Medium-term outcomes of the Universal-2 total wrist arthroplasty in patients with rheumatoid arthritis.

AIMS: The aims of this study were to evaluate the clinical and radiological outcomes of the Universal-2 total wrist arthroplasty (TWA) in patients with rheumatoid arthritis. PATIENTS AND METHODS: This was a retrospective review of all 95 Universal-2 TWAs which were performed in our institution between 2003 to 2012 in patients with rheumatoid arthritis. A total of six patients were lost to follow-up and two died of unrelated causes. A total of ten patients had bilateral procedures. Accordingly, 75 patients (85 TWAs) were included in the study. There were 59 women and 16 men with a mean age of 59 years (26 to 86). The mean follow-up was 53 months (24 to 120). Clinical assessment involved recording pain on a visual analogue score, range of movement, grip strength, the Quick Disabilities of the Arm, Shoulder and Hand (DASH) and Wrightington wrist scores. Any adverse effects were documented with particular emphasis on residual pain, limitation of movement, infection, dislocation and the need for revision surgery. Radiographic assessment was performed pre-operatively and at three, six and 12 months post-operatively, and annually thereafter. Arthroplasties were assessed for distal row intercarpal fusion and loosening. Radiolucent zones around the components were documented according to a system developed at our institution. RESULTS: The mean worst pain was 8.1 (3 to 10) pre-operatively and 5.4 (0 to 10) at latest follow-up (p < 0.001). Movements were preserved with mean dorsiflexion of 29o (0 o to 70 o) and palmar flexion of 21o (0o to 50o). The mean grip strength was 4.8 kg (1.7 to 11.5) pre-operatively and 10 kg (0 to 28) at final follow-up (p < 0.001). The mean QuickDASH and Wrightington wrist scores improved from 61 (16 to 91) to 46 (0 to 89) and 7.9 (1.8 to 10) to 5.7 (0 to 7.8) (p < 0.001). A total of six patients (7%) had major complications; three required revision arthroplasty and three an arthrodesis. The Kaplan-Meier probability of survival using removal of the components as the endpoint was 91% at 7.8 years (95% confidence interval 84 to 91). CONCLUSION: The Universal-2 TWA is recommended for use in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:1642-7.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature.

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

A systematic review of distal interphalangeal joint arthrodesis.

Arthrodesis of the distal interphalangeal joint of the hand is a reliable procedure for creating a painless stable joint. Numerous techniques are described within the literature for varying indications. We undertook a systematic review of all studies published within the English literature to provide a comparison of the different techniques. The published studies were predominantly of Level IV evidence. The most commonly employed techniques were Kirschner wire, headless compression screw and cerclage wires. There was no difference in infection rates. Headless compression screws appear to have increased union rates but are associated with complications not seen with other well-established and cheaper techniques. The screw diameter is often similar to or larger than the joint itself, which can result in penetration. Furthermore, they limit the available angle for achieving fusion. Other than in terms of union, there is insufficient evidence to show the headless compression screw is superior to other techniques.

A comparison of the functional difficulties in staged and simultaneous open carpal tunnel decompression.

There is no agreement about whether patients with bilateral carpal tunnel syndrome should undergo staged or simultaneous open decompression. The purpose of this study was to quantify and compare the functional difficulties during the recovery from surgery for patients undergoing staged or simultaneous decompressions. Sixty-three patients had surgery; 33 had staged decompression (Group 1) and 30 simultaneous decompressions (Group 2). Functional difficulties were recorded using the Levine and Quick-DASH scores along with a visual analogue score for pain. There were no complications in either group. There was no significant difference in terms of pain or satisfaction. Functional difficulties were greater in the simultaneous group; however, there was no difference in completing simple tasks. Patients reported high satisfaction with either management approach. However, significantly fewer would consider undergoing simultaneous decompression again.

Estimation of tissue volume irradiated by intracavitary implants.

PURPOSE: The volume of space enclosed by a specified isodose surface arising from an intracavitary implant may correlate with clinical outcome. Several investigators have proposed using the product of the three maximum orthogonal dimensions of the isodose surface as a measure of this volume. We have examined the accuracy of this proposal and compared it to a simpler model for estimating volume which requires only knowledge of the mgRaEq-hrs (total reference air kerma) and the dose level. METHODS AND MATERIALS: Orthogonal films from 204 intracavitary implants of 128 patients with carcinoma of the cervix were used to reconstruct the 137Cs-source coordinates. The source location, strength and duration data were used to calculate dose-volume histograms, yielding the volume enclosed by each dose level as well as its orthogonal dimensions: thickness, width, and height. Using bony landmarks to align films for different insertions in the same patient, similar calculations were repeated for composite implant source coordinates. RESULTS: Curve-fitting techniques revealed that the volume encompassed by each isodose level could be predicted by a modified power-law function of the mgRaEq-hr/dose ratio: predicted volume = [104.8 - 8.103.(M/D) + 0.437.(M/D)2].(M/D)1.635 where M/D = mgRaEq-hr/cGy. The volume predicted by this simple model is accurate within +/- 10% in 95% of the implants when mgRaEq-hr/cGy = 0.8. Accuracy increases with increasing mgRaEq-hr/cGy. In contrast, the ratio, product of orthogonal dimensions/actual volume, varies widely from implant-to-implant, as well as differing systematically from one implant type to another. Investigation of the individual orthogonal dimensions demonstrated that width and height, but not thickness, were moderately well correlated with corresponding maximum implant dimensions. However, in all cases the dimensions were more sensitive to changes in mgRaEq-hr/cGy than to changes in implant geometry. CONCLUSIONS: The product of the orthogonal dimensions is an unsatisfactory estimator of the actual irradiated volume encompassed by an isodose surface. Isodose surface volumes can be accurately estimated knowing only mgRaEq-hr. Prescribing intracavitary brachytherapy by mgRaEq-hr, or its derivative, total reference air kerma, is equivalent to requiring that an isodose surface encompass a specified volume which does not depend on the implant geometry. Constraining the mgRaEq-hr delivered therefore serves to limit the volume of tissue irradiated to high doses.

Tomographic assessment of craniofacial structures: cleft lip/palate.

The purpose of the investigation was to develop software and hardware modifications for computed tomography to provide high-resolution thin sections for the assessment of craniofacial anomalies in the pediatric population. Modifications were undertaken on an EMI 5005 head scanner. Section thickness of two millimeters and resolution of greater than ten lines per centimeter were achieved. Since this study was concerned with reduction of slice thickness and increase in resolution, radiation dose was not of immediate concern, but would be addressed subsequent to achievement of desired initial results. Initial results on investigation of a full-term human fetus with bilateral cleft lip, cleft of the posterior palate, and micrognathia are presented. The interrelationships of the affected structures are shown clearly. Soft tissues are visualized which cannot be seen by conventional tomography.

Anatomy and physiology related to cleft palate: current research and clinical implications.

The most important areas for future research related to the anatomy and physiology of cleft palate are thus: (1) the role of the tensor tympani muscle in auditory tube clearance; (2) the specific etiology of auditory tube dysfunction associated with cleft palate; (3) the nature and extent of variability in the muscular deformities associated with various types of cleft palate; (4) the nature and extent of vascular abnormalities associated with clefts of the palate; and (5) the investigation of cleft palate as one aspect of a craniofacial syndrome.

Comparison of dosimetry and image quality in computed and conventional tomography.

Comparison was made of tomograms of a phantom head and a normal adult cadaver head on GE CT/T, Delta 50, EMI 5005, and CGR Stratomatic units. Image quality was ranked as follows: First, GE CT/T 8800 system; second, EMI; third, GE CT/T 7800 and Delta. The GE CT/T 7800 imaged 3.7 line pairs at high contrast with an exposure to the head phantom of 2.5 R (6.5 X 10(-4) C kg-1). The EMI exposure level was 5 R (13 X 10(-4) C kg-1) in the fast mode and 12 R (31 X 10(-4) C kg-1) in the slow mode, while the Delta 50 exposure level was fixed at 2 R (5.2 X 10(-4) C kg-1). The GE CT/T 8800 could image 6.1 line pairs/cm in a high-contrast phantom with exposures as low as 100 mR (25.8 muC/kg) but a typical operating exposure would be about 1--2 R (2.58 -5.2 X 10 (-4) C kg-1). Dosimetry ranged from 1.1 to 5.5 R/scan section (2.8--14.2 x 10(-4) C kg-1) in the CT units but never increased by a factor of more than 2, irrespective of the number of sections scanned. In conventional tomography, however, exposure increased almost arithmetically with the number of contiguous sections scanned.

Microfissure between the round window niche and posterior canal ampulla.

The microfissure between the round window niche and the posterior canal ampulla was examined in fetal, child, and adult human temporal bones. The communication which was filled with mesenchymal tissue and blood vessels extending from the middle ear, was observed between the round window niche and the posterior canal ampulla in 10 to 15-week human fetuses. The mesenchymal tissue in the communication was replaced by cartilage with advancing age of the fetus. No communication was observed at birth. From newborn to 12 months of age, no microfissure was observed. After one year of age, the microfissure was first observed and the frequency of the observation increased with increasing age of the patient. After six years of age, the microfissure was observed bilaterally in 100% of cases studied. The microfissure has its origin from the communication between the round window niche and the posterior canal ampulla in fetal life, and is a normal developmental and anatomical structure, and not a pathological finding.

Anatomy of the normal and cleft palate Eustachian tube.

This report presents preliminary findings from a study of cleft palate and noncleft palate human fetuses to determine whether differences in Eustachian tube and cranial base structures could be found which might explain the universal appearance of otitis media in infants with cleft palate. Differences were found which are consistent with the previous hypothesis of reduced elasticity in the Eustachian tube. Principal findings included medial to lateral compression of the tube and reduced tubal width.