Beat R. Simmen

Late complications in elbow arthroplasty

The world literature (1986 to 92) reports an amazingly high complication rate of elbow arthroplasty, amounting to 43%. Accordingly, we also find a high revision rate (18% on average) and a considerable rate (15%) of permanent complications. These figures do not correspond to our own experience with the GSB III (Gschwend/Scheier/Bähler) elbow prosthesis, a sloppy hinge with flanges on the lower and anterior part of the distal humerus. Our respective figures of complications are two to four times lower for rheumatoid elbows. When complications are discussed, a clear distinction of the type of prosthesis is mandatory, because linked or nonlinked and nonconstrained or semiconstrained prostheses have specific complications. The following complications are discussed separately: loosening (radiologic and clinical), ulnar neuropathy, infection, dislocation and subluxation, uncoupling, intraoperative bone fractures, and failure of the implant. The possible causes are analyzed, and means to avoid or treat these complications are discussed. We conclude that even in the long term ( > 10 years), results obtained with elbow arthroplasty are approaching those of hip and knee arthroplasty.

Compression arthrodesis of the rheumatoid ankle and hindfoot.

The reported frequency of involvement of the rheumatoid ankle and hindfoot varies between 9% and 70%. Fusion of the ankle joint, the subtalar, talonavicular, or calcaneocuboidal joint (Choparts joint) or all of them is the preferred method of treatment for severe rheumatoid involvement causing pain, instability, and/or severe deformity. Ankle arthroplasty is indicated rarely. Pantalar arthrodesis is performed more frequently than talonavicular fusion or ankle fusion. Reported rates of fusion after compression arthrodesis of the ankle joint vary from 65% to 90%, averaging 80% to 85%. Higher success rates of as high as 95% were obtained with internal lag screw fixation as proposed by Wagner. The result of various combinations of arthrodesis (n = 54) of the ankle joint, the subtalar joint, and Choparts joint in 43 patients with rheumatoid arthritis operated on in a 10-year period from 1984 through 1993 are presented. In all cases internal fixation by lag screws according to Wagner was used with a modified lateral approach incorporating osteotomy of the distal fibula. The technique is described in detail. Solid fusion was obtained in 21% of the cases after 8 weeks, in 69% of the cases after 12 weeks, and in 92% of the cases after 16 weeks. In 8% (3 patients) revision because of delayed union or nonunion eventually led to bony fusion. Postoperative pain, walking capacity, gait, and the subjective outcome were assessed. Complications occurred in 16%, revision was performed in 11.6% of the cases; in all cases healing was obtained. Overall patient satisfaction was 93%.

Palmar approach in flexible implant arthroplasty of the proximal interphalangeal joint.

Joint replacement is an established method in the treatment of destroyed, painful, proximal interphalangeal joints. A palmar approach was used in which the main collateral ligaments were preserved, allowing immediate active rehabilitation with enhanced primary lateral stability. Fifty-nine proximal interphalangeal joint silicone arthroplasties in 38 patients with a minimum followup of 12 months were reviewed. Thirty-eight of the 59 joints had implantation from a palmar approach and 21 joints from a dorsal approach. The two groups were well-matched in terms of indication, preoperative range of motion, and patient age. No significant increase in the range of motion was found in either of the patient groups, with an overall average range of motion of 51° postoperatively. There was also no significant difference in the postoperative stability in the two patient groups. The choice of surgical approach at the proximal interphalangeal joint level for the silastic type of implants does not appear to be important. With more sophisticated types of implants in which the integrity of the collateral ligaments is crucial, a palmar approach might be beneficial.

Rheumatoid arthritis of the wrist. Classification related to the natural course.

The authors introduce a new functional classification of rheumatoid arthritis of the wrist. Unlike the classifications used today, it includes the aspect of the natural course of rheumatoid arthritis. The goal of this paper is to identify radiologic indicators that will classify rheumatoid arthritis into stable forms of the disease (Types I and II) and unstable forms of the disease (Type III). Of 144 wrists examined, the first available radiograph and the radiograph obtained at the time of the first surgery were assessed. The indicators measured were: carpal height ratio, ulnar translocation, radial rotation, and scapholunate dissociation. Noting the changes that occurred each year in these indicators, it was possible to identify a significant difference between stable forms (Types I and II) and unstable forms (Type III) for the parameters carpal height ratio, ulnar translocation, and scapholunate dissociation. The distribution of the indicators allowed the definition of three values: the 100% value, the cut off point, and the lower threshold value. Combining the three radiologic parameters at those values markedly enhanced the possibility to classify rheumatoid arthritis of the wrist. With the help of the three radiologic indicators carpal height ratio, ulnar translocation, and scapholunate dissociation, it is possible to classify wrists with an early stage of rheumatoid arthritis according to the Schulthess classification. The early identification of destabilizing forms of rheumatoid arthritis becomes possible, making the choice and timing of the surgical intervention easier. Wrists with a progressive unstable form of rheumatoid arthritis may be stabilized earlier.

Limited and complete fusion of the rheumatoid wrist

The correct surgical treatment of the rheumatoid wrist has an important impact on the function of the affected band. Surgical decisions should be based on individual deformity and poteustal progression of the disease. A classification of rheumatoid urist involvement is presented that considers the natural progression of the disease and helps to optimze the treatment of these pathents. If a destabilizing form of destruction is found, limited or complete wrist fusion is often the treatment of choice. Among partial fusions, the radiolunate arthrodesis gives consistent, good clinical results. Is preserves some wrist motion with realignment of the carpus and stabilization to prevent further dislocation. In cases of severe destruction and deformity, comples wrist fusion, preferably performed by using large-pin technique, gives pain-free long-term stability of the wrist.

Shortening Osteotomy for Treatment of Metacarpophalangeal Joint Deformity

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

GSB III Elbow

The history of elbow arthroplasty begins in the last century. The procedure of resection arthroplasty started to gain in importance in 1878 when Ollier [1] began to practice it with considerable success. In the 1960s we also used a modification of it in a great number of cases, and we were even able to mobilize elbows which, due to juvenile arthritis, had been ankylosed in extension (Fig. 1). Thirty years after elbow resection arthroplasty, one of these patients is able to use both formerly ankylosed and useless elbows so well that she is independent, can look after herself, and is even able to use two crutches for walking with her multiple joint replacements at the lower extremity.