日本肘関節学会雑誌 23（2）2016

The Interpositional Arthroplasty (OMS’s membrane) for Rheumatoid Elbow;
A Case Followed for 40 YearsMichio Minami1 Yasuhiko Nishio1 Makoto Kondo1 Sadatoshi Kato1
Hiroyuki Kato2 Akio Minami3 Masamichi Usui4 Seiichi Ishii5
1

2

Hokkaido Orthopedic Memorial Hospital
Department of Orthopaedic Surgery, Shinshu University School of Medicine
3
Hokkaidoh Chuo Rosai Hospital Spinal Cord Injury Center
4
Orthopaedic Surgery of Hitsujigaoka Hospital
5An Emeritus Professor of Sapporo Medical University

肘関節リウマチに対して中間挿入膜 （OMS 膜） を用いた関節形成術を行い 40 年経過した 1 例
三浪三千男 1

西尾泰彦 1近藤真1

加藤貞利 1

博之 2

三浪明男 3

薄井正道 4石井清一 5加藤12

北海道整形外科記念病院
信州大学整形外科
3
北海道中央労災病院せき損センター
45
札幌羊ヶ丘病院整形外科
札幌医科大学医学部名誉教授

OMS 膜は馬の小腸の腸間膜をクロム化して，1950 年代に北海道大学整形外科教室で開発された．開発にあたった三氏の頭文字をとって OMS 膜と命名され，動物実験で組織への安全性を確認し，1970 年代より臨床応用された．
28 歳時，左肘関節に OMS 膜を用いた関節形成術を行い，現在 68 歳女性のリウマチ（RA）患者で，その後，抗リウマチ剤による治療を続けた．左肘の経過は良く，RA の再発も毒性反応もなかった．RA の治療の効果は不十分であり，2010 年より生物学的製剤投与を開始した．投与 4 年目
頃より寛解期をむかえ改善してきた．同時に，左肘も順調な経過をとり，術後 40 年 68 歳時の可動域は － 40° ～ 130° と痛みもなく適合性に優れた X 線学的関節再生が認められた．この症例
では，OMS 膜が長期にわたった骨，関節への親和性を継続し，適切な治療による RA の低活動性の維持が良好な結果になったことを示唆していた．
Introduction

tenderness and local heat. The range of elbow motion wasfrom -35° in extension to 105° in flexion accompanied
by moderate pain. The X-ray of the left elbow at thattime showed that it was in Stage III according to
Steinbrocker’s classification (Fig.1).
Surgical Procedures: 1-2)
IPA-O was performed for this condition in 1976.
Through a J-shaped Kocher’s lateral skin incision,a dissection was made between the triceps muscle
posteriorly and the brachioradialis and extensor carpi
radialis longus muscles anteriorly to expose the lateralcondyle of the humerus and the joint capsule over thelateral surface of the radial head. Distal to the radialhead, the extensor carpi ulnaris was separated fromthe anconeus muscle, of which distal fibers were thenlongitudinally divided. The periosteum was reflectedfrom the anterior and posterior surfaces of the distal
humerus and the common origin of the extensor muscles
from the lateral epicondyle, either by subperiosteal
dissection or by detaching them from the bony insertion.

A 28-year-old woman with rheumatoid arthritis (RA)was surgically treated with interpositional arthroplasty(IPA) using the OMS’s membrane (IPA-O) for theleft elbow in 1976 and was followed for 40 years
postoperatively. This is the first report of IPA for RA
elbow followed for over 40 years.
A Case Report
This case was approved by the institutional review
board of the hospital (ID: 53). The patient was a 28-yearold female with a two-year history of RA. The laboratory
findings showed elevated erythrocyte sedimentation rate(ESR) at 75mm/1hr, C-Reactive Protein (CRP) being
4.7 mg/dl, and rheumatoid factor (RF) as being strongly
positive. Consequently, she was diagnosed as active
RA. The patient was treated with prednisolone (PSL)
5mg and metalcaptase 150mg/a day and non-steroidal
anti-inflammatory drugs (NSAIDS). The left elbow wasmost severely affected and showed remarkable swelling,

Key words : RA（関節リウマチ）， elbow（肘関節），arthroplasty（関節形成術）
Address for reprints : Michio Minami, Hokkaido Orthopedic Memorial Hospital, 7-13-5-22 Hiragishi, Toyohira-Ku, Sapporo
062-0937 Japan- 414 -The Interpositional Arthroplasty (OMS’s membrane) for Rheumatoid Elbow; A Case Followed for 40 Years

After incising the joint capsule longitudinally, the elbow
joint was subsequently dislocated.
First, the proliferated synovium was totally removed
and the radial head was resected. Then, the destroyed
articular surface of the distal humerus was resected by
1.0 to 1.5 cm and the trochlear notch was formed sothat it matched the shape of the end of the olecranon.
The distal end of the humerus was then covered with
one layer of the OMS’s membrane (Fig.2A, 2B). After
reducing the elbow joint, the periosteum and the triceps,
the brachioradialis, the extensor carpi ulnaris and theanconeus muscles were tightly sutured. For closing
procedures, the dissected muscles and ligaments werereattached to their anatomic positions and the elbow wasimmobilized with the posterior long arm splint. Three
weeks after IPA-O, active motion and physical therapy
were started.
Postoperative course
In 1988, the medications were changed to PSL 3.5 mgand Bucillamine 100mg/a day and methotrexate (MTX)
4mg/week until 2005. Since 2006, a smaller dose of PSL,
conventional synthetic DMARDs (cs DMARDs) andMTX were given. Stomatitis and leucopenia developedin 2008, which were thought to be side effects caused
by MTX. However, there was neither recurrence ofsynovitis nor toxic reactions from the OMS’s membranein the left elbow. The X-ray taken 27 years after IPA-O
demonstrated that the articular surface was reformed andadapted according to its functional demands (Fig.3). Theelbow maintained an active extension and flexion motion
from -50° to 125° and was free from pain (Fig.4).
On the other hand, the control of RA was unsatisfactory.
In 2010, biologic agents (b DMARDs) was administered
to control RA activity. Treatment with cs and b DMARDs
turned out to be very effective. The activity of RA wasdecreasing year by year. Table-1 demonstrates the eventsand treatments after cs and b DMARDs every two years
from 2010 to 2016. These data clearly suggested that she
achieved a remission of RA.
In April 2016 (in 40 years after IPA-O), the range ofthe elbow extension – flexion motion was from -40° to
130° with full forearm rotation and satisfactory function(Fig.5). She complained no pain and there was noswelling or tenderness on the left elbow. In addition,
there had been neither recurrence of synovitis nor toxic
reaction caused by the OMS’s membrane. The plainradiographs showed that joint space was maintained withsome remodeling of the articular surface (Fig. 6 AB),which was much better than that shown in the previous
X-ray (Fig. 3).

Fig.1 The X-ray of the left elbowFig.2

A: The OMS’s membrane.
B: The distal end of the humerus covered with 		one layer of the OMS’s membrane

Fig.3 The X-rays of the left elbow 27 years after IPA-O- 415 -

Michio Minami, et al.

Fig.4 Extension and flexion of the left elbow
27 years after IPA-O

Fig.5 Extension and flexion of the left elbow
40 years after IPA-O

Fig.6 The X-rays and CT 40 years after IPA-O- 416 -

The Interpositional Arthroplasty (OMS’s membrane) for Rheumatoid Elbow; A Case Followed for 40 Years

Discussion

ConclusionsThe IPA using an allogeneic membrane has beena challenging procedure to orthopedic surgeons.
Burton is credited in 1827 with the first such operation
for ankylosis of a joint 3) . Early reports indicatedthat surgeons were making efforts to produce a
pseudoarthrosis or neoarthrosis. However, the necessityof an interpositional membrane or materials was always
recognized to prevent bone contact and recurrence ofankylosis3).
The variety of resection arthroplasties withinterpositional membranes or materials included the useof soft tissue by Murphy 4), the chromicized pig bladderby Bear in 1918 6), and fascia lata by Putti in 19203),
owed shortly thereafter, in the USA by Campbell in19215). Autogenous fascia lata then became the standard.
In Europe, arthroplasty was popularized by Puttiand Payr6). Schüller7) was the first to recommend theprocedure for patients with RA. Autogenous or xeno
graft has been used as an interpositional membrane inresection arthroplasties (cutis arthroplasty) of various
joints 8). Since 1913, its successful use in the elbow hasbeen reported by several authors9, 10).
In Japan, the Jinnaka- Kono (JK membrane) was
the most popular 11, 12). In 1950s, a new membrane wasdeveloped by chromizing the small intestinal serosaof the horse at Orthopedic Department of Hokkaido
University 13). The membrane was named after three
originator’s initials: Dr. Y. Okuda, Dr. S. Matsuno(the late emeritus Prof. of Hokkaido Univ.) and Mr.
J. Satsuma. They conducted several experiments
to investigate the biological property of the OMS’s
membrane14-17) and revealed that it had low biological
toxicity, excellent affinity to the bone and joint andlittle character as a histologic foreign objects, althoughimmunological search wasn’t examined.
In our institute, IPA-O was performed for 12 elbows
of 10 RA patients who were followed up for 12.2 years
on an average. Recurrence of synovitis was observed in
two elbows and instability in one, but no toxic reaction
was observed. Four patients were free from pain1, 2). The
mechanism of the transformation to the new articulation
in IPA-O was studied by Phemister and Miller 18) who
demonstrated little histologic difference between thetissues in the resected area with and without interpositionmaterial.
For the current case, we considered that excellent
remission of RA and new articulation of the elbow werevery closely associated with the effective treatment withcs and b DMARDs, and the same medications would stillbe necessary to maintain her present condition of RA.
Since the 1980’s, the total elbow arthroplasty has
become common for the advanced rheumatoid elbow at
our institute because production of the OMS’s membrane
was stopped in 1980.

We reported a 68-year-old female with RA treated withIPA-O for her left elbow and medications by cs and bDMARDs who has been successfully followed- up for
40 years. Medications achieved the remission of RA
and her left elbow maintained excellent function andfavorable remodeling of the articulation on X-ray. Thiscase showed that the OMS’s membrane had no toxicity
and good affinity to the bone and joint over 40 years aftersurgery.
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