Urban Rydholm

Severe aseptic synovitis of the knee after biodegradable internal fixation : a case report

Biodegradable rods made of polyglycolide (Dexon, Biofix) or lactide-glycolide copolymer (Vicryl) have been used for the past 5 years for internal fixation of a variety of fractures and osteotomies (Böstman et al. 1989, 1990b). Experience from using such rods for fixation of intraarticular osteochondral lesions seems to be less extensive. We report a case of severe synovial reaction to biodegradable rods used for fixation of osteochondritis dissecans of the knee and discuss possible reasons for the increased risk of foreign-body reactions when these rods are used intraarticularly.

Tibio-talocalcaneal arthrodesis as a primary proce dure using a retrograde intramedullary nail : A retrospective study of 26 patients with rheumatoid arthritis

Background Arthrodesis of the ankle joint using screws or external fixation is often a demanding procedure, notably in patients with rheumatoid arthritis. We investigated whether tibio-talocalcaneal arthrodesis with the use of an intramedullary nail is a safe and simple procedure. Patients and methods We retrospectively reviewed 25 ankles (25 patients) at median 3 (1–7) years after tibio-talocalcaneal arthrodesis because of rheumatoid arthritis. All had been operated on by retrograde insertion of a retrograde nail. 5 types of nail had been used. Complications, functional outcome scores, and patient satisfaction were determined and the radiographs evaluated for healing. Results All but 1 ankle had a radiographically healed arthrodesis. We recorded 3 deep infections, all healed—in 2 cases after extraction of the nail—and the arthrodesis healed in all 3 patients. The average functional scores at follow-up were high, considering that the patients suffered from rheumatoid arthritis. 23 patients were satisfied with the outcome. We found a correlation between the functional scores and the general activity of the disease expressed as a Health Assessment Questionnaire score. Interpretation In patients with rheumatoid arthritis, tibio-talocalcaneal arthrodesis with a retrograde intra-medullary nail results in a high rate of healing, a high rate of patient satisfaction, and relatively few complications.BACKGROUND Arthrodesis of the ankle joint using screws or external fixation is often a demanding procedure, notably in patients with rheumatoid arthritis. We investigated whether tibio-talocalcaneal arthrodesis with the use of an intramedullary nail is a safe and simple procedure. PATIENTS AND METHODS We retrospectively reviewed 25 ankles (25 patients) at median 3 (1-7) years after tibio-talocalcaneal arthrodesis because of rheumatoid arthritis. All had been operated on by retrograde insertion of a retrograde nail. 5 types of nail had been used. Complications, functional outcome scores, and patient satisfaction were determined and the radiographs evaluated for healing. RESULTS All but 1 ankle had a radiographically healed arthrodesis. We recorded 3 deep infections, all healed--in 2 cases after extraction of the nail--and the arthrodesis healed in all 3 patients. The average functional scores at follow-up were high, considering that the patients suffered from rheumatoid arthritis. 23 patients were satisfied with the outcome. We found a correlation between the functional scores and the general activity of the disease expressed as a Health Assessment Questionnaire score. INTERPRETATION In patients with rheumatoid arthritis, tibio-talocalcaneal arthrodesis with a retrograde intra-medullary nail results in a high rate of healing, a high rate of patient satisfaction, and relatively few complications.

Cup arthroplasty of the rheumatoid shoulder

Hemiarthroplasty of the humeral head, using a stainless steel cup, was performed in 26 shoulders of patients with rheumatoid arthritis who had severe pain and loss of function. All the shoulders were Larsens radiographic Grade 4 or 5. After 2 (1-5) years, all the shoulders were painless and had satisfactory function. Partial radiolucent zones exceeding 1 mm were seen in three shoulders.

Interposition arthroplasty of the elbow with rheumatoid arthritis

Radiographic bone loss and clinical outcome were evaluated at a median of 6 years after interposition arthroplasty was performed in 35 elbows with rheumatoid arthritis. Seven early postoperative complications, two major and five minor, occurred. Three elbows subsequently required total elbow replacement. Clinical results were good in terms of pain relief but only fair in terms of joint mobility and stability. Radiographic elbow destruction progressed to a higher Larsen stage in half of the elbows. Measurements revealed humeral bone loss in two thirds of the elbows and ulnar bone loss in one third. In comparison with total elbow replacement, the long-term results of interposition arthroplasty were found to be inferior, with a total elbow replacement being required in one tenth of the elbows in the long term. In addition, bone loss often became extensive, making reoperation difficult or impossible. The authors recommend total elbow replacement as the first choice in the surgical treatment of the painful elbow with rheumatoid arthritis and cartilage destruction.

Surface replacement of the humeral head in the rheumatoid shoulder

The clinical results obtained an average of 4.2 years after resurfacing of the humeral head in 72 rheumatoid shoulders showed 94% of the patients being pleased regarding pain relief and 82% reporting improved shoulder mobility. Shoulder function was significantly improved. The radiographs were analyzed regarding the position of the humeral head resurfacing cup, proximal migration of the humerus, and glenoid attrition during the follow-up period. Change of the distance between the superior margin of the cup and the greater tuberosity and/or change of inclination of the prosthesis were regarded as signs of prosthetic loosening. With that definition, 25% of the cups were found to be loose at follow-up. Prosthetic loosening, however, had no bearing on the clinical result. Also, no relationship was found between the position of the cup and the clinical outcome. Neither progressive proximal migration of the humerus in 38% of the shoulders nor central attrition of the glenoid in 22% of the shoulders showed any relationship to gain of mobility, pain relief, or functional ability.

Talonavicular Arthrodesis in the Rheumatoid Foot

Arthrodesis of the talonavicular joint with a cylindrical dowel was performed in 19 feet in 17 rheumatoid patients with arthritic destruction of the talonavicular joint, but without fixed hindfoot deformity. Osseous union was achieved in 12 feet, but all patients experienced pain relief and no foot showed progressive valgus deformity of the hindfoot during follow-up. Staple fixation seemed to promote osseous union. The procedure, easy to perform and requiring only 6 weeks of immobilization, may, in the absence of fixed hindfoot deformity, supersede triple arthrodesis in rheumatoid patients with hindfoot arthritis.

Sonography, arthroscopy, and intracapsular pressure in juvenile chronic arthritis of the hip

Sonography was used in the preoperative evaluation of the hip joint in 14 patients with juvenile chronic arthritis (JCA). The joint capsule distension found at sonography and the intracapsular pressure were increased in patients with severe synovitis revealed at arthroscopy. Sonography and intracapsular pressure-recording can be recommended for assessments of synovitis of the hip joint in JCA.

Use of a trabecular metal implant in ankle arthrodesis after failed total ankle replacement

Background and purpose Arthrodesis after failed total ankle replacement is complicated and delayed union, nonunion, and shortening of the leg often occur—especially with large bone defects. We investigated the use of a trabecular metal implant and a retrograde intramedullary nail to obtain fusion. Patients and methods 13 patients with a migrated or loose total ankle implant underwent arthrodesis with the use of a retrograde intramedullary nail through a trabecular metal Tibial Cone. The mean follow-up time was 1.4 (0.6–3.4) years. Results At the last examination, 7 patients were pain-free, while 5 had some residual pain but were satisfied with the procedure. 1 patient was dissatisfied and experienced pain and swelling when walking. The implant-bone interfaces showed no radiographic zones or gaps in any patient, indicating union. Interpretation The method is a new way of simplifying and overcoming some of the problems of performing arthrodesis after failed total ankle replacement.

Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine

In patients with radiculopathy due to degenerative disease in the cervical spine, surgical outcome is still presenting with moderate results. The preoperative investigations consist of clinical investigation, careful history and most often magnetic resonance imaging (MRI) of the cervical spine. When MRI shows multilevel degeneration, different strategies are used for indicating which nerve root/roots are affected. Some authors use selective diagnostic nerve root blocks (SNRB) for segregating pain mediating nerve roots from non-pain mediators in such patients. The aim of the present study is to assess the ability of transforaminal SNRB to correlate clinical symptoms with MRI findings in patients with cervical radiculopathy and a two-level MRI degeneration, on the same side as the radicular pain. Thirty consecutive patients with cervical radiculopathy and two levels MRI pathology on the same side as the radicular pain were studied with SNRBs at both levels. All patients underwent clinical investigation and neck and arm pain assessment with visual analogue scales (VAS) before and after the blocks. The results from the SNRBs were compared to the clinical findings from neurological investigation as well as the MRI pathology and treatment results. Correlation between SNRB results and the level with most severe degree of MRI degeneration were 60% and correlation between SNRB results and levels decided by neurological deficits/dermatome radicular pain distribution were 28%. Twenty-two of the 30 patients underwent treatment guided by the SNRB results and 18 reported good/excellent outcome results. We conclude that the degree of MRI pathology, neurological investigation and the pain distribution in the arm are not reliable parameters enough when deciding the affected nerve root/roots in patients with cervical radiculopathy and a two-level degenerative disease in the cervical spine. SNRB might be a helpful tool together with clinical findings/history and MRI of the cervical spine when performing preoperative investigations in patients with two or more level of degeneration presenting with radicular pain that can be attributed to the degenerative findings.

OP-1 for cervical spine fusion: Bridging bone in only 1 of 4 rheumatoid patients but prednisolone did not inhibit bone induction in rats

We used OP-1 (also called BMP-7) on a collagen type-1 carrier in atlanto-axial posterior fusions to promote bony healing after wire fixation. 4 patients who had instability between the atlas and axis due to rheumatoid disease received the implants. The patients were examined with conventional radiography postoperatively at 2, 6 and 10 months. In 3 patients, no new bone formation was detectable. In 1 patient, new bone bridged the fusion site at 6 months. 3 patients were on chronic steroid treatment, including the patient in whom bone formation was detected. To determine whether steroid treatment could be responsible for the low rate of bone induction, 24 rats each received OP-1 implants in an abdominal muscle pouch. They were divided into 3 groups receiving saline, 0.1 or 1.0 mg/kg BW of prednisolone daily until they were killed 3 weeks postoperatively. Specimens were decalcified for histology and the amount of calcium in the decalcifying solution was measured. All groups showed ossicles induced by OP-1, and no effect of prednisolone was detected. Thus the failures in the patients may have causes other than prednisolone treatment.