1/32. Heterotopic ossification complicating total elbow replacement in a patient with rheumatoid arthritis.Heterotopic ossification after total elbow replacement is a new complication. In this particular case, it resulted in severe limitation of motion. Excision of the heterotopic bone resulted in an excellent functional outcome for the patient.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
2/32. Palmar shelf arthroplasty, the next generation: distraction/interposition for rheumatoid arthritis of the wrist.Rheumatoid arthritis affects approximately 1 percent of the adult population. Bilateral symmetric involvement of the wrist occurs in 85 percent of these patients, with recurrent flares and relentless progression. Anatomic changes consist of radiocarpal, intercarpal, and radioulnar subluxation and joint destruction. For advanced disease, both wrist arthrodesis and arthroplasty have been recommended. arthrodesis has been successful for pain relief at the expense of motion. Implant arthroplasty has been unreliable, with failure rates of 25 to 50 percent at 2 to 9 years. Palmar shelf arthroplasty was introduced in 1970 as a resectional fibrous arthroplasty. The results were good but the series was small. Subsequent reports of this procedure have been inconsistent. In 1990, I initiated and have since followed a series of patients treated with the palmar shelf arthroplasty. To the basic procedure, I added joint distraction by external fixator, collagen/bone wax interposition, scapholunate stabilization, and increased immobilization time. Fourteen consecutive patients were enrolled in this study. Each carried a diagnosis of rheumatoid or psoriatic arthritis of the wrist. There were 11 women and 3 men. Age ranged from 28 to 56 years. Follow-up ranged from 2 to 7 years (average 4.2). The patients were interviewed, examined, and x-rayed. A questionnaire using an analog scale as well as the Hospital for Special Surgery scoring system was completed to assess the clinical outcome of the wrist postoperatively compared with its preoperative status and with the contralateral wrist. No patient has requested or required a revision procedure. All patients experienced improvement with both pain and function; no wrist spontaneously fused. patient satisfaction was high. patients with ipsilateral arthroplasty and contralateral arthrodesis preferred the arthroplasty. Hospital for Special Surgery score increased from 53 to 91 out of 100 points (p < 0.001). Range of motion averaged 50 degrees flexion, 30 degrees extension. Palmar shelf arthroplasty remains a viable option for severe rheumatoid disease of the wrist. Ideally, the procedure is performed on the dominant wrist of a patient with bilateral wrist involvement in the setting of inflammatory arthritis.- - - - - - - - - - ranking = 2keywords = motion (Clic here for more details about this article) |
3/32. Case challenges in shoulder surgery: what would you do?The management of complex shoulder issues was discussed in an interactive case presentation session. Patient scenarios discussed included reoperation of a rotator cuff repair with a subscapularis tear; uncemented hemiarthroplasty presenting with pain and osteolysis; severe osteoarthritis with all nonoperative options exhausted; rheumatoid arthritis with pain and diminished function; and significant pain, limited motion, and weakness in an active patient.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
4/32. Spontaneous divergent elbow dislocation after Sauve-Kapandji procedure.This is a report on an unusual complication of the Sauve-Kapandji procedure in patients with rheumatoid arthritis. Two women with rheumatoid arthritis who previously had an ipsilateral Sauve-Kapandji procedure experienced spontaneous transverse divergent elbow dislocations without evident trauma. Their radiographs showed medial dislocation of the proximal ulna, which was separated from the radial head. The radial head and distal end of the ulnar shaft showed remarkable instability by a pronation and supination motion without the radial and ulnar shafts being separated from each other. Stress radiographic examination showed significant loosening of all ligaments except the medial collateral ligament around the elbow and did not show disruption of the interosseous membrane. A unique chronic twist radioulnar dissociation which consists of gross instability of the radial head and the distal ulna without disruption of the interosseous membrane was considered to cause instability of the humeroulnar joint, which results in medial dislocation of the proximal ulna. This report suggests that there is a direct cause and effect relationship between the residual distal ulnar instability and the development of transverse divergent dislocation of the elbow in patients with rheumatoid arthritis after the Sauve-Kapandji procedure.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
5/32. A challenging case of rheumatoid arthritis in an acromegalic patient.A 63-year-old man with complaints of joint pain and ankle swelling was evaluated. The arthralgias he described were mainly in the knees, elbows, and shoulders. Accompanying swelling and erythema in his left ankle and left second metacarpophalangeal (MCP) joint had recently ensued. His past history revealed acromegaly, somatotropinectomy, and radiotherapy. His neck, bilateral wrist, elbow, and shoulder joints were involved; there was pain and limited range of motion. The MCP joints, being worse than the interphalangeal joints, were likewise involved. His left ankle and MCP joints additionally were swollen and erythematous. Laboratory and radiological evaluations were carried out. Radiological and clinical findings confirmed a diagnosis of rheumatoid arthritis and concurrent acromegalic arthropathy. The patient was treated accordingly. Interestingly, he later developed colon cancer.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
6/32. Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis.BACKGROUND AND PURPOSE: Functional hallux limitus (FHL) is a condition that affects motion at the first metatarsophalangeal joint and may lead to abnormal forefoot plantar pressures, pain, and difficulty with ambulation. The purpose of this case report is to describe a patient with rheumatoid arthritis (RA) and FHL who was managed with foot orthoses, footwear, shoe modifications, and patient education. CASE DESCRIPTION: The patient was a 55-year-old woman diagnosed with seropositive RA 10 years previously. Her chief complaint was bilateral foot pain, particularly under the left great toe. Her foot pain had been present for several years, but during the past 5 months it had intensified and interfered with her work performance, activities of daily living, and social life. OUTCOMES: Following 4 sessions of physical therapy over a 6-week time period, the patient reported complete relief of forefoot pain despite no change in medication use or RA disease pathophysiology. She was able to continuously walk for up to 4 hours. Left hallux peak plantar pressures were reduced from 43 N/cm2 to 18 N/cm2 with the foot orthoses. DISCUSSION: patients with RA who develop FHL may benefit from physical therapist management using semirigid foot orthoses, footwear, shoe modifications, and patient education.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
7/32. Ender nailing for supracondylar fracture of the femur after total knee arthroplasty: five case reports.We studied 5 women with supracondylar fractures after total knee arthroplasty (TKA). The mean age at fracture was 67.4 years. Four patients had chronic rheumatoid arthritis, and 1 had osteoarthritis. The range of motion, knee score, femorotibial angle, and component alignment were investigated. Flexion was slightly decreased after Ender nailing, but extension only changed in 1 patient. The knee score decreased, but all patients were ambulatory. The femorotibial angle changed in all patients. Measurement of femoral component alignment showed a postoperative change of angle alpha (1 degrees to 11 degrees ) and angle gamma (0 degrees to 9 degrees ). Union was achieved in all patients. Ender nailing is an acceptable method of treatment for supracondylar fractures of the femur after TKA if the nails can be inserted deeply into the femoral condyles.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
8/32. Fractures adjacent to humeral prostheses.In a review of records and radiographs from 1974 through 1988, we identified seven patients who had a humeral fracture after either a total shoulder replacement or a shoulder hemiarthroplasty. All seven patients had complications after the fracture, and five fractures did not unite until an operation was done. All of the fractures that were treated operatively healed without sequelae. Four patients who were managed operatively had satisfactory relief of pain and one had fair relief. One patient who had a non-union refused further treatment for medical reasons. The one fracture that united without operative treatment healed with the tip of the prosthesis outside of the humeral shaft, but persistent pain led to a revision total shoulder replacement. The average time to union after the operation was approximately five months (range, four to seven months). There was a permanent decrease in the motion of the shoulder from preinjury levels in five of the six patients who had union of the fracture.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
9/32. Upper thoracic myelopathy caused by vertebral collapse and subluxation in rheumatoid arthritis: report of two cases.We report two cases of rheumatoid arthritis (RA) with upper thoracic myelopathy and a review of the literature. Clinical data of a 47-year-old woman (case 1) and a 54-year-old woman (case 2) are described. Case 1 showed a transverse-type myelopathy at the T2 segment level of the spinal cord and case 2 had the same type of myelopathy at the T4 segment level. Case 1 had anterior vertebral subluxation of C7 due to marked vertebral collapse and Case 2 had subluxation of T2 with vertebral destruction. These two patients had the mutilating type of RA with multilevel spontaneous fusion in the cervical spine. The lesions in the thoracic spine might be caused by the severe destructive inflammation that is characteristic in mutilating disease. The vertebral collapse might lead to subluxation of the upper thoracic vertebra, resulting in spinal cord compression. Upper thoracic subluxation might be caused by vertebral collapse due to RA and the increased motion as a compensation for decreased mobility caused by spontaneous fusion in the cervical spine.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
10/32. Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis.STUDY DESIGN: Case report. BACKGROUND: rehabilitation after shoulder hemiarthroplasty for rotator cuff tear arthropathy (RCTA) represents a significant challenge to physical therapists. Limited goals have been defined for this patient population and include no pain or slight pain at rest, moderate pain with vigorous activity, shoulder external rotation active range of motion (AROM) greater than 20 degrees, and shoulder abduction AROM greater than 90 degrees. CASE DESCRIPTION: The patient was a 60-year-old female elementary school teacher with functional class III adult-onset rheumatoid arthritis, who came to physical therapy 2 weeks after undergoing a hemiarthroplasty for RCTA of the right shoulder. Physical therapy included 33 treatment sessions involving 4 to 11 exercises each session. All sessions were performed under the direct supervision of a physical therapist utilizing specially designed equipment. Physical therapy emphasized early active assisted elevation range of motion (ROM), graded progressive exercise, and functional training. All exercises were performed in a pain-free ROM or a ROM that did not increase shoulder pain. OUTCOMES: Following physical therapy, subjective pain scale at rest was 0/10 and during vigorous activity 1/10 to 2/10. Shoulder AROM was normal and shoulder rotation and elevation strength was good. There was a significant improvement in shoulder proprioception and the patient demonstrated a negative belly press test for subscapularis muscle integrity. Additionally, the patient's score on the self-report section of the American Shoulder and elbow Surgeons Assessment Form increased from 0% at the initial examination to 70% at discharge. DISCUSSION: Despite limited expectations, this patient achieved normal shoulder ROM and near normal shoulder strength after 14 weeks of physical therapy. overall, an early, aggressive, progressively graded exercise program appears to be a safe and effective form of treatment after shoulder hemiarthroplasty for RCTA.- - - - - - - - - - ranking = 2keywords = motion (Clic here for more details about this article) |
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