Interpositional Arthroplasty of the First Metatarsophalangeal Joint with Bioresorbable Pldla Implant in the Treatment of Hallux Rigidus and Arthritic Hallux Valgus: A 9-Year Case Series Follow-Up.

BACKGROUND AND AIMS: The interpositional arthroplasty was developed to retain foot function and to relieve pain due to the arthritis of the first metatarsophalangeal joint. The bioabsorbable poly-L-D-lactic acid RegJoint® interpositional implant provides temporary support to the joint, and the implant is subsequently replaced by the patient's own tissue. In this study, we retrospectively examined the results of the poly-L-D-lactic acid interpositional arthroplasty in a 9-year follow-up study among patients with hallux valgus with end-stage arthrosis or hallux rigidus. MATERIAL AND METHODS: Eighteen patients and 21 joints underwent interpositional arthroplasty using the poly-L-D-lactic acid implant between February 1997 and October 2002 at Tampere University Hospital. Of these, 15 (83.3%) (21 joints) patients were compliant with clinical examination and radiographic examination in long-term (average 9.4 years) follow-up. The mean age of the patients was 48.3 (from 28 to 67) years at the time of the operation. Six patients underwent the operation due to arthritic hallux valgus and nine patients due to hallux rigidus. RESULTS: The mean Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale and visual analogue scale (VAS) for pain scores improved after the operation in all patients. The decrease of pain (visual analogue scale) after the operation was statistically significant (77.5 vs 10.0; p < 0.001). Postoperative complications were observed in 3 (14.3%) joints of two hallux rigidus patients. For these patients, surgery had only temporarily relieved the pain, and they underwent reoperation with arthrodesis. CONCLUSION: In conclusion, interpositional arthroplasty using a poly-L-D-lactic acid implant yielded good results. This study indicates that the poly-L-D-lactic acid interpositional implant may be a good alternative for arthrodesis for treatment of end-stage degeneration of the first metatarsophalangeal joint.

Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects.

Lower limb overuse injuries are common among people who are exposed to physical stress. Orthotic shoe insoles are widely used to prevent lower limb overuse injuries. Here, we conducted a randomized-controlled study to examine whether the use of orthotic insoles prevents lower limb overuse injuries. Participants (n=228) were randomly assigned to use (n=73) or not to use (n=147) orthotic insoles. The insoles were molded to the shape of the foot to provide support during physical activity. The main outcome measure in the present study was the physician-diagnosed lower limb overuse injury. Thirty-four (46.6%) subjects in the insole group were diagnosed with a lower limb overuse injury compared with 56 (38.1%) in the control group (P=0.29) during the 6-month study period. When body mass index and the results of a 12-min running test and muscle strength were adjusted in a Cox's regression model, the hazard ratio for lower limb overuse injury in the insole group was 1.3 (95% confidence intervals: 0.8-2.1) compared with the control group. Use of orthotic insoles was not associated with a decrease in lower limb overuse injuries. Our findings suggest that routine use of orthotic insoles does not prevent physical-stress-related lower limb injuries in healthy young male adults.

Anaplastic and poorly differentiated thyroid carcinoma: therapeutic strategies and treatment outcome of 52 consecutive patients.

Anaplastic thyroid carcinoma (ATC) is one of the most lethal malignancies; poorly differentiated thyroid carcinoma (PDTC) is a new diagnosis for rare aggressive thyroid tumours. Surgery is often considered the only chance for survival, but the benefit of surgery and subsequent multimodal therapy is unclear. We retrospectively analyzed the outcome of 44 ATC and 8 PDTC consecutive patients treated at Helsinki University Central Hospital between 1990 and 2008. All ATC and PDTC cases were re-examined and reclassified histologically. Median survival was only 3.1 months for ATC, but 3.7 years for PDTC. Most patients in both groups eventually died of cancer. ATC patients were older than PDTC patients (74 vs. 66 years). Nodal and distant metastases had a negative impact on survival (ATC; p = 0.038, p = 0.008). Long-term survivors in both groups were stage N0M0 at presentation. Multimodal therapy was successful for 9 (20%) ATC patients, and their median survival was the longest (11.6 months) among treatment groups. Most PDTC patients (88%) underwent total thyroidectomy followed by radioiodine ablation; the only 2 who received chemotherapy survived longest. Although ATC and PDTC are both aggressive thyroid carcinomas, multimodal therapy for both can provide a chance of prolonged survival in patients with locoregional disease.

Use of the de la Caffinière prosthesis in rheumatoid trapeziometacarpal destruction.

This study evaluated the outcome of the de la Caffinière prosthesis in patients with an inflammatory arthropathy affecting the trapeziometacarpal joint. The procedure was performed in 57 thumbs for rheumatoid arthritis (41 cases), juvenile chronic arthritis (ten cases), psoriatic arthritis (four cases) and other inflammatory joint diseases (two cases). Survival analysis with a revision procedure or radiographic implant failure as end points was performed. Five loosened cups and two permanently dislocated prostheses underwent revision surgery. These were managed with a bone graft and tendon interposition technique. Radiographic follow-up yielded four additional implant failures (two loosened cups, one loosened metacarpal stem and one permanent dislocation). The implant survival rate based on revision operation was 87% (95% CI 73-94) at 10 years, and the total radiographic and implant failure rate based on radiographic findings was 15% (95% CI 7-29) at 10 years.

Magnetic resonance imaging of the rotator cuff in destroyed rheumatoid shoulder: comparison with findings during shoulder replacement.

PURPOSE: To evaluate the predictive value of preoperative magnetic resonance imaging (MRI) with respect to rotator cuff ruptures. MATERIAL AND METHODS: Thirty-one patients with rheumatic disease underwent preoperative MRI before shoulder arthroplasty. The scans were reviewed independently by two experienced radiologists. Three surgeons performed all the replacements (hemiarthroplasties), and the condition of the rotator cuff was assessed. Complete and massive tears of the rotator cuff were recorded and compared at surgery and on MRI. RESULTS: With MRI, 21 shoulders (68%) were classified as having complete or massive tears of the rotator cuff and at surgery 14 shoulders (45%). Cohen's kappa coefficient was 0.44 (95% CI: 0.16 to 0.72) and accuracy 0.71 (95% CI: 0.52 to 0.86). CONCLUSION: In severely destroyed rheumatoid shoulder, the findings of soft tissues were incoherent both with MRI and at surgery. The integrity of tendons could not readily be elucidated with MRI because of an inflammatory process and scarred tissues; in surgery, too, changes were frequently difficult to categorize. Preoperative MRI of severely destroyed rheumatoid shoulder before arthroplasty turned out to be of only minor importance.

Follow-up of children with cerebral palsy after selective posterior rhizotomy with intensive physiotherapy or physiotherapy alone.

In all 21 children with spastic cerebral palsy (CP) underwent surgery involving selective posterior rhizotomy (SPR), followed by six months intensive physiotherapy (PT). Neurological and physiotherapeutic assessments were made one, three and five years after the operation. The children undergoing surgery were compared to 21 comparison children who took part in a regular physiotherapy programme during the same time period. At the preoperative assessment, the children undergoing surgery were similar to the comparative children in terms of age, sex, type of CP, spasticity of the legs and mean functional scores. The children were selected for SPR on the basis of more than half a year's arrest of motor development, which was the only significant difference to the comparative group. Motor function was measured using two different methods, the Illinois-St Louis Scale and the Gross Motor Functional Classification System (GMFC). Both groups experienced steady development during the five-year follow-up period and no significant differences were observed in the mean functional scores between the groups. We conclude that this comparative study, like most controlled studies, failed to demonstrate any additional effect of SPR on motor development of children with spastic CP. Nevertheless, SPR may contribute to a resumption of motor development in children with arrested motor development despite vigorous conservative therapy. SPR is therefore justified as treatment in selected cases.

Dual Articular Knee in demanding primary and revision replacements in patients with rheumatic diseases.

We report the results of 25 total knee replacements in 24 patients with rheumatoid arthritis (RA) using the Dual Articular Knee prosthesis. There were four primary and 21 revision procedures. The main indication was severe joint instability. In four infected arthroplasties a two-stage revision procedure was used. Four patellar tendon avulsions and one deep infection were encountered. Results were excellent in 18 patients. Dual Articular Knee proved to be favourable in both demanding primary as well as revision arthroplasties in patients with RA.

Insufficiency fractures in patients with chronic inflammatory joint diseases.

OBJECTIVE: To describe the typical sites of stress fractures in the lower extremities and pelvis in rheumatoid patients (rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, ankylosing spondylitis). METHODS: Thirty-three patients with 52 stress fractures [mean age 44 years (range 11-73)] were studied at the authors' institution when they were being treated for their rheumatic diseases. Fourteen patients had RA, 9 JCA, 5 PsoA, and 5 SPA. Stress fractures were detected from patient documents and from series radiographs in suspected cases. In some cases magnetic resonance imaging was also performed. RESULTS: One patient presented with 5 fractures, 2 patients with 4 and 3 fractures, and 7 patients with 2 fractures each. Other patients (n = 19) had only one fracture each. The metatarsal (MT) bones were the most common site of involvement. Twenty-five of the 52 fractures were located on MT I-V. The second and third most common sites were thefibula (n = 13) and tibia (n = 6). All fractures of the lower tibia or fibula were associated with valgus malalignment of the ankle. CONCLUSION: If a patient with rheumatic disease experiences sudden and unexplained pain localised in the forefoot, above the ankle, below the knee, or in the pelvis, a stress fracture should be suspected. Patients with severe osteoporosis, high-load corticosteroid or methotrexate therapy, or marked joint deformity are at high risk of developing stress fracture.

Evaluation of the cytotoxicity of selected systemic and intravitreally dosed drugs in the cultures of human retinal pigment epithelial cell line and of pig primary retinal pigment epithelial cells.

The cytotoxicity of the selected systemic and intravitreally dosed drugs tamoxifen, toremifene, chloroquine, 5-fluorouracil, gentamicin and ganciclovir was studied in retinal pigment epithelium (RPE) in vitro. The cytotoxicity was assayed in the human RPE cell line D407 and the pig RPE cell culture using the WST-1 test, which is an assay of cell proliferation and viability. The effects of experimental conditions on the WST-1 test (cell density, serum content in the culture medium, the exposure time) were evaluated. The EC50 values in tamoxifen-treated D407 cells ranged between 6.7 and 8.9 micromol/l, and in pig RPE cells between 10.1 and 12.2 micromol/l, depending on the cell density used. The corresponding values for toremifene were 7.4 to 11.1 micromol/l in D407 cells and 10.0 to 11.6 micromol/l in pig RPE cells. In chloroquine-treated cells, the EC50 values were 110.0 micromol/l for D407 cells and 58.4 micromol/l for pig RPE cells. Gentamicin and ganciclovir did not show any toxicity in micromolar concentrations. The exposure time was a significant factor, especially when the drug did not induce cell death, but was antiproliferative (5-fluorouracil). Serum protected the cells from the toxic effects of the drugs. Both cell cultures were most sensitive to tamoxifen and toremifene, and next to chloroquine. The drug toxicities obtained in the present study were quite similar in both cell types; that is, the pig RPE cells and the human D 407 cell line, despite the differences in, for example, the growth rate and melanin contents of the cell types. Owing to the homeostatic functions important for the whole neuroretina, RPE is an interesting in vitro model for the evaluation of retinal toxicity, but, in addition to the WST-1 test, more specific tests and markers based on the homeostatic functions of the RPE are needed.

Multiple stress fractures in a young girl with chronic idiopathic arthritis. Extended case report.

The occurrence of stress fractures in patients with long-standing rheumatoid arthritis (RA) is widely known. Osteoporosis, corticosteroid therapy, joint stiffness, contracture, angular deformity of the joint and failed joint reconstruction--all together or separately--predispose to bone loss and stress fractures. In the present report we describe the history of a girl with juvenile idiopathic arthritis (JIA) having multiple stress fractures. The relationship between corticosteroid therapy and immobilisation in the treatment of fractures is discussed.

What went wrong in triple arthrodesis? An analysis of failures in 21 patients.

Three hundred seven triple arthrodeses were done on 282 patients with rheumatic diseases between 1995 and 1999. Solid and painless fusion was achieved in 261 patients (93%, 286 arthrodeses). Twenty-one arthrodeses (in 21 patients) that failed were analyzed. Fourteen (66%) malunions, six (29%) nonunions, and one (5%) painful foot without malunion or nonunion were found. Of the failed procedures, valgus alignment was present in 13 feet and varus alignment was present in eight feet. The most common cause of failure was a misjudgment in the surgical technique, which occurred in 12 of 21 (57%) patients based on inadequate correction and repositioning of hindfoot deformity. In four (19%) patients, additional ankle destruction and instability was overlooked as a cause of malalignment. Revision triple arthrodesis was successful in 18 of 21 (86%) patients. Triple fusion offers challenges in surgical technique, postoperative treatment, and rehabilitation. Understanding the complexity of the rheumatic hindfoot is important when performing triple arthrodesis in patients with severe deformities manifesting typically as calcaneovalgus and pes planus.

Outcome of ankle arthrodesis performed by dowel technique in patients with rheumatic disease.

Between the years 1988 and 1994, 19 ankle arthrodeses were performed on 18 patients (nine men) using the dowel technique. Patients were followed until a fusion had occurred, a non-union was successfully rearthrodesed, or a pseudoarthrosis was stabilized with orthosis treatment. Patients' radiographs and documents were analyzed both preoperatively and during the healing period. Subtalar fusion had been performed previously in eight ankles and rheumatoid destruction of subtalar complex was observed in seven other hindfeet. The original dowel method was used in 13 ankles and a modified procedure was performed in six. Local bone grafts were utilized. Solid fusion was achieved in 13 ankles (68%), but with delayed union in two cases. Non-union was present in six ankles, and two re-arthrodeses were performed with successful fusion in the other. Orthosis treatment was necessary in three of five ankles with permanent non-union. One chronic infection leading to non-union was detected. Only two of the six ankles (33%) with the modified technique using additional exposures healed without complications. In the dowel technique, the preoperative position of the ankle and location of the guiding Kirschner wire are of crucial importance and the original technique with a large cutter should be used. In patients with rheumatic disease, this fusion method did not yield acceptable results.

Valgus deformity and proximal subluxation of the rheumatoid elbow: a radiographic 15 year follow up study of 148 elbows.

OBJECTIVE: To evaluate the nature of positional changes of humeroulnar (HU) and humeroradial (HR) joints in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA) followed up prospectively. METHODS: At the 15 year follow up standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated. The mediolateral HU angle of the elbow was measured from anteroposterior radiographs. The proximal subluxation of the HU joint was measured from lateral radiographs as the distance between the posterior aspect of the olecranon process and the posterior surface of the humerus. The anteroposterior subluxation of the HR joint was measured from lateral radiographs as the relation of the midpoint of head of the radius to the midpoint of the capitellum of the humerus. Destruction of the elbow joints was assessed with the Larsen method on a scale of 0 to 5 and compared with the measurements. RESULTS: Mean HU angle in 148 elbows of patients with RA was 11.5 degrees (SD 6.1), range -21 degrees (varus) to 34 degrees (valgus); 9.9 degrees (SD 4.3) in men and 12.0 degrees (SD 6.4) in women. The mean HU angle, 14.4 degrees (SD 6.0) of the affected joints (Larsen grades 2-4), showed more valgus than the mean 9.8 degrees (SD 2.5) of the non-affected (Larsen grades 0 to 1) joints; totally destroyed and unstable Larsen 5 joints were excluded. Mean HU and HR subluxations, 2.0 mm (SD 3.8) and 0.8 mm, of the affected joints (Larsen 2-5) were greater than the means, -1.1 mm (SD 1.5) and -0.4 mm (SD 0.9), of the non-affected joints. Both the HU proximal subluxation and the HR anterior subluxation correlated, r(s)=0.64 (95% CI 0.53 to 0.73 ) and r(s)=0.48 (95% CI 0.34 to 0.60), with the destruction of the elbow joint. CONCLUSIONS: The elbow seems to turn into valgus during rheumatoid destruction and excision of the radial head may speed up this process. However, totally unstable Larsen grade 5 joints may also have varus deformity owing to mutilating bone destruction. The ulna subluxates proximally in relation to the humerus, whereas the radius moves slightly anteriorly as a consequence of elbow involvement.

Why do ankle arthrodeses fail in patients with rheumatic disease?

Solid and painless fusion was achieved in 117/130 patients (90%) with rheumatic diseases after primary ankle arthrodesis at the authors' institution. Operations were performed using internal fixation according to the Adams technique. Critical retrospective analysis of failures in 13 patients (11 nonunions, one postoperative low-grade infection, and one painful arthrodesis) revealed errors in the primary operative technique in 10/13 ankles (77%), resulting typically from the surgeon's attempt to overcompensate a malaligned ankle while ignoring correction of the hindfoot deformity (subtalar complex). The optimum of 0-5 degrees of valgus was found in only 5/13 patients (38%). All four patients with varus alignment presented with malleolar pain. Bone grafting was adequate even in those patients with failure, whereas immobilization time was suboptimal in one patient (eight weeks). Patient satisfaction was lowered in every case of nonunion. Revision arthrodesis of failed primary fusion was successful in 10/13 patients (77%), however three additional stress fractures, two painful ankles without nonunions, and one superficial wound infection were detected. Ankle arthrodesis is a demanding procedure, and the operation should always be performed by an experienced surgeon, taking into account the alignment, ligament, and muscle balance of the rheumatoid ankle and hindfoot. Correction and rebalancing of these factors and the use of bone grafts are of crucial importance when considering the optimal conditions for fusion. Nonunions, infections, and stress fractures occurring after the primary arthrodesis are severe complications, leading eventually to revision operations and problems with osteoporotic bone, fragile soft tissues, and skin.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis. A 20-year follow-up study.

AIMS: In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). METHODS: An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzick's test. RESULTS: At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzick's test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. CONCLUSIONS: The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

Interferon alpha-2a therapy in 18 hemangioblastomas.

Multiple hemangioblastomas (HBs) of the central nervous system (CNS) and retina are associated with von Hippel-Lindau disease (VHL) and also predispose individuals to renal cell carcinomas and visceral cysts. In VHL, microsurgery or radiosurgery cannot prevent new HBs from arising in the CNS or coagulation of retinal HBs. Multiple but thus far asymptomatic HBs pose a therapeutic problem. IFN-alpha-2a has antiangiogenic activity with an especially favorable effect on life-threatening hemangiomas of the liver in children. This is the first study to assess the efficacy of IFN-alpha-2a in treatment of asymptomatic HBs of the CNS and retina. Four patients (three with VHL) with a combined total of 15 HBs of the CNS, 3 HBs of the retina, and 14 renal and 2 pancreatic cysts were treated with s.c. IFN-alpha-2a for 12 months at 3 x 10(6) IU, 3 times/week. Baseline workup consisted of detailed neurological, ophthalmological, and radiological examinations. Follow-up studies at 3, 13, and 21 months were used to monitor the response. No de novo HBs were detected during the therapy, but one appeared 9 months after cessation of IFN-alpha-2a therapy. HBs of the CNS did not shrink markedly during the therapy. IFN-alpha-2a may decrease blood flow in HBs as suggested by shrinkage and diminished leakage of two retinal HBs. However, the therapy did not prevent visceral cysts from growing. The systemic response was also monitored by measurement of serum levels of vascular endothelial growth factor and erythropoietin, which remained essentially unchanged during the treatment. No serious side effects were recorded.

Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis.

OBJECTIVE: Serum C reactive protein (CRP) concentration was evaluated in patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) to ascertain the postoperative CRP response. METHODS: Thirty seven consecutive patients with RA who had undergone THA or TKA were included in the study. The CRP concentration was measured in every patient once preoperatively and every other day for one week postoperatively. RESULTS: The peak median CRP concentration (94 mg/l) was achieved on the first and second day postoperatively and was seven times higher than the median preoperative concentration (13 mg/l). CRP declined to the preoperative concentration in about one week. The rise of the CRP concentration was significant (p< 0.001). No infection was encountered in this series. CONCLUSION: A rapid rise in the postoperative CRP concentration is normal in patients with RA treated by THA or TKA. The CRP concentration decreases to the preoperative value in about one week. Serial CRP measurements, including at least one preoperative measurement, are needed when the clinical significance of the postoperative CRP values is evaluated. When the postoperative CRP concentration remains raised for several days compared with the preoperative value, or even rises, it may indicate the presence of a complication in these patients.