We report our 11-year experience of performing arthroscopically assisted triangular fibrocartilage complex reconstruction in the treatment of chronic distal radio-ulnar joint instability resulting ...from irreparable triangular fibrocartilage complex injuries. Eleven patients were treated. Three skin incisions were made in order to create radial and ulna tunnels for passage of the tendon graft, which is used to reconstruct the dorsal and palmar radio-ulnar ligaments, under fluoroscopic and arthroscopic guidance. At a mean follow-up of 68 months all but one had a stable distal radio-ulnar joint. Pain and grip strength, Mayo wrist score, Disability of the Arm Hand and Shoulder and patient-rated wrist and hand evaluation scores improved. The ranges of forearm rotation remained largely unchanged. Complications included an early tendon graft tear, two late-onset graft ruptures, one ulna styloid fracture during surgery and persistent wrist discomfort during forearm rotation requiring tendon graft revision in one case. An arthroscopic assisted approach for triangular fibrocartilage complex reconstruction appears safe and produces comparable results with the open technique.
Level of evidence: IV
The classical definition of ‘Palmer Type IB’ triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that ...enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears.
Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies.
Level of evidence: II
Abstract Background Severe ulcerative colitis is a potentially life-threatening condition. Due to advances in medical therapy, the mortality rate has dropped to <2% over the past 30 years, but the ...colectomy rate reaches 30%. Recently, infliximab has been shown to be effective as rescue therapy but little is known about long-term benefits. Aim To evaluate short-and long-term colectomy rates for severe ulcerative colitis in the era of biological treatment and to identify predictive factors of long-term colectomy. Patients and methods From 2001 to 2006 all in-patients with severe ulcerative colitis, according to Truelove and Witts criteria, were retrospectively reviewed. All patients had received intravenous steroid treatment; infliximab (5 mg/kg at 0, 2 and 6 weeks) was used as rescue therapy in steroid-refractory patients; colectomy was performed in patients who deteriorated whilst on steroid treatment or failed to respond to infliximab. Results Of the 314 ulcerative colitis patients hospitalized during the study period, 52 (16.5%) met the criteria of severe ulcerative colitis. After median 7 days (range 4–15) on intravenous steroids, 37/52 (71%) patients showed a clinical response, while 15/52 (29%) were steroid-refractory. Of these, four underwent urgent colectomy and 11 received infliximab. A clinical response was observed in all infliximab-treated patients. In the long-term, another six patients underwent elective colectomy. The overall colectomy rate, following the acute attack, was 19%; the cumulative probability of a course without colectomy was 90%, 86%, 84%, 81%, after 6, 12, 18 and 24 months, respectively. No deaths occurred. The long-term colectomy risk was comparable in patients treated with infliximab and in steroid-responsive patients (18% vs. 11% respectively; OR 1.9; 95% CI 0.26–14.5). No predictive factors of colectomy, in the long-term, were identified. Conclusions Surgery continues to play an important role in acute severe ulcerative colitis. Infliximab can avoid urgent colectomy in steroid-refractory patients but the risk of elective colectomy, in the long-term, is not modified.
Aliment Pharmacol Ther 2011; 33: 902–910
Summary
Background Diverticular disease of the colon is a common gastrointestinal disease. Although most patients remain asymptomatic for their whole life, ...about 20–25% present symptoms related to ‘diverticular disease’. Several randomised trials verified efficacy of a poorly absorbed antibiotic, such as rifaximin‐α (rifaximin), in soothing symptoms and preventing diverticulitis.
Aim To evaluate the long‐term efficacy administration of rifaximin plus fibre supplementation vs. fibre supplementation alone, on symptoms and complications, in patient with symptomatic uncomplicated diverticular disease.
Methods Pertinent studies were selected from the Medline, and the Cochrane Library Databases, references from published articles and reviews. Conventional meta‐analysis according to DerSimonian and Laird method was used for the pooling of the results. The outcomes were 1‐ year complete symptom relief, and 1‐ year complication incidence. The rate difference (RD, with 95% CI) and the Number Needed to Treat (NNT) were used as measure of the therapeutic effect on each outcome.
Results Four prospective randomised trials including 1660 patients were selected. The pooled RD for symptom relief was 29.0% (rifaximin vs. control; 95% CI 24.5–33.6%; P < 0.0001; NNT = 3). The pooled RD for complication rate was −1.7% in favour of rifaximin (95% CI −3.2 to −0.1%; P = 0.03; NNT = 59). When considering only acute diverticulitis, the pooled RD in the treatment group was −2% (95% CI −3.4 to −0.6%; P = 0.0057; NNT = 50).
Conclusions In symptomatic uncomplicated diverticular disease, treatment with rifaximin plus fibre supplementation is effective in obtaining symptom relief and preventing complications at 1 year.
The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two ...surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001).
To evaluate the current management of carpal tunnel syndrome (CTS) at a national level.
A multicentric observational study was conducted in 34 Italian centers by specialists participating in the ...Management of Peripheral Neuropathies Study Group on 377 patients (age, mean±SD 56±14.4 years, 73.2% females) with CTS. The characteristics of the disease and its management were recorded at baseline and during a 2-month follow-up using a standardized clinical record and assessed with validated clinical tests.
A wide variability in the interventions prescribed and classified according to three categories (physical, pharmacological and neurotrophic therapies) was evident. A subgroup of 303 patients was treated with a combination of neurotrophic agents containing alpha-lipoic acid (ALA). At the end of the follow-up, a general improvement in symptoms and functional impairment was observed, with a significant reduction in BCTQ (Boston Carpal Tunnel Questionnaire) (p<0.001) and in NRS (Pain Numeric Rating Scale, p<0.001 for both nocturnal and diurnal pain).
An appropriate approach to CTS implies a multimodal and multidisciplinary management, involving several specialists and using a variety of conservative interventions. Conservative (physical and pharmacological) interventions can provide a clinical improvement in patients with CTS.
An Italian version of the patient-rated wrist/hand evaluation (PRWHE) questionnaire was obtained through the standardized process of cross-cultural adaptation. The PRWHE-Italian (IT) was tested on 63 ...patients in order to evaluate comprehension, reliability and validity as correlated to the validated version of the disabilities of the arm shoulder and hand (DASH)-IT and SF-36. No patients had difficulty completing the PRWHE-IT questionnaire. Psychometric testing demonstrated high reliability (Cronbach’s alpha coefficient = 0.9607) and internal and external validity (Pearson correlation coefficient r = 0.927 with PRWHE, r < 0.810 with DASH and r < −0.476 with SF-36). The Italian version of the PRWHE has equivalent evaluation capacities to the original English version and is a reliable functional outcome measurement instrument for wrist and hand disorders.
Abstract
Background
Isolated scaphotrapeziotrapezoid is a relatively rare condition, and there is still not complete consensus on the treatment of this pathology.
Purpose
The aim of the present ...study is to assess the utility of implant interposition after arthroscopic scaphoid distal pole resection for scaphotrapeziotrapezoid arthritis.
Material and Methods
The authors present a prospective study after the arthroscopic resection of the distal pole of the scaphoid in 24 patients. In a group of 11 patients, the simple resection was performed while in the other 13 patients the scaphoid resection and pyrocarbone implant interposition.
Results
All patients were clinically evaluated with disability of arm, shoulder, hand score. Dorsal intercalated segment instability deformity was also measured from X-ray analysis. Grip and pinch strength were measured too, and patients were also given a visual analog scale questionnaire. Both clinical and radiographic assessments were done at 24 months postoperatively.
Conclusions
The study showed comparable results with both the techniques.
Level of Evidence II
A prospective comparative study.
Aim:
To perform a meta‐analysis to assess the effectiveness and safety of oral budesonide for inducing remission in active Crohn’s disease and for preventing relapse in Crohn’s disease with ...medically‐ or surgically‐induced remission.
Methods:
All randomized, double‐blind controlled trials involving oral budesonide therapy in Crohn’s disease were retrieved from a Medline search, reviews articles or their bibliographies. Of 83 articles retrieved, 12 met the inclusion criteria. Data extraction was performed by three independent observers and scoring disagreements were resolved by consensus.
Results:
Six trials tested budesonide in active disease and six in quiescent disease. Budesonide was less effective than conventional corticosteroids for inducing remission of active Crohn’s disease (pooled rate difference, RD –8.5%; 95% CI: –16.4 to –0.7%; P=0.02), but corticosteroid‐related adverse events were reduced (RD –22.4%; 95% CI: –32 to –12.8%; P < 0.001). In quiescent Crohn’s disease, budesonide was as effective as placebo for preventing relapse in medically induced remission (RD –0.8%; 95% CI: –9.9 to 8.3%; P=0.42) and endoscopic recurrence in surgically induced remission (RD –3.5%; 95% CI: –16.9 to 9.8%; P=0.30). In the long term treatment, budesonide had an occurrence rate of corticosteroid‐related adverse effects similar to placebo (RD 5.3%; 95% CI: –3.9 to 14.5%; P=0.30).
Conclusions:
Budesonide is significantly less effective than conventional corticosteroids for inducing remission in active Crohn’s disease, but the risk of corticosteroid‐related adverse effects is significantly reduced. Budesonide is not effective in preventing relapse of Crohn’s disease after medically‐ or surgically‐induced remission.
Hyaloglide® is a hyaluronan-based gel based on a novel auto-crosslinked technology designed to reduce postsurgical adhesions. Its efficacy was assessed in a multicentred randomized controlled trial ...comparing the results of flexor tenolysis in zone 2 following failed flexor tendon repairs. In the control group a standard release was performed. In the treated group, Hyaloglide® was applied into the flexor sheath and around the site of tenolysis. Forty-five patients, 19 controls and 26 treated with Hyaloglide®, were enrolled in 13 centres. All the patients were evaluated at 30, 60, 90 and 180 days after surgery by testing Total Active Motion, Quick-DASH questionnaire and number of working days lost after surgery. Patients in the Hyaloglide® group had a statistically better recovery of finger motion at all time intervals and returned earlier to work and daily activities. The use of Hyaloglide® did not appear to increase the complication rate.
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