Reliability of the active and passive knee extension test in acute hamstring injuries

BACKGROUND

Hamstring flexibility measurements are of clinical relevance for the prognosis of hamstring injury and for monitoring recovery after such injury. The active knee extension test (AKET) and passive knee extension test (PKET) are proven to be reliable in healthy subjects. Reliability has not been determined in patients with acute hamstring injuries.

PURPOSE

The purpose of this study was to determine intertester reliability of the AKET and the PKET in patients with acute hamstring injuries.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Fifty consecutive athletes with acute hamstring injuries confirmed with magnetic resonance imaging were included in this study. For each subject, 2 testers performed the AKET and the PKET within 5 days after injury. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable difference (MDD) were determined.

RESULTS

In the injured leg, the ICC of the AKET was 0.89 and of the PKET 0.77, the SEM of the AKET was 5.3° and of the PKET 7.6°, and the MDD of the AKET of the 15° and of the PKET 21°.

CONCLUSION

Good intertester reliability was found for the AKET and the PKET in injured hamstrings. Thus, both tests can be reliably used to assess flexibility in injured hamstrings, despite pain and discomfort during testing.

Risk factors for the displacement of fractures of both bones of the forearm in children

Forearm fractures in children have a tendency to displace in a cast leading to malunion with reduced functional and cosmetic results. In order to identify risk factors for displacement, a total of 247 conservatively treated fractures of the forearm in 246 children with a mean age of 7.3 years (sd 3.2; 0.9 to 14.9) were included in a prospective multicentre study. Multivariate logistic regression analyses were performed to assess risk factors for displacement of reduced or non-reduced fractures in the cast. Displacement occurred in 73 patients (29.6%), of which 65 (89.0%) were in above-elbow casts. The mean time between the injury and displacement was 22.7 days (0 to 59). The independent factors found to significantly increase the risk of displacement were a fracture of the non-dominant arm (p = 0.024), a complete fracture (p = 0.040), a fracture with translation of the ulna on lateral radiographs (p = 0.014) and shortening of the fracture (p = 0.019). Fractures of both forearm bones in children have a strong tendency to displace even in an above-elbow cast. Severe fractures of the non-dominant arm are at highest risk for displacement. Radiographs at set times during treatment might identify early displacement, which should be treated before malunion occurs, especially in older children with less potential for remodelling.

Physical functioning four years after total hip and knee arthroplasty

Our previous study showed that 6 months after total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients reported having less difficulty with daily activities, showed better functional capacity, and performed activities in their natural environment faster compared to preoperatively. However, their actual daily activity level was not significantly improved. Six months is a rather short follow-up period and the discrepancy in recovery among different aspects of functioning might be explained by this limited duration of follow-up. The objective of the present study was to examine the recovery of different aspects of physical functioning at a follow-up nearly 4 years after THA/TKA. Special attention was given to the actual daily activity level, and whether it had increased 4 years after THA/TKA compared to 6 months postoperatively. Seventy-seven (35 hip, 42 knee) patients who were measured preoperatively and postoperatively (6 months after surgery) in a previous study were invited to participate; 44 patients (23 hip, 21 knee) agreed to participate. The 4-year follow-up data were compared with the preoperative and 6-month postoperative data. The daily activity level after 4 years was found to be actually lower than at 6 months post-surgery (128 min vs. 138 min activity per 24h; p-value 0.48). However, the patients continued to improve in other aspects of physical functioning. In conclusion, 4-year post-surgery patients continued to improve on perceived physical functioning, capacity, and performance of activities in daily life. However, even in this relatively healthy study population, patients did not adopt a more active lifestyle 4 years after surgery.

Real-time assessment of bone metabolism in small animal models for osteoarthritis using multi pinhole-SPECT/CT

OBJECTIVE

Destructive techniques such as histology and biochemical assays are still regarded the gold standard to study the effects of novel therapies or etiologic aspects of osteoarthritis in small animal models. These techniques are time-consuming and require many animals. Multi-pinhole single photon emission computed tomography (MPH-SPECT) is a relatively novel, high resolution imaging technique which enables assessment of biological processes in real-time and thus it might provide a good substitute for destructive assessment techniques.

DESIGN

For this study, we assessed mono-iodoacetate (MIA) induced osteoarthritic knees in 18 rats. The animals were scanned using MPH-SPECT/CT and a diphosphonate labelled with 99m-technetium as the radioactive tracer to monitor subchondral bone turnover (bone-scan) at 2 (n = 18), 14 (n = 12) and 42 (n = 6) days after injection of MIA. At each time-point six animals were sacrificed and also assessed with high-resolution micro-computed tomography (μCT) and histology.

RESULTS

At 2 days after injection of MIA, the MPH-SPECT/CT already showed elevated bone turnover in the affected knee, whereas with histology and μCT we could not detect clear alterations at all this time-point. The increase in bone turnover induced by MIA was elevated further at 14 and 42 days after injection. At this time alterations on histology and μCT scanning also became visible.

CONCLUSIONS

MPH-SPECT/CT proved to be a highly sensitive assessment technique for experimental osteoarthritis in small animal models, detecting real-time changes in bone turnover at a very early time point, which might make it a valuable technique to measure the direct effect of interventional strategies on osteoarthritis.

Selective laser melting-produced porous titanium scaffolds regenerate bone in critical size cortical bone defects

Porous titanium scaffolds have good mechanical properties that make them an interesting bone substitute material for large bone defects. These scaffolds can be produced with selective laser melting, which has the advantage of tailoring the structure's architecture. Reducing the strut size reduces the stiffness of the structure and may have a positive effect on bone formation. Two scaffolds with struts of 120-µm (titanium-120) or 230-µm (titanium-230) were studied in a load-bearing critical femoral bone defect in rats. The defect was stabilized with an internal plate and treated with titanium-120, titanium-230, or left empty. In vivo micro-CT scans at 4, 8, and 12 weeks showed more bone in the defects treated with scaffolds. Finally, 18.4 ± 7.1 mm(3) (titanium-120, p = 0.015) and 18.7 ± 8.0 mm(3) (titanium-230, p = 0.012) of bone was formed in those defects, significantly more than in the empty defects (5.8 ± 5.1 mm(3) ). Bending tests on the excised femurs after 12 weeks showed that the fusion strength reached 62% (titanium-120) and 45% (titanium-230) of the intact contralateral femurs, but there was no significant difference between the two scaffolds. This study showed that in addition to adequate mechanical support, porous titanium scaffolds facilitate bone formation, which results in high mechanical integrity of the treated large bone defects.

Unfocused extracorporeal shock waves induce anabolic effects in osteoporotic rats

Unfocused extracorporeal shock waves (UESW) have been shown to have an anabolic effect on bone mass. Therefore we investigated the effects of UESW on bone in osteoporotic rats with and without anti-resorptive treatment. Twenty-week-old rats were ovariectomized (n = 27). One group was treated with saline and another group with Alendronate (ALN) 2.4 µg/kg, 3×/week. UESW were applied 2 weeks after ovariectomy. Thousand UESW were applied to one hind leg, the contra-lateral hind leg was not treated and served as control. With the use of in vivo micro-CT scanning it was shown that in saline treated rats trabecular bone volume fraction (BV/TV) was higher at 2 weeks follow-up in UESW treated legs compared to control legs. However, at 4 and 10 weeks no difference was found. In ALN treated animals UESW led to a pronounced anabolic response resulting in an increase in BV/TV at all time-points. Furthermore, UESW resulted in increased cortical volume (CtV), higher trabecular connectivity and, more plate-like and thicker trabeculae. Biomechanical testing showed that UESW lead to a higher maximum force before failure and higher stiffness in all treatment groups. With histology abundant areas of intramembranous bone formation along the periosteal cortex and within the bone marrow were observed. In conclusion this study shows promising results for the use of UESW in the treatment of osteoporosis, especially when this treatment is combined with an anti-resorptive treatment.

Knee injury and Osteoarthritis Outcome Score or International Knee Documentation Committee Subjective Knee Form: which questionnaire is most useful to monitor patients with an anterior cruciate ligament rupture in the short term?

PURPOSE

To evaluate which questionnaire, the Knee Injury and Osteoarthritis Outcome Score (KOOS) or the International Knee Documentation Committee Subjective Knee Form (IKDC subjective), is most useful to evaluate patients with recent anterior cruciate ligament (ACL) ruptures or those within 1 year of an ACL reconstruction.

METHODS

Patients with recent (0-6 months) ACL ruptures or those with indications for ACL reconstruction were included. All patients completed the questionnaires shortly after trauma or preoperatively and again 1 year later. The KOOS has 5 subscales, each scored separately. The IKDC subjective consists of one total score. The following measurement properties of the KOOS and IKDC subjective were assessed: content validity (n = 45), construct validity (n = 100), test-retest reliability (n = 50), and responsiveness (n = 50).

RESULTS

Regarding content validity, 2 KOOS subscales (Pain and Activities of Daily Living) were scored as nonrelevant. Two of the 18 questions on the IKDC subjective were assessed as nonrelevant. Only the KOOS subscale Sport and Recreation Function had acceptable construct validity (79% confirmation of the predefined hypotheses). None of the KOOS subscales had a sufficient score for responsiveness (<75% confirmation of the predefined hypotheses). The IKDC subjective scored acceptable for construct validity (84% confirmation of the predefined hypotheses) and responsiveness (86% confirmation of the predefined hypotheses). All KOOS subscales and the IKDC subjective had a reliability (intraclass correlation coefficient [ICC]) of 0.81 or higher.

CONCLUSIONS

The IKDC subjective is more useful than the KOOS questionnaire to evaluate both patients with recent ACL ruptures and those in the first year after ACL reconstruction.

LEVEL OF EVIDENCE

Level III, prognostic validation study.

Epidemiology and health-care utilisation of wrist fractures in older adults in The Netherlands, 1997-2009

INTRODUCTION

Wrist fractures are common in older adults and are expected to increase because of ageing populations worldwide. The introduction of plate and screw fixation has changed the management of this trauma in many patients. For policymaking it is essential to gain insight into trends in epidemiology and healthcare utilisation. The purpose of this study was to determine trends in incidence, hospitalisation and operative treatment of wrist fractures.

METHODS

A population-based study of patients aged 50 years and older using the Dutch National Injury Surveillance System and the National Hospital Discharge Registry. Data on emergency department visits, hospitalisations and operative treatment for wrist fractures within the period 1997-2009 were analysed.

RESULTS

In women, the age-standardised incidence rate of wrist fractures decreased from 497.2 per 100,000 persons (95% confidence interval, 472.3-522.1) in 1997 to 445.1 (422.8-467.4) in 2009 (P for trend < 0.001). In men, no significant trends were observed in the same time period. Hospitalisation rates increased from 30.1 (28.3-31.9) in 1997 to 78.9 (75.1-82.8) in 2009 in women (P < 0.001), and from 6.4 (6.0-6.8) to 18.4 (17.3-19.5) in men (P < 0.001). There was a strong increase in operative treatment of distal radius fractures, especially due to plate fixation techniques in all age groups.

CONCLUSION

Incidence rates of wrist fractures decreased in women and remained stable in men, but hospitalisation rates strongly increased due to a steep rise in operative treatments. The use of plate and screw fixation techniques for distal radius fractures increased in all age groups.

Total hip replacement but not clinical osteoarthritis can be predicted by the shape of the hip: a prospective cohort study (CHECK)

OBJECTIVE

To investigate the association between baseline hip shape and both clinical hip osteoarthritis (OA) and total hip replacement (THR) at 5-year follow-up.

DESIGN

Individuals from the Cohort Hip and Cohort Knee (CHECK) study, with early symptomatic OA, having standardized anteroposterior pelvic radiographs at baseline and 5-year follow-up (n = 723) were included. Hip shape on the radiographs was assessed using statistical shape modeling (SSM). Hips fulfilling the American College of Rheumatology (ACR) criteria at follow-up were classified as clinical OA. The association between each mode of shape variation and both outcome measures was calculated by Generalized Estimating Equations (GEE).

RESULTS

The included individuals comprised 575 females and 148 males (mean age 55.9 ± 5.2 years). At baseline, 8% fulfilled the ACR criteria, 76% had no radiographic hip OA [Kellgren & Lawrence (K&L) = 0] and 24% had doubtful OA (K&L = 1). At follow-up, 147 hips (10.4%) fulfilled the ACR criteria and 35 hips (2.5%) had received THR. Five shape variants (modes) at baseline associated significantly with THR within 5 years. When combined in one GEE model, these shape variants resulted in a predictive power indicated by an area under the curve of 0.81. No shape variants associated with the presence of clinical OA at follow-up.

CONCLUSION

The shape of the hip as quantified by an SSM has a good predictive value for THR, whereas variation in shape cannot predict clinical OA. Minor shape variants may be used as a radiographic biomarker to predict the future risk of THR.

Re-displacement of stable distal both-bone forearm fractures in children: a randomised controlled multicentre trial

INTRODUCTION

Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires.

METHODS

Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n = 128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture.

RESULTS

A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (± 9.4)° vs. 14.3 (± 13.6)°) but more complications (14 vs. 1).

CONCLUSIONS

Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique.

Fibrates as therapy for osteoarthritis and rheumatoid arthritis? A systematic review

Fibrates are used as lipid-lowering drugs to prevent cardiovascular pathology. Fibrates are ligands of peroxisome proliferator-activated receptor α (PPARα). Besides altering lipid metabolism, PPARα ligands exert anti-inflammatory effects on various cell types. In this study, we hypothesized that PPARα agonists exert beneficial effects on osteoarthritis (OA) and rheumatoid arthritis (RA) by their local anti-inflammatory effects, but also by their systemic influences. A systematic literature search of Medline and EMBASE databases was performed up to August 2011. The main search items were osteoarthritis, rheumatoid arthritis, peroxisome proliferator-activated receptor alpha and fibrates. Inclusion criteria were in vivo or in vitro studies regarding humans or animals in which the effects of PPARα ligands were studied. Six in vivo human studies, four in vivo animal studies and seven in vitro studies were included. The in vivo human studies showed all beneficial clinical effects of PPARα ligands, but studies were small and only four were randomized. Ligands for PPARα significantly reduced pain, swelling of the joints and decreased systemic inflammatory markers. In vitro and in vivo animal studies indicate that PPARα agonists inhibit bone resorption, and reduce inflammatory and destructive responses in cartilage and synovium. PPARα agonists such as fibrates should be considered as potential therapeutic strategy for RA. There is no clinical evidence for their use in OA, although in vitro studies indicate that PPARα agonists demonstrate different joint-protective effects locally, and systemic effects on inflammation, serum lipid levels and vascular pathology. Animal studies should be performed and after confirmation of the protective effects of PPARα, large randomized controlled trials could investigate fibrates in OA and RA.

Re-sprains during the first 3 months after initial ankle sprain are related to incomplete recovery: an observational study

QUESTION

What are prognostic factors for incomplete recovery, instability, re-sprains and pain intensity 12 months after patients consult primary care practitioners for acute ankle sprains?

DESIGN

Observational study.

PARTICIPANTS

One hundred and two patients who consulted their general practitioner or an emergency department for an acute ankle sprain were included in the study.

OUTCOME MEASURES

Possible prognostic factors were assessed at baseline and at 3 months follow-up. Outcome measures assessed at 12 months follow-up were self-reported recovery, instability, re-sprains and pain intensity.

RESULTS

At 3 months follow-up, 65% of the participants reported instability and 24% reported one or more re-sprains. At 12 months follow-up, 55% still reported instability and more than 50% regarded themselves not completely recovered. None of the factors measured at baseline could predict the outcome at 12 months follow-up. Additionally, prognostic factors from the physical examination of the non-recovered participants at 3 months could not be identified. However, among the non-recovered participants at 3 months follow-up, re-sprains and self-reported pain at rest at 3 months were related to incomplete recovery at 12 months.

CONCLUSION

A physical examination at 3 months follow-up for the non-recovered ankle sprain patient seems to have no additional value for predicting outcome at 12 months. However, for the non-recovered patients at 3 months follow-up, self-reported pain at rest and re-sprains during the first 3 months of follow-up seem to have a prognostic value for recovery at 12 months.

Mesenchymal stem cells secrete factors that inhibit inflammatory processes in short-term osteoarthritic synovium and cartilage explant culture

OBJECTIVE

Mesenchymal stem cells (MSCs) are promising candidates for osteoarthritis (OA) therapies, although their mechanism of action remains unclear. MSCs have recently been discovered to secrete anti-inflammatory cytokines and growth factors. We studied the paracrine effects of MSCs on OA cartilage and synovial explants in vitro.

DESIGN

MSC-conditioned medium was prepared by stimulating primary human MSCs with tumour necrosis factor alpha (TNFα) and (50ng/ml each). Human synovium and cartilage explants were cultured in MSC-conditioned medium or in control medium, containing the same amount of added TNFα and IFNγ but not incubated with MSCs. Explants were analyzed for gene expression and the production of nitric oxide (NO). The presence of the inhibitor of nuclear factor kappa B alpha (IκBa) was assessed by Western blot analysis.

RESULTS

Synovial explants exposed to MSC-conditioned medium showed decreased gene expression of interleukin-1 beta (IL-1β), matrix metalloproteinase (MMP)1 and MMP13, while suppressor of cytokine signaling (SOCS)1 was upregulated. In cartilage, expression of IL-1 receptor antagonist (IL-1RA) was upregulated, whereas a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)5 and collagen type II alpha 1 (COL2A1) were downregulated. MSC-conditioned medium reduced NO production in cartilage explants and the presence of IκBa was increased in synoviocytes and chondrocytes treated with MSC-conditioned medium.

CONCLUSIONS

In an inflammatory environment, MSCs secrete factors which cause multiple anti-inflammatory effects and influence matrix turnover in synovium and cartilage explants. Thereby, the presented data encourage further study of MSCs as a treatment for joint diseases.

Computer-assisted surgery is not more accurate or precise than conventional arthroscopic ACL reconstruction: a prospective randomized clinical trial

BACKGROUND

Accurate and precise tunnel placement is critical to the success of anterior cruciate ligament (ACL) reconstruction. A new development, computer-assisted surgery, aids in placement of the ACL bone tunnels during surgery. Our hypothesis was that computer-assisted ACL reconstruction would allow more accurate and precise tunnel placement compared with conventional surgery.

METHODS

In a prospective, double-blind, randomized clinical study, 100 patients eligible for ACL reconstruction with a transtibial technique were stratified by surgeon and randomized to either conventional or computer-assisted surgery. Measurement of femoral and tibial tunnel placement with use of three-dimensional computed tomography (CT) was used as the primary outcome to compare conventional ACL surgery with computer-assisted surgery.

RESULTS

The placement of the femoral tunnel did not differ between groups (mean, 39.7% of the proximal-distal distance on the intracondylar axis [Blumensaat line] in the conventional group compared with 39.0% in the computer-assisted surgery group; p = 0.70). The anterior-posterior positioning of the tibial tunnel on the tibial plateau also did not differ significantly (38.9% in the conventional group compared with 38.2% in the computer-assisted surgery group; p = 0.58). There was no significant difference in the precision of either the femoral or the tibial tunnel placement between the two groups.

CONCLUSIONS

There was no significant difference in either the accuracy or the precision of tunnel placement between conventional and computer-assisted ACL reconstruction.

Reproducibility of 3D delayed gadolinium enhanced MRI of cartilage (dGEMRIC) of the knee at 3.0 T in patients with early stage osteoarthritis

OBJECTIVES

To assess the reproducibility of 3D delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 3 T in early stage knee osteoarthritis (OA) patients.

METHODS

In 20 patients, 3D dGEMRIC at 3 T was acquired twice within 7 days. To correct for patient motion during acquisition, all images were rigidly registered in 3D. Eight anatomical cartilage ROIs were analysed on both images of each patient. Capability of dGEMRIC to yield T1 maps that reproducibly distinguish spatial differences in cartilage quality was assessed in two ROIs within a single slice in each patient. Reproducibility was assessed using ICCs and Bland-Altman plots.

RESULTS

ICCs ranged from 0.87 to 0.95, indicating good reproducibility. T1 maps revealed reproducible spatial differences in cartilage quality (ICC 0.79). Based on the Bland-Altman plots, we defined a threshold of 95 ms to determine if a change in dGEMRIC outcome in longitudinal research was statistically significant.

CONCLUSIONS

3D knee dGEMRIC at 3 T combined with 3D image registration is a highly reproducible measure of cartilage quality in early stage OA. Therefore, dGEMRIC may be a valuable tool in the non-invasive evaluation of cartilage quality changes in longitudinal research in patients with early stage OA and focal cartilage defects.

Effect of Arthritic Synovial Fluids on the Expression of Immunomodulatory Factors by Mesenchymal Stem Cells: An Explorative in vitro Study

BACKGROUND

In diseased joints, the catabolic environment results in progressive joint damage. Mesenchymal stem cells (MSCs) can have immunomodulatory effects by secreting anti-inflammatory factors. To exert these effects, MSCs need to be triggered by pro-inflammatory cytokines. To explore the potential of MSCs as a treatment for diseased joints, we studied the effect of synovial fluid (SF) from donors with different joint diseases and donors without joint pathology on the immunomodulatory capacities of human MSCs in vitro. We hypothesized that SF of diseased joints influences the immunomodulatory effects of MSCs.

MATERIALS AND METHODS

MSCs were cultured in medium with SF of six osteoarthritis (OA) or six rheumatoid arthritis (RA) donors and three donors without joint pathology were used as control. Gene expressions of IL-6, HGF, TNFa, TGFb1, and indoleamine 2,3-dioxygenase (IDO) were analyzed. l-kynurenine concentration in conditioned medium (CM) by MSCs with SF was determined as a measure of IDO activity by MSCs. Furthermore, the effect of CM with SF on proliferation of activated lymphocytes was analyzed.

RESULTS

Addition of SF significantly up-regulated the mRNA expression of IL-6 and IDO in MSCs. SF(OA) induced significantly higher expression of IDO than SF(control), although no difference in IDO activity of the MSCs could be shown with a l-kynurenine assay. Medium conditioned by MSCs with SF(OA or RA) suppressed activated lymphocyte proliferation in vitro more than medium conditioned by MSCs without SF or with SF(control).

DISCUSSION

SF can influence the expression of genes involved in immunomodulation by MSCs and the effect on lymphocyte proliferation. We found indications for disease-specific differences between SFs but the variation between donors, even within one disease group was high. These data warrant further research to examine the potential application of MSC therapy in arthritic joints.

Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study

INTRODUCTION

Minimally displaced metaphyseal both-bone fractures of the distal forearm in children are often treated with an above-elbow cast (AEC). Treatment with a below-elbow cast (BEC) could give more comfort, but might lead to fracture displacement reducing pronation and supination. Because this has not been systematically investigated, we set up a randomised multicentre study. The purpose of this study was to find out whether BEC causes equal limitation of pronation and supination but with higher comfort level, compared with AEC.

PATIENTS AND METHODS

In four hospitals, consecutive children aged<16 (mean 7.1) years with a minimally displaced metaphyseal both-bone fracture of the distal forearm were randomised to 4 weeks BEC (n=35) or 4 weeks AEC (n=31). Primary outcome was limitation of pronation and supination 6 months after initial trauma. The secondary outcomes were cast comfort, limitation of flexion/extension of wrist/elbow, complications, cosmetics, complaints, and radiological assessment.

RESULTS

A group of 35 children received BEC and 31 children received AEC. All children attended for the final examination at a mean follow-up of 7.0 months (range 5.0-11.6 months). Limitation of pronation and supination 6 months after initial trauma showed no significant difference between the two groups [4.4° (± 5.8) for BEC and 5.8° (± 9.8) for AEC]. Children treated with BEC had significantly higher cast comfort on a visual analogue scale [5.6 (± 2.7) vs. 8.4 (± 1.4)] and needed significantly less help with dressing (8.2 days vs. 15.1 days). Six complications occurred in the BEC group and 14 in the AEC group. Other secondary outcomes were similar between the two groups.

CONCLUSIONS

Children with minimally displaced metaphyseal both-bone fractures of the distal forearm should be treated with a below-elbow cast.

Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK)

OBJECTIVE

To determine the association between cam impingement, which is hip incongruity by a non-spherical femoral head and development of osteoarthritis.

METHODS

A nationwide prospective cohort study of 1002 early symptomatic osteoarthritis patients (CHECK), of which standardised anteroposterior pelvic radiographs were obtained at baseline and at 2 and 5 years follow-up. Asphericity of the femoral head was measured by the α angle. Clinically, decreased internal hip rotation (≤20°) is suggestive of cam impingement. The strength of association between those parameters at baseline and development of incident osteoarthritis (K&L grade  2) or end-stage osteoarthritis (K&L grades 3, 4, or total hip replacement) within 5 years was expressed in OR using generalised estimating equations.

RESULTS

At baseline, 76% of the included hips had no radiographic signs of osteoarthritis and 24% doubtful osteoarthritis. Within 5 years, 2.76% developed end-stage osteoarthritis. A moderate (α angle>60°) and severe (α angle>83°) cam-type deformity resulted in adjusted OR of 3.67 (95% CI 1.68 to 8.01) and 9.66 (95% CI 4.72 to 19.78), respectively, for end-stage osteoarthritis. The combination of severe cam-type deformity and decreased internal rotation at baseline resulted in an even more pronounced adjusted OR, and in a positive predictive value of 52.6% for end-stage osteoarthritis. For incident osteoarthritis, only a moderate cam-type deformity was predictive OR=2.42 (95% CI 1.15 to 5.06).

CONCLUSIONS

Individuals with both severe cam-type deformity and reduced internal rotation are strongly predisposed to fast progression to end-stage osteoarthritis. As cam impingement might be a modifiable risk factor, early recognition of this condition is important.

The development of Cam-type deformity in adolescent and young male soccer players

BACKGROUND

Cam impingement is a well-recognized cause of hip pain and might cause osteoarthritis of the hip. Clinically, cam impingement is mostly observed in young, active male patients, but only a few studies have focused on the manifestation of cam-type deformities during skeletal development.

PURPOSE

To determine the age of onset and prevalence of cam-type deformities in young male soccer players versus controls.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

In this study, 89 elite preprofessional soccer players and 92 controls aged 12 to 19 years were included. In the soccer players, range of motion and impingement tests were performed. Both an anteroposterior (AP) pelvic radiograph and a frog-leg lateral radiograph of the hip were obtained according to a standardized protocol. Controls with both an AP pelvic and a frog-leg lateral radiograph and no hip disorders were obtained from radiology databases. The α angle was automatically determined in all radiographs, using a threshold value of 60° to define a cam-type deformity. Further, all radiographs were scored using a 3-point scoring system. The anterosuperior head-neck junction was classified as (1) normal, (2) flattened, or (3) having a prominence. Differences in prevalence were tested using logistic regression. Differences in range of motion were calculated using generalized estimating equations.

RESULTS

An α angle >60° was already found at the age of 12 years in some soccer players and controls. A cam-type deformity defined by α angle tended to be more prevalent in soccer players (26%) than in controls (17%; P = .31). In 13% of soccer players, a prominence was visible on radiographs and was first seen at the age of 13 years. The anterosuperior flattening (56% vs 18%, P = .0001) and prominence (13% vs 0%, P < .03) were more prevalent in soccer players than in controls.

CONCLUSION

Cam-type deformities were recognizable and present from the age of 13 years and were more prevalent in soccer players than in their nonathletic peers. Cam-type deformity develops during adolescence and is likely to be influenced by high-impact sports practice.

The most accurate approach for intra-articular needle placement in the knee joint: a systematic review

INTRODUCTION

Intra-articular needle placement in the knee joint, such as injection or aspirations, are commonly used for therapeutic, diagnostic, and research purposes. Although several approaches can be used to establish an intra-articular injection or aspiration of the knee joint, the accuracy differs per approach.

OBJECTIVE

To summarize the evidence concerning the accuracy of different approaches for intra-articular needle placements in the knee. Additionally, to assess whether the accuracy of different approaches is related to factors such as underlying disease, severity of underlying disease, approach-related factors, and/or the rate of local reactions.

METHODS

The literature was systemically reviewed until July 2010. Risk of bias of the included studies was assessed by the QUADAS tool. Study characteristics were extracted; accuracy results were pooled per approach.

RESULTS

Nine studies were included. The superolateral approach with the leg in extension was studied most (230 injections) and resulted in the highest pooled accuracy of 91% (95% CI 84-99%). The lateral midpatellar approach, the anterolateral approach, and the anteromedial approach resulted in the lowest pooled accuracy rates, 85% (95% CI 68-100%), 67% (95% CI 43-91%) and 72% (95% CI 65-78%), respectively.

CONCLUSIONS

The superolateral approach was investigated most and resulted in the highest pooled accuracy rate of 91% (95% CI 84-99%). Nevertheless, this approach still results in a substantial amount of extra-articular needle placements. Guidance of intra-articular needle placements by imaging techniques may enhance the accuracy. The costs and extra time associated with these techniques should be taken into consideration.

Low-magnitude whole body vibration does not affect bone mass but does affect weight in ovariectomized rats

Mechanical loading has stimulating effects on bone architecture, which can potentially be used as a therapy for osteoporosis. We investigated the skeletal changes in the tibia of ovariectomized rats during treatment with whole body vibration (WBV). Different low-magnitude WBV treatment protocols were tested in a pilot experiment using ovariectomized rats with loading schemes of 2 × 8 min/day, 5 days/week (n = 2 rats per protocol). Bone volume and architecture were evaluated during a 10 week follow-up using in-vivo microcomputed tomography scanning. The loading protocol in which a 45 Hz sine wave was applied at 2 Hz with an acceleration of 0.5g showed an anabolic effect on bone and was therefore further analyzed in two groups of animals (n = 6 each group) with WBV starting directly after or 3 weeks after ovariectomy and compared to a control (non-WBV) group at 0, 3, 6 and 10 weeks' follow-up. In the follow-up experiment the WBV stimulus did not significantly affect trabecular volume fraction or cortical bone volume in any of the treatment groups during the 10 week follow-up. WBV did reduce weight gain that was induced as a consequence of ovariectomy. We could not demonstrate any significant effects of WBV on bone loss as a consequence of ovariectomy in rats; however, the weight gain that normally results after ovariectomy was partly prevented. Treatment with WBV was not able to prevent bone loss during induced osteoporosis.

Effectiveness of intramuscular corticosteroid injection versus placebo injection in patients with hip osteoarthritis: design of a randomized double-blinded controlled trial

Background

Recent international guidelines recommend intra-articular corticosteroid injections for patients with hip osteoarthritis who have moderate to severe pain and do not respond satisfactorily to oral analgesic/anti-inflammatory agents. Of the five available randomized controlled trials, four showed positive effects with respect to pain reduction. However, intra-articular injection in the hip is complex because the joint is adjacent to important neurovascular structures and cannot be palpated. Therefore fluoroscopic or ultrasound guidance is needed.

The systemic effect of corticosteroids has been studied in patients with impingement shoulder pain. Gluteal corticosteroid injection was almost as effective as ultrasound-guided subacromial corticosteroid injection. Such a clinically relevant effect of a systemic corticosteroid injection offers a less complex alternative for treatment of patients with hip osteoarthritis not responsive to oral pain medication.

Methods/Design

This is a double-blinded, randomized controlled trial. A total of 135 patients (aged > 40 years) with hip osteoarthritis and persistent pain despite oral analgesics visiting a general practitioner or orthopaedic surgeon will be included. They will be randomized to a gluteal intramuscular corticosteroid injection or a gluteal intramuscular placebo (saline) injection. The randomization will be stratified for setting (general practitioner and outpatient clinics of department of orthopaedics). Treatment effect will be evaluated by questionnaires at 2, 4, 6, and 12 weeks follow-up and a physical examination at 12 weeks. Primary outcome is severity of hip pain reported by the patients at 2-week follow-up. Statistical analyses will be based on the intention-to-treat principle.

Discussion

This study will evaluate the effectiveness of an intramuscular corticosteroid injection on pain in patients with hip osteoarthritis. Patient recruitment has started.

Trial Registration

This trial is registered in the Dutch Trial Registry: number NTR2966.

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Background

Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.

Aim

To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme.

Study design

Part of a 5-year follow-up of a previously conducted randomised controlled trial.

Methods

58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.

Results

In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).

Conclusion

At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

Platelet-rich plasma releasate inhibits inflammatory processes in osteoarthritic chondrocytes

BACKGROUND

Platelet-rich plasma (PRP) has recently been postulated as a treatment for osteoarthritis (OA). Although anabolic effects of PRP on chondrocytes are well documented, no reports are known addressing effects on cartilage degeneration. Since OA is characterized by a catabolic and inflammatory joint environment, the authors investigated whether PRP was able to counteract the effects of such an environment on human osteoarthritic chondrocytes.

HYPOTHESIS

Platelet-rich plasma inhibits inflammatory effects of interleukin-1 (IL-1) beta on human osteoarthritic chondrocytes.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human osteoarthritic chondrocytes were cultured in the presence of IL-1 beta to mimic an osteoarthritic environment. Medium was supplemented with 0%, 1%, or 10% PRP releasate (PRPr, the active releasate of PRP). After 48 hours, gene expression of collagen type II alpha 1 (COL2A1), aggrecan (ACAN), a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)4, ADAMTS5, matrix metalloproteinase (MMP)13, and prostaglandin-endoperoxide synthase (PTGS)2 was analyzed. Additionally, glycosaminoglycan (GAG) content, nitric oxide (NO) production, and nuclear factor kappa B (NFκB) activation were studied.

RESULTS

Platelet-rich plasma releasate diminished IL-1 beta-induced inhibition of COL2A1 and ACAN gene expression. The PRPr also reduced IL-1 beta-induced increase of ADAMTS4 and PTGS2 gene expression. ADAMTS5 gene expression and GAG content were not influenced by IL-1 beta or additional PRPr. Matrix metalloproteinase 13 gene expression and NO production were upregulated by IL-1 beta but not affected by added PRPr. Finally, PRPr reduced IL-1 beta-induced NFκB activation to control levels containing no IL-1 beta.

CONCLUSION

Platelet-rich plasma releasate diminished multiple inflammatory IL-1 beta-mediated effects on human osteoarthritic chondrocytes, including inhibition of NFκB activation.

CLINICAL RELEVANCE

Platelet-rich plasma releasate counteracts effects of an inflammatory environment on genes regulating matrix degradation and formation in human chondrocytes. Platelet-rich plasma releasate decreases NFκB activation, a major pathway involved in the pathogenesis of OA. These results encourage further study of PRP as a treatment for OA.

Quantifying osteoarthritic cartilage changes accurately using in vivo microCT arthrography in three etiologically distinct rat models

In vivo microCT arthrography (µCTa) can be used to measure both quantity (volumetric) and quality (glycosaminoglycan content) of cartilage. This study investigated the accuracy of four segmentation techniques to isolate cartilage from µCTa datasets and then used the most accurate one to investigate if the µCTa method could show osteoarthritic changes in rat models during longitudinal follow-up. Volumetric measurements and glycosaminoglycan contents of patellar cartilage from in vivo µCTa-scans were compared with an ex vivo gold standard µCT-scan. Cartilage was segmented with three global thresholds and one local threshold algorithm. Comparisons were made for healthy and osteoarthritic cartilage. Next, three rat models were investigated for 24 weeks using µCTa. Osteoarthritis was induced by injection with a chemical (mono-iodoacetate), a surgical intervention (grooves applied in articular cartilage), and via exercise (strenuous running). After euthanasia, all knee joints were isolated for histology. Local thresholds accurately segmented cartilage from in vivo µCTa scans and best measured cartilage quantity and glycosaminoglycan content. Each of the three osteoarthritic rat models showed a specific pattern of osteoarthritis progression. All µCTa results were comparable to histology. In vivo µCTa is a sensitive technique for imaging cartilage degradation. Local thresholds enhanced the sensitivity of this method and will probably more accurately detect disease-modulating effects from interventional strategies. The data from rat models may serve as a reference for the time sequence of cartilage degeneration during in vivo testing of new strategies in osteoarthritis treatment.

An osteochondral culture model to study mechanisms involved in articular cartilage repair

Although several treatments for cartilage repair have been developed and used in clinical practice the last 20 years, little is known about the mechanisms that are involved in the formation of repair tissue after these treatments. Often, these treatments result in the formation of fibrocartilaginous tissue rather than normal articular cartilage. Because the repair tissue is inferior to articular cartilage in terms of mechanical properties and zonal organization of the extracellular matrix, complaints of the patient may return. The biological and functional outcome of these treatments should thus be improved. For this purpose, an in vitro model allowing investigation of the involved repair mechanisms can be of great value. We present the development of such a model. We used bovine osteochondral biopsies and created a system in which cartilage defects of different depths can be studied. First, our biopsy model was characterized extensively: we studied the viability by means of lactate dehydrogenase (LDH) excretion over time and we investigated expression of cartilage-related genes in osteochondral biopsies and compared it with conventional cartilage-only explants. After 28 days of culture, LDH was detected at low levels and mRNA could be retrieved. The expression of cartilage-related genes decreased over time. This was more evident in cartilage-only explants, indicating that the biopsy model provided a more stable environment. We also characterized the subchondral bone: osteoclasts and osteoblasts were active after 28 days of culture, which was indicated by tartrate acid phosphatase staining and alkaline phosphatase measurements, respectively, and matrix deposition during culture was visualized using calcein labeling. Second, the applicability of the model was further studied by testing two distinct settings: (1) implantation of chondrocytes in defects of different depths; (2) two different seeding strategies of chondrocytes. Differences were observed in terms of volume and integration of newly formed tissue in both settings, suggesting that our model can be used to model distinct conditions or even to mimic clinical treatments. After extensive characterization and testing of our model, we present a representative and reproducible in vitro model that can be used to evaluate new cartilage repair treatments and study mechanisms in a controlled and standardized environment.

Infrapatellar fat pad of patients with end-stage osteoarthritis inhibits catabolic mediators in cartilage

OBJECTIVE

Adipose tissue is known to release inflammatory cytokines and growth factors. In this exploratory study, the authors examined whether the infrapatellar fat pad (IPFP) closely located to cartilage in the knee joint can affect cartilage metabolism. In addition, the authors analysed whether the macrophage types present in IPFP could explain the effect on cartilage.

METHODS

IPFP explants obtained during total knee replacement of 29 patients with osteoarthritis (OA) were used to make fat-conditioned medium (FCM). Explants of bovine cartilage were cultured with or without FCM. Nitric oxide (NO) and glycosaminoglycan release and gene expression of matrix-degrading enzymes in cartilage were analysed. To stimulate catabolic processes in the cartilage, the authors added interleukin 1β, and the effect of six FCMs was evaluated. The presence of different types of macrophages (CD68+, CD86+ and CD206+) in OA IPFPs was compared with subcutaneous adipose tissue samples and IPFP samples from patients with an anterior cruciate ligament rupture.

RESULTS

FCM alone reduced NO and glycosaminoglycan release and matrix metalloproteinase (MMP)1 gene expression by the cartilage. Moreover, when catabolic conditions were enhanced with interleukin 1β, FCM inhibited NO production as well as MMP1 and MMP3 gene expression and increased collagen type II gene expression. Significantly more CD206+ cells were present in OA IPFP samples than in subcutaneous fat or anterior cruciate ligament IPFP samples.

CONCLUSION

In contrast to the authors' expectations, medium conditioned by end-stage OA IPFP inhibited catabolic processes in cartilage. CD206+ cells present in the IPFPs used for making the FCM might have contributed to the inhibition of catabolic processes in the cartilage.

Cost-effectiveness of exercise therapy versus general practitioner care for osteoarthritis of the hip: design of a randomised clinical trial

Background

Osteoarthritis (OA) is the most common joint disease, causing pain and functional impairments. According to international guidelines, exercise therapy has a short-term effect in reducing pain/functional impairments in knee OA and is therefore also generally recommended for hip OA. Because of its high prevalence and clinical implications, OA is associated with considerable (healthcare) costs. However, studies evaluating cost-effectiveness of common exercise therapy in hip OA are lacking. Therefore, this randomised controlled trial is designed to investigate the cost-effectiveness of exercise therapy in conjunction with the general practitioner's (GP) care, compared to GP care alone, for patients with hip OA.

Methods/Design

Patients aged ≥ 45 years with OA of the hip, who consulted the GP during the past year for hip complaints and who comply with the American College of Rheumatology criteria, are included. Patients are randomly assigned to either exercise therapy in addition to GP care, or to GP care alone. Exercise therapy consists of (maximally) 12 treatment sessions with a physiotherapist, and home exercises. These are followed by three additional treatment sessions in the 5th, 7th and 9th month after the first treatment session. GP care consists of usual care for hip OA, such as general advice or prescribing pain medication. Primary outcomes are hip pain and hip-related activity limitations (measured with the Hip disability Osteoarthritis Outcome Score [HOOS]), direct costs, and productivity costs (measured with the PROductivity and DISease Questionnaire). These parameters are measured at baseline, at 6 weeks, and at 3, 6, 9 and 12 months follow-up. To detect a 25% clinical difference in the HOOS pain score, with a power of 80% and an alpha 5%, 210 patients are required. Data are analysed according to the intention-to-treat principle. Effectiveness is evaluated using linear regression models with repeated measurements. An incremental cost-effectiveness analysis and an incremental cost-utility analysis will also be performed.

Discussion

The results of this trial will provide insight into the cost-effectiveness of adding exercise therapy to GPs' care in the treatment of OA of the hip. This trial is registered in the Dutch trial registry http://www.trialregister.nl: trial number NTR1462.

Statin use is associated with reduced incidence and progression of knee osteoarthritis in the Rotterdam study

BACKGROUND

Osteoarthritis is the most frequent chronic joint disease causing pain and disability. Besides biomechanical mechanisms, the pathogenesis of osteoarthritis may involve inflammation, vascular alterations and dysregulation of lipid metabolism. As statins are able to modulate many of these processes, this study examines whether statin use is associated with a decreased incidence and/or progression of osteoarthritis.

METHODS

Participants in a prospective population-based cohort study aged 55 years and older (n=2921) were included. x-Rays of the knee/hip were obtained at baseline and after on average 6.5 years, and scored using the Kellgren and Lawrence score for osteoarthritis. Any increase in score was defined as overall progression (incidence and progression). Data on covariables were collected at baseline. Information on statin use during follow-up was obtained from computerised pharmacy databases. The overall progression of osteoarthritis was compared between users and non-users of statins. Using a multivariate logistic regression model with generalised estimating equation, OR and 95% CI were calculated after adjusting for confounding variables.

RESULTS

Overall progression of knee and hip osteoarthritis occurred in 6.9% and 4.7% of cases, respectively. The adjusted OR for overall progression of knee osteoarthritis in statin users was 0.43 (95% CI 0.25 to 0.77, p=0.01). The use of statins was not associated with overall progression of hip osteoarthritis.

CONCLUSIONS

Statin use is associated with more than a 50% reduction in overall progression of osteoarthritis of the knee, but not of the hip.

Clinically applied CT arthrography to measure the sulphated glycosaminoglycan content of cartilage

OBJECTIVE

Similar to delayed gadolinium enhanced MRI of cartilage, it might be possible to image cartilage quality using CT arthrography (CTa). This study assessed the potential of CTa as a clinically applicable tool to evaluate cartilage quality in terms of sulphated glycosaminoglycan content (sGAG) and structural composition of the extra-cellular matrix (ECM).

METHODS

Eleven human cadaveric knee joints were scanned on a clinical CT scanner. Of each knee joint, a regular non-contrast CT (ncCT) and an ioxaglate injected CTa scan were performed. Mean X-ray attenuation of both scans was compared to identify contrast influx in seven anatomical regions of interest (ROIs). All ROIs were rescanned with contrast-enhanced μCT, which served as the reference standard for sGAG content. Mean X-ray attenuation from both ncCT and CTa were correlated with μCT results and analyzed with linear regression. Additionally, residual values from the linear fit between ncCT and μCT were used as a covariate measure to identify the influence of structural composition of cartilage ECM on contrast diffusion into cartilage in CTa scans.

RESULTS

CTa resulted in higher X-ray attenuation in cartilage compared to ncCT scans for all anatomical regions. Furthermore, CTa correlated excellent with reference μCT values (sGAG) (R=0.86; R(2)=0.73; P<0.0001). When corrected for structural composition of cartilage ECM, this correlation improved substantially (R=0.95; R(2)=0.90; P<0.0001).

CONCLUSIONS

Contrast diffusion into articular cartilage detected with CTa correlates with sGAG content and to a lesser extent with structural composition of cartilage ECM. CTa may be clinically applicable to quantitatively measure the quality of articular cartilage.

Unraveling the human bone microenvironment beyond the classical extracellular matrix proteins: a human bone protein library

A characteristic feature of bone, differentiating it from other connective tissues, is the mineralized extracellular matrix (ECM). Mineral accounts for the majority of the bone tissue volume, being the remainder organic material mostly derived from collagen. This, and the fact that only a limited number of noncollagenous ECM proteins are described, provides a limited view of the bone tissue composition and bone metabolism, the more so considering the increasing understanding of ECM significance for cellular form and function. For this reason, we set out to analyze and extensively characterize the human bone proteome using large-scale mass spectrometry-based methods. Bone samples of four individuals were analyzed identifying 3038 unique proteins. A total of 1213 of these were present in at least 3 out of 4 bone samples. For quantification purposes, we were limited to noncollagenous proteins (NCPs) and we could quantify 1051 NCPs. Most classical bone matrix proteins mentioned in literature were detected but were not among the highly abundant ones. Gene ontology analyses identified high-abundance groups of proteins with a functional link to mineralization and mineral metabolism such as transporters, pyrophosphatase activity, and Ca(2+)-dependent phospholipid binding proteins. ECM proteins were as well overrepresented together with nucleosome and antioxidant activity proteins, which have not been extensively characterized as being important for bone. In conclusion, our data clearly demonstrates that human bone tissue is a reservoir of a wide variety of proteins. In addition to the classical osteoblast-derived ECM, we have identified many proteins from different sources and of unknown function in bone. Thus, this study represents an informative library of bone proteins forming a source for novel bone formation modulators as well as biomarkers for bone diseases such as osteoporosis.

Walking and chair rising performed in the daily life situation before and after total hip arthroplasty

OBJECTIVE

An earlier study showed that 6 months after total hip arthroplasty (THA) patients' overall daily activity level had not increased, despite significant improvement in their perceived physical functioning. This discrepancy might be because postoperative recovery is not expressed by a more overall active lifestyle, but by the fact that patients could perform the individual activities of daily living (ADL) faster and/or for a longer period of time. The aim of this study was to assess whether patients perform ADL faster and/or for a longer period of time 6 months post-THA compared to baseline. Also examined was whether patients perform activities on the level of healthy matched controls.

METHOD

Thirty patients were measured at home with an accelerometry-based Activity Monitor, pre-operatively and 6 months post-THA. Patients were matched with healthy controls on gender and age (±2 years).

RESULTS

Compared with baseline, 6 months post-THA the stride frequency and body motility during walking of patients had increased [56.1 (54.3, 57.8)strides/min vs 52.1 (50.3, 54.1)strides/min; P-value<0.0001, and 0.265 (0.245, 0.286)g vs 0.219 (0.197, 0.240)g; P-value<0.0001], and they rose faster from a chair [2.6 (2.5, 2.8)s vs 3.0 (2.8, 3.2)s; P-value<0.0001]. Compared with controls, preoperative all patients had lower values for these parameters. Six months post-THA the stride frequency and body motility during walking were similar to that of controls, but patients rose slower from a chair than controls.

CONCLUSION

Six months post-THA patients walked faster and rose from a chair faster compared to baseline. Patients walked as fast as healthy controls but took longer rising from a chair.

One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial

BACKGROUND

Achilles tendinopathy is a common disease among both athletes and in the general population in which the use of platelet-rich plasma has recently been increasing. Good evidence for the use of this autologous product in tendinopathy is limited, and data on longer-term results are lacking.

PURPOSE

To study the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Fifty-four patients, aged 18 to 70 years, with chronic tendinopathy 2 to 7 cm proximal to the Achilles tendon insertion were randomized to receive either a blinded injection containing platelet-rich plasma or saline (placebo group) in addition to an eccentric training program. The main outcome was the validated Victorian Institute of Sports Assessment-Achilles score. Patient satisfaction was recorded and ultrasound examination performed at baseline and follow-up.

RESULTS

The mean Victorian Institute of Sports Assessment-Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% confidence interval, -4.9 to 15.8, P = .292). In both groups, 59% of the patients were satisfied with the received treatment. Ultrasonographic tendon structure improved significantly in both groups but was not significantly different between groups (adjusted between-group difference, 1.2%; 95% confidence interval, -4.1 to 6.6, P = .647).

CONCLUSION

This randomized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection in chronic Achilles tendinopathy at 1 year combined with an eccentric training program.

Peroxisome proliferator activated receptor alpha activation decreases inflammatory and destructive responses in osteoarthritic cartilage

OBJECTIVE

Peroxisome proliferator activated receptor α (PPARα) agonists are used in clinical practice as lipid-lowering drugs and are also known to exert anti-inflammatory effects on various tissues. We hypothesized that PPARα activation leads to anti-inflammatory and anti-destructive effects in human OA cartilage.

METHODS

Cartilage explants obtained from six OA patients were cultured for 48 h with 10 ng/ml interleukin (IL)1β as a pro-inflammatory stimulus. 100 μM Wy-14643, a potent and selective PPARα agonist, was added to the cultures and gene expression of matrix metalloproteinase (MMP)1, MMP3, MMP13, collagen type II (COL2A1), aggrecan and PPARα in cartilage explants and the release of glycosaminoglycans (GAGs), nitric oxide (NO) and prostaglandin E(2) (PGE(2)) in the culture media were analyzed and compared to the control without Wy-14643.

RESULTS

Addition of Wy-14643 decreased mRNA expression of MMP1, MMP3 and MMP13 in cartilage explants that responded to IL1β, whereas Wy-14643 did not affect gene expression of COL2A1 and aggrecan. Wy-14643 also decreased secretion of inflammatory marker NO in the culture medium of cartilage explants responding to IL1β. Wy-14643 inhibited the release of GAGs by cartilage explants in culture media.

CONCLUSION

PPARα agonist Wy-14643 inhibited the inflammatory and destructive responses in human OA cartilage explants and did not have an effect on COL2A1 or aggrecan mRNA expression. These effects of PPARα agonists on osteoarthritic cartilage warrant further investigation of these drugs as a potential therapeutic strategy for osteoarthritis (OA).

Trochanteric osteotomy versus posterolateral approach: function the first year post surgery. A pilot study

Background

Although no prospective studies have compared functional results of trochanteric osteotomy and a non-trochanteric approach, most surgeons feel that trochanteric osteotomy is outdated in simple hip arthroplasty. Reasons not to perform an osteotomy include the fear of longer rehabilitation and worse (final) functional outcome.

Method

This prospective study examines differences in rehabilitation between posterolateral and trochanteric approach one year post-surgery using questionnaires (WOMAC, SF-36, HHS) and functional tests (walking, climbing stairs, rising from sitting, and strength tests). Of the 109 patients 24 had a trochanteric osteotomy: the selected approach was based on the surgeon's preference. The trochanteric osteotomy group included more patients with developmental dysplasia of the hip. Before the start of the study no power analysis was performed.

Results

Data from the questionnaires showed no significant differences between the two groups at 3, 6 and 12-months follow-up. At 3-months follow-up patients in the trochanteric osteotomy group scored lower on the functional tests. This difference had disappeared at 6 and 12-months follow-up, except for abduction force which remained lower in the trochanteric osteotomy group in patients with a non union of the TO.

Conclusion

For simple hip arthroplasty an approach without osteotomy seems a logical choice. Although the power of this study is low, in experienced hands trochanteric osteotomy seems to give good functional results at 6-12 months post surgery if trochanteric union is obtained. Therefore, one should not hesitate to perform an osteotomy in difficult cases.

Corticosteroid injections for greater trochanteric pain syndrome: a randomized controlled trial in primary care

PURPOSE

We undertook a study to evaluate the effectiveness of corticosteroid injections in primary care patients with greater trochanteric pain syndrome (GTPS).

METHODS

We evaluated the effect of corticosteroid injections compared with expectant treatment (usual care) in a pragmatic, multicenter, open-label, randomized clinical trial in the Netherlands. Patients (aged 18 to 80 years) with GTPS visiting 81 participating primary care physicians were randomly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). Primary outcomes of pain severity (numerical rating scale 0 to 10) and recovery (yes or no total or major recovery) were evaluated at 3-month and 12-month follow-up visits. Adverse events were collected at 6 weeks.

RESULTS

At the 3-month follow-up visit, 34% of the patients in the usual care group had recovered compared with 55% in the injection group (adjusted OR = 2.38; 95% CI, 1.14-5.00, number needed to treat = 5). Pain severity at rest and on activity decreased in both groups, but the decrease was greater in the injection group, for an adjusted difference in pain at rest of 1.18 (95% CI, 0.31-2.05) and in pain with activity of 1.30 (95% CI, 0.32-2.29). At the 12-month follow-up, 60% of the patients in the usual care group had recovered compared with 61% in the injection group (OR = 1.05; 95% CI, 0.50-2.27). Pain severity at rest and on activity decreased in both groups and the 12-month follow-up showed no significant differences, with adjusted differences of 0.14 (95% CI, -0.75 to 1.04) for pain at rest and 0.45 (95% CI, -0.55 to 1.46) for pain with activity. Aside from a short period with superficial pain at the site of the injection, no differences in adverse events were found.

CONCLUSION

In this first randomized controlled trial assessing the effectiveness of corticosteroid injections vs usual care in GTPS, a clinically relevant effect was shown at a 3-month follow-up visit for recovery and for pain at rest and with activity. At a 12-month follow-up visit, the differences in outcome were no longer present.

Clinically translatable cell tracking and quantification by MRI in cartilage repair using superparamagnetic iron oxides

BACKGROUND

Articular cartilage has very limited intrinsic regenerative capacity, making cell-based therapy a tempting approach for cartilage repair. Cell tracking can be a major step towards unraveling and improving the repair process of these therapies. We studied superparamagnetic iron oxides (SPIO) for labeling human bone marrow-derived mesenchymal stem cells (hBMSCs) regarding effectivity, cell viability, long term metabolic cell activity, chondrogenic differentiation and hBMSC secretion profile. We additionally examined the capacity of synovial cells to endocytose SPIO from dead, labeled cells, together with the use of magnetic resonance imaging (MRI) for intra-articular visualization and quantification of SPIO labeled cells.

METHODOLOGY/PRINICIPAL FINDINGS

Efficacy and various safety aspects of SPIO cell labeling were determined using appropriate assays. Synovial SPIO re-uptake was investigated in vitro by co-labeling cells with SPIO and green fluorescent protein (GFP). MRI experiments were performed on a clinical 3.0T MRI scanner. Two cell-based cartilage repair techniques were mimicked for evaluating MRI traceability of labeled cells: intra-articular cell injection and cell implantation in cartilage defects. Cells were applied ex vivo or in vitro in an intra-articular environment and immediately scanned. SPIO labeling was effective and did not impair any of the studied safety aspects, including hBMSC secretion profile. SPIO from dead, labeled cells could be taken up by synovial cells. Both injected and implanted SPIO-labeled cells could accurately be visualized by MRI in a clinically relevant sized joint model using clinically applied cell doses. Finally, we quantified the amount of labeled cells seeded in cartilage defects using MR-based relaxometry.

CONCLUSIONS

SPIO labeling appears to be safe without influencing cell behavior. SPIO labeled cells can be visualized in an intra-articular environment and quantified when seeded in cartilage defects.

Unfocused extracorporeal shock waves induce anabolic effects in rat bone

BACKGROUND

Extracorporeal shock waves are known to stimulate the differentiation of mesenchymal stem cells toward osteoprogenitors and induce the expression of osteogenic-related growth hormones. The aim of this study was to investigate if and how extracorporeal shock waves affected new bone formation, bone microarchitecture, and the mechanical properties of bone in a healthy rat model, in order to evaluate whether extracorporeal shock wave therapy might be a potential treatment for osteoporosis.

METHODS

Thirteen rats received 1000 electrohydraulically generated unfocused extracorporeal shock waves to the right tibia. The contralateral, left tibia was not treated and served as a control. At two, seven, twenty-one, and forty-nine days after administration of the shock waves, in vivo single-photon-emission computed tomography (SPECT) scanning was performed to measure new bone formation on the basis of uptake of technetium-labeled methylene diphosphonate ((99m)Tc-MDP) (n = 6). Prior to and forty-nine days after the extracorporeal shock wave therapy, micro-computed tomography (micro-CT) scans were made to examine the architectural bone changes. In addition, mechanical testing, microcrack, and histological analyses were performed.

RESULTS

Extracorporeal shock waves induced a strong increase in (99m)Tc-MDP uptake in the treated tibia compared with the uptake in the untreated, control tibia. Micro-CT analysis showed that extracorporeal shock waves stimulated increases in both trabecular and cortical volume, which resulted in higher bone stiffness compared with that of the control tibiae. Histological analysis showed intramedullary soft-tissue damage and de novo bone with active osteoblasts and osteoid in the bone marrow of the legs treated with extracorporeal shock waves. Microcrack analysis showed no differences between the treated and control legs.

CONCLUSIONS

This study shows that a single treatment with extracorporeal shock waves induces anabolic effects in both cancellous and cortical bone, leading to improved biomechanical properties. Furthermore, treatment with extracorporeal shock waves results in transient damage to the bone marrow, which might be related to the anabolic effects. After further examination and optimization, unfocused extracorporeal shock waves might enable local treatment of skeletal sites susceptible to fracture.

Adverse effects of extra-articular corticosteroid injections: a systematic review

BACKGROUND

To estimate the occurrence and type of adverse effects after application of an extra-articular (soft tissue) corticosteroid injection.

METHODS

A systematic review of the literature was made based on a PubMed and Embase search covering the period 1956 to January 2010. Case reports were included, as were prospective and retrospective studies that reported adverse events of corticosteroid injection. All clinical trials which used extra-articular corticosteroid injections were examined. We divided the reported adverse events into major (defined as those needing intervention or not disappearing) and minor ones (transient, not requiring intervention).

RESULTS

The search yielded 87 relevant studies:44 case reports, 37 prospective studies and 6 retrospective studies. The major adverse events included osteomyelitis and protothecosis; one fatal necrotizing fasciitis; cellulitis and ecchymosis; tendon ruptures; atrophy of the plantar fat was described after injecting a neuroma; and local skin effects appeared as atrophy, hypopigmentation or as skin defect. The minor adverse events effects ranged from skin rash to flushing and disturbed menstrual pattern. Increased pain or steroid flare after injection was reported in 19 studies. After extra-articular injection, the incidence of major adverse events ranged from 0-5.8% and that of minor adverse events from 0-81%. It was not feasible to pool the risk for adverse effects due to heterogeneity of study populations and difference in interventions and variance in reporting.

CONCLUSION

In this literature review it was difficult to accurately quantify the incidence of adverse effects after extra-articular corticosteroid injection. The reported adverse events were relatively mild, although one fatal reaction was reported.

Stiffer fixation of the tibial double-tunnel anterior cruciate ligament complex versus the single tunnel: a biomechanical study

PURPOSE

The primary objective of this study was to evaluate the difference in graft pullout forces, stiffness, and failure mode of double-bundle anterior cruciate ligament (ACL) reconstruction of the tibial insertion by use of a single tunnel compared with a double-tunnel technique with interference screw fixation.

METHODS

ACL reconstruction on the tibial side was performed on 40 fresh-frozen porcine knees (mean bone mineral density of 0.64 g/cm(2) measured by dual-energy x-ray absorptiometry scan), randomly assigned to the single- or double-tunnel group. Interference screw fixation of the soft-tissue graft was used for both types of tibial reconstruction. Maximum failure load, stiffness, and failure mode were recorded.

RESULTS

There was no significant difference in maximum failure load between the single-tunnel group (400 +/- 26 N) and double-tunnel group (440 +/- 20 N). Stiffness of the tibial tunnel complex was significantly higher in the double-tunnel group (76 +/- 3 N/mm) than in the single-tunnel group (62 +/- 4 N/mm) (P = .013). All but 2 grafts (38 of 40) failed by slippage of the tendon past the interference screw.

CONCLUSIONS

There was significantly stiffer fixation of the tibial double-tunnel ACL complex when compared with the single tunnel. Our study did not show a different failure mode for the double-tunnel reconstruction compared with the single-tunnel reconstruction.

CLINICAL RELEVANCE

This study shows a biomechanical advantage with no potential deleterious side effects for fixation of the ACL with a double-tunnel technique on the tibial side.

Stimulation of osteogenic differentiation in human osteoprogenitor cells by pulsed electromagnetic fields: an in vitro study

BACKGROUND

Although pulsed electromagnetic field (PEMF) stimulation may be clinically beneficial during fracture healing and for a wide range of bone disorders, there is still debate on its working mechanism. Mesenchymal stem cells are likely mediators facilitating the observed clinical effects of PEMF. Here, we performed in vitro experiments to investigate the effect of PEMF stimulation on human bone marrow-derived stromal cell (BMSC) metabolism and, specifically, whether PEMF can stimulate their osteogenic differentiation.

METHODS

BMSCs derived from four different donors were cultured in osteogenic medium, with the PEMF treated group being continuously exposed to a 15 Hz, 1 Gauss EM field, consisting of 5-millisecond bursts with 5-microsecond pulses. On culture day 1, 5, 9, and 14, cells were collected for biochemical analysis (DNA amount, alkaline phosphatase activity, calcium deposition), expression of various osteoblast-relevant genes and activation of extracellular signal-regulated kinase (ERK) signaling. Differences between treated and control groups were analyzed using the Wilcoxon signed rank test, and considered significant when p < 0.05.

RESULTS

Biochemical analysis revealed significant, differentiation stage-dependent, PEMF-induced differences: PEMF increased mineralization at day 9 and 14, without altering alkaline phosphatase activity. Cell proliferation, as measured by DNA amounts, was not affected by PEMF until day 14. Here, DNA content stagnated in PEMF treated group, resulting in less DNA compared to control.Quantitative RT-PCR revealed that during early culture, up to day 9, PEMF treatment increased mRNA levels of bone morphogenetic protein 2, transforming growth factor-beta 1, osteoprotegerin, matrix metalloproteinase-1 and -3, osteocalcin, and bone sialoprotein. In contrast, receptor activator of NF-κB ligand expression was primarily stimulated on day 14. ERK1/2 phosphorylation was not affected by PEMF stimulation.

CONCLUSIONS

PEMF exposure of differentiating human BMSCs enhanced mineralization and seemed to induce differentiation at the expense of proliferation. The osteogenic stimulus of PEMF was confirmed by the up-regulation of several osteogenic marker genes in the PEMF treated group, which preceded the deposition of mineral itself. These findings indicate that PEMF can directly stimulate osteoprogenitor cells towards osteogenic differentiation. This supports the theory that PEMF treatment may recruit these cells to facilitate an osteogenic response in vivo.

Medial knee osteoarthritis treated by insoles or braces: a randomized trial

BACKGROUND

There is controversial evidence regarding whether foot orthoses or knee braces improve pain and function or correct malalignment in selected patients with osteoarthritis (OA) of the medial knee compartment. However, insoles are safe and less costly than knee bracing if they relieve pain or improve function.

QUESTIONS/PURPOSES

We therefore asked whether laterally wedged insoles or valgus braces would reduce pain, enhance functional scores, and correct varus malalignment comparable to knee braces.

PATIENTS AND METHODS

We prospectively enrolled 91 patients with symptomatic medial compartmental knee OA and randomized to treatment with either a 10-mm laterally wedged insole (index group, n = 45) or a valgus brace (control group, n = 46). All patients were assessed at 6 months. The primary outcome measure was pain severity as measured on a visual analog scale. Secondary outcome measures were knee function score using WOMAC and correction of varus alignment on AP whole-leg radiographs taken with the patient in the standing position. Additionally, we compared the percentage of responders according to the OMERACT-OARSI criteria for both groups.

RESULTS

We observed no differences in pain or WOMAC scores between the two groups. Neither device achieved correction of knee varus malalignment in the frontal plane. According to the OMERACT-OARSI criteria, 17% of our patients responded to the allocated intervention. Patients in the insole group complied better with their intervention. Although subgroup analysis results should be translated into practice cautiously, we observed a slightly higher percentage of responders for the insole compared with bracing for patients with mild medial OA.

CONCLUSIONS

Our data suggest a laterally wedged insole may be an alternative to valgus bracing for noninvasively treating symptoms of medial knee OA.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.