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  • | trevorlawrence

    COVID-19 UPDATE X Surgery for self-funding and insured patients is slowly returning to normal. There is a requirement for a two-week self-isolation period before operations can take place. ​ 72 hours before surgery, all patients are required to have a pre-operative coronavirus test, which is organised at Spire Parkway Hospital. For more information, or to book your face-to-face or Zoom consultation, please contact Jenny at our surgery. Stay safe. Stay healthy.

  • Knee | Complications | Trevor Lawrence Clinic | UK

    KNEE SURGERY Results Before surgery Operation After surgery Complications Keyhole surgery About 1% of patients will develop a complication after surgery. Some of the most common complications are outlined in this explainer: SURGICAL COMPLICATIONS Mr Lawrence, to date, has a 0.25% deep infection rate following total knee replacement at Parkway Hospital. A bug can get into the knee replacement via several routes. On occasion, the bug can be transferred into the joint from the patient's skin or from the air in the theatre at the time of surgery. In about 1/3 of cases, the bug is transferred by the patients' circulation (blood-borne contamination) and this may result in the joint becoming infected years after the operation. In order to prevent infection, Mr Lawrence takes certain precautions. Intra-venous antibiotics are given, the surgery is done in a specially ventilated theatre; If an infection develops in the joint, 2 or three operations will be required to put things right. In the first instance, the knee joint may be opened up and irrigated to remove the infection. This is followed by a period of 6 weeks of intravenous antibiotics. The infection can be treated by these simple measures in about 25% of cases. In most cases, the knee replacement will be removed for a minimum period of 6-8 weeks. During this time, the patient will require crutches or a frame to walk. Once the infection has been treated (90%) of cases, a new knee joint is inserted. Regrettably, there cannot be any guarantee of success with the second operation and recurrence of infection may occur in 5-10% of patients. The key to success is avoiding infection in the first place by being vigilant and by using good surgical techniques. On occasion, the thigh bone or the shin bone may become damaged by the infection and complex reconstruction is required. In Mr Lawrence's practice at Parkway Hospital, the deep infection rate to date is as low as 0.25% over 18 years. DAMAGE TO NERVES AND BLOOD VESSELS On very rare occasions the peroneal nerve, which runs close to the knee joint, may be damaged or stretched following surgery resulting in a foot drop. Recovery is variable. LOOSENING Over a period of years, the implants may loosen from the bones and this will result in pain. The rate of loosening varies according to the type of implants used and the skill of the surgeon. In Mr Lawrence's experience, the weight of the patient, their level of activity, and the thickness of their bones do not affect rates of loosening. In Mr Lawrence's practice at Parkway Hospital, the loosening rate over a 12 year period of time is 0%. FRACTURES In the event of a fall after the knee replacement, the bone around the knee replacement may break. This is a rare complication and usually requires further surgery to treat it. - - - MEDICAL COMPLICATIONS There is a risk to your general health following any major operation. Patients with poor blood supplies to their hearts or brain are at increased risk of heart attacks and strokes resulting from the stress of the surgery. Fit, healthy, active patients are at less risk. An attempt is made to assess your fitness for the surgery before the operation by looking at your heart tracing and blood results in conjunction with your previous medical history. Unfortunately, none of these investigations is 100% accurate, and as a result, some unexpected events may occur. Medical complications that may be encountered include: BLOOD CLOT FORMATION Any operation will increase the risk of blood clot formation in the limbs because the blood becomes a little thicker and stickier following an operation. Sometimes the blood clot can travel to the lungs which may be life-threatening. The risk of this complication is about 1-3 in 1000 patients. Every attempt is made to minimise this risk including the use of leg pump devices, heparin, and aspirin. Getting up out of bed and walking after the surgery is also very important to encourage a good blood flow through the legs. HEART ATTACK AND IRREGULAR HEART RHYTHM These complications are completely unpredictable. Some patients may have an unrecognised heart condition that only comes to light under the stress of surgery. STROKE The risk of developing a stroke after an operation depends on the quality of the pre-existing blood supply to the brain. It is unlikely that a fit and active patient will develop this complication whereas a patient with high blood pressure, who smokes heavily and has furred up arteries would be at greater risk. CHEST INFECTION Because patients undergoing surgery are less mobile than they are normally and their breathing pattern may be slightly different than normal, they are at greater risk of developing a chest infection. This is, however, a surprisingly rare occurrence and can be easily treated with physiotherapy and antibiotics. FAILURE TO PASS URINE Men are particularly prone to develop retention of urine following knee surgery. The risk is greatest in patients that have enlarged prostate glands. A combination of decreased mobility, pain from the knee joint surgery and a spinal anaesthetic is often enough to upset the waterworks. If you cannot pass urine for about 6 hours or so, a tube will be inserted into the bladder and your urine may be collected in a bag. Usually, this is a short-lived problem but on occasion, some patients may require prostate surgery at a later date. •• ​

  • | trevorlawrence

    KNEE surgery 2009 / 2019 Mr Lawrence's PRIMARY Mr Lawrence's REVISION National Average REVISION 594 4 11 The National Joint Registry (NJR) collects information on joint replacement surgery and monitors the performance of joint replacement implants. PRIMARY surgery = patients undergoing 1st-time KNEE replacement. REVISION surgery = patients needing 2nd KNEE operation due to a complication.

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    National Institute for Health Research (NIHR) First published on 8 December 2020 doi: 10.3310/alert_42879 - NIHR article A common surgical approach used for hip replacements carries higher risks of worse outcomes and should not be routinely adopted by trainee surgeons, a new analysis suggests. The study found significantly worse outcomes associated with so-called lateral procedures to the hip joint, in which surgeons access the hip by detaching muscle from the side of the thighbone (femur). Lateral procedures were compared with alternative methods in which the surgeon approaches the hip from in front of (anterior approach), or behind (posterior approach), the thighbone. Analysis of 723,904 hip replacement operations performed between 2003 and 2016 found that lateral procedures were associated with more deaths and a greater risk of further hip surgery. The researchers suggest it is probably unwise to ask experienced surgeons to change from using the lateral approach. However, new surgeons should be taught to use other approaches when performing hip replacements. What’s the issue? More than 100,000 hip replacement operations are carried out in the UK each year, and surgeons can access the hip joint using different approaches. The most commonly used is the posterior approach, in which surgeons access the hip from behind the thighbone. Other approaches include accessing the hip from in front of the thighbone (anterior) or, in about one in three operations, surgeons use the lateral approach and reach the hip by detaching muscle from the side of the femur. Each approach can be performed through a small (minimally invasive) cut or a standard, longer cut. The different approaches cause different amounts of soft tissue damage and bleeding. It has been assumed that patients’ recovery, their chances of needing further surgery, and the potential adverse outcomes will be influenced by the approach used. But, before this study, there was little large-scale evidence to assess and compare the outcomes from all of the different surgical approaches. What’s new? The study used data collected by the National Joint Registry to identify 723,904 primary total hip replacements carried out between 2003 and 2016 in England, Wales, Northern Ireland and the Isle of Man. It cross-referenced these data to reports of how the patients fared after surgery. Specifically, it looked at the risk of further (revision) surgery in the long-term, and the risk of death three months after surgery. Data on patient-reported outcomes such as pain, mobility and adverse outcomes six-months after surgery were also reviewed. The study compared these outcomes for each surgical method. Statistical analysis suggested the lateral approach had worse outcomes than the posterior approach. Compared to the posterior approach, the lateral approach: was predicted to have an increased risk (between 5% and 12%) of revision surgery at 12 years was predicted to have a 15% increased risk of death within three months of surgery was associated with only slightly more reports from patients of pain and mobility issues. Overall, the study found that the posterior approach had the lowest risk of revision surgery. Lateral or anterior approaches carried out using minimally-invasive techniques carried an increased risk of further surgery, but the difference was less certain in models accounting for patients' body mass index. The researchers therefore said the data supported the continued use of minimally-invasive techniques at this time. Why is this important? This is the largest study to compare the outcomes from the different ways of performing a common operation. The study was observational and cannot prove that the surgical approach caused the differences in outcomes. However, the data strongly indicate worse outcomes with the lateral approach. It was associated with more deaths and a greater risk of revision surgery. More than 20,000 hip replacements are performed each year in the UK using the lateral approach, and the study authors argue new surgeons should not routinely use it. A better option, they say, is posterior approach surgery, which is already the most common. At present, NICE guidelines state surgeons can choose a posterior or lateral approach for hip replacement. What’s next? The study authors say their findings parallel those from small studies and should be used to inform clinical practice when NICE and other bodies update guidelines. They suggest that surgeons should be steered away from the lateral approach for hip replacement. The posterior approach should be considered the preferred standard approach, they say, and should be used in training new surgeons. They acknowledge that it might be difficult to safely convert experienced surgeons familiar with the lateral approach to a new approach. Ideally, the findings of this large but observational study would be checked in a randomised controlled trial. Such a trial could compare the possible benefits of the minimally-invasive posterior approach, the conventional anterior approach and the conventional posterior approach. The present study suggests that these approaches may have the best outcomes. - - - You may also be interested to read: The full study: Blom AW, and others. The effect of surgical approach in total hip replacement on outcomes: an analysis of 723,904 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. BMC Medicine. 2020;18:242 Study from the same group looking at surgical techniques: Matharu GS, and others. The Effect of Surgical Approach on Outcomes Following Total Hip Arthroplasty Performed for Displaced Intracapsular Hip Fractures An Analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. The Journal of Bone and Joint Surgery. 2020;102:21-28 NICE guidance: Surgical approaches for primary elective hip replacement (NG157) (2020), advises in Section 1.8.1 to consider a posterior or anterolateral approach for primary elective hip replacement - - - Funding: The study was supported by the Healthcare Quality Improvement Partnership, National Joint Registry and the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust. Conflicts of Interest: A number of authors have received grants and fees from relevant organisations and device manufacturers. Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


    BJBJS - The Journal of Bone and Joint Surgery VOL 81-A, NO. 7. JULY 1999 begins on page 926 ANALYSIS OF ROUTINE HISTOLOGICAL EVALUATION OF TISSUES REMOVED DURING PRIMARY HIP AND KNEE ARTHROPLASTY TREVOR LAWRENCE, F.R.C.S.(ED) ORTH.†, CHARLOTTESVILLE JOSEPH T. MOSKAL, M.D.‡, ROANOKE DAVID R. DIDUCH, M.S., M.D.†, CHARLOTTESVILLE, VIRGINIA First published in The Journal of Bone & Joint Surgery Investigation performed at the Department of Orthopaedic Surgery. University of Virginia Health Sciences Center. Charlottesville, and Roanoke Memorial Hospital, Roanoke ABSTRACT Background: It has often hern hospital policy to send all resected specimens obtained during a total hip or knee arthroplasty for histological evaluation. This practice is expensive and may be unnecessary. We sought to determine the ability of surgeons to diagnose primary joint conditions correctly, and we attempted to identify any possible risks to the patient resulting from the omission of routine histological evaluation of specimens at the surgeon's discretion. Our objective was to ascertain whether routine histological evaluation could be safely omitted from the protocol for primary hip and knee arthroplasty without compromising the care of the patient. Methods: A total of 1388 consecutive arthroplasties in 1136 patients were identified from a database of primary total hip and knee arthroplasties that were prospectively maintained by the senior one of us. Followup data obtained at a mean of 53 years (range, two to ten years) were available after 92% (1273) of the 1388 arthroplasties. The preoperative diagnosis was determined from the history, findings on clinical examination. and radiographs. The intraoperative diagnosis was determined by gross inspection of joint fluid, articular cartilage, synovial tissue, and the cut surfaces of resected specimens. The combination of the preoperative and intraoperative diagnoses was considered to be the surgeon's clinical diagnosis. All resected specimens were sent for routine histological evaluation, and a pathological diagnosis was made. Attention was given to whether a discrepancy between the surgeon's clinical diagnosis and the pathological diagnosis altered the management of the patient. The original diagnoses were updated with the use of annual radiographs and clinical assessments. The cost of histological examination of specimens obtained at arthroplasty was determined by consultation with hospital administration, accounting. and pathology department personnel. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. Department of Orthopaedic Surgery. University of Virginia Health Sciences Center, Box 159. Charlottesville, Virginia 22908. Roanoke Orthopaedic Center. Box 21369, Roanoke. Virginia 24018-0546. Results: A pathological fracture or an impending fracture was diagnosed preoperatively and confirmed intraoperatively during twelve of the 1388 arthroplasties. Histological analysis demonstrated malignancy in specimens obtained during eleven of these arthroplasties and evidence of a benign rheumatoid geode in the specimen obtained during the twelfth arthroplasty. The preoperative and intraoperative diagnoses made before and during the remaining 1376 arthroplasties were benign conditions, which were confirmed histologically in all patients. No diagnosis changed during the follow-up period. As demonstrated by a comparison with the histological diagnosis, the surgeon's clinical diagnosis of malignancy had a sensitivity of 100percent (95 % confidence interval. 74.0 to 100percent), a specificity of 99.9 % (95 % confidence interval. 99.6 to 100 %), a positive predictive value of 91.7 % (95 % confidence interval. 64.6 to 983 %), and a negative predictive value of 100 % (95 % confidence interval.99.7 to 100 %). There was a discrepancy between the preoperative and intraoperative diagnoses associated with eleven ararthroplasties. All eleven intraoperative diagnoses were correct, as confirmed histologically. Excluding the patients who had a pathological or impending fracture, the accuracy of the surgeon's preoperative diagnosis was 992 % (95 % confidence interval. 98.6to 993 %). When the intraoperative and preoperative diagnoses were combined, the accuracy was 100percent (95 % confidence interval. 99.7 to 100percent). Histological evaluation at our hospital resulted in total charges, including hospital costs and professional fees, of $19627 and a mean total reimbursement of $10239 per evaluation. In our series of 1136 patients with 1388 arthroplasties, these costs could have been eliminated for all but the twelve patients who had a suspected malignant lesion and the one patient in whom pigmented villonodular synovitis was found. Conclusions: Benign conditions can be diagnosed accurately by an experienced surgeon. The preoperative diagnosis should be determined on the basis of a carefully obtained history; a detailed physical examination. and a thorough evaluation of radiographs. To complete the clinical diagnosis, the preoperative in­ formation should he combined with findings obtained through careful intraoperative observation of resected specimens and. in the case of hip arthroplasty, an inspection of the divided femoral head. In so doing, the surgeon can usually exclude clinically the possibility of malignancy or another condition that may alter the management of the patient and thus can reserve histological analysis for situations where the diagnosis is suspect or unexpected findings are noted intraoperatively. Illis selective, surgeon-directed use of histological analysis can result in notable financial savings. Escalating charges and declining reimbursements for total knee and hip arthroplasties have led to increasing demands for cost containment. Suggested measures for reducing costs have included decreasing the duration of the hospital slay*2’, standardization of prostheses and suppliers***, increasing the volume of procedures and establishing critical pathways*. However, these practices have been implemented in many hospitals and a plateau for savings may have been reached4. Charges for hospital services such as radiography and laboratory investigations account for about 4% of total costs1'. Many believe that the use of these services at the discretion of the clinician can result in notable savings without compromising patient outcomes (25,22,23,26). During the course of primary hip and knee arthroplasties, the femoral head or resected specimens from the knee are often sent routinely for histological evaluation. This practice may be in concordance with hospital bylaws or a result of the surgeon’s preference. DiCarlo el al. reported that, in a series of 1794 total hip arthroplasties, the rate of discrepancy between the clinical diagnosis and the histological diagnosis based on analysis of the resected femoral head was 5.4% (ninety-seven arthroplasties)’. Because morbid conditions were identified in seven patients, mandatory pathological evaluation of all resected specimens was advocated. However, recent evidence suggests that the surgeon can use his or her discretion in determining which specimens require a histological evaluation and that observed discrepancies between the preoperative and histological diagnoses have little bearing on patient outcome7**. It appears that selective use of histological examination of resected specimens could result in substantial savings. However, to our knowledge, guidelines for adequate clinical evaluation and the possible long-term risks to patients associated with the omission of routine histological evaluation remain to be established. The objective of the present study was to determine whether routine histological evaluation could be safely omitted from the protocol for primary hip or knee arthroplasty without compromising the care of the patient. The surgeon's preoperative and intraoperative diagnoses were compared with the histological diagnosis, and statistical relationships were established. Any change in diagnosis during the follow-up period was noted. Potential economic savings resulting from discretionary use of histological evaluation were also calculated. Materials and Method Between December 1987 and December 1995, the senior one of us (J. T. M.) performed 1388 consecutive primary total hip and knee arthroplasties in 1136 patients, and this group constituted the study population. All demographic and diagnostic data were recorded prospectively in a database. The group included 562 hips and 826 knees Three hundred and eighty-five of the patients were men. and 751 were women. The mean age at the time of the operation was sixty-nine years (range, twenty-two to 100 years). Preoperatively, a complete history was recorded for all patients and all patients were examined clinically and radiographically by the senior one of us who looked for evidence of trauma, tumour, infection, osteoarthritis (primary or secondary), inflammatory arthropathy (rheumatoid arthritis juvenile rheumatoid arthritis systemic lupus erythematosus spondyloarthropathies or crystalline arthropathies), or hemorrhagic arthropathy. Before all of the hip replacements, anteroposterior radiographs of the pelvis and the proximal part of the femoral shaft, as well as lateral radiographs of the involved hip joint, were made with the patient supine. Before the knee replacements, anteroposterior radiographs were made with the patient standing and lateral and Merchant patellar radiographs were made with the patient supine. Some radiographic features were characteristic of a particular diagnosis. For example, meniscal calcifications were seen in association with chondrocalcinosis; increased bone density and collapse, with avascular necrosis; sacroiliac joint fusions with ankylosing spondylitis; and erosive changes with inflammatory arthropathies12*. These findings were combined with information from other treating physicians to establish a preoperative diagnosis for the underlying joint abnormality, and this diagnosis was prospectively recorded in the database. Al the lime of the operation, the senior one of us inspected the joint fluid, the articular cartilage, and the synovial tissue for gross changes characteristic of the preoperative diagnosis In the total hip arthroplasties each femoral head was divided in half and viewed Intraoperatively for areas of collapse, cystic changes or abnormal architecture. Combining these observations al operation with the preoperative diagnosis allowed the determination of an intraoperative diagnosis which also was recorded prospectively. All specimens were then sent for histological evaluation, as required by the hospital bylaws and a pathological diagnosis was made. Preoperative, intraoperative, and histological diagnoses were made for all 1388 hips and knees treated with arthroplasty. The diagnoses were then reappraised al yearly follow-up intervals on the basis of an updated medical history, physical examination, and radiographs. Clinical evaluation included an assessment of joint pain and function with the use of the Knee Society1* or 11 arris14 hip-scoring system. Any change in medical history was noted. Anteroposterior radiographs of the pelvis and the proximal part of the femur and a true lateral radiograph of the hip were made with the patient supine al the follow-up evaluations after the hip replacements. Anteroposterior radiographs were made with the patient standing and lateral and Merchant patellar radiographs were made with the patient supine al the evaluations after the knee replacements. The prosthetic components were evaluated according to previously described radiographic crileriaMJ04UW\ Zonal analysis was used to determine the location, size, and any progression of radiolucent lines and osteolysis. Any changes in diagnosis during the follow-up period were recorded in the database. The surgeon’s diagnosis of underlying malignancy based on preoperative and intraoperative findings was compared with the pathologist's histological diagnosis for every specimen. The results were expressed in terms of sensitivity (the number of malignant lesions that were correctly diagnosed as malignant by the surgeon divided by the total number of malignant lesions identified histologically), specificity (the number of benign conditions that were correctly diagnosed as benign by the surgeon divided by the total number of benign conditions identified histologically), the positive predictive value (the number of malignant lesions that were correctly diagnosed as malignant by the surgeon divided by the total number of malignant lesions that were diagnosed by the surgeon), and the negative predictive value (the number of benign conditions that were correctly diagnosed as benign by the surgeon divided by the total number of benign conditions that were diagnosed by the surgeon). The accuracy of the surgeon's preoperative diagnoses of benign conditions was also calculated in relation to the histological diagnoses (the number of correct diagnoses that were made by the surgeon divided by the total number of the same diagnoses that were made on the basis of the histological evaluation). The overall accuracy of the surgeon’s diagnoses based on both preoperative and intraoperative findings was also calculated. 95 % confidence intervals were determined for all binomial proportions with the use of Wilson’s method. Three patients died perioperatively; one each died from cardiac failure (no autopsy), pulmonary embolism (confirmed at autopsy), and myocardial infarction (confirmed at autopsy). An additional sixty-four patients (seventy-five arthroplasties) died during the follow-up period from causes unrelated to the index operation. Twenty-nine patients (thirty-seven arthroplasties) were lost to follow-up, although none were lost fewer than six months postoperatively. Thus, data obtained al a minimum of two years (range, two to ten years; mean.5.5 years) were available for 1273 (92 %) of the 1388 arthroplasties. The pathology department provided details of professional charges and reimbursements, received according to various insurance options, that were incurred for the gross and histological evaluation of the specimens. Hospital costs associated with histological analysis were calculated after consultation with hospital administration and accounting personnel. The hospital costs included those for slides, reagents and stain preparation, decalcification solutions, equipment (including depreciation), labour, and indirect expenses. Result* The surgeon’s clinical diagnosis (based on the preoperative history, clinical examination, and radiographic findings combined with the intraoperative observations) was most commonly primary osteoarthritis (949 arthroplasties), avascular necrosis (112). rheumatoid arthritis (ninety-two), traumatic arthritis (eighty-two), or acute fracture (eighty-three). The other diagnoses included congenital dislocation of the hip (sixteen arthroplasties), pathological fracture or impending fracture (twelve), ankylosing spondylitis (nine), slipped capital epiphysis (nine), Legg-Calvé-Perthes disease (six), gout (five), chondrocalcinosis (three), Pagel disease (three), a reversal of an arthrodesis (two), juvenile rheumatoid arthritis (two), pigmented villonodular synovitis (one), Gaucher disease (one), and ochronosis (one). A pathological fracture or an impending fracture secondary to an underlying malignant lesion was diagnosed before twelve (1 %) of the 1388 arthroplasties. Intraoperative findings confirmed the preoperative diagnosis but did not yield additional information regarding the pathological condition. The histological diagnoses associated with the twelve pathological or impending fractures included metastatic carcinoma from the breast (four), lung (two), prostate (one), and kidney (one) as well as multiple myeloma (three). One patient in whom a malignant lesion had been suspected on the basis of the preoperative and intraoperative findings had a benign rheumatoid geode. The histological reports were essential to establish the underlying diagnosis in these twelve patients. No occult malignancy was detectedtopologically in the remaining 1376 specimens. The ability of the surgeon to identify malignancy correctly was determined by comparing the preoperative and intraoperative clinical diagnoses of malignancy with the histological diagnoses. This analysis yielded a sensitivity of 100 % (eleven of eleven), with a 95 % confidence interval of 74.0 to 100 %; specificity of 99.9 % (1376 of 1377), with a 95 percent confidence interval of 99.6 to 100 %; a positive predictive value of 91.7 % (eleven of twelve), with a 95 % confidence interval of 64.6 to 98.5 %; and a negative predictive value of 100 % (1376 of 1376), with a 95 % confidence interval of 99.7 to 100%. Since no additional periprosthetic tumours developed during the study period, these values remained unchanged al the latest follow-up evaluation (al a mean of 55 years (range, two to ten years)). ROUTINE HISTOLOGICAL EVALUATION OE TISSUES REMOVED DURING HIP AND KNEE ARTHROPLASTY Charges and Actual Reimbursement Per Payor Class, for Histological Evaluation of Specimens Resected During Total Hip or Knee Arthroplasty Roanoke Memorial Hospital During 1998 The preoperative diagnosis was a benign joint condition before 1376 of the arthroplasties. Eleven preoperative diagnoses, all of the primary osteoarthritis, differed from the intraoperative diagnoses. The revised intraoperative diagnosis was avascular necrosis (grade 3 or 4, according to the system of Ficat el al. (12)) during nine arthroplasties. This avascular necrosis, which was identified after the femoral head was divided, had not been seen on the preoperative radiographs because of the advanced degenerative changes. Ochronosis was diagnosed during one arthroplasty, on the basis of black staining of the synovial tissue, and pigmented villonodular synovitis was diagnosed during the eleventh arthroplasty, on the basis of the characteristic brown pigmentation in hyperproliferative synovial tissue. All of these revised intraoperative diagnoses were the same as the subsequent histological diagnoses. The accuracy of the surgeon’s preoperative diagnosis compared with the histological diagnosis was 99.2 % (1365 of 1376), with a 95 % confidence interval of 98.6 to 99.5 %. The accuracy of the surgeon's combined preoperative and intraoperative diagnoses compared with the histological diagnosis was 100 % (1376 of 1376), with a 95 % confidence interval of 99.7 to 100 %. No diagnoses were revised during the study period (mean duration, 55 years); therefore, the rate of accuracy remained unchanged after more than two years of follow-up. During the follow-up period, an infection developed in eleven patients (eleven arthroplasties), resulting in a two-stage revision in ten of them and a resection arthroplasty in one. Nineteen patients (nineteen arthroplasties) had a revision of one or more components because of aseptic loosening, osteolysis, polyethene wear, or periprosthetic fracture. Eight patients (eight arthroplasties) had an additional operation, without revision of components, because of periprosthetic fracture, instability, or rupture of the extensor mechanism. The findings al the subsequent operation did not alter the final diagnosis for any patient. Radiographs made al the lime of follow-up after the unrevised arthroplasties were analyzed for zonal interface radiolucency^!


    THE JOURNAL OF HAND SURGERY VOL. 20B No. 4 AUGUST 1995 T. LAWRENCE, P MOBBS, Y. FORTEMS and J. K. STANLEY From the Hand and Upper Limb Centre. Wrightington Hospital, Wigan, UK Radial tunnel syndrome results from compression of the radial nerve by the free edge of the supinator muscle or closely related structures in the vicinity of the elbow joint. Despite numerous reports on the surgical management of this disorder, it remains largely unrecognised and often neglected. The symptoms of radial tunnel syndrome can resemble those of tennis elbow, chronic wrist pain or tenosynovitis. Reliable objective criteria are not available to differentiate between these pathologies. These difficulties arc discussed in relation to 29 patients who underwent 30 primary explorations and proximal decompressions of the radial nerve. Excellent or good results were obtained in 70%, fair results in 13% and poor results in 17% of patients. The results can be satisfactory despite the prolonged duration of symptoms. We believe that a diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment. Patients with occupations requiring repetitive manual tasks seem to be particularly at risk of developing radial tunnel syndrome and it is also interesting to note that 66% of patients with on-going medico-legal claims had successful outcomes following surgery. Journal of Hand Surgery (British and European Volume. 1995) JOB 4: 454-459 ---------------------------- The radial nerve contains a combination of motor, cutaneous sensory, proprioceptive and autonomic fibres (Lluch and Beasley, 1989; Sprofkin. 1954). The precise site of nerve compression and the nature and distribution of the involved axons determines the symptoms associ­ated with radial tunnel syndrome These include pain in (he lateral extensor muscles with repeated pronation and supination, pain and sensory disturbance in the distribution of the superficial branch of the radial nerve, or diffuse wrist pain. There are three pathognomonic signs Intense tenderness is located over the radial nerve at the site of compression and pain may be induced by resisted extension of the middle finger and by resisted supination (Lister et al. 1979; Roles and Maudsley. 1972; Werner. 1979). The anatomy of the radial tunnel and radial nerve has been extensively studied (Abrams et al. 1992; Fuss and Wurzl. 1991; Henry . 1957; Prasartritha et al. 1993: Roles and Maudsley. 1972: Spinner. 1968; Wilhelm. 1958) and is illustrated in Figure 1. The structures implicated in radial tunnel syndrome are shown in Table I. Sites of radial nene compression outside the radial tunnel include the fibrous arch of the long head of triceps (Lotem et al. 1971) and (he lateral head of triceps (Nakamichi and Tachibana. 1991). which should be considered in cases of atypical radial tunnel syndrome. The results from surgical decompression of the radial nerve are generally satisfactory'. There are few reports however on the natural history of this condition. Kaplan (1984) found that after 5 years. 12 out of 15 patients with radial tunnel syndrome treated conservatively had complete resolution of their symptoms. Others, however, have noted the failure of conservative treatment after 9 months, then proceeded to surgery with encouraging outcomes (Moss and Switzer. 1983 ). The precise role of surgery remains to be established. The operation The extent of the radial nerve release is decided pre-operatively based on the symptoms of the patient and the site of maximal tenderness. Symptoms referred to the dorsal and radial aspects of the wrist arc probably due to irritation of (he superficial branch of the radial nerve (SBRN). Since this nerve always passes super­ficial to the arcade of Frohse. we can conclude that the site of irritation in these patients is proximal to the arcade where both the SBRN and the posterior inteross­eous nerves can be involved. It is therefore imperative to extend the release of the radial nerve proximal to the arcade of Frohsc and divide fascial bands when there are symptoms suggestive of SBRN involvement. We also believe that the proximal limit of the release should incorporate the site of maximum tenderness. Al present, it is impossible to correlate precisely the pre­ operative site of maximal tenderness with the structures found intra-operatively It is, therefore, prudent to extend the release of the radial nerve proximal to the arcade of Frohsc when dense fascial bands arc seen, especially when symptoms in the distribution of the SBRN pre­ dominate. For these reasons, we now prefer an extended anterior approach (Green. 1793) to (he radial tunnel allowing safe access proximal io the arcade of Frohse. Several other operations have also been described as a limited anterior exposure of supinator (Henry. 1957). transbrachioradialis approach (Roles and Maudsley. 1972) and a lateral approach (Capener. 1966). Extended anterior exposure (Green. 1993) A "lazy S” incision is made across the elbow joint lateral to biceps tendon The radial nerve is identified proximally between extensor carpi radialis longus and brachialis and followed distally to the Arcade of Frohsc. It is important to establish the anatomy and identify the radial nerve and its superficial branch. The arm is pronated and supinated to demonstrate the constricting structures and these are divided. The minimum inter­vention is a division of the fibrous arcade of Frohse. Exposure and release of the radial nerve from encasing proximal fascia can be undertaken with greatest cer­tainty and safety using the extended anterior approach the drawback of this technique is the long scar across the elbow but m our experience. this is rarely a practical problem except occasionally in young women who are concerned about cosmetic appearance before the scar lades. PATIENTS AND METHODS Between 1978 and 1993. 33 patients were identified who had undergone primary exploration of the radial tunnel Wrightington Hospital One patient underwent bilateral radial tunnel release. 29 patients who had a total of 30 primary operations were reviewed either al pre­ arranged clinics or in their homes. Four patients were lost to follow-up. The medical records of the patients under review were scrutinised and the patients were examined by questionnaire, visual analogue scales and lamination. Grip and pinch strengths were recorded, and the incisions were assessed for tethering, tenderness and cosmetic appearance. In the group of patients with poor results, an attempt was made to establish the factors contributing to an unsatisfactory outcome. 16 were female and 13 male, with a mean age of 415 years (range 16 69). Follow-up from the time of surgery- ranged from I year to 10 years with a mean of 4 5 years. There were 12 tertiary referrals Delay in diagnosis prior to surgery ranged from 0 to 10 years (mean 3 years). Six patients had ongoing medico-legal claims The oper­ated limbs were dominant in 26 cases and non-dominant in four. The right arm was operated on in 26 patients and the left in four. Nerve conduction studies were undertaken in 19 patients and were positive in only six. Clinical presentation A wide variety of symptoms were found in this group of patients (Table 2). Pain m the region of the arcade of Frohse was the commonest, often in association with writer’s cramp I Department of Social Security Prescribed Disease A4). In our scries, writer’s cramp was defined as proximal forearm pain associated with writing, severe enough to prevent prolonged activity; the alternative definition of focal dystonia with bizarre postures was not seen. All patients had tenderness localised over the radial nerve, distinct from the lateral epicondyle thereby differentiating the condition from chronic tennis elbow Tenderness over the radial nerve in the flexor compartment is a common finding and it is therefore important to compare the seventy with the unaffected limb Three patients presented with a palsy of the posterior interosseous nene. Patients describe the pain in the vicinity of ligament of Frohse as "constant aching” aggravated by or pre­venting activity. The distal symptoms in the region of the wrist or dorso-radial aspect of the forearm are poorly localised and consist of paraesthetic or burning sensations sometimes associated with painful finger or venous swelling. Table 2: Distribution of symptom associated with radial tunnel syndrome Symptom .Vu Proximal forearm pain near arcade of Frohse 20 Writers cramp* 17 Paraesthesia 12 Weakness of grip 9 Night cramp 7 Proximal radiation of pain into the arm 6 Distal radiation el pain into the hand 8 Pain in the distribution of the SBRS 5 Wrist tightness 3 Finger swelling 3 *See text for definition ---------------------------- Occupation The majority of patients had manual occupations requir­ ing repetitive pronation and supination (Table 3). Previous diagnoses prior to radial tunnel release Prior to the exploration of the radial tunnel, 20 out of 29 patients had received treatment for other suspected conditions (Table 4). Six patients underwent operative release of tennis elbow and three had undergone release of the first extensor compartment (de Quervain's tenovaginitis stenosans) without relief. Operative exposures of the radial nerve The number of patients undergoing full anterior expo­ sure of the radial nerve has increased recently. The exposures employed are summarized in Table 5. Operative findings Structures compressing the radial nerve were identified by pronating and supinating the forearm (Table 6). In some patients, several pathological structures were noted. No patients had evidence of permanent nerve injury, such as fibrosis, swelling or inflammation. Table 3 - Occupations Occupation No Professional student 20 Assembly line workers 3 Heavy' goods fitters carriers 6 Housewife 3 Secretarial VDU operator 3 Labourer 2 Multiple occupations 2 Table 4 - Diagnoses prior to release of radial tunnel Diagnoses No Tennis elbow 16 Tenosynovitis 3 de Quervain's 3 Wartenberg's 3 Ulnar nerve compression 1 Cervical radiculopathy 1 Table 5 - Operative procedures for release of radial nerve Anterior division of the arcade of Frohse only 14 Extended anterior release of radial nerve 13 Retrobrachialis approach to arcade to Frohse 3 Table 6 - Structures compressing the radial nerve Structure No. Tight arcade of Frohse 15 Dense proximal fascial bands 12 Tight superficial component of supinator 10 Compressive vessels 3 Nil of note 5 RESULTS On the basis of visual analogue assessment, our results can be classified as follows: excellent 18 30 (60%). good 3 30 (10%), fair 4 30 (13%), and poor 5 30 (17%). A score of 0 refers to no improvement and 100 corresponds to complete recovery. We consider that scores of 80 to 100 are excellent results. 50 to 79 good. 20 to 49 fair and 19 or less represent poor results. In our series, one patient felt that her symptoms were aggravated by the operation. The results are summarized in Figure 2. Functional outcome Three patients presented with weakness of forearm extensor muscles, two of which made a full recovery and the third failed to improve. Pain was the predomi­nant symptom in 29 out of 30 patients and restricted their activities. At review, 12 out of 29 patients (41%) were completely pain-free with all activities. Nine out of 29 (31%) patients fell that pain restricted only the most strenuous of activities, and eight out of 29 (28%) felt that light activity was restricted. These patients fell into the respective excellent, good, and poor result groups shown above. Objective assessment Two-point discrimination was initially assessed but was abandoned because of inconsistent results. There were no significant differences between operated and non­ operated hands regarding grip and pinch strengths. PARAESTHESIA 12 patients were troubled with paraesthesia pre- operatively. Of these, one (8%) had complete resolution of symptoms, two (17%) had some improvement, and ten (85%) failed to improve significantly. One patient developed paraesthesia after the operation. COMPLICATIONS Three patients developed mild reflex sympathetic dys­ trophy which resolved with physiotherapy and guanethidine block. One patient developed a transient posterior interosseous nerve palsy which resolved after 6 months of conservative treatment. One patient developed a scar contracture following a post-operative infection which was revised using a Z-plasty. Two patients developed hyperaesthesia in the distribution of the superficial radial nerve. The remaining scars were well healed and asymptomatic. ASSESSMENT OF POOR RESULTS Four out of five patients with poor results at review had evidence of additional pathology. These included an avulsion fracture of the lateral epicondyle, a loose body in the elbow joint, severe cervical radiculopathy and a progressive palsy of the radial nerve of unknown aeti­ ology despite extensive neurological investigation (mononeuritis). Three out of four patients with fair results also had evidence of additional pathology. One had ulnar impingement on the TFCC and is awaiting ulnar short­ening, one had advanced first carpometacarpal arthrosis and the third had suspected Wartenberg’s syndrome. Release of the superficial branch of the radial nerve did not improve symptoms. An attempt was made to assess which factors may be of predictive value regarding diagnosis and successful outcome. Only eight out of 14 men (57%) had successful procedures whereas 13 out of 16 (81%) of women were very satisfied with their operations. Five out of six patients with positive nerve conduction tests had good results. All patients with night pain had successful outcomes. Despite the presence of ongoing medico-legal claims, four out of six patients had good or excellent results. DISCUSSION Radial tunnel syndrome has been a recognised clinical entity for over 20 years. Capener (1966) described ten patients who underwent division of the arcade of Frohse because of chronic resistant tennis elbow. The first comprehensive account of this condition was given by Roles and Maudsley (1972). Subsequent series have been reported by Lister et al (1979). Moss and Switzer <1983). Hagert et al (1977). Ritts et al (1987) and Werner (1979). Our study confirms previous reports regarding the diversity of symptoms associated with radial tunnel syndrome (Moss and Switzer, 1983). Pain is the com­monest symptom and is usually located near to the site of compression over supinator. It can also be distributed to the dorsum of the wrist, dorso-radial aspect of the forearm and onto the volar aspect of the thenar emi­nence. This pattern of referred pain corresponds to the distribution of the posterior interosseous nerve to the carpus (Wilhelm. 1958) and to the distribution of the SBRN respectively. The distribution of the latter includes a variable area on the dorsum of the thumb, the carpus and first CM joint. A branch of the SBRN can also supply the skin over the thenar eminence (palmar cutaneous branch of the radial nerve). Paraesthesia is often poorly defined and is often commented upon as a symptom not corresponding to known anatomical or pathological patterns. In our series, the release of the radial tunnel resulted in general improvement in pain, but only three out of 12 patients with paraesthesia were relieved of their symptoms. One patient developed paraesthesia secondary to the oper­ation although the pain improved. It is not currently possible to explain all the symptoms associated with radial tunnel syndrome as it involves the complex interrelationship of cutaneous, propriocep­tive. motor and autonomic innervation. Finger swelling, painful venous dilation, dysaesthesia or allodynia (noxi­ ous sensations generated by non-noxious stimuli applied to normal skin) may be related to autonomic dysfunction as identified by Lluch and Beasley (1989). and Sprofkin (1954). The complexity is further illustrated by the observation that dysaesthesia following injury to the SBRN can be improved by division of the posterior interosseous nerve at the level of the wrist joint (Lluch and Beasley, 1989). The pathophysiology of radial tunnel syndrome remains unclear. There are no rigid bony confines to the radial tunnel as found in carpal tunnel and cubital tunnel syndromes. Werner et al (1980), demonstrated pressures of 40 to 50 mm Hg exerted by a fibrous ligament of Frohse and these pressures rose to 190 mm Hg under tetanic muscle contraction. This is of sufficient magnitude to induce nerve ischaemia and blockade of nerve impulses. In addition, the fibrous ligament of Frohse may directly traumatize the radial nerve resulting in oedema and later fibrosis. Lister et al (1979) saw evidence of narrowing, hyperaemia and pseudoneuroma formation in six cases. Excellent or good results for radial tunnel release range from 51% (Ritts et al. 1987) to 93% (Moss and Switzer. 1983). We found that 70"/,. of patients had good or excellent results. Ritts suggested that their •>oor results could be accounted for by the nature of the tertiary referrals and high incidence of worker's compen­sation at the Mayo clinic. We found that outstanding medico-legal claims did not adversely affect the clinical outcome although our numbers do not permit statistical analysis. We believe that seven out of nine patients with poor results had pathology other than radial tunnel syndrome, highlighting the need for improved patient selection and objective criteria for this disorder. Werner (1979) noted that lateral epicondylar tenderness, a posi­tive middle finger extension test, a muscular arcade of Frohse, and evidence of nerve injury were associated with a poor prognosis. We found that the best prognosis was associated with women and patients with positive nerve conduction tests and night pain. Having arrived at a diagnosis of radial tunnel syn­ drome, it is important to select the correct level for the release of the radial nerve. Pain over the dorsum of the wrist and over supinator is related to compression of the posterior interosseous nerve at the level of the arcade of Frohse. A limited anterior approach with division of the arcade will probably be adequate. If there are also symptoms in the distribution of the SBRN. the site of compression is probably proximal to the arcade of Frohse and therefore a more extensive release is required. For this reason, it is essential to determine the level of maximal tenderness pre-operatively and extend the release to that point. It is equally important to check for tenderness over the lateral head of triceps and at the level where the radial nerve passes through the intramus­cular septum, two additional sites of compression. A comprehensive analysis of the correlation between the site of nerve compression and the associated signs was given by Fuss and Wurzl (1991). We feel that it is unwise to undertake an extensive distal release of the SBRN even when symptoms suggest involvement of this nerve. In our unpublished series of Wartenberg’s disease, release of the SBRN proximal to the wrist was associated with a high incidence of reflex sympathetic dystrophy. A more proximal release of the SBRN may result in similar complications. Wartenberg’s disease (Wartenberg, 1932; Sprofkin 1954) is a monone­ uritis of the superficial branch of the radial nerve resulting from trauma of the nerve in its subcutaneous distribution. Compression can also occur as the SBRN pierces the deep fascia in the region of the tendinous intersection of brachioradialis and extensor carpi radialis longus (Mackinnon and Dellon. 1985). We are looking for ways of improving patient selec­tion. Fair or poor results can be due to incorrect diagnosis, incomplete release or irreversible nerve injury. In this series, four out of the five patients with poor results were probably incorrectly diagnosed. Unfortunately, nerve conduction studies are not sensi­tive or specific for diagnosing radial tunnel syndrome. Positive studies are useful in confirming the diagnosis and excluding cervical radiculopathy but the majority of tests are negative (12 out of 18 in our series) despite symptoms suggestive of significant compression (Ritts et al. 1987; Werner, 1979). Local injection of anaesthetic agents at the site of maximal tenderness has been reported (Ritts et al, 1987). It may be that this in combination with provocation testing will improve diag­nostic accuracy. Table 7—Possible presentations of radial tunnel syndrome • Forearm pain radiating from the elbow to the wrist • Chronic wrist pain with radial sided dysaesthesia • Dorsal, radial, and occasional thenar sited wrist pain associated with swelling • Failed tennis elbow treatment • Failed de Quervain's release • Wartenberg’s neuropathy (handcuff neuritis) • Dorsal ‘tenosynovitis’ without crepitus or thickening • Burning pain in the forearm and hand (autonomic dysfunction) The role of nerve conduction studies (NCS) in the diagnosis of radial tunnel syndrome remains contro­versial. In most series the techniques used for the studies were not described or were incomplete. Ritts (1987) found that only 9% of patients had positive studies. Werner (1979) demonstrated that only 13 out of 25 patients with suspected pathology had electromyo­ graphic evidence of nerve compression but no significant difference was noted in outcomes with respect to the electromyographic findings. In our series, 33% of patients who had undergone NCS had positive results and of those, five out of six had excellent outcomes. Rosen and Werner (1980) demonstrated that static motor nerve conduction at rest was not significantly different in the symptomatic patients compared with an asymptomatic control group. A significant difference however was demonstrated on active weak supination (less than 2 Newtons of force). These findings suggest that radial tunnel syndrome can present at various stages; in the early stages, symptoms are intermittent with variable involvement of motor and sensory compo­nents, and in the later stages nerve damage increases and may eventually become irreversible. The results of nerve conduction studies simply reflect the stage of compression at presentation. We conclude that the diagnosis of radial tunnel syn­drome should be considered in the circumstances given in-Table 7. We also believe that there is a need to develop objective assessment techniques that will more accurately identify patients suffering from radial tunnel syndrome and localise the site of compression. ---------------------------- References ABRAMS. R A.. BROWN. R A. and BOTTE. M J. (1992). The superficial branch of the radial nerve: An anatomic studs with surgical implication* Journal of Hand Surgery. 17A: 6: 1037 1041. CAPENER. N. ( 1966). The vulnerability of the posterior interosseous nerve of the forearm: A case report and an anatomical study Journal of Bone and Joint Surgery. 48B: 4: 770-773. FUSS. F. K. and WURZL. G. II. (1991). Radial nerve entrapment at the elbow. Surgical anatomy. Journal of Hand Surgery. 16A: 4: 742-747. GREEN. D. P Operative Hand Surgery 3rd Edn. Neu York. Churchill Livingstone. 1993. HAGERT. C G.. LUNDBORG. G and H ANSEN. T (1977). Entrapment e the posterior interosseous nerve. Scandinavian Journal of Plastic and Reconstructive Surgery. 11: 205 212. HENRY. A. K. Extensile Exposure. 2nd Edn.. Edinburgh. Livingstone. 195 KAPLAN. P. E. ( 1984). Posterior interosseous neuropathies: Natural history Archives of Physical Medicine and Rehabilitation. 65 399 40H. LISTER. G. D.. BELSOLE. R B and KLEINERT. H. E. (1979). The radial tunnel syndrome. Journal of Hand Surgery. 4: 1: 52-59. LLUCH. A. L. and BEASLEY. R. W. (1989). Treatment of dysesthesia of the sensory branch of the radial nerve by distal posterior interosseous neurec­tomy. Journal of Hand Surgery. 14A: 1: 121-124. LOTEM. M.. FRIED. A.. LEVY. M. et al. (1971). Radial palsy following muscular effort. Journal of Bone and Joint Surgery. 53B: 3: 500-506. MACKINNON. S. E. and DELLON. A. L. (1985). The overlap pattern of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve. Journal of Hand Surgery. 10A: 4: 522-526. MOSS. S. H. and SWITZER. H. E. ( 1983). Radial tunnel syndrome: A spectrum of clinical presentations. Journal of Hand Surgery. 8: 4: 414-420. NAKAM1CHI, K. and TACHIBANA. S. (1991). Radial nerve entrapment by the lateral head of triceps. Journal of Hand Surgery. 16A: 4: 748-750. PRASARTRITHA. T.. LIUPOLVANISH, P. and ROJANAKIT. A (1993). A study of the posterior interosseous nerve (PIN ) and the radial tunnel in 30 Thai cadavers. Journal of Hand Surgery. 18A: I: 107- 112. RITTS. G. D.. WOOD. M B. and LINSCHEID. R. L. (1987). Radial tunnel syndrome: A ten-year experience. Clinical Orthopaedics and Related Research. 219: 201-205. ROLES. N. C. and MAUDSLEY. R H. (1972). Radial tunnel syndrome: Resistant tennis elbow as a nene entrapment. Journal of Bone and Joint Surgery. 54B; 3: 499-508. ROSEN. 1. and WERNER. C. O. (1980). Neurophysiological investigation of Posterior interosseous nerve entrapment causing lateral elbow pain. Electroencephalography and Clinical Neurophysiology. 50: 125 133 SPINNER. M. (1968). The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. Journal of Bone and Joint Surgery. 50B: 4: 809-812. SPROFKIN. B. E. ( 1954). Cheiralgia paraesthetica: Wartenberg's Disease Neurology. 4: 857-862. WARTENBERG. R. (1932). Cheralgia paraesthetica (lsolierte Neuritis des Ramus superficialis nervi radialis). Zeitschrift fur die Gesante Neurologie und Psychiatrie. 141: 145-155. WERNER. C. O.. HAEFFNER. F. and ROSEN. I (1980). Direct recording of local pressure in the radial tunnel during passive stretch and active con­ traction of the supinator muscle. Archives of Orthopaedic and Traumatic Surgery. 96: 299-301. WERNER, C. O. (1979). Lateral elbow pain and posterior interosseous nerve entrapment. Acta Orthopaedica Scandinavica: Suppl. 174: 1-62. WILHELM. A. (1958). Zur Innervation der gelenke der oberen extremitat. Zeitschrift fur Anatomie und Enlwicklungsgeschichte. 120: 331-371. Accepted: 18 August 1994 MrJ.K. Stanley. Hand and Upper Limb Centre. Wrightington Hospital. Hall Lane. Wigan. UK © 1995 The British Society for Surgery of the Hand This text has been extracted from printed copy. Whilst every effort has been taken to accurately OCR the original paper, please see attached pdf of the original document for further reference.

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