Peter Burge

Smoking, Alcohol And The Risk Of Dupuytren's Contracture

We investigated the association of Dupuytrens contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire. Dupuytrens contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytrens contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa. Smoking increases the risk of developing Dupuytrens contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily.

The role of magnetic resonance imaging in the management of peripheral nerve tumours.

Fourteen cases of peripheral nerve tumour which had been examined by MRI were reviewed. T1-weighted images showed the tumours to be of intermediate signal and T2-weighted images showed a high signal with some heterogeneity. These appearances are not specific to peripheral nerve tumours, although the diagnosis may be suggested if the lesion arises from a major nerve trunk. The association with a nerve trunk may be defined by MRI, thus assisting with surgical planning. Neurilemmomas, neurofibromas and malignant nerve sheath tumours could not be differentiated with certainty using MR alone. The MR features of lipofibromatous hamartoma are reported.

Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement.

The results of total elbow replacement (TER) in 45 elbows of 38 patients with rheumatoid arthritis were compared with results of radial head excision with synovectomy (RHES) in 45 age-matched patients treated in the same unit. The groups were similar with respect to duration of disease and preoperative clinical status, although pain was of longer duration and slightly more severe in the TER group. Failure was defined as the onset of moderate or severe pain after surgery or revision surgery for any reason. Reduction in pain was greater after TER than after RHES (P < .05). Recurrence of pain was common after RHES but was not seen after TER. Movement increased by a similar amount in each group. Complications were more frequent and more serious after TER (4 dislocations, 4 ulnar nerve dysfunctions, 1 significant wound breakdown) than after RHES (2 ulnar nerve dysfunctions, 1 transient wound discharge). Complications after TER were most common in patients who had previous RHES. On survival analysis, TER results were better than RHES results in each successive year. Cumulative survival rates at 10 years were 85% for TER and 69% for RHES, but the difference in rates was not statistically significant. In the medium term, TER relieves pain more reliably than RHES and its use is justified despite the greater risk of complications. In view of the paucity of long-term results for TER, RHES may retain a role in younger patients or in those whose symptoms are related mainly to the radiohumeral joint.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis: Predictive factors and long-term outcome

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

GENETIC INFLUENCES IN END-STAGE OSTEOARTHRITIS

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95 % CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%. The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.

Effect of Surface Replacement Arthroplasty on Stability of the Ankle

Loosening after total ankle arthroplasty may result from absorption of tensile and shear forces by relatively small bone-cement interfaces. A surface replacement arthroplasty similar in principle to the Oxford knee arthroplasty offers theoretical advantages over other designs. The ability of such a prosthesis to provide a stable articulation was tested by examination of ankle laxity before and after replacement of the tibiotalar articular surfaces. The motion response characteristics of four specimens were measured for internal-external rotation moment (±3 nm), inversion-eversion moment (±3 nm), and anteroposterior displacement (±50 N). The prosthesis restored normal internal-external and inversion-eversion rotatory stability, but the mean anteroposterior laxity was increased from 5.5 to 9.7 mm (P < 0.05). Anteroposterior stability could not be restored by increasing the thickness of the bearing interposed between the prosthetic surfaces. The findings can be explained by consideration of the anatomy of the ligaments in relation to the contour of the normal and prosthetic articular surfaces. The normal tibial articular surface, which is concave in the sagittal plane, provides restraint against anteroposterior motion which is lost when the surface is replaced by the flat prosthetic surface. The findings question the suitability of this type of prosthesis for the ankle.

Rupture of extensor tendons due to osteoarthritis of the distal radio-ulnar joint.

Extensor tendons ruptured in 12 patients as a result of osteoarthritis of the distal radio-ulnar joint. Rupture occurred without warning in ten cases and was sequential in five. Perforation of the dorsal capsule of the distal radio-ulnar joint, allowing contact between the roughened ulnar head and extensor tendons, was present in every case. The capsular performation was demonstrated by arthrography, which may be used to identify patients who are at risk of extensor tendon rupture. Loss of independent extension of the little finger is a valuable clinical sign because rupture of extensor digiti minimi may be masked by a powerful contribution from the extensor tendon of the ring finger.

SYNOVECTOMY OF THE ELBOW AND RADIAL HEAD EXCISION IN RHEUMATOID ARTHRITIS

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Elastic Band Mobilisation after Flexor Tendon Repair; Splint Design and Risk of Flexion Contracture

Elastic band mobilisation of repaired flexor tendons in zone 2 may be complicated by flexion contracture of the P.I.P. joint. The mechanics of three types of elastic band mobilisation were analysed from lateral video-recordings of finger movement and the flexion moment at the P.I.P. joint was derived at every 10° of flexion. The conventional forearm attachment of the elastic band produced a steep rise in P.I.P. joint flexion moment during extension; this effect was greatest when the M.P. joint was at 70° and least at 20°. Flexion moments for attachments around the dorsum of the hand or under a palmar pulley were lower, uniform throughout the range of P.I.P. joint motion and independent of the position of the M.P. joint. The effort needed to extend the P.I.P. joint is strongly influenced by the method of elastic band attachment; consideration should be given to both tension and moment arm in application of elastic band mobilisation.

Ischaemic Contracture of the Intrinsic Muscles of the Hands a Hazard of Physical Restraint

A case is described of bilateral ischaemic contracture of the intrinsic muscles of the hands, presenting in a mentally-disturbed patient one year after a reported period of immobilisation in a physical restraint device. Involvement of the deep thenar muscles and the interossei on the radial side of the hand can be explained by consideration of the anatomy of the deep palmar arch. Division of the tendons of the contracted interosseous muscles proximal to the metacarpophalangeal joints and release of the left first web improved hand function. Those who supervise the use of physical restraint devices should be aware of the risk of intrinsic muscle ischaemia and of the need for prompt diagnosis and treatment.