Ultrasound-assisted surgical release of carpal tunnel syndrome: Results of a pilot open-label uncontrolled trial conducted outside the operating theatre.

OBJECTIVE: To confirm the feasibility of ultrasound-assisted surgical release of carpal tunnel syndrome in the interventional radiology room. MATERIALS AND METHODS: Study involving 39 patients suffering from carpal tunnel syndrome confirmed by electromyogram and unresponsive to medical treatment. The patients were recruited via orthopedic surgery and rheumatology consultations and were operated on in the interventional radiology room under local anesthesia. A single approach was used, at the wrist flexion crease. Patients were monitored over a 90-day period. This is a descriptive open-label uncontrolled study. RESULTS: Fifteen men and 24 women, aged between 21 and 86 years, were included, 23 of whom were in work. The mean surgical procedure time was of 19.0±4.6 minutes; the mean room occupancy time was of 38.0±8.1 minutes and the mean volume of local anesthetic used was of 14.7±2.3 cc. The score for pain, formication and discomfort experienced in the hand was significantly reduced by day 15 (49.1±21.1 vs. 23.5±19.5; P<0.001). Eight patients continued to present with paresthesia on day 15 and only 3 by day 30. Four patients had returned to work by day 15, 10 patients considered that they could have resumed work within an average of 9.9±4.9 days after the procedure. Twenty-five patients estimated that they could resume their daily activities within a mean period of 7±3.9 days. No postoperative complications related to the procedure were observed. CONCLUSION: According to the results of this study, ultrasound-assisted surgical release of carpal tunnel syndrome performed outside the operating theatre seems to be effective and well-tolerated.

Can we improve the diagnosis of spondyloarthritis in patients with uncertain diagnosis? The EchoSpA prospective multicenter French cohort.

UNLABELLED: Power Doppler ultrasound (PDUS) has proved to be a highly sensitive tool for assessing enthesitis in spondyloarthritis (SpA). In patients with a suspected SpA, diagnosis could be improved by detecting enthesitis with PDUS. OBJECTIVE: To evaluate the performance of PDUS for the diagnosis of SpA alone or combined with other clinical, laboratory and imaging findings in patients consulting for a suspected SpA. METHODS: Prospective, multicenter French cohort study (Boulogne-Billancourt, Brest, Caen, Grenoble, Marseille and Nancy). Outpatients consulting for symptoms suggestive of SpA (inflammatory back pain [IBP], arthritis or inflammatory arthralgia [IA], enthesitis or dactylitis [ED], HLA-B27 positive uveitis [B27+U], familiarity for SpA [Fam]) were recruited and followed up for at least 2 years. Sample size was set to 500 patients (for estimated prevalence of SpA of 30±5% after 2 years). At baseline, patients were submitted to standardized physical examination, pelvic X-ray, sacroiliac joints magnetic resonance imaging (MRI), HLA-B typing, and other tests judged useful for diagnosis. For each patient, a blinded PDUS examination of 14 enthesitic sites was performed at baseline and at years 1 and 2. Patients were planned to be followed during 5 years. The diagnosis of SpA ascertained by an experts' committee, blind to PDUS results, after at least 2 years of follow-up, with a revaluation of doubtful patients at 5 years will be used as gold standard for evaluating the diagnostic performance of PDUS and the best diagnostic procedure by combining PDUS, clinical symptoms and other tests. RESULTS: Between January 2005 and September 2007, 489 patients were included (96% of the target population). Nineteen patients (0.2%) retired their informed consensus or were lost to follow-up immediately after their inclusion. At baseline, mean age of the 470 remaining patients was 40 years, mean duration of symptoms was 6.1 years; 42% of them were HLA-B27+ and 63% were female. Primary inclusion criterion was IBP in 53%, IA in 27%, ED in 9%, B27+U in 8% and Fam in 4%. Follow-up is still ongoing. CONCLUSION: We have set up a unique diagnostic cohort which includes the entire spectrum of SpA manifestations. By using PDUS we expected to improve the diagnostic procedure of SpA.

Ultrasound-guided percutaneous surgery for carpal tunnel syndrome: a cadaver study.

OBJECTIVE: To assess the feasibility of ultrasound-guided surgery for carpal tunnel syndrome. METHOD: We first studied the ultrasound and anatomic findings in 30 cadaver wrists to determine the best surgical approach and the best plane for releasing the flexor retinaculum. We then used 104 cadaver wrists to assess the feasibility of our technique by performing the surgical procedure then extensively dissecting each wrist and hand. Our evaluation criteria were full release of the transverse carpal ligament and absence of injury to the vessels, nerves, and tendons. RESULTS: The transverse carpal ligament was fully released in all 104 forearms. Full release required a single pass in 61 forearms, two passes in 27 forearms, and three passes in 16 forearms. No injuries to adjacent structures were identified. CONCLUSIONS: Our cadaver study supports the feasibility of percutaneous surgery under ultrasound-guidance for carpal tunnel syndrome.

How to evaluate and improve the reliability of power Doppler ultrasonography for assessing enthesitis in spondylarthritis.

OBJECTIVE: To evaluate and improve the reliability of power Doppler ultrasonography (PDUS) for detecting and scoring enthesitis in patients with spondylarthitis, using a 3-step procedure. METHODS: In the first step, we evaluated the reliability of 5 sonographers by bilaterally scanning 5 entheses twice in 5 patients. In the second step, starting from disagreements observed during the first step, we established consensus guidelines. The sonographers' implementation was further evaluated in 2 reliability exercises: one on 60 PDUS enthesitis images and the other by scanning 5 new patients. In the third step, we performed a final reliability evaluation of 5 additional patients after 1 year. Kappa coefficients (kappa) as well as variance component analysis (VCA) and generalizability theory (GT) were used to assess reliability. RESULTS: The initial intra- and interobserver reliability were poor, especially for detecting and scoring Doppler signal. VCA and GT showed that most variability was accounted for by interaction between sonographer and enthesis. Implementation of consensus guidelines was associated with a significant improvement in Doppler reliability between the first and second steps (mean interobserver kappa increased from 0.13 to 0.51 for binary Doppler scoring in patients; P < 0.005), which persisted in the third step (mean interobserver kappa = 0.57). The high GT coefficients reached in the last steps supported such improvement. CONCLUSION: The 3-step procedure used in this study to standardize PDUS technique was associated with a significant improvement in interobserver reliability for detecting enthesitis in spondylarthritis patients. Such an approach can be useful to standardize PDUS assessment of musculoskeletal disorders.

Comparison of bone loss induced in female rats by hindlimb unloading, ovariectomy, or both.

INTRODUCTION: Clinical and experimental evidence supports a link between the effects of mechanical loading and those of estrogens on bone. The objective of this study was to compare bone loss induced in female rats by hindlimb unloading, ovariectomy, or both. MATERIALS AND METHODS: Thirty-six female Wistar rats aged 12 weeks were randomized to bilateral surgical ovariectomy without tail suspension (OV) or with tail suspension for 30 days (OV-TS) or to sham surgery without tail suspension (control group, C) or with tail suspension for 30 days (TS). Bone mineral density (BMD) of the distal femoral metaphysis was measured in g/cm2 by dual X-ray absorptiometry in all 12 animals on days 0, 7, 14, and 30. RESULTS: On D14 and D30, BMD (mean+/-S.D.) was significantly lower in the OV, TS, and OV-TS groups than in the control group (D14: 0.239+/-0.014, 0.243+/-0.016, and 0.227+/-0.018, respectively, vs. 0.258+/-0.005 in the controls; P<0.05; and D30: 0.241+/-0.011, 0.227+/-0.015, and 0.200+/-0.018, respectively, vs. 0.279+/-0.009 in the controls; P<0.001). On D30, the percentage BMD change versus baseline (mean+/-S.D.) differed significantly between the combination (OV-TS) group (-14.26+/-8.14) and the single-intervention groups (OV: +0.99+/-6.44, P<0.001; and TS: -6.36+/-4.56, P<0.05). As early as D7, bone loss was significantly greater in the combination (OV + TS) group than in the OV group (-1.79%+/-7.17 vs. +4.29%+/-9.55; P<0.05). CONCLUSION: In female rats, the rate and severity of bone loss were greater when estrogen deprivation was combined with mechanical unloading than when either intervention was used alone. Mechanical unloading induced a greater degree of bone loss than did estrogen deprivation. In this model of high-rate bone loss, mechanical unloading may predominate over estrogen deprivation in the genesis of bone loss.

Atypical pattern of acute severe shoulder pain: contribution of sonography.

A patient presented with an atypical pattern of acute severe shoulder pain. Sonography elucidated the mechanism of the pain and allowed effective treatment. The patient was unable not only to move her shoulder but also to flex and to extend her elbow. Sonography showed a calcific deposit in the subscapularis tendon with local edema displacing the long head of the biceps tendon out of the bicipital groove. Local injection of a glucocorticoid under ultrasonographic control was followed within 7 days by subsidence of the subscapularis tendon edema and by a return of the long head of the biceps tendon to its normal position in the bicipital groove.

Sympathetic nervous system as transmitter of mechanical loading in bone.

UNLABELLED: Sympathetic innervation has been demonstrated in bone. Adrenergic stimulation is one of the transmitters of bone loss by uncoupling between decreased bone formation and increased bone resorption. OBJECTIVE: By using a non-specific antagonist of -adrenergic pathway (propranolol per os), we hypothesized that we could rescue the uncoupling induced mechanical unloading bone loss in the rat model of tail-suspension. MATERIALS AND METHODS: Twenty-two female Wistar rats, 12 week-old, have been divided into three groups: eight tail-suspended rats (SR), six tail-suspended rats treated by propranolol (SRP) and eight non-suspended rats (NSR) during 30 days. Bone mineral density (BMD, g/cm2) has been measured by DXA (Hologic QDR-4500A) at D0 and D30 of the study, in the distal femoral metaphysis (DFM), the femoral diaphysis (FD), the whole body (WB, g) and body composition. RESULTS: Between D0 and D30, in DFM a significant variation in BMD is observed between NSR and SR (% BMD change: NSR +15.6 +/- 3.1% vs SR -1.0 +/- 1.4%, P < 0.0001) and BMD rescue in SRP group (% BMD change SRP +5.3 +/- 1.5% vs SR -1.0 +/- 1.4%, P = 0.03). In FD, gain of BMD is significant in NSR compared to SR (+17.5 +/- 1.5% vs +8.2 +/- 2.8%, P = 0.007) and to SRP (+17.5 +/- 1.5% vs +10.1 +/- 2.4%, P = 0.046). Gain in SRP group is not significant compared to SR group (P = 0.6). In WB, SRP gain more BMD than NSR (+14.0 +/- 1.8% vs +5.4 +/- 0.7%, P = 0.0002) and than SR (+14.0 +/- 1.8% vs +7.8 +/- 1.4%, P = 0.0043). There is no difference between NSR and SR groups (P = 0.19). CONCLUSION: We demonstrate that -adrenergic pathway of sympathetic nervous system is a major transmitter pathway of mechanical loading in rat bone. A specific study is necessary to analyse a possible systemic effect of propranolol in rat bone. Propranolol could be used to prevent the induced mechanical unloading bone loss as weightlessness