Results of the Universal 2 Prosthesis in Noninflammatory Osteoarthritic Wrists.

Background/Purpose Many treatment options are available for wrist osteoarthritis, with the objective of decreasing pain and preserving function. In later stages when midcarpal and radiocarpal osteoarthritis occur, two choices remain: total wrist arthrodesis or total wrist arthroplasty. The purpose of this study is to present the short-term functional changes following total wrist arthroplasty with the Universal 2 total wrist system (Integra Life Sciences) in patients with noninflammatory wrist osteoarthritis. Patients and Methods Patients with severe noninflammatory wrist osteoarthritis were assessed preoperatively, 6 and 12 months after surgery using a range of motion, grip strength, pain, and the disabilities of the arm, shoulder, and hand (DASH) score. The additional assessment was performed after 1 year for a range of motion using a biaxial electrogoniometer, grip strength, DASH, and the Michigan hand questionnaire. Results All range of motion directions and grip strength did not change from preoperative values. The DASH score improved from 53 preoperatively to 14 during latest follow-up. Median patients' satisfaction score decreased with approximately 20 points during the last follow-up. Conclusion The relatively good DASH score combined with the partly maintained wrist range of motion indicates that reconstruction with the Universal 2 total wrist prosthesis should be considered in patients with end-stage noninflammatory wrist osteoarthritis. Level of Evidence Level IV, therapeutic study.

Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial.

BACKGROUND: Both trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal arthrodesis are commonly performed procedures for the treatment of trapeziometacarpal osteoarthritis. The purpose of this study was to compare the outcomes of both treatments for symptomatic osteoarthritis of the thumb trapeziometacarpal joint in a randomized trial. METHODS: Women who were forty years of age or older were randomized either to trapeziectomy with ligament reconstruction and tendon interposition or to arthrodesis with plate and screws. Patients were evaluated preoperatively and at three and twelve months postoperatively with respect to pain, function (Patient-Rated Wrist/Hand Evaluation [PRWHE] and Disabilities of the Arm, Shoulder and Hand [DASH] questionnaires), joint motion, strength, complication rate, and patient satisfaction. RESULTS: Forty-three patients were enrolled. Since we found significantly more moderate and severe complications following arthrodesis compared with trapeziectomy with ligament reconstruction and tendon interposition (71% versus 29%; p = 0.016), the study was prematurely terminated before the sample size necessary to validly compare the two groups was reached. The higher complication rate for arthrodesis led to an increase in revision surgery (two of seventeen patients). Significantly more patients in the ligament reconstruction and tendon interposition group (86%) than in the arthrodesis group (53%) indicated they would consider the same surgery again under the same circumstances (p = 0.025). In both groups, PRWHE and DASH scores significantly improved over time; however, comparison of the groups showed that the results were similar. CONCLUSIONS: Women who are forty years or older with trapeziometacarpal osteoarthritis have fewer moderate and severe complications after trapeziectomy with ligament reconstruction and tendon interposition and are more likely to consider the surgery again under the same circumstances than are those who undergo arthrodesis. Twelve months after surgery, the PRWHE and DASH scores were similar in both groups. We do not recommend routine use of arthrodesis with plate and screws in the treatment of women who are forty years or older with stage-II or III trapeziometacarpal osteoarthritis.

Ligament reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby technique): prospective cohort study.

PURPOSE: The Weilby procedure is one of several accepted methods to treat primary thumb carpometacarpal osteoarthritis. We found no previous studies that included preoperative and postoperative subjective outcomes using validated questionnaires or preoperative and postoperative objective outcomes such as specific strength and range-of-motion measurements. Therefore, we performed a prospective cohort study in which we analyzed preoperative and postoperative objective and subjective outcomes after Weilby interposition tendoplasty. METHODS: Nineteen patients (20 thumbs) with primary thumb carpometacarpal osteoarthritis were treated with Weilby interposition tendoplasty. For subjective assessment, the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome data collection instrument was used to evaluate preoperative and postoperative outcomes at 0, 3, 6, and 12 months. Furthermore, patients completed a specific personal questionnaire at 12 months of follow-up. Objective assessments included interphalangeal joint flexion/extension; metacarpophalangeal joint flexion/extension; and carpometacarpal joint palmar abduction, opposition, and extension. Tip pinch, key pinch, 3-point pinch, and overall grip strengths were also measured. The measurements were performed preoperatively and at 3, 6, and 12 months after surgery. All complications were registered. RESULTS: The DASH score was significantly improved, and 17 of 19 patients were satisfied with the procedure. The interphalangeal joint flexion/extension, metacarpophalangeal joint flexion/extension, and carpometacarpal joint extension did not significantly change. Carpometacarpal joint palmar abduction and opposition were significantly improved at 12 months. The tip pinch and key pinch strengths were increased but not significantly. The 3-point pinch and overall grip strengths were significantly improved at 12 months. CONCLUSIONS: The Weilby procedure is a reliable alternative to treat primary thumb carpometacarpal osteoarthritis without requiring bone tunnel creation. It achieves pain relief, stability, mobility, and strength. The objective and subjective outcomes of this study compare favorably with those of earlier reports of the Weilby procedure and are similar to the published results of the more commonly performed Burton-Pellegrini technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three-dimensional carpal kinematics in vivo.

OBJECTIVE: The purpose of this study was to accurately quantify three-dimensional in vivo kinematics of all carpal bones in flexion and extension and radial and ulnar deviation. DESIGN AND METHODS: The right wrists of 11 healthy volunteers were imaged by spiral CT with rotational increments of 5 degrees during ulnar-radial deviation and of five of them also during flexion-extension motion. One regular-dose scan was used and the subsequent scans during wrist motion were performed with one-tenth of the regular dose. A three-dimensional matching technique using the internal structure of the bones was developed to trace the relative translations and rotations of the carpal bones very accurately. RESULTS: Most of our results are in concordance with previously published in vitro data. We could, among others, substantiate proof to the statement that there is more than one kinematic pattern of the scaphoid. Furthermore, we could accurately describe small adaptive intercarpal motions in vivo of the distal carpal row. CONCLUSIONS: To our knowledge, this is the first time the three-dimensional in vivo kinematics of all eight carpal bones is quantified accurately and non-invasively. RELEVANCE: Kinematics of an injured wrist can be compared to these reference data. It may become possible that in this way a ligament lesion can be detected with high specificity and sensitivity, and that no other diagnostic modality will be needed. With these data we made animations with which the complex movements of the bones during different motions of the wrist can be viewed. In the future it may become possible that this analysis provides valuable information on the long-term results of operative interventions and possibly predicts results of operative techniques.

Pisiform kinematics in vivo.

The purpose of this study was to quantify in vivo pisiform kinematics. Wrists of healthy volunteers were imaged by spiral computed tomography during ulnar-radial deviation (n = 11) and during flexion-extension (n = 5). Relative translations and rotations of the carpal bones were determined by using a 3-dimensional matching technique. The error of this registration procedure was less than 0.5 mm for translation and 0.4 degrees for rotation. With radial wrist deviation the pisiform flexes while the triquetrum extends; with ulnar deviation the triquetrum shows more ulnar deviation and extension. With wrist extension the pisiform translates over the distal part of the triquetrum while being pressed against it. With flexion the pisiform moves away from the triquetrum while translating proximally. These in vivo findings provide a further explanation for certain clinical entities, such as degenerative changes of the pisotriquetral joint, and may be used as a reference for normal kinematics of the pisiform.

Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results.

BACKGROUND: Although high tibial osteotomy has been proved effective for the treatment of painful osteoarthritis of the medial compartment of the knee, the role of proximal tibial varus osteotomy for the treatment of painful osteoarthritis of the lateral compartment still remains controversial. METHODS: From 1974 to 1993, we performed proximal tibial varus osteotomy for the treatment of osteoarthritis of the lateral compartment of the knee in thirty-six consecutive patients. The procedure consisted of a proximal lateral opening-wedge varus osteotomy of the tibia with use of corticocancellous bone grafts from the iliac crest. The valgus deformity was posttraumatic in twenty-three patients, followed a lateral meniscectomy in five, was due to overcorrection of a varus deformity in four, and was idiopathic in four. The preoperative valgus deformity averaged 11.6 degrees (range, 4 degrees to 22 degrees ). RESULTS: At a mean of eleven years (range, five to twenty-one years) after the operation, the clinical results for thirty-four of the thirty-six patients were analyzed. None of the patients had severe progression of the osteoarthritis after the osteotomy, and none had a meaningful loss in the range of motion of the knee joint. A superficial wound infection developed in one patient, and another patient had thrombophlebitis. Three patients (9%) had a transient palsy of the peroneal nerve. According to the system of Insall et al., the mean knee score was 84 points (range, 54 to 99 points). According to the knee score described by Lysholm and Gillquist, the subjective result was excellent in nine patients (26%), good in twenty-one (62%), fair in three (9%), and poor in one (3%). CONCLUSIONS: We concluded that when the indications outlined in this study are followed and our opening-wedge technique is used, a proximal lateral opening-wedge varus osteotomy of the tibia is a good alternative for the treatment of isolated osteoarthritis of the lateral compartment of the knee. High accuracy in preoperative planning, based on a slight overcorrection, is important to prevent failure.

Quantitative in vivo analysis of the kinematics of carpal bones from three-dimensional CT images using a deformable surface model and a three-dimensional matching technique.

The purpose of this study was to obtain quantitative information of the relative displacements and rotations of the carpal bones during movement of the wrist. Axial helical CT scans were made of the wrists of 11 volunteers. The wrists were imaged in the neutral position with a conventional CT technique, and in 15-20 other postures (flexion-extension, radial-ulnar deviation) with a low-dose technique. A segmentation of the carpal bones was obtained by applying a deformable surface model to the regular-dose scan. Next, each carpal bone, the radius, and ulna in this scan was registered with the corresponding bone in each low-dose scan using a three-dimensional matching technique. A detailed definition of the surfaces of the carpal bones was obtained from the regular-dose scans. The low-dose scans provided sufficient information to obtain an accurate match of each carpal bone with its counterpart in the regular-dose scan. Accurate estimates of the relative positions and orientations of the carpal bones during flexion and deviation were obtained. This quantification will be especially useful when monitoring changes in kinematics before and after operative interventions, like mini-arthrodeses. This technique can also be applied in the quantification of the movement of other bones in the body (e.g., ankle and cortical spine).

Activation of an adrenergic and vagally-mediated NANC pathway in surgery-induced fundic relaxation in the rat.

The aim of this study was to pharmacologically characterize and investigate the possible contribution of adrenergic and nonadrenergic noncholinergic (NANC) pathways involved in the relaxation of the rat gastric fundus following abdominal surgery. Using an intragastric balloon, the effect of skin incision (SI), laparotomy (LT) and manipulation of the small intestine followed by caecal resection (M + R) on fundic pressure was evaluated. SI resulted in a brief relaxation of the gastric fundus abolished by guanethidine and blocked by hexamethonium and the combination of phentolamine, propranolol and atropine (PPA). LT induced a longer lasting relaxation which was abolished by guanethidine and hexamethonium. It was blocked by PPA and the combination of ganglionectomy and vagotomy, but unaffected by atropine, vagotomy or ganglionectomy. M + R induced a long-lasting relaxation which was only partly blocked by guanethidine or PPA, illustrating an inhibitory NANC component. Vagotomy combined with guanethidine completely abolished the relaxation following M + R, whereas it was significantly blocked by hexamethonium and the combination of ganglionectomy with vagotomy. These results indicate that SI, LT and M + R induce inhibition of fundic motility via an adrenergic mechanism. During M + R, an additional vagally mediated inhibitory NANC pathway is activated. Finally, we suggest that LT and M + R inhibit the gastric fundus via both a splanchnic and a vagal reflex pathway.

Possible role of nitric oxide in postoperative ileus: a comparative study.

In the present study, the possible involvement of nitric oxide (NO) in the pathogenesis of postoperative ileus was investigated indirectly by measuring nitrate, a stabile metabolite of NO. Plasma levels and 24-h urinary excretion of nitrate and nitrite were determined in the peri-operative period in three different groups of patients undergoing surgery: group 1 (LT, n=11) underwent a laparotomy, group 2 (LS, n=12) underwent a laparoscopic procedure, whereas group 3 underwent an extra-abdominal procedure (EA, n=9). Duration of postoperative ileus was assessed clinically using first occurrence of flatus and defaecation as the end of the period of ileus. Postoperative ileus lasted significantly longer in the LT group (first flatus after 3.0 [3.0-4.0] days) compared with the LS (1.0 [1.0-2.0] days) and EA (1.0 [1.0-3.0] days) groups. Urinary nitrate excretion increased significantly in the LT and EA groups during the first 24 h after surgery (from 797.0 [214.0-810.0] and 551.5 [438.3-1215.8] to 2079.0 [889.0-4644.0] and 1102.5 [315.3-1238. 0] micromol/24 h, median [IQR]), but normalized before the end of postoperative ileus. Plasma levels of nitrate were unchanged after surgery, whereas CRP levels were significantly increased in all groups (LT > LS=EA). In the first 24 h following surgery, urinary nitrate excretion is increased, suggesting increased endogenous synthesis of NO postoperatively. As no correlation was found between urinary nitrate excretion and duration of postoperative ileus, we conclude that assessment of nitrate has no value in predicting clinical outcome after surgery.

Differential diagnosis of focal pancreatitis and pancreatic cancer.

UNLABELLED: The differentiation of focal, chronic pancreatitis (CP) and pancreatic cancer (PAC) poses a diagnostic dilemma. Both conditions may present with the same symptoms and signs. The complexity of differential diagnosis is enhanced because PAC is frequently associated with secondary inflammatory changes and CP may develop into PAC. The aim of this study was tot analyze two sets of patients (group A and B) who were misdiagnosed to have either CP or PAC. The clinical and radiographical features of these patients were reviewed. Group A consisted of 22 patients (median age 54.5 years) who were referred with PAC after a previous diagnosis of PC. Eleven patients had a history of CP of > 12 mths (mean 40.2 mths) whereas in 11 patients, PAC became apparent within 12 mths (mean 4.9 mths) after the diagnosis of CP was made. The etiology of CP was alcohol abuse in 9 patients, pancreas divisum in 3 patients and was undefined in the remaining 10 patients. Imaging studies showed features of CP (parenchymal calcifications, irregularities and stenoses of the pancreatic duct wall). Pseudocysts were present in 13 patients. A mass lesion was detected in 13 patients. At the time of diagnosis, 20 patients had unresectable tumors and 2 patients underwent a Whipple resection which proved non-radical. Group B consisted of 14 patients (median age 53 years) who underwent a Whipple resection for a presumed PAC that on histopathology of the lesion proved to be CP. These patients accounted for 6% of all 220 patients who had undergone resection for PAC in the same period. Reassessment of clinical presentation and all imaging studies confirmed a high index of suspicion on PAC in these patients. CONCLUSION: In patients known with CP, misdiagnosis of PAC is a potential pitfall leading to delay of treatment. For any lesion suspicious of PAC an aggressive surgical approach is justified lest a potentially curable lesion is missed. As a consequence, there is at least a 5% chance of resecting a lesion based on CP, mimicking PAC.

Postoperative weight gain after standard Whipple's procedure versus pylorus-preserving pancreatoduodenectomy: the influence of tumour status.

BACKGROUND: Recent reports suggest a better postoperative weight gain after pylorus-preserving pancreatoduodenectomy (PPPD) compared with standard pancreatoduodenectomy (PD). Factors that could also influence postoperative weight gain, such as tumour-positive resection margins and tumour recurrence, have not been taken into account in these studies. The aim of this prospective study was to evaluate weight gain in the first 15 months after PD or PPPD and to investigate the influence of other tumour-related factors. METHODS: From 1991 to 1995, 140 patients underwent subtotal pancreatoduodenectomy; 125 patients underwent resection for malignant disease of the pancreatic head region (56 had PD and 69 PPPD). Patients' weights were evaluated in the pre-illness phase, before operation and during four postoperative phases (at 3, 7, 11 and 15 months). Weight was calculated as a percentage of the pre-illness weight. Patients were subdivided according to tumour status: PD with positive and PD with negative tumour status; PPPD with positive and PPPD with negative tumour status. Tumour-positive status was defined as either microscopically tumour-positive resection margins or radiologically or cytologically proven tumour recurrence within 2 years of surgery. RESULTS: Five patients died during the hospital stay (PD, four; PPPD, one) (overall mortality rate 4 per cent). There was no difference in overall weight gain between patients having PD and PPPD. There was, however, a difference in patients with positive and negative tumour status for PD (P = 0.0003) and PPPD (P< 0.0001). CONCLUSION: There is only a minimal difference in postoperative weight gain between patients having PD and PPPD. Differences in postoperative weight gain are related more to positive resection margins and tumour recurrence than to the type of resection.

Gastrointestinal motility after pancreatoduodenectomy.

Pancreatoduodenectomy (PD) is a major surgical procedure which is accompanied by a high morbidity of between 30 and 50%. A large part of this morbidity is caused by delayed gastric emptying (DGE), which is reported to have an incidence of between 30 and 40% and is associated with prolonged hospital stay. Several pathophysiological mechanisms are thought to cause this complication. Peroperative trauma of the pylorus and the occurrence of intra-abdominal abscesses play a role. Neuronal changes and disruption of the gastrointestinal (GI) intramural nervous plexus may be especially important regarding the pivotal role of the duodenum in the initiation and coordination of antroduodenal motor activity. Another important factor is the postoperative administration of enteral nutrition. Recently, it was demonstrated that cyclic enteral nutrition through a catheter jejunostomy led to a faster return to normal diet and shorter hospital stay than patients on continuous enteral nutrition; this might be partly caused by continuously elevated cholecystokinin levels. The effect of prokinetic agents has not been studied extensively, but a beneficial action on the return of postoperative gastric function after gastrointestinal surgery seems limited.

Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer.

BACKGROUND: The differentiation between cancer and benign disease in the pancreatic head is difficult. The aim of this study was to examine common features in a group of patients that had undergone pancreatoduodenectomy for a benign, inflammatory lesion misdiagnosed as pancreatic head cancer. METHODS: Among 220 pancreatoduodenectomies performed on the suspiscion of pancreatic head cancer, an inflammatory lesion in the pancreas or distal common bile duct was diagnosed in 14 patients (6%). Of these patients, all preoperative clinical information and radiologic images (ultrasound, endoscopic retrograde cholangio-pancreaticography [ERCP]) were critically reassessed. For each examination, the suspicion of cancer was scored on a 0/+/++ scale. RESULTS: Clinical presentation (pain, weight loss, jaundice) raised a suspicion of cancer in 12 patients. On ultrasound, a tumor (mean size: 2.8 cm) was found in the pancreatic head in 13 patients; 12 of 14 ultrasound examinations raised a suspicion of cancer. ERCP showed a distal common bile duct stenosis (length: 1 to 4 cm), stenosis of the pancreatic duct (length: 1 to 5 cm), or a "double duct" stenosis, suspicious for cancer in 13 evaluable patients. The overall index of suspicion was + in seven patients and ++ in seven patients, confirming the initial interpretation of preoperative data. CONCLUSION: When undertaking pancreatoduodenectomy for a suspicious lesion in the pancreatic head, it is necessary to expect at least a 5% chance of resecting a benign, inflammatory lesion masquerading as cancer.

Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy.

OBJECTIVE: The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis. METHODS: From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols. RESULTS: Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05). CONCLUSIONS: Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.