Rheumatoid Arthritis: Rüther W

Schmidt K, Rüther W. · Klinik für Orthopädie und Rheumaorthopädie, Katholisches Krankenhaus Dortmund-West, Zollernstrasse 40, 44379, Dortmund. · Z Rheumatol. · Pubmed #18779969 No free full text.

This publication has no abstract.

Rüther W. · Orthopädische Klinik der Rheumaklinik Bad Bramstedt, Universitätsklinikum Hamburg-Eppendorf. · Z Rheumatol. · Pubmed #17896423 No free full text.

This publication has no abstract.

Kothe R, Wiesner L, Rüther W. · Klinik und Poliklinik für Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany. · Z Rheumatol. · Pubmed #15338253 No free full text.

Abstract: The rheumatoid involvement of the cervical spine can be divided into three phases. In the early stage of the disease there is an isolated atlantoaxial subluxation (AAS), followed by vertical instability and subaxial instability. If patients show clear symptoms of cervical myelopathy, which can occur during any stage of the disease, the progression cannot be stopped by conservative treatment, which is of great importance at the beginning of the cervical manifestation. Patient education, physiotherapy and immobilization with a stiff collar can significantly reduce pain. Early and effective DMARD therapy can have a positive effect on the natural history of the disease. In case of progressive instability, cervical myelopathy or severe pain operative treatment is indicated. If there is an isolated AAS, fusion can be restricted to the C1/C2 segment. The Magerl transarticular screw fixation is the preferred technique for stabilization. If there is evidence for vertical instability or severe destruction of the C0/C1 joints, occipital cervical fusion has to be performed. Durin the preoperative planning it is necessary to look for signs of subaxial instability. If this is the case, fusion should include the entire cervical spine. Transoral decompression may be necessary when there is persistent anterior compression of the myelon, typically seen in fixed AAS. Non-ambulatory myelopathic patients are more likely to develop severe surgical complications. Therefore, it is important to avoid the development of severe cervical instability by early surgical intervention. The right timing for surgery is still a matter of controversy. Future prospective randomized trials should address this topic to improve the treatment concept for the rheumatoid patient.

Göttsche T, Kothe R, Adam G, Rüther W. · Radiologisches Zentrum, Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. · Z Rheumatol. · Pubmed #15338252 No free full text.

Abstract: Rheumatoid arthritis leads to characteristic findings at the synovial joints, the intervertebral discs and the processes of the cervical spine. Isolated findings are not specific for rheumatoid arthritis. In fact, due to common underlying pathophysiologic changes they also develop in other inflammatory diseases affecting the cervical spine. Therefore, each radiological examination is to be understood and used as a piece in the diagnostic puzzle. Only in conjunction with clinical information does it add to a conclusive diagnosis. Nevertheless certain patterns of findings help in narrowing the list of differential diagnosis. Besides their role in initial diagnosis, radiological examinations are crucial tools in the peri- and post-operative work-up and in the detection of typical complications of rheumatoid arthritis with cervical manifestations, i. e. various instabilities and their consequences, as those have an impact on the therapeutic approach and prognosis.

Müller-Ladner U, Rüther W, Burmester GR. · Bereich Rheumatologie/Klinische Immunologie, Klinik und Poliklinik für Innere Medizin I der Universität Regensburg. · Dtsch Med Wochenschr. · Pubmed #15179592 No free full text.

Abstract: In the past years, the substantially increased number of potent drugs for the therapy of rheumatoid arthritis has made the goal of an early, highly effective therapy more feasible. In addition, combination therapy trials including biologics revealed that joint protection and downregulation of inflammation can be achieved also in stages of active articular destruction, and the detection of novel markers such as antibodies against cyclic citrullinated peptides supports an earlier diagnosis of the disease. The price for these advances, however, are more complex, demanding and expensive therapeutic regimens that need to be handled carefully by the rheumatologist, especially with regard to a new field of side effects inherent with the use of TNF inhibiting agents. Finally, the current therapeutic standard includes also the ongoing clinical and scientific exchange with the orthopedic surgeon to optimize the long-term treatment for the individual patient.

Benthien JP, Rüther W. · Orthopädische Klinik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany. · Z Rheumatol. · Pubmed #15112093 No free full text.

Abstract: A biomechanically altered rheumatic forefoot with a resulting shoe conflict and an impaired immune system due to underlying disease and medical treatment are often cause for infection. Often infected bursae perforate into the corresponding joints and may consequently lead to severe infectious states of the foot. The multiplicity of possible biomechanical adjustments makes it difficult to develop an undisputed concept. Conservative versus operative therapeutic options are possible and may be individually applied. It should be questioned, if the same general rules in septic joint surgery also apply to the rheumatoid forefoot. This retrospective clinical study will evaluate a concept for possible operative treatment of the infected rheumatoid forefoot in selected cases. Our conception advocates operative procedures on a patient adapted basis in order to prevent recurrent infections. Suggestions for operative procedures are given.

Fuerst M, Fink B, Rüther W. · Department of Orthopedics, Rheumaklinik Bad Bramstedt, Bad Bramstedt, Germany. · J Bone Joint Surg Am. · Pubmed #18829941 No free full text.

Abstract: BACKGROUND: Rheumatoid arthritis often leads to severe destruction of the glenohumeral joint, including synovitis and inflammation-induced alterations of the rotator cuff. Cup arthroplasty, or surface replacement of the shoulder, was introduced in the 1980s. The aim of this study was to evaluate the midterm results of the DUROM cup surface replacement for patients with rheumatoid arthritis affecting the glenohumeral joint. METHODS: From 1997 to 2000, forty-two DUROM cup hemiprostheses were implanted in a cohort of thirty-five patients (forty-two shoulders), who were evaluated preoperatively and again at three, twelve, and more than sixty months postoperatively. Six patients (seven shoulders) were lost to follow-up. Thirty-five shoulders in twenty-nine patients (twenty-one women and eight men with an average age of 61.4 years) could be evaluated prospectively after an average follow-up period of 73.1 months. Patients were evaluated clinically with the use of the Constant score, and a detailed radiographic analysis was performed to determine the presence of endoprosthetic loosening, glenohumeral subluxation, and glenoid bone loss. RESULTS: The mean Constant score for the thirty-five shoulders increased from 20.8 points preoperatively to 64.3 points at a mean of 73.1 months postoperatively. There were three revisions: one to replace an implant that was too large, another to treat glenoid erosion, and a third due to loosening of the implant. No additional cases of loosening of the prosthesis or changes in cup position were observed radiographically. Over the five-year follow-up period, proximal migration of the cup increased in 63% of the shoulders, and glenoid depth increased in 31%. With the numbers studied, no differences in clinical outcome were identified between patients with a massive rotator cuff tear and those with a smaller or no tear. CONCLUSIONS: The midterm results of the cemented DUROM cup surface replacement for patients with advanced rheumatoid arthritis of the shoulder are very encouraging, even for patients with a massive tear of the rotator cuff. The advantage of this cup arthroplasty is the less complex bone-sparing surgery. In the event of failure of the implant, other reliable salvage options remain available.

Fuerst M, Fink B, Rüther W. · Department of Orthopedics, Rheumaklinik Bad Bramstedt, OskarAlexander-Strasse 26, D-24576, Bad Bramstedt, Germany. · J Bone Joint Surg Am. · Pubmed #17671015 No free full text.

Abstract: BACKGROUND: Rheumatoid arthritis often leads to severe destruction of the glenohumeral joint, including synovitis and inflammation-induced alterations of the rotator cuff. Cup arthroplasty, or surface replacement of the shoulder, was introduced in the 1980s. The aim of this study was to evaluate the midterm results of the DUROM cup surface replacement for patients with rheumatoid arthritis affecting the glenohumeral joint. METHODS: From 1997 to 2000, forty-two DUROM cup hemiprostheses were implanted in a cohort of thirty-five patients (forty-two shoulders), who were evaluated preoperatively and again at three, twelve, and more than sixty months postoperatively. Six patients (seven shoulders) were lost to follow-up. Thirty-five shoulders in twenty-nine patients (twenty-one women and eight men with an average age of 61.4 years) could be evaluated prospectively after an average follow-up period of 73.1 months. Patients were evaluated clinically with the use of the Constant score, and a detailed radiographic analysis was performed to determine the presence of endoprosthetic loosening, glenohumeral subluxation, and glenoid bone loss. RESULTS: The mean Constant score for the thirty-five shoulders increased from 20.8 points preoperatively to 64.3 points at a mean of 73.1 months postoperatively. There were three revisions: one to replace an implant that was too large, another to treat glenoid erosion, and a third due to loosening of the implant. No additional cases of loosening of the prosthesis or changes in cup position were observed radiographically. Over the five-year follow-up period, proximal migration of the cup increased in 63% of the shoulders, and the glenoid depth increased in 31%. With the numbers studied, no differences in clinical outcome were identified between patients with a massive rotator cuff tear and those with a smaller or no tear. CONCLUSIONS: The midterm results of the cemented DUROM cup surface replacement for patients with advanced rheumatoid arthritis of the shoulder are very encouraging, even for patients with a massive tear of the rotator cuff. The advantage of this cup arthroplasty is the less complex bone-sparing surgery. In the event of failure of the implant, other reliable salvage options remain.

Wiesner L, Steinhagen J, Hansen-Algenstaedt N, Rüther W. · Orthopädische Wirbelsäulenchirurgie am Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg. · Z Rheumatol. · Pubmed #17268787 No free full text.

Abstract: The urgency of spinal procedures for rheumatoid inflammatory disease is presented in three typical spinal involvements. Characteristic connections between rheumatoid arthritis and the cervical spine, spinal fractures in ankylosing spondylitis and the occurrence of bacterial spondylodiscitis as a side effect of immunosuppression are discussed.

Lohmann CH, Fürst M, Niggemeyer O, Rüther W. · Lehrstuhl für Orthopädie, Universitätsklinikum Hamburg-Eppendorf. · Z Rheumatol. · Pubmed #17221249 No free full text.

Abstract: Periprosthetic infections are severe complications following total joint arthroplasty. The infection rate is estimated to be 0.5-2%. Systemic diseases such as rheumatoid arthritis and previous surgery are considered risk factors for infection. The infection rate in the present patient cohort was low (0.72%). The recurrence rate (23.4%) is due to patients with rheumatoid arthritis and septic total knee arthroplasties. Successful treatment is dependent on various factors, one of which involves accurate preoperative bacterial diagnostics. Joint fluid aspiration is the appropriate procedure. Open biopsy or arthroscopically guided biopsy can be performed in cases of unclear diagnostic results. Early infection can be treated with thorough joint debridement without exchanging fixed implant components; "low-grade" or late infections require revision with implant removal in a one or two stage septic revision according to clearly determined algorithms. Antibiotic therapy is mandatory, and a combination with rifampicin is a very useful basis.

Kothe R, Kohlmann T, Klink T, Rüther W, Klinger R. · Department of Orthopedics, University Hospital Hamburg-Eppendorf, Germany. · Pain. · Pubmed #16982148 No free full text.

Abstract: Low back pain (LBP) and rheumatoid arthritis (RA) are common orthopedic problems, but there is little information on the importance of LBP in RA patients. The aim of this study was to investigate how LBP affects functional limitations, depressed mood, and quality of life in patients with RA. A complex questionnaire was answered by 281 RA patients, including questions about their RA and their experience of LBP. Functional limitations were assessed using the Hannover Activities of Daily Living questionnaire (ADL), depressed mood using the Center for Epidemiological Studies Depression Scale (CES-D) and health-related quality of life using the Short Form 12 health questionnaire (SF-12). The prevalence of LBP in RA patients was 53.4%. RA patients with LBP displayed a significantly higher degree of disability and depression than RA patients without LBP. There were no differences between the two groups with regard to the duration of RA, the number of operations or medication. LBP is an important factor for the physical and psychological behavior of RA patients. Therefore, the onset of LBP should not be overlooked or underestimated.

Fuerst M, Möhl H, Baumgärtel K, Rüther W. · Department of Orthopedics, Rheumaklinik Bad Bramstedt, Oskar-Alexander-Str. 26, 24576 Bad Bramstedt, Germany. · Rheumatol Int. · Pubmed #16736164 No free full text.

Abstract: The aim of this object is to study whether treatment with biological or leflunomide increases the risk of wound-healing complications after elective orthopedic surgery. Between March 2002 and September 2003, 201 patients participated in this study with the following inclusion criteria: (a) Rheumatoid arthritis (RA) or psoriatic arthritis (psA), (b) therapy with: MTX, leflunomide, etanercept, infliximab, adalimumab, anakinra, (c) undergoing elective orthopedic surgery. The incidence of early postoperative wound-healing complications was compared among the different groups. In comparison with patients who received MTX therapy (n = 59), the risk of postoperative wound-healing complications in patients undergoing leflunomide therapy (n = 32) was significantly higher: 13.6% in the MTX group, 40.6% in the leflunomide group (P = 0.01). It is recommended that leflunomide medication for patients with RA undergoing elective orthopedic surgical procedure is interrupted preoperatively to reduce the risk of early wound-healing complications or infections.

Fuerst M, Fink B, Rüther W. · Department of Orthopaedics, Clinic of Joint replacement, Markgröningen, Germany. · J Rheumatol. · Pubmed #16652420 No free full text.

Abstract: OBJECTIVE: To evaluate longterm results and survival rate of open synovectomy of the elbow joint in patients with rheumatoid arthritis (RA). METHODS: Between 1986 and 2000, synovectomy of the elbow was performed on 103 joints in 92 patients with RA. Eighty-five joints were included in this study. Mean age at time of surgery was 52 years (range 13 to 62 yrs). On 13 elbows with Larsen stage I and II disease, early synovectomy preserving the radial head was performed; in 72 cases with Larsen stage III and IV, late synovectomy with radial head resection was necessary. RESULTS: In early synovectomy, one joint received prosthetic joint replacement and 2 joints underwent resynovectomy a mean of 9 years after primary surgery. The survival rate (no further operations) was 91% after 5 years and 78% after 10 years. In late synovectomy, 16 elbow joints were operated again a mean of 4.6 years after primary surgery (10 prosthetic joint replacements, 2 resection interposition arthroplasties, 4 resynovectomies). Survival rate was 82% after 5 years and 66% after 10 years. Sixty-one elbows were examined clinically at a mean followup period of 8.7 years (range 2.8-17.3 yrs). There was a significant improvement of the Morrey score at followup, especially due to effective relief of pain. Improvement of joint motion was seen in late synovectomy for pronation and supination. The mean preoperative Larsen stage was 3.11, which decreased significantly to 3.66 at followup. CONCLUSION: Our findings suggest that synovectomy is a safe and effective procedure in differential treatment of RA of the elbow.

Fink B, Singer J, Lamla U, Rüther W. · Department of Endoprosthetic, General Orthopaedic and Rheuma-Surgery, Orthopaedic Clinic Markgröningen, Kurt-Lindemann-Weg 10, 71703 Markgröningen, Germany. · Arch Orthop Trauma Surg. · Pubmed #15133697 No free full text.

Abstract: INTRODUCTION: The concept of a newly developed cup arthroplasty (Durom Cup) involves the replacement of the destroyed joint surface of the humeral head with minimal bone resection. In cases of additional massive cuff tear, the cup can be placed in a more valgic position to articulate with the glenoid and the acromion. The aim of this prospective study was to evaluate the results of this surface replacement as a hemiarthroplasty in rheumatoid arthritis. MATERIAL AND METHODS: Forty-five Durom Cups in 39 patients (30 women, 9 men) with rheumatoid arthritis were evaluated preoperatively and every 3 months postoperatively. Their average age was 62.7+/-12.3 years and the average follow-up 45.1+/-11.6 months with a minimum of 36 months. Concerning the cuff, 15 shoulders had an intact cuff (group A), 18 shoulders a partial tearing or a repaired rotator cuff (group B), and 12 shoulders a massive cuff tear (group C). The Constant Score was used, and the cups were examined radiologically. RESULTS: In group A rheumatic shoulders, the Constant Score increased from 21.5+/-9.6 points preoperatively to 66.1+/-9.8 points at 36 months postoperatively; in shoulders of group B, from 19.6+/-9.7 points preoperatively to 64.9+/-9.6 points at 36 months postoperatively; and in shoulders of group C, from 17.5+/-8.7 points to 56.9+/-9.8 points at the latest follow-up examination. All shoulders were pain-free at the latest examination. No complications, component loosening or changes of cup position were observed. CONCLUSION: The results of the Durom Cup are encouraging. In shoulders with additional massive cuff tear, the limited goal criteria were always achieved. Therefore, cup arthroplasty is a good alternative to other kinds of shoulder endoprostheses in rheumatic shoulders with and without massive cuff tear.

Fink B, Protzen M, Hansen-Algenstaedt N, Berger J, Rüther W. · Orthopaedic Department, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. · Arch Orthop Trauma Surg. · Pubmed #14586628 No free full text.

Abstract: INTRODUCTION: Survivorship analysis was performed on 479 Link V-type threaded cups and on 110 modified V-type Bad Bramstedt cups (a modification of the Link V-type cup since 1993 with a smaller primary coil) to evaluate the effect of the modifications. MATERIALS AND METHODS: Indication for hip arthroplasty with a Link V-type cup was an inflammatory arthritis in 310 patients, osteoarthritis in 138 patients and dysplastic hip joints in 31 patients. The average follow-up was 8.6+/-3.2 (range 3.0-15.2) years. The 110 modified V-type Bad Bramstedt cups had a mean follow-up period of 4.5+/-0.7 (range 3.0-5.9) years, including 49 with inflammatory arthritis, 49 with osteoarthritis and 12 with dysplastic hip joints. To evaluate the migration rate and radiolucent lines, radiographical examination according to the method of Nunn et al. and Delee and Charnley was performed on 264 Link V-type cups with a mean follow-up period of 8.2+/-2.7 years and 59 modified V-type Bad Bramstedt cups with a mean follow-up period of 4.6+/-0.7 years. Relevant parameters influencing cup migration were analysed. RESULTS: The cumulative survival rate of the former Link V-type acetabular cup was 94.5% after 5 years, 88.1% after 10 years and 70.2% after 15 years. The Bad Bramstedt cup showed a 5-year survivorship rate of 97.9%. Migration of more than 3 mm or tilting of the cup greater than 5 degrees was found in 73% of the former type and in 39% of the modified cup. Radiolucent lines greater than 2 mm and detectable in two zones appeared in 6.4% of the former Link V-type and in 1.7% of the Bad Bramstedt cup design. Among the influencing factors analysed, length of follow-up and primary cup positioning showed a significant correlation to cup migration. CONCLUSION: The modification of the Link V-type cup showed no satisfactory improvement in cup migration. Therefore, both threaded cups were abandoned in favour of cementless press-fit cups.

Benthien JP, Delling G, Rüther W. · Orthopädische Klinik, Rheumaklinik Bad Bramstedt, Oskar-Alexander-Str. 26, 24576 Bad Bramstedt, Germany. · Z Rheumatol. · Pubmed #12928945 No free full text.

Abstract: A 66-year old patient sustained a non-traumatic rupture of her left achilles tendon. She suffered from Sjögren's syndrome which occurred in conjunction with a systemic vasculitis, and recurrent episcleritis. The combination of Sjögren's syndrome and systemic vasculitis is well known. Subsequently, she was treated with high-dose systemic steroids over a period of 2 years. In order to reduce the amount of steroids due to preexisting severe osteoporosis and thoracic vertebral fractures, her medication was changed to cyclophosphamide shortly before her injury. Intraoperatively, a granuloma was discovered at the site of the rupture. This granuloma had infiltrated most of the achilles tendon at this site and virtually replaced viable tendon tissue. Originally, the rupture was supposedly due to the high dose steroids. This theory had to be revised according to the intraoperative findings. Following excision of the granuloma and operative treatment of the achilles tendon rupture, the continuity of the tendon could be completely restored. A MRI scan 3 months after the procedure demonstrated a completely healed Achilles tendon. Spontaneous achilles tendon rupture due to a granuloma in patients with vasculitis seems to be a rare event. However, tendon ruptures in combination with systemic lupus erythematodes have been described. Mostly, these events are attributed to long term application of steroids. Spontaneous rupture in combination with high dose treatment of steroids seems to be an underestimated problem.

Kothe R, Wiesner L, Rüther W. · Orthopädische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg. · Orthopade. · Pubmed #12486537 No free full text.

Abstract: The involvement of the cervical spine in patients with rheumatoid arthritis (RA) is common,and has recently received growing attention. In the early stage of the disease, there is an isolated atlantoaxial subluxation (AAS). With further progression, osseous destruction of the joints can lead to vertical instability. While the involvement of the middle and lower cervical spine can cause a subaxial instability, neurological deficits can occur at any time. The onset of cervical myelopathy in patients with RA is often missed because of additional problems related to the hands and feet. If patients show clear symptoms of cervical myelopathy, the progression of the disease cannot be stopped by conservative treatment. Other indications for operative treatment are severe pain and radiological evidence of progressive instability. In the case of an isolated AAS, fusion can be restricted to the C1/C2 segment. If there is evidence for vertical or subaxial instability, an occipitocervical fusion has to be performed. To avoid instability adjacent to the fusion, the surgeon must check for signs of potential subaxial instability. If this is the case, fusion should include the entire cervical spine. Additional transoral decompression may be necessary when there is persistent retrodental pannus or osseous compression by an irreducible transverse dislocation or cranial migration of the dens. Non-ambulatory myelopathic patients are more likely to present severe surgical complications with limited prospects of functional recovery. Therefore, it is important to avoid the development of severe cervical myelopathy by early surgical intervention.

Fink B, Krey D, Schmielau G, Tillmann K, Rüther W. · Orthopaedic Department, Clinic for Rheumatology Bad Bramstedt, University of Hamburg, Germany. · J Shoulder Elbow Surg. · Pubmed #12195254 No free full text.

Abstract: Fifty-nine patients with rheumatic destruction of the elbow received 20 St Georg, 20 GSB III, 13 Souter-Strathclyde, and 13 Kudo endoprostheses. Among the various prosthetic categories, 43.9% of the joints had had preceding rheumatoid surgery (a previous synovectomy had been performed in 10 joints at a mean of 4.1 +/- 3.7 years and a resection interposition arthroplasty had been performed in 19 cases 4.2 +/- 1.8 years before endoprosthetic replacement). We examined 51 patients with 54 prostheses after a mean follow-up of 5.7 +/- 4.1 years using the Inglis score and analyzing all radiographs. Complications occurred in 20% of the St Georg prostheses, 25% of the GSB III prostheses, and 23% of the Souter-Strathclyde prostheses. Of the St Georg prostheses, 6 (30%) had to be exchanged, as well as 4 (20%) of the GSB III prostheses and 4 (30.7%) of the Souter-Strathclyde prostheses. Of the primarily implanted joints, the St Georg prostheses measured 77.7 +/- 7.7 on the Inglis score, GSB III 89.6 +/- 7.2, Souter-Strathclyde 88.4 +/- 6.5, and Kudo 89.7 +/- 4.4. Radiolucent lines greater than 1 mm were observed in 26% of the St Georg prostheses, 23% of the GSB III prostheses, 27% of the Souter-Strathclyde prostheses, and 9% of the Kudo prostheses. In contrast to the clinical results, the intraoperative and postoperative complications, as well as the rate of failure and radiolucent lines, showed a statistically significant relationship to previous operations of the joints, especially with the resection interposition arthroplasty. We conclude that resection interposition arthroplasty seems to be associated with complications and failures when a subsequent endoprosthesis is used.

Fink B, Sallen V, Guderian H, Tillmann K, Rüther W. · Orthopaedic Department, Clinic for Rheumatology, University of Hamburg, Bad Bramstedt, Germany. · J Shoulder Elbow Surg. · Pubmed #11517367 No free full text.

Abstract: To determine the therapeutic value of resection-interposition arthroplasty (RIAP) of shoulders in rheumatoid or other inflammatory arthritis, 53 patients were reviewed clinically and radiographically after a mean follow-up period of 8.2 +/- 4.3 years (3.5 to 17.5 years). The Constant Score averaged 42.33 +/- 16.2 (12 to 76). Patients with a follow-up period of more than 10 years performed significantly worse than those with shorter follow-up periods. In most cases, radiographs showed a progressive medial displacement and loss of size of the humeral head as well as a decrease of the joint space with time. Abduction proved to be highly dependent on the degree of medial displacement of the humeral head, whereas the Constant Scores correlated with the width of the joint space. Despite initially acceptable postoperative results, outcome at longer follow-up periods worsened as the result of wear of the glenoidal cartilage and osseous resorption of the humeral head, resulting in a progressive medialization of the center of rotation.

Fink B, Strauss JM, Lamla U, Kurz T, Guderian H, Rüther W. · Orthopädische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg. · Orthopade. · Pubmed #11480090 No free full text.

Abstract: The concept of an endoprosthetic surface replacement of the humeral head differs from that of stemmed endoprostheses. It is the replacement of the destroyed joint surface with reconstruction of the normal anatomy and minimal bone resection. The aim of this prospective study was to evaluate the short-term results of a newly developed cup arthroplasty (Durom-Cup) for the humeral head. In a prospective study, 39 patients with 46 Durom-Cups were evaluated preoperatively and every 3 months postoperatively. The average follow-up was 15 +/- 9 months. The group included 28 shoulders with rheumatoid arthritis, 15 joints with osteoarthritis, and 3 humeral head necroses. The Constant-score and SAS-function score were used. The Constant-score increased from 20.25 +/- 9.06 points preoperatively to 46.62 +/- 14.05 at 3 months, to 48.11 +/- 14.49 at 6 months, and to 55.25 +/- 11.6 at 9 months postoperatively. The Constant-score stayed at this level during further follow-up and was 55.81 +/- 16.31 at 12 months postoperatively. The best results were seen in the group of humeral head necroses with a Constant-score of 71.0 +/- 12.2 compared to 54.66 +/- 13.89 in the group of osteoarthritis and 56.78 +/- 13.33 in patients with rheumatoid arthritis at 12 months postoperatively. The results with the Durom-Cup are encouraging so that cup arthroplasty seems to be a good alternative to stemmed prostheses. The main advantages of the humeral head resurfacing are the bone-preserving fixation and the relatively simple surgical technique.

Fink B, Berger I, Siegmüller C, Fassbender HG, Meyer-Scholten C, Tillmann K, Rüther W. · Orthopaedic Department, Clinic for Rheumatology, University-Hospital-Hamburg-Eppendorf, Bad Bramstedt, Germany. · J Bone Joint Surg Br. · Pubmed #11380140 links to  free full text

Abstract: We evaluated histologically samples of synovial tissue from the knees of 50 patients with rheumatoid arthritis (RA). The samples were taken during revision for aseptic loosening. The findings were compared with those in 64 knees with osteoarthritis (OA) and aseptic loosening and in 18 knees with RA without loosening. The last group had been revised because of failure of the inlay or the coupling system of a constrained prosthesis. All the patients had had a total ventral synovectomy before implantation of the primary prosthesis. In all three groups a foreign-body reaction and lymphocellular infiltration were seen in more than 80% of the tissue samples. Deposits of fibrin were observed in about one-third to one-half of the knees in all groups. Typical signs of the reactivation of RA such as rheumatoid necrosis and/or proliferation of synovial stromal cells were found in 26% of knees with RA and loosening, but not in those with OA and loosening and in those with RA without loosening. Our findings show that reactivation of rheumatoid synovitis occurs after total knee replacement and may be a cofactor in aseptic loosening in patients with RA.

Fink B, Siegmüller C, Schneider T, Conrad S, Schmielau G, Rüther W. · Orthopaedic Department, Clinic for Rheumatology Bad Bramstedt, Univerisity of Hamburg, Bad Bramstedt, Germany. · Arch Orthop Trauma Surg. · Pubmed #10853899 No free full text.

Abstract: The thrust plate prosthesis is an implant with metaphyseal fixation to the proximal femur, which leaves the diaphyseal bone untouched. Therefore, this implant is preferred in younger patients. It is dependent on good bone quality in the proximal femur. Because the bone quality is reduced in patients with polyarthritis, this kind of endoprosthesis may have a higher failure rate than conventional stemmed endoprostheses in these patients. Therefore, in patients with polyarthritis, even short- and medium-term results of the thrust plate prosthesis should be analyzed. In all, 47 thrust plate prostheses were implanted in 42 patients with polyarthritis (29 with rheumatoid arthritis, 6 with juvenile chronic arthritis, and 7 with spondylarthritis) and followed prospectively. The average age at operation was 40.8+/-10.7 years. Each patient was clinically and radiologically examined preoperatively, 3 and 6 months after the operation, and at the end of each postoperative year. The mean follow-up was 26.1+/-10.7 months. The clinical findings were evaluated using the Harris hip score. Radiologically, 8 different zones of the thrust plate prosthesis were analyzed for radiolucencies. During the 1st year, the Harris hip score rose continuously from the preoperative average of 42.4+/-6.5 points to 78.8+/-10.3 points 3 months postoperatively, 82.3+/-9.8 points 6 months postoperatively, and 86.8+/-10.1 points 1 year after the operation. The subsequent examinations showed Harris hip score remained at the same level. Five patients (5 joints, 10.6%) had to undergo a revision of the thrust plate prosthesis due to aseptic loosening in 3 and septic loosening in 2. Six prostheses (12.6%) showed radiolucencies, mostly below the thrust plate in zones 1 and 2. Two of them were certainly radiologically loose, which raised the failure rate to 7 of 47 (14.8%). The thrust plate prosthesis improves function and alleviates pain in patients with polyarthritis to a satisfactory degree. Concerning the failure rate, this type seems to yield slightly worse results than cementless stemmed endoprostheses in the same patient group. Due to the preservation of the diaphyseal bone of the femur and the possibility of an unproblematic change to a stemmed endoprosthesis, the thrust plate prosthesis can be recommended for younger patients with polyarthritis.

Fink B, Schneider T, Tillmann K, Rüther W. · Orthopädische Abteilung der Rheumaklinik Bad Bramstedt. · Z Orthop Ihre Grenzgeb. · Pubmed #10441831 No free full text.

Abstract: PURPOSE: Aim of this study was the examination of clinical middle- and long-term results of total femoropatellar endoprostheses type Lubinus (Link, Germany). METHOD: From 1983 to 1996 12 patients (15 joints) underwent total femoropatellar joint replacement (type Lubinus, Link, Hamburg). All of them have been controlled 7.2 +/- 2.6 years (2 to 12 years) after surgery. The indication was primary osteoarthritis in 6, chondrocalcinosis in 2 and rheumatoid arthritis in 7 cases. In addition to the femoropatellar implants femorotibial endoprostheses have been used in 10 knees: 2 unicondylar medial, 1 unicondylar lateral and 7 bicondylar unicompartimental ones. RESULTS: According to a modified Hungerford knee rating scale 8 knees resulted excellent, 2 fair and 4 poor. One knee was excluded after revision surgery due to a loosened tibial component of a medial unicompartimental knee arthroplasty. The 4 poor outcomes resulted from femoropatellar replacements in chondrocalcinosis (2 cases), rheumatoid arthritis and osteoarthritis, (one case each), affecting the femorotibial joint as well. CONCLUSIONS: In those cases of simultaneous femorotibial joint affection--even if this is merely slight and beginning and if the femoropatellar complaints are actually clearly dominating--the sole femoropatellar surface replacement seems to be contraindicated according to our experiences. Providing correct and strict indications this endoprosthesis can be recommended for sole femoropatellar osteoarthritis especially since loosening of endoprosthetic components was not been found in this study.