Outcomes of ulna shortening osteotomy: a cohort analysis of 106 patients.

BACKGROUND: Ulna shortening osteotomy (USO) for ulnar impaction syndrome (UIS) aims to improve pain and function by unloading the ulnar carpus. Previous studies often lack validated patient-reported outcomes or have small sample sizes. The primary objective of this study was to investigate patient-reported pain and hand function at 12 months after USO for UIS. Secondary objectives were to investigate the active range of motion, grip strength, complications, and whether outcomes differed based on etiology. MATERIALS AND METHODS: We report on 106 patients with UIS who received USO between 2012 and 2019. In 44 of these patients, USO was performed secondary to distal radius fracture. Pain and function were measured with the Patient Rated Wrist/Hand Evaluation (PRWHE) before surgery and at 3 and 12 months after surgery. Active range of motion and grip strength were measured before surgery and at 3 and 12 months after surgery. Complications were scored using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions (ICHAW) tool. RESULTS: The PRWHE total score improved from a mean of 64 (SD = 18) before surgery to 40 (22) at 3 months and 32 (23) at 12 months after surgery (P < 0.001; effect size Cohen's d = -1.4). There was no difference in the improvement in PRWHE total score (P = 0.99) based on etiology. Also, no clinically relevant changes in the active range of motion were measured. Independent of etiology, mean grip strength improved from 24 (11) before surgery to 30 (12) at 12 months (P = 0.001). Sixty-four percent of patients experienced at least one complication, ranging from minor to severe. Of the 80 complications in total, 50 patients (47%) had complaints of hardware irritation, of which 34 (32%) had their hardware removed. Six patients (6%) needed refixation because of nonunion. CONCLUSION: We found beneficial outcomes in patients with UIS that underwent USO, although there was a large variance in the outcome and a relatively high number of complications (which includes plate removals). Results of this study may be used in preoperative counseling and shared decision-making when considering USO. LEVEL OF EVIDENCE: Therapeutic III.

Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a randomized controlled trial.

BACKGROUND: Both trapeziectomy with ligament reconstruction and tendon interposition and trapeziometacarpal arthrodesis are commonly performed procedures for the treatment of trapeziometacarpal osteoarthritis. The purpose of this study was to compare the outcomes of both treatments for symptomatic osteoarthritis of the thumb trapeziometacarpal joint in a randomized trial. METHODS: Women who were forty years of age or older were randomized either to trapeziectomy with ligament reconstruction and tendon interposition or to arthrodesis with plate and screws. Patients were evaluated preoperatively and at three and twelve months postoperatively with respect to pain, function (Patient-Rated Wrist/Hand Evaluation [PRWHE] and Disabilities of the Arm, Shoulder and Hand [DASH] questionnaires), joint motion, strength, complication rate, and patient satisfaction. RESULTS: Forty-three patients were enrolled. Since we found significantly more moderate and severe complications following arthrodesis compared with trapeziectomy with ligament reconstruction and tendon interposition (71% versus 29%; p = 0.016), the study was prematurely terminated before the sample size necessary to validly compare the two groups was reached. The higher complication rate for arthrodesis led to an increase in revision surgery (two of seventeen patients). Significantly more patients in the ligament reconstruction and tendon interposition group (86%) than in the arthrodesis group (53%) indicated they would consider the same surgery again under the same circumstances (p = 0.025). In both groups, PRWHE and DASH scores significantly improved over time; however, comparison of the groups showed that the results were similar. CONCLUSIONS: Women who are forty years or older with trapeziometacarpal osteoarthritis have fewer moderate and severe complications after trapeziectomy with ligament reconstruction and tendon interposition and are more likely to consider the surgery again under the same circumstances than are those who undergo arthrodesis. Twelve months after surgery, the PRWHE and DASH scores were similar in both groups. We do not recommend routine use of arthrodesis with plate and screws in the treatment of women who are forty years or older with stage-II or III trapeziometacarpal osteoarthritis.

Ligament reconstruction arthroplasty for primary thumb carpometacarpal osteoarthritis (weilby technique): prospective cohort study.

PURPOSE: The Weilby procedure is one of several accepted methods to treat primary thumb carpometacarpal osteoarthritis. We found no previous studies that included preoperative and postoperative subjective outcomes using validated questionnaires or preoperative and postoperative objective outcomes such as specific strength and range-of-motion measurements. Therefore, we performed a prospective cohort study in which we analyzed preoperative and postoperative objective and subjective outcomes after Weilby interposition tendoplasty. METHODS: Nineteen patients (20 thumbs) with primary thumb carpometacarpal osteoarthritis were treated with Weilby interposition tendoplasty. For subjective assessment, the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome data collection instrument was used to evaluate preoperative and postoperative outcomes at 0, 3, 6, and 12 months. Furthermore, patients completed a specific personal questionnaire at 12 months of follow-up. Objective assessments included interphalangeal joint flexion/extension; metacarpophalangeal joint flexion/extension; and carpometacarpal joint palmar abduction, opposition, and extension. Tip pinch, key pinch, 3-point pinch, and overall grip strengths were also measured. The measurements were performed preoperatively and at 3, 6, and 12 months after surgery. All complications were registered. RESULTS: The DASH score was significantly improved, and 17 of 19 patients were satisfied with the procedure. The interphalangeal joint flexion/extension, metacarpophalangeal joint flexion/extension, and carpometacarpal joint extension did not significantly change. Carpometacarpal joint palmar abduction and opposition were significantly improved at 12 months. The tip pinch and key pinch strengths were increased but not significantly. The 3-point pinch and overall grip strengths were significantly improved at 12 months. CONCLUSIONS: The Weilby procedure is a reliable alternative to treat primary thumb carpometacarpal osteoarthritis without requiring bone tunnel creation. It achieves pain relief, stability, mobility, and strength. The objective and subjective outcomes of this study compare favorably with those of earlier reports of the Weilby procedure and are similar to the published results of the more commonly performed Burton-Pellegrini technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Carpal boss: effect of wedge excision depth on third carpometacarpal joint stability.

PURPOSE: We hypothesize that carpal-metacarpal (CMC) instability after carpal boss wedge excision is not caused only by damage to the dorsal ligament but mainly depends on the depth of the bony resection. METHODS: To test our hypothesis, this study analyzes the effect of wedge excisions with different depths (0, 15%, 35%, 55% of the third CMC joint) and the effect of different forces (0, 50, 100 N.m) on the stability (measured as the passive flexion) of the third CMC joint using 12 fresh-frozen human cadaver wrists. The passive flexion is defined as the increase in angular motion of the third CMC joint and represents change in stability during flexion of the joint. RESULTS: The results show that the mean passive flexion measured in the wedge excisions of 15% and 35% of the joint did not differ from that of neutral controls. Joints analyzed after a 55% wedge excision showed a significant increase in angular motion (increased passive flexion). This relates to the 50 N.m as well as the 100 N.m loaded test position. CONCLUSIONS: This study shows that a wedge excision of clinically applicable depth of 35% does not create instability during flexion of the third CMC joint when loaded with physiologically relevant forces. Yet an extended and hardly clinically relevant 55% wedge excision results in a change in stability of the joint. To prevent instability when performing a wedge excision for symptomatic carpal boss, care must be taken to avoid excisions that exceed 35% of the third CMC joint.

Changes in the vaginal flora after two percent clindamycin vaginal cream in women at high risk of spontaneous preterm birth.

OBJECTIVE: To analyse alterationS in the vaginal flora after 2% clindamycin vaginal cream or placebo administered for the prevention of preterm delivery in high risk women. DESIGN: Observational study during a randomised multicentre double-blind placebo controlled trial. SETTING: Twelve city hospitals in The Netherlands. PARTICIPANTS: One hundred and sixty-eight women were enrolled. Alterations in the vaginal flora could be analysed in one hundred and twenty-four women by comparing the Nugent score on entry to the trial and at 31 weeks' gestation. The Nugent score was classified into normal, intermediate and bacterial vaginosis. INTERVENTIONS: Two percent clindamycin vaginal cream or placebo cream administered daily for seven days at week 26 of pregnancy. MAIN OUTCOME: Changes in the vaginal flora at week 31 of pregnancy. RESULTS: The placebo group consisted of 64 women and the clindamycin group of 60 women. At week 31 the vaginal flora was similar to week 26 with placebo cream but changed from normal vaginal flora to intermediate or bacterial vaginosis with 2% clindamycin vaginal cream. CONCLUSION: Obstetricians should not prescribe 2% clindamycin vaginal cream to pregnant women with normal vaginal flora in order to reduce the incidence of preterm birth. because it has no beneficial effects and is actually harmful. 2% Clindamycin vaginal cream encourages the presence of bacterial vaginosis which is epidemiologically associated with preterm birth.

Perinatal risk factors for cranial ultrasound abnormalities in neonates born after spontaneous labour before 34 weeks.

OBJECTIVE: The aim of this study was to identify risk factors for cranial ultrasound abnormalities in neonates born after spontaneous preterm labour with or without prolonged premature rupture of the membranes (PROM). METHODS: The presence of intraventricular haemorrhage and cystic periventricular leucomalacia was investigated in a cohort of neonates born between 24 and 34 weeks using cranial ultrasound. A stepwise forward logistic regression was performed to analyse the influence of antenatal and postnatal variables on cranial ultrasound abnormalities. RESULTS: The study group consisted of 205 neonates and cranial ultrasound abnormalities were identified in 27 infants. Early onset neonatal infectious disease (OR 3.09, 95% CI 1.24--7.70, P=0.01) increased the risk for cranial ultrasound abnormalities. Gestational age at birth (OR 0.96, 95% CI 0.93--0.99, P=0.03) and a full course of antenatal steroids (OR 0.33, 95% CI 0.13--0.85, P=0.02) reduced the risk for cranial ultrasound abnormalities. CONCLUSION: Early onset neonatal infectious disease is an independent risk factor for cranial ultrasound abnormalities in the very preterm neonate born after spontaneous labour with or without PROM.

Perinatal risk factors for adverse neurodevelopmental outcome after spontaneous preterm birth.

OBJECTIVE: The aim of this study was to investigate to what extend perinatal factors contribute to the neurodevelopmental outcome in a group neonates born after spontaneous preterm labour with or without prolonged rupture of the membranes (PROM). METHODS: In a cohort of neonates born after the spontaneous onset of labour with or without PROM before 34 weeks of gestation a stepwise forward logistic regression was performed to analyse the influence of antenatal and postnatal variables on adverse outcome. Adverse neurodevelopmental outcome was defined as a Griffith's developmental score <85, cerebral palsy, a major disability or perinatal death associated with severe cerebral damage. RESULTS: The study group consisted of 185 neonates. Seven neonates died with severe cerebral damage. After a forward logistic regression analysis three factors appeared to have an independent influence: gestational age protected against an adverse outcome (odds ratio (OR) per day increase 0.95, 95% confidence interval (CI) 0.90-0.97) while abnormal cranial ultrasound (intraventricular haemorrhage and periventricular leucomalacia) (OR 6.33, 95% CI 2.16-18.52) and the need for a second course of antibiotics (OR 1.85, 95% CI 1.02-3.33) increased the risk for adverse outcome. Comparing the group with a normal neurodevelopmental outcome with those with cerebral palsy, cranial ultrasound abnormalities were independently associated with cerebral palsy (OR 48.75, 95% CI 11.78-201.76). CONCLUSION: The most important way of preventing neurological damage in infants is to increase gestational age at birth and to avoid the development of intraventricular haemorrhage and periventricular leucomalacia.

Prophylactic administration of clindamycin 2% vaginal cream to reduce the incidence of spontaneous preterm birth in women with an increased recurrence risk: a randomised placebo-controlled double-blind trial.

OBJECTIVE: To test the hypothesis that prophylactic administration of clindamycin 2% vaginal cream can reduce the incidence of preterm birth in a high risk population. DESIGN: A multi-centre, randomised, double-blind, placebo-controlled trial. SETTING: Twelve city hospitals in The Netherlands. PARTICIPANTS: One hundred and sixty-eight women with a singleton pregnancy and a history of a spontaneous preterm delivery in the preceding pregnancy. INTERVENTIONS: Clindamycin 2% vaginal cream, or placebo cream, administered daily for seven days at 26 and 32 weeks of gestation. MAIN OUTCOME MEASURES: Spontaneous preterm birth at < 37 weeks, admission for threatened preterm labour, neonatal infectious morbidity. RESULTS: In the intention-to-treat analysis no difference was found in overall preterm birth between clindamycin and placebo (23% vs 18%, respectively). In the subgroup who completed the trial and administered all medication, more women delivered before 34 weeks in the clindamycin group (1.4% in the placebo vs 9.0% in the clindamycin group; P < 0.05). The length of admissions for threatened preterm labour did not differ. More infectious neonatal morbidity was seen in the clindamycin group (5/83 vs 0/85; P < 0.05). CONCLUSION: Clindamycin 2% vaginal cream given prophylactically to women with a spontaneous preterm birth in the preceding pregnancy did not prevent preterm delivery or reduce the number of admissions for threatened preterm labour. The neonatal infectious morbidity in the group treated with clindamycin was significantly higher and a major concern.

PIP: This multi-center, randomized, double-blind, placebo-controlled trial aimed to determine whether prophylactic administration of clindamycin 2% vaginal cream can reduce the incidence of preterm birth in a high risk population. A total of 168 eligible women attending the antenatal clinics of 12 hospitals in Netherlands participated in the study. Clindamycin 2% vaginal cream was administered to 83 women, and placebo cream to 85 women, daily for 7 days at 26 and 32 weeks of gestation. Results of the study showed no difference in the overall preterm birth between clindamycin (23%) and placebo (18%) in the intention-to-treat analysis. In the subgroup, which completed the trial and administered all medication, more women delivered before 34 weeks in the clindamycin group (9%) compared to the placebo group (1.4%). Moreover, occurrence of neonatal infectious morbidity was higher in the clindamycin group (5/83 vs. 0/85; P 0.05). In conclusion, clindamycin 2% vaginal cream given prophylactically to women with a spontaneous preterm birth in the preceding pregnancy did not prevent preterm delivery or reduce the number of admissions for threatened preterm labor.

[Shoulder dystocia; a retrospective study]. / Schouderdystocie; een retrospectief onderzoek.

A retrospective study was made of the incidence in The Netherlands in 1987 of shoulder dystocia in women delivered vaginally of a child with cephalic presentation and a birth weight of 2,500 g or more. Patient data were obtained from the LVR (Landelijke Verloskundige Registratie, National Obstetric Registration). Shoulder dystocia, coded in the LVR form as 'problems with the shoulders', was reported for 844 out of 54,820 parturitions (1.5%). Study of files of the St. Joseph Hospital, Eindhoven, for the period 1983-1987 revealed a frequency of shoulder dystocia of 1.5% (56 out of 3,642 births), in good agreement with the nationwide incidence. The concordance between the LVR code 'problems with the shoulders' and shoulder dystocia as mentioned in the childbirth reports of our hospital was 94%. It is pointed out that familiarization with the manipulations for shoulder dystocia is desirable, and that these should be carried out in a fixed sequence.