Early outcomes of pyrolytic carbon hemiarthroplasty for the treatment of trapezial-metacarpal arthritis.

PURPOSE: Pyrolytic carbon implants have been successfully used in the treatment of osteoarthritis of the metacarpophalangeal and proximal interphalangeal joints. Recently, pyrolytic carbon hemiarthroplasties have been proposed for the treatment of osteoarthritis of the trapezial-metacarpal (TM) joint of the thumb. We wished to review our short-term outcomes for this device in the treatment of TM arthritis. METHODS: Fifty-four arthritic TM joints in 49 patients, with a mean age of 59 years, were treated with use of a pyrolytic carbon hemiarthroplasty procedure. Underlying diagnoses included osteoarthritis in 44 thumbs, rheumatoid arthritis in 8 thumbs, psoriatic arthritis in 1 thumb, and juvenile rheumatoid arthritis in 1 thumb. The patients were followed up clinically as well as radiologically for an average of 22 months postoperatively. RESULTS: The overall 22-month survival rate excluding scaphotrapezio-trapezoidal joint arthritis was 80% according to a Kaplan-Meier analysis. Ten metacarpal subluxations were observed. Seven of these cases were salvaged by increasing the depth of the trapezial cup. A total of 15 reoperations were required in this cohort. No complications were seen in the patients with inflammatory arthritis. Thirty-five patients were pain free at the latest follow-up, and 6 reported mild to occasional pain with repetitive activities. The overall satisfaction rate was 40 of 49 patients (81%). Grip strength recovered to 86% of that of the contralateral side. Apposition key and opposition pinch strength improved to 92% and 95%, respectively, of those of the contralateral hand. CONCLUSIONS: Pyrolytic carbon thumb arthroplasty may prove to be an acceptable option for the treatment of TM, although a high complication rate was observed in this early cohort, with many cases of subluxation attributed to the creation of a too shallow trapezial cup. Further comparative studies are warranted. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Metacarpal neck fractures: results of treatment with traction reduction and cast immobilization.

Although fractures of the fifth metacarpal neck (boxer's fractures) are common, their treatment can be problematic. A description of a technique utilizing traction reduction is presented in this paper. The records and radiographs of 59 patients who underwent reduction using longitudinal traction and subsequent immobilization in a specially molded cast were retrospectively reviewed. On average, 80% of initial fracture angulation in the sagittal plane was corrected, and only 1 degrees of this correction was lost at the discontinuation of casting (3-4 weeks). We have found this technique to be highly effective in the treatment of boxer's fractures. Advantages of this treatment include its efficacy, ease, and improved patient tolerance over other casting techniques.

Atypical rheumatoid nodules: a possible precursor to a rheumatoid variant in a rheumatoid-factor-negative patient. Case report.

Subcutaneous nodules occur in approximately 20-25% of rheumatoid factor (RF)-positive rheumatoid patients. In this paper, we present a unique case of a 47-year-old healthy RF-negative woman with a 3-year history of necrobiotic nodules over the dorsum of her hands, extensor forearms, and lower extremities. This may represent an atypical presentation or a new rheumatoid variant.

Preliminary results of nonconstrained pyrolytic carbon arthroplasty for metacarpophalangeal joint arthritis.

PURPOSE: To review early outcomes of arthritic metacarpophalangeal (MCP) joints treated with nonconstrained pyrolytic carbon implants to evaluate efficacy, clinical outcomes, and durability. METHODS: One hundred forty-two consecutive arthroplasties (61 patients) were retrospectively reviewed. Diagnoses included osteoarthritis (OA), traumatic arthritis, and inflammatory arthritis. One hundred thirty were primary joint replacements, and 12 were prior-silicone revisions. The average patient age was 55 years (range, 21-77 years); 36 patients were women and 25 were men. Average follow-up period was 17 months (range, 3-42 months), and 43 patients were followed up for a minimum of 1 year. RESULTS: For OA patients, according to the analog pain scale used, pain decreased from 73.0 to 8.5 of 100, functionality increased from 20.1 to 86.6 of 100, and appearance improved from 62.7 to 93.6 of 100. The rheumatoid arthritis (RA) group showed decreased pain from 43.1 to 8.9 of 100, functional improvement from 26.7 to 83.3 of 100, and increased appearance from 25.2 to 77.1 of 100. At 1 year, satisfaction was greater than 90% for both groups. Arc of motion for OA patients improved from 44 degrees to 58 degrees . Oppositional pinch increased 126%, and grip strength improved 40%. Rheumatoid arthritis patients increased their MCP joint motion arc from 32 degrees to 45 degrees . Oppositional pinch increased 89%, but grip strength decreased. Radiographs at 1 year demonstrated stable prostheses in all of the OA joints. The RA group overall demonstrated evidence of axial subsidence (10.5% of joints) and periprosthetic erosions (16.4% of joints). In RA joints with greater than 1-year follow-up period, 55.0% had axial subsidence, 95.0% had an increased radiolucent seam, and 45.0% had periprosthetic erosions. The overall implant survivorship is 141 joints to date. The overall minor complication rate was 6%, and major complication rate was 9%. CONCLUSIONS: Preliminary results suggest that pyrolytic carbon MCP joint arthroplasty provides good pain relief, patient satisfaction, and functional improvement in managing OA and select cases of RA. Longer follow-up evaluation will help validate these promising early results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two-year follow-up evaluation.

PURPOSE: To retrospectively review the surgical technique, postoperative therapy/splinting protocols, and clinical and radiographic outcomes of patients who had pyrolytic carbon proximal interphalangeal (PIP) joint arthroplasty. METHODS: A total of 50 PIP joint replacements in 35 patients were performed with a minimum follow-up period of 27 months. Indications for surgery included pain, decreased range of motion, instability, and/or deformity. The preoperative diagnosis was osteoarthritis in 14, rheumatoid arthritis in 11, and posttraumatic arthritis in 10. There were 20 women and 15 men affected. The average age at the time of surgery was 53 years. The fingers replaced included the index (15), middle (18), ring (10), and small (7). The preoperative arc of motion averaged 40 degrees (0 degrees-60 degrees ), and the pinch and grip measurements averaged 3 and 19 kg, respectively. The preoperative pain scores averaged 6 (scale, of 0-10) on a visual analog space scale. RESULTS: The arc of motion was 47 degrees after surgery, and the average pinch and grip measurements were 4 and 25 kg, respectively. Pain scores improved to 1. At the final follow-up evaluation the overall patient satisfaction was nearly 80%. The results of index finger PIP replacements are compatible with other digits. Fourteen joints (in 14 patients) to date have required additional procedures to improve or maintain joint motion/function or pain; 5 for minor reasons and 9 for major complications. The revision arthroplasty rate was 8%. No infections were noted. Although not medically necessary, 2 patients requested and had an amputation. Radiographic subsidence and subsequent settling (in accordance with Wolff's law) without apparent loosening occurred in 20 joints. CONCLUSIONS: Our 2-year minimum follow-up evaluation of pyrolytic carbon implant arthroplasty showed improved pain relief and good overall patient satisfaction. Twenty-eight percent of patients required a second procedure and 8% required a revision arthroplasty. Radiographs showed gross changes in implant and eventual settling to a stable position in 40% of the joints. A longer follow-up period will help to better determine the efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Nonrheumatoid metacarpophalangeal joint arthritis. Unconstrained pyrolytic carbon implants: indications, technique, and outcomes.

Unconstrained pyrolytic surface replacement arthroplasty provides the benefits of a more natural center of rotation with preservation of native ligamentous joint stability. Initial short-term results show excellent motion, pain relief, and restoration of pinch and grip strength. These results are encouraging, and suggest that pyrolytic carbon arthroplasty may be a reasonable option for joint salvage in patients suffering from MP joint osteoarthritis.

Results of biaxial total wrist arthroplasty with a modified (long) metacarpal stem.

PURPOSE: To evaluate the results of Biaxial (DePuy Orthopedics, Inc., Warsaw, IN) total wrist arthroplasty (TWA) with a long metacarpal stem. METHODS: A retrospective review of the results of 17 long-stem metacarpal components for the Biaxial TWA implanted between 1993 and 1997 is presented. RESULTS: After surgery pain and grip strength improved markedly. Overall motion improved but only radial deviation was significantly better. All of the patients were satisfied. At the most recent follow-up evaluation 4 cases showed evidence of radiographic lucency about the cement mantle, but with no gross loosening or settling. No failures at a greater than 6-year average (4-year minimum) follow-up period have been noted. Two cases of intraoperative third metacarpal fracture and one case of dorsal metacarpal component placement were encountered but did not affect the outcomes. CONCLUSIONS: To date the survivorship of the Biaxial TWA with the long stem is favorable compared with previous reports with the standard Biaxial distal component.

Treatment of mucous cysts of the fingers: review of 134 cases with minimum 2-year follow-up evaluation.

PURPOSE: To evaluate the results of a single surgeon's treatment of mucoid cysts, comparing outcomes between injection and surgery. METHODS: One hundred thirty-four cysts were treated, with a minimum 2-year follow-up period. Thirty-one patients had nail ridging or deformity at presentation. Eighty patients had multiple soft-tissue punctures into the cyst with a 25-gauge needle and injection with local anesthetic and steroid. Fifty-four patients had surgical excision and joint debridement. RESULTS: In the injection group, complete resolution of the cyst occurred in 48 cases (60%). Among the 32 that recurred, repeat injections were performed in 8 cases; 3 resolved. No recurrences were noted in the surgery group. Nail ridging resolved after surgery in 25 digits; the remaining 6 digits had partial improvement or persistent ridging. Five infections occurred and were treated successfully with antibiotics (4) or debridement (1), or both. CONCLUSIONS: Aspiration and injection was convenient but had a 40% recurrence rate. Surgery provided definitive treatment with no major long-term problems.

CD8 T cells are required for the formation of ectopic germinal centers in rheumatoid synovitis.

The assembly of inflammatory lesions in rheumatoid arthritis is highly regulated and typically leads to the formation of lymphoid follicles with germinal center (GC) reactions. We used microdissection of such extranodal follicles to analyze the colonizing T cells. Although the repertoire of follicular T cells was diverse, a subset of T cell receptor (TCR) sequences was detected in multiple independent follicles and not in interfollicular zones, suggesting recognition of a common antigen. Unexpectedly, the majority of shared TCR sequences were from CD8 T cells that were highly enriched in the synovium and present in low numbers in the periphery. To examine their role in extranodal GC reactions, CD8 T cells were depleted in human synovium-SCID mouse chimeras. Depletion of synovial CD8 T cells caused disintegration of the GC-containing follicles. In the absence of CD8 T cells, follicular dendritic cells disappeared, production of lymphotoxin-alpha1beta2 markedly decreased, and immunoglobulin (Ig) secretion ceased. Immunohistochemical studies demonstrated that these CD8 T cells accumulated at the edge of the mantle zone. Besides their unique localization, they were characterized by the production of interferon (IFN)-gamma, lack of the pore-forming enzyme perforin, and expression of CD40 ligand. Perifollicular IFN-gamma+ CD8 T cells were rare in secondary lymphoid tissues but accounted for the majority of IFN-gamma+ cells in synovial infiltrates. We propose that CD8+ T cells regulate the structural integrity and functional activity of GCs in ectopic lymphoid follicles.