The relationship of pre- and postoperative median and ulnar nerve conduction measures to a self-administered questionnaire in carpal tunnel syndrome.

STUDY AIMS: Following carpal tunnel release (CTR), only very modest correlations have been found between subjective symptoms and function indexes compared to neurophysiological measures. The objective of this study was to evaluate this relationship by comparing the self-administered Boston symptom severity score and function severity score questionnaire against nerve conduction studies (NCS) before and after CTR using two different electrophysiological techniques. PATIENTS AND METHODS: Carpal tunnel release was performed in 51 patients (62 hands). Pre- and postoperative NCS were evaluated using both conventional neurophysiological methods and by means of a new hand-held device. RESULTS: Preoperatively there was almost no correlation between symptom severity and function scores and NCS results. Following surgery however, both symptom severity and function showed a modest, but significant improvement in their correlation to NCS (at highest r=0.405, P<0.01). This improvement in the relation of subjective measures to neurophysiological results was seen in both median nerve sensory and motor conduction as well as in ulnar nerve motor conduction. CONCLUSIONS: In addition to median-nerve dysfunction, it might be suggested that ulnar nerve changes can contribute to symptoms of carpal tunnel syndrome in patients. Several associations were found using a median-ulnar sensory latency difference in the finger-wrist segment and a sensory conduction difference in the palm to wrist segment. Significant correlations were established by both conventional NCS and the new hand-held device.

Outcome of carpal tunnel decompression: the influence of age, gender, and occupation.

The aim of this study was to investigate the effect of age, gender, and occupation on the outcome of carpal tunnel decompression. A total of 479 patients (342 females, 137 males) with a mean age of 56 years undergoing 608 carpal tunnel decompressions were prospectively studied. Outcome was assessed using the Brigham Hospital carpal tunnel questionnaire at two weeks pre-operatively and six months post-operatively. Cases were divided into four age categories (less than 40 years of age, 40-59, 60-79, and over 80 years of age) and two occupation (repetitive and non-repetitive) groups. The mean differences for both the symptom-severity and functional-status scores amongst the four age categories were similar and no significant difference was found. The mean differences for both the symptom-severity and functional-status scores between females and males and the two occupation groups were similar and no significant differences were found. The majority of the patient's symptoms improved following carpal tunnel decompression. However, we found no influence of age, gender, or occupation on the outcome of carpal tunnel decompression in our series of patients.

Pigmented villonodular synovitis of the talonavicular joint: a case report and review of the literature.

Pigmented villonodular synovitis (PVNS) is a locally aggressive synovial proliferative disorder of unknown aetiology affecting the linings of joints, tendon sheaths, and bursae. A 22-year-old female patient presented with a 3-year history of an increasingly painful swelling on the dorsum of her right foot. Examination revealed a 4 cm x 2 cm swelling that was fluctuant, tender on palpation, unattached to overlying skin and partially mobile. A firm, pedunculated intra-articular lesion from the talonavicular joint was removed at surgery. Histology revealed a nodular lesion of stromal cells and numerous giant cells with villous architecture as well as abundant haemosiderin deposition with foamy macrophages (in keeping with PVNS). The patient is currently under review by the orthopaedic oncology team. Talonavicular joint PVNS is rare. MRI scanning is the optimum investigation. Complete excision is necessary to minimise high risk of recurrence.

Comparing the outcome of a carpal tunnel decompression at 2 weeks and 6 months.

PURPOSE: The purpose of the study was to evaluate if 2-week Levine score can provide an adequately responsive outcome measure in carpal tunnel decompression by comparing it with 6-month score. METHODS: The treatment outcome of 300 patients with carpal tunnel decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 56 years, 71% (214) were women, and 55% (167) of operations were performed on the right hand. All patients were scored using the Levine questionnaire preoperatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated. RESULTS: Although statistical significance was found between the preoperative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months after surgery. Multiple regression analysis with the 2 week-6 month score difference as the dependent variable shows a predictable outcome at 2 weeks. CONCLUSIONS: We conclude that the Levine score at 2 weeks is a reliable, responsive, and practical instrument for outcome measure in carpal tunnel surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium-term results in a high percentage of treated patients. We conclude that the 2 time points, 2 weeks and 6 months, are equivalent in outcome because a less than 10-point difference is not clinically meaningful.

Clinical outcome following a modified approach for psoas lengthening for coxa saltans in adults.

Internal snapping often resolves with conservative treatment but persistent significant symptoms may require surgical treatment. Different surgical approaches have been suggested in the literature with varying results. We describe a modified surgical approach for internal snapping of hip in adults with good results. Patients who failed conservative treatment for internal snapping over 11/2 years were included. A skin crease incision was made just lateral to the ASIS in supine position. The psoas tendon was reached sub-periosteally along the internal iliac surface and a hole was made in periosteum. Then the tendon was hooked into the wound and divided releasing its musculotendinous junction. The patients were allowed to mobilise as able in the postoperative period. There were 8 snapping hips (7 patients, 6 females) with average age of 30 years (17-51 yrs). The mean follow-up was 11 months. The average duration of symptoms before operation was 4.5 years (range 2-10 years). Painful symptomatic clicking was relieved in all patients. Two patients felt slight weakness of hip flexion. One patient had temporary neuropraxia of lateral cutaneous nerve of thigh. The diagnosis is made by ultrasound or examination for a palpable click. Surgical correction of snapping is considered after failure of conservative treatment. Different extrapelvic (medial and iliofemoral) and intrapelvic extraperitoneal approaches have been described with varying results. With our slightly modified intrapelvic and subperiosteal approach through oblique inguinal incision in adults, psoas muscle release at musculotendinous junction seems a safe and effective method and could be used as an alternative surgical approach for treatment of internal snapping of hip in adults.

Accessory soleus muscle: a case report and review of the literature.

Accessory soleus muscle is a rare condition which presents as a soft-tissue mass medial to the calcaneum and distal Achilles tendon. Though congenital in origin, it manifests in the second and third decades of life as a soft-tissue mass due to muscle hypertrophy. Patients may be asymptomatic or present with a painful ankle mass. It is important to be aware of this condition when interpreting CT or MRI of the ankle, which show characteristic findings of a normal muscle in an abnormal location.

Autophor cementless total hip arthroplasty for osteoarthrosis secondary to congenital hip dysplasia.

The authors present a consecutive series of 38 arthroplasties for osteoarthrosis secondary to hip dysplasia. All arthroplasties were performed by a single surgeon using Mittelmeier II (Autophor, Osteo AG, Selzach, Switzerland) ceramic cementless components. Crowe grades of subluxation were 60% grade I, 16% grade II, 12% grade III, and 12% grade IV. In all cases, the acetabular component was seated in the true acetabulum. The mean follow-up period was 75 months (range, 40-122 months). By the time of review, six hips (16%) had required revision for aseptic loosening, mainly of the femoral component. Good or excellent results were achieved in only 63% of the patients. In the group of surviving arthroplasties, the median Charnley hip scores before surgery were: pain, 2; movement, 3; and walking, 3. After surgery, the scores were: pain, 5; movement, 5; and walking, 6. All improvements were significant. The mean postoperative Harris hip score was 84. Poor scores were associated with contralateral hip disease (2 cases) and spina bifida (2 cases), significantly affecting function. The Autophor prosthesis can produce satisfactory results in some of these young patients with hip dysplasia. However, femoral loosening is a major problem and because of this, the authors have since changed to a newer stem design.

Revision of failed open reduction of congenital dislocation of the hip.

We report a review of 33 hips (32 patients) which had required repeat open reduction for congenital dislocation of the hip. They were followed up for a mean of 76 months (36 to 132). Factors predisposing to failure of the initial open reduction were simultaneous femoral or pelvic osteotomy, inadequate inferior capsular release, and inadequate capsulorrhaphy. Avascular necrosis had developed in more than half the hips, usually before the final open reduction. At review, 11 of the hips (one-third) were in Severin grade 3 or worse; five had significant symptoms and only ten were asymptomatic and radiographically normal. Once redisplacement has occurred after primary open reduction, attempts to reduce the head by closed means or by pelvic or femoral osteotomy are usually unsuccessful and a further open reduction is necessary.

Tibial external fixation, weight bearing, and fracture movement.

Axial fracture movement and loading has been measured during weight bearing in 45 patients with tibial diaphyseal fractures treated with unilateral external skeletal fixation. Mean axial fracture displacement reached a maximum of 0.6 mm between seven and 12 weeks postfracture. Very little movement occurred during the first five weeks after fracture. A micromovement module attached to the fixator increased axial movement at the fracture site by 50% during walking. Weight bearing reached 75% of mean body weight by ten weeks after the fracture. Weight bearing was not decreased by any biofeedback mechanism. A randomized prospective clinical study of diaphyseal tibial fractures treated with external fixation showed a significant reduction in time to healing when micromovement was imposed. Controlled fracture site movement can be imposed very early after fixator frame application when mechanical stimulation may be most effective, and the active loading by the patient is least.

Epiphyseal distraction for bony bridges: a biomechanical and morphologic study.

Partial physeal bridges were produced by resecting part of the lower femoral physis in 8-week-old rabbits. After 4 weeks, an external fixator, strain-gauged to measure distraction forces, was applied across the physis. Distraction was performed for 15 days: 1.0 mm/day medially and 0.5 mm/day laterally. Weekly radiographs were obtained. Animals were killed at 0, 3, and 6 weeks after distraction. Characteristic force patterns were evident if the bridge fractured. Medial fixator forces just before bridge fracture were very high (mean 89 N, SD 28 N), although forces in the lateral fixator were low (mean 25 N, SD 15 N). All animals killed 3 and 6 weeks after distraction ceased showed complete physeal closure. Results suggest that distraction epiphysiolysis may have high potential for producing premature physeal fusion.

Revision total hip arthroplasty for aseptic failure. A review of 276 cases.

The results of 276 cemented revision total hip arthroplasties performed for aseptic failure between 1977 and 1986 have been reviewed. The mean time between revision and review was 75 months (range 30 to 144). Of 220 cases available for review, 159 were assessed clinically and radiographically, and 32 by postal questionnaire. Eighteen hips required further revision, 12 for loosening, two for sepsis, two for persistent pain, and one each for fracture and recurrent dislocation. A further six hips were radiologically and symptomatically loose. Pain was mild or absent in 83%. Over half were able to walk a mile or more; 70% flexed more than 70 degrees; 15% had a flexion deformity, but in only 7% was this more than 10 degrees. The mean Harris hip score was 74. Survival at five years was 95% and at 10 years, 77%.

Biomechanical measurement of fracture healing.

Three techniques for measuring fracture healing are presented. These techniques are: (1) use of strain gauge measurements of the forces in an external fixator to determine fracture stiffness, (2) measurement of the vibration modes of a fractured long bone compared to the unfractured contralateral and (3) comparison of the ultrasound velocity across the fracture site with that for the normal unfractured bone. Examples of clinical results obtained using these techniques are presented, and the advantages and disadvantages of each technique are discussed.

The Oxford Knee for unicompartmental osteoarthritis. The first 103 cases.

The Oxford Knee, a resurfacing prosthesis with a meniscal bearing, can be used for either bicompartmental or unicompartmental arthritis. The first 103 unicompartmental cases are presented at a mean time since operation of 36 months (range 21 to 56 months). In those cases with surviving arthroplasties, pain was relieved in 96%. The full range of pre-operative flexion was maintained and flexion deformity was improved from a mean of 6.7 to 5.4 degrees. Stability and alignment were restored to normal in nearly all the knees. Absence of the anterior cruciate ligament was associated with a significantly greater incidence of failure. Six failures occurred in 37 knees lacking a normal anterior cruciate ligament (16.2%); three occurred in 63 knees with a normal anterior cruciate ligament (4.8%) (p less than 0.02). Criteria for the future selection of patients have been deduced from our experience. The operation is recommended for knees with severe unicompartmental osteoarthritis in which all the ligaments are still intact.

Gas gangrene in a diabetic after intramuscular injection.

A 47 year old male insulin-dependent diabetic developed two synchronous life-threatening Clostridium perfringens infections under unusual circumstances. Numerous sterile abscesses were also present, being the result of regular pentazocine intramuscular injections. Extensive surgical debridement and parenteral antibiotic therapy proved effective in treating the septicaemia and the large soft tissue abscesses in the buttock and thigh. The patient made an excellent functional recovery. The pathogenesis of gas gangrene after injection is discussed with particular reference to the diabetic patient.

The Attenborough knee. A four- to ten-year review.

The results of 132 Attenborough total knee replacements after a follow-up period of from four to 10 years are presented. Long-term relief of pain and improvement in stability and walking distance were maintained in over two-thirds. The cumulative survivorship with the prosthesis in situ, little or no pain and no radiological loosening was 65% at six years. Problems with wound healing were common, and there was a complication rate of 20% in primary replacements, including a deep-infection rate of 3.5%. Almost 20% of the prostheses needed revision because of aseptic loosening, and there is evidence of radiological and clinical loosening in a further 7.5%.