Secondary Arthrosis Research Articles

THE OTTO AUFRANC AWARD: Highly Cross-linked Polyethylene in Total Hip Arthroplasty

The annual wear rate in polyethylene articulations should be 0.1 mm or less to avoid future osteolysis. Highly cross-linked polyethylene shows an 80 to 90% wear reduction in hip simulator testing, but the clinical documentation of this new polyethylene is still inadequate. We evaluated the highly cross-linked polyethylene in two prospective randomized clinical studies. Thirty-two patients (12 men, 20 women; 64 hips) with a median age of 48 years (range, 29-70 years) with bilateral primary or secondary arthrosis of the hip had hybrid total hip arthroplasty with liners made of highly cross-linked polyethylene on one side and conventional polyethylene on the other. Twenty-seven patients in this study have passed 2 years followup. A further group, comprised of 60 patients (61 hips) with a median age of 55 years (range, 35-70 years), was randomized to receive either highly cross-linked polyethylene or conventional cemented all-polyethylene of the same design. Forty-nine of these 60 patients have been observed for 3 years. In both studies all patients received Spectron stems with 28-mm Co-Cr heads. Radiostereometric examinations with the patient supine or standing were done at regular intervals. Wear was measured in the supine position from the first postoperative week, whereas standing examinations were initiated 3 months after the operation. The penetration rate almost was identical in the study and control groups at 6 months after the operation. Thereafter, the penetration rate leveled out in the two groups with highly cross-linked polyethylene. At 2 years the highly cross-linked polyethylene liner showed 62% lower proximal penetration and 31% lower total (three-dimensional) penetration when the patients were examined in supine position. The highly crosslinked all-polyethylene cemented cups showed lower proximal penetration in both positions. The better wear performance of highly cross-linked polyethylene could increase the implant longevity. Longer followup is needed to evaluate if this new material is associated with less occurrence of osteolysis.

Arthrotomy versus arthroscopy in the treatment of the fragmented medial coronoid process of the ulna (FCP) in 421 dogs

SummaryIn a retrospective trial over eight years 518 joints from 421 dogs with fragmented medial coronoid process of the ulna (FCP) were included. Seventy-five joints had an additional osteochondrosis dissecans of the medial aspect of the humeral condyle. Forty-six point eight percent of the dogs (197/421) were younger than one year. Two hundred and forty-seven joints were treated by conventional arthrotomy and 271 joints were treated by arthroscopy. Two hundred and thirty-eight cases (103 treated by arthrotomy and 135 by arthroscopy) were re-evaluated clinically and radiographically and 191 cases (88 treated by arthrotomy and 103 by arthroscopy) by means of a questionnaire at an average of 23 and 21 months after the operations, respectively. Forty-two point four percent (81/191) of the cases treated by arthrotomy did not show any lameness, 29.3% (56/191) showed temporary lameness after rest or heavy exercise, and 28.3% (54/191) showed constant lameness. The signs of which had, however, been reduced by surgery in 14 of these cases. Sixty point one percent (143/238) of the cases treated by arthroscopy did not show any lameness, 29.4% (70/238) showed temporary lameness after rest or heavy exercise and 10.5% (25/238) showed constant lameness, out of which four cases had improved after surgery. In the cases treated by arthroscopy, the period of convalescence was shorter. Differences between these methods were not observed with respect to the development of subsequent arthrosis. The results of the study show that arthroscopy, with its minimal invasive character, gives better functional results than conventional arthrotomy. However, the development of secondary arthrosis cannot be avoided by either method.

Lessons learned after more than 250 periacetabular osteotomies.

The Bernese periacetabular osteotomy (PAO) has become the procedure of choice in many centers for the treatment of young patients with symptomatic hip dysplasia in the absence of severe secondary arthrosis. This article concerns our institution's "learning curve" with this procedure and focuses on patient selection, exposure, technical aspects of performing the bone cuts, mobilizing the fragment, and obtaining proper correction.

Does foot position in tibiotalar arthrodesis have an effect on development of secondary arthrosis

Twenty-nine patients with 30 isolated arthrodeses of the upper ankle done by a resection and compression technique to treat post-traumatic arthrosis or irreparable pilon fractures, were assessed clinically and radiologically 15–32 years (average, 23.5 years) postoperatively. Foot position, talar retrodeviation, and the various angles of the hindfoot were determined by clinical and radiologic evaluation. Eighteen patients (60%) achieved a good or very good result (American Orthopaedic Foot and Ankle Society AOFAS Score more than 70 points). In contrast, the radiologic examination revealed that additional development or increased arthrosis of the hindfoot and midfoot was present in 26 feet. No correlation was found between the foot position in which the arthrodesis was done and the localization and extent of secondary arthrodeses. Arthrodesis done in a neutral position without talar retroposition can be done without deterioration of longterm effects.

RADIOLUNATE ARTHRODESIS IN THE RHEUMATOID WRIST: A RETROSPECTIVE CLINICAL AND RADIOLOGICAL LONGTERM FOLLOW-UP

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.

Prosthetic Replacement of the Ankle in Posttraumatic Arthrosis 10-Year Experience with the Cementless ESKA Ankle Prosthesis

As a result of numerous failed implantations of cemented ankle prostheses since the early 70s, ankle arthrodesis represented the “gold standard” in the treatment of ankle arthrosis. Due to a change to cementless implantations in the 90s it came to a remarkable reduction in early loosening, bone necrosis and sintering of the prosthesis which were the main reasons for former failures. In cooperation with ESKA Implants, Lubeck, we have developed a cementless anatomic ankle prosthesis. Patients and Methods: At our hospital, the ESKA prosthesis has been implanted in 56 patients (72% posttraumatic) since 1990. In our study, we report the examination results of 40 out of these 56 patients at least 1 year post implantation (21 of them more than 5 years). For evaluation, we used the Kofoed ankle score, which allows an easier comparison with other studies. This score showed an average improvement from 34.75 points preoperatively to 91.25 points postoperatively. Results: The persistent preoperative pain had completely disappeared in all patients; only twelve patients complained of intermittent pain under fairly heavy loading. 23 patients were able to walk > 2km and 13 > 5 km without pain. The overall range of motion was 40–60° in 14 patients, 25–40° in 21, and < 25° in only five. We did not see any kind of secondary arthrosis in the adjacent joints. An arthrodesis which posed no problems had to be performed only three times: in two cases in 1991, during the 1st postoperative year, with both patients showing infections of the prosthesis; in the third case, the prosthesis had to be changed after 9 years. Conclusions: According to our good results and those of other studies on cementless ankle prostheses, we consider a cementless upper ankle prosthesis, implanted by a highly experienced surgeon, the preferable alternative to upper ankle arthrodesis.

The Richards type II patellofemoral arthroplasty: 26 cases followed for 1-20 years

We followed 26 Richards type II patellofemoral arthroplasties in 24 patients (19 women) for a mean of 11 (1-20) years. Their mean age was 59 (22-90) years. The preoperative diagnoses were primary patellofemoral arthrosis in 17 cases and secondary arthrosis in 9 (8 malalignment, 1 patellar fracture). Patellectomy was later performed for persistent pain or patellar malalignment in 3 cases and a conversion to a total knee arthroplasty for progressive tibio-femoral degeneration or patella malalignment in 2. The mean Knee Society knee score for 21 knees at follow-up was 90 (65-100) points. The patients rated the results of surgery in 9 knees as excellent, 7 good, 4 improved, and 1 unimproved at follow-up. None of the implants showed signs of loosening or infection. The Richards type II patellofemoral arthroplasty yields acceptable long-term results in patients with isolated end-stage patellofemoral osteoarthrosis. Patient selection and patella alignment are important.

Differential diagnosis and therapy of post-traumatic limited forearm rotation

Limited forearm rotation is an extremely disabling condition for patients. For forearm function, simultaneous rotation in the proximal and distal radioulnar joint is necessary, being connected by the radius and ulnar shaft. Any malalignment of these bony components as well as injuries to the stabilizing soft tissues will lead to an impaired function of the forearm joint. The combination of bony malalignment and joint instability is possible and must be recognized. Any chronic incongruency of the joints will lead to secondary arthrosis that allows only salvage procedures. Therefore, the underlying pathology of restricted forearm motion must be recognized and the original anatomy restored. Using clinical examples, the possible posttraumatic reasons for disturbed forearm rotation and the principle of anatomical reconstruction are presented.

The Quantitative Detection of Posttraumatic Osteoarthrosis after Fractures of the Tibial Plateau Using MRI-based Chondrovolumetry

Despite developing better treatment for fractures of the tibial head, particularly intraarticular ones, late degenerative arthritis still presents a very serious problem. Difficulties in the diagnosis of early secondary degenerative changes derive from the fact that plain radiographs are limited to the detection of late manifestations and indirect signs of osteoarthritis because articular cartilage is not visible radiographically. To examine the extent of secondary arthrosis after intraarticular fracture and surgical treatment of the tibial head, we reviewed 25 patients for an objective quantitative measurement of the hyaline cartilage volume of the injured knee. Using magnetic resonance imaging and computer-assisted three-dimensional reconstruction, these MRI-based chondrovolumetric measurements were compared with the hyaline cartilage volume of the uninjured knee of the same patient. We discovered a highly significant reduction (p < 0.001) of the hyaline cartilage volume at the tibial plateau of the injured side. Additionally, there was not only a significant decrease of the joint cartilage at the tibial plateau but also of the cartilage volume of the patella (p = 0.001) and of the femur (p = 0.007) at the injured knee. None of the reviewed patients showed equal or more cartilage volume at the tibial plateau of the injured knee compared to the uninjured side. Our findings indicate that every intraarticular fracture leads more or less to secondary posttraumatic osteoarthrosis. MRI-based chondrovolumetry provides a promising new method for detecting and monitoring articular cartilage leasions and for evaluating various kinds of chondroprotective treatment, such as osteochondral grafting, drugs, physiotherapy, and correction osteotomy.

Bowers hemi-resection-interposition arthroplasty for treatment of post-traumatic arthrosis of the distal radio-ulnar joint after distal radius fractures

Arthrosis of the distal radioulnar joint (DRUJ) is a common problem following fractures of the distal radius. The treatment options include the hemiresection-interposition technique (Bowers procedure) or Kapandji-Sauvé procedure. In a retrospective study, we assessed the results of the Bowers procedure. From 1992 to 1997, 24 patients were treated by the hemiresection-interposition technique (Bowers procedure) for arthrosis of the DRUJ following fracture of the distal radius. The average follow-up time was 30.5 (9 to 55) months. The average preoperative pronation was 67 degrees, the supination 45 degrees. Postoperatively, we found a pronation of 80 degrees and a supination of 62 degrees. Grip-strength compared to the opposite site could be improved from 38 to 57% postoperatively. Pain was reduced markedly in 78% of the patients. However, ten patients developed a postoperative instability of the distal ulna. In only two patients did painful instability necessitate revision procedures. The hemiresection-interposition technique is a salvage procedure for the destroyed DRUJ, leading to good clinical results in most patients. Painful instability of the distal ulna and remaining functional deficits can be the reasons for failure. Therefore, adequate primary reduction of fractures of the distal radius or secondary reconstruction of the anatomy is necessary to prevent secondary arthrosis of the DRUJ.

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome.

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12 degrees in the lateral talometatarsal angle, 7 degrees in the lateral talocalcaneal angle, and 10 degrees in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Results of Periacetabular Osteotomy in Patients With Previous Surgery for Hip Dysplasia

The results of 19 periacetabular osteotomies in 18 patients who had undergone prior bony surgical procedures for hip dysplasia were evaluated. There were 10 females and eight males with an average age of 30.9 years. Previous surgical interventions included 18 intertrochanteric osteotomies, nine pelvic osteotomies, and two shelf acetabuloplasties. The average clinical followup for this group was 45 months. Harris hip score averages improved from 60 to 90 points. Merle d'Aubigne scores showed similar elevations from 13.1 to 16.4 points. Radiographic assessment documented increased coverage and lower Tönnis secondary arthrosis grades in a significant number of hips. No significant differences in outcome were found between this group and a reference group of patients undergoing periacetabular osteotomy who had no previous hip surgery. These intermediate term results are encouraging and seem to discount anticipated problems of prior scarring and distorted pelvic and proximal femoral anatomy.

Deltoid contracture: A radiographic survey of bone and joint abnormalities

We performed a radiographic survey on 12 shoulders in 11 patients with a contracture of the deltoid present since childhood (juvenile) but left untreated until adulthood and on 14 shoulders in 10 patients with the same disorder first developed in adulthood (adult type). The greater tuberosity was located either under or near the acromion in all but 1 shoulder. Flattening of the humeral head, a high-positioned greater tuberosity, posterior rotation and vertical disposition of the acromion, inferior angulation of the lateral clavicle, and anterosuperior subluxation of the humeral head were noted in 58%, 33%, 75%, 67%, and 8% of the juvenile cases, respectively. Scoliosis and narrowing of the thoracic cage were each detected in 36% of the patients with juvenile deltoid contracture. Six of the juvenile cases were treated surgically and followed-up for a lengthy period. In these cases, however, the abnormalities persisted, except for subluxation of the humeral head and abnormal proximity of the acromion and greater tuberosity. In the adult-type cases no abnormalities were observed except for scoliosis in 4 patients and anterosuperior subluxation of the humeral head in 1 shoulder. We conclude that treatment by surgical intervention should be performed at an age when spontaneous correction of the bone deformity can prevent future development of secondary arthrosis.

Triple Arthrodesis in Adults

Surgical fusion of the subtalar, talonavicular, and calcaneocuboid joints historically evolved for the treatment of paralytic deformities of the foot where there was often notable bone deformity. Today most of these procedures are performed in adults for posttraumatic arthritis, rheumatoid arthritis, or end-stage posterior tibial tendon rupture with fixed bone deformity. Triple arthrodesis is a technically demanding procedure that generally involves a prolonged recovery time. When proper alignment is obtained, predictable and significant improvement in symptoms occurs, but the resultant loss of hindfoot motion is not without consequence. Residual discomfort and secondary arthrosis of the ankle and tarsometatarsal joints should be expected. Because of the complications of residual deformity, pseudarthrosis, avascular necrosis of the talus, and ankle and midtarsal arthritis, it has been recommended that it be used only as a salvage operation in older patients who have a painful, fixed deformity or disabling instability refractory to other treatment options. Despite these caveats, most patients who undergo triple arthrodesis for appropriate indications report significant improvement in their symptoms and level of function.

Dynamics of Thermographic Indices in Rheumatoid Damage of Knee Joint Before and After Mobilizing Operations

Thermographic indices were studied in 35 patients, aged 23-56, with 3-4 stage rheumatoid damage of the knee joint before and after mobilizing operations. It was detected that local inflammatory process achieved its maximum and involved total joint structure in the stage of expanded development of flexor contracture. In ankylosis of the joint thermoradiation decreased abruptly and while the minimum weight-bearing function (fibrous ankylosis) was preserved thermographic indices were higher than in complete bone ankylosis. After surgical intervention thermoradiation increases abruptly that was stipulated by operative injury. During the next 2 years thermoradiation decreases but due to irreversible pathologic changes in the joint complete restoration never occured. In late terms after mobilizing operations (5-9 years) the repeated increase of thermoradiation was observed and it was connected with the additional degenerative dystrophic process that was as a rule accompanied by secondary arthrosis. As after joint mobilization restoration of thermoradiation indices continued during 2 years, rehabilitation measures were recommended for that period.

Hospital- and patient-related characteristics determining length of hospital stay for hip and knee replacements.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patient- and hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.

Biological fixation of ankle arthroplasty: A sequential consecutive prospective clinico-radiographic series of 20 ankles with arthrosis followed for 1–4 years

18 patients representing 20 uncemented hydroxy-apatite-coated total ankle arthroplasties (2 bilateral cases) were reviewed for 1–4 years. The diagnoses were primary arthrosis in 4 ankles, secondary arthrosis (following malleolar fractures) in 14 ankles, and haemochromatosis in 2 ankles. The patients were assessed preoperatively and at every follow-up, according to an ankle score system, giving 100 points for a normal ankle (50 points for no pain, 30 points for normal everyday life function and 20 points for normal mobility). Image intensification was used to assess loosening or subsidence of the prosthetic components and of the subtalar joint radiologically. The mean preoperative ankle score was 27.5 ± 11.5 SE. At the latest follow-up the ankle score was 91.8 ± 10.2 SE ( P < 0.001) corresponding to 17 excellent, 1 good and 2 unacceptable clinical results. All tibial components showed firm radiological fixation without signs of loosening and with typical irradiating bony sclerosis adjacent to the component. The talar component cannot be assessed easily radiographically and subsidence was measured. In 1 patient both the tibial and the talar components showed axial settlement within the first month but not later. No infections occurred. No patient died during follow-up. There was 1 case of injury to the posterior tibial nerve. The clinical and radiological results at the first year follow-up remain satisfactory and have not changed for the worse in any of the cases.

Intertrochanteric Corrective Osteotomy as a Joint-Saving Surgical Treatment for Femoral Head Necrosis

Forty-seven intertrochanteric osteotomies were performed in 9 years on 40 patients with femoral head necrosis in Arlet and Ficat stages II and III in the Orthopaedic Department of the Medical School, Hannover. With an average follow up of 5.9 years (minimum 2.3 years, maximum 9.3 years), the study shows only 46% of the patients with satisfactory, good and very good results. After the joint saving operation, 26% of treated patients with pre-operative employment went into premature retirement. The average postoperative non-working period was 11 months (7-18 months). Clinical Relevance The results after the joint-saving operation were better when the operation was performed at an early stage of the disease with only a small area of necrosis. Although the operation will not prevent a progression of necrosis and a secondary arthrosis, we recommend that the joint-saving operation be performed during stages I and II to prolong the period before a total hip joint replacement becomes necessary. During stage III a total hip joint replacement may be preferable depending on clinical symptoms, patient age and the radiological findings (necrosis angle &gt; 180°).

Revision of the PCA unicompartmental knee. 52 arthrosis knees followed for 2-5 years.

We evaluated 52 unicompartmental PCA arthroplasties for primary (46) or secondary (6) arthrosis after 3 (2-5) years. Cementless fixation was used in 35 femoral and in 28 tibial components. There were indications for revision in 11 cases. Conversion to a total knee had been performed in 4 cases, and 1 tibial as well as 1 femoral component had been exchanged, mainly because of polyethylene wear with increasing deformity. 2 femoral components were loose and 1 had fractured.

Proteoglycan fragments in rabbit joint fluid correlated to arthrosis stage.

Proteoglycan fragment concentrations in joint fluid of rabbit knees with various degrees of secondary arthrosis after meniscal resection, meniscal substitution, and anterior cruciate ligament transection, were related to the gross appearance of the articular cartilage. Knees with normal cartilage were distinguishable by the concentration of proteoglycan fragments in joint fluid from knees with arthrosis. We found a correlation (r 0.61) between increasing arthrosis and increasing concentrations of proteoglycan fragments.