13th Congress of the European Rheumatoid Arthritis...

13th Congress of the European Rheumatoid Arthritis

Surgical Society

Lund, SwedenJune 3–5, 2004

Programme

Main sponsors:

Program XIIIth ERASS Congress in Lund 2004

Wednesday, June 2nd

12.00–18.00 Registration15.00 ERASS EC and SC meeting17.00–20.00 Get-together party (STAR Conference Center)20.00 Faculty meeting (Trolleholm castle)

Thursday June 3rd

07.00–18.00 Registration

08.00–08.20 Welcome addresses – Uarda P Rozing, F Wollheim, L Lidgren, U Rydholm

08.20–09.30 Surgery in juvenile idiopathic arthritis – Uarda Chairmen: A Paus, U Rydholm

Surgery in JIA—an overview U Rydholm The place for synovectomy in JIA A Paus Side effects of growth hormone treatment in JIA B Månsson Modern medical treatment of JIA R ten Cate

09.30–10.00 Coffee, exhibition and posters

10.00–12.00 The young arthritic upper extremity – Uarda Chairmen: P Kopylov, A Lluch

Etiopathogenesis of wrist joint deformities A Lluch Treatment of wrist joint deformities in JIA D Herren MP joint deformities in JIA P Kopylov Finger deformities A Nilsson Growth disturbances M Arner Mid- and long-term outcome of shoulder arthroplasty for adult JRA patients ER Bogoch

12.00–13.00 Lunch, exhibition and posters

13.00–14.00 Workshop 1 room A, KMI Workshop 2 room B, Zimmer

14.00–15.15 Free papers A – Uarda Chairmen: D Herren, P Kopylov

Short term failures of Neuflex® MCP prostheses. Doorn PFunctional assessment of bilateral wrist arthrodesis for inflammatory disease. Fontaine C, Prodhomme G, Chantelot, C, Limousin MShort- and midterm results of the uncemented, unconstrained HM-MCP arthro-plasty in RA—a multicenter study. Hagena FW, Mayer B, Gottstein J, Meuli HC ASCENSION® MCP meta-carpo-phalangeal non constrained pyrolytic carbon prosthesis in rheumatoid arthritis—clinical experience and results. Kopylov P, Tägil M

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Radial inclination of the metacarpals secondary to the ulnar drift of the fingers in the rheumatoid hand. Lluch AWound healing after surgery of the forearm and hand in patients with systemic sclerosis. Dietrich J, Kopylov P, Tägil M

Free papers B – room C Chairmen: K Tillman, A Stefansdottir

The S.T.A.R. total ankle arthroplasty in patients with RA—a prospective com-parative study in patients with RA and OA. Christ RM, Hagena FW Arthrodesis versus Mayo resection in total rheumatoid forefoot reconstruc-tion—a prospective, randomised study. Gröndal L, Stark A Total ankle replacement in patients with RA. Knupp M, Horisberger M, Valderrabano V, Hinterman B, Dick W Forefoot reconstruction in RA: a peri-operative cost analysis. Matricali GA, Verduyckt J, Boonen A, Westhovens R Total knee arthroplasty in JRA. Tiusanen H, Lybäck C, Belt E Treatment of deep infection complicating triple arthrodesis in rheumatoid patients. Yli-Luukko S, Hyvönen P, Ristiniemi J, Syrjälä H, Haataja A-L, Leppilahti J


15.45–16.00 Intermezzo

16.00–17.00 Free papers C – Uarda Chairmen: B Simmen, M Tägil

A new spacer with joint stabilisation for arthroplasty of the TMC joint—3 year follow-up results. Nilsson A, Sollerman CTen years experience with our own method of total wrist arthrodesis. Pech J, Popelka S, Rybka V, Vavrik P, Veigl D Operative treatment of shoulder sepsis in RA. Smith AM, Sperling JW, Cofield RHFixation of proximal humerus fractures in patients with RA. Smith AM, Sperling JW, Cofield RH

Free papers D – room C Chairmen: A Paus, U Rydholm

The clinical results of bipolar hip arthroplasty for protrusio acetabuli in patients with RA. Kaku N, Tsumura H, Kataoka M, Fujikawa Y, Torisu TSurvival of uncemented Bi-metric total hip arthroplasty in patients with juve-nile chronic arthritis. Kyrö A, Lybäck CC, Lybäck CO, Kautuinen H, Belt EACementless hip arthroplasty in juvenile idiopathic arthritis—report of 62 cases in young patients. Odent T, Glorion C, Prieur AM, Pouliquen JC Indication of mobile type of LPS-FLEX TKA for rheumatoid arthritis. Tsumura H, Ono T, Kataoka M, Kaku N, Torisu T

17.00–17.30 Report from the European–Japanese fellowship M Wilkinson, R Nelissen, H Inoue

18.00– Lund on your own

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Friday June 4th

08.00–18.00 Registration

08.30–09.30 The young arthritic hip and knee – Uarda Chairmen: C Howie, B Bylander

Mid- and long-term outcome of total hip arthroplasty for adult JRA patients B Jolles Non-prosthetic and prosthetic surgery of the juvenile arthritic hip U Rydholm Mid- and long-term outcome of total knee arthroplasty for adult JRA patients ER Bogoch


10.00–11.00 Surgical complications – Uarda Chairmen: R Nelissen, K Knutson

Complications of hip surgery C Howie Complications of knee surgery K Hamelynck Complications of shoulder and elbow arthroplasty in JIA M Thomas Wrist and hand complications P Kopylov

11.00–12.00 Workshop 3 room A, Biomet (Frostic: The Discovery® elbow prosthesis) Workshop 4 room B, DePuy (Piconi: A new ceramic bearing surface material for THR) Workshop 5 room C, Smith+Nephew (Soft tissue balancing of the knee)


13.00–14.00 Workshop 6 room A, DePuy (Hamelynck: The LCS® mobile bearing knee system in RA) Workshop 7 room B, Biomet (Knutson: The AES® ankle prosthesis) Workshop 8 room C, Centerpulse (Kesteris: The Durom® hip resurfacing prosthesis) start 12.30

14.00–15.15 Analysis of outcome of surgical intervention – Uarda Chairmen: M Hazes, A Nilsdotter

Outcome measures M Hazes Functional assessment of the upper extremity J Nagels Quality of life after shoulder surgery B Simmen Patient generated versus standard outcome assessment of total hip arthroplasty in adult JRA patients B Jolles


15.45–17.00 Free papers E – Uarda Chairmen: P Rozing, C Munck Jensen

Results of 42 Kudo total elbow prostheses for inflammatory disease at 5 years of mean follow-up. Fontaine C, Dos Remedios C, Chantelot C, Giraud F

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Long-term results after GSB III elbow arthroplasty—evaluation of elbow func-tion with a new assessment set. John M, Angst F, Pap G, Flury MP, Herren D, Schwyzer HK, Simmen B Results of the Kudo total elbow arthroplasty in patients with severe destruction of the elbow joint due to RA—four to eleven years follow-up of 44 prostheses. Reinhard R, van der Hoeven M, de Vos MJ, Eygendaal D Total elbow arthroplasty in JIA. Souter WA, Lockerbie L, Nicol AC“Conservative” surgery at the rheumatoid elbow. Tillman K

Free papers F – room C Chairmen: W Souter, A Nilsson

Ipsilateral shoulder and elbow replacement. Ali FResults of total elbow arthroplasty with distal ulna resection for patients with RA. Fujiwara K, Nishida K, Inoue HThe effect of cement restrictors on cemented total elbow replacements. Hallett A, Howie CR, Souter WACauses of recurrence of ulnar drift after MP joint arthroplasties. Lluch ADeterminants of range of motion in unconstrained shoulder arthroplasty. Nagels J, Stokdijk M, Rozing PIs open synovectomy for rheumatoid elbow an effective operation? Nakagawa N, Abe S, Saegusa Y, Imura S, Kubo H, Nishibayashi Y, Yoshiya S

17.00–18.00 ERASS General Assembly Swedish, Danish and Finnish assemblies

19.00 Bus transport to Swedish Midsummer Party Informal outdoor activities, casual dress (sweater optional)

Saturday June 5th

08.30–09.45 Disease monitoring and effect of DMARDS – Uarda Chairmen: FW Hagena, T Saxne

Tissue markers as tools for disease monitoring in arthritis T Saxne Radiological progression and the use of DMARD, the past and the future M Hazes JIA—complications of disease and treatment R ten Cate


10.15–11.15 Free papers G – Uarda Chairmen: K Hamelynck, M Tägil

The development of a classification system of forefoot disorders in RA. Doorn PF, Louwerens JWK, de Waal Malefijt, MC, van Limbeek J, van ’t Pad P, Bosch, Laan RThree-dimensional rheumatoid wrist deformity and the risk of extensor tendon rupture. Ishikawa H, Murasawa A, Nakazono KPatients’ expectations before rheumasurgery. Nilsdotter A, Mannerkorpi K, Rydholm U, Strand L

Surgery in acromelic arthritis: dorsal and palmar wrist, hand and forefoot. Welby F, Alnot JY

Free papers H – room C Chairmen: P Aaser, K Knutson

Increased risk of early dislocation after primary total hip arthroplasty in RA. Doets HC, Zwartelé RE, Brand RNo mechanical failure of a HA-coated press-fit cup in primary total hip arthroplasty for OA and RA. Doets HC, Olsthoorn PGM, Pöll RGCustom made endoprostheses—possibilities techniques and limitations. Nassutt R, Hartung I, Grundei HIndividual uncemented femoral components in hip arthroplasty—a prospective clinical study. Benum P, Aamodt A, Haugan KCoating of bone transplants with anti-resorptive agent—a novel treatment of threatening joint collapse—animal experiments and a case study. Tägil M, Rydholm U, Åstrand J

11.15–12.45 The young arthritic ankle and foot – Uarda Chairmen: P Briggs, H Tiusanen

Ankle and foot surgery—general aspects JW Louwerens Clinical outcome and gait analysis after mobile bearing total ankle arthroplasty HC Doets The rheumatoid forefoot—long term results of the Stainsby forefoot arthroplasty PJ Briggs Percutaneous ankle arthrodesis in patients with RA H Lauge-Pedersen Revision of failed ankle arthroplasties Å Carlsson


13.30– Poster and paper awards Concluding remarks and farewell

Post congress tours

Co-sponsors:

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POSTERSP 1. Arthroscopic debridement for osteoarthritis of the knee. Abe N, Doi T, Takahara,

Uchida Y, Dan-ura I, Inoue HP 2. The Anatomical Prosthesis in shoulder arthroplasty—1- to 5-year results with the

Anatomical shoulder arthroplasty. van Brakel RW, de Vos MJ, Eygendaal DP 3. Photochemical internalization (PCI). Dietze AP 4. Treatment of extensor tendons ruptures in rheumatoid patients at the time of wrist

fusion. Ferreres A, Pacha D, Lluch A, Garcia-Elias MP 5. Primary total elbow arthroplasty. Experience with a semiconstrained prosthesis.

Gottlieb H, Houe T, Milting K, Jensen CMP 6. Toxic effects of povidone-iodine on synovial cell and articular cartilage. Kataoka M,

Tsumura H, Kaku N, Torisu T P 7. Effects of arthroscopic synovectomy in RA knees. Kitamura A, Abe N, Okuda K,

Nishida K, Kuroda T, Inoue H. P 8. Ascension® PIP non constrained pyrolytic carbon prosthesis in osteoarthrosis—early

results. Kopylov P, Mrkonjic A, Tägil M, Hanff G P 9. The results of the surgical treatment of rheumatoid arthritis in our local patient popu-

lation. Lakatos T, Dènes Rács TG, Irgalmasrendi B, Kht KP 10. Ultrasonography and rheumatoid arthritis. Lick-Schiffer WP 11. Reduced bone mineral density and bone turnover markers in postmenopausal women

with rheumatoid arthritis. Momohara S, Ikari S, Mizumura T, Tomatsu TP 12. Minimal invasive hip replacement. Oehme S, Haasters J P 13. Radiographic changes after resection of the distal ulna in rheumatoid arthritis.

Rahimtoola ZO, Jansen SPL, Rozing P, Nelissen RGHHP 14. Early results of NeuFlex-Silastic implant in MCP-Arthroplasty. Schindele S, Herren D,

Simmen BR P 15. Hydroxyapatite augmentation for bone loss in total ankle replacement in rheumatoid

arthritis. Shi K, Hayashida K, Hashimoto J. Tomita T, Fujii M, Sugamoto K, Kawai H, Yoshikawa H

P 16. Thirty years of JIA-surgery in Lund, Sweden. Simonsson M, Rydholm U. P 17. Core decompression of the femoral head in juvenile idiopathic arthritis (JIA).

Simonsson M, Månsson B, Rydholm UP 18. Arthroscopic shoulder synovectomy in patients with RA. Smith MA, Sperling JW, Cofield RHP 19. Ipsilateral shoulder and elbow prosthesis in one session. Rozing PM, Bohy B P 20. Revision of elbow replacement. Rozing P P 21. Short-term results and in vivo kinematic analyses of Dual Bearing Knee Prosthesis.

Tomita T, Watanabe T, Tsuji S, Yamazaki T, Hashimoto J, Sugamoto K, Yoshikawa HP 22. Avanta versus Swanson silicone implants—a prospective randomised comparison of 30

rheumatoid patients. Tägil M, Kopylov P, Möller K, Geijer M, Sollerman CP 23. Morphological studies of receptor activator of NF-αB ligand (RANKL), IL-17, and

IL-1ß expression in rodent collagen-induced arthritis. Weiss RJ, Erlandsson-Harris H,Wick MC,Wretenberg PF, Stark A, Palmblad K

P 24. Molecular mechanisms in osteolysis. Wilkinson JMP 25. Total elbow arthroplasty in rheumatoid arthritis using GUEPAR prosthesis. Alnot JY,

Welby F, Hemon D, Abiad RE, Masmejean E

1XIIIth ERASS Congress in Lund, Sweden, June 2–5, 2004

SURGERY IN JUVENILE IDIOPATHIC ARTHRITIS—AN OVERVIEW

U. Rydholm

Depatment of Orthopaedics, University Hospital in Lund, Sweden

Since several decades most surgical procedures in juveniles with idiopathic arthritis in Sweden have been centralized to Lund. About 2000 procedures have been registered.

We have experience with arthroscopies, arthroplasties, arthrodeses, osteotomies, synovecto-mies, tenosynovectomies, soft tissue releases, physiodeses and core decompressions.

The annual number of procedures remains fairly constant despite the introduction of more effective DMARDs. The types of procedures, however, have changed with less synovectomies and more arthroplasties being performed in later years.

Arthritic affection of the growing child means the risk of growth disturbances, sometimes resulting in a demand for x-small or custom made implants. Limb length inequality is common and may require temporary stapling of the growth plates around the knee.

Children planned for surgery must be handled by an anaesthesiologist used to fiber intubation due to micrognathia, arthritic temporomandibular joints and stiffness or instability of the neck.

Many procedures are rewarding in short as well as long term but the long-term results of hip arthroplasty are inferior to those obtained in older RA patients.

Foot deformities may be severe and are as a rule technically demanding to correct.A summary of our experiences will be given and typical cases presented.


THE PLACE FOR SYNOVECTOMY IN JIA

A.C. Paus

Rikshospitalet, 0027 Oslo, Norway

Synovectomy is gradually decreasing in numbers, but in patients with refractory synovitis, it is still a valuable addition to treatment possibilities. Our departement has had a national responsi-bility for rheumatoid arthritis surgery in children for 25 years. In 1990 we operated almost 200 children with JIA, while in 2003 the number of operations was reduced to 65.

The introduction of new drugs and the more aggressive treatment both locally and systemi-cally by the rheumatologists have reduced the numbers of patients with refractory synovitis.

There is no agreement in the literature as to the definition of “refractory synovitis” and indi-cations for synovectomy may also be persistent mon- or oligoarticular synovitis, where the rheumatologists are reluctant to start with heavy systemic treatment. There is no agreement on methods of synovectomy either, and the professional distance between the rheumatologists and the rheumasurgeons are well documented.

The results with radionucleotide synoviorthesis, arthroscopic and open synovectomy have been documented separately, and only to some extent prospectively compared. There is rela-tive high agreement about the symptomatic effect of synovectomy. The prophylactic effect is claimed, but with poorer documentation.

The combination of arthroscopic synovectomy and synoviorthesis may give a lesser recur-rence rate at 5 years than either alone. Osmic acid has a higher risk of recurrence at 5 years.

Almost all joints are still at risk. Synovectomy for these children may be one of many surgical procedures for these children, and it is of outmost importance to handle these procedures in a multiprofessional setting, where the children get the necessary treatment and help both before and after surgery and develops confidence to the clinic

We use arthroscopic synovectomy as our primary aid for most joints, while the tenosynovec-tomies are peformed as open surgery. If synovitis recurs before 5 years (20%), resynovectomy combined with synoviorthesis is performed.

The most common surgical procedures in 2003 were tenosynovectomies of hands and artrhro-scopic synovectomies of knees and ankles. The number of synoviorthesises is increased to about 10 to 15 per year. This treatment was only used for the haemophiliacs in our department until 5 years ago.

ReferencesBessant R, Steuer A, Rigby S, Gumpel M. Osmic acid revisited: Rheumatology (Oxford) 2003; 42(9):

1036-43.Dirienzo G, Osti L, Merlo F. Our experience in the treatment of rheumatoid knee by arthroscopic syno-

vectomy. Chir Organi Mov 1997; 82(3): 275-8Jacob R, Smith T, Prakasha B, Joannides T. Yttrium90 synovectomy in the management of chronic knee

arthritis: a single institution experience. Rheumatol Int 2003; 23(5): 216-20.Pirich C, Schwameis E, Bernecker P, Radauer M, Friedl M, Lang S, Kritz H, Wanivenhaus A, Trattnig

S, Sinzinger H. Influence of radiation synovectomy on articular cartilage, synovial thickness and enchantment ac evidenced by MRI in patients with chronic synovitis. J Nucl Med 1999; 40(8): 1277-84.

Sculco TP. The knee joint in rheumatoid arthritis. Rheum Dis Clin North Am. 1998; 24(1): 143-56.Smiley P, Wasilewski SA. Arthroscopic synovectomy. Arthroscopy 1990; 6(1): 18-23.


SIDE EFFECTS OF GROWTH HORMONE TREATMENT IN JIA

B. Månsson

Department of Rheumatology, Lund University Hospital, Lund, Sweden

Background and objective: Growth disturbances, both local and generalised, are common in juvenile idiopathic arthritis (JIA). In oligoarticular disease they are restricted to the growth plates surrounding the affected joints. In polyarticular and systemic disease, more widespread growth disturbances resulting in short stature are more common.

The therapeutic effect of growth hormone (GH) in children with JIA has been studied in uncontrolled as well as in controlled studies. They all show that GH treatment increases growth velocity. Although encouraging, no firm conclusion can be drawn regarding the influence on the final adult height. In published studies, no serious side effects, neither metabolic nor growth related, have been reported.

After observing the rapid development of unexpected skeletal abnormalities during GH treat-ment in children with arthritis, we decided to perform a systematic review of all GH treated children with JIA in our department with regard to presence of growth disturbances.

Methods: The case records of all patients with JIA treated for more than one year with recom-binant growth hormone (n=15) were examined retrospectively. In two cases the patients also suffered from Turner’s syndrome. The indication for therapy was in all children short stature, except for one girl who was treated due to precocious puberty. A standard dosage of recombi-nant growth hormone (median 24 U/week/m2) was given.

Results: In all patients, except the girl with precocious puberty, some skeletal abnormality, suggesting disturbance of growth, was noted. The most prevalent abnormality was development or progression of scoliosis, which was noted in 8/15 patients.

Conclusion: Growth hormone treatment of children with arthritis may be associated with development of skeletal abnormalities or aggravation of pre-existing ones. These risks should be weighed against the possible benefits of this treatment.


MODERN MEDICAL TREATMENT OF JIA

R. ten Cate

Leiden University Medical Center, the Netherlands

Juvenile idiopathic arthritis (JIA) is a heterogenous group of diseases. Several subsets are recog-nised, mainly based upon clinical and laboratory findings.

The main principle of treatment is to achieve remission in order to prevent damage of carti-lage and bone. The basic treatment consists of cooling of the involved joints, maintenance of position/function and non-steroidal anti-inflammatory drugs.

In case this treatment is insufficient sulfasalazine or methotrexate is prescribed. The dose of methotrexate can be increased until 1 mg/kg/week.

The use of oral glucocorticosteroids is restricted to lifethreatening situations although in some children low doses are used to bridge or support. Intra-articular steroids are widely used.Topical application in the eye is indicated in chronic anterior uveitis.

Etanercept is the only biological of the anti TNFalpha strategies that is registered for the use in children. In children with methotrexate resistant disease it has proven to be succesful in accomplish remission in about 3⁄4 of the children.

Autologous stemcell transplantation has been used in children with therapy resistant systemic and polyarticular JIA.


ETIOPATHOGENESIS OF WRIST JOINT DEFORMITIES

A. Lluch

Institut Kaplan, Paseo Bonanova 9, 08022 Barcelona, Spain

Purpose: The carpal bones displace ulnarly and anteriorly, as well as supinate in relation to the radius. Radial inclination of the wrist is commonly observed in the presence of an ulnar devia-tion of the fingers. The question that remains is, which came first?

Materials and methods: To find an answer to this question, we have studied the x-ray films of 122 hands affected by rheumatoid arthritis.

Results: In 44 hands, the disease was restricted to the wrist joint, presenting an average ulnar inclination of 15º, ranging from neutral to 43º of ulnar inclination. When both the wrist and MP joints were altered by the disease, a compensatory radial inclination of the metacarpals, propor-tional to the ulnar drift of the fingers, was observed. After surgical correction of the MP joint deformity in 37 hands, the radial inclination of the metacarpals corrected itself.

Conclusions: When just the wrist joint is involved, the metacarpals deviate towards the ulnar side. Only in the presence of an ulnar drift of the fingers, will the wrist radially deviate in an attempt to align the fingers along the long axis of the forearm.


TREATMENT OF WRIST DEFORMITIES IN JIA

Daniel Herren

Schulthess Clinic Zurich/Switzerland

After the knee the wrist joint is the most common target in juvenile arthritis. Seropositive dis-ease is more aggressive and the destruction pattern is similar as in adult rheumatoid arthritis. After premature appearance of the carpal bones fusion of the ulnar epiphysis with consecutive shortening of the ulna may occur. The carpus often undergoes significant ulnar translation and in a later stage an intracarpal or even a radiocarpal fusion occurs, often in flexed position.

Treatment options:There is little literature about surgical treatment in juvenile rheumatoid wrists. Most series are limited to case reports; consecutive series are missing, probably due to the heterogeneity of the disease pattern. The early treatment strategy seeks to prevent defor-mity not only in the wrist but also in the distal part of the hand. Besides adequate medication and splinting, surgery at this stage is limited to measures, which do not affect further skeletal growth. This includes mainly synovectomy of the wrist, which is rarely indicated and may be reserved for therapy resistant cases. In patients with significant ulnar shortening and ongoing ulnar carpal translation, ulnar lengthening might be discussed. There is some evidence that the wrist deformity can be corrected with that procedure also in the long run. Severe flexion deformity of the wrist may require soft tissue release with or without removal of the proximal carpal row. In cases of mainly subluxation of the carpus with only slight ulnar drift interposition arthroplasty, using a silastic spacer is an option. Since hand function is grossly impaired in most of these patients there is less implant wear over time. Wrist arthrodesis, using the Mannerfelt technique, is the only treatment possibility in cases of severe and aggressive disease.

Conclusion: There is no standardized protocol for the treatment of wrist deformities in juve-nile arthritis and individual solutions have to be found according to the disease pattern.


MP JOINT DEFORMITIES

Philippe Kopylov

Hand and Upper Extremity Unit, Department of Orthopedics, Lund University, Sweden

Etiopathogenesis: The frequent involvement of MP joint in Rheumatoid arthritis results in severe painful deformity and functional loss. The causes of MP joint deformity are anatomical, pathological and indirect. However the permanent pathophysiological element leading to the classic ulnar drift and volar luxation is synovitis of the joint.

ClassificationWithout prognostic factor the following classification gives information on the stage of the

deformation and the treatment that can be proposed. 1 – Synovitis without deformation, normal radiographs.2 – Synovitis with ulnar deviation, normal radiographs.3 – Synovitis with ulnar deviation and volar subluxation, volar luxation on radiographs with

almost normal cartilage.4 – Ulnar deviation and volar luxation with or without active synovitis, destroyed cartilage and

more or less bone erosion on radiographs.TreatmentIndication are pain, loss of function and cosmesis.

1 – Synovectomy. The synovectomy is unpredictable as a real prophylactic procedure.2 – Stabilization and realignment procedures have always to be part of a synovectomy. If the

destruction of the cartilage and the bone erosion are irreversible process, the elongation of the ligaments or the destruction of their bony insertions can always be reconstructed.

3 – Arthroplasty. The silicon arthroplasties are the most often used. They associate a reduction of the ulnar and volar deformation and opened the hand. More recently, new non-con-strained implants have been proposed in order to offer an earlier treatment. When used with good ligament reconstruction and tendon rebalancing these devices have good results on pain, cosmesis and function.

Conclusion: MP joint deformity in rheumatoid arthritis is complex. The etiopathogenesis will guide the treatment most appropriate in each patient. However, some principles has to be respected in all cases. A good stabilization and recentralization is the key stone of the surgical procedure.


FINGER DEFORMITIES IN JIA

A. Nilsson and C. Sollerman

Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden

Common rheumatoid deformities of the fingers such as Swan-neck and Boutonnière occur also in JIA, but there is often a severe tendency of developing joint contractures, which may be the main cause of impaired hand function. is obvious. Prolonged inflammatory activity in the vicin-ity of growth plates involves the risk of developing growth disturbances.

Treatment of manifest finger deformities may be based on a simple algorithm:Stage 1 (actively redressable deformity)

– Splints, exercises – Changing handles and tools

Stage 2 (passively redressable, normal x-ray) – Splints – Soft tissue procedures

Stage 3 (contracture, normal x-ray) – Splints – Soft tissue procedures

Stage 4 (contracture, pathological x-ray) – Joint fusion or arthroplasty

The use of splints, especially at night, is very common in JCA. Splinting of finger deformities may be used to prevent flexion contractures (a static night splint with extended PIP-joints). Dynamic splinting may be used to increase range of motion in progressive joint stiffness.

Surgical procedures Fusion or arthroplasty is never indicated until the growth plates are closed. Hence, the surgical options in JIA are in most cases soft tissue procedures.

Arthrosynovectomy is seldom performed nowadays, when medical treatment has become more effective.

Tenosynovectomy is indicated in longstanding tenosynovitis when non-operative treatment has proven ineffective.

Teno-arthrolysis may be performed in progressive joint stiffness when grip function is threa-thened. An early motion protocol is difficult to follow before the age of 10.

Tendon transfer or reattachment is indicated in Swan-neck or Boutonnière deformities with normal x-ray.

Fusion or arthroplasty of the PIP-joint can be performed when growth is finished. Correction of destroyed and deformed PIP-joints has mainly been performed with a fusion. Replacement of the PIP-joint is more commonly performed when newer implants and techniques show reli-able results.


GROWTH DISTURBANCES AND OTHER CONSIDERATIONS WHEN TREATING CHILDREN WITH ARTHRITIC HANDS

M. Arner

Hand Unit, Department of Orthopedics, Lund University Hospital, Lund, Sweden

Performing hand surgery on children with arthritis presents special problems, some of which will be addressed during this panel. The initial diagnosis can often be difficult due to discrete clinical symptoms and limited radiological signs. Ossification of the carpal bones, e.g., is usu-ally not complete until around the age of eight years and variations in skeletal maturation are common. The hands and wrists of these children are often involved at an early stage of the dis-ease and various growth disturbances may occur. Surgery itself may also affect growth. When performing soft tissue surgery, like synovectomies or arthrolyses on the juvenile arthritic hand, a significant risk of postoperative joint stiffness has to be considered. Surgical treatment of arthritic hands in children are often delayed until adolescence, and doing any kind of surgery in a teenager is a difficult task which requires special attention and finesse.

Personal experiences from the Children’s Hospital in Lund, Sweden will be presented and the session will be concluded with a panel discussion around some clinical cases.


MID- AND LONG-TERM OUTCOME OF SHOULDER ARTHROPLASTY FOR ADULT JUVENILE RHEUMATOID ARTHRITIS PATIENTS

B. M. Jolles, P. Grosso and E. R. Bogoch1

1St. Michael’s Hospital, 55 Queen St. East, Suite 800, Toronto, Ontario, M5C 1R6, Canada.

Purpose: We reviewed the clinical and radiographic shoulder pathology in adult patients with advanced juvenile rheumatoid arthritis (JRA) to identify the principal surgical challenges of shoulder reconstruction and to evaluate the long-term outcomes of this surgery. No published report of the results of shoulder arthroplasty in this rare patient group was identified in the lit-erature, other than one abstract reference and individual cases included in series of adult RA patients.

Materials and methods: Between 1986 and 1997, 13 shoulders in ten adult patients with severe polyarticular onset JRA were treated with primary arthroplasty, utilizing a deltopectoral approach. The shoulders had severe deformity and contracted, inelastic soft tissues. All patients required lengthening of the subscapularis tendon and circumferential capsular release. One patient could not be located for follow-up, and another declined participation. Eight patients (11 shoulders) were evaluated (follow-up: mean 9.1 years, range 4-15 years) for pain Visual Analogue Scale (VAS), range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score and Short-Form 36 (SF-36). No implants were revised or removed.

Results: External rotation improved significantly, by 39.1° on average to a mean of 30.5° (s.d. 9.61, p<0.0001), with no evidence of shoulder instability. Internal rotation of the shoulder improved three vertebral levels on average. Forward elevation improved an average of 41.1° (final mean 89.1°, s.d. 19.21, p<0.003). Patients’ postoperative pain (average VAS score 1.3, s.d. 1.56) was significantly less than preoperative pain (p<0.0001), with a mean change of 6.7. Notwithstanding the poor follow-up DASH scores (mean 44.7) and SF-36 scores in these patients who have severe, lifelong, polyarticular disease, they all rated themselves as satisfied with the procedure.

Conclusions: Shoulder arthroplasty provided pain relief for end stage shoulder involvement in adult JRA. Improvement in external rotation in this severely affected group appears to have a beneficial effect on function. Neither SF-36 nor DASH scores were responsive to the positive results identified by these profoundly disabled patients.


SHORT TERM FAILURES OF NEUFLEX® MCP PROSTHESES

Peter Doorn

Mr. P.J. Troelstraweg 78, 8917 CR / Leeuwarden, The Netherlands

A common complication of MCP arthroplasties with Swanson prostheses is fracture of the hinge portion. Alternatively, Neuflex® prostheses are developed with an eccentric hinge and a 30° flexion position in order to decrease strain forces on the hinge portion. Question in this study was if short-term failures as a result of fracture in these Neuflex® prostheses could be avoided, and if there are predictive factors for fracture.

Patients and methods: From March 1999 to June 2002, 91 Neuflex® prostheses were placed in 25 patients with rheumatoid arthritis, juvenile arthritis and in one case osteoarthritis. Clinical and radiological data were prospectively recorded, including SODA tests, VAS scores and hand radiographs, preoperatively, 6 months postoperatively, and at the time of this study (average 1 year and 10 months postoperatively).

Results: In 5 patients (11 prostheses) a fracture of the prostheses was found, on the average 1 year and 11 months postoperatively (range 9 months to 3 year and 5 months). Analysis of possible predictive factors, including preoperative ulnar or radial deviation with (sub) luxation of the MCP joints, postoperative ulnar deviation, perioperative complications, and age, did not show a positive correlation with the fractures. However, 2 of these 5 patients showed a higher VAS pain score and only 1 of these 5 patients showed a lower VAS satisfaction score compared to the average scores.

Conclusion: This study shows that the incidence of Neuflex® MCP prostheses fracture is comparable to the percentage that is found in the literature for Swanson prostheses (Klomp-maker et al. 1989). No predictive factors were found for short term fractures of the prostheses. Possibly the amount of activity with the operated hand plays an important role, which is not recorded in this study.

Reference: Klompmaker J, Nienhuis RLF, Marck KW. Resectie-artroplastiek van de meta-carpofalangeale gewrichten wegens reumatoïde artritis; een na-onderzoek. NTVG 1989; 133: 25-29.


FUNCTIONAL ASSESSMENT OF BILATERAL WRIST ARTHRODESIS FOR INFLAMMATORY DISEASE

C. Fontaine, G. Prodhomme, C. Chantelot, M. Limousin

Orthopaedics B Department, Roger Salengro Hospital, Academic Hospital, 59037 Lille, France

Arthrodesis is a classical treatment of rheumatoid wrist. When both wrists are severely involved, one may discuss a double arthrodesis (whose position is still debated: both in neutral position or one in extension and one in flexion), a double prosthesis, or the association of one arthrodesis and one prosthesis. Our aim was to assess the functional result of bilateral wrist arthrodesis in neural position.

This retrospective study involved seven patients (1 male, 6 female) mean aged 46 years (28-69), who underwent bilateral wrist arthrodesis for inflammatory disease (6 rheumatoid arthritis, 1 juvenile arthritis). The mean follow-up was 5 years. They were assessed both clinically and radiographically: upper limb goniometry, Jebsen hand function test (questionnaire based on the daily activities), measurement of pinch and grasp force (Jamar) and functional evaluation according to Buck-Gramcko and Lohmann, AP and lateral X-rays.

The average position of wrist arthrodesis was 2° of flexion [(-5°)–(+10°)] and 6° of ulnar deviation [(-5°)–(+20°)]. All wrists were fused. At follow-up, 3 patients have returned to their work, 1 has found a new placement, 1 was considered as disabled, 1 was housewife and 1 retired. The Jebsen hand function test showed that the 7 patients were able to do 32 out of the 49 gestures (65%). For daily activities, there were 3 excellent, 2 good and 2 fair results. Buck-Gramcko and Lohmann test showed a mean result of 6.8/10 points [2–10], which corresponded to a good result. All patients were satisfied with the operation.

After bilateral wrist arthrodesis in neutral position, patients are able to perform daily activity gestures. Perineal care was possible in 5 out of 7 patients, despite no writs has been fused in flexion. Only hard and precise gestures were sometimes difficult, because of apprehension and loss of fine dexterity. Bad results were due to metacarpo-phalangeal deviation and grasp force decrease; indeed grasp force decreased of 80% in relation to that of a sample of non-operated RA patients. Wrist fusion in neutral position allows all gestures, even perineal care. Bilateral wrist arthrodesis is a valuable alternative for bilateral prosthesis or to the association arthrod-esis-prosthesis. It does not expose the patient to mechanic complications of wrist prostheses.


SHORT- AND MIDTERM RESULTS OF THE UNCEMENTED, UNCONSTRAINED HM-MCP ARTHROPLASTY IN RA—A MULTICENTER STUDY

F.-W. Hagena, B. Mayer, J. Gottstein, H.-C. Meuli

Auguste-Viktoria-Klinik, Bad Oeynhausen, GermanyRheumazentrum Köln, Eduarduskrankenhaus, Cologne, GermanyLindenhofspital, Bern, Swiss

In 85% of the patients with rheumatoid arthritis the MCP-joints are involved with increasing deterioration and loss of function. The standard replacement of the MCP-joints using the Swan-son-Silastic Spacers shows pain reduction and a realigment of the fingers, but the functional capacity is not improved.

The HM-MCP arthroplasty offers a concept for better function an restoration of the rheuma-toid hands and osteoarthritis.

In a prospective multicenter study, 63 HM-MCP endoprostheses have been implanted. We used the redesigned model (PE-metacarpal head and Ti-ODH phalangeal base) with titanium stems. The follow up-time was 18 (6–40) months. All patients were controlled with clinical and radiographic evaluation.

The active ROM of the MCP joints was on average flex./ext. 65°/10°/0 (preop. 70°/15°/0). The grip strength at follow up was 80% of the untreated contralateral control hand. Pain had been reduced using the verbal pain scale at 1.6 (preop. 2.1).

Radiographically all metacarpal and phalangeal stems showed osseointegration of the implants. Radiolucent lines of < 1 mm have been detected at the phalangeal base without any sign of loosening.

Complications: 1 palmar luxation with a successful closed reposition, 1 ulnar subluxation of the fifth finger, 1 unsuccessful revised palmar luxation.

The results of the uncemented, unconstrained HM-MCP arthroplasty showed an improve-ment of the hand function and pain reduction. This endoprosthesis gives a new chance to treat the rheumatoid hand at an earlier stage of destruction before severe contracture of the soft tis-sues.


ASCENSION® MCP META-CARPO-PHALANGEAL NON CONSTRAINED PYROLYTIC CARBON PROSTHESIS IN RHEUMATOID ARTHRITIS—CLINICAL EXPERIENCE AND RESULTS

P. Kopylov and M. Tägil

Hand and Upper Extremity Unit, Department of Orthopedics, Lund University, Sweden

The MetaCarpoPhalangeal (MCP) joints are often affected in rheumatoid arthritis. As artificial joint replacements, silicone spacers are the most commonly used. Due to their limitations, such as poor range of motion and fracture of the implant, prosthetic replacement is often performed rather late in the evolution of the disease.

Material and methods: A new prosthetic design has evolved, enabling earlier treatment. These articulating prostheses are non-hinged, and made of pyrolytic carbon, which has shown to be a biologically compatible, wear resistant, material for arthroplasty. No cement was used.

We report the results of 40 MCP joints in 14 patients (16 hands) with a diagnosed rheumatoid arthritis and with a minimum follow-up of 3 years. The mean age was 55 (36–67) years.

Results: All patients became painfree and increased their range of motion. Ulnar deviation was corrected and stability of the joints achieved. Ten joints in 4 patients were revised. One joint dislocated early and was revised with Swanson silicone prosthesis. 2 patients (7 joints) showed a recurrence of stiffness and ulnar deviation. After release and tendon rebalancing the same Ascension® MCP implants could be used. 1 patient (2 joints) had loose implants after 40 months and was reoperated with reinsertion of Ascension® MCP implants with a bone packing technique.

Conclusion: The results of Ascension® MCP implant are encouraging with patients reporting mobile, stable and painfree joints. This implant gives us the opportunity to treat early young and active rheumatoid patients, however, the revision rate in rheumatoid patient is still too high but perhaps more in relation with the disease itself than with the implant.


RADIAL INCLINATION OF THE METACARPALS SECONDARY TO THE ULNAR DRIFT OF THE FINGERS IN THE RHEUMATOID HAND

Alberto Lluch


Introduction and aim: In the rheumatoid hand, a radial inclination of the wrist is commonly observed in the presence of an ulnar deviation of the fingers. The question that remains is: which came first? To find an answer to this question, we have studied the radiographs of 122 hands affected by rheumatoid arthritis.

Material and methods: In group I (44 hands), the disease was restricted to the wrist joint, which presented an average ulnar inclination of 15º, ranging from neutral to 43º of ulnar incli-nation.

In group II (13 hands), the disease was limited to the MP joints, with an average of 30º of ulnar deviation of the fingers, ranging from 10º to 70º. A compensatory radial deviation of 12º was observed at the wrist, ranging from 2º to 26º.

In group III (28 hands), both the wrist and MP joints were affected by the disease. The fin-gers presented an average ulnar deviation of 17º, ranging from 7º to 40º. The wrist presented an average radial inclination of 4º.

In groups IV (34 hands) and V (3 hands), measurements were done before and after the finger deformity was corrected from a average of 45º to 7º, while the wrist deformity corrected itself, without wrist balancing procedures, on an average from 30º to 2º of radial deviation.

Results: When only the wrist is involved, the metacarpals are inclined towards the ulnar side. The wrist deviates radially only in those cases in which the fingers are inclined towards the ulnar side. When the ulnar drift of the fingers is surgically corrected, the radial inclination of the wrist will correct itself.

Conclusion: It has been generally accepted that radial inclination of the metacarpals is one of the causes of the ulnar drift of the fingers, but from our studies the radial inclination of the metacarpals should not be considered the cause but rather a consequence of the ulnar drift of the fingers.


WOUND HEALING AFTER SURGERY OF THE FOREARM OR HAND IN PATIENTS WITH SYSTEMIC SCLEROSIS

J. Dieterich, P. Kopylov and M. Tägil

Lund University Hospital, SE-221 85 Lund, Sweden

Systemic sclerosis is an uncommon form of arthritis. Due to a decreased microcirculation, wound-healing problems are feared for and surgical interventions often avoided. We report the results after surgery in the hand and forearm of patients with systemic sclerosis with special reference to wound healing problems.

Patients and methods: Forty-one consecutive operations were performed in 19 patients between 1985 and 2000. The mean age was 50 (14–84) years. Sixteen patients were female and 3 male. Twelve patients were operated twice or more. Operations were elective in 27 cases, with excision of calcinosis, with or without skin transplant in 10 patients, neurolysis in 7 patients, wrist procedures (fusion or implant) in 3 patients and other procedures (e. g. finger joint fusion, removal of osteosynthetis material, finger osteotomy) in 7 patients.

In 14 cases the operations were acute due to spontaneous wounds and skin necrosis resulting in amputation with or without flap in 3 cases, wound revision in 6 cases, wound revision and flap in 5 cases.

Results: In the 27 elective operations, one patient had the osteosynthetic material removed before the wound healed. In the 14 acute operations, 7 patients in the group with spontane-ous skin necrosis healed uneventfully after operation. Two patients had wound infections that caused a longer healing period of 5 months. Another patient also had a prolonged healing period but his wounds healed shortly after he quit smoking. Four patients had necrosis/infections, which required additional surgery.

Conclusion: In systemic sclerosis, surgery performed in elective operations does not seem to have an increased rate of infections, ischemia or other wound healing problems. Even larger operations like wrist arthrodesis or wrist prosthesis can be performed. In non-elective cases with spontaneous skin necrosis the wound healing is not that obvious and several operations sometimes are necessary.


THE S.T.A.R. TOTAL ANKLE ARTHROPLASTY IN PATIENTS WITH RA—A PROSPECTIVE COMPARATIVE STUDY IN PATIENTS WITH RA AND OA

R.M. Christ and F. W. Hagena

Auguste–Viktoria–Klinik, Hospital for orthopedic and rheuma surgery, D–32545 Bad Oeynhausen, Germany

Introduction and aim: In a prospective comparative study we were interested in the question, whether total ankle arthroplasty in the midterm follow-up, especially in patients with RA, is a successful and correctly indicated surgical procedure. We compared our clinical and radio-logical results with a cohort of patients with OA. Furthermore we analysed especially the RA patients for periarticular osteopenia and the cementless fixation as a possible contraindication for ankle arthroplasty.

Material and methods: With a mean follow-up of 4.4 years and a total number of 153 total ankle arthroplasties from 07/1997 to 12/2003 we assessed 92 patients with 94 S.T.A.R. total ankle arthroplasties. Indication for this surgical procedure was RA in 26 patients (28%), idi-opathic OA in 29 cases (31%) and posttraumatic OA in 39 patients (42%).

Results: The functional increase in their range of motion (ROM) and the significant decrease of pain are the most important and impressing facts for the patients. The increase of ROM in all patients is 17.9º (RA:18.7º/OA:16.6º). Significant pain relief is described by 92.4% of the patients, here all groups showed no significant differences. An increase in the clinical outcome measured by the Kofoed Ankle Score is seen from <70 points preoperatively (100% of the patients) to >75 points postoperatively (82.3% of the patients). The most frequent complication especially in patients with RA is delayed wound healing (19%), but the revision rate is higher in patients with posttraumatic and idiopathic osteoarthritis (17% OA/13% RA). A secondary arthrodesis has to be performed only in 2 OA cases.

Conclusion: RA in LDE stage IV and V is the adequate indication for the S.T.A.R. prosthesis. The functional benefit and the clinical outcome is satisfying, the results for the RA patients are comparable to other indications. The periarticular osteopenia is not considered as a contraindi-cation.


ARTHRODESIS VERSUS MAYO RESECTION IN TOTAL RHEUMATOID FOREFOOT RECONSTRUCTION—A PROSPECTIVE, RANDOMISED STUDY

Lollo Gröndal 1 and André Stark 2

1 Dept. of Orthopaedic Rehabilitation, Red Cross Hospital, Stockholm and2 Dept. of Orthopaedic Surgery, Karolinska Hospital, Stockolm, SwedenE-mail: [email protected]

Painful rheumatoid forefoot deformity may surgically be treated with resection of lesser meta-tarsal heads combined with either resection or arthrodesis of the first MTP joint. Retrospective comparisons between the methods seem to favour arthrodesis but not entirely. Our aim was a prospective, randomised comparison.

Patients and methods: 31 patients were allocated to either Mayo resection or arthrodesis of MTP 1 in a total forefoot reconstruction. All were examined preoperatively, after 6 and mean 36 (24–52) months with Foot Function Index and concerning degree of deformity. Radiographs were taken preoperatively and after 6 months.

Results: Preoperatively, the groups were comparable. At 6 months significant reduction of FFI was obtained without any statistically significant differences between the groups. This result remained throughout the study. The subjective satisfaction score was > 92 points out of 100. There were no recurrent prominences or severe hallux valgus. The fusions healed in 93% without risen risk for IP joint problems. The operating time was 90 minutes mean for resection and 106 minutes for arthrodesis.

Conclusion: In a prospective, randomised study we found excellent patient satisfaction rate and significant, lasting reduction of FFI score with no statistically significant differences between the groups. There were no differences in other parameters either except for longer oper-ating time in the fusion group. These results indicate that Mayo resection may still be a good choice for MTP 1 approach in total rheumatoid forefoot reconstruction.


TOTAL ANKLE REPLACEMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS

Markus Knupp, Monika Horisberger, Victor Valderrabano, Beat Hintermann, Walter Dick

Orthopaedic University Clinic, Kantonsspital Basel, 4031 Basel, Switzerland

Introduction: 90% of the people with rheumatoid arthritis develop symptoms at the foot or ankle. Progressed ankle involvement can be treated with arthrodesis or arthroplasty. Dissatisfac-tion in arthrodesis has encouraged attempts to find a more physiological solution. Earlier studies showed good results in ankle arthroplasty in patients with rheumatoid arthritis. The purpose of this study is to present our experience with total ankle replacement in patients with rheumatoid arthritis and to compare them to arthroplasty in patients without systemic arthritis.

Methods: 122 consecutive arthroplasties (116 patients) were analysed in a prospective study, 5 on patients with rheumatoid arthritis. History, function, pedobarographic and radiographic findings were analysed. The patients were seen after 6 weeks, 6 months, 1 and 2 years. The last examination was done after 18.9 (12–36) months. Additional procedures, e.g. calcaneal length-ening osteotomy, arthodesis were done where needed, which was in all patients with systemic arthritis.

Results: 8 patients (7%) had revisions, all of them treated for posttraumatic arthritis. 81% had good or excellent results, 16% were satisfactory and 3% were poor. Patients with systemic arthritis were all good or excellent. 68% were without pain, 30% had little pain (VAS 2.6) and 2% had strong pain (VAS >6). The motion in the joint was clinically 39° (15–55°) and 37° (7–62°) measured under the image intensifier. The AOFAS Hindfoot Score improved from 40 to 85 and from 23 to 83 in patients with rheumatoid arthritis.

Conclusion: Total ankle replacement in systemic arthritis gives good results when respect-ing the contraindications. Additional surgical procedures, such as arthrodesis or correction of the alignment must be considered to achieve good satisfactory, as these patients have a high predisposition for destruction of the neighbouring joints.


FOREFOOT RECONSTRUCTION IN RHEUMATOID ARTHRITIS—A PERI-OPERATIVE COST ANALYSIS

Giovanni A. Matricali, Johann Verduyckt, Annelies Boonen, Rene Westhovens

Weligerveld 1, B-3212 / Pellenberg, Belgium

MTP1 arthrodesis combined with a Hoffmann resection arthroplasty has become one of the standard forefoot procedures in RA. Unfortunately there is a distinct lack of information on the economic impact of this procedure. We evaluated the peri-operative in-hospital costs.

Materials and methods: 19 RA patients (22 feet) were operated upon (fiscal year 2002). All procedures were unilateral. Hospital bills were analyzed retrospectively for factors contributing to the total costs and their share in costs to the health care system (HCS) and those to the patient. Age and length of hospital stay (LOS) were listed also. Descriptive statistics are used to report the amount and share of the various cost items; a Spearman’s Rank Analysis was performed to evaluate correlations.

Results: Total peri-operative in-hospital costs amount to a mean of € 1982.05 (+ € 672.68) of which € 1858.69 (=93.8%) paid by the HCS. The cost-of-stay is the most costly factor (€ 968.23) nearly fully paid by the HCS. Doctors’ wages result to be the second most costly factor (40.7% of costs), paid entirely by the HCS. The single contribution of costs for radiology, labo-ratory examinations, drug therapy, implants and fixed amount charges results rather low (<5%), but together they constitute 58.4% of the costs to be paid by the patient. No significant correla-tion can be found between age and other parameters. A significant, positive correlation is found between LOS and cost-of-stay (p=0.045), and between cost-of-stay and total costs (p<0.0001). Otherwise total cost is correlated significantly and positively (p<0.001) to the costs for labora-tory examinations only.

Conclusions: Cost-of-stay is the single most important cost factor in RA forefoot surgery. A significant, positive correlation was found between LOS and cost-of-stay, and between cost-of-stay and total costs, but not between LOS and total costs (p=0.056). The cost to the patient is low compared to the cost to the HCS and correlates significantly and positively (p=0.0003) to the fixed amount charges only. Age has no significant influence on the costs for this intervention.


TOTAL KNEE ARTHROPLASTY IN JUVENILE RHEUMATOID ARTHRITIS

Hannu Tiusanen, Christer Lybäck and Eero Belt

Oulo University, Finland

Juvenile chronic arthritis is a heterogeneous group of arthritis; it can be arthritis in only a few joints, or arthritis in many joints or systemic form of arthritis with fewer and internal organ affection. The JCA incidence is about 11:10,000. Approximately 60% of patients with JCA attain remission in 10 years. 10% of JCA patients are left with severe disability and functional impairment. The knee joint is involved in two thirds of the JCA patients during the course of the disease. Indications for TKA in JCA are: correction of deformity, improvement of range of motion and pain relieve. A 13-year follow-up of 77 knees, with AGC total knee replacement in JCA is presented. The study analyzed the survivorship and results of 77 knee replacements in52 patients with juvenile chronic arthritis using the nonconstrained Anatomically Graduated Com-ponents (AGC) prosthesis design. Patients were operated on between the years 1985 and 1995. The mean duration of the general disease was 24 years (range, 10–56 years).The mean age of the patients at the time of operation was 33 years (range, 16–64). Bone grafts were installed into 15 knees, custom-made components were used in 5 knees, and cemented fixation in 4 knees. The patella was resurfaced in 23 knees. 55 of 73 (75%) knees were subjectively excellent, 18 (25%) were fair, and none was poor. Radiolucent lines of 1.0–1.5 mm were found under 14 tibial trays but not adjacent to femoral components. No deep infections were detected. One knee was revised 4 years after implantation. The overall survival was 99% (95% confidence interval, 92–100) at 5 years. The nonconstrained AGC prosthesis with cementless fixation proved to be feasible in knee replacement in patients with juvenile chronic arthritis


TREATMENT OF DEEP INFECTION COMPLICATING TRIPLE ARTHRODESIS IN RHEUMAROID PATIENTS

S Yli-Luukko, P Hyvönen, J Ristiniemi, H Syrjälä, A-L Haataja, J Leppilahti

PL 21, FIN-90290 OYS, Oulu, Finland

Six rheumatoid patients with a deep infection in the sinus tarsi region complicating triple arthrodesis were treated from January 1997 to April 2004 using a protocol including either open cancellous bone grafting (Papineau technique) or local soft tissue transfer (adductor digiti minimi). Five of the patients were women. The mean age at the time of arthrodesis was 53 (range 33–63) years. Four patients used systemic glucocorticoids and three had methotrexate medication. The surgical technique included fixation of arthrodesis with Richard’s stables. Bone grafting from iliac crest was used in two cases.

The deep infections were diagnosed within four months postoperatively in five patients and 23 months postoperatively in one case. Each patient had undergone surgical debridements, removal of staples and systemic antibiotic therapy.

Two deep infections were treated with a local soft tissue transfer (adductor digiti minimi) 1 and 19 months after the diagnosis. These wounds healed completely after 4 and 6 months.

Four deep infections were treated with Papineau-grafting mean 6 (1–13) months after the diagnosis. Two of these healed completely during 2 and 5 months. The third infection healed clinically in 4 months, but 17 months later the patient gained a septic chock, which led to leg amputation, and the patient died 11 months later. The fourth infection was treated recently with Papineau-grafting and the healing is proceeding.Conclusion: Deep infections complicating triple arthrodesis are rare but cause a prolonged

morbidity. Surgical debridement and systemic antibiotic therapy combined with Papineau-grafting or local soft tissue transfer gives mostly the successful results.


A NEW SPACER WITH JOINT STABILISATION FOR ARTHROPLASTY OF THE TMC JOINT—3 YEAR FOLLOW-UP RESULTS

Anders Nilsson and Christer Sollerman

Department of Hand Surgery, University of Göteborg, Sweden. [email protected]

TMC osteoarthritis causes pain and thus results in reduced pinch strength. Earlier studies with joint prosthesis have not been successful due to a high degree of dorsoradial prosthesis luxation. To meet this need, a novel spacer with the purpose to act both as interposition and to stabilise the TMC joint has been developed.

Material: The Artelon TMC spacer (S) is made of polyurethan urea fibers woven into a T-shape. The vertical spacer part separates the trapezium and the first metacarpal, while the horizontal wings stabilise the joint. Fifteen patients with radiographic verified osteoarthritis and pain related to the TMC joint were included in the study. Ten (9 female and 1 male; age 22–66, median: 60) were operated with the spacer and 5 patients (5 female, age 51–72, median 59) who were treated with trapezium resection arthroplasty with APL stabilisation (APL). Parameters like pain (VAS), strength (key, tripod) and opening grip and the Sollerman hand function test were measured before and 3 year after surgery by an independent observer.

Results: All 15 patients were clinically stable in the TMC joint without sign of synovitis.In the spacer group 4 patients were working before surgery and have returned to earlier occu-

pation. In the APL-group one patient was working before surgery but was retired due to the surgical outcome.

Pain was reduced in both groups: (median values) S preop 5.5, three years 0 and APL preop 5.0, three years: 0. Key grip was increased in the S group, preop 6.2 and after three year 8.0 and reduced in the APL group (preop 6.0, three years 5.0). Tripod pinch was also increased in the spacer group (preop 6.0, three years 7.8), and reduced in the APL-group (preop 5.0, three years 4.0). The opening grip and the Sollerman function score were unchanged.

Conclusion: The results of this pilot study, three years after surgery, indicates that the novel spacer stabilises the TMC joint and might results in better grip strength than resection arthro-plasty with APL stabilisation. The degree of pain relief was similar in both groups. To confirm these results a multicenter study has been started.


TEN YEARS EXPERIENCE WITH OUR OWN METHOD OF TOTAL WRIST ARTHRODESIS

J Pech, S Popelka, V Rybka, P Vavrík, D Veigl

Orthopaedic Clinic of 1st Med. Faculty of Charles University. Prague, Czech Republic

Purpose of the study: We developed our own method based on the use of a special implant. In this study we report our long-term results.

Material: Since 1992 we have carried out 54 total carpal arthrodeses using our method, on 51 patients. Three patients were treated bilaterally. This group comprised 34 woman and 19 men, with the average age of 47 years. We used the method mainly in patients with wrist destruction due to rheumatoid arthritis or psoriasis. In two patients, this method was indicated because of a nonreparable lesion of the nervus radialis. It was also used in two patients who had their wrist replacements removed due to failure.

Methods: We use dorsal approach to the carpal joint. After opening the capsule, we resected the facies articularis radii, the carpal bones, and the distal ulna. This L-shaped plate, only 2 mm thick, with its concave curve fitting the palm, allows for three-point fixation of the metacarpal region and also maintains slight autocompression.

Results: In all the patients we achieved osseous fusion on average at 12 weeks postopera-tively. The grasping function of the hand improved in all patients. The patients reported the absence of pain and instability.

Conclusions: The method described here is based on an original implant in the form of an L-shaped plate that permits sufficient fixation without using grafts taken from the pelvis. In patients with rheumatic arthritis, if needed, it facilitates peritenosynovectomy or reconstruction of spontaneous tendon ruptures in one operation. It does not require log-term immobilization in plaster cast and permits early rehabilitation of the finger joints.


OPERATIVE TREATMENT OF SHOULDER SEPSIS IN PATIENTS WITH RA

Adam M. Smith, John W. Sperling and Robert H. Cofield

Mayo Clinic, Rochester, MN, USA

Currently, there is no information available concerning the results of surgery for sepsis of the native shoulder in patients with rheumatoid arthritis. Therefore, we reviewed our experience with operative treatment of shoulder sepsis in patients with rheumatoid arthritis.

Materials and methods: Twenty shoulders in seventeen patients with rheumatoid arthritis underwent surgical intervention for shoulder sepsis. Twelve were associated with multiple joint infection, five of which were associated with prosthetic hip or knee infection. All patients demonstrated gross signs of infection at surgical intervention with seventeen shoulders having positive cultures (fifteen with Staph. aureus). Ten patients were identified to have immune compromising diseases not related to rheumatoid arthritis including diabetes, end-stage renal failure, cancer, COPD, lupus, hepatitis and asplenia.

Results: Three patients died during initial admission to the hospital (at 7 days, 5 months, and 6 months) due to multi-system organ failure and multiple joint infection. There were fifteen shoul-ders in fourteen patients who survived for postoperative examination. There were two excellent, six satisfactory, and seven shoulders with unsatisfactory results. Mean active elevation was 100 degrees. Further surgery was required in three patients, one requiring synovectomy for chronic pain and effusion and two requiring shoulder arthrodesis due to massive cuff tearing.

Discussion: Patients with rheumatoid arthritis with sepsis of the native shoulder were found to have a high rate of multi-joint sepsis. The presence of immune compromising conditions and chemotherapy places these patients at risk for multi-joint sepsis. Functional outcome in this patient population was likely compromised by the infectious process preexisting shoulder pathology.


FIXATION OF PROXIMAL HUMERUS FRACTURES IN PATIENTS WITH RA

Adam M. Smith, John W. Sperling and Robert H. Cofield


Currently, there is no information in the literature on complications of operative treatment of proximal humeral fractures in patients with rheumatoid arthritis.

Methods: Eleven patients underwent operative fixation of the proximal humerus from December 1987 to December 2002. Nine patients were treated for acute fractures, and two patients were treated for nonunion. Patients were critically assessed for pain, satisfaction, range of motion, radiographic outcomes, and occurrence of complications.

Results: Four patients had loss of reduction with three of these associated with loosened fixa-tion (two of these went on to significant malunion). Two patients treated for pseudoarthrosis with internal fixation and bone graft had complications (one requiring hemiarthroplasty after painful nonunion, and one with chondrolysis). Six of the eleven patients had unsatisfactory results. One patient had an excellent result, and four patients had satisfactory results. All acute fractures achieved union. At most recent follow-up, mean active elevation was ninety-five degrees and external rotation was forty degrees.

Conclusions: The rate of complications in patients undergoing internal fixation for fractures of the proximal humerus is high. Achieving stable reduction is difficult due to poor bone quality and preexisting shoulder abnormalities. Patients and treating physicians should be aware of the potential complications of operative treatment in this complex patient population.


THE CLINICAL RESULTS OF BIPOLAR HIP ARTHROPLASTY FOR PROTRUSIO ACETABLI IN PATIENTS WITH RHEUMATOID ARTHRITIS

Nobuhiro Kaku, Hiroshi Tsumura, Masashi Kataoka, Yousuke Fujikawa and Takehiko Torisu

Hasama-machi Oitagun Oita 879-5593, Japan

Introduction and aim: Since 1983, the authors have been evaluating an expanded application of bipolar hip prosthesis with bone grafting for acetabular protrusion caused by rheumatoid arthritis. The purpose of the current paper is twofold: (1) to describe in detail the specific sur-gical technique for grafting and socket preparation using a bipolar shell, and (2) to report the clinical results of its use.

Patients and methods: The instances of hip destruction of protrusio acetabuli type which was over to the medial the Köhler line was 24 joints in 22 patients. The average age of the patients at the time of surgery was 58 years. The patients were mobilized immediately following their operations. The average follow–up was 5.1 years.

Clinical results were evaluated using Japanese Orthopaedic Association Hip Score at the point of admission and final follow–up.

Radiographic study was performed using serial radiographs of each patient. The progression of the degree of ventral migration and superior migration can be followed by measuring them.

Results: The Japanese Orthopaedic Association Score (maximum points 100) improved by 38 points from 37.5 points to 77.8 points.The pain score (maxmum points 40) improved from 11.9 points to 38.8 points. The flexion angle of the hip improved from 77.7° to 85.3° and the abduction improved from 18.2° to 29.3°.

As measured serially from the radiographs made immediately after the operation, the overall distance of the movement of the outer head in central and vertical direction was 4.8mm and 6.3mm respectively on average at two years after the operation. These were each 6.3mm, 8.0mm at five years postoperatively.

Conclusion: Bipolar hip arthroplasty combined with bone grafting was clinically useful as a reconstruction technique for destroyed hip joints accompanied by acetabular deficiency.


SURVIVAL OF UNCEMENTED BI-METRIC TOTAL HIP ARTHROPLASTY IN PATIENTS WITH JUVENILE CHRONIC ARTHRITIS

A. Kyrö1, C. C. Lybäck1,2, C. O. Lybäck3, H. Kautiainen1, E. A. Belt1

1Rheumatism Foundation Hospital, Orthopaedic Department, FIN-18120 Heinola, Finland, 2University of Helsinki, Faculty of Medicine, Töölöntullinkatu 8, 00014 Helsinki University, Finland, 3Porvoo District Hospital, Sairaalantie 1, 06200 Porvoo, Finland

Purpose: The purpose of the study was to determine the survival of 81 total hip arthroplasties in 56 patients with juvenile chronic arthritis (JCA) using the uncemented Bi-metric prosthesis.

Materials and methods: The operations of the patients were performed between the years 1986 and 1998. The mean age of the patients was at the onset of disease 7.9 years and at the time of surgery 28.1 years. The average follow-up time was 9.2 years, range 0.4 to 15.8. Follow-up visits at the outpatient department were conducted 3 months, and 1, 4, 8, 12 and 16 years post-operatively. Revision surgery, death of the patient or the end of the year 2002 were used as end points in survival analysis.

Results: During the follow-up period one deep infection was encountered, and five patients deceased unrelated to the hip replacement. The combined survival of acetabular and femoral components was 69.0% (95% CI 56.7 to 78.5) at ten years. Of the acetabular components the TTAP-ST cup had a survival of 46.3% (95% CI 21.8 to 67.8), and the Romanus cup 77.8% (95% CI 63.7 to 86.7) at ten years. The overall survival was 97.5% (95% CI 90.2 to 99.4) for the femoral component at ten years. No femoral components were revised due to aseptic loosening. The survival of the Bi-metric stem was 100% at ten years with respect to aseptic loosening.

Conclusion: Uncemented Bi-metric femoral component yielded excellent results with the survival rate of 100% for aseptic loosening during the average follow-up time of 9 years, but the results of the two cup types used were poor.


CEMENTLESS HIP ARTHROPLASTY IN JEUVENILE IDIOPATIC ARTHRITIS—REPORT OF 62 CASES IN YOUNG PATIENTS

Thierry Odent, Christophe Glorion, Anne-Marie Prieur and Jean-Claude Pouliquen

Paediatric Orthopaedic Department, Hôpital des Enfants Malades , 149 Rue de Sèvres 75015 Paris, France. [email protected]

Juvenile Idiopathic Arthritis (JIA) is the most frequent rheumatic disease in children. The hip is affected most commonly and it’s involvement is the most frequent cause of disability. Fail-ure of medical and conservative treatment, significant joint destruction, and/or multiarticular involvement may necessitate total hip arthroplasty (THA) to restore good function. Related clinical trials show good results in most of the series, but long term outcomes are uncertain due to a significant loosening rate in the initial years particularly with cemented stems. We report encouraging results with using uncemented hip arthroplasty.

The results of 62 non cemented THA with rough surface made of titanium alloy (Zweymuller SL system, Endoplus®, Courbevoie France) in 34 children with JIA are reported. Mean follow-up was 6 years (3 to 13 years). Mean age at surgery was 18.3 years (11.8 to 31 years). Thirty-six arthroplasties were performed before the age of 18 years. Fourteen of the 34 patients had an active disease.

Clinical results were good for hip function, but less for global function. Mean PMA(Postel-Merle d’Aubigné) score increased from 5.8 before surgery to 16.8 after hip replacement. There were no infections or dislocation. Two acetabular cups failed in the initial years and had to be revised. Loosening was due to a bad primary fixation of the acetabular implant. Survivorship analysis was performed with Kaplan-Meïer method. At 13 years, survival rate (with 95% con-fidence intervals) was 100% for the femoral component and 90,1% for the acetabular compo-nent.

Encouraging results are shown with uncemented implants in JIA. Failure analysis indicates that primary stabilisation is necessary to provide secondary osteointegration for excellent long term outcome.


INDICATION OF MOBILE TYPE OF LPS-FLEX TKA FOR RHEUMATOID ARTHRITIS

Hiroshi Tsumura, Takashi Ono, Masashi Kataoka, Nobuhiro Kaku, Takehiko Torisu

1-1 Idaigaoka, Hasama-machi, Oita-gun, Oita, 879-5593, Japan

A total knee system of LPS-FLEX allows an enlarged flexion angle. This prosthesis has mobile bearing, but it does not have a mechanism to prevent bearing lift off. A strict control of soft tissue balance is required for this implant. The decision of using this TKA is made during the operation according to the soft tissue balance. Mobile type TKA was not used in cases without a perfect balance and/or an interchangeability between femoral and tibial components. This study has focused on the indication of mobile type TKA for Rheumatoid Arthritis.

Between January 2000 and December 2002, 86 knees in 75 patients TKA. (RA: 29 knees in 24 patients, OA: 57knees in 51 patients) Ages of patients were 68 years in average. In addition to the ordinary clinical results, the relationships between the types of TKA and preoperative alignment were examined.

The mobile type implants were used in 19 knees. In RA, 5 knees underwent mobile type implants (17%), while 14 knees (25%) underwent mobile type implants in OA. The improve-ment of alignment was from 183.1±7.3 to 173.1±2.2 in FTA of OA. In RA, the FTA was about 173 degrees both before and after operation. In 31knees with over 185 degrees in FTA (OA: 29knees), the mobile type implants were used in 9 knees, all of that were OA.

Deformity of knees is not extreme in most cases of RA. However, the usage rate of mobile type implants for RA is lower than that for OA. The conclusion is that the indication of mobile type implants does not depend on the degree of deformity, but on the laxity of joint due to RA.


MID- AND LONG-TERM OUTCOME OF TOTAL HIP ARTHROPLASTY FOR ADULT JUVENILE RHEUMATOID ARTHRITIS PATIENTS

B. M. Jolles1 and E. R. Bogoch1 Hôpital Orthopédique de la Suisse Romande, University of Lausanne, 4 Avenue Pierre Decker, 1005 Lausanne, Switzerland.

Purpose: To evaluate the mid- and long-term outcomes, clinically and radiographically, of total hip arthroplasty (THA) in adult patients who have advanced juvenile rheumatoid arthritis (JRA), using established and new scoring systems.

Methods: Between 1985 and 1999, 52 hips in 34 adult patients who have severe polyarticular or systemic onset JRA were treated with primary arthroplasty using a direct lateral approach. Technical problems of surgery included osteoporosis, small bones with narrow femoral canal, increased femoral anteversion, acetabular protrusion and contracted, inelastic soft tissues. Thirty-one patients (49 hips) were evaluated (follow-up: mean 6.8 years, range 3–17 years) for pain Visual Analogue Scale (VAS), stiffness VAS, range of motion, Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol in 5 dimensions (EQ-5D), Short-Form 36 (SF-36), and five patient-generated items of the Patient Specific Index (PASI-pg), and recalled preoperative pain VAS, stiffness VAS, and PASI-pg. Patients’ expecta-tions and satisfaction were also recorded. One patient died of a brain abscess, one underwent acetabular revision for aseptic loosening, and one underwent revision for late infection (revision rate 3.8%).

Results: Patients’ postoperative pain and stiffness decreased significantly after surgery, with mean VAS reductions of 9.1 and 8.7 points, respectively. A post-operative flexion arc of 96° (range 50°–140°) was observed. Distal cortical hypertrophy (57%) and pedestal forma-tion (31%) were not associated with signs of loosening in this group. Post-operative SF-36, EQ-5D, WOMAC and Harris Hip scores were low compared to general population norms or patients with operated for osteoarthritis, but 94% of patients rated themselves satisfied with the procedure. Salient subjective issues of JRA patients were revealed only by the PASI-pg ques-tionnaires, with a shift in issues generated by patients pre-operatively versus post-operatively, indicative of subjective improvement.

Conclusion: Hip arthroplasty provided relief of pain and stiffness, improved range of motion, and satisfied patients’ expectations in this uncommon and severely affected patient group with end stage hip involvement in adult JRA. Poor SF-36, EQ-5D, WOMAC and Harris Hip scores did not reflect the patients’ generally positive evaluations of the benefit of the surgery.


NON-PROSTHETIC AND PROSTHETIC SURGERY OF THE JUVENILE ARTHRITIC HIP

U. Rydholm

Department of Orthopedics, Lund University Hospital, Lund, Sweden

Control of hip disease is very important for maintaining mobility and independence in patients with juvenile idiopathic arthritis (JIA). Hip deformity and pain must be treated early by drugs and physiotherapy, and if necessary by arthroscopic joint lavage and cortico-steroids. Core decompression is a minor procedure that may give considerable relief from aching pain. Soft tissue releases as well as intertrochanteric osteotomy may affect the loading situation of the whole lower extremity, and also give the possibility of regeneration of cartilage in children with clinical deformities and radiographic growth disturbances of the hip.

Minor surgical procedures should always be considered if they can delay the requirement for total joint replacement.

Prosthetic replacement may be necessary in juveniles with severe destruction and pain. The survival of hip prostheses in this patient category is, however, inferior than what is reported for adult RA patients. In our own experience the 10-years survival with revision as endpoint is only about 70%. The figure is even lower if radiographic loosening is chosen as endpoint for the analysis. Revision often means technical problems due to bone loss in a skeleton that is already deficient due to the patients’ small size and frequent growth disturbances.


MID- AND LONG-TERM OUTCOME OF TOTAL KNEE ARTHROPLASTY FOR ADULT JUVENILE RHEUMATOID ARTHRITIS PATIENTS

B. M. Jolles and E. R. Bogoch1

1St. Michael’s Hospital, 55 Queen St. East, Suite 800, Toronto, Ontario, M5C 1R6, Canada.

Purpose: To evaluate the mid- and long-term outcomes, clinically and radiographically, of total knee arthroplasty (TKA) in adult patients who have advanced juvenile rheumatoid arthritis (JRA), using established and new scoring systems.

Methods: Between 1989 and 2001, 22 knees in 14 adult patients with severe polyarticular or systemic onset JRA were treated with primary arthroplasty, utilizing a medial approach. Surgi-cal challenges included relative condylar and patellar overgrowth within a contracted, inelastic soft tissue envelope, osteoporosis, small sized bones and fixed valgus and flexion deformity including ankylosis. All patients were evaluated (follow-up: mean 8.0 years, range 2–13 years) for pain Visual Analogue Scales (VAS), stiffness VAS, range of motion, Patient Specific Index (PASI), Knee Society Score, EuroQol in 5 dimensions (EQ-5D), Western Ontario and McMas-ter Universities Osteoarthritis Index (WOMAC), Short-Form 36 (SF-36), and recall preopera-tive pain VAS, stiffness VAS, and PASI-pg. Patients’ expectations and satisfaction were also recorded. One patient who had knee stiffness underwent arthroscopy and manipulation three weeks post-surgery. One patient suffered a cerebrovascular event. There were no revision pro-cedures.

Results: Patients’ postoperative pain and stiffness VAS were significantly less than pre-operative scores, with mean changes of 8.8 (s.d. 1.6) and 7.2 (s.d. 2.3), respectively. A mean post-operative flexion arc of 77° (range 30°–130°) was observed. All lower limbs were post-operatively aligned between 0° and 5° of mechanical valgus. Incomplete radiolucent lines were present in 27% of knees, but were not associated with clinical symptoms. Final SF-36, EQ-5D and WOMAC scores were relatively low, but 82% of patients rated themselves satisfied with the functional outcome, 100% with pain relief, and 100% stated that the outcome met or exceeded their expectations. Issues deemed by JRA patients to be important were identified by the PASI-pg questionnaire, but not by the SF-36, EQ-5D or WOMAC.

Conclusion: Knee arthroplasty provided relief of pain and stiffness and moderate improve-ment in range of motion in this uncommon and severely affected group of adult JRA patients who have end stage knee involvement. Although outcomes were scored poorly on established instruments, patients rated their satisfaction with and benefits of the operation highly.


COMPLICATIONS OF HIP SURGERY

Colin Howie

The Coach House, Glenbrook Road, Balerno, GB–Edinburgh EH14 7BE, Scotland


COMPLICATIONS OF KNEE SURGERY IN JIA

Karel J. Hamelynck

van Breestraat 52, 1071 ZR Amsterdam, The Netherlands

Surgical interventions may be needed in the treatment of JIA to overcome the local complica-tions of the disease: contractures, synovitis and bony deformity, or to replace the knee joint. Each intervention has its indication and complication.

Contractures: surgical treatment is necessary if conservative treatment has failed. The most important question is to correct where and how! Releases must be performed step by step. An important risk is to produce instability. Splinting must follow each correction.

Synovectomy: may cause unnecessary harm to the cartilage and the anterior cruciate liga-ment. Scars of incisions may have a negative influence on wound healing after a later total knee arthroplasty.

Osteotomy of the tibial head may be performed to correct flexion deformity. The negative effect on total knee replacement in the future must not be underestimated.

Total knee arthroplasty may be compromised by soft tissue problems like contractures and laxities, and bone problems like defects, subchondral cysts and osteopenia cq osteoporosis. Fixation of prosthetic components may be difficult in soft bone. Femoral condyles may be hyper- or hypoplastic causing valgus- or varus-malalignment. Correction may be difficult and the correct size of the femoral component questionable. There may be considerable doubt about the quality of ligaments. For that reason surgeons may consider the implantation of prostheses that are intrinsically constraint. That choice may be incorrect, as most of the rotational and shear forces encountered during walking will now be conducted directly to the bone-prosthesis interface and mechanical loosening is more likely to occur. The way the surgeon is solving the soft tissue problem is also crucial in the prevention of postop complications: over-release must be prevented, as these knees will certainly become unstable shortly after the implantation of the prosthesis. The true nature of the contracture may well be found outside the joint: the posterior superficial fascia. Cleaning the posterior compartment of the knee may be more important than performing a release.

In summary: Surgery is performed in JIA to correct contractures and bony deformity, to treat synovitis and to replace the knee. The correction of contractures may be difficult and should never result in instability. TKA is compromised by the poor quality of bone. In total knee arthroplasty prostheses with free anatomical motion relieving the stresses from the interface are preferred.


COMPLICATIONS OF SHOULDER AND ELBOW ARTHROPLASTY IN JUVENILE IDIOPATHIC ARTHRITIS

M. Thomas

Heatherwood &Wexham Park Hospital Trust, Berkshire, United Kingdom

There are no series of shoulder replacements in JIA reported in the literature. My own series consists of 15 cases (10 stemmed implants and 5 surface replacements), of which 5 required extra small implants to be made. The average follow-up time for the stemmed implants is now in excess of 6 years. 2 of these cases have developed rotator cuff tears within 2 years of sur-gery and one case required excision of an acromio-clavicular joint which was not done at the primary surgery. There has been no evidence of loosening and Constant scores have improved significantly in all cases.

Surface replacement of the shoulder has been carried out over the past 3 years in 5 patients in this group. To date there have been no complications from this operation at all.

Elbow arthroplasty in JIA has been reported twice in the literature with complication rates of 30 and 50%.

My own series consists of 12 elbow replacements (5 linked and 7 unlinked prostheses). 3 cases required customized small implants. Five cases had undergone previous surgery to the elbow.

Three patients developed a transient ulnar neuritis. One patient developed a triceps rupture which was repaired.

One patient developed an undisplaced fracture of the olecranon which was treated conserva-tively with an uneventful recovery.

Two unlinked replacements in the same patient developed tilting due to mal-alignment of the ulnar component. One remains asymptomatic but one was revised and required a short stem customized ulnar implant to correct the mal-alignment.

There are 2 cases of loosening. One elbow is loose at 5 years and awaits revision. Revision of one linked implant at 5 years for loosening was complicated by infection and this required salvage to an excision arthroplasty.

All but one complication occurred in patients who had undergone previous surgery to the elbow.


WRIST AND HAND COMPLICATIONS

P. Kopylov



OUTCOME MEASURES

M. Hazes

Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands


FUNCTIONAL ASSESSMENT OF THE UPPER EXTREMITY

J. Nagels and P. M. Rozing

Department of Orthopaedics, Leiden university medical center, Leiden, The Netherlands, [email protected]

Analysis of the complex movements of the shoulder girdle and the muscle forces acting herein requires a measurement technique that can simultaniously record kinematic and electromyo-graphic input data and ultimately give results that are interpretable in a clinical setting. Analysis of upper extremity function in the laboratory includes three-dimensional (3D) motion analysis, measurement of external generated force at the elbow or hand and electromyography (EMG).

An electromagnetic tracking device, the ‘Flock of Birds’ (Ascension technologies, USA) is used for 3D motion tracking. Sensors are attached onto the skin of the sternum, the distal humerus and the wrist. One sensor is attached to a tripod, which can be adjusted to fit onto three palpable bony landmarks of the scapula. Several standardised motions of the shoulder are then performed by the subject and processed using a computer, resulting in the joint angles of the different shoulder joints during the performed motions. This can be used for a statistical analysis of shoulder kinematics or serve as input for the Delft Shoulder Model, a computer generated model, which can predict the individual muscle forces and joint contact forces.

Isometric force measurements are obtained with 6D force transducer. A visual feedback crosshair controls the amount and direction of applied forces. Simultaneous EMG recordings from 12 shoulder muscles are acquired. After normalisation of the EMG data the ‘principal action’ of each individual muscle can be calculated. This is the direction of force in the plane perpendicular to the humerus, where a specific muscle had its highest EMG signal, indicating the prime function of a muscle per shoulder position.

A functional assessment of the upper extremity using these modalities helps in identifing spe-cific defects in shoulder conditions and provides the clinician with a tool to evaluate the success operative procedures.


QUALITY OF LIFE AFTER SHOULDER SURGERY

B. Simmen

Schulthess Clinic, Zürich, Switzerland


PATIENT GENERATED VERSUS STANDARD OUTCOME ASSESSMENT OF TOTAL HIP ARTHROPLASTY IN ADULT JUVENILE RHEUMATOID ARTHRITIS PATIENTS

B. M. Jolles1, E. R. Bogoch and D. E. Beaton1 Hôpital Orthopédique de la Suisse Romande,University of Lausanne, 4 Avenue Pierre Decker, 1005 Lausanne, Switzerland.

Purpose: The purpose of this study was to identify issues of importance to adult Juvenile Rheu-matoid Arthritis (JRA) patients before and after total hip arthroplasty, and to determine if these issues are included in standardized outcome measures that are widely utilized in evaluation of hip arthroplasty, particularly the Western Ontario and McMaster Universities Arthritis Index (WOMAC).

Methods: Adult JRA patients who underwent hip replacement between 1986 and 1999 in our institution participated in the study (n=31). Data gathered included patient demographics, a postoperative WOMAC questionnaire and the 5 last patient-generated items of the Patient Specific Index for total hip arthroplasty (PASI-pg). Data were gathered for post-operative and recalled pre-operative states.

Results: Issues deemed important by JRA patients could be grouped in four symptom areas (pain, joint motion, strength, discomfort) and five activity areas (light household, leisure, cloth-ing, sports, sex); some patients indicated they had no symptoms or difficulties. Before surgery, key issues as recalled by patients were principally symptoms, whereas at follow-up, patients primarily identified recreational and social activities as the issues of importance to them. Com-parison of the self-generated patient items and WOMAC items for outcome assessment revealed major differences. Almost all the items that patients deemed to be important and pre- and post-operatively in the PASI-pg questionnaire were not part of the WOMAC questionnaire. The shift in the PASI-pg towards more physically demanding activities after surgery indicates that patients improved, which is not reflected in the WOMAC. For the pain subscale scores, poor Spearman’s rank correlation coefficients of 0.53 were observed between PASI-pg and WOMAC.

Conclusion: The self-generated and self-reported portion of the PASI-pg questionnaire per-formed better in identifying issues considered to be important by the adult JRA patient with severe hip disease than the WOMAC. Standard outcome measures generally score the JRA patient low due to polyarticular and systemic ill health, rendering them less responsive to the benefits of a single joint intervention.


RESULTS OF 42 KUDO TOTAL ELBOW PROSTHESES FOR INFLAMMATORY DISEASE AT 5 YEARS OF MEAN FOLLOW-UP

C. Fontaine, C. Dos Remedios, C. Chantelot and F. Giraud

Orthopaedics B Department, Roger Salengro Hospital, Academic Hospital, 59037 Lille, France

Kudo prosthesis is one of the most spread non-constrained total elbow arthroplasties (TEA) (with the Souter–Stracthclyde). Kudo’s papers show good results and do not elaborate on complica-tions. Our series shows not so good results and we have thought they have to be described.

From 1992 to 1998, 35 patients mean aged 55 (28–76) years underwent 47 Kudo TEA (7 types II, 23 types III) for inflammatory disease (23 rheumatoid arthritis RA, 2 psoriasis arthritis, 1 juvenile arthritis), which had began 15 (2–44) years ago. 4 patients were lost for follow-up, 1 was dead, 30 patients (23 females, 7 males) with 42 TEA were available for retrospective study at 57 ±30 (6–114) months. In 24 cases, both humeral and ulnar implants were cementless, in 11 cases, the humeral implant was cementless and the ulnar one cemented, in 7 cases both implants were cemented.

Pain was improved (7.2/10 preop, 2.1/10 post-op); 2 permanent and 4 mild painful elbows corresponded with loosening. Mobility increased in flexion (111° preop, 123° post-op) and extension (-47° preop, -39° post-op). Mayo Clinic performance index was improved (32 bad and 4 fair preop, 16 excellent, 6 good, 6 fair but 8 bad post-op). At follow-up there were 4 humeral loosening, 5 ulnar loosening, 1 humeral and ulnar loosening.

Thirteen revisions were necessary: 7 for loosening (6 replacements with another Kudo implant, 1 replacement with a Coonrad-Morrey prosthesis), 4 for humeral implant fracture (Kudo Mark IV, 3 with loosening, 1 without), 2 early instability, 1 polyethylene and titanium synovitis due to major laxity, asymmetric load and wear, 1 removal for late infection without loosening.

Kaplan-Meier survival rates were 96.7% at 24 months, 89% at 42 months, 82% at 54 months, 77.2% at 62 months, 72.4% at 66 months and 60% at 84 months.

The Kudo prosthesis is a non-constraint non-anatomical TEA. The shape of the trochlea and the absence of radial head replacement expose the joint to early instability or progressive laxity with eccentric loading and asymmetric wear. Cementless fixation, even on the humeral compo-nent (as recommended by Kudo) is not always efficient.

Our survival rates are worse than those of Tanaka et al. (90% at 13 years) and Gallagher et al (97.6% at 5 years and 86.7% at 10 years) with the same Kudo prosthesis. They are worse than those of Ikävalko et al. (85% at 10 years), Souter (84% at 12 years), Trail et al. (87% at 12 years) and Rozing et al. (69% at 10 years) with the Souter-Stracthclyde prosthesis. They are worse than those achieved with semi-constraint prostheses. We do not recommend the use of the Kudo prosthesis. We now use a non-constraint but more anatomically designed prosthesis with radial head replacement.


LONG-TERM RESULTS AFTER GSB III ELBOW ARTHROPLASTY—EVALUATION OF ELBOW FUNCTION WITH A NEW ASSESSMENT SET

M. John1,2, F. Angst3), G.Pap2, M. P. Flury1, D. Herren1, H. K. Schwyzer1 and B.R. Simmen1

1 Schulthess Clinic, Zürich, Switzerland. [email protected] Department of Orthopaedics, Otto-von-Guericke University, Magdeburg, Germany3 Clinic for Rheumatology and Rehabilitation, Zurzach, Switzerland

In the evaluation of the major joints, self assessment tools have become wide spread aiming at a more precise quantification of joint function. For the elbow joint, different such tools have been developed. However, there are only few data on the relationship between subjective self-assessment of joint function and objective measures.

Therefore, we developed a comprehensive assessment set for the evaluation of elbow func-tion and objective clinical investigations. In a first study, we used this set for the assessment of long-term results after implantation of GSB III Elbow arthroplasties.

Material and Methods: 79 patients (56 female, 23 male, mean age 64 years), who were consecutively treated with cemented GSB III Elbow prosthesis between 1984 and 1996 due to rheumatoid (59) or posttraumatic (20) arthritis, were includet in this study. In 62 patients implantation was performed unilaterally and in 17 patients arthroplasties were implanted in both elbows, resulting in 96 elbow joints altogether. The mean follow up time was 11,2 years.

For the assessment of elbow function we used a newly developed evaluation set including the SF-36, the DASH, the PREE and the mASES (patients assessment part and clinical examina-tion part). All scores were fitted to a range of 0–100. The questionnaires were completed by the patients prior to the clinical examination.

Results: In the SF-36 score, the mean physical component scale (PCS) was worse (37.2 points vs 41.7 expected, p=0.004), the mean mental component scale (MCS) was better (52.3 points vs 50.3 expected, p=0.092) than normativ values of a german population. Subjective assessment of the elbow function by the PREE questionnaire revealed a mean of 66.8 points (pain: 71.2; function: 62.4) and 63.1 points (pain: 69.6; satisfaction: 81.0; function: 57.4) by the mASES. The DASH yieled a mean score of 56.5 points. Clinical examination resulted in a mean mASES score of 71.6 points (motion: 78.3; stability: 81.3; strength: 90.0; symptoms: 87.2). Comparison between the patients self assessment and the objektive score revealed a significant correlation between the DASH (r = 0.46, p < 0,001), PREE (r = 0.54, p < 0.001) and mASES (r = 0.60, p < 0.001) with the clinical mASES. In contrast, no significant correlation was found between the physical component scale (PCS) and mental component scale (MCS) of SF-36 and the clinical mASES. Also the patients assessment scores DASH, PREE and mASES showed a strong significant correlation among one another ( r = 0.74–0.92, p < 0.001) and with the physi-cal component scale (PCS) (r = 0.58–0.75, p < 0.001) but not with the mental component scale (MCS) of SF-36.

Conclusion: Assessment of long term results after elbow arthroplasty yielded favourable clinical and subjektive results. The clinical outcome tended to be higher than results of the patient self-rated scores. Hereby, the newly developed assessment set proved to be a feasible tool for a comprehensive assessment of elbow function. In addition to clinical outcome assess-ment, with this set it is possible to gain important and new insights on the relationship between objective measures and subjective patients-assessment of elbow disorders and postoperative conditions. For this, however, further studies will have to be conducted.


RESULTS OF THE KUDO TOTAL ELBOW ARTHROPLASTY IN PATIENTS WITH SEVERE DESTRUCTION OF THE ELBOW JOINT DUE TO RHEUMATOID ARTHRITIS—A 4–11 YEAR FOLLOW-UP OF 44 PROSTHESES

Rinze Reinhard, Margarita van der Hoeven, Maarten J. de Vos and Denise Eygendaal

Sint Maartenskliniek, Sint Maartenskliniek, Nijmegen, the Netherlands

Despite increased experience with total elbow arthroplasty there is no consensus whether to use an unconstrained or semi-constrained prosthesis in severely destructed elbow joints. In this study we evaluated the results of the Kudo type-4 unconstrained total elbow prosthesis in severely destructed elbows.

Methods: From 1990 to 1997 fifty-seven elbows in 45 patients with rheumatoid arthritis (RA) underwent a primary, non-cemented total elbow arthroplasty with use of the Kudo type-4 pros-thesis. All elbows were graded as Larsen III, IV or V. After an average of 7 (4.4–11.2) years, 34 patients (44 elbows) were available for clinical follow-up. The Mayo Clinic Performance Index for the elbow (MCPI) was used to classify the results. Anteroposterior and lateral radiographs of the operated on elbow were obtained in a standardised way at follow-up examination.

Results: According to the MCPI, 29 elbows were excellent or good and 4 were fair or poor. Four elbows had a limited range of motion and one patient had a superficial infection. Ulnar neuropathy occurred in 9 patients; 4 were operated additionally. Thirteen elbows (30%) needed a revision procedure for ulnar loosening (7), fractured humeral components (5) and for a frac-tured ulnar component (1). No (sub)luxations were seen.

Conclusion: Kudo unconstrained type-4 total elbow arthroplasty generally results in accept-able scores and function, without dislocation or instability. However, our study confirms high rates of ulnar neuropathy and revision procedures. Fatigue breakage of the humeral stem seems to be overcome by the development of the Kudo type-5 prosthesis. To prevent ulnar loosening we advise to use an extended ulnar stem and fixate the ulnar component with cement.


TOTAL ELBOW ARTHROPLASTY IN JUVENILE IDIOPATHIC ARTHRITIS

W. A. Souter1, L. Lockerbie2 and A. C. Nicol3

1New Edinburgh Royal Infirmary, 2Medical Statistics Unit, Edinburgh University, 3Bioengineering Dept., University of Strathclyde, Glasgow.

The elbow may be involved in some 30–40% of patients with JIA. Patients with severe involve-ment may present as potential surgical candidates in their late teenage years or early adult dec-ades. This paper presents a prospective study of 18 consecutive Souter-Strathclyde arthroplast-ies undertaken in 15 such patients operated on by one surgeon (WAS) over the past 20 years.

Methodology: Patient data were recorded on computerised charts pre- and per-operatively, at 6 months after surgery and annually thereafter. The cases fall into 3 groups:

Group 1: 6 patients (6 elbows) with complete bony ankylosis,Group 2: 6 patients (7 elbows) with major restriction of movement and with severe pain.Group 3: 3 patients (5 elbows) with severe pain and rapid joint destruction.Because of the growth disturbances which were frequently present, alterations to the opera-

tive technique were required in most cases e.g. small implants tailored to the individual patient, and techniques to deal with ankylosis and/or tight soft tissues.

Results: Group 1: In these 6 elbows, arthroplasty resulted in early restoration of painfree movement

(ROM) through arcs varying from 66°–100°. The 5 elbows available for longer follow-up (9–23 years), all remain painfree with varying arcs from 74°–105°. The patient followed for 23 years has shown some radiological loosening over the past 11 years.

Group 2: 6 of these elbows, with follow-up of 7–22 years, remain painfree with improvement in the mean ROM from 36°–76°. The remaining patient had a very successful clinical result for 10 years, but then suffered a heavy fall on the elbow with fracture and complete displacement of the prosthesis.

Group 3: One patient from abroad has been lost to follow-up. The other 4 elbow replace-ments in 2 patients have follow-ups ranging from 12–17 years. These all had good early painfree results with ROM increased from 73°–92°. 2 of the elbows later sustained humeral fractures at 7 and 12 years respectively but have been successfully revised using longer stemmed humeral components. A third elbow at 16 years is currently awaiting revision surgery for a similar prob-lem.

Conclusion: In JIA, elbow arthroplasty can be of great value. Implant longevity has been acceptable and revision possible because of the diaphyseal sparing design.


CONSERVATIVE SURGERY AT THE RHEUMATOID ELBOW

Karl Tillman

Rheumaklinik, D-24576 Bad Bramstedt, Germany

In case of insufficiency of painful inflammation of the elbow, surgery has to be considered. Just for young patients it is important to bear in mind the ways of retreat.

The first option in early cases should be synovectomy; arthroscopically or open. The question of superiority seems to be still unanswered and actually an individual decision, depending on the local situation and the personal experience of the surgeon.

In advanced cases we find a similar situation regarding the differential indication between resection arthroplasty and endoprosthetic replacement. Arguments of the sequence will be discussed, based on our experience and the result of four different prostheses and of resection interposition arthroplasty (long- and medium-term results).

Medium-term results of our actual technique of resection interposition suspension arthro-plasty in 12 joints, 5.0 (1.7–8.3) years postoperatively will be presented. The results, especially regarding the postoperative mobility, are amazingly good (gain of ROM +54° flexion/extension, on average), but the indication has to be very strict in order to avoid failures.

In case of failure, the retreat to a (preferably semiconstrained) endoprosthesis is not problem-free, but possible.


IPSILATERAL SHOULDER AND ELBOW REPLACEMENT

Farhan Ali

Wrightington Hospital, WN6 9EP / Wigan. U.K.

Patients with advanced rheumatoid arthritis who were managed with ipsilateral shoulder and elbow arthroplasties were reviewed to determine appropriate sequence of surgery, operative technique and thefunctional outcome.

Patients and methods: Between 1992 and 2002, twenty-two patients with advanced rheu-matoid arthritis underwent ipsilateral elbow and shoulder arthroplasties. Nineteen patients were available for final review. Clinical and radiological assessments were done on these patients.

Results: Twenty-four upper limbs in nineteen patients were reviewed. Mean age at final follow-up was 61 (50–73; SD 8.2) years. Mean duration of follow-up from the last operation was 56 months (12–129; SD 33). The average interval between the operations was 40 months; it was 41 months when elbow operated first and 39 months when shoulder was operated first. This difference was not significant (p=0.8).

All movements showed significant improvement after respective joint replacements. There was a significantly greater improvement in external rotation of the shoulder when it was oper-ated first (p=0.48). The average improvement in Constant-Murley scores was 28.8 points; with no statistically significant difference between either sequence of operations (p=0.5). However, there was statistically significant improvement in the average Mayo elbow performance score after the elbow arthroplasty when it was operated first (p=0.03).

Two patients needed conversion of shoulder hemi-arthroplasty to total shoulder replacement due to subsequent erosion of the glenoid. One elbow replacement was revised because of recur-rent dislocations. There were four patients who developed ulnar neuropathy, of which two were permanent. There were no peri-prosthetic fractures in this series. One patient needed custom-made short-stemmed shoulder prosthesis due to the presence of a long-stemmed humeral com-ponent of total elbow prosthesis in situ.

Conclusion: Ipsilateral shoulder and elbow replacements significantly improve pain and function of the limb, when there is advanced arthritis. The joint that appears clinically and radiologically worse should be replaced first. However, if both the joints are equally involved we feel that elbow should be replaced first as the functional improvement seems to be better. Careful preoperative planning is required in choosing the type and size of prosthesis, to avoid potential complications.


RESULTS OF TOTAL ELBOW ARTHROPLASTY WITH DISTAL ULNA RESECTION FOR PATIENTS WITH RA

K. Fujiwara, K. Nishida and H. Inoue

2-5-1 Shikata-cho, Okayama-city, Okayama 700-8558, Japan

Total elbow arthroplasty (TEA) has been recognized as a useful surgical intervention for the damaged RA elbow. The restriction of forearm rotation is one of the post-operative complaints by patients with destruction of the distal radio-ulnar joint (DRUJ). Therefore, we believe simul-taneous distal ulna resection (DUR) would be beneficial for such cases as long as radio-carpal joint is stabilized. In the current study, we report the surgical outcome of TEA+DUR.

Method: TEA by unlinked stem type almina ceramic (Okayama) elbow was performed on 169 RA elbows from 1986 to 2003. TEA+DUR was indicated for 12 elbows in 10 patients (1 men, and 9 women)(group A). For the control, we selected 5 elbows of 5 patients (group B) who received TEA without DUR. The wrists of these 15 patients had pain in the DRUJ, and were all classified into Type I (ankylosis type) according to the Schulthess classification. We evaluated surgical outcomes according to the Japanese Orthopaedic Association Elbow score (JOA elbow score); pain, function, range of motion (ROM), instability, valgus or varus deformity. Statistical analysis of the differences between the two groups was by Student’s t–test and ANOVA.

Result: JOA elbow score after surgery significantly improved in both groups. JOA score was increased from 45.1 to 77.7 points in group A and from 42.6 to 74.6 points in group B. Statisti-cal analysis showed that improvement in forearm rotation was significantly greater in group A (from 103.8 to 161.3 points) than in group B (from 83.0 to 117.0 points)(p=0.027). Complica-tions due to simultaneous resection of radial and ulnar heads didn’t occur in any case.

Conclusion: TEA + DUR combined surgery is a useful procedure for RA patients who have restriction of forearm rotation caused by both proximal and distal radio-ulnar joints as long as the radio-carpal joint is stable.


THE EFFECT OF CEMENT RESTRICTORS ON CEMENTED TOTAL ELBOW REPLACEMENTS

A. Hallett, C.R. Howie and W. A. Souter

New Royal Infirmary of Edinburgh, Little France, Edinburgh, Scotland

The aim of the study is to assess the effect of cement restrictors on Barracks grading achieved, the development of a complete 1mm radiolucency and revision rates in primary cemented total elbow replacements (TERs) in adult rheumatoid patients.Methods: We reviewed 150 consecutive primary TERs in patients with adult rheumatoid

arthritis. Group A consisted of 75 elbows immediately prior to the introduction of cement restrictors and Group B 75 elbows with cement restrictor. Grade of disease was determined from preoperative radiographs and Barracks grade on first available postoperative radiographs. All postoperative radiographs were assessed for the development of a complete 1mm radiolucency, all by the same assessor. All revised elbows were reviewed and survival data produced.Results: There were 53 patients (44 female) with a mean age of 60 years in Group A and 49

patients (27 female) with a mean age of 59 years in Group B. The mean follow up was 10 years in Group A and 8 years in Group B. The dominant side was replaced in 41 elbows in Group A and 36 in Group B.

The use of a cement restrictor did not seem to have an effect on the ulna but an improved Barracks grading was seen on the humerus (90% A/B with cement restrictor and 80% A/B without).

11 elbows developed a complete 1 mm radiolucency in Group A compared with only 8 in Group B. However revision rates for aseptic loosening were very similar in both groups (4 versus 5). Conclusion: The use of a cement restrictor in cemented TER does not appear to have demon-

strable effect on the ulna but there is an improved cement mantle in the humerus and a reduction in the development of a complete 1mm radiolucency.


CAUSES OF RECURRENCE OF ULNAR DRIFT AFTER MP JOINT ARTHROPLASTIES

Alberto Lluch


Recurrence of ulnar inclination of the fingers is the most frequent complication after MP joint arthroplasties. There is no single cause for the deformity, but rather a combination of several factors, and the relative importance of each of them is difficult to determine. The following have been described as contributing to ulnar drift of the fingers in the rheumatoid hand:1. Gravity.2. Thumb pressure.3. Morphology of the metacarpal heads4. Length of the collateral ligaments5. Radial inclination of the wrist6. Pull of the flexor tendons7. Intrinsic muscle spasticity or retraction8. Dislocation of the extensor tendons.

Radial inclination of the wrist has classically been described as the main cause of ulnar incli-nation of the fingers at the MP joint level. However, when only the wrist is involved, the meta-carpals always deviate towards the ulnar side. Radial inclination of the wrist is only seen in the presence of an ulnar drift of the fingers. When the finger deformity is surgically corrected, the radial inclination of the wrist tends to spontaneously correct, unless the deformity has already been fixed from capsular or bone remodelling. From our clinical and radiological studies we concluded that the radial inclination of the metacarpals is a volitional deformity made by the patient in order to get the fingers aligned with the long axis of the forearm, for aesthetic and functional purposes.

Pull of the flexor tendons can bring the index finger into ulnar inclination, particularly in cases where the proximal pulley is elongated from underlying flexor tendon sinovitis. However, the ulnar drift usually starts and is more evident in the ring and small fingers, where the pull of the flexor tendons will tend to deviate them towards the radial side.

The most important factors seem to be the ulnar dislocation of the extensor tendons towards the ulnar side of the MP joints, and the secondary remodelling in a shortened position of the intrinsic musculature.

The most important surgical step to prevent recurrence of ulnar drift is a good reconstruction of the soft tissues around an MP joint arthroplasty: release of the shortened ulnar sagital band and plication of the radial sagital band in order to maintain the extensor tendon dorsal to the joint during joint flexion. If extensor tendon gliding is restricted, flexion of the MP joints will tend to dislocate the extensor tendons towards one side of the arthroplasty, usually the ulnar side. Lim-ited extensor tendon gliding is often present in the rheumatoid hand, either from adhesions at the dorsum of the wrist secondary to previous surgery, or because the muscle mass has remodelled in a shortened position after a prolonged finger deformity. Release of shortened ulnar intrinsic muscles is also very important. Cross intrinsic transfer, although it is often recommended, the practical benefit is debatable. Most important, although difficult to achieve in some patients, is the correction of the radial inclination of the wrist and the strengthening of the radial intrinsic muscles to each individual finger, mainly the first dorsal interosseous muscle.


DETERMINANTS OF RANGE OF MOTION IN UNCONSTRAINED SHOULDER ARTHROPLASTY

J. Nagels, M. Stokdijk and P. M. Rozing

Department of Orthopaedics. Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands. [email protected]

A normal range of motion (ROM) is seldom regained after shoulder arthroplasty, even despite an anatomical reconstruction. The goal of this study was to identify the factors determining the ROM after shoulder arthroplasty. In 102 shoulders, 26 with osteoarthritis and 76 with rheuma-toid arthritis, the ROM of the shoulder of each patient was assessed pre-operatively and post-operatively at regular follow-up moments. The relative medio-lateral and cranio-caudal position of the geometric centre of the humeral head with respect to the humerus and the scapula were expressed by four ratios, obtained from measurements on true-antero posterior radiographs. An analysis of variance was performed, where the mean post-operative ROM was a function of the pre-operative ROM, the four ratios describing geometry, the per-operative status and quality of repair of the rotator cuff and the use of a glenoid component.

Post-operatively the ROM improved in all patients. In the osteoarthritic patients a relative medial position of the humeral head centre with respect to the humeral shaft and a relative lateral position of the humeral head in relation to the scapula resulted in significantly better abduction, anteflexion and external rotation. It is proposed that this is due to larger lever arms of several shoulder muscles. Using a slightly smaller head diameter while maintaining head thick-ness will result in a medial position of the geometrical centre in relation to the humeral shaft. In the rheumatoid patients, a limited pre-operative ROM and a superior articulation lead to significantly poorer outcome. Changes in geometry of the glenohumeral joint had no significant effect. Poor soft tissue conditions in this patient group are likely to be the cause. An improve-ment in ROM can be expected when rheumatoid patients are operated before the motion of the shoulder is severely impaired.


IS OPEN SYNOVECTOMY FOR RHEUMATOID ELBOW AN EFFECTIVE OPERATION?

N. Nakagawa, S. Abe, Y. Saegusa, S. Imura, H. Kubo, Y. Nishibayashi and S. Yoshiya

Saijo 1545-1, kanno-cho Kakogawa 675-8545, Japan

Rheumatoid arthritis is the most common cause of elbow arthritis. Although clarified. The purpose of this study is to evaluate the long-term effectiveness of the synovectomy elbow synovectomy is considered to be an effective treatment option for patients with RA, sequential time-dependent results of this procedure have not been of the rheumatoid elbow.

Materials and methods: From 1988 to 1995, 21 elbow joints in 18 patients with symptoms caused by RA were treated with open synovectomy. We reviewed 15 elbow joints in 12 patients (2 males and 10 females, mean age: 51.5 years, raging from 38 to 66 years) both clinically and radiographically. The mean time from operation to the most recent follow-up was 8.7 years (range: 5.8–12.6 months). The Mayo Clinic performance score was used to assess the clinical results. The elbow joints were evaluated at two time points with the average follow-up periods of 4 and 8.7 years.

Results: Clinical evaluation with the Mayo Clinic performance score showed significant postoperative improvement at both of the two time periods, while radiological grading did not deteriorate with time.

Conclusion: The results of this study suggest that open elbow synovectomy should be con-sidered as a reliable procedure as an option for surgical treatment of the rheumatoid elbows even in advanced cases.


TISSUE MARKERS AS TOOLS FOR DISEASE MONITORING IN ARTHRITIS

T. Saxne

Department of Rheumatology, Lund University Hospital, Lund, Sweden.

Cartilage continuously remodels in a finely tuned balance between matrix synthesis and deg-radation. In joint disease, the balance is shifted towards degradation in established disease. As a consequence of the disturbed matrix turnover, increased amounts of macromolecules or fragments thereof are released into synovial fluid and the blood stream. This scenario forms the rationale for efforts to identify alterations in the tissue by quantifying matrix macromolecules, ”molecular markers”, in body fluids by immunoassay with the purpose to define non-invasive methods to monitor pathological tissue processes.

Analyses of such molecular markers, e.g. cartilage oligomeric matrix protein (COMP), are currently explored for diagnostic and prognostic purposes and for monitoring effects of therapy on cartilage. Increased release of tissue markers indicates upregulated tissue turnover which, if persistent and not compensated by repair, eventually will lead to permanent joint damage. Thus, increased release of cartilage macromolecules represents a potential prognostic indicator of future cartilage destruction. Delineating the fragment pattern will also aid in identifying the enzymes responsible for the tissue breakdown which will facilitate the design of agents that block destructive pathways in joint diseases.

Molecular markers for cartilage involvement are important biological measures of disease processes and mechanisms and promise to be very important instruments in the routine care of patients with joint diseases in the future.


RADIOLOGICAL PROGRESSION AND THE USE OF DMARD, THE PAST AND THE FUTURE

M. Hazes

Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands


JUVENILE IDIOPATHIC ARTHRITIS: COMPLICATIONS OF DISEASE AND TREATMENT

R. ten Cate

Leiden University Medical Center, the Netherlands

Juvenile Idiopathic Arthritis (JIA) is one of the commonest chronic diseases of childhood with major impact on many aspects of life. Chronic inflammation not only affect the joints but has systemic consequences as well. Growth retardation and osteoporosis are well recognised and are aggrevated by the use of systemic glucocorticosteroids. Growth hormone and bisfosfonates are currently studied.

Local growth abnormalities may lead to leg length discrepancy, valgus or varus deformation and can have a negative effect on the placing of prosthesis in later life.

Intensive immunesuppression, especially in combination treatments and with the use of the biologicals has brought back rare infections such as tuberculosis.

Visual impairment or even blindness can be the outcome of chronic anterior uveitis mainly in children with oligoarticular JIA with circulating antinuclear antibodies.

Dental malalignement and jaw malformation are frequently seen and not only in children with a polyarticular course of the disease but also in oligoarticular JIA.

All children with JIA are at risk for psychosocial problems that warrant intensive begeleiding form the onset of the disease.

A child with JIA needs to be treated by a team of medical specialists and allied health profes-sionals that has expertise on all aspects of the disease.


THE DEVELOPMENT OF A CLASSIFICATION SYSTEM OF FOREFOOT DISORDERS IN RHEUMATOID ARTHRITIS

P. F. Doorn, J. W. K. Louwerens, M. C. de Waal Malefijt, J. van Limbeek, P. van ’t Pad Bosch and R. Laan

P.O. Box 9011, 6500GM, Maartenskliniek, Nijmegen, The Netherlands

Objective of study: A reproducible classification system concerning forefoot disorders in patients with rheumatoid arthritis is so far still lacking. Such a classification system is neces-sary in order to perform prospective clinical studies. Forefoot disorders are usually classified according to the degree of erosive/degenerative radiographic changes. However, it is likely that biomechanical changes related to pathology of the lesser MP-joints, rather than the presence of erosions of these joints as such, are the cause of complaints. Purpose of the present study is, the development of a classification system of forefoot disorders based on the grade of deformity of the MTP joints and the quality of the plantar soft tissue support. Reproducibility and clinical relevance of the classification is determined.

Materials and methods: A classification system was set up based on clinical experience and literature. 94 Patients with rheumatoid arthritis and without active synovitis of the foot joints were included by rheumatologists. The patients were graded by two different orthopaedic sur-geons and twice by one of the surgeons. In addition, patients filled out a VAS pain score, the Foot Function Index, and plantar foot pressures were measured. The inter-and intraobserver variability was statistically determined, as well as the relation between the different grades according to the classification and the pain score, function score and plantar foot pressures.

Results and conclusions: The intraobserver analysis shows an intraclass correlation coef-ficient of 0.96 (scale 0 to 1), the interobserver analysis shows a kappa of 0.86 (scale –1 to 1). Analysis with respect to pain, function and plantar foot pressures shows a trend towards more pain, less function and higher pressures at the plantar aspect of the foot with higher grades of dislocation in the joints. In conclusion, the developed classification system is reproducible and seems to be clinically relevant.


THREE-DIMENSIONAL RHEUMATOID WRIST DEFORMITY AND THE RISK OF EXTENSOR TENDON RUPTURE

H. Ishikawa, A. Murasawa and K. Nakazono

Rheumatic Center, Niigata Prefectural Senami Hospital, Senami Onsen 2-4-15, Murakami, Niigata 958-0037, Japan

Purpose: The purpose of this study was to clarify the concrete objective conditions of the extensor tendon rupture using a 3DCT (three-dimensional computed tomography) image of the rheumatoid wrist.

Patients and methods: Sixty rheumatoid wrists, which underwent operative treatment for active synovitis with/without extensor tendon rupture, were included in this study. Twenty-eight wrists had a rupture of more than one of these extensor tendons, EDCIII, IV, V or EDM. In the remaining 32 wrists, there was no extensor tendon rupture. Preoperatively, a 3DCT image of the affected wrist was taken with the forearm in maximal pronation, the wrist in neutral, and the fingers extended. The first 3DCT image was constructed to see the dorsal aspect of the wrist from the tip of fingers proximally oriented in a 10-degree angle to the frontal plane. The second image was constructed to see the lateral aspect of the wrist from the ulnar side, determined by the shape of the radius. Using these two images, dorsal subluxation ratio (DSR) of the ulnar head and carpal supination angle (CSA) were measured.

Results: In the group with extensor tendon rupture, the mean DSR was 35% and the mean CSA was 16 degrees, whereas in the group without extensor tendon rupture, the mean DSR and CSA were 20% and 9 degrees, respectively. There was a significant difference in the DSR and CSA between the two groups. If the DSR was over 40% and/or the CSA was over 10 degrees, the incidence of tendon rupture increased to 51%, and these values were considered to have a critical meaning in the risk of rupture.

Conclusion: With the use of a 3DCT image of the rheumatoid wrist, the risk of extensor tendon rupture can be predicted.


PATIENTS’ EXPECTATIONS BEFORE RHEUMA SURGERY

Anna Nilsdotter1, Kaisa Mannerkorpi2, Linda Strand3, Urban Rydholm3

Spenshult Hospital for Rheumatic Diseases, Halmstad1, Department of Rheumatology, Sahl-gren University Hospital, Göteborg2, Department of Orthopaedics, Lund Uiversity Hospital, Lund3, Sweden

Objective: To investigate, in a pilot study, the expectations before rheuma surgery in patients with RA.

Methods: 27 patients (24 women, mean age 52), with RA were operated on at the Department of Orthopaedics at Lund University Hospital. 24/27 were operated on in the lower extremity.

The patients were investigated preoperatively with the generic measurement SF-36 and the disease specific instrument HAQ. They also responded to four questions concerning expected pain relief, relief in other symptoms, improvement in activity of daily living and in sports and recreation functioning. The alternatives were much better, better, same, worse and much worse.

Results: 25 of the patients responded to all questions. Their preoperatively mean HAQ score was 1.29. Their mean scores (0-100, worst to best) in the SF-36 subscale Physical Function was 32, Role Function, Physical 33, Bodily Pain 36, General Health 45, Vitality 47, Social Function 63, Role Function, Emotional 63 and Mental Health 71.

64% of the patients expected much less pain, 48% expected much less other symptoms, 28% expected much better ADL function and 20% expected much better sport and recreation func-tion following rheuma surgery.

Conclusion: Patients with RA assigned for orthopaedic surgery seem to be most concerned about pain relief. The SF-36 scores also indicate that the patients’ physical function, pain and general health were more deteriorated than their social function and mental health. When fol-lowing these patients prospectively we will have the opportunity to find out whether expecta-tions and perception of health influence the outcome after rheuma surgery.


SURGERY IN ACROMELIC ARTHRITIS—DORSAL AND PALMAR WRIST, HAND AND FOREFOOT

F. Welby and J.Y. Alnot.

Service de chirurgie orthopédique et traumatologique, département de chirurgie du membre supérieur, chirurgie nerveuse périphérique, chirurgie de la main, Hôpital Bichât, 46 rue Henri-Huchard, 75877 Paris cedex 18, France.

Purpose of the study: Few patients with rheumatoid arthritis present isolated acromelic bone and joint destructions. Concerned joints are wrist, MP, PIP, DIP and forefoot. The aim of the current study is to evaluate the long-term results of wrist-, hand- and forefoot- surgery in an acromelic arthritis group.

Material and methods: 93 patients with acromelic arthritis were included in the study. 202 surgical procedures were performed between 1981 and 2001 in addition to medical treatment. 93 procedures concerned dorsal wrist surgery. The mean follow-up of this group was 5.2 years (7 months to 17.3 years). 78 synovectomies of radio-carpal and medio-carpal joints with a Sauvé-Kapandji procedure (SK) were performed and 10 with a radio-lunate arthrodesis (RLA) and 5 with other surgeries. The main indication for surgery was severe pain. 17 dorsal wrist procedures were accessed with a more than 10 years follow-up (4 with RLA – 13 with SK).

Results: Functional results and radiographic evolution (Larsen X-ray classification) were studied. All patients were satisfied or very satisfied and pain was significantly reduced. The global wrist motion decreased from 67° (before surgery) to 64° (at review). Radiographic lesions progressed but Larsen’s stage remained unchanged in 73% of patients. All patients with forefoot surgery recovered total walk autonomy.

Discussion: Acromelic arthritis is a particular form of rheumatoid arthritis that progresses very slowly. Surgery should be indicated earlier, for a better joint function stabilisation.


INCREASED RISK OF EARLY DISLOCATION AFTER PRIMARY TOTAL HIP ARTHROPLASTY IN RHEUMATOID ARTHRITIS

H. C. Doets1, R. E. Zwartelé1 and R. Brand2

1 Slotervaart Hospital, Amsterdam, The Netherlands. [email protected] Leiden University Medical Center, Leiden, The Netherlands

Patient-related risk factors of dislocation after total hip arthroplasty (THA) that have been identified are previous hip surgery, old age and female gender. However, there have been no prospective reports whether rheumatoid arthritis (RA) is an independent risk factor.

Materials and methods: Prospective evaluation of the incidence of early (< 2 year post-surgery) dislocation in a consecutive series of primary THA. From 1996 to 1999 341 THA in 311 patients with primary or secondary osteoarthritis (OA) and 70 THAs in 60 patients with RA were included in this study. One type of prosthesis having a 28 mm ball head was implanted in every hip through an anterior appoach.

Results: Both groups were comparable with respect to the following risk factors: gender, position of the acetabular component and experience of the surgeon. Average age was lower in the RA group than in the OA group: 61.0 vs 68.1 years. Furthermore, the incidence of previous hip surgery was higher in the OA group. Despite this, the incidence of dislocation was higher in RA than in OA: 10% vs. 2.9% (p=0.006). Multivariate analysis showed that RA is an indepen-dent risk factor for dislocation (Odds Ratio 3.7, 95% CI 1.3–10.6). All dislocations in RA where posterior, in OA 5 were posterior and 4 were anterior (1 unknown).

Conclusion: Rheumatoid arthritis is an independent risk factor of dislocation after THA. Both the polyarticular impairments and the lower quality of the soft tissues in RA could explain this increased risk.


NO MECHANICAL FAILURE OF A HA-COATED PRESS-FIT CUP IN PRIMARY TOTAL HIP ARTHROPLASTY FOR OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

H. C. Doets, P. G. M. Olsthoorn, R. G. Pöll

Slotervaart Hospital, Amsterdam, The Netherlands. [email protected]

Purpose: To evaluate the results of a novel modular press-fit acetabular cup in primary total hip arthroplasty (THA) for osteoarthritis and rheumatoid arthritis (RA).

Materials and methods: From February 1996 to December 1999 in 381 patients (292 women, 89 men) 423 primary THA using a novel cup has been carried out. The titanium shell is non-hemispherical on cross-section and has a hydroxyapatite coating on porous titanium for osseointegration. Diagnosis was: primary osteoarthritis (OA) 282, developmental dysplasia 26, posttraumatic arthrosis 33, avascular necrosis 6, inflammatory arthritis (mainly RA) 76. Aver-age age at operation was 66 (15–89) years. The patients were studied prospectively using Harris Hip Score (HHS), by measuring any radiolucency around the cup and by looking for signs of migration.

Results: Median follow-up was 5.5 years. At follow-up, 35 patients had deceased and 4 were lost to follow-up. Revision for infection was carried out in 5 hips (3 low-grade infections). No loosening occurred with low-grade infection. Recurrent dislocations required revision of 2 cups. Only 1 cup in a RA patient with severe superior bone loss became unstable after a fall 4 months postoperatively. Survival with aseptic loosening of the cup as endpoint was 100% in OA and 98% (95% CI 96–99%) in RA. In all 376 THA in follow-up the cup was functioning well, both clinically and radiographically. HHS increased from 44.5 preoperatively to 90.4 at follow-up in OA and from 39.2 to 88.1 in RA. No signs of migration such as tilting of the cup or the develop-ment of radiolucencies in zone 3 were noticed.

Conclusion: Press-fit fixation using a modern acetabular component is an excellent treatment option in primary total hip arthroplasty for both osteoarthritis and rheumatoid arthritis.


CUSTOM MADE ENDOPROSTHESES—POSSIBILITIES, TECHNIQUES AND LIMITATIONS

R. Nassutt, I. Hartung and H. Grundei

ESKA, 23556 Luebeck, Germany

Rheumatoid arthritis often demands endoprosthetic joint replacement at very early ages. Due to still limited lifetime of today’s implants multiple revisions and osteoporotic reactions cause severe bone substance loss. To maintain mobility and life quality for these patients special implants are necessary which originally were designed for tumor cases.

The authors present the latest technologies in custom made revision and tumor implants, from design over manufacturing processes to implantation techniques and legal issues. Additionally CAS is considered for future prospectives. The use of the described implants is shown by sev-eral cases.

Generally, patient specific implants for joint replacement can either be combined from a set of standardized implant components or they are completely custom made. Revision and tumor sets are designed in modular structure containing a large variety of articulating, connecting, extension, and stem components. This allows to construct intraoperatively either stable joint reconstructions or complete femoral and tibial replacements including artificial hip and knee joints. One of the central requirements is a durable soft tissue connection to achieve satisfying function and long term stability.

Custom made implants mostly represent acetabular or pelvis reconstructions. According to European guideline 93/42/EWG these implants have to be ordered by the surgeon - planned, designed and manufactured only for the individual patient. Today’s designing tools base upon a five axes milling machine and multiple CAS systems. The mill is used to machine 3D foam models based on CT data. Supplementary computer based planning and simulation applications allow to prepare best fitting implants and tools within a minimized period of time.


INDIVIDUAL UNCEMEMENTED FEMORAL COMPONENTS IN HIP ARTHROPLASTY—A PROSPECTIVE CLINICAL STUDY

Pål Benum, Arild Aamodt, and Kristin Haugan

Norwegian Orthopaedic Implant Research Unit, Orthopaedic Department, Trondheim University Hospital, Trondheim, Norway.

At the beginning of the 1990-ies the results after using uncemented femoral stems were rather disappointing. To optimize the stability of the stems, the strain distribution to the femur, and the biomechanics of the hip in uncemented femoral components a CT-based individual femoral stem (Unique SCP) was developed. The individual stem has now been in clinical use for more than 8 years. The aim of this paper is to present the preliminary results of a prospective clinical study of this type of stem.

Patients and methods: The prostheses are designed to obtain a femoral neck anteversion of 10 degrees after insertion, optimized medial femoral head offset and correction of leg length discrepancies up to 3 cm. The surgeon takes part in the planning of the center of the femoral head, this is now done over the internet. The stem is coated with a porous layer and HA down to an area 1–2 cm below the lesser trochanter. 352 hips have been operated, 7.1 % of the patients had rheumatoid arthritis or Mb. Bechterew. Mean age of the patients was 51.5 (24–66) years. 39.2 % of the hips were dysplastic. All patients have been followed radiologically and clinically; 104 for 3 years, 64 for 5 years and 19 for 7 years. Merle d’Aubigné score was used. RSA and DEXA-studies have been performed in some groups of the patients.

Results: We have experienced that the use of this type of prosthesis offers obvious advan-tages in patients with abnormal size and geometry of the upper femur. An intraoperative fissure in the proximal femur occurred in 3 patients (0.9 %), they were treated successfully with wires. Two patients sustained a late periprosthetic femoral fracture (0.6%). A dislocation of the joint occurred by severe injuries in three patients (0.9 %), all these joints have been stable after non-operative reduction. Mean total score at 3, 5 and 7 years was 17.04 (preop. 9.33), 17.19 (preop. 8.37) and 17.31 (preop. 9.21), respectively. The pain scores at the corresponding observations were 5.63 (preop. 2.71), 5.75 (preop. 2.79) and 5.84 (preop. 2.58). There have been no radio-logical signs of aseptic loosening. DEXA-studies in a group of patients have shown good pres-ervation of the femoral bone stock in most of the hips. RSA has shown no significant migration of the stems.

Conclusions: Individual femoral stems give good results up to 7 years postoperatively. Mechanical complications are rare.


COATING OF BONE TRANSPLANTS WITH ANTI-RESORPTIVE AGENT—A NOVEL TREATMENT OF THREATENING JOINT COLLAPSE. ANIMAL EXPERIMENTS AND A CASE STUDY

M. Tägil U. Rydholm and J. Åstrand

Lund University Hospital 221 85, Lund, Sweden

After osteonecrosis, bone resorption often lead to collapse in load bearing areas. Bisphospho-nates are potent osteoclast inhibitors and might protect the subchondral bone from collapse and maintain the joint architecture during remodeling. To test this hypothesis, we used a rat bone chamber model to subject an osteochondral graft to a large mechanical load during remod-eling.

In Systemic Lupus Erythematosus (SLE) the femoral head sometimes turns necrotic. After osseous decompression the joint collapse often progresses. We report a clinical pilot case with intracapital impaction grafting using zolendronate impregnated bone allografts.

Methods: Cylindrical osteochondral grafts were taken from the patellar groove of rats. The grafts were flushed with alendronate solution and placed in titanium bone chambers, inserted into the proximal tibia of rats. After two weeks the transplanted osteochondral plugs were mechanically loaded for 4 weeks, once a day with ten cycles of a 2 MPa at 0.16 Hz.

Results: At harvest, the graft length had decreased during remodeling in 5 of the 6 untreated controls, but only in 2 out of 8 alendronate treated rats (p=0.05). Histologically, the bone graft in the non-treated controls was resorbed in the remodeled part of the graft, whereas in the alen-dronate treated a dense trabecular bone was found.

Discussion: In conclusion, local treatment of the graft by bisphosphonate diminishes the risk for collapse during revascularization in a mechanically loaded osteochondral graft in rats. A 19-year-old woman with SLE and bilateral caput necrosis was operated with a transcervikal decompression of the femoral head. The burr canal was filled with bank bone allografts up to the subchondral bone plate. To prevent the collapse that might occur as the allograft bone is successively revascularized and remodeled, the graft was washed for five minutes in zolendro-nate solution (Zometa® 4mg/5ml, Novartis). At present no signs of femoral head collapse can be seen.


ANKLE AND FOOT SURGERY: GENERAL ASPECTS

J. W. K. Louwerens

P. O. Box 9011, 6500 GM, Maartenskliniek, Nijmegen, The Netherlands

Beginning at the ankle joint and descending to the forefoot, the indications and results for standard surgical procedures to treat rheumatoid foot deformities are discussed. Selected new developments are also presented.

Much is to say in favour of total ankle joint replacement when treating the rheumatoid patient. A 9-year survival rate of 83% has been reported for this technically demanding procedure. Although the starting conditions are often less favourable than those for arthrosis patients, no important difference in outcome has been reported at the 5-year follow-up. The alternative, a fusion of the ankle joint, remains the standard salvage procedure in case for severe deformity, post-infection, failed ankle prosthesis, etc. For the ‘nearly ankylosed’ , but ‘well-aligned’ ankle joint, arthroscopic or percutaneous techniques should be considered.

Tarsal or midfoot problems are most often treated by arthrodesis of one or more joints (with correction of alignment if necessary). The functional results of isolated subtalar fusion are superior to those after triple arthrodesis. Collapse of the medial longitudinal arch with valgus deformity is commonly seen in rheumatoids. When this valgus deformity is still fully flexible, reconstructive procedures should at least be considered. At present the union rate after triple fusion should be around 95%, with good to excellent outcome in approximately 80%. Persisting malalignement can cause important problems and makes the possibility for a future total ankle joint replacement unlikely.

Resection arthroplasty of the lesser MP joints is still the standard procedure for operative treatment of forefoot deformity. Fusion of the 1st MP joint is now widely advocated. It is sug-gestedf that reconstruction of the lesser MP joints might give better functional results than resection arthroplasty. During the present ERASS meeting, a forefoot classification system will be introduced. This system is based on the amount of deformity and not the extent of joint destruction.


CLINICAL OUTCOME AND GAIT ANALYSIS AFTER MOBILE BEARING TOTAL ANKLE ARTHROPLASTY

H.C. Doets1, R. Brand2, M. Middelkoop3, H. E. J. Veeger3, R. G. H. H. Nelissen2

1 Slotervaart Hospital, Amsterdam, The Netherlands. [email protected] Leiden University Medical Center, Leiden, The Netherlands3 Free University, Amsterdam, The Netherlands

Total ankle arthroplasty (TAA) is an alternative for ankle arthrodesis in the treatment of the severely affected ankle joint. As arthrodesis leads to a disturbed gait we prefer to carry out TAA, especially for patients with inflammatory arthritis (IA).

Material and methods: From 1988 to 1999 a prospective study on primary TAA using a mobile bearing prosthesis was carried out in a consecutive series of 93 ankles in 76 patients having IA (mainly rheumatoid arthritis). Survival curves were calculated and a logistic regres-sion analysis was carried out for the risk factors: gender, age at surgery, tibial component posi-tion and an ankylosis of the hindfoot.

Separately, a 3-D kinematic analysis was carried out in 10 patients with a successful TAA and 10 matched controls.

Results: AOFAS ankle score increased from 27 to 78 at 1 year after surgery, dorsi-plan-tarflexion from 4-22 to 7-25 at 1 year. In 2004, 15 TAA had failed for the following reasons: deep infection 2, wound necrosis 1, varus or valgus deformity 6 and aseptic loosening 6. Mean overall survival at 8 years with revision for any reason as an endpoint was 83%, when a tibial component of correct size was implanted 91%. With logistic regression analysis, no risk factor for failure could be identified as being significant, only ankylosis of the hindfoot showed a trend to significancy.

Gait analysis showed no significant differences in motion of the knee, ankle and midfoot during level walking compared to controls. Only velocity was slightly reduced.

Conclusions: Mobile bearing TAA provided a satisfactory result at medium- to long-term follow-up if preoperative alignment was good and if a prosthesis of proper size was implanted,. Aseptic loosening, persistent deformity and disturbed wound healing were the most important modes of failure. During level walking, a near-normal gait pattern could be demonstrated.


THE RHEUMATOID FOREFOOT: LONG TERM RESULTS OF THE STAINSBY FOREFOOT ARTHROPLASTY

Peter J Briggs

The Freeman Hospital, Newcastle upon Tyne, England

Excision of the prominent metatarsal heads for rheumatoid forefoot deformity is well estab-lished in clinical practice. Although early clinical results may be satisfactory, deterioration with time is often seen with recurrent plantar callosities and toe deformities.

The Stainsby forefoot arthroplasty is designed to preserve all metatarsal heads and reposi-tion the plantar plates and forefoot fat pad underneath them. The procedure will be briefly described.

Long term results in 41 feet in 29 patients using this procedure are presented. Complete pain relief is reported in 93% of feet and maintained at up to eleven years follow up. The need for chiropody skin care reduced from 63% pre-operatively to 7% at review (p < 0.001). The need for orthoses and specialist footwear are similarly reduced. Five year results show a reduction of forefoot peak pressures and improved gait parameters.

Stainsby’s method of forefoot arthroplasty recognizes the function and importance of the plantar plate, plantar aponeurosis, and fat pad in the pathology of claw toe deformity. Pain relief is excellent and maintained in the long term because the fat pad is in the correct weight-bearing position as metatarsal length is preserved. It is not necessary to remove the metatarsal heads.


PERCUTANEOUS ARTHRODESIS OF THE ANKLE IN PATIENTS WITH RHEUMATOID ARTHRITIS

H. Lauge Pedersen


It has been generally accepted that residual cartilage and subchondral bone has to be removed in order to get bony fusion in arthrodeses. In 1998 we reported successful fusion of 11 rheu-matoid ankles, all treated with percutaneous fixation only. This method is restricted for ankles with normal or at least functional alignment. Animal studies confirmed that it is possible to achieve arthrodesis without removal of cartilage and that synovial depletion is the possible mechanism behind cartilage disappearance. The stability of the fixation achieved at arthrodesis surgery is an important factor in determining success or failure. A good fit of the bone surfaces appears necessary. The results of our biomechanical studies, indicates that the arch shape and the subchondral bone should be preserved performing ankle arthrodesis. The importance of this is likely to increase in weak rheumatoid bone. Overall, inserting the two screws at a 30 degree angle with respect to the long axis of the tibia, and crossing them above the fusion site improves stability for ankle arthrodesis.

In conclusion the percutaneous technique is suitable for patients with rheumatoid arthritis and a painful ankle with complete loss of joint space, but with no deformity to correct.


REVISION OF FAILED ANKLE ARTHROPLASTIES

Å. Carlsson1, T. Anderson1, U. Rydholm2 and J. Besjakov1

1 Dept. of Orthopaedics and Clinical Radiology, Malmö University Hospital and

2 Dept. of Orthopaedics, Lund University Hospital, Sweden

Between 1996 and 2002, 14 ankles with failed ankle prostheses were operated on with tibio-talocalcanear arthrodesis using different retrograde intramedullary nails. The patients who all suffered from rheumatoid arthritis aged 31- 82 years. At follow up after minimum 1 year, 11 of the 14 ankles were considered radiographically healed - 9 at the first attempt and 2 after repeat arthrodesis. However, 2 of these 11 ankles were not fused according to the clinical evaluation. In 3 cases the radiologist and the surgeon were unanimous that the ankles had not fused.

In 9 cases the major part of the talus was missing and in 7 of these ankles radiographic fusion had occurred between the calcaneus and tibia.

Equinus position was not observed in any of the ankles but 6 ankles had a valgus position between 5 and 10 degrees. Ankles with valgus position had a significantly lower AOFAS score (p=0.03) than ankles that had fused in neutral position.

We conclude that tibiotalocalcanear arthrodesis with the use of a retrograde intramedullary nail may be a good alternative in patients suffering from rheumatoid arthritis, provided that neutral position is achieved.


Poster 1ARTHROSCOPIC DEBRIDEMENT FOR OSTEOARTHRITIS OF THE KNEE

N. Abe, T. Doi, Y. Takahara, Y. Uchida, I. Dan-ura and H. Inoue

2-5-1 Shikata-cho, Okayama, 700-8558, Japan

Previous reports suggested that arthroscopic debridement was effective in early stage OA due to the dilution of inflammatory cytokines. However, the other reports attributed such results to the placebo effect citing a lack of evidence of biological experimental data and poor correla-tion with the natural course of the disease. We retrospectively reviewed cases of arthroscopic debridement of osteoarthritis in patients more than 50-years-old to assess the efficacy of this procedure.

Patients: Eighty nine patients (92 knees: 43 in men and 49 in women) underwent arthroscopic knee debridement for the treatment of degenerative osteoarthritis. Their average age was 59.8 years (range, 50–80 years). The average follow-up period was 10 months (range, 2–59 months). These knees were classified by the Kellgren & Lawrence (K&L) Grading System for radio-graphic osteoarthritic change, and the radiographic femoro-tibial angle (FTA) was measured to assess knee alignment. We assessed the articular findings of meniscal injury and cartilage damage by ICRS (International Cartilage Repair Society) grading system intra-operatively. The arthroscopic debridement procedure included synovectomy, meniscal excision, osteophyte excision and chondroplasty for ICRS Grade 4 injury. The outcomes were evaluated by Knee Society Rating Systems (Knee Score) that included the knee rating and functional assessment.

Result and Discussion: Knee Score increased significantly after arthroscopic debridement in all cases in spite of K&L grade and FTA. Joint swelling improved after the procedure in 45% of the cases. Fifty-four knees with ICRS Grade 4 injury had significantly improved Knee Score, and their outcomes were same as those of ICRS Grade 0 to 3.

Conclusion: Our study suggested that arthroscopic debridement, even in knees with severe cartilage damage, had positive short-term effects: reduced pain and swelling, and improved Knee Score.


Poster 2THE ANATOMICAL PROSTHESIS IN SHOULDER ARTHROPLASTY—1- TO 5-YEAR RESULTS WITH THE ANATOMICAL SHOULDER ARTHROPLASTY

Richard W. van Brakel, Maarten J. de Vos and Denise Eygendaal

Department of Orthopedics, Sint Maartenskliniek Nijmegen, PO Box 9011, 6500 GM Nijmegen, The [email protected]

Aim and background: Although not as common as total knee or total hip arthroplasty, pros-thetic replacement arthroplasty of the glenohumeral joint in rheumatoid arthritis is a well-devel-oped technique providing good pain relief and acceptable function in most cases. Up until now, no data is available regarding the Anatomical total and hemiarthroplasty of the shoulder. There-for, we evaluated the Anatomical prosthesis in shoulder arthroplasty in a series of 40 shoulders in 40 patients (9 male, 31 female, average age 62.6 years).

Methods: In this prospective cohort study we performed 40 Anatomical total or hemi-arthroplasties in 40 patients. Evaluation took place just before replacement and after one to five years. During evaluation function, patient satisfaction and pain were objectivated by means of a clinical rating index, containing among other things the functional rating index by Constant and Murley. Pain was also assessed by means of Visual Analog Scales.

Results: The Constant Murley functional rating index improved in all patients and activities of daily living were positively influenced. Pain showed a clear clinical decrease, resulting in a remarkeble high patient satisfaction. Complications during surgery did not occur.

Conclusion: Shoulder replacement with the Anatomical shoulder prosthesis provides clinical relevant improvement of function and distinct decrease of pain resulting in a remarkeble patient satisfaction.


Poster 3PHOTOCHEMICAL INTERNALIZATION (PCI)

Andreas Dietze

Betanien Hospital Skien, Bj. Bjoernsonsgate 7, N-3722 / Skien, Norway

Modern immunotherapy has change the picture of synovitis dramatically. Although the need for surgi-cal synovectomy is still seen the techniques should be adapted to the new situation. The combination of modern drug delivery systems with our surgical skills may give the orthopaedic surgeon a new roll within joint preserving treatment modalities. Since the mid 1990s several authors have investigated the possibility to use photodynamic therapy (PDT) in the treatment of rheumatoid arthritis, mainly by inducing cell necrosis in the treated tissue. The aim was to develop a photodynamic synovectomy technique and some encouraging results are published. The aim of this study was to investigate the possibility of using photochemical internalisation (PCI) to improve the PDT effect by introducing a protein toxin into fibroblast-like synoviocytes derived from rheumatoid arthritis patients and to show the possibility of using PCI to achieve transduction of genes in cells of same origin.

Patients and methods: PDT as a treatment modality is characterised by selective retention of a photosensitising substance in the target tissue. These substances are excited by absorption of light at appropriate wavelengths. When the sensitizer is located in endocytic vesicles of the target cells the photochemical reaction causes the rupture of these vesicles even at sublethal doses. Thus, the endosomal escape of genes and other macromolecules by such photochemical treatment may increased their biological activity. The technique is named photochemical internalisation (PCI) and has the advantage of minimal side effects since the treatment is localised to the irradiated area with no systemic effect. Synovial tissue was obtained under synovectomy of RA patients. Primary single cell suspensions were treated with the photosensitizer meso-tetraphenylporphine (TPPS2a ) and light exposure (PDT) followed by evaluation of cell survival by flow cytometry. PCI of gelo-nin, a type 1 ribosome inactivating protein toxin (RIP), was performed on fibroblast-like synovio-cytes (FLS) in passage 4 and 5 after removal from patients followed by measurements of protein synthesis 24 hours after treatment. Additionally FLS were transduced with an adenovirus encod-ing the E. coli lacZ gene and treated with PCI to evaluate the effect on the transduction rate.

Results: All cells in the primary cell suspension were susceptible to PDT but CD 106- (FLS) and CD14- positive (tissue macrophages) cells were more sensitive to inactivation by PDT than CD2-(T-cells) and CD19-positive (B-cells) cells. With respect to protein synthesis FLS became up to 4-fold more sensitive to light when combining the photochemical treatment with gelonin incubation. The fraction of virally transduced FLS was about doubled by means of PCI .

Conclusion: Our data provided evidence that PCI have a potential impact on viral gene delivery and protein toxins in fibroblast-like synoviocytes derived from RA patients. To our knowledge this is the first time the PCI principle is shown on human cells derived from patient with RA. Our studies have demonstrated that both the amount of sensitizer and light needed to induce a cytotoxic reac-tion in FLS could be reduced significantly by combining a photochemical treatment with a protein toxin. Further, our experiments demonstrate that PCI has a potential effect on the endosomal escape of therapeutic substances after their endocytotic uptake in FLS. The effective and safe delivery of genes into synovitis tissue, while sparing the normal tissue is the main problem in gene therapy. PCI combines the possibility of light directed and molecular targeting which may reduce the side effects of the treatment. In conclusion, PCI may be a new therapeutical instrument for orthopedic surgeons for the light directed treatment of synovitis in RA patients and other diseases.


Poster 4TREATMENT OF EXTENSOR TENDONS RUPTURES IN RHEUMATOID PATIENTS AT THE TIME OF WRIST FUSION

A. Ferreres, D. Pacha, A. Lluch and M. García-Elías

Hand Unit. Dept Orthopaedics. Hospital Clínic Unversitari. Barcelona, Villarroel 170, 08036 Barcelona, and Institut Kaplan, Pg Bonanova 9, 2-2. 08022 Barcelona. Spain

Patients with rheumatoid arthritis often complaint about wrist problems. Some patients arrive to the hand clinic with destruction of all wrist joints and the whole wrist has to be fused. Some-times, extensor tendons are also ruptured and they have to be repaired at the same time

Material and method: From 1996 to 1999 we repaired extensor tendons ruptures at the time of wrist fusion in rheumatoid patients by means of tendon grafts taken from the ECRL o ECRB.

Eleven wrists with extensor tendons ruptures were arthrodesed in the 1996–1999 period in the Hand Unit. In five cases, 9 ruptures, “end to side” repair was used to treat tendon ruptures. In the other six cases, 20 ruptures, a graft from the ECRL o ECRB was used.

Results: Motion of MP joint is the parameter analysed. Degree of motion of MP joints with affected tendons is similar in patients treated either with suture or graft. Mobility of MP joints averaged 20/72 in end to side repairs and 10/76 in graft cases. When all tendons are affected, degree of motion is reduced and this fact has to be in relation with the muscle belly inactivity and contracture for some period of time since the last rupture occurred

Conclusion: Tendon graft for extensor tendons ruptures is a good option to suture or trans-position. Advantages, from a biomechanical point of view, have been outlined by Mountney et al. (1998).


Poster 5PRIMARY TOTAL ELBOW ARTHROPLASTY—EXPERIENCE WITH A SEMICONSTRAINED PROSTHESIS

Hans Gottlieb, Thomas Houe, Kristina Milting and Claus M Jensen

Department of Orthopaedic Surgery, Gentofte Amtssygehus, Copenhagen, Denmark

Introduction and aim: In order to evaluate the long term efficiancy of a total elbow arthroplasy (TEA) with a semiconstrained design, we examined 14 patients with 16 capitellocondylar TEA’s, who were left of the original cohort of 28 patients with 32 TEA’s.

Patients and methods: During 1995 and 2001, 32 primary TEA’s were performed in 28 patients at the Department of Orthopaedic Surgery, Gentofte Amtssygehus, Copenhagen. All arthroplasties were of the Osteonic or Osteonic Solar type with a semiconstrained design.

The TEA was inserted through a posterior access with a triceps split, both component were fixated with gentamycin-cement which was vacuum mixed, put in with retrograde filling and pressurisation of the cement.

The excluded patients concist of eight patients (10 TEA’s) who, and two patients were excluded because of additional concomitant surgery because of loosening. Four patients declined participation in this study. We used a standardized 100-point Hospital Surgery Score (HSS) rating system, modified with some additional questions on the subjective experience of the arthroplasty, the mobility in degrees and a radiological evaluation.

Results: The average duration of follow-up was 5 (3.2–6.9) years. This follow-up included 3 (21%) men and 11 (79%) women, with a mean age at 64 (37–80) years, of these 14 (88%) elbows had rheumatoid arthritis. The rest of the patients had posttraumatic osteoarthritis in the elbow.

There were no radiolucency in the 16 TEA’s in the follow-up, neither any long-term affection of the ulnar nerve. Comparison of data registered before operation with this follow-up showed a change in extension defect from 30 to 20 degrees (range 0–45) and flexion from 80 to 130 degrees (range 110–155).

The pain-score was 50 (45–50) points, maximum score was 50 points. The population had an activity score at 10 (6–12) points, maximum score was 12 points. The endurance-score was 8 (4–8) points, maximum score was 8. All the scores and degrees are median values.

Subjective satisfaction with the arthroplasty was also improved. All the patients would rec-ommend the operation to others with the same condition and all got better function and lesser pain.

Revision ratio was 2 out of 32 TEA’s.Conclusion: In patients with severe impairment of function and quality of life due to RA TEA

with a semiconstrained design can be recommended because of reliable and satisfactory results. None of the patients in the follow-up had any radiolucency. Revision ratio was 2/32 TEA’s.


Poster 6TOXIC EFFECTS OF POVIDONE-IODINE ON SYNOVIAL CELL AND ARTICULAR CARTILAGE

Masashi Kataoka, Hiroshi Tsumura, Nobuhiro Kaku, Takehiko Torisu

1-1 Idaigaoka, Hasama-machi, Oita, 879-5593, Japan

Purpose: The purpose is the examination of the effects of povidone-iodine preparation (PI) on human synovial membrane as well as its in vivo effects on rats’ synovial membrane and articular cartilage.

Materials and method: We have extracted the synovial membrane of the patient with rheu-matoid arthritis who underwent total knee arthroplasty and made cultured cell using collagenase and tripsin. We have identified the effects of the density and duration of PI stimulation on the cultured synovial cell through the examination of cytotoxicity by MTT assay and studied in the mRNA and protein level of lactate dehydrogenase (LDH) of synovial cell. After having admin-istered PI into rats’ joints, the synovial membrane and the articular cartilage were analysed.

Results: Cytotoxicity to the cultured synovial cell was respectively proportional to the dura-tion of stimulation and density of stimulation. The histopathological analysis performed 24 hours after the intra-articular administration of PI indicated clear morphological alterations.

Conclusion: Our experiment disclosed that povidone-iodine preparation is strongly cytotoxic to synovial cells and articular cartilage. Moreover, another of our experiments revealed that the centuplicate diluents of PI have no bactericidal effect against bacillus. We may have to consider abstaining from intra-articular irrigations by PI solution diluted with saline, because there is no advantage in doing so.


Poster 7EFFECTS OF ARTHROSCOPIC SYNOVECTOMY IN RA KNEES

A. Kitamura, N. Abe, K. Okuda, K. Nishida, T. Kuroda, H. Inoue

2-5-1, Shikata-cho, Okayama City, 700-8558, Japan

The controversy regarding efficacy studies of arthroscopic debridement for rheumatoid arthritis (RA) of the knee revealed the paucity of quality data on effectiveness and long-term results. The aim of our case review was to identify key factors other than pain, which could measure efficacy of the procedure.

Methods: The multiportal approach (at least 4 portals) for arthroscopic synovectomy was done only after conservative treatment had failed and inflammation persisted in RA patients with an American Rheumatism Association classification score of at least 4. The study included the cases treated by synovectomy, which had follow-up examinations within 65.4 months. We treated 33 knees in 24 cases (3 knees of 2 men, and 30 knees of 22 women). Their average age was 55.9 years (range 29 to 71). In this group, 11 knees in 9 patients (TKA group) had total knee arthroplasty at an average of 44 months after the synovectomy due to joint destruction. The long-term outcomes of the TKA group and the synovectomy only group (AS) (23 knees in 15 patients) were compared by age, case history, Steinbrocker class, Larsen’s grade, degree of inflammation, medication and the EULAR Committee’s criteria for histological assessment of synovial tissue. Statistical analysis of the differences was by the Mann-Whitney U test.

Results: There was a statistically significant correlation between the level of C-reactive protein (CRP) and the administration time of methotrexate (MTX). Histological findings of the synovial tissues from the TKA group tended to be high by EULAR evaluation. Fibrosis and vas-cular changes also were statistically greater than in the AS group. Although all patients treated by this procedure initially benefited from marked reductions in pain, swelling, and synovitis.

Conclusion: The control of RA activity, especially with MTX, appears to be the key in delay-ing TKA by mitigating joint destruction.


Poster 8ASCENSION® PIP PROXIMAL-INTER-PHALANGEAL NON CONSTRAINED PYROLYTIC CARBON PROSTHESIS IN OSTEOARTHROSIS—EARLY RESULTS

P. Kopylov, A. Mrkonjic, M. Tägil and G. Hanff

Hand and Upper Extremity Unit, Department of Orthopedics, Lund University andDepartment of Orthopedics, Blekinge Hospital, Karlshamn-Karlskrona, Sweden

In osteoarthrosis of the proximal interphalangeal (PIP) most often conservative treatment is encouraged and the only surgical alternative has been joint fusion. The results of artificial joint replacements have not been satisfactory. We report the early results of a new surface replace-ment prosthetic design and material.

Material and methods: The Ascension® PIP prosthesis is non-hinged and made of pyro-lytic carbon. The material is strong and wear resistant and the material properties allows the prosthesis to be made small but still with sufficient strength. No cement was used. The respect of the anatomical structures like the collateral ligaments and a precise surgical technique using adequately the instruments for implantation of the components are the prerequisite for this small joint surgery. A good postoperative rehabilitation and physiotherapy are also necessary

Results: We report the results of 20 osteoarthrosis joints in 15 patients with a minimum follow-up of 18 months. The mean age was 56 (48–64) years.

All patients became painfree and increased their range of motion. After 3 months the mean ROM was 53 (30–90) degrees. No deterioration of the ROM could be observed later on.

No infection occurred. One patient was reoperated after one year with teno-arthrolysis due to an inferior range of motion.

Conclusion: The results of Ascension® PIP implant are encouraging with patients reporting mobile, stable and painfree joints. The size of the Ascension® PIP prevents overstuffing of the joint and the tendency of deterioration overtime of the ROM observed with other implants has not be seen. The follow-up is short in term of prosthesis survival.


Poster 9THE RESULTS OF THE SURGICAL TREATMENT OF RHEUMATOID ARTHRITIS IN OUR LOCAL PATIENT POPULATION

Thomas Lakatos, Tibor GuntherDénes Rács, Budai Irgalmasrendi and Kórház Kht

Orthopedic Department, Polyclinic of the Hospitaller Brothers of the St. John of God, Budapest, Hungary

Modern therapy of rheumatoid arthritis consists more and more of aggressive early treatment of the underlying pathogenic problem.

Purpose: We wanted to investigate if the conservative treatment of Rheumatoid Arthritis has changed and if had indeed changed, to what degree it has done so.

Materials and methods: Our purpose was to analyze the results of the surgical treatment of Rheumatoid Arthritis in our patients during the period of Jan 1st 2000 to Jan 30th 2004. We analyzed every surgical intervention that occurred with respect to the region involved as well as which articulation was treated. We then compared the type of surgery with the age of the patient and the length of their illness. We then went on to compare these results with previous studies.

Results: During the time of our study, 208 patients with Rheumatoid Arthritis were treated. Their average age was 51.6 years of age, and 17 different types of surgical interventions were done. The surgical procedures that were done were, in order of decreasing frequency total knee replacement (88), yotal hip replacement (79), forefoot resection arthroplasty ( 32), followed by synovectomies (28). In the upper extremity, large joint surgeries predominated, so we find that total shoulders were the most frequent (9), followed by elbow surgeries where we interposed dura matter (6). With respect to the region of the operation, we find that surgeries in the lower extremity (349) were more frequent than surgeries in the upper extremity (141). With respect to the articulations involved we find (listed in decreasing frequency): knee (178), foot (92), hip (79), hand (78), wrist (26), elbow (24), shoulder (13). When we correlate the age of the patient with the type of surgery, we find that bone-in growth hip replacement occurred at an average ago of 41 years of age, knee synovectomy occurred at an average age of 45 years of age, knee arthrodesis 46 years of age, and finally cemented hip prosthesis occurred at an average age of 69 years of age.

Discussion: In our department, if we compare the surgical practice with what we did in the near past, we can definitely see a difference. The percentage of surgical interventions in the lower extremity grew in proportion to the surgical procedures done in the upper extremity, and in the upper extremity, we are now carrying out procedures on the shoulder and the elbow. In addition, of all the surgeries that was done, the surgeries done on the knee predominated, and in that area, Knee arthroplasties predominated. We performed roughly five times the amount of knee arthroplasties than preventive surgeries on the knee. We also can note, that the average age for surgical interventions on the knee was 14 years younger than surgeries on the hip.

The data we presented from our department is very interesting, for it suggests we need to re-think the current indications for the surgical treatment in rheumatoid arthritis.


Poster 10ULTRASONOGRAPHY AND RHEUMATOID ARTHRITIS

W. Lick-Schiffer

Orthopaedic Clinic Stolzalpe, Austria. [email protected]

Introduction and aim: In our hospital, ultrasound is a traditional and common method to examine painful and swollen joints. Getting an orthopaedic surgeon in our house, is growing up with a linear transducer.

With ultrasound examination we are able to find synovialitis, tendosynovialitis, tendinitis, bursitis and even erosions as well.

Patients/material and methods: The musculoskeletal ultrasound is performed with patients from our interdisciplinary rheumatoid out patient department (about 500 a year). We do a clini-cal examination of the painful joints and use the ultrasound as a painless, free usable bedside procedure.

Even children from our specialized rheumaorthopaedic department tolerate this kind of examination.

A 5 or 7.5 MHz linear transducer is used. The arthritic joint is examined and the alteration are documented on a special paper or film.

Results: With the ultrasound examination we are able to document the activity of rheumatoid arthritis. So the effect of therapy can be judged and adapted if necessary. The ultrasound is even helpful to make a decision about operation. We differentiate soft tissue, tendons, bony surface and even cartilage erosions. The possibility of a dynamic examination of tendon sliding for example give us more information about compression or swelling of a nerve. It is no problem to repeat the ultrasound examination of a painful region. The patients, even little children, tolerate the painless and quick procedure.

Conclusion: The musculoskeletal ultrasound is a working method that gets more important in diagnose and controlling of rheumatoid arthritis.


Poster 11REDUCED BONE MINERAL DENSITY AND BONE TURNOVER MARKERS IN POSTMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS

S. Momohara, K. Ikari, T. Mizumura, and T. Tomatsu

10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan

The symtoms of rheumatoid arthritis (RA) on bone include structural joint damage and osteo-porosis. The aim of this study was to investigate determinants of joint destruction and reduced bone mineral density (BMD) in postmenopausal women with RA and to evaluate if there are common markers of bone loss.

140 postmenopausal women who had not received treatment with bisphosphonates or hor-mone replacement therapy were entered into the study. All patients fulfilled the American Col-lege of Rheumatology criteria for RA. The mean age of the patients was 64.3 years (48–89) at study and the mean duration of RA disease was 14.4 years (1.9–38.5).

34 patients (45%) had femoral osteopenia (T score -1 to -2.5) and 23 patients (31%) had osteoporosis (T < - 2.5). The body mass index (BMI) of patients with a normal BMD (T score ≥ -1.0) was significantly higher (p < 0.01) than in patients with osteoporosis at the femoral neck. The T score exhibited a significant negative correlation with age and the duration of RA disease. Serum bone-specific alkaline phosphatase (BALP) and serum osteocalcin (OC), markers of osteoblast function, were negatively related to erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and matrix metalloproteinase-3 (MMP-3). However, serum crosslinked N-telo-peptidases of type 1 collagen (NTx), a marker of resorptive function, exhibited a positive corre-lation with ESR (r=0.286, p=0.0006), CRP (r=0.284, p=0.0006) and MMP-3 (r=0.214, p=0.01). There was no correlation between BALP and NTx levels and daily prednisolone (PSL) dosage whereas OC exhibited a negative correlation with the daily PSL dosage (r=-0.228, p=0.04).

This study suggests that generalized bone loss occurs in active RA and is characterized by evidence of bone resorption that is correlated with the high levels of inflammation. BMI, disease duration, the daily PSL dosage and high NTx level were common risk factors in RA osteopo-rosis.


Poster 12MINIMAL INVASIVE HIP REPLACEMENT

S. Oehme and J. Haasters

Ostseeklinik Damp, D-24349 DAMP, Germany

Purpose: More and more younger patients needs primary hip replacement. Specially for these patients the so called calcar prosthesis have been developed; short stems with fixation, bone ingrowth and loading only in the proximal parts of the femur.

Using these type of prosthesis in cases of primary operation, later on in cases of first revision the so called standard prosthesis can be used.

Materials and methods: We have experience with more than 350 calcar prosthesis type MAYO in the last 3 years. The indication for operation in this group of patients is different to the older patients group; the younger patients needs hip replacement because of rheumatic diseases, dysplasia or posttraumatic arthrosis.

The implantations have been done by a modified antero-lateral Watson Jones approach. All the cases we have done are under clinical and radiological follow up.

Results: Reporting all our cases according to the Harris-Hip-Score, we saw good and excel-lent results; especially the good functional results could be reached in a short period of time after the operation.

95% of the operations could be done without any incision to the gluteal muscles at the greater trochanter of the femur; the mean length of skin incision has been less than 8 cm.

The radiographic follow up shows in none of our cases any osteolysis in the region of the calcar femoris.

Conclusion: With the MAYO Hip System, from our point of view, good and excellent results can be reached; especially in cases of younger patients this type of short stem hip prosthesis should be used. The primary hip replacement therefore can be done with an minimum of bone lost at the calcar and with an maximum of atraumatic operation technique to the soft tissue around the hip joint.


Poster 13RADIOGRAPHIC CHANGES AFTER RESECTION OF THE DISTAL ULNA IN RHEUMATOID ARTHRITIS

Z. O. Rahimtoola, S. P. L. Jansen, P. Rozing and R. G. H. H. Nelissen

Department of Orthopaedics, University Hospital Leiden, NL-2300 Leiden, The Netherlands


Poster 14EARLY RESULTS OF NEUFLEX-SILASTIC IMPLANT IN MCP-ARTHROPLASTY

S. Schindele, D. Herren and B. R. Simmen

Schulthess Clinic, Dept. of Upper Extremity/ Handsurgery, 8008 Zurich, Switzerland

Introduction and aim: Silastic implant arthroplasty is still the golden standard in the correction of deformed and destroyed metacarpophalangeal (MCP) joints in rheumatoid arthritis (RA). In order to enhance the functional performance of these spacers, new implant designs were cre-ated. Compared to the original Swanson implant the NeuFlex Silicone prosthesis has a different rectangular 30° prebend hinge, which should provide more flexion, and thus, more mobility. So far there is little literature about this new implant.

Patients and methods: A prospective consecutive series including 13 patients with 37 replaced MCP joints, using the NeuFlex prosthesis was analysed. All patients were females and suffering from RA. The average age at the time of intervention was 56 and the minimal follow-up was 1 year. All patients were reviewed according to a standardized protocol clinically and radiologically. The implantation and rehabilitation was performed according to guidelines from Swanson.

Results: There were no complications in all cases. The average range of motion could be improved from 37° preoperatively to 57° postoperatively with an average flexion of 71°. The pre-existing ulnardrift could be reduced from 20.2° to 3.3°. The average improvement of grip strength was 4.2 kg. There were no implant failure or fractures. All patients were pleased with their results and would choose the procedure again.

Conclusion/interpretation: Limited range of motion and implant failure are the major prob-lems with Silicone implants in the MCP joints. Compared to an own series of 207 Swanson prosthesis (Simmen et al. 1988) the early results of the NeuFlex implant shows a better range of motion of 57° compared to 32° of the original Swanson implant. With comparable exten-sion, the better flexion is functionally important for these patients. Several personal reports speculated that the better motion will increase the fracture rate of the implant. After a minimum follow up of 1 year, this could not be confirmed. A longer follow-up will show if these favour-able results of the NeuFlex prosthesis will withstand the test of time.


Poster 15HYDROXYAPATITE AUGMENTATION FOR BONE LOSS IN TOTAL ANKLE REPLACEMENT IN RHEUMATOID ARTHRITIS

K. Shi, K. Hayashida, J. Hashimoto, T. Tomita, M. Fujii, K. Sugamoto, H. Kawai and H. Yoshikawa

4-8-1 Hoshigaoka, Hirakata, Osaka 573-8511, Japan2-2 Yamadaoka, Suita, Osaka 565-0871, Japan6-14-1 Aomadani-nishi, Minoh, Osaka 562-8567, Japan

Purpose: Total ankle replacement (TAR) is now widely performed for ankle destruction in rheumatoid arthritis (RA). However, early implant failures such as loosening and sinking are often, due to poor bone quality of implanted site. For this problem, especially of tibia, we origi-nally designed hydroxyapatite (HA) for augmentation of bone loss.

Materials and methods: Sixteen feet of 14 RA patients operated with aforementioned method were studied with average follow-up of 23.1 months. Clinical outcomes were evaluated by use of a published rating scale which includes pain relief as well as functional improvement. Anteroposterior (AP) and lateral radiographs taken immediately post-operatively and at the last follow-up were analyzed for placement and sinking of tibial component (TC). Placement was represented with two angles; alpha angle, formed with tibial axis and TC transverse line on AP radiographs; beta angle, formed with tibial axis and TC longitudinal line on lateral radiographs. Clear zone was also examined on AP radiographs, either between HA and bone, HA and TC, or TC and bone.

Results: Clinical rating scale improved from 30.7 points pre-operatively to 65.9 at the last follow-up. Of all symptoms examined, pain relief was most outstanding. Mean alpha angle was 87.4 post-operatively and was 87.7 at the last follow-up. Mean beta angle was 79.3 and 81.0, respectively. No statistical significance was noted in both angles with regard to the change from post-operative to the last follow-up. The average sinking was 0.2 mm, which was not significant from post-operative to the last follow-up, either. One demonstrated clear zone between HA and bone, nine between HA and TC, and 6 between TC and bone.

Conclusion: Our originally designed HA was shown to secure implant fixation and to bond firmly with bone. This can be thought a useful augmentation for tibial bone loss in TAR in RA.


Poster 16JUVENILE IDIOPATHIC ARTHRITIS (JIA) SURGERY DURING THREE DECADES—A SINGLE CENTRE EXPERIENCE

M. Simonsson, G. Pettersson and U. Rydholm

Dept. of Rheumatology, Pediatrics and Orthopedics, Lund University Hospital, Sweden

Objective: To describe and analyse all surgical procedures for JIA during three decades (1970–2003) at the Swedish Pediatric Rheumatology Centre of Lund University Hospital.Methods: The vast majority of surgical procedures for JIA in Sweden has been performed at

one centre for many years. Since 1970 all surgery have been registered. This register has been analysed according to types of surgery, changes over time and number of surgical interventions per patient.Results: In total, 1507 procedures were performed in 444 patients (2–60 years of age). The

majority, 886 surgical procedures, were in children (≤18years). 300/1507 interventions were in the hand or wrist. The annual number of procedures have remained fairly constant. There is an obvious decrease in synovectomies since the mid-eighties, which is compensated for by an increase of arthroplasties during the whole time span, making the total number of these proce-dures practically constant over time.

Hip replacement constituted 65% of the total number of arthroplasties. Thirty-two of the arthroplasties were performed in children <16 years of age. Primary as well as revision arthro-plasties show a steady increase, with revision procedures making up 25% of the total number. The fraction of revision arthroplasties has increased over time.

The 18% of the patients, who underwent >5 interventions, consumed 53% of the total number of operations.


Poster 17CORE DECOMPRESSION OF THE FEMORAL HEAD IN JUVENILE IDIOPATHIC ARTHRITIS (JIA)

M. Simonsson, B. Månsson and U. Rydholm1

Departments of Rheumatology and 1Orthopaedics, Lund University Hospital, Lund, Sweden

Objective: To describe the effect of core decompression of the femoral head regarding relief from aching pain and to identify characteristics that predict good effect.Methods: The main part of orthopaedic surgery for juvenile idiopathic arthritis (JIA) in

Sweden is centralized to one centre at Lund University Hospital. All surgery since 1970 has been registered. A retrospective medical record review was performed of all JIA patients that were operated with core decompression of the hip.Results: Since 1985 twenty-eight core decompression procedures were made in 19 patients

with longstanding intolerable aching pain in the hip. The median age was 18 (12–28) years, and the median disease duration 9 years at the time of operation. A dramatic pain reduction for more than six months was obtained in eight cases. In total twelve cases had more than one month of pain relief, in median 8.5 months. Five cases that initially had good effect were re-drilled but none of these operations were successful. We did not find any correlation between pain reduction and disease activity, number of previous DMARDs, or disease duration. It seems that teenagers respond somewhat better (10/20) than those more than 20 years of age (2/8). A radiographically spherical femoral head did not seem to be a prerequisite for good response to drilling. Of those with signs of osteonecrosis, about two thirds had clinical benefit.Conclusion: Minor surgical procedures should always be considered if they can delay the

requirement for total joint replacement. Core decompression is a simple operation without any known side effects. In this retrospective study about half of the patients had good effect measured as pain relief. The responders though had a fairly long lasting effect. However, if symptoms recur, repeated decompression does not seem accurate. It might be the reduction of intraosseous pressure that gives the pain relief. We hypothesise that there might be an early stage of osteonecrosis in these patients, as core decompression has been shown to be effective in the treatment of osteonecrosis of the femoral head of other aetiology in adults.


Poster 18ARTHROSCOPIC SHOULDER SYNOVECTOMY IN PATIENTS WITH RA

Adam M. Smith, John W. Sperling, Robert H. Cofield


Currently, there is little information available concerning the results of shoulder synovectomy in patients with rheumatoid arthritis. Therefore, we reviewed our experience with synovectomy in patients with rheumatoid arthritis with a functionally intact rotator cuff.

Methods: Sixteen shoulders in thirteen patients with rheumatoid arthritis were treated with arthroscopic shoulder synovectomy with a mean follow-up of 5.5 years. Patients with full thickness rotator cuff tears or partial tears that required repaired were excluded. Patients were assessed clinically and by questionnaire to assess pain, satisfaction, range of motion, radio-graphic outcomes, and occurrence of complications.

Results: Pain was improved in thirteen of sixteen patients (p=0.0001). Active shoulder ele-vation improved from a mean of 135 degrees to 150 degrees but was not significant (p=0.09). There were 5 excellent, 8 satisfactory, and 3 unsatisfactory results. Three of the thirteen patients reported pain that was no better or worse than before surgery. All three of these patients had radiographic arthrosis with periarticular erosions and reduction of the glenohumeral articular space. Preoperative radiographic findings were not associated with final outcome.

Discussion: Arthroscopic synovectomy of the shoulder in patients with rheumatoid arthritis with an intact rotator cuff offers reliable decrease in pain with less predictable improvements in range of motion. Limitations with predicting final results based on preoperative radiographs should be noted and discussed with patients.


Poster 19IPSILATERAL SHOULDER AND ELBOW PROSTHESIS IN ONE SESSION

P. M. Rozing and B. Bohy

Department of Orthopaedics, University Hospital Leiden, NL-2300 Leiden, The Netherlands

There is often an indication for performing an arthroplasty of multiple joints in the same upper extremity but only a few studies have been published on the results after arthroplasty of an ipsi-lateral shoulder and elbow. This study will report on the results of this group and of 11 patients with a one-stage ipsilateral shoulder and elbow arthroplasty.

Materials and methods: In a consecutive series of 231 primary arthroplasties of reumatoid elbows operated since 1982, 43 elbow replacements were combined with a replacement of the ipsilateral shoulder. In 11 patients (13 upper limbs) the shoulder and elbow arthroplasty was performed as a one-stage procedure. All patients were scored clinically and radiographically before the operation and at regular intervals afterwards. For the assessment of the elbows the score of Souter was used. For the shoulder the HSS 100 point scoring system was used. The one-stage procedures were studied as a separate group.

Results: After elbow arthroplasty most of the patients improved with regard to pain and func-tion and the average gain in the arc of flexion was 22°. The HSS score of the shoulder improved from 41 preoperatively to 62 postoperatively and the flexion with 45°. Complications will be discussed and the results will be compared with one-stage procedures.

Conclusion: One stage arthroplasty of the shoulder and elbow should be considered in reu-matoid patients with advanced destruction of both joints.


Poster 20REVISION OF ELBOW REPLACEMENT

Piet M. Rozing and J. C. T. van der Lugt

LUMC, mailbox 9600, 2300 RC / Leiden, The Netherlands

The complication-rates of revised total elbow prostheses are of concern and significant post-operative problems are described in revision of elbow prostheses. In this study we present our experience with revision surgery after failure of this non-constrained cemented elbow prosthe-sis.

Patients and methods: Between 1982 and 2002 we have performed 236 primary Souter-Strathclyde total elbow prostheses at our center. Of these, 24 have been revised after mean 53 (3–151) months. There are 20 women and 4 men and the average age at initial operation was 60.8 years. Twenty-one elbow had destruction of the elbow joint caused by rheumatoid arthritis (Larsen IV in 13 and Larsen V in 8 elbows). The mean follow-up after revision is 65 (3–153) months. The clinical examination was done according the Souter protocol.

Results: Revision of the primary elbow prostheses was performed because of aseptic loos-ening (10 cases), loosening after fracture (4 cases), septic loosening (2 cases), dislocation (4 cases), fracture 1 case), restricted ROM (1 case). The postoperatieve clinical outcome is almost equal to the outcome of primary replacement. Rerevision because of loosening was performed in 7 cases and the overall rerevision rate was 42%.

Conclusion: The clinical results after revision are satisfactory. The change of failure is high because of the increased loosening rate of the humeral component.


Poster 21SHORT-TERM RESULTS AND IN VIVO KINEMATIC ANALYSES OF DUAL BEARING KNEE PROSTHESIS

T.Tomita, T.Watanabe, S.Tsuji, T.Yamazaki, J.Hashimoto, K.Sugamoto and H.Yoshikawa

2-2 Yamada-oka, Suita, Osaka 565-0871, Japan

The Dual Bearing Knee (DBK) prosthesis (Finsbury, Surrey, UK) is the latest generation of the mobile-bearing knee prosthesis which has a mobile-bearing insert that is fully congruent with the femoral component throughout flexion and allows axial rotation and a 4-6 mm limited anterior/posterior translation. The aim of the present study was to evaluate the short-term results of DBK prostheses.

From 1998 to 2002, we performed 139 consecutive replacements with DBK prostheses in 129 patients. The mean patient age at surgery was 64.9 ± 11.6 years. All the prostheses were implanted with use of bone-cement. The patients were evaluated clinically using the rating system of Knee Society for both the knee score and the functional score. Using video fluoroscopy, 12 subjects were analyzed to determine the in vivo kinematic patterns.

Patients have been followed up from 15 to 62 months, with a mean follow-up of 41.9 months. The average knee score and function score were significantly increased at final follow-up examination compared with preoperative examination. At the latest follow-up evaluation, the mean range of motion was 1.5º ± 4.6º to 111.8º ± 16.8º of flexion. Postoperative infection occurred in 2 knees. Spin off of mobile bearing occurred in one knee. In vivo kinematic analyses demonstrated that the average range of femoral axial rotation was 12.7˚. The average medial condyle moved anterior 5.7 mm with extension to 100˚ of knee flexion, and posterior movement was 3.9 mm for terminal flexion. The average anterior movement for the lateral condyle was 1.4 mm for extension to 40˚of flexion, and afterwards moved 6.1 mm to the posterior during full flexion.

DBK total arthroplasty provided a good short-term outcome and reproduces normal knee motion with respect to femoral external rotation during flexion and femoral rollback motion in terminal flexion.


Poster 22AVANTA VERSUS SWANSON SILICONE IMPLANTS—A PROSPECTIVE, RANDOMIZED COMPARISON OF 30 RHEUMATOID PATIENTS

M. Tägil1, P. Kopylov1, K. Möller2, M. Geijer3 and C. Sollerman3

Lund University Hospital1, Lundby Hospital, Gothenburg2 and Sahlgrenska Hospital3, Gothenburg, Sweden

Silicone arthroplasty is the gold standard for severe arthritic changes of the MCP-joints in rheu-matoid patients. Swanson prostheses are most commonly used. In one study Sutter/Avanta gave better motion but showed a high prosthetic fracture rate. In the present study the two implants were randomised to compare outcome, hand function and fracture rate.

30 patients with rheumatoid arthritis or psoriatic arthritis were randomised to either Swanson or Avanta implants, 15 patients in each group. ROM, extension deficit and ulnar deviation were measured with goniometer. Grip strength was measured with Grippit, hand function with the Sollerman test and subjective outcome with VAS.

ROM improved from 32 (8–58) to 42 (20–60) degrees in the Avanta group (p=0.04), 7 degrees more in Avanta than in Swanson (p=0.05). The extension deficit decreased in both the Avanta (from 47 (2–86) to 19 (-1–43) degrees) and the Swanson (from 42 (26–74) to 16 (1–35) degrees) groups (p=0.0001 and p=0.0001, respectively). Ulnar drift decreased with no differ-ences between the groups. Hand function as measured with the Sollerman hand function test remained unchanged in both groups, as did the grip strength. Twenty-four patients (80%) were satisfied with the results, equally distributed in each group. Implant fracture was seen in overall 20 implants (12 Avanta and 8 Swanson, ns). Men were at larger risk for implant fracture than women (p=0.04). Two joints luxated.

Our results show that silicone MCP joint implants improve ROM some, but more importantly, changes the arc of motion towards an open palm. The improvement in ROM was 7 degrees more in Avanta implants. Sollerman hand function test and grip strength were unaltered, while VAS ratings showed subjective improvements and patient satisfaction was high.


Poster 23MORPHOLOGICAL CHARACTERIZATION OF RECEPTOR ACTIVATOR OF NFκB LIGAND (RANKL), IL-17, AND IL-1β EXPRESSION IN RODENT COLLAGEN-INDUCED ARTHRITIS

R. J. Weiss, H. Erlandsson-Harris, M. C. Wick, P.F . Wretenberg, A. Stark, and K. Palmblad

Karolinska University Hospital, Stockholm, Sweden

Purpose: Osteoclasts play an important role in the pathogenesis of bone-erosions. In rheuma-toid arthritis (RA), cytokines such as IL-1β, TNF, and IL-17 increase the formation and activity of osteoclasts. The receptor activator of nuclear factor (NF)–κB ligand (RANKL) is essential for the development and activation of osteoclasts and thus a key-regulator of bone-remodeling. The aim of the study was to determine the temporal and spatial expression of the inflammatory and bone destructive cytokines IL-17 and RANKL locally in the arthritic synovium, compared with the well characterized cytokine IL-1β.

Material and methods: Collagen-induced arthritis (CIA) in the Dark Agouti (DA) rat is a well established model of RA. Thirty-two male DA rats were immunized with type II collagen, cryo-cut sections of ankle-joints were immuno-histochemically stained for intracellular expres-sion of IL-17, RANKL, and IL-1β. To evaluate cell-infiltration, cartilage-damage, proteogly-can-depletion, and bone-erosions additional sections were stained with Haematoxylin-Eosin and Safranin-O. Osteoclasts were visualized by a Tartrate-resistant acid-phosphatase staining using leukocyte acid-phophatase kit.

Results: A strong IL-17- and RANKL-expression coincided with maximal clinical severity. The expression of IL-17, RANKL, and IL-1β as well as cartilage- and bone-destruction were still striking at time of transition to a chronic phase of CIA. The expressions of all three cyto-kines were especially pronounced in areas with bone-erosions, where also osteoclasts could be visualized. A continuous high cytokine-expression was seen through the chronic phase and commenced with severe synovitis, infiltration, cartilage-damage, proteoglycan-depletion, and bone-erosions.

Conclusion: This is the first study to show the kinetics of IL-17-, RANKL-, and IL-1β-expression in rodent CIA in relation to synovitis and bone-erosions. The pronounced expression of IL-17, RANKL, and IL-1β by synovial cells in regions of bone-erosions implicates their importance in the pathogenesis of bone destruction. Development of specific inhibitors may represent new therapeutic strategies to diminish joint destruction in inflammatory arthritis.


Poster 24MOLECULAR MECHANISMS IN OSTEOLYSIS

J. M. Wilkinson

Department of Orthopaedics, Northern General Hospital, Sheffield, U.K.

Aseptic loosening is responsible for over 70% of implant failures after total hip arthroplasty (THA). Factors that affect implant survival include implant design, surgical technique, and patient characteristics. However, much of the variation in risk of osteolysis between individuals remains unexplained. One possible source is natural genetic variation within the population, termed ‘polymorphism’. Tissue retrieval, cell, and organ culture studies have shown that the pro-inflammatory cytokines play an important role in the pathogenesis of osteolysis. Polymor-phisms within the genes coding for these cytokines are associated with differences in suscepti-bility to a number of inflammatory conditions.

In recent studies we found that subjects with osteolysis carry differences in the genetic forms of the TNF gene and the IL-I gene family versus subjects with surviving implants. Subjects with osteolysis are more likely to carry the TNF promoter allele ‘-238A’. Subjects with long-term successful implants are more likely to carry the IL-I receptor antagonist ‘+2018T’ polymor-phism. The association of TNF–238A with osteolysis and that of IL-IRN+2018T for protection against osteolysis is independent of other risk factors.

Genetic polymorphism may lead to a difference in activity of a particular gene between individuals. An experimental method called a reporter gene assay allows the gene activity to e measured. Using this technology we found that stimulation of macrophage-like cells carrying the TNF-238A allele with polyethylene particles results in increased gene transcriptional activ-ity when compared with the more common -238G form of the gene.

Aseptic loosening is a complex process involving the interaction of many messenger mol-ecules. Identification of genes that are responsible for variation in the risk of loosening will fur-ther our understanding of its pathogenesis. This may allow the application of emerging biologic therapies, such as those recently introduced in rheumatoid arthritis, to intervene in the osteolytic process.


Poster 25TOTAL ELBOW ARTHROPLASTY IN RHEUMATOID ARTHRITIS USING GUEPAR PROSTHESIS

J. Y. Alnot, F. Welby, D. Hemon, R. El Abiad, E. Masmejean and GUEPAR Group.

Service de chirurgie orthopédique et traumatologique, département de chirurgie du membre supérieur, chirurgie nerveuse périphérique, chirurgie de la main, Hôpital Bichât, 46 rue Henri-Huchard, 75877 Paris cedex 18, France.

Purpose of the study: We report a retrospective analysis of 16 patients with rheumatoid arthri-tis treated with a total humero-ulnar and humero-radial GUEPAR prosthesis (GIII).

Material and methods: The GUEPAR III elbow prosthesis is an anatomic polyethylene-metal gliding prosthesis designed to maintain physiological valgus. Right and left models are available in two sizes. On the humero-ulnar side of the prosthesis was associated with a radial head, born on an intramedullary metallic stem, that can be fit with several sizes of mobile poly-ethylene cups. The 16 GIII prosthesis were implanted in 1997 to 2001 by posterior approach with V triceps transection. Mean follow-up was 3 years.

Results: Before surgical treatment, all patients had severe and invalidating pain. The Mayo Clinic score was 33 points. The Larsen radiographic score was grade III (7 elbows) or grade IV (9 elbows). Patients were reassessed 1 to 5 years after implantation of the GIII (mean follow-up 2 years). At last follow-up the mean Mayo Clinic score had improved from 33 to 90 points. Outcome was considered excellent for 15 elbows and fair for 1.

Discussion: We review the indications for total elbow arthroplasty in patients with rheuma-toid arthritis. Semi-constrained prostheses are useful and necessary for the treatment of elbows exhibiting massive destruction, but the use of minimally constrained prostheses such as the GUEPAR III is becoming increasingly widespread. We use the GUEPAR III for 70% if our patients, particularly those with rheumatoid arthritis.

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