Intra-articular injection of a substance P inhibitor affects gene expression in a joint contracture model

Substance P (SP), a neurotransmitter released after injury, has been linked to deregulated tissue repair and fibrosis in musculoskeletal tissues and other organs. Although SP inhibition is an effective treatment for nausea, it has not been previously considered as an anti-fibrotic therapy. Although there are extensive medical records of individuals who have used SP antagonists, our analysis of human registry data revealed that patients receiving these antagonists and arthroplasty are exceedingly rare, thus precluding a clinical evaluation of their potential effects in the context of arthrofibrosis. Therefore, we pursued in vivo studies to assess the effect of SP inhibition early after injury on pro-fibrotic gene expression and contractures in an animal model of post-traumatic joint stiffening. Skeletally mature rabbits (n = 24) underwent surgically induced severe joint contracture, while injected with either fosaprepitant (a selective SP antagonist) or saline (control) early after surgery (3, 6, 12, and 24 h). Biomechanical testing revealed that differences in mean contracture angles between the groups were not statistically significant (P = 0.27), suggesting that the drug neither mitigates nor exacerbates joint contracture. However, microarray gene expression analysis revealed that mRNA levels for proteins related to cell signaling, pro-angiogenic, pro-inflammatory, and collagen matrix production were significantly different between control and fosaprepitant treated rabbits (P < 0.05). Hence, our study demonstrates that inhibition of SP alters expression of pro-fibrotic genes in vivo. This finding will motivate future studies to optimize interventions that target SP to reduce the formation of post-traumatic joint contractures.

The natural progression of adult elbow osteonecrosis related to corticosteroid treatment

BACKGROUND

In patients with corticosteroid treatment, the elbow is a rare site of osteonecrosis; there is little information about the rate and risk factors of disease progression in symptomatic and asymptomatic elbows.

QUESTION/PURPOSES

We determined the delay between the beginning of corticosteroid treatment and different stages of osteonecrosis and which stage and dose of steroids influenced disease progression.

METHODS

Osteonecrosis related to corticosteroids was diagnosed by MRI in 50 elbows of 35 adult patients. Thirty elbows were asymptomatic at initial evaluation (19 with Stage I, 11 with Stage II osteonecrosis). Among the 20 elbows symptomatic at initial evaluation, 13 had radiographic evidence of osteonecrosis without collapse (Stage II) and seven had lesions evident only on MRI (Stage I).

RESULTS

At latest followup (average, 17 years; range, 10-25 years), of the 30 previously asymptomatic elbows, pain developed in 24 and collapse occurred in 14; of the 20 previously symptomatic elbows, 15 showed collapse (seven initially with Stage I, eight with Stage II osteonecrosis). The average time between diagnosis and collapse was 8 and 5 years, respectively, for symptomatic elbows with Stages I and II osteonecrosis. Stage at initial visit, development of pain, and continuation of peak doses of corticosteroids were risk factors for disease progression in asymptomatic elbows. In symptomatic elbows, the extent in contact with the articular surface and lesion location were the main risk factors for disease progression.

CONCLUSIONS

Untreated asymptomatic and symptomatic elbow osteonecrosis related to corticosteroids has a moderate likelihood of elbow collapse, with decrease in ROM, but none of the patients in this case series followed for 10 to 20 years had elbow arthroplasty.

LEVEL OF EVIDENCE

Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Efficacy of recombinant human alpha-L-iduronidase (laronidase) on restricted range of motion of upper extremities in mucopolysaccharidosis type I patients

The aims of the study were to assess the effectiveness of enzyme replacement therapy (ERT) with laronidase on the range of motion (ROM) of upper extremities and influence on activities of daily living (ADLs) of patients with mucopolysaccharidosis type I (MPS I). The ROM of 17 patients with MPS I was followed from the first year of life until the introduction of ERT and after 52-208 weeks of treatment. In all patients (group 1, n = 10), passive ROM was assessed. In patients with Hurler/Scheie or Scheie phenotype (group 2, n = 7) both passive and active ROM, as well as daily life activities, were evaluated. Passive and active ROM was measured by a goniometer, while a health assessment questionnaire was used to assess activities of daily living. The data since the first months of life until the beginning of treatment were obtained by retrospective review of patients' charts. Restriction in ROM of the upper extremities of patients with MPS I was observed from the first year of life. These limitations intensified and became more severe with the patients' age, making patients' self-care more difficult or even impossible. Introduction of ERT led to slower progression of symptoms, especially in the passive range of motion in all patients. Additionally, patients with normal mental development, or only slightly delayed (group 2), who underwent active physical rehabilitation (including mobilisation of nerve system, passive techniques for joint mobility, active gymnastics for muscle power, as well as massage and the training of families for therapy at home) showed improvement in active movement followed by enhanced self-care.

Intra-articular injection of hyaluronic acid is not effective for the treatment of post-traumatic osteoarthritis of the elbow

PURPOSE

In this study we evaluated the effect and safety of intra-articular injection of hyaluronic acid in 19 consecutive elbows with post-traumatic osteoarthritis.

METHODS

In 18 patients (10 male and 8 female patients; mean age, 45.6 years [SD, 15.0 years]), 3 injections of sodium hyaluronate were given within 4 weeks at regular intervals. Evaluation took place just before the first injection, as well as after 3 and 6 months, and consisted of the Elbow Function Assessment Score, the Functional Rating Index of Broberg and Morrey, and the Modified Andrews Elbow Scoring System. Pain was also assessed by means of visual analog scales.

RESULTS

Viscosupplementation resulted in slight, short-term pain relief and a very limited decrease in activity impairment at evaluation after 3 months. After 6 months, no beneficial effects were noticed in any of the 19 injected elbows. Other parameters were not influenced by treatment with viscosupplementation at any time. Systemic or local adverse effects did not occur.

CONCLUSIONS

Because the use of viscosupplementation for the treatment of post-traumatic osteoarthritis of the elbow provides only slight, short-term pain relief and a very limited decrease in activity impairment and the other parameters were not modified, we believe that viscosupplementation is not suitable for this indication.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Botulinum toxin for treatment of cocontractions related to obstetrical brachial plexopathy

Botulinum toxin type A was recently introduced for treatment of biceps - triceps muscle cocontraction, which compromises elbow function in children with obstetrical brachial plexopathy. This is our preliminary experience with this new approach. Eight children were treated with 2 - 3 U/kg of botulinum toxin injected in the triceps (4 patients) and biceps (4 patients) muscle, divided in 2 or 3 sites. All patients submitted to triceps injections showed a long-lasting improvement of active elbow flexion and none required new injections, after a follow-up of 3 to 18 months. Three of the patients submitted to biceps injections showed some improvement of elbow extension, but none developed anti-gravitational strength for elbow extension and the effect lasted only three to five months. One patient showed no response to triceps injections. Our data suggest that botulinum toxin can be useful in some children that have persistent disability secondary to obstetrical brachial plexopathy.

Effect of load level and muscle pain intensity on the motor control of elbow-flexion movements

This study assessed interactions between mild/moderate muscle pain and inertial load on the control of human elbow-flexion movements. It is hypothesized that high inertial load combined with moderate muscle pain intensity affect the motor control more than for low inertial-load combined with low-intensity pain. Fifteen subjects performed horizontal pointing movements (70 degree range) under three load conditions: 0, 4, and 10 kg. Pain was induced by injection of 0.5 ml and 1.5 ml hypertonic saline into the biceps muscle. Subjects scored the muscle pain intensity on a visual analogue scale (VAS). Elbow joint position, VAS, and the electromyograms (EMG, m. biceps brachii, m. triceps brachii, m. brachioradialis, and m. trapezius) were recorded. Mild and moderate muscle pain attenuated acceleration profiles [6.1(0.9)%], effective movement amplitude [3.2 (0.7)%], peak velocity [5.8 (0.9)%] and prolonged the reaction time [21 (5)%]. No interaction between muscle pain intensity and inertial load was found for the kinematic parameters. EMG profiles from m. biceps brachii, m. triceps brachii, and m. brachioradialis were similarly attenuated [10.2 (0.80)%] by mild and moderate muscle pain in all inertial load conditions. For high inertial load, the initial agonist EMG burst activity was more attenuated [50 (5.3)%] by moderate muscle pain compared with mild muscle pain [34 (4.2)%]. These data suggest that for high effort-demanding tasks muscle pain differently affects the motor planning according to the pain-intensity level. Perturbations of motor planning lead to changes on movement strategies, which might be a potential cause of musculoskeletal problems.

Reactive oligoarthritis in a patient with Clostridium difficile pseudomembranous colitis. Review of the literature

A 57-year-old man developed oligoarthritis of the right sacroiliac joint, knee and elbow in the wake of Clostridium difficile pseudomembranous colitis. He was HLA B27-positive and had a history of Reiter's syndrome. His joint manifestations resolved after a course of nonsteroidal antiinflammatory drug therapy and injection of the right knee with triamcinolone acetonide. Clostridium difficile should be recognized as a rare cause of reactive arthritis.

Action tremor and weakness in Parkinson's disease: a study of the elbow extensors

We have previously shown that action tremor persists during maximal wrist extension in patients with Parkinson's disease, and that this contributes to weakness at this joint by preventing the fully fused contraction of the forearm extensor muscles. Antiparkinsonian medication reduces the action tremor in torque and electromyographic (EMG) records, thereby improving strength at the wrist. In the present experiments, peak torque and action tremor were recorded during maximal extension of the elbow in nine patients with Parkinson's disease while they were on and off antiparkinsonian medication, and in eight age- and sex-matched healthy subjects. Peak torque and mean rectified EMG levels were reduced by 34% and 36%, respectively, during maximal elbow extension when patients off medication were compared to those in the treated state. Action tremor was visible in torque records and had a frequency of approximately 10 Hz both in parkinsonian patients and in normal controls. Activity of a similar frequency was often detected in EMG records, especially in patients off therapy. The absolute amplitude of action tremor in torque (A[torque]) and EMG (A[EMG]) records from the elbow was unaffected by therapy and was little different from that recorded in healthy controls. The relative action tremor in torque ([A(torque)/peak torque] x 100) and EMG ([A(EMG)/mean rectified EMG] x 100) was reduced by treatment, but this was the result of the increase in peak torque and mean rectified EMG. Thus, in contrast to the results at the wrist, antiparkinsonian medication has little effect on the 10-Hz action tremor at the elbow. Increased strength is produced by a different mechanism which allows recruitment of triceps motor units outside of this synchronizing influence.

Chemical synoviorthesis for hemophilic synovitis

For many years, Rifampicin has been used empirically for the treatment of hemophilic chronic synovitis with encouraging results. A study was performed in which Rifampicin was shown to reduce the inflammation of joints affected by hemophilic synovitis. A clinical study was performed on 48 hemophilic patients (48 joints). Seventeen elbows, eight knees, and 23 ankles were treated. The mean age of the patients was 6 years (range, 4-23 years) and the mean followup was 29 months (range, 24-53 months). Overall, 40 excellent results and eight good results were obtained. The average number of weekly injections of Rifampicin was 3.06 (range, 1-10 injections). Eight patients experienced pain on the first injection, which subsided gradually with the subsequent procedures. Synoviorthesis with Rifampicin seems to be a good method for the treatment of hemophilic synovitis, especially in small joints (elbows and ankles) and in younger children.

The diagnostic challenge of acute polyarthritis

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Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth

OBJECTIVES

To assess the efficacy and effects on cartilage and statural growth of intraarticular corticosteroid (IAS) therapy for chronic arthritis in children and adolescents.

METHODS

We examined 21 children and adolescents with chronic arthritis (median duration, 8 months) that did not respond to nonsteroidal antiinflammatory drugs. The 21 joints injected with triamcinolone-hexacetonide were examined before and 7 weeks after IAS therapy by gadolinium-enhanced magnetic resonance imaging; 14 joints were also examined 13 months after IAS therapy.

RESULTS

All joints treated with IAS had improvement. Magnetic resonance imaging showed long-lasting suppression of inflammation and pannus without evidence of toxic effects on cartilage. Statural growth was not affected.

CONCLUSION

In experienced hands, IAS therapy may be a safe and effective tool in the treatment of chronic arthritis in childhood. Long-term follow-up is mandatory.

The rheumatoid elbow: patterns of joint involvement and the outcome of synoviorthesis

Rheumatoid arthritis of the elbow is a common condition. A group of 86 patients has been reviewed. Patterns of joint involvement are described. These patients have been subjected to 137 radioisotopic synoviortheses. 72% achieved a result classed as "good" and this review underlines the efficacy of the procedure of synoviorthesis. Radiological staging has been shown to have prognostic significance; 89% of good results were obtained in management of Steinbrocker grade I. No complications were recorded.

Efficacy and safety of ibuprofen for hemophilic arthropathy

The safety and usefulness of ibuprofen (Motrin) were evaluated in 15 patients suffering from hemophilic arthropathy via a double-blind protocol with individual crossover. No significant increase in hemorrhagic episodes or alteration in platelet function was observed. A decrease in morning stiffness was noted in nine patients, and three decreased markedly their use of other pain medications. We conclude that ibuprofen represents a relatively safe agent for the management of discomfort caused by hemophilic arthropathy in a select group of hemophilic patients.