Clinical added value of MRI to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): study protocol for an international multicentre prospective diagnostic accuracy study.

BACKGROUND: Abdominal computed tomography (CT) is the standard imaging method for patients with suspected colorectal liver metastases (CRLM) in the diagnostic workup for surgery or thermal ablation. Diffusion-weighted and gadoxetic-acid-enhanced magnetic resonance imaging (MRI) of the liver is increasingly used to improve the detection rate and characterization of liver lesions. MRI is superior in detection and characterization of CRLM as compared to CT. However, it is unknown how MRI actually impacts patient management. The primary aim of the CAMINO study is to evaluate whether MRI has sufficient clinical added value to be routinely added to CT in the staging of CRLM. The secondary objective is to identify subgroups who benefit the most from additional MRI. METHODS: In this international multicentre prospective incremental diagnostic accuracy study, 298 patients with primary or recurrent CRLM scheduled for curative liver resection or thermal ablation based on CT staging will be enrolled from 17 centres across the Netherlands, Belgium, Norway, and Italy. All study participants will undergo CT and diffusion-weighted and gadoxetic-acid enhanced MRI prior to local therapy. The local multidisciplinary team will provide two local therapy plans: first, based on CT-staging and second, based on both CT and MRI. The primary outcome measure is the proportion of clinically significant CRLM (CS-CRLM) detected by MRI not visible on CT. CS-CRLM are defined as liver lesions leading to a change in local therapeutical management. If MRI detects new CRLM in segments which would have been resected in the original operative plan, these are not considered CS-CRLM. It is hypothesized that MRI will lead to the detection of CS-CRLM in ≥10% of patients which is considered the minimal clinically important difference. Furthermore, a prediction model will be developed using multivariable logistic regression modelling to evaluate the predictive value of patient, tumor and procedural variables on finding CS-CRLM on MRI. DISCUSSION: The CAMINO study will clarify the clinical added value of MRI to CT in patients with CRLM scheduled for local therapy. This study will provide the evidence required for the implementation of additional MRI in the routine work-up of patients with primary and recurrent CRLM for local therapy. TRIAL REGISTRATION: The CAMINO study was registered in the Netherlands National Trial Register under number NL8039 on September 20th 2019.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation.

BACKGROUND: Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME. METHODS: Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence. RESULTS: The implementation cohort of 120 patients had a median follow up of 21·9 months. Short-term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre). CONCLUSION: TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

ANTECEDENTES: La escisión total del mesorrecto por vía transanal (Transanal Total Mesorectal Excision, TaTME) se ha propuesto como abordaje quirúrgico en pacientes con cáncer de recto medio e inferior. La técnica TaTME se ha introducido en los Países Bajos mediante un proceso de formación estructurado que incluye la supervisión. Este estudio evaluó el porcentaje de recidiva local durante la fase de implementación de TaTME. MÉTODOS: Se recogieron los resultados oncológicos de los primeros 10 procedimientos realizados mediante TaTME en cada uno de los 12 centros participantes como parte de una auditoría externa de implementación del procedimiento. Se reunió una cohorte más amplia de pacientes procedentes de 4 centros para analizar los efectos de la curva de aprendizaje. El criterio de valoración principal fue la presencia de recidiva locorregional. RESULTADOS: La cohorte de implementación de 120 pacientes tuvo una mediana de seguimiento de 21,9 meses. Los resultados a corto plazo incluyeron una tasa del margen de resección circunferencial positivo del 5% y una tasa de fuga anastomótica del 17,4%. La tasa global de recidiva local en la cohorte de implementación fue del 10% (12/120) con un intervalo medio de recidiva de 15,2 (DE 7) meses. El patrón de recidiva local fue multifocal en 8 de 12 casos (67%). En la cohorte ampliada (n = 266), la tasa global de recidiva fue del 5,6% (4,0%, excluyendo a los primeros 10 pacientes). CONCLUSIÓN: TaTME se asoció con un porcentaje de recidiva local multifocal que puede relacionarse con una ejecución subóptima, más que con la técnica en sí. Se recomienda una supervisión prolongada, la optimización de la técnica para evitar la diseminación tumoral, así como un control de calidad.

Volume-outcome relationship of liver surgery: a nationwide analysis.

BACKGROUND: Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit. METHODS: This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien-Dindo grade IIIA or higher) and 30-day or in-hospital mortality. RESULTS: A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20-69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non-CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher-volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events. CONCLUSION: Hospital volume and postoperative outcomes were not associated.

ANTECEDENTES: La asociación entre el volumen hospitalario y los resultados de la cirugía hepática no está clara. Según la recomendación actual de las guías holandesas se requiere un volumen mínimo de 20 procedimientos anuales por centro. El objetivo de este estudio fue analizar la asociación entre el volumen hospitalario con los resultados postoperatorios en la auditoría hepatobiliar obligatoria holandesa a nivel nacional. MÉTODOS: Se realizó un estudio a nivel nacional en los Países Bajos. Se incluyeron todas las resecciones hepáticas registradas en la auditoría hepatobiliar holandesa entre 2014 y 2017. El volumen anual del centro se calculó y se clasificó en categorías de 20 procedimientos por año. Los objetivos principales fueron la morbilidad de mayor grado (Clavien-Dindo grado IIIA o superior) y la mortalidad hospitalaria o la mortalidad a los 30 días. RESULTADOS: Se realizaron un total de 5.590 resecciones en 34 centros con una mediana (rango intercuartílico) de volumen anual de 35 procedimientos (20-69). La tasa global de morbilidad mayor fue del 11% y la mortalidad del 2%. La mortalidad fue de 1,9% después de la resección por metástasis hepáticas colorrectales (colorectal liver metastases, CRLM), 1,2% para no CRLM, 0,4% para tumores benignos, 4,9% para carcinoma hepatocelular, y 10,3% para tumores biliares. Los centros de mayor volumen realizaron más resecciones hepáticas mayores y más resecciones por carcinoma hepatocelular y cáncer biliar. En el análisis multivariable después de ajustar por factores de riesgo conocidos de eventos adversos, no se observó ninguna asociación entre el volumen hospitalario y la morbilidad o mortalidad mayor. CONCLUSIÓN: No hubo asociación entre el volumen hospitalario y los resultados postoperatorios de la cirugía hepática en los Países Bajos.

Evaluation of PET and laparoscopy in STagIng advanced gastric cancer: a multicenter prospective study (PLASTIC-study).

BACKGROUND: Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3-4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. METHODS: This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3-4b, N0-3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. DISCUSSION: In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems. TRIAL REGISTRATION: NCT03208621 . This trial was registered prospectively on June 30, 2017.

Prognostic value of BRAF and KRAS mutation status in stage II and III microsatellite instable colon cancers.

Microsatellite instability (MSI) has been associated with favourable survival in early stage colorectal cancer (CRC) compared to microsatellite stable (MSS) CRC. The BRAF V600E mutation has been associated with worse survival in MSS CRC. This mutation occurs in 40% of MSI CRC and it is unclear whether it confers worse survival in this setting. The prognostic value of KRAS mutations in both MSS and MSI CRC remains unclear. We examined the effect of BRAF and KRAS mutations on survival in stage II and III MSI colon cancer patients. BRAF exon 15 and KRAS exon 2-3 mutation status was assessed in 143 stage II (n = 85) and III (n = 58) MSI colon cancers by high resolution melting analysis and sequencing. The relation between mutation status and cancer-specific (CSS) and overall survival (OS) was analyzed using Kaplan-Meier and Cox regression analysis. BRAF V600E mutations were observed in 51% (n = 73) and KRAS mutations in 16% of cases (n = 23). Patients with double wild-type cancers (dWT; i.e., BRAF and KRAS wild-type) had a highly favourable survival with 5-year CSS of 93% (95% CI 84-100%), while patients with cancers harbouring mutations in either BRAF or KRAS, had 5-year CSS of 76% (95% CI 67-85%). In the subgroup of stage II patients with dWT cancers no cancer-specific deaths were observed. On multivariate analysis, mutation in either BRAF or KRAS vs. dWT remained significantly prognostic. Mutations in BRAF as well as KRAS should be analyzed when considering these genes as prognostic markers in MSI colon cancers.

Maspin is a marker for early recurrence in primary stage III and IV colorectal cancer.

BACKGROUND: Little is known about the factors that drive metastasis formation in colorectal cancer (CRC). Here, we set out to identify genes and proteins in patients with colorectal liver metastases that correlate with early disease recurrence. Such factors may predict a propensity for metastasis in earlier stages of CRC. METHODS: Gene expression profiling and proteomics were used to identify differentially expressed genes/proteins in resected liver metastases that recurred within 6 months following liver surgery vs those that did not recur for >24 months. Expression of the identified genes/proteins in stage II (n=243) and III (n=176) tumours was analysed by immunohistochemistry on tissue microarrays. Correlation of protein levels with stage-specific outcome was assessed by uni- and multivariable analyses. RESULTS: Both gene expression profiling and proteomics identified Maspin to be differentially expressed in colorectal liver metastases with early (<6 months) and prolonged (>24 months) time to recurrence. Immunohistochemical analysis of Maspin expression on tumour sections revealed that it was an independent predictor of time to recurrence (log-rank P=0.004) and CRC-specific survival (P=0.000) in stage III CRC. High Maspin expression was also correlated with mucinous differentiation. In stage II CRC patients, high Maspin expression did not correlate with survival but was correlated with a right-sided tumour location. CONCLUSION: High Maspin expression correlates with poor outcome in CRC after spread to the local lymph nodes. Therefore, Maspin may have a stage-specific function possibly related to tumour cell dissemination and/or metastatic outgrowth.

[Meagre evidence so far for effectiveness of in-home comprehensive geriatric assessment: a literature review]. / Bewijs voor effectiviteit van Comprehensive Geriatric Assessment in de thuissituatie nog mager: een literatuurreview.

BACKGROUND: Most elderly people attach great value to staying functionally independent for as long as possible. A targeted detection and treatment of factors that threaten functional independence, through comprehensive geriatric assessment, might promote this. This paper describes a review on the effect of in-home comprehensive geriatric assessment. METHODS: A search was carried out in Pubmed (1977-2012) for randomized controlled trials investigating the effectiveness of multidisciplinary multidimensional in-home geriatric assessment. Data was extracted about effectiveness, costs and factors that had a positive or negative influence on the outcome of CGA. RESULTS: Nine RCTs could be included in the study. All studies were of moderate to good quality, except for one study of poor quality. A positive effect was found in three out of six studies on functional status and in two out of four studies on quality of life. No effect was found on number of hospital admissions, nursing home admissions and on mortality. Most studies showed a rise in total health care expenditure. CONCLUSION: In-home CGA has a modest positive effect on functional status and quality of life. Evidence suggest that in-home CGA might be most effective in elderly that have a relatively high level of functioning.

High lymph node yield is related to microsatellite instability in colon cancer.

BACKGROUND: Lymph node (LN) yield in colon cancer resection specimens is an important indicator of treatment quality and has especially in early-stage patients therapeutic implications. However, underlying disease mechanisms, such as microsatellite instability (MSI), may also influence LN yield, as MSI tumors are known to exhibit more prominent lymphocytic antitumor reactions. The aim of the present study was to investigate the association of LN yield, MSI status, and recurrence rate in colon cancer. METHODS: Clinicopathological data and tumor samples were collected from 332 stage II and III colon cancer patients. DNA was isolated and PCR-based MSI analysis performed. LN yield was defined as "high" when 10 or more LNs were retrieved and "low" in case of fewer than 10 LNs. RESULTS: Tumors with high LN yield were significantly associated with the MSI phenotype (high LN yield: 26.3% MSI tumors vs low LN yield: 15.1% MSI tumors; P=.01), mainly in stage III disease. Stage II patients with high LN yield had a lower recurrence rate compared with those with low LN yield. Patients with MSI tumors tended to develop fewer recurrences compared with those with MSS tumors, mainly in stage II disease. CONCLUSIONS: In the present study, high LN yield was associated with MSI tumors, mainly in stage III patients. Besides adequate surgery and pathology, high LN yield is possibly a feature caused by biologic behavior of MSI tumors.

Lymph node negative colorectal cancers with isolated tumor deposits should be classified and treated as stage III.

BACKGROUND: The prognostic role of pericolic or perirectal isolated tumor deposits (ITDs) in node-negative colorectal cancer (CRC) patients is unclear. Rules to define ITDs as regional lymph node metastases changed in subsequent editions of the TNM staging without substantial evidence. Aim of this study was to investigate the correlation between ITDs and disease recurrence in stage II and III CRC patients. MATERIALS AND METHODS: The medical files of 870 CRC patients were reviewed. Number, size, shape, and location pattern of all ITDs in node-negative patients were examined in relation to involvement of vascular structures and nerves. The correlation between ITDs and the development of recurrent disease was investigated. RESULTS: Disease recurrence was observed in 50.0% of stage II patients with ITDs (13 of 26), compared with 24.4% of stage II patients without ITDs (66 of 270) (P < .01). Disease-free survival of ITD-positive stage II patients was comparable with that of stage III patients. Also within stage III, more recurrences were observed in ITD-positive patients compared with ITD-negative patients (65.1 vs. 39.1%, respectively). No correlation was found between size of ITDs and disease recurrence. More recurrences were seen in patients with irregularly shaped ITDs compared with patients with 1 or more smooth ITDs present. CONCLUSIONS: Because of the high risk of disease recurrence, all node-negative stage II patients with ITDs, regardless of size and shape, should be classified as stage III, for whom adjuvant chemotherapy should be considered.

A comparison of survival of moulded monoblock and modular tibial components of 751 AGC total knee replacements in the treatment of rheumatoid arthritis.

We evaluated the survival of moulded monoblock and modular tibial components of the AGC total knee replacement in patients with rheumatoid arthritis. Between 1985 and 1995, 751 knees with this diagnosis were replaced at our institution. A total of 256 tibial components were of the moulded design and 495 of the modular design. The mean follow-up of the moulded subgroup was 9.6 years (0.5 to 14.7), and that of the modular group 7.0 years (0.1 to 14.7). The groups differed significantly from each other in Larsen grade, cementing of components and patellar resurfacing, but no statistically significant difference between the survival of the components was found (Log rank test, p = 0.91). The cumulative success rate of the moulded group was 96.8% (95% confidence interval 93.6% to 98.4%) at five years and 94.4% (95% confidence interval 90.4% to 96.7%) at ten years, and of the modular group 96.2% (95% confidence interval 94% to 97.6%) and 93.6% (95% confidence interval 89.7% to 96%), respectively. Revision was required in 37 total knee replacements, the main causes were infection, pain, loosening of the tibial component and patellar problems. Survival rates for both components were satisfactory.

Stapling of knees with valgus deformity in children with juvenile chronic arthritis.

OBJECTIVE: Leg length discrepancy and excessive knee valgus are potential complications of juvenile chronic arthritis of the knee. The aim of the present study was to evaluate retrospectively the safety and efficacy of temporary stapling of the knee epiphyses in management of valgus deformities of the knee in children with JCA. METHODS: Medical data of the patients with temporary epiphyseodesis due to knee valgus deformity (KVD) were studied. 177 knees in 112 patients were found with sufficient data for evaluation. Patient documents and radiographs of these patients were evaluated. RESULTS: Mean age at the time of operation was 8 years (range: 2 - 17) in 19 males and 93 females. The patients are predominantly affected by aggressive polyarticular disease. Preoperative mean valgus angle was 11 degrees (IQR: 9, 14) and at staple removal 4 degrees (IQR: 2, 5). In 120 of 177 knees (68% [95% CI: 61 - 74], p < 0.001) the physiological angle (3-8 degrees) was reached. Median time of stapling was 10 months (IQR: 8, 13). Five reversible and one irreversible (3% [95% CI: 2 to 7]) major complications were documented among the 177 stapled knees. CONCLUSION: Temporary epiphyseal stapling enables flexible correction of KVD in children with JCA. Low complication rate encourages the use of the method. Prompt follow-up is, however, important in avoing excess over-correction to varus.

Grading of radiographic osteolytic changes after silastic metacarpophalangeal arthroplasty and a prospective trial of osteolysis following use of Swanson and Sutter prostheses.

The purpose of this study was to compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter metacarpophalangeal implants in rheumatoid arthritis patients. The mean follow-up time in the two groups of patients was 57 (40-80) and 55 (36-79) months, respectively. This paper proposes a new method of classifying radiographic osteolysis. The remarkable number of osteolytic changes seen in the bones adjacent to MCP prostheses in this study would suggest that silastic prostheses should only be used when other surgical alternatives cannot be used and that long-term control by radiography be maintained after implantation of silicone prostheses into the MCP joint. In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group in this study, suggesting that use of the Sutter rather than the Swanson implant is questionable.

Use of the de la Caffinière prosthesis in rheumatoid trapeziometacarpal destruction.

This study evaluated the outcome of the de la Caffinière prosthesis in patients with an inflammatory arthropathy affecting the trapeziometacarpal joint. The procedure was performed in 57 thumbs for rheumatoid arthritis (41 cases), juvenile chronic arthritis (ten cases), psoriatic arthritis (four cases) and other inflammatory joint diseases (two cases). Survival analysis with a revision procedure or radiographic implant failure as end points was performed. Five loosened cups and two permanently dislocated prostheses underwent revision surgery. These were managed with a bone graft and tendon interposition technique. Radiographic follow-up yielded four additional implant failures (two loosened cups, one loosened metacarpal stem and one permanent dislocation). The implant survival rate based on revision operation was 87% (95% CI 73-94) at 10 years, and the total radiographic and implant failure rate based on radiographic findings was 15% (95% CI 7-29) at 10 years.

"Bamboo spine" starts to bend--something is wrong.

A typical complication of ankylosing spondylitis with an atypical patient history is reported and the topic is discussed. The diagnosis of a spinal fracture may be difficult in a "bamboo spine".

Insufficiency fractures in patients with chronic inflammatory joint diseases.

OBJECTIVE: To describe the typical sites of stress fractures in the lower extremities and pelvis in rheumatoid patients (rheumatoid arthritis, juvenile chronic arthritis, psoriatic arthritis, ankylosing spondylitis). METHODS: Thirty-three patients with 52 stress fractures [mean age 44 years (range 11-73)] were studied at the authors' institution when they were being treated for their rheumatic diseases. Fourteen patients had RA, 9 JCA, 5 PsoA, and 5 SPA. Stress fractures were detected from patient documents and from series radiographs in suspected cases. In some cases magnetic resonance imaging was also performed. RESULTS: One patient presented with 5 fractures, 2 patients with 4 and 3 fractures, and 7 patients with 2 fractures each. Other patients (n = 19) had only one fracture each. The metatarsal (MT) bones were the most common site of involvement. Twenty-five of the 52 fractures were located on MT I-V. The second and third most common sites were thefibula (n = 13) and tibia (n = 6). All fractures of the lower tibia or fibula were associated with valgus malalignment of the ankle. CONCLUSION: If a patient with rheumatic disease experiences sudden and unexplained pain localised in the forefoot, above the ankle, below the knee, or in the pelvis, a stress fracture should be suspected. Patients with severe osteoporosis, high-load corticosteroid or methotrexate therapy, or marked joint deformity are at high risk of developing stress fracture.

Atlantoaxial disorders in rheumatoid arthritis associate with the destruction of peripheral and shoulder joints, and decreased bone mineral density.

OBJECTIVE: To evaluate whether cervical spine changes are associated with the destruction of shoulder or peripheral joints and with bone mineral density (BMD) in patients with long-term RA. METHODS: An inception cohort of 67 patients with seropositive and erosive RA were followed up for 20 years. Cervical spine, shoulder, hand and foot radiographs, and the BMD of the lumbar spine and femoral neck were evaluated. RESULTS: A positive relationship was detected between the occurrence of atlantoaxial disorders and the destruction of both shoulder (p < 0.001) and peripheral (p = 0.001) joints. In addition, the severity of anterior atlantoaxial subluxation and atlantoaxial impaction positively correlated with the grade of destruction in the evaluated joints. Furthermore, patients with atlantoaxial disorders presented decreased BMD of the femoral neck (p = 0.019). The occurrences of subaxial subluxations (SAS) and subaxial disc space narrowings only associated with higher onset age of RA. CONCLUSIONS: Patients with severe RA and osteoporosis have an increased risk for atlantoaxial disorders. The co-existence of shoulder destruction and cervical spine disorders makes the differential diagnosis of shoulder and neck pain challenging.

Long-term results of leg length discrepancy treated with temporary epiphyseal stapling in children with juvenile chronic arthritis.

OBJECTIVE: The aim of the present study was to evaluate retrospectively the long-term efficacy of temporary stapling of the knee epiphyses over four decades of use in children with JCA. METHODS: Medical data of the patients with temporary epiphyseodesis due to leg length discrepancy (LLD) were studied. Seventeen knees in 17 patients were found with sufficient follow-up data for evaluation. Patient documents and radiographs of these patients were evaluated. RESULTS: The mean age at the time of the operation was 11 years (range: 6-15) in 3 males and 14 females. The preoperative mean LLD was 21 mm (SD 8) and at staple removal 4 mm (SD 10). The difference was -17 mm (95% CI: -10 to -23). Statistically the result remained the same during the follow-up. Two reversible complications were documented among the 17 stapled knees. In five (29%) cases the correction was affected by re-occurrence of LLD quickly after removal of the staples. CONCLUSION: In this study with 17 patients and a wide range of follow-up times we found that the good correction of LLD achieved by stapling is usually permanent.

Development rate of mutilans fingers in patients with rheumatic disease.

OBJECTIVE: To describe arthritis mutilans (AM) deformity during the progression of rheumatic disease. METHODS: The development of mutilans-like hand deformities in 2 patients with juvenile chronic arthritis (JCA) and in 2 patients with adult onset rheumatoid arthritis (RA) are presented. The hands of these patients were evaluated at least at two time points during the course of disease using two different scoring methods based on differently summed Larsen grades of the hand joints. RESULTS: Two patients (one with JCA and one with RA) showed AM changes after a disease period of less than 10 years and 2 not until after 30 years. The patients with adult onset disease were young at the onset of joint disease. Early wrist fusions were performed on both patients showing a slow development rate. CONCLUSIONS: The development rate of AM is very variable, even in patients with the same diagnoses. Wrist fusion prevents shortening of the carpus and may decrease the development rate of AM.

Need and sequence of large joint replacements in rheumatoid arthritis. A 25-year follow-up study.

OBJECTIVE: The aim of the present study was to evaluate the number and sequence of large joint replacements (LJR) performed in long-term rheumatoid arthritis (RA) from an inception cohort of 103 patients with rheumatoid factor (RF)-positive RA followed over 25 years. METHODS: A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Patient documents and radiographs were evaluated in the beginning of 2001 and a complementary interview was arranged to assess the number and sequence (timing) of LJRs performed. RESULTS: The cumulative number of LJRs performed for 22 patients (19 women) during the 25 years of follow-up was 41. Seventeen total hip joint replacements (THR) (42% of the total number of 41 LURs) were performed on 13 patients, median time from the diagnosis to the operation being 14 years; 14 total knee replacements (TKR) (34%) on 11 patients (after a median time of 17 years); 3 total shoulder replacements (TSR) (7%) on 3 patients (median time of 18 years); and 7 total elbow replacements (TER) (17%) on 4 patients (median time of 21 years), respectively. Six patients had undergone three or more LJRs during the follow-up period. CONCLUSION: During our 25 years of follow-up, in 27% of RA patients LUR was needed, and 41% of them needed more than one replacement.