Avanta Versus Swanson Silicone Implants in the MCP Joint—A Prospective, Randomized Comparison of 30 Patients Followed for 2 Years

The results of Swanson and Avanta metacarpophalangeal joint arthroplasties in rheumatoid patients were compared in a prospective, randomized study of 30 patients (120 implants). At 2-year follow-up, grip strength was measured, hand function was assessed with the Sollerman test and the subjective outcome was determined with visual analogue scores. With both implants ulnar deviation and flexion deformities decreased, and there was no difference between the groups. The increase in range of motion was 7° greater with Avanta implants than with Swanson implants. Grip strength and hand function were unaltered but the visual analogue scales showed decreased pain levels and subjective improvements in hand function, grip strength and cosmesis. Twenty-four of 30 patients were satisfied. Fracture of the silicone spacer occurred with 12 Avanta (20%) and eight Swanson implants (13%), with a higher fracture frequency in men.

A new force measurement device for evaluating finger extension function in the healthy and rheumatoid arthritic hand

Although often neglected, finger extension force is of great importance for developing grip strength. This paper describes the design and evaluation of a new finger extension force measurement device (EX-it) based on the biomechanics of the hand. Measurement accuracy and test-retest reliability were analysed. The device allows measurements on single fingers as well as all the fingers (excluding the thumb) of both healthy and deformed hands. The coefficient of variation in the device was 1.8% of the applied load, and the test-retest reliability showed a coefficient of variation no more than 7.1% for healthy subjects. This study also provides reference values for finger extension force in healthy subjects and patients with rheumatoid arthritis (RA). Significant differences were found in extension strength between healthy subject and RA patients (men, p < 0.05 and women, p < 0.001). EX-it provides objective and reliable data on the extension force capacity of normal and dysfunctional hands and can be used to evaluate the outcome of therapeutic interventions after hand trauma or disease.

A new computed tomography-based radiographic method to detect early loosening of total wrist implants

BACKGROUND

Diagnosis of loosening of total wrist implants is usually late using routine radiographs. Switching modality to computed tomography (CT) should aid in early diagnosis.

PURPOSE

To propose and evaluate the accuracy of a new CT method for assessing loosening of the carpal component in total wrist arthroplasty.

MATERIAL AND METHODS

A protocol encompassing volume registration of paired CT scans of patients with unexplained pain in a prosthetically replaced wrist (used in clinical routine) is presented. Scans are acquired as a dynamic examination under torsional load. Using volume registration, the carpal component of the prosthesis is brought into spatial alignment. After registration, prosthetic loosening is diagnosed by a shift in position of the bones relative to the prosthesis. This study is a preclinical validation of this method using a human cadaverous arm with a cemented total wrist implant and tantalum markers. Seven CT scans of the arm were acquired. The scans were combined into 21 pairs of CT volumes. The carpal component was registered in each scan pair, and the residual mismatch of the surrounding tantalum markers and bone was analyzed both visually and numerically.

RESULTS

The detection limit for prosthetic movement was less than 1 mm.

CONCLUSION

The results of this study demonstrate that CT volume registration holds promise to improve detection of movement of the carpal component at an earlier stage than is obtainable with plain radiography.

Task design, psycho-social work climate and upper extremity pain disorders--effects of an organisational redesign on manual repetitive assembly jobs

A company redesign was carried out to improve production efficiency and minimise the prevalence of work-related musculoskeletal disorders and sick leave. The redesign was evaluated on the basis of studies of assembly workers before (17 workers) and after (12 workers) the redesign. The redesign resulted in more varied, less repetitive, and more autonomous assembly jobs. The psycho-social work climate was both improved and impaired. A medical examination showed that eight of 17 workers before and nine of 12 workers after the redesign suffered from upper extremity pain disorders. Neither the production goals nor the goals of the redesign were fulfilled. Our conclusion was that the increased task variation and impaired psycho-social work climate, combined with a lack of skill and competence, actually increased the physical stress, risk for disorders and difficulties in fulfilling the production goals.

[New methods of joint replacement in the hand yield better function and pain relief]

Arthroplasty of the hand has hitherto been performed with rather simple methods such as the interposition of soft tissue or silicone implants. Surface replacement techniques, both cemented and cementless, currently routine methods in orthopaedic surgery, are becoming more and more commonly used in hand surgery. The article consists in a review of old and new methods for the replacement of wrist and finger joints, and a report of the results of osseo-integrated titanium implants in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, and of short-term outcome of non-constrained implants in wrist and PIP joints.

Osseointegrated silicone implants. 18 patients with 57 MCP joints followed for 2 years

20 patients were operated on consecutively with osseointegrated MCP joint prostheses in 64 joints at our department between September 1993 and February 1995. The one-stage procedure included joint resection and cancellous bone grafting from the iliac crest before insertion of screw-shaped titanium fixtures, connected with a flexible silicone spacer. 18 patients (57 joints) were clinically and radiographically examined at median 28 (18-37) months postoperatively. Indications for surgery were joint destruction due to chronic arthritis in 17 patients (56 joints), and posttraumatic arthrosis in 1 patient (1 joint). Postoperative median range of motion was 40 (15-85) degrees, with an extension deficit of 30 (-20-70) degrees. 16 patients were satisfied, and had good pain relief and substantially improved postoperative hand function, evaluated with the standardized Sollerman hand function test. Radiographic osseointegration was obtained in 112 of 114 titanium fixtures (98%), but fracture of the silicone spacer was observed in 14 implants (25%). We conclude that osseointegration of longitudinal titanium fixtures in the bone marrow canal is possible in a one-stage procedure, but our findings show the need for a new, more durable joint spacer.

Early results with osseointegrated proximal interphalangeal joint prostheses

Osseointegrated endoprostheses were used in 22 proximal interphalangeal joint replacements in 12 patients between 1993 and 1995. Indications for surgery were joint destruction due to rheumatoid arthritis (13 joints), primary osteoarthrosis (7 joints), posttraumatic arthrosis (1 joint), and psoriatic arthritis (1 joint). The prostheses consisted of 2 screw-shaped titanium fixtures with a flexible silicone spacer. The 1-stage surgical procedure included joint resection and cancellous bone grafting from the iliac crest before insertion of the titanium fixtures. At a follow-up examination 27 months (range, 12-37 months) after surgery, the average active range of motion was 56 degrees (20 degrees to 80 degrees) with an extension lag of 11 degrees (-5 degrees to 45 degrees), corresponding to an average arc of motion of from 11 degrees to 67 degrees flexion. Radiographs indicated that 41 of 44 fixtures were osseointegrated. Four of the 22 joint mechanisms showed fracture of the silicone spacer; deformation of the silicone was noted in an additional 27%. Patient satisfaction was high (20 of 22 joints), with significantly improved range of motion and hand function, increased grip strength, good pain relief, and satisfactory appearance. The results of this study indicate good early clinical findings using osseointegrated implants for proximal interphalangeal joint replacement but also show the need for further development regarding the durability of the flexible silicone joint spacer.

Expression of the mucosal lymphocyte integrin alpha E beta 7 and its ligand E-cadherin in the synovium of patients with rheumatoid arthritis

The synovial expression of the mucosal lymphocyte integrin alpha E beta 7 and its ligand E-cadherin was analysed in order to study the relationship between T lymphocytes of the gastrointestinal tract and the synovium in patients with rheumatoid arthritis (RA). Immunohistochemical evaluation of synovium revealed that the alpha E beta 7-expression was detectable in 16 of the 38 samples examined. A concomitant examination on circulating lymphocytes by flow cytometry showed that alpha E beta 7-expressing lymphocytes occur less frequently in peripheral blood (PB). In vitro culture of lymphocytes increased the alpha E beta 7-expression on synovial lymphocytes six-fold, whereas PB lymphocytes expressed a two-fold increase. The addition of PHA to the culture medium did not dramatically increase the alpha E beta 7-expression on synovial lymphocytes, in contrast to PB lymphocytes where a 24-fold increase was detected. The addition of TGF-beta 1 to the culture of PB lymphocytes increased the alpha E beta 7-expression three-fold. E-cadherin expression was found in all synovial tissues analysed by immunohistochemistry. These results demonstrate that synovial T lymphocytes have the capacity to express the 'mucosal-type' integrin alpha E beta 7, possibly due to high levels of intra-articular TGF-beta 1. This expression might be of physiological importance since E-cadherin, the ligand for alpha E beta 7, is richly expressed by synoviocytes. In addition, the results indicate that a high in vivo expression of alpha E beta 7 is suppressed in the synovial tissue by a hitherto unknown mechanism.

Sollerman hand function test. A standardised method and its use in tetraplegic patients

A standardised hand function test based on seven of the eight most common hand grips is reported. The test consists of 20 activities of daily living. The test procedure and the method of scoring are described as is our evaluation of the validity and reliability of the test. Fifty-nine tetraplegic patients were evaluated using the test before reconstructive surgery to their hands. The test score correlated well with the accepted international functional classification of the patient's arm (r = 0.76, p < 0.001). The mean test score in the arms of patients lacking sensation was significantly lower than in those with tactile gnosis (O:1-3 compared with OCu:1-3, p < 0.001).

The gut as an inductive site for synovial and extra-articular immune responses in rheumatoid arthritis

OBJECTIVES

To analyse the immunological interactions between the gut lymphoid tissue, synovium, and peripheral blood compartments in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS).

METHODS

Patients with RA and AS and healthy controls were orally or parenterally immunised with an influenza virus vaccine. Antigen-specific antibody responses were measured at the single cell level by ELISPOT assay using lymphocytes isolated from peripheral blood and from enzymatically dispersed synovial tissues.

RESULTS

Both oral and parenteral immunisations induced antigen-specific antibody-secreting cells in the synovial tissue of patients with RA. Parenterally immunised patients with RA showed significantly decreased antigen-specific antibody responses in peripheral blood compared with patients with AS and with healthy controls. In contrast, oral vaccination evoked comparable peripheral blood antibody responses in all three study groups.

CONCLUSIONS

Despite a decreased immune responsiveness in the systemic compartment, the functional status of the gut-associated lymphoid tissue in patients with RA is intact. In addition, there is evidence that the lymphocytes in the inflamed joints are accessible for signals both from the systemic and mucosal compartments. The findings of immunological 'cross-talk' are relevant to future vaccination and tolerization procedures in patients with RA.

Replacement of the os trapezium by polyurethane implants

Twenty-five patients with arthrosis of the first carpometacarpal joint had the os trapezium replaced by a polyurethane implant (Tecoflex), and the results were evaluated after three years (range 28-47 months). There were three failures in which the implants had been removed because of dislocation with pain. The clinical results in the remaining 22 cases in terms of relief of pain and thumb function were comparable with previous series of silicone implants. Radiographic examination showed no signs of bone resorption or other unfavourable tissue reactions around the implants, but subluxation of the implants was seen in half of the cases. Implant subluxation might be caused by poor design of the implant or the limited amount of fibrous foreign-body reaction around the polyurethane material that resulted in less firm encapsulation than occurred around silicone implants.

Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. A prospective randomized study of 63 cases

In a prospective randomized study that included 63 consecutive thumbs with injuries of the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb, plaster cast immobilization was compared with functional treatment with a splint. The splint allowed flexion and extension of the MCP joint, but prevented ulnar and radial deviation of the thumb. The study included both operated on and nonoperated on cases where surgery was performed only when the torn ligament was regarded as displaced. Of 40 thumbs treated nonsurgically, 21 were treated with a cast and 19 with a splint. Of 23 thumbs treated surgically, 10 were immobilized postoperatively in a plaster cast and 13 were treated with the splint. At the follow-up examination after 15 (11-41) months, there was no difference between the treatment groups as regards stability, range of motion, strength of the injured thumb, and length of sick leave. However, the patients considered the splint more comfortable than plaster cast immobilization. We conclude that immobilization of the thumb after a ligamentous injury with a movable splint is strongly preferred by the patients and that the functional results of this technique are equal to plaster cast immobilization after both surgical and nonsurgical treatment.

Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb

In a prospective study of 24 consecutive patients with posttraumatic instability of the metacarpophalangeal joint of the thumb, clinical examination including instability tests and palpation of displaced ulnar collateral ligaments was used to separate the patients into two groups--nondisplaced and displaced ruptures. Palpable displaced ruptures were treated surgically, whereas nonpalpable ruptures were interpreted as nondisplaced and were treated with plaster, irrespective of the instability. At follow-up 1 year later both groups showed similar results with respect to stability, strength, and function. Our results indicate that a clinical examination with palpation of the torn ligament ends identifies displaced ruptures of the ulnar collateral ligament, i.e., those cases needing surgery. Nondisplaced ruptures might be treated nonoperatively.

Lipofibromatous hamartoma of a digital nerve. A case report

Lipofibromatous hamartoma is a rare, benign tumor, most often affecting the median nerve. Our case involved the volar radial digital nerve of the index finger, treated with a partial excision of the tumor. Important nerve branches should not be sacrificed in order to achieve radical excision.

Cooling enhances alpha 2-adrenoceptor-mediated vasoconstriction in human hand veins

The contribution of different receptor subtypes in the contractile response during cooling in human hand vessels is of considerable interest in the understanding of cold-induced peripheral vasospasm as it appears in Raynaud's phenomenon. Subcutaneous vein segments from 50 patients undergoing hand operations not related to vascular disorders were examined in vitro. The temperature in the organ bath was initially 37 degrees C and was either continuously lowered to 10 degrees C or kept constant at 37 degrees C, 29 degrees C or 20 degrees C. The characteristics of the alpha-adrenoceptor-mediated motor response were elucidated with the use of the alpha 1-antagonist, prazosin, and the alpha 2-antagonist, yohimbine. A great variability between individuals in the proportions of alpha 1- and alpha 2-adrenoceptors was found. In the majority of the vessels continuous cooling to 25 degrees C augmented a noradrenaline-induced contraction. This augmentation was unaltered in the presence of prazosin but abolished by yohimbine, suggesting that it was mediated via the alpha 2-adrenoceptor. In the remaining vessels with a predominating alpha 1-adrenoceptor-mediated response a cold-induced relaxation was registered. This could be the result of a reduced alpha 1-adrenoceptor-mediated contraction at this low temperature. These varying reactions to cooling were unaffected by the beta-antagonist, propranolol, and by endothelial denudation. The results obtained in corresponding experiments with the alpha 1-agonist methoxamine and alpha 2-agonist, oxymetazoline, were conflicting, probably due to the poor selectivity of these agonists in human tissues.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of osteochondral defects in the rabbit knee with Gore-Tex (expanded polytetrafluoroethylene). An experimental study

In 28 knee joints in 14 rabbits 4 mm circular osteochondral defects were created in each medial femoral condyle. In 24 of the knee joints 4 mm Gore-Tex (E-PTFE) patches were glued into the defects with fibrin glue. Four joints were left without implants and served as controls. In 16 joints the membrane showed good macroscopic incorporation into the joint surface. In four joints the E-PTFE patches were lying loose. In the controls the defects were covered by thin irregular layers of reparative tissue. On histological examination at 12 weeks, cells were seen proliferating through the membrane and overlying its joint facing surface with the morphological appearance of the outer layers of the normal articular surface. We conclude that Gore-Tex might be of potential value in restoring the architecture of a damaged articular surface.

Wrist synovectomy in juvenile chronic arthritis (JCA)

Synovectomy of 20 wrist joints in 15 patients with juvenile chronic arthritis (JCA) was performed and results were evaluated 3 (0.5-5) years after surgery. The surgical procedure consisted of synovectomy of the radiocarpal joint, around the ulnar head and in all intercarpal joints. Resection of the ulnar head was not performed. Results at follow-up showed that four wrist joints had been re-operated by arthrodesis because of persistent pain. In one case a spontaneous ankylosis had developed. These cases were not included in the re-examination. Of the remaining 15 cases, 12 were improved and 7 of these were totally pain-free. At follow-up, clinical examination revealed a mean improved grip strength (0.2 kp/cm2) and a mean decreased range of motion (10 degrees of flexion and extension, 16 degrees of pronation, supination unchanged). All wrist joints showed some radiographic changes preoperatively and at follow-up about half showed some further deterioration. This study indicates that the results of wrist synovectomy in patients with juvenile chronic arthritis do not differ significantly from results of wrist synovectomy in adult arthritic patients.

Silastic Replacement of the Trapezium for Arthrosis—A Twelve Year Follow-Up Study

Thirty-three patients with 39 Swanson silastic trapezium implants have been studied. Three years after operation no dislocation or evidence of implant wear was found, but re-examination at an average of 12 years after operation revealed dislocations and implant wear in about half of the cases. Cyst formation in surrounding carpal bones was found in twenty cases. The result in terms of pain relief and thumb function was good and comparable to the three-year follow-up. A significant correlation was found between weakness of the pinch grip and dislocation of the implant. No correlation was found between pain and dislocation of the implants, nor between pain and presence of intraosseous cysts.

Lateral elbow pain caused by anconeus compartment syndrome. A case report

A carpenter presented with lateral elbow pain and bulging tenderness and impaired function of the anconeus muscle. Computed tomography showed enlargement of the muscle. The intracompartmental pressure was increased at rest, during and after exercise, and had a prolonged recovery time. The patient recovered immediately after fasciotomy of the anconeus muscle, and 6 months later he was still free from pain and intracompartmental pressures were normal.

A case of phalangeal lengthening

A severely shortened and deformed index finger--due to osteomyelitis of the middle phalanx--of a 12-year-old boy was lengthened by using a Kessler distraction device. Distraction for 2 weeks followed by interposition of a 15-mm bone graft resulted in a stable painless finger of normal length.

A new principle for assessing vibrotactile sense in vibration-induced neuropathy

The vibrotactile perception threshold has been evaluated in 20 manual workers not exposed to occupational vibration and in 27 workers using hand-held vibrating tools. Threshold values were evaluated with a Békesy type of vibrometer at frequencies ranging from 8 to 500 Hz. The earliest sign of vibration lesion was a reduction of sensation at frequencies of 125 to 250 Hz, indicating dysfunction in receptors of the fast adapting type II (stage 1 curve), followed in more severe cases by a prominent loss of sensation at all frequencies higher than 65 Hz (stage 2 curve). The stage 3 curve indicated the most severe loss of sensation in which the function of slowly adapting type I receptors, as well as fast adapting type I receptors, was deteriorated; consequently the vibrotactile thresholds at low-, median-, and high-frequency ranges were impaired. The vibrotactile changes corresponded well to numbness and the presence of vibration-induced white finger.

Digital vibrogram: a new diagnostic tool for sensory testing in compression neuropathy

A Békésy audiometer was modified for use in analysis of vibrotactile sensibility of the hand at frequencies ranging from 8 to 500 Hz. In control subjects the "digital vibrogram" has a typical shape, which differs characteristically in patients with carpal tunnel syndrome (CTS). Changes in digital vibrogram usually parallel or precede abnormalities in neurophysiologic tests, and appear long before changes in two-point discrimination (2PD). One-hundred-thirty-two hands of 76 patients diagnosed as having CTS were tested with a vibrometer. Of 113 hands with normal 2PD, the digital vibrogram showed abnormal in 86 cases. Of 19 hands with abnormal 2PD, the digital vibrogram showed abnormal in all but three cases. Twenty-six hands with neurophysiologically normal appearance had abnormal digital vibrogram in 14 cases, while 53 hands neurophysiologically classified as CTS showed abnormal digital vibrogram in 44 cases. It is concluded that the digital vibrogram is a useful tool for early diagnosis of CTS.

Swanson implant arthroplasty of the wrist in rheumatoid arthritis

Sixty rheumatoid wrists operated with Swanson implant arthroplasty were evaluated after a mean observation time of thirty-three months. Grip function in daily living improved in 60%, pain decreased in 88%, range of motion increased in 83% and grip strength increased in 69% of operated wrists. Significantly impaired function was found in wrists with implant fracture (12%) and in cases with pronounced bone resorption around the implant (23%). Ulnar deviation and carpal collapse were commonly found but did not impair the function significantly. In seven patients the contralateral wrist had been fused and was compared to the arthroplasty. The merits and indications of arthroplasty are discussed.