Wrist arthroscopy

Major advancement in arthroscopic equipment and techniques has extended the ability of large joint arthroscopy to be performed in smaller joints. Although wrist arthroscopy is performed in small numbers, the same advantages are afforded as in large joint procedures. It provides important diagnostic information and therapeutic intervention, while avoiding the significant morbidity of open techniques. Patients with mechanical wrist pain are the best candidates for arthroscopy to evaluate ligamentous injuries or triangular fibrocartilage complex injuries. Arthroscopy is also an effective tool in the evaluation and treatment of intra-articular distal radius fractures and is particularly useful in radial styloid fractures. Wrist arthroscopy is a technically demanding procedure. However, it remains a safe and effective method for diagnosis and treatment if performed using a precise technique and if the surgeon has a precise understanding of the anatomy of the wrist.     

The New Millennium Palliative Care Project (2000-2003): the impact of specialised GP advisors.

This study describes a novel type of support for GPs caring for patients dying at home: the establishment and evaluation of a telephone advisory service for GPs, run by GPs with a special interest in palliative care (GPwSIs) in the Netherlands 2000-2003. A growing number of GPs called for advice, 10% during out of hours. Prognosis of the patients was generally short (days to weeks in 70% of cases). Most advice sought by GPs concerned symptom management and on evaluation, 85% of the GPs followed the advice.     

Luteal phase deficiency in recreational runners: evidence for a hypometabolic state

Exercising women with amenorrhea exhibit a hypometabolic state. The purpose of this study was to evaluate the relationship of luteal phase deficient (LPD) menstrual cycles to metabolic hormones, including thyroid, insulin, human GH (hGH), leptin, and IGF-I and its binding protein levels in recreational runners. Menstrual cycle status was determined for three consecutive cycles in sedentary and moderately active women. Menstrual status was defined as ovulatory or LPD. Subjects were either sedentary (n = 10) or moderately active (n = 20) and were matched for age (27.7 +/- 1.2 yr), body mass (60.2 +/- 3.3 kg), menstrual cycle length (28.4 +/- 0.9 d), and reproductive age (14.4 +/- 1.2 yr). Daily urine samples for the determination of estrone conjugates, pregnanediol 3-glucuronide, and urinary levels of LH were collected. Blood was collected on a single day during the follicular phase (d 2-6) of each menstrual cycle for analysis of TSH, insulin, total T3, total T4, free T4, leptin, hGH, IGF-I, and IGF binding protein (IGFBP)-1 and IGFBP-3. Among the 10 sedentary subjects, 28 of 31 menstrual cycles were categorized as ovulatory (SedOvul). Among the 20 exercising subjects, 24 menstrual cycles were included in the ovulatory category (ExOvul), and 21 menstrual cycles were included in the LPD category (ExLPD). TSH, total T4, and free T4 levels were not significantly different among the three categories of cycles. Total T3 was suppressed (P = 0.035) in the ExLPD (1.63 +/- 0.07 nmol/liter) and the ExOvul categories of cycles (1.75 +/- 0.8 nmol/liter) compared with the SedOvul category of cycles (2.15 +/- 0.1 nmol/liter). Leptin levels were lower (P < 0.001) in both the ExOvul (5.2 +/- 0.4 microg/liter) and the ExLPD categories of cycles (5.1 +/- 0.4 microg/liter) when compared with the SedOvul category of cycles (13.7 +/- 1.7 microg/liter). Insulin was lower (P = 0.009) only in the ExLPD category of cycles (31.9 +/- 2.8 pmol/liter) compared with the SedOvul (60.4 +/- 8.3 pmol/liter) and ExOvul (61.8 +/- 10.4 pmol/liter) categories of cycles. IGF-I, IGFBP-1, IGFBP-3, IGF-I/IGFBP-1, IGF-I/IGFBP-3, and hGH were comparable among the different categories of cycles. These data suggest that exercising women with LPD menstrual cycles exhibit hormonal alterations consistent with a hypometabolic state that is similar to that observed in amenorrheic athletes and other energy-deprived states, although not as comprehensive. These alterations may represent a metabolic adaptation to an intermittent short-term negative energy balance.     

Neuro-psychiatric effects of antimalarials

Objective: To study the neuro-psychiatric adverse effects of antimalarial drugs. Setting: Persons who visited a Travel Clinic in Rotterdam over a period of 3 months. Design: Prospective cohort study on 394 persons taking mefloquine, 493 persons taking proguanil and 340 persons not taking antimalarial drugs who visited Africa, South America, Asia, or the Middle East. Methods: All persons received a structured questionnaire within 14 days of their return to the Netherlands. The questionnaire consisted of questions regarding use of alcohol, smoking, general health, medical history, tropical diseases during the trip, and other medicines, and contained an extensive list of general complaints regarding all body systems at four levels of severity. A modified and validated version of the Profile of Mood States was included. Results: In the study period, 2541 persons visited the Travel Clinic, of whom 1791 (70%) were both eligible and willing to co-operate. Of these 1791, data were obtained from 1501 (84%). Insomnia was most frequently encountered in users of mefloquine and mouth ulcers in proguanil users. After adjustment for gender, age, destination, and alcohol use, the relative risk for insomnia to mefloquine versus non-users of antimalarials was 1.6, and the excess risk was 6 per 100 users over an average period of 2 months. There were no significant differences between groups in depression, anxiety, agitation, and confusion. Stratification by gender demonstrated that insomnia was more common in women on mefloquine, but not in men. Also, women more frequently mentioned palpitations as an adverse event. After adjustment for age, destination, and alcohol use in women, the relative risks for insomnia and palpitations to mefloquine versus non-use of antimalarials were 2.4, and 22.5, respectively. When travellers were specifically asked for the adverse reactions they had experienced, anxiety, vertigo, agitation, and nightmares were significantly more frequently mentioned by mefloquine users. Conclusion: Insomnia was more commonly encountered during use of mefloquine than proguanil or during non-use of antimalarials.     

Ulnar growth patterns in radial longitudinal deficiency

PURPOSE: To determine the association between centralization surgical procedures and the longitudinal growth of the ulna in radial longitudinal deficiency (RLD). METHODS: The charts of 90 patients with 124 affected limbs were reviewed. Thirty-four patients were affected bilaterally and 56 were affected unilaterally. Based on the Bayne and Klug classification there were 5 type I, 3 type II, 9 type III, and 107 type IV deformities. Seventy-two limbs had available radiographs, which were measured for ulnar length. We plotted 384 ulnar length measurements in 72 limbs and compared these with both normative ulnar length data and ulnar length data in RLD. The average ulnar length was compared for the group (n = 46) treated with surgical centralization versus the nonsurgically treated group (n = 22). RESULTS: The nonsurgically treated group attained 64% of normal ulnar length whereas the nonnotched centralization group attained 58% of normal ulnar length. The notched centralization group attained 48% of normal ulnar length. Ulnar growth for the surgically treated group averaged 0.54 cm/y and the for the nonsurgically treated group averaged 0.71 cm/y, which showed no statistical significance. CONCLUSIONS: Wrist centralization procedures effectively increase the overall length of the limb by centralizing the hand and carpus over the shortened ulna; this must be weighed against the high rate of recurrent radial deviation deformity and some loss of ulnar growth.     

Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases

We reviewed 4 biceps-to-triceps transfers for active elbow extension in 3 tetraplegic patients using a medial routing technique. The biceps-to-triceps transfer to regain active elbow extension in tetraplegic patients is an alternative to the more commonly described deltoid-to-triceps transfer. Before surgery, all 3 patients had absent triceps function and active biceps, brachialis, and supinator function. Postoperative results were assessed by a modified University of Minnesota Functional Improvement questionnaire and by follow-up evaluation of range of motion and muscle strength. All 3 patients had marked functional improvement in activities that involve active elbow extension, and no loss of function was noted in any activities. No patient achieved less than grade 4 extension strength; none had an extension lag greater than 8 degrees. Supination and flexion strength following transfer were rated as at least grade 4 in each limb. Based on the results of this study, we recommend the biceps-to-triceps transfer as an alternative to the deltoid-to-triceps transfer in spinal cord injury patients with active brachialis and supinator function. The medial routing technique has the advantage of avoiding the potentially devastating radial nerve injury that could occur with the previously described lateral routing.     

Upper extremity surgical treatment of cerebral palsy

The purpose of this report is to review the surgical treatment of the upper extremity involved with cerebral palsy over a 25-year period and present our results with regard to changes in upper limb function. Surgical results were assessed by comparison of preoperative and postoperative levels of upper extremity functional use using a previously described 9-level scale. The effect of the following cofactors on surgical outcome were examined: type of cerebral palsy, age, voluntary control, mental impairment, sensibility, and type of surgical treatment. One hundred eighty operations representing 718 procedures in 134 patients were reviewed. Surgical treatment was based on the following principles: soft tissue releases of deforming spastic muscles, tendon transfers to augment antagonistic activity, and joint stabilization. Surgical planning was tailored to each child's particular needs. Comparison of the preoperative and postoperative 9-level functional use scores showed an average improvement of 2.6 functional levels for all patients. Patients with fair and good voluntary control had significantly greater improvement in functional use scores than those with poor voluntary control. No other statistically significant predictive cofactor was found. In selected patients with upper extremity dysfunction secondary to spastic cerebral palsy, surgical intervention improves function, as measured by the upper extremity functional use scale.