[Western Ontario shoulder instability index (WOSI): translation and cross-cultural adaptation for use by German speakers]. / "Western Ontario Shoulder Instability Index" (WOSI) : Ubersetzung und transkulturelle Anpassung für den deutschsprachigen Gebrauch.

BACKGROUND: Outcome assessment after orthopaedic interventions is becoming more and more important. However, there are no disease-specific instruments for patient self-assessment of shoulder instability. The goal of our study was to translate and test the Western Ontario Shoulder Instability Index (WOSI) using a standardised approach. The guidelines of the American Association of Orthopedic Surgeons were used for the translation and cross-cultural adaptation process. MATERIAL AND METHOD: Understanding was tested in 20 healthy subjects, and reliability and validity were quantified in 30 patients with shoulder instability. The quality of the translated version was described using the criteria of homogeneity, reliability, and construct validity. RESULTS: The test-retest reliability of the total score [intraclass correlation coefficient (ICC), 0.87] and of the subscores with the ICC (sports, leisure, and work 0.73; sensitivity 0.81; physical symptoms 0.82; and behaviour 0.90) was high. The internal consistency of the total scale was also high (Cronbach's alpha 0.89). CONCLUSIONS: The WOSI covers a broad range of symptoms and impaired functioning in patients with shoulder instability. The German translation shows good results regarding understanding, homogeneity, reliability, and validity. Therefore, it is a useful instrument for self-assessment in patients with shoulder instability.

Age- and gender-specific normative data of grip and pinch strength in a healthy adult Swiss population.

Assessment of hand strength is used in a wide range of clinical settings especially during treatment of diseases affecting the function of the hand. This investigation aimed to determine age- and gender-specific reference values for grip and pinch strength in a normal Swiss population with special regard to old and very old subjects as well as to different levels of occupational demand. Hand strength data were collected using a Jamar dynamometer and a pinch gauge with standard testing position, protocol and instructions. Analysis of the data from 1023 tested subjects between 18 and 96 years revealed a curvilinear relationship of grip and pinch strength to age, a correlation to height, weight and significant differences between occupational groups. Hand strength values differed significantly from those of other populations, confirming the thesis that applying normative data internationally is questionable. Age- and gender-specific reference values for grip and pinch strength are presented.

The patient-rated wrist evaluation (PRWE): cross-cultural adaptation into German and evaluation of its psychometric properties.

OBJECTIVE: To cross-culturally adapt the Patient-Rated Wrist Evaluation form (PRWE) into German (PRWE-G) and to evaluate its reliability and validity. METHODS: A cross-cultural adaptation of the PRWE was carried out, according to established guidelines. 103 patients, who had undergone resection interposition arthroplasty (RIAP) for carpometacarpal osteoarthritis approximately 6.2 years earlier, completed a questionnaire booklet containing the PRWE-G, the Short Form 36 (SF-36), the Disabilities of Arm, Shoulder, and Hand (DASH); they also underwent clinical assessment with the Hand Function Index (HFI, Keitel) and Custom Score including grip and pinch strength tests. The results were used to assess the criterion and construct validity of the PRWE-G. To measure the re-test reliability, 51 patients completed a second PRWE-G within 2 weeks. RESULTS: The test-retest reliability of the PRWE-G was acceptable for the pain and function sub-scales and for the global score, with intraclass correlation coefficients of 0.78-0.87. The PRWE-G showed a high internal consistency (Cronbach's alphas of 0.92-0.97 for the scales and the total score). The typical error of measurement for the global score was 8.1 points, giving a minimal detectable change (MDC95%) of approximately 22.5 points. The PRWE-G scores correlated well with those of the DASH (r=0.82, p<0.001) but less well with those of the physical component summary of the SF-36 (r=0.53, p<0.001) and not at all with the mental component summary scores of the SF-36 (r=0.04, p>0.05). The PRWE-G scores correlated moderately with certain clinical findings of the HFI, Custom Score, and grip/pinch strength tests (r=0.30-0.59, p<0.001). CONCLUSION: The PRWE-G represents a valid and reliable instrument to evaluate self-rated outcome in German-speaking patients with hand and wrist pathology.

Development of a predictive model for estimating the probability of treatment success one year after total shoulder replacement - cohort study.

OBJECTIVE: To Estimate the probability of treatment success 1 year after a total shoulder arthroplasty by developing a model based on preoperative clinical factors. METHOD: Between June 2003 and December 2006, 140 patients undergoing shoulder operations were assessed for age, gender, current rheumatoid arthritis, Short Form (SF) 36 physical and mental sum scores, previous shoulder operations, the Disabilities of Arm, Shoulder and Hand (DASH) symptom and function scores, the Shoulder Pain and Disability Index (SPADI), and insurance status. One year after the operation a Constant score of 80 or more out of 100 indicated successful treatment. Patient variables were analyzed with a logistic regression model augmented in a stepwise manner and bootstrapped 100 times. Variables selected at least 33 times were incorporated into a final model and the Area under the Receiver Operating Characteristics Curve (aROC) was calculated. RESULTS: There were 47/140 (33.6%) successful treatments. The probability of success was reduced in patients with previous shoulder operations (Odds Ratio [O.R.] 0.17, 95% Confidence Interval (95%CI) 0.04-0.85; P=0.03) and older than 75 years (O.R. 0.21, 95%CI 0.05-0.77; P=0.02). The probability of success increased in patients with a higher SF 36 mental sum score (O.R. 1.03, 95%CI 0.96-1.09, P=0.42) and a higher DASH function score (O.R. 1.05, 95%CI 1.02-1.07, P=0.001). The aROC was 0.79 (0.70-0.88) indicating that the model has a high predictive capacity. CONCLUSION: Once validated this model based on four preoperative clinical factors offers a prediction of whether a patient will respond to treatment 1 year after total shoulder arthroplasty.

Key factors for a successful National Arthroplasty Register.

Since the introduction of the first National Arthroplasty Register in Sweden in 1975, many other countries have tried to adopt the successful Scandinavian system. However, not all have overcome the political and practical difficulties of establishing a working register. We have surveyed the current registries to establish the key factors required for an effective database. We have received detailed information from 15 arthroplasty registers worldwide. The legal conditions under which they operate together with the methods of collection and handling of the data differ widely, but the fulfilment of certain criteria is necessary achieve a high degree of completeness of the data to ensure the provision of statistically relevant information.

Cross-cultural adaptation, reliability and validity of the German Shoulder Pain and Disability Index (SPADI).

OBJECTIVE: To cross-culturally adapt the Shoulder Pain and Disability Index (SPADI) from English into German, and to test the reliability and validity of the German version. METHODS: Cross-cultural adaptation of the SPADI was performed according to international guidelines. One hundred and eighteen patients who had undergone shoulder arthroplasty, on average 4 yr previously, completed a questionnaire booklet containing the German SPADI, the Short Form 36 (SF-36), the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, and the American Shoulder and Elbow Surgeons (ASES) questionnaire for the shoulder to assess SPADI's construct validity. One week later, they completed the SPADI again to assess test-retest reliability. RESULTS: The six-step cross-cultural adaptation procedure revealed no major problems with the content or language. The intraclass correlation coefficients for the individual items of the SPADI were between 0.68 and 0.89, and that for the SPADI total score was 0.94. The SPADI total score showed a correlation of 0.61-0.69 with the SF-36 physical scales, of 0.88 with the DASH and of 0.92 with the ASES. CONCLUSIONS: The German SPADI is a practicable, reliable and valid instrument, and can be recommended for the self-assessment of shoulder pain and function.

Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): when is a repair indicated?

Ruptures of the subscapularis tendon, isolated or combined, are rare, and the treatment modalities are controversial. Of 1345 patients who underwent rotator cuff repair in a 7-year period, 73 had either an isolated rupture of the subscapularis or a subscapularis rupture combined with rupture of the supraspinatus. All reconstructions were performed through a deltopectoral approach. Reinsertion of the subscapularis was combined with reconstruction of the supraspinatus in 32 patients. Of the patients, 63 (86%) were re-examined at a mean follow-up of 35 months. The modified Constant score improved from 62% preoperatively to 91% at follow-up. Isolated or combined reconstructions did not result in significant differences with respect to the Constant score. Of the patients, 62 (98%) were satisfied with the operation. Rerupture was found by ultrasound in 8 subscapularis tendons (13%) and 4 supraspinatus tendons (13%). The rerupture rate showed a significant correlation with the Goutallier stage of fatty degeneration and the interval between injury and operation.

Problematic bone fixation with pyrocarbon implants in proximal interphalangeal joint replacement: short-term results.

Seventeen pyrocarbon PIP prostheses were implanted into 14 patients, followed prospectively and reviewed clinically. The patients were assessed after a mean follow-up of 20.5 months subjectively by a VAS pain scale and radiographically. Significant pain relief was noted in all patients from a mean of 7.6 pre-operatively to 1.3 at final follow-up. Migration of one, or both, components was observed radiographically in eight joints and radiolucent lines were evident in three more cases. The clinical results of the implants which had migrated were less favourable for range of motion and grip strength than the stable joints of this series, although, statistically, the results were not significant. The number of possibly unstable prostheses in this series raises the question as to whether pyrocarbon is suitable for uncemented pressfit fixation in combination with early functional rehabilitation.

Trichostatin A sensitises rheumatoid arthritis synovial fibroblasts for TRAIL-induced apoptosis.

BACKGROUND: Histone acetylation/deacetylation has a critical role in the regulation of transcription by altering the chromatin structure. OBJECTIVE: To analyse the effect of trichostatin A (TSA), a streptomyces metabolite which specifically inhibits mammalian histone deacetylases, on TRAIL-induced apoptosis of rheumatoid arthritis synovial fibroblasts (RASF). METHODS: Apoptotic cells were detected after co-treatment of RASF with TRAIL (200 ng/ml) and TSA (0.5, 1, and 2 micromol/l) by flow cytometry using propidium iodide/annexin-V-FITC staining. Cell proliferation was assessed using the MTS proliferation test. Induction of the cell cycle inhibitor p21Waf/Cip1 by TSA was analysed by western blot. Expression of the TRAIL receptor-2 (DR5) on the cell surface of RASF was analysed by flow cytometry. Levels of soluble TRAIL were measured in synovial fluid of patients with RA and osteoarthritis (OA) by ELISA. RESULTS: Co-treatment of the cells with TSA and TRAIL induced cell death in a synergistic and dose dependent manner, whereas TRAIL and TSA alone had no effect or only a modest effect. RASF express DR5 (TRAIL receptor 2), but treatment of the cells with TSA for 24 hours did not change the expression level of DR5, as it is shown for cancer cells. TSA induced cell cycle arrest in RASF through up regulation of p21Waf1/Cip1. Levels of soluble TRAIL were significantly higher in RA than in OA synovial fluids. CONCLUSION: Because TSA sensitises RASF for TRAIL-induced apoptosis, it is concluded that TSA discloses sensitive sites in the cascade of TRAIL signalling and may represent a new principle for the treatment of RA.

[Comparison of rheumatic and post-traumatic elbow joints after total elbow arthroplasty. Comprehensive and specific evaluation of clinical picture, function, and quality of life]. / Vergleich des rheumatischen und posttraumatischen Ellenbogengelenks nach Totalprothese. Eine umfassende sowie spezifische Beurteilung von Klinik, Funktion und Lebensqualität.

BACKGROUND: Patients with elbow destruction due to rheumatoid arthritis (RA) or trauma (PT) were compared to population-based normative data and to each other after total elbow arthroplasty. PATIENTS AND METHODS: Pain, function, and biopsychosocial health were multidimensionally assessed by the generic Short Form 36 (SF-36), the condition-specific Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the Patient Related Elbow Evaluation form (PREE) instrument and analyzed by uni- and multivariate methods. RESULTS: Compared to normative values, the examined 59 RA patients were significantly affected in the function scales of the SF-36 and in all DASH scales. The 20 PT patients were worse than the norm only in the DASH function. Function was lower in RA than in PT in the SF-36 scales and in the DASH (RA: 44.4, PT: 70.3, p<0.001). This difference was less distinct in the PREE. CONCLUSION: Total elbow arthroplasty led to a pain-free outcome and normal quality of life, but failed to restore complete function. Functional deficits were larger in the RA patients and could also be measured by the SF-36, possibly due to polyarticular affection.

[Early results of NeuFlex silastic implant in MCP arthroplasty]. / Frühresultate des arthroplastischen Grundgelenkersatzes mit der NeuFlex-Silikonprothese.

For the reconstruction of destroyed metacarpophalangeal (MP) joints in rheumatoid arthritis, the Swanson silicon spacer is still the golden standard. However, long-term follow-up reveals an increasing number of complications, particularly mechanical failure. In order to deal with these problems a number of new, biomechanically different silicone implants have been designed. Among these, the NeuFlex prosthesis has a preflexed hinge of 30 degrees in relation to the shaft axis, a more palmar lying center of rotation and a rectangular hinge with a collarlike platform against the bony surfaces. In a prospective study, the early results of the first thirteen patients operated with the NeuFlex arthroplasty are reported. All patients suffered from rheumatoid arthritis with destruction of the MP joints. The mean follow-up was 12.3 months. A total of 37 joints were replaced. All patients were female with an average age of 56 years. Postoperative reduction of pain, measured on a visual analog scale with the maximum of 10 (VAS), decreased from 6.6 to 0.7 (p < 0.001). Jamar grip strength improved from 4.2 kg preoperatively to 9.9 kg postoperatively (p < 0.005). Range of motion improved from 37 degrees to 57 degrees (p < 0.0001) as a result of a reduction in active extension deficit which reduced from 35 degrees to 15 degrees postoperatively. Ulnar drift was reduced from 20.2 degrees to 3.4 degrees at follow-up (p < 0.005). Radiological evaluation showed no implant failure, no subsidence, and no signs of inflammatory reaction. Overall the NeuFlex silicone implants show encouraging early results which must be confirmed in the long term.

Analysis of a retrieved delta III total shoulder prosthesis.

A reversed Delta III total shoulder prosthesis was retrieved post-mortem, eight months after implantation. A significant notch was evident at the inferior pole of the scapular neck which extended beyond the inferior fixation screw. This bone loss was associated with a corresponding, erosive defect of the polyethylene cup. Histological examination revealed a chronic foreign-body reaction in the joint capsule. There were, however, no histological signs of loosening of the glenoid base plate and the stability of the prosthetic articulation was only slightly reduced by the eroded rim of the cup.

[Endoprosthetic surgery of the elbow]. / Endoprothetik des Ellenbogens.

Artificial joint replacement has found a firm place in orthopaedic surgery since its first introduction in the late 1960s. While the initial fixed bearing implants tended to progress to early loosening, the development of so-called "sloppy joints" has seen a major advance in the survival and success rate of this arthroplasty. The surgical approach and technique have also been modified in such a way as to allow a complete ventral release of a flexion contracture, while at the same time preserving the integrity of the extensor mechanism. In this way, the improvement of the biomechanics of the implant combined with diligent surgical technique have enhanced this procedure dramatically. Between 1978 and 1999, 305 GSB 3-type prosthesis were implanted, with the underlying pathologies being rheumatoid arthritis (77%), posttraumatic arthritis (21%) and degenerative arthritis (2%). The range of motion could be significantly improved from the pre-operative state for extension as well as flexion. This was even more obvious in the rheumatoid than in the posttraumatic situation. The survival rate for this type of implant was 90% at 10 years, with the implants after rheumatoid surgery faring somewhat better than those of the posttraumatics. Alternative treatment options, such as resection arthroplasty, distraction arthroplasty, or arthrodesis, are nowadays employed only in rare cases where a previous infection, personal preference or an inability by the patient to co-operate in a rehabilitation program have to be considered. The overall functional results of these types of treatments seem to be inferior to that of elbow arthroplasty. Therefore, this procedure is recommended not only for advanced degenerative and rheumatoid pathologies, but also in cases of posttraumatic arthrosis.

Osteoarthritis of the scaphoidtrapezium joint: an early sign of calcium pyrophosphate dihydrate disease.

The aim of this study was to determine the value of scaphoidtrapezium osteoarthritis (ST osteoarthritis) as an early sign of calcium pyrophosphate dihydrate disease (CPDD) in a cohort of patients undergoing surgery for osteoarthritis of the first carpometacarpal joint. We examined whether patients with cartilage calcification of the wrist at the time of operation had ST osteoarthritis, indicating CPDD at an earlier time (retrospective study), and whether patients with ST osteoarthritis but without cartilage calcification at the time of surgery develop radiological or clinical signs of CPDD at a later time (prospective study). From 1 January 1989 to 31 December 1995 a total of 169 patients (from an orthopaedic clinic) with a diagnosis of osteoarthritis of the first carpometacarpal joint were included in the study; 167 underwent surgery and two were treated without. Of the 16 patients showing calcification on surgery and therefore included in the retrospective study, 12 had prior radiographs, of which eight showed ST osteoarthritis. Among these, four had no concomitant cartilage calcification in the prior radiographs. Of the 32 patients in the prospective group having ST osteoarthritis but no calcifications at the time of surgery, 27 could be clinically examined. Of these, two showed cartilage calcifications on the follow-up radiographs of the hands. The presence of ST osteoarthritis is a helpful diagnostic finding for the diagnosis of CPDD, especially in cases without radiographic cartilage or fibrocartilage calcification of the wrist. ST osteoarthritis may then point to the correct diagnosis.

Expression of osteoclast differentiation factor in rheumatoid arthritis.

OBJECTIVE: To analyze the expression pattern of osteoclast differentiation factor (ODF) and its contribution to osteoclastogenesis in rheumatoid arthritis (RA). METHODS: The expression of ODF was analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR) in RA synovial fibroblasts (RASF) isolated from 7 RA patients and in normal skin fibroblasts. Using RNA probes specific for ODF, in situ hybridization was performed. Immunohistochemical double labeling for CD68 was applied to characterize the ODF-expressing cells. ODF protein and messenger RNA (mRNA) expression by RASF with or without 1,25(OH)2D3 was studied by Western blot analysis and quantitative real-time PCR. In addition, we performed coculture experiments with RASF and normal peripheral blood mononuclear cells with or without 1,25(OH)2D3. RESULTS: By RT-PCR, ODF mRNA expression was found in all RASF investigated, but not in normal skin fibroblasts. In situ hybridization revealed that in RA synovial tissues, ODF mRNA was expressed mainly in the lining layer and at sites where synovium was attached to bone. Immunohistochemical double labeling demonstrated ODF mRNA expression mainly in CD68-fibroblast-like synoviocytes and CD68+ multinucleated osteoclast-like cells. By Western blotting, all RASF expressed ODF protein. However, different levels of ODF expression were found in the RASF from different patients. Interestingly, RASF expressing higher levels of ODF induced a larger number of osteoclast-like cells than did RASF expressing only low levels of ODF. Although 1,25(OH)2D3 did not alter the levels of ODF expression in RASF on either Western blot or quantitative real-time PCR, osteoclastogenesis required the presence of 1,25(OH)2D3. CONCLUSION: The present results suggest that activated RASF, by expressing ODF, play an important role in rheumatoid bone destruction. Moreover, the data provide evidence that RASF not only activate osteoclasts, but also contribute directly to osteoclastogenesis.

Palmar approach in flexible implant arthroplasty of the proximal interphalangeal joint.

Joint replacement is an established method in the treatment of destroyed, painful, proximal interphalangeal joints. A palmar approach was used in which the main collateral ligaments were preserved, allowing immediate active rehabilitation with enhanced primary lateral stability. Fifty-nine proximal interphalangeal joint silicone arthroplasties in 38 patients with a minimum followup of 12 months were reviewed. Thirty-eight of the 59 joints had implantation from a palmar approach and 21 joints from a dorsal approach. The two groups were well-matched in terms of indication, preoperative range of motion, and patient age. No significant increase in the range of motion was found in either of the patient groups, with an overall average range of motion of 51 degrees postoperatively. There was also no significant difference in the postoperative stability in the two patient groups. The choice of surgical approach at the proximal interphalangeal joint level for the silastic type of implants does not appear to be important. With more sophisticated types of implants in which the integrity of the collateral ligaments is crucial, a palmar approach might be beneficial.

Rheumatoid arthritis of the wrist. Classification related to the natural course.

The authors introduce a new functional classification of rheumatoid arthritis of the wrist. Unlike the classifications used today, it includes the aspect of the natural course of rheumatoid arthritis. The goal of this paper is to identify radiologic indicators that will classify rheumatoid arthritis into stable forms of the disease (Types I and II) and unstable forms of the disease (Type III). Of 144 wrists examined, the first available radiograph and the radiograph obtained at the time of the first surgery were assessed. The indicators measured were: carpal height ratio, ulnar translocation, radial rotation, and scapholunate dissociation. Noting the changes that occurred each year in these indicators, it was possible to identify a significant difference between stable forms (Types I and II) and unstable forms (Type III) for the parameters carpal height ratio, ulnar translocation, and scapholunate dissociation. The distribution of the indicators allowed the definition of three values: the 100% value, the cut off point, and the lower threshold value. Combining the three radiologic parameters at those values markedly enhanced the possibility to classify rheumatoid arthritis of the wrist. With the help of the three radiologic indicators carpal height ratio, ulnar translocation, and scapholunate dissociation, it is possible to classify wrists with an early stage of rheumatoid arthritis according to the Schulthess classification. The early identification of destabilizing forms of rheumatoid arthritis becomes possible, making the choice and timing of the surgical intervention easier. Wrists with a progressive unstable form of rheumatoid arthritis may be stabilized earlier.

Does trapeziectomy destabilize the carpus?

Trapeziectomy for the treatment of trapeziometacarpal arthritis is an in vivo model of an isolated lesion of the scaphotrapeziotrapeziod ligament complex. We analysed the radiological changes in the wrist retrospectively in 86 patients after trapeziectomy. On standardized PA and lateral films the revised carpal height ratio, the radiolunate angle, the scapholunate angle and ulnar translation were compared pre- and postoperatively. None of these parameters showed a statistically significant change after operation. Grouping the patients into shorter (< 36 months) and longer (> 36 months) follow-ups also failed to show any significant differences.