Good Clinical Scores Research Articles

A method to analyze the evolution of malignant gliomas using MRI

To introduce a novel approach for the monitoring of glioma evolution by the extraction of mathematical parameters from follow-up MRI. The method consists of the registration of follow-up MR images and the analysis of the deformation field. The registration was performed through an affine transformation followed by a non-rigid registration using free-form deformations (FFDs). A subsequent analysis of the transformation non-linear component is then performed by using the jacobian operator in order to extract information related to tumor evolution. In order to test the algorithm’s performance two different validations were performed: (a) a numerical validation utilizing both physical and digital phantoms, (b) a clinical validation using neurosurgeon clinical judgements. Quantitative validation showed that the jacobian describes the volumetric variations of the physical phantom with an error of 5%. Furthermore, simulations with a digital phantom provided an estimation of the error introduced by registration (6.4%). Clinical validation provided good clinical scores: the score evaluating the correspondence between extracted variables and patient evolution was 4.37 ± 0.89 for the deformation field and 4.43 ± 0.82 for the jacobian image (top score: 5). The novel approach leads to an objective and quantitative description of tumor evolution. Therefore, it could be valuable for planning interventions and/or treatments.

Functional outcome of complex intercondylar fractures of the distal humerus treated through a triceps-sparing approach

Complex intra-articular fractures of the distal humerus (AO/ASIF type C) pose a significant challenge to the treating surgeon. This study aimed to review the functional outcome of these fractures managed with open reduction and internal fixation through a posterior triceps-sparing approach. Nine cases were treated over a 7-year period, with 7 patients available for review. Of note, the majority of cases were accompanied with significant associated injuries, including vascular and soft tissue trauma. A retrospective analysis of a consecutive series, managed by a single surgeon, was conducted at a mean follow-up period of 35.1 months (range, 6-78). The mean age was 41 years (range, 12-73). At the time of review, all fractures had united and the median arc was 90 degrees (range, 70-115). All patients achieved good clinical scores as determined by the Mayo Clinic Performance Index. Quality of life assessment (SF-36) revealed no significant difference compared to the general population. The mean DASH score was 17.9, indicating mild residual impairment. There was no x-ray evidence of heterotopic ossification or post-traumatic osteoarthritis. The posterior triceps-sparing approach provides adequate exposure to the fracture site and allows early rehabilitation. Satisfactory functional outcome can be achieved for complex type C fractures of the distal humerus treated through this approach.

Increased Displacement Maximizes the Utility of the Distal Chevron Osteotomy for Hallux Valgus Deformity Correction

Correction of hallux valgus deformity with distal chevron osteotomy is limited by the amount of lateral translation achieved. Since 1999, the senior author has performed a modified technique referred to as increased displacement distal chevron osteotomy in which the distal fragment is translated laterally as far as necessary to obtain correction. This technique can be applied to a deformity with an intermetatarsal angle of up to 18 degrees. The surgical technique and results of this modified procedure are reported. The senior author's (JLB) database was searched for correction of hallux valgus deformity by distal chevron osteotomy performed over a 2-year period. Patients having undergone lateral displacement greater than 50% of the width of the head were studied. At a minimum of two years after surgery, patients were invited to participate in a telephone interview and a final followup office visit. Sixty-two patients underwent 72 procedures during the investigation period. Thirty-three patients having undergone 39 procedures completed comprehensive followup at an average of 34 (range, 24 to 47) months. No patients were dissatisfied and all patients would have surgery again under similar circumstances. AOFAS score averaged 93 with a standard deviation of 8.7 (range, 65 to 100). Radiographic union occurred in all 39 feet. Lateral translation averaged 8.2 mm (60%). No cases of radiographic avascular necrosis or advancement of degenerative joint disease were noted. Correction of the hallux valgus angle (HVA) averaged 22.2 degrees, intermetatarsal angle (IMA) 7.9 degrees, and sesamoid position 1.6 stages. Nine complications were identified in nine feet, two of which required additional surgery. Increasing the displacement achieved with distal chevron osteotomy resulted in reliable correction including moderate to severe deformity. At 2 years, patients displayed a high rate of satisfaction, good clinical outcomes scores, and a complication rate similar to other techniques.

Results of Biofeedback Therapy Together with Electrical Stimulation in Faecal Incontinence with Myogenic Lesions

Reports about biofeedback therapy together with electrical stimulation with faecal incontinence are rare. This study is to investigate the effectiveness of biofeedback therapy in faecal incontinence patients with myogenic lesions. Methods: One hundred and twenty-six patients with faecal incontinence caused by myogenic lesions were referred to this programme, comprising three sessions of supervised therapy in hospital followed by 2 months of home exercise. Biofeedback therapy methods that consist of strengthening muscles biofeedback, sensory discrimination biofeedback, synchronizing biofeedback, and electrical stimulation were selected to improve the programme. Clinical scores and outcomes of the anorectal function were assessed before and after the programme, and t test was performed for statistical analysis.Results : Before this programme, there were 19 patients with good clinical scores, 46 patients with fair and 61 patients with poor clinical scores. After therapy, 98 patients achieved good scores, 24 patients fair, and only four patients had poor clinical scores. The squeeze pressure and the sphincter electromyography amplitude were improved significantly, the rectal sensory threshold was decreased significantly, and 80 patients who previously had no external anal sphincter reflex acquired such a reflex. At the two-year follow-up, 60.2% (65/108) of patients maintained the clinical outcomes. Conclusion : biofeedback therapy together with electrical stimulation is an effective method for faecal incontinence in patients with myogenic lesions. Patients should be offered this choice of therapy.

Total hip arthroplasty of dysplastic hip after previous Chiari pelvic osteotomy

Many reports have suggested that Chiari pelvic osteotomy would improve the results of acetabular component placement and fixation in subsequent total hip arthroplasty. However, little is known concerning the biomechanical, radiological, and clinical effects of Chiari pelvic osteotomy on subsequent total hip arthroplasty. Ten total hip arthroplasties for developmental dysplasia of the hip after previous Chiari pelvic osteotomy (Chiari group) were compared with 20 total hip arthroplasties for developmental dysplasia of the hip without previous surgery (control group). Preoperative patient demographic data and operative technique were well matched between the groups. The mean duration of follow-up was 3.0 years. Biomechanical, radiological, and clinical evaluations were performed. No acetabular or femoral components exhibited loosening. All patients had good or excellent clinical score according to the Merle d'Aubigne-Postel rating system at the most recent follow-up. Abductor force and joint force were smaller in the Chiari group, although long operative time, more blood loss, and verticalization of joint force were noted in this group. This limited study suggested that Chiari pelvic osteotomy changed the biomechanical features of the hip joint, and that this alteration might have compromised subsequent total hip arthroplasty.

Combination of Hook Plate and Tibial Pro-Fibular Screw Fixation of Osteoporotic Fractures: A Clinical Evaluation of Operative Strategy

Internal fixation of osteoporotic ankle fractures is technically difficult and may fail because of unreliable purchase. This study was undertaken to determine if a combination of a hook plate and tibial pro-fibular screws can provide secure fixation until fracture union. Thirty-one patients between the ages of 55 and 90 years had open reduction and internal fixation of ankle fractures between April, 2001, and April, 2003. Sixteen patients with an average age of 71.4 years had ankle fracture fixation with a combination of hook plate and tibial pro-fibular screws for the distal fibular fracture, and 15 patients with an average age of 71.9 years had fixation of their ankle fractures with standard fixation technique using AO/ASIF principles but no tibial pro-fibular screws. All patients were followed with clinical and radiologic assessment at 2 weeks, 6 weeks, and 12 weeks postoperatively. At an average of 15.8 months after injury, patients also completed a mailed questionnaire with the Olerud-Molander ankle score and the AOFAS ankle-hindfoot score for preoperative and postoperative status. All patients who had tibial pro-fibular screw fixation had fracture union without hardware failure or complications. In the standard fixation group two patients had wound breakdown and one had a valgus malunion with screw pull out. The AOFAS and Olerud-Molander scores for the standard open reduction and internal fixation were 57.3 and 82.8 before injury and 37 and 43.8 postoperatively, respectively. The AOFAS and Olerud-Molander scores for the hook plate and tibial pro-fibular fixation group were 55.9 and 81.3 before injury and 42.4 and 50.3 postoperatively, respectively. The combination of hook plate and tibial pro-fibular screws in osteoporotic ankle fractures in a series of patients has not been reported before. This novel technique provides stable fixation for osteoporotic ankle fractures in elderly patients until union is achieved with good clinical scores.

Proximal ingrowth components.

The advantage of using a proximal ingrowth hip revision component is restoring physiologic load to the revision femur. Although first generation components had limited survivorship and diminished clinical outcomes, subsequent designs have proven much better with rates of aseptic loosening of 2% to 5%, and good clinical scores. Titanium is the favored substrate metal for these components because of its bone affinity and low modulus of elasticity. A series of 107 consecutive revisions of standard stems is presented using a calcar replacement long stem design with an overall 92.7% 11-year survivorship. Bone ingrowth was achieved in all but two components. Radiographic stress shielding was seen in 11.4% with 42.6% having some calcar healing. These implants can be used in most revision situations, but require sufficient proximal metaphysis of the femur to provide support of the component. Supplemental allograft may need to be used. These implants require a tight fit in the isthmus of the femur and fill of the proximal femur. Modularity makes achieving this easier, but monoblock designs also can be successful.

Osteolysis associated with a cemented modular posterior-cruciate-substituting total knee design : five to eight-year follow-up.

Most intermediate and long-term studies of cemented posterior-cruciate-substituting total knee prostheses were performed with nonmodular tibial components. The purpose of this study was to evaluate the intermediate-term results of posterior-cruciate-substituting total knee arthroplasties in which a cemented modular tibial component had been used, with a particular focus on evaluating the prevalence of radiographic osteolysis. Between 1992 and 1995, 176 consecutive primary total knee arthroplasties with use of the Insall-Burstein II system were performed in 134 patients at our institution. A modular metal-backed tibial component was inserted in 145 knees, and an all-polyethylene tibial component of the same design was inserted in thirty-one. Standard-terminology questionnaires were completed or Knee Society and The Hospital for Special Surgery scores were determined preoperatively and at the time of final follow-up, at an average of 6.4 years (range, 5.0 to 7.9 years). Initial postoperative radiographs were compared with those made at the time of final follow-up to assess component position, wear, radiolucent lines, and osteolysis. Ninety-two patients (128 knees) treated with the modular tibial component were alive at the time of final follow-up. No patient was lost to follow-up. Radiographs were available for 105 knees (82%). Three knees had been revised because of instability or infection; none had been revised because of loosening or osteolysis. The mean Knee Society clinical and functional scores were 85 points (range, 41 to 100 points) and 79 points (range, 30 to 100 points), respectively, at the time of final follow-up. According to The Hospital for Special Surgery score, 94% of the knees had a good or excellent result. Knee flexion averaged 113 degrees (range, 90 degrees to 130 degrees ) at the time of final follow-up. Osteolysis was present in seventeen (16%) of the knees with radiographic follow-up. Osteolysis did not develop in any knee in which an all-polyethylene tibial component had been used. Two knees (in one patient) were revised because of osteolytic lesions found at the time of follow-up for the study. Both of these knees had anterior wear of the tibial post due to impingement and backside tibial polyethylene wear. Modular Insall-Burstein II total knee prostheses were found to function well after five to eight years of follow-up. However, the high prevalence of osteolysis in patients who had good or excellent clinical scores is worrisome. Particular attention should be paid to preventing flexion of the femoral component, posterior slope of the tibial component, or hyperextension of the knee when posterior-cruciate-substituting total knee arthroplasty is performed. We also recommend routine follow-up radiographs after all total joint arthroplasties to detect asymptomatic osteolytic changes.

Quantitative evaluation of gait pattern in patients with osteoarthrosis of the knee before and after total knee arthroplasty. Gait analysis using a pressure measuring system

Using a pressure measuring system, we quantitatively evaluated gait pattern in patients with osteoarthrosis (OA) of the knee before and after total knee arthroplasty (TKA). In the OA group, the stance time was longer, and the average vertical component of the floor reaction force (AVF) was lower than the values in normal age-matched subjects. These gait parameters correlated with the clinical score. These results suggest that changes in the gait parameters reflect gait patterns that reduce load on the knee. The center of pressure (COP) under the foot was correlated with the axial alignment of the lower limb in the mid-stance phase. In the TKA group, the clinical scores and gait parameters were improved 12 months after surgery compared with the preoperative values. The COP in the mid-stance phase moved inward after the TKA. However, in patients examined more than 2 years after a TKA, stance time and AVF did not reach normal levels, despite the patients’ good clinical scores. These findings indicate that the gait pattern before surgery continues although pain on walking is reduced early after a TKA. Gait evaluation with a simple pressure measuring system revealed the changes in gait that are difficult to define by subjective clinical assessment.

Reproductive issues in adults with cystic fibrosis: Implications for genetic counseling

This article reviews reproductive issues faced by the growing number of individuals with cystic fibrosis (CF) who reach adulthood. Approximately 97-98% of males with CF are infertile and they may have an increased risk for genitourinary anomalies. Females with CF may experience delayed puberty, irregular menstrual cycles, and decreased fertility. Women with CF who have good clinical scores, good nutritional status, and normal lung volumes with mild to moderate airway obstruction, have a better chance for successful pregnancies. The role of the genetic counselor in counseling adults with CF is discussed and resources for CF adults are provided.

Relationships between essential fatty acid levels, pulmonary function and fat absorption in pre-adolescent cystic fibrosis children with good clinical scores.

Twenty-one pre-adolescent cystic fibrosis (CF) children with good clinical scores had significant (P less than 0.001) deficiencies of arachidonic (mean 3.8% of total plasma fatty acids +/- SD 1.4) and linoleic (18.1 +/- 6.3) acids compared with controls (6.0 +/- 1.0, and 27.6 +/- 3.9, respectively). Despite the presence of pulmonary involvement of varying severity in all the CF children, neither arachidonic nor linoleic acid levels correlated significantly with pulmonary function measured by spirometry. All children had adequate caloric and fat intakes, and the coefficient of fat absorption correlated with none of the deficient fatty acid levels. These findings suggest that deficiencies of arachidonic and linoleic acids are of minor importance in the early development of pulmonary involvement in CF, and that factors other than fat malabsorption and decreased dietary intake probably contribute to fatty acid deficiency.