GJ 3.1
Alumina ceramic total elbow arthroplasty in rheumatoid elbows
– 3 to 13 years follow-up of 57 elbows –
Inoue H, Nishida K, Miyazawa S, Kishimoto M
Department of Orthopaedic Surgery, Faculty of Medicine, Okayama University Medical School,
Okayama, JAPAN
Introduction
Total elbow arthroplasty (TEA) is a widely accepted for the treatment for damaged rheumatoid elbows
to achieve sufficient joint function. The current prospective study reports the long term follow-up of
TEA with an unlinked stem type (Stemmed Kyocera type I, SKC-I) with a solid trochlea on patients
who have rheumatoid arthritis (RA). SKC-1 is derived from an unlinked surface replacement prosthesis
using polycrystalline alumina ceramics on high-density polyethylene (Kyocera type I), which was
developed in 1979, based on the measurement study on the cadaveric elbows.
Materials and Methods
57 elbows (Larsen’s grade IV and V) from 45 RA patients replaced by SKC-1 were investigated .
Cement fixation was used in all cases. The duration of follow-up ranged from 36 to 154 (average 73.7)
months. The clinical condition of each elbow before and after operation was assessed according to the
scoring system of Japanese Orthopaedic Association (JOA) elbow scoring system (maximum 100
points), which is composed of scores for pain, activity of daily life, muscle strength, range of motion,
instability, and deformity of the joint. On the basis of this system, the results are defined as excellent
(90-100 points), good (75-89), fair (60-74), and poor (<60). Radiographic loosening was defined as a
progressive radiolucent line of more than two millimeters that completely surrounded the prosthesis.
Results
The average postoperative JOA score improved from 43.5±10.2。to 81.0±10.3。, with marked pain
relief. The mean range of motion (ROM) of extension/flexion before the surgery was –
35.7±22.4/117.1±19.1。and at last follow-up was –17.5±12.7/136.3±11.4。. The mean ROM of
pronation /supination improved from 51.1±23.4/56.5±28.5。to 78.3±16.8/82.3±16.5。. Of the 57
elbows, 9 elbows were judged to have excellent results, 37 had good results, 8 had fair results, and 3
had poor results.
There were no instances of ulnar nerve palsy, triceps avulsion, or postoperative infection. Medial or
lateral epicondylar fracture occurred in 2 cases during the operation, and union was achieved 3
months later. Massive instability with joint dislocation was seen in 3 cases of mutilans arthritis,
resulting in poor results. Aseptic loosening was seen in 3 elbows. Revision surgery was performed in
1 case of accidental post-operative distal humerus fracture, and in another of olecranon fracture with
the breakage of the ulnar component. With loosening defined as the end point, Kaplan-Meier curve of
the cumulative probability of survivorship demonstrates the likelihood of survival of the prosthesis at
93.8 percent for as long as 10 years.
Discussion
The results of the current study showed a high reliability of the SKC-1 prosthesis with the novel
alumina ceramic component over a long period when implanted with cement. However, the use of
non-constrained devices is limited by the amount of bone and by the need for ligamentous stability. If
soft tissues are damaged along with marked bone loss or inflammatory changes, the ligament should
be repaired or a semiconstrained type of prosthesis is indicated. It is important to note that a high
level of surgical technique is required for TEA in RA elbows to avoid typical postoperative
complications.
GJ 3.2
RADIOLUNATE ARTHRODESIS FOR THE RHEUMATOID WRIST
- A LONG-TERM FOLLOW-UP
H.Ishikawa1, A.Murasawa1 and T.Hanyu2
1Rheumatic
Center, Niigata Prefectural Senami Hospital, Murakami
of Orthopaedic Surgery, Niigata University, Niigata
2Department
Introduction
The wrist is the ”key-stone” of hand function. Painless stability is a prerequisite for the rheumatoid
wrist to perform various manual tasks. Synovectomy of the extensor tendons and the wrist joint with a
Darrach procedure is offered for painful wrists, which are not controlled by conservative treatment with
medication and orthosis. Radiolunate arthrodesis is performed on wrists with an unstable radiocarpal
joint and preserved midcarpal joint space. This study describes the long-term (more than 10 years)
follow-up of these operative procedures.
Materials and methods
The follow-up study was performed on 25 wrists in 25 rheumatoid patients (22 women and 3 men),
whose average age was 52 years (range, 33 to 66 years) with an average disease duration of 12
years (range, 1 to 38 years). The average follow-up period was 12.5 years (range, 10 to 18 years).
Five wrists were Larsen-Dale-Eek’s grade II, 14 were grade III, and 6 were grade IV. Depending on
the severity of bone destruction, the scaphoid in 6 wrists and the triquetrum in 3 wrists were included
in the fusion site.
Results
Preoperative pain (88%) and swelling (96%) decreased remarkably at follow-up (12%, 4%). Average
grip strength increased significantly from 100mmHg to 140mmHg (p<0.01). The total arc of wrist
extension/flexion decreased to two-thirds of the preoperative arc with a major loss in flexion (preop.:
26/28degrees, follow-up: 23/13degrees). The range of forearm rotation increased due to a Darrach
procedure. In periodical X-ray assessments of 23 wrists, carpal collapse initially improved following
the operation, however, it returned to the preoperative level after 5 years. Ulnar carpal shift improved
significantly after the operation (p<0.01), and the position remained unchanged over 10 years. In
palmar carpal subluxation, no remarkable change was noted. Bone union occurred in 87% of the
operated wrists and the remaining 13% had fibrous union. Widening at the lunocapitate joint (>2mm)
was noted in 4 wrists (17%) and progressive instability at the midcarpal joint occurred in one wrist with
the mutilating type of disease. Narrowing (<1mm) was noted in 5 wrists (22%) and 3 wrists were
totally fused in the functional position.
Discussion
Radiolunate arthrodesis provides good stability with some motion for the moderately deteriorated
rheumatoid wrist more than 10 years after the operation, in spite of some radiological progression of
the disease. This operation is considered to convert the natural course of the rheumatoid wrist from
the unstable form to the stable form.
Keywords
Rheumatoid arthritis, Wrist, Arthrodesis, Radiolunate, Stability
Address for correspondence
Hajime Ishikawa,M.D., Rheumatic Center, Niigata Prefectural Senami Hospital, Senami Onsen 2-4-15,
Murakami, Niigata, 958-0037, Japan
Tel: +81-254-53-3154, Fax: +81-254-52-1309, e-mail: rasenami@poppy.ocn.ne.jp
GJ 3.3
Revision Arthrodesis for the Rheumatoid Wrist
M. Lautenbach, M. Mochkabadi
Immanuel-Krankenhaus,
Academic Hospital Free University of Berlin,
Orthopaedic Department, Upper Extremity
There is an incidence of failures of total wrist arthroplasties. We review our experiences in revising
total wrist implant arthroplasties to arthrodeses. The most common mode of failure of the
arthroplasties in our series was metacarpal loosening with dorsal perforation of the stem.
We used for the revision arthrodesis in all our cases tricortical iliac crest bone grafts and additional
spongiosa transplants from this donor site region. In one case we used a vascularized iliac crest bone
graft to bridge the bone defect because of a bad host quality of the recipient area. Fixation was
achieved with plates and screws.
Our average follow-up period was 28 month. 14 patients with 15 failed wrist implants were treated with
this technique. 14 patients undergoing arthrodesis attained a solid painless fusion after a single
operation. In one case a non-union with a loosening of the screws due to using a non-rigid plate was
seen. In this case a revision was necessary to achieve a bone healing. All patients were pain free and
achieved an increased grip strength after bony fusion.
Arthrodesis after failed total wrist arthroplasty is a satisfactory salvage procedure even in cases with a
bad quality of the recipient area. We recommend a rigid fixation technique to prevent non-unions.
Address for correspondence:
Dr. M. Lautenbach, Immanuel-Krankenhaus, Academic Hospital Free University of Berlin
Orthopaedic Department, Upper Extremity, Königstr. 63, 14109 Berlin, 0049-30-80 50 50
GJ 3.4
Implant arthroplasties of the PIP joint in the rheumatoid patients
Y. Minamikawa1, M. Nakamura1, H. Iida1, K. Nakatani2 and T. Nieda2
1 Kansai Medical University, Osaka Japan
2 Misato Marine Hospital, Kochi Japan
Objective
Destruction and deformity in both PIP and MP joints are not uncommon and cause sever disabilities.
Arthroolasty of the MP joint combined with arthrodesis of the PIP joint are the usual choice for this
condition. Some motion in ulnar digits provides great benefits for rheumatoid patients. We report
implant arthroplasty of the PIP joint and also simultaneous replacement of PIP and MP joint in same
finger.
Material & Methods
Twenty-five joints in 15 patients underwent PIP arthroplasty either with silicone or surface replacement
implant. Twelve PIP joints in 6 patients used Silicone implant (6 Swanson and 6 Avanta) alone and
mean follow up was 42(6-84) months. New cementless surface implant (Self Locking Finger Joint,
SLFJ) were developed and clinically used for about 3 years. Because of the stem design, SLFJ are
able to use both PIP and MP joint simultaneously or combined with silicone implant. Four PIP joints in
3 patients used SLFJ alone and 6 patients underwent both PIP and MP joint with implant
simultaneously. Combination of SLFJ PIP and silicone MP was 4 finger in 2 hand, SLFJ PIP and
SLFJ MP was 3 finger in 2 hand, silicone PIP and SLFJ MP was 3 finger in 2 patients and silicone PIP
and silicone MP was 1 finger. Mean follow up for SLFJ in either PIP or MP was 18(4-37) months.
Results
Average arc of the PIP with silicone implant alone was 38(10-50）°、and SLFJ alone was 55(45-60) °.
One PIP SLFJ dislocates immediate after surgery and was converted silicone later on. Of 7 SLFJ with
combined PIP and MP arthroplasties, 2 PIP lost motion completely, one PIP move only 15°, 4 PIP
move 75 °in average. Four silicone PIP combined with MP arthroplasties move 45°in average.
One PIP SLFJ had breakage in stem legs, which believed to occur during interaction of stem insertion
from both side of the basal phalanx, and was seen at immediate post op X-ray. There was one
instability in index replaced with SLFJ for sever Swan neck deformity and no infection. Patient
satisfaction for simultaneous replacement in PIP and MP joint were excellent except one whose age
was 72.
Discussion
Stability of the PIP joint in index finger is important for pinch and PIP motion of ring and little fingers
are required for grip motion. Although arthrodesis of the PIP joint were performed more often and
functional improvement usually obtained compared to pre-operative condition, ulnar 2 digits better to
preserve some motion in the PIP joint as long as there is a possibility, and especially for the young
patients. The results of the simultaneous replacement in PIP and MP joint seems discourage,
however, when considering the severity of the deformities of this series, there is a good chance in the
future. We will improve implant design and surgical technique as well as post-operative therapy, and
continue to challenge the simultaneous replacement of PIP and MP joint.
GJ 3.5
Short term result of metatarsal realignment for rheumatoid forefoot
deformities by metatarsal shortening offset osteotomy
Hajime Owaki, Jun Hashimoto, Kenji Hayashida, Hideo Hashimoto, Takahiro Ochi, Hideki Yoshikawa
Department of Orthopaedic Surgery, Osaka University Medical School
[Objectives] Hallux valgus, dorsal sublaxation or dislocation of metatarsophalangeal joints and clawing
of the lateral toes are seen frequently in patients with rheumatoid arthritis (RA). Resection arthroplasty
of the metatarsophalangeal joints (MTP joints) are widely used to correct these forefoot deformities
and the clinical results are almost good. However lateral toes tend to displace dorsally and painful
callosity tends to recur. We used the metatarsal shortening offset osteotomy for shortening and
dorsal/medial displacement of the prominent metatarsal head. In this report, we introduce the surgical
techniques of shortening offset osteotomy and postoperative changes of plantar pressure measured
with F-scan system (Tekscan, Inc.), and review the short term result during 1 to 4 year follow-up.
[Materials and Methods] This study involved 26 feet of 18 patients with RA which were performed with
the metatarsal osteotomy for lateral toes and followed more than 1 year (average follow-up 29 months,
range 14-46 months). The average age of the 17 women and 1 man was 61 years (range, 51-77
years). The mean duration from the onset of RA to operation on the forefoot was 17 years (range, 7-42
years). Skin incision was placed on the dorsum of the foot and the extensor digitorum brevis and
longus were severed (or elongated). After reposition of MTP joint, transverse osteotomy of distal fifth
of the lateral metatarsal bone was performed with resection of few millimeters length metaphysial
bone. Cortical bone of the distal end of the proximal stump was chiseled into a small rod between two
ditches with rongeur and then the rod was put into medullary canal mortise of distal stump. This
procedure make offset shift of metatarsal head medially or dorsally. Swanson implant arthroplasty,
distal osteotomy was performed on the great toe. Postoperative clinical and radiological results were
evaluated with AOFAS rating system. We measured dynamic plantar pressure before and one year
after operation in one representative case.
[Results] At the time of follow-up, the mean AOFAS score was 80 points (59-95) and the mean pain
score was 36 points. The recurrence of painful callosity was one case. Nevertheless, the range of
motion of the MTP joint remained low: 30 degrees and less in 16 feet (62%) including 3 bony ankylosis
of MTP joints. There was no nonunion case. [Discussion]
Resection arthroplasty has been accepted as the treatment of choice for forefoot deformities in RA
patients. Recent advance of drug therapy against RA encouraged us to preserve the joint in correction
of forefoot deformities. Our technique aimed at preservation of the function of the MTP joints and is
suitable for mild deformities in which only one or two rays are involved. Furthermore it is easy to
correct the deformity of spray foot and reduce the plantar prominence of metatarsal head. This study
revealed the good clinical result in short term follow-up. Although the long term result must to be
waited, this method is one of recommendable options for RA patients with forefoot deformities.