Bipolar shoulder arthroplasty

Bipolar shoulder arthroplasty was designed as a salvage procedure for the arthritic shoulder with a massive rotator cuff tear. Between 1985 and 1989, 14 patients were treated with a bipolar shoulder arthroplasty and were followed for a mean of 3.3 years (range, 2-4.8 years). Two patient populations were studied, including: (1) rheumatoid patients undergoing a primary shoulder arthroplasty, and (2) reconstructive patients undergoing a secondary reconstructive procedure. The rheumatoid group had overall good pain relief. The average postoperative active forward flexion, abduction, and external rotation was 79 degrees, 66 degrees, and 20 degrees, respectively. The reconstructive group had fair pain relief, with an average postoperative active forward flexion, abduction, and external rotation of 39 degrees, 44 degrees, and 12 degrees, respectively. Six of seven complications were noted in the reconstructive group, including two bipolar cup dislocations, one bipolar cup subluxation, and one loosening of the prosthesis. The factors associated with complications included absence of an intact subacromial arch and deltoid abnormality. The bipolar shoulder arthroplasty appears to be an alternative to a primary arthroplasty for the arthritic rheumatoid shoulder with a massive rotator cuff tear.

Cementless or hybrid total elbow arthroplasty with titanium-alloy implants. A study of interim clinical results and specific complications

Twenty-six patients (32 elbows) with rheumatoid arthritis had a total elbow arthroplasty with insertion of a cementless prosthesis. The humeral component was made of titanium alloy and it was fixed without cement in all elbows. The patients were followed for an average of 3 years 1 month (range, 2 years 2 months to 4 years 4 months). A good result was seen in 25 elbows, a fair result in 2, and a poor result in 5. The reason for the poor results was a breakage of the humeral component at the junctional portion of its stem. In all five of these elbows a marked resorption of bone mass within the condylar portion of the humeral component was observed on the lateral radiograph. The five elbows with a poor result had a revision operation, and in each of these black staining of the soft tissues within the joint was seen. This tissue metallosis due to wear debris of the titanium alloy was responsible for the osteolysis within the condylar portion. It became clear from this study that even in a non-weight-bearing joint, such as the elbow, titanium alloy may wear and result in tissue metallosis when used as a bearing surface of the implant. However, it was also found that in the majority of the elbows an establishment of the biologic fixation of the porous-coated stem could be achieved by use of this alloy.

Results of the Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis. A preliminary report

The results of 19 consecutive Souter-Strathclyde total elbow arthroplasties (Zimmer, London) in 17 patients with a mean follow-up time of 41 months are reported. Pain relief was achieved in all cases, with 13 elbows becoming entirely pain-free. The mean range of flexion increased 24 degrees and extension improved 8 degrees, with upper limb function greatly improved. The complication rate was 32%, including three nerve palsies, of which two resolved completely, and three early postoperative dislocations. There were two cases of prosthetic loosening, one following revision surgery for a traumatic humeral fracture in the early postoperative period. The authors consider the overall functional results with the Souter-Strathclyde prosthesis to be satisfactory in this group of patients.

Flexible implant resection arthroplasty of the proximal interphalangeal joint

Flexible implant arthroplasty of the PIP joint in post-traumatic disorders can have very successful long-term results provided that the recommended surgical indications, operative techniques, and postoperative rehabilitation programs are carefully adhered to. Stability of the collateral ligament system and integrity of the extensor and flexor mechanism are essential prerequisites. A central slip splitting, central slip sparing, and palmar approach are described. The latter is preferred in post-traumatic conditions provided that the extensor mechanism is intact.

Biomaterial and design concepts to minimize wear in total joint arthroplasties

The evolution of high technology-based total joint arthroplasty (TJA) materials and designs has resulted in systems that provide significant advantages related to surgical procedures, functional mechanics, and short-term and long-term rehabilitation. The research and development community has been addressing key issues associated with attachment-to-tissues for force transfer and wear and debris from articulating surfaces. To minimize wear, multiple material and design technologies have been applied, with recent emphasis on surface and bulk modifications of alloys and polymers plus the reconsideration of ceramic and metallic articulations. This article provides an overview of the biomaterial considerations for articulating surfaces of existing TJA systems, efforts to control wear phenomena, and implications on the clinical aspects of long-term function.

Does the use of methylmethacrylate cement in total shoulder replacement induce hemodynamic or pulmonary instability?

STUDY OBJECTIVE

To investigate whether the use of methylmethacrylate cement causes hemodynamic or pulmonary instability during total shoulder replacement surgery.

DESIGN

Prospective, nonrandomized study.

SETTING

Operating room.

PATIENTS

9 ASA physical status I and II patients.

INTERVENTIONS

A 20-gauge radial artery catheter was placed in the wrist opposite the surgical site. Sedation with midazolam was provided, and a pulmonary artery catheter was placed through an 8.5-Fr introducer into the patient's right internal jugular vein.

MEASUREMENTS AND MAIN RESULTS

Before induction of anesthesia, systolic, diastolic, and mean arterial blood pressures; heart rate; central venous pressure; systolic, diastolic, and mean pulmonary artery pressures; pulmonary capillary wedge pressure; and thermodilution cardiac output measurements were obtained. Arterial and mixed venous blood gas samples also were collected and analyzed for calculation of Qs/Qt. These hemodynamic and pulmonary parameters were measured again just before cementing of each prosthesis with methylmethacrylate cement and at 1, 5, 10, and 20 minutes after cementing. There were no statistically significant changes in any of the measured hemodynamic parameters at any time. There was no statistically significant difference in the calculated intrapulmonary shunt fraction.

CONCLUSION

In this study population, the use of methylmethacrylate for total shoulder replacement was not associated with adverse hemodynamic events or increased intrapulmonary shunting.

Niebauer trapeziometacarpal arthroplasty: a long-term follow-up

A retrospective review of long-term follow-up of Niebauer trapeziometacarpal arthroplasty for treatment of disabling arthritis of the basal joint was performed. Thirty implants in 27 patients were reviewed, with an average follow-up of 9 years (minimum, 4 years). All surgical procedures were performed by the senior author. Eighty-eight percent of the patients were subjectively pleased and would undergo the procedure again. Postoperative subluxation occurred in 83% of the patients. This was not painful unless the prosthesis dislocated. Subluxation increased with time. One case of silicone synovitis necessitated implant removal; however, this was also after removal of a previous Eaton prosthesis. In the light of our results, we believe that the Niebauer trapeziometacarpal arthroplasty is a worthwhile procedure with a rare incidence of particulate synovitis. In 24 of 27 patients, pain was relieved and satisfactory motion and stability were achieved.

Silicone granulomatous reactions after first metatarsophalangeal hemiarthroplasty

We reviewed 55 patients (78 feet) who had undergone silicone hemiarthroplasty of the first metatarsophalangeal joint for hallux valgus (40) or hallux rigidus (38). At a mean period of 4.5 years (1 to 11), 56 feet had radiological evidence suggestive of silicone granulomatous disease. The frequency and severity of the changes increased with time from the operation. Histological material from three revisions confirmed the presence of silicone granulomata. We recommend that the operation of silicone hemiarthroplasty for hallux valgus and hallux rigidus be abandoned.

Long-term results of Swanson silastic arthroplasty in the rheumatoid wrist

We report a long-term follow-up of 6 to 11.8 years (mean = 8 years) of our first 50 Swanson wrist arthroplasties. All patients had long standing sero-positive rheumatoid arthritis with a mean age of 48 years. A detailed clinical and radiologic assessment was carried out on all the wrists. There was excellent sustained pain relief (mean score = 1.7) with improved activities of daily living. A mean range of wrist movement of 25 degrees of extension and 31 degrees of flexion was obtained. The prosthetic fracture rate was 22% of which 14% were symptomatic and needed re-operation. Carpal collapse was seen in all wrists, but was often symmetrical and accompanied by radial new bone formation on X-ray (86%). We feel that our long-term results justify the continued selective use of the Swanson wrist in the low-demand patient with quiescent disease who desires pain-free limited mobility and sophisticated grasp.

The Guildford elbow

The Guildford elbow is a new unconstrained elbow arthroplasty. From 1985 to 1991, this arthroplasty was used in 24 patients with rheumatoid arthritis. The patients were reviewed after an average of 28 months (4-59 months). Good to excellent results were obtained in 95% regarding pain relief and functional improvement. Complications were few, with only one case of clinical loosening and three of radiological loosening. Ulnar nerve hypo-aesthesia was common but did not jeopardize the final result in any patient.

A 5-year profile of the incidence of total joint replacement in South Africa (1985-1989)

This survey was conducted to determine the number of total joint replacements (TJRs) carried out annually in South Africa from 1985 to 1989 and the number of surgeons performing these procedures. During this period there was a 28% increase in the number of TJRs performed annually with an average increase of 20% in total hip replacements and 40% in total knee replacements. The number of surgeons involved in joint replacement during the survey period decreased by 7% in state-subsidised institutions but increased by 57% in the private sector. This is reflected in the number of TJRs performed each year, which has remained static in the state institutions but exhibits a threefold increase in the private sector. This probably reflects a shift in emphasis in state health care policy.

[GUEPAR total trapeziometacarpal prosthesis in the treatment of arthritis of the thumb. 36 case reports]

The authors review a series of 36 total GUEPAR trapezometacarpal arthroplasties, performed between 1981 and 1990 in 32 patients, with a Dell stage III or IV carpometacarpal arthritis of the thumb (primary arthritis = 34 cases; secondary arthritis: 2 cases, 1 case of chondrocalcinosis, 1 case of osteochondromatosis). Scaphotrapezial arthritis present in 7 cases is not a contraindication to total arthroplasty. The mean follow-up period was 3 and a half years, with a range of 1 to 9 years. Functional results were considered to be good in 89%, without limitation of activity. X-ray study shows: 1) A radioclinical concordence in 64% of cases with good clinical and X-ray results, stable in the long term. 2) A radioclinical discordance in 22% of cases with good functional result but mobilisation of metacarpal stem. 3) Failure in 5 cases (14%) with unsealing and trapezial fracture. This radioclinical study yields two failure factors: preoperative destruction of trapezium in all the failures and these cases are now a contraindication to the prosthesis and inadaptation between stem arthroplasty and metacarpal cavity. This study supports total arthroplasty in trapezometacarpal arthritis of the thumb: III or IV Dell's stage, with preserved trapezium configuration.

Extended indications for functional limb-sparing surgery in extremity sarcoma using complex reconstruction

From 1980 to 1991, 29 patients underwent complex reconstruction following extremity sarcoma resection. Soft tissue was the site of origin in 15 patients (52%) and bone was the site of origin in 14 patients (48%), with 20 sarcomas (69%) in the lower extremity. Resection consisted of the following procedures: extended anatomical soft-tissue resections (21 patients [72%]), bone resections (18 patients [62%]), and joint resections (14 patients [48%]). Reconstruction involved the following: myocutaneous flaps (20 patients [69%]), joint prosthesis (eight patients [28%]), and bone reconstruction (15 patients [52%]). There was no surgical mortality; one patient required an amputation owing to surgical complications. The site of the first failure was local (four [31%] of 13 patients), lung (five patients [38%]), others (four patients [31%]). At a median follow-up of 23 months, 18 patients (62%) had no evidence of disease, 27 (93%) had no local disease, 21 (72%) had good extremity function, three (10%) had major disabilities, and five (17%) underwent amputations. Local control improved when the margin of resection was larger than 10 mm. Disease-free survival was 67% at 3 years. Overall survival was 51% at 5 years. Tumor size was an independent predictor of overall survival. Local recurrence did not affect overall survival.

De la Caffinière arthroplasty for basal thumb joint osteoarthritis

We performed 20 de la Caffinière trapeziometacarpal arthroplasties for osteoarthritis occurring only at this joint and reviewed all patients after periods of up to ten years. Eighteen arthroplasties were satisfactory postoperatively, although all 20 patients had a satisfactory range of motion and only one experienced pain after surgery such that it impeded normal function. Failure occurred in two patients and was due to overreaming of the trapezium during surgery and a traumatic dislocation. A radiolucency between the prosthesis and bone was observed in one arthroplasty, although this patient was asymptomatic. We recommend arthroplasty using the de la Caffinière prosthesis as a satisfactory method of treatment for the osteoarthritic trapeziometacarpal joint.

Swanson silicone arthroplasty of the wrist in rheumatoid arthritis: a long-term follow-up

Twenty-three Swanson silicone rubber implants in patients with stage III or stage IV rheumatoid arthritis were reviewed at an average of 72 months after surgery. Minimum follow-up in patients with unrevised implants was 44 months. Results were rated good or excellent in 48%, fair in 4%, and poor in 48%. Pain was the primary indication for surgery. Patient satisfaction and pain relief were achieved in 63%. Implant fracture occurred in 52%. Revision rate was 30%, including one recommended revision. Radiographic changes consistent with particulate synovitis were seen in 30%. Prosthesis settling and bony resorption were seen in more than 75% of the patients. Survivorship analysis demonstrated 42% survival at 77 months. Progressive clinical and radiologic deterioration was seen. Swanson silicone rubber implant is recommended only in the very low demand patient with stage III or stage IV rheumatoid arthritis and in those with insufficient bone stock to allow total wrist arthroplasty with a metal-on-plastic design.

Total wrist arthroplasty. Experience with Swanson flexible silicone implants, 1982-1988

In a study of the results of silicone rubber arthroplasty of the wrist 18 patients (19 operated wrists) were re-examined after a mean follow up of five years. Experience with the ulnar head implant was discouraging, and it was not used in the last eight wrists. This did not affect the outcome, patients having good supination and pronation without pain. The range of motion with the radiocarpal prostheses was 0-70 degrees, mean 39 degrees. Radiological results showed severe subsidence in all patients followed up for more than two years, and prosthetic fracture in five (26%), which was disappointing. Nevertheless the patients had a useful range of motion and all but two were relieved of pain. By the patients' own assessments 16 wrists were considered good, one fair, and two poor. Predictors of failure (prosthetic fracture) were poor alignment before operation, postoperative range of motion of more than 50 degrees, and rupture of the carpal extensor tendon. With these reservations we recommend the silicone spacer as the best solution for most patients with severe problems of the wrist as a result of rheumatoid arthritis.

Silicone rubber implants for arthrosis of the scaphotrapezial joint

Between 1980 and 1983, 10 patients received high performance silicone rubber condylar implants for the treatment of isolated degenerative changes of the scaphotrapezial joint. Early clinical and radiographic results (at a mean of 15 months) were excellent. Late follow up of these 10 together with a further 11 patients, however, showed migration of the implant and radiological signs of silicone particle synovitis in all but two. We no longer recommend this operation for treatment of isolated arthrosis of the scaphotrapezial joint.

Allograft prosthetic composite arthroplasty for osteosarcoma and other aggressive bone tumors

Allograft prosthetic composite arthroplasty is a reconstruction alternative after limb salvage for aggressive bone tumors. It combines an off-the-shelf implant with a fresh-frozen allograft and has several potential advantages over conventional techniques. Good clinical results can be achieved with acceptable morbidity. The procedure can be performed successfully even in patients receiving chemotherapy. Nonunion was the most common complication encountered but was amenable to autogenous iliac bone graft. The procedure can be customized to meet the needs of the patient, making custom implant manufacturing delay and expense unnecessary.

The wrist in juvenile arthritis

Patients with juvenile arthritis affecting the wrist have been reviewed six months or more after treatment, which has included steroid injection, synovectomy, arthroplasty, arthrodesis and distraction lengthening of the ulna. The pattern of wrist involvement is described, the general management reviewed, and the indications, techniques and results of these various procedures are presented.

Silastic implant arthroplasty for post-traumatic stiffness of the finger joints

In the years 1981 to 1987, 50 patients had 59 replacements of the finger joints. Of these, 41 patients with 49 joint operations were reviewed, with follow-up ranging from two to eight years (average 32 months). About 80% of these patients were satisfied that silastic implant arthroplasty had relieved their pain and stiffness and improved function of the finger and hand. They were satisfied that this procedure was preferable to amputation or fusion. Success or failure was assessed not only on the range of movement of the joint being replaced, but on relief of pain, correction of deformity, stability and overall finger function. The seven patients regarded as failures are analysed in detail.

Total replacement for post-traumatic arthritis of the elbow

Fifty-three of 55 consecutive elbow replacements for post-traumatic arthritis were followed for a minimum of two years (mean 6.3, range 2 to 14.4). The patients presented difficult management problems, having undergone an average of two previous operations per joint; 22 joints had suffered prior complications; 18 had less than 50 degrees of flexion and six were flail. One of three versions of the Coonrad prosthesis was employed in all. During the follow-up period, 10 patients underwent 14 revision procedures for aseptic loosening; 38 elbows are currently without progressive radiolucent lines. In two patients an elbow had to be resected, one for deep infection and the other for bone resorption following a foreign-body reaction to titanium. The current design of the Coonrad prosthesis offers a reliable option for the treatment of post-traumatic arthritis but should be used only in carefully selected patients over the age of 60 years.

The Keller arthroplasty with use of the Dow Corning titanium hemi-implant

Complications following the Keller arthroplasty, such as instability, shortening, and recurrence, are well known. Implants acting as a joint spacer may present some of these complications. Presently, silicone is the implant material most widely accepted and used, despite its unsuitability for long-term use and potential to produce bone and soft tissue pathology. Titanium is a more suitable material for long-term implantation and has been available since 1986 for use in the first metatarsophalangeal joint. Presented is a brief review of first metatarsophalangeal arthroplasty progressing to the development of the Titanium hemi-implant and a case report of its use with a 3-year followup.

Flexible implant arthroplasty of the radiocarpal joint

The radiocarpal, distal radioulnar, and intercarpal joints can be affected individually or in combination. Selection of the appropriate treatment method is based on accurate evaluation of the extent and severity of involvement. The durability of flexible implant resection arthroplasty of the radiocarpal joint has been further enhanced by the use of titanium grommets to protect the implant midsection, by secure dorsal and palmar capsuloligamentous reconstruction to restrict the mobility of 30 degrees flexion/30 degrees extension and 10 degrees ulnar/10 degrees radial deviation, by 6 weeks' postoperative immobilization, and by avoidance of abusive hand usage.

Silicone rubber arthroplasty of the wrist

The wrist is often referred to as the keystone of the hand. It is often affected in rheumatoid arthritis. Salvage procedures for patients with rheumatoid arthritis involving the wrist include silicone wrist arthroplasty, total joint arthroplasty, and wrist arthrodesis. In 1967, Swanson developed a double-stem, flexible-hinge implant for the radial carpal joint. In 1982, metal titanium bone liners (grommets) were added to help decrease the incidence of fractures. The authors feel that the gold standard is still wrist arthrodesis. However, they would use a flexible wrist arthroplasty in a patient who has bilateral wrist involvement with marked digital deformity and/or proximal interphalangeal stiffness. This is especially true in low-demand patients who have good alignment, good bone stock, and the associated proximal and distal disease. If these criteria are met and meticulous technique used, successful reconstruction of the wrist with a flexible wrist silicone implant can be performed in the patient with rheumatoid arthritis.

Distal interphalangeal joint silicone interpositional arthroplasty: surgical technique and functional outcome

Distal interphalangeal joint arthroplasty is effective in alleviating the pain of degenerative arthritis while preserving motion and stability. This procedure was undertaken as an alternative to arthrodesis for 17 women with osteoarthritis and 1 woman with rheumatoid arthritis. Silicone interpositional arthroplasty was performed in 31 digits of patients whose mean age was 58.3 years. The patients were evaluated at an average of 72.2 months (range, 12.6 to 123.1 months) after surgery. All patients reported that their primary preoperative symptom of pain was effectively eliminated by the procedure. At reevaluation, the active range of motion of the distal interphalangeal joint averaged 32.2 degrees and extension lag averaged 12.7 degrees . Lateral stability of the distal joint was present in all but one middle finger implant. Two implants were removed at 3 months postoperatively for wound problems and one at 31 months because of prothesis fracture.

Proximal interphalangeal joint arthroplasty: the volar approach

Reconstruction of the proximal interphalangeal joint by arthroplasty using the Swanson implant is greatly simplified by the volar approach. The extensor tendon system is not violated, making an immediate motion program feasible. Combining this approach with local anesthesia allows for active and complete evaluation of the technique during the operative procedure.

Total ankle arthroplasty: new concepts and approaches

A new type of total ankle arthroplasty developed with the use of a CAD-CAM computer was used in a series of 27 ankles between 1985 and 1989. Follow-up in 19 ankles ranging from 18 months to 5.5 years postoperatively indicates that the design of this implant appears to avoid the problems of subsidence and malleolar impingement. Based upon the results in this series, it appears that the best candidates for use of this type of total ankle implant are patients with rheumatoid arthritis.

Silicone rubber arthroplasty of the proximal interphalangeal joint: dorsal and lateral approaches

Although arthrodesis of an arthritic proximal interphalangeal joint provides excellent relief of pain, it does so at the expense of mobility. Silicone rubber implant arthroplasty also provides predictable relief of pain and approximately 60 degrees of motion. Insertion of the implant through a dorsal extensor-splitting approach is preferred when a tendon reconstruction is necessary, as in cases of boutonniére deformity. If tendon reconstruction is not necessary, the lateral approach is an excellent alternative because it does not disturb the extensor mechanism and therefore permits earlier rehabilitation exercises. The following article outlines the dorsal and lateral techniques and postoperative rehabilitation of silicone rubber arthroplasty.

Early failure of silicone radial head implants in the rheumatoid elbow. A complication of silicone radial head implant arthroplasty

Three cases of early recurrent synovitis of the rheumatoid elbow following silicone radial head implant arthroplasty are presented. All three patients underwent synovectomy with silicone radial head implant for pain and loss of function due to rheumatoid synovitis. All three implants failed within 4-9 months after surgery. This failure was associated with radiographic medial joint space widening. At reexploration, recurrent synovitis with hemosiderin pigmentation was noted. Patterns of prosthetic failure included fracture, fraying, and compressive deformation or rotary wear ("motar and pestle") of the silicone radial head; a prosthetic stem fracture was also present. Histologic examination of the synovium revealed evidence of silicone-induced synovitis; particulate, refractile silicone debris was associated with inflammatory and foreign body giant cells. The presence of rheumatoid destruction of the joint surface may have accelerated this process and may be a relative contraindication to silicone radial head implant arthroplasty.

Comparative investigations of regional lymph nodes and pseudocapsules after implantation of joint endoprostheses

Morphological alterations of pseudocapsules and regional lymph nodes were studied by light and electron microscopy and by Laser Microprobe Mass Analysis (LAMMA). The tissue specimens originated from 32 autopsies of patients with hip joint endoprostheses (time in situ: 3 weeks - 15 years, average: 6 years) and two cases with knee joint endoprostheses. Characteristic changes of the lymph nodes as well as of the pseudocapsules consisted in an infiltration by monocytic histiocytes with various intracytoplasmatic wear particles. The foreign material consisted mainly of the components of bone cement: polymethylmethacrylate (PMMA) and zirconium oxide, to a lesser degree of polyethylene from the articulating surfaces. In two cases with special types of prostheses ceramic or metallic wear particles could be detected too. Most of the wear particles were found in the ipsilateral parailiac lymph nodes and in the paraaortic lymph nodes bilaterally. In the cases with mostly stable prostheses small amounts of wear particles were found in the lymph nodes as soon as 1.5 years after insertion and their number increased in all groups of lymph nodes after longer duration of the implant. The phagocytosing histiocytes showed degenerative changes. At present it is not clear, if the cell damage is caused by the amount of phagocytosed wear particles alone or if specific toxic effects of certain substances are of importance.

Modular total shoulder: early experience and impressions

All design considerations in shoulder arthroplasty are based on reconstructing normal anatomy and enhancing prosthetic fixation, particularly on the glenoid side. These goals are further enhanced by meticulous attention to detail in placement of the component parts relative to the bony anatomy. In addition, great attention must be paid to management of the soft tissue tensions and placement of the component parts relative to soft tissue origins and insertions so that asymmetric overloading of the components can be avoided and loosening and wear can be minimized. The problem of management of prosthetic replacement with associated massive rotator cuff tears continues to be a dilemma. Use of an oversized humeral head articulating with the acromion can offer a compromise solution to the problem. This technique can be combined with altered glenoid component placement or reshaping of the bony glenoid to accommodate its altered relationship with the humeral articular surface. Future design changes are needed to deal with this complex problem.

Integral surgical maneuvers in prosthetic shoulder arthroplasty

Total shoulder arthroplasty has advanced beyond addressing only the techniques of implant placement. To improve clinical results and assure maximum implant longevity, the surgeon needs to address soft tissue contractures, soft tissue deficiencies, glenohumeral instability, and bone deficiencies with a number and often a combination of surgical maneuvers. These techniques include excision of abnormal tissue, division of adhesions, selective tissue releases, variation in bone osteotomy or preparation to modify implant position, use of a variety of standard implants or custom devices, and supplementation of certain tissue deficiencies with autologous or allograft tissues. When the reconstruction is completed, the surgeon needs to assess movement, stability, and strength of the supporting tissues to plan an optimal rehabilitation program.

Prosthetic replacement in acute fractures of the proximal humerus

The surgical treatment of selected displaced fractures of the proximal humerus with a humeral head prosthesis is a challenging procedure. Adequate knowledge of the pertinent anatomy and biomechanics of the shoulder as well as a clear roentgenographic evaluation of the displaced fracture patterns are essential. Successful prosthetic replacement requires adherence to technical factors involving soft tissue mobilization, prosthetic insertion, and tuberosity repair. Also, it is important to have a closely supervised rehabilitation program to achieve early passive motion and strengthening after fracture healing.

Schultz metacarpophalangeal arthroplasty: a long-term follow-up study

We describe a prospective, long-term evaluation of the Schultz metacarpophalangeal joint implant. The prosthesis is a semiconstrained, cemented implant with a ball-in-socket articulation. Thirty-six implants were followed for an average of 10.9 years. There was a progressive decrease in range of motion and strength and a recurrence of ulnar deviation. The neck of the proximal phalangeal component fractured in 39% of the joints. Periarticular heterotopic bone formed in all joints, but was extensive in only 22%. Although some lucency of the bone-cement interface was seen in 80% of the joints, no prosthetic loosening occurred in this series. Our results indicate that long-term, intramedullary cement fixation of relatively long-stemmed components can be satisfactory. However, the articulated portion of this implant does not consistently withstand the stresses transmitted across the joint and does not provide long-term joint stability.

The use of ultrasonic tools in revision arthroplasty procedures

Cemented and uncemented prostheses removed from bone using ultrasonic tools were evaluated grossly, microscopically, and microradiographically. The findings in this study indicate that application of an ultrasonic tool to the intramedullary canal is a safe method for removal of a variety of components. In addition, when the energy is coupled directly to the metallic component, it can be separated from the cement-bone or prosthesis-bone interface instantly.

Silicone cap osteoarthroplasty for temporomandibular joint ankylosis, with a kinesiologic study

In spite of the small experiences, silicone capping with gap osteoarthroplasty in high level is thought to be one of the valuable procedures for TMJ ankylosis. In the view of kinesiology, a normal joint cannot be reconstructed, because the mandibular movement in ankylosis is far from the normals.

Alloplastic reconstruction of the temporomandibular joint

The Proplast TMJ condylar implant, the glenoid fossa implant, and the TMJ interpositional implants should be singled out as having provided a new and more predictable mode of TMJ reconstruction. The use of these implants in cases of ankylosis, degenerative joint disease, orthognathic deformities, and traumatic injuries has greatly contributed to the success of these reconstructions. These implants represent the state of the art in TMJ reconstruction and increasing data from longer-term follow-up have shown a rate of success much higher than any previous implant used in the TMJ. TMJ reconstruction requires careful surgical planning, meticulous surgical technique, and intelligent perioperative care. Postoperative physical therapy is considered essential in the management of these patients. Complications related to reankylosis have been virtually eliminated, as no postoperative immobilization is required in most cases. Long-term stability of these implants, due to the ingrowth of tissue into Proplast, appears to be assured. Continued experience with the implants and close follow-up of reconstruction patients is necessary in the future to adequately assess the performance of the newer glenoid fossa and TMJ interpositional implants. Certainly, a new era in TMJ reconstruction has begun, resulting in increased benefits to the patients whom we all serve.

Osteochondral hemiarthroplasty. An experimental investigation in baboons

Hemiarthroplasty using osteochondral autografts and allografts were performed on 40 hip, 23 knee and 5 shoulder joints in baboons. Follow-up at one, two and three years revealed good results as assessed by clinical and radiological examination. Histological and radionuclide studies revealed cartilage viability in 70 to 80% of cases.

Diagnosis and reconstruction of the human temporomandibular joint after trauma or internal derangement

This study reviewed the standardized records of 1100 patients with the symptoms of temporomandibular joint syndrome. Of these patients, only 4.5 percent required surgical intervention. The remaining patients were found to have masticatory muscle spasm and were treated by conservative dental methods. Over half the surgical patients had significant macrotrauma to the jaws in their past history. In addition, electromyographic measurement of the masseteric silent period duration in these patients did not reveal muscle spasm. These factors further serve to differentiate the surgical patient from the patient with myofascial pain dysfunction. The patients selected for surgery demonstrated moderate to severe joint disease and required arthroplasty with partial meniscectomy. A surgical technique is presented demonstrating the reconstruction of the meniscus with silicone implant. This same surgical technique is studied in 10 monkeys, and their joints are examined histologically. The results of surgery reveal that 87 percent of the patients reported improvement 1 year after surgery. In all patients complaining of temporomandibular joint clicking or crepitus, surgery produced complete alleviation of these symptoms. The results of surgery were also associated with a 62 percent increase of jaw opening. Histologic evaluation of the human meniscal resections revealed that in addition to an anatomic displacement of the meniscus, there are also significant cellular changes. These changes consisted of calcification, a decrease in cellularity, hyperemia, and a decrease in elastin content.

Total trapeziometacarpal arthroplasty. Report on seventeen cases of de generative arthritis of the trapeziometacarpal joint

The authors have studied the results of 17 total trapeziometacarpal arthroplasties, performed in 15 patents between 1973 and 1983. The indications were essentially arthritis of the trapeziometacarpal joint either isolated or associated with peritrapezial lesions. The mean follow-up period was 3 years, the extremes ranged from 1 to 10 years. Results were judged as good in 13 cases, average in one case with 3 failures. Good results allow to recuperate complete mobility with adequate strength and stability.. The key point of this study was that first, cemented total arthroplasty does not represent a surgical escalade, a repeat operation is always possible in case of failure, and second, the concept of peritrapezial arthritis, and especially Crosby's stage 1 or stage 2 scaphotrapezial arthritis, is not a contraindication for total trapeziometacarpal arthroplasty. The best indications seems to be intense Dell's stage 3 or stage 4 trapeziometacarpal arthritis either isolated or associated with moderated peritrapezial arthritis. Two elements must be particularly studied before thinking about total trapeziometacarpal arthroplasty: the size, the consistancy and the configuration of trapezium; the degree of eventually associated scaphotrapezial arthritis.

Workshop on the bone-joint implant interface

A workshop on the bone-implant interface, as related to loosening of total joint implants, was held in Chicago on September 14-16, 1983. More than 60 orthopaedic clinicians and researchers and basic connective tissue biologists met to review problems and potential solutions to joint implant loosening. The following is a synopsis of the presentations and discussions.

Strength of polymethylmethacrylate increased by vacuum mixing

The mechanical strength of high and low viscosity gentamicin-containing cement was analysed using three different mixing procedures: hand, vibration, and vacuum stirring. Vacuum mixing improved the flexural and compression strength and the modulus of elasticity by 15-30 per cent, especially for high viscosity cement.

Extensive posterior exposure of the elbow. A triceps-sparing approach

Difficulty with triceps avulsion or loss of continuity after total elbow arthroplasty has prompted the development of a modified posterior approach to the elbow joint. The characteristic feature of this approach is that the triceps mechanism is reflected from medial to lateral in continuity with the forearm fascia and the olecranon and ulnar periosteum. A variant of the technique reflects the extensor mechanism from lateral to medial. The ulnar collateral ligament may be released from the humerus to provide more exposure, but the ligament must then be securely reattached. This approach, which provides extensive exposure to the elbow joint, has been employed in 49 consecutive total elbow arthroplasties and results show no loss of triceps function and no significant weakness. The approach has proved useful for treatment of intra-articular fractures of the distal end of the humerus and with synovectomy in the rheumatoid arthritic patient.