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PubMed1987

Benign joint hypermobility with neuropathy: documentation and mechanism of tarsal tunnel syndrome.

Eleven consecutive patients with tarsal tunnel syndrome were reviewed. All had pes planus, 8 had calcaneal valgus hindfoot, and generalized benign joint hypermobility syndrome was evident in 9. Detailed enquiry was necessary to identify apparently trivial precipitating events. In 6 patients there was superimposed secondary reflex sympathetic dystrophy which tended to obscure symptoms of the causative tarsal tunnel syndrome. Wider recognition of this cause-effect mechanism and early management with orthotic footwear and intrinsic foot muscle exercises may obviate the need for surgical intervention in many cases.

Exercise Therapy↗
PubMed1986

Anterior tibial tubercle elevation in the young adult.

A modification of Maquet's procedure, longitudinal proximal tibial osteotomy, was performed on 36 adults under the age of 40. The tibial tubercle was elevated between 2.0 and 2.5 cm. Fourteen were operated on for significant osteochondral injury to the underside of the patella, including patellar fracture; 16 were operated on because of osteoarthrotic change in the patellofemoral joint secondary to recurrent subluxation. Six were operated on because of pain persisting after previous patellectomy. Follow-up ranged between 2 and 5 years, was at least 2 years, and averaged 3.53 years. A good result was determined to be one in which the patient had no pain requiring medication or activity limitation; a poor result was designated when the patient had pain requiring medication or activity limitation. The success rate among the trauma or fracture group was 94 per cent, among the subluxation group 88 per cent, and among the postpatellectomy group 66 per cent. Failures included unrecognized osteoarthrosis of the tibiofemoral joint, psychiatric problems, a reflex sympathetic dystrophy, a compensation neurosis, a failure to correct excessive knee valgus with recurrent subluxation, and a fall displacing the operation. Serious complications, osteomyelitis and a displaced graft resulting from a postoperative fall, occurred at a rate of 5 per cent; minor complications, tenuous skin healing and tibial tubercle shingle fractures, occurred at a rate of 19 per cent. This operation is indicated only for patients with osteoarthrosis of the patellofemoral joint and is contraindicated in the presence of tibiofemoral osteoarthrosis. High success rates are attributed to careful attention to indications and contraindications and to the design and details of performing the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Increased extremity uptake on three-phase bone scans caused by peripherally induced ischemia prior to injection.

During arterial flow scintigraphy, increased tracer uptake in the upper extremity has been noted secondary to induced ischemia distal to blood-pressure cuffs and simple tourniquets, employed prior to the injection. We prospectively studied 68 patients undergoing three-phase bone scintigraphy to evaluate the frequency and magnitude of this artifact. The results showed that when a blood-pressure cuff was applied virtually all patients demonstrated increased activity in the extremity of cuff application. When a simple rubber tourniquet was applied few patients demonstrated the artifact. Only one patient, a case of reflex sympathetic dystrophy syndrome, had increased uptake on blood-pool and skeletal-phase images. We recommend that in flow studies of the hands, wrists, and forearms, blood pressure cuffs not be employed and that at least 3 min should elapse between release of the occlusive device and injection. Asymmetry of flow under these conditions is unlikely to be artifact.

Blood Pressure Determination↗
PubMed1987

Median nerve compression by volarly displaced fragments of the distal radius.

Median nerve compression may occur acutely, subacutely, or late following fractures of the distal radius. Hematoma and swelling at the mouth of the carpal tunnel are the likely cause in acute cases. A contributing factor generally not recognized initially is a volarly displaced fragment of distal radius compressing the median nerve against the proximal edge of the flexor retinaculum. In nine such fractures, median nerve compression occurred in eight. Lack of recognition led to the delay in diagnosis and treatment of two patients. The volar fragment could always be seen on the first postreduction roentgenogram. Carpal tunnel release and removal or reduction of the displaced volar fragment should be carried out as early as possible to avoid the complications of reflex sympathetic dystrophy. Removal of the bony fragment alone, without carpal tunnel decompression, may be insufficient.

Carpal Tunnel Syndrome↗
PubMed1985

Temporal changes in electrophysiological, clinical and radiological parameters in the hemiplegic's shoulder.

The relationship between electrophysiological, clinical and radiological parameters in the shoulder of hemiplegic patients was examined in a group of 24 subjects. Measurements and observations were made about the fourth month after CVA and again some eight months later. Total follow-up period extended to a maximum of 28 months. Electrophysiological tests included concentric needle EMG and conduction tests. In the shoulder X-ray four stages were described: normal, V-shaped space, initial subluxation and advanced subluxation. The presence of pain, reflex sympathetic dystrophy, atrophy and return of movement were registered. The most striking findings, consistent with lower motor neuron lesion, were those of parallel changes in axillary nerve latencies (obtained through stimulation from Erb's point) and shoulder X-ray stage. Age and time lapse between examinations turned out to be significantly related to such changes: younger patients did better and changes were registered even after one year from the first examination. An anatomical explanation linking the axillary nerve with humeral head disposition on the hemiplegic side is offered.

Cerebrovascular Disorders↗
PubMed1985

Systemic and specific autonomic reactions in pain: efferent, afferent and endocrine components.

The sympathetic nervous system is hierarchically organized. At the bottom of this organization are the sympathetic pre-post-ganglionic channels which supply the autonomic target organs, at the top the hypothalamus and cortical structures. Each level of this hierarchy contains neuronal programmes which govern the sympathetic activity in a patterned fashion. According to this hierarchy the reactions to noxious, tissue-damaging events, which are organized by the hypothalamus and suprahypothalamic brain structures, are of a more general character than those organized by the spinal cord, these being of a more specific character. The spinal cord is probably much more important than hitherto believed for integration and in determining the characteristic discharge patterns of the sympathetic pre- and post-ganglionic neurones. The defence reaction is described as a general reaction to noxious stimuli. Its sympathetic components consist of the patterns of discharge in sympathetic neurones supplying skin, skeletal muscle, viscera and adrenal medulla. It is organized in the hypothalamus and upper brain stem. The spinal cord integrates more specific somato-sympathetic, viscero-sympathetic and viscero-visceral reactions to noxious stimuli which are of a protective character. Visceral thoraco-lumbar afferents in 'sympathetic' nerves innervate visceral organs in the pelvic abdominal and thoracic cavities. Some innervate deep somatic structures of the ventral compartment of the vertebral column. No conclusive experimental evidence exists to show that they innervate skin and deep tissues of the extremities. Noxious events in the visceral domain are encoded by these visceral afferents. However, no convincing experimental evidence exists to show that this occurs by 'specific' visceral nociceptive afferents. It may well be that visceral noxious events are encoded by the intensity of the discharges in these neurones. No conclusive experimental evidence exists to show that peripheral nociceptors are controlled by activity in sympathetic post-ganglionic neurones. In certain pathophysiological situations, however, it may happen that activity in sympathetic post-ganglionic neurones, which supply an extremity, leads to excitation of afferent axons, thus establishing a vicious circle between primary afferent neurones, spinal cord and sympathetic outflow. This situation may occur after partial lesions of peripheral nerves in a syndrome which is called 'reflex sympathetic dystrophy'.

Animals↗
PubMedDate not supplied

Antibodies directed against ribosomal protein determinants in the sera of patients with connective tissue diseases.

A collection of sera from patients with systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, Sjögren's syndrome, progressive systemic sclerosis, and the reflex sympathetic dystrophy syndrome was screened for the presence of antibodies recognizing determinants on the protein moiety of human ribosomes after electrophoretic separation in polyacrylamide and blotting on nitrocellulose. In addition to the antibodies already described against the RNA moiety or against the whole ribosome, some autoimmune sera contain antibodies against the protein moiety. The results obtained by this methodology were compared with those obtained by a microtiter procedure.

Antibodies↗
PubMed1981

[Pain and pain therapy - neurophysiologic view].

Usually, pain is caused by the excitation of nociceptors or of nociceptive afferent fibers. The responsiveness of the nociceptors can be modulated by endogenously released algesic substances or local hormones. Lesioned and regenerating nerve fibers show enhanced excitability and spontaneous activity. Motor and sympathetic reflexes sometimes have an excitatory action on nociceptors, a positive feedback which often is essential in chronic pain states such as the sympathetic reflex dystrophies. Proper diagnosis of these influences on nociceptor excitation is crucial if therapeutic interference is to be rendered possible at the peripheral site of encoding of pain stimuli. No pain center exists in the central nervous system. The cognitive, affective, motor and vegetative dimensions of pain perception and pain behaviour are based on a complex interaction of several brain systems. An important feature of brain function in relation to pain is the fact that nervous information related to pain can be modulated in the central nervous system. Various inhibitory modulations have recently been described which may be used for pain therapy. Inhibition of spinal neurons, and analgesia, can be produced by stimulation of brain stem structures. Pharmacologically, pain inhibitory systems may involve serotonin and endogenous opioids as transmitter or modulator substances. For pain therapy, pain inhibitory systems may be activated e.g. by morphine and ther analgesic drugs, focal brain stimulation, various means of somatosensory afferent stimulation and by psychological influences such as stress.

Afferent Pathways↗
PubMed1995

[Dislocated intra-articular calcaneus fractures. Long-term follow-up after open reposition and osteosynthesis].

A series of 98 patients with a total of 105 intra-articular fractures of the os calcis were operated on during a 10-year period between 1983 and 1992. We were able to follow up 60 patients with 64 fractures an average of 44 months (range, 18-105 months) postoperatively. At the time of follow up, 83.9% of patients had been back to work, 78.6% with the same employer as before. Five of the patients followed up had had to retire from work; each of these had one or more severe coexisting injuries. A compromising nerve injury occurred postoperatively in 3 out of 58 patients with closed fractures, in all cases following surgery with a medial or bilateral approach. In only 1 of the 58 patients followed up after closed fractures did a deep infection requiring arthrodesis occur. One patient had sympathetic reflex dystrophy (Sudeck). A good functional result in the lower ankle joint correlated with a good outcome. In contrast, postoperative improvement of the tuber angle and the degree of arthrosis seen radiographically did not. We conclude that operative repair of intraarticular calcaneal fractures is a procedure that can safely be procedure used to restore the ability to work in the majority of patients. The medial approach should preferably not be used, nor should the metal be extracted from the medial approach if this can be avoided.

Adolescent↗
PubMed1995

Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations.

We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups.

Adult↗
PubMed1995

[The efficacy of intravenous lidocaine on various types of neuropathic pain].

We examined the efficacy of systemic local anesthetics on various types of neuropathic pain in 89 patients. Lidocaine 1.5 mg.kg-1 was infused intravenously for one minute. Pain score (PS) by visual analogue scale (VAS, 0-10) was measured 1, 5, 15 and 35 min after the infusion. The efficacy of intravenous lidocaine was evaluated by PS which was lowest after infusion. PS decreased to less than 50 percent of pre-infusion value in more than 75 percent of cases of cancer pain, postherpetic neuralgia, trigeminal neuralgia, low back pain with signs of root pain or spinal canal stenosis, peripheral nerve injury and thalamic pain, in 50-75 percent of cases of herpetic neuralgia, and in less than 50 percent of cases of cervical spondylosis, spinal cord injury, reflex sympathetic dystrophy, causalgia and psychogenic pain. This study suggests that systemic local anesthetics is effective in neuropathy due to cancer pain, postherpetic neuralgia, trigeminal neuralgia, low back pain with signs of root pain or spinal canal stenosis, peripheral nerve injury and thalamic pain.

Aged↗
PubMed1994

The open palm technique in the treatment of Dupuytren's disease.

Twenty-eight patients (33 hands) were reviewed an average 2.5 years after an open palm technique combined with partial fasciectomy for the correction of Dupuytren's disease. They were assessed by diathesis evaluation and Tubiana's score. Results show a recurrence rate of 33.5% (3% severe), an extension rate of 51.5% and an overall complication rate of 21% without reflex sympathetic dystrophy. Fifteen percent and 12% had an important deficit in flexion and extension respectively. These findings are comparable to those found in the literature.

Adult↗
PubMed1994

[Mid-term results of 173 cases of surgery of the anterior cruciate ligament using the Mac Intosh procedure, reinforced by the Kennedy Ligament Augmentation Device].

UNLABELLED: This is a retrospective study of 173 chronic laxities of the knee operated on between May 1985 and December 1988 using the Mac Intosh procedure, reinforced by the Kennedy L.A.D. Follow-up was between 4-8 years and the same surgeon operated on all the knees. MATERIALS AND METHODS: 171 patients were operated on (113 men and 58 women) aged between 15-49 years (average age 26.5 years). The vast majority were sportsmen both at competition level (51 cases) and at recreational level (119 cases). The average time-span between accident and intervention was 15 months (1-240 months). In the pre-operative assessment, 80 cases (46.2 per cent) were found to have a grade II Lachman test and 91 cases (52.6 per cent), a grade III Lachman test; a positive pivot shift was found in more than 95 per cent of cases. There were lesions of the medial meniscus in 101 cases (58.4 per cent), of the lateral meniscus in 94 cases (54.4 per cent) and there was no meniscal lesion in only 41 cases (23.8 per cent). Finally there were 22 chondral lesions of the medial femoral condyle (12.7 per cent) and 7 of the lateral condyle (4.1 per cent). RESULTS: These were based on 159 cases (14 lost to follow-up before the third post-operative month), but only 107 (61.8 per cent) were reviewed by one of us (i.e. not the original surgeon). Tolerance of the L.A.D. was excellent. There was no sign of synovitis or joint effusion persisting beyond 1 year. Furthermore, there were no serious complications (no sepsis, only 4 cases (2.3 per cent) of joint stiffness, 2 cases of reflex sympathetic dystrophy and 5 cases of sural phlebitis (2.9 per cent). Moreover, the few minor complications that arose resolved with the appropriate treatment. Anatomical results, evaluated using. Lachmans test (maximum manual Lachman measured with the Bercovy Laximeter) showed 24 cases (22.4 per cent) with zero differential residual laxity, 54 cases (50.5 per cent) with a differential laxity of between 0-2 mm; 20 cases (18.7 per cent) with a laxity of between 2-4 mm and in 9 cases (8.4 per cent) a laxity of greater than 4 mm. Functional results, using the Arpège C.L.A.S. system showed good results in 83 per cent (score > and unsatisfactory results in 17 per cent of cases. The long time-span between intervention and subsequent review with the C.L.A.S. system should be taken into account. However, the proportion of competitive sportsmen to recreational sportsmen was practically identical when comparing pre-traumatic figures (C = 29.5 per cent, R = 68.8 per cent) to figures at the time of follow-up (C = 21 per cent, R = 69.5 per cent). Radiological results (A.P. and Schuss films) showed 63 knees (58.9%) with no signs of either medial or lateral, preliminary or full-blown, femoro-tibial osteo-arthritis. DISCUSSION: With an average follow-up of > 5 years (4-8 years), it is possible to say that ligamentoplasty of the anterior cruciate ligament using the Mac Intosh procedure reinforced with the Kennedy L.A.D. is not causative of any iatrogenic problems. The anatomical results were totally satisfactory (almost normal) in 72.9 per cent of cases; the radiological results showed ""normal'' knees in 58.9 per cent of cases and functional results were identical to results obtained using many other techniques.

Adolescent↗
PubMed1994

Clinical use of a syndesmosis screw in stage IV pronation-external rotation ankle fractures.

The purpose of this study was to determine if biomechanical data obtained in studies on cadavers correlates with clinical results in the surgical treatment of stage IV pronation-external rotation (PER-IV) ankle fractures. We surgically treated 20 patients who sustained isolated PER-IV ankle injuries and followed 18 of the patients for an average of 2.5 years. Radiographs were evaluated using previously established methods, and clinical outcome was based on the criteria of Cedell. Eleven patients sustained a PER-IV injury with a medial malleolus fracture; 2 required a syndesmosis screw due to poor medial fixation. Good or excellent results were obtained in 90% of the patients in this group; the poor outcome of 1 patient was due to the development of reflex sympathetic dystrophy. Seven patients had a PER-IV injury with a deltoid ligament tear; because of widening of the syndesmosis, 1 patient required an early operation (within 1 week), and 2 patients required late operations (after 1 month). None of these patients should have required a syndesmosis screw based on biomechanical studies. Good or excellent results were obtained in 71% of the patients in this group. We conclude that the biomechanical data concerning placement of a syndesmosis screw in PER-IV ankle fractures does not correlate with in vivo outcome when a deltoid ligament injury occurs. A screw that stabilizes the distal tibiofibular syndesmosis should probably be placed in patients who sustain PER-IV injuries with deltoid ligament ruptures regardless of the level of the fibula fracture.

Adult↗
PubMed1994

Total knee arthroplasty after failed high tibial osteotomy. A comparison with a matched group.

The results of 73 total knee arthroplasties in 67 patients after a high tibial osteotomy (HTO) were carefully reviewed at an average follow-up period of 73 months (range, 24-132 months). An extensive clinical as well as radiographic review was performed in an attempt to evaluate parameters that might portend more favorable or worse outcomes. Additional comparisons were made with two groups of 73 primary TKAs matched according to age, gender, diagnosis, prosthetic fixation, and length of follow-up period. The two comparison groups differed in that one (Group A) was additionally matched to deformity before TKA with a second comparison group (B) matched to pre-HTO deformity. On the basis of a 100-point knee rating scale, 36% of the study group patients had either a fair or poor result or required additional surgery. This was significantly greater than either comparison group (p < 0.01). Factors that prognosticated a worse outcome in the HTO patients (p < 0.01) included (1) workmen's compensation patient, (2) history of reflex sympathetic dystrophy after HTO, (3) early onset (less than one year) or no period of relief of pain after HTO, (4) multiple surgeries before HTO, and (5) an occupation as a laborer.

Adult↗
PubMed1994

The outcome status of chronic pain patients 4 years after multidisciplinary care.

Thirty-three patients previously treated for a variety of chronic pain syndromes (largely non-surgical back problems) were selected for study on the basis of 2 years or greater post-discharge status. A patient profile was developed revealing an 86% successful return-to-work rate and minimal use of narcotics 4 years after discharge. In addition, there was relatively low use of either inpatient or outpatient medical services after treatment. These patient behaviors were specific goals of the pain management program in which these patients had participated. Interesting data were also collected on medication use after treatment and methods of pain control used most successfully. Selected outcome variables were also studied across specific diagnostic categories (surgical v non-surgical back problems, amputee pain, reflex sympathetic dystrophy, and others) for this group. In general, rather compelling positive outcomes are shown for the long-term effects of multi-disciplinary pain management.

Adult↗
PubMed1994

[Evaluation of selective lumbar radiculography and radicular block].

We analyzed 56 patients who received selective lumbar radiculography and radicular block (88 procedures in total). The underlying conditions were spinal diseases in 43 cases, cancer pain in 6 cases, post-herpetic neuralgia (PHN) in 5 cases and reflex sympathetic dystrophy (RSD) in 2 cases. In the spinal disease group, 24 cases showed complete pain relief and 12 cases showed partial pain relief after the therapy, with a success rate of 83.7%. In the cancer pain group, 3 cases showed complete pain relief and one showed partial pain relief (success rate: 66.7%). In the PHN group, 1 case showed complete pain relief and 2 showed partial pain relief (success rate: 60%). In the RSD group, all cases showed pain relief. When examined 3 months after this treatment, the effect had persisted in 15 cases from the spinal disease group, in 1 case from the cancer pain group, in 2 cases from the PHN group and in 2 cases from the RSD group. Selective lumbar radiculography and radicular block are useful in identifying a nerve root responsible for abnormalities. In addition, this procedure is expected to exert a long-lasting therapeutic effect in cases indicated for the procedure.

Adult↗