Knee rheumatoidard.bmj.com/content/annrheumdis/33/1/1.full.pdfIsometric quadriceps exercises and...

Ann. rheum. Dis. (1974), 33, 1

Knee arthroplasty in patients withrheumatoid arthritis

B. BLUM,* A. G. MOWAT, G. BENTLEY, AND J. R. MORRISRheumatology Unit, Nuffield Departments ofMedicine and Orthopaedic Surgery,University ofOxford, Nuffield Orthopaedic Centre, Oxford

MacIntosh metallic tibial plateau prostheses havebeen used in the Nuffield Orthopaedic Centre since1966 in the knees of patients with rheumatoid arthri-tis, following the description of the use of theseprostheses for the relief of pain and the correction ofdeformity by MacIntosh (1966). Since that timethfre have been several reports of the use of theseprostheses in both rheumatoid and osteoarthroticknees (Potter, 1969; MCCollum, Goldner, and Lang,1970; Clary and Couk, 1972; Jessop and Moore,1972; Kay and Martins, 1972; MacIntosh andHunter, 1972; Potter, Weinfeld, and Thomas, 1972).

In view of the different indications for and theresults of the operation described by these variousauthors, it seemed valuable to undertake an in-dependent review of the patients treated in thishospital, and to use the results to try and determinethe factors which affect the outcome ofthe procedure,and thereby to define our own indications for theoperation.

Patients39 patients were reviewed, in fourteen of whom theoperation had been performed on both knees. Two patientswere lost to follow-up, leaving 51 knees available forassessment. 32 patients with 44 knees had definite rheuma-toid arthritis and five patients with seven knees hadjuvenile rheumatoid arthritis extending into adult life.There were eleven operations on men and forty on women.The age of the patients at the time of surgery ranged from26 to 73 yrs (average 56). The postoperative follow-upperiod ranged from 6 mths to 6 years (mean 19-4 mths).

All patients had undergone a trial of conservativetherapy. 23 were receiving corticosteroids, the averagedaily dose of these drugs being equivalent to 8 mg.prednisolone (range 2 to 15 mg.) which had been givenfor a mean of 4 yrs preoperatively. In all cases the samedosage had been maintained postoperatively after theusual brief increase at the time of surgery. A few patientshad undergone previous operations on the affected knee;these included synovectomy, proximal tibial osteotomy,patellectomy, and joint debridement.

Indications for surgeryThe decision to perform MacIntosh arthroplasty was

based upon the failure of conservative therapy manifested by unrelievable pain, limitation of function, anddeformity. In all cases there was greater articular surfacedamage than could be expected to be improved bysynovectomy. The radiographic appearances wereotherwise not important unless there was gross jointcollapse or destruction, since there was considerablediscrepancy between the radiographic appearances andthe findings at operation.

MethodsMETHOD OF REVIEWAt final review the patients were interviewed and examinedby an independent orthopaedic surgeon (B.B.), followinga standard protocol* which assessed the technical successof the procedure and stressed functional improvementsand difficulties.The medical records were used to provide preoperative

information on the duration of the local and generaldisease, previous therapy, functional abilities of thepatient, examination of the knee, laboratory results,operative technique and findings, and postoperativemeasurements ofjoint movement.

Using the immediate preoperative radiographs, meas-urements were made of genu valgum and varum, andgradings were made of the extent of tibial and femoralcondylar damage, the degree of subluxation of the tibiaon the femur, and the extent of any patello-femoralarthritis. The same measurements and gradings were madeon the postoperative radiographs, and in addition theangle of tilt of the prosthesis with respect to the tibialshaft was measured. It proved impossible to measure boneloss or collapse of the tibial and femoral condyles orsettling of the prosthesis reliably. The presence of anyposterior tibial buttress was noted.The data were transferred to punch-cards and a program

was prepared for an IBM 1130 computer to record andcorrelate the information.

OPERATIVE TECHNIQUESAfter the application of a pneumatic thigh tourniquet, thejoints were opened through medial or lateral parapatellarincisions or both. A synovectomy was performed if themembrane was hypertrophied.A thin sliver of bone was removed from the tibial

plateau, leaving an intact subchondral bone plate as an* Copies of the protocol available on request.

Accepted for publication May 24, 1973.Presented to the Heberden Society on June 1, 1973* Present address: 1375 South Eliseo Drive, Greenbrae, California 94904, U.S.A.Reprints requests should be addressed to A. G. Mowat.

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2 Annals of the Rheumatic Diseases

horizontal bed in the tibia. A small posterior rim of bonewas left in several cases. Care was taken to preserve thetibial spine.The length of the prosthesis was chosen to fit the size

of the tibial plateau and the depth to eliminate collateralligament laxity. The prosthesis was checked for stabilityon the tibial plateau through 900 of joint flexion beforewound closure. The patellar tendon was not detached, butin five cases the patella was excised since it was severelyinvolved in the arthritic process. In a few cases trimmingof osteophytes and loose fragments of articular cartilagefrom the femoral condules was performed (Figs 1, 2, 3,and 4).There was no routine use of suction drainage or anti-

biotics. Anticoagulants were never employed. The limbwas enclosed in a Robert Jones bandage postoperatively.

POSTOPERATIVE CAREIsometric quadriceps exercises and knee flexion withinthe confines of the bandage were encouraged from thefirst day. The dressing was reduced on the 5th day andsutures were removed on the 14th day. Weight-bearingwas permitted as soon as muscle control allowed although,in a few cases in which the tibia was markedly osteoporotic,weight-bearing was restricted for 6 weeks. The mean timefrom operation on one knee until discharge was 35 days.In seven cases manipulation of the knee under anaestheticwas carried out.

In four early cases a different technique was employed.The patellar tendon was detached from the tibial tuberclethrough a curved longitudinal mid-line incision. The bonewas removed from the tibial condyles with an electric sawrather than a chisel. The tendon was re-sutured and theknee was held in a semi-rigid dressing until flexion began6 weeks after operation.

ASSESSMENT OF THE QUALITY OF RESULTSOn the basis of the final history and examination of thepatient, the results were graded as good, fairly good, fair,or poor. The computer was used to determine whichcriteria were associated with a good result (Table I,opposite).

Again using the computer, it was determined whichpatients fulfilled these criteria and as expected some ofthe original good results were excluded and some pre-viously rated fair were included. The criteria for a poorresult were similarly determined. Two further, smallerpatient groups also emerged from these assessments.Patients rated fairly good had less knee movement butwere otherwise identical with good results, whereaspatients rated fair had additional unsatisfactory featuresbut were still clearly better than those rated poor (Table I).

FIGS 1 AND 2 Antero-posterior radiographs, showing thevalue of standing views in demonstrating the extent ofarticular cartilage damage and in influencing the decisiontoperform MacIntosh arthroplasty rather than sivnovectomv



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Knee arthroplasty in patients with rheumatoid arthritis 3

Table I Criteria for assessing results ofMacIntosh arthroplasty

Result Pain Flexion Maximum Flexion Valgus Functional capacitydeformity flexion arc or varus

Good* None or slight <200 >800 >600 <100 Normal housework and employmentNo drugs Walk 100 metres

One stickRise from normal height surfaces

Fairly good* Same as good <200 >600 >450 <100 Same as good

Fair* Slight or - >45 - Overall improvementmoderate Walk 50 metres

Two sticksRise from chair unassisted

Poort Severe <450 - No improvement* Result requires fulfilment of all the criteria.t Result requires fulfilment of only one of the criteria.

FIGS 3 AND 4 Same patient as in Figs I and 2. Post-operative radiographs demonstrating horizontal position ofprosthesis and central articulation offemoral condyle



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4 Annals ofthe Rheumatic Diseases

Results

In the 51 knees there were 22 good results, five fairlygood, seven fair, and seventeen poor.

Using the computer, it was possible to determinesome factors which were associated with each typeof result. Results will be shown by using the lettersG; F-G; F; and P preceded by a number indicatingthe number of knees with that result.

FACTORS INFLUENCING RESULTS

(1) Duration offollow-upThe mean duration (and range) of follow-up was notdifferent for any grade of result. Further, few resultschanged after discharge from hospital, although fourknees graded poor had fair results for intervals of3 months, 3 months, 1 year, and 2 years.

(2) General conditionsThere was no correlation between haemoglobin leveland erythrocyte sedimentation rate and the finalresult, nor did the presence of rheumatoid factor orits titre in the serum correlate with the results.Similarly, there was no correlation between theduration of the general or local disease and theresults.The quality of the final result was unrelated to the

dosage or duration of corticosteroid therapy. Inparticular, there was no higher incidence of woundinfection or delayed healing in patients receivingthese drugs.

(3) Bilateral arthroplastyThe results in five patients who underwent bilateralarthroplasties during the same hospital admissionwere 3G, 3F, and 4P, whereas the results in the ninepatients who underwent bilateral arthroplasty duringseparate hospital admissions were llG, 1F-G, 2F,and 4P. However, the overall results of bilateralarthroplasty were comparable with those ofunilateralarthroplasty (Table II).

Table II Result ofMacIntosh arthroplasty in 51knees

Surgical Resultprocedure

Good Fairly Fair Poorgood

Unilateral 8 4 2 9Bilateral 14 1 5 8Bicompartmental 3 2 2 11Medial 5 1 2 1Lateral 14 2 3 5

(4) Other surgical procedures(a) SynovectomyAlthough synovectomy was undertaken as a prelim-inary to the arthroplasty if the membrane washypertrophied, mild recurrence of synovial prolifera-tion and effusion did not influence the results. Theresults of 5G and IF in six patients who had under-gone previous synovectomy were better than average.(b) Contralateral stiff kneeArthroplasties undertaken in three patients withprevious contralateral knee arthrodeses led to poorresults.

(5) Preoperative state(a) Ligamentous laxityMedial and lateral collateral and anterior cruciateligamentous laxity bore no relationship to the finalresult. The degree of valgus or varus which rangedfrom 3 to 30° of valgus in 27 knees and from 3 to 200of varus in four knees did not influence the finalresult.(b) Flexion deformityIn most cases some correction of flexion deformitywas made with the use of serial plaster of Paris splintsbefore operation. However, the extent of this finalfixed flexion deformity did not influence the operativeresult, since further correction of the deformityusually occurred at the time of operation.(c) Range of movementThe range of preoperative flexion was 800 or more,the range accepted as a criteria for a good result, inall but five cases. This range did not appear toinfluence the final result. There were as many goodresults as bad for each flexion range over 800. Inthe patients with a good result the operation did notsignificantly alter the range of flexion, whereas in allpatients with a fair or poor result there was a seriousloss of movement. The final range of movement wasachieved at approximately 2 months' after theoperation.

(6) PatellectomyIn five knees which had undergone previous patellec-tomy the results were 1 G, 2F, and 2P, whereas infive knees with concomitant patellectomy theresults were 2G, 1F-G, and 2P. The latter resultswere very similar to those of the whole series. Patel-lectomy was not associated with quadriceps muscleweakness.

(7) Size ofprostheses (Fig. 5)The size of the prostheses was carefully chosen tosuit the size of the tibial plateau, to correct as muchof the valgus or varus deformity as possible, and to



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was required to produce a good result. However,there was no correlation between pre- and post-operative ligamentous and capsular laxity and thefinal results.

(8) UnicompartmentalandbicompartmentalprosthesesA single compartment prosthesis was associated withbetter results than bicompartmental prostheses(Tables II and III). In particular, it was associatedwith more motion, less lateral deformity, and more

capsular laxity. Lateral prostheses alone were used

more frequently than medial prostheses alone but the

results were similar. In Table IV (overleaf) the extentof the disease in the medial and lateral compartmentsofthe knees based upon the pre-operative radiographsis compared with the results obtained with the uni-or bicompartmental prostheses. Unicompartmentaldisease occurred only in the lateral compartmentand was treated with a lateral prosthesis in all but

£oxX+ one case. In the presence of disease in both compart-ments, better results were achieved with a singleprosthesis whatever the extent of the disease. Detailedanalysis of the eleven knees which had a poor resultwhen treated for bicompartmental disease with bothmedial and lateral prostheses did not reveal any

factors whichwould explain these findings completely.

(9) Manipulation under anaesthesiaThis was performed on seven knees because ofdelayedreturn of motion. In four the procedure led to an

increased range of motion with final results of 3Gand 1F-G. However, in two knees the motion failed

FIG. 5 Antero-posterior radiograph. There is a 2 S to increase and one patient sustained a supracondylarprosthesis in the lateral compartment and a 1 S in the fracture of the femur. These three knees had a poor

medial compartment to correct valgus deformity in a knee result.with advanced bicompartmental damage

(10) Different operation techniquereduce ligamentous and capsular laxity. To some In the four patients in whom mobilization was

extent this practice appears to have been beneficial, delayed for 6 weeks the final results were 1G, 1F-G,since less than 100 of valgus or varus postoperatively IF, and IP.

Table III Results with unicompartmental and bicompartmental prostheses

Prosthesis Result Radiographic damage

Good Fairly good Fair Poor

Bicompartmental 3 1 11 BicompartmentalMedial 3 1 2 1Lateral 9 2 1 2

Bicompartmental - 1 Lateral compartmentLateral 5 2 3

Bicompartmental - 2 Radiographs lostMedial 2



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Table IV Comparative criteria for a 'good' result ofMacIntosh arthroplasty

Series Date Pain Fixedflexion

Clary and Couk 1972 Relief

Henderson and 1969 ReliefPeterson

Jessop and 1972 ReliefMoore

Kay and Martins 1972 Relief

Lowe and others 1971 Pain free

MacIntosh and 1972 ReliefHunter

Murray 1967 Relief

Potter and 1972 None orothers* slight

Present series None orslight

Maximum Flexion Varus Valgus Stability Quadri- Support Function Radiographflexion arc ceps

strength

<10° > 700 Good None Improved

<10° Improved Improved Improved None Improved

< 10° >700 < 10° < 10°

> 750 Good Satisfactory

< 10° > 900 Stable

<200 > 600 <50 <10° Stable Strong I stick Improved

Increase Correction Restored

<5-15' >60-80' < 10 <10° 10' Normal 1 stickwobble

<20° >80' >600 < 10° < 10° 1 stick Normal houseworkand employment

A point scale was used in which a bad value in one column could outweigh a good value in another.

S RADIOGRAPHIC ANALYSIS

(1) Unicompartmental and bicompartmental disease(Figs 6, 7, and 8)Lateral subluxation of the tibia upon the femur wasnoted in fourteen cases, but was not associated with

^ an increased incidence of unsatisfactory results. Nineknees with slight subluxation had results 2G, 2F,and 5P, and five knees with marked subluxation hadresults 3G, F-G, and IP.

(2) Tilt ofprosthesisThere was a slightly increased incidence of poorresults if the prosthesis was tilted posteriorly.However, medial or lateral tilt of the prosthesis of upto 20' was not associated with adverse results. Aposterior bony buttress was associated with rathermore poor results.

COMPLICATIONS

.......There were fifteen complications in fourteen knees.

Six wound edges gaped, leading to delayed woundhealing; these knees were associated with average

M.U l ;; |results for the series........... There were three superficial wound infections, but

it was not necessary to remove a prosthesis because....!.....of infection.

One patient had a serious skin slough necessitatingskin grafting and in addition had foot drop due todamage to the lateral popliteal nerve; skin integrityand foot function was restored but the knee was apoor result.Another patient had a mild foot drop, but with full

prompt recovery.One prosthesis dislocated anteriorly and despite

re-operation the result was poor.One patient sustained a supracondylar fracture of

FIG.6 Antero-posteriorradiographofapatientwithgross the femur during manipulation under anaesthesia.lateral subluxation of the tibia and tarus deformity One patient had a minor pulmonary embolism.

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FIGS 7 AND 8 Same patient as in Fig. 6. Radiographsafter insertion of a medial MacIntosh prosthesis. Despitepersistent subluxation of the knee and poor positioning ofthe prosthesis the patient had a good result 4 years post-operatively

Discussion

There remains considerable debate about theindications for and the merits of the various arthro-plasties that have been used in the rheumatoid knee.The history of development of these arthroplastieshas been reported by Jessop and Moore (1972), andPotter and others (1972) and MacIntosh and Hunter(1972) have described the development of theMacIntosh arthroplasty. This form of knee arthro-plasty is the most popular of the non-hinge type,although Potter and others (1972) have achievedsimilar results with both MacIntosh and McKeevertibial plateau prostheses.Comparison of the results achieved in patients with

rheumatoid arthritis with the MacIntosh arthroplastyby different surgical groups is difficult since differentmethods of assessment have been used by each group(Tables IV and V). Further, not all reports haveincluded sufficient details of the methods of assess-ment to permit their proper use. This is unfortunate,since it means that direct comparison of results is

difficult or impossible. The importance of comparingvarious methods of measurement has recently beendemonstrated by Anderson (1972) who employednine different methods of assessment on patientswho had undergone hip surgery and found thepercentage of good results varied from 97 5 to30 per cent.Our method of assessment, in common with some

others (Potter and others, 1972; Jessop and Moore,1972), included assessment of the patient's functionalcapacity and indicated the patient's degree of satis-faction with the procedure. This compares with othermethods which appear to measure chiefly or solelythe technical success of the procedure (Kay andMartins, 1972; MacIntosh and Hunter, 1972) andwhich may also fail to record the patient's opinionof the procedure for fear of biased results due to thepatient's loyalty to his surgeon (MacIntosh andHunter, 1972). We, like others, used an independentassessor to overcome the possible enthusiasm of thesurgeon for the procedure.The operativetechnique and postoperativemanage-

ment described in this paper are similar to those usedby other authors. However, it seems that con-siderable differences in management achieve similarresults. Thus McCollum and others (1970) andMurray (1967) delayed full weight-bearing for 6weeks and 3 months' respectively, and Murray (1967)



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Table V Comparative results ofMacIntosh arthroplasty in patients with rheumatoid arthritis

Series Date Number Excellent Good Successful Fairly good Satisfactory Fair Poor Failureofknees No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent.

ClaryandCouk 1972 26 8 31 7 27 8 31 3 11

Henderson and 1969 21 6 29 4 19 11 52Peterson

Jessop and 1972 28 12 42-8 4 144 12 42-8Moore

Kay and Martins 1972 40 19 47-5 10 25 11 27-5

Lowe and others 1972 83 52 62-6 17 20 14 17-4

MacIntosh and 1972 89 61 68 5 24 27 4 4-5Hunter

Murray 1967 20 10 50 6 30 2 10 2 10

Potter and 1972 99 36 36-3 20 20-2 16 16-2 27 27-3others

Present series 51 22 43 5 10 7 13-5 17 33-5

manipulated all knees approximately 3 weeks afterthe operation. Other authors have employed manipu-lation for selected knees showing a slower thanaverage return of movement and, as in our sevencases, the final results do not appear to differ from theseries as a whole (Potter, 1969; MacIntosh andHunter, 1972). It may be important carefully toremove the posterior cortical rim of bone, since wenoted poorer results in those cases with posteriorbuttresses to the prosthesis, although it must beadmitted that rotational effects in the lateral radio-graphs make the identification of a true buttressdifficult.Lowe, Kates, and Kay (1971) have recommended

the use of methyl methacrylate bone cement inconjunction with slightly altered undersurfaces ofthe prostheses to aid in fixation. This was associatedwith an increase from 47 to 71 per cent. in successfulcases.

There was no correlation between the activity ofthe local or general rheumatoid disease, the durationof the disease, the presence of rheumatoid factor inthe serum, or the use of corticosteroid therapy andthe final results. Lowe and others (1971) havereported similar findings. Further, there was noevidence that corticosteroid therapy impaired woundhealing (Gamer, Mowat, and Hazleman, 1973).

Patients who underwent arthroplasties on bothknees during separate hospital admissions achievedbetter results than those in whom bilateral arthro-plasties were performed during a single admission.This may reflect difficulties in mobilizing both kneestogether. Further, the poor results in three patientswho had had contralateral knee arthrodeses may alsoreflect difficulties in encouraging joint flexion andnormal ambulation.

Insertion of a MacIntosh tibial plateau prosthesisoften reduces or eliminates considerable flexion andangular deformity. Most authors consider that up

to 300 flexion deformity and up to 200 varus deformitycan be eliminated by appropriate surgical techniquesand the selection of suitable prostheses. Our resultsconfirm these findings, but it must be stressed thatcomplete correction of these deformities is notnecessary to achieve satisfactory results. Lowe andothers (1971) found that better results were achievedin those knees with moderate preoperative laxity;less satisfactory results being found in very lax ortight knees. Our results did not support thesefindings; similar results being found with all degreesof ligamentous laxity.There is reluctance to combine patellectomy with

the MacIntosh arthroplasty in the belief that theresults will be poorer and mobilization delayed. Wefound no difference in the results in patients whohad had previous patellectomy, no patellectomy, orconcomitant patellectomy. Similarly MacIntosh andHunter (1972), although advising against concomitantpatellectomy, found seven good results in twelveknees. Nevertheless, we remove the patella only ifthere are specific patello-femoral symptoms.MacIntosh and Hunter (1972) emphasized that,

although they use radiographs including a standingview, arthroscopy, and arthrography in an attemptto determine the degree of damage in the medial andlateral joint compartments, a decision on the needfor uni- or bicompartmental prostheses must bemade at the time of the operation. This was also ourpolicy, but it was often found that adequate correctionof deformity and restoration of function could beachieved by the use of a single prosthesis even in theface of severe bicompartmental damage. Our resultsshow that in these circumstances unicompartmentalsurgery achieved better results than bicompartmentalsurgery. Detailed analysis of the eleven poor resultsof bicompartmental surgery did not reveal anyfactors which could explain these findings. It ispossible that the insertion of two prostheses into an



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extensively damaged joint produces a poorer bio-mechanical situation than when one prosthesis isused. Our findings are in agreement with those ofKay and Martins (1972), although the results havebeen interpreted differently. These authors statedthat unicompartmental surgery produced poorerresults, but their figures show that twelve of fifteenknees so treated had relief of pain compared with22 of 29 knees treated with bicompartmental surgery.Similarly nine of the fifteen knees showed an increasein motion, while a further three showed no changeand three showed a decrease in motion. The com-parative figures for motion for the 24 knees treatedwith bicompartmental surgery in which motion wasmeasured were six, nine, and eight, and one kneewas ankylosed. Jessop and Moore (1972) found goodresults in four of ten (40 per cent.) unicompartmentaloperations and eight of eighteen (44 per cent.) bi-compartmental operations. Although MacIntosh andHunter (1972) used mostly bicompartmental surgeryand Clary and Couk (1972) mostly unicompartmentalsurgery, the results do not favour either operativeprocedure.Although it appears important to provide a

satisfactory bed for the prosthesis, we found that upto 200 of tilt of the prosthesis was not associated withpoorer results. Similarly, Lowe and others (1971)found that, although sloping of both prostheses in amedial or lateral direction could be associated withsubluxation, there could, otherwise, be a widevariation in the positioning of the prostheses withoutchange in results. Poor results may be associatedwith abnormal settling of the prosthesis, since thecorrection for depth is no longer accurate. Measure-ment of this from postoperative radiographs provedunreliable.Our complications are very similar in type and

frequency to those noted by other authors. Problemsof wound healing, skin sloughing, and foot dropmay arise from over-distraction of tissues. Weincurred fewer complications when two incisionswere used during bicompartmental surgery. Theprosthesis dislocation occurred anteriorly in anover-weight male during the first week of full kneeflexion. The prosthesis was re-sited without difficultyand although it has remained in good position thefinal result has been poor. Deep infection, necessitat-ing removal of the prosthesis, is uncommon. It isworth noting that the operation causes little perman-ent alteration to the structures in and around theknee joint and does not jeopardize further surgicalprocedures.

It should be possible, after reviewing the results ofany form of therapy, to identify a group of patientswho will benefit from such therapy. This has proveddifficult with the MacIntosh arthroplasty in patientswith rheumatoid arthritis. There is general agreementthat the operation should not be undertaken in the

extensively damaged joint from whatever cause.However, it may be difficult to define or measure theextent ofthe damage. Kay and Martins (1972) suggest-ed that significant damage should be confined tothe tibial condyles and that the destruction shouldnot exceed 5 mm. in depth. We found measurementsof this destruction on preoperative radiographsunreproducible. The operation is rather moresuccessful in patients with osteoarthrosis (MacIntoshand Hunter, 1972; McCollum and others, 1970;Clary and Couk, 1972; Potter and others, 1972),and has a limited place in the management of tibialcondyle fracture (Crellin, 1965). However, it is clearthat marked local and general rheumatoid disease,a wide range of knee deformities, concomitantpatellectomy, subsequent manipulation, bilateraloperations, and previous knee surgery are not barsto successful results in well motivated patients. Inour hands uniformly poor results occurred only inpatients with arthrodesis of the contralateral knee.Similarly, in many of the cases with poor results, itwas not possible to determine the factors which ledto these results. Other authors have clearly had thesame difficulties in interpreting their results and itdoes not therefore seem wise to produce a list ofcriteria which make the knee joint unsuitable forMacIntosh arthroplasty if as many as 56 per cent.of the patients may be deprived of a good or satis-factory result (Kay and Martins, 1972).

Summary

(1) The results of MacIntosh arthroplasty in 51knees in patients with rheumatoid arthritis havebeen assessed by an independent observer.

(2) Good results associated with the ability toundertake normal housework and employmentwere found in 22 knees (43 per cent.); fairly goodresults associated with similar function but lessknee motion in five knees (10 per cent.); fairresults associated with some functional improve-ment and reduction of pain in seven knees (13-5per cent.); and poor results associated withsevere pain or poor motion or no functionalimprovement in seventeen knees (33 5 percent.).

(3) Severe bicompartmental joint damage andarthrodesis of the contralateral knee wereassociated with poor results, and are probablycontraindications for the operation.

(4) Better results were achieved with the use of asingle prosthesis than with two prostheses evenin the presence of serious bicompartmental jointdamage. The reasons for this finding are largelyunexplained.

(5) The severity of the general rheumatoid disease,the duration of the local and general disease, the



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presence of rheumatoid factor in the serum, andthe use of corticosteroids did not affect the result.

(6) Ligamentous laxity and preoperative valgusdeformity of 300, varus deformity of 200, andflexion deformity of 300 were consistent withgood results.

(7) Patellectomy, moderate tilt of the prosthesis,and varying methods of postoperative manage-ment did not influence the results.

(8) It is concluded that the MacIntosh arthroplastycan reduce pain and improve function in a widerange of rheumatoid knees, and that it is difficultto list definite indications and contraindicationsfor the operation.

We wish to thank Prof. R. B. Duthie and members of histeam who undertook the surgical treatment of themajority of the patients. We are most grateful to Mr. J. W.Goodfellow for allowing us to include five of his patientsin this study. We also extend our thanks to Mr. R.Emmanuel for the photographs and Mrs. M. Evans fortyping the paper.

Dr. Alastair G. Mowat is in receipt of a grant from theArthritis and Rheumatism Council.

DISCUSSIOND R. A. G. S. HILL (Stoke Mandeville) I speak with somediffidence because what I have to say is based on a veryrecently concluded survey of only 22 patients. But first ofall I must congratulate Dr. Mowat and his group on theircritical approach to the evaluation of a surgical procedurewhich we so badly need. We differ slightly, though ournumbers are small, eleven were unicompartmental andeleven bicompartmental procedures. Although the differ-ences cannot be statistically significant, our results to datefavour the bicompartmental operation. One question weasked the patients, which is something we took from theU.K. synovectomy trial, was, 'given your time over againwould you have the same thing done?' The patients may

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have tried to be kind to their surgeons but, for what itsworth, twenty ofthe 22 patients said 'yes' they would haveit done again. The two who said 'no' were unicompart-mental cases. Dr. Mowat said the duration of follow-uphad no bearing on the outcome and our findings for re-covery of movement after the operation are shown in FigsA and B. This is the total range of flexion, and the rangepre-operatively is put at 100 per cent, so that all thepatients start at 100 per cent. The horizontal scale is inmonths and from 3 months onwards, even 5 from monthsonwards, there was still quite an improvement in range inpatients with the lines approaching the 100 per cent. level.So I think that, as after synovectomy, one can afford tobe fairly optimistic, even though the initial rate of im-provement is perhaps a little disappointing. We use chartsof this nature in synovectomy cases to discourage peoplefrom doing manipulations, and the purpose of this chartis the same! Fig. B shows the bicompartmental groupand Fig. A, dealing with the unicompartmental group, isvery much the same, although the slope is flatter and moregradual.DR. MOWAT It is interesting that themovement continuesto improve and I think that this has been our finding aswell. Patients with early 'good' results may continue toshow further improvement in the range of movement;they do not improve at first and then start to deteriorate.This is important, and means that this does not appear tobe an 18-month or 2-year operation.PROF. V. WRIGHT (Leeds) Dr. Mowat did not let us intothe secret of how the assessments were made. I am inter-ested to know whether the patients were assessed pre-operatively and postoperatively by the same technique.We are engaged in a controlled trial of osteotomy and wefind that it is most valuable to have a full assessment bythe occupational therapist and another independentobserver.DR. MOWAT This was a retrospective survey, so that wedid not have such complete preoperative data; thishad to be culled from the notes and other availableinformation.

Months

FIG. A Recovery of movementafter unicompartmental surgery ineleven cases. Percentage scoresformaximumflexion.



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FIG. B Recovery of movement after10* ~~~~~~~~~~~~~~~~~bicompartmentalsurgery in eleven cases.O ~~~~~~~~~~~~~~~~~Percentagescores for maximumflexion.

References

ANDERSON, G. (1972) J. Bone Jt Surg., 54B, 621 (Hip assessment: a comparison of nine different methods)CL.~ARY, B. B., AND COIJK, D. E. (1972) Sth. med. J., 65, 265 (Experience with the MacIntosh knee prosthesis)CRELLIN, R. Q. (1965) J. Bone Jt Surg., 47B, 196 (MacIntosh prosthesis for tibial plateau fractures)GARNER, R. W., MOWAT, A. G., AN.D HAZLEMAN, B. L. (1973) Ibid., 55B, 134 (Post-operative wound healing in

patients with rheumatoid arthritis)HENDERSON, E. D., AND PETERSON, C. A. (1969) Sth. med. J., 62, 1311 (Experience with the use of the MacIntosh

prosthesis in knees of patients with rheumatoid arthritis)JESSOP, J. D., AND MOORE, C. J. (1972) Rheum. phys. Med., 11,217 (FOlloW-UP of the MacIntosh artbroplasty of the

knee joint)KAY, N. R. M., AND MARTINS, H. D. (1972) J. Bone Jt Surg., 54B, 256 (The MacIntosh tibial plateau hemi-prosthesis

for the rheumatoid knee)LOWE, L. W., KATES, A., AND KAY, A. G. L. (1972) Ibid., 54B, 170 (MacIntosh arthroplasty in the rheumatoid

knee)MCCOLLUM, D. E., GOLDNER, J. L., AND LANG, S. N. (1970) Ibid., 52A, 827 (Tibial plateau prosthesis in arthroplasty

of the knee)MACINrrOSH, D. L. (1966) Ibid., 48B, 179 (Arthroplasty of the knee in rheumatoid arthritis)

AND HUNTER, G. A. (1972) Ibid., 54B, 244 (Te use of the hemi arthroplasty prosthesis for advancedosteoarthritis and rheumatoid arthritis of the knee)

MURRAY, W. R. (1967) Ibid., 49A, 193 (Arthroplasty of the knee in rheumatoid arthritis)POTrER, T. A. (1969) Surg. Clin. N. Amer., 49, 903 (Arthroplasty of the knee with a tibial metallic implant of the

McKeever and MacIntosh design)--, WEINFELD, M. S., AND ThOMAS, W. H. (1972) J. Bone Jt Surg., 54A, 1 (Arthroplasty of the knee in rheumatoid

arthritis and osteoarthritis. A follow-up study after implantation of the McKeever and MacIntosh prostheses)



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