Uncemented total hip arthroplasty in rheumatoid arthritis diseases. A two- to six-year follow-up study.

Forty primary uncemented total hip arthroplasties (THAs) were performed in 34 patients with an average age of 41.2 years (range, 21-78 years). Four hips had one component placed with cement: three femoral, one acetabular. Diagnoses included rheumatoid arthritis (30 hips), juvenile rheumatoid arthritis (seven hips), and systemic lupus erythematosus (three hips). The follow-up period averaged 3.7 years (range, two to six years). Thirty-five percent of the patients were using corticosteroids before hip replacement and throughout the follow-up period, whereas 44% of the patients had been using steroids in the past. Additionally, 79% of the patients were taking some form of antiinflammatory medications at follow-up examination. Clinical evaluation based on a ten-point rating scale indicated significant improvements from preoperative to the most recent follow-up examination for pain (from 3.1 to 9.0), walking (4.0-7.3), function (3.5-6.0), and activity (3.0-4.9). None of the hips required revision surgery, and none are pending. There was no evidence of roentgenographic failure; however, 43% of femoral and 12.8% of acetabular components showed some minor radiolucencies with sclerotic lines. None of these involved 100% of the bone-prosthesis interface. Femoral component subsidence occurred in two hips, and acetabular component migration occurred in one hip. Complications included three (8.1%) intraoperative femoral fractures, of which two required internal fixation. One patient had postoperative, culture negative, wound drainage. No deep sepsis occurred. These findings suggest that uncemented THA may be successful in the rheumatoid patient. Pain relief, walking, function, and activity levels are similar to those seen in cemented replacements with this length of follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)     

Total hip arthroplasty in rheumatoid arthritis. A long-term follow-up study

This study was undertaken to assess the clinical and radiographic results of total hip arthroplasty in rheumatoid arthritis patients with a minimum of 10 years of follow-up evaluation. Eighty-three hips in 51 of the original 104 patients were available for follow-up study an average of 12.1 years following surgery. The average age of the patients at the time of surgery was 39.9 years (range, 14-72 years). Fourteen hips were revised, 11 for mechanical loosening and 3 for late infection. The overall revision rate is 16.7%; the revision rate for mechanical loosening was 13.3%. According to Merle D'Aubigne-Postel hip rating scores in the 69 hips that did not require revision, 19 hips were excellent (28%), 37 were good (54%), 11 were fair (15%), and 2 were poor (3%). Therefore, 67 of 83 hips (80.7%) were satisfactory on follow-up study. Radiographic evidence of loosening in nonrevised hips was found in 11 acetabular and 2 femoral components.     

Total knee arthroplasty in juvenile rheumatoid arthritis. A seven-year follow-up study

Total knee arthroplasty (TKA) for preservation of ambulation is indicated in young adults with juvenile rheumatoid arthritis (JRA). The bony deformities of JRA require special measures to adequately seat the prosthesis. Thirteen patients with 25 knee arthroplasties were followed an average of 61 months. Prior surgical operations did not affect the outcome of this procedure. A 55% reduction in pain plus an average 30-point gain on Jergesen's functional assessment scale reflected the overall improvement attributable to TKA. To date, no revisions, infections, or loosenings have occurred in this series of patients.     

Knee arthrodesis following total knee arthroplasty in rheumatoid arthritis

Twenty-seven knees in 23 patients, all with seropositive rheumatoid arthritis and failed total knee arthroplasty, were treated by arthrodesis. Twenty of the 27 knees were solidly fused. A fusion aligned in 7 degrees +/- 5 degrees of valgus and knee flexion from zero to 30 degrees was associated with the highest rate of arthrodesis, the lowest rate of progression of disease in other joints, and the highest functional scores. Stable fixation using either internal or external fixation gave the most predictable rate of arthrodesis. Persistent sepsis and bone stock losses were associated with failure of arthrodesis, even under the best circumstances. All of the 20 successfully arthrodesed knees were completely functional.     

Kudo total elbow arthroplasty in patients with rheumatoid arthritis: a long-term follow-up study.

BACKGROUND: Improvements in the design of total elbow prostheses over the last two decades have led to better and more consistent results. The type-3 Kudo total elbow prosthesis was developed in 1980. The long-term results of use of this implant have not been reported. Because it is an unlinked prosthesis, it is not known whether preservation of the anterior oblique component of the ulnar collateral ligament at the time of implantation is important. METHODS: A type-3 Kudo total elbow arthroplasty with cement was performed in forty-seven patients (fifty elbows) with rheumatoid arthritis. Revision rates, clinical symptoms, postoperative complications, and radiographic changes were assessed eleven to sixteen years (mean, thirteen years) postoperatively. RESULTS: The overall survival rate of the prosthesis was 90% at sixteen years. The mean Mayo elbow performance scores were all poor (mean overall score, 43 points) initially. The overall score was substantially improved at both the intermediate follow-up examination (four to six years after the operation) and the late follow-up examination (eleven to sixteen years after the operation), to 81 and 77 points, respectively. The overall rate of radiolucency about the humeral component was 45% at the intermediate follow-up examination and 100% at the long-term follow-up examination. The rate of radiolucency about the ulnar component at the intermediate and late follow-up examinations was 4.3% and 8.9%, respectively. No great differences in results were found with preservation of the anterior oblique component of the ulnar collateral ligament. CONCLUSIONS: This long-term follow-up study showed acceptable results of the type-3 Kudo total elbow arthroplasty in patients with rheumatoid arthritis. Preservation of the ulnar collateral ligament does not seem to be necessary when performing this procedure.     

15-year follow-up study of total knee arthroplasty in patients with rheumatoid arthritis

In 25 patients with rheumatoid arthritis, 36 cases of cemented Kinematic total knee arthroplasty were reviewed clinically and radiographically at 13 to 19 years after surgery. The mean age at the time of surgery was 51.6 +/- 8.9 years. According to the follow-up results evaluated with the Hospital for Special Surgery knee scoring system, 28 knees (77.7%) were classified as good or excellent. The mean flexion angle at follow-up evaluation was 99 degrees +/- 24 degrees (10 degrees -140 degrees ). At the tibial or femoral bone-cement interfaces, a radiolucent line was seen in 10 of 36 knees (27.8%) at follow-up evaluation. The survival rate of prostheses with revision as the endpoint was estimated to be 93.7% at 15 years. Kinematic total knee arthroplasty in rheumatoid arthritis patients provided a good long-term outcome.     

Long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis

Seventy-five primary cemented total hip arthroplasties (THAs) were performed in 53 patients with rheumatoid arthritis and juvenile rheumatoid arthritis. All patients were followed for an average of 7.4 years, unless their prosthetic hips failed before that time. Clinical evaluation was based on a 10-point maximum rating scale, and ratings for pain, walking, function, and activity improved from preoperative values to the most recent follow-up examination. Revision THA was performed for aseptic acetabular loosening in four hips, and femoral loosening in one hip. Sepsis occurred in another four hips. Complications of wound healing occurred in 14 hips. Roentgenographic evidence of loosening was seen in six acetabular components, in three femoral components, and in the femoral and acetabular component of one hip; none of these hips have as yet required revision THA. The Kaplan-Meier survivorship analysis revealed a 93% survival probability at seven years, which fell to 77% at 12 years in these patients. A trend was that younger, larger patients had increased failure and component loosening rates. Cemented primary THA has been a satisfactory operation in the rheumatoid patient. The relatively high rate of wound healing problems and sepsis may be due to the systemic immune nature of rheumatoid arthritis; however, 25% of these prosthetic hips either failed or are at risk for future failure. Thus, improved techniques are still necessary to increase the long-term success of THA in the rheumatoid patient.     

Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up.

Twenty-three Swanson silicone rubber implants in patients with stage III or stage IV rheumatoid arthritis were reviewed at an average of 72 months after surgery. Minimum follow-up in patients with unrevised implants was 44 months. Results were rated good or excellent in 48%, fair in 4%, and poor in 48%. Pain was the primary indication for surgery. Patient satisfaction and pain relief were achieved in 63%. Implant fracture occurred in 52%. Revision rate was 30%, including one recommended revision. Radiographic changes consistent with particulate synovitis were seen in 30%. Prosthesis settling and bony resorption were seen in more than 75% of the patients. Survivorship analysis demonstrated 42% survival at 77 months. Progressive clinical and radiologic deterioration was seen. Swanson silicone rubber implant is recommended only in the very low demand patient with stage III or stage IV rheumatoid arthritis and in those with insufficient bone stock to allow total wrist arthroplasty with a metal-on-plastic design.     

Total elbow arthroplasty with a non-constrained surface-replacement prosthesis in patients who have rheumatoid arthritis. A long-term follow-up study

Thirty-seven elbows in thirty-six patients who had rheumatoid arthritis had a total elbow arthroplasty with insertion of a non-constrained surface-replacement prosthesis. The patients were followed for an average of nine years and six months, the longest follow-up being seventeen years. A good result was seen in twenty-nine elbows; a fair result, in one; and a poor result, in seven. The reasons for the poor results were gross posterior displacement of the humeral component in five elbows, persistent subluxation with pain in one, and recurrent ankylosis in one. Of the five elbows that had gross posterior displacement, four had a revision operation with a new humeral component, and a satisfactory result was eventually achieved. Radiographic examination revealed various degrees of proximal subsidence of the humeral component in 70 per cent of the elbows. However, in most of the elbows the subsidence was not progressive and was compatible with a good clinical result. In contrast, the rate of loosening of the ulnar component was low; loosening was seen in only 5 per cent of the elbows. Seventeen elbows were followed for ten years or more, and comparison of the clinical results in the intermediate period with those at the most recent review revealed that the results improved with time. Because of the number of elbows in which subsidence of the humeral component developed, we now use a humeral component with an intramedullary stem, and were no longer recommend the use of our Type-1 and Type-2 prostheses.     

Radial head replacement in capitellocondylar total elbow arthroplasty. 2- to 6-year follow-up evaluation in rheumatoid arthritis

We reviewed six capitellocondylar metal-to-plastic total elbow replacement prostheses with radial head components, implanted in patients with rheumatoid arthritis. At an average of 4.7 +/- 1.5 years, relief of pain, improvement of function, and a functional range of motion were preserved. Five of the six elbows (83%) were clinically rated good or excellent. Radiolucent lines were seen at the bone-cement interface in 50% of the humeral component stems and in all ulnar component boats within 2 years after surgery; none had progressed at subsequent examination. Most were less than or equal to 1 mm wide, and none were associated with clinical deterioration. Only one of the humeral components was radiographically loose. No radiolucent lines were seen along the stems of the ulnar or radial components. There were no postoperative dislocations when the radial component was used, presumably because the prosthetic radial head provided increased constraint. None of these elbows have required revision. Radial head replacement in capitellocondylar arthroplasty had been discontinued because radiolucent lines were observed at early review. However, the absence of clinical failure, dislocation, or progression of radiolucency at long-term follow-up examination favor radial head replacement in primary unconstrained total elbow arthroplasty.     

Total condylar knee arthroplasty in osteoarthritis. A four- to six-year follow-up evaluation of 103 cases

One hundred and three consecutive total condylar knee prostheses in patients with gonarthrosis inserted from 1979 to 1981 have been prospectively followed for four to six years. According to the New York Hospital for Special Surgery Knee Rating Scale, 58 knees (56%) were rated excellent; 34 (33%), good; seven (7%), fair; and four (4%), poor at the latest follow-up evaluation. The median preoperative score was 57 points and the median postoperative score 87 points. Thirteen knees (13%) had a radiolucency with a width of 2 mm or more beneath one or more of three tibial zones. In only one case did this represent a clinical loosening. Six knees (6%) had complications requiring reoperation. One deep infection was treated with an arthrodesis, one patellar button was revised after a traumatic patellar fracture, and three superficial skin necroses were surgically managed. Moreover, in one mechanically loosened tibial component, a revision has been planned. No complications were fatal. The modified total condylar I prosthesis is an excellent prosthetic design with a low failure rate in gonarthrosis.     

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis

Although metacarpophalangeal joint arthroplasty is occasionally performed for joints affected by osteoarthritis, it is most often done in patients with rheumatoid arthritis. The metacarpophalangeal joint is critical for proper finger function but is the most common site of involvement in the rheumatoid hand. A thorough understanding of the anatomy, pathophysiology, and mechanics of the metacarpophalangeal joint is a prerequisite for the evaluation and treatment of patients requiring metacarpophalangeal arthroplasty. Silicone rubber implants are the most frequently used device for treatment of revised metacarpophalangeal arthroplasty. Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction.     

Total knee arthroplasty in rheumatoid arthritis

The course of rheumatoid arthritis varies from mild disease to severe joint destructive variant that progresses rapidly, eventually leading to unremitting pain and joint deformity. In advanced disease, total knee arthroplasty has proven to be the most successful intervention that reduces knee pain and improves physical function in rheumatoid arthritis patients. However, as rheumatoid arthritis patients carry additional potential for late complications, many important considerations regarding preoperative evaluation and surgical technique must be taken into account in order to improve the results of total knee arthroplasty in this subgroup of patients.     

Bipolar hip arthroplasty in rheumatoid arthritis

Bipolar hip arthroplasty with bone grafting was performed on 25 joints with rheumatoid arthritis from 1981 to 1985. The results and roentgenographical progress of the grafted bone were followed for a minimum of two years, the longest follow-up examination occurring six years after the operation. The clinical score was assessed by the hip rating score of the Japanese Orthopaedic Association, which assigns a maximum of 100 points. The preoperative clinical score ranged from 22 to 59 points (mean, 42.6). The postoperative score improved to a range of 65-92 points (mean, 72.8). Of 24 hips examined, 21 (87.5%) were painless. As measured serially from the roentgenograms made immediately after the operation, the overall distance of central migration in 24 hips was 0-8.5 mm (average, 2.7 mm). The overall distance of superior migration in 24 hips was 0-10 mm (average, 3.7 mm). A single massive bone graft using extracted femoral head was considered to be better than bone fragments as the procedure for acetabular reconstruction during bipolar hip arthroplasty in rheumatoid arthritis.     

Total shoulder arthroplasty in rheumatoid arthritis

Twenty-nine Neer-type total shoulder arthroplasties were performed in 26 patients with rheumatoid arthritis. The average age was 55.5 years and the average follow-up period was 37 months. On a 100-point scoring system, the average preoperative score of 25 improved to 71 after surgery. The most significant improvement was noted in pain relief. Radiographs demonstrated nonprogressive radiolucent lines in 86% of the glenoid components and 31% of the humeral components. Surgical problems included bone loss of the glenoid, acromioclavicular joint arthritis, and rotator cuff tears, in 7 of 29 shoulders. Follow-up study demonstrated poorer results for patients with rotator cuff tears. However, significant pain relief was achieved in 93% of our patients, despite limited functional improvements.