Total joint replacement at the base of the thumb--preliminary report

Twenty-nine patients have been studied after trapeziometacarpal total joint replacement with a system of the author's design using a titanium metacarpal component and a polyethylene trapezium component cemented to bone with polymethyl methacrylate. Replacement was performed for arthritis, failure of attempted arthrodesis, previous Silastic or total joint arthroplasty failure, or postparalytic fibrous ankylosis of the joint. Twenty-six patients have achieved a good range of painless motion since the study was initiated in 1974. There have been no cases of implant fracture or infection, but three cases have demonstrated loosening at the cement--bone interface. The results appear to warrant cautious optimism at this time.

Silicone spacer or tendon spacer for trapezium resection arthroplasty--comparison of results

A comparison study was done for 25 consecutive trapeziectomies in 21 women with silicone replacements and 25 consecutive trapeziectomies in 24 women without silicone replacements who were reviewed from 1 to 9 years postoperatively. The patients, who ranged from 35 to 75 years of age, were housewives and clerical workers. All had trapeziometacarpal osteoarthritis. Among the patients with silicone replacement of the trapezium, 90% reported pain relief; mean thumb abduction was 42.5 degrees, pronation was 37.5 degrees, and pinch strength averaged 5 kg. Among the patients without silicone replacement after trapeziectomy, 95% reported pain relief; mean thumb abduction was 46.8 degrees, pronation was 41.4 degrees, and pinch strength averaged 4.6 kg. For those patients with only one hand operated upon, pinch strength in that hand averaged 85% that of the opposite hand in patients with silicone trapezial replacement and 82% for those without silicone trapezial replacement. In this patient population, trapeziectomies with or without silicone replacement as treatment for trapeziometacarpal osteoarthritis appear to give similar results.

[Testing of cementless stepped-stem prosthetic devices replacing the hip shoulder joint of the dog. Comparison of two animal models (author's transl)]

In 6 dogs the hip joint was experimentally replaced using a ceramic stepped-stem prosthetic device implanted in the thigh bone. In six other dogs V4A steel stepped-stem prosthetic devices inserted in the arm bone was used for replacing shoulder joint. The six devices replacing the shoulder joint healed up without complications and proved to be mechanically stable. From six devices replacing the hip joint only one was successful; the remaining five implants did not heal up due to fractures of the stem, loosening in the thigh bone and osteomyelitis. We suggest that these different results are based not on the different material, but on the different conditions characteristic for each implantation sites. The devices implanted in the arm bone of the dog, corresponding to the conditions in man, were stressed mainly by pressure and pull. In such conditions the newly formed bone tissue anchoring in the steps on the stem stabilized the device. On the other hand, the biomechanical load on the hip joint replacing device in the dog is represented mainly by rotation at stress, for which the devices are not conceived. The stepped profile of the stem can not work; it twists in the thigh bone and remains unstable causing consequences such as fractures, osteomyelitis and loosening. For experimental testing of bone and joint replacing prosthetic devices of cementless anchoring systems replacing human hip joint and thigh bone we recommend the shoulder joint of the dog instead of hip joint, because of the comparable biomechanics.

Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty

Radial head resection is the accepted treatment of comminuted radial-head fractures in adults, but the results are not always satisfactory. This study examines the results of silicone replacement arthroplasty of the radial head in acute fractures and as a salvage procedure after failed resections of the radial head. The first group of patients was evaluated both before and after silicone replacement arthroplasty had been done as a salvage procedure following a previous radial head fracture. This group comprised twelve patients with an average follow-up of 3.8 years. Improvement was found in a number of parameters, including supination and grip strength. The second group of patients had had a primary silicone replacement arthroplasty following a comminuted radial-head fracture. This group was composed of six patients with an average follow-up of 3.6 years. The radial head implant was found to provide a spacer effect that maintained good radiocapitellar contact and prevented radial shortening. Silicone replacement arthroplasty has a role as a useful, safe, and reliable alternative in the treatment of comminuted radial-head fractures in adults and as a salvage procedure in patients with failed radial-head resections. This is especially true in young, active individuals, who were found to be at the greatest risk of failure after radial head resection alone. This was attributed to greater demands being placed on the involved extremity.

Joint function after total hip arthroplasty: a four-year follow-up of 72 cases with Charnley and Müller replacements

To help determine the duration of benefits in functional performance resulting from total hip arthroplasty (THA), multiple kinesiologic measurements were made before surgery and two and four years after 32 Charnley and 40 Müller THA procedures were done in 58 patients. There were no complications of loosening or infection, nor was there additional disability in other joints of the lower extremities. Measurements of functional performance included range of hip motion, hip abductor and adductor muscle strength, weight distribution between the feet during standing, forces applied to canes or crutches, and multiple components of free-speed and fast-walking performance. The average measurements showed significant improvement in almost all components of function from the time preceding surgery to two years afterward. The two-year level of function was then maintained without significant improvement or decline in function four years postoperation.

Arthroprosthesis of the ankle joint

The authors report the results obtained with arthroprostheses of the ankle joint in twelve patients. The surgical indications were severe post-traumatic degenerative, lesions, rheumatoid arthritis and post-traumatic necrosis of the talus. The types of prosthesis used were the St. Georg-Buchholz, Smith and TPR designs. The joint was exposed in the majority of cases by an antero-medial approach. The results (at a minimum of one year and a maximum of two and a half years) were satisfactory, being excellent in eight cases, fair in three and negative in one. The one failure was partly due to the surgical exposure, which involved osteotomy of the distal third of the fibula.

Trapezium implant arthroplasty. Long-term evaluation of 150 cases

Arthritis of the joints at the base of the thumb can be painful and severely disabling, interfering with normal functional activity. The trapezium implant, which acts as a replacement for the removed pathologic bone, must have certain features if it is to be tolerated by the host tissue and be stable and durable. Implant resection arthroplasty of the trapezium, with careful correction of other associated deformities, has resulted in long-term, excellent functional and cosmetic results in this group of cases.

Complications and technical errors in endo- and arthroprostheses of the wrist and hand. A critical reappraisal of 89 operations

The authors analyse eighty-nine operations performed between 1969 and 1975 for the insertion of endo- and arthroprostheses is the wrist and hand, with special reference to the complications and errors of technique of this type of surgery. They have paid particular attention to possible errors of diagnosis, faulty indications, and technical operative errors. They confirm that this type of surgery, which is still in the developmental stages, should be restricted to carefully selected cases and performed only in specialist centres.

Silastic rod pseudosheaths and tendon graft healing

By examining the breaking strength and gap formation of tendon graft junction sites covered with pseudosheath at various times of immobilization, no significant increase was found compared to junction sites not covered by the pseudosheath. The optimum time for immobilization following tendon grafting is between 4 and 5 weeks in the chicken. Total coverage of the junction sites by pseudosheath did not affect gap formation.

Arthroplasty of the wrist

The history of the artificial wrist joint is brief and begins as recently as 1971. The prosthesis is designed as a ball-and-socket joint. The metallic trunnion component is cemented into the radius and the metallic cup component into the carpal and metacarpal II and III bones. There is a central articulating polyethylene ball. The surgical technique itself requires only a few special instruments. The centering of the prosthesis is of utmost importance and requires great care. The fixation stems of the prosthesis can and must be bent and adapted to the skeletal conditions of the individual. The wrist joint prosthesis is indicated for the treatment of severe painful wrist joint destruction--mainly rheumatoid arthritis or degenerative osteoarthritis--in patients not concerned with heavy manual work. Clinical experience over a period of 8 years with 41 wrist arthroplasties has shown that although initially technical errors resulted in a number of re-operations, in almost all cases, however, the final outcome was satisfactory. When necessary, a change of prosthesis or a subsequent arthrodesis of the wrist was always possible.

Volz total wrist arthroplasty in rheumatoid arthritis: a preliminary report

The results of 20 Volz design total wrist arthroplasties in 19 patients with stages III and IV rheumatoid arthritis are presented. Follow-up averaged 18 months. Using a 100-point evaluation form, there were 75% excellent or good results and 10% poor results. An effective extensor carpi radialis brevis tendon and the presence of volar and ulnar contractures were the most important factors influencing the results. This operation is recommended in patients with painful stage III or IV rheumatoid wrist disease, and in whom the extensor carpi radialis brevis is functioning where preservation of motion is desired.

Ligament augmentation with replacement arthroplasty of the carpo-metacarpal joint

A method of ligament augmentation at the time of Swanson silicone replacement arthroplasty of the trapezium is presented. This has effectively solved the problem of prosthetic dislocation. One of the twenty-six patients had a prosthesis dislocate and this was felt to be due to improper positioning of the thumb post-operatively. A successful closed reduction and subsequent prosthetic stability was achieved. All twenty-six patients had stable and pain free thumbs with good range of motion.

Flexible implant arthroplasty of the proximal interphalangeal joint of the fingers

The use of an intramedullary stemmed flexible (silicone) hinge in reconstruction of the proximal interphalangeal joint has allowed us to obtain more predictable, durable, and reproducible results. The indications, surgical technique, and postoperative rehabilitation of this technique vary with each type of deformity presented and must be carefully followed. Adequate reconstruction of the extensor mechanism and the collateral ligament system, and appropriate postoperative rehabilitation are essential to obtain good balance of the digit, with functional mobility and stability of the reconstructed proximal interphalangeal joint.

The correction of rheumatoid ulnar drift by silicone prostheses with tendon transfer

Fifty hands with rheumatoid ulnar drift treated by resection of the metacarpal heads and replacement with silicone prostheses were studied. The procedure is outlined which consists of an arthroplasty using a silicone prosthesis with tendon transfer. The complications are also studied and the results evaluated. Of the cases studied 20% were excellent, 40% were good, and 40% fair.

Total joint arthroplasty. The hip

Total hip arthroplasty, one of the most successful orthopedic procedures of this century, can provide relief of pain and improved function in a wide variety of hip conditions. Long-term follow-up has shown, however, that problems can occur, especially with the femoral prosthesis. As a result of this, surface-replacement total hip arthroplasty was developed, and at present it appears to be a very useful procedure for younger patients with concentric hip disease. Both procedures are discussed along with restrictions and complications inherent in their use.

Total joint arthroplasty. The knee

Total knee replacement has become an established form of treatment for gonarthrosis and usually results in excellent relief of pain and approximately 90 degrees of joint motion with satisfactory joint stability. The anatomic stability that cannot be restored at surgery must be provided for by additional prosthetic stability. Fixation of prosthetic devices, particularly in the tibia, is marginal and results in an increased incidence of loosening when the quality of bone is weak, as in osteoporosis, or when shear stress is increased because of malalignment or prosthetic constraint. Resurfacing techniques provide the greatest options if surgical revision is necessary. Surgical goals should be realistically assessed so as to maintain the best potential for future treatment options.

Acetabular reinforcement in total hip replacement

In conclusion, based on our experimental and clinical material and analysis of failures, we recommend wire mesh reinforcement and bone graft for patients with mild to moderate protrusio. If the floor is strong but the pillars deficient, then the Eichler ring alone is the best implant. The combined system of wire mesh and Eichler ring should be used in cases of protrusion with a large deficiency of the acetabular floor and for protrusio with pillar weakness. Furthermore a bone graft should be used to reinforce the acetabular floor in addition to any prosthetic device.

Assessment of past results and current practice in the treatment of rheumatoid metacarpophalangeal joints. Five year review

A new design of prosthetic finger joint for the rheumatoid patient, and the technique for its insertion is described, which has now been in use for five years. The technique includes the soft tissue correction of the ulnar deviation. Results are reported for all the cases performed in one year giving a two year follow up, assessing flexion strength, pinch strength and the degree of recurrence of ulnar drift associated with loss of pinch strength.

Unicompartmental replacement for medial compartment gonarthrosis: preliminary report

Unicompartmental replacement using the Marmor prosthesis was done in 40 knees (37 patients) with medial compartment gonarthrosis. Of the 27 available for follow-up, results were considered excellent in 18 cases and good in seven, while two cases were considered failures. Meticulous removal of osteophytes by intercondylar burring and accurate alignment of the femoral component of the tibial medial compartment with the axis of the normal medial femoral condyle are essential to success. Preservation of a good articular surface and early mobilization with excellent report indicate that unicompartmental replacement may be useful in the treatment of medial gonarthrosis.

[New method of endoprosthesis of the femur head]

The author has developed an original method of endoprothetics of joints (application N 2651054/13). Endoprothesis is fabricated from plastics to a cast taken from the removed articular end of the bone. This allows to manifacture an exact replica. An individual endoprothetics has been used successfuly in the treatment of 12 patients with fractures and pseudoarthroses of the femoral neck.

Total hip replacement in congenital dislocation and dysplasia of the hip

The results of thirty-one total hip replacements in twenty-four patients with either severe congenital dysplasia or dislocation, after an average follow-up of four years, were excellent in eleven, good in sixteen, fair in one, and poor in one. The operative technique included superolateral bone grafts to increase the acetabular coverage in six hips. Twenty-seven hips required smaller and straighter femoral components than normal. The incidence of major complications was 19 per cent.

Reconstruction of articular cartilage with free autologous perichondrial grafts. An experimental study in rabbits

An experimental study in adult rabbits has been performed to find out whether the cartilage forming capacity of the perichondrium could be utilized in reconstruction of articular cartilage. The normal articular cartilage of the glenoid surface of the humero-scapular joint was completely removed. Auricular perichondrium was grafted to cover the exposed bony surface with the active chondrogenic layer of the perichondrial graft facing the joint cavity. The joint was not immobilized but the operated limb was amputated at wrist level to avoid weight bearing. The animals were sacrificed at different time intervals ranging from 1 to 17 weeks. In 12 out of 14 grafted rabbits regeneration of cartilage occurred. In 6 of 10 control cases where no perichondrium was grafted to cover the resected surface no cartilage was found. In the other 4, only small areas of mature cartilage were seen, probably remnants of the original articular cartilage.

Implant arthroplasty of the scapho-trapezial joint

Degenerative changes in the scapho-trapezial-trapezoidal (ST) joint may occur as an isolated process or more frequently as a dominant part of pantrapezial degenerative joint affections. In the present study results of surgery on 24 hands with isolated degenerative changes in the ST joint have been assessed. Arthrodesis was previously the sole procedure and has resulted in normal hand function in those cases where bony union was achieved without complications. The ST joint is difficult to fuse, however, and prolonged immobilization implies obvious risks of rigidity and impaired hand function. During the last 5 years a new technique for implant arthroplasty of the ST joint has been tried. The distal articular surface of the scaphoid has been resected and replaced with a heat-molded silicone rubber implant. In the present paper the method is presented and anatomical and technical points and pitfalls are discussed. It is concluded that implant arthroplasty may become a useful method for treatment of isolated ST arthrosis provided that the implant material will tolerate the compressive stress created during pinch.

Treatment of unreduced traumatic posterior dislocations of the hip

A study was made of thirty-nine traumatic posterior dislocations of the hip that had remained unreduced for from three days to nine years. The purpose of the review was to compare the results of closed and open reduction with those of primary reconstructive surgery. Three of the twenty hips that had closed or open reduction had good results as compared with ten of the thirteen hips that had primary reconstructive surgery. Six hips that were left dislocated had uniformly poor results.

Synovectomy or total replacement of the knee in hemophilia

Eighteen major operations on the knee joint were performed in sixteen patients with hemophilia, eight operations being synovectomy and ten being total knee replacement. Synovectomy was performed for recurrent bleeding associated with synovitis. The average age at operation for patients who underwent synovectomy was 16.4 years, and the average follow-up was thirty-one months. No patient had a recurrent hemorrhage following synovectomy. The patients who had total knee arthroplasty for disabling pain had an average age at surgery of 35.7 years and an average follow-up of twenty-three months. The pain was markedly reduced in all eight patients and all achieved full unprotected weight-bearing. Loss of some motion was observed in twelve patients, but the functional gain outweighed the loss of knee mobility. Seven major complications occurred in the sixteen patients, but none of them affected the outcome.

Anatomy and osteotomy of the greater trochanter

Eleven human cadaver hips were dissected to define exactly the musculofascial anatomy of the greater trochanter and the supportive structures around it. A readily identifiable plane was defined that permitted osteotomy of the greater trochanter from an anterior approach leaving the vastus lateralis attached to it so that the trochanter could be folded posteriorly and then replaced securely. The osteotomy has been used in difficult total hip replacements at Waterbury (Conn) Hospital and found to be very satisfactory with no wire or bolt fixation necessary to maintain trochanter stability after surgery. Until a large series of these osteotomies has been reviewed, however, additional fixation may be advisable.

Mechanical failures in total hip replacement requiring reoperation

During the years 1971 through mid-1977, approximately 3,000 total hip replacements were performed at The Hospital for Special Surgery using metal-to-plastic prostheses. During that period of time, thirty-five operations were done for mechanical failure in the absence of infection. The mechanical failures were distributed as follows: Fourteen patients had dislocations of the prostheses and seven patients had loosening of the femoral component, mostly with varus positioning of the femoral stem. Six patients, most of them heavy, active men, had fractures of the femoral stem. Three patients had loosening of the acetabular component. (In two of three there was insufficient bone stock over the acetabulum.) Four patients had proximal migration of the greater trochanter and one had a fracture-dislocation of the acetabulum. In all cases a technical or anatomical problem could be identified as the reason for mechanical failure necessitating reoperation. By careful preoperative planning, proper selection of procedures and positioning of prostheses, bone-grafting when necessary, and stricter attention to the technique of using cement, we could conceivably have avoided two-thirds of these failures.

Prosthetic replacement of the patellofemoral joint

We are just beginning to fully appreciate the significant role of the patellofemoral joint in total knee replacement surgery. Most of the new generation prostheses have a flanged femoral component. The tendency is to make the flange more anatomic in shape as more attention is paid to patellar tracking. Most systems have an optional polyethylene button to resurface the patellar side of the patellofemoral joint, and indications for its use are increasing. Although pain relief with patellar buttons seems uniform, the potential complications of stress fracture, loosening, and wear must temper our enthusiasm for their use until there is longer follow-up. Vitallium hemiarthroplasty of the patella is available in prostheses with and without the requirement for cement fixation. Most investigators have good results in chondromalacia (as a secondary procedure), but the experience in the literature is small. Results have been poor when the femoral side of the joint has been involved. Metal to plastic isolated patellofemoral prostheses have been designed to treat disease on both sides of the patellofemoral joint or to salvage unflanged total knee replacements with residual patellofemoral symptoms. Short term experience has been promising.