Corticosteroids (CS) and norepinephrine (NE) support each other's biological effects. Thus, deficiency of cortisol and reduced synovial sympathetic innervation (SSI) may be proinflammatory in rheumatoid arthritis (RA). This study tested the anti-inflammatory cooperativity of CS and NE in human RA synovial tissue. In an in vivo study, 32 patients with RA (with prior CS therapy/without SSI: n=7; without prior CS therapy/with SSI: 6; with prior CS therapy/with SSI: 19) were investigated for synovial inflammation. In an in vitro study with synoviocytes from RA and OA patients, the separate and combined effects of cortisol and NE were studied. In the in vivo study, patients with prior CS therapy/with SSI showed lower secretion of synovial IL-8 than the other groups, lower synovial density of T cells and macrophages, and lower overall inflammation. In the in vitro study, a cooperative suppressive effect of NE (10(-6) M to 10(-8) M) and cortisol (10(-6) M and 10(-7) M) on secretion of IL-8 and TNF from primary early culture mixed RA synoviocytes was observed. This cooperative effect was not observed in OA synoviocytes. In the same RA and OA patients, the cooperative effect was lost in 3rd passage synovial fibroblasts. This study demonstrates the cooperativity of cortisol and NE for inhibition of proinflammatory mediators produced in the synovial tissue of RA patients. These results underscore that coupling of an efficient secretion of systemic cortisol together with local production of NE is important in order to lower synovial inflammation.

Thirty-seven patients with 20 cemented Thompson-Richards prostheses and 19 cementless S.T.A.R. prostheses (2 bilateral cases) were followed up after 1-12 years. Rheumatoid arthritis was the main diagnosis in both populations, with females dominating. The investigation was based on the Kofoed ankle score. At follow-up the total scoring improved to 86.9 pts. in S.T.A.R. and to 77.7 pts. in T.R.P. replacement. The radiological examination showed a high rate of radiolucency for the tibial component (53.3%) in cemented T.R.P.; subsidence of talar component was seen in 3 cases with T.R.P. In cementless S.T.A.R. prothesis only 3 cases showed small radiolucent lines of the flat tibial component. Talar subsidence was not seen at all. In T.R.P. we had two revisions due to prothesis loosening and one maleollar fracture, giving a cumulative estimated survival rate of 87% at 12 years. In the S.T.A.R. prosthesis group two revisions had to be performed because of one meniscal breakage and correction of meniscal height. The estimated survival rate at 6 years was 94.3%.

Late Synovectomy of the rheumatoid wrist combined with ulna head resection and dorsal wrist stabilization will not prevent carpal instability and dislocation. Depending on the radiological destruction pattern and the natural course of the wrist according to Simmen, dorsal wrist synovectomy is combined with soft-tissue or osseus stabilization procedures.This article describes the mid- and long-term results of radio-lunate arthrodesis in patients with rheumatoid arthritis. We present a retrospective study of 69 radiolunate arthrodesis performed from 1988 to 1994. Fifty patients with 57 wrists were available for clinical and radiological follow-up. All patients were suffering from rheumatoid arthritis (dominating female). The average length of R.A. illness was 9.6 years. The mean age at operation was 54.4 years. Postoperative results were reviewed with the Clayton score. The radiographic analysis included measurement of the carpal height index and ulnar translation of the carpus. The follow-up period ranged from 4 to 10.8 years (average: 7 years). The postoperative Clayton score averaged 74.2 points, representing 70% good or excellent results. Twelve wrists achieved satisfactory results and five were judged poor. The most benefit was achieved in pain relief and restoration of wrist function and extensor strength. Complete pain relief was achieved in 36 wrists, while 16 reported slight pain from loads. Five patients still complained about pain with daily wrist activity. We noticed a moderate decrease for extension-flexion (-39 degrees ) and for combined ulnar-radial deviation (-10 degrees ). The radiographic analysis proved stabilization of ulnar translocation in most cases. We routinely noticed a moderate radiographic progression according to the Larsen classification (+0.7) with reduction of the carpal height ratio. In conclusion radioulnate arthrodesis proved satisfactory pain relief and maintenance of functional wrist motion. Despite radiographic deterioration, partial wrist arthrodesis restrains ulnar translocation, while stabilization of the rheumatoid wrist is achieved.

Despite frequent involvement, the rheumatoid shoulder is neglected in operative treatment of the upper extremities. The slow course of omarthritis, the compensation mechanism of scapulothoracic motion and neighbouring joints as well as dominating disabilities of the lower extremities and the rheumatoid hand are possible explanations. The pattern of destruction of the rheumatoid shoulder is characterized by progressive joint and soft tissue deterioration. Soft tissue involvement determines the course of the shoulder joint. The subacromial space is a common and early site for rheumatoid involvement, often leading to bursitis, tenosynovitis of the biceps tendon and rotator cuff rupture. Sonography and MRI enable the early detection of subacromial and glenohumeral pathology before deterioration is visible radiologically. Surgical intervention in patients with rheumatoid arthritis of the shoulder is based on the degree of radiological destruction according to Larsen, the natural course of the shoulder joint and the soft-tissue condition. The goals of surgery are to relieve pain, increase motion and restore shoulder function. Surgery should be carried out early in the course of the disease, thus determining the long-term prognosis and the remaining surgical options. Depending on the pattern of destruction of the rheumatoid shoulder, the options for treatment can be divided into early and late procedures.Joint-preserving surgery is indicated in the early stages of radiological destruction according to Larsen classification O-III, whereas the late stages of destruction (Larsen IV-V) require reconstructive surgery. The introduction of arthroscopic and semiarthroscopic techniques has improved the acceptance of early synovectomy for the rheumatoid shoulder, but there is still a place for open synovectomy in patients with extensive soft-tissue repair and bone-remodelling procedures. Arthroscopic and open synovectomy are supplementary and noncompetitive surgical procedures for the rheumatoid shoulder. With proceeding bone and soft-tissue destruction corresponding to Larsen stage IV and V, synovectomy is not successful and reconstructive surgery is necessary. Resection-interposition-arthroplasty (RAIP) remains a controversial alternative to arthroplasty in young patients with sufficient bone stock and a reconstructable rotator cuff. The success of cup-replacement will additionally restrict the indications for RAIP. RIAP remains a possible salvage procedure after aseptic and septic loosening of shoulder arthroplasty. Glenohumeral replacement arthroplasty has become the procedure of choice in reconstructive surgery of the shoulder. The severity of soft-tissue and bone destruction determines the choice of shoulder prosthesis. Current modular shoulder systems with increased numbers of humeral-head stem combinations are calculated to achieve a better adjustment of the soft-tissue tension and to optimize the adaptation between head geometry and the natural shape of the glenoid.The surrounding soft-tissue structure, especially the co...

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From January 2003 to September 2006, 15 patients with infected ankle prosthesis loosening (six Thompson-Richards prostheses, eight S.T.A.R. prostheses, and one Salto prosthesis) were treated. All patients underwent tibiotalocalcaneal interposition arthrodesis with femoral nailing in retrograde technique. The average AOFAS (American Orthopaedic Foot and Ankle Society) Score was 57.9 points (35-81 points) postoperatively. One patient developed a nonunion and revision surgery will have to be performed. Another patient with delayed wound healing and skin necrosis needed plastic surgery.

Silicone-wrist arthroplasty has dominated reconstructive surgery of the rheumatoid wrist for a long time. Silicone interposition wrist arthroplasty yielded good clinical results in short and midterm studies. The durability and longevity of the prosthesis however is limited and progressive X-ray deterioration and silicone synovialitis are the main shortcomings. We present the ten-year follow-up results of 102 rheumatoid wrists operated between 1984 and 1992. 72 patients with 82 wrist arthroplasties were clinically and radiologically examined. The mean age at operation was 56.9 years. The average onset of R.A. was 16.1 years. Each wrist was rated on a 100-point scale, with points based on wrist balance, range of motion, pain relief and extensor strength. The postoperative Clayton score averaged 69.4 points. Including revision cases, 51% of the Swanson implants were rated good or excellent, 16% fair, and 33% were judged poor because of pain or prosthesis breakage. Patient satisfaction and pain relief were achieved in 68.2%. Active motion with unrevised implants was 21 degrees extension and 31 degrees flexion. We noticed a moderate increase (7 degrees) for ulnar-radial deviation. There was a progressive deterioration in the radiographic appearance. Implant fracture occurred in 31% of the patients. Subsidence of the implant and significant reduction of carpal height was noticed in 82.5% of the prosthesis. Revision procedures were performed in eleven cases. We conclude that the clinical and radiological results of Swanson silicone interposition arthroplasty will deteriorate with the passage of time. Beyond the potential deleterious effects of silicone, long-term radiological complications such as implant fracture, subsidence and carpal collapse are the main disadvantages of Swanson arthroplasty of the wrist. We therefore currently recommend the MPH-total wrist design in patients with rheumatoid arthritis.

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