POS0035 ONE IN TWENTY INFLAMMATORY BOWEL DISEASE PATIENTS WHO UNDERWENT ABDOMINOPELVIC COMPUTED TOMOGRAPHY HAVE UNDIAGNOSED AXIAL SPONDYLOARTHRITIS

Background:

The diagnosis of axial spondyloarthritis (axSpA) is challenging and hindered by delay. There may be an opportunity to identify sacroiliitis for further rheumatology review in inflammatory bowel disease (IBD) patients who undergo Computed Tomography (CT) for non-musculoskeletal (MSK) indications.

Objectives:

To identify what proportion of IBD patients who underwent abdominopelvic CT for non-MSK indications have axSpA and to explore the role of an imaging strategy for identifying axSpA.

Methods:

Abdominopelvic CT scans of verified IBD patients were identified retrospectively from eight years of imaging archive. Patients between 18-55 yrs. were selected as having the highest diagnostic yield for axSpA. CT review (using criteria from a validated CT screening tool developed by Chan1) was undertaken by a trained radiology team for presence of CT-defined sacroiliitis (CTSI). All CTSI patients were sent a screening questionnaire. Those with self-reported chronic back pain (CBP), duration > 3 months, onset < 45 years were invited for rheumatology review. This included a medical interview, physical examination (joint count, MASES, dactylitis count, BASMI), patient reported outcomes (BASDAI, BASFI, BASGI, Harvey-Bradshaw-Index, Partial-Mayo-Index), relevant laboratory tests (CRP, ESR, HLA-B27), axSpA protocol MRI, and remote review by a panel of experienced rheumatologists with a special interest in axSpA.

Results:

CTSI was identified in 60 of 301 patients. Thirty-two (53%) responded to the invitation to participate and 27 (84%) were enrolled. Of these, eight had a pre-existing axSpA diagnosis and five did not report chronic back pain. Fourteen patients underwent rheumatological assessment; three of 14 (21.4% [95% CI: 4.7%, 50.8%]) had undiagnosed axSpA. In total, 11 of 27 (40.7% [95% CI: 22.4%, 61.2%]) patients had a rheumatologist verified diagnosis of axSpA.

Conclusion:

One in five patients (60/301) with IBD who underwent abdominopelvic CT for non-MSK indications have CTSI and at least one in five (11/60) have axSpA. Five percent (3/60) were previously undiagnosed. This highlights a hidden disease burden and a potential strategy for identifying new cases.

References:

[1]Chan J, Sari I, Salonen D, Inman RD, Haroon N. Development of a Screening Tool for the Identification of Sacroiliitis in Computed Tomography Scans of the Abdomen. J Rheumatol 2016; 43(9); 1687-94.

Acknowledgements:

We are indebted to Baljeet Dhillon and Shin Azegami for their assistance in the scoring of the CTSI.

Disclosure of Interests:

Chong Seng Edwin Lim Grant/research support from: AbbVie, Louise Hamilton: None declared, Samantha Low: None declared, Andoni Toms: None declared, Alex MacGregor: None declared, Karl Gaffney Speakers bureau: AbbVie, Eli Lilly, Novartis, UCB Pharma, Consultant of: AbbVie, Eli Lilly, Novartis, UCB Pharma, Grant/research support from: AbbVie, Gilead, Eli Lilly, Novartis, UCB Pharma.

966 Implementation of Regional Scalp Blockade for Painless Removal of ICP Bolts: A Quality Improvement Project

Introduction

Intracranial pressure (ICP) monitoring through insertion of a bolt is a common neurosurgical procedure for diagnosing cerebrospinal fluid disorders. The first step of our quality improvement project identified ICP bolt removal the most painful part of the procedure. We implemented and tested the efficacy of a scalp nerve block for bolt removal.

Method

Two groups were identified: (A) receiving oral analgesia only and (B) receiving ipsilateral supraorbital and supratrochlear nerve blocks. We then retrospectively compared satisfaction ratings of insertion versus removal process for the two bolt types using a telephonic questionnaire

Results

Eighty-five patients had ICP bolts (32M:53F, mean age 42.7±16.0 SD). Fifty-four were removed with oral analgesia (A) and 31 with oral and regional anaesthesia (B). Removal experience was reported as worse for group A than for group B (p &lt; 0.01). Most patients (66%) reported would have preferred local anesthetic during removal. No complications occurred from the block.

Conclusions

Regional nerve blocks are a safe and effective adjuvant for the painless removal of frontal ICP monitoring bolts. The final stage of the project was to implement nerve blocks as standard practice for bolt removal, to improve patient experience.

P1236Revealing cardiac mechanics with CMR whilst CRT is active: the first step

Introduction

Cardiac resynchronisation therapy (CRT) is a routine treatment for heart failure with reduced ejection fraction and conduction delay to improve symptoms and prognosis. Technological advancements both in cardiac magnetic resonance (CMR) and devices (MRI-conditional modes) now enable investigation of the haemodynamic response to CRT over a range of heart rates.

Methods

Patients with a CRT-D device were enrolled from heart failure clinics at a single tertiary centre. A complete device system assessment and baseline device check was conducted to ensure MRI compatibility and suitability. Left ventricular (LV) volumes and systolic blood pressure were measured at baseline and heart rates of 75, 90, 100, 115, 125, and 140 bpm (randomised order) with CRT active and intrinsic conduction (AOO). MRI conditional mode parameters were replicated through standard parameter modification to ensure biventricular pacing during CRT active scans. All scans were conducted using a 3.0 T Siemens Prisma MRI scanner with analysis on commercially available software. Contractility was derived from the systolic blood pressure and left ventricular end systolic volume. A post scan device and lead assessment was conducted to assess for scanning safety.

Results

Scanning was conducted in 22 patients (safety cohort). Post scan battery voltage reduced by 2.9±1.0%. Mean change in atrial, right ventricular and left ventricular lead impedance was 0.5±0.06%, 3.0±0.04% and −1.7±0.05% respectively. Mean change in atrial, right ventricular and left ventricular pacing threshold was 0.0±0.3%, 8.3±0.3% and 5.6±0.3%. No patient experienced symptoms related to scanning or device failure.

Preliminary data for patients with CRT on and off have been analysed (paired analysis cohort, n=8, 6 men). Mean age was 71.1±8.2, aetiology was primarily ischaemic (62.5%) with the remainder dilated cardiomyopathy. The mean LV ejection fraction at baseline was 29.4±12.9%. Biventricular pacing led to acute improvements in ejection fraction (p=0.005), left ventricular cardiac output (p<0.0001) and contractility (p=0.05) over the entire range of heart rates studied. We also noted an improvement in the force frequency relationship during biventricular pacing with a higher peak contractility (p=0.05), a higher heart rate at which this occurred (HR=130) and a generally up sloping relationship when compared with intrinsic conduction.

Conclusion

We have demonstrated for the first time, the mechanistic improvements in cardiac contractility consequent to CRT using CMR and also that MRI scans of conditional devices can be safe with CRT active.

Acknowledgement/Funding

Dr A Koshy is conducting a PhD supported by grant from Medtronic. Dr Klaus Witte has received honoraria from Medtronic

Breast fat volume measurement using wide-bore 3 T MRI: comparison of traditional mammographic density evaluation with MRI density measurements using automatic segmentation

AIM

To compare magnetic resonance imaging (MRI)-derived breast density measurements using automatic segmentation algorithms with radiologist estimations using the Breast Imaging Reporting and Data Systems (BI-RADS) density classification.

MATERIALS AND METHODS

Forty women undergoing mammography and dynamic breast MRI as part of their clinical management were recruited. Fat-water separated MRI images derived from a two-point Dixon technique, phase-sensitive reconstruction, and atlas-based segmentation were obtained before and after intravenous contrast medium administration. Breast density was assessed using software from Advanced MR Analytics (AMRA), Linköping, Sweden, with results compared to the widely used four-quartile quantitative BI-RADS scale.

RESULTS

The proportion of glandular tissue in the breast on MRI was derived from the AMRA sequence. The mean unenhanced breast density was 0.31±0.22 (mean±SD; left) and 0.29±0.21 (right). Mean breast density on post-contrast images was 0.32±0.19 (left) and 0.32±0.2 (right). There was "almost perfect" correlation between pre- and post-contrast breast density quantification: Spearman's correlation rho=0.98 (95% confidence intervals [CI]: 0.97-0.99; left) and rho=0.99 (95% CI: 0.98-0.99; right). The 95% limits of agreement were -0.11-0.08 (left) and -0.08-0.03 (right). Interobserver reliability for BI-RADS was "substantial": weighted Kappa k=0.8 (95% CI: 0.74-0.87). The Spearman correlation coefficient between BI-RADS and MRI breast density was rho=0.73 (95% CI: 0.60-0.82; left) and rho=0.75 (95% CI: 0.63-0.83; right) which was also "substantial".

CONCLUSION

The AMRA sequence provides a fully automated, reproducible, objective assessment of fibroglandular breast tissue proportion that correlates well with mammographic assessment of breast density with the added advantage of avoidance of ionising radiation.

Abstract P6-10-04: Determining the optimal vaccination strategy using a combination of the folate binding protein (FBP) peptide vaccine (E39+GM-CSF) and an attenuated version (E39') to maximize the immunologic response in breast cancer patients

BACKGROUND FBP is overexpressed in 20-50% of breast(B) cancers(Ca) and roughly 90% of endometrial(E) and ovarian (Ov) Ca. E39 (FBP191-199, EIWTHSYKV)+GM-CSF is an HLA-A2 restricted FBP peptide vaccine, which has been shown to generate significant in vivo immunologic response(IR) in a phase I/IIa trial in E Ca and Ov Ca patients (pts). There is a risk of inducing immunologic tolerance after multiple inoculations with a highly immunogenic vaccine. Thus, we are investigating a novel vaccination series using combinations of E39 and E39' (EIWTFSTKV, an attenuated version of E39) in a phase Ib, randomized, single-center trial. We are assessing short and long-term IR. Here, we present the initial IR analysis to the primary vaccination series (PVS) within B Ca pts.

METHODS HLA-A2 positive B or Ov Ca pts were enrolled after completion of standard of care therapy and randomized into three arms: EE (6 inoculations of E39); EE'(3 inoculations of E39, then 3 of E39'); or E'E(3 of E39', then 3 of E39). Theoretically, due to lower FBP expression and less aggressive chemotherapy regimens, B Ca pts are more antigen naïve and have a less suppressed immune system. Thus, only B Ca pts were included in this analysis. The PVS includes 6 inoculations total (R1-R6), one every 3-4 weeks, and containing 250mcg GM-CSF+500mcg peptide in the first 5 pts per arm and 1000mcg of peptide in second 5 pts. To assess the in vivo IR, local reaction(LR) was measured 48 hours after each inoculation (R1-R6), and delayed type hypersensitivity(DTH) was measured pre-PVS (R0), 1, and 6-months post-PVS (RC1, RC6). Ex vivo IR was measured via dextramer assay for E39-specific CD8+ T-cells at R0, RC1, and RC6. Statistical analyses were completed using appropriate tests.

RESULTS Thirty-five B Ca pts were enrolled, with 27 completing the PVS (EE n=10, EE' n=8, E'E n=9). No clinicopathologic differences between groups or significant toxicities &gt; grade 2 were appreciated. LR increased from R1 to R6 in all groups (ΔEE= 24.80mm, p=0.14; ΔEE'=38.13mm, p=0.07; ΔE'E=8.05mm, p=0.38), the greatest increase approaching statistical significance in the EE' arm. The only arm with a statistically significant increase for in vivo DTH from R0-RC1-RC6 was in the EE' arm (ΔEE=-6.17mm, p=0.27; ΔEE'= 44.58mm, p&lt;0.05; ΔE'E=-1.42, p=0.37). Ex vivo analysis of IR revealed no significant difference between groups at R0(p=0.45) or RC6(p=0.72), nor within groups over time (EE p=0.32, EE' p=0.47, E'E p=0.30).

CONCLUSION In this phase Ib trial analyzing the IR of B Ca pts receiving a different vaccination strategy, both peptides were noted to be safe and immunogenic. While no difference was seen in E39-specific CD8+ T cells between groups, the in vivo response was enhanced with the use of E39' after E39; this may indicate expansion of more effective clonal populations of CD8+ T cells with this strategy. These results may be specific to B Ca pts who are relatively antigen-naïve with relatively intact immune systems. Further analysis of these pts as this trial continues will determine the optimal vaccination strategy capable of stimulating and maintaining an IR to prevent B Ca recurrence.

Citation Format: Jackson DO, Qiao N, Peace KM, Hale DF, Vreeland TJ, Greene JM, Berry JS, Trappey AF, Clifton GT, Ibrahim N, Toms A, Peoples GE, Mittendorf EA. Determining the optimal vaccination strategy using a combination of the folate binding protein (FBP) peptide vaccine (E39+GM-CSF) and an attenuated version (E39') to maximize the immunologic response in breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-10-04.

International consensus on the definition and classification of fibrosis of the knee joint

AIMS

The aim of this consensus was to develop a definition of post-operative fibrosis of the knee.

PATIENTS AND METHODS

An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds.

RESULTS

Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed.

CONCLUSION

The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.

Allergy in total knee arthroplasty: a review of the facts

We explored the literature surrounding whether allergy and hypersensitivity has a clinical basis for implant selection in total knee arthroplasty (TKA). In error, the terms hypersensitivity and allergy are often used synonymously. Although a relationship is present, we could not find any evidence of implant failure due to allergy. There is however increasing basic science that suggests a link between loosening and metal ion production. This is not an allergic response but is a potential problem. With a lack of evidence logically there can be no justification to use 'hypoallergenic' implants in patients who have pre-existing skin sensitivity to the metals used in TKA.

Complications associated with opening wedge high tibial osteotomy--A review of the literature and of 15 years of experience

BACKGROUND

Complication rates following opening wedge high tibial osteotomy (OWHTO) is an issue that has not been comprehensively addressed in current literature.

METHODS

We performed a retrospective study of local patients who underwent OWHTO for isolated medial compartment knee osteoarthritis from 1997 to 2013. We analysed survivorship and complication rates and compared this to a literature review of previously reported data.

RESULTS

One hundred and fifteen patients met the inclusion criteria. Mean follow-up=8.4 years. Mean age=47 (range 32 to 62). Mean Body Mass Index (BMI)=29.1 (range 20.3 to 40.2). Devices used consisted of Tomofix (72%), Puddu plate (21%) and Orthofix (seven percent) (no significant differences in age/sex/BMI). Wedge defects were filled with autologous graft (30%), Chronos (35%) or left empty (35%). Five years survival rate (without requiring conversion to arthroplasty)=80%. Overall complication rate=31%. Twenty five percent of patients suffered 36 complications including minor wound infections (9.6%), major wound infections (3.5%), metalwork irritation necessitating plate removal (seven percent), non-union requiring revision (4.3%), vascular injury (1.7%), compartment syndrome (0.9%), and other minor complications (four percent). No thromboembolic complications were observed.

CONCLUSION

No significant differences existed in complication rates following OWHTO relative to BMI, implant type, type of bone graft used or patient age at surgery. When the complications from OWHTO were analysed closely they appear higher than previously reported in the literature; however serious complications appear rare. LEVEL OF EVIDENCE 3: Retrospective cohort study.

Do you have an infection problem?

In England and Wales more than 175 000 hip and knee arthroplasties were performed in 2012. There continues to be a steady increase in the demand for joint arthroplasty because of population demographics and improving survivorship. Inevitably though the absolute number of periprosthetic infections will probably increase with severe consequences on healthcare provision. The Department of Health and the Health Protection Agency in United Kingdom established a Surgical Site Infection surveillance service (SSISS) in 1997 to undertake surveillance of surgical site infections. In 2004 mandatory reporting was introduced for one quarter of each year. There has been a wide variation in reporting rates with variable engagement with the process. The aim of this article is to improve surgeon awareness of the process and emphasise the importance of engaging with SSISS to improve the quality and type of data submitted. In Exeter we have been improving our practice by engaging with SSISS. Orthopaedic surgeons need to take ownership of the data that are submitted to ensure these are accurate and comprehensive.

Cite this article: Bone Joint J 2015;97-B:1170–4.

Serial magnetic resonance imaging of metal-on-metal total hip replacements. Follow-up of a cohort of 28 mm Ultima TPS THRs

Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1-C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years.

Mercury fractionation in the sediments of Vembanad wetland, west coast of India

Transformations among different mercury species associated with sediments can have a major effect on the metal's mobility and potential for methylation and hence bioaccumulation. In the present study, various fractions of mercury in the sediments of Vembanad wetland system analysed. Total mercury (THg) concentration in the surface sediment varied from 16.3 to 4,230 ng/g. The results of sequential extraction showed that the major portion of mercury in these sediments existed as elemental form followed by organo-chelated form. The least portion observed was the residual fraction (mercury of natural origin). Even though the percentage of mercury observed in the easily available fractions is relatively small, absolute values of these mobile Hg fractions are quite high due to the very high total mercury values. The fractionation of mercury in the sediment was controlled by the organic matter, sulphur complexes and concentration of THg. The results showed that the bioavailability of mercury is high as the amount of mercury found in the initial three fractions is high, which can also enhance the methylation potential of the Vembanad wetland sediments. The fractionation pattern of mercury also revealed the presence of anthropogenic mercury content in the Vembanad wetland sediments.

Reliability of radiographic measurements of knee motion following knee arthroplasty for use in a virtual knee clinic

INTRODUCTION

We sought to validate radiographic measurements of range of motion of the knee after arthroplasty as part of a new system of virtual clinics.

METHODS

The range of motion of 52 knees in 45 patients was obtained by 2 clinicians using standardised techniques and goniometers. Inter-rater reliability and intraclass correlation coefficients (ICCs) were calculated. Radiographs of these patients' knees in full active flexion and extension were also used to calculate intra and inter-rater reliability compared with clinical measurements using four different methods for plotting angles on the radiographs.

RESULTS

The ICC for inter-rater reliability using the goniometer was very high. The ICC was 0.91 in extension and 0.85 in flexion while repeatability was 8.49° (-8.03-8.99°) in extension and 5.23° (-4.54-5.74°) in flexion. The best ICC for radiographic measurement in extension was 0.86, indicating 'near perfect' agreement, and repeatability was 5.43° (-4.04- 6.12°). The best ICC in flexion was 0.95 and repeatability was 5.82° (-3.38-6.55°). The ICC for intrarater reliability was 0.98 for extension and 0.99 for flexion on radiographic measurements.

CONCLUSIONS

Validating the use of radiographs to reliably measure range of motion following knee arthroplasty has allowed us to set up a 'virtual knee clinic'. Combining validated questionnaires and radiographic measurement of range of motion, we aim to maintain high quality patient surveillance following knee arthroplasty, reduce our ratio for new to follow-up patients in line with Department of Health guidelines and improve patient satisfaction through reduced travel to hospital outpatients.

Pyoderma gangrenosum: a report of a rare complication after knee arthroplasty requiring muscle flap cover supplemented by negative pressure therapy and hyperbaric oxygen

Pyoderma gangrenosum (PG) is rare ulcerating skin condition easily confused with wound infection following surgery. We report a complicated case of PG following knee arthroplasty where delayed diagnosis and repeated debridements lead to significant tissue loss. Successful reconstruction was achieved with a muscle flap, but subsequent reactivation of PG and superadded infection placed both the reconstruction and patient's life at risk. Prolonged combined use of negative pressure therapy (NPT), immunosuppression and hyperbaric oxygen (HBO) was successfully used to reduce the wound size, enhance wound granulation, promote re-epithelialisation, and provide pain relief. There is little or no published literature on these treatment modalities for the management of PG, with only one reported case using both NPT and HBO for PG (not following knee arthroplasty). More studies are necessary to determine the role of both modalities in the management of pathergy in large and complex wounds and the rare nature of this complication following knee arthroplasty explains the lack of evidence-based guidance. In conclusion, we suggest a surgical algorithm. This is the first report of PG following knee arthroplasty with the use of both NPT and HBO in order to achieve soft tissue coverage.

Pyoderma gangrenosum: a report of a rare complication after knee arthroplasty requiring muscle flap cover supplemented by negative pressure therapy and hyperbaric oxygen

Pyoderma gangrenosum (PG) is rare ulcerating skin condition easily confused with wound infection following surgery. We report a complicated case of PG following knee arthroplasty where delayed diagnosis and repeated debridements lead to significant tissue loss. Successful reconstruction was achieved with a muscle flap, but subsequent reactivation of PG and superadded infection placed both the reconstruction and patient's life at risk. Prolonged combined use of negative pressure therapy (NPT), immunosuppression and hyperbaric oxygen (HBO) was successfully used to reduce the wound size, enhance wound granulation, promote re-epithelialisation, and provide pain relief. There is little or no published literature on these treatment modalities for the management of PG, with only one reported case using both NPT and HBO for PG (not following knee arthroplasty). More studies are necessary to determine the role of both modalities in the management of pathergy in large and complex wounds and the rare nature of this complication following knee arthroplasty explains the lack of evidence-based guidance. In conclusion, we suggest a surgical algorithm. This is the first report of PG following knee arthroplasty with the use of both NPT and HBO in order to achieve soft tissue coverage.

Early failure of the Ultima metal-on-metal total hip replacement in the presence of normal plain radiographs

Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell. Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%). At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis. Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.

Midcarpal instability: a diagnostic role for dynamic ultrasound?

PURPOSE

The aim of this study was to describe the technique of dynamic ultrasound (US) examination of the triquetral clunk, and to illustrate the range of findings in four patients with midcarpal instability (MCI).

MATERIALS AND METHODS

Four patients were identified (3 men, 1 woman). The case notes, plain radiographs, MRI and dynamic US for each patient were reviewed. Digital video files recording the dynamic US of the triquetral clunks were analysed for the following features of abnormal triquetral mobility: direction and speed of triquetral snap, amount of anteroposterior translocation, and flexion or extension during the snap.

RESULTS

Five different triquetral clunks were recorded in 4 patients. In four out of five cases the clunk occurred during ulnar translocation of the wrist, and in one during radial translocation. Anteroposterior translocation was anterior (3.4 - 4.7 mm) in three of the clunks and posterior (1 - 10 mm) in two. The degree of flexion or extension varied between 1 and 16 degrees . The snapping phase of the clunk lasted between 0.17 and 0.25 seconds.

CONCLUSION

Dynamic US can be used to confirm the diagnosis of midcarpal instability by identifying a triquetral catch-up clunk. Quantification of carpal mobility with US may lead to further insights into the mechanics of MCI.

Reconstruction of femoral defects in revision hip surgery: risk of fracture and stem migration after impaction bone grafting

The use of impaction bone grafting during revision arthroplasty of the hip in the presence of cortical defects has a high risk of post-operative fracture. Our laboratory study addressed the effect of extramedullary augmentation and length of femoral stem on the initial stability of the prosthesis and the risk of fracture. Cortical defects in plastic femora were repaired using either surgical mesh without extramedullary augmentation, mesh with a strut graft or mesh with a plate. After bone impaction, standard or long-stem Exeter prostheses were inserted, which were tested by cyclical loading while measuring defect strain and migration of the stem. Compared with standard stems without extramedullary augmentation, defect strains were 31% lower with longer stems, 43% lower with a plate and 50% lower with a strut graft. Combining extramedullary augmentation with a long stem showed little additional benefit (p = 0.67). The type of repair did not affect the initial stability. Our results support the use of impaction bone grafting and extramedullary augmentation of diaphyseal defects after mesh containment.

Body computed tomography in critically ill patients

The aim of the study was to assess the effectiveness of computed tomography in the management of critically ill patients. We performed a prospective study over a 4-month period. The requesting clinician was asked to document their clinical diagnosis and confidence thereof on a visual analogue scale. They were also asked about their management plan if computed tomography had not been available. After imaging, any change in the management plan was assessed. During the study period, 16 computed tomograms were performed on 14 patients. There were 21 possible clinical diagnoses: of these eight were confirmed, and 13 were refuted. Seven new diagnoses were established. Computed tomography did not help in the management of two patients and it led to more confusion in the management of one patient. The management of seven patients was altered after computed tomography and in six the management depended solely on computed tomography findings.

Radiolabeled leucocyte imaging in diffuse granulomatous involvement of the meninges in Wegener's granulomatosis: scintigraphic findings and their role in monitoring treatment response to specific immunotherapy (humanized monoclonal antilymphocyte antibodies)

BACKGROUND AND PURPOSE

Diffuse involvement of the meninges by remote granulomas in Wegener's granulomatosis is rare. This study reports the radiolabeled leucocyte imaging findings in five such patients. The diagnosis was made by MR imaging in five patients and confirmed in four by findings at meningeal biopsy. The potential role of serial radiolabeled leucocyte examinations in assessing treatment response is discussed.

METHODS

Three of the five patients underwent whole-body planar 111In-labeled leucocyte imaging. Two of these patients had serial imaging and one had, in addition, a 99mTc-HMPAO-labeled leucocyte single-photon emission CT brain examination. Two of the five patients had whole-body planar 99mTc-HMPAO-labeled leucocyte imaging. Of these, one patient had serial imaging. The radiolabeled leucocyte imaging findings were correlated with MR findings and with the patients' clinical course.

RESULTS

In four patients there was a midline linear area of increased tracer uptake in the brain, and in one of these, tracer uptake also extended laterally over the brain convexity. In two patients linear tracer uptake extended in an inferolateral direction from the midline. These abnormalities correlated with meningeal thickening in the falx, over the brain convexity, and in the tentorium cerebelli on MR images. Serial imaging in three patients revealed a reduction or disappearance in tracer uptake after treatment with anti-CD52, which correlated with clinical improvement.

CONCLUSION

In patients with Wegener's granulomatosis, abnormal uptake corresponding to meningeal thickening can be seen on planar radiolabeled leucocyte images. Leucocyte imaging may be useful for monitoring treatment response.

The immunohistochemical response of the rat periodontal ligament endothelium to an inflammatory stimulus

Recently, inflammation has been recognised as an important co-requisite to orthodontic tooth movement. When such a reaction is initiated, the process of up-regulation of certain adhesion molecules may occur, resulting in the extravasation of leukocytes. This may stimulate progenitor/precursor pathways and signals that regulate the biological responses resulting in tooth movement. We propose that up-regulation of leukocyte adhesion molecules occurs in response to orthodontic forces, resulting in circulating monocyte attraction, extravasation and differentiation into osteoclasts, which are responsible for bone resorption that results in orthodontic tooth movement. To investigate this hypothesis, it is necessary to determine whether periodontal ligament (PDL) endothelium responds to inflammatory stimuli as other organs do. We studied the normal distribution of endothelial adhesion molecule ICAM-1 within PDL vessels, and then the following exposure to an inflammatory endotoxin. The rat PDL blood vessels expressed ICAM-1 in response to the inflammatory stimulus, similar to other organs, suggesting that the inflammatory responses are similar. Whether and where in the PDL microvascular bed orthodontic forces cause up-regulation of ICAM-1 needs to be established.

The consent form signature: a useful clinical sign?

The quality of a patient's consent form signature was assessed in 42 adult patients undergoing emergency major abdominal surgery. Patients with a poor quality or absent consent form signature had a significantly higher mortality and higher APACHE II scores than those with a satisfactory consent form signature.

A comparison of clinical index and ejection fractions in predicting cardiac complications following infrarenal aortic reconstruction

OBJECTIVE

To compare the Detsky clinical cardiac risk index with ejection fraction measurements in predicting postoperative cardiac events.

DESIGN

Prospective study.

SETTING

District General Hospital.

MATERIALS

48 patients undergoing infrarenal aortic reconstruction.

CHIEF OUTCOME MEASURES

Ejection fractions were measured both by echocardiography and a technetium 99 MUGA scan.

MAIN RESULTS

Three patients developed four major cardiac events (LVF three, fatal myocardial infarction one). Fourteen patients experienced 15 minor cardiac events (arrhythmia 11, ST segment depression four). The clinical index predicted postoperative cardiac problems (p = 0.0001). There was no correlation between ejection fraction measurement and postoperative cardiac events nor between ejection fraction measurements and the clinical index. Combining the index with ejection fraction measurement provided no additional information over the index alone.

CONCLUSIONS

Calculation of a clinical index before aortic reconstruction is a simple and reliable way of selecting patients who are at risk of developing postoperative cardiac events.

Influence of side-chain substituents on the position of cleavage of the benzene ring by Pseudomonas fluorescens

Pseudomonas fluorescens was grown on mineral salts media with phenol, p-hydroxybenzoic acid, p-hydroxy-phenylacetic acid, or p-hydroxy-trans-cinnamic acid as sole carbon and energy source. Each compound was first hydroxylated, ortho to the hydroxyl group on the benzene ring, to give catechol, protocatechuic acid (3,4-dihydroxy-benzoic acid), homoprotocatechuic acid (3,4-dihydroxy-phenylacetic acid), and caffeic acid (3,4-dihydroxy-trans-cinnamic acid), respectively, as the ultimate aromatic products before cleavage of the benzene nucleus. Protocatechuic acid and caffeic acid were shown to be cleaved by ortho fission, via a 3,4-oxygenase mechanism, to give beta-substituted cis, cis-muconic acids as the initial aliphatic products. However, catechol and homoprotocatechuic acid were cleaved by meta fission, by 2,3-and 4,5-oxygenases, respectively, to give alpha-hydroxy-muconic semialdehyde and alpha-hydroxy-gamma-carboxymethyl muconic semialdehyde as initial aliphatic intermediates. Caffeic acid: 3,4-oxygenase, a new oxygenase, consumes 1 mole of O(2) per mole of substrate and has an optimal pH of 7.0. The mechanism of cleavage of enzymes derepressed for substituted catechols by P. fluorescens apparently changes from ortho to meta with the increasing nephelauxetic (electron donor) effect of the side-chain substituent.