Reliability of the Radiographic Sagittal and Frontal Tibiotalar Alignment after Ankle Arthrodesis.

BACKGROUND: Accurate measurement of the tibiotalar alignment is important in radiographic outcome assessment of ankle arthrodesis (AA). In studies, various radiological methods have been used to measure the tibiotalar alignment leading to facultative misinterpretation of results. However, to our knowledge, no previous study has investigated the reliability of tibiotalar alignment measurement in AA. We aimed to investigate the reliability of four different methods of measurement of the frontal and sagittal tibiotalar alignment after AA, and to further clarify the most reliable method for determining the longitudinal axis of the tibia. METHODS: Thirty-eight weight bearing anterior to posterior and lateral ankle radiographs of thirty-seven patients who had undergone AA with a two screw fixation technique were selected. Three observers measured the frontal tibiotalar angle (FTTA) and the sagittal tibiotalar angle (STTA) using four different methods. The methods differed by the definition of the longitudinal tibial axis. Method A was defined by a line drawn along the lateral tibial border in anterior to posterior radiographs and along the posterior tibial border in lateral radiographs. Method B was defined by a line connecting two points in the middle of the proximal and the distal tibial shaft. Method C was drawn "freestyle"along the longitudinal axis of the tibia, and method D was defined by a line connecting the center of the tibial articular surface and a point in the middle of the proximal tibial shaft. Intra- and interobserver correlation coefficients (ICC) and repeated measurement ANOVA were calculated to assess measurement reliability and accuracy. RESULTS: All four methods showed excellent inter- and intraobserver reliability for the FTTA and the STTA. When the longitudinal tibial axis is defined by connecting two points in the middle of the proximal and the distal tibial shaft, the highest interobserver reliability for the FTTA (ICC: 0.980; CI 95%: 0.966-0.989) and for the STTA (ICC: 0.997; CI 95%: 0.996-0.999) is provided. Intergroup analysis for FTTA measurements revealed a statistically significant difference between the method in which the lateral border of the tibia was used to determine the longitudinal axis of the tibia, and the other methods in which the longitudinal axis was defined by bisecting the tibia. CONCLUSIONS: When the longitudinal axis of the tibia is defined by connecting two points in the middle of the proximal and the distal tibial shaft for measuring the FTTA and STTA, the most favorable interobserver reliability is provided. Therefore, this method can be recommended for evaluating the frontal and the sagittal alignment on anterior to posterior and lateral radiographs after ankle arthrodesis.

Correction power and complications of first tarsometatarsal joint arthrodesis for hallux valgus deformity.

PURPOSE: First tarsometatarsal joint (TMTJ) arthrodesis is known as a powerful operative procedure to correct moderate to severe hallux valgus deformity. However, there is little evidence about actual complication rates and angular correctional power. The aims of the present study were to evaluate the (1) angular correction power and (2) complication rates of pooled data for this procedure and to perform subgroup analysis of different methods of fixation. METHODS: A systematic search for the MeSH terms "(hallux OR bunion) AND (lapidus OR TMT OR tarsometatarsal OR metatarsocuneiform) AND (fusion OR arthrodesis)" with use of the online databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was conducted. RESULTS: Twenty-nine studies with a total amount of 1,470 operated feet in 1,268 patients with a mean age of 46.9 years (range, 16.5-61.9) and a mean follow-up period of 28.5 months (range, 6.0-75.6) were included. The correction of IMA averaged 9.12 degrees for screw fixation, 9.75° for staple fixation, 12.41° for combined locking plate with screw fixation, 14.36° for screw with K-wire fixation, 8.50° for pin fixation and 8.60° for external fixation (p = .0251). The overall complication rate reached 16.05 % with a nonunion rate of 4.01 %. CONCLUSION: Based on meta-analysis data, first TMTJ arthrodesis reveals higher corrective power compared to meta-analysis data on proximal, diaphyseal and distal metatarsal osteotomies.

Hydrogen sulphide decreases IL-1ß-induced activation of fibroblast-like synoviocytes from patients with osteoarthritis.

Balneotherapy employing sulphurous thermal water is still applied to patients suffering from diseases of musculoskeletal system like osteoarthritis (OA) but evidence for its clinical effectiveness is scarce. Since the gasotransmitter hydrogen sulphide (H2 S) seems to affect cells involved in degenerative joint diseases, it was the objective of this study to investigate the effects of exogenous H2 S on fibroblast-like synoviocytes (FLS), which are key players in OA pathogenesis being capable of producing pro-inflammatory cytokines and matrix degrading enzymes. To address this issue primary FLS derived from OA patients were stimulated with IL-1ß and treated with the H2 S donor NaHS. Cellular responses were analysed by ELISA, quantitative real-time PCR, phospho-MAPkinase array and Western blotting. Treatment-induced effects on cellular structure and synovial architecture were investigated in three-dimensional extracellular matrix micromasses. NaHS treatment reduced both spontaneous and IL-1ß-induced secretion of IL-6, IL-8 and RANTES in different experimental settings. In addition, NaHS treatment reduced the expression of matrix metallo-proteinases MMP-2 and MMP-14. IL-1ß induced the phosphorylation of several MAPkinases. NaHS treatment partially reduced IL-1ß-induced activation of several MAPK whereas it increased phosphorylation of pro-survival factor Akt1/2. When cultured in spherical micromasses, FLS intentionally established a synovial lining layer-like structure; stimulation with IL-1ß altered the architecture of micromasses leading to hyperplasia of the lining layer which was completely inhibited by concomitant exposure to NaHS. These data suggest that H2 S partially antagonizes IL-1ß stimulation via selective manipulation of the MAPkinase and the PI3K/Akt pathways which may encourage development of novel drugs for treatment of OA.

Comparison of plantar-pressure distribution and clinical impact of anatomically shaped sandals, off-the-shelf sandals and normal walking shoes in patients with central metatarsalgia.

PURPOSE: Metatarsalgia is one of the most frequent pathological conditions of the foot and ankle. Numerous studies exist on plantar-pressure characteristics in various types of shoes. However, to the best of our knowledge, plantar-pressure distribution and clinical effects in sandals has not as yet been the the focus of any study. METHODS: Twenty-two patients (42 feet) with central metatarsalgia were assessed. Time and distance until symptom occurrence in terms of metatarsalgia were evaluated for normal walking shoes (WS), standard sandals (SS) and anatomically shaped, custom-made sandals with a metatarsal pad (AS). Pain intensity was measured with the visual analogue (VAS), and clinical assessment was performed with the American Orthopaedic Foot and Ankle Society (AOFAS) score for the respective shoes. Additionally, plantar-pressure distribution was assessed with the emed-at platform (Novel GmbH) and the F-scan insole system (Tekscan Inc.), respectively. RESULTS: The average walking distance until symptoms occurred was 1,894 m [standard deviation (SD) 1,196 m) for WS, 1,812 m (SD 1,079 m) for SS and 3,407 m (SD 1,817 m) for AS (p < 0.01). Mean duration until occurrence of symptoms was 22.3 min (SD 14.9 min) for the WS, 21.8 min (SD 13.4 min) for the SS and 42.0 min (SD 23.0 min) for the AS (p < 0.01). Plantar-pressure parameters were significantly reduced in the forefoot region for the AS compared with the other walking devices. CONCLUSIONS: The results of this study reveal that a modified standard sandal can significantly influence the onset of metatarsalgia, as increased walking time and distance in these patients was observed.

Plantar pressure characteristics in hallux valgus feet.

Due to the pathoanatomical changes in hallux valgus feet, the plantar flexion moment of the first metatarsophalangeal joint is reduced. Therefore, load bearing of the hallux is decreased during push-off. We assessed loading parameters in hallux valgus feet. Based on dorsal-plantar weight bearing radiographs of 61 feet, the intermetatarsal-, hallux valgus-, distal metatarsal articulation-angle, and sesamoid position were evaluated. Plantar pressure assessment was performed with the emed® system during level walking. We found negative correlations between hallux valgus angle and peak pressure in the great toe (r=-0.301, p<0.023), the maximum force of the hallux (r=-0.481, p<0.001), and contact time of the great toe (r=-0.448, p<0.001), and positive correlations for force time integral (r=0.348, p<0.001), contact area (r=0.307, p<0.020), maximum force (r=0.430, p<0.001), and peak pressure (r=0.361, p<0.006) of the fifth metatarsal head. A positive correlation between the sesamoid and the metatarsal subluxation regarding maximum force (r=0.294, p<0.034), and a negative correlation between the contact area of the hallux (r=-0.232, p<0.020) was shown. Depending on the severity, hallux valgus angle, and sesamoid subluxation, load shows significant lateral transmission in hallux valgus feet.

Biomechanical analysis of two fixation methods for proximal chevron osteotomy of the first metatarsal.

PURPOSE: The proximal chevron osteotomy provides high correctional power. However, relatively high rates of dorsiflexion malunion of up to 17 % are reported for this procedure. This leads to insufficient weight bearing of the first ray and therefore to metatarsalgia. Recent biomechanical and clinical studies pointed out the importance of rigid fixation of proximal metatarsal osteotomies. Therefore, the aim of the present study was to compare biomechanical properties of fixation of proximal chevron osteotomies with variable locking plate and cancellous screw respectively. METHODS: Ten matched pairs of human fresh frozen cadaveric first metatarsals underwent proximal chevron osteotomy with either variable locking plate or cancellous screw fixation after obtaining bone mineral density. Biomechanical testing included repetitive plantar to dorsal loading from 0 to 31 N with the 858 Mini Bionix(®) (MTS(®) Systems Corporation, Eden Prairie, MN, USA). Dorsal angulation of the distal fragment was recorded. RESULTS: The variable locking plate construct reveals statistically superior results in terms of bending stiffness and dorsal angulation compared to the cancellous screw construct. There was a statistically significant correlation between bone mineral density and maximum tolerated load until construct failure occurred for the screw construct (r = 0.640, p = 0.406). CONCLUSION: The results of the present study indicate that variable locking plate fixation shows superior biomechanical results to cancellous screw fixation for proximal chevron osteotomy. Additionally, screw construct failure was related to levels of low bone mineral density. Based on the results of the present study we recommend variable locking plate fixation for proximal chevron osteotomy, especially in osteoporotic bone.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for the treatment of stage II posterior tibial tendon dysfunction: kinematic and functional results of fifty one feet.

PURPOSE: Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients. METHODS: Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO. Plantar pressure distribution and American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed 48 months after surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI). RESULTS: In the lesser-toe region, PP, MF, CT, FTI and CA were reduced and MF in the forefoot region was increased. These changes were statistically significant. We found statistically significant correlations between AOFAS score and loading parameters of the medial midfoot. CONCLUSIONS: Study results reveal that FDL tendon transfer and MDCO leads to impaired function of the lesser toes during the stance phase. However, there seems to be a compensating increased load in the forefoot region.

The Weil osteotomy for correction of the severe rheumatoid forefoot.

PURPOSE: In rheumatoid arthritis the metatarsophalangeal (MTP) joints are predominantly affected with resultant metatarsalgia and dislocation. Therapy options include many different surgical procedures with results that are not always satisfying. We present the oblique Weil metatarsal osteotomy as a treatment option for the rheumatic forefoot. METHODS: A total of 216 osteotomies in 63 consecutive patients (72 feet) with a mean age at the time of surgery of 59.3 years and long-standing rheumatoid arthritis were observed prospectively for an average of 57.4 months (minimum 36 months). All patients received a Weil osteotomy of the lesser metatarsals with at least one additional procedure of the forefoot. Patients were evaluated prospectively for clinical outcome by the American Orthopaedic Foot and Ankle Society (AOFAS) lesser MTP-interphalangeal scale and subjective satisfaction. In the radiological evaluation weight-bearing X-rays were analysed for alignment, shortening and union. RESULTS: American Orthopaedic Foot and Ankle Society score increased significantly from 21.9 ± 6.7 to 63.3 ± 9.8 (p < 0.05). The increase was significant for all subgroups regarding pain, function and alignment. All joints were dorsally dislocated preoperatively; a subluxation was present in 13.6 % at follow-up. There was a significant decrease of callositas in 82 %, a decrease in need for orthopaedic shoes in 61 %, a decrease of MTP joint stiffness in 96 % and a relief of severe pain in 97 % of all patients. No metatarsal head dislocation or necrosis, pseudoarthrosis or screw perforation was observed. Of 63 patients, 55 (88 %) subjectively reported excellent or good results. CONCLUSIONS: We conclude that the Weil procedure for lesser metatarsals is a satisfactory method for correcting the rheumatic forefoot and can be recommended as an approach for the future.

Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity.

PURPOSE: Proximal first metatarsal osteotomies are recommended for the surgical treatment of moderate to severe hallux valgus deformity. This study aimed to compare correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies. METHODS: A systematic search for the keywords "(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR Ludloff) AND osteotomy" in the online databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed. RESULTS: There was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7-21.4] and of intermetatarsal angle of 8.1° (CI 7.7-8.9). The overall complication rate reached 18.7 %. CONCLUSIONS: The results of this study reveal higher corrective power of proximal osteotomies compared to meta-analysis data on diaphyseal osteotomies.

Temporary Kirschner wire transfixation versus strapping dressing after second MTP joint realignment surgery: a comparative study with ten-year follow-up.

BACKGROUND: Instability of the second metatarsophalageal (MTP) joint is a common disorder of the forefoot and can be addressed operatively. The objective of this study was to compare a temporary K-wire fixation (tKW) to a postoperative strapping dressing (SD) after realignment surgery of second MTP instability in combination with correction of claw toe deformity. METHODS: Fifty-four consecutive patients with metatarsal index plus or neutral and a collective total of 62 operative interventions were examined at 10 years postoperatively. The operative intervention included dorsal capsulotomy, incision of the extensor hood, and lengthening of the extensor tendon. All operations were carried out at a single institution by orthopedic surgeons experienced in foot surgery. One team preferred fixation with tKW, whereas the other team used only noninvasive SD for postoperative management. The assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) metatarsophalangeal-interphalangeal score as well as the visual analogue scale (VAS) for pain. Kaplan Meier analysis with recurrence of subluxation as the end point was performed, and plain radiographs of the forefoot were investigated. RESULTS: Survival without recurrence of second MTP subluxation was significantly higher in the tKW group (93%) compared with the SD group (88%) (P < .001). There was no statistical significant difference in pre- to postoperative AOFAS and VAS pain between the 2 groups. CONCLUSION: Temporary K-wire fixation had a significantly lower recurrence rate of second MTP subluxation compared with postoperative SD for postoperative alignment management in second MTP instability. LEVEL OF EVIDENCE: Level III, therapeutic study.

Kinematic changes in patients with double arthrodesis of the hindfoot for realignment of planovalgus deformity.

Double fusion (i.e., fusion of the subtalar and talonavicular joint) represents a modification of triple arthrodesis preserving integrity of the calcaneocuboidal joint. Our aims were (1) to evaluate dynamic plantar pressure distribution in patients undergoing double arthrodesis, (2) to obtain a comparison of kinematic changes to healthy feet, (3) to evaluate the influence of radiographic alignment, and (4) to assess functional outcome. Sixteen feet (14 patients) treated by double fusion due to fixed planovalgus deformity were included. Dynamic plantar pressure distribution was assessed using a capacitive pressure platform. Results were compared with a demographically matched control group. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and radiographic assessment included measurement of talometatarsal, calcaneal pitch, and talocalcaneal (TC) angle on lateral radiographs. Significant differences in plantar pressure distribution were found for maximum force of the hindfoot, midfoot, and big toe region: While the hindfoot and hallux represented decreased load in the double arthrodesis patients, load increased in the midfoot region compared with healthy controls. The lateral talus-first metatarsal-angle increased from -16.3° to -8.2°, and the TC angle decreased from 41.3° to 35.8° (p < 0.05). The pre- and post-operative AOFAS score increased from 37 points (SD, 16.3) to 70 points (SD, 16.7). These results revealed that double arthrodesis represents a reliable method for correction of planovalgus deformity. Compared with healthy feet, force transmission of the midfoot is increased whereas push-off force decreases.

In-vitro comparison of biomechanical efficiency of three cannulated screws for arthrodesis of the hindfoot.

BACKGROUND: Sufficient inter-fragmentary compression is helpful to achieve successful bony fusion in hindfoot arthrodesis using internal fixation by screws. Beside bone quality, the design of a screw influences inter-fragmentary compression. Compressive force is achievable for any kind of screw system; however, the primary deformation of the bone is different for the different screw systems. The work necessary to achieve compressive force for primary stability was measured for different screw systems and compared to an AO screw with washer. MATERIALS AND METHODS: The compressive force was determined as a function of screw advancement for 3 different cannulated screw types (7.3-mm AO screw with and without washer, the 6.5-mm Herbert screw and the 6.5-mm Ideal Compression Screw (I.CO.S) using different synthetic bone density (0.16, 0.24, 0.48 g/ccm). Compressive force was measured indirectly, via screw tension measurement with strain gauges. RESULTS: We calculated the work to reach a limit of 60 N and the corresponding ratios to the value of the golden standard: I.CO.S (35.2%), Herbert (89.0%), AO screw without washer (116%). CONCLUSION: All screw systems yielded acceptable results but the ICOS did produce greater compression. The essential differences were the primary deformation of the bone before reaching the sufficient compressive force for primary stability.

Long-term outcome of total knee replacement in patients with rheumatoid arthritis.

OBJECTIVES: We analysed the long-term clinical and radiological results of 68 consecutive total knee replacements in 50 patients with rheumatoid arthritis. METHODS: At a mean follow-up of 11.2+/-1.2 years (range, 9.7-13.7) all revisions were included. Thirty-seven knees in 28 patients still alive were followed retrospectively clinically and radiologically, all other patients who died without revision were censored at time of the last clinical follow-up and no patient was lost to follow-up. Revision was necessary in 13 knees (19%, one revised twice), including an overall deep infection rate of 1.47%. RESULTS: The survival rate was 81.6+/-0.05% at 12 years with any revision or removal of the prosthesis as an end point. There was no significant difference in survival between cemented, uncemented or hybrid fixation (log rank, 0.2544). The average Knee Society Scores were 77.2 points clinical (range, 40-95 points) and 75.3 points functional (range, 30-100 points), respectively, at final follow-up. The body mass index (BMI) was 25.9 at surgery and 25.3 at follow-up (n.s.). There was no correlation between BMI, age, side, gender and revision frequency. No arthroplasty was at risk for removal or revision at follow-up. CONCLUSIONS: The study shows good 10-12-year clinical and radiological results for the PCA knee replacement in patients with rheumatoid arthritis without preference for the method of fixation or patient weight.

Selective COX-2 inhibitor versus indomethacin for the prevention of heterotopic ossification after hip replacement: a double-blind randomized trial of 100 patients with 1-year follow-up.

INTRODUCTION: Recent reports have suggested that selective COX-2 inhibition may be sufficient for the prevention of heterotopic ossification. METHODS: We performed a randomized controlled study to evaluate the effect of the selective COX-2 inhibitor rofecoxib compared to that of indomethacin on the incidence and extent of heterotopic ossification in patients who had undergone hip replacement surgery. 50 patients received a daily dose of 25 mg rofecoxib and 50 patients received a daily dose of 100 mg indomethacin (25, 25, and 50 mg). RESULTS: No ossifications were found in 48 patients. Grade-II ossifications were seen in 5/46 patients in the rofecoxib group and in 6/50 patients in the indomethacin group. Grade-III and grade-IV ossifications were seen in 3/46 patients in the rofecoxib group only. The differences were not statistically significant. The study medication had to be discontinued in 2 patients in the indomethacin group, due to dyspepsia. INTERPRETATION: After short-term administration, the selective COX-2 inhibitor rofecoxib was effective in preventing heterotopic ossification after total hip arthroplasty.

Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis.

OBJECTIVE: To investigate the pathologic nature of features termed "bone erosion" and "bone marrow edema" (also called "osteitis) on magnetic resonance imaging (MRI) scans of joints affected by rheumatoid arthritis (RA). METHODS: RA patients scheduled for joint replacement surgery (metacarpophalangeal or proximal interphalangeal joints) underwent MRI on the day before surgery. The presence and localization of bone erosions and bone marrow edema as evidenced by MRI (MRI bone erosions and MRI bone marrow edema) were documented in each joint (n=12 joints). After surgery, sequential sections from throughout the whole joint were analyzed histologically for bone marrow changes, and these results were correlated with the MRI findings. RESULTS: MRI bone erosion was recorded based on bone marrow inflammation adjacent to a site of cortical bone penetration. Inflammation was recorded based on either invading synovial tissue (pannus), formation of lymphocytic aggregates, or increased vascularity. Fat-rich bone marrow was replaced by inflammatory tissue, increasing water content, which appears as bright signal enhancement on STIR MRI sequences. MRI bone marrow edema was recorded based on the finding of inflammatory infiltrates, which were less dense than those of MRI bone erosions and localized more centrally in the joint. These lesions were either isolated or found in contact with MRI bone erosions. CONCLUSION: MRI bone erosions and MRI bone marrow edema are due to the formation of inflammatory infiltrates in the bone marrow of patients with RA. This emphasizes the value of MRI in sensitively detecting inflammatory tissue in the bone marrow and demonstrates that the inflammatory process extends to the bone marrow cavity, which is an additional target structure for antiinflammatory therapy.

Outcome assessment of hemiarthroplasty of the shoulder: a 5-year follow-up with 4 evaluation tools.

BACKGROUND: Outcome measurement of shoulder arthroplasty is not standardized. We compared 3 scores and 1 evaluation form. PATIENTS AND METHODS: We report on 35 hemiarthroplasties of the shoulder (32 cementless). Mean age of the patients was 62 (29-87) years. After a mean follow-up of 6 years (range 2-18 years) patients were evaluated with the Neer score, the Constant-Murley score, the score of the University of California in Los Angeles (UCLA) and the Society of Shoulder and Elbow Surgeons Basic Shoulder Evaluation Form. We also performed radiographic evaluation and sonographic evaluation of the rotator cuff. RESULTS: Although pain relief and patient satisfaction were promising, the overall results of the respective score showed low values (Neer score 56/100 points, Constant-Murley score 43/100 points, and UCLA score 19/35 points on average). INTERPRETATION: We recommend choice of a score with a high impact of pain and patient satisfaction. Furthermore, ability to cope with activities of daily living should be of more importance than strength.

Performance of the disabilities of the arm, shoulder and hand outcome questionnaire and the Moberg picking up test in patients with finger joint arthroplasty.

OBJECTIVE: To compare the performance of the Disabilities of the Arm, Shoulder and Hand Outcome (DASH) Questionnaire and the Moberg Picking Up Test (MPUT) with other outcome measurement tools in assessing both hand function and aspects of general health in finger joint arthroplasty in patients with rheumatoid arthritis (RA). DESIGN: Case series, with an average follow-up duration of 104.9 months. SETTING: Orthopedic outpatient clinic at a university hospital. PARTICIPANTS: Of 64 consecutive patients (21 dead, 6 lost to follow-up), 37 patients with 140 spacers in 107 metacarpophalangeal and 33 proximal interphalangeal joints of 51 hands were evaluated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Hand function tests and general health measures. RESULTS: The DASH correlated with both hand function (Health Assessment Questionnaire: r=.72, P<.01; MPUT: r=0.6, P<.01) and general health (Medical Outcomes Study 36-Item Short-Form Health Survey subscales: r range, -.73 to -.31; P range, <.001 to <.05). The MPUT was a suitable tool for precision grip testing. CONCLUSIONS: The DASH has the advantage of being self-administered and assesses both functional and health aspects. It can be recommended as an instrument for a routine clinical follow-up for patients with hand surgery and RA. Additional tests should be applied when detailed information is needed.

Interaction between synovial inflammatory tissue and bone marrow in rheumatoid arthritis.

Rheumatoid arthritis (RA) leads to destruction of cartilage and bone. Whether rheumatoid arthritis also affects the adjacent bone marrow is less clear. In this study, we investigated subcortical bone marrow changes in joints from patients with RA. We describe penetration of the cortical barrier by synovial inflammatory tissue, invasion into the bone marrow cavity and formation of mononuclear cell aggregates with B cells as the predominant cell phenotype. B cells expressed common B cell markers, such as CD20, CD45RA, and CD79a, and were mature B cells, as indicated by CD27 expression. Plasma cells were also present and were enriched in the regions between aggregates and inflammatory tissue. Moreover, molecules for B cell chemoattraction, such as BCA-1 and CCL-21, homing, mucosal addressin cell adhesion molecule-1 and survival, BAFF, were expressed. Endosteal bone next to subcortical bone marrow aggregates showed an accumulation of osteoblasts and osteoid deposition. In summary, we show that synovial inflammatory tissue can reach the adjacent bone marrow by fully breaking the cortical barrier, which results in formation of B cell-rich aggregates as well as increased formation of new bone. This suggests that bone marrow is an additional compartment in the disease process of RA.

Quality of drainage blood: survival of red cells after re-transfusion and content of free hemoglobin and potassium.

Re-transfusion of drainage blood is widely used in orthopedic surgery, but objective evidence of the efficacy of re-transfusion of drainage blood in view of post-transfusion survival of RBC has not been given so far. With this study we wanted to evaluate the efficacy and safety of transfusion of drainage blood collected with HandyVac autotransfusion system. In 7 patients red cells in drainage blood were labeled with biotin and percentage of labeled red cells in circulation were determined immediately after re-transfusion, and during 10 days after surgery. To assess further unwanted side-effects of re-transfusion of drainage blood potassium and free hemoglobin were determined in the collected blood. Ten days after re-transfusion at mean 78.9% of drainage-blood derived RBC were found in circulation. Free hemoglobin in drainage blood ranged from 16.8 to 59.2 mg/dL; potassium in drainage blood ranged from 3.84 to 4.52 mmol/L. Our results suggest that re-transfusion of drainage blood collected with HandyVac autotransfusion system is an efficient procedure that seems to be safe in view of free hemoglobin and potassium in the product.