Assessing damage in individual joints in rheumatoid arthritis: a new method based on the Larsen system.

OBJECTIVES: To evaluate observer agreement using the Larsen system (LS) and a Modified Larsen system (ML) when assessing individual joints of the hands and wrists in rheumatoid arthritis, and to compare the two systems. To determine the minimally important difference (MID) for the ML. METHODS: Thirty radiographs of hands and wrists from 10 patients who presented with RA were graded by two blinded observers, using the LS and then the ML. Patients were followed for a mean of 7.2 years (range: 4-10 years). Inter- and intra-observer agreement were calculated using the kappa statistic with linear incremental weights. Inter-observer agreement was also computed for the summed score, using an intraclass correlation coefficient. Inter-observer error was estimated by calculating the mean and standard deviation of the grading differences between the two observers. Prevalence of damage was calculated as a ratio of damage: no damage and expressed as a percentage. Pairs of radiographs were comparatively graded using a seven-point Likert scale. RESULTS: The kappa statistic for inter-observer agreement was 0.38 (marginal reproducibility) for the LS and 0.52 (good reproducibility) for the ML (P = 0.004). Using a difference of one grade as perfect agreement, it was 0.56 (good reproducibility) for the LS and 0.87 (excellent reproducibility) for the ML (P = 0.001). Intra-observer agreement was high in both systems. The distribution of ML-grade differences varied according to the level of the Likert scale: for "a little bit worse", representing the smallest amount of detectable damage progression, the distribution differences peaked around two grades. This value represented a MID 87% of the time. CONCLUSIONS: The LS lacks precision for individual joints. The ML, it is proposed, has more detailed definitions of grades, and is more reliable. When pairs of radiographs were compared, a two-grade difference on the ML was the MID.

Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis.

We conducted this study to determine the relative influence of various mechanical and patient-related factors on the incidence of dislocation after primary total hip asthroplasty (THA). Of 2,023 THAs, 21 patients who had at least 1 dislocation were compared with a control group of 21 patients without dislocation, matched for age, gender, pathology, and year of surgery. Implant positioning, seniority of the surgeon, American Society of Anesthesiologists (ASA) score, and diminished motor coordination were recorded. Data analysis included univariate and multivariate methods. The dislocation risk was 6.9 times higher if total anteversion was not between 40 degrees and 60 degrees and 10 times higher in patients with high ASA scores. Surgeons should pay attention to total anteversion (cup and stem) of THA. The ASA score should be part of the preoperative assessment of the dislocation risk.

Computer-assisted decision analysis in orthopedics: resurfacing the patella in total knee arthroplasty as an example.

The purpose of the present study was to illustrate the use of computer-assisted decision analysis in making decisions in the field of orthopaedic surgery, using the choice between resurfacing and not resurfacing the patella in total knee arthroplasty as an example. We used a decision analysis technique based on probability theory and on Bayesian logic, with the help of an especially developed computer software. The process involves building a decision tree, searching for probabilities and utilities in the literature, folding back the tree to compute the baseline result, and running sensitivity analyses. Our literature search provided 26 useful articles, only 3 of which were randomized controlled trials. In the baseline analysis, both options were rated similarly, with resurfacing the patella faring slightly better. Sensitivity analyses revealed that not resurfacing becomes the procedure of choice if the probability of postoperative anterior knee pain with an unresurfaced patella falls below 14%, or if the probability of having pain with a resurfaced patella rises above 8% or if the utility of patellar implant failure falls below 80% of the utility of a perfect health state. Computer-assisted decision analysis is a promising, evidence-based tool to assist clinical decision making in orthopaedic surgery. However, its validity is limited by the poor quality of data found in the orthopaedic literature, especially the scarcity of randomized controlled trials.

Outcome of total hip replacement for avascular necrosis in systemic lupus erythematosus.

OBJECTIVE: To describe the short and medium term results of total hip arthroplasty (THA) for avascular necrosis in patients with systemic lupus erythematosus (SLE). METHODS: Nineteen patients with SLE and avascular necrosis of the femoral head (AVNFH), who underwent 26 THA were retrospectively reviewed with a minimum followup of 2 years. To determine whether these patients had results similar to those of patients with other conditions, we formed a control group of 19 patients who had 29 THA. They were matched for age, sex, and followup to the patients with SLE. Controls had THA for juvenile rheumatoid arthritis (n = 7), osteoarthritis (5), adult onset rheumatoid arthritis (8), developmental dysplasia of the hip (4), and other diagnoses (5). Outcome measures included a 10 point visual analog scale (VAS) for pain, the Harris hip score, and the SF-36 self-administered health outcome questionnaire. We used the methods of Delee, Harris, and Engh for radiological assessment. RESULTS: Mean age at surgery was 46 years (range 21-71 years) and average followup was 4 years, 7 months (range 1 yr 9 mo to 9 yrs 6 mo), similar in both groups. Technical problems, mostly consisting of small, nonpropagating cracks of the calcar in uncemented stems, were encountered in 4 SLE hips and 1 control hip. Six complications were noted in the SLE group, including 2 early, nonrecurrent dislocations, 1 patient with thigh pain for 1 year, 1 pericarditis, 1 sick-sinus syndrome, and 1 urinary tract infection. There was one case of urinary tract infection in the control group. One SLE patient developed a low grade prosthetic infection and underwent successful revision 2 years after primary surgery. Clinical outcome measures had similar scores in the 2 groups: average VAS pain score = 2.00 in SLE hips (maximum 10) and 1.97 in control hips; mean Harris hip score = 86.7 in SLE patients (maximum 100) and 81.9 in controls; average SF-36 score = 63.4 in SLE patients (maximum 100) and 60.5 in controls. There was no radiological evidence of implant loosening in controls; there was 1 asymptomatic cup migration in the SLE group. CONCLUSION: In the short and medium term, patients with SLE and AVN had good results after THA. Results were similar in patients who had hip replacement for other diagnoses. Less favorable clinical outcomes of hip replacement have been reported in young patients who have AVN of other etiology (e.g., alcoholic, post-traumatic), but this was not the case in our young patients who had AVN and SLE. Thus, AVNFH and SLE should not constitute a contraindication to hip replacement.

Type and outcome of reconstructive surgery for different patterns of psoriatic arthritis.

OBJECTIVE: To describe our experience of musculoskeletal surgery in patients with different patterns of psoriatic arthritis (PsA). METHODS: From 1986 to 1996, 71 operations in 43 patients with established PsA were performed at our institution. The patterns of PsA recognized in this patient group were: distal PsA, oligoarticular PsA, and polyarticular PsA, with or without associated spondylitis. Surgical findings and procedure, intra- and postoperative complications were recorded. Nineteen patients were available for clinical evaluation, both by conventional surgeon generated and by patient generated self-administered questionnaires. RESULTS: The majority of patients had polyarticular PsA. All operations in patients with distal PsA were distal interphalangeal (DIP) and proximal interphalangeal (PIP) joint fusions. All operations in patients with oligoarticular PsA involved the hip or knee. Polyarticular patients underwent a range of procedures. Soft tissue contractures and bone loss required specific attention in 14 procedures. In the 19 patients who were reviewed clinically, conventional scoring of individual procedures showed good to excellent results. Patient oriented outcomes had low scores compared to a disease-free general population. CONCLUSION: The 3 principal patterns of PsA are associated with different types of surgery. Although traditional surgeon generated scores evaluating individual procedures indicated results comparable to patients who have osteoarthritis, patient generated outcome measures of global health and function scored substantially lower than a general, arthritis-free population, reflecting the burden of polyarticular involvement.

[Chlamydia abortion in sheep: possibilities for serological diagnosis using a competitive ELISA and insight into the epidemiologic situation in Switzerland]. / Chlamydienabort beim Schaf: Möglichkeiten der serologischen Diagnostik mit einem kompetitiven ELISA und Einblick in die epidemiologische Situation in der Schweiz.

466 sheep sera out of 19 flocks in Switzerland were examined by a competitive enzyme linked immunosorbent assay (cELISA) for antibodies against Chlamydia psittaci "serotype 1" ("ovine enzootic abortion"). Since numerous positive reactors were found in flocks without abortion history, 30 fecal samples out of two of these flocks were examined by PCR for evidence of chlamydial DNA. One of these samples turned out to contain DNA of Chlamydia psittaci "serotype 1". These results suggest, that in Switzerland "serotype 1" of Chlamydia psittaci is widespread not only as cause of chlamydial abortion but also as latent intestinal infection in sheep. The resulting difficulties for serological diagnosis of chlamydial abortion and possible solutions based on the cELISA are discussed. The complement fixation test (CFT), still considered as standard method for serological examination for Chlamydiae, has additionally been applied.

The Simmen classification of wrist destruction in rheumatoid arthritis. Experience in patients with early disease.

In this radiological study, bilateral radiographs of the wrist in 48 patients with early rheumatoid arthritis (RA) were graded by the Simmen classification, at different times, to determine its potential use in early disease. Interobserver agreement was good. The Simmen classification of wrist destruction in RA could be applied to the radiographs of approximately 50% of patients with early disease. It has some consistency over time.

Musculoskeletal surgery in psoriatic arthritis.

OBJECTIVE: To determine the probability that patients with psoriatic arthritis (PsA) will require musculoskeletal surgery. To identify factors predictive of surgery in patients with PsA. To determine the clinical outcome of patients with PsA who underwent surgery compared to patients who did not. METHODS: The database of the Psoriatic Arthritis Clinic was searched to identify individuals who had undergone musculoskeletal surgery. Biological and clinical data such as erythrocyte sedimentation rate (ESR), rheumatoid factor, clinical pattern, nail changes, functional class, number of inflamed joints, and radiological damage, as well as health scores such as Arthritis Impact Measurement Scale 2 (AIMS-2), SF-36, and Health Assessment Questionnaire (HAQ) were available for these patients. Patients who had surgery were compared to those who did not. RESULTS: Out of 444 patients with confirmed PsA, 31 had musculoskeletal surgery (6.98%). This probability increased with the duration of PsA. Surgery patients had their first operation at an average of 13.9 years (range 1-46) after onset of joint disease. Age at onset of PsA, clinical pattern, constancy of clinical pattern over time, rheumatoid factor, functional class, symmetry, nail changes, and the time separating the onset of skin disease and the onset of joint disease were not significantly different at the 0.05 confidence level. Patients who had surgery had significantly more radiological damage (p < 0.001) and more actively inflamed joints (p < 0.02) at first assessment than patients who did not. AIMS2, SF-36, and HAQ scores at final review were not statistically different across both groups. CONCLUSION: In our patients the probability of having musculoskeletal surgery for PsA was 7%. It increased with disease duration. Patients had their first surgery after an average of 13 years. The number of actively inflamed joints and the extent of radiological damage at first assessment were highly predictive of subsequent surgery: patients with the highest numbers of severely affected joints, both clinically and radiologically, were more likely to have surgery. "Baseline characteristics" such as ESR, rheumatoid factor, functional class, clinical pattern, nail changes, and symmetry were not predictive of subsequent orthopedic surgery.

[Use of laser in arthroscopy of the ankle. Indications, method, first results]. / Laseranwendung in der Arthroskopie des oberen Sprunggelenks. Indikationen, Technik, erste Ergebnisse.

As in the knee joint, lasers can be used during ankle arthroscopy for their resective and ablative properties. Reports on arthroscopic treatment of degenerative and post-traumatic disorder of the ankle by conventional techniques are encouraging. We have used laser in ankle arthroscopy in three main situations: (1) When exuberant scar tissue from previous capsulo-ligamentous damage (e.g. after ankle sprain) symptomatically restricts range of motion and causes pain (ankle impingement). Laser is used in this case at middle energy, as a resector. (2) In the presence of cartilaginous lesions, as in osteoarthritis, flake fractures or osteoarthritis, flake fractures or osteochondrosis dissecans. Here laser is used at lower energy to reshape the cartilaginous surface without resective effect ("welding"). (3) When impaired range of motion is due to osteophytic rims, mainly at the anterior tibia, resulting from previous capsular lesions. Laser is then used at high energy to cut excessive bone. A series of 16 patients underwent ankle arthroscopy at our clinic, mainly for post-traumatic disorders, including impingement, osteochondrosis dissecans and osteoarthritis. The most frequently encountered intraarticular findings were impingement by post-traumatic synovitis and scar tissue of the anterio-lateral and postero-lateral compartments, with or without an osteophytic rim of the distal anterior tibial border. Scar tissue, synovitis and osteophytes were debrided in half of the patients purely mechanically (with arthroscopic scissors or shaver) and in the other half with the holmium laser. The results are encouraging; 50% of patients had no symptoms at all at follow-up (9.5 months on average), and another 38% were satisfied with a significant improvement. In two cases, no improvement at all occurred: one patient complained of persistent pain with lack of objective findings and is believed to have developed "insurance neurosis." The other had severe postinfectious osteoarthritis that was operated too late in the course to influence pain positively. Concerning the clinical, functional and subjective follow-up results there was no relevant difference between the two groups. We recommend ankle arthroscopy to treat post-traumatic impingement syndromes of the antero-lateral, antero-medial and postero-lateral compartments of the ankle joint; the use of lasers seems to have a slightly better analgetic effect, allows an easier approach than is the case with shavers or other bulky arthroscopic resectors, and allows shaping of convex resection surfaces, which cannot be performed with a shaver.

MRI findings in Caroli's disease and intrahepatic pigmented calculi.

This paper reports a case of Caroli's disease confined to the left lobe of the liver that mimicked left portal vein thrombosis on MRI studies because of the very high signal intensity on T1-weighted images of intrahepatic pigmented calculi. The preoperative diagnosis was a cholangiocarcinoma infiltrating the left hepatic bile duct and portal branch. The final macroscopic and histological diagnosis was Caroli's disease of the left liver lobe with wide enlarged left bile duct containing multiple pigmented calculi.

[Hospital management and short-term outcome of the severely injured: Lausanne experience]. / Prise en charge hospitalière et évolution à court terme des blessés graves: expérience Lausannoise.

Several physiological and anatomical methods of scoring severely injured patients have been developed since the 1970s, based on very large series of patients. In this study, 59 patients are assessed by the ISS (Injury Severity Score) and the RTS (Revised Trauma Score). The mean ISS is 28, and the mean RTS is 6; the overall evolution shows a 42.4% mortality. Analysis by the TRISS method shows 12 out of 18 "unexpected" deaths, the majority of which can be explained by the fact that the ISS underestimates severe neurological trauma, and that the RTS is not consistently obtained in the early patient notes in our emergency care system.

Spontaneous ruptures of flexor tendons secondary to extreme DISI deformity of the lunate in a rheumatoid wrist. A case report.

Spontaneous flexor tendon ruptures in rheumatoid arthritis are associated with flexor tenosynovitis and/or with attrition due to bony prominences in the carpal tunnel. The commonest bony prominence observed is the distal pole of a rotated scaphoid. We are reporting the case of an eighty-year-old woman with long-standing rheumatoid arthritis who presented with the inability to actively flex both the interphalangeal and the metacarpophalangeal joints of the right index finger, with preservation of passive motion. There was also loss of active flexion of the interphalangeal joint of the right thumb. Roentgenograms revealed a marked dorsal intercalated segment instability (DISI) pattern in both wrists associated with advanced joint destruction and collapse. Surgical exploration revealed total rupture of the FDS and FDP of the index finger and of the FPL, as well as partial rupture of the flexor tendons of the long finger. Rupture of the FPL was found to be due to attrition on the relatively common finding of a prominent and malrotated scaphoid. Ruptures of the flexor tendons of the index and long fingers appeared to be caused by a markedly prominent palmar protrusion of the lunate. Surgical repair was undertaken, including correction of the DISI deformity and reconstruction of carpal height by radiolunate fusion from a palmar approach. In addition the tubercle of the scaphoid was resected, and the FDS tendon of the ring finger was transferred to the distal stump of the FDP of the index finger; the FPL tendon was not reconstructed as arthrodesis of the interphalangeal joint of the thumb was planned at a later date.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction and stabilization of lumbar and thoracolumbar spine fractures with Louis' plates and internal fixator: a comparative study.

In this retrospective study, 28 patients who presented isolated fractures from T11 to L4 were surgically treated using a posterior approach. The fractures were reduced and stabilized in half of the cases with Louis' plates and in the other half with an internal fixator. Twelve patients had partial neurological deficits on admission. They were reviewed after a mean period of 24 months from time of injury, and 10 months after implant removal. The kyphosis of the fractured vertebral body was measured, and showed a mean value of 18 degrees before surgery and 10.3 degrees at the last visit. The regional statics of the spine were also studied. The residual mobility of the fixated and neighbouring spinal units was assessed, comparing "long" segment fixation (plates) with "sh ort" segment fixation (internal fixator). The residual mobility of the adjacent, non-fixed segments was significantly better when the internal fixator had been used than with the Louis' plates. Of the 12 patients with neurological involvement, 11 had increased their Frankel score by one grade. Results were evaluated by clinical parameters (pain, neurological deficit, occupational disability); scores were as follows: 32% good, 57% satisfactory and 11% poor. There was no significant difference in clinical score between the two treatment modalities.

[Analysis of health care needs and evaluation five years after severe brain injuries]. / Bedürfnisanalyse und Bilanz 5 Jahre nach schweren Hirnverletzungen.

Five years after severe head injury with persistent and extensive deficits of brain functions and loss of working capacity, an assessment and analysis of demand was performed with 31 patients and their relatives. The main impairments consist in the severe changes of personality and in cognitive deficits; they contrast with the spare physical handicaps. A main demand of the relatives are local family groups which are still lacking in many parts of the country.

Adjusted hypervolemic hemodilution in acute ischemic stroke.

We prospectively randomized 47 patients with acute ischemic stroke of the middle cerebral artery of less than 24 hours' duration to either adjusted hypervolemic hemodilution or control treatment and followed them up for 90 days. Rapid hemodilution to a target hematocrit of 30-35% as monitored with bedside determinations was achieved by using infusions of dextran 40, venesections, and infusions of additional crystalloid solution when necessary. There was no difference in the death rate between the two treatment groups. Of these 47 patients, 37 (19 in the hemodilution group and 18 in the control group) could be followed up for the entire study period of 3 months. The relative improvement in neurologic function from day 1 to days 8, 21, and 90 was significantly better in the hemodilution group than in the control group. In accordance, special tests for fine motor control of the paretic arm disclosed better performance in the hemodilution group. The frequency of patients with severe disability was significantly lower in the hemodilution group on days 8 and 21. Plasma viscosity (measured in 11 patients) was not affected by infusions of dextran 40. Vigorous hypervolemic hemodilution in patients with acute ischemic stroke is well tolerated and improves early neurologic outcome with an effect lasting at least 3 months.

[Rehabilitation of polytraumatized brain-injured patients]. / Die Rehabilitation von polytraumatisierten hirnverletzten Patienten.

After head injury, motor deficits (paralysis, spasticity, ataxia) dominate together with cognitive and personality disturbances. Optimal positioning and physiotherapy is important in early treatment to prevent complications later, due to spasticity. Memory and learning deficits can be compensated for with alternate cognitive strategies. Restoration of function after severe cognitive deficits takes a minimum of one year. Personality changes are disruptive to the rehabilitation process and to family reintegration. Therefore an intensive support system for the family is needed.

'Fusimotor set': new evidence for alpha-independent control of gamma-motoneurones during movement in the awake cat.

The discharge activity of single muscle spindle receptors was recorded in freely moving cats. Large changes in responsiveness to length variations was observed in different types of movement. In separate stimulations on anaesthetised cats, the activity of the gamma-fusimotor neurones responsible for these changes was reconstructed. The results suggested that fusimotor action on a given spindle afferent during the movements studied was not rigidly alpha-linked, but 'set' by the CNS to steady levels, and that it could switch from largely static (gamma s) to largely dynamic (gamma d) according to the motor tasks performed.

The effect of dorsal root transection on the efferent motor pattern in the cat's hindlimb during locomotion.

Mesencephalic cats can walk on a treadmill if the midbrain locomotor region is stimulated. The motor pattern of different hindlimb muscles is similar to that of th intact cat. The present experiments in the mesencephalic preparation test if the complex motor pattern in one hindlimb is causally dependent on the afferent signals arising in the same limb during walking. The electromyographical activity and the movement pattern during locomotion were compared before and after transecting all dorsal root fibres originating from one hindlimb. Flexor and extensor muscles at different joints may retain their general pattern after the dorsal root transection. This applies also to muscles such as the knee flexors, which have a short and early flexor burst and a second burst during the extension phase, and the short toe dorsiflexor , which has an early burst in the transition between flexor and extensor activity. After the dorsal root transection the pattern of activity may become more variable and it can even break down altogether. The present results demonstrate that the central nervous system devoid of phasic afferent inflow from one hindlimb can produce a complex motor output to this limb rather than a motor pattern degraded to a simple alternation between flexors and extensors.