Komplikationen in der orthopädischen Rheumatologie – Besonderheiten operativer Verfahren

The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are still necessary in many patients but a change in surgical indications could be observed. The previously predominant synovectomy of inflamed rheumatic joints is now reduced to a few so-called rebellious joints with persistent inflammation. Joint-preservation and tenoplasty are standard surgical procedures requiring a specific approach including potential complications. The basic immunosuppressive medication has to be considered for all rheumatological interventions. Recommendations extensively evaluate the risk profile of immunosuppressants. The available clinical data are difficult to assess and incomplete. Advances in modern joint replacement procedures have increased the quality of life of patients. Compared to degenerative osteoarthritis, patients with rheumatism tend to present at a lower age, with poorer bone quality and have an increased risk for bacterial joint infections. In cases of a multilocular rheumatoid manifestation including all joints of the extremities, joint replacement specifics need to be taken into account. In patients with rheumatic diseases the mechanical stability of joint replacements, revision options, potential risk of joint infections and periprosthetic fractures vary sometimes considerably from patients with degenerative osteoarthritis. Missing clinical signs of joint infection despite a life-threatening, possibly multilocular dissemination of the disease due to immunosuppressants represents a particular challenge with respect to the diagnostics and treatment. The confusion of this with a rheumatic exacerbation might lead to general septicemia with a high mortality.     

Total wrist arthroplasty

Although surgeons typically prefer arthrodesis for the treatment of severe wrist arthritis, the resulting sacrificed motion may significantly impair function, especially when multiple joints in the extremity are affected by arthritis. Total wrist arthroplasty enhances the performance of daily activities and is preferred by rheumatoid patients to arthrodesis. Historically, wrist replacement has had an unacceptable complication rate, particularly involving wrist imbalance and implant loosening. Recent developments in prosthetic design have substantially improved the performance and durability of wrist replacement. When performed technically well in properly selected patients, total wrist arthroplasty provides a functional, durable wrist and high patient satisfaction. Copyright © 2001 by the American Society for Surgery of the Hand     

Bilateral joint replacement of hip and knee joints in patients with rheumatoid arthritis

Between 1973 and 1981, bilateral total replacement of hip and knee joints was performed in 22 patients with rheumatoid arthritis. During follow-up, 2 patients died of diseases not directly related to the operation. Besides these patients, there were 2 patients who could not be followed up. The remaining 18 patients constituted the subjects for study. We studied the postoperative results, emphasing improvement in the ability to perform everyday activities. Walking ability was improved in 16 patients. There was an increase in the number of patients able to rise from a chair, go up and down stairs, and get in and out of a car, bus or train. Of the 14 married patients (not including 2 patients who were unable to walk and 5 patients over 60 years of age) 7 were able to perform sexual intercourse as well as they had been able to when healthy. The patients who underwent bilateral total replacement of hip and knee joints often presented various problems, for example with regard to indications, the operative technique to use, as well as complications such as heart disease, pulmonary disease, and secondary amyloidosis. We have found, however, that bilateral total replacement of hip and knee joints can accomplish the operative objectives of eliminating pain and improving the quality of daily life in severely handicapped rheumatoid patients.     

Longitudinal radiographic analysis of rheumatoid arthritis in the hand and wrist

PURPOSE: To assess the longitudinal radiographic osseous changes of the wrist and hand other than interphalangeal joints in rheumatoid disease. METHODS: Serial wrist and hand x-rays in 96 patients with long-standing rheumatoid disease were reviewed. The average number of years between initial and most recent x-rays was 15.1. The Larsen scoring system was used to assess the degree and severity of joint involvement. We identified patterns of involvement in the wrist, thumb, and finger metacarpophalangeal (MCP) joints. RESULTS: The radioscaphoid and radiolunate joints had the earliest and most severe progression of all joints studied. Scaphoid erosions often were seen early (27%) and their presence was a predictor of progressive involvement. Ulnar styloid erosions commonly were seen as early isolated findings (25%). The distal radioulnar joint showed a rapid increase in Larsen score and was involved in 78% of patients on late x-rays. The thumb showed considerable late MCP joint disease that often led to boutonniere deformity and the trapeziometacarpal joint had the least rate of progression of all joints studied. The most severely and frequently involved MCP joints were the radial (index and middle), which also had the greatest increase in score over the span of the study. Finger MCP joint disease was observed to progress temporally in a predictable pattern: first radial MCP joints of the dominant hand, followed by the nondominant radial MCP joints, and last the ulnar MCP joints of the nondominant hand with small finger involvement preceding that of the ring finger. Of all MCP joints, the ring finger was least affected. CONCLUSIONS: This study clarified the longitudinal osseous radiographic changes of the wrist and hand (excluding interphalangeal joint) in rheumatoid disease.     

Therapy of rheumatoid cubarthritis

With the progression of rheumatoid arthritis (RA),more than half of the patients develop an affliction of the elbow.Cub arthritis has to be regarded as a part of systemic rheumatoid disease. Thus, the indication for operative treatment depends not only on local changes but is determined by the pattern of all affected joints, the activity of the basic rheumatic disease as well as the effect of physical therapy and medication. The complexity of the rheumatic disease, which typically affects many joints, demands an individual therapeutic plan that can only be developed and accomplished successfully when rheumatologists, rheumatoid surgeons and other specialists cooperate. In cases of recurrent cub arthritis,in spite of adequate medication, synoviorthesis or synovectomy should be performed. This may relieve pain and swelling,however if lesions of the cartilage already exist,progressive joint destruction cannot be prevented. Arthroscopic surgery of the elbow provides all of the known advantages of minimal traumatisation. In RA,it is used mainly when there is ligament laxity in late synovectomies eventually combined with arthroscopically assisted resection of caput radii. In contrast to monoarticular diseases in RA,the adjoining bursa olecrani, neighbouring joints and nerve entrapment syndromes also require treatment. The treatment for advanced cub arthritis is arthroplasty. Due to progress in the development of elbow endoprotheses, the range of indications for resection (interposition) arthroplasty has increased.It is now preferred mainly in younger patients with ankylosing arthritis. Rheumatoid changes in the bone and soft tissue impede the implantation of artificial joints and require time consuming and precise preparation techniques. When choosing either an unconstrained or semi-constrained prosthesis,one has to bear in mind the actual ligament stability and its often unpredictable changes during the course of the disease.Perioperative measures, postoperative care and therapy is made even more difficult due to the involvement of several joints, often extensive permanent medication, secondary lesions such as ldquo;corticoid skin" and in most cases the multimorbidity of patients after many years of chronic disease.When comparing elbow surgery in osteoarthritis and RA,we found that patients with RA clearly required more elaborate surgery and more extensive perioperative and postoperative care.     

Silastic Radial Head Prosthesis in Rheumatoid Arthritis

This paper reports our experience of using the Silastic radial head prosthesis in 18 elbow joints affected by rheumatoid arthritis. There was a varying degree of severity of involvement in 15 of the elbows, and in a further 3 cases replacement was carried out at an early stage of the disease. The 3 cases in whom early replacement was carried out had the best results at follow-up and 11 of the remaining 15 were considered to have a satisfactory overall result. The major benefit of operation has been the relief of pain, even in the late cases, whilst preserving stability of the elbow in all but 3 cases.     

The normal and pathological mobility of the metacarpo-phalangeal joint.

The pathological mobility of the metacarpo-phalangeal joints of 100 patients affected by rheumatoid arthritis was studied, and the results were analysed and compared with the results obtained in a control non-rheumatoid group. This report seems to suggest that rheumatoid metacarpo-phalangeal joints become more lax the longer the rheumatoid disease has been present. However, when there is marked local involvement of the joint this hyperlaxity cannot be proven because of pain and/or mechanical blockage.     

壤塘县藏区成人大骨节病多个大关节受累与分度的关系研究

目的研究阿坝州壤塘县藏区大骨节病（Kashin-Beck disease,KBD）多个大关节受累与分度之间的相关关系,探索成人大骨节病的合理分级标准,指导临床治疗的可行性。方法由骨科、风湿免疫科和地方病专家联合研究组设计专用调查表,采用现场流行病学调查法,包括一般情况、关节疼痛、视觉模拟疼痛评分（visual analoguescale,VAS）、关节畸形和功能障碍等,随机调查阿坝州壤塘县6个村24～93岁藏族成人大骨节病患者81例,按我国关于成人大骨节病分度标准：Ⅰ度30例,Ⅱ度30例,Ⅲ度21例。大关节定义为肩、肘、腕、髋、膝、踝共12个关节,其中任何一个关节出现疼痛、畸形或功能障碍即为大关节受累。分别统计Ⅰ、Ⅱ、Ⅲ度大骨节病患者大关节受累关节数和VAS评分。结果全部患者均存在2个以上大关节受累,其中肘关节和膝关节受累最多见,9～12个大关节受累在成人大骨节病Ⅱ度患者中比例最高,肘关节和膝关节疼痛VAS评分在成人大骨节病Ⅱ度患者中最高,踝关节受累和疼痛在Ⅲ度成人大骨节病患者中最重,肩、腕、髋关节受累及VAS评分在Ⅰ、Ⅱ、Ⅲ度成人大骨节病患者间无统计学差异,4个以上大关节受累人数在Ⅰ、Ⅱ、Ⅲ度成人大骨节病患者间无统计学差异。结论壤塘县藏区成人大骨节病患者常存在多个大关节受累,大关节受累的比例和程度与目前大骨节病分度之间无统一性;有必要对目前成人大骨节病分度进行合理的修订或改进、完善,使之更符合临床诊治并合理指导成人大骨节病的临床治疗。     

Bilateral hip and knee replacement for rheumatoid arthritis

A series of 19 patients with severe rheumatoid arthritis had replacement of both hips and both knees. They are reviewed after a mean follow-up of 27 months. The preferred programme is to replace hips before knees. Pain was relieved in all the patients and function was improved in all but two. Severe rheumatoid disease and prolonged immobilisation before the operations were not contra-indications to a successful outcome, but the presence or the development of cervical myelopathy combined with gross upper limb deformity militated against a good result.     

Arthroplasty for ochronotic arthritisNo failure of 11 replacements in 3 patients followed 6–12 years

Background?Alkaptonuria is a rare single-gene disorder characterized by black pigmentation of cartilage and other connective tissues. Premature degenerative arthritis affects the large joints in many of these of patients. Medical treatment is limited to a protein-restricted diet (phenylalanine and tyrosine) with surgery reserved for end-stage joint disease. As in other metabolic bone diseases, there are concerns about the quality and strength of affected bones and therefore the suitability and longevity of replacement arthroplasty. The histopathology and outcome of joint replacement for alkaptonuric arthritis is unknown and limited to sporadic case reports.Patients and results?We describe 11 joint replacements in 3 patients with alkaptonuric polyarthropathy, including shoulder and elbow replacements not previously reported. No prosthetic failures occurred in up to 12 years of follow-up.Interpretation?Total joint replacement is an acceptable treatment for degenerative joint disease in alkaptonuric patients, with implant survival comparable to that found in patients with osteoarthritis.     

Non-constrained total shoulder replacement in patients who have rheumatoid arthritis and class-IV function

The results of twenty-four non-constrained total shoulder replacements that were done in twenty patients who had treatment of rheumatoid arthritis were retrospectively reviewed to determine how those results were affected by the severity of the disease. All of the patients had Class-IV functional capacity, and 92 per cent had Stage-III or IV rheumatoid progression. Nine (38 per cent) of the shoulders had a tear of the rotator cuff. The mean length of clinical follow-up was 4.5 years (range, two to ten years). Preoperatively, all of the patients had disabling pain and limited function. Postoperatively, twenty-two (92 per cent) of the patients had no appreciable pain, and eighteen (75 per cent) had no significant functional limitation (p less than 0.001). Active elevation improved by 88 per cent, and external and internal rotation also improved significantly. Motion, relief of pain, and functional improvement were not significantly greater in the patients who had an intact rotator cuff. Radiolucent lines developed around ten (42 per cent) of the glenoid prostheses, but only two of the prostheses were surrounded by a complete line and were thought to be loose. No revisions were done. We believe that a non-constrained total shoulder replacement affords excellent relief of pain, satisfactorily improves range of motion, and improves function in patients who have severe rheumatoid involvement of the shoulder. However, because motion and function are severely restricted preoperatively, the end-results are not comparable with those that have been reported for patients who have less severe rheumatoid disease.     

Arthroplasty for ochronotic arthritis: no failure of 11 replacements in 3 patients followed 6-12 years

BACKGROUND: Alkaptonuria is a rare single-gene disorder characterized by black pigmentation of cartilage and other connective tissues. Premature degenerative arthritis affects the large joints in many of these of patients. Medical treatment is limited to a protein-restricted diet (phenylalanine and tyrosine) with surgery reserved for end-stage joint disease. As in other metabolic bone diseases, there are concerns about the quality and strength of affected bones and therefore the suitability and longevity of replacement arthroplasty. The histopathology and outcome of joint replacement for alkaptonuric arthritis is unknown and limited to sporadic case reports. PATIENTS AND RESULTS: We describe 11 joint replacements in 3 patients with alkaptonuric polyarthropathy, including shoulder and elbow replacements not previously reported. No prosthetic failures occurred in up to 12 years of follow-up. INTERPRETATION: Total joint replacement is an acceptable treatment for degenerative joint disease in alkaptonuric patients, with implant survival comparable to that found in patients with osteoarthritis.     

Shortening osteotomy for treatment of metacarpophalangeal joint deformity.

The results of a new subcapital shortening osteotomy for correction of metacarpophalangeal joint deformity in patients with rheumatoid arthritis of the hands are presented. Seven patients (16 joints) were followed up for a mean of 33.5 months. The mean shortening of the metacarpal bone was 4.6 mm (range, 4-8 mm), and seven joints had additional intrinsic release. Only four (25%) joints held the correction of the deformity; all other joints had recurrence of palmar subluxation with or without additional ulnar drift. The range of motion of the joints with preserved correction after surgery was 80 degrees compared with 28 degrees of the joints with recurrent deformity. The possible mechanism of failure was analyzed. The results of the current series suggest that subcapital shortening osteotomy may not be indicated for treatment of severe metacarpophalangeal joint deformity in patients with rheumatoid arthritis.     

Glucocorticoid-induced osteoporosis: pathogenesis and management

Glucocorticoid- (GC-) induced osteoporosis and an increased risk of fractures are one of the most serious problems for patient using long-term GC therapy, such as those with rheumatoid arthritis, autoimmune diseases, inflammatory bowel diseases, bronchial asthma, and chronic lung diseases. GCs are known to affect both bone formation and resorption. In rheumatoid arthritis, the etiology of bone loss is multifactorial, including local inflammation around joints, release of bone-absorbing cytokines, physical inactivity, and malnutrition, in addition to the use of GC. Two guidelines have been published, by the American College of Rheumatology Task Force in 1966 and by the UK Consensus Group in 1998. Both guidelines recommend that patients receiving GC therapy at doses of 7.5 mg/day of prednisolone or more for 6 months or longer should have their bone mineral density measured and begin preventive therapies. Calcium and vitamin D supplements, sex hormone replacement, and weight-bearing exercise are the first-line therapies. For patients who are unable to take sex hormone replacement therapy (HRT), bisphosphonates are recommended by both guidelines. In this article, we briefly summarize the pathogenesis of GC-induced osteoporosis and its prevention and treatment. Received: April 7, 2000     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Repair of radiographic hip joint in juvenile rheumatoid arthritis patients treated with etanercept plus methotrexate

For patients suffering from rheumatoid arthritis (RA), structural damage, i.e. bone erosion and joint space narrowing, is a major factor leading to functional disability. Negative radiographic progression has been shown in joints, especially in RA patients treated with tumor necrosis factor alpha (TNFα) inhibitors in combination with methotrexate. Bone erosion repair in small joints have been observed but only one study selected large weight-bearing joints. We reported 2 cases of patients with severe seropositive juvenile RA who shown improvement of joint space narrowing and subchondral erosion in hip joint when treated with etanercept in combination with methotrexate for at least 1 year. Two Japanese cases were also published but with different TNF inhibitors. The mechanisms of bone erosion or joint space narrowing repair are unclear. One study investigated whether bone erosions in rheumatoid arthritis patients show evidence of repair in metacarpophalangeal joints when treated with TNF inhibitors and MTX. These results suggested that repair in RA emerged from the bone marrow and the endosteal lining rather than the periosteal compartment. No study investigated joint space narrowing repair in hip joint in rheumatoid arthritis patients. Larger studies needed to confirm joint space narrowing improvement in hip joint in patients treated with TNF inhibitors and to explain the mechanisms of repair.     

Souter arthroplasty for elbows with severe destruction

One hundred fifty-eight primary Souter elbow arthroplasties were done on 134 patients (121 women) with severe joint destruction (Larsen Grade 5) or large bone defects or both. Joint replacement operations were done at our institution from 1985-1997. The study group comprised 156 joints in 132 patients with rheumatoid arthritis or other variants of chronic inflammatory joint disease, one in a patient with osteoarthritis, and one patient with posttraumatic arthrosis. The mean age of the patients at the time of surgery was 57 years (range, 26-81 years) and the mean disease duration was 27 years (tinge, 2-70 years). Radiographically, severe bone defects were detected in 100 humeri and 134 ulnas. Retentive (snap-fit) ulnar components were implanted in 110 joints, and bone grafts were used on 26 humeri and 14 ulnas. Major complications led to five early and 16 late reoperations in 19 patients. Four reoperations were done because of dislocation and eight because of aseptic loosening. One reoperation was done because of early infection and five were done because of late infection. One patient had reoperation because of superficial infection in the bursa olecrani and one triceps tendon rupture also was repaired. One patient had wound repair because of marginal necrosis. In the survival analysis, the cumulative success rate without revision for aseptic loosening at 5 years followup was 97%. Despite the demanding nature of these arthroplasties, the primary results are encouraging. Technically, it is possible to do elbow replacement, even on elbows where the humeral condyles or olecranon or both are missing, if there is sufficient bone left on the diaphyseal areas for primary stem fixation. However, in these extreme cases, the poor general condition of the patient or the difficult soft tissue problems in the elbow region may prove to be a contraindication for joint replacement.     

Late results of total shoulder replacement in patients with rheumatoid arthritis

Rheumatoid arthritis of the shoulder is a progressive and destructive joint disease, and similar to arthritis in other joints, progression of the disease is unpredictable and may stop at any stage of involvement. Between 1983 and 1996, more than 500 shoulder prostheses were implanted in patients at the authors' institution. Total shoulder replacement yields satisfactory short and long term results even in patients with severely destructed joints. Pain relief is reliable and significant as reported in short and long term studies. In most patients the functional result is good or acceptable. Although range of motion is only slightly increased, a satisfactory overall range of motion is achieved by most patients because of the unaffected scapulothoracic motion. However, deteriorating results, emphasizing the complexity of shoulder arthroplasty, were seen with increasing observation time in patients with rheumatoid arthritis. Proximal migration of the humeral prosthesis attributable to rotator cuff failure, with secondary eccentric glenoid loading and progressive loosening, is latent in patients with chronic progressive rheumatoid disease and was by far the most common complication (42%) in the present series.     

Die Arthrodese beim Rheumatiker

The hand of rheumatoid patients is frequently affected. Inflammation and swelling of the fingers and the wrist affect patients in early stages with pain and restriction of mobility. Subsequently, inflammation leads to destruction of the joints, deformation, and, thus, to severe functional impairment of the hand. Arthrodesis is primarily related to the distal interphalangeal joints, the metacarpophalangeal and interphalangeal joints of the thumbs, and the wrist. One also can use partial arthrodesis to stabilize a destroyed joint and to prevent further destabilization. Arthrodesis of the joints mentioned in the hand is an effective way to treat rheumatic destruction.     

Changes in the cervical spine in juvenile rheumatoid arthritis

One hundred and twenty-one patients with juvenile rheumatoid arthritis were studied clinically and roentgenographically for evidence of disease of the cervical spine. None of the fifty-seven patients with pauciarticular-onset juvenile rheumatoid arthritis had cervical symptoms or signs, and only one had minor roentgenographic changes of disease in the cervical spine. In contrast, clinical stiffness and roentgenographic changes in the cervical spine occurred commonly in the fifty-one patients with polyarticular-onset disease and in the thirteen patients with systemic-onset disease. Despite extensive roentgenographic involvement of the cervical spine, however, pain in the neck was not a common complaint. Neither severe pain in the neck nor torticollis, occurring either separately or concomitantly, is frequently found in patients with juvenile rheumatoid arthritis, and its presence may suggest an intercurrent problem such as a fracture or infection. As patients with juvenile rheumatoid arthritis rarely have disease in the cervical spine alone, the patient should be carefully examined for involvement of multiple joints.