A comparison of survival of moulded monoblock and modular tibial components of 751 AGC total knee replacements in the treatment of rheumatoid arthritis.

We evaluated the survival of moulded monoblock and modular tibial components of the AGC total knee replacement in patients with rheumatoid arthritis. Between 1985 and 1995, 751 knees with this diagnosis were replaced at our institution. A total of 256 tibial components were of the moulded design and 495 of the modular design. The mean follow-up of the moulded subgroup was 9.6 years (0.5 to 14.7), and that of the modular group 7.0 years (0.1 to 14.7). The groups differed significantly from each other in Larsen grade, cementing of components and patellar resurfacing, but no statistically significant difference between the survival of the components was found (Log rank test, p = 0.91). The cumulative success rate of the moulded group was 96.8% (95% confidence interval 93.6% to 98.4%) at five years and 94.4% (95% confidence interval 90.4% to 96.7%) at ten years, and of the modular group 96.2% (95% confidence interval 94% to 97.6%) and 93.6% (95% confidence interval 89.7% to 96%), respectively. Revision was required in 37 total knee replacements, the main causes were infection, pain, loosening of the tibial component and patellar problems. Survival rates for both components were satisfactory.

Revision total knee arthroplasty with the Total Condylar III system in inflammatory arthritis.

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122). The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62 degrees (0 degrees to 120 degrees) to 98 degrees (0 degrees to 145 degrees) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection. These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis.

Surgical outcomes of hip and knee arthroplasties for primary osteoarthritis in patients with Alzheimer's disease: a nationwide registry-based case-controlled study.

We compared the length of hospitalisation, rate of infection, dislocation of the hip and revision, and mortality following primary hip and knee arthroplasty for osteoarthritis in patients with Alzheimer's disease (n = 1064) and a matched control group (n = 3192). The data were collected from nationwide Finnish health registers. Patients with Alzheimer's disease had a longer peri-operative hospitalisation (median 13 days vs eight days, p < 0.001) and an increased risk for hip revision with a hazard ratio (HR) of 1.76 (95% confidence interval (CI) 1.03 to 3.00). Dislocation was the leading indication for revision. There was no difference in the rates of infection, dislocation of the hip, knee revision and short-term mortality. In long-term follow-up, patients with Alzheimer's disease had a higher mortality (HR 1.43; 95% CI 1.22 to 1.70), and only one third survived ten years post-operatively. Increased age and comorbidity were associated with longer peri-operative hospitalisation in patients with Alzheimer's disease.

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.

The effects of early mobilisation and immobilisation on the healing process following muscle injuries.

The biological processes following muscle injury include 2 competitive events; regeneration of muscle fibres and the simultaneous production of granulation tissue. We have studied the effects of early mobilisation and immobilisation on the healing of rat gastrocnemius muscle following partial rupture by a controlled contusion mechanism. Muscle fibre regeneration is inhibited by the formation of dense connective tissue scar. Immobilisation following injury limits the size of the connective tissue area formed within the site of injury; the penetration of muscle fibres through the connective tissue is prominent but their orientation is complex and not parallel with the uninjured muscle fibres. Immobilisation for longer than 1 week is followed by marked atrophy of the injured gastrocnemius muscle. Mobilisation started immediately after injury is followed by a dense scar formation in the injury area prohibiting muscle regeneration. When mobilisation is started after a short period of immobilisation a better penetration of muscle fibre through the connective tissue is found and the orientation of regenerated muscle fibres is aligned with the uninjured muscle fibres. Although a little delay in healing processes in muscles mobilised after short immobilisation was found morphologically, the gain in strength and energy absorption capacity was quite similar and as good as that of muscles treated by early mobilisation alone.

Insufficiency fractures in patients with chronic inflammatory joint diseases.

OBJECTIVE: To describe the typical sites of stress fractures in the lower extremities and pelvis in rheumatoid patients (rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, ankylosing spondylitis). METHODS: Thirty-three patients with 52 stress fractures [mean age 44 years (range 11-73)] were studied at the authors' institution when they were being treated for their rheumatic diseases. Fourteen patients had RA, 9 JCA, 5 PsoA, and 5 SPA. Stress fractures were detected from patient documents and from series radiographs in suspected cases. In some cases magnetic resonance imaging was also performed. RESULTS: One patient presented with 5 fractures, 2 patients with 4 and 3 fractures, and 7 patients with 2 fractures each. Other patients (n = 19) had only one fracture each. The metatarsal (MT) bones were the most common site of involvement. Twenty-five of the 52 fractures were located on MT I-V. The second and third most common sites were thefibula (n = 13) and tibia (n = 6). All fractures of the lower tibia or fibula were associated with valgus malalignment of the ankle. CONCLUSION: If a patient with rheumatic disease experiences sudden and unexplained pain localised in the forefoot, above the ankle, below the knee, or in the pelvis, a stress fracture should be suspected. Patients with severe osteoporosis, high-load corticosteroid or methotrexate therapy, or marked joint deformity are at high risk of developing stress fracture.

Development rate of mutilans fingers in patients with rheumatic disease.

OBJECTIVE: To describe arthritis mutilans (AM) deformity during the progression of rheumatic disease. METHODS: The development of mutilans-like hand deformities in 2 patients with juvenile chronic arthritis (JCA) and in 2 patients with adult onset rheumatoid arthritis (RA) are presented. The hands of these patients were evaluated at least at two time points during the course of disease using two different scoring methods based on differently summed Larsen grades of the hand joints. RESULTS: Two patients (one with JCA and one with RA) showed AM changes after a disease period of less than 10 years and 2 not until after 30 years. The patients with adult onset disease were young at the onset of joint disease. Early wrist fusions were performed on both patients showing a slow development rate. CONCLUSIONS: The development rate of AM is very variable, even in patients with the same diagnoses. Wrist fusion prevents shortening of the carpus and may decrease the development rate of AM.

Image processing for femoral endosteal anatomy detection: description and testing of a computed tomography based program.

A computed tomography (CT)-based image processing computer program was developed for three-dimensional (3D) femoral endosteal cavity shape modelling. For the examinations 50 cadaver femora were used. In the CT imaging 30 axial slices were taken above and below the lesser trochanter area from each femur. Different image analysis methods were used for femoral cavity detection depending on the structure of the processed slice. In the femoral shaft area simple thresholding methods succeeded, but in the problem areas of the metaphyseal femur edge, detection operators and local thresholding were required. In contour tracking several criteria were used to check the validity of the border pixels. The results were saved as four output data files: (i) a file for the longest anteroposterior (ap), mediolateral (ml) and oblique diameters computed by a Euclidian method, (ii) and (iii) files for 2D and 3D data respectively, and (iv) a file for centre points of each slice. Finally, testing of the results and dimensions obtained from the image analysis were carried out manually by sawing the femora into 10 stipulated horizontal slices. The ap and ml dimensions were measured with a caliper ruler. The CT-based image processing yielded a peak distribution of dimensions with a negative difference to those obtained in manual measurements. The mean difference between the image processing and the manual measurements was 1.1 mm (+/-0.7 mm, +/-1 SD). The difference was highest in the proximal slices of the femora of group I (with lowest cortical thickness), i.e. 1.3 mm (+/-0.8 mm) and lowest in the distal slices of the femora from group III (with highest cortical thickness), i.e. 0.9 mm (+/-0.6 mm). The results are acceptable for further use of the program to study endosteal anatomy for individual femoral component selection and designing basis.

Patellar dislocation. The long-term results of nonoperative management in 100 patients.

One hundred patients were treated nonoperatively for primary acute patellar dislocations, either by plaster cast (N = 60), by posterior splint (N = 17), or by patellar bandage or brace (N = 23). Follow-up examinations were performed at an average of 13 years later (range, 6 to 26 years). Overall, there were 0.17 redislocations per follow-up year; the redislocation frequencies per follow-up year for each patient group were 0.29, patellar bandages or braces; 0.12, plaster cast; and 0.08, posterior splint. In addition, there were fewer recurrences and subsequent problems (patellofemoral pain or subluxations) in the group treated with posterior splints compared with the two other treatment groups. The most marked restrictions of knee joint movements were seen in the patients treated with plaster casts. Subjective assessment of treatment, however, did not differ significantly between the groups. Patients were also evaluated in relation to the treatment of redislocations and management of subsequent problems (i.e., patellofemoral pain or subluxations). Patients who were treated operatively for their redislocations exhibited better outcomes than patients treated nonoperatively. In the patients who had subsequent problems, the operation did not relieve the symptoms.

Chronic achilles paratenonitis. An immunohistologic study of fibronectin and fibrinogen.

Pathological alterations in chronic Achilles paratenonitis were studied histologically and using immunofluorescence techniques for fibronectin and fibrinogen in tissue samples obtained operatively from 11 athletes with this complaint and from 4 male cadavers serving as controls. The average duration of the paratenonitis was 20.4 months. The paratendineal fatty areolar tissue was clearly thickened and edematous, showing widespread fat necrosis and considerable connective tissue proliferation. The blood vessels were often obliterated and degenerated. Fibronectin and fibrinogen were commonly found in the proliferating connective tissue areas and in the vascular walls. Exudates rich in fibrinogen and fibronectin were seen in the inflamed paratendineal tissues, but not in the controls. The results indicate that increased vascular permeability and fibrin formation still persist in chronic Achilles paratenonitis and that marked obliterative and degenerative alterations of the blood vessels are frequent. The presence of fibronectin and fibrinogen points to an immature nature of scar tissue in chronic paratenonitis.

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.

The Souter-Strathclyde elbow arthroplasty. A clinical and radiological study of 525 consecutive cases.

We present the results of 525 primary Souter elbow arthroplasties undertaken in 406 patients between 1982 and 1997. There were 372 women and 34 men with a mean age of 57 years; 119 patients had a bilateral procedure. The elbows were affected by chronic inflammatory disease, usually rheumatoid arthritis, which had been present for a mean of 24.7 years (2 to 70). In about 30% the joints were grossly destroyed with significant loss of bone. In 179 elbows the ulnar components were metal-backed and retentive; in the remaining 346, with better bone stock, non-retentive, all-polyethylene prostheses were used. Because of complications, 108 further operations were required in 82 patients. During the early years the incidence of complications was higher. Dislocation was the indication for 30 further procedures in 26 patients. Thirty patients underwent 33 revision procedures for aseptic loosening, 12 had 29 operations because of deep infection, two for superficial infection, and 14 further operations were done for other reasons. The cumulative rate of success, without aseptic loosening, five and ten years after surgery, was 96% and 85%, respectively.

When does subluxation of the first carpometacarpal joint cause swan-neck deformity of the thumb in rheumatoid arthritis: a 20-year follow-up study.

The aim of our study was to assess the incidence of subluxation of the first carpometacarpal joint (CMC I) and to evaluate which degree of subluxation produces swan-neck deformity of the thumb in rheumatoid arthritis (RA) occurring over 20 years. The hands of 83 rheumatoid factor (RF)-positive RA patients with recent (< or = 6 months) arthritis were evaluated radiographically at onset and at 1, 3, 8 and 15 years; 68 patients were evaluated at 20 years from entry. Subluxation was assessed in millimetres and compared with the MCP-I angle measurement to evaluate the thumb deformity. A statistical end-point analysis was performed between two different grades of subluxation. Subluxation of 2-3 mm was non-specific and only one third of these thumbs showed swan-neck deformity. At the end-point, subluxation of > or = 4mm was present in 17% of the thumbs, 81% of which had the swan-neck deformity; only five thumbs did not show this deformity, but presented deformed and unstable MCP I and interphalangeal joints. The frequency of swan-neck deformity was highly significantly (p < 0.0001) increased in the thumbs with severe CMC I subluxation (> or = 4 mm) compared with lesser subluxation (< 4 mm). When subluxation of the CMC I exceeds 4 mm, the swan-neck deformity of the thumb is a common consequence. This deformity is often progressive, and the hand function of such patients should be followed up carefully, both clinically and radiographically.

Multiple stress fractures in a young girl with chronic idiopathic arthritis. Extended case report.

The occurrence of stress fractures in patients with long-standing rheumatoid arthritis (RA) is widely known. Osteoporosis, corticosteroid therapy, joint stiffness, contracture, angular deformity of the joint and failed joint reconstruction--all together or separately--predispose to bone loss and stress fractures. In the present report we describe the history of a girl with juvenile idiopathic arthritis (JIA) having multiple stress fractures. The relationship between corticosteroid therapy and immobilisation in the treatment of fractures is discussed.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis. A 20-year follow-up study.

AIMS: In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). METHODS: An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzick's test. RESULTS: At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick's test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. CONCLUSIONS: The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

A comparative study of methods for demonstration and quantification of capillaries in skeletal muscle.

Histological, histochemical, immunohistochemical, and microangiographic methods were compared for the demonstration of capillaries in skeletal muscle. Microangiography visualized the arterioles and venules, but was unsuitable for the quantification of capillaries. The histological and enzyme histochemical methods gave variable staining reactions for capillaries. The most reliable and reproducible enzyme histochemical reactions were those for alkaline phosphatase (Gomori) and ATPase (after preincubation at pH = 4.2 or 4.6 or 7.2) as well as PAS staining after amylase preincubation. Among the immunohistochemical reactions, type V collagen and fibronectin were suitable for the demonstration and quantification of capillaries in skeletal muscle.

Outcome of ankle arthrodesis performed by dowel technique in patients with rheumatic disease.

Between the years 1988 and 1994, 19 ankle arthrodeses were performed on 18 patients (nine men) using the dowel technique. Patients were followed until a fusion had occurred, a non-union was successfully rearthrodesed, or a pseudoarthrosis was stabilized with orthosis treatment. Patients' radiographs and documents were analyzed both preoperatively and during the healing period. Subtalar fusion had been performed previously in eight ankles and rheumatoid destruction of subtalar complex was observed in seven other hindfeet. The original dowel method was used in 13 ankles and a modified procedure was performed in six. Local bone grafts were utilized. Solid fusion was achieved in 13 ankles (68%), but with delayed union in two cases. Non-union was present in six ankles, and two re-arthrodeses were performed with successful fusion in the other. Orthosis treatment was necessary in three of five ankles with permanent non-union. One chronic infection leading to non-union was detected. Only two of the six ankles (33%) with the modified technique using additional exposures healed without complications. In the dowel technique, the preoperative position of the ankle and location of the guiding Kirschner wire are of crucial importance and the original technique with a large cutter should be used. In patients with rheumatic disease, this fusion method did not yield acceptable results.

Why do ankle arthrodeses fail in patients with rheumatic disease?

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors' institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0-5 degrees of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Surgical outcomes of primary hip and knee replacements in patients with Parkinson's disease: a nationwide registry-based case-controlled study.

We evaluated the duration of hospitalisation, occurrence of infections, hip dislocations, revisions, and mortality following primary hip and knee replacement in 857 patients with Parkinson's disease and compared them with 2571 matched control patients. The data were collected from comprehensive nationwide Finnish health registers. The mean follow-up was six years (1 to 13). The patients with Parkinson's disease had a longer mean length of stay (21 days [1 to 365] vs 13 [1 to 365] days) and an increased risk for hip dislocation during the first post-operative year (hazard ratio (HR) 2.33, 95% confidence intervals (CI) 1.02 to 5.32). There was no difference in infection and revision rates, and one-year mortality. In longer follow-up, patients with Parkinson's disease had higher mortality (HR 1.94, 95% CI 1.68 to 2.25) and only 274 (34.7%) were surviving ten years after surgery. In patients with Parkinson's disease, cardiovascular and psychiatric comorbidity were associated with prolonged hospitalisation and cardiovascular diseases also with increased mortality.