Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial

BACKGROUND

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow.

METHOD

Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months.

RESULTS

Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection.

CONCLUSION

L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising

Background

It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images.

Methods

Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05.

Results

Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality.

Conclusions

Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

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Diffuse bruises may be measured on conventional & cross polarized imaging.

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Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo.

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Measurements of bruises using infrared imaging may be smaller than other modalities.

Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements

BACKGROUND

Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques.

METHODS

24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests.

RESULTS

Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7).

CONCLUSIONS

Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.

Early migration of a partially cemented fluted glenoid component inserted using a cannulated preparation system

Aims

Radiostereometric analysis (RSA) allows an extremely accurate measurement of early micromotion of components following arthroplasty.

Patients and Methods

In this study, RSA was used to measure the migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent total shoulder arthroplasty using an improved surgical technique (seven men, four women, mean age 68). Patients were evaluated clinically using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores and by CT scans two years post-operatively.

Results

There were two patterns of migration, the first showing little, if any, migration and the second showing rotation by > 6° as early as three months post-operatively. At two years, these two groups could be confirmed on CT scans, one with osseointegration around the central peg, and the second with cystic changes. Patients with osteolysis around the central peg were those with early migration and those with osseointegration had minimal early migration. Both groups,however,had similar clinical results.

Conclusion

Rapid early migration associated with focal lucency and absence of osseointegration was observed in three of 11 glenoid components, suggesting that lack of initial stability leads to early movement and failure of osseointegration. Cite this article: Bone Joint J 2017;99-B:674–9.

Medium-term outcomes of the Universal-2 total wrist arthroplasty in patients with rheumatoid arthritis

AIMS

The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis.

PATIENTS AND METHODS

This was a retrospective review of all 95 Universal-2 TWAs which were performed in our institution between 2003 to 2012 in patients with rheumatoid arthritis. A total of six patients were lost to follow-up and two died of unrelated causes. A total of ten patients had bilateral procedures. Accordingly, 75 patients (85 TWAs) were included in the study. There were 59 women and 16 men with a mean age of 59 years (26 to 86). The mean follow-up was 53 months (24 to 120). Clinical assessment involved recording pain on a visual analogue score, range of movement, grip strength, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores. Any adverse effects were documented with particular emphasis on residual pain, limitation of movement, infection, dislocation and the need for revision surgery. Radiographic assessment was performed pre-operatively and at three, six and 12 months post-operatively, and annually thereafter. Arthroplasties were assessed for distal row intercarpal fusion and loosening. Radiolucent zones around the components were documented according to a system developed at our institution.

RESULTS

The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29^o (0 ^o to 70 ^o) and palmar flexion of 21^o (0^o to 50^o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91).

CONCLUSION

The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642-7.

MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up

The MatOrtho proximal interphalangeal replacement is a cementless cobalt-chromium metal-on-polyethylene mobile-bearing surface replacement arthroplasty. The aim of this study is to report the outcome and complications of this implant at a minimum of 2 years follow-up from a single institution. A retrospective case review was performed on all MatOrtho proximal interphalangeal joint replacements performed with a minimum of 2 years follow-up. Patient demographics, diagnosis, implant revision and other surgical interventions were recorded. Subjective and objective outcomes were evaluated at latest follow-up, including pain scores, range of motion, function and radiographic assessment. A total of 109 implants were inserted in 56 patients. Nine implants (six patients) were lost to follow-up. Of the remaining 100 implants, 75 had been undertaken in females. The mean age at time of surgery was 64 years and the principal diagnosis was osteoarthritis in 74%. The mean follow-up was 47 months (range 24-77). Within the group there was a statistically significant diminution in pain. There was also an improvement in functional scores post-operatively. Improvement in range of motion was seen in those joints with a pre-operative range of motion greater than 20°. Radiologically there was no evidence of loosening or of implant subsidence at final follow-up. The revision rate was 13%. Nine joints were revised to the NeuFlex (silicone rubber) prosthesis, three were converted to an arthrodesis and one had exchange of the MatOrtho prosthesis. The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. Patients can be advised that the procedure achieves good pain relief, improvement in functional scores and may improve range of motion. We would, however, caution against this implant's use in joints that are either stiff or have significant deformity and/or instability pre-operatively.

A Comparative Study of Outcome between the Neuflex and Swanson Metacarpophalangeal Joint Replacements

This prospective double blind trial compares the clinical findings of Swanson and Neuflex metacarpophalangeal joint replacements in patients with rheumatoid arthritis, up to 2 years follow-up. There were 37 joints (10 patients) in the Swanson group and 40 joints (12 patients) in the Neuflex group. Assessments of range of movement, grip strength and hand function were undertaken in a double blind fashion, preoperatively and up to 2 years following implantation. The mean and standard deviation of the data were calculated. A two-tailed student’s t-test was used when comparing groups of data. An X-ray analysis was also undertaken to identify any implant failure.

There was no significant difference between the two groups with respect to flexion and extension before surgery. At follow-up there was also no significant difference in the extensor lag, with mean extension lags of 19° and 16° for the Swanson and Neuflex implants, respectively. However, there was a significant difference in flexion, with mean active flexion values of 59° and 72° for the Swanson and Neuflex implants, respectively. There were no differences between the two groups in respect to arc of metacarpophalangeal joint motion, ulnar deviation, grip strength or the SODA function test at follow-up. At this early stage there was no evidence of any case of implant failure.

In conclusion, patients who underwent Neuflex metacarpophalangeal joint replacements obtained greater flexion than those who underwent a Swanson replacement.

Radiostereographic analysis of a shoulder surface replacement: does hydroxyapatite have a place?

Resurfacing of the humeral head is commonly used within the UK to treat osteoarthritis (OA) of the shoulder. We present the results of a small prospective randomised study of this procedure using the Global CAP prosthesis with two different coatings, Porocoat and DuoFix hydroxyapatite (HA). We followed two groups of ten patients with OA of the shoulder for two years after insertion of the prosthesis with tantalum marker beads, recording pain, Constant-Murley and American Shoulder and Elbow Surgeons (ASES) outcome scores, and using radiostereometric analysis to assess migration. The outcomes were similar to those of other series, with significant reductions in pain (p = 0.003) and an improvement in the Constant (p = 0.001) and ASES scores (p = 0.006). The mean migration of the prosthesis three months post-operatively was 0.78 mm (0.51 to 1.69) and 0.72 mm (0.33 to 1.45) for the Porocoat and DuoFix groups, respectively. Analysis of variance indicated that the rate of migration reached a plateau after three months post-operatively in both groups. At follow-up of two years the mean migration was 1 mm (sd 1 (0.25 to 3.32)); in the Porocoat group and 0.8 mm (sd 0.4 (0.27 to 1.45)) in the DuoFix HA group. Significant migration of the prosthesis was seen in one patient who had received an anterior humeral bone graft. This prosthesis was later revised after 2.7 years. The addition of a coating of HA to the sintered surface does not improve fixation of this prosthesis.

The outcome of wrist surgery: what factors are important and how should they be reported?

A prospective longitudinal study was carried out on a cohort of 86 patients who had undergone surgery for diverse wrist conditions. Disabilities of Arm Shoulder and Hand questionnaire, a pain assessment, a wrist functional score, range of movement and grip strength measures were completed. The Mayo Clinic wrist score was also calculated. The World Health Organization International Classification of Function was used as a framework for analysis. The responsiveness of each outcome measure was calculated in terms of distribution- and anchor-based methods. Pain was the most important factor in determining outcome. Changes in objective measures were less important. The responsiveness of the various measures was similar except for the Mayo Clinic wrist score, which was less responsive than the others. Patient-completed measures currently in use are multidimensional. Classifying the content according to the International Classification of Function would clarify the effects of wrist surgery on the different aspects of health.

Role of pulmonary infection in the development of chronic lung disease of prematurity

We studied the role of ante- and post-natal infection in the development of chronic lung disease (CLD) of prematurity. 192 newborn infants (61 term and 131 pre-term of <34 weeks gestation: 88 with respiratory distress syndrome, 35 developed CLD and eight died) were recruited. 16S ribosomal RNA (rRNA) genes were identified by PCR of DNA isolated from 840 gastric and lung fluid samples. Ureaplasma spp. were also cultured. Presence of 16S rRNA genes (OR 1.6, 95% CI 1.2-2.2) and Ureaplasma spp. (OR 3.6, 95% CI 1.7-7.7) was significantly associated with the development of CLD. This association remained if the 16S rRNA genes and Ureaplasma spp. were first identified within the first 3 days of life (OR 2.4 (95% CI 1.4-4.1) and 3.8 (95% CI 1.4-10.0), respectively) or if first identified after 3 days of age (OR 1.7 (95% CI 1.1-2.8) and OR 5.1 (95% CI 1.3-19.8), respectively). Peak lung fluid interleukin (IL)-6 and IL-8 were significantly associated with presence of microbes (p<0.0001 and p=0.0001, respectively) and development of CLD (p=0.003 and 0.001, respectively). Both early and late microbial presence in neonatal lung fluid samples was significantly associated with the development of CLD suggesting that both ante- and post-natal infection play a role in the development of CLD.

Early results of the Acclaim total elbow replacement in patients with primary osteoarthritis

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4).

Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved.

This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.

The effect of the offset humeral head on the micromovement of pegged glenoid components

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis.

Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them.

Survivorship of the Neuflex silicone implant in MCP joint replacement

The Neuflex silicone metacarpophalangeal (MCP) joint replacement has previously been shown to provide improved movement, particularly flexion, when compared with the Swanson implant. In this study, we reviewed the outcome of 237 Neuflex implants in 66 patients with a follow-up of up to 7 years. Kaplan-Meier analysis using revision as the end stage revealed survival at 7 years to be 88%. If however an implant fracture, as seen radiographically, is taken as the end point, the survivorship drops to 68% at 7 years. These figures are comparable with a similar analysis for the Swanson implant. We conclude that the improved range of motion of the Neuflex implant demonstrated previously does not result in either a higher or a lower revision or implant fracture rate when compared with the Swanson implant.

The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10−6) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

Early results of the Acclaim elbow replacement

The Acclaim total elbow replacement is a modular system which allows implantation in both unlinked and linked modes. The results of the use of this implant in primary total elbow replacement in 36 patients, operated on between July 2000 and August 2002, are presented at a mean follow-up of 36 months (24 to 49). Only one patient did not have good relief of pain, but all had improved movement and function.

No implant showed clinical or radiological loosening, although one had a lucent area in three of seven humeral zones. The short-term results of the Acclaim total elbow replacement are encouraging. However, 11 patients (30.5%) suffered an intra-operative fracture of the humeral condyle. This did not affect the outcome, or the requirement for further surgery, except in one case where the fracture failed to unite. This problem has hopefully been addressed by redesigning the humeral resection guide. Other complications included three cases of ulnar neuropathy (8.3%) and one of deep infection (2.8%).

The results of arthroplasty in osteoarthritis of the shoulder

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff. When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present.

Survivorship of the Souter-Strathclyde elbow replacement in the young inflammatory arthritis elbow

We divided 309 patients with an inflammatory arthritis who had undergone primary elbow replacement using the Souter-Strathclyde implant into two groups according to their age. The mean follow-up in the older group (mean age 64 years) was 7.3 years while in the younger patients (mean age 42 years) it was 12 years. Survivorship for three different failure end-points (revision, revision because of aseptic loosening of the humeral component, and gross loosening of the humeral implant), was compared in both groups.

Our findings showed that there was no significant difference in the incidence of loosening when young rheumatoid patients were compared with an older age group.

Seventeen-year survivorship analysis of silastic metacarpophalangeal joint replacement

We reviewed the records and radiographs of 381 patients with rheumatoid arthritis who had undergone silastic metacarpophalangeal joint replacement during the past 17 years. The number of implants was 1336 in the course of 404 operations. Implant failure was defined as either revision or fracture of the implant as seen on radiography. At 17 years, the survivorship was 63%, although on radiographs two-thirds of the implants were seen to be broken. Factors which improved survival included soft-tissue balancing, crossed intrinsic transfer and realignment of the wrist. Surgery to the thumb and proximal interphalangeal joint had a deleterious effect and the use of grommets did not protect the implant from fracture.

Demonstrating the economic value of occupational health services

Many large companies operate some form of occupational health service (OHS). More companies now require specific evaluative information to justify the continued provision of an in-house OHS. This is in the face of increased pressure to control costs, combined with an awareness that the service itself can induce activity (supplier-induced demand) and could be substituted with health care provided or even funded outside the company. The lack of routinely collected data and the conceptual difficulty in defining and measuring the outcomes of an OHS provide challenges for economic evaluation. A purely human capital approach, where people are valued by their wage rates, is likely to be insufficient, since OHSs have multiple objectives. These objectives include fulfilling statutory obligations, contributing to the creation of a culture of partnership, reduction of potential costs to the company (sickness benefit, production loss, poor performance, litigation, insurance) and providing a suitable environment for the cost-effective reduction of the social and health service costs of illness at work. Evidence is needed to quantify some of these arguments and demonstrate to decision makers the value generated by OHSs. The aim of this paper is to consider the practicality of different economic evaluation methodologies, specifically cost models, contingent valuation (willingness-to-pay) and development of OHS-specific outcome measures. In considering different approaches, we present the results of our research in two UK companies.

The results of shoulder arthroplasty in patients with rheumatoid arthritis

We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups.

In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ.

The results of shoulder arthroplasty in patients with rheumatoid arthritis

We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups. In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ.

Biaxial total wrist replacement in patients with rheumatoid arthritis. Clinical review, survivorship and radiological analysis

We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist replacements. On the basis of the Hospital for Special Surgery scoring system, 49 wrists (74%) were graded as fair to excellent. More than half of the 27 patients who had an arthrodesis on the contralateral wrist would have preferred a second arthroplasty. Five replacements were revised or fused because of loosening and a further nine showed signs of radiological loosening, three of which were asymptomatic. The probability of survival of the biaxial total wrist replacement at eight years was 83% with revision surgery as the terminal event, 78% with radiological loosening as the endpoint and 82% with dorsal migration and displacement from the metacarpal as the terminal event. There was a linear relationship between subsidence of the component and distal loosening. There was no evidence that the length of the stem of the carpal component, within the third metacarpal, affected any of the terminal events. The position and alignment of the carpal component within the bone at the time of surgery significantly affect the outcome and can be used to predict failure.

Comparison of survivorship between standard and long-stem souter-strathclyde total elbow arthroplasty

This study compared 107 cases of rheumatoid arthritis that had the long-stem humeral component of the Souter-Strathclyde total elbow arthroplasty introduced as a primary procedure with a similar group of 202 cases that had the standard component. Both groups were comparable with regard to age range and sex ratio. Follow-up of the longer-stem component was somewhat shorter, being a mean of 4.4 years as opposed to 9.3 years. Kaplan-Meier survival analyses were undertaken for both revision and radiologic loosening of components as terminal events. There was no significant difference between the cumulative survival of the standard and long-stem humeral implants when revision was the endpoint. Although survival of both implants was similar, the reasons for this were different. More specifically, for the standard humeral component, 25 out of 32 revisions were for humeral loosening. For the long stem, however, 5 out of a total of 7 revisions were due to instability; no long-stem humeral component had been revised for loosening. In addition, linking the components by way of a snap-fit component was associated with a higher rate of loosening; more specifically, 5 out of 16 cases were revised. As a result of this study, we recommend the use of a long-stem Souter-Strathclyde humeral component as a primary implant. Other crucial components for long-stem survival, however, are surgical technique and alignment of the implant.

Biaxial total wrist replacement in patients with rheumatoid arthritis

We have implanted 76 biaxial total wrist prostheses as a primary procedure in patients with rheumatoid arthritis of the wrist. A total of 66 was reviewed at a mean follow-up time of 52 months. Pain was relieved in 67% of the surviving wrist replacements. On the basis of the Hospital for Special Surgery scoring system, 49 wrists (74%) were graded as fair to excellent. More than half of the 27 patients who had an arthrodesis on the contralateral wrist would have preferred a second arthroplasty. Five replacements were revised or fused because of loosening and a further nine showed signs of radiological loosening, three of which were asymptomatic.

The probability of survival of the biaxial total wrist replacement at eight years was 83% with revision surgery as the terminal event, 78% with radiological loosening as the endpoint and 82% with dorsal migration and displacement from the metacarpal as the terminal event. There was a linear relationship between subsidence of the component and distal loosening. There was no evidence that the length of the stem of the carpal component, within the third metacarpal, affected any of the terminal events. The position and alignment of the carpal component within the bone at the time of surgery significantly affect the outcome and can be used to predict failure.

The effect of epidemiologic and intraoperative factors on survival of the standard Souter-Strathclyde total elbow arthroplasty

Previously published work has revealed an 87% survivorship after 12 years for the standard Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis. Of the 13% that were revised, 75% were due to loosening of the humeral component. The aim of this research was to identify the specific epidemiologic and intraoperative factors that predisposed to this humeral loosening. Specifically, factors such as age, sex, radiologic staging of the disease, position of the implant in bone, and size of the implant inserted were evaluated. After analysis of 186 cases, we concluded that the position of the humeral component within the humerus is crucial for long-term survivorship. Specifically in the lateral plane, the stem should be aligned in the plane of the humerus and the implant inserted to the correct depth. The articular surface of the implant should lie at the level of the normal trochlea. At the anteroposterior plane, the implant should sit centrally and not be lateralized. We conclude that good surgical technique is crucial to the long-term effectiveness of this implant.

A patient-reported comparison of trapeziectomy with Swanson Silastic implant or sling ligament reconstruction

A retrospective review of two types of operations for carpometacarpal osteoarthritis of the thumb was done for patients operated on between 1991 and 1996. Follow-up ranged from 18 to 90 months (mean 62 months). Fifty-eight Swanson Silastic arthroplasties and 56 sling excision arthoplasties were reviewed. Eight patients with Swanson arthroplasties underwent removal of the implant. Eight patients in the sling excision group required further surgery. These patients were excluded from further analysis. Questionnaires about pain, general satisfaction and function were sent to the other patients and 87 responses were received (sling 45, implant 42). In the implant group significantly better results were obtained for pain at 1 year, carrying a milk bottle and taking a handbrake off a car, and overall function. We conclude that trapeziectomy combined with Swanson implant gives better results in the short term if there are no complications of the operation.

Survivorship and radiological analysis of the standard Souter-Strathclyde total elbow arthroplasty

We undertook a radiological analysis of 186 standard Souter implants to determine survivorship and to analyse the pattern of failure in those needing revision. The implants had been inserted as a primary procedure in patients with rheumatoid arthritis of the elbow at our hospital over the last 12 years.

Taking revision as an endpoint, the survivorship after 12 years was 87%. If, however, revision and loosening, defined as the Hindex value equivalent to demarcation of 1 mm around the whole implant, are also included, the survivorship falls to 80%. Of the 24 implants revised, 18 (75%) were for problems with the humeral component, three (12.5%) with the ulnar component and three (12.5%) for instability.

Loosening of the humeral component occurred when the implant extended into the humerus, with the tip moving anteriorly on to the anterior humeral cortex. Our study indicates that loosening can be predicted by the rate of change in this angle of extension of the prosthesis.

Survivorship and radiological analysis of the standard Souter-Strathclyde total elbow arthroplasty

We undertook a radiological analysis of 186 standard Souter implants to determine survivorship and to analyse the pattern of failure in those needing revision. The implants had been inserted as a primary procedure in patients with rheumatoid arthritis of the elbow at our hospital over the last 12 years. Taking revision as an endpoint, the survivorship after 12 years was 87%. If, however, revision and loosening, defined as the Hindex value equivalent to demarcation of 1 mm around the whole implant, are also included, the survivorship falls to 80%. Of the 24 implants revised, 18 (75%) were for problems with the humeral component, three (12.5%) with the ulnar component and three (12.5%) for instability. Loosening of the humeral component occurred when the implant extended into the humerus, with the tip moving anteriorly on to the anterior humeral cortex. Our study indicates that loosening can be predicted by the rate of change in this angle of extension of the prosthesis.

Movement of the scaphoid in the normal wrist

The radiological images of 30 normal wrists in varying degrees of radial and ulnar deviation were analysed by measuring parameters of flexion and translation of the scaphoid bone. Results demonstrated a linear relationship, indicating that movement is consistently either by flexion of the scaphoid, translation or more commonly a combination of the two. The significance of this is discussed. There did not appear to be any age or sex related differences.