Fusion of the wrist in rheumatoid arthritis: a clinical and functional evaluation of two surgical techniques.

We retrospectively compared wrist arthrodesis using the Mannerfelt technique in 19 or an AO-plate in 23 patients with long-standing rheumatoid arthritis. The mean follow-up was for 76 months. Compared with the Mannerfelt fusion group, patients in the AO-plate group reported greater satisfaction with their wrist function (74% vs 37%, p = 0.015). Complications were reported in six wrists in the AO-plate group and two wrists in the Mannerfelt fusion group (p = 0.258). At final follow-up, 95% of patients (41) reported either no pain or only mild pain. There was improvement in flexion of the finger joints in both groups but no significant improvement in the extension lag in either group. Both methods relieve pain and improve function. Overall, the activities of daily living scores and the patients' subjective assessment of outcome tended to be higher in the AO-plate group than in the Mannerfelt fusion group, although the difference was not statistically significant. Similarly, although more postoperative complications occurred in the AO-plate group, the difference between the two groups was not statistically significant.

Changes in bone mineral density in the proximal femur after cementless total hip arthroplasty. A five-year longitudinal study.

We investigated prospectively the bone mineral density (BMD) of the proximal femur after implantation of a tapered rectangular cementless stem in 100 patients with a mean age of 60 years (16 to 87). It was determined using dual energy x-ray absorptiometry, performed one week after surgery and then every six months until the end-point of five years. The BMD increased significantly in Gruen zones 2, 4 and 5 by 11%, 3% and 11% respectively, and decreased significantly in Gruen zones 1, 6 and 7 by 3%, 6% and 14% respectively, over the five-year period. The net mean BMD did not change over this time period. The changes in the BMD were not confined to the first 12 months after surgery. This investigation revealed no change in the overall periprosthetic BMD, but demonstrated a regional redistribution of bone mass from the proximal to distal zones.

Recurrence of curetted and bone-grafted giant-cell tumours with and without adjuvant phenol therapy.

AIMS: Giant-cell tumour of bone (GCT) represents 5% of all primary bone tumours. The aim of this study was to compare the outcome of GCT treated with or without phenol. METHODS: Out of 53 patients primarily treated for a giant-cell tumour, 47 were followed, with a median follow-up of 11 (range 4-43) years. All patients were disease-free at the latest follow-up. Of the 40 tumours (85%) located in long bones, 14 (35%) were treated by curettage and bone grafting and 12 (30%) by additional adjuvant phenol treatment. Fourteen patients (35%) received different therapies, including en-bloc resection, endoprosthesis, cement packing or other therapy. RESULTS: There were seven (17.5%) recurrences in long bones after a median of 12 (range 4-60) months, three (3/14, 21%) in the group treated without phenol and three (3/12, 25%) in the group with phenol. Of the seven tumours located in the axial skeleton, two patients died within the first year after surgery. The remaining five patients were followed, with a median follow-up of 12 (range 8-23) years. No patients had metastases or a multicentric tumour. CONCLUSIONS: Despite the different rates of recurrence reported in literature, this study suggests that local recurrence rate of giant-cell tumours located in long bones treated with or without phenol is similar. Adequate removal of the tumour seems to be a more important predictive factor for the outcome of surgery than the use of phenol as an adjuvant therapy.

Overexpression of transcription factor Ets-1 in rheumatoid arthritis synovial membrane: regulation of expression and activation by interleukin-1 and tumor necrosis factor alpha.

OBJECTIVE: To investigate the expression of the transcription factor Ets-1 in synovial tissue and cultured synovial fibroblasts from patients with rheumatoid arthritis (RA) and osteoarthritis (OA) and to study the regulation of Ets-1 expression and activation in synovial fibroblasts by proinflammatory cytokines. METHODS: In situ expression of Ets-1 in synovial tissue from RA and OA patients was examined by double immunohistochemistry. The effects of interleukin-1 (IL-1) or tumor necrosis factor alpha (TNFalpha) on Ets-1 expression and activation (DNA binding) in cultured synovial fibroblasts were analyzed by Western blotting and DNA gel shift assay, respectively. In addition, the intracellular location of Ets-1 in synovial fibroblasts was determined by immunofluorescence. RESULTS: Pronounced expression of Ets-1 was detected in synovial tissues from all RA patients evaluated, particularly in the synovial lining layer and the sublining areas. Ets-1 was expressed by both fibroblasts and macrophages as well as by endothelial cells, while only a few T cells stained positive for Ets-1. In synovial specimens from OA patients, Ets-1 expression was much less frequently observed and was largely restricted to vascular cells. Ets-1 was expressed to a similar degree in cultured synovial fibroblasts from RA and OA patients, as demonstrated by reverse transcriptase-polymerase chain reaction and Western blotting. Both IL-1 and TNFalpha induced pronounced up-regulation of Ets-1 in synovial fibroblasts. Moreover, binding of Ets-1 to its specific DNA binding site was induced by both cytokines, although with different time courses. Immunofluorescence staining revealed a dominant nuclear localization of Ets-1 in IL-1- or TNFalpha-stimulated synovial fibroblasts. CONCLUSION: The overexpression of Ets-1 observed in RA synovial tissue appears to be caused by TNFalpha and IL-1, suggesting that Ets-1 may be an important factor in the cytokine-mediated inflammatory and destructive cascade characteristic of RA.

[Serum cobalt and serum chromium level in 2 patients with chronic renal failure after total hip prosthesis implantation with metal-metal gliding contact]. / Serumcobalt- und Serumchromspiegel bei zwei chronisch niereninsuffizienten Patientinnen mit Hüfttotalendoprothese und Metall-Metall-Gleitpaarung.

PURPOSE: The influence of chronic renal failure on serum cobalt and serum chromium in two patients with metal-on-metal bearing (Metasul) and cementless total hip arthroplasty (Alloclassic) is investigated. METHODS: Serum cobalt and serum chronium levels were determined in the postoperative course using atomic absorption spectrometry. RESULTS: Maximum values are found to be more than 100-fold elevated when compared to the reported median serum cobalt concentrations in patients with the same prosthesis type and no known renal disease. CONCLUSION: Chronic renal failure seems to be responsible for the marked elevation of serum cobalt and serum chromium. CLINICAL RELEVANCE: Despite evidence of adverse health reactions, a possible effect of long-term cobalt and chromium loading cannot be neglected. In our opinion, metal-on-metal bearings in THA should not be inserted in patients with chronic renal failure. Follow-up investigations (serum cobalt, serum chromium, serum creatinine, BUN, echocardiography) should be performed at short intervals.

Activation, differential localization, and regulation of the stress-activated protein kinases, extracellular signal-regulated kinase, c-JUN N-terminal kinase, and p38 mitogen-activated protein kinase, in synovial tissue and cells in rheumatoid arthritis.

OBJECTIVE: To investigate whether stress- and mitogen-activated protein kinases (SAPK/MAPK), such as extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinase (JNK), and p38 MAPK, are significantly activated in rheumatoid arthritis (RA) synovial tissue compared with their activation in degenerative joint disease; to assess the localization of SAPK/MAPK activation in rheumatoid synovial tissue; and to search for the factors leading to stress kinase activation in human synovial cells. METHODS: Immunoblotting and immunohistology by antibodies specific for the activated forms of SAPK/MAPK were performed on synovial tissue samples from patients with RA and osteoarthritis (OA). In addition, untreated and cytokine-treated human synovial cells were assessed for SAPK/MAPK activation and downstream signaling by various techniques. RESULTS: ERK, JNK, and p38 MAPK activation were almost exclusively found in synovial tissue from RA, but not OA, patients. ERK activation was localized around synovial microvessels, JNK activation was localized around and within mononuclear cell infiltrates, and p38 MAPK activation was observed in the synovial lining layer and in synovial endothelial cells. Tumor necrosis factor alpha, interleukin-1 (IL-1), and IL-6 were the major inducers of ERK, JNK, and p38 MAPK activation in cultured human synovial cells. CONCLUSION: Signaling through SAPK/MAPK pathways is a typical feature of chronic synovitis in RA, but not in degenerative joint disease. SAPK/MAPK signaling is found at distinct sites in the synovial tissue, is induced by proinflammatory cytokines, and could lead to the design of highly targeted therapies.

Tumor necrosis factor alpha promotes the expression of stem cell factor in synovial fibroblasts and their capacity to induce mast cell chemotaxis.

OBJECTIVE: To investigate the expression of the stroma cell product stem cell factor (SCF) in synovial fibroblasts (SFB) in patients with rheumatoid arthritis (RA) and osteoarthritis (OA), and to analyze the capacity of SFB to induce mast cell (MC) chemotaxis. METHODS: Synovial tissue was obtained from 29 patients with RA and 25 patients with OA. Tissue was dispersed by enzymatic digestion using collagenase. SFB were grown in serial passage and exposed to tumor necrosis factor alpha (TNFalpha) or control medium. Expression of SCF in cultured SFB was analyzed by reverse transcription-polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and immunostaining. The ability of SFB (supernatants) to induce MC migration was analyzed using a double-chamber chemotaxis assay and the human mast cell line HMC-1. In situ expression of SCF in synovial tissue from patients with RA (n = 6) and OA (n = 6) was examined by double immunohistochemistry using antibodies against SCF and the fibroblast-specific antibody AS02. RESULTS: In both RA and OA, cultured SFB were found to express SCF messenger RNA, as assessed by RT-PCR. In addition, the SCF protein was detectable in cell lysates and supernatants of SFB by ELISA. Incubation of SFB with TNFalpha resulted in an increased expression and release of SCF. Recombinant human SCF (rHuSCF) and SFB supernatants induced significant migration of HMC-1 cells above control levels. In addition, exposure of SFB to TNFalpha led to an increased migration of HMC-1, and a blocking anti-SCF antibody inhibited the rHuSCF- and SFB-induced migration of HMC-1. In situ double immunostaining revealed expression of SCF in AS02-positive SFB in the synovium of patients with RA. CONCLUSION: Our results show that SFB (in RA and OA) express SCF and induce MC chemotaxis. Furthermore, TNFalpha was found to augment SCF expression in SFB. It is hypothesized that these cellular interactions play an important role in MC accumulation and related events in RA.

Six-year results of a cementless stem with prophylaxis against heterotopic bone.

The hypothesis of a possibly diminished bony ingrowth revealed by the development of radiolucency or a radiodense line with time around a cementless femoral stem subsequent to indomethacin administration for prevention of heterotopic ossification was investigated. Eighty prospective patients with indomethacin prophylaxis were compared with 82 patients without indomethacin prophylaxis chosen retrospectively. The same cementless implant was used in all cases, and patients were observed clinically and radiologically for a minimum of 6 years. The mean postoperative Harris hip score at 6 years was 91 versus 88 points, respectively, and there were significantly more excellent results (Harris hip score > 90) in the indomethacin group. None of the patients underwent revision surgery. Radiologic signs such as loss of bone density and radiodense lines were observed around the shoulder of the prosthesis in a similar percentage in both groups. Significant subsidence of the stem was observed in one instance in the indomethacin group and in three instances in the control group. The results of this study are a strong indication that indomethacin does not influence the development of radiolucency or other radiologic changes around a cementless stem after 6 years.

[Rheumatic diseases of the ankle joint and tarsus]. / Rheumatische Erkrankungen des Sprunggelenkes und der Fusswurzel.

Diseases of the hindfoot are associated with considerable functional impairment and therefore may hamper patients' movements during gait considerably. Because of biomechanical overload, articular structures, tendons and ligaments are prone to early degenerative changes during the course of rheumatic diseases as visible with plain film radiography, sonography (US), or magnetic resonance imaging (MRI). Findings may occur as arthritis of major joints or in the form of fibroostitis and bursitis of the os calcis. Despite the progressive course of rheumatic diseases and characteristic imaging findings, high variability of X-ray signs may occur. Plain film radiograms and high-resolution ultrasonography play a key role in imaging rheumatic diseases of the hindfoot. MRI supports imaging diagnosis in selected cases. The principal goals of diagnostic imaging are precise and reproducible documentation of morphologic abnormalities and differentiated analysis for planning proper conservative or surgical treatment.

Plantar pressure distribution after resection of the metatarsal heads in rheumatoid arthritis.

Surgical correction of the forefoot in rheumatoid arthritis by resection of all metatarsal heads in combination with a resection arthroplasty of the first metatarsophalangeal joint showed excellent and good results in 20 (77%) of 26 cases and satisfactory and fair results in 6 (23%) of 26 cases. Twenty-six feet in 16 patients were operated on by a plantar approach and examined after a mean follow-up period of 50 months (range, 24-90 months). Seventy-three percent of the patients were free of pain. In 75 (58%) of all 130 investigated toes, complete absence of load distribution was noted. In the remaining 55 (42%) toes, we observed a variable extent of function, depending on the length of resection. Although toe function is better in minimal metatarsal resection, single excessive length or plantar spike formation revealed pressure peaks in the metatarsal area. Metatarsal head resection provided reduction of pain and correction of severe deformities, and permitted the patients to wear ordinary shoes in 24 (93%) of 26 cases.

Elevated serum cobalt with metal-on-metal articulating surfaces.

We determined serum cobalt levels in 55 patients by atomic absorption spectrophotometry before and after implantation of uncemented total hip arthroplasties. In a randomised, prospective trial 27 wrought Co-28Cr-6Mo-0.2C metal-on-metal articulations were compared with 28 ceramic-on-polyethylene hips which did not contain cobalt. Other sources of iatrogenic cobalt loading were excluded. The metal-on-metal group produced detectable serum cobalt levels (median 1.1 microg/l after one year) which were significantly different (p < 0.0001) from those of the ceramic-on-polyethylene control group (median below detection limit of 0.3 microg/l after one year). Our findings indicate that metal-on-metal bearings generate some systemic release of cobalt.

[Incidence of recurrence of aneurysmal bone cysts following surgical treatment and adjuvant therapy with phenol]. / Die Rezidivhäufigkeit aneurysmatischer Knochenzysten nach chirurgischer Behandlung und adjuvanter Therapie mit Phenol.

Between 1966 and 1991, at the Department of Orthopaedics 34 patients with a mean age of 15.7 years (range 7-46 years) underwent surgery because of aneurysmatic bone cysts. Mean follow-up was 11 years (range 1-26.3 years). We observed a total rate of recurrence of 11.8%. In a group of 9 patients who received local phenol therapy after curettage and bone transplantation no recurrence was observed. The different surgical and conservative methods of treatment are discussed also with respect to rates of recurrence stated in the literature.