Incorporating pathological gait into patient-specific finite element models of the haemophilic ankle

Haemarthrosis is an inherent clinical feature of haemophilia, a disease characterised by an absence or reduction in clotting proteins. Patients with severe haemophilia experience joint bleeding leading to blood-induced ankle arthropathy (haemarthropathy). Altered biomechanics of the ankle have been reported in people with haemophilia; however, the consequence of this on joint health is little understood. The aim of this study was to assess the changes in joint contact due to haemophilia disease-specific gait features using patient-specific modelling, to better understand the link between biomechanics and joint outcomes. Four, image-based, finite element models of haemophilic ankles were simulated through consecutive events in the stance phase of gait, using both patient-specific and healthy control group (n = 36) biomechanical inputs. One healthy control FE model was simulated through the healthy control stance phase of the gait cycle for a point of comparison. The method developed allowed cartilage contact mechanics to be assessed throughout the loading phase of the gait cycle. This showed areas of increased contact pressure in the medial and lateral regions of the talar dome, which may be linked to collapse in these regions. This method may allow the relationship between structure and function in the tibiotalar joint to be better understood.

Acute biomechanical responses to wearing a controlled ankle motion (CAM) Walker boot during walking

BACKGROUND

Controlled ankle motion (CAM) boots are often prescribed during the rehabilitation of lower limb injuries and pathologies to reduce foot and ankle movement and loading whilst allowing the patient to maintain normal daily function.

RESEARCH QUESTION

The aim of this study was to quantify the compensatory biomechanical mechanisms undergone by the ipsilateral hip and knee joints during walking. In addition, the compensatory mechanisms displayed by the contralateral limb were also considered.

METHODS

Twelve healthy participants walked on an instrumented treadmill at their preferred walking speed. They underwent kinematic and kinetic analysis during four footwear conditions: normal shoes (NORM), a Malleo Immobil Air Walker on the right leg (OTTO), a Rebound® Air Walker on the right leg with (EVEN) and without (OSS) an Evenup Shoelift™ on the contralateral leg.

RESULTS

CAM boot wear increased the relative joint contribution to total mechanical work from the ipsilateral hip and knee joints (p < 0.05), which was characterised by increased hip and knee abduction during the swing phase of the gait cycle. EVEN increased the absolute work done and relative contribution of the contralateral limb. CAM boot wear reduced walking speed (p < 0.05), which was partially compensated for during EVEN.

SIGNIFICANCE

The increased hip abduction in the ipsilateral leg was likely caused by the increase in effective leg length and limb mass, which could lead to secondary site complications following prolonged CAM boot wear. Although prescribing an even-up walker partially mitigates these compensatory mechanisms, adverse effects to contralateral limb kinematics and kinetics (e.g., elevated knee joint work) should be considered.

Decline in health-related quality of life and foot and ankle patient reported outcomes measures in patients with haemophilia and ankle haemarthropathy

BACKGROUND

Haemophilia is an X-linked recessive genetic disorder characterised by bleeding within soft tissue and joints. The ankle is disproportionally affected by haemarthropathy when compared to the elbows and knees; reported as the most affected joints in patients with haemophilia. Despite advances in treatment, patients still report ongoing pain and disability, however, the impact has not been evaluated, nor has the effect on health-related quality of life (HRQoL) or foot and ankle patient-reported outcome measures (PROMs). The primary aim of this study was to establish the impact of ankle haemarthropathy in patients with severe and moderate haemophilia A and B. Secondly to identify the clinical outcomes associated with a decline in HRQoL and foot and ankle PROMs.

METHODS

A cross-sectional multi-centre questionnaire study was conducted across 18 haemophilia centres in England, Scotland and Wales with a recruitment target of 245 participants. The HAEMO-QoL-A and Manchester-Oxford Foot Questionnaire (MOXFQ) (foot and ankle) with total and domain scores measured impact on HRQOL and foot and ankle outcomes. Demographics, clinical characteristics, ankle haemophilia joint health scores, multi-joint haemarthropathy and Numerical Pain Rating Scales (NPRS) of "ankle pain over the past six months" were collected as a measure of chronic ankle pain.

RESULTS

A total of 243 of 250 participants provided complete data. HAEMO-QoL-A and MOXFQ (foot and ankle) total and index scores indicated worse HRQoL with total scores ranging from a mean of 35.3 to 35.8 (100 best-health) and 50.5 to 45.8 (0 best-health) respectively. NPRS (mean (SD)) ranged from 5.0 (2.6) to 5.5 (2.5), with median (IQR) ankle haemophilia joint health score of 4.5 (1 to 12.5) to 6.0 (3.0 to 10.0) indicating moderate to severe levels of ankle haemarthropathy. Ankle NPRS over six months and inhibitor status were associated with decline in outcome.

CONCLUSIONS

HRQoL and foot and ankle PROMs were poor in participants with moderate to severe levels of ankle haemarthropathy. Pain was a major driver for decline in HRQoL and foot and ankle PROMs and use of NPRS has the potential to predict worsening HRQoL and PROMs at the ankle and other affected joints.

The impact of ankle haemarthropathy in patients with moderate haemophilia

INTRODUCTION

Moderate haemophilia has traditionally been associated with less complications than severe haemophilia. Changes in treatment recommendations have highlighted the burden of moderate haemophilia with a subset of patients with a severe bleeding phenotype. The ankle joint is disproportionally affected by ankle haemarthropathy however the impact has not been evaluated in moderate haemophilia, nor the effect on health related quality of life (HRQoL) or foot and ankle outcomes.

AIMS

To establish the impact of ankle haemarthropathy in patients with moderate haemophilia.

METHODS

A multicentre questionnaire study recruited patients from 11 haemophilia centres in England, Scotland and Wales. The HAEMO-QoL-A and Manchester-Oxford foot and ankle questionnaire (MOXFQ) with total and domain scores measured impact. Measures of pain and ankle haemophilia joint health (HJHS) scores were also collected.

RESULTS

Twenty-nine participants were recruited. HAEMO-QoL A mean (SD) total scores of 10.8 (5.2) of 100 (best health) and foot and ankle specific MOXFQ total scores of 45.5 (24.7) above zero (best outcome) indicate poor HRQoL and foot and ankle outcomes. Average ankle pain over past 6 months of (0-10) 5.5 (SD2.5) was reported and median (IQR) ankle HJHS of 3.0 (1;12.5) to 4.5 (0;9.5) for the left and right ankles.

CONCLUSION

HRQoL and foot and ankle specific outcomes are poor in patients with moderate haemophilia and ankle haemarthropathy, driven by chronic levels of ankle joint pain. Despite moderate haemophilia being considered less affected by haemarthrosis and haemarthropathy, patients with a bleeding or haemarthropathy phenotype are clinically similar to patients with severe haemophilia A.

P129 Quantification of longitudinal joint and cartilaginous changes within ankles with haemophilia joint degeneration using MRI imaging

Background/Aims

Haemophilia is an X-linked recessive genetic disorder characterised by episodes of spontaneous and traumatic intra-articular bleeding. 90% of bleeds are of musculoskeletal origin, with the ankle being most affected joint. Recurrent bleeding results in haemosiderin accumulation, linked to progressive, end-stage ankle haemarthropathy in adolescent and adult patients. Magnetic Resonance Imaging (MRI) is gold-standard for the evaluation of early soft tissue and cartilage changes in ankles with haemarthropathy. This study utilised MRI sequences to quantify longitudinal changes within the ankle joint, via changes in cartilage thickness (CT), subchondral thickness (ST) and joint space width (JS) over time.

Methods

Clinical T1 Sagittal MRI scans of HJD ankles were selected (N = 5). Each patient had a minimum of two MRI scans available, at least one year apart, to allow for comparison of longitudinal changes. All images were identity coded but fully anonymised. The earliest available and most recent MRI scan were measured in three slices (medial, lateral and middle slice) and at different points along the joint space (anterior, middle and posterior). Measurements taken were cartilage thickness on the talar dome (CT) and the distance between the subchondral bone of the tibial plafond and talar dome (ST). The joint space width (JS) was then determined by subtracting CT from ST.

Results

Chondral thickness measurements showed most reduction, particularly at the antero-lateral aspect (-0.4mm) compared to the antero-medial and middle sections, with -0.24mm and -0.34mm (Table 1). ST and JS reduction was predominantly seen in the anterior joint, with most reduction in antero-lateral joint (-1.13mm). The posterior joint showed minimal reduction in the postero-medial and middle sections, with the posterior-lateral joint space width increasing (0.2mm). Subchondral thickness and joint space measurements were variable and did not demonstrate linear change over time.

Conclusion

A systematic longitudinal decrease in cartilage thickness was seen in the antero-lateral and antero-medial aspect of the ankle joint. The antero-lateral aspect of the ankle showed the greatest reduction in joint space and cartilage thickness. This suggests that this area of the joint is likely to provide the best early indications of haemarthropathy when using MRI as a diagnostic tool.

Disclosure

M. Schaper: None. M. Sharrock: None. R.A. Wilkins: None. A.C. Redmond: None.

A systematic review and narrative synthesis of footwear and orthotic devices used in the management of ankle haemarthrosis and haemarthropathy in haemophilia

Introduction

Haemarthrosis is a clinical feature of haemophilia leading to haemarthropathy. The ankle joint is most commonly affected, resulting in significant pain, disability and a reduction in health‐related quality of life. Footwear and orthotic devices are effective in other diseases that affect the foot and ankle, such as rheumatoid arthritis, but little is known about their effect in haemophilia.

Aims

To review the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia.

Methods

A systematic literature review was conducted. Two review authors independently screened studies for inclusion and appraised methodological quality using Joanna Briggs Institute Critical Appraisal checklists. A narrative analysis was undertaken.

Results

Ten studies involving 271 male participants were eligible for inclusion. All studies were quasi‐experimental; three employed a within‐subject design. Two studies included an independent comparison or control group. A range of footwear and orthotic devices were investigated. Limited evidence from non‐randomised studies suggested that footwear and orthotic devices improve the number of ankle joint bleeding episodes, gait parameters and patient‐reported pain.

Conclusion

This review demonstrates a lack of robust evidence regarding the efficacy and effectiveness of footwear and orthotic devices in the management of ankle joint haemarthrosis and haemarthropathy in haemophilia. Methodological heterogeneities and limitations with the study designs, small sample sizes and limited follow‐up of participants exist. Future studies utilising randomised designs, larger sample sizes, long‐term follow‐up and validated patient‐reported outcome measures are needed to inform the clinical management of ankle joint haemarthrosis and haemarthropathy.

Twelve-month prevalence of haemarthrosis and joint disease using the Haemophilia Joint Health score: evaluation of the UK National Haemophilia Database and Haemtrack patient reported data: an observational study

OBJECTIVES

To report the 12-month prevalence of joint bleeds from the National Haemophilia Database (NHD) and Haemtrack, a patient-reported online treatment diary and concurrent joint disease status using the haemophilia joint health score (HJHS) at individual joint level, in children and adults with severe haemophilia A and B (HA/HB) without a current inhibitor.

DESIGN

A 2018 retrospective database study of NHD from which 2238 cases were identified, 463 patients had fully itemised HJHS of whom 273 were compliant in recording treatment using Haemtrack.

SETTING

England, Wales and Scotland, UK.

PARTICIPANTS

Children (<18 years) and adults (≥18 years) with severe HA and HB (factor VIII/factor IX, <0.01 iu/mL) without a current inhibitor.

PRIMARY AND SECONDARY OUTCOMES

Prevalence of joint haemarthrosis and concurrent joint health measured using the HJHS.

RESULTS

The median (IQR) age of children was 10 (6-13) and adults 40 (29-50) years. Haemarthrosis prevalence in HA/HB children was 33% and 47%, respectively, and 60% and 42%, respectively, in adults. The most common site of haemarthrosis in children was the knee in HA and ankle in HB. In adults, the incidence of haemarthrosis at the ankles and elbows was equal. The median total HJHS in HA/HB children was 0 and in adults with HA/HB, were 18 and 11, respectively. In adults with HA/HB, the median ankle HJHS of 4.0 was higher than the median HJHS of 1.0 for both the knee and elbow.

CONCLUSION

Despite therapeutic advances, only two-thirds of children and one-third of adults were bleed-free, even in a UK cohort selected for high compliance with prophylaxis. The median HJHS of zero in children suggests joint health is relatively unaffected during childhood. In adults, bleed rates were highest in ankles and elbows, but the ankles led to substantially worse joint health scores.

Morphological variation of the hemophilic talus

Flattening of the trochlear tali is clinically observed as structural and functional changes advance in patients with hemarthropathy of the ankle. However, the degree of this flattening has not yet been quantified, and distribution of the morphological changes across the talus not yet defined. Chronologically sequential MR images of both a hemophilic patient group (N = 5) and a single scan from a nondiseased, sex-matched, control group (N = 11) were used to take four measurements of the trochlear talus morphology at three locations (medial, central and lateral) along the sagittal plane. Three ratios of interest were defined from these to assess whether the talar dome flattens with disease. The control group MRI measurements were validated against literature data obtained from CT scans or planar X-Rays. The influence of disease on talar morphology was assessed by direct comparison of the hemophilic cases with the control group. The values for all three ratios, in all locations, differed between the control and the hemophilic group. Flattening was indicated in the hemophilic group in the medial and lateral talus, but differences in the central talus were not statistically significant. This work demonstrates that morphological assessment of the talus from MR images is similar to that from CT scans or planar X-Rays. Talar flattening does occur with hemarthropathy, especially at the medial and lateral edges of the joint surface. General flattening of the trochlear talus was confirmed in this small patient sample, however the degree and rate of change is unique to each ankle.

P107 Prevalence of haemarthrosis and clinical impact on the musculoskeletal system in people with haemophilia in the United Kingdom: evaluation of UKHCDO and haemtrack patient reported data

Background

Haemarthrosis whereby bleeding occurs within a joint is a significant feature of haemophilia. Despite the availability of prophylaxis clotting factor concentrates in the United Kingdom haemarthrosis is associated with worsening joint health and haemarthropathy in people with severe haemophilia. The ankle joint has been identified as the most affected joint followed by the knee and elbow. Whilst annual joint bleed rates (AJBR) are commonly reported in haemophilia research, bleed rates in individual affected joints and joint health status in paediatric and adult patients is yet to be established.

Methods

In 2018, paediatric (&lt;18 years) and adult (≥18 years) patients with severe non-inhibitor haemophilia A and B registered with the United Kingdom Haemophilia Centres Doctors Organisation (UKHCDO) National haemophilia Database (NHD) were evaluated for haemarthrosis prevalence and associated joint health. Fully itemised Haemophilia Joint Health Scores (HJHS) were obtained from NHD records in combination with AJBR from Haemtrack (HT) compliant patients. Haemarthrosis prevalence and AJBR were reported as a total and for individual joints (ankles, knees and elbows).

Results

During 2018, 2233 individuals were identified; 273 reported ≥75% simultaneous HT compliance and electronic fully itemised HJHS data. The median (range) age of children is 10 (6-14) years and adults 40 (25-51) years. The joint bleed prevalence of haemophilia A and B in children is 33% and 47% respectively, and in adults 42% and 60% respectively. In children with haemophilia A (n = 80) the knee (data) was the most common site of bleeding. In haemophilia A adults (n = 157) the ankle and elbow were equally affected. In haemophilia B children (n = 17) and adults (n = 19) the elbow was the most prevalent site. Total HJHS scores in children with haemophilia A and B were 0.00 (1.00 SD) and 0.40 (0.90 SD) respectively. Total HJHS scores in adults with haemophilia A and B were 21.20 (16.80 SD) and 15.40 (15.10 SD) respectively. Mean HJHS scores itemised by joint were higher in adults compared with children. In children with haemophilia A and haemophilia B, mean (3.80) and median (4.00) scores for the ankle joint were higher than for the knee (2.90 and 1.00) and elbow joint (3.30 and 1.00).

Conclusion

Whilst there are limitations to this self-select subset of individuals with severe haemophilia, the prevalence of haemarthrosis is evenly distributed in all adult joints with a trend towards the knee in paediatrics. Despite prophylaxis 30% of children and 60% adults still reported bleeding over a 12-month period. Irrespective of the prevalence of joint bleeds in children with haemophilia the HJHS does not appear to be clinically sensitive enough to detect changes in joint health. Adults deemed adherent with prophylaxis and haemtrack still demonstrate worsening HJHS scores despite a low AJBR.

Disclosures

R.A. Wilkins Grants/research support; Funded by the National Institute for Health Research. H.J. Siddle Grants/research support; Funded by the National Institute for Health Research. G. Chapman None. A.J. Redmond None. H. Xiang None. M. Scott None. M. Richards None. L. Horn None. B. Palmer None. D. Stephensen None.

Plantar forefoot pressures in psoriatic arthritis-related dactylitis: an exploratory study

Dactylitis is a common feature of psoriatic arthritis (PsA); local physical trauma has been identified as a possible contributing factor. The aim of this study was to explore differences in forefoot plantar pressures in patients with PsA with and without dactylitis and compare to healthy controls. Thirty-six participants were recruited into three groups: group A PsA plus a history of dactylitis; group B PsA, no dactylitis; group C control participants. Forefoot plantar pressures were measured barefoot and in-shoe at the left second and fourth toes and corresponding metatarsophalangeal joints. Temporal and spatial parameters were measured and data from the foot impact scale for rheumatoid arthritis (FIS-RA), EQ5D and health assessment questionnaire (HAQ) were collected. Pressure time integral peak plantar pressure, and contact time barefoot and in-shoe were not significantly different between groups. Temporal and spatial parameters reported no significant differences between groups. ANOVA analysis and subsequent post hoc testing using Games-Howell test yielded significance in FIS-RA scores between both PsA groups versus controls, A p ≤ 0.0001 and PsA group B p < 0.0001 in the FIS-RA impairment and footwear domain, PsA group A p < 0.03 and PsA group B p ≤ 0.05 in the FIS-RA activity and participation domain compared to controls. This is the first exploratory study to investigate forefoot plantar pressures in patients with and without historical dactylitis in PsA. FIS-RA scores indicate PsA patients have significant limitations compared to controls, although a history of dactylitis does not appear to worsen patient reported outcomes.

Foot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study

This randomised feasibility study aimed to examine the clinical and biomechanical effects of functional foot orthoses (FFOs) in the treatment of midfoot osteoarthritis (OA) and the feasibility of conducting a full randomised controlled trial. Participants with painful, radiographically confirmed midfoot OA were recruited and randomised to receive either FFOs or a sham control orthosis. Feasibility measures included recruitment and attrition rates, practicality of blinding and adherence rates. Clinical outcome measures were: change from baseline to 12 weeks for severity of pain (numerical rating scale), foot function (Manchester Foot Pain and Disability Index) and patient global impression of change scale. To investigate the biomechanical effect of foot orthoses, in-shoe foot kinematics and plantar pressures were evaluated at 12 weeks. Of the 119 participants screened, 37 were randomised and 33 completed the study (FFO = 18, sham = 15). Compliance with foot orthoses and blinding of the intervention was achieved in three quarters of the group. Both groups reported improvements in pain, function and global impression of change; the FFO group reporting greater improvements compared to the sham group. The biomechanical outcomes indicated the FFO group inverted the hindfoot and increased midfoot maximum plantar force compared to the sham group. The present findings suggest FFOs worn over 12 weeks may provide detectable clinical and biomechanical benefits compared to sham orthoses. This feasibility study provides useful clinical, biomechanical and statistical information for the design and implementation of a definitive randomised controlled trial to evaluate the effectiveness of FFOs in treating painful midfoot OA.

Debridement of painful forefoot plantar callosities in rheumatoid arthritis: the CARROT randomised controlled trial

The objective of this study was to evaluate the long-term benefits of sharp scalpel debridement of painful forefoot plantar callosities in rheumatoid arthritis (RA). The null hypothesis: sharp scalpel debridement would offer no additional long-term advantage in terms of pain and function. Sixty-five people with RA were randomised to receive regular sharp scalpel debridement of painful forefoot plantar callosities in conjunction with a combined therapeutic approach or a combined therapeutic approach alone. The primary outcome measure was change at 18 months in participant-reported forefoot plantar pain measured by a 100-mm visual analogue scale (VAS). Secondary outcome measures were recorded at baseline and study exit and included revised Foot Function Index, Health Assessment Questionnaire, Foot Impact Scale and gait parameters. At 18 months, there were no differences between groups for the primary outcome VAS-measured forefoot plantar pain (left foot (F = 0.23, p = 0.635), right foot (F = 2.14, p = 0.148)). Within-group changes were highly significant (treatment arm, difference = 16.9 (95 % confidence interval (CI) 9.4, 24.4), t = 4.6, p < 0.0001; control arm, difference = 17.5 (95 % CI 9.4, 25.5), t = 4.4, p < 0.0001). There was little change in scores of overall function and foot impact in either group and there were no significant changes in gait parameters noted. The long-term effects of sharp scalpel debridement of painful forefoot plantar callosities in people with RA, when used in conjunction with a combined therapeutic approach, produced no additional benefit over the combined therapeutic approach alone. Trial registration http://www.controlled-trials.com/ISRCTN05190231.

Long-segment (> or = 10 cm) femoropopliteal angioplasty: improved technical success and long-term patency

PURPOSE

To assess angioplasty as a treatment for symptomatic long-segment (> or = 10 cm) femoropopliteal atherosclerotic disease.

MATERIALS AND METHODS

Angioplasty performed on 44 lesions that measured 10-40 cm (mean, 24.3 cm) were assessed for technical success and 12-24-month patency. Disease severity was assessed with the Doppler ankle-brachial index (ABI) and clinical evaluation before angioplasty and at follow-up examinations 1 month and 12-24 months (mean, 18 months) later. Technical success was defined as a restoration of vessel lumen (< 30% residual stenosis) and a rise in ABI values of at least 0.2. Arterial patency (< 50% residual stenosis) was determined with color duplex sonography.

RESULTS

Angioplasty was technically successful at 41 of 44 sites (93%). There was no mortality related to the procedure or emergency surgical referral. At 18-month follow-up, mean ABI values had risen from 0.53 to 0.80. Cumulative primary patency was 69%. Clinical symptoms had improved in 83% of patients.

CONCLUSION

Angioplasty is useful in the treatment of long-segment femoropopliteal atherosclerotic disease.

Percutaneous aspiration thromboembolectomy: a preliminary experience

Percutaneous aspiration thromboembolectomy (PAT) is a radiological alternative to surgical embolectomy or thrombolysis in the treatment of acute arterial thromboembolic disease. We report our experience in eight patients aged 63-83 years (mean 71 years). Indications were graft thrombosis (1) or emboli from atrial fibrillation (3), abdominal aneurysm (2) or proximal angioplasty (2). PAT was performed at 10 arterial sites; common iliac (1), profunda femoris (1), superficial femoral (2), femoro-popliteal graft (1), popliteal (2) and arteries of the trifurcation (3). PAT was used as an adjunct to thrombolysis or angioplasty in five patients and as the sole procedure in three patients. It was successful in six patients (seven sites) with mean ABI rising from 0.4 pre- to 0.8 post-procedure. Two of the failures required amputations. One of these was a completely thrombosed dacron femoro-popliteal graft with poor run-off, and the second case had a failed surgical embolectomy prior to amputation. There were no major complications, and no mortality on follow-up at 1 month. PAT is a useful adjunct to thrombolysis and balloon angioplasty in the radiological treatment of acute thromboembolic disease. In patients in whom thrombolysis is contraindicated, it offers an alternative to surgical embolectomy.

Radiological definition of a new model of portal diversion in the rat

Diversion of portal blood away from the liver can be accomplished in the rat by two straightforward surgical procedures: subcutaneous transposition of the spleen followed later by portal vein ligation. This experimental model has great potential value in the study of liver cell transplants, porto-systemic shunts and hepatic porto-privation. Contrast medium radiology has been used to clarify and define the model further. Splenography, achieved by direct percutaneous puncture, demonstrated the developing spleno-subcutaneous vessels. Collaterals are seen as early as 3 days and appear extensive by 21 days after transposition. Almost all emanate from the convex outer surface of the spleen and course cranially and caudally in the subcutaneous tissues to drain into the subclavian and iliac veins. The appearance of these collaterals correlates well with survival after portal vein occlusion subsequent to splenic transposition. Direct portography demonstrates that, following portal vein ligation, contrast medium is diverted away from the liver into the splenic veins, through and around the spleen, before draining into the systemic circulation through spleno-subcutaneous collaterals. These radiological studies have demonstrated the changed circulatory pathways of this model of portal diversion and have confirmed that it is the splenic veins and the spleno-subcutaneous collaterals which are fundamental to its successful outcome.

The ossification of the costal element of the seventh cervical vertebra with particular reference to cervical ribs

During 16 years of study at Northwick Park Hospital 715 fetuses were radiographed to determine the incidence of skeletal malformations. A technique using low kV and industrial film provided higher resolution radiographs than would have been possible in live births because of dose considerations. Gestational age calculated from LMP and ultrasound findings ranged from less than 18 weeks to 42 weeks. A separate costal element of C7, the possible precursor of a cervical rib, could be identified in 63% of fetuses. Males outnumbered females 403:311 but there was no intersex difference in the presence of such rudimentary cervical ribs with 63 and 64% respectively in each group. Of the 452 cases with separate costal elements, 73% were bilateral. Of the unilateral group 60% occurred on the right and 40% on the left. There was no significant difference in the incidence between the gestational age groups from 20 weeks onwards, confirming that the disappearance of the separate element occurs predominantly after birth, 394 cases (87%) of fetuses had an otherwise normal skeleton.

Peripheral laser assisted angioplasty: results, complications and follow-up

Detailed results including complications and ultimate outcome of 24 laser assisted angioplasties in 22 patients are presented. Despite the enthusiasm expressed in other published reports, we remain sceptical of the value of laser using a 1.5 mm 'hot-tip' probe for assisting angioplasty of peripheral occlusions. The tendency for this type of probe to damage the vessel wall and in so doing prohibit the use of subsequent balloon dilatation is a major problem. In this small series the long-term patency was not improved compared with conventional angioplasty. We have established the relative safety of this laser technique and further advances in probe design may lead to greater success in crossing long lesions. Long-term maintenance of patency in these diseased arteries will need further advances in technique and assessment preferably by a controlled trial.

A double blind clinical study comparing the safety, tolerance and efficacy of ioversol 240 and iohexol 240 (Omnipaque 240) in ascending venography

A randomised, double blind, parallel group study was performed comparing the efficacy, tolerance and safety of ioversol-240 and iohexol-240 (Omnipaque-240) in 50 patients undergoing venography. Adult patients of either sex, 18 years of age or older, who were referred to the Department of Radiology at Northwick Park Hospital, Harrow, England, for ascending venography were study candidates. There were 25 patients in each drug group, who were comparable in relation to age, sex, weight, height and race. The drug groups were comparable with respect to contrast volume and iodine dose administered. All film sets were rated as diagnostic and the patient groups were comparable with respect to quality of procedure. The incidence of patients reporting heat and pain as a result of the injection of contrast medium was minimal and comparable in the drug groups. Safety was assessed by monitoring vital signs (blood pressure, pulse and respiration), clinical laboratory studies and observation of adverse effects prior to and after injection of contrast medium. Vital signs remained stable in all study patients. There were no abnormal post-procedural laboratory data which were judged to have been drug related. There were no drug related adverse effects in either group. It is concluded that ioversol-240 is a safe, well-tolerated and effective contrast agent when used for venography.

Safety and pharmacokinetics of ioversol in healthy volunteers

Ioversol 320, a new nonionic iodinated contrast medium, was injected intravenously into 24 healthy male volunteers using saline as a control. Physical examination, vital signs, electrocardiogram, biochemical and hematological data were recorded before and at intervals after injection. No significant changes were observed. Seventeen volunteers reported no side effects; six volunteers had mild transitory symptoms considered to be related to the contrast medium. The authors conclude that broader clinical trials can be safely conducted to determine safety and tolerability of ioversol.

The expansion of interventional radiology. Report of a survey conducted by the Royal College of Radiologists

The Interventional Radiology Group of the Royal College of Radiologists sent a questionnaire to major hospitals in the United Kingdom in 1982 and 1987 in order to assess the impact of the introduction and growth of interventional procedures on patient management over the 5-year period and to consider the implications of these data for the future staffing and equipment requirements of radiology departments. In the 194 hospitals correctly completing the most recent survey, a total of 30,794 interventional procedures were performed in a 12 month period, representing an overall increase of 116% since the previous survey of 1982.

Pneumoperitoneum, omental emphysema and intramural barium perforation following double contrast barium enema

Perforation above the peritoneal reflection is a rare complication of a barium enema. We describe a case in which perforation in the transverse colon during a double contrast study resulted in intramural extravasation of barium, pneumoperitoneum and omental emphysema.

Unrecognised aneurysmal disease in male hypertensive patients

The risk of an aneurysm leaking is related to its size. The operative mortality of elective surgery should be less than 5% but is frequently more than 50% following rupture. Many patients previously undiagnosed present with rupture, yet are on long-term treatment for hypertension. Two-hundred hypertensive male patients over the age of 50 have been clinically examined, and subsequently undergone ultrasound examination of the abdominal aorta. Fourteen asymptomatic aneurysms were detected, 9 on clinical examination, confirmed by ultrasound and C.T., and a further 5 detected by ultrasound, and also confirmed by C.T. Twenty-four patients were found to have carotid bruits, in 12 of whom the bruits were bilateral. Sixty-seven patients were found to have peripheral vascular disease. Routine abdominal ultrasound examination should be included in the regular assessment of hypertensive patients.

Extrarenal arterial connections of the normal renal artery

An angiographic study in cadavers has demonstrated connections between the renal artery and remote vessels including the intercostal, testicular, and inferior mesenteric arteries in subjects with no known history of renal disease. Such communications are a potential route by which embolic material introduced into the renal artery may inadvertently reach other organs.

Peripheral vascular disease: prospective study of intraarterial digital subtraction angiography using a 9-inch intensifier

A prospective randomized study was undertaken to evaluate the role of intraarterial digital subtraction angiography (IADSA) in the study of peripheral vascular disease. Patients underwent either conventional film-based angiography alone, digital subtraction angiography (DSA) alone, or a combined study. With a 9-inch image intensifier, DSA alone resulted in cost savings of film and contrast material but required a significantly longer examination period than the other groups and an increased iodine dose per examination. When the images were analyzed by a radiologist and a vascular surgeon, the DSA studies provided less detail in the aortoiliac region than the other techniques but had advantages in demonstrating the runoff vessels. IADSA examination should not replace conventional arteriography in patients with peripheral vascular disease but has a useful complementary role.

Preliminary colon cleansing for small-bowel examinations: results and implications of a prospective survey

The findings in 133 consecutive patients having a small-bowel barium follow-through examination are presented. Two conclusions are drawn: colon cleansing does not decrease transit time to the caecum and colon cleansing does not affect the examination quality.

Skin necrosis: a complication of alcohol infarction of a hypernephroma

A case of skin infarction after transcatheter ablation of a hypernephroma using alcohol is described. Possible avenues for migration are discussed.

The fate of the EEA stapled anastomosis: a clinico-radiological study of 38 patients

Despite the widespread use of the EEA stapling device, little is known about the eventual fate of the stapled anastomosis. In a study of 38 stapled colonic anastomoses the staples were found to have passed out rectally in 11 patients (29%) within 6 months of surgery. Staple loss occurred only when the small or medium sized cartridges were used (P less than 0.02). Anastomotic stenosis developed in 5 patients (13.2%) and was also related to the use of the smaller size cartridges. In order to minimise these problems every effort should be made to use the large EEA cartridge.

Embolisation of gastroduodenal artery aneurysm caused by chronic pancreatitis

Chronic pancreatitis is known to cause vascular lesions, which produce gastrointestinal haemorrhage. Visceral vessel aneurysms are an unexpectedly common finding in arteriograms of patients with chronic pancreatitis. Gastrointestinal bleeding from these aneurysms carries a high mortality, making early diagnosis and treatment essential. Coeliac and mesenteric arteriography readily confirm the diagnosis. Surgical ligation or resection of the aneurysm entails a high mortality. Cessation of such gastrointestinal haemorrhage may be achieved by transcatheter embolisation under radiological control. This report describes a case in which bleeding from a gastroduodenal artery aneurysm, caused by chronic pancreatitis, was successfully treated by embolisation using a Gianturco coil.

Ureteric stone displacement using a new technique

Transcutaneous displacement of ureteric stones has not been widely employed. The technique described here is one in which four ureteric stones were actively displaced into the bladder using a balloon catheter. Major ureteric surgery was thus avoided. This new technique may be useful as an alternative to Dormia basket extraction of ureteric calculi.

Infusion cholecystography in the diagnosis of acute cholecystitis

The use of infusion cholecystography as an aid in the diagnosis of acute cholecystitis was investigated in 21 patients. Seventeen of 18 patients (94 per cent) with positive cholecyst-tomograms who underwent laparotomy had confirmation of acutely inflamed gallbladders both macroscopically and histologically. These findings suggest that infusion cholecystography can make a significant contribution in reducing the incidence of misdiagnosis in acute cholecystitis, and that the investigation should be part of the management of patients in whom early surgery is planned.

Invitro and in vivo defoaming action of three antacid preparations

The defoaming activity of three tablet antacids (hydrotalcite, hydrotalcite/dimethicone and aluminium hydroxide/dimethicone) powdered to 60 mesh was measured in vitro using a new static/dynamic technique. Their antacid actions and that of aluminium hydroxide gel B.P.C. were also measured using a modified Fuch's test. Combination of dimethicone with hydrotalcite conferred good defoaming activity with little effect on pH profile whilst combination of aluminium hydroxide with dimethicone markedly altered both. Additionally, the defoaming actions of the three commercial antacids were assessed in vivo. Radiographs were taken after administration of antacid, a foaming mixture and a normal barium meal. The radiographs were then ranked blind by 5 radiologists. The rankings assigned the significantly greatest (Mann-Whitney U-test) defoaming effect to the hydrotalcite/dimethicone combination, there being no difference between the other two preparations. The in vitro results were thus confirmed.

Place of ultrasound and radiography in obstetrics

In the two years after an ultrasound service was introduced at this hospital obstetric referrals for abdominal radiography decreased by over 55%. Most of these were for estimation of fetal maturity. Out of 349 such patients subjected to radiography in 1976, 176 had already been examined by ultrasound; in only four did radiography appear to influence management. We believe that if a satisfactory ultrasound scan is obtained before 30 weeks of gestation subsequent radiological estimation of fetal maturity is unjustified. Radiography may still be necessary, however, for diagnosing fetal abnormalities.

Cholangiopancreatography and pancreatic cytology in carcinoma of the pancreas

Twenty-three histologically proved cases of carcinoma of the pancreas were investigated preoperatively with endoscopic retrograde cholangiopancreatography and cytologic examination of pure pancreatic juice collected after secretin stimulation. In 12 cases in which radiology was highly suggestive of carcinoma, cytology confirmed the result in seven. When radiologic findings were equivocal, cytology was helpful in two of six cases. Cytology was most helpful in the patients in whom no diagnosis could be reached radiologically due to tumor invasion of the structures adjacent to the papilla. Malignant cells were found in all cases.

Radiology in Mendelson's syndrome

Four cases of Mendelson's syndrome (acid pulmonary aspiration) are presented. They all demonstrate an acute diffuse alveolar filling pattern. This appearance is by no means specific. However, in the absence of other causes for this pattern and of evidence of left ventricular failure the radiologist may alert the clinician to the correct diagnosis. Early recognition of this syndrome will result in prompt treatment which differs significantly from that of other causes of this radiographic appearance. The differential diagnosis is discussed.

Duodenal inhibition of gastric secretion by osmotic agents in normal subjects and patients with duodenal ulcer

Gastric secretion in man is inhibited by the presence in the duodenum of hyperosmolar and hypoosmolar solutions. Both acid and pepsin outputs are affected. There is no change in hydrogen, sodium, or potassium ion concentration in the gastric juice. Pepsin concentration, however, is reduced by all inhibitory stimuli. Inhibition is thought to act directly upon parietal and chief cells, and a possible basis for this mechanism is discussed. The response is similar in control subjects and duodenal ulcer patients; there is in particular no evidence of impaired inhibition in the ulcer group. An anomalous feature is the relatively small inhibition of acid output after hypertonic saline in control subjects compared with the duodenal ulcer patients.