Limited Joint Motion Research Articles

Ostéotomies correctrices des métacarpiens et des phalanges stabilisées avec plaques et vis « AO

Although digital or metacarpal nonunion with resultant functional disability of the hand is encountered often enough that corrective osteotomy becomes a consideration, many surgeons are reluctant to attempt osteotomy in the hand. This reluctance is reflected in the sparse number of cases reported in the literature. Since the effectiveness of AO plates and screw fixation for acute phalangeal and metacarpal fractures is well established, it seems logical to perform osteotomies in phalanges or metacarpals and stabilize them in the same fashion. We have reviewed 36 such osteotomies from the files of the AO Documentation Center. The osteotomies were done through either phalanges or metacarpals to correct angulation and/or rotary malunion, and yielded twenty-three very good, eight good and five poor results, or an overall satisfactory result rate of 86%. All osteotomy sites healed and the poor results reflect persistent deformity or limited adjacent joint motion. Thus, it appears that previously expressed pessimism regarding potential non-union or joint stiffness following phalangeal or metacarpal osteotomy is not warranted in angular and/or rotational osteotomy in the hand can yield satisfactory results in a very high percentage of patients.

Permanent Proplast temporomandibular joint implants: MR imaging of destructive complications.

We studied the radiologic and pathologic changes in 30 patients (34 joints) in which there were locally destructive bone and soft-tissue complications associated with previously inserted permanent temporomandibular joint (TMJ) Proplast-Teflon implants. The cases were selected as representative examples of patients with failed Proplast interpositional arthroplasty, in whom images of the TMJ were obtained with conventional radiography, tomography, and MR, and in whom both surgical and histologic findings were available. Clinical indications for imaging included joint pain, restricted joint motion, crepitus, preauricular swelling, regional lymphadenopathy, malocclusion either acquired or changed since implant surgery, and facial deformity. Surgery was then performed for the purposes of implant retrieval and joint debridement because of destructive soft-tissue and osseous changes observed from the imaging analysis in conjunction with significant clinical signs and symptoms. The pathologic changes, observed 4-54 months after implant surgery, included a destructive foreign-body-type granuloma and avascular necrosis of the mandibular condyle and condylar neck. Our findings suggest that MR is useful in the detection and evaluation of destructive complications that may accompany failed Proplast-Teflon implants in the TMJ. MR is superior to conventional radiography and tomography in detecting soft-tissue lesions and avascular necrosis of bone. Tomography more accurately delineates soft-tissue calcifications and cortical margins of osseous structures.

Ｓｅｃｏｎｄａｒｙ Ａｍｙｌｏｉｄｏｓｉｓを合併した重症慢性関節リウマチ患者に対するＣｒｙｏｆｉｌｔｒａｔｉｏｎの効果について

Cryofiltration was applied to two severe RA patients with secondary amyloidosis, who had been treated with conventional steroids or analgesics administration in vain, in order to remove pathogenic substances such as immune complex and other abnormal proteins. Continuous cryofiltration with double filtration was performed by using the apparatus of Asahi Plasauto 1000 (Asahi medical, Tokyo, Japan) in extra-corporeal circulation with AP-05H (Asahi medical, Tokyo, Japan) as the first plasma separator and AC-1730 (Asahi medical, Tokyo, Japan) as the second macromolecule filter. One processed plasma volume by cryofiltration was about 4000ml at the averaged plasma flow rate of 30ml per minute and separated plasma after the first separator was led to cooling chamber at 4°C and then filtered at the second filter. Cryogel was eluted by saline and analysed immunochemically. After 4 processes of cryofiltration performed at 5 day interval, clinical symptoms of arthralgia, restriction of joint movement, joint swelling and morning stiffness were fairly relieved. Cryogel precipitated at 4°C in the second filter was analysed by gel and ion exchange chromatography. Cryogel was fractioned into very low molecule protein (MW 20-30K), albumin, IgG and high molecule protein designated as X-RF (MW ca. 800K). Molecular weight of X-RF is similar to that of IgM but X-RF was turned out to possess a different property from IgM by ion exchange chromatography. X-RF is regarded as main pathogenic substance and could be reduced from serum by repeated process of cryofiltration. And moreover, low molecule protein is conceived to be compatible to amyloid protein which was shown in the sera of amyloidosis patients by same chromatography method. This low molecule protein could be also reduced like X-RF by cryofiltration.We could conclude that cryofiltration was fairly effective method to remove the pathogenic substance from RA patients and could relieve clinical symptoms.

The assessment of people with arthritis who wish to drive a car.

In Great Britain 504,565 people are in receipt of Mobility Allowance; this, together with improved technology and an increase in public awareness, has increased the mobility aspirations of disabled people. Among those wishing to learn to drive for the first time, or to continue driving, are people with arthritis. In many cases pain and restriction of joint movement necessitate modification of car controls or driving technique. Between May 1982 and April 1985, 83 people with arthritis were assessed at Banstead. This paper describes the techniques used at Banstead Place Mobility Centre to assess these drivers, the difficulties which they experience, and the modifications which have been recommended.

Fractures about the interphalangeal joints in children.

Fracture patterns in 87 interphalangeal joint fractures in children's hands were studied and correlated with unique anatomic features of these joints. The collateral ligaments, which extend beyond the physis into the metaphysis, were found to protect the growth plate in the frontal plane. With laterally directed forces, fractures on the proximal side of the joint occurred, rather than epiphyseal fractures. There was good remodeling of angular deformities in the sagittal plane, but minimal correction in the frontal plane. In those patients treated surgically, angular deformities did not result. Of 24 condylar fractures followed for an average of 55 months, 11 (46%) demonstrated some restriction of joint motion.

Cybex II isokinetic dynamometer for passive load application and measurement. Suggestion from the field.

The prolonged application of low loads has been demonstrated to be an effective means of increasing range of motion in patients with limited joint motion.1–3 Methods of applying low loads precisely and documenting their effect over time in a clinical setting, however, have not been published widely. Knowledge of the specific load applied to a joint allows for a more consistent approach to patient assessment and treatment than otherwise might be realized.4 Because this knowledge may assist the clinician in judging the immediate and residual effects of patient treatment, the clinician may be interested in instrumentation that will provide this capability. The purpose of this suggestion from the field is to share our method of using the Cybex® II isokinetic dynamometer* to apply replicable loads and measure their effect on passive knee flexion in patients with deficits of knee flexion ROM.

Utilization of the Autorange®to Increase Range of Motion: A Pilot Study

The purpose of this paper was to examine the use of the Autorange® to increase range of motion in patients with restricted joint motion. Twenty subjects were treated with the Autorange for decreased motion of knee flexion, elbow extension, or elbow flexion after conventional therapy had failed. Results indicated a significant improvement in range of motion utilizing the Autorange when compared to conventional therapy.

Workspace Analysis of Regional Structures of Manipulators

The fundamental equations for conducting workspace analysis of a class of manipulators having the last three revolute joint axes intersect orthogonally at a point are provided in this paper. These equations are intended for application of the basic theory given in [1] and are concisely arranged in tables. Several examples are included illustrating the use of the tables and equations for determining (a) the boundary surfaces, (b) the surfaces separating the regions of different order of accessibility, and (c) the boundaries due to joint motion limitation.

812 MITRAL VALVE PROLAPSE (MVP) AS A FEATURE OF FRONTO METAPHYSEAL DYSPLASIA (FMD)

FMD is a rare disorder of the bone and connective tissue consisting of a characteristic facies, prominent bony supraorbital ridges, progressive mixed hearing loss, and a series of musculo-skeletal alterations including limited joint motion and poorly developed musculature, especially of the hypothenar and interosseous muscles of the hands. Other clinical findings include micrognathia and abnormal dentition with retained deciduous teeth. Roetgenographic examination demonstrates hyperostosis of calvarium with a “Nazi helmet” configuration of the cranial vault, thick frontal ridges with absence of frontal sinuses and splayed metaphysis of the long bones. A heart murmur has been reported in a third of the cases, however, no further delineation of the cardiovascular findings have been made.We would like to report a 15 year old patient with typical features of this disorder who had MVP diagnosed by abnormal physical and echocardiographic findings. With mounting evidence that MVP may be a systemic connective tissue disorder, the findings of MVP in our patient is most likely related to the underlying connective tissue defect. Although MVP tends to be a benign disorder, it has been associated with infective endocarditis, cardiac arrhythmias and sudden death. Antibiotic prophylaxis against infective endocarditis is mandatory. In light of the potential morbidity, it is recommended that patients with FMD be investigated for the presence of MVP.

Variability in limb malformations and possible significance in the pathogenesis of an inherited congenital neuromuscular disease of Charolais cattle (syndrome of arthrogryposis and palatoschisis).

Limb abnormalities in 30 calves with an inherited congenital neuromuscular disorder known as syndrome of arthrogryposis and palatoschisis were classified according to the range of severity of joint deformity in either flexion or extension, and restricted joint movement. Joint movement was variably affected; it was either normal, lax, restricted in the range of mobility, or occasionally, fixed. The characteristic findings were: bilateral hyperextension of the hind fetlock, flexion deformity of the forelimb that particularly involved the fetlock and the carpus, with restricted articular movement and complete rigidity in some cases. One-third of calves also had medial deviation of the forelimb due to angular deformity of articular surfaces in the carpus. All nine live calves were floppy due to marked generalized muscular hypotonia. Birth weight of deformed calves was reduced. In some calves muscle development was impaired as judged by muscle weight, and histological examination. In some calves the gross appearance, muscle weight and histological examination revealed no abnormal development and indicated that the effects on skeletal muscle were secondary. No lesions were found in the spinal cord of 23 of 24 calves examined histologically. The remaining calf had a localized cavitation in the dorsal white matter at T2-3. Based on the observations in calves in this study it is proposed that both primary and secondary factors contribute to the phenotypic expression of this congenital deformity. The primary lesion is considered to be a neurogenic abnormality of differentiation in the central nervous system. Cytogenetic analysis of 16 carrier cows and two deformed calves showed normal karyotypes. Serology for Akabane virus in 16 carrier cows was negative.

Joint distraction with a functional maxillomandibular orthopedic appliance.

AbstractWhen the disk of the temporomandibular joint is positioned more anterior than is normal, the patient will often experience pain and dysfunction. Limited joint movement and weakening of the connective tissue posterior to the disk may worsen the problem and lead to an anteriorly displaced disk. A functional orthopedic appliance made up of a maxillary and a mandibular splint attached by a wire spring is often helpful for gently distracting the joint. This functional distraction appliance will allow the biology of the connective tissue and the joints to regain its normal physiology, and this in turn can help the disk return to its normal position. The patient will then be physiologically ready for more permanent treatment of the temporomandibular problems.

Fractures of the os Calcis in Children

Thirty-four os calcis fractures were encountered in 32 children between 1974 and 1982. As commonly occurs in adults, a fall striking the heel was the most common mechanism of injury. Both intra-articular and extra-articular fractures were noted and classified accordingly. Involvement of the posterior subtalar joint was common, occurring in 28 fractures. The joint involvement in the childhood injury was often subtle and the fracture easily overlooked on initial radiographic examination. Minor involvement of the posterior subtalar joint was usually identified by a bursting of the lateral wall of the os calcis, producing a longitudinal silver of bone noted on the axial os calcis radiograph. All cases were treated conservatively, including those with marked deformities of the subtalar joint. Follow-up assessment revealed very satisfactory results in those cases with extra-articular fractures or minor posterior subtalar joint involvement. Patients with more marked joint displacement revealed persisting limitation of subtalar joint motion, but an absence of discomfort or pain.

Diagnostic considerations in arthrogry‐posis syndromes in South Africa

Congenital rigidity of multiple joints poses a difficult diagnostic and therapeutic problem. There are also semantic difficulties as the non-specific term "arthrogryposis" is often used for any individual with congenital limitation of joint movement. Many distinct syndromes present in this way and as they differ in their course, prognosis and genetic implications, diagnostic precision is crucial. A diagnostic analysis is given of 247 South African patients in whom "arthrogryposis" had been recorded, and the pathogenesis and nosology of congenital contractures are discussed in this paper. Three of these stiff joint conditions were originally described in South African patients, i.e. Liebenberg synostosis syndrome, digitotalar dysmorphism, and the Gordon syndrome of autosomal dominant cleft palate, camptodactyly and club feet.

Office Management in Legg-Calve-Perthes Syndrome

As a result of the information offered, one can assume that most patients with Legg-Calve-Perthes syndrome could be treated in the outpatient area. Most patients can be treated by the primary orthopedist and do not require a pediatric orthopedist. The simplest precaution remains for each patient to be very carefully evaluated throughout the treatment course for pain, muscle spasm, and limitation of hip motion. Usually pain and limited joint motion are not prominent and certainly are to be alleviated if at all possible. Early in the course of the disease these complaints can usually be eliminated by bed rest, traction, and warm compresses. An exact time to achieve this goal is not available, but it is usually a matter of weeks. On occasion, it may require months for the irritability to subside prior to application of containment therapy. Weight bearing during the healing stage should be avoided in the presence of pain and limitation of motion. Persistence of these symptoms usually portends a poor prognosis.

Patellofemoral abnormalities in renal osteodystrophy.

Seven patients with renal osteodystrophy demonstrated characteristic abnormalities of the patellofemoral compartment of the knee. The abnormalities consisted of narrowing of the patellofemoral space and ill-defined osseous erosions on the posterior surface of the patella, which in some cases were accompanied by similar alterations on the anterior surface of the femur. Clinical manifestations were not infrequent, including restriction of joint motion and a traumatic synovitis with accumulation of intra-articular fluid. The mechanism accounting for the patellofemoral alterations appears to be subchondral fracture of weakened trabeculae due to the presence of osteomalacia or osteitis fibrosa cystica, or both. Calcium pyrophosphate dihydrate crystal deposition is not required to produce these characteristic abnormalities.

The articular manifestations of progressive systemic sclerosis (scleroderma).

The articular manifestations of progressive systemic sclerosis (PSS) were studied in 38 patients. Of these, 66% experienced joint pain and 61% had signs of joint inflammation. Limitation of joint movement was seen in 45%. Radiological abnormalities included periarticular osteoporosis (42%), joint space narrowing (34%), and erosions (40%). Erosive disease did not correlate with disease duration, presence of rheumatoid factor, antinuclear antibodies, distal tuft resorption, or the extent of the scleroderma skin changes. Calcinosis was seen more frequently in those patients with articular erosions (67%). Erosive osteoarthritis of the distal interphalangeal joints (7 patients) was associated with impaired finger flexion. Joint involvement in PSS occurs frequently and may resemble rheumatoid arthritis in the early stages but is less destructive. The occurrence of unrelated arthropathy, such as primary osteoarthritis, is not uncommon, and its differentiation from true PSS joint disease can be difficult.

A new camptodactyly syndrome.

A family is reported in which scoliosis and camptodactyly occurred in members over four generations. Additional features were torticollis, fusion of cervical vertebrae, and occasional limitation of joint movement in the upper limbs. Inheritance is autosomal dominant.

Tuberculosis of the knee -- a long term follow-up.

Thirty cases of tuberculosis of the knee followed up for an average of 15 years were reviewed. The majority of patients developed the disease during childhood. All had received standard anti-tuberculous drug treatment. Fifteen were treated conservatively alone, while the other 15 had a debridement type of surgery in addition to drugs. At review, one-third had occasional mild pain, but this was only present in the conservatively treated group. Stiffness, however, was more predominant in the operated and in the late onset groups. Some mild deformity was seen in 17 out of 30 patients and was related not so much to disturbance of epiphyseal growth, but rather, to bone collapse. Interesting X-ray appearances at follow-up were found. The factors which could lead to a good outcome included young age of onset, treatment within six months of onset, and early mobilisation. If the disease is well advanced, surgical treatment will lead to a painless joint, but with greater restriction of joint movement.

Eosinophilic fascitis (Shulman syndrome) in a 13-year-old girl

Symptoms compatible with the diagnosis of eosinophilic fasciitis (morphea-like changes of the skin, restricted joint movement, eosinophilia, elevated immunoglobulin levels in serum) in a 13-year-old girl and the response to systemic corticosteroid treatment are reported. The literature is reviewed.

Osteochondritis Dissecans of Elbow, Ankle and Hip

In 36 patients treated for osteochondritis dissecans (OCD) of the elbow, ankle and hip during a period of 20 years in the same hospital, trauma seems to have been the main etiologic factor in about half of the patients. The first symptoms of the lesions occurred when the patients were between 15 and 20 years of age. Osteochondritis dissecans of the elbow was seen in 19 men. Osteochondritis dissecans in the ankle occurred in 6 men and 5 women. Osteochondritis dissecans in the hip appeared in 5 men and one woman. The first symptoms were pain and restriction of joint movement. Conservative treatment was satisfactory for about one-half of the patients. When operative treatment was indicated, extirpation of loose bodies or loosening fragments was the treatment of choice in OCD of the elbow and ankle. Fixation of the fragment gave satistfactory results in some cases of OCD of the hip. Late results were excellent in only about one-half of the patients. Osteoarthritic changes appeared in the hip, elbow, ankle, in order of decreasing frequency.