Secondary Joint Research Articles

Résultats de l’arthroplastie de type Ivory (r) dans le traitement de l’arthrose trapezométacarpienne avec un suivi d’au moins 10 ans – étude prospective cohorte d’un seul centre

This study investigated the long-term functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Stryker Corporate, Kalamazoo, Michigan, USA) for trapeziometcarpal joint osteoarthritis. In this prospective study, range of motion, overall function, pain and radiologic outcome of the trapeziometacarpal arthroplasty were analysed after a minimum of 10 years of follow-up. The opening of the first web space and metacarpophalangeal flexion and extension were graded. Opposition and retropulsion were graded by Kapandji scores. Key pinch, precision pinch and grip strength were measured using a calibrated hydraulic pinch gauge and a calibrated hydraulic hand dynamometer. To assess the overall function, the Quick Disabilities of the Arm, Shoulder and Hand score was used. Pain score was assessed with the Visual Analogue Scale. Radiologic outcome was evaluated using frontal and profile views as described by Kapandji and Eaton views with and without stress. A total of 26 Ivory arthroplasties was evaluated. Out of the 32 patients eligible, 24 patients were included in the study. Two patients had bilateral arthroplasties. The female to male ratio was 22–2 and the mean age was 71 (range 57–83) years. The mean follow-up period was 130 (range 120–142) months. Patient satisfaction was high, with 85 % of the patients willingly to repeat surgery. The mobility of the operated thumb was improved compared to the contralateral thumb, except for metacarpophalangeal extension (78 % less than contralateral). Key pinch deteriorated with 7 % compared to preoperatively, grip strength improved with 3 %. The overall function, according to the Quick Disabilities of the Arm, Shoulder and Hand score improved by 54 %. Pain decreased by 81 % with a mean Visual Analogue Scale score of 13/100 at a minimum of 10 years follow-up. Radiologic evaluation revealed polythene wear with secondary joint instability that needed revision in two patients, and a broken implant that needed revision in another male patient. Three patients had asymptomatic polythene wear that required no revision but remain in follow up. One patient had a failure of the prosthesis and was converted to a trapiezectomy. The 10 year overall survival of the prosthesis was 85 %. These long term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal osteoarthritis, since it gives an important improvement in overall function and pain reduction. However, revision of the implant within 10 years after surgery is needed in 15 % of the cases.

Consistency in patient-reported outcome measures after total knee arthroplasty using patient-specific instrumentation: a 5-year follow-up of 200 consecutive cases

PurposeThe purpose of this study was to evaluate the 5-year follow-up results of the first 200 total knee arthroplasties (TKA) performed by one high-volume surgeon, using patient-specific information (PSI). To date, there has been no other research into the mid-term follow-up of TKA performed using PSI.Materials and methodsA total of 184 consecutive patients (200 TKA) were evaluated. Outcome measures included implant survival rate, adverse events, and the following patient-reported outcome measures (PROMs); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Pain Visual Analogue Score (VAS) and EuroQol-5D Score (EQ-5D).ResultsRevision surgery was performed for late secondary prosthetic joint infection (n = 1, total revision), aseptic loosening (n = 1, tibial component revision), instability (n = 1, isolated polyethylene insert exchange), and polyethylene insert breakage (n = 1, isolated polyethylene insert exchange). Other adverse events were as follows: debridement, antibiotics and implant retention for early prosthetic joint infection (n = 1), surgical debridement for haemarthrosis (n = 1), superficial wound infection (n = 2), thromboembolic events (n = 2), compartment syndrome (n = 1), and nerve injury (n = 2). All median outcome scores for patient reported outcome measures at 5 years improved significantly compared with the preoperative values (p ≤ 0.05). Median outcome scores were not significantly different between 1- and 5-year moments of follow-up, except for a significant decrease of EQ-VAS (p ≤ 0.05) between these two follow-up moments.ConclusionPROMs are consistent for 5-year follow-up of TKA using PSI. After 5 years of follow-up, revision surgery for any reason occurred in four patients (2%).Level of EvidenceIII.

Long-term Results of Intercalary Endoprosthetic Short Segment Fixation Following Extended Diaphysectomy.

Intercalary endoprosthetic reconstruction following diaphyseal resection of osseous tumors offers functional advantages through preservation of native joints adjacent to the resected defect. Use of such implants is restricted by the amount of bone available for stem fixation adjacent to the defect. This study aimed to determine whether short osseous segment fixation with acceptable outcomes and complication rate can be reliably achieved with a customized intercalary endoprosthesis following extended diaphysectomy. A retrospective review of prospectively collected data was performed on 6 patients receiving customized anchor plugs for short segment fixation with a double compressive osseointegration intercalary implant to reconstruct segmental defects. Five of the implants were augmented with cement to support fixation in metaphyseal bone. Patient age at surgery ranged from 12 to 86 years. At mean follow-up of 39 months, mean Musculoskeletal Tumor Society functional score was 26.3, with 5 of 6 patients achieving scores of 27 or greater. Stable fixation was achieved in all patients, with the shortest segment of bone 3.7 cm in length. Three mechanical implant failures requiring revision surgery occurred. No patient required revision of the entire implant, secondary adjacent joint replacement, or secondary amputation. No patient exhibited aseptic loosening, and no case was complicated by infection. Excellent functional outcomes were seen with follow-up out to 9 years. This suggests that cement-augmented double compressive osseointegration intercalary endoprosthetic reconstruction can extend the benefits of intercalary replacement to many patients who otherwise might require adjacent joint or physeal sacrifice. However, patients should be counseled on the high risk of implant failure with subsequent need for revision surgery. [Orthopedics. 2017; 40(6):e964-e970.].

Total knee arthroplasty in patients with a history of illicit intravenous drug abuse.

Injection drug users are at high risk for both infection with blood-borne pathogens, namely, human immune deficiency virus (HIV), hepatitis-B, -C virus, various bacterial infections, as well as early primary and secondary joint degeneration. When total knee arthroplasty (TKA) is anticipated the risk of septic complications is a major concern. The purpose of this study was to assess the clinical and radiographic outcome of patients with a history of intravenous drug use after total knee arthroplasty. The primary outcome was revision rate. Secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Score (KSS) and radiographic loosening. We retrospectively reviewed the records of 1,692 TKA performed or revised in our institution. Data of 18 TKA in 12 patients (11 male, 1 female; average age 42, range 23-62years) with a history of intravenous opioid abuse were available for final analysis. The mean follow up was 125 (range 25-238) months. Seven patients required revision surgery due to periprosthetic joint infection after 62 months (range 5-159): one two staged revision, three arthrodesis and three amputations. The median prosthesis survival was 101 (95%-CI 48-154) months. Total knee arthroplasty in patients with a history of intravenous drug abuse is associated with major complications, including above-the-knee amputation. If permanent abstinence from intravenous drug abuse is doubtful, other therapeutic options including primary arthrodesis should be considered.

Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self Locking Finger Joint Implant: Minimum Two Years Follow-up.

The Self Locking Finger Joint (SLFJ) implant is a new type of surface replacement implant. The purpose of this study was to evaluate midterm clinical outcomes of the proximal interphalangeal (PIP) arthroplasty with the SLFJ implant. We retrospectively studied 26 PIP joint arthroplasties using the SLFJ implant in 17 patients with osteoarthritis or posttraumatic osteoarthritis. Preoperative and postoperative range of motion, grip strength and key pinch, radiographic findings, and complications were evaluated. The Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS) score, course of pain, and patient satisfaction were obtained. The mean follow-up time was 44 months (range, 24-76 months). The average active PIP joint arc of motion improved from 36° before surgery to 44° after surgery. Grip strength and key pinch showed no statistical difference between preoperative and postoperative assessments. The average DASH score and VAS score improved from 40 to 15 and from 5 to 1, respectively. Overall patient satisfaction was 94%. Ninety percent of implants showed osteointegration, and there were no radiographic signs of migration and loosening. Three joints (12%) showed abnormal heterotopic bone formation. Four joints (15%) had secondary surgery-1 joint needing joint head and socket replacement and 3 joints needing contracture release. Our minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion. The SLFJ implant showed good osteointegration. Further longer-term prospective studies with various types of currently available implants are needed.

Influence of various displacement modes of lateral malleolus associated with ankle fracture on tibiotalar joint contact: a finite element analysis

Objective To investigate the impacts of various displacement modes of lateral malleolus on the tibiotalar joint contact in ankle fractures. Methods The computed tomography scans of a normal adult volunteer were used for three-dimensional reconstruction of the whole ankle joint, including its cartilage and adjacent ligaments. Axial compressive loads during mid-stance and boundary conditions were set to sim-ulate the lateral displacement, shortening, internal rotation and external rotation of the fibula following ankle fracture. Magnitude and distribution of the peak contact stress on the tibiotalar joint were compared among various displacement modes of the lateral malleolus. Results The magnitude and distribution of the peak contact stress on the tibiotalar joint varied among the 4 fibular displacement modes. Compared to the reference model, the deviations of peak contact stress for the modes of shortening, lateral displacement, internal rotation and external rotation were 10.23%, 45.22%, 17.68%, and 17.68%, respectively. Regarding the distri-bution of contact stress on the tibiotalar joint, the fibular shortening significantly increased the contact area on the anterior facet and the lateral displacement of the fibula widened the ankle joint and pulled the talus out-wards. This made the articular contact migrate medially, resulting in a decreased contact area. When either internal or external rotation occurred to a certain extent, the contact area was transferred from the medial malleolus to the anterior tibiotalar facet. Conclusions In ankle fractures, various displacement modes of the lateral malleolus may affect the tibiotalar contact condition, especially the lateral displacement, internal rotation and external rotation of the lateral malleolus. This study may provide a theoretical basis for diagnosis and reconstruction of malreduction, maluion, secondary joint pain and arthritis following an ankle fracture. Key words: Ankle joint; Fractures, bone; Biomechanics; Finite element analysis

Kinematics of Different Components of the Posterolateral Corner of the Knee in the Lateral Collateral Ligament-intact State: A Human Cadaveric Study

To determine the static stabilizing effects of different anatomical structures of the posterolateral corner (PLC) of the knee in the lateral collateral ligament (LCL)-intact state. Thirteen fresh-frozen human cadaveric knees were dissected and tested using an industrial robot with an optical tracking system. Kinematics were determined for 134N anterior/posterior loads, 10Nm valgus/varus loads, and 5Nm internal/external rotatory loads in 0°, 20°, 30°, 60°, and 90° of knee flexion. The PLC structures were dissected and consecutively released: (I) intact knee joint, (II) with released posterior cruciate ligament (PCL), (III) popliteomeniscal fibers, (IV) popliteofibular ligament, (V) arcuat and popliteotibial fibers, (VI) popliteus tendon (PLT), and (VII) LCL. Repeated-measures analysis of variance was performed with significance set at P < .05. After releasing the PCL, posterior tibial translation increased by 5.2mm at 20° to 9.4mm at 90° of joint flexion (P < .0001). A mild 1.8° varus instability was measured in 0° of flexion (P= .0017). After releasing the PLC structures, posterior tibial translation further increased by 2.9mm at 20° to 5.9mm at 90° of flexion (P < .05) and external rotation angle increased by 2.6° at 0° to 7.9° at 90° of flexion (P < .05, vs II). Varus stability did not decrease. Mild differences between states V and VI were found in 60° and 90° external rotation tests (2.1° and 3.1°; P < .05). The connecting ligaments/fibers to the PLT act as a primary static stabilizer against external rotatory loads and a secondary stabilizer against posterior tibial loads (when PCL is injured). After releasing these structures, most static stabilizing function of the intact PLT is lost. The PLC has no varus-stabilizing function in the LCL-intact knee. Anatomy and function of these structures for primary and secondary joint stability should be considered for clinical diagnostics and when performing surgery inthePLC.

Complications after orthognathic surgery: our experience on 423 cases.

Orthognathic surgery is widely used to correct dentofacial discrepancies. However, this procedure presents numerous possible complications. The aim of our study is to review intraoperative and postoperative complications related to orthognathic surgery based upon a 10-year period in the Maxillofacial Surgery Department of Federico II University of Naples. Medical records of 423 patients who undergone orthognathic surgery in a 10-year period were retrospectively analyzed and complications was noted. Statistical analysis was conduced in order to understand if the type of surgical procedure influenced complications rate. One hundred eighty-five complications in 143 (33.8%) of the 423 treated patients were reported. Complications detected were nerve injury (49 cases, 11.9%), infections (10 cases, 2.4%), complications related to fixation plates or screws (30 cases, 7.1%), bad split osteotomy (8 cases, 1.9%), secondary temporo-mandibular joint disorders (36 cases, 8.5%), dental injuries (21 cases, 5%), condilar resorption (2 cases, 0.5%), and necessity of a second-time surgery (24 cases, 5.7%). Serious complications seem to be quite rare in orthognathic surgery. Some of the surgical complications found are related to the surgeon experience and not strictly to the risks of the operation itself. Understanding potential complications allows the surgeon to guarantee safe care through early intervention and correctly inform the patient in the preoperative colloquy.

Conscious performance and arthroscopic findings in athletes with anterior cruciate ligament injuries treated via conservative therapy during the competitive season.

Athletes often receive conservative treatment for injured anterior cruciate ligaments (ACLs) so that they can continue to play to the end of their season. The purpose of this study was to examine the conscious performance and arthroscopic findings of athletes who received conservative therapy for ACL injuries. Forty-two patients with ACL injuries underwent conservative treatment. After the season ended, ACL reconstruction was performed. We examined the following parameters: (1) time required for return to competition after injury, (2) conscious performance after return to competition, (3) whether the injured knee gave way during conservative therapy or after return to competition, and (4) cause of performance deterioration if applicable. To determine conscious performance, patients were asked to rate their performance after therapy relative to their performance before injury. Thirty-eight of the 42 patients (90.5%) returned to competition after conservative treatment. The mean time to return was 13.8 ± 7.6 weeks, and the mean conscious performance score was 58.4 ± 16.5%. Thirty-eight patients (90.5%) experienced their knee giving way, of whom 36 (94.9%) stated that fear of their knee giving way hampered their performance. At the time of ACL reconstruction, 9 patients had chondral injuries and 22 patients had meniscus injuries. Most athletes with damaged ACLs returned to the field within the same season after conservative treatment. However, conscious performance was only about 60%. It is possible that knees giving way caused secondary meniscus and joint cartilage damage. Therefore, conservative treatment of individuals with ACL injuries should be considered carefully.

The Nature of Age-Related Differences in Knee Function during Walking: Implication for the Development of Knee Osteoarthritis.

BackgroundChanges in knee kinematics have been identified in the early stages of osteoarthritis (OA). However, there is a paucity of information on the nature of kinematic change that occur with aging prior to the development of OA, This study applied a robust statistical method (Principal Component Analysis) to test the hypothesis that coupling between primary (flexion) and secondary (anterior-posterior translation, internal-external rotation) joint motions in walking would differ for age groupings of healthy subjects.MethodsSeventy-four healthy participants divided into three groups with mean ages of 24 ± 2.3 years (younger), 48 ± 4.7years (middle-age) and 64 ± 2.4 years (older) were examined. Principal Component Analysis was used to characterize and statistically compare the patterns of knee joint movement and their relationships in walking.ResultsThere were significant differences between the younger group and both the middle-age and older groups in the knee frontal plane angle and the coupling between knee flexion (PC1, p≤0.04) and the relative magnitudes of secondary plane motions in early and late stance (PC3, p<0.01). Two additional principal components (PC2, p = 0.03 and PC5, p<0.01) described differences in early stance knee flexion and relationship with secondary plane motion through-out stance for the older compared with middle-age group.ConclusionsIt appears there are changes in knee kinematics that occur with aging. The kinematic differences were identified for middle-aged as well as older adults suggesting midlife changes in neuromuscular physiology or behavior may have important consequences. These kinematic measures offer the potential to identify early markers for the risk of developing knee OA with aging.

Polyarthritis secondary to septic thrombophlebitis in an Arabian mare

SummaryA 3‐year‐old Arabian mare presented with diarrhoea and depression. During hospitalisation, the mare developed septic thrombophlebitis associated with a jugular catheter. One week later, she developed secondary bilateral tarsocrural joint septic arthritis. Following surgical intervention and intensive medical therapy, the mare recovered successfully. The case highlights an unusual and previously unreported complication of septic thrombophlebitis.

Influence de la réconstruction du ligament radio-dorsal sur la stabilité de l’articulation trapeziometacarpien

Introduction Biomechanical and anatomical research has shown that the dorsal radial ligament (DRL) is thicker and stiffer then the anterior oblique ligament (AOL). The DRL as the key stabilizing structure of the trapeziometacarpal (TMC) joint has been documented extensively. The aim of the current study is to quantify the influence of a surgical DRL reconstruction on TMC stability in non-traumatic instability patients. Methods Eight patients with symptomatic TMC instability but no radiographic signs of osteoarthritis were recruited and dynamic CT scans of the thumb were made during active abduction-adduction, flexion-extension and two functional grip task using a radiolucent jig. After image acquisition and segmentation, metacarpal translation was expressed relative to the trapezial articular surface. In addition, intersection points and inclination angles of instantaneous helical axes with an anatomically defined plane were determined to facilitate motion comparison between subjects. Scans were acquired before and 6–12 months after reconstruction of the DRL. Results During active motion, there is motion at both the trapeziometacarpal (TMC) and trapezioscaphoid (STT) joints. However, joint motion patterns, defined as changes in helical axis inclination angles during opposition, differ between patients. In most patients, dorsal luxation of the first metacarpal (MC1) could be clearly seen and quantified during the full range of motion, as well as during function grip tasks. Furthermore, dorsal luxation results in higher point loading of TMC cartilage as could be demonstrated by mapping the changes in articular contact area for each active motion. After DRL reconstruction, patients report improvement in pain and subjective stability in the joint. Analyses of the dynamic CT scans demonstrate reduced translation and luxation of MC1 in all patients as well as reduced cartilage point loading. Conclusion After DRL reconstruction, luxation of MC1 was reduced in all patients. We quantified movement in both TMC & STT joint, suggesting that pathologies at the TMC joint could lead to compensatory movements at the more proximal joints or vice versa. Simple DRL reconstruction is an attractive alternative for the more invasive anterior oblique ligament reconstruction described by Eaton, serving the same purpose, stabilizing the CMC joint. Future research should investigate if TMC instability and its altered kinematics lead to secondary joint problems (e.g. osteoarthritis) if left unattended.

A New Radiofrequency Ablation Procedure to Treat Sacroiliac Joint Pain

Background: Low back pain may arise from disorders of the sacroiliac joint in up to 30% of patients. Radiofrequency ablation (RFA) of the nerves innervating the sacroiliac joint has been shown to be a safe and efficacious strategy. Objectives: We aimed to develop a new RFA technique to relieve low back pain secondary to sacroiliac joint disorders. Study Design: Methodology development with validation through prospective observational non-randomized trial (PONRT). Setting: Academic multidisciplinary health care system, Ohio, USA. Methods: We devised a guide-block to facilitate accurate placement of multiple electrodes to simultaneously ablate the L5 dorsal ramus and lateral branches of the S1, S2, and S3 dorsal rami. This was achieved by bipolar radiofrequency ablation (b-RFA) to create a strip lesion from the lateral border of the base of the sacral superior articular process (L5-S1 facet joint) to the lateral border of the S3 sacral foramen. We applied this technique in 31 consecutive patients and compared the operating time, x-ray exposure time and dose, and clinical outcomes with patients (n = 62) who have been treated with the cooled radiofrequency technique. Patients’ level of pain relief was reported as &lt; 50%, 50 – 80%, and &gt; 80% pain relief at one, 3, 6, and 12 months after the procedure. The relationship between RFA technique and duration of pain relief was evaluated using interval-censored multivariable Cox regression. Results: The new technique allowed reduction of operating time by more than 50%, x-ray exposure time and dose by more than 80%, and cost by more than $1,000 per case. The percent of patients who achieved &gt; 50% pain reduction was significantly higher in the b-RFA group at 3, 6, and 12 months follow-up, compared to the cooled radiofrequency group. No complications were observed in either group. Limitations: Although the major confounding factors were taken into account in the analysis, use of historical controls does not balance observed and unobserved potential confounding variables between groups so that the reported results are potentially confounded. Conclusion: Compared to the cooled radiofrequency ablation (c-RFA) technique, the new b-RFA technique reduced operating time by more than 50%, decreased x-ray exposure by more than 80%, and cut the cost by more than $1000 per case. The new method was associated with significantly improved clinical outcomes despite the limitations of the study design. Thus this new technique appeared to be safe, efficacious, and cost-effective. Key words: Sacroiliac joint pain, sacroiliac joint, low back pain, radiofrequency ablation (RFA), bipolar radiofrequency ablation (b-RFA), cooled radiofrequency ablation (c-RFA), cost-effectiveness

Prospective Utility Study of Patients with Multiple Cardiovascular Events

Objectives The effects of acute coronary syndrome (ACS) events on health-related quality-of-life (HRQoL) and the time dependency of these effects are unknown. This study aimed to characterize health utilities in ACS patients to aid development of future economic models estimating the cost per quality-adjusted life-year impact of ACS events and potential treatments. Methods Multi-center, non-interventional, longitudinal evaluation of health utility in patients experiencing ACS or stroke events. EuroQol-5 dimension 3 level (EQ-5D-3L) surveys were sent to patients (≥18 years) from three UK centers, 1 month after hospital discharge for myocardial infarction (MI), unstable angina (UA), or stroke. Patient demographics, lifestyle, and baseline utility score were collected in the first survey. Follow-up surveys were sent at 6, 12, 18, and 24 months to prospectively capture utility and subsequent health events. Two methods of patient identification were adopted-prospective, where the patient's qualifying events occurred after the study index date, and retrospective, where the patient's qualifying event occurred prior to the study index date. General healthy population utility values were assumed for pre-event HRQoL. Results Between January 2011 and March 2014, 2,103 prospectively (n = 1,350)/retrospectively (n = 753) identified patients (mean age = 68.3 years; 67.9% male) responded: MI = 55.9% (n = 1,176), UA = 42.7% (n = 898), stroke = 1.4% (n = 29); 24% had type 2 diabetes. Post-event utility values were lower than general healthy population values, although significant differences in utility between subsequent 6 (n = 1,031, change = -0.002), 12 (n = 1,096, change = -0.008), 18 (n = 1,246, change = -0.007), and 24 (n = 1,277, change = -0.004) month timepoints were not detected. Through multivariate regression analyses, wheelchair use, current smoking, and secondary mental and joint health events were associated with the greatest statistically significant utility decrements. Conclusions This study indicates that health utility decreases following a cardiovascular event and, although some improvement occurs over the subsequent 24 months, general healthy population utility is not necessarily attained.

Joint loads resulting in ACL rupture: Effects of age, sex, and body mass on injury load and mode of failure in a mouse model.

Anterior cruciate ligament (ACL) tears are a common knee injury with a known but poorly understood association with secondary joint injuries and post-traumatic osteoarthritis (OA). Female sex and age are known risk factors for ACL injury but these variables are rarely explored in mouse models of injury. This study aimed to further characterize a non-surgical ACL injury model to determine its clinical relevance across a wider range of mouse specifications. Cadaveric and anesthetized C57BL/6 mice (9-52 weeks of age) underwent joint loading to investigate the effects of age, sex, and body mass on ACL injury mechanisms. The ACL injury load (whole joint load required to rupture the ACL) was measured from force-displacement data, and mode of failure was assessed using micro-dissection and histology. ACL injury load was found to increase with body mass and age (p < 0.001) but age was not significant when controlling for mass. Sex had no effect. In contrast, the mode of ACL failure varied with both age and sex groups. Avulsion fractures (complete or mixed with mid-substance tears) were common in all age groups but the proportion of mixed and mid-substance failures increased with age. Females were more likely than males to have a major avulsion relative to a mid-substance tear (p < 0.01). This data compliments studies in human cadaveric knees, and provides a basis for determining the severity of joint injury relative to a major ACL tear in mice, and for selecting joint loading conditions in future experiments using this model. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1754-1763, 2017.

Chronic ligamentous instability of the elbow

Chronic ligamentous instability of the elbow is an important pathology as itis accompanied with pronounced dysfunction. Moreover, it represents an established risk factor for the development of osteoarthritis. Posterolateral rotatory instability (PLRI) caused by insufficiency of the lateral collateral ligament (LCL) is the most common type of chronic elbow instability and is usually asequel of traumatic elbow dislocation. Chronic overload can lead to insufficiency of the ulnar collateral ligament (UCL) with subsequent valgus instability, especially in overhead athletes. Subjective instability and recurrent elbow dislocations are not always the main symptoms but elbow instability is instead often characterized by pain and secondary joint stiffness. Many clinical tests are available yet eliciting them can be difficult and inconclusive. A"drop sign" on lateral radiographs as well as the detection of collateral ligament injuries and joint incongruity on MRI scans can support the suspected diagnosis. In some cases, instability can only be verified by diagnostic arthroscopy. Reconstruction of the lateral ulnar collateral ligament (LUCL) for treatment of PLRI generally leads to good clinical results, yet recurrent instability remains an issue and has been reported in 8 % of cases. UCL reconstruction for chronic valgus instability leads to areturn-to-sports rate of about 86 % in the overhead athlete. Ulnar neuropathy, which is seen in approximately 6 % of patients, represents the most common complication. On the rare occasion of multidirectional instability, the box-loop technique can be used for simultaneous reconstruction of the LUCL and UCL with acircumferential graft. 15cases with promising results have been reported in literature thus far.

Quality of life following total hip arthroplasty in patients with acetabular fractures, previously managed by open reduction and internal fixation

PurposeTotal hip replacement (THR) is one of the most successful and cost-effective surgical procedures and remains the treatment of choice for long-term pain relief and restoration of function for patients with diseased or damaged hips. Acetabular fractures managed either conservatively or operatively by fixation tend to present later with secondary joint changes that require THR. In this study we evaluated the functional outcome and quality of life achieved by such patients. MethodsOur study was carried out as a retrospective trial by recruiting patients who underwent THR from June 2006 to May 2012. A total of 32 patients were included with a mean age of 46.08 years ranging from (25–65) years. We evaluated the quality of life in the patients using scoring techniques of Short Musculoskeletal Functional Assessment (SMFA) and the 12-Item Short Form Health Survey (SF-12). Functional outcome was assessed using Harris Hip Score (HHS). ResultsThe mean HHS of the patients was 84.3 with a range from 56 to 100. The SMFA averaged 13.3. The SF-12 score averaged 49.1. The correlation of the HHS with SF-12 was positive (p = 0.001) while with SMFA there was a negative correlation (p = 0.001). ConclusionFrom this study it is inferred that the functional outcome of THR and quality of life in patients who had acetabular fractures and were initially managed by open reduction and internal fixation is good.

ESCAPE-into the community--a community-based rehabilitation programme for elderly people with chronic joint pain.

The impact of osteoarthritisThe Global Burden of Disease study identified musculoskeletal (MSK) disorders as the largest cause of years lived with disability and the third largest cause of disability-adjusted life years.1 A major contributor to MSK disorders is chronic knee and hip pain, usually labelled osteoarthritis (OA). OA affects eight and a half million people in the United Kingdom, of whom six million are in constant pain.2 It impairs their physical, mental and emotional wellbeing, independence, family and social lives and quality of life. Four in five people with OA have difficulties with daily activities such as walking, rising from a chair, stairs, gardening, housework and so on, often forcing them to give up or reduce activity.2 Reduced mobility and activity attributable to joint pain increases the risk of developing comorbidity such as diabetes, cardiac and respiratory disorders, depression, obesity and mortality - more people with pain die than those in the pain-free population.3The personal and societal consequences of OA are equally dismaying. People with OA retire prematurely by eight years on average and 45% give up work, change their type of work or reduce their hours. In addition to loss of earnings, OA increases personal costs by £480 per person per year. The annual direct, indirect and hidden healthcare costs of OA are substantial, a result of 150,000 knee and hip replacements were two million general practitioner (GP) visits and 36 million lost working days.4All these problems are increasing as sedentary lifestyles, obesity and the number of people living longer increases. The number of people in pain is predicted to double by 2030,2 producing greater demands of health and social care.Joints are comprised of bone, cartilage, ligaments and muscles. Although most research and clinical attention has focused on arthritic changes in bone and cartilage, muscle sensorimotor dysfunction (weakness, fatigability, proprioceptive deficits) is involved in the pathogenesis of OA.5 This is fortunate because of all the tissues comprising synovial joints, muscle is the tissue we can most easily manipulate. Exercise programmes can improve muscle function and pain.6 Therefore, muscle function is a modifiable risk factor for OA; maintaining well-conditioned muscles might prevent primary or secondary joint damage.Management of OAEvidence-based management guidelines for OA endorse giving people information about their condition, simple advice about how to self-manage it and exercise to reduce pain and disability.4 Unfortunately, the general attitude towards OA is one of defeated resignation. Healthcare professionals and the lay population regard OA as an inevitable consequence of living, which is not only incurable but untreatable and involves slow, relentless deterioration. Few people are referred for exercise - most are maintained on analgesia which is often ineffective, unpopular, expensive, with harmful side effects7 and little, if any, ongoing support, until the pain becomes so disabling they are referred for surgery, if they are not too old and have no contraindications. Consequently, many people endure years of unnecessary pain and disability.People consider exercise harmful as they associate activity with the onset of pain. They infer that the pain is a signal that they are harming their joints and refrain from activity in order to preserve the joint, called fear-avoidance behaviour. Our joints are there to enable us to move; if we don't move our bones, cartilage and muscles atrophy and become weaker and stiff, exacerbating pain and disability. Mismanagement, erroneous health beliefs and confusion about the safety and benefits of exercise lead to people being frozen in inactivity.Effecting Behavioural ChangePatient education and self-management programmes should convey simple, clear and consistent information about a health problem, the need to change an unhealthy behaviour and stress the importance of activity. …

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial-lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing +17% and -23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce ±0.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement.

Observing the development of the temporomandibular joint in embryonic and post-natal mice using various staining methods.

The temporomandibular joint (TMJ) is a specialized synovial joint that is essential for the movement and function of the mammalian jaw. The TMJ develops from two mesenchymal condensations, and is composed of the glenoid fossa that originates from the otic capsule by intramembranous ossification, the mandibular condyle of the temporal bone and a fibrocartilagenous articular disc derived from a secondary cartilaginous joint by endochondral ossification. However, the development of the TMJ remains unclear. In the present study, the formation and development of the mouse TMJ was investigated between embryonic day 13.5 and post-natal day 180 in order to elucidate the morphological and molecular alterations that occur during this period. TMJ formation appeared to proceed in three stages: Initiation or blastema stage; growth and cavitation stage; and the maturation or completion stage. In order to investigate the activity of certain transcription factors on TMJ formation and development, the expression of extracellular matrix (ECM), sex determining region Y-box 9, runt-related transcription factor 2, Indian hedgehog homolog, Osterix, collagen I, collagen II, aggrecan, total matrix metalloproteinase (MMP), MMP-9 and MMP-13 were detected in the TMJ using in situ and/or immunohistochemistry. The results indicate that the transcription factors, ECM and MMP serve critical functions in the formation and development of the mouse TMJ. In summary, the development of the mouse TMJ was investigated, and the molecular regulation of mouse TMJ formation was partially characterized. The results of the present study may aid the systematic understanding of the physiological processes underlying TMJ formation and development in mice.