Arthrodesen bei Patienten mit rheumatisch bedingten Sprunggelenks- und Rückfußarthrosen

Background

Ankle and hindfoot deformities as well as degenerative changes are often found in patients with rheumatological diseases. They often suffer from severe pain and complain of increasing immobility. Corrective procedures with ankle or hindfoot arthrodesis are promising options.

Objectives

This article presents epidemiological data and describes the clinical aspects, diagnostics and treatment options for patients with ankle and hindfoot osteoarthritis.

Materialsand methods

The retrospective results of 56 patients after ankle or hindfoot arthrodesis are presented.

Results

After an average follow-up of 52 months the majority of results were good or excellent with relief of pain and reconstruction of the function of the foot.

Conclusion

Ankle or hindfoot arthrodesis represents a promising option for patients with severe osteoarthritis and can safeguard patients from increasing immobility.     

Assessment of Ankle and Hindfoot Stability and Joint Pressures Using a Human Cadaveric Model of a Large Lateral Talar Process Excision: A Biomechanical Study

Lateral talar process fragment excision may be followed by hindfoot instability and altered biomechanics. There is controversy regarding the ideal fragment size for internal fixation versus excision and a concern that excision of a large fragment may lead to significant instability. The aim of this study was to assess the effect of a simulated large lateral talar process excision on ankle and subtalar joint stability.A custom-made seesaw rig was designed to apply inversion/eversion stress loading on 7 fresh-frozen human cadaveric lower legs and investigate them in pre-excision, 5 cm³ and 10 cm³ lateral talar process fragment excision states. Anteroposterior radiographs were taken to assess ankle and subtalar joint tilt and calculate angular change from neutral hindfoot alignment to 10-kg forced inversion/eversion. Ankle joint pressures and contact areas were measured under 30-kg axial load in neutral hindfoot alignment.In comparison to the pre-excision state, no significantly different mediolateral angular change was observed in the subtalar joint after 5 and 10 cm³ lateral talar process fragment excision in inversion and eversion. With respect to the ankle joint, 10-cm³ fragment excision produced significantly bigger inversion tibiotalar tilt compared with the pre-excision state, P = .04. No significant change of the ankle joint pressure and contact area was detected after 5 and 10-cm³ excision in comparison with the pre-excison state.An excision of up to 10 cm³ of the lateral talar process does not cause a significant instability at the level of the subtalar joint but might be a destabilizing factor at the ankle joint under inversion stress. The latter could be related to extensive soft tissue dissection required for resection.     

Hallux valgus deformity after total ankle arthroplasty for rheumatoid arthritis: A case report

Hallux valgus (HV) deformity is associated with hindfoot valgus deformity. We experienced a case that suggests the possibility that valgus correction for varus hindfoot with bony ankylosis of the subtalar joint by total ankle arthroplasty may have caused a forefoot HV deformity, despite adequate valgus correction.     

Ankle/hindfoot arthrodesis in rheumatoid arthritis improves kinematics and kinetics of the knee and hip: a prospective gait analysis study

OBJECTIVES: To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip. METHODS: In this prospective follow-up study, 14 RA patients scheduled for ankle/hindfoot arthrodesis (talo-calcaneal, talo-navicular, calcaneo-cuboid and/or talo-crural joints) and 14 age- and sex-matched healthy controls were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- vs post-operative conditions, Wilcoxon's matched pairs test and Friedman ANOVA by rank test were used. RESULTS: At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up. CONCLUSIONS: Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.     

Foot and Ankle Kinematics in Rheumatoid Arthritis: Influence of Foot and Ankle Joint and Leg Tendon Pathologies

Objective

From early onset of the disease, patients with rheumatoid arthritis (RA) experience walking impairments. Pathologic effects of RA on foot and ankle structures have been studied clinically, but little is known as to how they relate to kinematic changes during gait. The aim of this study was to explore the relationship between clinically observed pathologies of foot and ankle joints and leg tendons and the corresponding gait kinematics.

Methods

The gait of 25 subjects with varying stages of RA was recorded and foot and ankle kinematics were assessed. Magnetic resonance imaging was performed for each subject: first metatarsophalangeal (MTP) joint, midfoot, and hindfoot synovitis, erosion scores, and leg tendon involvement were determined. The joint alignment and motion score represented daily clinical assessment. The 95% confidence intervals of the Spearman's correlation coefficient tests were used to explore the relationships between the clinical and kinematic parameters.

Results

Maximum first MTP joint dorsiflexion at preswing was related to reduced first MTP joint passive motion, first MTP joint synovitis and erosion, midfoot synovitis and erosion, and hindfoot erosion. Midfoot pronation range of motion during single stance was related to subtalar alignment and Achilles tendon involvement. Hindfoot eversion range of motion during single stance was related to subtalar alignment and peroneus longus tendon involvement. Involvement of the tibialis posterior tendon could not be identified as an independent factor influencing foot or ankle kinematics.

Conclusion

Our findings suggest moderate to strong relationships between foot and ankle gait kinematics and structural pathologies.     

Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series

Summary. The standard treatment for end‐stage osteoarthritis of the ankle joint in haemophilic patients has been fusion of the ankle joint. Total ankle replacement is still controversial as a treatment option. The objective of this prospective study was to evaluate the mid‐term outcome in patients treated with total ankle replacement using an unconstrained three‐component ankle implant. Ten haemophilic ankles in eight patients (mean age: 43.2 years, range 26.7–57.5) treated with total ankle replacement were followed up for a minimum of 2.7 years (mean: 5.6, range 2.7–7.6). The outcome was measured with clinical and radiological evaluations. There were no intra‐ or peri‐operative complications. The AOFAS‐hindfoot‐score increased from 38 (range 8–57) preoperatively to 81 (range 69–95) postoperatively. All patients were satisfied with the results. Four patients became pain free; in the whole patient cohort pain level decreased from 7.1 (range 4–9) preoperatively to 0.8 (range 0–3) postoperatively. All categories of SF‐36 score showed significant improvements in quality of life. In one patient, open ankle arthrolysis was performed because of painful arthrofibrosis. For patients with haemophilic osteoarthritis of the ankle joint, total ankle replacement is a valuable alternative treatment to ankle fusion.     

Additive hindfoot arthrodesis for rheumatoid hindfoot disease: a clinical study of patient outcomes and satisfaction

Advanced rheumatoid hindfoot disease causes significant pain and disability. Hindfoot arthrodesis is a useful procedure but is often overlooked as a treatment option. The objective of this study was to report the improvements in patients’ health, pain, functional ability and satisfaction following this procedure. Thirty-seven patients with rheumatoid arthritis (RA) were recruited from the outpatient clinic and underwent 42 hindfoot arthrodesis procedures by a single surgeon. Outcome measures were SF12 score, Manchester–Oxford Foot Questionnaire index score, visual analogue pain score and satisfaction scores, as well as radiographic assessment. Assessment was undertaken at the pre-admission clinic and at 6 and 12 months post-operatively. Statistically significant improvements were seen at 6 and 12 months in all measured outcomes. The union rate was 97.6 %. The satisfaction rate was 92.5 %. The complication rate was 7.1 %. The functional benefit and outcome scores are comparable to those reported following hip and knee replacement in patients with RA. The findings of this study provide evidence that hindfoot arthrodesis should be considered a worthwhile surgical treatment in the rheumatoid patient with advanced hindfoot disease. Healthcare professionals involved in the management of these patients should be aware of the potential benefits of this procedure and refer early to a foot and ankle surgeon specialist when conservative treatment modalities have failed.     

Diabetic peripheral neuropathy in ankles and feet: muscle strength and plantar pressure

This study aims to evaluate and correlate the vascular, sensory and motor components related to the plantar surface in individuals with diabetic peripheral neuropathy. 68 patients were categorized into two groups: 28 in the neuropathic group and 40 in the control group. In each patient, we assessed: circulation and peripheral perfusion of the lower limbs; somatosensory sensitivity; ankle muscle strength; and pressure on the plantar surface in static, dynamic and gait states. We used the Mann–Whitney test and analysis of variance (ANOVA and MANOVA) for comparison between groups, and performed Pearson and Spearman linear correlations amongst the variables (P?<?0.05). The somatosensory sensitivity, peripheral circulation and ankle muscle strength were reduced in the neuropathic group. In full peak plantar pressures, no differences were seen between groups, but differences did appear when the foot surface was divided into regions (forefoot, midfoot and hindfoot). In the static condition, the plantar surface area was greater in the neuropathic group. In the dynamic state, peak pressures in the neuropathic group, were higher in the forefoot and lower in the hindfoot, as well as lower in the hindfoot during gait. There were positive or negative correlations between the sensitivity deficit, dorsal ankle flexor strength, plantar surface area, and peak pressure by plantar region. The sensitivity deficit contributed to the increased plantar surface area.     

Hindfoot arthrodesis for neuropathic deformity

Acquired neurologic disorders of the foot lead to arthrosis, deformities, instabilities, and functional disabilities. Hindfoot arthrodesis is the current option available for irreducible or nonbraceable deformities of neuropathic feet. However, the role of ankle arthrodesis in these patients has been questioned because of high nonunion and complication rates. From 1990 to 2001, 17 cases of acquired neuropathic foot deformities were treated by four tibiotalocalcaneal (TTC) arthrodeses and 13 ankle arthrodeses. TTC arthrodesis was performed on cases with combined ankle and subtalar arthritis or cases whose deformities or instabilities could not be corrected by ankle fusion alone. There was no nonunion of TTC arthrodesis and seven ununited ankle arthrodeses were salvaged by two TTC-attempted arthrodeses and five revision ankle-attempted arthrodeses. Eventually in these cases, there was one nonunion in TTC arthrodesis and one nonunion in revision ankle arthrodesis. The final fusion rate was 88% (15 of 17 cases) with average union time of 6.9 months (range, 2.5-18 months). The American Orthopaedic Foot and Ankle Society ankle hindfoot functional scores were evaluated: one was excellent (5.8%), seven were good (41%), eight were fair (53.3%), and one was poor (5.8%) in terms of total functional outcome. We conclude that TTC arthrodesis is indicated for cases with ankle and subtalar involvement and ankle arthrodesis is an alternative for cases with intact subtalar joint. We recommend revision ankle arthrodesis if the ankle fails to fuse and the bone stock of the talus is adequate. TTC arthrodesis is reserved for ankles with poor bone stock of the talus with fragmentation.     

Physiology of the retrocalcaneal bursa.

To clarify the function of the retrocalcaneal bursa the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid prevented the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus.     

Multiple stress fractures in the hindfoot in rheumatoid arthritis

A case of nontraumatic bilateral multiple stress fractures of the hindfoot in a 60-year-old white man with rheumatoid arthritis (RA) is described. Review of the literature indicates that stress fractures of the calcaneus and other bones of the hindfoot are an unusual complication of RA and have not been reported previously. Factors leading to the development of stress fractures in the patient with RA are discussed.     

Posterior subtalar joint synoviography and corticosteroid injection in rheumatoid arthritis.

Ten posterior subtalar joints of 8 patients with rheumatoid arthritis and 12 posterior subtalar joints of 6 cadavers were studied by contrast synoviography. In the rheumatoid group the abnormalities included posterior capsule distension, filling defects caused by hypertrophic synovitis, limited or irregular filling of the anterior recess of the joint in 5 out of 10, and communication with the ankle joint in 3 out of 10. None of the cadaveric joints showed posterior capsule distension or limited or irregular filling of the anterior recess of the joint, but communication with the ankle was present in 2 joints. The joints of the patients were injected with a 1:1 mixture of sodium iothalamate 70% (Conray 420) and triamcinolone hexacetonide (Lederspan) 20 mg/ml. All patients noticed a decrease in and an improvement in walking beginning 24-48 hours after the examination. Quantitative thermography was done immediately before and 1 after injection in 2 patients who showed an improvement in thermographic index. We conclude that hindfoot inflammatory pain arising from the posterior subtalar joint is caused by distension with hypertrophic synovitis which can be difficult to detect clinically.     

A Three-Dimensional Printed Foot Orthosis for Flexible Flatfoot: An Exploratory Biomechanical Study on Arch Support Reinforcement and Undercut

The advancement of 3D printing and scanning technology enables the digitalization and customization of foot orthosis with better accuracy. However, customized insoles require rectification to direct control and/or correct foot deformity, particularly flatfoot. In this exploratory study, we aimed at two design rectification features (arch stiffness and arch height) using three sets of customized 3D-printed arch support insoles (R+U+, R+U−, and R−U+). The arch support stiffness could be with or without reinforcement (R+/−) and the arch height may or may not have an additional elevation, undercutting (U+/−), which were compared to the control (no insole). Ten collegiate participants (four males and six females) with flexible flatfoot were recruited for gait analysis on foot kinematics, vertical ground reaction force, and plantar pressure parameters. A randomized crossover trial was conducted on the four conditions and analyzed using the Friedman test with pairwise Wilcoxon signed-rank test. Compared to the control, there were significant increases in peak ankle dorsiflexion and peak pressure at the medial midfoot region, accompanied by a significant reduction in peak pressure at the hindfoot region for the insole conditions. In addition, the insoles tended to control hindfoot eversion and forefoot abduction though the effects were not significant. An insole with stronger support features (R+U+) did not necessarily produce more favorable outcomes, probably due to over-cutting or impingement. The outcome of this study provides additional data to assist the design rectification process. Future studies should consider a larger sample size with stratified flatfoot features and covariating ankle flexibility while incorporating more design features, particularly medial insole postings.     

Study of arteriosclerosis in patients with hiatal hernia and reflux esophagitis

BACKGROUND AND AIM: It has been reported that the prevalence of hiatal hernia (HH) and reflux esophagitis (RE) increases with age, as does the degree of arteriosclerosis. However, it has not been investigated whether or not arteriosclerosis is correlated with the presence of HH and RE. Therefore, we prospectively investigated the degree of arteriosclerosis in patients with HH and RE compared with subjects without HH and RE. METHODS: We prospectively enrolled 1683 people who visited Shimane Environment and Health Public Corporation for annual medical check-ups. All subjects were investigated by upper gastrointestinal endoscopy for the possible presence of HH and RE. Factors used for assessing cardiovascular risk were sex, age, body mass index (BMI), smoking and drinking habits, serum total cholesterol, triglyceride (TG), and high-density lipoprotein cholesterol (HDLC). Arteriosclerosis was investigated by measuring systolic blood pressure, heart-carotid pulse wave velocity (HCPWV), bilateral ankle brachial index (ABI) and heart-ankle PWV (HAPWV). RESULTS: The number of patients with HH and RE was 624 (37.1%) and 143 (8.5%), respectively. The HDLC level of the patients with HH was significantly lower, and the levels of BMI, TG and arteriosclerotic parameters were higher than those of the subjects without HH after adjusting for confounding factors (sex, age and smoking and drinking habits). Cardiovascular and arteriosclerosis parameters except for TG did not differ between the subjects with and without RE. CONCLUSION: Levels of arteriosclerosis parameters in patients with HH were higher than in those without HH. However, the association between arteriosclerosis and presence of RE was not clarified.     

Total ankle replacement in patients with haemophilia and virus infections – a safe alternative to ankle arthrodesis?

Despite reliable results of ankle fusion for advanced haemophilic arthropathy, total ankle replacement (TAR) may be functionally advantageous. There is only very limited literature data available on TAR in patients with haemophilia. The objective of this study is to evaluate the short‐ and mid‐term results after TAR in patients with end‐stage haemophilic ankle arthropathy and concomitant virus infections. In a retrospective study, results after eleven TAR in 10 patients with severe (n = 8) and moderate (n = 2) haemophilia (mean age: 49 ± 7 years, range, 37–59) were evaluated at a mean follow‐up of 3.0 years (range, 1.2–5.4). Nine patients were positive for hepatitis C, five were HIV‐positive. Range of motion (ROM), AOFAS‐hindfoot‐score, pain status (visual analogue scale, VAS) as well as patient satisfaction were evaluated. In two cases deep prosthesis infection occurred leading to the removal of the implant. In the remaining eight patients the mean AOFAS score improved significantly from 21.5 to 68.0 points (P < 0.0005), the VAS score decreased significantly from 7.6 to 1.9 points (P < 0.0005). ROM increased from 23.2 to 25.0 degrees (P = 0.51). At final follow‐up all patients without any complications were satisfied with the postoperative results. Radiographic examination did not reveal any signs of prosthetic loosening. TAR is a viable surgical treatment option in patients with end‐stage ankle osteoarthritis due to haemophilia. It provides significant pain relieve and high patient satisfaction. However, due to the increased risk of infection and lack of long‐term results, TAR particularly in patients with severe haemophilia and virus infections should be indicated carefully.     

Ankle fusion in patients with haemophilia

Ankle fusion in patients with haemophilia is a well‐accepted treatment for end‐stage arthropathy. However, current published outcome data are based on small sample sizes and generally short‐term follow‐up. The aim of this study was to evaluate the long‐term results of ankle fusion in a large group of haemophilic patients treated at a single institution. The results of 57 ankle fusions performed on 45 patients between 1971 and 2010 were reviewed retrospectively. Data were gathered for type and severity of haemophilia, HIV status, fixation technique, postoperative complications and requirement of additional surgeries. A modified American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was calculated for 20 ankles available for follow‐up. Patients were followed for a mean of 6.6 years. There were no intra‐operative or immediate postoperative complications related to fusion of the ankle. The overall non‐union rate was 10.4% for tibio‐talar fusion and 8.3% for sub‐talar fusion. This rate was reduced to 3.7% and 5.6%, respectively, after the introduction of newer surgical techniques in 1995. None of these non‐unions required revision surgery. The modified AOFAS scale demonstrated that 75% had no pain in the operated ankle a mean of 7.2 years following surgery. The remaining 25% scored their average pain as 3 of 10. The functional portion of the score suggested that patients have good alignment, minimal activity limitations or gait abnormalities, and can walk long distances. We conclude that ankle fusion successfully relieves pain and provides a good functional outcome. It is an appropriate treatment for end‐stage haemophilic arthropathy of the ankle.     

Resistance of three immortalized human hepatocyte cell lines to acetaminophen and N-acetyl-p-benzoquinoneimine toxicity

BACKGROUND/AIMS: Acetaminophen toxicity in hepatocytes is attributed to generation of the toxic metabolite N-acetyl-p-benzoquinoneimine, leading to depletion of intracellular glutathione, alteration of redox potential and ultimately, cellular necrosis. We aimed to determine the effect of acetaminophen and N-acetyl-p-benzoquinoneimine on three human hepatocyte cell lines HH25, HH29 and HHY41, and for comparison, on primary rat hepatocytes, a cell type that is relatively resistant to acetaminophen-induced toxicity. METHODS: We investigated the effect of incubation of rat hepatocytes and 3 hepatocyte cell lines with acetaminophen or N-acetyl-p-benzoquinoneimine on LDH release, glutathione status, mitochondrial function, CYP1A activity, albumin synthesis and DNA content. RESULTS: We demonstrated that HH25, HH29 and HHY41 are resistant to the toxic effects of acetaminophen under conditions that induce cytotoxicity in rat primary hepatocytes, as indicated by maintenance of glutathione levels and basal LDH release. Incubation with N-acetyl-p-benzoquinoneimine caused a dose-dependent cytotoxicity in rat hepatocytes. Under comparable conditions N-acetyl-p-benzoquinoneimine had no effect on any of the hepatocyte cell lines. Nevertheless, when culturing the cells for a further 48 h, a decrease in glutathione levels, albumin synthesis, CYP1A activity, DNA content and mitochondrial function was apparent. CONCLUSION: HH25, HH29 and HHY41 cells are highly resistant to acetaminophen and N-acetyl-p-benzoquinoneimine-induced toxicity. They tolerate a much higher concentration of both toxins for a longer period of time compared to rat primary hepatocytes. These results are of relevance in the use of these cell lines to investigate acetaminophen hepatotoxicity, and may be of importance in the choice of cells for use in bioartificial liver support systems.     

老年H型高血压患者踝臂指数变化的临床意义

目的探讨老年H型高血压患者踝臂指数(ABI)的异常情况及临床意义。方法选择127例患者,根据血浆高同型半胱氨酸和诊室血压水平分为H型高血压组(HH组)65例、非H型高血压组(NHH组)32例和正常血压组(NT组)30例。测定ABI、高敏C反应蛋白(hs-CRP)、髓过氧化物酶(MPO)水平和血管内皮功能。结果与NT组比较,HH组和NHH组ABI明显降低(P<0.05,P<0.01);与NHH组比较,HH组ABI明显降低(P<0.05)。与NT组比较,HH组MPO、hs-CRP明显升高,内皮依赖性舒张功能(FMD)明显降低(P<0.05,P<0.01);与NHH组比较,HH组FMD明显降低(P<0.05)。相关分析显示,HH组ABI与hs-CRP和MPO呈负相关(r=-0.739、r=-0.723,P<0.01),与FMD呈正相关(r=0.927,P<0.01)。结论 ABI降低与炎性反应及血管内皮功能受损密切相关,对评估老年H型高血压患者动脉功能损害及识别高危患者有重要的临床意义。     

Hereditary hemochromatosis--new developments after discovery of the HFE gene

Hereditary hemochromatosis (HH) is an autosomal recessive disorder of iron metabolism, resulting in an increased iron deposition and multiorgan failure. Recently a candidate gene of HH, termed HFE, has been identified on chromosome 6, coding for a protein homologous to major histocompatibility complex (MHC) class I molecules. Two mutations of the hemochromatosis gene leading to an exchange of cysteine to tyrosine at aminoacid 282 and histidine to asparagine at aminoacid 63, are retained responsible for the development of hereditary hemochromatosis. The Cys282Tyr-mutation disrupts a disulfid bond and thus abrogates binding of the mutant HFE-protein to beta 2-microglobulin and its presentation on the cell surface. The His63Asp-mutation seems to play a role in pH-regulated dissociation of the transferrin receptor/transferrin complex in the lysosome. Mutations of the HFE-protein alter the affinity of the transferrin receptor for its ligand transferrin and may thus cause an intracellular accumulation of iron. Knowledge of the responsible gene allows a molecular diagnosis of HH. The new genetic marker can be used for screening and confirmation of HH reducing the need for confirmatory liver biopsies. Compared to standard screening parameters like ferritin and transferrin saturation genetic testing will allow the diagnosis of HH in an early, asymptomatic state before iron accumulation has occurred. As a normal life expectancy of patients with HH can be achieved if iron reduction is initiated early, genetic testing may thus be of great benefit for patients with HH.     

Endoscopic diagnosis of hiatus hernia under deep inspiration is not consistent with esophageal manometric diagnosis

Background

To investigate the relationship between endoscopic and esophageal manometric hiatus hernia (HH).

Methods

Forty-six gastroesophageal reflux disease patients with endoscopic HH under maintenance therapy were recruited. Endoscopy was performed on all patients in a fully conscious state. Endoscopic HH was defined as apparent separation greater than 1 cm of the lower margin of the esophageal palisade vessels and the diaphragm hiatus on endoscopy under deep inspiration. Esophageal manometry was conducted using high-resolution manometry (HRM). The length between the lower margin of the lower esophageal sphincter and pulmonary inversion point was measured 10 times. The mean and maximum of the length was then calculated.

Results

The mean HH length on HRM was 0 cm (0–0) [median (25th to 75th percentile)], 0 cm (0-0), 0.5 cm (0–1.1), and 2.2 cm (1.3–2.5) in the groups with endoscopic HH lengths of 1–2, 2–3, 3–4, and 4–5 cm, respectively. The maximum HH length on HRM was 0 cm (0–0), 0 cm (0–0), 0.8 cm (0–1.4), and 2.4 cm (1.5–2.9) in the 1–2, 2–3, 3–4, and 4–5 cm endoscopic HH groups, respectively. The mean and maximum HH lengths increased significantly in the group with an endoscopic HH length of 4–5 cm compared with the other groups, but did not differ significantly among the 1–2, 2–3, and 3–4 cm groups. Of patients with endoscopic HH less than 3 cm, few had esophageal manometric HH greater than 2 cm.

Conclusions

Endoscopic diagnosis of HH under deep inspiration is not consistent with esophageal manometric diagnosis, leading to overdiagnosis.