Incidence of rheumatoid arthritis-related ankle replacement and ankle arthrodesis: a Finnish nationwide register-based study from 1997­2010.

BACKGROUND AND PURPOSE: For 20 years, medical treatment of rheumatoid arthritis (RA) has been improving and the incidence of joint surgery has decreased. We investigated the rates of primary ankle joint arthrodesis and total ankle arthroplasty in patients with RA in Finland between 1997 and 2010 to establish whether trends have changed during that period. METHODS: The annual figures for primary ankle joint arthrodeses and total ankle replacements performed in patients with RA were obtained from nationwide population-based registries. Incidences were calculated per population of 10(5) and they are reported in 2-year periods. RESULTS: During the study period, 593 primary ankle joint arthrodeses and 318 total ankle arthroplasties were performed in patients with RA. The incidence of ankle joint arthrodesis reached its highest value (2.4/10(5)) in 1997-1998 and it was lowest in 2001-2002 (1.1/10(5)). After 2002, the incidence increased slightly but did not reach the level in 1997-1998, even though total ankle replacements almost ended in Finland during the period 2009-2010. From 1997, total ankle replacements increased until 2003-2004 (incidence 1.5/10(5)) and then gradually decreased. In 2009-2010, the incidence of total ankle replacements was only 0.4/10(5). INTERPRETATION: During the observation period 1997-2010, while total ankle replacements generally became more common in patients with RA, the incidence of primary ankle joint arthrodesis decreased and did not increase in the period 2009-2010, even though total ankle replacement surgery almost ended in Finland. No change in the incidence of these operations, when pooled together, was observed from 1997 to 2010.

High rate of osteolytic lesions in medium-term followup after the AES total ankle replacement.

BACKGROUND: Some previous studies have shown a high percentage of early-onset and rapidly progressing osteolysis associated with total ankle arthroplasty (TAA) by the Ankle Evolutive System (AES). The purpose of our study was to analyze medium-term results at our institution. MATERIALS AND METHODS: Altogether 38 TAAs using AES prostheses were carried out between 2003 and 2007. Diagnoses were rheumatoid arthritis (71%), post-traumatic and idiopathic osteoarthritis (29%). The mean age was 54 years, followup 28 months. Tibial and talar components had hydroxyapatite coating on metal (Co-Cr) components (HA-coated). Since 2005 the design was changed and components were porous coated with titanium and hydroxyapatite (dual-coated). RESULTS: Two-year survival was 79% (95% CI: 56 to 98). At followup 34 (89%) primary tibial and talar components were preserved. In 19 (50%) TAAs osteolysis (more than or equal to 2 mm) occurred in the periprosthetic bone area and in nine (24%) comprised large "cyst-like osteolysis''. In HA-coated prostheses radiolucent lines (less than or equal to 2 mm) or osteolysis (more than or equal to 2 mm) were detected in 11 (100%) cases and in dual-coated prostheses in 19 (74%) (p = 0.08). On the other hand there was more large "cyst-like osteolysis'' around the dual-coated prosthesis and lesions were larger (p = 0.017). In rheumatoid arthritis osteolysis was detected in 14 (52%) and large "cyst-like osteolysis'' in seven (26%) prostheses and in the group of traumatic and idiopathic osteoarthritis in six (55%) and two (18%), respectively. CONCLUSION: This study showed a high frequency of osteolysis in medium-term followup after the AES ankle replacement. The outcome was not sufficiently beneficial and we have discontinued use of this prosthesis.

Comparison of bioreplaceable interposition arthroplasty with metatarsal head resection of the rheumatoid forefoot.

BACKGROUND: Interposition arthroplasty with bioreplaceable poly-L/D-lactic acid (PLDLA) implants has been studied in Finland with promising results in reconstruction of the rheumatoid hand. We evaluated this material in a series of patients with rheumatoid forefoot deformities. MATERIALS AND METHODS: Thirty-five patients were randomized to either PLDLA metatarsophalangeal joint interposition arthroplasty group (16 patients) or to conventional metatarsal head resection group (19 patients). RESULTS: At 3 months after surgery, the function VAS was significantly better in the control group (p = 0.003). The difference disappeared by 12 months. Otherwise, comparison between the two groups did not reveal any statistically significant differences in the AOFAS scores or the pain VAS at 3 or 12 months. CONCLUSION: Early results after PLDLA interposition arthroplasty of metatarsophalangeal joints were not as promising as previously reported with rheumatoid metacarpophalangeal reconstruction.

Outcome after temporary physeal stapling for knee valgus deformity in children with JIA.

INTRODUCTION: Majority of children with secondary knee valgus deformity due to juvenile idiopathic arthritis (JIA) are affected by the polyarthritic disease subtype. Progressive rheumatoid knee destruction in patients with JIA and valgus deformity may necessitate total knee replacement (TKR) at a young age. Temporary physeal arrest is a safe and effective method for correction of knee valgus malalignment prior to closure of the epiphyseal growth plates even during active arthritis. RESULTS: Most of the angular correction achieved in the stapled knees (n = 103) in the present cohort remained the same through the long-term follow-up though in some patients the deformity did recur. The advantages of angular correction prior to possible future TKR include easier soft tissue balancing, diminished bony deformity and less deranged collateral ligaments reducing the need for expensive custom and constrained implants. CONCLUSION: However, the effect of the correction on postponing the early need for TKR is limited.

Osteolysis after Sutter metacarpophalangeal arthroplasty: a prospective study of 282 implants followed up for 5.7 years.

Our aim was to evaluate the incidence and degree of osteolysis in a prospective series of patients with rheumatoid arthritis operated on with Sutter implants. Eighty-seven of the 110 operated hands (104 patients) with 282 implants were evaluated after a mean of 5.7 years (2.1-7.4). Osteolytic changes were present in 142 (50%) of the metacarpal and 152 (54%) of the phalangeal bones. Twenty-six of the metacarpal (9%) and 36 of the proximal phalangeal (13%) bones had osteolytic changes that did not affect the cortical bone. Cortical invasion was recorded in 100 (35%) of the metacarpal and 103 (37%) of the proximal phalangeal bones. The cortex was perforated in both bones in 14 (5%). Osteolytic changes were related to fractures of implants and to the dominant hand, but not to pain. Surgeons who operate on patients with rheumatoid diseases should note that silicone rubber implants often cause osteolytic changes.

Survival and complications are similar after Swanson and Sutter implant replacement of metacarpophalangeal joints in patients with rheumatoid arthritis.

We compared the survival, fracture, and deformation rates of Swanson and Sutter implants in a prospective series of 53 patients with rheumatoid arthritis (RA). Fifty-eight hands were operated on with 215 silastic implants. The Swanson group comprised 25 hands and 89 implants, and the Sutter group 33 and 126, respectively. Follow up was 58 (37-80) months. During a period of 48 months the survival of Swanson and Sutter prostheses did not differ significantly: 92% (95% CI 84% to 96%) and 97% (95% CI 92% to 99%), respectively. The fracture rate was high in both groups: 26 (34%) in the Swanson and 25 (26%) in the Sutter group. There was no significant difference between the groups in definite fracture rates of implants. The Sutter prosthesis appears to be at least as durable an implant in rheumatoid patients' metacarpophalangeal arthroplasty as the Swanson.

Stress fractures of the ankle and forefoot in patients with inflammatory arthritides.

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

Beware of the biologicals--hospitals may die: the Rheumatism Foundation Hospital, Heinola, Finland (1951-2010).

The first patient entered the Rheumatism Foundation Hospital, Heinola, Finland in July 1951. From that point on, the hospital helped patients suffering from rheumatic disorders. Specialists in the hospital actively developed treatments and published a large number of scientific articles in international journals. The hospital was well known internationally among people working in the field. Progress in the development of disease-modifying medication (biological agents in particular) has dramatically improved the life of patients with rheumatic diseases, but all effective treatments may also have adverse effects. In this article, we briefly review the history of the Rheumatism Foundation Hospital, which was closed permanently in March 2010 due to bankruptcy. The economical difficulties were caused primarily by the progress made in disease-modifying therapy, which decreased the need of rehabilitation and operative treatment of patients with rheumatic diseases. It seems that a great success in biological agents can carry "serious adverse effects", which may kill hospitals. This is an important primary observation, which should be noticed when the future of specialised institutes is planned.

Reconstruction of the trapeziometacarpal joint in inflammatory joint disease using interposition of autologous tendon or poly-L-D-lactic acid implants: a prospective clinical trial.

Interposition arthroplasty with bioreplaceable poly-L-D-lactic acid (PLDLA) implants has yielded promising results in reconstruction of rheumatoid hands. In this prospective clinical study we compared the PLDLA implant arthroplasty (n = 17) with that of tendon interposition (n = 12) for destruction of the trapeziometacarpal joint in arthritic patients. There was no significant difference between the two groups preoperatively. At one-year follow-up, the mean pain and function scores were 5 and 13 in the PLDLA group, and 19 and 43 in the tendon interposition group, respectively. At one-year follow-up the visual analogue scale (VAS) for function of the PLDLA group differed significantly from that of the tendon interposition group (p = 0.03). This difference was not found at three months postoperatively, and disappeared again at two-year follow-up. Otherwise, no significant difference was found between the groups in the pain or function scores, functional tests, or range of movement. Bioreplaceable interposition arthroplasty works at least as well as tendon interposition. The operation is easier.

Subaxial cervical vertebrae in patients with juvenile idiopathic arthritis--something special?

OBJECTIVES: To describe the main dimensions of the cervical vertebrae and spinal canal in two groups with juvenile idiopathic arthritis (JIA) and a non-inflammatory control group. METHODS: There were altogether 158 female patients in three different groups included in the study: a group with severe, complicated JIA (sJIA), a population based JIA group (pJIA), and fibromyalgia patients as a non-inflammatory control group (pFM). The patients' clinical records and cervical spine radiographs taken in adult age (>17 years) were evaluated. RESULTS: The patients with sJIA had the mean area of the 3rd-6th cervical vertebrae bodies and the average width and height of the 3rd-6th cervical vertebrae bodies significantly smaller than the patients in the pJIA and pFM groups. The mean value of the maximal difference between the successive vertebral body areas of each individual was significantly larger in the sJIA group than the other groups (p=0.047; the body height adjusted). There were no significant differences in the mean diameter of the sagittal spinal canal between study groups. CONCLUSIONS: Inflammatory changes of the cervical spine are common, and growth disturbances of cervical vertebrae in patients with JIA have been described previously. We found that patients with severe complicated JIA have a smaller cervical vertebral body size in general. They also have more differences in the sizes of their own vertebrae, representing growth disturbances of individual vertebral bodies. This is probably caused by the inflammatory disease and/or its more aggressive pharmacotherapy. The spinal canal diameter was only slightly smaller in the sJIA group. Thus the disturbed growth of the vertebral body in sJIA does not, in general, increase the risk of spinal canal compression.

Survival of the AGC total knee arthroplasty is similar for arthrosis and rheumatoid arthritis. Finnish Arthroplasty Register report on 8,467 operations carried out between 1985 and 1999.

We report the survival of AGC knee endoprosthesis from the Finnish Arthroplasty Register for 2 indications, osteoarthrosis (OA, 6,306 knees) and rheumatoid arthritis (RA, 2,161 knees) during 1985-1999. Survivorship analysis was performed with revision as an endpoint. We found similar survival rates. In the OA group, survival after 5 years was 97% and it was 94% after 10 years. In the RA group the corresponding figures were 97% and 96%, respectively. There was no significant difference in survival whether or not cement was used for fixation. The revision rates were higher in men and in younger patients.

Comparison of Swanson and Sutter metacarpophalangeal arthroplasties in patients with rheumatoid arthritis: a prospective and randomized trial.

PURPOSE: To perform a prospective and randomized comparison of the clinical outcome of patients with rheumatoid arthritis who had Swanson or Sutter implant replacement arthroplasty of the metacarpophalangeal joints. METHODS: There were 45 patients (3 men, 42 women) and 49 hands; a total of 75 Swanson and 99 Sutter implants were inserted. The mean time between surgery and the final follow-up control visit was 58 months (range, 37-80 mo). Preoperative and postoperative measurements were performed including active extension and flexion, correction of ulnar deviation, and strength. RESULTS: There was no statistically significant difference between groups with regard to active extension deficit correction. Mean active flexion decreased less in the Sutter group than in the Swanson group but difference between the groups was statistically significant in only the index finger. At the final follow-up examination no significant differences existed between the groups in the correction of ulnar deviation or arc of motion. Grip strengths, chuck pinch, and thump-to-fingertip grip strengths did not improve in either of the groups. CONCLUSIONS: In this study clinical results showed no significant difference between the groups with the single exception of the amount of index finger metacarpophalangeal joint flexion.

Incidence of severe outcome in rheumatoid arthritis during 20 years.

OBJECTIVE: Information from successive inception cohorts is needed to reveal changes in the endpoint severity of rheumatoid arthritis (RA). We assessed joint destruction and disability 8-20 years after the onset of RA to estimate the number of patients with severe disease at the endpoint. METHODS: Radiographs of the hands and feet were taken at onset and at 1, 3, 8, 15, and 20 years from entry among 103 patients with recent onset (< 6 mo) seropositive RA. The Larsen score of 0-100 of 20 joints of hands and feet, the Health Assessment Questionnaire (HAQ) index, and the number of large joint arthroplasties were used to assess severity. The cumulative number of patients with amyloidosis was recorded. RESULTS: The median progression of small joint destruction was 2-3% yearly. At the endpoint 36% of the patients had Larsen score 50-100 and 23% scored 67-100. The endpoint HAQ index was 2-3 in 16% of the 81 patients investigated. The number of large joint arthroplasties was 29 in 16 patients. A high Larsen score or HAQ was registered in 30 (29%) patients. The incidence of amyloidosis was 13.6%; at the end of the 20 year followup 9 of the 14 patients with amyloidosis had died. CONCLUSION: Our prospective 20 year RA study is the first epidemiological survey in which 20 year severity in RA has been determined by 4 clinical measures; these data will serve as a basis for discussion of methods and comparison with other cohorts in the future.

Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty: incidence of revisions of different components used in 522 consecutive cases.

We present the prosthesis survival of the 7 most commonly used component types of 522 primary Souter elbow replacements performed in the Rheumatism Foundation Hospital during the years 1982-1997. The cohort comprised 370 female and 33 male patients with a mean age of 57 (20-81) years. 119 patients had a bilateral procedure. The indications for operation in all cases were rheumatoid arthritis and other chronic inflammatory joint disease. The mean duration of the disease at the time of operation was 25 (2-70) years. Elbows were often severely destroyed and, in one thiird of the joints, essential bone structures were missing. Therefore, in 178 cases, the ulnar components were retentive and in the remaining 344 elbows with better bone stock non-retentive. 47 patients had 51 operations for aseptic loosening up to the end of year 2000. In the survival analysis, the general cumulative success rates for the whole study cohort, without revision because of aseptic loosening 5 and10 years after surgery, were 96% and 84%, respectively. Revision was used as an end point. Cumulative success rates of the 7 most commonly used components are presented separately. The highest 5-year-survival rate was 100%, the lowest 93%. The corresponding 10-year-survival rates were 91% and 76%, respectively.

Souter arthroplasty for elbows with severe destruction.

One hundred fifty-eight primary Souter elbow arthroplasties were done on 134 patients (121 women) with severe joint destruction (Larsen Grade 5) or large bone defects or both. Joint replacement operations were done at our institution from 1985-1997. The study group comprised 156 joints in 132 patients with rheumatoid arthritis or other variants of chronic inflammatory joint disease, one in a patient with osteoarthritis, and one patient with posttraumatic arthrosis. The mean age of the patients at the time of surgery was 57 years (range, 26-81 years) and the mean disease duration was 27 years (tinge, 2-70 years). Radiographically, severe bone defects were detected in 100 humeri and 134 ulnas. Retentive (snap-fit) ulnar components were implanted in 110 joints, and bone grafts were used on 26 humeri and 14 ulnas. Major complications led to five early and 16 late reoperations in 19 patients. Four reoperations were done because of dislocation and eight because of aseptic loosening. One reoperation was done because of early infection and five were done because of late infection. One patient had reoperation because of superficial infection in the bursa olecrani and one triceps tendon rupture also was repaired. One patient had wound repair because of marginal necrosis. In the survival analysis, the cumulative success rate without revision for aseptic loosening at 5 years followup was 97%. Despite the demanding nature of these arthroplasties, the primary results are encouraging. Technically, it is possible to do elbow replacement, even on elbows where the humeral condyles or olecranon or both are missing, if there is sufficient bone left on the diaphyseal areas for primary stem fixation. However, in these extreme cases, the poor general condition of the patient or the difficult soft tissue problems in the elbow region may prove to be a contraindication for joint replacement.

Treatment of leg length discrepancy with temporary epiphyseal stapling in children with juvenile idiopathic arthritis during 1957-99.

Temporary epiphyseal stapling is a flexible method for correction of leg length discrepancy. Due to a high risk of premature epiphyseal plate closure and other complications reported in previous studies, the technique has not been in wide use. In this study a retrospective analysis of 71 knees in patients with juvenile idiopathic arthritis was performed to determine the safety and effectiveness of the method. Only seven minor reversible complications were encountered, and the authors found the method suitable even for immunologically compromised patients.

Elbow synovectomy on patients with juvenile rheumatoid arthritis.

Twenty-four primary elbow synovectomies were done between 1991 and 1998 at the authors' institution on 19 patients (15 females, four males) with juvenile rheumatoid arthritis. Five bilateral and 14 unilateral procedures were done. The mean age of the patients was 29 years (range, 11-64 years) at the time of surgery and the mean disease duration was 19 years (range, 2-51 years). Preoperatively radiographic destruction of Larsen Grade 1 was detected in 21% of elbows, Grade 2 in 54%, and Grade 3 in 4%. In 21% of elbows no radiographic destruction was present (Grade 0). The cumulative survival rate of elbow synovectomy was 84% (95% confidence interval, 68-98) at 5 years. Four resynovectomies and two elbow replacement arthroplasties were done during the followup period. Complete pain relief was documented in 44% of patients and subjective outcome was excellent or good in 72% of patients. No significant improvement was observed in functional ability or range of motion in extension and flexion or pronation and supination. The results of the current study (mean followup, 5 years; range, 2-9 years) are slightly worse compared with the short-term results of elbow synovectomy in patients with adult-onset rheumatoid arthritis.

A comparison of postoperative C-reactive protein changes in primary and revision hip arthroplasty in patients with rheumatoid arthritis.

C-reactive protein (CRP) response was studied in 40 consecutive patients with rheumatoid arthritis undergoing primary (n = 20) or revision (n = 20) total hip arthroplasty (THA). In patients with primary THA, the median preoperative CRP concentration was 10 mg/L (interquartile range [IQR], 6-17 mg/L), and the median change in CRP was 69 mg/L (IQR, 43-69 mg/L) at the 1st or 2nd postoperative day (P< .001). In the patients with revision THA, the results were 8 mg/L (IQR, 0-32 mg/L) and 48 mg/L (IQR, 21-78 mg/L) (P< .001). Median change in CRP from preoperative to postoperative values did not differ significantly among the patients with primary and revision THA. No correlation was found between the preoperative and perioperative background variables and the change in CRP compared with patients with primary and revision THA. It seems that the revision operation has no significant additional influence on the postoperative CRP response. More detailed analyses are needed to evaluate the significance of endocrine, metabolic, and inflammatory responses in these patients.

Bone destruction patterns of the rheumatoid elbow: a radiographic assessment of 148 elbows at 15 years.

A cohort of 74 patients with rheumatoid arthritis (RA) was followed prospectively for 15 years. At the end of the study, 148 elbows were radiographed with standard methods. The bone destruction of the humerus was measured from the anteroposterior (AP) radiograph as the bone attrition of the trochlea (TM) and the capitellum (CM). The bone destruction of the ulna was measured from the AP radiograph as the width (WO) and from the lateral radiograph as the thickness (TO) of the olecranon. Moreover, elbow joint destruction was graded by the Larsen system on a scale of 0 to 5. The relation of bone destruction to Larsen grade of the elbows was examined. The mean TM of the nonaffected (Larsen grades 0 to 1, n = 73) joints was 17.5 mm (SD, 2.1 mm; range, 10-22 mm), whereas the mean of Larsen grade 3 to 5 joints (n = 26) was 11.5 mm (SD, 5.2 mm). The mean CM of the nonaffected joints was 19.6 mm (SD, 2.6 mm; range, 15-25 mm), and the corresponding mean of Larsen grade 3 to 5 joints 15.5 mm (SD, 4.5 mm). The mean TO of the nonaffected joints was 18.9 mm (SD, 1.5 mm; range, 17-23 mm), and the mean of Larsen grade 3 to 5 joints was 13.9 mm (SD, 4.1 mm). The mean WO of the nonaffected joints was 23.3 (SD, 2.4 mm; range, 18-28 mm), and the mean of Larsen grade 3 to 5 joints was 22.4 mm (SD, 6.2 mm). Spearman correlation coefficients between TM, CM, and TO and Larsen grade of the joint were -0.45 (95% CI, -0.31 to -0.57), -0.38 (95% CI, -0.23 to -0.51), and -0.46 (95% CI, -0.31 to -0.57), respectively. Bone destruction in both the humerus and the olecranon appears to be a late consequence of rheumatoid elbow involvement. Bone loss is always present in the situation of rheumatoid elbow replacement, and it is most remarkable in Larsen grade 5 joints; the risk of preoperative and intraoperative complications due to bone destruction is significantly increased in this group.