Various radiological classification systems exist for rheumatoid wrist progression but few have been evaluated for reliability and clinical application. In order to research these three sets of wrist radiographs of 35 rheumatoid patients, with an average duration of disease of 11 years, were classified according to four different classification systems (Larsen, Simmen, Wrightington and Modified Wrightington). The inter- and intraobserver reliability of each was calculated. The reliability of the Larsen and both Wrightington systems were good but the Simmen system had poor interobserver and intraobserver reproducibility. None of the classification systems satisfactorily assessed the distal radioulnar joint (DRUJ) and the Modified Wrightington system could not classify DRUJ disease in 6 of the 35 wrists.

Introduction: Silicon-implant-arthroplasty in cases of severe destruction of the radiocarpal joint was a routinely used procedure in rheumatoid arthritis to restore mobility and function. However in many cases an implant failure with a fracture rate of up to 50% with massive synovitis and a severe carpal collaps must be documented. Main problem is the extensive bone loss which makes further procedures difficult. Revision-wrist-arthrodesis with bone grafting (iliac bone, allograft or free fibula-graft) is the commonly used procedure. Therefore non-union in these cases is documented in up to 40%.

Material and Methods: Between 1999 and 2003 we performed in 2 cases of severe seropositive rheumatoid arthritis and in one case of psoriatic wrist joint destruction with extensive bone loss only a revision arthroplasty with debridement and insertion of a new Swanson silicon implant. At the time of revision mean age was 61 years and primary silicon arthroplasty was done 11 years ago. In one case a decompression of the median nerve in the carpal canal was necessary. In one case a transposition of the ECU to ECRB was performed to neutralize the ulnar drift of the remaining carpus.

Results: In all patients a good mobility in the wrist with pain free function could be achieved. All patients were satisfied with this procedure. Clinical, subjective and radiological results are presented.

Conclusion: Revision after silicon-wrist arthroplasty with severe bone loss without or only minimal carpal bone stock and a thin trumpet-like distal radius is difficult. Revision arthrodesis often ends in a non-union despite substantial bone-grafts. Debridement and revision with a new silicon implant is easy to perform and respectable function and a pain free situation might be achieved.

Introduction: In the evaluation of the major joints, self assessment tools have become wide spread aiming at a more precise quantification of joint function. Different tools have been developed for the elbow joint. However, there are only few data on the relationship between subjective self-assessment of joint function and objective measures.

We developed a comprehensive assessment set for the evaluation of subjective elbow function and objective clinical findings and investigate long-term results after implantation of GSB III Elbow arthroplasties in a first study. The PREE-G was cross-culturally adapted, following the recommendations of the American Association of Orthopedic Surgeons.

Material and Methods: 79 patients (56 female, 23 male, mean age 64 years) after elbow arthroplasty between 1984 and 1996 due to rheumatoid (59) or posttraumatic (20) arthritis underwent an assessment of the joint function using the PREE, the Short Form 36 (SF-36), the Disabilities of Arm, Shoulder, Hand (DASH)) and the modified American Shoulder and Elbow Surgeons (mASES) for a clinical evaluation. In 62 patients implantation was performed unilaterally and in 17 patients bilaterally, resulting in 96 elbow joints altogether. The mean follow up time was 11,2 years

Results: In the SF-36 score, the mean physical component scale (PCS) was worse (37,2 vs 41,7, p=0,004), the mean mental component scale (MCS) better (52,3 vs 50,3, p=0,092) than normative values of a German population. Subjective assessment by the PREE revealed a mean of 66,8, by the mASES of 63,1 and by the DASH of 56,5 points. Clinical examination resulted in a mean mASES score of 71,6 points. Comparison between the patients self assessment and the objective score revealed a significant correlation between the DASH (r=0,46, p< 0,001), PREE (p=0,54, p< 0,001) and mASES (r=0,60, p< 0,001) with the clinical mASES. In contrast, no significant correlation was found between the physical component scale (PCS) and mental component scale (MCS) of SF-36 and the clinical mASES. Also the patients assessment scores DASH, PREE and mASES showed a strong significant correlation among one another (r=0,74–0,92, p< 0,001) and (PCS) (r=0,58–0,75, p< 0,001) but not with the (MCS) of SF-36.

Conclusion: Assessment of long term results after elbow arthroplasty yielded favourable clinical and subjective results. The clinical outcome tended to be higher than results of the patient self-rated scores. Hereby, the newly developed assessment set proved to be a feasible tool for a comprehensive assessment of elbow function. In addition to clinical outcome assessment, with this set it is possible to gain important and new insights on the relationship between objective measures and subjective patients-assessment of elbow disorders and postoperative conditions.

Correct placement of the total elbow endoprosthesis is a critical factor for the long-term success of an artificial joint. Correct restoration of the centre of rotation is essential for optimal outcome. To evaluate whether surgical navigation has the potential to improve accuracy during Total Elbow Arthroplasty (TEA), an existing CAS system was applied on one plastic model and three patients.

The spine module of the SurgiGATE™ navigation system (Medivision, Oberdorf, Switzerland) was used. To apply it during TEA, a standard 3.5-mm drill guide was instrumented with infrared LEDs and calibrated. A dynamic reference base (DRB) was developed. Its base consisted of an X-shaped, scissors-like construct that could be clamped rigidly onto the distal humerus after exposure. On a plastic model, the DRB design was evaluated, and three landmarks suitable for intraoperative matching were identified. Subsequently, the Spine system was applied during three TEA surgeries. For the first surgery no pre-operative CT scan was acquired, but the design of the DRB, its camera visibility, and the accessibility of the landmarks were verified. For the other cases, the elbows were CT-scanned preoperatively. Planning consisted of 3-D segmentation as well as the definition of matching landmarks and a trajectory representing the position of a Steinmann pin, with which the humeral implant position is defined. Intraoperatively, the DRB was fixated, and matching was performed. Using the navigation system, the drill guide could then be aligned with the planned trajectory.

For the second patient, no accurate matching was achieved, hence surgery was completed conventionally. The last patient could be registered precisely, and the Steinmann pin was placed as planned.

Preliminary results show that CT-based navigation can be applied during TEA. Given a positive output of an ongoing clinical study, the development of a special TEA navigation system is planned.