Severity Of Contracture Research Articles

Prevention of postoperative contracture of the masticatory muscles using a multifunctional gnathic device when removing retinated teeth

Full rehabilitation of patients after atypical extraction of wisdom teeth is not among the priority issues in dentistry, however, the duration and severity of postoperative inflammatory contracture of the masticatory muscles significantly affects the duration of the postoperative period, increasing the patient’s period of disability. Numerous studies indicate the advisability of local effects on tissues in order to improve blood and lymph circulation in the area of inflammation, which enhances the exchange of intercellular fluid and relaxes the masticatory muscles. A method of adaptive myogymnastics for early rehabilitation of patients is proposed and proved the effectiveness of its use.

Fat Grafting and Prepectoral Prosthetic Reconstruction with Polyurethane-Covered Implants: Protective Role against Adjuvant Radiotherapy.

Background/Objectives: Breast cancer treatment increasingly incorporates immediate prepectoral prosthetic reconstruction after conservative mastectomy, including nipple-sparing (NSMs) and skin-sparing mastectomies (SSMs). Although recent data from the literature show that postmastectomy radiotherapy (PMRT) after prepectoral reconstruction presents good clinical results, with reduction in capsular contracture and implant migration, compared to the traditional submuscular technique, these patients have higher rates of long-term complications when compared with nonradiated patients. This study evaluates the protective effects of autologous fat grafting to reduce long-term radiotherapy-induced complications in breast cancer patients submitted for prepectoral reconstruction with polyurethane-covered (PU) implants. Methods: A pilot study with two parallel cohorts of patients undergoing an NSM or SSM followed by PMRT was conducted. Patients were randomly assigned to either of the two groups to ensure homogeneity. One cohort underwent autologous fat grafting sessions, individually tailored based on periodic evaluations by the principal investigator (PI), M. Salgarello, at least six months after PMRT. The control group received standard clinical follow-ups without fat grafting. Inclusion criteria ensured participants were disease-free, non-smokers, and had a LENT-SOMA score within 2. Results: Preliminary findings indicate significant differences between the groups, with improved outcomes observed in patients undergoing tailored lipofilling. Specifically, these patients experienced a notable reduction in capsular contracture severity and reported higher satisfaction with the aesthetic results compared to the control group. Conclusions: Autologous fat grafting, customized per patient by the PI based on ongoing evaluations, appears to mitigate some adverse effects of radiotherapy in prepectoral breast reconstruction, suggesting a viable option for enhancing surgical outcomes in irradiated patients. Further research is needed to substantiate these findings and evaluate long-term benefits.

Clinical Outcomes of Collagenase Injections in Management of Dupuytren Contracture of the Proximal Interphalangeal Joint

Dupuytren contracture is characterized by the formation of cords and nodules in the palm. Surgical release has historically been the definitive treatment. Collagenase clostridium histolyticum (CCH) has been used successfully as an alternative to surgery. The treatment of proximal interphalangeal (PIP) contractures is the most challenging. The purpose of this study was to evaluate CCH treatment for Dupuytren contracture of the PIP joint. A retrospective chart review was performed for CCH treatment of Dupuytren contracture at a single institution from January 2010 to April 2023. Data collected included pretreatment/posttreatment total flexion contracture and adverse events. Contractures were analyzed both by severity (high >40° and low <40°) and type (isolated PIP; combined metacarpophalangeal and PIP). A total of 304 patients with 470 PIP joints treated were included. Digits with isolated and combined contractures each had an average pre-CCH treatment contracture of 51 (±23) degrees. Postmanipulations the contractures were 6 (±13) and 7 (±16) degrees, respectively. Clinical success (<5° residual contracture) and improvement (>50% correction of contracture) were associated with low severity contractures at postmanipulation. There were 256 adverse events recorded (54.5%), including 187 skin tears (39.8%), 68 cases of lymphadenopathy (14.5%), and one injection site infection (0.2%). High severity and combined contractures were independently associated with an increased incidence of skin tears upon manipulation. Collagenase clostridium histolyticum treatment is effective for isolated or combined PIP joint contractures. Adverse events were associated with more severe contractures. Given the degree of improvement based on contracture severity, earlier intervention may provide better correction of contracture. Therapeutic III.

Impact of Hematoma on Capsular Contracture: A Comparative Study of Smooth and Textured Implants in a Miniature Pig Model.

Capsular contracture is a significant complication following mammaplasty, with varying incidence rates and symptoms. The etiology of capsular contracture is multifactorial, with postoperative hematoma recognized as a potential contributing factor. In this study we aimed to investigate the impact of postoperative hematoma on capsular contracture following mammaplasty, utilizing pig models and modified biomechanical testing. We sought to compare the severity of capsular contracture between smooth and textured implants in the presence of hematoma, assess the biomechanical properties of the capsules, and explore the histological and molecular changes associated with the condition. The study involved 5 female miniature pigs, implanted with both smooth and textured implants. Hematoma models were established, and various methods were employed to evaluate the impact of the prosthesis surface and hematoma on capsular contracture, including ultrasound assessment, biomechanical tests, scanning electron microscopy, histological analysis, and transcriptome sequencing. Capsules in hematoma groups were classified as Baker III/IV, with significantly unfavorable thickness, elastic modulus, and relaxation and creep amounts compared to nonhematoma groups. Smooth implants under hematoma conditions exhibited increased muscle content and biomechanical strength of the capsule. Transcriptomic analysis highlighted differential gene expression related to muscle development and contraction in smooth implants with hematomas. Hematomas increase the risk of capsular contracture, with smooth implants exacerbating this effect by enhancing pathways related to muscle development and contraction. This underscores the importance of hematoma prevention and treatment strategies, particularly when placing smooth implants, to minimize the occurrence of capsular contracture. The study provides insights into the mechanisms underlying capsular contracture and offers evidence to guide surgical and postoperative management strategies.

Abstract PO3-23-05: Capsular contracture after post-mastectomy radiotherapy in the patients undergoing implant-based breast reconstruction: impact of implant positioning and two-stage surgery

Abstract Background Capsular contracture is a significant concern in patients undergoing post-mastectomy radiotherapy (PMRT) following implant-based breast reconstruction. It negatively impacts cosmetic outcomes and can have a profound effect on the individual's quality of life. Our study aimed to explore whether the degree of capsular contracture varies based on the placement of the inserted implant and the type of operation (one- or two-staged). Patients and Methods This retrospective study was conducted at a single center, Ganganm Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea. Our study included patients who underwent PMRT following total mastectomy and implant-based breast reconstruction surgery between January 2017 and September 2022. To assess the degree of capsular contracture, we evaluated the presence of capsular contracture, particularly severe capsular contracture classified as Baker grade 3 or higher, as well as implant migration. The implants were placed either in the pre-or sub-pectoral position, and the surgical approach employed was either direct-to-implant (DTI) or two-staged operation. Results A total of 195 patients were included in the study, with 83 (42.6%) patients in the pre-pectoral group and 112 (57.4%) patients in the sub-pectoral group. In addition, 116 underwent a two-stage operation, while 79 underwent DTI surgery. There was a significant difference in the occurrence of capsular contracture based on the implant placement, with 16 patients (19.3%) in the pre-pectoral group and 46 patients (41.1%) in the sub-pectoral group experiencing this complication (OR 4.142 [1.973-8.698]). Furthermore, the severity of capsular contracture differed significantly between the two groups, with 5 patients (6.0%) in the pre-pectoral group and 16 patients (14.3%) in the sub-pectoral group affected (OR 3.434 [1.153-10.227]). The incidence of capsular contracture was lower in the two-stage operation group compared to the DTI group (28 [23.9%] vs 34 [38.6%]; OR 3.064 [1.528-6.141]), and the severity of capsular contracture was also reduced (9 [7.7%] vs 12 [14.5%]; OR 2.854 [1.092-7.455]). There were no significant differences in other complications such as seroma and infection. In addition, sub-pectoral placement was identified as a significant risk factor for implant upward migration (OR 2.531 [95% CI, 1.263-5.071]). Conclusions Our findings suggest that pre-pectoral reconstruction and the two-stage operation are beneficial for patients who may undergo PMRT based on their initial nodal stage. These approaches can help reduce the incidence of capsular contracture and abnormal implant migration following radiation, leading to improved aesthetic outcomes and greater patient satisfaction. Citation Format: Sohyun Moon, Kyunghyun Min, Jung Hwan Eom, Yoonwon Kook, Seung Ho Baek, Junghyun Kim, Min Ji Kim, Seung Eun Lee, In Sik Yun, Tai Suk Roh, Soong June Bae, Joon Jeong, Young Seok Kim, Sung Gwe Ahn. Capsular contracture after post-mastectomy radiotherapy in the patients undergoing implant-based breast reconstruction: impact of implant positioning and two-stage surgery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-23-05.

Development and Validation of a Diagnostic Histopathological Scoring System for Capsular Contracture Based on 720 Breast Implant Capsules.

Capsular contracture is traditionally evaluated with the Baker classification, but this has notable limitations regarding reproducibility and objectivity. The aim of this study was to develop and validate procedure-specific histopathological scoring systems to assess capsular contracture severity. Biopsies of breast implant capsules were used to develop histopathological scoring systems for patients following breast augmentation and breast reconstruction. Ten histological parameters were evaluated by multivariable logistic regression to identify those most associated with capsular contracture. Significant parameters (P < .05) were selected for the scoring systems and assigned weighted scores (1-10). Validation was assessed from the area under the curve (AUC) and the mean absolute error (MAE). A total of 720 biopsies from 542 patients were included. Four parameters were selected for the augmentation scoring system, namely, collagen layer thickness, fiber organization, inflammatory infiltration, and calcification, providing a combined maximum score of 26. The AUC and MAE for the augmentation scoring system were 81% and 0.8%, which is considered strong. Three parameters were selected for the reconstruction scoring system, namely, fiber organization, collagen layer cellularity, and inflammatory infiltration, providing a combined maximum score of 19. The AUC and MAE of the reconstruction scoring system were 72% and 7.1%, which is considered good. The new histopathological scoring systems provide an objective, reproducible, and accurate assessment of capsular contracture severity. We propose these novel scoring systems as a valuable tool for confirming capsular contracture diagnosis in the clinical setting, for research, and for implant manufacturers and insurance providers in need of a confirmed capsular contracture diagnosis.

The Relative Efficacy of Available Proteasome Inhibitors in Preventing Muscle Contractures Following Neonatal Brachial Plexus Injury.

Contractures following neonatal brachial plexus injury (NBPI) are associated with growth deficits in denervated muscles. This impairment is mediated by an increase in muscle protein degradation, as contractures can be prevented in an NBPI mouse model with bortezomib (BTZ), a proteasome inhibitor (PI). However, BTZ treatment causes substantial toxicity (0% to 80% mortality). The current study tested the hypothesis that newer-generation PIs can prevent contractures with less severe toxicity than BTZ. Unilateral brachial plexus injuries were surgically created in postnatal (5-day-old) mice. Following NBPI, mice were treated with either saline solution or various doses of 1 of 3 different PIs: ixazomib (IXZ), carfilzomib (CFZ), or marizomib (MRZ). Four weeks post-NBPI, mice were assessed for bilateral passive range of motion at the shoulder and elbow joints, with blinding to the treatment group, through an established digital photography technique to determine contracture severity. Drug toxicity was assessed with survival curves. All PIs prevented contractures at both the elbow and shoulder (p < 0.05 versus saline solution controls), with the exception of IXZ, which did not prevent shoulder contractures. However, their efficacies and toxicity profiles differed. At lower doses, CFZ was limited by toxicity (30% to 40% mortality), whereas MRZ was limited by efficacy. At higher doses, CFZ was limited by loss of efficacy, MRZ was limited by toxicity (50% to 60% mortality), and IXZ was limited by toxicity (80% to 100% mortality) and loss of efficacy. Comparisons of the data on these drugs as well as data on BTZ generated in prior studies revealed BTZ to be optimal for preventing contractures, although it, too, was limited by toxicity. All of the tested second-generation PIs were able to reduce NBPI-induced contractures, offering further proof of concept for a regulatory role of the proteasome in contracture formation. However, the narrow dose ranges of efficacy for all PIs highlight the necessity of precise proteasome regulation for preventing contractures. Finally, the substantial toxicity stemming from proteasome inhibition underscores the importance of identifying muscle-targeted strategies to suppress protein degradation and prevent contractures safely. Although PIs offer unique opportunities to establish critical mechanistic insights into contracture pathophysiology, their clinical use is contraindicated in patients with NPBI at this time.

Risk factors for burn contractures: A cross-sectional study in a lower income country

Risk factors for burn contractures require further study, especially in low and middle-income countries (LMICs); existing research has been predominantly conducted in high income countries (HICs). This study aimed to identify risk factors for burn contractures of major joints in a low-income setting. Potential risk factors (n = 104) for burn contracture were identified from the literature and a survey of clinicians with extensive experience in low and middle-income countries (LMIC). An observational cross-sectional study of adult burn survivors was undertaken in Bangladesh to evaluate as many of these risk factors as were feasible against contracture presence and severity. Forty-eight potential risk factors were examined in 48 adult patients with 126 major joints at risk (median 3 per participant) at a median of 2.5 years after burn injury. Contractures were present in 77% of participants and 52% of joints overall. Contracture severity was determined by measurement of loss of movement at all joints at risk. Person level risk factors were defined as those that were common to all joints at risk for the participant and only documented once, whilst joint level risk factors were documented for each of the participant’s included joints at risk. Person level risk factors which were significantly correlated with loss of range of movement (ROM) included employment status, full thickness burns, refusal of skin graft, discharged against medical advice, low frequency of follow up and lack of awareness of contracture development. Significant joint level risk factors for loss of ROM included anatomical location, non-grafted burns, and lack of pressure therapy. This study has examined the largest number of potential contracture risk factors in an LMIC setting to date. A key finding was that risk factors for contracture in low-income settings may differ substantially from those seen in high income countries, which has implications for effective prevention strategies in these countries. Better whole person and joint outcome measures are required for accurate determination of risk factors for burn contracture. Recommendations for planning and reporting on future contracture risk factor studies are made.

Cathelicidin LL-37 Expression in Human Breast Implant Capsules.

Capsular contracture is the most common complication following breast implant placement. Cathelicidin LL-37 is a cationic peptide involved in innate immunity. Initially investigated for its antimicrobial role, it was found to have pleiotropic activities, such as immunomodulation, angiogenesis stimulation, and tissue healing. The aim of the study was to investigate the expression and localization of LL-37 in human breast implant capsules and its relationship with capsular formation, remodeling, and clinical outcomes. The study enrolled 28 women (29 implants) who underwent expander substitution with definitive implant. Contracture severity was evaluated. Specimens were stained with hematoxylin and eosin, Masson trichrome, immunohistochemistry, and immunofluorescence for LL-37, CD68, α-smooth muscle actin, collagen type I and type III, CD31, and Toll-like receptor-4. LL-37 was expressed in macrophages and myofibroblasts of capsular tissue in 10 (34%) and nine (31%) of the specimens, respectively. In eight cases (27.5%), it was expressed by both macrophages and myofibroblasts of the same specimen. In infected capsules, expression by both cell types was found in all (100%) specimens. LL-37 expression by myofibroblasts positively correlated with its expression by macrophages ( P < 0.001). Moreover, LL-37 expression by macrophages of periexpander capsules negatively correlated with the severity of capsular contracture on definitive implants ( P = 0.04). This study demonstrates the expression of LL-37 in macrophages and myofibroblasts of capsular tissue and its negative correlation with the severity of capsular contracture following permanent implant placement. Expression or up-regulation of LL-37 may be involved in myofibroblast and macrophage modulation, thus playing a role in the pathogenic fibrotic process underlying capsular contracture. This is the first study to demonstrate LL37 expression in capsular tissue and to hypothesize its role in contracture and as a prognostic marker for contracture severity. If confirmed, medical strategies or implant coating could be implemented to reduce the risk of contracture for high-risk patients.

A Forgotten Entity following Breast Implant Contracture: Does Baker Need a Change?

Introduction: Breast augmentation is one of the most common operative procedures in Plastic and Reconstructive surgery. However, it is associated with different postoperative complications. Local inflammation around the implant is followed by loss of cellular activity, shrinkage and necrosis. In very rare cases, the ultimate step of the process is capsular contracture and calcification (CC). Here we present the clinical case of a female patient with capsular calcification. In this patient we performed different examinations and the surgical removal of the implant. Although CC is traditionally staged with the Baker classification system, there is smarted heterogeneity between the objective contracture severity and patients’ subjective symptoms. Considering our clinical case and the need for a more comprehensive classification, we present an upgrade of the traditional Baker classification. Materials and Methods: We performed ultrasonography, RX-array and magnetic resonance imaging. In addition we performed a core needle biopsy and the surgical removal of breast implants. After a deep analysis of the history and the etiopathogenesis of capsular calcification and considering the heterogeneity of patients’ clinical signs and symptoms, we upgraded the traditional Baker classification system. Results: The addition of “(A)” (without symptoms) and “(B)” (with symptoms) should be added to all stages of the classification. Both for classification purposes and to potentially match patients’ objective data to clinical and histological parameters. The addition of a grade V within the classification will allow surgeons to report any neoformations present within the capsular microenvironment and better predict patients’ outcomes. Conclusion: By analyzing the current histological and clinical classification systems for CC by Wilflingseder and Baker, we additionally provide a “symptomatic” modification of the traditional Baker stages. The introduction of a symptomatic classification with the addition of grade within the Baker classification will allow surgeons to better report the clinical presentation of patients with CC.

Postburn Reconstruction of the Face and Neck.

After studying this article, the participant should be able to: 1. Understand the cardinal principles in the management of postburn deformities in the face and neck. 2. Understand reconstruction of specific subsites in the face and neck affected by burn contracture. 3. Acquire knowledge about the various techniques of burn reconstruction of the face and neck. 4. Grasp technical nuances and select appropriate surgical options for individual cases. Postburn contractures in the face and neck region are multifactorial in origin and difficult to prevent in extensive burns. Facial burns lead to distortion of anatomical landmarks, causing aesthetic, functional, and psychological problems. Each subunit of the face is unique in structure; thus, the surgeon needs to adjust the timing of surgery and the technique according to region and the severity of contracture. Contracture of one unit, especially that of the neck and forehead, can exaggerate the contracture in neighboring subunits. The role of these extrinsic influences must be considered while sequencing surgical procedures. The burn surgeon must be adept in all reconstructive surgery techniques from skin grafting to tissue expanders to microsurgery to obtain the best outcomes. Surgery must be followed up with long-term physical therapy and psychological rehabilitation to help burn survivors with head and neck contractures to integrate back into society.

Study of the effectiveness of the experimental model of immobilization contractures in rats

Immobilization contractures are a common complication that can arise following prolonged immobilization of a joint or limb. They occur due to a combination of factors, including muscle atrophy, joint stiffness, and tissue adhesions. The aim of the study was to study the effectiveness of the experimental model of immobilization contractures in rats. The experimental study was conducted on 21 non-linear white male rats aged 6 months. We used 4-week plaster immobilization to evaluate the severity of changes in the knee joints of experimental rats. The immobilization and post-immobilization period in our study lasted 4 weeks each. Every week, the angles of extension and flexion, range of motion and severity of contracture were measured. During the period of immobilization, there was a progressive impairment of the function of the immobilized knee joints of all experimental animals. Thus, at the end of the 4th week of immobilization, the limits of flexion and extension on the immobilized limb gained high statistical significance in comparison with both the opposite intact limb and with 1st week of immobilization. In the post-immobilization period (from the 5th to the 8th week of the study), a progressive recovery of the studied indicators was observed. The indicators of extension and flexion of the limbs after immobilization were significantly differed from the initial values, but were also significantly better than the values at the end of the immobilization period. As for the range of motion, this indicator for both limbs was significantly higher than the values at 4th week of the study, but was also significantly lower than the initial values. Limitation of movements after immobilization was statistically significant both when compared with the opposite limb and when compared with baseline and 4th week of immobilization data. Experimental model of 4-weeks plaster immobilization of the knee joint allows to create a persistent pronounced limitation of movements and can be used for further study of various methods of prevention and treatment of immobilization contractures. Keywords: knee joint; immobilization contractures; experiment; rats.

The Sex-Dependent Role of Myostatin Signaling in Contractures Following Neonatal Brachial Plexus Injury

Purpose: Neonatal brachial plexus injury (NBPI) causes disabling and incurable muscle contractures, arising from impaired longitudinal growth of denervated muscles. This growth impairment is caused by dysregulation of muscle proteostasis characterized by increased proteasome-mediated protein degradation. Myostatin (MSTN), a secreted growth differentiation factor and prominent muscle-specific negative regulator of proteostasis, drives muscle protein degradation. MSTN signaling is thus a possible pathway through which denervation impairs muscle growth and a potential muscle-specific molecular target for preventing contractures. This study uses pharmacologic inhibition of MSTN signaling in a mouse model of NBPI to test the hypothesis that NBPI induces contractures through MSTN-dependent impairment of longitudinal muscle growth. Methods: Unilateral NBPI was generated in postnatal day (P)5 mice. Mice were treated weekly with Dulbecco’s phosphate-buffered saline (DPBS) or ACVR2B-Fc, a soluble inhibitory decoy receptor for MSTN, starting at P4. Mice were sacrificed at P33, whereupon elbow and shoulder range of motion were measured to assess contractures. Brachialis muscles were prepared for microCT assessment of cross-sectional area (CSA) and volume, then processed for sarcomere length measurement as a readout of longitudinal muscle growth. Total protein content in biceps was assessed via Bradford assay. Protein degradation in triceps was quantified via 20S proteasome β1 subunit activity assay. Results: In female mice, myostatin inhibition with ACVR2B-Fc enhanced muscle weight and total protein content of denervated biceps (Figure 1), increased cross-sectional and volumetric growth of denervated brachialis (Figure 2), preserved longitudinal growth in denervated brachialis (Figure 3), and reduced elbow and shoulder contracture severity in the denervated limbs (Figure 4). Analysis of protein dynamics demonstrates the improvements in female denervated muscles were associated with a reduction in proteasome β1 subunit activity (Figure 5). However, no such improvements in denervated muscles occurred in male mice with ACVR2B-Fc. Conversely, myostatin inhibition increased muscle weight, CSA, volume, and total protein content of the normally innervated, contralateral control muscles in both male and female mice (Figures 1 and 2). Conclusion: Our findings reveal MSTN as a driver of impaired muscle growth and contracture formation in female but not male mice. This sex dimorphism lies in the pathophysiology of denervation-induced contractures rather than drug pharmacodynamics, given the sex-independent effects of MSTN inhibition on normally innervated muscle. Future studies must rigorously interrogate the contributions of sex in contracture pathophysiology. Significance: Our discovery identifies MSTN as a signaling target for modulating contractures in females and highlights the overlooked role of sex in the pathophysiology of acquired neuromuscular disorders. Level of Evidence: Not Applicable FDA: The FDA has not cleared the following pharmaceuticals and/or medical devices for the use described in this presentation.

Impact of Active and Passive Range of Motion Exercises on Contracture Severity among Burn Patients

Impact of Active and Passive Range of Motion Exercises on Contracture Severity among Burn Patients

Low-Level Laser Therapy Attenuates Arthrogenic Contracture Induced by Anterior Cruciate Ligament Reconstruction Surgery in Rats

Therapeutic approaches to treat joint contracture after anterior cruciate ligament (ACL) reconstruction have not been established. Arthrofibrosis accompanied by joint inflammation following ACL reconstruction is a major cause of arthrogenic contracture. In this study, we examined whether anti-inflammatory treatment using low-level laser therapy (LLLT) can prevent ACL reconstruction-induced arthrogenic contracture. Rats underwent ACL transection and reconstruction surgery in their right knees. Unoperated left knees were used as controls. After surgery, rats were reared with or without daily LLLT (wavelength: 830 nm; power output: 150 mW; power density: 5 W/cm2; for 120 s/day). We assessed the passive extension range of motion (ROM) after myotomy at one and two weeks post-surgery; the reduction in ROM represents the severity of arthrogenic contracture. ROM was markedly decreased by ACL reconstruction at both time points; however, LLLT partially attenuated the decrease in ROM. One week after ACL reconstruction, the gene expression of the proinflammatory cytokine interleukin-1beta in the joint capsule was significantly upregulated, and this upregulation was significantly attenuated by LLLT. Fibrotic changes in the joint capsule, including upregulation of collagen type I and III genes, shortening of the synovium, and thickening were caused by ACL reconstruction and seen at both time points. LLLT attenuated these fibrotic changes as well. Our results indicate that LLLT after ACL reconstruction could attenuate the formation of arthrogenic contracture through inhibition of inflammation and fibrosis in the joint capsule. Thus, LLLT may become a novel therapeutic approach for ACL reconstruction-induced joint contracture.

Surgical management of the spastic elbow.

We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed flexion contracture. Data collected included age, Modified Ashworth Score, pre and post-operative range of motion, indications for surgery and the Goal Attainment Score. Contracture severity was classified into five groups based on goniometric measurements. Surgical procedures were categorised into three groups. A total of 114 elbows underwent surgical release. The mean age at surgery was 18.5 years and the mean follow-up was 20 months. Preoperatively, the median Modified Ashworth Score was 2 and the mean contracture was 68° (35° fixed and 33° dynamic). The median number of structures released was 3 (range: 1-6). Surgical procedures were classified as biceps sparing (27%), biceps lengthening (53%) and extended releases (18%). Mean improvement in extension was 59°, and the mean improvement in Goal Attainment Score was 36 (mean attainment score 62). The mean residual contracture was 9°. Patient satisfaction was high with over 90% of surgical indications met. Contracture severity of the spastic elbow can be categorised by degree of fixed flexion deformity and therefore treatment can be allocated accordingly.

Teriflunomide treatment exacerbates cardiac ischemia reperfusion injury in isolated rat hearts.

PurposePrevious work suggests that Dihydroorotate dehydrogenase (DHODH) inhibition via teriflunomide (TERI) may provide protection in multiple disease models. To date, little is known about the effect of TERI on the heart. This study was performed to assess the potential effects of TERI on cardiac ischemia reperfusion injury.MethodsMale and female rat hearts were subjected to global ischemia (25 min) and reperfusion (120 min) on a Langendorff apparatus. Hearts were given either DMSO (VEH) or teriflunomide (TERI) for 5 min prior to induction of ischemia and during the reperfusion period. Left ventricular pressure, ECG, coronary flow, and infarct size were determined using established methods. Mitochondrial respiration was assessed via respirometry.ResultsPerfusion of hearts with TERI led to no acute effects in any values measured across 500 pM–50 nM doses. However, following ischemia–reperfusion injury, we found that 50 nM TERI-treated hearts had an increase in myocardial infarction (p < 0.001). In 50 nM TERI-treated hearts, we also observed a marked increase in the severity of contracture (p < 0.001) at an earlier time-point (p = 0.004), as well as reductions in coronary flow (p = 0.037), left ventricular pressure development (p = 0.025), and the rate-pressure product (p = 0.008). No differences in mitochondrial respiration were observed with 50 nM TERI treatment (p = 0.24–0.87).ConclusionThis study suggests that treatment with TERI leads to more negative outcomes following cardiac ischemia reperfusion, and administration of TERI to at-risk populations should receive special considerations.

Disease Course of Primary Dupuytren Disease: 5-Year Results of a Prospective Cohort Study.

Predicting progression of Dupuytren disease becomes relevant in an upcoming era with progression-preventing treatment. This study aimed to determine the course of Dupuytren disease and identify factors associated with progression. Two hundred fifty-eight patients with Dupuytren disease participated in this prospective cohort study, obtaining 17,645 observations in 5 years. Outcomes were disease extent (surface area) and contracture severity (total passive extension deficit). Demographics, lifestyle, health status, exposure to manual work, and genetic risk scores were gathered as potential predictors. Subject-specific, mixed-effects models were used to estimate disease course, and logistic regression with least absolute shrinkage and selection operator was used to evaluate factors associated with the presence of progression. On average, Dupuytren disease was progressive in all finger rays with regard to area [yearly increase, 0.07 cm2 (95% CI, 0.02 to 0.13 cm2) to 0.25 cm2 (95% CI, 0.11 to 0.39 cm2)]. Progression in total passive extension deficit was only present on the small finger side [yearly increase, 1.75 degrees (95% CI, 0.30 to 3.20 degrees) to 6.25 degrees (95% CI, 2.81 to 9.69 degrees)]. Stability or regression in area and total passive extension deficit was observed in 11 and 13 percent and 16 and 15 percent (dominant and nondominant hands), respectively. Smoking, cancer, genetic risk score, and hand injury were univariate associated with progression in area, but after multivariate variable selection, none of these associations remained. No predictors for progression in total passive extension deficit were found. Dupuytren disease is progressive, especially with respect to disease extent. Progression in contracture severity is mainly present on the small finger side of the hand. None of the traditional risk and diathesis factors were associated with progression, indicating that new hypotheses about Dupuytren disease progression might be needed. Risk, III.

Development of Contractures in DMD in Relation to MRI-Determined Muscle Quality and Ambulatory Function.

Joint contractures are common in boys and men with Duchenne muscular dystrophy (DMD), and management of contractures is an important part of care. The optimal methods to prevent and treat contractures are controversial, and the natural history of contracture development is understudied in glucocorticoid treated individuals at joints beyond the ankle. To describe the development of contractures over time in a large cohort of individuals with DMD in relation to ambulatory ability, functional performance, and muscle quality measured using magnetic resonance imaging (MRI) and spectroscopy (MRS). In this longitudinal study, range of motion (ROM) was measured annually at the hip, knee, and ankle, and at the elbow, forearm, and wrist at a subset of visits. Ambulatory function (10 meter walk/run and 6 minute walk test) and MR-determined muscle quality (transverse relaxation time (T2) and fat fraction) were measured at each visit. In 178 boys with DMD, contracture prevalence and severity increased with age. Among ambulatory participants, more severe contractures (defined as greater loss of ROM) were significantly associated with worse ambulatory function, and across all participants, more severe contractures significantly associated with higher MRI T2 or MRS FF (ρ: 0.40-0.61 in the lower extremity; 0.20-0.47 in the upper extremity). Agonist/antagonist differences in MRI T2 were not strong predictors of ROM. Contracture severity increases with disease progression (increasing age and muscle involvement and decreasing functional ability), but is only moderately predicted by muscle fatty infiltration and MRI T2, suggesting that other changes in the muscle, tendon, or joint contribute meaningfully to contracture formation in DMD.

Relationship between Severity of Varus Osteoarthritis of the Knee and Contracture of Medial Structures.

Knees with severe varus osteoarthritis can develop medial structure contracture. However, there is no report on the relationship between severity of varus deformity and contracture of the medial structure. We aimed to determine the threshold angle that could be corrected in proportion to the width of medial osteophyte removal and to examine correction differences between angles larger and smaller than the threshold angle in total knee arthroplasty. This study included 27 varus osteoarthritic knees scheduled for total knee arthroplasty (TKA). A navigation system was used to measure hip-knee-ankle angle (HKA) in all knees at maximum extension and 30˚ and 60˚ flexion, before and after osteophyte removal and with and without external 10 N-m valgus torque loads. Subsequently, resected osteophyte widths were measured. Mean correction angle per 1 mm of osteophyte removal was calculated, and the threshold angle was calculated with the receiver operating characteristic curve. HKA differences were compared against deformities larger and smaller than the threshold angle. Mean osteophyte width was 7.1±2.20 mm. Osteophyte removal produced a mean 3.1° correction, which equaled a 0.4° correction per 1 mm of osteophyte width removal. The varus deformity threshold angle was 9.5°. However, when comparing groups with angles larger and smaller than the threshold angle, there was no significant difference in HKA difference between each step and flexion angle. The threshold angle for expected correction with medial osteophyte removal was 9.5˚. However, because there were no differences in correction between those with angles larger or smaller than this, medial structure contracture seemed to be unrelated to the severity of deformity.