BOERHAAVE CURSUS

UPPER EXTREMITY SURGERY IN ARTHRITIS:

WHERE DO WE STAND?EUROPEAN RHEUMATISM AND

ARTHRITIS SURGICAL SOCIETY

Onder redactie van:R. Nelissen

Boerhaave Commissie voor Postacademisch Onderwijs in de Geneeskunde Leids Universitair Medisch Centrum

(www.boerhaavenet.nl)

ISBN/EAN 978-90-0000-000-0

Alle rechten zijn voorbehouden aan het Leids Universitair Medisch Centrum (Boerhaave Commissie). Niets uit deze publicatie mag worden verveelvoudigd en/of openbaar gemaakt door middel van druk, fotokopie of welke andere wijze dan ook zonder voorafgaande toestemmening. De toestemming moet

worden aangevraagd bij het Bureau van de Boerhaave Commissie, Postbus 2084, 2301 CB LEIDEN.

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INHOUDSOPGAVE

pag

Programma VII

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VII

PROGRAMMA

WELCOME Conference Room 5, building 1

08.30 - 09.00 Registration

SHOULDER Chairman: R.G.H.H. Nelissen

09.00 - 09.10 Surgical Anatomy M.C. de Ruiter

09.10 - 09.25 Biomechanics Duth Shoulder Model F.C.T. van der Helm

09.25 - 09.40 Implant Design J. Nagels

09.40 - 09.55 Rotator Cuff and Tendon transfers F. Steenbrink

09.55 - 10.10 Preoperative destruction and function M.J. van de Sande

10.10 - 10.45 Coffee break

10.45 - 11.00 Preop Planning and Virtual Surgery P.R. Krekel

11.00 - 11.10 Shoulderprostheses evolution P.M. Rozing

11.10 - 11.25 Imaging

11.25 - 11.45 Orthopaedics in the Future C.J.M. Getty

VIII

11.45 - 12.00 Discussion

12.00 - 13.30 Lunch

ELBOW BURUMA room, building 3

13.30 - 13.45 Surgical Anatomy C.J.M. Fontaine

13.45 - 14.05 Arthritis of the elbow: Surgical Options C.R. Howie

14.05 - 14.30 Supracondylar/radialhead Fractures: Prosthesis? D. Stanley

14.30 – 14.50 Tea break

WRIST

14.50 - 15.05 Anatomical aspects C.J.M. Fontaine

15.05 - 15.25 Surgical options in arthritis of the wrist A. LLuch

15.25 - 15.40 Indications for wristprostheses? Z.O. Rahimtoola

15.45 - 16.15 Tea break

16.15 - 17.15 Lessons learned in Upper extremity Surgery P.M. Rozing

17.15 Drinks

IX

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Voorwoord van Rob NelissesenVolgt maandag 27 augustus 2007

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TERES MAJOR TENDON TRANSFER FOR MASSIVE ROTATOR CUFF TEARS SOLVES THE FORCE AND

MOMENT DISCREPANCY

F. Steenbrink, J.H. de Groot, C.G.M. Meskers, M.A.J. van der Sande, R.G.H.H. Nelissen, P.M. Rozing

AbstractMusculo-tendinous transfers have been proposed as a treatment for irreparable rotator cuff tears. Biomechanical model simulations predicted the teres major tendon as the best option in terms of mechanical and functional parameters. We present the results of a teres major tendon transfer to the insertion of the supraspinatus on the tuberculum major, in one patient suffering massive cuff tears and we discuss the underlying mechanism.Clinical results are based on a pain Visual Analog Scale and the Constant Score. Force direction depended electromyography (Principal Action) is used to evaluate function of the transposed teres major muscle.After surgery the patient reported less pain and increased functionality. Maximum Range of Motion increased, as did maximum exerted arm force. Both pre-and post operative force direction dependent electromyography revealed teres major co-activation during upwards force exertion. The improved functionally and decreased pain after the teres major tendon transfer is explained by the observed teres major principal action. Pre operative maximum teres major activation was observed during upwards force exertion, which endeavors glenohumeral stability at the cost of maximum arm elevation. After the teres major muscle tendon was transferred this same co-contraction pattern promotes arm elevation.

IntroductionMassive rotator cuff tears restrict patients in their daily activities.1 This is mainly caused by limitations in maximum arm elevation, external rotation and pain, due to the lack of glenohumeral stability as a result of the lost rotator cuff function. [2;3] In a healthy situation the rotator cuff centers the humeral head on the glenoid fossa, without generating substantial moments. This allows antagonistic activation. When a massive cuff tear is present,

Frans Steenbrink1, Jurriaan H. de Groot2, Carel G.M. Meskers2, Michiel A.J. van der Sande1, Rob G.H.H. Nelissen1,

Piet M. Rozing1 Laboratory for Movement Analysis; Departments of Orthopaedics1 & Rehabilitation Medicine2 ,

Leiden University Medical Center (als footnote?)

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during abduction elevation, the deltoid muscles will be activated to generate the required abduction moment. Compared to the supraspinatus the deltoids generate a larger upwards directed force component, causing superior translation of the humeral head, resulting in a possible painful impingement of the subacromial tissues. Surgical repair of a massive rotator cuff tear is known for suboptimal functional recovery, caused by the poor quality of the residual tendon (fatty degeneration). [4] As fatty degeneration of the rotator cuff is thought irreversible re-tears often occur. [5] Various types of muscle tendon transfers have been successfully proposed as a salvage procedure for irreparable massive rotator cuff tears.[6-11;7;8;11;12] Until recently the success of the transfers was mainly attributed to compensating muscle forces for external rotation. [11] Celli et al. (1998) fi rst described the teres major tendon transfer to the insertion of the supraspinatus tendon on the greater tubercle with successful results similar to the latissimus dorsi transfer, without the adduction force defi cit. This transfer was later confi rmed as the most optimal tendon transfer in a rotator cuff defi cit patient, using a biomechanical model (Dutch Shoulder Model). [13] The ability to perform specifi c movement trajectories was calculated most successful for the tendon transfer of the teres major and the latissimus dorsi, or the teres major alone. [14] Further analysis demonstrated the preference for the teres major transfer, because of its favourable moment arm, muscle length and force production. [13]

In our laboratory we evaluate the solitary teres major tendon transfer to the greater tubercle as a treatment for irreparable massive rotator cuff tears, by means of clinical, kinematical and electrophysiological assessments. The success of the teres major transfer is illustrated with the potential moment vector as calculated by the Dutch Shoulder Model. [15]

MethodsOne male patient (age 58, male) was managed for a teres major tendon transfer after a MRI proven full thickness traumatically developed supraspinatus and infraspinatus tear. Duration of the tear was approximately 1 year. The patient was informed that his rotator cuff tears could not be repaired and that a tendon transfer of the teres major was the proposed treatment. Pre-and

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post-operative pain experience was conducted using a visual analogue score (0 to 100mm, in which 0 represents no pain, and 100 represents the worst pain ever imaginable). Arm function was assessed using the Constant score. [16] Active Range of Motion (abduction elevation, antefl exion elevation en external rotation) was recorded by an electromagnetic tracking device (Flock of Birds, Ascension Technology Corp, Burlington, VT, USA). For a detailed description of the procedure see Meskers et al.. [17] Arm force, which could maximal be exerted in every direction perpendicular to the humerus, was recorded using a 6 degrees-of-freedom (2 degrees were constricted) force transducer (AMTI-300, Advanced Mechanical Technology Inc., Wavertown MA, U.S.A.).

Principal ActionAnalysis of the teres major muscle function was done using the direction of maximum muscle activation, or principal action. To evaluate pre-and postoperative muscle functioning we used force direction dependent electromyography (EMG), evolving in one direction of maximum activation, as described by de Groot, Meskers and co-workers. [18;19] Comparison with healthy maximum muscle activation, derived from anatomical muscle moment arms, provides us with a tool to qualify pathological activation patterns of shoulder muscles. Patients were seated with their injured arm in a splint with the humerus positioned in 30o of forward rotation relative to the frontal plane, about 45o elevation and the elbow in 90o fl exion (Figure 1a). The splint was connected to a 6 degrees-of-freedom force transducer (AMTI-300, Advanced Mechanical Technology Inc., Wavertown MA, U.S.A.). The experimental set-up only allowed forces in directions perpendicular to the longitudinal axis of the humerus because of free translations and rotations around all three perpendicular axes. Patients were asked to maintain an arm force for 3 seconds in each of 24 equidistant directions (Figure 1b) while simultaneously EMG data were collected (Figure 1c). The electrode was placed on the middle of the muscle belly (inter-electrode distance 21mm, maximum skin resistance 10kOhm, Bandwidth 20Hz-500 Hz, CMRR 86dB). Force was set at a level in which the patient could exert it comfortably in all 24 directions perpendicular to the humerus. Force magnitude and direction were controlled by a moving cursor on a display, which responded to the force task.

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Figure 1. Principal Action Method for teres major; Patients (n=10) were seated with their injured arm in a splint (a). During an isometric force task in 24 different directions (b) isometrical and isotonic force sections were selected and simultaneously recorded EMG’s were identifi ed (black) based on these force selections (c). The rectifi ed and intergraded (d) EMG was subsequently averaged (e). The EMG–force vectors were plotted in polar coordinates and a curve was estimated through the data points resulting in one direction of maximum muscle activation, the Principal Action (PA) (f).

For each of the 24 force directions the rectifi ed, average EMG over 3 seconds was determined, and subsequently normalized between minimum (rest level) and maximum EMG level.Thus, we obtained the muscle activation level in all directions perpendicular to the longitudinal axis of the humerus. Through the force direction related activation levels (n=24) a function was fi tted in a least squares sense. This resulted in an on-and off set of muscle activation, describing the range in

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which the muscle is active, and the direction of maximal EMG activity or principal action (PA)(Fig. 1a). A minimum range of activation was enforced by restricting the distance between on-and offset to a minimum of 110o. Principal actions are expressed by positive values between 0o and 360o (= 0o).Antagonistic activity is considered a deviating direction of maximum activation, principle action, compared to principal action data obtained from healthy subjects by Meskers et al.. [19] A change >100o is considered to comprehend co-activation (Figure 1b).

Operative and post-operative procedureThe patient is positioned on his non-injured side, and his injured shoulder is disinfected. The whole patient except the operation area is covered. An incision is made from the posterior angle of the acromion in the direction of the posterior armpit, in order to reveal the insertion of the teres major. The teres major is released from the latissimus dorsi, the humerus and the neurovascular system using knife and scissors up to the insertion on the humerus. The teres major tendon is released from the anterior part humerus very close to the bone and two fi rm mersileen sutures are attached to it. The surgeon uses his index fi nger to release the bursa subacromialis from the proximal part of the humerus and creates a passage posterior of the humerus for the teres to pass thru. The sutures are guided thru the passage. The humeral head is located and two anchors are attached; one on the location of the supraspinatus insertion on the greater tuberculum and one just below the fi rst one. The sutures on the teres major are used to attach the teres major tendon to the anchors in the humerus to obtain a fi rm fi xation. The wound is closed in layers. The operation was carried out by our very experienced orthopedic surgeon (PMR).

Model SimulationThe Dutch Shoulder model is a biomechanical model, which calculated muscle forces to meet moment equilibrium and stability constraints. The model also calculates the potential moment vector (PMV), which combines the effect of muscle moment arm and force direction. [20] The muscles contribution around the three axes of rotation of the glenohumeral joint can be interpreted using the PMV.

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Resultsthe operative procedure caused no complications. Clinical assessment took place 14 months after surgery. Post operative care consisted off an exorotation/abduction pillow in order prevent any teres major shortening during immobilization. The operated arm was immobilized for a period of 8 weeks for the newly fi xation of the teres major to get strengthened. After this period, physical therapy started with guided semi-active arm movements.

Figure 2. Principal Teres Major activation of patient suffering a massive rotator cuff tear. Both pre-and post operative maximum teres major activation was found during upwards force exertion. The grey triangles indicate the 95% confi dence interval for the direction of maximum activation (principal action), as measured in healthy subjects (Meskers et al., 2004). The circles describe the range of activation, while the thicker line points out the direction of maximum activation.

After surgery the patient reported less pain on a Visual Analogue Scale (-57 mm), and scored higher on the Constant Score (+34). Maximum abduction and antefl exion elevation increased (+32.7o and +39.3o), as did maximum external rotation of the humerus (+23.1o). The applied external force in all direction could be increased (factor 2) and external rotation arm force increased signifi cantly (+5.1N). The principle action methodology revealed both pre-and post operative teres major co-activation during upwards force exertion (Figure 2).

DiscussionLike Celli [21] and Pearle et al., [22] we experienced no diffi culties in splitting the teres major in order to perform an isolated transfer; the length

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of the teres major turned out to be suffi cient to allow its reinsertion on the greater tubercle; the thickness of the tendon did not hazard impingement of the subacromial tissues and the surgical procedure could be carried out without risking to damage the neurovascular tissues. Post operative pain as reported on a VAS-scale decreased and functionality as reported by the Constant-score increased. Active range of motion in terms of forward fl exion, abduction elevation and external rotation increased as did maximum exerted arm force. So we found functional improvement after a teres major tendon transfer in our patients suffering a massive rotator cuff tear. But what is the underlying mechanism which explains this restoration of functionality?

The increased external rotation force, necessary for active arm elevation [23] might explain the improved functional outcome for some part. However, based on the observed changes in the directions of maximum muscle activation (principal action) compared to healthy controls it is plausible that an alternative mechanism of co-contraction is at work. [24]To increase our perception in this mechanism we need to be cognizant of normal rotator cuff muscle function. These are twofold;

Firstly the synergistic function implies that the cuff muscles generate –moments to move the humerus in support of the prime movers. Secondly, the antagonistic function, which implies that the muscles co- –activate to exert forces which stabilize the glenohumeral joint. This stabilizing function of the rotator cuff muscles has its origin in the relative small moment arms around the glenohumeral joint. This enables them to produce relative large forces which compress the humeral head to the glenoid cavity, without generating large antagonistic moments.25;26 In other words, rotator cuff activity can stabilize the glenohumeral joint during arm elevation by co-contraction, without interference with the intended elevation moment.

In addition to the rotator cuff muscles, any muscle that crosses the glenohumeral joint can contribute to mobility (moment production) and to stability (force production). When the complex interplay between the shoulder muscles is compromised, the balance between mobility and stability in the shoulder is upset; this may initiate subsequent functional limitations caused by compensating mechanisms. In the case of our massive rotator cuff tear

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the lost function of the supraspinatus is taken over by the deltoids, resulting in an increased upwards directed force on the humeral head. The stabilizing cuff force dissipation entails the patients to be incapable of stabilizing the glenohumeral joint anymore, which has become even more diffi cult because of the increased deltoid activity. Corporately, this results in an increased proximal migration of the humeral head and a (painful) inclination of the subacromial tissues. In an attempt to prevent this painful inclinations patient’s appeal to other muscles to compensate for the lost stabilizing, humeral head depressing forces. [27]

We observed co-activation of the teres major during upwards force exertion, which indeed is suitable to pull down the humeral head and stabilize the glenohumeral joint. However, it is in confl ict with the intended abduction moment, resulting in a pre-operative limitation in arm elevation and maximum arm force, demonstrated by our pre-operative data. In other words, there is a confl ict between glenohumeral stability and arm mobility; stability is preserve at the cost of mobility. This confl ict can be solved by transferring the teres major. To maintain the stabilizing downward force on the humeral head, but to undo the eminent arm adduction moment, the teres major tendon transfer to the insertions of the supraspinatus on the tuberculum major proved to be an adequate solution.

This is illustrated by the potential moment vector, calculated by the Dutch Shoulder Model using a cadaver data set and an arm position of the experimental set-up as an input. Pre-operative the teres major has a potential contribution to retrofl exion, adduction en endorotation as can be seen in the projections on the three axes of rotation of the glenohumeral joint (Figure 3a). So when active it can pull down the humeral head, but it counteracts with the intended elevation moment. After transfer, the teres major has a potential contribution to forward fl exion, abduction, and exorotation (Figure 3b). It can still pull down the humeral head, but it does not interfere with the intended elevating moment anymore. Pre-operative, teres major co-contraction constrained maximum arm elevation, while this same co-activation pattern supported arm elevation post-operative. The transferred teres major can compensate for stability by delivering downward forces on the humeral head. And it can do so without the adverse depressing moment production. The confl ict between mobility and stability is solved!

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Figure 3. Potential moment vector plot of the teres major illustrates the muscles potential contribution to the external moment a. pre-teres transfer and b. post-teres transfer

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LITERATURE

B. Jost, C.W. Pfi rrmann, C. Gerber, and Z. Switzerland, “Clinical outcome after 1. structural failure of rotator cuff repairs,” J. Bone Joint Surg. Am., 2000, 82: 304-314.R.H. Cofi eld, “Rotator cuff disease of the shoulder,” J. Bone Joint Surg. Am., 1985, 2. 67: 974-979.R.A. McCabe, S.J. Nicholas, K. D. Montgomery, J.J. Finneran, and M. P. McHugh, 3. “The effect of rotator cuff tear size on shoulder strength and range of motion,” J. Orthop. Sports Phys. Ther., 2005, 35: 130-135.F. Postacchini and S. Gumina, “Results of surgery after failed attempt at repair of 4. irreparable rotator cuff tear,” Clin. Orthop. Relat Res., 2002, 332-341.C. Gerber, B. Fuchs, and J. Hodler, “The results of repair of massive tears of the rotator 5. cuff,” J. Bone Joint Surg. Am., 2000, 82: 505-515.L. Celli, C. Rovesta, M.C. Marongiu, and S. Manzieri, “Transplantation of teres major 6. muscle for infraspinatus muscle in irreparable rotator cuff tears,” J. Shoulder. Elbow. Surg., 1998, 7: 485-490.C. Gerber, T.S. Vinh, R. Hertel, and C.W. Hess, “Latissimus dorsi transfer for the 7. treatment of massive tears of the rotator cuff. A preliminary report,” Clin. Orthop., 1988, 51-61.A. Miniaci and M. MacLeod, “Transfer of the latissimus dorsi muscle after failed repair 8. of a massive tear of the rotator cuff. A two to fi ve-year review,” J. Bone Joint Surg. Am., 1999, 81: 1120-1127.R.H. Cofi eld, “Subscapular muscle transposition for repair of chronic rotator cuff 9. tears,” Surg. Gynecol. Obstet., 1982, 154: 667-672.S.E. Karas and T.L. Giachello, “Subscapularis transfer for reconstruction of massive 10. tears of the rotator cuff,” J. Bone Joint Surg. Am., 1996, 78: 239-245.J.J. Warner and I.M. Parsons, “Latissimus dorsi tendon transfer: a comparative analysis 11. of primary and salvage reconstruction of massive, irreparable rotator cuff tears,” J. Shoulder. Elbow. Surg., 2001, 10: 514-521.M. Aoki, K. Okamura, S. Fukushima, T. Takahashi, and T. Ogino, “Transfer of latissimus 12. dorsi for irreparable rotator-cuff tears,” J. Bone Joint Surg. Br., 1996, 78: 761-766.D.J. Magermans, E.K. Chadwick, H.E. Veeger, F.C. van der Helm, and P.M. Rozing, 13. “Biomechanical analysis of tendon transfers for massive rotator cuff tears,” Clin. Biomech. (Bristol. , Avon. ), 2004, 19: 350-357.D.J. Magermans, E.K. Chadwick, H.E. Veeger, P.M. Rozing, and F.C. van der Helm, 14. “Effectiveness of tendon transfers for massive rotator cuff tears: a simulation study,” Clin. Biomech. (Bristol. , Avon. ), 2004, 19: 116-122.F.C. van der Helm, “A fi nite element musculoskeletal model of the shoulder mechanism,” 15. J. Biomech., 1994, 27: 551-569.C.R. Constant and A.H. Murley, “A clinical method of functional assessment of the 16. shoulder,” Clin. Orthop. Relat Res., 1987, 160-164.C. . Meskers, H.M. Vermeulen, J.H. de Groot, F. C. Der Helm, and P.M. Rozing, “3D 17. shoulder position measurements using a six-dgree-of-freedom electromagnetic tracking device,” Clin. Biomech. (Bristol. , Avon. ), 1998, 13: 280-292.J.H. de Groot, L.A. Rozendaal, C.G.M. Meskers, and H.J. Arwert, “Isometric shoulder 18. muscle activation patterns for 3-D planar forces: A methodology for musculo-skeletal model validation,” Clinical Biomechanics, 2004, 19: 790-800.C.G.M. Meskers, J.H. de Groot, H.J. Arwert, L.A. Rozendaal, and P.M. Rozing, 19. “Reliability of force direction dependent EMG parameters of shoulder muscles for clinical measurements,” Clinical Biomechanics, 2004, 19: 913-920.

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H.E. Veeger and F.C. van der Helm, “Shoulder function: The perfect compromise 20. between mobility and stability,” J. Biomech., 2007.L. Celli, C. Rovesta, M.C. Marongiu, and S. Manzieri, “Transplantation of teres major 21. muscle for infraspinatus muscle in irreparable rotator cuff tears,” J. Shoulder Elbow Surg., 1998, 7: 485-490.A.D. Pearle, B.T. Kelly, J.E. Voos, E.L. Chehab, and R.F. Warren, “Surgical technique 22. and anatomic study of latissimus dorsi and teres major transfers,” J. Bone Joint Surg. Am., 2006, 88: 1524-1531.M. Stokdijk, P.H. Eilers, J. Nagels, and P.M. Rozing, “External rotation in the 23. glenohumeral joint during elevation of the arm,” Clin. Biomech. (Bristol. , Avon. ), 2003, 18: 296-302.J. . de Groot, M.A. van de Sande, C.G. Meskers, and P.M. Rozing, “Pathological Teres 24. Major activation in patients with massive rotator cuff tears alters with pain relief and/or salvage surgery transfer,” Clin. Biomech. (Bristol. , Avon. ), 2006, 21 Suppl 1: S27-S32.S. Lippitt and F. Matsen, “Mechanisms of glenohumeral joint stability,” Clin. Orthop. 25. Relat Res., 1993, 20-28.F.A. Matsen, III, D.T. Harryman, and J.A. Sidles, “Mechanics of glenohumeral 26. instability,” Clin. Sports Med., 1991, 10: 783-788.F. Steenbrink, J.H. de Groot, H.E. Veeger, C.G. Meskers, M.A. van de Sande, and P.M. 27. Rozing, “Pathological muscle activation patterns in patients with massive rotator cuff tears, with and without subacromial anaesthetics,” Man. Ther., 2006, 11: 231-237.

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CLINICAL IMPLICATIONS OF ROTATOR CUFF DEGENERATION IN THE RHEUMATOID SHOULDER

M.A.J. van de Sande, J.H. de Groot and P.M. Rozing

ObjectiveIn Rheumatoid Arthritis (RA) disease of the shoulder loss of cartilage and soft tissue degeneration co-exists with pain and reduction of range of motion. In this study we evaluate the presence of bony and rotator cuff degeneration in RA of the shoulder joint and assess their relation with pain and loss of function. We hypothesized that rotator cuff degeneration plays an important role in presence of pain and function-loss of the rheumatoid shoulder.

MethodsTo test this hypothesis a cross-sectional study was set-up to assess both bony and rotator cuff involvement using plain AP-radiographs, ultrasound and CT-images. In addition we used an electromagnetic tracking device and a force transducer to evaluate the Range of Motion and the maximum force of the shoulder muscles. Between January 2003 and July 2004 we included 26 consecutive patients (51 shoulders) 21 showed no or slight joint destruction, 15 were intermediate and 15 severe.

ResultsOnly 19 shoulders showed an intact rotator cuff. Proximal migration of the humeral head and especially fatty degeneration of the infraspinatus showed a signifi cantly strong correlation with increased pain and function loss.(R2 0.36 p< 0,001) In a multivariable-regression-analysis proximal migration and fatty degeneration of the infraspinatus muscle, were most signifi cantly related with the amount of pain and function in the shoulder joint.

ConclusionsOur results support the view that rotator cuff degeneration plays an important role in the daily function of the rheumatoid shoulder. Prevention of rotator cuff degeneration may therefore play an important part in the treatment of the rheumatoid shoulder.

Michiel A.J. van de Sande, MD, PhD-student at the department of Orthopaedics, Leiden University Medical Center, Leiden, The NetherlandsJurriaan H. de Groot, PhD, Department of Rehabilitation, Leiden University Medical Center, Leiden, The NetherlandsPiet M. Rozing, MD, PhD, Professor and head of the department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands (ALS FOOTNOTE?)

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IntroductionRheumatoid Arthritis affects approximately 1% of the adult population and exhibits a chronic fl uctuating course that often results in progressive joint destruction, deformity and disability. [1] In the etiology of glenohumeral arthritis, shoulder involvement generally occurs late in the disease process and usually after other joints have manifested arthritic change. Any of four shoulder girdle articulations can be involved, but the glenohumeral joint is most frequently symptomatic. [2] Symptoms vary between patients, in etiology and intensity. Swelling, stiffness, pain, decreased strength and loss of range of motion are cited as most important. [3] Rheumatoid arthritis destruction of the shoulder is characterized by proliferative synovitis (pannus), which is capable of degrading bone and cartilage matrix within and around the joint capsule. Thus, it not only results in cartilage thinning and bone loss but also in soft tissue detachment and destruction (e.g. muscle atrophy, fatty infi ltration and tendonitis). Recent studies have reported that between 24-52% of all 50-year-old and older patients with rheumatoid arthritis of the shoulder joint have at least one large rotator cuff tear. [4;5] This might explain poorer functional results and signifi cantly more postoperative pain after shoulder arthroplasty in RA patients, compared to osteoarthritis. [6;7] In concordance with these results fatty degeneration of the rotator cuff proved a signifi cant predictor for inferior functional results after surgical rotator cuff tear repair. [8-10] In RA both bony and soft tissue involvement in the disease process have been related to increased pain and decreased range of motion and force in the shoulder joint. [3;7;11;12] However, no report is available about the individual contribution of joint and soft tissue destruction on pain, motion and force. Further, physical function was scored mainly using the Health Assessment Questionnaire, a qualitative measure for pain, range of motion, shoulder function and force. [13;14] No quantitative or individual measurements for pain, function and force of the shoulder were found in recent literature. However complex, this study was set up to evaluate the incidence and severity of joint destruction and rotator cuff degeneration in the rheumatoid shoulder. In addition we set out to assess the relation between shoulder joint degeneration and pain, range of motion and force. It was hypothesized that besides joint destruction, rotator cuff degeneration is also a relevant factor in the loss of function and force of the rheumatoid shoulder. Furthermore as rotator cuff degeneration

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and proximal migration of the humeral head were strongly correlated, [5] we hypothesized that proximal migration causing subacromial impingement signifi cantly relates to the amount of pain experienced.

Materials and MethodsTo test our hypotheses: bony and soft tissue involvement were assessed using plain AP-radiographs, CT-images and ultrasound. Shoulder motion was recorded by means of six-degree-of-freedom electromagnetic tracking and a force transducer to accurately evaluate the range of motion (RoM) and the nett maximum force about the glenohumeral joint. Between January 2003 and July 2004 26 consecutive patients with rheumatoid arthritis were included (51 shoulders). One shoulder was excluded due to insuffi cient clinical data, caused by a computer malfunction during RoM and force measurements. Patients were included after their treating physician had obtained bilateral AP-radiographs in the assessment their shoulder complaints. Final inclusion was based on the following criteria: (1) a clinical diagnosis of rheumatoid arthritis (RA) according to the “American Rheumatism Association criteria 1987” [15] (2) patients aged over 50 years of age. This age limit was chosen to impose the smallest risk from radiation exposure (effective dose 1.6 mSv, (EU guidelines)); (3) patient complaints of shoulder symptoms in at least one shoulder; (4) no prior trauma or surgery to the shoulder. The study had prior institutional review board approval. All patients were informed and provided signed informed consent. Six male and twenty female patients with an average age of 63 years (range: 50-81 yrs) participated in the study. The mean Constant score was 68 (95%-CI 35-88). [16] Forty-one shoulders were symptomatic (objective pain and loss of function) with a mean Constant score of 65.2. Ten shoulders were non-symptomatic (mean Constant score: 77.9). The mean interval between the diagnosis of RA and the CT scan was 13 years (range: 1-40 yrs).

Image analysisIn order to assess the bony and cartilage involvement of RA standard protocol anterior-posterior radiographs were taken of all patients in the supine position, slightly turned to image side (20°), and the arm in external rotation, palm facing forward. [17] Film-focus distance was measured at 115 cm and a 15 degrees cranio-caudal tilt was used to project the undersurface

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of the acromion perpendicular. This created an optimal approximation of the true anterior-posterior projection 90 degrees towards the glenohumeral joint (Figure 1). All radiographs were taken in a clinical setting in the presence of the principal investigator (MS) who controlled image quality and positioning. [5]

Figure 1. Approximated true A-P radiograph used to calculate the Upward migration Index (UI=CA/R) and the medial displacement (CG/R and CC’/R) and rank the Larsen score (here 4). A = undersurface acromion; C = center of the humeral head; R = radius of the humeral head; AH = acromiohumeral interval; G = medial articular surface of Glenoid, C’ most lateral border of the base of the coracoid process.

Proximal migration, an indicator for fatty degeneration of the rotator cuff muscles, [5] was measured using the Upward migration Index (UI = CA / R)[5;18] as the distance between the centre of the humeral head to the under surface of the acromion (CA) divided by the radius of the humeral head (R) (Figure 1). Subacromial space measurement using the UI was validated with CT-imaging. [19] The mean absolute difference between the upward migration index measured on AP radiographs and CT images was only 0.06 (SD 0.07), providing a difference smaller than 5% of the

19

mean upward migration index measured on CT reconstructions. Medial displacement, an indicator for cartilage loss, was measured as the distance between the centre of the humeral head to the most medial articular surface of the glenoid (CG) divided by the radius of the humeral head (R). [18] We also calculated the medial displacement compared to the coracoid process as the distance between the centre of the humeral head to the most lateral surface of the base of the coracoid process (C’) divided by the radius of the humeral head (R) as a measure for bone loss (Figure 1). [20] All radiographs were scored for progression of rheumatoid disease using the Larsen score.[21;22] (The Larsen score ranges from no to slight joint space narrowing: grade 0-1 to subchondral destruction; grade 3 to disappearance of original articular structure: 5)Subsequently, all shoulders were scanned using a Toshiba Aquilion 16-slice CT-scanner using a constant protocol and calibration technique. [23] Fatty degeneration was measured using the Mean Muscle Density (MMD). [24] Individual rotator cuff muscles were outlined manually, carefully excluding pixels containing subcutaneous / inter-muscular fat (Figure 2). A histogram was constructed from all voxels within the outlined region of interest in order to calculate the MMD of the rotator cuff muscles. The MMD is defi ned as the mean voxel intensity measured as the CT number within one outlined rotator cuff muscle in Hounsfi eld units. To correct for individual muscle-fat content, the MMD was divided by the body mass index (BMI) of the patient (normalised MMD = nMMD). [25] The MMD showed an interclass correlation coeffi cient for repeated measurements and interobserver measurements of 0.99 An ICC of 1 indicates that 99% of variation was caused by the difference between the patients.(23) The teres minor and infraspinatus muscles were analyzed together, as separation of these muscles has been proven very diffi cult and unreliable. [26]All shoulders were examined for rotator cuff pathology by an experienced musculoskeletal radiologist using ultrasound (Table 1). All rotator cuff muscles were screened for the presence of tendonitis, a small tear or a massive tear using standard ultrasonic methods. [27] Dinnes et al reported the pooled sensitivity of ultrasound in diagnosing full and partial-thickness tears was 0.87 and 0.67, respectively. [28]

20

Tabl

e 1.

Ave

rage

clin

ical

resu

lts in

rela

tion

to fo

r rot

ator

cuf

f pat

holo

gy; m

ean

(SD

).

Seve

rity

of F

atty

Infi l

trat

ion

of

Supr

aspi

natu

s mus

cle(

5)Se

veri

ty o

f Fat

ty Infi l

trat

ion

of

Infr

aspi

natu

s mus

cle(

5)A

ll(n

=51)

No

tear

(n =

39)

Supr

a-sp

inat

us te

ar(n

=12

)

Infr

a-sp

inat

us te

ar(n

=3)

Abs

ent

(n=1

3)M

ild(n

=20)

Seve

re(n

=18)

Abs

ent

(n=1

2)M

ild(n

=29)

Seve

re(n

=10)

Pain

in re

st

(0-1

00)

21 (2.3

)20 (2.4

)27 (1.9

)51 (1.2

)13 (2.1

)12 (1.7

)37 (2.3

)12 (1.4

)19 (2.2

)40 (2.4

)Pa

in d

urin

g ac

tiviti

es(0

-100

)35 (2.8

)35 (2.8

)39 (2.9

)57 (3.1

)27 (2.7

)32 (2.9

)47 (2.7

)27 (2.6

)31 (2.6

)61 (2.6

)A

bduc

tion

(Deg

rees

)10

9(2

5.4)

114

(23.

6)10

7(2

7.0)

75(2

4.0)

124

(15.

4)11

4(1

1.5)

91(3

8.2)

121

(17.

2)11

2(2

0.6)

81(3

7.3)

Exte

rnal

rota

tion

(Deg

rees

)54

(25.

1)53

(23.

8)59

(23.

2)20

(21.

6)55

(23.

6)56

(16.

5)53

(13.

2)53

(19.

0)58

(16.

6)48

(11.

8)Fo

rwar

d fl e

xion

(Deg

rees

)10

5(2

4.2)

111

(19.

8)88 30.9

)74

(23.

6)11

4(2

6.2)

109

(13.

3)94

(32.

2)11

6(2

7.4)

107

(19.

9)86

(27.

5)M

axim

um fo

rce

for

abdu

ctio

n (N

/kg)

0.52

(0.2

0)0.

51(0

.20)

0.54

(0.1

8)0.

350.

01)

0.58

(0.2

5)0.

55(0

.17)

0.47

(0.1

7)0.

64(0

.17)

0.52

(0.1

6)0.

43(0

.26)

Max

imum

forc

e fo

r fo

rwar

d fl e

xion

(N/k

g)0.

52(0

.20)

0.53

(0.2

1)0.

47(0

.17)

0.40

(0.0

2)0.

43(0

.23)

0.60

(0.1

8)0.

43(0

.15)

0.54

(0.2

2)0.

56(0

.19)

0.38

(0.1

7)

21

Figure 2. Regions of interest for the Supraspinatus, the combined Infraspinatus and Teres minor and the Subscapularis muscles (SSp, ISp+TMI, SSc) on the parasaggital CT-images. SSp and ISp muscles. In this example a mild fatty degeneration is present (white arrows). (TMa: Teres Major)

Clinical analysisThe range of motion was measured using the six degree-of-freedom electromagnetic tracking device “Flock of Birds tm” (FoB) (Ascension Technology Inc., Burlington, VT, USA). This system consists of a transmitter, emitting an electromagnetic fi eld in which position and orientation of several receivers can be tracked. Prior to the measurements a fi eld calibration was performed. [29] Four receivers were applied around the patients shoulder: one was taped to the sternum; one was strapped to the upper arm, another to the wrist. The fi fth receiver was mounted on the fl at upper surface of the acromion, in the most latero-caudal corner. [30;31] The full active range of movement of the shoulder was measured. The skin-fi xed method was found suitable for dynamic recordings of scapular rotations as its intra observer RMSE was only 5°.The maximum force of the shoulder muscles was assessed using a six-degrees-of-freedom force transducer (AMTI-300, Adv. Mech. Techn., Inc., Watertown, MA, USA). Subjects were seated with the right arm in a splint

22

with the elbow in 90° of fl exion. The humerus was elevated 60° in the scapu lar plane (30° angle with the frontal plane). The forearm was positioned in a splint. The splint was attached to a 3D force transdu cer measuring the task force in an x-y plane perpendi cular to the longitudinal axis of the humerus. The arm was suspen ded in order to compensate for gravity. The force transdu cer was mounted on a sled so that it could move freely in the z-direction parallel to the humeral longitudi nal axis. Axial rotation of the humerus was mechanically not restric ted to prevent the subjects from generating supplementary moments. [32;33] The force exerted on the force transdu cer was displayed to the subject by a cursor on a video screen. The subjects were asked to generate a maximum force in 12 equidistant directions, 30o apart, by moving the cursor along the displayed spokes of a wheel that denoted the force direction and where concentric circles denoted the force magnitu de. The maximum force that could be exerted in all 12 directions was measured (e.g. forward fl exion 0o, abduction 120o). Force measurements were normalised for body weight.

Statistical analysisA student t-test was used to evaluate the differences in shoulder joint abnormalities within subgroups for the parameters presented above. All parameters were checked for outliers and were verifi ed to have a reasonably symmetric distribution. The modifi ed t-test for unequal variances was used in case the Levene’s test for equal variances was signifi cant.Multivariable linear regression analysis, Pearson and Spearman correlation were used to evaluate the relationship between bony and soft tissue involve-ment and the clinical parameters. Pearson’s correlation coeffi cient was used on variables measured on a ratio scale using actual values; Spearman’s Rank correlation was used only for ordinal or ranked data. For each outcome (function, force, pain) a multivariable linear model was constructed starting from a full model incorporating radiodiagnostic para-meters and using backward elimination of non-signifi cant predictors. The resulting model is then the “smallest” model for prediction of the outcome in the sense that deletion of any of the remaining predictors would signifi cantly reduce the predictive ability of the model. By dividing each beta (slope of the regression line) by the standard deviation of the associated independent variable in the data set, the coeffi cient mea-sures the effect on the outcome of one standard deviation (the unit of measurement becomes the standard deviation). Signifi cances are of course

23

not infl uenced by this linear transformation. This results in mutually comparable regression lines and emphasizes the individual reliability of the radiodiagnostic measures. Additional infl uences of age, sex, dominance, arm side and duration of rheumatoid disease were included in the analysis. All analyses were performed using SPSS for Windows version 14.0 (SPSS Inc. Chicago. Il. USA). Using a Bonferroni adjustment for our t-tests and correlation analysis, p-values smaller than 0,005 and 0,02 respectively were considered signifi cant.

ResultsClinical results and incidence of bony and soft tissue degeneration in the rheumatoid patient Results for pain, range of motion and force are subdivided for bony and rotator cuff degeneration and are presented in Tables 1 and 2.

Radiographic evaluation of bone destruction and cartilage losTwenty-one shoulders showed no or slight joint destruction (Larsen 0-1), 15 were intermediate (Larsen 2-3) and 15 severe (Larsen 4-5). The average Medial migration Index, a relative measure for cartilage loss, [18] was 1.08 (SD 0.17), median 1.05 (1st quartile to 3rd quartile Q1-3 = 0.95 – 1.18) relatively to the glenoid and 1.14 (SD 0.19), median 1.16 (Q1-3: 1.06 – 1.28) relatively to the coracoid process. The average Proximal Migration Index (UI), a relative indicator for rotator cuff pathology, [5] was 1.31 (SD 0.07), median 1,32 (Q1-3: 1.28 – 1.36). In 13 shoulders no proximal migration was observed (UI >1.35). In 26 shoulder moderate proximal migration (1.25 – 1.35) and in 12 shoulders severe proximal migration (UI ranging from 1 – 1.25) [5] was present.

Computed tomography analysis of rotator cuff qualityThe Mean Muscle Density divided by the BMI (normalised MMD = nMMD), a quantitative measure for fatty degeneration, [5] for the supraspinatus and infraspinatus muscles were subsequently 1.30 (SD 0.9) and 1.60 (SD 0.47). There was no signifi cant (cross) relationship between the BMI and the clinical parameters (pain, RoM and function of the shoulder). Fatty degeneration of the rotator cuff muscles is presented in three severity groups no (>1.74= Hounsfi eld units/BMI), mild (0.82-1.74) and severe fatty degeneration (<0.81). [5]

24

Tabl

e 2.

Ave

rage

clin

ical

resu

lts su

bdiv

ided

for r

adio

diag

nost

ic p

aram

eter

s, m

ean

(SD

))

All

(n=5

1)N

o pr

oxim

al

mig

ratio

n(n

= 1

3)

Mild

pro

xim

al

mig

ratio

n(n

=26

)

Seve

re

prox

imal

m

igra

tion

(n=1

2)

No

med

ial

disp

lace

men

t(n

=29)

Mod

erat

e-se

vere

med

ial

disp

lace

men

t(n

=22)

Lar

son

0-2

No-

Mild

de

stru

ctio

n(n

=29)

Lar

son

3-5

Mod

erat

e-

Seve

re

dest

ruct

ion

(n=1

5)Pa

in in

rest

(0-1

00)

21 (2.3

)15 (2.0

)16 (1.9

)39 (2.5

)20 (2.2

)26 (1.8

)18 (2.2

)29 (2.4

)Pa

in d

urin

g ac

tiviti

es(0

-10)

35 (2.8

)25 (2.6

)33 (2.7

)52 (2.8

)21 (2.2

)50 (2.7

)30 (2.5

)48 (3.2

)A

bduc

tion

(Deg

rees

)10

9(2

5.4)

113

(16.

9)11

8(1

8.0)

82(3

6.4)

123

(14.

8)11

5(2

2.6)

113

(25.

0)99

(30.

7)Ex

tern

al ro

tatio

n(D

egre

es)

54(2

5.1)

55(2

3.9)

56(1

5.4)

49(1

1.4)

39(1

1.7)

55(1

4.2)

58(1

6.2)

47(1

4.6)

Forw

ard fl e

xion

(Deg

rees

)10

5(2

4.2)

103

(24.

6)11

3(1

6.8)

89(3

3.8)

119

(15.

9)11

8(2

9.8)

108

(24.

7)98

(25.

4)M

axim

um fo

rce

in

abdu

ctio

n (N

/kg)

0.52

(0.2

0)0.

52(0

.10)

0.58

(0.2

0)0.

43(0

.22)

0.52

(0.1

9)0.

51(0

.20)

0.58

(0.2

0)0.

50(0

.19)

Max

imum

forc

e in

fo

rwar

d fl e

xion

(N/k

g)0.

52(0

.20)

0.52

(0.1

9)0.

58(0

.21)

0.39

(0.1

3)0.

58(0

.20)

0.52

(0.2

1)0.

60(0

.21)

0.47

(0.1

8)

25

Tabl

e 3.

Coe

ffi ci

ents

of d

eter

min

atio

n (R

2 ) be

twee

n cl

inic

al p

aram

eter

s and

bon

y / s

oft t

issu

e ab

norm

aliti

es (*

p< 0

,01,

**p

<0,

001)

Lar

son

scor

eM

edia

l di

spla

cem

ent

Prox

imal

m

igra

tion

Supr

aspi

natu

s te

arIn

fras

pina

tus

tear

Fatt

y infi l

trat

ion

of S

upra

spin

atus

mus

cle

Fatt

y infi l

trat

ion

of In

fras

pina

tus

mus

cle

Pain

in re

st0.

08*

0.03

0.2*

*0.

1*0.

12*

0.13

**0.

2**

Pain

dur

ing

activ

ities

0.1

0.19

0.12

*0.

130.

1*0.

030.

18**

Abd

uctio

n0.

11*

0.00

10.

24**

0.16

*0.

26**

0.24

**0.

38**

Exte

rnal

rota

tion

0.07

0.21

0.01

0.15

0.06

0.00

70.

007

Forw

ard fl e

xion

0.07

0.00

20.

080.

15**

0.25

**0.

13*

0.30

**M

axim

um fo

rce

in a

bduc

tion

0.01

0.01

0.05

0.01

0.05

0.03

0.12

*M

axim

um fo

rce

in fo

rwar

d fl e

xion

0.02

0.07

0.05

0.05

0.03

0.02

0.11

*

26

Ultrasound evaluation of the rotator cuff tendonsThe majority of shoulders showed rotator cuff pathology. Tendonitis was found in 20 supraspinatus, 22 infraspinatus and 13 subscapularis tendons. Six small tears were found in the supraspinatus tendon, 1 additional tear was found in the infraspinatus and subscapularis tendon. A massive tear was diagnosed in six supraspinatus and in two infraspinatus tendons.

The relation between radiographic parameters and functional resultsCoeffi cients of determination (R2) between radiodiagnostic and clinical parameters are presented in table 3. Proximal migration of the humeral head and especially fatty degeneration of the infraspinatus muscle showed the strongest correlation with increased pain and a decreased Range of Motion (abduction/forward fl exion). The maximum range of abduction (R2=0.25) and forward fl exion (R2=0.16) were also related to the amount of pain experienced.

The partial correlation between range of motion and fatty degeneration of the infraspinatus muscle, controlled for pain, remained relevant and signifi cant (R2=0.25 p<0.01). Bony deformation (Larsen score) was also correlated to the perception of pain, yet not as strong. The presence of an infraspinatus tear showed a stronger negative correlation with range of motion and pain, compared to an isolated supraspinatus tear alone. The combined correlation coeffi cients for all parameters presented in table 2 and 3 were: R2=0.44 for pain, R2=0.43 for abduction and R2=0.66 for abduction force (p< 0.001).

Results for the univariable regression analysis of pain, function and force (dependants) with bony and soft tissue parameters (independents) are presented in table 4. Using backward multivariable regression analysis for all parameters above, proximal migration and the mean muscle density of the infraspinatus muscle, were calculated as the strongest and most signifi cant predictors for the amount of pain and dysfunction in the shoulder joint. Proximal migration presented the most signifi cant infl uence on the amount of pain experienced (Beta -1; p=0.002). The mean muscle density of the infraspinatus muscle was the most signifi cant predictor for the amount of range of abduction (Beta 9.9; p=0.008) and forward fl exion (Beta 12,5;

27

p<0.0001). Further input of age, sex, side and duration of rheumatoid disease in this multivariable regression analysis revealed no confounders for the regression and correlation presented above.

We found a signifi cant relation between the Larsen score and fatty degeneration of the rotator cuff muscles. (R2 0.15, Beta 0.37 (p<0.001)) and also a signifi cant relation between the duration of the disease and pain in rest (Beta 1.2 (0.2/1.9). Yet, individually the Larsen score or the duration of rheumatoid disease were no relevant predictors for shoulder dysfunction in a linear regression analysis. We also found a signifi cant difference for the mean amount of joint destruction, according to the Larsen score, between early (0-2 years) and progressed rheumatoid disease (>2 years). A signifi cant difference for the mean amount of fatty degeneration of the rotator cuff muscles in early and progressed rheumatoid disease (mean difference 0.36 p =0.003) was also found.

DiscussionFunctional disability has been associated with pain, joint destruction and rheumatoid disease activity. [12;34] In the early stage of the disease functional ability may be infl uenced more by disease activity than joint destruction. [35] Also reports show a signifi cant relation between joint destruction and functional impairment later in the disease process. [34] However, in these studies pain and function loss were either measured subjective or by use of a questionnaire. [12;36] A quantitative comparison between pain, function (Range of Motion and force) and shoulder joint destruction has added value therefore. Primarily we set out to evaluate the incidence of bony and soft tissue abnormalities diagnosed using radiographs, computed tomography and ultrasound in the rheumatoid shoulder. Additionally we sought to determine the relation between these radiodiagnostic changes and clinically relevant parameters such as pain, range of motion and force.

Our results indicate a diverse involvement of bony and the rotator cuff degeneration in the rheumatoid shoulder. Although shoulder dysfunction and pain were related to multiple factors, we observed that rotator cuff quality in the rheumatoid shoulder predicted a distinct increase in pain and a signifi cant decrease of range of motion and force. Involvement especially of

28

the infraspinatus and teres minor muscles showed a relevant and signifi cant relationship with these clinical parameters. Although abduction and forward fl exion force are mainly the result of deltoid muscle contraction, shoulder muscle imbalance caused by fatty degeneration of the infraspinatus muscle causes the adductors to compensate for lost downward force resulting in a decreased total upward moment. We believe that pain and fatty degeneration of the infraspinatus / teres minor muscles can therefore both induce proximal migration due to imbalance of shoulder muscle forces and cause ‘secondary’ pain due to impingement or shoulder instability. [5;37] As fatty degeneration is thought irreversible early referral and treatment of shoulder involvement in rheumatoid disease may protect rheumatoid patients from this downward spiral. [12;37;38]

Clinical implicationsWe hypothesized above, that pain caused by RA (e.g. synovitis, swelling or cartilage loss) leads to shoulder immobilization and disuse. This may initiate fatty degeneration of the rotator cuff muscles, causing shoulder muscle imbalance, dysfunction and ‘secondary’ subacromial shoulder pain.

[37;40;41] Clinical reports on shoulder arthroplasty in rheumatoid patients have stated that they are referred too late for surgical treatment due to advanced shoulder joint destruction. [6;36] Kelly hypothesized a relationship between this late referral and the clinical course of rheumatoid disease. [6;36] Also, it has been stated that rheumatoid shoulders with a rapidly progressive joint destruction showed signifi cantly more rotator cuff abnormalities and that these were related to superior subluxation of the shoulder joint. [18;36] In accordance with these results we found a signifi cant relation between the bony destruction and rotator cuff involvement, as well as a signifi cant correlation between proximal migration of the humeral head and fatty degeneration of the rotator cuff. In particular, infraspinatus and teres minor degeneration was related to proximal migration. [6] As we found no signifi cant relation between the duration of rheumatoid disease and pain or function (RoM and force), it seems more likely that the severity of rheumatoid arthritis and not disease duration infl uences shoulder pain and function.

29

Tabl

e 4.

Uni

vari

able

regr

essi

on a

naly

sis b

etw

een

clin

ical

and

radi

odia

gnos

tic p

aram

eter

s. Th

e Be

ta (s

lope

) of t

he c

linic

al p

aram

eter

is p

rovi

ded

per

one

stan

dard

dev

iatio

n ch

ange

of t

he ra

dio-

diag

nost

ic p

aram

eter

. (*s

ignifi c

ant r

elat

ion)

Stan

dard

ized

Bet

a (+

/- 2

SD)

Lar

son

scor

e M

edia

l di

spla

cem

ent

(MM

I)

Prox

imal

m

igra

tion

(UI)

Fatt

y infi l

trat

ion

of

Supr

aspi

natu

sM

uscl

e (n

MM

D)

Fatt

y infi l

trat

ion

of

Infr

aspi

natu

s mus

cle

(nM

MD

)Pa

in in

rest

(0-1

00)

6.6*

(0.4

/13)

-1.6

(-

5/8)

-9.9

*(-

16/-4

)-8

.2*

(-14

/ - 2

)-9

.8 *

(-15

/ - 4

)Pa

in d

urin

g ac

tiviti

es (0

-100

)9.

1*(1

.3/1

9)-1

.1-2

.3/0

.6-9

.9*

(-18

/-2)

-13

(-13

/3.5

)-1

2*(-

19/-4

)A

bduc

tion(

0-18

0°)

-8.8

*(-

16/1

.2)

0.4

(-8/

8.5)

12.8

*(5

.6/2

0)13

*(6

/20)

16.6

*(1

0/23

)Ex

tern

al ro

tatio

n (0

-90°

)-4

(-9/

1)-7

(-20

/5)

1.9

(-4.

6/8.

6)2

(-6/

10)

1.4

(-4/

7)Fo

rwar

d fl e

xion

(0-1

80°)

-6.5

(-13

/0.5

)0.

8(-

7/9)

-7.1

(-3/

14.5

)9*

(2.1

-16)

13*

(7-2

0)M

axim

um fo

rce

in a

bduc

tion

(0-5

0 N

)-0

.1(-

0.8/

0.4)

-0.0

3(-

0.8/

0.7)

0.22

(-1.

8/1.

0)0.

16(-

0.03

/0.1

)0.

34*

(0.0

1/0.

13)

Max

imum

forc

e in

forw

ard fl e

xion

(0-5

0 N

)-0

.13

(-0.

9/0.

03)

-0.2

7(-

0.1/

0.04

)0.

22(-

0.2/

1.1)

0.13

(-0.

4/0.

1)0.

33*

0.01

/0.1

30

The presence of rotator cuff dysfunction, caused by fatty degeneration or tears, has been related to inferior functional results and increased pain after shoulder arthroplasty. [37;42;43] This may be explained by glenohumeral instability in rotator cuff defi cient patients. In massive rotator cuff tear patients compensatory co-contraction of the adductor muscles (teres major, latissimus dorsi) was measured. [40] It was hypothesized that this co-contraction prevents superior subluxation due to deltoid muscle forces in order to decrease subacromial pain. [40;41]

Limitations of this studyAs earlier reports suggested a signifi cant relation between of rheumatoid disease activity and functional performance [39] we included both sympto-matic and non-symptomatic shoulders. Although we did not analyze patients for disease activity using the DAS score, we could not reproduce the signifi cance of disease duration or clinical activity of the disease on shoulder dysfunction. In addition, we did not fi nd any correlation between duration of rheumatoid disease and pain, shoulder function, joint destruction or muscle involvement. Only two dimensional AP-radiographs were used to assess bony and cartilage destruction. Soft tissue degeneration as well as function and force measurement were measured with very high accuracy and reliability. Thus, it could be argued that the presented relationship between bony destruction and clinical parameters is questionable. Further evaluation of cartilage and bone loss is needed to evaluate its relation with synovitis, function-loss and pain. A relationship between soft tissue degeneration and cartilage loss also can be hypothesised as the result of shoulder muscle imbalance and increased proximal joint loading. Although only assessed by qualitative measures we did fi nd a signifi cant relation between the Larsen score and fatty degeneration. More accurate measurement of cartilage and bone loss may provide better insight on its relationship with pain and loss of function. Shoulder muscle force is thought related to pain. [40] Our results supported this relation as pain was signifi cantly correlated to abduction and antefl exion force (R2 =0.3). Although pain in rest and during activities was evaluated before and after force and range of motion measurement, pain measurement remains subjective. This may explain the difference between pain in rest and pain during activities (Table 3).

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Further more force measurement was only normalised for body weight, not for arm length (distance from GH joint to transducer on splint). Although we found decreased forces during abduction and forward fl exion in patients with severe supra- and infraspinatus degeneration, this relation was not found for mild degeneration. One could argue this difference originates from a less reliable measurement of force. However, we believe this difference supports our hypothesis that severe fatty degeneration of the rotator cuff muscles is related to subacromial impingement pain due to muscle imbalance and therefore relates to a decreased range of motion and loss of abduction force.

General conclusion:Though no causal relations were found, our results support the hypothesis that subacromial pain is induced by incapacity of the depressor muscles of the rotator cuff, as pain and range of motion are signifi cantly related to proximal migration and fatty degeneration of the infraspinatus en teres minor muscles. Prevention of rotator cuff involvement in rheumatoid disease of the shoulder may therefore lead to better functional results after shoulder arthroplasty. In already severe rotator cuff defi cient shoulders a transfer of the teres major muscle combined with shoulder arthroplasty (in either one or two sessions) may be used as a salvage procedure to give rheumatoid patients suffi cient pain relief and increased postoperative range of motion. [4;40]We believe it is of great importance to screen rheumatoid arthritis patients for shoulder involvement at an early stage, even if other joints are the cause for medical concern. As Proximal migration of the shoulder measured with the Upward Migration index is strongly correlated (R2 = 0.74) with rotator cuff disease an AP radiograph provides easy to use and reliable screening of the rotator cuff. [5] This study again underlines the importance of this measurement, as it was also strongly correlated to shoulder pain and functional parameters. Measurement of proximal migration at an early stage can therefore play an important role in timely initiation of functional and medicinal treatment of rheumatoid arthritis and may present patients with better possible outcome when shoulder arthroplasty is indicated.

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LITERATURE

Scutellari PN, Orzincolo C. Rheumatoid arthritis: sequences. Eur J Radiol 1998; 27 1. Suppl 1:S31-S38.Bennett WF, Gerber C. Operative treatment of the rheumatoid shoulder. Curr Opin 2. Rheumatol 1994; 6(2):177-182.Parsons IM, Campbell B, Titelman RM, Smith KL, Matsen FA, III. Characterizing the 3. effect of diagnosis on presenting defi cits and outcomes after total shoulder arthroplasty. J Shoulder Elbow Surg 2005; 14(6):575-584.Rozing PM, Brand R. Rotator cuff repair during shoulder arthroplasty in rheumatoid 4. arthritis. J Arthroplasty 1998; 13(3):311-319.van de Sande MA, Stoel BC, Rozing PM. Subacromial space measurement: a reliable 5. method indicating fatty infi ltration in patients with rheumatoid arthritis. Clin Orthop Relat Res 2006; 451:73-79.van de Sande MA, Rozing PM. Modular total shoulder system with short stem. A 6. prospective clinical and radiological analysis. Int Orthop 2004; 28(2):115-118.Hettrich CM, Weldon E, III, Boorman RS, Parsons IM, Matsen FA, III. Preoperative 7. factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg Am 2004; 86-A(7):1446-1451.Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Infl uence of cuff 8. muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 2003; 12(6):550-554.Goutallier D, Postel JM, Van Driessche S, Godefroy D, Radier C. Tension-free cuff 9. repairs with excision of macroscopic tendon lesions and muscular advancement: results in a prospective series with limited fatty muscular degeneration. J Shoulder Elbow Surg 2006; 15(2):164-172.Fuchs B, Gilbart MK, Hodler J, Gerber C. Clinical and structural results of open 10. repair of an isolated one-tendon tear of the rotator cuff. J Bone Joint Surg Am 2006; 88(2):309-316.Smith AM, Sperling JW, Cofi eld RH. Arthroscopic rotator cuff debridement in patients 11. with rheumatoid arthritis. J Shoulder Elbow Surg 2006.Breedveld FC, Han C, Bala M, van der HD, Baker D, Kavanaugh AF et al. Association 12. between baseline radiographic damage and improvement in physical function after treatment of patients with rheumatoid arthritis. Ann Rheum Dis 2005; 64(1):52-55.Hakkinen A, Kautiainen H, Hannonen P, Ylinen J, Arkela-Kautiainen M, Sokka T. 13. Pain and joint mobility explain individual subdimensions of the health assessment questionnaire (HAQ) disability index in patients with rheumatoid arthritis. Ann Rheum Dis 2005; 64(1):59-63.Ramey DR, Raynauld JP, Fries JF. The health assessment questionnaire 1992: status 14. and review. Arthritis Care Res 1992; 5(3):119-129.Clegg DO, Ward JR. Diagnostic criteria in rheumatoid arthritis. Scand J Rheumatol 15. Suppl 1987; 65:3-11.Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. 16. Clin Orthop 1987;(214):160-164.Lehtinen JT, Belt EA, Lyback CO, Kauppi MJ, Kaarela K, Kautiainen HJ et al. 17. Subacromial space in the rheumatoid shoulder: a radiographic 15-year follow-up study of 148 shoulders. J Shoulder Elbow Surg 2000; 9(3):183-187.Hirooka A, Wakitani S, Yoneda M, Ochi T. Shoulder destruction in rheumatoid arthritis. 18. Classifi cation and prognostic signs in 83 patients followed 5-23 years. Acta Orthop Scand 1996; 67(3):258-263.

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van de Sande MA, Rozing PM. Proximal migration can be measured accurately on 19. standardized anteroposterior shoulder radiographs. Clin Orthop Relat Res 2006; 443:260-265.Rozing PM, Obermann WR. Osteometry of the glenohumeral joint. J Shoulder Elbow 20. Surg 1999; 8(5):438-442.Larsen A, Dale K, Eek M. Radiographic evaluation of rheumatoid arthritis and related 21. conditions by standard reference fi lms. Acta Radiol Diagn (Stockh) 1977; 18(4):481-491.Paimela L, Laasonen L, Helve T, Leirisalo-Repo M. Comparison of the original and the 22. modifi ed Larsen methods and the Sharp method in scoring radiographic progression in early rheumatoid arthritis. J Rheumatol 1998; 25(6):1063-1066.van de Sande MA, Stoel BC, Obermann WR, Lieng JG, Rozing PM. Quantitative 23. assessment of fatty degeneration in rotator cuff muscles determined with computed tomography. Invest Radiol 2005; 40(5):313-319.Stoel BC, Vrooman HA, Stolk J, Reiber JH. Sources of error in lung densitometry with 24. CT. Invest Radiol 1999; 34(4):303-309.Goodpaster BH, Carlson CL, Visser M, Kelley DE, Scherzinger A, Harris TB et al. 25. Attenuation of skeletal muscle and strength in the elderly: The Health ABC Study. J Appl Physiol 2001; 90(6):2157-2165.Zanetti M, Gerber C, Hodler J. Quantitative assessment of the muscles of the rotator 26. cuff with magnetic resonance imaging. Invest Radiol 1998; 33(3):163-170.Farin PU, Kaukanen E, Jaroma H, Vaatainen U, Miettinen H, Soimakallio S. Site and 27. size of rotator-cuff tear. Findings at ultrasound, double- contrast arthrography, and computed tomography arthrography with surgical correlation. Invest Radiol 1996; 31(7):387-394.Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests 28. for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7(29):iii, 1-iii166.Meskers CG, Fraterman H, van der Helm FC, Vermeulen HM, Rozing PM. Calibration 29. of the “Flock of Birds” electromagnetic tracking device and its application in shoulder motion studies. J Biomech 1999; 32(6):629-633.Meskers CG, van de Sande MA, de Groot JH. Comparison between tripod and skin-30. fi xed recording of scapular motion. J Biomech 2006.Karduna AR, McClure PW, Michener LA, Sennett B. Dynamic measurements of three-31. dimensional scapular kinematics: a validation study. J Biomech Eng 2001; 123(2):184-190.Meskers CG, de Groot JH, Arwert HJ, Rozendaal LA, Rozing PM. Reliability of force 32. direction dependent EMG parameters of shoulder muscles for clinical measurements. Clin Biomech (Bristol , Avon ) 2004; 19(9):913-920.de Groot JH, Rozendaal LA, Meskers CG, Arwert HJ. Isometric shoulder muscle 33. activation patterns for 3-D planar forces: a methodology for musculo-skeletal model validation. Clin Biomech (Bristol , Avon ) 2004; 19(8):790-800.Clarke AE, St Pierre Y, Joseph L, Penrod J, Sibley JT, Haga M et al. Radiographic 34. damage in rheumatoid arthritis correlates with functional disability but not direct medical costs. J Rheumatol 2001; 28(11):2416-2424.Guillemin F, Briancon S, Pourel J. Functional disability in rheumatoid arthritis: two 35. different models in early and established disease. J Rheumatol 1992; 19(3):366-369.Kelly IG. Unconstrained shoulder arthroplasty in rheumatoid arthritis. Clin Orthop 36. 1994;(307):94-102.

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Williams GR, Jr., Wong KL, Pepe MD, Tan V, Silverberg D, Ramsey ML et al. The 37. effect of articular malposition after total shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement. J Shoulder Elbow Surg 2001; 10(5):399-409.Uhthoff HK, Matsumoto F, Trudel G, Himori K. Early reattachment does not reverse 38. atrophy and fat accumulation of the supraspinatus--an experimental study in rabbits. J Orthop Res 2003; 21(3):386-392.Drossaers-Bakker KW, de Buck M, van Zeben D, Zwinderman AH, Breedveld FC, 39. Hazes JM. Long-term course and outcome of functional capacity in rheumatoid arthritis: the effect of disease activity and radiologic damage over time. Arthritis Rheum 1999; 42(9):1854-1860.de Groot JH, van de Sande MA, Meskers CG, Rozing PM. Pathological Teres Major 40. activation in patients with massive rotator cuff tears alters with pain relief and/or salvage surgery transfer. Clin Biomech (Bristol , Avon ) 2006; 21 Suppl 1:S27-S32.Steenbrink F, de Groot JH, Veeger HE, Meskers CG, van de Sande MA, Rozing PM. 41. Pathological muscle activation patterns in patients with massive rotator cuff tears, with and without subacromial anaesthetics. Man Ther 2006; 11(3):231-237.Sanchez-Sotelo J, Cofi eld RH, Rowland CM. Shoulder hemiarthroplasty for 42. glenohumeral arthritis associated with severe rotator cuff defi ciency. J Bone Joint Surg Am 2001; 83-A(12):1814-1822.Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C, Cofi eld RH. Shoulder 43. arthroplasty for arthritis after instability surgery. J Bone Joint Surg Am 2002; 84-A(10):1775-1781.

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37

PRE-OPERATIVE PLANNING AND VIRTUAL SURGERY

P.R. Krekel

IntroductionWe describe a pre-operative planning system for shoulder arthroplasty, designed for the simulation of patient-specifi c bone-determined range of motion (ROM). The system enables surgeons to plan a shoulder replacement and get interactive feedback on the quality of their planning. In particular, it allows optimization of the placement with regards to ROM, thereby reducing the risk of impingement complications.In general, success rates for shoulder replacements are considerably lower than for knee and hip replacements, mainly due to the complexity of the shoulder anatomy. The small incision, combined with the density of muscles and ligaments, entail a limited fi eld of view for the surgeon and provide little space for maneuvering the instruments. The occurrence of malalignment due to a limited fi eld of view by the surgeon can be reduced by providing pre-operative knowledge of the patients’ shoulder state and by making this information available during surgery. This information is usually acquired using radiography and computed tomography (CT) scanning systems. We have created a pre-operative planning system which enables surgeons to effectively take advantage of the available image data. By using CT-data, we can simulate bone-determined ROM for the shoulder for a given planning. The prosthesis placement parameters can be adjusted interactively in our simulator, during which an intuitive visualisation technique depicts the differences between the current and previous planning with regards to ROM. This assists the surgeon in the complex decision-making process involved in shoulder arthroplasty.

MethodsThe standard technique for planning a shoulder replacement procedure is template-over-x-ray planning, which involves overlaying several transparent templates of different prostheses on radiographs of the shoulder to determine an appropriate prosthesis type and size. However, the radiographs lack

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spatial information along the view direction, leading to visual ambiguities that complicate the planning. Our pre-operative planning system improves on this by enabling the surgeon to simulate the surgery in 3-D.The patient-specifi c CT-data is segmented and converted to surface models. The planning stage corresponds with the actual procedure as it is being done at the Leiden University Medical Center. First, the center of rotation of the humerus is automatically calculated. Combined with the position of the glenoid, the resection plane through the humerus is determined. The plane can be manually adjusted, if necessary. The planning of the glenoid component is performed by means of point selection. After the planning stage is complete, we apply a simplifi ed biokinematic model to simulate ROM. A generally accepted hypothesis is that the gleno-humeral joint can be approximated by a ball-joint. ROM is predicted by systematically reorienting the humerus model, while using collision detection to check whether impingement restricts movement. The numerical results of these ROM simulations are visualised using envelopes. When the surgeon adapts the shoulder replacement procedure planning, the ROM simulations are updated interactively. The new ROM envelope is shown with the former ROM envelope. Using red and green surfaces we depict where ROM has deteriorated and where it has improved (see accompanying fi gure). The surgeon is then able to optimise his planning.

39

Figure 1. Range of motion envelope as depicted in our simulator. The planning of the surgery can be adjusted. While the planning changes, green surfaces show that ROM is improving, while red surfaces show that it is deteriorating.

ResultsThe pre-operative planning system was used by an expert (an orthopaedic surgeon) on multiple datasets. We received positive feedback on the interactively updated comparative visualisation, which was experienced as both fast and intuitive. Using the BrainLAB VectorVision navigation system, we have performed a pilot study to validate the ROM predictions of our simulator. Two cadaveric shoulders were scanned with a CT-scanner. Next, joint replacements were carried out by an orthopaedic surgeon. The base platforms of ESKA modular prostheses were installed, allowing us to quickly switch the type and sizes of the prostheses. This enabled us to experiment with multiple confi gurations, using only two cadaveric shoulders. Marker trees were fi xed to the bones, which were tracked by an infra-red camera system. With a pointing device, landmarks were selected on the bones and linked to the models in our pre-operative planning system. Subsequently, passive motion of the humerus could be tracked and visualised. We systematically analysed when impingement occurred during antefl exion, abduction and abduction-endorotation.

40

For both shoulders 53 motion recordings were performed, comprising a total of 106 measurements. The actual incidence of impingement generally corresponded to the impingement as shown by our simulator. However, registration was not perfect in all cases, resulting in visualisation errors. This can be ascribed to the diffi culty of landmark selection. Also, we measured the accuracy of the BrainLAB system with regards to marker tracking. The tip of the pointing device showed a standard deviation of 0.1, 0.05 and 0.25 in the x, y, and z directions respectively. This error is acceptable for our application, but does not leave much room for error in the registration process.

Figure 2 Experimental setup of the motion tracking system used for the cadaver study. The markes are attached to the bones and tracked by a camera system. Our software shows the CT-scanned bones and their relative position to each other.

DiscussionOur pre-operative planning system enables fast and effi cient planning of shoulder arthroplasty. In combination with the prediction of bone-determined

41

ROM, the system facilitates the planning process of shoulder replacement procedures. The simulator gives an approximation of the post-operative ROM and can be used to avoid impingement complications. The system we describe in this paper concerns bone-determined ROM, which provides feedback on the risk of impingement. We plan to extend this with information on the presence of muscle tissue, ligaments and cartilage. Alternatively, a model of these aspects can be used, such as the Delft Shoulder and Elbow Model (DSEM). [1] The DSEM is a complete musculoskeletal model of the shoulder and elbow joint that mainly focuses on muscle function and the involved forces and energy.The presented techniques are generic and applicable to other joints as well, such as the hip and knee joint. Based on the results from the pilot study, we aim to perform additional experiments for the validation of the ROM simulations.Finally, the pre-operative planning system will be linked to an intra-operative guidance system, which is also currently in development. As a result of this, the surgeon is able to easily perform the actual surgery in accordance with the pre-operative plan.

42

LITERATURE

F.C.T. van der Helm. A fi nite element musculo-skeletal model of the shoulder 1. mechanism. Journal of Biomechanics, 27(5):551–569, 1994.

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45

ELBOW ANATOMY AND SURGICAL MANAGEMENT OF RHEUMATOID ELBOW

C. Fontaine and G. Wavreille

Rheumatoid arthritis (RA) is a synovial disease, which can involve the synovial membrane of the elbow. Two kinds of operation can be performed: open or arthroscopic synovectomy, with or without redial head resection, and total elbow arthroplasty. Anatomical knowledge useful for understanding its pathophysiology and for such procedures is presented here.

1. Elbow jointsElbow gathers 3 different articulations in the same synovial cavity: 1) the humeroulnar joint, a hinge joint (ginglymus), allowing only fl exion-extension, 2) the proximal radioulnar joint, a pivot (trochoidal) joint, allowing only axial rotation (pronation-supination), and 3) the humeroradial joint, a ball and socket (spheroidal) joint, allowing theoretically 3 kinds of movements, but practically only two, fl exion-extension and pronation-supination.There is practically no normal mobility in the frontal plane (only about 5°) due to ligament laxity. Varus-valgus strains are absorbed by the collateral ligaments and the shoulder.This complex building has practical consequences for articular replacement. If the shoulder is stiff, shoulder replacement has to be performed fi rst, to prevent early loosening and/or collateral ligament damaging. Surgeons can choose between two major kinds of prostheses: 1) a simplifi ed joint in case of humeroulnar prosthesis and radial head resection (semi constrained prosthesis) and 2) a 3-compartment prosthesis, resurfacing the lateral compartment, but hard to build.

2. Mechanical strainsArm and forearm are not aligned in complete extension and show a carrying angle, whose value has been measured between 11° and 18°. This valgus angle has two pathophysiological consequences: 1) an excess of strains on the radial head and the ulnar collateral ligament, and 2) the fi rst involvement of the humeroradial joint at the early stage of the disease.

C. Fontaine1,2 and G. Wavreille1,2 1 Institute of Anatomy, Henri Warembourg Medical Faculty, Lille 2 University, Place de Verdun, F-59045 Lille, France2 Orthopaedic Department, Roger Salengro Hospital, University Hospital, Rue Emile Laine, F-59037 Lille, France (ALS FOOTNOTE?)

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Actually, despite one do not walk on the hands, compression forces cross the elbow. For example, in complete extension and in neutral position, the forces are quite equally transmitted by both the lateral and medial compartments (40%-60%). In valgus, the balance changes to 88%-12%, that overload the lateral compartment and stretches the medial collateral ligament. A radial head resection can lead to delayed consequences: the progressive weakening of the medial collateral ligament, as shown by Schemitsch et al. (1996).

3. Ulnar nerveBecause of the vicinity of ulnar nerve and elbow joint and of the carrying angle, elbow RA can have consequences on ulnar nerve. Ulnar nerve sensory or sensory and motor defi ciency is often present in case of elbow arthritis. It is due of course to the course of the ulnar nerve behind the medial epicondyle and to the stretching of the nerve if the carrying angle increases. When the patient complains of disturbances in the ulnar nerve area, he must think to elbow instability in valgus, due to medial collateral ligament laxity, spontaneous or favoured by a previous radial head resection. It can need an anterior transposition of the ulnar nerve and can infl uence the choice of elbow prosthesis.

4. Articular cavityIn average, the articular elbow cavity can contains 25-30 ml of synovial fl uid. In case of excess of fl uid, the painless position is about 80° of fl exion. When operating on a rheumatoid elbow, one always removes a great amount of synovial tissue at synovectomy.

5. Articular fi brous capsuleThe fi brous capsule is weak anteriorly and posteriorly, without important reinforcement, and it can be removed. There are two collateral reinforcements, the collateral ligaments, which must be kept as intact as possible.

5.1 Medial collateral ligament (MCL)It arises from the anterior inferior aspect of medial epicondyle. Its anterior bundle is the largest and the strongest (6mm x 6mm); one describe an anterior fascicle, extracapsular, cord-like, ending on a triangular surface at the medial aspect of the coronoid process, and a posterior fascicle, less

47

important. Its posterior bundle, 5-6 mm wide, ends on the medial aspect of olecranon. The whole medial collateral ligament is usually severed during arthroplasty, except the longest part of the anterior bundle.

5.2 Lateral collateral ligament complexIt is made of the annular ligament and the lateral collateral ligament.The annular ligament is inserted on the anterior and posterior borders of radial notch of ulna. Its deep aspect is covered by fi brocartilage. It is severed when performing the radial head resection or replacement.The lateral collateral ligament is made of two kinds of fi bres. The anterior lateral fi bres arising from the lateral epicondyle, spreading on the annular ligament; this pat is called the lateral radial collateral ligament (LRCL). The posterior fi bres form a strip which crosses over the annular ligament and ends on the ulna. Its terminal insertion, below the radial notch, on the supinator crest, is separated from the annular ligament by a triangular space; this part is called the lateral ulnar collateral ligament (LUCL). The LUCL is the only ligament which is not severed during arthroplasty.

6. Bone anatomy useful to prosthesis design6.1 Distal humerus The distal humerus shows an anteversion of 30°, responsible of the anterior projection of the articular surfaces, whose concentric arrangement of geometric centres of trochlea and capitulum is aligned with the anterior cortex of distal third of humeral shaft.The geometric centres of trochlea and capitulum are on a line which is not perfectly aligned with the axis of the humeral shaft. Both lines draw a 4-8° valgus angle in the frontal plane and a 3-8° medial rotation angle with the biepicondylar line in the transverse plane. It is important to respect or rebuild this anatomy while performing a non constrained prosthesis, in order to restore the collateral ligament isometry, to prevent early dislocation, wear and loosening.

6.2 Proximal radiusDuring pronation and supination, the radial tuberosity must pass through the narrow upper part of the interosseous space, without any contact with the ulna. To prevent such a contact, two mechanical strategies are possible:

48

1) The radial head is an oval whose great axis is the same as that of radial tuberosity, and cervicodiaphyseal angle is quite low; 2) The radial head is quite cylindrical, and cervicodiaphyseal angle is higher. Anatomical study have shown that both exist, that make diffi cult to build a 3-compartment prosthesis.

6.3 Trochlear notch of ulnaThe trochlear notch of ulna shows a sagittal angular value of about 180°. The great axis of its opening makes with the shaft axis a 30° angle in the sagittal plane, a 4° angle in the frontal plane. The height of its centre must be restored perfectly to restore the collateral ligament isometry. To open the ulnar medullary canal , the surgeon must work on the lateral half of the articular surface of the coronoid process.

7. Extensor apparatusTo perform an elbow total replacement, one must carefully manage the extensor apparatus. It is forbidden to cut the olecranon, because it should be impossible to rebuild it. The triceps can be cut transversely or in drawing a reversed V, or elevated subperiosteally from the olecranon, preserving its continuity with the antébrachial fascia, usually from medial to lateral.

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51

WRIST ANATOMY AND SURGICAL MANAGEMENT OF RHEUMATOID WRIST

C. Fontaine, G. Wavreille and V. Feipel

Rheumatoid arthritis (RA) is a synovial disease, which can involve both the synovial membrane of the wrist joints and the synovial sheaths of fl exor and extensor tendons. Anatomical knowledge useful for understanding its pathophysiology is presented here.

1. Joint anatomyIn the wrist regions, there are 3 synovial joints, theoretically independent one from another: 1) the distal radioulnar joint, 2) the radiocarpal joint, and 3) the midcarpal joint. They are normally transversely separated by 1) the distal radioulnar (DRU) articular disk, and 2) by the scapholunate and lunotriquetral interosseous ligaments. Therefore, at the beginning stages of the disease, rheumatoid arthritis can involve 1, 2 or 3 of these joints and require localized synovectomy. At advanced stages of the disease, the transverse separations between the 3 joints are most often perforated or completely ruptured. Therefore, at advanced stages, surgery must always involve the 3 joints in the same operation, including the DRU joint.Bony erosions are located at the points of insertion of the synovial membrane: ulnar styloid process, ulnar head, ulnar notch of radius, distal radius at the level of the scapholunate ligament, radial styloid process, scaphoid waist, etc.

2. Ligament anatomySynovitis weakens all the ligaments, specially the thinnest ones, and this is the main factor for joint instability in RA.

2.1 Radiocarpal and midcarpal ligamentsThe radioscapholunate ligament is made of connective tissue covered by synovium (Poirier’s fold) containing the end of the anterior interosseous vascular bundle; it arises from the volar border of radius, between scaphoid and lunate notches and ands on the proximal pole of scaphoid, the scapholunate

C. Fontaine1,2, G. Wavreille1,2 and V. Feipel3 1 Institute of Anatomy, Henri Warembourg Medical Faculty, Lille 2 University, Place de Verdun, F-59045 Lille, France 2 Orthopaedic Department, Roger Salengro Hospital, Universitary Hospital, Rue Emile Laine, F-59037 Lille, France 3 Department of Functional Anatomy, Faculty of Medicine, Free University of Bruxelles, Roure de Lennik 808, B-1070 Bruxelles, Belgium (als footnote?)

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interosseous ligament and anterior horn of lunate; it is vertical and deep to radiolunotriquetral ligament. When RA involves the synovium covering the radioscapholunate ligament, one sees an osseous cyst developing in the distal radius in front of the scapholunate ligament, at the anterior part of the carpal surface of radius. It can lead to the rupture of the scapholunate ligament.At the volar aspect of the wrist, fi brous capsule is reinforced by the volar radiocarpal and midcarpal ligaments, which draw 2 volar vertical “V” structures, arising from the anterior border of radius and DRU articular disk and ending on the anterior horn of lunate for the proximal volar “V”, and on the body of capitate for the distal volar “V”.At the dorsal aspect of the wrist, fi brous capsule is reinforced by the dorsal radiocarpal and midcarpal ligaments, which draw a unique dorsal horizontal “V” structure; all the dorsal ligaments converge toward triquetrum. Among them, the dorsal radiocarpal ligament (dorsal radiolunotriquetral ligament) fi ghts against ulnar translation of carpus.Weakening of the ligaments allows carpal gliding, following the global slope of the carpal surface of radius directed toward proximally and medially for 20-25°, proximally and anteriorly for 10-15°. This radial slope explains the spontaneous trend of carpus to glide proximally, ulnarly and volarly.This mediovolar gliding of carpus can lead to a total volar dislocation, with protrusion of the carpus in the carpal tunnel and chronic compression of the median nerve.Weakening of the dorsal ligaments allows carpal pronation, which enhances the impression of dorsal ulnar head dislocation.

2.2 Distal radioulnar stabilizationWeakening of the DRU stabilizers leads to dorsal ulnar head dislocation (or palmar dislocation of the distal radius). These stabilizers form the TFCC (Triangular Fibro-Cartilaginous Complex). It is made of many anatomical structures: 1) the DRU articular disc, 2) the volar and dorsal DRU ligaments, 3) the ulnocarpal ligaments, and 4) the ECU sheath. The DRU articular disc is a fi brocartilage inserted on the base of ulnar styloid process and the edge between carpal and ulnar articular surfaces of distal radius.

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The volar and dorsal DRU ligaments take their lateral insertion on the volar and dorsal borders of ulnar notch of radius, respectively, their medial insertion on the ulnar head, and their distal insertion on the broad peripheral border of the DRU articular disc.The extensor carpi ulnaris sheath is made of 2 laminae: 1) a deep proper sheath, adhering to the dorsal border of the DRU articular disc and to dorsal DRU ligament, and 2) the extensor retinaculum.

3. Synovial sheath of the extensor tendonsThe extensor tendons of wrist and fi ngers run in six dorsal compartments: 1) abductor pollicis longus (APL) and extensor pollicis brevis (EPB) in the 1st compartment; 2) extensor carpi radiales longus et brevis (ECRL & ECRB) in the 2nd compartment; 3) extensor pollicis longus (EPL) in the 3rd compartment; 4) extensor digitorum (ED) and extensor indicis proprius (EIP) in the 4th compartment; extensor digiti minimi (EDM) in the 5th compartment; 6) extensor carpi ulnaris (ECU) in the 6th compartment. Each of these six compartments is equipped with its own synovial sheath.Among these dorsal extensors, the more exposed to rupture are: 1) the extensor pollicis longus, that refl ects onto the dorsal tubercle of radius, and 2) the extensor digiti minimi, in case of dorsal dislocation of ulnar head. Because of the dorsal dislocation of ulnar head, irregular because of DRU synovitis, the Extensor digiti minimi, weakened by the 5th compartment synovial sheath, rubs on this irregular surface and ruptures. Its rupture can be entirely hidden by the extensor communis tendon to the little fi nger (when present, in 75% of cases). Its rupture is immediately visible when the EDM is the only extensor tendon to the little fi nger and there is only a weak intertendinous connection from the extensor communis tendon to the ring fi nger (in 25% of cases).

4. Synovial sheath of the fl exor tendonsThere are classically in the wrist region 3 tendon sheaths: 1) the tendon sheath of fl exor carpi radiales, 2) the tendon sheath of fl exor pollicis longus, and 3) the tendon sheath of fl exor superfi cialis and profundus. The tendon sheath of fl exor carpi radiales is rarely involves in RA.When RA involves the synovium covering the fl exor tendons, it weakens them. Those which rub against bony protrusions in the carpal tunnel are

54

the most exposed to rupture: 1) fl exor pollicis longus and fl exor digitorum profundus for the index fi nger an the radial side, against the protruded scaphoid tubercle, in case of scapholunate rupture, and 2) the fl exor tendons of the little fi nger in case of ulnar deviation of wrist, against the hook of hamate.

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56

57

SURGICAL OPTIONS IN ARTHRITIS OF THE WRIST

A. Lluch

Wrist joint deformitiesThe wrist consists of more than 13 joints which, from the functional point of view, can be grouped into three main joints: radio-carpal, midcarpal and distal radio-ulnar. The distal radio-ulnar joint is mainly designed to provide rotation of the distal radius around the ulnar head, allowing for pronation and supination of the forearm. Extension, fl exion, radial and ulnar inclinations of the wrist take place at the radio-carpal and midcarpal joints. Synovitis of the radio-carpal jointBecause the joint surface of the distal radius presents an anterior inclination of about 10º and an ulnar inclination of about 23º, the forces transmitted by the musculature of the wrist and fi nger fl exor tendons will tend to displace the carpal bones into an anterior and ulnar direction. To prevent this, the radiocarpal ligaments are obliquely oriented, running from radial-proximal to distal-ulnar.

Radio-carpal joint synovitis will cause capsular and ligament destruction, which leads to a progressive displacement of the carpal bones. Although the deforming forces are mainly in an anterior direction, anterior translation of the carpus is less commonly observed because the radio-lunate joint is more constrained in this plane due to the concavity of the distal radius. Only in those cases with acute and intense joint synovitis, causing severe ligament destruction, will the carpus be completely dislocated anteriorly, with the possibility of displacing the lunate bone a few centimeters proximal to the anterior edge of the distal radius. Most frequently, in cases of chronic and less intense synovitis, the carpus will progressively displace towards the ulnar side.

Synovitis of the midcarpal jointThe midcarpal joint is more constrained, and therefore deformities at this level are less important than at the radio-carpal joint.

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Synovitis of the distal radio-ulnar jointDistal radio-ulnar joint synovitis is very common in rheumatoid arthritis, causing attenuation of the radio-ulnar and ulno-carpal ligaments. Destruction of the radio-ulnar ligaments will cause dorsal dislocation of the distal ulna, mainly when pronating the forearm. Destruction of the ulno-carpal ligaments (ulno-lunate and ulno-triquetral) will cause the ulnar side of the carpus to displace anteriorly due to the forces transmitted by the fi nger fl exors, the fl exor carpi ulnaris and the anteriorly dislocated extensor carpi ulnaris tendons. This will also cause a supination deformity of the carpus, which clinically will appear more severe due to the dorsal displacement of the distal ulna. The frequent involvement of the distal radio-ulnar joint will be responsible for the loss of ulnar buttress to the carpus provided by the triangular fi brocartilaginous complex (TFCC), and therefore another reason to observe a greater ulnar than anterior displacement of the carpus in most rheumatoid wrists.

In summary, rheumatoid arthritis can produce the following deformities at the wrist.

Ulnar translocation of the carpus. 1. Anterior displacement of the carpus2. Supination deformity of the carpus3. Ulnar inclination of the metacarpals.4.

Following an observation made by Jules Shapiro in 1970, [1] it is commonly stated that wrist joint synovitis causes an ulnar inclination of the metacarpals. However, the truth is that wrist joint synovitis, regardless of its etiology, will always cause an ulnar inclination of the metacarpals. The radial inclination commonly observed in the rheumatoid hand is secondary to the ulnar inclination of the fi ngers at the metacarpo-phalangeal joint level. This is a volitional deformity, produced by the patient, in an attempt to align the fi ngers with the longitudinal axis of the forearm, to obtain a better digital function as well as appearance. [2;3]

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Treatment of radio-carpal and midcarpal jointsJoint synovectomySynovectomy of the radiocarpal and midcarpal joints is not done as frequently as indicated, due to the following reasons: it is technically diffi cult, causes joint stiffness and its results are sometimes deceiving. However, it has more advantages than disadvantages, as even an incomplete joint synovectomy and the ensuing postoperative joint stiffness will slow the destruction process. [4;5;6] (Figure 1).

Figure 1. Synovectomy of the distal radio-ulnar joint

Tendon transfersThe use of tendon transfers has been proposed to correct the radial inclination of the metacarpals and the supination deformity of the carpus., mainly at the same time a joint synovectomy or arthroplasty of the metacarpal joints is done. Transfer the ECRL tendon to the ECU tendon has been proposed to correct the radial inclination of the metacarpals. [7] In our opinion, it is diffi cult to measure the outcomes of this transfer as, from our experience, the radial inclination of the wrist tends to spontaneously correct after the ulnar drift of the fi ngers is corrected.

Correction of the supination deformity of the carpus is recommended, and several techniques can be used. Preserving the distal insertions of the ulno-triquetral and ulna-lunate ligaments, the ligaments are brought under tension

60

and sutured to the distal end of the ulna. The same can be done with a slip of a distally inserted ECU tendon. However, it seems easier to relocate the entire ECU tendon at the dorsum of the ulnar head with a sling made with the extensor retinaculum. [8]

Radio-scapho-lunate and radio-lunate arthrodesisThese procedures are recommended in those patients who have a progressive displacement of the carpus into an anterior and ulnar direction. (fi gure 2).

Radio-lunate arthrodesis, was fi rst described by Chamay and Della Santa. [9] A radio-lunate arthrodesis is preferred to a radio-scapho-lunate arthrodesis as more mobility of the midcarpal joint is preserved. A synovectomy of the midcarpal joint should always be done at the same time. [10;11]

Figure 2. Radio-lunate arthrodesis.

Total wrist arthrodesisIn cases of severe radio-carpal and midcarpal joint destruction, a total wrist arthrodesis should be considered, particularly in patients with important bone destruction and instability, as the long term results of an arthroplasty are more deceiving.

Position of wrist arthrodesisThe wrist should be fused in a neutral position, and some degree of ulnar inclination is preferable to radial inclination. When performing a bilateral

61

fusion, one of the wrists should be placed in slight fl exion to facilitate perineal cleaning. [12]

Methods of internal fi xation for the arthrodesisIn non rheumatoid patients, with good cortical bone and when the wrist fusion is being done as a single procedure, dorsal plate and screw fi xation is a good choice, using a low profi le and slightly curved plate. However, this technique is not recommended in rheumatoid patients as the dorsal skin is usually thinner and more friable, and the fi nger extensor tendons may be ruptured or weakened by the disease.

When the bone stock is not adequate for screw fi xation or to minimize surgical time, when multiple procedures are done in one stage, endomedulary fi xation with Steinman rods is recommended. Proximal fi xation is obtained with two intramedulary rods in the radius, and distal fi xation with the rods inside the index and middle fi nger metacarpals. In patients who have already had an implant arthroplasty of the MP joints, this technique may not be feasible. In these cases the distal rods will have to be placed through the carpal bones and in between the index and middle fi nger, and the middle fi nger and ring fi nger metacarpals. [13;14;15;16] (fi gure 3).

Figure 3. Total wrist arthrodesis stabilized with an endomedulary nail

Wrist arthroplastiesThere are two types of wrist implant arthroplasties: fl exible hinge silicone and rigid with two components.

In 1967 Swanson designed a silicone implant to replace the radio-carpal joint. [17;18] Silicone implants should be considered as spacers and provide good functional results as far as pain relief, correction of the deformity and maintaining or restoring joint mobility. However, fl exible silicone implants

62

do not withstand the forces transmitted across the wrist joint. With the passing of time, they subside into the distal carpal row, may rupture and cause cystic bone destruction due to foreign body granulomas to the silicone particles abraded from its surface, also known as “silicone sinovitis” or just “siliconitis”. [20;21;22;23;24] Clinical results are not always parallel to the radiographic fi ndings. (fi gures 4a and 4b).

Figures 4a and 4b. Swanson silicone implant with titanium grommets in A-P and lateral projections

The fi rst total wrist arthroplasty was done by Themistocles Gluck inn 1890, using a ball and socket implant made of ivory, which produced a chronic fi stula and was no longer used. [25]

Total wrist joint implants are made of polyethylene and metal components, and are fi xed in bone by porous stem fi xation, in growth, or screw fi xation with or without using with bone cement. There is a currently trend to move

63

to cementless fi xation of proximal components and screw fi xation of distal components in fused carpal bones. (fi gures 5a and 5b) (fi gures 6a and 6b). Controversy exists in the material of the articulating components (plastic on concave or convex side) and in the location of surfaces (cup distal or proximal), but all models except one (Meuli prosthesis) have developed from a ball and socket design to an ellipsoidal interface which simulates more normal wrist motions. [26;27;28;29;30;31;32;33;34;35;36;37;38;39;40;41;42;43;44]

Figures 5a and 5b. Severe wrist destruction in AP and lateral projections

64

Figures 6a and 6b. Universal Total Wrist in the AP and lateral projections

The proximal component of the wrist implant is placed in the medulary cavity of the distal radius, which will be well supported by cortical bone. However, the distal component, although it may have some metacarpal anchoring, is mainly supported by the distal carpal row, which consists of cancellous bone, as well as intercarpal and carpo-metacarpal joints with more or less ongoing synovitis. This is the most contributing factor to subsidence and loosening of the distal component. When an implant arthroplasty is performed in cases where the distal carpal row is relatively well preserved, an intercarpal synovectomy and bone fusion is recommended, with the addition of an abundant intercarpal bone graft, so as to obtain a solid fi xation of the distal component.

Indications for wrist arthrodesis and wrist arthroplastiesWhen both radio-carpal and midcarpal joints are destroyed by the arthritic process, only two surgical alternatives can be considered: arthrodesis or arthroplasty. Correction of the deformity and pain relief can be obtained

65

by either procedure. Many surgeons recommend a wrist artrodesis because it is reliable and technically relatively easy. Conversely, arthroplasty has historically been fraught with complications, primarily loosening. For this reason, wrist arthroplasty is not recommended for patients with high mechanical demands on their wrists, such as those who use crutches or walkers or who would like to perform sports activities. Although patients who undergo an arthrodesis, may adjust to the loss of wrist mobility, they prefer a functional arthroplasty over a wrist fusion.

The surgeon should let the patient decide which procedure he prefers to have done, after being fully and clearly informed of the advantages and disadvantages of each. Given the choice, most patients with rheumatoid arthritis would prefer to maintain or improve wrist mobility to compensate for the loss of function in the rest of the joints of the upper extremity. However, it is also the responsibility of the surgeon not to recommend an arthroplasty in certain patients.

There are no formal contraindications for an arthrodesis. On the other hand, before recommending an arthroplasty, the patient’s general condition and the characteristics of the wrist pathology should be carefully evaluated. An arthroplasty has more risk of mechanical failure in young patients, as well as in those who only have the wrist joint involved, or who need walking aids due to problems in their lower extremities. Rupture of wrist extensor tendons is also considered a contraindication for an arthroplasty, although it can be performed in certain cases, when the rupture occurred recently. The ruptured tendons can be repaired at the same time the arthroplasty is done, and should be immobilized postoperatively for a few weeks to allow healing of the repair. Simultaneous tendon repair should not be considered in those cases in which the implant requires immediate postoperative mobilization, as wrist fl exion may be limited after a prolonged immobilization in extension. In most cases it is diffi cult to know for how long the wrist extensor tendons have been ruptured, as frequently they suffer partial rupture and progressive elongation bridged by scar tissue. The degree of joint deformity and loss of passive wrist extension are other factors responsible for making the diagnosis of tendon rupture even more diffi cult. Long standing wrist extensor tendon ruptures are more diffi cult to treat, as not only the tendon gap is wider, but

66

the muscle fi bres undergo atrophy and retraction of its sarcomere, losing its capability to elongate and contract.Further considerations when considering an arthroplasty are the status of the skin in the dorsum of the hand and wrist, and the degree of destruction and instability of the carpal bones. If the skin in the dorsum of the wrist is extremely thin, scarred or adherent to deep structures, the risk of becoming necrotic or infected is much higher, seriously jeopardizing the functional outcome of an arthroplasty. Probably, the most important contraindication for a wrist arthroplasty is the destruction of the distal carpal row. In patients with a disintegrating type of disease, where the carpal bones and the intercarpal and carpo-metacarpal ligaments are destroyed, the risk of loosening of the distal implant component is high. (fi gures 7a and 7b) (fi gure 8). The proximal component of the wrist implant is placed in the medullary cavity of the distal radius, well supported by cortical bone. However, the distal component, although it may have some metacarpal anchoring, is mainly supported by the distal carpal row, which consists of cancellous bone, as well as intercarpal and carpo-metacarpal joints with more or less ongoing synovitis. This is a contributing factor to subsidence and loosening of the distal component. [45;46]

When an implant arthroplasty is performed in cases where the distal carpal row is relatively well preserved, an intercarpal synovectomy and bone fusion it is recommended, with the addition of an abundant intercarpal bone graft, so as to obtain a solid fi xation of the distal component.

67

Figures 7a and 7b. “Loose” wrist in the AP and lateral projections

Figure 8. “Stiff” wrist

68

Treatment of distal radio-ulnar jointJoint synovectomySynovectomy of the distal radio-ulnar joint is easier to perform than that of the radiocarpal and midcarpal joints and should be done more frequently. It is very important to perform a synovectomy of the ulno-carpal compartment simultaneously, to prevent attenuation of the ulno-carpal ligaments.

Excision of the head of the ulna (Darrach’s procedure)It is technically easy to perform and will provide quick postoperative relief of symptoms, mainly supination of the forearm. Increased ulnar translocation of the carpus has been a criticism for this procedure in rheumatoid hands, but it is probably mostly due to the attenuation of the radio-carpal ligaments from radio-carpal sinovitis. [47]

Distal radio-ulnar arthrodesis with proximal ulnar pseudoarthrosis (Sauvé-Kapandji’s procedure)This technique will provide excellent results, as fusion of this joint will prevent further deterioration of the radio-carpal and ulno-carpal ligaments, adding further stability to the wrist. In cases of complete dislocation of the ulna, this procedure will only offer the advantage of being a bone graft to the ulnar side of the distal radius, which can be useful for some cases of radio-lunate arthrodesis where there is little contact between the distal radius and the lunate bone.

69

LITERATURE

Shapiro JS. A new factor in the aetiology of ulnar drift. Clin Orthop 1970; 68: 32-43.1. Lluch A. Radial deviation of the metacarpals secondary to ulnar drift of the fi ngers in 2. the rheumatoid hand. Presented at the 49th Annual Meeting of the American Society for Surgery of the Hand. Cincinnati, Ohio. 1994.Lluch A: Aspects actuels du poignet rhumatoïde. Cahiers d’enseignement de la 3. SOFCOT. Amsterdam: Elsevier, 2000: 203-221. Allieu Y, Lussiez B, Asencio G : Résultats à long terme des synovectomies chirurgicales 4. du poignet rhumatoïde. A propos de 60 cas. Rev Chir Orthop 1989; 75: 172-178.Adolfsson L: Arthroscopic synovectomy of the rheumatoid wrist. A 3.8 year follow-up. 5. J Hand Surg 1997; 22-B: 711-713.Park MJ et al: Arthroscopic synovectomy of the wrist in rheumatoid arthritis. J Bone 6. Joint Surg 2003; 85-B: 1011-1015.Rowland SA. Stabilization of the ulnar side of the rheumatoid wrist, following 7. radiocarpal Swanson’s implant arthroplasty and resection of the distal ulna. Bull Hosp Joint Dis 1984; 44: 442-448.Tubiana R, Dumontier Ch, La synovectomie dorsale du poignet avec stabilization 8. tendino-ligamentaire. In : Traité de chirurgie de la main. Vol 5. Paris : Masson ; 1995. p. 405-425.Chamay A, Della Santa D, Vilaseca A : L’arthrodèse radio-lunaire facteur de stabilité 9. du poignet rhumatoïde. Ann. Chir. Main 1983; 2: 5-17.Borisch N, Haussmann P: Radiolunate arthrodesis in the rheumatoid wrist: a 10. retrospective clinical and radiological long-term follow-up. J Hand Surg 2002; 27-B: 61-72.Stanley JK, Boot DA: Radio-lunate arthrodesis. J Hand Surg 1989; 14-B: 283-287.11. Weiss AC, Wiedeman G Jr, Quenzer D, Hanington KR, Hastings H 2nd, Strickland 12. JW. Upper extremity function after wrist arthrodesis. J Bone Joint Surg 1995; 20-A: 813-817. Barbier O, Saels P, Rombouts JJ, Thonnard JL: Long term functional results of wrist 13. arthrodesis in rheumatoid arthritis. J Hand Surg 1999; 24-B: 27-31.Howard AC, Stanley D, Getty CJ: Wrist arthrodesis in rheumatoid arthritis. A 14. comparison of two methods of fusion. J Hand Surg 1993; 18-B: 377-380.Ishikawa H, Murasawa A, Nakazono K: Long-term Follow-up study of radiocarpal 15. arthrodesis for the rheumatoid wrist. J Hand Surg 2005; 30-A: 658-666.Mannerfelt L: New technique for arthrodesis of the wrist in the treatment of rheumatoid 16. arthritis. Technic not requiring external immobilization. Rev Chir Orthop Reparatrice Appar Mot 1972; 58: 471-80. Swanson AB: Flexible implant arthroplasty for arthritic disabilities of the radiocarpal 17. joint. A silicone rubber intramedullary stemmed fl exible hinge implant for the wrist joint. Orthop Clin North Am 1973; 4: 383-394.Swanson AB, de Groot Swanson G, Maupin BK: Flexible implant arthroplasty of the 18. radiocarpal joint: Surgical technique and long-term study. Clin Orthop 1984; 187: 94.Lluch A, Proubasta I: Les implants radio-carpiens de Swanson. Résultats à long terme. 19. La Main 1998; 3: 176-183.Lluch A. Flexible hinged silicone. In: Hand Arthroplasties. Eds: Simmen BR, Allieu Y, 20. Lluch A, Stanley J. London: Martin Dunitz, 2000: 193-2000. Allieu Y: First results of arthroplasty of the wrist by Swanson’s implant. Twenty-fi ve 21. cases. Ann Chir Main 1982; 1: 307-318.

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Fatti JF et al: The long-term results of Swanson silicone rubber interpositional wrist 22. arthroplasty. J Hand Surg 1986; 11-A: 166-175.Schernberg F: Arthroplasty of the rheumatoid wrist by silicone implants. Experience 23. with forty cases. Ann Chir Main 1983; 2: 18-26. Stanley JK, Tolat AR: Long-term results of Swanson silastic arthroplasty in the 24. rheumatoid wrist. J Hand Surg 1993; 18-B: 381-388.Ritt MJPF, Stuart PR, Naggar L, Beckenbaugh RD: The early history of arthroplasty of 25. the wrist. From amputation to total wrist implant. J Hand Surg 1994; 19-B: 778-782.Adams BD: Total wrist arthroplasty. Orthopedics 2004; 27: 278-84. 26. Alnot JY, Aubriot JH, Condamine JL, Feron F, Langlais F, groupe Guépar : L’arthroplastie 27. totale Guépar de poignet dans la polyarthrite rhumatoïde. Rev Chir Orthop 1988; 74: 340-345.Beckenbaugh RD, Linscheid RL: Total wrist arthroplasty: A preliminary report. J Hand 28. Surg 1977; 2: 337-344.Beckenbaugh RD: Implant arthroplasty in the rheumatoid hand and wrist: Current state 29. of the art in the United States. J Hand Surg 1983; 8: 675-678.Coob TK, Beckenbaugh RD: Biaxial long-stemmed multipronged distal components 30. for revision/bone defi cit total-wrist arthroplasty. J Hand Surg 1996; 21-A: 764-770.Courtman NH et al: Biaxial wrist replacement. Initial results in the rheumatoid patient. 31. J Hand Surg 1999; 24-B: 32-34.Dennis DA et al: Volz total wrist arthroplasty in rheumatoid arthritis: a long-term 32. review. J Hand Surg 1986; 11-A: 483-490.Dibelviss BJ, Sollerman C, Adams BA : Early results of the Universal total wrist 33. arthroplasty in rheumatoid arthritis.J Hand Surg 2002; 27-A: 195-204.Ferlic DC, Clayton ML: Results of CFV total wrist arthroplasty: review and early 34. report. Orthopedics 1995; 18: 1167-1171.Figgie MP et al: Trispherical total wrist arthroplasty in rheumatoid arthritis. J Hand 35. Surg 1990;15-A: 217-223.Goth D: Initial experience with the Meuli cementless total endoprosthesis of the wrist 36. joint. Handchir Mikrochir Plast Chir 1993; 25: 256-261. Menon J: Universal Total Wrist Implant: experience with a carpal component fi xed 37. with three screws. J Arthroplasty 1998; 13: 515-523.Meuli HC: Total endoprosthesis of the wrist joint using Meuli’s method. Aktuelle Probl 38. Chir Orthop 1977; 2: 49-57.O’Flynn et al: Failure of the hinge mechanism of a trispherical total wrist arthroplasty: 39. a case report and review of the literature. J Hand Surg 1999; 24-A: 156-160.Rahmintola ZO et al: Total modular wrist prosthesis: a new design. Scand J Plast 40. Reconstr Surg Hand Surg 2004; 38: 160-165.Rahmintola ZO et al: Preliminary results of total wrist arthroplasty using the RWS 41. Prosthesis. J Hand Surg. 2003; 28-B: 54-60.Vogelin E, Nagy L: Fate of failed Meuli total wrist arthroplasty. J Hand Surg 2003; 42. 28-B: 61-68.Volz RG: The development of a total wrist arthroplasty. Clin Orthop 1976; 116: 209-43. 214.Volz RG: Total wrist arthroplasty: A review of 100 patients. Orthop Trans 1979; 3: 44. 268.Lluch A : Aspects actuels du poignet rhumatoïde. Cahiers d’enseignement de la 45. SOFCOT. Amsterdam: Elsevier, 2000: 203-221.

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Lluch A. Indications for wrist arthrodesis vs arthroplasty. Report of the International 46. Federation of Societies for Surgery of the Hand. 2007.Rahimtoola ZO, Jansen SPL, Rozing PM, Nelissen RGHH. Radiographic changes after 47. resection of the distal ulna in rheumatoid arthritis. J Hand Surg 2004; 29B: 148-151.

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73

SURGERY OF THE WRIST IN RHEUMATOID ARTHRITIS

Z.O. Rahimtoola

SummaryFollowing a brief epidemiological introduction, a historical and contemporary overview of the treatment options of the rheumatoid wrist is presented. Surgical therapy of the radiocarpal joint is summarised, including discussion of soft-tissue procedures, partial and total wrist arthrodeses and total wrist arthroplasty.

The wrist and rheumatoid arthritisIn the early nineteenth century, Augustin Jacob Laudre Beauvais, a French medical student made the fi rst reference to an arthritic process resembling rheumatoid arthritis (RA). This was presented in his thesis entitled “Should we recognize a new type of gout to be called primary asthenic gout?”. [68] In 1859, Sir Alfred Baring Garrod introduced the term rheumatoid arthritis, a disease effecting multiple joints of the body, and yet distinctively different from gout or the more well-known rheumatic fever. [71] In 1987, the American Rheumatism Association provided revised criteria for the diagnosis of RA, of which a minimum of six weeks of swelling (arthritis) of the proximal interphalangeal (PIP), metacarpophalangeal (MCP), or wrist joints is one of the four clinical criteria required. [8] It was not until the turn of the 20th century that RA was considered a separate entity, and advances were made in reference to aetiology as well as treatment forms. [10.71]Today, RA represents the most common chronic infl ammatory joint disease. It has a prevalence of approximately 1% worldwide and an incidence of 0.03%. [3] It can develop at any age but has a peak onset between the ages of 30 and 60, and women are two to three times more likely to be affected than men.75 It is important to realize that RA is associated with a decreased life expectancy of almost three to ten years in both men and women. Factors implicated in this increased mortality are the chronicity of the synovitis, causing decreased functional activity and, a rheumatoid factor positivity. [3]

74

The wrist joint can be the initial manifestation of RA (2.4%) and the MCP joints, mainly those of the index and middle fi ngers, have a higher predilection (14.7%). The PIP and distal interphalangeal (DIP) joints are spared in the vast majority of patients and the right wrist is more commonly affected than the left. Initially, 30% of unilateral involvement is usually found, however, in 90% both wrists become symptomatic at some stage during the disease and 85% show evidence of radiographic changes. [18;32;59] Of all surgical procedures performed in a RA patient the wrist joint represents approximately 20 to 40%. [6] Synovitis is the underlying pathology that most commonly affects the distal radioulnar joint (DRUJ), frequently remaining asymtomatic, except for some discomfort during supination of the forearm. Chronic hypertrophic joint synovitis leads to the well-recognized deformities of the radiocarpal, ulnar-carpal and MCP joints. [6;41] For the RA patient the functional consequences can be devastating. The resultant instability, decreased mobility and pain make use of the hand diffi cult and may cause the characteristic deformities seen in the RA hand. Loss of a few degrees of wrist motion decreases the reach of fi ngers in space and may have consequences for patients with multi-level disease of the upper extremity. [64] For it is true, when questioned, patients will often refer to their wrist when asked what is the main problem they have in their hands. [6]Although the true aetiology of RA is unknown, improved understanding of RA and the biomechanics of the hand and wrist have provided us with an arsenal of surgical treatment options. There are fi ve basic surgical procedures performed in the RA hand and wrist: joint synovectomy, tenosynovectomy, tendon transfers, arthrodesis and arthroplasty. Nerve decompression could be added to this, which is often carried out in concert with one of the others. Although surgery has evolved in its role in preventing and correcting deformities it must be seen in conjunction with modern pharmacological management to decrease pain and prevent joint and tendon destruction. Ultimately, the treatment of the RA patient requires a multi-disciplinary approach remembering that each RA patient is unique, requiring individualized care from a broad therapeutic perspective.

75

Surgical management of the radiocarpal joint in RASynovectomy of the hand and wristThe recognition of synovial panni infi ltrating the soft-tissues of joints in RA has made synovectomy in the wrist a popular procedure, particularly when performed in the early stages of the disease. Dickson, in 1925, was the fi rst to perform a synovectomy in the hand, and Allison and Coonse subsequently proceeded in the wrist. [58] In the past, most controversy on the procedure centered around its indication, timing and prophylactic effect during the course of the disease, however, open tenosynovectomy of the wrist has gained widespread acceptance today and, may even be implicated in late stages. [23]Extensor tenosynovectomy, often combined with distal ulna resection, has proven its effects on pain relief with little consequence to motion. [6;18;23;41;42;48;67;72] Souter considers this procedure to be a “winner” having the highest success rates and reliable outcome when performed in the RA patient. [62] The recurrence of tendon synovitis and ruptures is rarely seen and good results are maintained long-term. [18;23;42;72] Radiographic progression of the disease at the level of the radiocarpal, mid-carpal and radioulnar joints has been noted, however, this is most likely due to the natural progression of the disease process itself, rather than the surgery performed. [23;72] Arthroscopic synovectomy has been proposed to overcome some of the disadvantages of conventional open surgery such as, post-operative stiffness and longer periods of rehabilitation. [2] Follow-up has been short (six months) and, as synovectomy is often combined with some form of treatment of the DRUJ, the role of the arthroscope in rheumatoid wrist surgery remains questionable. The post-operative stiffness of the wrist has been considered one of the drawbacks of open synovectomy. This inconvenience could, however, be of benefi t to the patient who may stabilise the wrist as a result of such stiffness and have less chance of developing further deformity. [41]Flexor tendon synovitis is more diffi cult to appreciate in clinical practice compared to the more commonly located dorsal involvement. Primary rupture of the extensor pollicis longus tendon at Lister’s tubercle of the distal radius and of the ring and small extensor digitorum communis tendons at the distal ulna head is a common fi nding. Similar damage can be found of the fl exor pollicis longus tendon and of the fl exor digitorum profundus tendon

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of the index fi nger from attrition against the tubercle of a fl exed scaphoid (Mannerfelt’s syndrome). [42] In some patients, pain in the wrist and hand is attributed to arthritis when the true aetiology is compression of the median nerve in the carpal tunnel due to fl exor tendon synovitis. Accurate history and physical examination is essential to elicit a possible classic carpal tunnel syndrome. Characteristic bogginess along the digital fl exor sheaths and functional examination of the digits may aid the diagnosis. Flexor tenosynovectomy may be technically more demanding than its counterpart but when performed well, success rates following surgery are similar to those found in the dorsal compartment. [17;23;42;43;67]Tenolysis and tenosynovectomy should be performed if symptoms do not resolve after an arbitrary four months of medical therapy in an attempt to prevent tendon ruptures and the less favorable results of delayed fl exor tendon repair. [50;63] Although extensor or fl exor compartment tenosynovectomy is a reliable procedure in alleviating symptoms due to synovitis, it should be remembered that disease progression is not prevented in the long-term. [23;72]

Partial (radiolunate and radioscapholunate) arthrodesis of the wristImproved understanding of the kinematics of the wrist involved in RA and the characteristic deformities that develop introduced the concept of partial arthrodesis of the wrist. The fundamental cause of deformity of the RA wrist is found in the instability of the lunate and scaphoid carpal bones and their articulation with the distal radius. It would, therefore, seem logical to stabilise this unit to allow the distal row of the carpus a fi rm buttress from which to function. This, together with evidence of the natural progression seen in some RA wrists, was the principle behind the Chamay radiolunate fusion. [16;17] Radiolunate arthodesis in the RA patient is indicated when localized radiolunate arthritis exists and there is some degree of volar and ulnar displacement of the lunate. The scaphoid fossa and mid-carpal integrity should, however, be maintained. [16;41;64] It has been further indicated in cases of wrist synovectomy combined with ulnar head resection, where carpal translocation exists in association with disruption of the DRUJ. [15;16;22] Chamay et al. [15] reported good short-term results on pain relief and function, which was about half the normal range. Similar results were documented in longer follow-up studies and according to most,

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approximately 35º of extension and 30º of fl exion is obtained. [5;22;38;41;65] Although radiographic progression of the disease at the mid-carpal level is not prevented, this procedure allows the RA patient some degree of pain-free function for, albeit, limited duration. When there is evidence of signifi cant radioscaphoid joint destruction in addition to radiolunate arthritis, a radioscapholunate arthrodesis is warranted. In such cases, the mid-carpal articulation is relatively spared and a considerable amount of fl exion of the scaphoid can occur. This protrusion of the scaphoid into the carpal tunnel, as mentioned above, may subsequently endanger certain fl exor tendons. Overall functional results are similar to radiolunate arthrodesis and motion remains within a range required for activities of daily living. Radial deviation can further be augmented by excising the distal pole of the scaphoid, which also improves mid-carpal mobility. [29;62;57] Alternatively, when the proximal pole of the capitate is destroyed, Taleisnik proposes combining the procedure with replacement of the capitate head using a silicone implant. [71]

Total arthrodesis of the wristIn 1918, Steindler described fusion of the wrist in patients suffering from polio and spastic hemiparesis. Its indication was further expanded to treat other conditions such as; tuberculosis, Volkmann’s ischaemic contracture, trauma and tumours. [49]Panarthrodesis of the wrist in RA produces a pain-free and stable wrist. Correction of deformity can be achieved, the pain diminishes and the arthritis stops. The procedure is indicated when there is such signifi cant bone destruction that any other form of treatment is unrealistic. A proximal row carpectomy and interpostional arthroplasty using autogenic fascia lata may be an alternative choice in the very active and younger population.1

Most destroyed and painful wrists are, however, best satisfi ed with total arthrodesis. Contraindication to total wrist arthrodesis is obviously in the patient who is not willing to lose function and has no pain. In the young patient, a limited intercarpal fusion may be considered or alternatively, wrist denervation can be attempted with caution to expected outcome. [25,73] Arthrodesis is further contraindicated in tetraplegics or quadriparetics who require wrist motion for passive function following tendon transfers.

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There are various methods of wrist arthrodesis consisting of, intramedullary fi xation (Mannerfelt Rush nail, Stanley pin, Steinman pin) and plate and screw osteosynthesis. [18;41;42;50] Most intramedullary devices transfi x the third metacarpal through the carpus to the distal radius. In certain cases, where future surgery of the metacarpal joints is envisaged, introducing the material from the radius to the third metacarpal is advised. Subsequent rotational control can be obtained by the use of kirschner wires placed obliquely between the radius and carpus. [41] The Stanley pin allows sinking into the third metacarpal bone and offers similar advantages. [66] Alternatively, a specially contoured osteosynthesis plate can be used in cases of failed total wrist arthroplasty with or without the use of bone graft. [11] Caution should be given to the primary use of plate osteosynthesis in the presence of severely osteopenic bone and complications of non-union, soft-tissue tenderness and tendon adhesion have been reported following its application. [34] Although the absence of mobility can be dramatic in a RA patient with multi-level arthropathy, the long-term results on pain relief and daily activity following this procedure are good and, most patients cope well even with bilateral arthrodesis. [9] Moreover, no statistical differences have been found in functional survey scores between two comparable groups of patients receiving arthrodesis and arthroplasty. [48] These fi ndings should be approached with caution, however, as the patient who has received an arthrodesis of one side and arthroplasty of the other will often give preference to the joint that has been replaced. [38] Most clinicians would agree that the position of arthrodesis of any joint should be as functionally restoring as possible. This is represented by approximately 15º of extension and 5º of ulnar deviation in the wrist joint. In a unilateral case of non-rheumatic wrist destruction this would be the most appropriate position of arthrodesis, thereby, conserving maximal grip strength. However, in a RA patient it may be advisable to fuse the wrist in a neutral position in unilateral disease or one wrist in slight fl exion in bilateral cases to allow for personal hygiene, with specifi c regards to perineal care. [33;41] It cannot be over-emphasized that in the RA patient one should carefully evaluate, preoperatively, the functional gain of any defi nite wrist position aspired, either in neutral, extension or fl exion alignments.

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Total wrist arthroplastyTotal replacement of a joint destroyed by disease or trauma can be traced back to Greek mythology where the demi-goddess Klotho replaced a shoulder of Pelops, the son of King Tantalus, after it had been eaten by Demeter. The new shoulder was made of ivory. [57] The concept of total wrist arthroplasty was introduced by Themistocles Gluck in 1890, coincidently using the same material to salvage a wrist destroyed by tuberculosis in a 19-year-old patient (Figure 1). Since then, prosthetic design and surgical technique have evolved to provide us with a range of prostheses for the treatment of radiocarpal arthritis. The fi rst-generation prosthesis developed by Swanson in 1973 consisted of a silastic fl exible implant. It provided initial good results but resulted in early failure due to implant fracture and/or foreign body reaction to silicone particles. The second-generation prostheses such as the Volz, the Meuli and the GEUPAR were introduced in the 1970s and consisted of separate radial and carpal components (Figure 2). Fracturing, loosening and soft-tissue imbalance have all reduced the success of these implants and explain why total wrist arthroplasty remains controversial in comparison to other total joint replacements. Newer third- and fourth-generation prostheses in the 1980s have been designed to respect the natural biomechanics of the wrist and attempt to maintain the normal centre of rotation, prevent soft-tissue imbalance and restore carpal height. [45;56] (Figure 3).

Figure 1. The Father of total wrist arthroplasty: Themistocles Gluck (1853-1942).

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Figure 2. First- second- and third-generation prostheses used in total wrist arthroplasty

81

Figure 3. The RWS (Rozing Wrist System Prosthesis).

Total wrist arthroplasty should be considered for the RA wrist when there is severe carpal destruction and partial arthrodesis is no longer an appropriate treatment form. Patients who are candidates for a total wrist arthrodesis, but in whom the loss of motion would increase their functional disability, should be offered the option of a total wrist implant. RA patients are suitable candidates because of their low demands and low levels of activity. The procedure remains very questionable and, possibly, contraindicated in patients who are suffering from osteoarthritic or post-traumatic arthritis and are engaged in heavy manual labour. Threatened premature loosening of the prosthesis in such individuals with subsequent loss of bone stock may disadvantage any salvage arthrodesis in the future. In such patients, primary total wrist arthrodesis may then be the preferred choice. When bilateral RA wrist involvement exists, arthroplasty of the dominant side and arthrodesis on the non-dominant side would seem the appropriate choice, however, the choice of surgical procedure should always be tailored to the patients level of activity. [19;26;52] Furthermore, it should be emphasized that patients often give preference to a mobile wrist when compared to the contralateral side, if having been fused. Contraindications for arthroplasty are: recent infection, gross bone destruction and severe ligamentous laxity, such as often seen in systemic lupus erythrematodes.Pain relief and improvement in range of motion are good after implantation

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of most of the prosthetic designs and there seems to be little deterioration with time unless the implant fails. [56] Disappointing clinical results have been found, however, when evaluating some of the fi rst-generation implants such as the Swanson silicone spacer. [26;40] Complication (i.e. loosening, fracturing) and revision surgery remains high when compared to arthroplasty of other joints in RA and tends to disfavor its application. Fixation of the distal carpal component is most commonly the cause of implant failure. [45;56] Restoration of the centre of rotation of the wrist and maintenance of carpal bony support with adequate fi xation techniques have been factors implicated in this failure. [26;45] Newer modular designs for primary and revision arthroplasty have been designed to address these issues, including treatment of the DRUJ. [54] (Figure 4). IS NOT SENT!

Figure 4. The TMW (Total Modular Wrist Prosthesis); note the optional components for the treatment of the distal radioulnar joint

83

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