Effect of Intraarticular Triamcinolone Acetonide Injection for Wrist Pain in Rheumatoid Arthritis Patients: A Statistical Investigation.

BACKGROUND: A significant number of patients on long-term treatment and users of biologics complain of wrist pain due to synovial proliferation and arthropathic changes. Synovectomy or joint arthroplasty is often indicated for such patients, but many refuse surgery. For these patients triamcinolone acetonide was injected into the dorsum of the wrist, and evaluated the clinical benefit and safety of the wrist joint. METHODS: We injected triamcinolone acetonide into the dorsum of the wrist. We evaluated the clinical benefit and safety of intraarticular triamcinolone acetonide by analyzing data on (1) the number of injections, (2) decrease in visual analog scale pain, (3) changes in carpal height ratio, radio carpal distance ratio, and radial rotation angle in X-ray imaging, and (4) the adverse reactions of triamcinolone acetonide injection on the subcutaneous tissue and extensor tendons. RESULTS: 1. The number of injections per patient over 3 years 8 months was 1 for 44 wrists, 2 for 21 wrists, 3 for 17 wrists, 4 for 6 wrists, 5 for 3 wrists, 6 for 3 wrists, 7 for 2 wrists, 9 for 2 wrists, 12 for 4 wrists, and 13 for 1 wrist. 2. The overall mean VAS improved from 79 mm at baseline to 11 mm post-injection. 3. In the grade I and II group, CHS, RCDR and RRA were not statistically significant. In the grade III and IV group, CHR showed a significant decrease. 4. Neither subcutaneous atrophy nor extensor tendon rupture was reported. CONCLUSIONS: More than 90% of patients of all disease grades responded to an average of 1 to 4 injections per year.

Partial tarsal arthrodesis for rheumatoid feet.

Partial intertarsal joint arthrodesis was performed on 12 feet of 11 patients as a surgical treatment for planovalgus deformity of the foot and lesions of the intertarsal joints caused by rheumatoid arthritis. Single arthrodesis was performed on the talocalcaneal joint in eight feet, two of which underwent simultaneous total ankle arthroplasty, and on the talonavicular joint in two feet. Double arthrodesis was done on the talocalcaneal and talonavicular joints in one foot and on the talonavicular and calcaneocuboid joints in one foot. Screws or staples were used for fixation. Patients were followed for 2 years to 8 years 7 months (average 4 years 3 months). Osseous fusion was achieved in all feet, and satisfactory pain relief was obtained in all cases except one. We performed this surgery in patients who were relatively active, and the results indicated that arthrodesis of a small number of joints that caused pain and deformity was effective in reducing pain and correcting the deformity. We concluded that partial tarsal arthrodesis should be performed on a limited number of joints during the early stages of planovalgus deformity of the foot because more joints are found to be fixed during the advanced stages. However, progression of the osteoarthritis was found in the neighboring joints. Close follow-up observation is needed.

Gamma heavy chain disease screening showing a discrepancy between electrophoretic and nephelometric determinations of serum gamma globulin concentration.

A 75-year-old woman with rheumatoid arthritis showed a discrepancy between the reduced level of serum gamma globulin on cellulose acetate electrophoresis and the normal level of serum IgG determined by laser nephelometry. Although no M-peak was detectable on cellulose acetate electrophoresis, immunoelectrophoresis of the patient's serum revealed a monoclonal protein reacting with anti-IgG antiserum but not with anti-kappa or anti-lambda light chain antiserum. Western blotting of the patient's serum showed abnormal low-molecular-weight gamma chains. Thus, the patient was diagnosed with gamma heavy chain disease. A comparison of gamma globulin levels determined by different methods may be useful when screening for this disease.

Vascularized composite tissue transfers or open fractures with massive soft-tissue defects in the lower extremities.

From 1982 to 1998, we treated 39 patients with type IIIB and IIIC fractures in the lower extremities by vascularized composite tissue transfers. Thirty-four of the lesions affected the lower leg, and 5 the foot and ankle. The peroneal flap was used in 25 cases, the latissimus dorsi musculocutaneous flap in 12, the scapula flap in 1, and the gracilis muscle flap in 1. In cases with a peroneal flap transfer, 18 cases used osteocutaneous flap with a fibula. Postoperative circulatory disturbances resulted in revision surgery in 9 patients. Eventually, grafting was successful in 37 patients. In patients with a lower leg reconstruction, additional bone grafting was performed in 7 of 16 patients with cutaneous or musculocutaneous flap transfers. No patient with osteocutaneous flap transfers required an additional bone grafting. The mean periods between injury and time to bone union were 11.7 months in patients with cutaneous flap transfers, and 7.5 months in patients with osteocutaneous flap transfers.