Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status.
PURPOSE: The intermediate success and outcome of primary forefoot amputations in patients with diabetes mellitus who have sepsis limited to the forefoot and presumed adequate forefoot perfusion, as determined by means of noninvasive methods, was studied. METHODS: Cases of a university hospital-based practice from January 1984 to April 1998 were retrospectively reviewed. Patients included had diabetes mellitus with forefoot sepsis requiring immediate hospitalization for digit amputations who had adequate arterial circulation for healing based on noninvasive and clinical assessment: palpable pedal pulses (29%), "compressible" ankle pressure of 70 mm Hg or higher (48%), pulsatile metatarsal waveforms (67%), and/or toe pressure higher than 55 mm Hg (36%). All patients underwent a primary single- or multiple-digit amputation (through the interphalangeal joint, metatarsal head, or metatarsal shaft). Additional forefoot procedures (debridement, digit amputation) were performed during the follow-up period as needed for persistent or recurrent infection. The main outcome variables were recurrent or persistent foot infection (defined as requiring rehospitalization for antibiotics, wound care, and/or reoperation), the number of repeat operations and hospitalizations for salvage of limbs with recurrent or persistent infections, and time to complete forefoot healing or foot amputation. RESULTS: Ninety-two patients who had diabetes mellitus with 97 forefoot infections comprised the study group. Ninety-seven primary digit amputations (34 through interphalangeal joints, 28 through metatarsal heads, 35 through metatarsal shafts) were performed. The median length of hospital stay was 10 days. There were no operative deaths. The mean follow-up period was 21 months (range, 3 days to 105 months). The primary amputation healed (without persistent infection) in only 38 limbs (39%), at a mean time of 13 +/- 10 weeks. Twenty-three limbs (24%) had not healed the primary amputation without evidence of persistent infection at last follow-up (mean, 12 weeks). Infection persisted in 35 limbs (36%), and infection recurred in 15 of 38 (40%) healed limbs. An average of 1.0 reoperations (range, 0 to 3) and 1.6 rehospitalizations (range, 1 to 4) were involved in salvage attempts in these recurrent/persistent infections. Five persistent and five recurrent infections ultimately healed (mean, 53 weeks). Complete healing was achieved in only 33 of 97 limbs (34%). Twenty-two foot amputations (20 transtibial, two Syme's) were performed (mean, 49 +/- 74 weeks; 20 for persistent infection). Eighteen persistent/recurrent infections remained unhealed at the last follow-up examination (mean, 105 weeks). CONCLUSION: Patients with diabetes mellitus who have sepsis limited to the forefoot requiring acute hospitalization and undergoing primary digit amputations have a high incidence of intermediate-term, persistent, and recurrent infection, leading to a modest rate of limb loss, despite having apparently salvageable lesions and noninvasive evidence of presumed adequate forefoot perfusion. (+info)
Reliability and sensitivity to change of a simplification of the Sharp/van der Heijde radiological assessment in rheumatoid arthritis.
OBJECTIVE: To determine the reliability and sensitivity to change of a simplified radiological scoring method [simple erosion narrowing score (SENS)] for rheumatoid arthritis (RA). SENS was compared to the Sharp/van der Heijde score (SHS) as a gold standard. METHODS: Sets of seven radiographs of hands and feet were taken of 20 RA patients with a wide spectrum of radiological damage. For 14 patients, these seven radiographs were taken during a follow-up period of 5 yr, and for six patients during a follow-up of 10 yr. Each set of radiographs was scored twice by the same observer (DvdH). Erosions and joint space narrowing were scored with SHS (range 0-448) in 32 and 30 joints in the hands, respectively, and both in 12 joints in the feet. SENS gives a score of 1 if there is any erosion in a joint and also 1 if there is any narrowing in the joint (range 0-86). In each case, SENS was derived from SHS. To analyse data, generalizability theory and repeated measurements ANOVA were used. RESULTS: The overall reliability coefficient was 0.81 for SHS and 0.80 for SENS. Intra-observer reliability [intraclass correlation coefficient (ICC)] was 0.99 and 0.98 for SHS and SENS, respectively. The ICC for the sensitivity to change was 0.84 for SHS and 0.88 for SENS. The smallest detectable difference (SDD) could be determined for both methods. The presence of progression based on this SDD was very comparable between the two methods. CONCLUSION: The measurement properties of SENS are good and comparable to SHS. This makes SENS suitable for use in clinical practice and in large (epidemiological) studies, especially in the first years of disease. (+info)
Joint symmetry in early and late rheumatoid and psoriatic arthritis: comparison with a mathematical model.
OBJECTIVE: To establish a mathematical model to predict the probability of symmetry of joint involvement as a function of the number of joints involved and to compare expected with actual probabilities in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) and in early and late disease. METHODS: Random involvement of joints was assumed, and the binomial theorem was used to give the frequency distribution of involved joints as a function of each joint count. Ten joint pairs were included: shoulder, elbow, wrist, metacarpophalangeal joints, proximal interphalangeal (PIP) joints of the hands, hip, knee, ankle, metatarsophalangeal joints, and PIP joints of the feet. Observed probabilities were obtained from subjects with early (duration < or =12 months) and late PsA and RA. RESULTS: The number of subjects in each of the disease subgroups was as follows: early PsA n = 33, late PsA n = 77, early RA n = 61, late RA n = 93. Observed probabilities of symmetry exceeded predicted probabilities for all disease subgroups. The median number of involved joints in each group was as follows: early PsA 4, late PsA 8, early RA 8, late RA 15 (chi2 = 95.3, 3 degrees of freedom, P = 0.0001, by Kruskal-Wallis test). After correcting for the discrepancy in the number of involved joints, no difference in joint symmetry was found between the groups (chi2 = 1.77, P = 0.62 by Friedman two-way analysis of variance). Similar results were obtained when individual hand and foot joints were analyzed separately. CONCLUSION: The pattern of joint involvement is often used to distinguish between rheumatoid and psoriatic arthritis. This study confirms that symmetry is largely a function of the total number of joints involved and that, in terms of joint pattern, differences between these disorders are more quantitative than qualitative. Both disorders have high absolute values of symmetry, particularly in the joints of the wrist and hand. (+info)
Concrete use of the joint coordinate system for the quantification of articular rotations in the digital joints of the horse.
A method is detailed allowing the computation of three-dimensional (3D) joint angles. Each joint of the equine digit is modelled as a sequence of three single axis rotary joints. The Joint Coordinate System was used; it involves a specific sequence of cardanic angles. The decomposition of the angles was chosen so that the three elementary angles coincide with the flexion/extension, passive abduction/adduction and lateral/medial rotations. The algorithms and kinematic procedures were described for the equine front digital joints. This method was tested in vitro on four forelimbs. For each limb, angle values were measured while the member was loaded by a press (from 500 to 6000 N). These tests were repeated while a wedge raised one part of the hoof (toe, heel, lateral and medial sides) in order to induce modifications of the angular patterns of the joints. This method allowed a precise quantitative determination of 3D joint movements. The modifications occurring with the wedges are clearly identified and confirm some previously published semi-quantitative observations. Moreover, this method provides a way to collect objective data on the functional anatomy of joints and could be used to study connective shoeing thoroughly. It may be directly applied to other species and may be used by researchers interested in discreet articular movements, especially occurring in other planes than the sagittal one. (+info)
The course of radiologic damage during the first six years of rheumatoid arthritis.
OBJECTIVE: To describe the radiologic course in a large cohort of patients with early rheumatoid arthritis (RA) and to analyze individual components of damage. METHODS: Five hundred two patients with recent-onset RA (disease duration <1 year) underwent annual radiologic assessment for a maximum of 6 years in this longitudinal prospective study. The study was designed to investigate the efficacy of 3 different therapeutic strategies. For the assessment of radiologic damage, radiographs of the hands and feet were scored according to the modified Sharp/van der Heijde method (SHS; range 0-448). A mean of 2.9 (range 1-7) radiographs was read per patient. RESULTS: Stable rates of progression of the SHS, erosion score, and narrowing score were found over the course of RA: the mean rates were 8.6, 5.4, and 3.2 modified Sharp units per year, respectively. The rate of progression of newly (not previously) damaged joints declined, and the rate of progression of already damaged joints (which became more damaged) increased during followup, leading to an equal contribution to progression of the SHS at 5 years. The joints of the feet, especially the fifth metatarsophalangeal joint, generally became eroded earlier and more of them became eroded compared with the joints of the hands. CONCLUSION: Radiologic damage progresses at a constant rate. In advanced disease, monitoring the progression of previously existing damage is as important as assessing new abnormalities in previously undamaged joints. Radiographs of the feet should be included in assessments of radiologic damage that are used in clinical intervention trials and daily practice. (+info)
Time to first occurrence of erosions in inflammatory polyarthritis: results from a prospective community-based study.
OBJECTIVE: To examine the time of occurrence of first radiographic erosions in a cohort of patients with inflammatory polyarthritis. METHODS: Patients were recruited through the Norfolk Arthritis Register, which follows up patients annually. Patients with features of rheumatoid arthritis (other than erosions) sufficient, together with erosions, to meet the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 revised criteria were requested to undergo radiographic examinations of the hands and feet at the first and/or second annual followup visits. All patients were requested to undergo radiographic examinations at the fifth annual followup visit. The most recent erosion-free radiograph was identified for 416 eligible patients, and these data were used to derive the duration of disease since the recalled date of onset of first symptoms. The rate of occurrence of first erosions was then determined (as a cumulative prevalence and as an incidence rate using Poisson regression) from analysis of followup films. Patients were assumed to be free of erosions at symptom onset. RESULTS: The cumulative prevalence of erosions in patients whose first film was obtained 12-24 months after disease onset was 36%, equivalent to an incidence rate of 24.5/1,000 patient-months. We identified 3 analysis groups of patients who were free of erosions based on films obtained 12-24 months, 24-36 months, and 36-60 months since the recalled date of onset of first symptoms. New erosions were observed in all 3 groups, with cumulative prevalences of 23%, 28%, and 47%, respectively. These were equivalent to first-erosion incidence rates/1,000 patient-months of 5.4 (95% confidence interval [95% CI] 3.8-83), 6.8 (95% CI 4.7-10.0), and 13.0 (95% CI 8.9-19.2), respectively. CONCLUSION: Many patients with erosive disease first develop their erosions >2 years from disease onset. (+info)
Metatarsal osteotomy for metatarsalgia.
An oblique osteotomy in the distal half of the metatarsal shaft is described for the treatment of metatarsalgia due to prolapse of one or more of the middle three metatarsal heads. Thirty-eight patients who have had this operation have been followed up for a period of from two to five years. The operation is simple, recovery is rapid and symptoms have been well relieved. (+info)
Dorsal dislocation of the first metatarso-phalangeal joint. Report of four cases.
The anatomy of the first metatarso-phalangeal joint and of dorsal dislocation of the phalanx are described. As similar lesions in the hand, closed reduction is impossible because of interposition of the volar plate. Open reduction is essential and should be performed as soon as possible after the injury. (+info)