruktion des Azetabulums mit strukturiertem Knochentransplantat in Press-fit-Technik.

OBJECTIVE: Reconstruction of defects of the superior acetabular rim with structured bone grafts in press-fit technique before total hip replacement. INDICATIONS: Defects of the superior acetabular rim following hip dysplasia Crowe type II-IV, avascular necrosis of the femoral head Ficat stage IV, or aseptic loosening of the cup with acetabular defects Paprosky type 2a and 2b. CONTRAINDICATIONS: Acetabular defects Paprosky type 2c, 3a and 3b, septic loosening, severe osteoporosis. SURGICAL TECHNIQUE: Exposure of the acetabular defect and debridement with a spherical reamer to create a concave bleeding graft bed. Shaping of the bone graft with an inverted reamer of corresponding size and oscillating saw. Press-fit insertion of the bone graft into the defect and temporary fixation with Kirschner wires. Rereaming of the acetabulum with the spherical reamer. Implantation of a cemented cup of corresponding size. Removal of Kirschner wires after setting of cement. POSTOPERATIVE MANAGEMENT: Full weight bearing in case of small or medium graft, 6-week non-weight bearing in case of big load-bearing graft. Mobilization on 1st day postoperatively. Stair climbing on 7th day postoperatively. Suture removal after 10 days. RESULTS: In 46 patients with 55 total hip replacements with structured grafts in press-fit technique, the Harris Hip Score improved from 38.9 points to 92.3 points after 29.4 months (12.0-84.4 months). There were two cases of delayed wound healing and one cup exchange because of aseptic loosening. Radiologically, one graft sintering by 5 mm was detected.

Strength and voluntary activation of quadriceps femoris muscle in total knee arthroplasty with midvastus and subvastus approaches.

To determine and compare the influence of 2 different approaches on quadriceps femoris muscle function in total knee arthroplasty (TKA), 20 patients (14 women, 6 men) with bilateral knee osteoarthritis underwent a 1-stage bilateral TKA. Surgical approaches (subvastus, midvastus) were performed by a random selection. Measurements of quadriceps voluntary activation and maximal voluntary contraction were estimated by a twitch interpolation technique before, 3 and 6 months after TKA. Knee pain was quantified by the Lewis Score. There was no difference between the 2 approaches at 3 and 6 months after TKA with regard to maximal voluntary contraction (P = 0.84, F = 0.041) and voluntary activation (P = .863, F = 0.031). In the subvastus group was a significantly higher knee pain until 6 months after surgery (P = .02). The subvastus approach for TKA does not provide any advantages compared with the midvastus approach with respect to the quadriceps femoris muscle strength in the early postoperative period. Furthermore, the subvastus approach caused significantly more pain postoperatively.

Clinical comparison of fixation methods for patellar bone quadriceps tendon autografts in anterior cruciate ligament reconstruction: absorbable cross-pins versus absorbable screws.

BACKGROUND: Recently, the use of the quadriceps tendon transplant with bone block (patellar bone quadriceps tendon autografts) for anterior cruciate ligament reconstruction has increasingly been reported. HYPOTHESIS: Clinical results after the implantation of a patellar bone quadriceps tendon autograft fixed with cross-pins or screws will show no significant difference between the 2 techniques with regard to stability, function, and subjective satisfaction. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 1998 and 2004, 193 patients with anterior cruciate ligament ruptures were implanted with a patellar bone quadriceps tendon autograft. For 100 of these patients, fixation was carried out using absorbable cross-pins, and for the remaining 93, fixation was carried out using absorbable screws. The results were evaluated by means of International Knee Documentation Committee, Noyes, and Lysholm scores, as well as KT-1000 arthrometer measurement and subjective satisfaction. RESULTS: The mean follow-up postoperative control period was 29 months. In the International Knee Documentation Committee overall evaluation, the pin group showed a significantly better result (P =.03). The values of the Noyes score produced no significant differences. The mean value of the Lysholm score was 94 points in the screw group and 89 points in the pin group (P <.001). Overall, 90% of the patients subjectively judged their conditions as good or very good. CONCLUSION: With both operating processes examined, 80% to 90% of the cases achieved good to very good results. The use of cross-pins can be recommended for fixing patellar bone quadriceps tendon autografts.

The effect of locally applied vascular endothelial growth factor on meniscus healing: gross and histological findings.

INTRODUCTION: Tears in the peripheral part of the menisci have a better healing potential than tears in the central part, because the central two-thirds of the menisci are avascular. We hypothesized that healing of meniscus tears in the avascular zone can be promoted by the local application of the angiogenic factor vascular endothelial growth factor (VEGF). MATERIALS AND METHODS: A tear was created in the avascular zone of the medial meniscus in 18 merino sheep. The tear was then repaired with an uncoated suture (group 1), a suture coated with PDLLA (group 2), and by a suture coated with PDLLA/VEGF (group 3). RESULTS: After 6 weeks, we observed increased immunostaining for factor VIII in the VEGF-treated group 3. However, in this treatment group no meniscus healed completely. In the uncoated suture group and in the PDLLA-coated-suture group, partial healing was observed in three animals and complete healing in three animals, respectively. CONCLUSION: In this experiment the local application of VEGF via PDLLA-coated sutures did not promote meniscus healing. Growth factors might not always be a promising tool for tissue repair.

The treatment of proximal humeral fractures with intramedullary titanium helix wire by 97 patients.

INTRODUCTION: The displaced proximal humeral fracture continues to be a problem and remains the "unsolved fracture". Many guidelines for surgical treatment of different types of these fractures have been described. A conservative functional therapy is recommended as well as a closed or open reposition and internal fixation. Other authors prefer the primary prosthetic replacement of the displaced humeral head. The purpose of this article is to describe a minimal invasive technique--the intramedullary titanium helix wire--and to analyse results and specific problems of this method compared to other techniques. MATERIALS AND METHODS: In a prospective study done over a period of 5 years from 1998 to 2002, 97 patients with two-, three- and four-part-fractures of the proximal humerus were treated with the intramedullary titanium helix wire and given follow-up clinical and radiological checks after 12 months. The functional outcome was evaluated with a 1-year follow-up in 95 of 97 patients. RESULTS: Our 1-year results include: 41 very good, 24 good, 16 satisfactory, 14 poor (average 76 points Constant functional score, 30.7 points UCLA score). CONCLUSION: The advantages of the method arising from the results lie in both the simple operation approach without nerve lesions or wound infections, and also in the indirect, intramedullary splinting of the fracture without damage to the surrounding soft parts, while iatrogenic necroses of the humeral head can be avoided.

Gene transfer of tissue inhibitor of metalloproteinases-3 reverses the inhibitory effects of TNF-alpha on Fas-induced apoptosis in rheumatoid arthritis synovial fibroblasts.

Apart from counteracting matrix metalloproteinases, tissue inhibitor of metalloproteinases-3 (TIMP-3) has proapoptotic properties. These features have been attributed to the inhibition of metalloproteinases involved in the shedding of cell surface receptors such as the TNFR. However, little is known about effects of TIMP-3 in cells that are not susceptible to apoptosis by TNF-alpha. In this study, we report that gene transfer of TIMP-3 into human rheumatoid arthritis synovial fibroblasts and MRC-5 human fetal lung fibroblasts facilitates apoptosis and completely reverses the apoptosis-inhibiting effects of TNF-alpha. Although TNF-alpha inhibits Fas/CD95-induced apoptosis in untransfected and mock-transfected cells, fibroblasts ectopically expressing TIMP-3 are sensitized most strongly to Fas/CD95-mediated cell death by TNF-alpha. Neither synthetic MMP inhibitors nor glycosylated bioactive TIMP-3 are able to achieve these effects. Gene transfer of TIMP-3 inhibits the TNF-alpha-induced activation of NF-kappaB in rheumatoid arthritis synovial fibroblasts and reduces the up-regulation of soluble Fas/CD95 by TNF-alpha, but has no effects on the cell surface expression of Fas. Collectively, our data demonstrate that intracellularly produced TIMP-3 not only induces apoptosis, but also modulates the apoptosis-inhibiting effects of TNF-alpha in human rheumatoid arthritis synovial fibroblast-like cells. Thus, our findings may stimulate further studies on the therapeutic potential of gene transfer strategies with TIMP-3.

Retroviral gene transfer of an antisense construct against membrane type 1 matrix metalloproteinase reduces the invasiveness of rheumatoid arthritis synovial fibroblasts.

OBJECTIVE: Membrane type 1 matrix metalloproteinase (MT1-MMP) is expressed prominently in rheumatoid arthritis synovial fibroblasts (RASFs), but the specific contribution of MT1-MMP to fibroblast-mediated destruction of articular cartilage is incompletely understood. This study used gene transfer of an antisense expression construct to assess the effects of MT1-MMP inhibition on the invasiveness of RASFs. METHODS: Retroviral gene transfer of a pLXIN vector-based antisense RNA expression construct (MT1-MMPalphaS) to MT1-MMP was used to stably transduce RASFs. Levels of MT1-MMP RNA and protein were determined by quantitative polymerase chain reaction, Western blotting, and immunocytochemistry in MT1-MMPalphaS-transduced RASFs as well as in control cells, with monitoring for 60 days. The effects of MT1-MMPalphaS on the invasiveness of RASFs were analyzed in the SCID mouse co-implantation model of RA. RESULTS: MT1-MMPalphaS-transduced RASFs produced high levels of antisense RNA that exceeded endogenous levels of MT1-MMP messenger RNA by 15-fold and resulted in a down-regulation of MT1-MMP at the protein level. Inhibition of MT1-MMP production was maintained for 60 days and significantly reduced the invasiveness of RASFs in the SCID mouse model. Whereas prominent invasion into cartilage by non-transduced and mock-transduced RASFs was observed (mean invasion scores 3.0 and 3.1, respectively), MT1-MMPalphaS-transduced cells showed only moderate invasiveness (mean invasion score 1.8; P < 0.05). CONCLUSION: The data demonstrate that an antisense RNA expression construct against MT1-MMP can be generated and expressed in RASFs for at least 60 days. Inhibition of MT1-MMP significantly reduces the cartilage degradation by RASFs.

Clinical outcomes in the revision of unicondylar arthoplasties to bicondylar arthroplasties. A matched-pair study.

INTRODUCTION: The aim of the following study was to find out how much a previously implanted unicondylar prosthesis affects the clinical and functional outcome of a total knee arthroplasty in case of revision surgery. MATERIALS AND METHODS: A matched-pair comparative analysis was performed on 28 patients (group A) who required bicondylar knee arthroplasty following failed unicondylar arthroplasty and 28 patients (group B) with primary bicondylar knee arthroplasty. Both groups were matched according to age, sex, weight, height, type of prosthesis, and follow-up time after bicondylar arthroplasty. The patients' evaluation was based on the Knee Society Score and the WOMAC Score. Radiographs (AP weight-bearing and lateral) were taken of the knee. The average follow-up time after bicondylar arthroplasty was 55+/-15 months in group A and 56+/-13 months in group B. RESULTS: The knee score was 71.8+/-18 and 80.4+/-10 points (p=0.01) and the function score 56.1+/-15 and 64.1+/-19 points (p=0.1) for group A and group B, respectively. The subjective assessment according to the WOMAC Score was statistically significant in terms of the functional outcome. Increased postoperative range of motion of 109 degrees +/-11 degrees was noticed for group B in comparison with group A (101 degrees +/-8 degrees ; p=0.004). Patients revised from an unicondylar arthroplasty required a significantly thicker polyethylene inlay (12.9+/-3 mm) compared with the primarily implanted group (10.3+/-3 mm; p=0.004). CONCLUSION: Revision of an unicondylar to a bicondylar knee replacement showed inferior functional results in comparison to primary bicondylar knee arthroplasty. Patients are satisfied after conversion of an unicondylar to bicondylar prosthesis, but not quite as much as patients who received a primary bicondylar arthroplasty. However, in the small number of patients where revision surgery after failed unicondylar prosthesis is required, the patient had already been successfully treated for many years.

Strength and motion after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1-6 years.

We evaluated 27 patients with shoulder hemiarthroplasty after displaced four-fragment fracture of the proximal humerus after mean 4 (1-6) years. Isometric strength measurements (Kintrex) and three-dimensional motion analysis (Elite-System) were performed on the operated and unoperated shoulders. Clinical assessment was based on Constant's score and Neer's scoring system. The isometric strength of the operated and unoperated sides were 22 (SD 8.6) Nm and 24 (SD 5.9) Nm in abduction and 48 (SD 14) Nm and 65 (SD 21) Nm, respectively in adduction (the latter was statistically significant). Motion analyses at follow-up showed a mean reduction in glenohumeral movement. Increases in acceleration and deceleration of the acromion at the operated side were noted, indicating a change in glenohumeral rhythm during maximal abduction. The Constant score was 45 (SD 15) points with a significant reduction in the range of motion. 15 patients had some degree of heterotopic ossification. On the basis of our findings, the impaired function seems to be caused by reduced glenohumeral mobility rather than muscle strength. We also found a better outcome after early than late hemiarthroplasty.

Higher susceptibility to Fas ligand induced apoptosis and altered modulation of cell death by tumor necrosis factor-alpha in periarticular tenocytes from patients with knee joint osteoarthritis.

The aim of the present study was to investigate the expression of Fas in periarticular tenocytes of patients with osteoarthritis (OA) and to study their susceptibility to Fas ligand-mediated apoptosis. Tendon samples were obtained from the quadriceps femoris muscle of patients with knee OA and used for histological evaluation, for immunohistochemical detection of Fas, and to establish tenocyte cultures. The expression of Fas mRNA was determined by quantitative PCR. Levels of soluble Fas and soluble tumour necrosis factor (TNF) receptor I were measured using ELISA. Apoptosis was induced with recombinant human Fas ligand and measured by a histone fragmentation assay and flow cytometry. The effects of TNF-alpha were studied by stimulation with TNF-alpha alone or 24 hours before the induction of apoptosis. Tendon samples from non-OA patients were used as controls. Histological evaluation revealed degenerative changes in the tendons of all OA patients but not in the controls. Fas was detected by immunohistochemistry in all specimens, but quantitative PCR revealed significantly higher levels of Fas mRNA in OA tenocytes. In contrast, lower levels of soluble Fas were found in OA tenocytes by ELISA. OA tenocytes were significantly more susceptible to Fas ligand induced apoptosis than were control cells. TNF-alpha reduced the Fas ligand induced apoptosis in OA tenocytes but had no effects on control tenocytes. These data suggest that knee OA is associated with higher susceptibility of periarticular tenocytes to Fas ligand induced apoptosis because of higher expression of Fas but lower levels of apoptosis-inhibiting soluble Fas. These changes may contribute to decreased cellularity in degenerative tendons and promote their rupturing. The antiapoptotic effects of TNF-alpha in OA tenocytes most likely reflect regenerative attempts and must be taken into account when anti-TNF strategies are considered for OA.