Morphological comparison of the paretic to the non-paretic knee in people with stroke: An exploratory study

Background: This study was designed to quantify torque production at different joint angles in the paretic and nonparetic knee joints of individuals with stroke. Methods: Extension and flexion torques were measured at 6 angles of the knee joint and normalized to peak torque in 19 subjects with stroke and 19 controls. Results: Paretic knee extension torque was lower than controls when the knee was positioned near extension. In contrast, nonparetic knee extension and flexion torques were higher than controls when the knee was positioned near full flexion. Conclusions: The paretic knee extensors demonstrated exaggerated weakness at short muscle lengths and the nonparetic knee extensors and flexors demonstrated selective strength gains. Clinicians should therefore consider paretic knee extensor strengthening near full extension and promote symmetrical use of the legs to prevent compensatory overuse of the nonparetic leg.

An advanced ultrasound imaging technique, sonoelastography (SE) is used to evaluate tissue elasticity. To determine SE potential to detect pathological-related changes, and characteristics related to tendon pathology we aimed to (1) compare quadriceps and patellar tendon findings in individuals with knee osteoarthritis (KOA) and asymptomatic older adults (AC), and (2) explore associations between SE, participant characteristics (age, BMI, and leg circumference) and KOA status. 84 participants (47; KOA and 37; asymptomatic older adults) underwent SE examination of quadriceps (distal) and patellar (distal, proximal) tendon in a supine position with the knee bent at 30°. Colour score (CS) and Elasticity Ratio (ER) analysis were performed by a blinded experienced operator using Esaote Mylab 70 XVG Ultrasound equipment. Significantly reduced elasticity in the distal quadriceps (median (IQR) 2(2), 3(1), p = 0.033 for KOA and AC, respectively) and proximal patellar (3(1), 3(0), p = 0.001) tendons and more elastic distal patellar (1.50 (0.55), 1.87 (0.72), p = 0.034) tendons were observed in the KOA group. Significant associations) were identified between SE and participant BMI (Rs = − 0.249–0.750, p < 0.05) and leg circumference (Rs = − 0.260–0.903, p < 0.05). Age, BMI and KOA status, were independent explanatory variables of SE CS findings at the distal quadriceps tendon patellar tendon, proximal patellar tendon and distal patellar tendon, explaining 66%, 81% and 64% of variance, respectively. Age, BMI and KOA status were independent explanatory variables of SE ER findings at the distal patellar tendon explaining 19% of variance. Potentially clinically relevant altered tendon stiffness were observed between individuals with KOA and asymptomatic controls. Key KOA risk factors and participant characteristics explained variance in tendon stiffness. Findings provide context for future studies to investigate the potential for targeted SE detected early clinical management based on associated participant characteristics.

Helicobacter pylori is a major cause of gastritis and a potential trigger of inflammatory disease. The effect of Hpylori infection on distal femoral cartilage has yet to be evaluated. The aim of this study was to evaluate femoral cartilage thickness in patients with Hpylori infection and to find whether this infection affects femoral cartilage thickness. This cross-sectional study included 199 patients. To measure the thickness of femoral articular cartilage, 99 patients with Hpylori infections and 100 with Hpylori-negative controls were enrolled into two groups. The measurements were made using linear probe ultrasonography with the patients in supine positions and their knees in maximum flexion. Demographic, clinical, endoscopic and laboratory data were collected for all patients. Both the right and left femoral condyles had thinner cartilage thickness in the Hpylori-positive group than in the Hpylori-negative group (P=.016, P=.036). For the intercondylar area and lateral femoral condyles, although the Hpylori-positive patients had thinner femoral cartilage thickness than the Hpylori-negative individuals for both extremities, this finding was not statistically significant (P>.05). Femoral cartilage was thinner in patients with Hpylori than patients without Hpylori for right and left medial femoral condyles. This study suggests that Hpylori infections may affect femoral cartilage thickness and potentially increase the risk of cartilage degeneration.

Changes in lower extremity alignment in individuals with flatfoot may be associated with differences in morphology of the tendons or cartilage in lower extremities. The purpose of the present study was to investigate the potential association of flatfoot with the morphology of the Achilles tendon, patellar tendon, and femoral cartilage. This study was conducted with 40 participants with flatfoot (28 females, 12 males) and 40 participants with a normal foot posture (28 females, 12 males). The thickness of the Achilles tendon (at points 2 and 3 cm proximal to the superior aspect of the calcaneus), patellar tendon (at the inferior pole of the patella and 1 cm proximal of the inferior pole of the patella), and femoral cartilage (at the intercondylar area, medial condyle, and lateral condyle) was measured by an ultrasonography device. The Achilles tendon thickness at 2 cm (P = .009) and 3 cm (P = .010) proximal of the superior aspect of the calcaneus was on average 4% to 6% lower in individuals with flatfoot compared with controls. The cartilage thickness at the intercondylar area (P = .005) and medial condyle (P = .018) was on average 8% to 12% greater in individuals with flatfoot; however, the cartilage thickness at the lateral condyle and patellar tendon thickness was similar in both groups. The results obtained suggest that foot posture is associated with the morphology of the Achilles tendon and femoral cartilage. Level III, diagnostic comparative study.

In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement. A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022. There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates. The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research. level V.

Background Ultrasound (US) has received an increasing attention in detecting uric monosodium urate (MSU) deposits, and US is included in the ACR/EULAR classification criteria for gout. OMERACT has developed definitions for US elementary lesions in gout including double contour (DC) sign (deposits of crystals on the surface of cartilage), tophus (larger hypo-echoic aggregation of crystals, usually well delineated) and aggregates (small hyper-echoic deposits). Objectives The present objective was to explore by US the most frequent locations of MSU deposits. Methods Baseline data from a prospective observational study were used where patients with crystal-proven gout who presented after a recent gout flare were included (202 patients (mean (SD) age 56.6 (14.2) years, disease duration 8.0 (7.7) years, 94.1% men), all with insufficiently treated serum uric acid level (>360 μmol/L/>6 mg/dl). We performed an extensive assessment with US (GE E9 machine, grey scale 15MHz) for semi-quantitative scoring of MSU deposits (0=none, 1=possible/small, 2=moderate, 3=major) using OMERACT definitions for DC, tophi and aggregates. The following locations were examined bilaterally; radiocarpal, MCP 2 and MTP 1 joints, triceps and quadriceps insertions, patellar (proximal and distal) and Achilles tendons as well as distal femur (maximal flexed knee) and talar cartilage. Sum scores for each crystal deposit were calculated and correlations were performed by use of Spearman rho, comparisons by paired samples test, and frequencies of deposits were calculated as percentages. Results The baseline mean (SD) serum uric acid level was 494 (87) μmol/L. Table 1 shows uric acid deposits to be correlated with kidney function and disease duration. Table 2 includes frequencies with at least moderate US scores (≥2) in the different joint and tendon localisations and shows DC primarily to be found in MTP1, followed by talar and femoral cartilage. Tophi and aggregates were primarily found in MTP1, followed by distal patellar and triceps tendons. There were no major differences between right and left side. In 25 patients (12.5%) DC was seen on femoral or talar cartilage but with no depositions in the MTP1 joint. Conclusion Uric acid deposits were associated with reduced kidney function as well as disease duration. When gout is suspected the present study suggests US examinations of MTP1, distal patellar and triceps tendons as well as talar and femoral cartilage to be the most important sites to examine for presence of MSU deposits. Disclosure of Interests Hilde Berner Hammer Grant/research support from: AbbVie, Pfizer and Roche, Paid instructor for: AbbVie, Pfizer, UCB, Novartis, Roche, Speakers bureau: AbbVie, Pfizer, UCB, Novartis, Roche, Lars Fridtjof Karoliussen: None declared, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, Tore K. Kvien Grant/research support from: AbbVie, BMS, MSD, Pfizer, Roche and UCB., Consultant for: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Celltrion, Eli Lilly, Hospira, Merck-Serono, MSD, Novartis, Oktal, Orion Pharma, Pfizer, Roche, Sandoz, Sanofi, Mylan and UCB, Speakers bureau: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Celltrion, Eli Lilly, Hospira, Merck-Serono, MSD, Novartis, Oktal, Orion Pharma, Pfizer, Roche, Sandoz, Sanofi and UCB, Till Uhlig Consultant for: Grunenthal, Novartis, Speakers bureau: Grunenthal, Novartis

Background:Patellar tendinopathy is a common chronic condition caused by mechanical loading that leads to patellar tendon (PT) degeneration, with an estimated incidence of 13% across all sports in adolescents. Musculoskeletal ultrasound (MSK-US) evaluation is becoming more common in the diagnostic process, but normative data are extremely rare for the adolescent population. These normative data are needed to aid in proper interpretation of the MSK-US image.Purpose:The purpose of this study was to determine standard reference values for thickness, width, and cross-sectional area (CSA) of the PT using MSK-US in asymptomatic adolescent athletes.Methods:IRB approval, parental consent, and athlete assent were obtained prior to data collection. Bilateral PT were scanned using a portable US unit with a 12-4MHz linear array transducer. Long axis images were captured at the apex and 1cm distal to the patella, 1 cm proximal to the insertion and at the PT insertion (Figure 1a & 1b). Short axis images were captured 1 cm proximal and distal to the attachments. PT thickness, width, and CSA were measured using ImageJ by a single evaluator. Additional exploratory analyses were also conducted.Results:Seventy-one adolescent athletes (27 males, 44 females) between 11-18 years old (13.8 ±1.8 years) volunteered. Mean values for PT thickness, width, and CSA are found in Table 1. Significant differences in PT thickness and CSA between sex were identified at each measurement location (P<.05), with males ranging 4.0-9.9 mm thicker than females. PT width was not significantly different proximally or distally. The left proximal PT was significantly wider than right (P<.0001), but no other side differences were found. Lastly, significant weak positive correlations were present in distal tendon CSA with height (left PT: r(52)=.348, P=.014, right PT: r(49)=.369, P=.007) and weight (left PT: r(50 )=.290, P=.041). There was no correlation with age.Conclusion:These data represent one of the largest healthy cohorts of adolescent athletes from which normative data have been collected. This preliminary analysis reveals some interesting trends, such as the thickness of the PT is greatest at the insertion and origin, while thinner at mid-tendon, with the insertion the thicker of the two. Age was not correlated with PT size, but distal PT CSA was larger with taller and heavier individuals. These data will contribute to the paucity of adolescent PT MSK-US data, which should aid clinicians in interpretation, diagnostic accuracy, and management of active adolescent patients with patellar tendinopathy.Figure 1.Long axis US images of the proximal (a) and distal patellar tendon (b)Table 1.Patellar tendon means and standard deviation

Background Biomechanics of the paretic knee during gait are well documented, yet these data have yet to be systematically summarised and analysed. Objective To analyse three-dimensional optic-based biomechanical data of the paretic knee post-stroke, compared to non-paretic or control participants’ knees, during overground gait. Methods Database searches were completed, with observational studies and baseline data from randomised controlled trials considered. Two reviewers independently screened studies, extracted data, and determined risk of bias using the Downs and Black Quality Index. Quantitative and descriptive analyses were undertaken, with level of evidence considered. Results 31 studies were included, with 719 participants with stroke and 274 controls. Pooled data were heterogenous. Descriptive analyses demonstrated: reduced peak knee flexion at the paretic knee compared to non-paretic knee; reduced knee flexion during swing at the paretic knee compared to control knee; reduced sagittal range of motion at the paretic knee compared to non-paretic, and control knee; and reduced peak (internal) extension moments at the paretic knee compared to non-paretic knee. Most studies were at high risk of bias, demonstrating limited quality evidence in the current evidence base. Conclusion The paretic knee demonstrated reduced peak knee flexion, knee flexion during swing, range of motion, and knee extension moments compared to the non-paretic and/or control knee. Considerable heterogeneity prevented meta-analyses. The current evidence base reflects limited quality, with further research required to better explore biomechanical differences occurring in well documented post-stroke gait patterns.

Knee hyperextension is one of the most common compensatory mechanisms in stroke patients. The first aim of the study was to measure knee hyperextension and femoral cartilage thickness in stroke patients. The second aim was to compare the femoral cartilage thickness of the paretic and nonparetic limbs in stroke patients with and without knee hyperextension. Forty stroke patients were included in the study. The patients were divided into two groups according to the presence of knee hyperextension based on kinematic analyses performed during walking with a three-dimensional motion analysis system. The medial femoral cartilage, lateral femoral cartilage, and intercondylar cartilage thicknesses of the paretic and nonparetic sides of the patients were measured by ultrasonography. In the study group, medial femoral cartilage, intercondylar, and lateral femoral cartilage thicknesses were less on the paretic side than on the nonparetic side, while the femoral cartilage thicknesses on the paretic and nonparetic sides were similar in the control group. Paretic side medial femoral cartilage and intercondylar thicknesses were less in the study group compared with the control group, and lateral femoral cartilage thickness was similar between the two groups. Knee hyperextension during walking causes femoral cartilage degeneration in stroke patients.Clinical Trial code: NCT05513157.

To examine Achilles and patellar tendon morphology in dancers with and without tendon pain. Fifty-three dancers with and without Achilles and/or patellar tendon pain participated. Eleven age-matched non-dancers served as controls. Longitudinal ultrasound images of the middle and distal Achilles and proximal and distal patellar tendons were acquired. To assess macromorphology, the thickness of the middle and distal Achilles and proximal and distal patellar tendons were measured. Micromorphology was analyzed by selecting 2 x 2-mm2 regions of interest in the tendons; spectral analysis using the fast Fourier transform was run for several kernels (2 x 2-mm2 subimages) within each image, and the peak spatial frequency (PSF) was extracted. A one-way ANOVA compared asymptomatic, symptomatic, and control tendon thickness and PSF. Macromorphology: There was no significant difference between asymptomatic and symptomatic dancers in middle or distal Achilles tendon thickness and distal patellar tendon thickness. Proximal patellar tendons in control subjects were thinner than those in asymptomatic (p=0.036) and symptomatic (p=0.003) dancers. Micromorphology: There was no significant difference in PSF between asymptomatic and symptomatic dancers and controls in the Achilles or patellar tendon. Increased proximal patellar tendon thickness without changes in tendon micromorphology suggests that tendon adaptations are more likely activity-related and less likely influenced by degeneration.

To examine if cross-sectional area (CSA) differs along the length of the human patellar tendon (PT), and if there is PT hypertrophy in response to resistance training. Twelve healthy young men underwent baseline and post-training assessments. Maximal isometric knee extension strength (MVC) was determined unilaterally in both legs. PT CSA was measured at the proximal-, mid- and distal PT level and quadriceps muscle CSA was measured at mid-thigh level using magnetic resonance imaging. Mechanical properties of the patellar tendons were determined using ultrasonography. Subsequently, subjects performed 12 weeks of heavy resistance knee extension training with one leg (Heavy-leg), and light resistance knee extension training with the other leg (Light-leg). The MVC increased for heavy-leg (15 +/- 4%, P < 0.05), but not for light-leg (6 +/- 4%). Quadriceps CSA increased in heavy-legs (6 +/- 1%, P < 0.05) while unchanged in light-legs. Proximal PT CSA (104 +/- 4 mm(2)) was smaller than the mid-tendon CSA (118 +/- 3 mm(2)), which again was smaller than distal tendon CSA (127 +/- 2 mm(2), P < 0.05). Light-leg PT CSA increased by 7 +/- 3% (P < 0.05) at the proximal tendon level, but was otherwise unchanged. Heavy-leg PT CSA increased at the proximal and distal tendon levels by 6 +/- 3% and 4 +/- 2% respectively (P < 0.05), but was unchanged at the mid tendon level. PT stiffness increased in heavy-legs (P < 0.05) but was unchanged in light-legs. Modulus remained unchanged in both legs. To our knowledge, this study is the first to report tendon hypertrophy following resistance training. Further, the data show that the human PT CSA varies along the length of the tendon.

Intra-articular corticosteroid injection (IACI) is a safe first-line or adjunct therapy used in any subtype of juvenile idiopathic arthritis (JIA). Limited studies evaluated the effect of IACI on cartilage. Our study aimed to examine the femoral cartilage thickness of patients with JIA who received IACI to the knee joint using ultrasound. We randomly selected JIA patients who performed IACI in the knee joint. Baseline bilateral joint cartilage and tendon thicknesses were measured. The articular fluid was aspirated, and applied IACI at the same period. Six months after injection, the exact measurements were repeated. Distal femoral cartilage, quadriceps tendon, and distal and proximal patellar tendon thicknesses were compared at the baseline (before IACI) and 6 months after IACI. Thirty patients with JIA were included, and 23 (76.7%) were female. The median age was 11 years (interquartile range, 6 to 14), and the median disease duration was 3.3 years (interquartile range, 5 months to 5 years). The subtypes of JIA were oligoarticular in 25 (83.3%), polyarticular in 2 (6.7%), enthesitis-related arthritis in 2 (6.7%), and juvenile psoriatic arthritis in 1 (3.3%). Distal femoral cartilage thickness was 2.96 ± 0.79 mm at baseline and 2.85 ± 0.70 mm at 6 months after IACI (P = .35). The tendon thicknesses were similar at 6 months after baseline measurements. Our findings reveal that knee IACI in patients with JIA did not significantly change cartilage and tendon thicknesses. This observation could indicate that IACIs have no detrimental effects on the cartilage and the tendons.

The objective for this study is to evaluate the femoral cartilage thickness in patients with/without uveitis in Behçet's disease (BD). Patients with BD aged 18-70years were included. The demographic and clinical characteristics of the patients were recorded. The thickness of femoral articular cartilage was measured with musculoskeletal ultrasound. Cartilage thickness was measured bilaterally from the central points of medial condyle (MFC), lateral condyle (LFC), and intercondylar area (ICA). 20 patients with uveitis [uveitis (+)] and 20 patients without uveitis [uveitis (-)] were included. Both right and left MFC and LFC had statistically significant thinner cartilage in uveitis (+) group (p < 0.05). For the ICA, uveitis (+) patients had thinner femoral cartilage than uveitis (-) patients; however, in the left side, statistically significance could not be detected. Femoral cartilage was thinner in uveitis (+) patients than in uveitis (-) patients in BD. This relationship between uveitis and femoral cartilage thickness may be helpful in the prevention and early treatment of cartilage degeneration.

Background Systemic sclerosis (SSc) is a connective tissue disease characterized by different degrees of skin fibrosis and visceral organ involvement. The etiology of SSc remains obscure; the disease appears to be the result of a multistep and multifactorial process, including immune system alterations, under the influence of genetic and exogenous factors. The aim of this work is to study levels of vitamin D in relation to the femoral cartilage thickness (FCT) in patients with SSc and to analyze the associations between the (FCT), vitamin D levels, SSc- disease severity score. Patients and methods This is a cross sectional study which included 40 adult systemic sclerosis patients diagnosed according to ACR/EULAR (2013) classification criteria of systemic sclerosis. Patients were categorized into two groups according to vitamin D sufficiency; Group I: n = 14, sufficient vitamin D (level ≥ 30 ng/ml), Group II: n = 26, insufficient vitamin D (level &amp;lt; 30 ng/ml). Serum levels of 25-hydroxyvitamin D (25[OH] D) were assessed by (ELISA). The thickness of femoral articular cartilage was measured by muscloskeletal ultrasound. Three measurements were taken from each knee: lateral femoral condyle (LFC), femoral intercondylar area (ICA) and medial femoral condyle (MFC). Results The majority of patients (60%) had thin femoral cartilage of knee joint, we found that (35%) of patients had sufficient vitamin D level while (65%) of patients had insufficient vitamin D level. We compared the insufficient vitamin D level group with sufficient vitamin D level group according to femoral cartilage thickness, and concluded that vitamin D level related to femoral cartilage thickness at left medial condylar area and left lateral condyle, meanwhile we found no relation between disease severity and cartilage thickness or vitamin D level. There was significant relation between vitamin D sufficiency and sex of studied patients more in females, also showed significant inverse correlation between parity in females and femoral cartilage thickness at Rt intercondylar area and Rt medial condyle. There was highly significant statistical relation between disease severity grades and proximal muscle weakness among studied patients. Conclusion Vitamin D level has significant relation with femoral cartilage thickness in SSc patients in two of six of measured cartilage areas and proximal muscle weakness was associated with vitamin D insufficiency and disease severity.

Decreased Femoral Cartilage Thickness in Patients With Systemic Sclerosis