Bioreconstructive joint scaffold implant arthroplasty in metacarpophalangeal joints: short-term results of a new treatment concept in rheumatoid arthritis patients.

Swanson silicone implant is the "gold standard" of metacarpophalangeal joint reconstruction in rheumatoid arthritis (RA) patients. However, durability problems of silicone implants have led us to develop a new technique based on bioreconstructive implants. PLA96 (poly-L,D-lactide copolymer, L:D ratio of 96:4) scaffolds were engineered. Bioabsorption and substitution of porous PLA96 scaffold with living tissue eventually produce a neojoint. In the current prospective study, 23 RA patients (80 joints) were operated on, using PLA96 implants. Fifteen patients (54 joints) have been monitored for at least 1 year. Pain alleviation was well achieved. Range of motion improvement was emphasized to extension direction of functional arc. The average ulnar deviation was preoperatively 26 degrees, and at follow-up it was 6 degrees. Volar subluxation was noticeable in 56% of joints preoperatively and in 6% at 1-year follow-up. This is the first report of the formation of a living, functional joint in situ by means of a synthetic bioreconstructive joint scaffold. Results of this preliminary short-term study are comparable with previously published data on silicone arthroplasty. However, bioreconstructive prostheses can aid in preventing problems that occur with biostable prostheses. Tissue engineering has created a new era in the reconstruction of damaged joints.

Charnley total hip arthroplasty in ankylosing spondylitis: survivorship analysis of 76 patients followed for 8-28 years.

76 consecutive Charnley low friction hip arthroplasties were performed in 54 (37 men) patients with ankylosing spondylitis from 1971 to 1991 in the Rheumatism Foundation Hospital. Their mean age was 40 (16-67) years. They were followed until the end of 1999. The overall prosthesis survival was 80% at 10 years, 66% at 15 years and 62% at 20 years. The survival of the acetabular component was 91%, 77% and 73% at 10, 15 and 20 years and that of the femoral component 82%, 79% and 77%, respectively. We found no significant risk factor that predicted prosthesis survival.

Charnley low-friction arthroplasty in rheumatoid patients: a survival study up to 20 years.

The survivorship of 1,553 consecutive Charnley low-friction arthroplasties (LFA) in 1,086 patients with rheumatoid arthritis (RA) were analyzed. There were 846 women (1,236 hips) and 240 men (317 hips), with a mean age of 53.1 years (range, 24-77 years; standard deviation, 10.7). A uniform postoperative regimen with protected weight bearing for 2 months (6 months in patients with bone grafting on the acetabular side) was used throughout the whole study. The overall survival with revision as the endpoint was 90.5% (95% confidence interval [CI], 88.7-92.2) at 10 years and 83% (95% CI, 80.3-85.7) at 15 years. The survival of the femoral component was 93.2% (95% CI, 91.8-96.7) and 89.9% (95% CI, 88.0-93.0) at 10 and 15 years, and survival of the acetabulum was 93.6% (95% CI, 92.1-95.1) and 87.1% (95% CI, 84.6-89.5) at 10 and 15 years. The indication for revision was late deep infection in 19 patients (1.2%) and in others aseptic loosening of prosthetic components. Young age, male sex, and secondary reactive amyloidosis impaired significantly the survival of LFA in the RA patients. In all, cemented LFA provided good results, and it can be justified for the treatment of hip destruction in RA.

Hip involvement in seropositive rheumatoid arthritis. Survivorship analysis with a 15-year follow-up.

In a prospective survey of recent arthritis 96 patients had erosive and seropositive rheumatoid arthritis (RA). Severe radiological changes in the hipjoint (Larsen grade 3-5) were observed in 31 (32%) and acetabular protrusion in five (5%) patients 15 years after the onset of arthritis. At the end of follow-up Larsen score 0-100 of peripheral joints (p < 0.015), HAQ (p < 0.001), ESR (p < 0.001), and CRP (p < 0.01) were significantly higher in patients with hip joint destruction than in those without. Secondary amyloidosis was found in eight patients with and in three patients without hip involvement (p = 0.002). In survivorship analysis (the Larsen 0-2 grade hips) an overall predicted rate of survival was 80% after 14 years of rheumatoid arthritis. When analyzed according to HLA-B27 the rate of radiological survival for the patients with a positive test was 62% and 87% for the others (p = 0.02). In conclusion, RA patients with high number of destructive peripheral joints (Larsen score) and high ESR or CRP should be carefully monitored due to the increased risk of hip destruction.

Survivorship of the Charnley total hip arthroplasty in juvenile chronic arthritis. A follow-up of 186 cases for 22 years.

Between 1971 and 1991 we performed Charnley low-friction arthroplasty (LFA) on 116 patients (186 hips) with juvenile chronic arthritis (JCA). We have now carried out a survival study, taking endpoints as revision, death or the end of the year 1993. Overall survival was 91.9% at ten years and 83.0% at 15 years. That of the femoral component was 95.6% at ten years and 91.9% at 15 years and of the acetabulum 95.0% and 87.8%, respectively. Only the use of steroids significantly impaired the survival. We therefore recommend the use of Charnley LFA for young patients with JCA requiring total hip replacement.

Arthrodesis of the first metatarsophalangeal joint in rheumatoid arthritis. Biodegradable rods and Kirschner-wires in 39 cases.

The first metatarsophalangeal joint was arthrodesed in 39 patients with rheumatoid arthritis. Fixation material was either biodegradable self-reinforced poly-L-lactide rods or Kirschner-wires. There were 3 clinical nonunions in the biodegradable group, and none in the K-wire group, and radiographic nonunion in 5 and 2 cases, respectively. The fixator had to be removed in 3 cases in the K-wire group. The biodegradable rods did not seem to be any better than K-wires.

Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck.

A consecutive clinical series of 33 patients with either an undisplaced (Garden I) or minimally displaced (Garden II) femoral neck fracture was randomly divided into two operative protocols. Half of the fractures were treated with three cannulated cancellous bone screws, while the other half were treated with a standard screw-angle plate device. After a mean follow-up of 2 years, 4 patients had died, while 20 of the remaining 29 hips showed excellent or good, 3 fair and 6 poor functional results. The three-screw fixation seemed to yield more technical complications as compared to the screw-angle plate fixation. However, the differences in functional end-results were of no clear statistical significance. We conclude that the screw-angle plate device gives acceptable results in this group of fractures. The use of cannulated hip screws may be more advantageous in the treatment of dislocated femoral neck fractures, where the torsional strength of fracture fixation and femoral head viability are more critical.

Incidence of hip involvement and need for total hip replacement in rheumatoid arthritis. An eight-year follow-up study.

In an 8-year follow-up of a prospective study of recent arthritis, 103 patients were found to have erosive and 97% seropositive rheumatoid arthritis. A 20% incidence of hip joint involvement was observed among them. Moderate radiological changes could be seen in 10%, severe destruction (Larsen 4 or 5) in 3%, and acetabular protrusion in 1% of the patients. It was estimated that the minimum annual need of total hip replacement in rheumatoid arthritis in Finland would be 470. This is about 100 per million in the overall population. At the end of the follow-up the Larsen X-ray index was highly significantly (p less than 0.001), ESR significantly (p less than 0.005), and CRP clearly (p less than 0.03) higher in the 13 patients with radiologically confirmed hip changes than in the 90 without them. Thus their hip destruction is attributable to a more severe disease condition and not to the glucocorticoids administered. Furthermore, HLA-B27 was positive in 69% of the above-mentioned 13 patients compared with 27% of the rest, and this difference (p less than 0.005) may also explain the poor prognosis for true rheumatoid arthritis patients.