Eero A. Belt

High Rate of Osteolytic Lesions in Medium-Term Followup after the AES Total Ankle Replacement

Background: Some previous studies have shown a high percentage of early-onset and rapidly progressing osteolysis associated with total ankle arthroplasty (TAA) by the Ankle Evolutive System (AES). The purpose of our study was to analyze medium-term results at our institution. Materials and Methods: Altogether 38 TAAs using AES prostheses were carried out between 2003 and 2007. Diagnoses were rheumatoid arthritis (71%), post-traumatic and idiopathic osteoarthritis (29%). The mean age was 54 years, followup 28 months. Tibial and talar components had hydroxyapatite coating on metal (Co-Cr) components (HA-coated). Since 2005 the design was changed and components were porous coated with titanium and hydroxyapatite (dual-coated). Results: Two-year survival was 79% (95% CI: 56 to 98). At followup 34 (89%) primary tibial and talar components were preserved. In 19 (50%) TAAs osteolysis (more than or equal to 2 mm) occurred in the periprosthetic bone area and in nine (24%) comprised large “cyst-like osteolysis”. In HA-coated prostheses radiolucent lines (less than or equal to 2 mm) or osteolysis (more than or equal to 2 mm) were detected in 11 (100%) cases and in dual-coated prostheses in 19 (74%) (p= 0. 08). On the other hand there was more large “cyst-like osteolysis” around the dual-coated prosthesis and lesions were larger (p= 0. 017). In rheumatoid arthritis osteolysis was detected in 14 (52%) and large “cyst-like osteolysis” in seven (26%) prostheses and in the group of traumatic and idiopathic osteoarthritis in six (55%) and two (18%), respectively. Conclusion: This study showed a high frequency of osteolysis in medium-term followup after the AES ankle replacement. The outcome was not sufficiently beneficial and we have discontinued use of this prosthesis. Level of Evidence: IV, Retrospective Case Series

Survival of the AGC total knee arthroplasty is similar for arthrosis and rheumatoid arthritis. Finnish Arthroplasty Register report on 8,467 operations carried out between 1985 and 1999.

We report the survival of AGC knee endoprosthesis from the Finnish Arthroplasty Register for 2 indications, osteoarthrosis (OA, 6 306 knees) and rheumatoid arthritis (RA, 2 161 knees) during 1985- 1999. Survivorship analysis was performed with revision as an endpoint. We found similar survival rates. In the OA group, survival after 5 years was 97% and it was 94% after 10 years. In the RA group the corresponding figures were 97% and 96%, respectively. There was no significant difference in survival whether or not cement was used for fixation. The revision rates were higher in men and in younger patients.

What went wrong in triple arthrodesis? An analysis of failures in 21 patients.

Three hundred seven triple arthrodeses were done on 282 patients with rheumatic diseases between 1995 and 1999. Solid and painless fusion was achieved in 261 patients (93%, 286 arthrodeses). Twenty-one arthrodeses (in 21 patients) that failed were analyzed. Fourteen (66%) malunions, six (29%) nonunions, and one (5%) painful foot without malunion or nonunion were found. Of the failed procedures, valgus alignment was present in 13 feet and varus alignment was present in eight feet. The most common cause of failure was a misjudgment in the surgical technique, which occurred in 12 of 21 (57%) patients based on inadequate correction and repositioning of hindfoot deformity. In four (19%) patients, additional ankle destruction and instability was overlooked as a cause of malalignment. Revision triple arthrodesis was successful in 18 of 21 (86%) patients. Triple fusion offers challenges in surgical technique, postoperative treatment, and rehabilitation. Understanding the complexity of the rheumatic hindfoot is important when performing triple arthrodesis in patients with severe deformities manifesting typically as calcaneovalgus and pes planus.

Why do ankle arthrodeses fail in patients with rheumatic disease

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors’ institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeons attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0–5° of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Bone destruction, upward migration, and medialisation of rheumatoid shoulder: a 15 year follow up study

OBJECTIVE To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively. METHODS At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space. RESULTS Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=−0.49 (95% CI −0.36 to −0.60) and r=−0.58 (95% CI −0.46 to −0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5. CONCLUSIONS Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.

Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis

OBJECTIVE Serum C reactive protein (CRP) concentration was evaluated in patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) to ascertain the postoperative CRP response. METHODS Thirty seven consecutive patients with RA who had undergone THA or TKA were included in the study. The CRP concentration was measured in every patient once preoperatively and every other day for one week postoperatively. RESULTS The peak median CRP concentration (94 mg/l) was achieved on the first and second day postoperatively and was seven times higher than the median preoperative concentration (13 mg/l). CRP declined to the preoperative concentration in about one week. The rise of the CRP concentration was significant (p< 0.001). No infection was encountered in this series. CONCLUSION A rapid rise in the postoperative CRP concentration is normal in patients with RA treated by THA or TKA. The CRP concentration decreases to the preoperative value in about one week. Serial CRP measurements, including at least one preoperative measurement, are needed when the clinical significance of the postoperative CRP values is evaluated. When the postoperative CRP concentration remains raised for several days compared with the preoperative value, or even rises, it may indicate the presence of a complication in these patients.

Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty

We present the prosthesis survival of the 7 most commonly used component types of 522 primary Souter elbow replacements performed in the Rheumatism Foundation Hospital during the years 1982-1997. The cohort comprised 370 female and 33 male patients with a mean age of 57 (20-81) years. 119 patients had a bilateral procedure. The indications for operation in all cases were rheumatoid arthritis and other chronic inflammatory joint disease. The mean duration of the disease at the time of operation was 25 (2-70) years. Elbows were often severely destroyed and, in one third of the joints, essential bone structures were missing. Therefore, in 178 cases, the ulnar components were retentive and in the remaining 344 elbows with better bone stock non-retentive. 47 patients had 51 operations for aseptic loosening up to the end of year 2000. In the survival analysis, the general cumulative success rates for the whole study cohort, without revision because of aseptic loosening 5 and 10 years after surgery, were 96% and 84%, respectively. Revision was used as an end point. Cumulative success rates of the 7 most commonly used components are presented separately. The highest 5-year-survival rate was 100%, the lowest 93%. The corresponding 10-year-survival rates were 91% and 76%, respectively.

Stress Fractures of the Ankle and Forefoot in Patients with Inflammatory Arthritides

Twenty-four stress fractures occurring in the metatarsal bones and ankle region were examined in 17 patients with inflammatory arthritides. There were 16 metatarsal, four distal fibular, two distal tibial, and two calcaneus fractures. Radiographic analyses were performed to determine the presence of possible predisposing factors for stress fractures. Metatarsal and ankle region stress fractures were analyzed separately. Stress fractures occurred most frequently in the second and third metatarsals. In metatarsal fractures, there was a trend for varus alignment of the ankle to cause fractures of the lateral metatarsal bones and valgus alignment of the medial metatarsal bones. Valgus deformity of the ankle was present in patients with distal fibular fractures in the ankle region group. Calcaneus fractures showed neutral ankle alignment. Malalignment of the ankle and hindfoot is often present in distal tibial, fibular, and metatarsal stress fractures. Additionally, patients tend to have long disease histories with diverse medication, reconstructive surgery and osteoporosis. If such patients experience sudden pain, tenderness, or swelling in the ankle region, stress fractures should be suspected and necessary examinations performed.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis.A 20-year follow-up study

AIMS In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). METHODS An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzicks test. RESULTS At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzicks test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. CONCLUSIONS The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

Survivorship of AGC Knee Replacement in Juvenile Chronic Arthritis 13-Year Follow-Up of 77 Knees

This study analyzed the survivorship and results of 77 knee replacements in 52 patients with juvenile chronic arthritis using the nonconstrained Anatomically Graduated Components (AGC; Biomet, Warsaw, IN) 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), and the mean age of the patients at the time of surgery was 33 years (range, 16-64 years). 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. Clinical follow-up examinations were conducted 3 months, 1 year, 4 years, and 8 years postoperatively. An interview was arranged at the end of 1998, 3 to 13 years after surgery; 2 patients were not reached, and 2 died during the follow-up. Fifty-five of 73 (75%) knees were subjectively excellent, 18 (25%) were fair, and none was poor. Radiolucent lines of 1.0 to 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 the implantation. The overall survival was 99% (95% confidence interval, 92-100) at 5 years. We consider these results excellent in this demanding patient material. The nonconstrained AGC prosthesis with cementless fixation proved to be feasible in knee replacement in patients with juvenile chronic arthritis.