Clinical Outcomes of Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis: Minimum 10-Year Follow-Up Study.

PURPOSE: We developed a semiconstrained total wrist prosthesis that was used in a series of patients with rheumatoid arthritis. We previously reported favorable clinical outcomes for up to 5 years after surgery; however, the longer-term outcomes remain unclear. The objective of this study was to evaluate the clinical outcomes of this wrist prosthesis for the treatment of severe wrist rheumatoid arthritis during a minimum 10 years of follow-up. METHODS: From 2010 through 2012, total wrist arthroplasty using the semiconstrained total wrist arthroplasty device was performed in 20 wrists in 20 patients with rheumatoid arthritis (five men and 15 women). The mean patient age was 64 years (range, 50-84 years). Preoperative radiographs showed Larsen grade IV changes in 16 wrists and grade V changes in four wrists. Patients were evaluated clinically and radiologically before surgery, 5 years after surgery, and 10 years or more after surgery. Evaluated parameters were the visual analog scale for pain, range of motion, Figgie score, and Disabilities of the Arm, Shoulder, and Hand score. RESULTS: The minimum 10-year follow-up clinical results (mean, 11.3 years) were available for all 14 surviving patients (three men and 11 women). Significant improvements in the mean visual analog scale for pain, Figgie score, and Disabilities of the Arm, Shoulder, and Hand score, compared with those before surgery, were maintained from 5 years after surgery to the final follow-up. The mean wrist flexion angle tended to slightly decrease at 5 years after surgery compared with that before surgery but remained similar from 5 years after surgery to the final follow-up. The increase in the mean wrist extension angle, compared with that before surgery, was maintained from 5 years after surgery to the final follow-up. Radiographic evaluation had already revealed implant loosening in five of the 19 wrists at 5 years after surgery, but there were no new cases of component loosening identified at the final follow-up. CONCLUSIONS: Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Minimum 5-Year Longitudinal Study of a New Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis.

PURPOSE: To evaluate the longitudinal clinical outcomes using a new semiconstrained wrist prosthesis for the treatment of severe rheumatoid arthritis of the wrist. METHODS: Twenty patients with rheumatoid arthritis (20 wrists) underwent total wrist arthroplasty with the prosthesis in a clinical trial. The preoperative Larsen classification was grade IV in 16 wrists and grade V in 4 wrists. Assessments were performed before surgery, 1.5 years after surgery, and at final follow-up (≥ 5 years after surgery) using the visual analog scale for pain, Figgie wrist score, Japanese version of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and plain radiographs. RESULTS: At final follow-up, no patient had wrist pain. The preoperative flexion-extension arc at final follow-up was similar to the preoperative range. The mean 1.5-year postoperative Figgie score was significantly improved and was unchanged at final follow-up. The DASH score significantly improved from before surgery to 1.5 years after surgery; the DASH score was improved further at final follow-up, but not significantly. Five of the 19 wrists evaluated had radiographic findings indicating carpal component loosening at final follow-up; however, all patients with the loosening were asymptomatic and had not undergone revision surgery. CONCLUSIONS: Total wrist arthroplasty using this wrist prosthesis leads to favorable clinical outcomes regarding pain relief and retained range of wrist motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A child with acute transverse myelitis requiring permanent pacemaker implantation.

We diagnosed a 3-year-old girl with acute transverse myelitis (ATM). She presented with weakness of the limbs and developed urination difficulty and respiratory disturbance. Magnetic resonance imaging revealed a symmetric area of high signal intensity on T2-weighted images involving the lower end of the medulla oblongata to the level of the fourth thoracic vertebra. Anti-aquaporin-4 antibody was negative. She was treated with intravenous methylprednisolone pulse therapy, immunoglobulin therapy, and plasmapheresis; however, her clinical symptoms did not change. At 10 and 20days after symptom onset, cardiac arrest occurred on postural change, requiring cardiopulmonary resuscitation. A permanent pacemaker was implanted 23days after onset. In the presence of sympathetic nerve hypofunction, relative hyperactivity of the parasympathetic nerves may have led to severe bradycardia and cardiac arrest in the presence of an inducer, such as a postural change. This is the first reported case of pacemaker implantation for management of ATM.

Oral frostbite due to dry ice.

OBJECTIVES: Dry ice is a commercially available cryogen that is used worldwide. It may cause frostbite if misused. However, frostbite of the oral cavity due to dry ice has not been previously reported. Here, we describe the first case of dry ice-induced frostbite of the oral cavity. METHODS: We present a case of oral frostbite due to dry ice and subsequent swelling of the submandibular area and lower lip. We discuss the clinical features of oral frostbite due to volatile substance abuse. RESULTS: Oral frostbite not only may result in the impairment of the affected mucosae directly, but also may adversely affect the tissues in the vicinity of the oral cavity floor indirectly. Oral frostbite may cause edema of the upper airway tract. In case of severe pharyngolaryngeal edema, either tracheal intubation or tracheostomy is necessary. Steroids and antibiotics may be effective in preventing the development of pharyngolaryngeal edema. CONCLUSIONS: It is important to bear in mind that volatile substance abuse may possibly induce unusual events. In particular, special attention should be paid to delayed unusual events.

Sensorineural Hearing Loss due to Air Bag Deployment.

Deployment of the air bag in a passenger vehicle accident rarely causes otologic injuries. However, sensorineural hearing loss induced by air bag deployment is extremely rare, with only a few cases reported in the English literature. A 38-year-old man involved in a traffic accident while driving his car at 40 km/hour presented with right sensorineural hearing loss and tinnitus, without associated vertigo. Pure-tone audiometry demonstrated elevated thresholds of 30 dB and 25 dB at 4 kHz and 8 kHz, respectively, on the right side. Air bag deployment in car accidents is associated with the risk of development of sensorineural hearing loss.

Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes: surgical technique.

BACKGROUND: Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. METHODS: From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. RESULTS: Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112° ± 17° preoperatively to 128° ± 12° postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 ± 23 points preoperatively to 191 ± 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. CONCLUSIONS: The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions.

[Study of an efficacy and a pharmacokinetics of intranasal midazolam for status epilepticus on childhood epilepsy].

We reviewed the efficacy and a pharmacokinetics of intranasal midazolam (MDL) for status epilepticus in childhood epilepsies. This trial was planned for the patients who developed status epilepticus at least once in the past and had no responses with diazepam. Intranasal midazolam was proved to be effective (complete remission;65%), rapidly (an average time to stop seizures; 5.7 min) and safe with no adverse effects including respiratory depression with this dosage (an average of 0.26 mg/kg). In patients whose longitudinal concentrations of MDL in the blood were measured, MDL level was increased rapidly within five minutes after nasal application. Intranasal MDL is useful as a simple and safe method in the child emergency situation.

Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes.

BACKGROUND: Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. METHODS: From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. RESULTS: Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112 degrees +/- 17 degrees preoperatively to 128 degrees +/- 12 degrees postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 +/- 23 points preoperatively to 191 +/- 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. CONCLUSIONS: The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions.

Factors affecting results of ulnar shortening for ulnar impaction syndrome.

Although ulnar shortening osteotomy is the most frequently performed operation for ulnar impaction syndrome, little attention has been given to detect certain preoperative factors affecting clinical outcomes of this procedure. We asked whether preoperative factors influenced the postoperative score of ulnar shortening osteotomy combined with arthroscopic debridement of the triangular fibrocartilage complex. We retrospectively reviewed 51 patients (53 wrists) with ulnar impaction syndrome treated with this procedure. There were 28 males and 23 females ranging in age from 14 to 67 years (mean, 37.5 years). The minimum followup was 12 months (mean, 26.3 months; range, 12-95 months). At last followup, we determined a modified Mayo wrist score for each patient. Preoperative factors affecting the clinical score were identified using multiple regression analysis. The clinical score ranged from 40 to 100 points (mean, 84.5 points). A long duration of symptoms and workers' compensation predicted worse clinical scores. We recommend considering these two factors when deciding whether to perform this procedure.

Motion analysis of the wrist joints in patients with rheumatoid arthritis.

We investigated the characteristics of the wrist joint motion in patients with rheumatoid arthritis (RA), using a biaxial flexible goniometer. Wrist joint range of motion and velocity were measured on the dominant hand in RA patients (n = 22) and normal individuals (n = 5). We investigated flexion-extension (FE) task, radial-ulnar deviation (RUD) task, and functional motion tasks, such as writing letters or unscrewing the lid of a jar. In normal individuals, there was cooperative coupling of FE and RUD during wrist movement, and this coupling motion was essential for normal wrist movements. On the other hand, in RA patients, wrist joint range of motion was restricted at various degrees, with reduced joint motion velocity that was severe on RUD. Functional wrist motion tasks indicated circumductive movement with both FE and RUD in normal individuals, whereas the direction of movement was limited in RA patients, and results revealed failure of cooperative coupling of FE and RUD. Our results indicate that disturbed coupling of FE and RUD results in difficulties in the cooperative movements and have great influence on the daily activities in RA wrist joint.

Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients.

BACKGROUND: Autologous osteochondral mosaicplasty is a new technique to provide hyaline repair for articular defects. Although recent studies have reported the successful treatment of articular defects in the knee and ankle joints with this surgical procedure, little attention has been given to the surgical efficacy of mosaicplasty in the treatment of osteochondritis dissecans of the humeral capitellum. PURPOSE: To clarify the clinical outcomes of mosaicplasty for teenaged patients with advanced lesions of capitellar osteochondritis dissecans. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eight teenaged patients with advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. All patients were baseball players who were affected on the right side, which was also their throwing side. The surgical technique involves obtaining small-sized cylindrical osteochondral grafts from the lateral periphery of the femoral condyles and transplanting them to prepared osteochondral defects. At a mean follow-up of 24 months, all patients were evaluated clinically and radiographically. RESULTS: Seven of the 8 patients were free from elbow pain, and the remaining patient had mild pain occasionally. The mean clinical score described by Timmerman and Andrews (a maximum of 200 points) significantly improved from 140 points to 183 points postoperatively. All patients except one had excellent or good clinical results. Radiographically, the graft incorporation and a normal contour of the subchondral cortex were found in all patients. Magnetic resonance imaging showed that the preoperative heterogeneity of the lesion had disappeared and the signal intensity returned to normal. Six of the 8 patients, including all 3 pitchers, returned to competitive-level baseball. CONCLUSION: Mosaicplasty for advanced lesions of capitellar osteochondritis dissecans in teenaged baseball players can provide satisfactory clinical and radiographic results.

Radial osteotomies for teenage patients with Kienböck disease.

Age seems to affect the efficacy of radial osteotomies for Kienböck disease. We questioned whether an osteotomy would produce acceptable results in teenagers. We retrospectively identified 11 patients (six males and five females) between 11-19 years of age who were treated with radial osteotomies for Kienböck disease. Preoperatively, three patients had Lichtman Stage II disease, two patients had Stage IIIA disease, and six patients had Stage IIIB disease. Two patients with zero or positive ulnar variance had lateral closing wedge osteotomies, and nine patients with negative ulnar variance had radial shortenings. All patients were evaluated clinically and radiographically. At a mean followup of 50 months, 10 of 11 patients were free from pain, and the remaining one patient had moderate wrist pain during strenuous activity. All patients except one, who had Stage IIIB disease, had an excellent clinical outcome. Radiographic improvement, indicating lunate revascularization, was seen for eight patients. Despite Stage IIIB disease, radial osteotomies produced excellent clinical results in five of six teenage patients. The current results indicate that radial osteotomies are effective in improving not only short-term clinical outcomes, but also radiographic findings in teenage patients with Kienböck disease.