Mack L. Clayton

Surgical Treatment at the Wrist in Rheumatoid Arthritis: A Review Of Thirty-seven Patients

The wrist is the key joint for hand function and is also a key area for rheumatoid arthritic involvement. The role of rheumatoid synovitis in the natural history of the disease at this level has been discussed; the indications for surgical treatment and the results in thirty-seven patients with forty-seven surgical procedures have been presented. Splinting of the wrist should not be neglected. Many patients deserve early consideration of surgical treatment since good results can be obtained and maintained by such treatment.

Synovectomy and Débridement of the Knee in Rheumatoid Arthritis

1. The results of twenty-eight synovectomies and debridements in adults and three synovectomies in children are discussed. Eighty-five per cent of the procedures in adults were performed in late stages of destruction. All adult patients had classic rheumatoid arthritis with multiple joint involvement. Seventy-nine per cent of the knees were rated improved by the patient as compared with 65 per cent rated improved by the examiner. In 46.5 per cent definite or probable recurrence was found. 2. The results and the incidence of recurrence were found to be time dependent and proportional to the general activity of the disease as well as to the extent of damage present at the time of operation. When synovectomy was done bilaterally at an identical stage of the disease, the results were comparable. 3. Scoring of a patients disability and local disease activity were found to be very useful in order to evaluate the results quantitatively. 4. Joint instability and joint narrowing were used as the criteria of the extent of joint damage and were found to be reliable in predicting the chances of success of synovectomy in a patient with low or moderate disease activity. 5. Angular deformity, antedating rheumatoid involvement, tends to progress rapidly with the onset of arthritis and should probably be corrected early. 6. Recurrence does not always become apparent during the first few months after synovectomy. 7. In advanced stages of destruction the objective of synovectomy is temporary relief of pain and functional improvement. Synovectomy alone is not indicated when there is severe instability and loss of articular cartilage. 8. Synovectomy is strongly indicated for a knee which has shown persistent involvement of short duration when there is advanced joint destruction of the opposite knee. 9. With early mobilization, the range of motion is not significantly affected and does not correlate with the final subjective and objective result in most patients. 10. Only two complications occurred: one a separation of the patellar tendon and the other, thrombophlebitis.

A Visual, Histological, and Enzymatic Study of Regenerating Rheumatoid Synovium in the Synovectomized Knee

In the knees of twenty-five patients with rheumatoid arthritis who had had synovectomy an average of thirty-one months previously (range one to 120), arthroscopy, aspiration, and biopsy were done. The findings were that the regenerated synovium became histologically indistinguishable from that found in patients not operated on—grossly and microscopically active areas alternated with inactive ones, lysosomal glycosidases were elevated and rose with time, and the synovium of eighteen of twenty-one of the patients two years after synovectomy met the criteria for rheumatoid disease.

Surgery of the Thumb in Rheumatoid Arthritis

Experiences in the treatment of rheumatoid deformities of the thumb at the University of Colorado Arthritis Clinic over the last eight years are described. The number of surgical cases (eighteen) is too small for any statistical analysis. In general the results have been gratifying. In most cases the patient, surgeon, and physician have been pleased with the results as all have realized that one is striving for a limited gain in function and that results in a chronic progressive disease cannot be compared with the results in static conditions. Many patients deserve evaluation for surgical reconstruction.

Performance of a hinged metal knee prosthesis. A case report with a follow-up of three and one-half years and histological and metallurgical data.

1. A patient with a Vitallium hinged knee prosthesis studied at autopsy forty-two months after implantation was presented. 2. Clinically, the patient had no complications or clinical evidence of tissue reaction while receiving good, pain-free service from the prosthesis. 3. Pathologically, a massive amount of Prussian blue positive staining material was found in the capsule and lining the canals formed by the stems of the prosthesis. 4. Mechanical wear (corrosion) was evident at the areas of contact and on the central axis of the hinge. 5. The importance of mechanical design and composition is seen to be a significant consideration of reconstructive surgery.