Natural history of ileo-caecal Crohn's disease after surgical resection. A long term study.

AIM: Surgery is an almost inevitable event in Crohn's disease (CD) but is not curative; postoperative recurrence follows a predictable course. Several factors potentially affecting the risk of recurrence have been investigated but results are largely inconclusive. The aim of the present study was to evaluate the long-term course of ileo-caecal CD after surgery and to identify possible predictors of clinical and surgical recurrence. METHODS: Patients with ileo-caecal CD who had undergone surgical resection and with at least one year of post-operative follow-up were studied. The postoperative course was retrospectively evaluated. The primary end-points were clinical recurrence (defined as reappearance of symptoms requiring steroid treatment in the presence of endoscopic and/or radiologic recurrence) and surgical recurrence, defined as need for reoperation. RESULTS: Two hundred and twelve patients were included in the study. Median follow-up after surgery was 117 months (interquartile range 51-216). The cumulative probability of a post-operative course without clinical and surgical recurrence after 30, 60, 90, 120 months was 78.2%, 69.4%, 58.0%, 50.6% and 97.0%, 96.4%, 85.6%, 72% respectively. Early surgery (within three years from diagnosis) was associated with a longer postoperative course without clinical recurrence compared with late surgery (performed after three years from diagnosis). None of the other clinical variables considered (gender, age, family history for IBD, smoking habits, pattern of CD, and postoperative prophylactic treatment) was associated with the risk of clinical and surgical recurrence. CONCLUSION: Surgery is an excellent treatment for patients with isolated ileo-caecal CD. The overall long-term outcome is good: by 10 years after operation approximately 50% of patients are free of clinical recurrence and over 70% do not require further surgery. Surgery, therefore, continues to play an important role in ileo-caecal CD and should therefore not be considered only a failure of medical treatment.

Arthroscopic resection of volar wrist lipoma: a case report.

We present the case of a patient who showed a volar radiocarpal mass confirmed to be a lipoma by the ultrasonographic examination. The whole procedure was done by arthroscopy, using portal 1-2 for the shaver and 3-4 for the arthroscope. The patient returned to daily activities within a few days, with a mobility of the operated wrist identical to that of the contralateral wrist, with no pain and only two little dorsal scars.

Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears.

We report our 11-year experience of performing arthroscopically assisted triangular fibrocartilage complex reconstruction in the treatment of chronic distal radio-ulnar joint instability resulting from irreparable triangular fibrocartilage complex injuries. Eleven patients were treated. Three skin incisions were made in order to create radial and ulna tunnels for passage of the tendon graft, which is used to reconstruct the dorsal and palmar radio-ulnar ligaments, under fluoroscopic and arthroscopic guidance. At a mean follow-up of 68 months all but one had a stable distal radio-ulnar joint. Pain and grip strength, Mayo wrist score, Disability of the Arm Hand and Shoulder and patient-rated wrist and hand evaluation scores improved. The ranges of forearm rotation remained largely unchanged. Complications included an early tendon graft tear, two late-onset graft ruptures, one ulna styloid fracture during surgery and persistent wrist discomfort during forearm rotation requiring tendon graft revision in one case. An arthroscopic assisted approach for triangular fibrocartilage complex reconstruction appears safe and produces comparable results with the open technique. LEVEL OF EVIDENCE: IV.

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears.

The classical definition of 'Palmer Type IB' triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears. Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies. LEVEL OF EVIDENCE: II.

Observational multicentric survey on carpal tunnel syndrome: demographic and clinical data from 34 Italian centers.

OBJECTIVE: To evaluate the current management of carpal tunnel syndrome (CTS) at a national level. PATIENTS AND METHODS: A multicentric observational study was conducted in 34 Italian centers by specialists participating in the Management of Peripheral Neuropathies Study Group on 377 patients (age, mean±SD 56±14.4 years, 73.2% females) with CTS. The characteristics of the disease and its management were recorded at baseline and during a 2-month follow-up using a standardized clinical record and assessed with validated clinical tests. RESULTS: A wide variability in the interventions prescribed and classified according to three categories (physical, pharmacological and neurotrophic therapies) was evident. A subgroup of 303 patients was treated with a combination of neurotrophic agents containing alpha-lipoic acid (ALA). At the end of the follow-up, a general improvement in symptoms and functional impairment was observed, with a significant reduction in BCTQ (Boston Carpal Tunnel Questionnaire) (p<0.001) and in NRS (Pain Numeric Rating Scale, p<0.001 for both nocturnal and diurnal pain). CONCLUSIONS: An appropriate approach to CTS implies a multimodal and multidisciplinary management, involving several specialists and using a variety of conservative interventions. Conservative (physical and pharmacological) interventions can provide a clinical improvement in patients with CTS.

Protective coverage of the median nerve using fascial, fasciocutaneous or island flaps.

PURPOSE: The aim of the study is to present our experience with fascial or fasciocutaneous pedicle and island flaps in the treatment of recurrences of CTS with and without median nerve lesions. MATERIAL AND METHODS: From 1987 to 2006 we have operated on 25 patients (17 women and 8 men, ages ranging from 38 to 76 years with a mean age of 55 years) due to a recurrence of CTS. All the patients required nerve coverage using a local or distant flap. There were 19 hypothenar fat flaps; two forearm radial artery flaps, a forearm ulnar artery flap, an ulnar fascial-fat flap and a posterior interosseous flap. Patients were clinically and instrumentally evaluated before the operation. Assessments of the evaluation parameters were classified in excellent, good, fair and poor according to clinical and return to work criteria. RESULTS: Patients were evaluated after a mean follow-up of 51 months (12 to 168 months). The pain evaluation showed an improvement passing from a mean value of 9 to 4. The best results were for those patients in whom the median nerve was undamaged (mean value of 1). Eleven patients obtained excellent results; good results were obtained in twelve cases; two patients demonstrated fair results due to partial median nerve injury. In these cases, a hypothenar fat flap and an ulnar fascial-fat flap were used, respectively. CONCLUSION: Protective coverage of the median nerve by using fascial or fasciocutaneous flaps after failure of CTR and/or unsuccessful re-operations is a good solution to furnish to the median nerve a gliding tissue to avoid adherences with the surrounding tissue of previous surgery. The protection of the nerve can reduce painful symptoms even if it does not permit a return to a painless condition. However, the clinical results in terms of median nerve functional recovery cannot be predicted: if the median nerve is damaged, protective coverage of it by flaps cannot give a favourable result in terms of recovery of both sensory and motor deficits.

[Incidence and causes of failures in wrist arthroscopic techniques]. / Fréquence et causes des mauvais résultats de l'arthroscopie du poignet.

OBJECTIVES: Arthroscopy represents a new and promising technique for the diagnosis and treatment of disorders of the wrist. Causes predis posing to clinical failure can arise during any phase of the approach to a patient who is a candidate for arthroscopic treatment. The author examine the causes of failure during pre-operative diagnostic workup, operative procedure and post-operative rehabilitation program and discus how to prevent them. MATERIALS AND METHODS: Three hundred fifty outpatients who had wrist arthroscopy were reviewed to determine type of procedure, type of anaesthetic, portals used and incidence and nature of preoperative, operative, and postoperative complications. Complications were divided in two groups: major and minor. The first group consists of isolated or combined vascular, nerve and/or tendon injuries, compartment syndrome joint infection and RSD, wrist rigidity. The second group includes transient superficial dorsal ulnar sensory neurapraxia, superficial portal sit infection, skin burns, tendonitis, instrumentation breaking inside the wrist joint, ganglion formation, haematomas. In a separate group othe causes of failure, especially those due to surgical or rehabilitation failures, are considered. RESULTS: Ten cases of surgical and post-surgical complications (2,9%) and 8 other cases of failure considered separately (2,3%) were identified, making a total of 18 cases of clinical failure (5,1%). Among these complications 4 cases were classified as "major" [sensory nerve branch lesions of ulnar nerve (3 cases) and of radial nerve (1 case)] and 6 cases were classified as "minor" [sensory neurapraxia (3 cases), instrumentation breakage (1 case), ganglion formation (1 case), a large subcutaneous haematoma (1 case)]. CONCLUSIONS: Wrist arthroscopy is a sophisticated procedure, requiring dedicated surgical training and a thorough knowledge of joint disorders in order to lower the risks of complications and surgical failures.

[Arthroscopic wrist arthrolysis]. / Arthrolyse arthroscopique du poignet.

Wrist stiffness is a complication of wrist trauma or surgery. Rehabilitation is the treatment of choice to improve the wrist range of motion. Since 1988 we used the arthroscopic wrist arthrolysis. Criteria for patient inclusion in our preop and postop study were wrist stiffness with or without pain, unsuccessful results from rehabilitation after 3 to 6 months. From 1988 to 2003, 47 cases (45 patients: 35 males and 10 females), with a mean age of 36 years were operated on. All the radiocarpal, midcarpal and DRUJ portals were used in relationship with the site of rigidity. At a mean follow up of 58 months (range from 3 to 176 months) no complications were documented. Pain was almost absent in all the cases, mean flexion-extension ROM increased from 92 degrees preop to 106 degrees postop, mean pronation/supination increased from 145 degrees preop to 155 degrees postop, and mean grip strength increased from 25 to 31 kg postop. The average modified Mayo Wrist Score improved from 39 to 87, and the postop DASH Questionnaire obtained an average of 21 points.

[Set-up, portals and normal exploration in wrist arthroscopy]. / Installation, voies d'abord et exploration normale en arthroscopie du poignet.

Arthroscopy is an accepted technique for evaluation of intra-articular pathology and treatment of a variety of disorders even in the wrist joint. Dedicated miniaturized instrumentation is needed along with a specific traction system. The external distraction alone (dry technique) allows for complete joint exploration and several type of arthroscopic surgery, avoiding annoying leaking in the subcutaneous tissues, though further distension of the articular pouches can be achieved by saline infusion (fluid distension or wet technique). Knowledge of surface anatomic landmarks and careful surgical technique are required for proper portal placement and in order to avoid injury to the numerous noble structures crossing nearby. Description of radio- and medio-carpal portals is provided along with the different bony, condral, synovial and ligamentous structures that can be visualised or treated through each portal. Surgeon can choose the most suitable portal for scope or instruments, according to specific needs for diagnostic or therapeutic purposes.

Arthroscopic Resection of Distal Pole of the Scaphoid for Scaphotrapeziotrapezoid Joint Arthritis: Comparison between Simple Resection and Implant Interposition.

BACKGROUND: Isolated scaphotrapeziotrapezoid is a relatively rare condition, and there is still not complete consensus on the treatment of this pathology. PURPOSE: The aim of the present study is to assess the utility of implant interposition after arthroscopic scaphoid distal pole resection for scaphotrapeziotrapezoid arthritis. MATERIAL AND METHODS: The authors present a prospective study after the arthroscopic resection of the distal pole of the scaphoid in 24 patients. In a group of 11 patients, the simple resection was performed while in the other 13 patients the scaphoid resection and pyrocarbone implant interposition. RESULTS: All patients were clinically evaluated with disability of arm, shoulder, hand score. Dorsal intercalated segment instability deformity was also measured from X-ray analysis. Grip and pinch strength were measured too, and patients were also given a visual analog scale questionnaire. Both clinical and radiographic assessments were done at 24 months postoperatively. CONCLUSIONS: The study showed comparable results with both the techniques. LEVEL OF EVIDENCE II: A prospective comparative study.

Budesonide in the treatment of Crohn's disease: a meta-analysis.

AIM: To perform a meta-analysis to assess the effectiveness and safety of oral budesonide for inducing remission in active Crohn's disease and for preventing relapse in Crohn's disease with medically- or surgically-induced remission. METHODS: All randomized, double-blind controlled trials involving oral budesonide therapy in Crohn's disease were retrieved from a Medline search, reviews articles or their bibliographies. Of 83 articles retrieved, 12 met the inclusion criteria. Data extraction was performed by three independent observers and scoring disagreements were resolved by consensus. RESULTS: Six trials tested budesonide in active disease and six in quiescent disease. Budesonide was less effective than conventional corticosteroids for inducing remission of active Crohn's disease (pooled rate difference, RD -8.5%; 95% CI: -16.4 to -0.7%; P=0.02), but corticosteroid-related adverse events were reduced (RD -22.4%; 95% CI: -32 to -12.8%; P < 0.001). In quiescent Crohn's disease, budesonide was as effective as placebo for preventing relapse in medically induced remission (RD -0.8%; 95% CI: -9.9 to 8.3%; P=0.42) and endoscopic recurrence in surgically induced remission (RD -3.5%; 95% CI: -16.9 to 9.8%; P=0.30). In the long term treatment, budesonide had an occurrence rate of corticosteroid-related adverse effects similar to placebo (RD 5.3%; 95% CI: -3.9 to 14.5%; P=0.30). CONCLUSIONS: Budesonide is significantly less effective than conventional corticosteroids for inducing remission in active Crohn's disease, but the risk of corticosteroid-related adverse effects is significantly reduced. Budesonide is not effective in preventing relapse of Crohn's disease after medically- or surgically-induced remission.

Structural specificities and significance for coeliac disease of wheat gliadin peptides able to agglutinate or to prevent agglutination of K562(S) cells.

Two peptides corresponding to bread wheat A-gliadin fragments 31-43 and 44-55, well known for their ability to damage the coeliac disease intestinal mucosa both in vitro and in vivo, have been confirmed to be very active in inducing in vitro agglutination of K 562 (S) cells. Removal of six amino acid residues from the carboxy-terminal end of the 31-43 peptide, or of five amino acid residues from the amino terminal end of the 44-55 peptide, resulted in a lower, but still very significant, cell agglutination activity. The peptide consisting of ten amino acid residues with a molecular mass of 1157.5 Da, isolated from durum wheat gliadin, was able to prevent agglutination of K 562 (S) cells induced not only by prolamine peptic-tryptic digests from all the cereals toxic in coeliac disease (i.e. bread wheat, rye, barley and oats), but also by the 31-43 and 44-55 peptides. The ability to protect K 562 (S) cells from agglutination was exhibited to the fullest extent also by all the peptides derived from the 1157.5-Da peptide by five progressive deletions of the terminal carboxylic residue, whereas the sixth consecutive deletion yielded a completely inactive peptide. A similar total loss of activity was observed upon addition of a glycine residue to the amino terminal residue of the 1157.5-Da peptide and all the above-mentioned active peptides derived from it. The remarkable sequence homologies existing between peptides able to induce [Gln-Gln-Gln-Pro and -Pro-Ser-Gln-Gln-] or to prevent [H2N-Gln-Gln-Pro-Gln-Asp-COOH] induction of cell agglutination strongly suggest that all these peptides compete for identical or structurally related binding sites on the cell surface.

New approaches to the prediction of the folding of membrane proteins with redox function.

A new method is elaborated for determining the hydropathy profile of membrane haemoproteins. The method is called membrane propensity for haemoproteins (MPH) and is based on the statistical analysis of the amino acid composition of the predicted transmembrane regions of cytochrome b from the bc1 and the b6f complexes. The accuracy of the MPH method in predicting the ends of the known transmembrane segments of the reaction center of Rhodopseudomonas viridis is higher than that obtained by hydropathy methods based on physico-chemical parameters. The MPH method is able to clearly exclude from the membrane polypeptides that are not consistently predicted to be transmembrane by other methods or techniques, for instance the region corresponding to helix IV of mitochondrial cytochrome b. A correlation has been found between the shape of the hydropathy profile of the transmembrane segments predicted by this new method and the known structure of the membrane-spanning helices of Rhodobacter reaction centers. From the above correlation it is proposed that the haem-coordinating domain of mitochondrial cytochrome b is folded in a novel structure, called "clepsydra domain", which is formed by distorted transmembrane helices packed in a waisted antiparallel bundle.

Correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls.

We investigated pressures at 1 cm intervals along the carpal tunnel in 39 patients with carpal tunnel syndrome (CTS) and 12 controls. Pressures were measured for relaxed and gripping hand positions in combination with neutral, extended, and flexed wrist positions. Patient pressures exceeded control pressures, were below the previously reported 30 mmHg threshold for four of five locations in the relaxed neutral position and were typically greater in extension than in flexion. In the neutral position, both patient and control pressures were slightly above threshold levels just distal to the tunnel. Maximum intratunnel pressures were generally found in the central part of the tunnel and minimum pressures in the distal tunnel. Gripping hand pressures in the tunnel were lowest with the wrist flexed. In both controls and CTS patients, only in the neutral wrist and relaxed hand positions were pressures highest at the point where nerve conduction studies have indicated the nerve is most likely to be compromised (in the midpalm just distal to the distal margin of the carpal tunnel).

Assessment of sensory nerve conduction in carpal tunnel syndrome before, during and after operation.

Sensory conduction velocities of the median nerve before, during and after operation were compared in nine patients with carpal tunnel syndrome and four controls, in order to evaluate the prognostic value of the pre-operative and intra-operative findings. Sensory conduction velocity was higher after operation than before in all patients (mean difference 31.33%), but not in control subjects. One patient showed a dramatic increase of 157% immediately after decompression. Comparing the intra-operative with the post-operative findings all patients but one showed an increase of antidromic sensory conduction velocity (mean 44.37%), while in control subjects again minimal changes were found (mean -4.25%). The study confirms the high diagnostic value of the pre-operative antidromic sensory conduction velocity findings. However, the prognostic value of both pre-operative and intra-operative ASCV findings is low.

Proximal row carpectomy through a palmar approach.

From 1990 to 1994, nine proximal row carpectomies were done through a palmar approach. With an average follow-up of 20 months, seven of the nine patients were completely painfree. Average range of wrist flexion/extension remained unchanged, and average radial/ulnar deviation increased from 25 degrees to 46 degrees . All the patients demonstrated an increase in grip strength in the operated hand. Four cases showed a slight reduction in articular space and subchondral sclerosis in the radiocapitate articulation, in spite of good function. Dynamic studies demonstrated no sign of radiocarpal instability. All the patients were very satisfied with the results and returned to their previous work within 2 months, on average.

Ischaemic isolated retraction of the abductor digiti minimi.

A case of hyperabduction of the little finger due to ischaemic retraction is presented. Operative release of the abductor digit minimi produced good result. The differential diagnosis is discussed.

Carpal tunnel syndrome in Madelung's deformity.

The authors describe a case of carpal tunnel syndrome due to Madelung's deformity. They discuss the pathophysiological causes of median nerve entrapment to explain the compression which occurs in this disease and its clinical implications. They take also into consideration the surgical approach to the carpal tunnel in this particular condition.

Neurophysiological assessment of the early phases of carpal tunnel syndrome with the inching technique before and during operation.

In 14 patients with early carpal tunnel syndrome, the diagnostic sensitivity of the measurement of the segmental sensory nerve conduction velocity at 1 cm. steps ("inching") was compared with the distal sensory latency and the pre-operative wrist-digit and wrist-palm S.C.V. and with similar measurements made at operation immediately after surgical decompression of the nerve. Before operation, distal sensory latency and wrist-digit S.C.V. were normal in all cases, while wrist-palm S.C.V. was pathological in five patients and inching in all 14 patients. Moreover, inching allowed us to determine the site of the slowing across the carpal tunnel, this being between 1-2 cm. from the distal wrist crease in 57% and between 2-3 cm. in 21% of cases. Focal slowing disappeared immediately after decompression in five patients, as is evident from the intra-operative recordings. Inching is, therefore, the most sensitive diagnostic method in early carpal tunnel syndrome.

Serial overnight recordings of intracarpal canal pressure in carpal tunnel syndrome patients with and without wrist splinting.

In 15 carpal tunnel syndrome patients pressure was measured during the day and at 2-hourly intervals from midnight to 6 a.m., via a catheter introduced into the carpal canal, using the constant infusion technique. Intracarpal tunnel pressure of the patients always exceeded the critical pressure of 30 mmHg and the highest values were found at 6 a.m. Slightly lower pressures were found when the wrist was splinted, but the difference was not significant, nor were critical pressure levels prevented by splinting.