Our approach to reconstructing forefoot deformities in patients with rheumatoid arthritis was as follows. In the lateral toes with mild or moderate joint destruction, shortening oblique osteotomy of the metatarsals is performed. With severe joint destruction, metatarsal head is resected. Arthrodesis of the first MTP joint is performed as a rule with resection arthroplasty in the lateral toes. When shortening oblique osteotomy in the lateral toes is indicated, the great toe is managed as follows: in young patients with mild joint destruction in the great toe (Larsen grades I and II) and who are able to ambulate well, Mitchell’s osteotomy is done. In older patients, or in patients with moderate or severe joint destruction (Larsen grades III to V), flexible hinge toe prosthesis is implanted. Between 1987 and 2000, Mitchell’s osteotomy was performed on 47 feet in 31 patients, whose mean age was 53 years, Larsen grade was 2.5 and hallux valgus angle (HVA) was 35.0 (SD11.9). Arthroplasty with flexible hinge toe prosthesis was performed on 31 feet in 23 patients, 58 years, Larsen grade was 3.7 and HVA was 45.3 (SD12.9). After 1995, grommets were used in 17 feet. In 2002, we studied clinical results of them. 40 feet of Mitchell’s osteotomy had no pain and 7 feet had some pain. 26 feet of arthroplasty with flexible hinge toe prosthesis had no pain and 5 feet had some pain. Radiologically, HVA was 17.2 (SD10.3) in Mitchell’s osteotomy and 12.1 (SD6.3) in arthroplasty with flexible hinge toe prosthesis. Maintenance of correction by arthroplasty with flexible hinge toe prosthesis was better than Mitchell’s osteotomy significantly, especially more than 30 degrees of HVA. Without grommets, grade 0 was 8 feet, grade I was 3, and grade II was 3 feet judged by Granberry’s grade. But no revision surgery was performed by silicone synovitis or fracture of implant. With grommets, there were no fractures. We added degree of HVA to management of operation after 2002. More than 40 degrees of HVA was considered flexible hinge toe prosthesis. After 2002, Mitchell’s osteotomy was performed on 7 feet in 6 patients, 53.7 years, Larsen grade was 2.4 and HVA was 32.3 (SD6.8). Arthroplasty with flexible hinge toe prosthesis was performed on 14 feet in 10 patients, 60.7 years, Larsen grade was 3.9 and HVA was 42.5 (SD7.5). Radiological result in these patients at 2005, HVA was 14.6 (SD4.9) in Mitchell’s osteotomy and 14.9 (SD2.5) in arthroplasty with flexible hinge toe prosthesis.
The wrist is the ”key-stone” of hand function. Painless stability is a prerequisite for the rheumatoid wrist to perform various manual tasks. Synovectomy of the extensor tendons and the wrist joint with a Darrach procedure is offered for painful wrists, which are not controlled by conservative treatment with medication and orthosis. Radiolunate arthrodesis is performed on wrists with an unstable radiocarpal joint and preserved midcarpal joint space. This study describes the long-term (more than 10 years) follow-up of these operative procedures.
The follow-up study was performed on 25 wrists in 25 rheumatoid patients (22 women and 3 men), whose average age was 52 years (range, 33 to 66 years) with an average disease duration of 12 years (range, 1 to 38 years). The average follow-up period was 12. 5 years (range, 10 to 18 years). Five wrists were Larsen-Dale-Eek’s grade II, 14 were grade III, and 6 were grade IV. Depending on the severity of bone destruction, the scaphoid in 6 wrists and the triquetrum in 3 wrists were included in the fusion site.
Preoperative pain (88%) and swelling (96%) decreased remarkably at follow-up (12%, 4%). Average grip strength increased significantly from 100mmHg to 140mmHg (p<
0. 01). The total arc of wrist extension/ flexion decreased to two-thirds of the preoperative arc with a major loss in flexion (preop. : 26/28degrees, follow-up: 23/13degrees). The range of forearm rotation increased due to a Darrach procedure. In periodical X-ray assessments of 23 wrists, carpal collapse initially improved following the operation, however, it returned to the preoperative level after 5 years. Ulnar carpal shift improved significantly after the operation (p<
0. 01), and the position remained unchanged over 10 years. In palmar carpal subluxation, no remarkable change was noted. Bone union occurred in 87% of the operated wrists and the remaining 13% had fibrous union. Widening at the lunocapitate joint (>
2mm) was noted in 4 wrists (17%) and progressive instability at the midcarpal joint occurred in one wrist with the mutilating type of disease. Narrowing (<
1mm) was noted in 5 wrists (22%) and 3 wrists were totally fused in the functional position.
Radiolunate arthrodesis provides good stability with some motion for the moderately deteriorated rheumatoid wrist more than 10 years after the operation, in spite of some radiological progression of the disease. This operation is considered to convert the natural course of the rheumatoid wrist from the unstable form to the stable form.
The wrist is the ”key-stone” of hand function. Painless stability is a prerequisite for the rheumatoid wrist to perform various manual tasks. Synovectomy of the extensor tendons and the wrist joint with a Darrach procedure is offered for painful wrists, which are not controlled by conservative treatment with medication and orthosis. Radiolunate arthrodesis is performed on wrists with an unstable radiocarpal joint and preserved midcarpal joint space. This study describes the long-term (more than 10 years) follow-up of these operative procedures.
The follow-up study was performed on 25 wrists in 25 rheumatoid patients (22 women and 3 men), whose average age was 52 years (range, 33 to 66 years) with an average disease duration of 12 years (range, 1 to 38 years). The average follow-up period was 12. 5 years (range, 10 to 18 years). Five wrists were Larsen-Dale-Eek’s grade II, 14 were grade III, and 6 were grade IV. Depending on the severity of bone destruction, the scaphoid in 6 wrists and the triquetrum in 3 wrists were included in the fusion site.
Preoperative pain (88%) and swelling (96%) decreased remarkably at follow-up (12%, 4%). Average grip strength increased significantly from 100mmHg to 140mmHg (p<
0. 01). The total arc of wrist extension/ flexion decreased to two-thirds of the preoperative arc with a major loss in flexion (preop. : 26/28degrees, follow-up: 23/13degrees). The range of forearm rotation increased due to a Darrach procedure. In periodical X-ray assessments of 23 wrists, carpal collapse initially improved following the operation, however, it returned to the preoperative level after 5 years. Ulnar carpal shift improved significantly after the operation (p<
0. 01), and the position remained unchanged over 10 years. In palmar carpal subluxation, no remarkable change was noted. Bone union occurred in 87% of the operated wrists and the remaining 13% had fibrous union. Widening at the lunocapitate joint (>
2mm) was noted in 4 wrists (17%) and progressive instability at the midcarpal joint occurred in one wrist with the mutilating type of disease. Narrowing (<
1mm) was noted in 5 wrists (22%) and 3 wrists were totally fused in the functional position.
Radiolunate arthrodesis provides good stability with some motion for the moderately deteriorated rheumatoid wrist more than 10 years after the operation, in spite of some radiological progression of the disease. This operation is considered to convert the natural course of the rheumatoid wrist from the unstable form to the stable form.
Since 1981, we have used various types of the total hip prosthesis for the reconstruction of the acetabular protrusion in rheumatoid arthritis. The cemented Charnley prosthesis was used during the initial 8 years, and we experienced loosening of the cemented acetabular socket in some cases. The bipolar femoral head prosthesis, which started to be used from 1984, was one of the cementless prosthesis. And it showed high frequency of proximal migration of outerhead. The threaded socket also showed frequent loosening. To overcome these problems, we started to utilize a new method from 1988. This method included packing morselized bone grafts into the acetabulum and fix them using a porous coated socket and screws. This study describes the results of cementless total hip arthroplasty (THA) for the acetabular protrusion in rheumatoid arthritiswith this method.
Sixty -one cementless THAs with use of porous coated acetabular socket were performed in 50 patients who had sever protruded acetabulum due to rheumatoid arthritis. The average follow –up period was 9 years and 5 months (range, 5 to 13 years). A Mallory/ Head prosthesis with porous coated socket was used in 43 hips and other types in 18 hips. In all operated hips, autogenous morselized bones were grafted on the thin acetabullar wall.
The clinical improvement in pain was the most apparent. X-ray findings of the grafted bone in the acetabulum showed a homogenous pattern in most cases (90. 2%) at 6 months after the operation. A radiolucent zone at a non-weight-bearing area between the grafted bone and socket was seen in 20 hips (32. 7%) for 3 years after the operation, and it gradually disappeared and changed to a sclerotic zone. Collapse and /or absorption of the grafted bone were noted in 3 hips of the patients with sever osteoporosis and high disease activity.
There are several technical key points to succeed THA in patients with rheumatoid arthritis. The first is the selection of the acetabular socket. The second is the method of bone grafting, and the third is the size and the shape of grafted bones. We have used various types of prosthesis for the protruded acetabulum so far, and it was considered that the bipolar and threaded types are not acceptable because of their high frequency of proximal migration and loosening. The mass and /or block bone should not be used, because they are liable to fall into collapse. It is safely recommended to use slice or morselized bones to lead the grafts to early survival and remodelling caused by tight and close contacts.
THA with the use of morselized bone grafting into the acetabulum and a fixation with a porous coated socket-and screws is a simple and useful procedure for treating protruded acetabulum in rheumatoid arthritis.
