Rheumatoid Arthritis: Migaud H

Girard J, Herent S, Combes A, Pinoit Y, Soenen M, Laffargue P, Migaud H. · Service d'Orthopédie C, Hôpital Salengro, CHRU de Lille, Lille, France. · Rev Chir Orthop Reparatrice Appar Mot. · Pubmed #18555860 No free full text.

Abstract: PURPOSE OF THE STUDY: Early loosening, before a three-year follow-up, has been observed with cemented cups having a metal-on-metal insert in a polyethylene cup. The metal-on-metal bearing has been incriminated as the source of the problem because of its rigidity (particularly for small cups measuring less than 50 mm) and the creation of stress conditions unfavorable for a cemented fixation. The purpose of this retrospective study was to determine whether this phenomenon is observed when the cement is fixed not directly into the bone, but via a Muller reinforcement ring. MATERIAL AND METHODS: From 1998 to 2004, 23 arthroplasties using a cemented Metasul cup in a reinforcement ring were implanted in 22 patients (16 women and six men) aged on average 44 years (range 24-56 years). The series included six primary total hip arthroplasties (three for dysplasia, two for protrusions, one for rheumatoid arthritis and one for arthritic degradation) and seventeen revisions (two septic). The Metasul cup (Zimmer-Centerpulse) combined a 28 mm modular head anchored in a femoral implant (two cemented, 21 pressfit) and a polyethylene cup with a Metasul insert (13 of 23 measuring<50mm). In all cases, the cup was fixed with low-viscosity cement in a Myller metal reinforcement ring fixed with screws (Zimmer-Centerpulse). All patients were reviewed clinically and radiographically at a mean 5-year follow-up (range 3-8 years). Acetabular and femoral fixation were analysed (search for lucency and implant migration). RESULTS: Revision was not necessary in any patient for failure of the acetabular fixation. The mean Postel-Merle-d'Aubigné score improved from 12.9 points (range 7-17) to 17.5 points (range 16-18). The radiographic analysis did not reveal any sign of lucency between the cup and ring, nor any migration of the ring. There was no evidence of femoral osteolysis but one femoral revision was needed due to fracture of the lateral cortical identified six weeks after implantation. DISCUSSION AND CONCLUSION: Cementing the metal-on-metal cup into a reinforcement ring can avoid the risk of loosening observed after direct cementing into bone. In our study, the large number of small cups (13/23) would have been expected to produce a high rate of acetabular lucent lines and/or a high rate of early revision, as reported by others, as early as 24 months. Our series was also different from others by the use of pressfit femoral implants in most patients, which should reduce the risk of cement debris in the bearing. Longer follow-up will be necessary to confirm the good results observed to date which suggest that direct cementing of the cup into the bone should be incriminated rather than the metal-on-metal bearing to explain the reported failure of cemented Metasul cups.

Devauchelle V, Essabbani A, De Pinieux G, Germain S, Tourneur L, Mistou S, Margottin-Goguet F, Anract P, Migaud H, Le Nen D, Lequerré T, Saraux A, Dougados M, Breban M, Fournier C, Chiocchia G. · Institut Cochin, Département d'Immunologie, 27 rue du Faubourg Saint-Jacques, 75674 Paris Cedex 14, France. · J Immunol. · Pubmed #17056579 links to  free full text

Abstract: We previously compared by microarray analysis gene expression in rheumatoid arthritis (RA) and osteoarthritis (OA) tissues. Among the set of genes identified as a molecular signature of RA, clusterin (clu) was one of the most differentially expressed. In the present study we sought to assess the expression and the role of CLU (mRNA and protein) in the affected joints and in cultured fibroblast-like synoviocytes (FLS) and to determine its functional role. Quantitative RT-PCR, Northern blot, in situ hybridization, immunohistochemistry, and Western blot were used to specify and quantify the expression of CLU in ex vivo synovial tissue. In synovial tissue, the protein was predominantly expressed by synoviocytes and it was detected in synovial fluids. Both full-length and spliced isoform CLU mRNA levels of expression were lower in RA tissues compared with OA and healthy synovium. In synovium and in cultured FLS, the overexpression of CLU concerned all protein isoforms in OA whereas in RA, the intracellular forms of the protein were barely detectable. Transgenic overexpression of CLU in RA FLS promoted apoptosis within 24 h. We observed that CLU knockdown with small interfering RNA promoted IL-6 and IL-8 production. CLU interacted with phosphorylated IkappaBalpha. Differential expression of CLU by OA and RA FLS appeared to be an intrinsic property of the cells. Expression of intracellular isoforms of CLU is differentially regulated between OA and RA. We propose that in RA joints, high levels of extracellular CLU and low expression of intracellular CLU may enhance NF-kappaB activation and survival of the synoviocytes.

Chantelot C, Feugas C, Ala Eddine T, Migaud H, Gueguen G, Fontaine C. · Service d'Orthopédie-Traumatologie B, Hôpital B, CHRU de Lille, place de Verdun, 59037 Lille Cedex. · Rev Chir Orthop Reparatrice Appar Mot. · Pubmed #12124540 No free full text.

Abstract: PURPOSE OF THE STUDY: We analyzed retrospectively 30 Kudo non-constrained elbow prostheses to determine: 1) functional outcome and mobility, 2) frequency of loosening and any complications. MATERIAL AND METHODS: From 1992 to 1998, 30 Kudo total elbow arthroplasties were performed in 29 patients, mean age 55 years. Mean follow-up was 36 months. These patients had severe joint disease: rheumatoid arthritis for 24, psoriatic arthritis for 2, and hemophilic arthritis for 3. The 29 patients experienced severe pain before surgery. RESULTS: At review, 21 elbows were pain free and the 9 others had only occasional pain. Among these 9 elbows, 3 exhibited a rupture of the humeral implant; one had already been revised but remained painful. One patient had a stiff painful elbow after reflex dystrophy and five others had pain but no other complication. Twenty-six patients were satisfied or very satisfied. Three patients were unsatisfied because of the humeral implant fracture. Mean mobility at last follow-up was: 128 degrees flexion, -35 degrees extension, 72 degrees pronation, and 74 degrees supination. Mean gain in flexion-extension was 15 degrees and mean gain in pronosupination was 3 degrees. Pronosupination was greater than 100 degrees except for two patients. There was one immediate post-operative dislocation with failure of prolonged orthopedic treatment after reduction; this patient underwent revision reconstruction with repair of the ulnar collateral ligaments (plasty of the medial collateral ligament with a synthetic ligament). Painful movement of the radial stump was observed with one Kudo prosthesis and required resection to achieve cure. In all, there were 3 fractures of the Kudo I prosthesis at the junction of the trochlea and the humeral stem. Among these patients, one underwent revision due to persistent pain, and two others with currently acceptable symptoms are awaiting revision. At last follow-up, we had: 1 ulnar loosening associated with cortical thinning facing the end of the ulnar implant that had migrated and showed a circular lucent line measuring > 1 mm and progressing; 9 unique ulnar lucent lines measuring<1 mm without progression at the proximal part of the implant (6 at the bone-cement interface and 3 at the bone-implant interface); 3 humeral radiolucent lines (<1 mm without progression) on the distal part of the Kudo II humeral stems corresponding to a zone without surfacing. We also observed 13 cases of incomplete ossification between the humerus and ulna and among these 13, 7 elbows had amplitudes of less than 100 degrees. DISCUSSION AND CONCLUSION: Elbow arthroplasty can restore a painless joint and maintain or improve elbow motion. The procedure is indicated when the joint disease impair daily life activities. Final mobility basically depends on the preoperative mobility. The bone stock remains the greatest problem with these resurfaced prostheses. The GUEPAR elbow prosthesis would appear to be more adapted due to the reconstruction of the trochlea. Resection of the radial head is a source of instability for elbow prostheses and should lead to the design of three-compartment prostheses.

Chantelot C, Feugas C, Strouck G, Migaud H, Fontaine C. · Service d'orthopédie B, hôpital Roger Salengro, CHRU de Lille, 59037 Lille, France. · Chir Main. · Pubmed #11885381 No free full text.

Abstract: Combined resection of radial head and distal ulna could jeopardize the stability and kinematics of the forearm bones. The goals of this retrospective study was to investigate these data after resection of distal ulna and proximal radius in rheumatoid arthritis. Between 1990 and 1998, eleven patients had these bone resections combined with implantation of elbow prostheses (eight Kudo and three GSB III). Wrist surgery consisted in five wrist arthrodeses combined with Darrach procedure, four Sauvé-Kapandji procedures and two isolated Darrach procedures. Mean age at surgery was 58 years and the average follow-up was 40 months. We assessed at follow-up: 1) wrist and elbow pain according to Gschwend; 2) stability of the forearm bones (cubitus valgus angle, impingement of the proximal radial stump with humerus, giving away accident of the ulnar distal stump); 3) wrist and elbow mobility. At follow-up six patients had no pain at the elbow and five had slight occasional pain. At the wrist, five patients had no pain and six slight occasional pain. Elbow motion was increased (from mean 83 degrees [50 degrees-100 degrees] to mean 110 degrees [85 degrees-135 degrees]) excepted in supination which slightly decreased (from mean 3 degrees [40 degrees-90 degrees] to mean 75 degrees [85 degrees-90 degrees]). Mean wrist mobility was impaired because of the five combined radiocarpal arthrodeses. If these five wrist arthrodeses were excluded, the mean ranges of motion were: 10 degrees in flexion, 16 degrees in extension, 2 degrees in radial deviation, 14 degrees in ulnar deviation. At follow-up, no patient had giving away accident of the ulnar distal stump nor impingement between radial stump and humerus in full flexion. Average cubitus valgus was 10 degrees. This study pointed out the predominant effect of the interosseous membrane in stability of the forearm bones.

Chantelot C, Fontaine C, Flipo RM, Migaud H, Le Coustumer F, Duquennoy A. · Department of Orthopaedics B, R. Salengro Hospital, Lille CHRU, France. · J Hand Surg Br. · Pubmed #10473145 No free full text.

Abstract: The aim of synovectomy-stabilization (synovectomy combined with the Sauvé-Kapandji procedure) of the rheumatoid wrist is to obtain a stable painless wrist, retaining enough mobility for function. Thirty-nine wrists were retrospectively examined, at a mean follow up of 64.8 months. The improvement in pain was very significant. We noticed a decrease in wrist motion affecting both flexion and radial deviation. The arthritic change in the wrist continued to increase. We noticed a mean ulnar shift of 2.2 mm and a mean increase in the radial deviation of the wrist of 7 degrees. Only transfer of the extensor carpi radialis longus tendon to the extensor carpi radialis brevis tendon was effective in correcting radial deviation of the carpus. Ninety-seven per cent of patients were very satisfied or satisfied. These encouraging results, even at advanced stages of wrist arthritis, have prompted us to lessen the indications for wrist arthrodesis.