Rheumatoid hand surgery: differing perceptions amongst surgeons, rheumatologists and therapists in the UK.

Rheumatoid arthritis is a systemic disease that requires coordinated management by rheumatologists, surgical specialists and therapists working in a multidisciplinary team. Differences of opinion within the team may adversely affect patient care. Our aim was to assess differences in perception about rheumatoid hand surgery between rheumatologists, hand surgeons and hand therapists in the UK. We used a postal questionnaire to assess commonly performed rheumatoid hand operations. For each procedure, respondents rated the most important indication for surgery and scored effectiveness at reducing pain, improving function and aesthetics, and preventing deformity. Statistically significant differences were found between all three groups with regards to expected outcome and main indications for surgery. We concluded that significant differences do exist in the perceptions of rheumatologists, surgeons and therapists. Rheumatoid hand operations require more detailed study, clarifying indications and outcome to allow consistent advice to patients from all members of the multidisciplinary team.

A 6-year outcome of patients who cancelled carpal tunnel surgery.

The long-term outcomes of patients with carpal tunnel syndrome who were scheduled for release but did not proceed to surgery were compared to patients who underwent surgery, matched on preoperative symptom scores. Both groups completed the Levine-Katz questionnaire 6 years after enrolment to our multicentre carpal tunnel syndrome outcomes database. Symptom and function scores improved for the surgical (n = 24) and non-surgical (n = 36) groups (p < 0.001). Improvement in symptom scores was greater in surgical patients compared to non-surgical patients (n = 24 matched pairs; p = 0.007) but improvement in function scores between groups was not significantly different (p = 0.13). For surgical patients, function and symptom scores improved by 6 months and were unchanged at 6 years. Patients planning surgical release can expect symptomatic and functional benefits within 6 months. Overall improvement was experienced by both groups, with a superior outcome achieved with surgery. The symptoms of carpal tunnel syndrome may improve without surgery, but further studies are needed to understand the natural history of the disorder.

Long-term outcome after carpal tunnel decompression - a prospective randomised study of the Indiana Tome and a standard limited palmar incision.

This randomised trial compared the results of carpal tunnel decompression using the TM Indiana Tome (Biomet, Warsaw, Indiana, USA) and a standard limited palmar open incision. Two hundred patients were randomly selected to have a carpal tunnel decompression with either the Indiana Tome or a limited palmar technique. They were assessed clinically for 3 months and using the Levine-Katz self-assessment evaluation for 7 years. After 7 years, there were 62 returned questionnaires from the open group and 53 from the Tome group. There were no significant differences in functional scores, pain, scar tenderness, pinch and grip strength at 3 months. There were two complications in the open group and nine in the Tome group, including one median nerve injury. There was both a higher rate of immediate complications, and more recurrences and persisting symptoms at 7 years in the Indiana Tome group.

Study to assess differences in outcome following open carpal tunnel decompressions performed by surgeons of differing grade.

INTRODUCTION: Carpal tunnel decompression is the most commonly performed surgical procedure within a hand unit. Although very effective, the complications following the procedure can be significant. In an attempt to identify the causes of such complications, we assessed whether seniority of the surgeon impacts on outcome for open carpal tunnel decompression. PATIENTS AND METHODS: Data were jointly and prospectively gathered from two units from either side of the Atlantic - the Pulvertaft Hand Center, UK and the Curtis Hand Center, USA. The aim of the study was to assess outcome following carpal tunnel decompression. Completed data were gathered following open carpal tunnel decompression on 352 hands. Surgeons of a consultant grade had performed 123 of these procedures whilst surgical trainees had performed 229 of the procedures. Assessment was by Levine Katz questionnaire results, Semmes-Weinstein testing, grip strength and pinch grip strength testing performed both pre-operatively and 6 months' postoperatively. Complications following the procedure were also recorded. RESULTS: Mean results were found to be better in those patients where the surgeon was of a consultant grade. However, this was only found to be of statistical significance on Semmes-Weinstein testing. Complications following the procedure were also noted to be higher in the group of patients operated on by trainee grades. CONCLUSIONS: Our results show the carpal tunnel decompression performed by a surgeon of consultant grade offers slightly better results in objective neurological testing when compared with those performed by a more junior grade.

A prospective assessment of carpal tunnel surgery with respect to age.

Six hundred and thirty five carpal tunnel decompressions in 490 patients were studied prospectively in two hand surgery centres to assess the effect of increasing age on the outcome after surgery. The outcome was assessed using the Levine-Katz carpal tunnel questionnaire, Tinel's sign, Phalen's test, Semmes-Weinstein monofilaments and pinch and grip strengths. Assessments were made pre-operatively, at 2 weeks and 6 months postoperatively. Information was also sought concerning co-morbid conditions. Cases were divided into four groups (less than 40 years of age, 40 to 60, 61 to 80, and over 80 years of age). Patients improved significantly in all age groups after carpal tunnel surgery. Despite a relatively high number of co-morbidities, older patients had an acceptable complication rate and their improvement was comparable to all other age groups.

Providing care for hand disorders a re-appraisal of need.

An audit of hand surgery activity in Derby during the period 1989-1990 produced manpower and resource recommendations for the speciality per 100,000 of population per year for the United Kingdom. The decade that followed the audit has seen major changes in health care provision, including reduced service activity by trainee doctors through restricted hours of work and less unsupervised surgery. A further audit of hand surgery activity was performed during 2000-2001 to assess the effects of these and other changes. This showed that there has been a 2% rise in trauma attendances, though trauma bed utilization had reduced by 12% and surgery time by 38%. Trauma out-patient visits had also reduced by 11%. Day-case trauma surgery rates were virtually unchanged at 63%. Women attend more frequently with traumatic hand injuries than they did 10 years ago and there is a rising incidence of hand injuries in the home, with a falling incidence at work. Elective referrals have risen by 36% and operations by 34%. The top ten diagnoses relate to the same conditions although their rankings have changed. Elective day-case surgery rates have risen from 64% to 94% over the decade. The 34% increase in elective operations has been absorbed within a 5% reduction in elective bed use and a 23% reduction in surgery time. Elective out-patient visits have also dropped 14% overall. This audit indicates that in 2000-2001 one whole time equivalent hand surgeon can service a population of 125,000. The national requirement for a 56 million population would be 448 whole time equivalent hand surgeons.

Carpal tunnel syndrome and work.

The incidence, age at presentation, disability and outcome after surgery were investigated in 327 consecutive women of working age presenting to a hand unit with carpal tunnel syndrome. Two hundred and seventeen were working, 55 of these in repetitive occupations. One hundred and ten were not in employment. All three groups had similar mean ages (around 46 years). On a population basis more women in non-repetitive occupations presented with carpal tunnel syndrome (220/100,000/year) than those in repetitive work (122/100,000/year) or those not working (129/100,000/year), and more were offered surgery (82% versus 67% for those in repetitive work and 58% for those not working). However, symptoms and disability; as assessed with the Michigan Hand Questionnaire and the SF-12, were less severe in working women. This study suggests that working in repetitive or non-repetitive occupations does not cause, aggravate or accelerate carpal tunnel syndrome. Working women may struggle to accommodate their symptoms compared to women who are not in employment causing more to seek help.

Primary care management of carpal tunnel syndrome.

Carpal tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Workplace task modification and wrist splints can reduce or defer referral to hospital for surgical decompression. Nerve and tendon gliding exercises may also be of benefit. Steroid injections to the mouth of the carpal tunnel are particularly useful for symptomatic women in the third trimester of pregnancy. However inadvertent neural injection may cause disabling chronic pain. Referral to a minority of practitioners trained in the technique would ensure sufficient patient numbers to maintain skill levels.

Primary care referral protocol for wrist ganglia.

The paper summarises current knowledge on ganglia of the wrist including the views of patients and doctors. The efficacy of available treatment options are discussed. Summary points are derived from the available knowledge with a referral protocol from primary care.

Characterization of guided microwave spectrometry using water-ethanol mixtures.

On-line measurement of food composition plays an important role in ensuring good quality control during processing operations. Microwave based instruments provide on-line measurement of the bulk sample due to the relatively long wavelength. Characterization of Guided Microwave Spectrometry (GMS) was conducted in this study. The GMS spectra and dielectric properties of water-ethanol mixtures with ethanol contents (v/v) of 0, 25 and 50% were measured at 10 degrees C, 23 degrees C and 40 degrees C. The effects of coaxial cables and antenna were examined and the detection limits of the GMS analyzer were determined. The dielectric properties of the material being measured affected the GMS spectrum by shifting the cutoff region and changing the spectral amplitude over the entire operating frequency span. Temperature affected the spectrum by changing the dielectric properties of the material. Coaxial cables did not have a significant effect on the spectrum and the characteristic dip in the passband region was due to antenna resonance. The antenna affected the number of the resonances present in the spectrum, the frequency location and the amplitude of the resonances. GMS system has both a lower and upper amplitude limit beyond which its resolution decreases significantly. This can be resolved by using a signal attenuator and a smaller sensor body.

Primary care referral protocol for carpal tunnel syndrome.

Carpal tunnel syndrome is an extremely common upper limb nerve compression syndrome, widely distributed in the community. There are a variety of treatment options which may be applied to the syndrome, depending on the severity of symptoms. Some options are available in a primary care setting, others require secondary referral. This paper is a detailed review of the available literature and provides a protocol that could be used to assist in the referral of patients from primary care.

An in-vitro study to understand successful free-hand ultrasound guided intervention.

AIMS: To describe the optimum conditions for successful free-hand ultrasound guided intervention using an in-vitro experiment. MATERIALS AND METHODS: Optimal free-hand biopsy conditions were determined using targets buried in a purpose-built interventional phantom. The needle/probe distance and probe/phantom surface angle were changed whilst recording the needle track lengths and needle conspicuity. RESULTS: Optimal free-hand conditions included a needle/probe distance of 2-3 cm in combination with a needle/probe angle 55-60 degrees. This enabled excellent needle conspicuity with short needle track length and early needle tip visualization. CONCLUSION: Understanding how to optimize the free-hand conditions will help the interventionalist to obtain greater performance using a variety of puncture devices. This concept is likely to be particularly important to the novice interventionalist as well as to those teaching the free-hand technique.

The role of colour flow Doppler in the investigation of the salivary gland tumour.

AIMS: Ultrasound is a highly effective imaging technique to determine salivary gland tumours and may help to identify many benign lesions. The aim of this study is to evaluate whether colour Doppler is able to further differentiate the malignant tumour. METHODS: Fifty-six patients with salivary gland lesions were prospectively assessed using ultrasound imaging with colour flow and power Doppler. The peak systolic velocity (PSV) was measured and the pulsatility index (PI) and resistive index (RI) calculations were performed on the pulsed wave traces. The real time ultrasound morphology and the Doppler information were correlated with the histology. RESULTS: In 18 of the 56 patients, no internal colour flow or power Doppler changes could be detected. The real time ultrasound morphology diagnosed benign disease with sensitivity of 89.7% with specificity of 57.1%. The positive predictive value was 93.6%. There were no significant differences in the colour Doppler appearances in terms of vessel type or intratumour distribution which could separate benign from malignant conditions. However, there was statistical discrimination for PI and RI values (P = 0.0006, P = 0.0002, respectively). No malignant lesions were seen when the PI was less than 1.8 and RI was less than 0.8. The PSV was elevated in several cases (> 50 cm per s) but there was no statistical correlation with malignancy. CONCLUSION: The risk of malignancy increases by a third when the colour Doppler demonstrates increased intratumour vascular resistance (RI > 0.8 and PI > 1.8), with positive predictive value of 97.3% (sensitivity 75.5%, specificity 85.7%).Bradley, M. J. (2000). Clinical Radiology55, 759-762.

Sonographic findings in masseter-muscle metastases.

Symptomatic metastases in skeletal muscles are rare, and involvement of the masseter muscle is extremely rare, with only 3 reported cases. We report 2 additional cases of masseter-muscle metastases. Sonographically, the masseter-muscle metastases appeared as ill-defined, hypoechoic, heterogeneous lesions aligned with the long axis of the muscle. Fine-needle aspiration was confirmatory. The combination of sonography and fine-needle aspiration is the ideal method for diagnosing masseteric metastases.

Evidence for the involvement of Fas ligand and perforin in the induction of vascular leak syndrome.

Endothelial cell injury resulting in vascular leak syndrome (VLS) is one of the most widely noted phenomenons in a variety of clinical diseases. In the current study we used IL-2-induced VLS as a model to investigate the role of cytolytic lymphocytes in the cytotoxicity of endothelial cells. Administration of IL-2 (75,000 U/mouse, three times a day for 3 days) into BL/6 wild-type mice triggered significant VLS in the lungs, liver, and spleen. Interestingly, perforin-knockout (KO) mice exhibited a marked decrease in IL-2-induced VLS in all three organs tested. Also, Fas ligand-defective (gld) mice and Fas-deficient (lpr) mice exhibited decreased VLS in the liver and spleen, but not in the lungs. The decreased VLS seen in perforin-KO, gld, and lpr mice was not due to any defect in lymphocyte migration or homing to various organs because histopathologic studies in these mice demonstrated significant and often greater perivascular infiltration of lymphocytes compared with the IL-2-treated wild-type mice. Ultrastructural studies of the lungs demonstrated significant damage to the endothelial cells in IL-2-treated wild-type mice and decreased damage in perforin-KO mice. IL-2 administration caused up-regulation of CD44 in all strains of mice tested and triggered increased LAK activity against an endothelial cell line in wild-type and gld mice, but not in perforin-KO mice. The current study demonstrates for the first time that perforin and Fas ligand may actively participate in endothelial cell injury and induction of VLS in a variety of organs.

Outcomes of hand surgery. British Society for Surgery of the Hand.

The findings are presented of a conference on Outcomes of Hand Surgery organized by the audit committee of British Society for Surgery of the Hand in 1993. Measures of outcome in terms of movement, power, sensibility, pain, activities of daily living, complications and patient satisfaction are considered, and an example of a patient evaluation measure given as an appendix.