A new total elbow arthroplasty for rheumatoid arthritis

We have followed up the results of total elbow arthroplasties on 36 elbows in 28 patients using a prosthesis newly designed in our department. The characteristics of this elbow joint (NR type) were: none constrained type, minimum bone resection and adapting each elbow joint size. The results were compared before and after operations on the basis of the Elbow Evaluation Sheet prepared by the Japanese Orthopaedic Association. The usefulness of the new prosthesis is evaluated and the problems involved are discussed. Seven years and 8 months on average (from 3 years 6 months to 13 year 9 months) after the operation, relief of pain and an increase in the flexion angle were particularly remarkable. As compared with the preoperative conditions, the activities of daily living of patients were improved, especially washing their faces, buttoning-up their shirts and eating food with greater ease. The most frequent complication was restriction to extension, which developed in 12 elbows (33%). Postoperative infection was seen in two joints of two patients (5.5%), fall out the ulnar component due to fracture of olecranon in one (2.8%) and dislocation of the elbow joint in another (2.8%). The survival rate of this elbow joint was 90% at an average 7 years and 8 months follow-up. This new elbow joint has good durability and is very useful in improving the function of the elbow joint destroyed by rheumatoid arthritis.     

Limited extension after linked total elbow arthroplasty in patients with rheumatoid arthritis

Objective: Total elbow arthroplasty (TEA) has become an established procedure to relieve pain and to increase the range of motion of the destructed elbow in patients with rheumatoid arthritis (RA). However, some patients still have limited extension after TEA, and the causes of limited extension after TEA have yet to be elucidated.

Methods: To examine whether widening of the joint space can cause such limited extension, we retrospectively analyzed 55 cases of linked TEA in patients with RA. There were seven male and 40 female with a mean age of 63.8 years (range, 30–80 years) and a mean follow-up of 7.5?±?4.2 years (range, 2.5–15.6 years). The Mayo Elbow Performance Score (MEPS) and radiological measurements were recorded. Widening of the joint space was calculated by subtracting the length measured on postoperative radiograph from preoperative radiograph.

Results: MEPS and range of motion were significantly improved after surgery except for extension. The degree of extension was significantly correlated with radiological widening of the joint space in the limited extension group. Correlation analyses showed that postoperative limited extension was correlated with lower MEPS daily function.

Conclusions: Limited extension after linked TEA is partly derived from perioperative widening of the joint space and potentially limits daily function in patients with RA.     

Outcome of shortened extra-small ulnar component in linked total elbow arthroplasty for patients with rheumatoid arthritis*

Objective. We compared the clinical and radiological results of the 3-inch shortened ulnar stem of the extra-small component of Coonrad–Morrey prosthesis with those of the other ulnar components for patients with rheumatoid arthritis (RA).

Methods. A total of 33 Coonrad–Morrey total elbow arthroplasty (TEA) procedures were performed. Of these, 27 elbows of 25 patients with RA underwent primary TEA. The results of the clinical and radiological findings were compared between groups of patients receiving the shortened ulnar stem of extra-small components (shortened group) and of those receiving the components of the other sizes (control group).

Results. The mean follow-up was 6.2 ± 2.8 years in the shortened group and 7.2 ± 2.5 years in the control group. The Mayo elbow performance score and range of motion results were substantially improved after the operation for both groups. We encountered several peri- and postoperative complications, but no significant differences in clinical results were found between the groups. The control group had three cases of osteolysis around the implant, while the shortened group did not.

Conclusions. TEA with a shortened ulnar implant of the extra-small size of the Coonrad–Morrey prosthesis gave satisfactory mid-term results among patients with RA.     

Bone scintigraph of rheumatoid or osteoarthritic knees after total arthroplasty

Aim: This investigation was carried out to observe mineral metabolism around the implanted prosthesis in the knee. Method: Follow‐up with technetium‐99m methylene‐di‐phosphate bone scintigraphy was performed on 69 knees of 57 patients (41 rheumatoid and 28 osteoarthritic knees) from 10 days to 91 months after total knee replacement results. Results: Uptake of injected isotope was seen only around the artificial joint in the scintigram, at 10 days’ post‐operatively and became denser with wider distribution thereafter. Maximum uptake was noted at 3 months. Post‐operatively, mineral metabolism began to decrease from 6 months on, and uptake was seen only in the bone near the prostheses, especially at the proximal end of the tibia, in scintigrams performed after more than 2 years. Uptake counts on the medial side of the tibial proximal end were higher than those on the lateral side in nine out of 11 knees in scintimetry performed more than 1 year after surgery. Persistent high uptake was observed in three knees, with subsequent loosening. Local high uptake was seen in the femoral shaft of three knees before the appearance of heterotopic ossification in X‐rays, and in an area of fracture in two knees. Conclusion: Loosing, heterotopic ossification and stress fracture can be detected by bone scintigraphy earlier than by roentgenogram.     

Biaxial total wrist arthroplasty in rheumatoid arthritis. Satisfactory functional results

We reviewed 16 uncemented biaxial total wrist arthroplasties (TWA) in 14 patients with rheumatoid or juvenile arthritis. The mean follow-up was 25 months (range 5–60). According to the Hospital for Special Surgery scoring system (HSS), good-to-excellent results were accomplished in 69%, moderate in 19%, and poor in 12%. The mean pain score was 0.4 on a visual analog scale from 0–10 (0=no pain). The Wrightington activities of daily life assessment chart showed a 63% improvement, and we found a threefold increase in range of motion at follow-up. Four TWAs showed early dislocation, one of which was revised. Biaxial TWA yields good short-term results in rheumatoid patients, although instability is a frequent complication.     

Risk factors for total knee arthroplasty in rheumatoid arthritis

We conducted a study to assess the predictive factors for total knee arthroplasty (TKA) in a cohort of rheumatoid arthritis (RA) patients recruited and followed prospectively for 5 years. A linked registry study using information from a large observational cohort of RA patients followed at the Institute of Rheumatology, Tokyo Women's Medical University (IORRA) was done. Baseline routine clinical and laboratory assessments were recorded. The data were analyzed using the multivariate piecewise-linear Cox (PL-Cox) regression model; the model initially included variables such as gender, age, duration of the disease, visual analog scale (VAS) generated by physicians (VAS-physician), patient-reported VAS for pain (VAS-pain), VAS for general health (VAS-GH), disability level using the Japanese version of the Health Assessment Questionnaire (J-HAQ), C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor (RF), and hemoglobin. Of the 3945 patients registered at baseline, 955 (24.2%) had pain or tenderness in their knee joints, and 114 (11.9%) had TKA surgery in one or both knee joints. On PL-Cox regression, the variables with positive coefficients were J-HAQ, VAS-pain, VAS-physician, and RF positive; advanced age was associated with a reduced risk of TKA. The hazard ratios were: 0.920 for age >60 years; 2.64 for J-HAQ <1.5; 1.01 for J-HAQ >1.5; 1.47 for VAS-pain >6 (cm); 1.20 for VAS-physician >4 (cm); and 2.08 for RF positive. The consistently predictive factors for TKA in RA were age, J-HAQ, VAS-pain, VAS-physician, and RF positive. Age greater than 60 years was associated with a decreased risk of TKA, while J-HAQ from 0 to 1.5, VAS-pain >6 (cm), and VAS-physician >4 (cm) were associated with an increased risk for TKA surgery. These results suggest that, when treating RA patients, physicians should pay particular attention to pain complaints, the patient's daily activity level, and the RF factor status.     

Systematic review of primary total elbow prostheses used for the rheumatoid elbow

Total elbow prosthesis (TEP) has been shown to be a viable option for treatment of the rheumatoid elbow. Many types of TEP have been studied, but the heterogeneity of the studies makes most conclusions subject to discussion. The aim of this systematic review is to show the differences between the most commonly used TEP for the destroyed rheumatoid elbow. After a search in Pubmed (NLM, Bethesda, USA) the senior author selected eight frequently used TEP: the Capitellocondylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Norway, Roper–Tuke and Souter–Strathclyde. For inclusion studies we arbitrarily formulated nine criteria , after which clearly adverse events were defined for comparison purposes. The Capitellocondylar and Souter–Strathclyde prostheses are the most-studied treatments for replacing the rheumatoid elbow. In contrast to the Capitellocondylar, the Souter–Strathclyde prosthesis showed higher loosening rates but implemented modifications of the design have reduced these rates in recent studies. Nevertheless, in relation to most other joint replacements in rheumatoid patients, all TEP still have higher complication rates. For this reason an elbow prosthesis may just be warranted in seriously disabled patients. Abbreviations TEP Total elbow prosthesis     

Minimum 10-year results of cementless total hip arthroplasty in patients with rheumatoid arthritis

Objectives: To retrospectively evaluate the long-term results of cementless total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA) and postoperative patient mortality after THA.

Methods: This study included 191 hips in 149 RA patients who underwent cementless THA between 1998 and 2005. Mean age at surgery was 54.2 years, and mean follow-up was 12.6 years. Implant and patient survivorships were determined using the Kaplan–Meier method, and the associated influencing factors were determined.

Results: Implant survivals at 17 years were 99.5% for stems, 93.9% for cups, and 90.8% for liners. Among the liners used, THAs with highly cross-linked polyethylene showed better survivals compared with those with conventional polyethylene and alumina-bearing surface (93.4%, 90.9%, and 52.2%, respectively). A total of 64 deaths occurred; 45 patients died within 10 years and 19 patients died between 10 and 17 years. Malignancy (25.0%) was the leading cause of death, followed by pneumonia (20.8%) and sepsis (20.8%). The patient survival rate was 36.9% at 17 years after THA. Multivariate analysis exhibited that older age at operation and greater dose of concomitant corticosteroid resulted in shorter patient survivals.

Conclusions: Cementless THA worked well in patients with RA. Mortality remained high among RA patients who needed THA.     

A total wrist arthroplasty in rheumatoid arthritis: a case followed for 24 years

We report a case of rheumatoid arthritis treated with a total wrist arthroplasty. A Meuli-type total wrist arthroplasty was performed on the left wrist in 1979. We have treated the patient's rheumatoid arthritis with disease-modifying antirheumatic drugs (DMARDs) (Actarit 100 mg and Mijoribine 50 mg) and nonsteroidal anti-inflammatory drugs (NSAIDs) for a total of 26 years before and after the total wrist arthroplasty. The activity of the rheumatoid arthritis has been kept at a low level. The operated wrist was followed up for 24 years postoperatively. It is thought that the antirheumatic treatments over a long period have been very successful in preventing the destruction of the operated wrist.     

A total wrist arthroplasty in rheumatoid arthritis: a case followed for 24 years

Abstract

We report a case of rheumatoid arthritis treated with a total wrist arthroplasty. A Meuli-type total wrist arthroplasty was performed on the left wrist in 1979. We have treated the patient's rheumatoid arthritis with disease-modifying antirheumatic drugs (DMARDs) (Actarit 100?mg and Mijoribine 50?mg) and nonsteroidal anti-inflammatory drugs (NSAIDs) for a total of 26 years before and after the total wrist arthroplasty. The activity of the rheumatoid arthritis has been kept at a low level. The operated wrist was followed up for 24 years postoperatively. It is thought that the antirheumatic treatments over a long period have been very successful in preventing the destruction of the operated wrist.     

Radiographic study of joint destruction patterns in the rheumatoid elbow

Knowledge of the pattern of joint destruction is important for planning the therapeutic approach to rheumatoid arthritis (RA) of the elbow. Accordingly, we carried out a large-scale radiographic study with the objective of elucidating the joint destruction pattern in rheumatoid elbows. From 2001 through 2003, we examined and took plain X-rays of both elbows of 193 RA patients (i.e., 386 elbows), consisting of 18 men and 175 women, with a mean age of 57.0 years. Radiographic images of the elbow joints were used to classify the degree of bone loss in various zones on the elbow joint surface into four grades of severity, and joint destruction was compared between the left and right elbows. In addition, correlation in the extent of bone loss between each of the zones of the same elbow and differences in the extent of bone loss were analyzed statistically. The results showed direct correlations for destruction of the elbow joint surface among the zones for the left and right elbow joints and in the same elbow joint. However, more severe destruction was observed on the radial side of the humeral trochlea, and it was surmised that destruction of the elbow joint must begin at that site and gradually spread mediolaterally. In addition, in the same elbow joint, the correlation in the degree of bone loss between the trochlea of humerus and the trochlear notch was especially strong, indicating that the bone destruction at both sites represented mirror lesions. We conclude that when performing radiographic diagnosis of the joint damage in the rheumatoid elbow, knowledge of this pattern of joint destruction will be useful for assessing whether there is joint destruction in the initial stage and for deciding the therapeutic approach.     

Long-term clinical and radiographic results of cementless total hip arthroplasty for patients with rheumatoid arthritis: minimal 10-year follow-up

Abstract

Objectives. The aim of this study was to clarify the long-term clinical and radiographic results of cementless total hip arthroplasty (THA) for patients with rheumatoid arthritis (RA).

Methods. Twenty-eight total hip arthroplasties in 24 patients with a diagnosis of RA were performed from October 1992 to October 1996. All components were titanium alloy with a circumferential porous coating. Six patients (six hips) died before the 10-year follow-up, and one patient (one hip) was lost to follow-up, leaving 21 joints of 17 patients for review at a minimum 10-year follow-up after surgery. There were 3 men and 14 women with an average age of 55.0 years. The average duration of RA at the time of the operation was 12.6 years, and the average follow-up period was 12.2 years. We evaluated the Japanese Orthopaedic Association (JOA) hip scores, radiographic changes and survivor rates of components.

Results. Compared with the preoperative JOA hip scores, there was significant improvement in the postoperative scores. Spot welds consistent with bone ingrowth were identified in 95.0% of the femoral components. No femoral components showed radiographic loosening or required revision for aseptic loosening, but two acetabular revisions were performed because of aseptic loosening. The 14-year survivor rates of the stem and cup with the end point of loosening were 100% and 88.2%, respectively.

Conclusions. Cementless THA with this component design in patients with RA appears to be a promising treatment.     

Treatment of infected total knee arthroplasty in patients with rheumatoid arthritis

The primary aim of treating infected knee joints after total knee arthroplasty is to eradicate the infection, but this is difficult to achieve. We reviewed the treatment of infections that occurred after total knee arthroplasty in patients with rheumatoid arthritis. The subjects were 14 patients with rheumatoid arthritis (3 men, 11 women; ages 38–81 years) who had 14 infected knee joints. The outcome was preservation of the implant in two cases, revision arthroplasty in six cases, arthrodesis in three cases, resection arthroplasty in one case, amputation in one case, and death in one case. If there is no loosening, preservation of the implant should be attempted. If preservation is impossible, revision arthroplasty is the next best option considering the effect on daily activities in patients with the disease affecting multiple joints.     

Treatment of infected total knee arthroplasty in patients with rheumatoid arthritis

Abstract

The primary aim of treating infected knee joints after total knee arthroplasty is to eradicate the infection, but this is difficult to achieve. We reviewed the treatment of infections that occurred after total knee arthroplasty in patients with rheumatoid arthritis. The subjects were 14 patients with rheumatoid arthritis (3 men, 11 women; ages 38–81 years) who had 14 infected knee joints. The outcome was preservation of the implant in two cases, revision arthroplasty in six cases, arthrodesis in three cases, resection arthroplasty in one case, amputation in one case, and death in one case. If there is no loosening, preservation of the implant should be attempted. If preservation is impossible, revision arthroplasty is the next best option considering the effect on daily activities in patients with the disease affecting multiple joints.     

Hallux valgus deformity after total ankle arthroplasty for rheumatoid arthritis: A case report

Hallux valgus (HV) deformity is associated with hindfoot valgus deformity. We experienced a case that suggests the possibility that valgus correction for varus hindfoot with bony ankylosis of the subtalar joint by total ankle arthroplasty may have caused a forefoot HV deformity, despite adequate valgus correction.