Carpal Tunnel Volume after Basal Joint Arthroplasty in Postmenopausal Women.

Background: Carpal tunnel syndrome is occasionally associated with basal joint arthritis and is more common in postmenopausal women than in the general population. Currently, more evidence is needed to describe changes in the carpal tunnel after basal joint arthroplasty (BJA) of the thumb and to determine whether it is better to combine the release of the flexor retinaculum. The purpose of this study was to clarify the changes in the carpal tunnel cross-sectional area and carpal tunnel shape after complete removal of the trapezium during BJA of the thumb, according to computed tomography (CT) findings. Methods: We retrospectively investigated the carpal tunnel cross-sectional area with CT findings obtained pre- and postoperatively in 20 postmenopausal women who underwent BJA of the thumb. Results: The average horizontal plane area of the carpal tunnel was 1.11 ± 0.19 cm2 preoperatively and increased to 1.23 ± 0.2 cm2 at 3 months postoperatively (p = 0.0411). The ratio of the longitudinal diameter to the horizontal diameter was significantly increased from 0.6 ± 0.13 preoperatively to 1.23 ± 0.2 postoperatively (p = 0.0439). Conclusions: The increase in the carpal tunnel cross-sectional area was confirmed after BJA of the thumb. This increased carpal tunnel cross-sectional area changed as the longitudinal diameter increased, without changes in the horizontal diameter. Level of Evidence: Level IV (Therapeutic).

The Combination of Modified Mitchell's Osteotomy and Shortening Oblique Osteotomy for Patients with Rheumatoid Arthritis: An Analysis of Changes in Plantar Pressure Distribution.

The present study aims to evaluate changes in plantar pressure distribution after joint-preserving surgery for rheumatoid forefoot deformity. A retrospective study was performed on 26 feet of 23 patients with rheumatoid arthritis (RA) who underwent the following surgical combination: modified Mitchell's osteotomy (mMO) of the first metatarsal and shortening oblique osteotomy of the lateral four metatarsals. Plantar pressure distribution and clinical background parameters were evaluated preoperatively and one year postoperatively. A comparison of preoperative and postoperative values indicated a significant improvement in the visual analog scale, Japanese Society for Surgery of the Foot scale, and radiographic parameters, such as the hallux valgus angle. A significant increase in peak pressure was observed at the first metatarsophalangeal joint (MTPJ) (0.045 vs. 0.082 kg/cm2; p < 0.05) and a significant decrease at the second and third MTPJs (0.081 vs. 0.048 kg/cm2; p < 0.05, 0.097 vs. 0.054 kg/cm2; p < 0.05). While overloading at the lateral metatarsal heads following mMO has been reported in previous studies, no increase in peak pressure at the lateral MTPJs was observed in our study. The results of our study show that this surgical combination can be an effective and beneficial surgical combination for RA patients with mild to moderate joint deformity.

Vascularized Bone Grafting for Scaphoid Nonunion with Humpback Deformity: The Surgical Technique.

Background Scaphoid nonunion with humpback deformity and avascular necrosis (AVN) is a challenging problem. Correction of dorsal intercalated segment instability (DISI) requires grafting of a large and hard vascularized bone segment onto the volar side of the scaphoid. Purposes We have been treating the patients with one-incision vascularized bone grafting technique for scaphoid nonunion to improve blood supply and correct humpback deformity. We evaluated these cases retrospectively to the surgical efficacy of our procedure. Methods We harvested vascularized bone from the dorsal side of the radius using the method by Zaidemberg et al and inserted the cortical aspect into the scaphoid volar side using a direct lateral approach. Totally, 11 patients (nine males andtwo females) with a mean age of 40 years were recruited for this study. The mean time from fracture to treatment was 6 years and 3 months. The mean preoperative radiolunate angle was 25 degrees. All the patients showed AVN of the proximal scaphoid on T1-weighted images. An averaged follow-up period was 2 years and 3 months. Results Postoperative computed tomography revealed bony union in 10 patients (91% of union rate) with a mean modified Mayo'swrist score of 88 points (range, 75-100 points) and a mean disabilities of arm, shoulder, and hand (DASH) score of 4 points (range, 0-20 points). The mean radiolunate angle was corrected from 25 to 5 degrees. No adverse events were observed, except temporary mild paresthesia of the radial nerve territory in two patients. Conclusion This technique effectively corrected DISI in patients with scaphoid nonunion accompanied by humpback deformity and AVN.

Two-year Outcomes of Infliximab Discontinuation in Patients with Rheumatoid Arthritis: A Retrospective Analysis from a Single Center.

Objective To investigate the clinical outcomes of rheumatoid arthritis (RA) patients who discontinued infliximab (IFX) treatment at our hospital. Methods Among 249 patients receiving IFX from 2007 to 2015, we retrospectively investigated the clinical courses of 18 who discontinued IFX after achieving the 28-joint disease activity score based on the erythrocyte sedimentation (DAS28-ESR) clinical remission (CR) and whose clinical courses were available continuously for 96 weeks after discontinuation. Results At IFX introduction, the median age was 56.9 (range 36.1-72.4) years, and the disease duration was 5.2 (0.4-25.6) years. The median duration of maintaining either CR or a low disease activity (LDA) with IFX was 37.2 (4.0-91.4) months, and the total duration of IFX therapy was 45.8 (17.1-96.9) months. After discontinuation, 8 patients (44.4%) maintained CR/LDA for 96 weeks (no-flare group), and 10 (55.6%) experienced flares (DAS28-ESR≥3.2) within 96 weeks (flare group). In the no-flare group, six patients receiving intensified conventional synthetic disease-modifying antirheumatic drug (csDMARD) therapy to prevent flare ups simultaneously either with or immediately after discontinuing IFX. In the flare group, four patients received intensified csDMARD therapy. Six patients restarted biological DMARDs (bDMARDs), and all achieved CR again. Ultimately, 12 patients (66.7%) maintained a Bio-free disease control for 96 weeks. A comparison of the clinical backgrounds between the flare and no-flare groups showed no marked difference in their disease duration, IFX dosage, duration of maintaining CR with IFX, or concomitant csDMARDs use. Conclusion Irrespective of the RA disease duration, more than half of all patients maintained a Bio-free condition for 96 weeks. Continuing LDA with IFX for a sufficiently long period of time before discontinuation and preventive intensification of csDMARD therapy may help maintain a Bio-free condition.

Therapeutic failure and eventual solution for skin necrosis and exposed tendon of the dorsum of the foot: A case report.

For the treatment of skin necrosis with exposed tendons in rheumatoid arthritis (RA) foot, we should perform microvascular free flap surgery at an early stage without conservative treatment considering the increased risk of infection and the decreased physical activity.

Metacarpophalangeal Joint Arthroplasty Using Flexible Hinge Toe Implant with Grommets for Boutonnière Deformity of Rheumatoid Thumb.

BACKGROUND: MP joint arthroplasty is one of the treatment options for the rheumatoid thumb with boutonniere deformity. The use of flexible hinge toe implant for MP joint reconstruction was introduced; however, the outcome of flexible toe implantation for the reconstruction of the MP joint has not as yet been reported in detail. Therefore, in this study, we retrospectively investigated the clinical outcome and radiological findings. METHODS: We assessed 56 Swanson implant arthroplasties that used flexible hinge toe implants with grommets to address boutonnière deformity of the thumb MP joint. The minimum follow-up period was 6 months. Pain, the range of motion, grip strength, pinch strength, General health Visual analogue scale and DASH (Disabilities of Hand, Shoulder and Hand) were assessed. RESULTS: For most of the patients, the procedure provided painless motion and stability to the thumb. In the radiological assessments, the preoperative flexion angles at the MP joint were 45° improved to 17°. The origin of arc was shifted toward the extended position and the average arc of motion was 21°, with a flexion arc from 23° to 44°. The severity of boutonniere deformity was improved in most cases. The average grip strength changed from 110 to 121 mmHg and the average side pinch power changed from 1.5 to 2.2 kgf. General health VAS improved from 40 to 29 (p = 0.019), and the DAS28-CRP decreased from 3.3 to 2.4 (p < 0.001). Infection occurred in one case, and there were no implant fractures. CONCLUSIONS: Swanson flexible hinge toe implant arthroplasty with grommets applied to the MP joint of the thumb was one of the recommended procedures for the reconstruction of boutonnière deformity of the thumb.

Plantar pressure and surgical indication of toe arthroplasty for rheumatoid forefoot deformity.

OBJECTIVES: The objective of this study is to clarify the surgical indication for rheumatoid forefoot deformity according to background characteristics and plantar pressure. METHODS: Patients with rheumatoid arthritis were divided into a non-surgical group (group N) and a surgical group (group S). The former consisted of 225 ft, and the latter consisted of 88 ft. DAS28, Japanese Society for Surgery of the Foot rheumatoid arthritis foot and ankle scale (JSSF scale) and hallux valgus angle (HVA) were evaluated as background characteristics. Distribution of peak pressure as plantar pressure was measured in nine sections. RESULTS: In groups N and S, the mean DAS28 was 3.6 and 3.0, the mean JSSF scale was 81.1 and 63.0, and the mean HVA was 19.9° and 35.3°, respectively. The mean peak pressure of group S at the first and third metatarsophalangeal joints was significantly higher compared with group N. Significant differences between the two groups were also seen in Δ pressure (the difference between the maximum and minimum peak pressure values). The cut-off values were 75.0 for JSSF scale, 24.9° for HVA and 3.94 kg/cm2 for Δ pressure. CONCLUSIONS: The combined assessment of HVA and Δ pressure was found to be useful as an indication for surgical treatment of the forefoot.