Articular Pathology Research Articles

Measuring Outcomes in Knee Articular Cartilage Pathology

Measuring outcomes following treatment of knee articular cartilage lesions is crucial to determine the natural history of disease and the efficacy of treatments. Outcome assessments for articular cartilage treatments can be clinical (based on failure, lack of healing, reoperation, need for arthroplasty), radiographic (X-ray, MRI), histologic, or patient reported and functional. The purpose of this review is to discuss the application and properties of patient-reported outcomes (PROs) with a focus on articular cartilage injuries and surgery in the knee. The most frequently used and validated PROs for knee articular cartilage studies include: the Knee injury and Osteoarthritis and Outcome Score, International Knee Documentation Committee Subjective Knee Form, and Lysholm score as knee-specific measures; the Marx Activity Rating Scale and Tegner Activity Scale as activity measures; and EQ-5D and SF-36/12 as generic quality-of-life measures. Incorporating these validated PROs in studies pertaining to knee articular cartilage lesions will allow researchers to fully capture clinically relevant outcomes that are most important to patients.

Hyaluronic Acid: Redefining Its Role.

The discovery of several unexpected complex biological roles of hyaluronic acid (HA) has promoted new research impetus for biologists and, the clinical interest in several fields of medicine, such as ophthalmology, articular pathologies, cutaneous repair, skin remodeling, vascular prosthesis, adipose tissue engineering, nerve reconstruction and cancer therapy. In addition, the great potential of HA in medicine has stimulated the interest of pharmaceutical companies which, by means of new technologies can produce HA and several new derivatives in order to increase both the residence time in a variety of human tissues and the anti-inflammatory properties. Minor chemical modifications of the molecule, such as the esterification with benzyl alcohol (Hyaff-11® biomaterials), have made possible the production of water-insoluble polymers that have been manufactured in various forms: membranes, gauzes, nonwoven meshes, gels, tubes. All these biomaterials are used as wound-covering, anti-adhesive devices and as scaffolds for tissue engineering, such as epidermis, dermis, micro-vascularized skin, cartilage and bone. In this review, the essential biological functions of HA and the applications of its derivatives for pharmaceutical and tissue regeneration purposes are reviewed.

Practical rationale for an empirical approach to the treatment of articular pathology in broiler chickens

Relevance. The work is devoted to the results of bacteriological studies in articular pathology in broiler chickens and conducting production experience to obtain higher production indicators compared with the use of the approved antibacterial treatment regimen at the enterprise.The aim of our research was to develop an empirical treatment regimen for broiler chickens with articular pathology.Methods. Laboratory research was carried out at the State Scientific Center for Applied Microbiology and Biotechnology, Federal State Budgetary Institution, and production experience on broiler chickens from the Cobb-500 cross was performed at one of the broiler enterprises in the Central Region for the cultivation of poultry meat.Results. On the basis of laboratory studies, including monitoring and determining the sensitivity of the isolated bacteria to antibacterial drugs, the proposed empirical treatment scheme, including Colikvinol® and Pulmosol® in case of articular pathology of broiler chickens, allowed to obtain higher production indicators compared to the approved treatment regimen at the enterprise .

Classification, Categorization, and Algorithms for Articular Cartilage Defects.

There is a critical unmet need in the clinical implementation of valid preventative and therapeutic strategies for patients with articular cartilage pathology based on the significant gap in understanding of the relationships between diagnostic data, disease progression, patient-related variables, and symptoms. In this article, the current state of classification and categorization for articular cartilage pathology is discussed with particular focus on machine learning methods and the authors propose a bedside-bench-bedside approach with highly quantitative techniques as a solution to these hurdles. Leveraging computational learning with available data toward articular cartilage pathology patient phenotyping holds promise for clinical research and will likely be an important tool to identify translational solutions into evidence-based clinical applications to benefit patients. Recommendations for successful implementation of these approaches include using standardized definitions of articular cartilage, to include characterization of depth, size, location, and number; using measurements that minimize subjectivity or validated patient-reported outcome measures; considering not just the articular cartilage pathology but the whole joint, and the patient perception and perspective. Application of this approach through a multistep process by a multidisciplinary team of clinicians and scientists holds promise for validating disease mechanism-based phenotypes toward clinically relevant understanding of articular cartilage pathology for evidence-based application to orthopaedic practice.

Meniscal and Articular Cartilage Predictors of Outcome following Revision ACL Reconstruction: A 6-Year Follow-up Study

Objectives:Previous work has shown that having a lateral meniscectomy prior to revision ACL surgery, as well as grade 3-4 chondral damage to the trochlea at the time of revision ACL surgery results in poorer outcomes at 2 years. Alternatively, meniscal or articular cartilage (AC) pathology documented at the time of a revision surgery were not found to be significant risk factors for 2-year activity levels. The purpose of this study was to follow this cohort for a longer time period, to determine if either meniscal and/or articular cartilage pathology noted at the time of revision ACL surgery significantly affects a patient’s activity level, sports function, and OA symptoms at 6-year follow-up.Methods:Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 6 years and asked to complete the identical set of outcome instruments.Regression analysis was used to control for age, gender, BMI, smoking status, activity level, baseline outcome scores, revision number, time since their last ACL reconstruction, graft choice, and previous and current meniscal and articular cartilage pathology, in order to assess the meniscal and AC pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction.Results:1234 patients met the inclusion criteria and were successfully enrolled, with 716 (58%) males and a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Surgeons noted previous pathology in the medial meniscus (39%), lateral meniscus (20%), and articular surfaces (12%) at the time of revision surgery. Surgeons reported current pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (MFC; 43%), lateral femoral condyle (LFC; 29%), medial tibial plateau (MTP; 11%), lateral tibial plateau (LTP; 17%), patella (30%), and trochlea (21%). At 6 years, follow-up was obtained on 77% (949/1234). Previous and current meniscal pathology (both medial and lateral), as well as current AC pathology (in the MFC, LTP, trochlea, and patella) were found to be significant drivers of poorer outcomes at 6 years. The most consistent cartilage-related factors driving outcome in revision patients were either a previous or current repair or excision of the medial meniscus and patellofemoral AC pathology. Six-year Marx activity levels were negatively impacted by having either a repair or an excision of the medial meniscus (odds ratio range =0.58-66; 95% CI=0.38-0.91; p=0.01) or having grade 3-4 patellar chondrosis (OR=0.57; 95% CI= 0.35-0.95; p=0.03). Conversely, 6-year activity levels significantly improved by having either a lateral meniscus repair or excision (OR=1.49-2.22; 95% CI=1.07-4.04; p=0.005). Previous medial or lateral meniscal pathology negatively affected all KOOS subscales except for sports/recreation (p<0.05). Articular pathology significantly impaired KOOS symptoms, sports/recreation and the quality of life subscales (p<0.05). The KOOS sports/recreation subscale was significantly affected by articular cartilage pathology (LTP, patella, trochlea; p<0.03). Lower baseline outcome scores, lower baseline activity level, and being a smoker all significantly increased the odds of reporting poorer clinical outcomes at 6 years.Conclusion:Meniscal and articular cartilage pathology was found to have a larger impact at 6 years following revision ACL surgery, as compared to 2-year follow-up. In contrast to 2-year follow-up, incidence of medial meniscal and AC pathology at the time of a patient’s revision surgery were found to significantly diminish a patient’s activity level at 6 years, whereas the incidence of lateral meniscal repair or excision was found to improve a patient’s activity level. Having a previous medial meniscal repair or excision or exhibiting grade 2-4 chondral damage noted at the time of ACL revision reconstruction results in poorer IKDC and KOOS scores and worse WOMAC pain and ADL scores at 6 years following revision surgery.

Clinical Application of the Basic Science of Articular Cartilage Pathology and Treatment.

The joint is an organ with each tissue playing critical roles in health and disease. Intact articular cartilage is an exquisite tissue that withstands incredible biologic and biomechanical demands in allowing movement and function, which is why hyaline cartilage must be maintained within a very narrow range of biochemical composition and morphologic architecture to meet demands while maintaining health and integrity. Unfortunately, insult, injury, and/or aging can initiate a cascade of events that result in erosion, degradation, and loss of articular cartilage such that joint pain and dysfunction ensue. Importantly, articular cartilage pathology affects the health of the entire joint and therefore should not be considered or addressed in isolation. Treating articular cartilage lesions is challenging because left alone, the tissue is incapable of regeneration or highly functional and durable repair. Nonoperative treatments can alleviate symptoms associated with cartilage pathology but are not curative or lasting. Current surgical treatments range from stimulation of intrinsic repair to whole-surface and whole-joint restoration. Unfortunately, there is a relative paucity of prospective, randomized controlled, or well-designed cohort-based clinical trials with respect to cartilage repair and restoration surgeries, such that there is a gap in knowledge that must be addressed to determine optimal treatment strategies for this ubiquitous problem in orthopedic health care. This review article discusses the basic science rationale and principles that influence pathology, symptoms, treatment algorithms, and outcomes associated with articular cartilage defects in the knee.

Kruppel-like factor 4 upregulates matrix metalloproteinase 13 expression in chondrocytes via mRNA stabilization.

Matrix metalloproteinase 13 (MMP13) is indispensable for normal skeletal development and is also a principal proteinase responsible for articular joint pathologies. MMP13 mRNA level needs to be tightly regulated in both positive and negative manners to achieve normal development and also to prevent joint destruction. We showed previously that Kruppel-like factor 4 (KLF4) strongly induces the expression of members of the MMP family of genes including that for MMP13 in cultured chondrocytes. Through expression-based screening of approximately 400 compounds, we identified several that efficiently downregulated MMP13 gene expression induced by KLF4. Compounds grouped as topoisomerase inhibitors (transcriptional inhibitors) downregulated MMP13 expression levels, which proved the validity of our screening method. In this screening, trichostatin A (TSA) was identified as one of the most potent repressors. Mechanistically, increased MMP13 mRNA levels induced by KLF4 were not mainly caused by increased rates of RNA polymerase II-mediated MMP13 transcription, but arose from escaping mRNA decay. TSA treatment almost completely blunted the effect of KLF4. Importantly, KLF4 was detected in chondrocytes at the joint destruction sites in a rodent model of osteoarthritis. Our results partially explain how KLF4 regulates numerous proteinase gene expressions simultaneously in chondrocytes. Also, these observations suggest that modulation of KLF4 activity or expression could be a novel therapeutic target for osteoarthritis.

Laser treatment of synovial inflammatory process in experimentally induced microcrystalline arthritis in Wistar rats.

The presence of intra-articular crystals is detected in different articular pathologies of acute or chronic nature. The aim of this work was to analyze the action of the indium gallium aluminum and phosphorus (InGaAlP) (λ = 670nm) laser on the synovial membrane present in the knee joint in experimentally induced microcrystalline arthritis in male adult Wistar rats. The animals were divided into three experimental groups (n = 24): control (A), experimentally induced arthritis (B), experimentally induced arthritis+InGaAlP laser therapy (C). The laser treatment was made daily in the patellar region of the right knee after 48h of the experimental induction. After 7, 14, and 21days of therapy, the rats were euthanized and the right knees were removed and processed for histomorphometric, immunohistochemical, ultrastructural, and biochemical investigation of the synovium. The number of granulocytes on the 14th and 21st days was higher in B and lower in C and, lastly, in A. The number of fibroblasts on the 14th and 21st days was similar between A and C and below B. The number of blood vessels on the 21st day was higher in B than in the other groups. The positive number of cells for the TUNEL test was higher on the 14th and 21st days in B compared to the others. The percentage of tissue area occupied by birefringent collagen fibers was higher in B on the 21st day than in the others. The ultrastructure of cells showed fibroblast-like morphology in all groups and periods evaluated. The quantification of glycosaminoglycans did not present significant differences between the groups in all the experimental periods. The amount of hydroxyproline was higher in B compared to the other groups on the 14th and 21st days. The content of non-collagen proteins was higher in B on the 21st day in relation to the other groups. Quantification of TNF-α on the 21st day was higher in A and B than in C. For TGF-β on the 21st day, groups B and C presented similar and higher values than A. For MMP-13, groups A and B presented data similar to and above C. In relation to ADAMT-S4, on the 21st day, groups B and C presented data similar to and lower than A. InGaAlP-670nm therapy reduced the inflammatory process and tissue injuries of the synovial membrane in comparison to the untreated group, indicating its potential utilization in clinical studies aiming in the recovery of acute arthritis in patients.

AB0064 CHANGES IN THE VASCULAR ENDOTHELIAL GROWTH FACTOR A (VEGFA) SPLICING AXIS IN HUMAN SYNOVIUM ARE RELATED TO INFLAMMATION IN ARTHRITIS

Background:VEGF-A is a key regulator of rheumatoid (RA) and osteoarthritis (OA). During articular inflammation in OA and RA there is increased synovial angiogenesis and upregulation of angiogenic growth factors such as VEGF-A. VEGF-A comprises two splice variant families, VEGF-Axxxa and VEGF-Axxxb (xxx represents the number of amino acids, from 121 to 206), resulting from alternative splice site selection in exon 8. This site selection is controlled by Serine/Arginine Rich Splicing Factor Kinase 1 (SRPK1), which phophorylates Serine/Arginine Rich Splicing Factor 1 (SRSF1), inducing it to translocate to the nucleus. In most normal tissues, VEGF-Axxxb isoforms predominate, with anti-nociceptive and anti-angiogenic functions. I contrast, in pathological conditions such as inflammation and solid tumours, VEGF-Axxxa isoforms predominate, with pro-nociceptive and pro-angiogenic functions. VEGF-A has been proposed as a therapeutic target in RA and OA. To date, there are no published data on the functionally distinct VEGF-A splice variants in either RA or OA.Objectives:To determine the patterns of, and relationships between, VEGF-A, SRPK1, and SRSF1 expression and activation and synovial inflammation in human RA and OA.Methods:The study was approved by the Nottingham Research Ethics Committee 1 (05/Q2403/24) and Derby Research Ethics Committee 1 (11/H0405/2). Tissues were selected from age- and sex-matched cases in the University of Nottingham joint tissue repository. Post-mortem (PM) samples of healthy knee synovium (n=14, no history of arthritis or knee pain in the 12 months prior to death, no significant articular or synovial pathology) and arthroplasty-derived synovium samples from OA (n=35) or RA (n=14) patients were compared. OA samples were selected to represent the variety of inflammation levels, from low to high grade (0-3, Haywood et al., 2003). 8um thick sections were stained for SRSF1, SRPK1, total VEGF-A and VEGFxxxb via immunohistochemistry. Expression was estimated as fractional area, relative staining intensity (VEGF-Axxxb), and SRSF1 activation quantified by the degree of nuclear localisation. Statistical analyses were performed using Kruskal-Wallis followed by Dunn’s tests and Spearman’s rank correlations.Results:SRPK1 expression was similar across all conditions. SRSF1 showed significantly higher expression in the OA tissue compared to PM (H(2)= 11.29, p=0.002; OA median=0.2, IQR(0.15, 0.28); PM median=0.09, IQR(0.07, 0.16)), and significantly higher nuclear localisation (indicating activation) in RA vs. OA, and in both RA and OA vs PM (H(2)=37.65, p&lt;0.0001 RA cf. PM; p=0,007 OA cf. PM; RA median=89, IQR(83, 93); OA median=36.1, IQR(29, 42); PM median=19.8, IQR(14,21)). Nuclear SRSF1 was significantly correlated with inflammation score (r= 0.52, p&lt;0.05). Total VEGF-A expression was significantly increased in RA compared to PM and OA (H(2)=23.3, p&lt;0.001 RA cf. PM; RA median=0.4, IQR(0.37,0.59); PM median=0.18, IQR(0.15,0.2)) and was also correlated with the severity of inflammation (r=0.47 p&lt;0.05). VEGF-Axxxb showed no changed in expression in OA or RA, although VEGF-Axxxb staining intensity was significant higher in RA samples, compared to controls (H(2)=7.2 p=0.02; RA median=2.3(1, 4); PM median=0.9 (0.7, 1.4)).Conclusion:Increased levels of SRSF1 activation, and the association of total VEGF-A expression with inflammation score, support the hypothesis that there is activation of alternative splicing in inflamed synovium in RA and OA. Targeting this pathway could be a novel therapeutic strategy in OA &amp; RA.

Arthroscopic approaches to and anatomy of the shoulder joint of cattle: a cadaver study

BackgroundArthroscopic surgery is described as a minimally invasive technique for diagnosis, exploration and treatment of joint disorders. It allows intraarticular structures to be assessed accurately, thereby improving the diagnostic capabilities, and it broadens the spectrum of surgical techniques feasible for treatment of articular pathologies in cattle.This study aimed to assess for cattle the described arthroscopic approaches to the shoulder joint of horses, and to describe the appearance of the corresponding intraarticular structures of the shoulder joint. Additionally, to perform histological examination where tissues were identified and assessed arthroscopically, but the tissue type was uncertain using cadaveric limbs from cattle of different age categories without any signs of orthopedic diseases of the front limbs.ResultsAn anatomic and arthroscopic investigation with 34-cadaveric forelimbs from 20-cattle was performed. The arthroscope was inserted either immediately cranial or 1-cm caudal to the tendon of the infraspinatus muscle for the cranial and caudal approaches, respectively. The shoulder joints were examined with the limbs in either horizontal non-pulled position, abducted non-pulled position using a three-pod limb holder adjustable in height, or horizontal manually pulled position. Arthroscopy was performed using a rigid 30°arthroscope (18-cm length, 4-mm outer diameter) to view the synovial pouches with their synovial villi and the following structures: cranial rim of the glenoid, cranial portion of the humeral head, incisura-glenoidalis, caudal rim of the glenoid, caudal portion of the humeral head, and cranial and caudal cul-de-sac. Abduction of the limb allowed improved visualization of the lateral portion of the joint. Pulling the limb facilitated investigation of the medial portion of the joint. Generally, the distention range was higher in younger as compared to adult cattle, and visualization of the medial portion of the joint was, therefore, facilitated in younger animals. The main complications observed were subcutaneous fluid extravasations and partial-thickness articular cartilages wear-lines.ConclusionThe described arthroscopic techniques allowed good overall visualization of the most relevant anatomical structures within the healthy cadaveric joint. Further investigations are warranted to evaluate the diagnostic and therapeutic applications of these techniques and the prognosis of arthroscopic surgery as a tool for the treatment of joint lesions.

DELAY IN DIAGNOSIS AND MANAGEMENT OF ADOLESCENT ANTERIOR CRUCIATE LIGAMENT INJURIES IN A PUBLICLY FUNDED HEALTHCARE SYSTEM

Background:Delay to surgical anterior cruciate ligament (ACL) reconstruction after injury has been associated with increased frequency and severity of meniscal and articular cartilage pathology. Patient factors that contribute to delayed ACL reconstruction are not well understood.Hypothesis/Purpose:Identify patient factors contributing to delayed ACL reconstruction in a publicly funded healthcare system.Methods:A retrospective review of all patients who had a primary ACL reconstruction at a single institution between 2014 and 2018 was completed. Patient demographic data, side, history of physical therapy, and intraoperative status of the meniscus and articular cartilage were collected. Household income was determined based on federal census data of mean household income by postal code. Time from injury to orthopedic referral (W0), consult (W1), and ACL reconstruction (W2) was calculated. A logistic regression model was constructed to determine the impact of household income, age, and sex on W0, W1, and W2.Results:Eighty-three patients were identified with a mean age of 14 years (range, 9-17). Twenty-eight patients were male (33.7%). Mean time from injury to orthopedic consult was 124 days (range, 0-1096). Mean time from injury to reconstruction was 286 days (range, 51-1623). Eleven patients (13%) had ligament reconstruction within 90 days of injury. Fifty-three patients (63.8%) had meniscal or articular cartilage damage at the time of ACL reconstruction. There was no significant effect of patient sex, age, or history of physical therapy on time to ACL reconstruction. Household income was found to have a significant effect on time to ACL reconstruction. For every $10,000.00 increase in household income, time to reconstruction was reduced by 19%. Using median time to reconstruction (223 days), this represents a decrease of 42 days. Household income only had an effect on W0 with a decrease of 38.4% for every $10,000.00 incremental increase in household income. No association was found between time to ACL reconstruction and odds of meniscal or articular cartilage damage.Conclusion:At a pediatric tertiary care hospital in a public health care system, most adolescent patients are having their ACL reconstructed in a delayed fashion contributing to an increased frequency of intra-articular pathology. Increase in household income was associated with a significant decrease in time to orthopaedic referral. There was no difference in wait time for consultation (W1) or wait time for surgery (W2). Further research is needed to determine specific factors causing this discrepancy in access to healthcare within a publicly funded system.

An investigation of the anatomy of the infrapatellar fat pad and its possible involvement in anterior pain syndrome: a cadaveric study.

The infrapatellar fat pad (IFP) is an extrasynovial, intracapsular, adipose body occupying the space in the knee joint between the inferior border of the patella, the femoral condyles, tibial plateau and patellar tendon. Little is known about the anatomy and normal function of the IFP, but it has been suggested to play a role in the aetiology of Anterior knee pain syndrome, including that associated with osteoarthritis. Forty-three knees from 11 male and 15 female embalmed cadavers (mean age 84years; range 55-97years) were investigated. The cadavers were donated and the study performed in compliance with the provisions of the UK Human Tissue Act (2004). The quadriceps tendon and the medial and lateral patellar retinacula were dissected from the patella, which was then reflected antero-distally. The IFP was carefully excised and details of its morphology and attachments to components of the knee joint were recorded, together with the presence of articular surface pathology on the patella and femoral condyles. The principal novel findings of the current study were that 81% of IFPs were attached to the superior border of the patella by supero-medial extensions and 65% were attached by supero-lateral extensions; the supero-medial extensions were larger than the supero-lateral extensions. The superior extensions of the IFP were always attached anteriorly to the patellar retinacula and in four individuals the extensions formed a full loop around the superior border of the patella. The volume of IFPs with attachments to the superior border of the patella was significantly greater (p=.007) than those without, and the IFP was attached to the medial meniscus in significantly (p=.009) more knees with IFP attachment to the superior border of the patella than those without. All IFPs were attached to the medial anterior horn of the meniscus and the medial Kaplan's ligament. Ninety-seven percent were attached to the lateral anterior horn of the meniscus and 97% to the lateral Kaplan's ligament. The length of IFP attachment to the lateral meniscus was significantly longer (p=.004) than that to the medial meniscus. Ninety-seven per cent of IFPs were attached to the superior portion of the patellar tendon with the mean tendon attachment being 60%. Ninety-one percent of IFPs were attached to the inferior border of the patella. Significantly fewer knees with patellar (p=.001) and femoral (p=.002) articular surface osteophytes exhibited superior IFP extensions and these extensions were significantly shorter in knees with patellar (p=.000) and femoral (p=.006) osteophytes, compared with those without. The IFP was attached to the medial meniscus in significantly fewer knees with femoral (p=.050) and patellar (p=.023) osteophytes than those without. All IFPs not attached to the anterior horn of the lateral menisci, medial Kaplan's ligament, superior patella or inferior border of the patella, were in knees with articular surface osteophytes. This relationship between IFP morphology and knee joint pathology suggests a functional role for the IFP that requires further investigation.

Nonunion and malunion in proximal humerus fractures

Proximal humerus fractures are common injuries and the development of nonunion or malunion is infrequent. However, these complications can occur with both operative and non-operative treatment of the fracture. A complete evaluation of these patients must include an investigation of the original fracture, bone and soft tissue quality as well as an extensive radiological study with X-Ray, CT and MRI. Asymptomatic and low demanding patients can benefit from conservative treatment, otherwise surgery is necessary. Multiple treatment options exist with no consensus upon the gold standard. The management of these complications is case-specific and needs extensive pre-operative planning. Arthroscopic procedures, osteotomies and bone grafting are viable joint preservation techniques. Bone loss or articular pathology are indications for joint replacement. The surgical treatment of nonunion and malunion is challenging even for experienced surgeons.

Evaluation of the caudal cervical articular process joints by using a needle arthroscope in standing horses.

To determine the safety and efficacy of caudal cervical articular process joint arthroscopy by using needle arthroscopy in standing sedated horses. Prospective experimental case series. Six adult horses. Three horses underwent exploration of bilateral C5-6 vertebral articular process joints and three bilateral C6-7 articular process joints by using a 1.2 × 65-mm needle arthroscope under standing sedation. The 16-gauge arthroscopic trocar and canula assembly was inserted in the desired articular process joint under ultrasonographic guidance without distention of the joint. All 12 articular process joints were successfully explored. Entering the joint on the first attempt was achieved in 10 of 12 joints. A craniodorsal approach for arthroscope insertion allowed evaluation of the most cranial aspect of the articular cartilage surface. Triangulation with a spinal needle was determined to be difficult and resulted in a limited space for movement. Needle arthroscopy of the caudal cervical facet joints was performed safely and efficiently in standing sedated horses. Standing cervical articular process needle arthroscopy is a minimal morbidity technique with the potential to be an advantageous technique for the diagnosis and treatment of cervical articular process pathology.

Clinical features of reactive arthritis in children

Summary. Reactive arthritis includes inflammatory non-purulent diseases of the joints that develop within 2-4 weeks after intestinal or urogenital infection due to immune disorders. Given the nonspecificity of the clinical manifestations of reactive arthritis, its similarity to other rheumatic diseases, which have a more unfavorable course and prognosis, it must be recognized that the problem of reactive arthritis in children remains relevant and on many issues not developed. Objective: this is to identify the characteristics of the debut and currents of reactive arthritis in accordance to etiology in children today. Materials and methods: There were observed 81 children with a reactive arthritis in the age of from 2 till 17 years have been examined. During specification the nosology of articular pathology were used clinical, laboratory and instrumental investigations, identified specific antibodies to Chlamydia, Mycoplasma, Iersiniya, Ureaplazma, Citomegalovirus, Herpes simplex virus, Epstein-Bar’s virus by ELISA. Results: For reactive arthritis chlamydial etiology characterized by loss of large and medium-sized joints of the lower limbs, which often is accompanied by a brief morning stiffness and rapid emergence of transient regional hypotrophy of muscles. Feature ureaplazmial reactive arthritis is the formation of bursitis in the heel and tendinitis. Reactive arthritis, which is accompanied by elevated titers to ASL-O, had different polymorphisms of articular manifestations of the syndrome and to a certain degree of similarity with juvenile rheumatoid arthritis. Reactive arthritis of not specified etiology has a number of the general features with others reactive arthritis and it is characterized by rather good-quality current, long conservation of function of joints and low laboratory activity. Conclusions: The clinical manifestation of the disease and the nature of its course to some extent depend on the etiological pathogen of arthritis. The most unfavorable variants of reactive arthritis are arthritides caused by Chlamydia and Mycoplasma. Regardless of the pathogen, the infectious factor can be assessed as a trigger for the development of juvenile rheumatoid arthritis. The presence of recurrent reactive arthritis is the basis for re-differential diagnosis and reclassification of reactive arthritis in favor of juvenile rheumatoid arthritis, despite the low degree of inflammatory activity of the disease and ANA and HLAB27 negativity.

Comparison of intra-articular steroid injection and hyaluronic acid in mono-articular synovitis knee

Introduction: Mono articular presentation of rheumatoid arthritis is infrequent and has been previously reported to involve the hip and knee joints. Rheumatoid arthritis is a common symmetrical chronic inflammatory arthritis with the prevalence of 1% worldwide. Mono- articular rheumatoid arthritis is a rare entity reported to initially affect large joints such as hips and knees, progressing to a poly articular presentation within 3 to 5 years. Synovitis is an important component of rheumatoid arthritis, so we conducted a study to include all the recurrent effusion of knee cases, and we have compared the functional outcome of intra-articular steroid injection and hyaluronic acid in the treatment of such cases. Material and Methods: 40 cases of recurrent effusion of knee joint attending the OPD or emergency services at Government Medical College and Rajindra hospital, Patiala between July 2016 to July 2019 were evaluated with the clinical examination, haematological investigations and radiological investigations. In all the cases, the joint was aspirated with a 16 G Needle and aspirated fluid was sent for pus cultural sensitivity in a microbiology Department of our hospital and was sent for CBNAAT to chest and TB hospital of our hospital. In Group 1, following the aspiration, injection of local corticosteroid (methylprednisolone acetate 80 mg) was given and in group 2, injection of hyaluronic acid was given, followed by a short course of antibiotics for 5 days and short course of non-steroidal anti-inflammatory drugs was given for 10 days and a crêpe bandage was applied for 2 days. The results were assessed by VAS for pain and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Results: In all 40 patients, the pus cultural sensitivity was negative for any microorganism and CBNAAT was negative in all the 40 patients. By comparing the results obtained in KOOS scale it was seen that symptoms improved after six months in both steroid (P = 0.017) and HA groups (P = 0.004). Besides, daily activity improved in both steroid (P = 0.027) and HA groups (P = 0.047). On the contrary, pain did not decrease 6 months after intervention in both steroid (P = 0.096) and HA groups (P = 0.17) Conclusion: Mono articular synovitis in an otherwise seronegative patient is due to recurrent inflammatory response due to recurrent stress or any other intra articular pathology. Patients are advised rest, and a short course of steroidal anti-inflammatory drugs, which also helped to relieve the inflammation. This was markedly improved by intra-articular HA injection as shown by the recovery in intra-articular HA injection group as compared to the steroid group.

Evaluating plasma extracellular vesicle microRNAs as possible biomarkers for osteoarthritis

MicroRNAs (miRNAs) are being launched as biomarkers for various diseases, but a robust biomarker for articular cartilage pathology has yet to be discovered. Here we evaluate plasma extracellular vesicle (EV) miRNAs as possible biomarkers for osteoarthritis (OA). We compared miRNA levels found in plasma EVs from patients with OA with controls without OA using next generation sequencing (NGS) technique. The patient and control pairs were matched for age, gender and body mass index. 23 pairs of patients and controls were included. Patients with OA differed significantly from controls in both clinical and radiological assessment of OA. We identified 177 canonical miRNAs in plasma EVs, but found no difference in miRNA levels between the two groups. Interestingly, the concentration of each miRNA in plasma EVs showed minimal difference between the participants, suggesting that the release of miRNAs in EVs from cells within the various organs is a tightly controlled process. This is the first study using NGS in search of a miRNA biomarker in plasma EVs in OA. The levels of each plasma EVs miRNA were surprisingly similar for all participants. No plasma EVs miRNA can be used as a biomarker for OA.

Technologies for producing platelet masses for regenerative medicine

The development of regenerative medicine is to improve existing and to search for new tools for morphological and functional tissue repair, among which plasma or fi brin enriched with platelets (PRP and PRF) can be signifi cant. Autogenic platelet masses stimulate collagen synthesis, induce vascular growth, reduce pain, provide hemostasis, accelerate regeneration, reduce the risk of postoperative infectious and infl ammatory complications, and also have powerful osteoinductive properties. Due to the ability to produce the majority of growth factors, platelets can aff ect all stages of the infl ammatory-regenerative process, and therefore their biological products are of great importance in solving the problems of regenerative medicine. The technologies for obtaining PRP and PRF are based on centrifugation of blood, as a result of which its active components are concentrated in certain areas of the centrifuge. Blood sampling with or without an anticoagulant, as well as modifi cation of centrifugation protocols, allows to obtain various forms of platelet masses, such as a liquid, gel or clots. They are classifi ed, depending on the cellular content and architecture of fi brin, into several categories, namely: pure plasma enriched in platelets (P-PRP), plasma enriched in leukocytes and platelets (L-PRP); injectable fi brin enriched with platelets (i-PRF) and pure fi brin enriched with platelets (P-PRF), as well as fi brin enriched with white blood cells and platelets (L-PRF). The main diff erence in the manufacture of PRP compared to PRF is the use of anticoagulants and activators, as well as the possibility of using two-stage centrifugation. Platelet mass is used as an independent component mainly to stimulate the restoration of muscle tissue, to heal chronic wounds, to treat articular pathologies, and in combination with other materials, in particular to replace bone defects. The mechanisms of infl uence of each of the categories of platelet mass on tissue regeneration remains poorly understood. It is necessary to standardize the protocols for their preparation, taking into account the infl uence of additional substances, such as platelet activators or blood clotting and anticoagulants, as well as optimization of the methods for using each of the platelet mass forms. Key words: platelets, PRP, PRF, centrifuges, centrifugal force.

Rehabilitation and Return to Sport After Hip Arthroscopy

Advancement in hip arthroscopic technique, expanding indications, and a growing body of literature support its use for addressing intra- and extra- articular hip pathology. As a result of expanding treatment options, hip rehabilitation protocols have evolved to meet the demands of a diverse, active patient population. Rehabilitation following hip arthroscopy focuses on activity modifications to allow for soft tissue healing, gait training, reestablishment of neuromuscular control, strength and endurance training, and sports-specific training. Hip arthroscopy has also shown reliable improvement in patient-reported outcome measures over short- and intermediate- term follow-up. The literature involving return-to-play rates after hip arthroscopy in athletes demonstrates favorable outcomes. The incidence of complications following hip arthroscopy, including but not limited to venous thromboembolism and heterotopic ossification, is low. Current rehabilitation regimens are based primarily on physical therapist and clinician experience. Future studies are needed to define objective outcome measures to determine appropriate postoperative protocol.

Massive complex Baker’s cyst treatment with open excision and arthroscopic partial meniscectomy: a case report

&lt;p class="abstract"&gt;Baker’s cyst is known to be associated with intra articular pathologies such as meniscus tears, chondral lesions, synovitis, synovial plica and cruciate ligament injuries. Complex Baker’s cyst excision alone is known to have high chance of recurrence. Combined treatment strategies that addresses intra-articular pathologies with excision of the cyst and closure of the valve, are thought to reduce chances of recurrence of such cysts. We present a case of massive complex Baker’s cyst treated with arthroscopic partial medial meniscectomy, synovectomy, open cystectomy and closure of the valve.&lt;/p&gt;