Palmitate has proapoptotic and proinflammatory effects on articular cartilage and synergizes with interleukin-1

Abstract

Objectives Obesity is a major risk factor for the development of osteoarthritis (OA) that is associated with a state of low-grade inflammation, and increased circulating adipokines and free fatty acids (FFA). The aim of this study was to analyze effects of saturated (palmitate) and monounsaturated (oleate) free fatty acids (FFA) on articular chondrocytes, synoviocytes and cartilage. Methods Human articular chondrocytes and fibroblast-like synoviocytes obtained from young healthy donors, and OA chondrocytes from patients undergoing totalknee replacement were treated with palmitate or oleate alone or with interleukin 1-β (IL-1β). Cell viability, caspase activation, and gene expression of proinflammatory factors, extracellular matrix proteins, and proteases were studied. In addition, chondrocyte viability, interleukin-6 (IL-6) production and matrix damage were assessed in bovine and human articular cartilage explants cultured with FFA with or without IL-1β. Results Palmitate, but not oleate, induced caspase activation and cell death in IL-1β-stimulated normal chondrocytes, and upregulated il6 and cox2 expression in chondrocytes and fibroblast-like synoviocytes through toll-like receptor-4 signaling. In cartilage explants, palmitate induced chondrocyte death, IL-6 release and extracellular matrix degradation. Palmitate synergized with IL-1β in stimulating proapoptotic and proinflammatory cellular responses. Pharmacological inhibition of caspases or TLR-4 signaling reduced palmitate and IL-1β-induced cartilage damage. Conclusions Palmitate acts as a pro-inflammatory and catabolic factor that, in synergy with IL-1β, induces chondrocyte apoptosis and articular cartilage breakdown. Collectively, our data suggest that elevated levels of saturated FFA often found in obesity may contribute to OA pathogenesis. © 2014 American College of Rheumatology.

Copyright © 2014 American College of Rheumatology.

KEYWORDS:

Osteoarthritis, cartilage, fatty acids

Evaluation of the effect of Lake Hévíz thermal mineral water in patients with osteoarthritis of the knee: a randomized, controlled, single-blind, follow-up study

Abstract

Background: Osteoarthritis is the most frequent joint disease and is a leading cause of pain and locomotor disability in elderly people. The treatment of osteoarthritis includes nonpharmacological, pharmacological, and surgical therapies. Silver level evidence has been found concerning balneotherapy in osteoarthritis. Aim of the study: The aim of this study was to evaluate how Lake Hévíz thermal mineral water therapy influences pain, kneefunction, and quality of life in patients with knee osteoarthritis, compared to the control group. Study Design: randomized, controlled, singleblind, followup study. Setting: Spa Hévíz and St. Andrew Hospital for Rheumatic Diseases Population: This study included 77 outpatients between 45 and 75 years of age with mild to moderate osteoarthritis of the kneemeeting the American College of Rheumatology classification criteria. Methods: Patients were randomized into two groups. In group I (n=38), subjects bathed in Lake Hévíz and in group II (n=39), patients were treated in a pool full of tap water. Water temperature was 34°C for both groups. Participants underwent 30minute therapy sessions, five times a week for three weeks. Outcome measures were pain visual analogue scale scores, active flexion degree, knee circumference, stairclimb time, Western Ontario and McMaster Universitiesosteoarthritis index (WOMAC), and EuroQoL Group 5Dimension SelfReport Questionnaire score (EQ5D). Study parameters were recorded at baseline, immediately after treatment, and after 15 weeks. Results: Comparison of the two groups revealed a statistically significant difference in pain visual analogue scale scores (p<0.01), active flexion degree (p<0.01), physical function components of WOMAC (p<0.05), and EQ5D scores (p<0.05) even after 15 weeks. Conclusions: Balneotherapy improved pain, function as well as the quality of life in patients with knee osteoarthritis. Clinical Rehabilitation Impact: Balneotherapy is a potentially useful treatment modality for patients with knee osteoarthritis.

PMID:

 

24594851

 

[PubMed - as supplied by publisher]

Autologous Chondrocyte Implantation in the Patella: A Multicenter Experience

Abstract

BACKGROUND:Cartilage defects in the patella are common, and a subset of patients does not respond to nonoperative measures. While most cartilage repair techniques have demonstrated good outcomes in the femoral condyles, the patellofemoral compartment poses special challenges. HYPOTHESIS:Repair of patellar cartilage defects with autologous chondrocyte implantation (ACI) will provide lasting improvements in pain and function. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Patients were treated at 1 of 4 participating cartilage repair centers with ACI for cartilage defects in the patella; bipolar (patella + trochlea) defects were included as well. All patients were followed prospectively for at least 4 years with multiple patient-reported outcome instruments, including the International Knee Documentation Committee, Short Form-12, modified Cincinnati Rating Scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee Society scores. Treatment failure was defined as structural failure of the graft combined with pain requiring revision surgery. RESULTS:A total of 110 patients were available for analysis. As a group, they experienced both statistically significant and clinically important improvements in pain and function in all physical outcome scales. The International Knee Documentation Committee improved from 40 ± 14 preoperatively to 69 ± 20 at the last follow-up; the Cincinnati Rating Scale, from 3.2 ± 1.2 to 6.2 ± 1.8; and the Western Ontario and McMaster Universities Osteoarthritis Index, from 50 ± 22 to 29 ± 22 (all P < .0001). Ninety-two percent of patients stated that they would choose to undergo ACI again, and 86% rated their knees as good or excellent at the time of final follow-up. Nine patients (8%) were considered treatment failures, and 16% reported that their knees were not improved. CONCLUSION:Cartilage repair in the patellofemoral joint is arguably not without its challenges. Autologous chondrocyte implantation remains off-label in the patella, a fact that needs to be discussed with prospective patients during the informed consent process. However, when performed with attention to patellofemoral biomechanics, self-rated subjective good and excellent outcomes can be achieved in more than 80% of patients treated with ACI, even in a patient population with large and frequently bipolar defects such as the one presented in this study. However, final functional scores, although significantly improved, still reflected residual disability in this challenging group of patients.

KEYWORDS:

autologous chondrocyte implantation, cartilage repair, multicenter study, patellofemoral

PMID:

 

24595400

 

[PubMed - as supplied by publisher]

A pre-operative group rehabilitation programme provided limited benefit for people with severe hip and knee osteoarthritis

Abstract

Abstract Purpose: To determine if a pre-operative group rehabilitation programme can improve arthritis self-efficacy for people with severe hip and knee osteoarthritis. Method: Single group, repeated measures design: 4-week baseline phase followed by a 6-week intervention phase of water exercise, and education with self-management strategies. The primary outcome was arthritis self-efficacy. The secondary outcomes were measures of pain (WOMAC), activity limitation (WOMAC), activity performance (30 s chair stand test, 10 m walk test) and health-related quality of life (EuroQol). Results: Twenty participants (10 kneeosteoarthritis and 10 hip osteoarthritis) with a mean age of 71 years (SD 7) attended 92% (SD 10%) of the scheduled sessions. All measures demonstrated baseline stability between two time points for measurements at week 1 and measurements at week 4. After the 6-week intervention programme there were no significant improvements for arthritis self-efficacy. There was a 12% increase for fast walking speed (mean increase of 0.14 m/s, 95% CI 0.07, 0.22). There were no significant improvements for other secondary outcomes. Conclusions: A pre-operative water-based exercise and educational programme did not improve arthritis self-efficacy, self-reported pain and activity limitation, and health-related quality of life for people with hip and knee osteoarthritis who were candidates for joint replacement. While there was a significant increase in one measure of activity performance (walking speed), these findings suggest the current programme may be of little value. Implications for Rehabilitation This pre-operative group rehabilitation programme for people with severe hip and knee osteoarthritis did not change arthritis self-efficacy, pain, activity limitation and health-related quality of life. This programme may have little value in preparing people for jointreplacement surgery. The optimal pre-operative programme requires further design and investigation.

PMID:

 

24597936

 

[PubMed - as supplied by publisher]

Outcomes of total knee arthroplasty in relation to preoperative patient-reported and radiographic measures: data from the osteoarthritis initiative

Abstract

INTRODUCTION:

Total knee arthroplasty (TKA) is the preferred surgical treatment for end-stage osteoarthritis. However, substantial numbers of patients still experience poor outcomes. Consequently, it is important to identify which patient characteristics are predictive of outcomes in order to guide clinical decisions. Our hypothesis is that preoperative patient-reported outcome measures and radiographic measures may help to predict TKA outcomes.

METHODS:

Using cohort data from the Osteoarthritis Initiative, we studied 172 patients who underwent TKA. For each patient, we compiled pre- and postoperative Western Ontario and McMaster University Arthritis Index (WOMAC) scores. Radiographs were measured for knee joint angles, femorotibial angles, anatomical lateral distal femoral angles, and anatomical medial proximal tibial angles; Kellgren and Lawrence (KL) grades were assigned to each compartment of the knee. All studied measurements were compared to WOMAC outcomes.

RESULTS:

Preoperative WOMAC disability, pain, and total scores were positively associated with postoperative WOMAC total scores (P = .010, P = .010, and P = .009, respectively) and were associated with improvement in WOMAC total scores (P < .001, P < .001, and P < .001, respectively). For radiographic measurements, preoperative joint angles were positively associated with improvements in postoperative WOMAC total scores (P = .044). Combined KL grades (medial and lateral compartments) were negatively correlated with postoperative WOMAC disability and pain scores (P = .045 and P = .044) and were positively correlated with improvements in WOMAC total scores (P = .001).

CONCLUSIONS:

All preoperative WOMAC scores demonstrated positive associations with postoperative WOMAC scores, while among the preoperative radiographic measurements only combined KL grades and joint angles showed any correlation with postoperative WOMAC scores. Higher preoperative KL grades and joint angles were associated with better (lower) postoperative WOMAC scores, demonstrating an inverse correlation.

KEYWORDS:

Kellgren and Lawrence grades, outcome predictors, patient-reported outcome measures, primary total knee arthroplasty, radiographic measures

PMID:

 

24600532

 

[PubMed] 

PMCID:

 

PMC3943364

 

The immediate effect of lateral wedge insoles, with and without a subtalar strap, on the lateral trunk lean motion in patients with knee osteoarthritis

Abstract

BACKGROUND:

Orthotic interventions for knee osteoarthritis (OA) aim to reduce mechanical loading on the medial compartment of the knee and may lessen the lateral trunk lean as the most important compensatory gait strategy. The lateral wedge insole is a known orthotic intervention for knee OA. However, the question whether the addition of a subtalar strap to the wedge improves its effect has not been addressed in the literature.

OBJECTIVE:

To compare the effects of lateral wedge insoles, with and without a subtalar strap, on the lateral trunk lean in patients with knee OA.

METHODS:

Twenty-three patients aged over 40 years, with grade I or II OA of the medial compartment of one knee, based on the American College of Rheumatology criteria, were included in this study. The patients were diagnosed with OA based on a clinical examination, and the diagnosis was confirmed with radiographs. A 3-dimensional motion measurement system was used to collect the gait data for 3 different conditions: (1) with no insole, (2) with a lateral wedge insole, and (3) with a lateral wedge insole and a subtalar strap. The immediate effect of the 3 test conditions on the lateral trunk lean was compared during a gait cycle a stance phase and at the point of midstance.

RESULTS:

Based on the laboratory coordinate system, the 3 conditions had no significant effect on the lateral trunk lean during a gait cycle and a stance phase and at the point of midstance in patients with knee OA.

CONCLUSION:

The results of this study demonstrated that the lateral wedge insoles, with and without a subtalar strap, had no immediate effect on the lateral trunk lean in patients with knee OA. However, the long-term effect of lateral wedge insoles on the lateral trunk lean in these patients requires further investigation.

KEYWORDS:

insole, knee, osteoarthritis, subtalar strap, trunk

PMID:

 

24600533

 

[PubMed] 

PMCID:

 

PMC3943361

 

No Benefit of Patient-specific Instrumentation in TKA on Functional and Gait Outcomes

Abstract

BACKGROUND:

Although some clinical reports suggest patient-specific instrumentation in TKA may improve alignment, reduce surgical time, and lower hospital costs, it is unknown whether it improves pain- and function-related outcomes and gait.

QUESTIONS/PURPOSES:

We hypothesized that TKA performed with patient-specific instrumentation would improve patient-reported outcomes measured by validated scoring tools and level gait as ascertained with three-dimensional (3-D) analysis compared with conventional instrumentation 3 months after surgery.

METHODS:

We randomized 40 patients into two groups using either patient-specific instrumentation or conventional instrumentation. Patients were evaluated preoperatively and 3 months after surgery. Assessment tools included subjective functional outcome and quality-of-life (QOL) scores using validated questionnaires (New Knee Society Score^©[KSS], Knee Injury and Osteoarthritis Outcome Score [KOOS], and SF-12). In addition, gait analysis was evaluated with a 3-D system during level walking. The study was powered a priori at 90% to detect a difference in walking speed of 0.1 m/second, which was considered a clinically important difference, and in a post hoc analysis at 80% to detect a difference of 10 points in KSS.

RESULTS:

There were improvements from preoperatively to 3 months postoperatively in functional scores, QOL, and knee kinematic and kinetic gait parameters during level walking. However, there was no difference between the patient-specific instrumentation and conventional instrumentation groups in KSS, KOOS, SF-12, or 3-D gait parameters.

CONCLUSIONS:

Our observations suggest that patient-specific instrumentation does not confer a substantial advantage in early functional or gait outcomes after TKA. It is possible that differences may emerge, and this study does not allow one to predict any additional variances in the intermediate followup period from 6 months to 1 year postoperatively. However, the goals of the study were to investigate the recovery period as early pain and functional outcomes are becoming increasingly important to patients and surgeons.

LEVEL OF EVIDENCE:

Level I, therapeutic study. See the Instructions to Authors for a complete description of levels of evidence.

PMID:

 

24604110

 

[PubMed - as supplied by publisher]

Changes in bone mineral density of both proximal femurs after total knee arthroplasty

BACKGROUND:

This study investigated the effects of total knee arthroplasty (TKA) on bone mineral density (BMD) of the proximal femur in patients who underwent the procedure.

METHODS:

Forty-eight patients scheduled to undergo unilateral TKA because of primaryknee osteoarthritis were included in this study, which was conducted at a medical center between October 2006 and October 2009. In these 48 patients, 96 hips were evaluated. Measurement of BMD was performed preoperatively and one month, three months, six months, and one year after unilateral TKA. Repeated measured analysis of variance and paired t-tests for comparison of two repeated samples were used to compare differences between time points (preoperation, one, three, six, and 12 months) and between the operative and nonoperative sides.

RESULTS:

Preoperatively, BMD of the femoral neck, trochanter, and total hip on the operative side were lower than on the nonoperative side; however, there was no statistical difference. BMD of both femoral neck areas was significantly lower than preoperative BMD at one month and three months after TKA. BMD of both trochanter areas was significantly lower than preoperative BMD at one month and three months after TKA. BMD of both total hips was significantly lower than preoperative BMD at three months after TKA. However, no statistical differences of changes in BMD were observed between the operative and nonoperative sides at each measurement time.

CONCLUSIONS:

According to our results, TKA was found to affect both proximal femurs during the acute period. However, TKA did not affect a change in BMD of the proximal femur during one year postoperative.

KEYWORDS:

Bone mineral density, Proximal hip, Total knee arthroplasty

Return to sport following shoulder surgery in the elite pitcher: a systematic review

Abstract

CONTEXT:

The ability to return to elite pitching, performance, and clinical outcomes of shoulder surgery in elite baseball pitchers are not definitively established.

OBJECTIVE:

To determine (1) the rate of return to sport (RTS) in elite pitchers following shoulder surgery, (2) postoperative clinical outcomes upon RTS, and (3) performance upon RTS and to compare RTS rates in different types of shoulder surgery.

DATA SOURCES:

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.

STUDY SELECTION:

Levels I-IV evidence were eligible for inclusion if performance-based (eg, RTS) and/or clinical outcome-based reporting of outcomes were reported following surgical treatment of shoulder pathology in elite pitchers (major or minor league or collegiate).

DATA EXTRACTION:

Subject, shoulder, and pre- and postoperative performance-based variables of interest were extracted. All shoulder surgery types were potentially inclusive (eg, open, arthroscopic, rotator cuff, labrum, biceps, acromioclavicular joint, fracture). Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS).

RESULTS:

Six studies were analyzed (287 elite male pitchers [mean age, 27 years] who underwent shoulder surgery, with 99% on the dominant, throwing shoulder). MCMS was 38 (poor). Most pitchers were professional, with a mean career length of 6.58 years and postoperative clinical follow-up of 3.62 years. In 5 of 6 studies, multiple diagnoses were addressed concomitantly at surgery. Rate of RTS was 68% at mean 12 months following surgery. Twenty-two percent of Major League Baseball (MLB) pitchers never RTS in MLB. Overall performance did improve following surgery; however, this did not improve to pre-injurylevels.

CONCLUSION:

In this systematic review, the rate of return to elite baseball pitching following surgery was established. Performance tended to decrease prior to surgery and gradually improve postoperatively, though not reaching pre-injury levels of pitching.

LEVEL OF EVIDENCE:

IV (systematic review of studies level I-IV evidence), therapeutic.

KEYWORDS:

Major League Baseball, arthroscopy, pitcher, shoulder, surgery

PMID:

 

24459557

 

[PubMed] 

PMCID:

 

PMC3899910

 [Available on 2014/7/1]

Rotator cuff tears in children and adolescents: experience at a large pediatric hospital

Abstract

BACKGROUND:

Prior literature, limited to small case series and case reports, suggests that rotator cuff tears are rare in adolescents. However, we have identified rotator cuff tears in numerous children and adolescents who have undergone shoulder MRI evaluation.

OBJECTIVE:

The purpose of this study is to describe the prevalence and characteristics ofrotator cuff tears in children and adolescents referred for MRI evaluation of the shoulder at a large pediatric hospital and to correlate the presence of rotator cuff tears with concurrent labral pathology, skeletal maturity and patient activity and outcomes.

MATERIALS AND METHODS:

We reviewed reports from 455 consecutive non-contrast MRI and magnetic resonance arthrogram examinations of the shoulder performed during a 2-year period, and following exclusions we yielded 205 examinations in 201 patients (ages 8-18 years; 75 girls, 126 boys). Rotator cuff tears were classified by tendon involved, tear thickness (partial or full), surface and location of tear (when partial) and presence of delamination. We recorded concurrent labral pathology when present. Physeal patency of the proximal humerus was considered open, closing or closed. Statistical analysis was performed to evaluate for a relationship between rotator cuff tears and degree of physeal patency. We obtained patient activity at the time of injury, surgical reports and outcomes from clinical records when available.

RESULTS:

Twenty-five (12.2%) rotator cuff tears were identified in 17 boys and 7 girls (ages 10-18 years; one patient had bilateral tears). The supraspinatus tendon was most frequently involved (56%). There were 2 full-thickness and 23 partial-thickness tears with articular-side partial-thickness tears most frequent (78%). Insertional partial-thickness tears were more common (78%) than critical zone tears (22%) and 10 (43%) partial-thickness tears were delamination tears. Nine (36%) patients with rotator cuff tears had concurrent labral pathology. There was no statistically significant relationship between rotator cuff tears and physeal patency (P > 0.05). Most patients were athletes (76%). Five tears were confirmed at surgery. Poor clinical follow-up limited evaluation of patient outcomes.

CONCLUSION:

Rotator cuff tears can be identified during MRI examination of symptomatic child and adolescent shoulders and often consist of tear patterns associated with repetitive microtrauma in overhead athletic activities or with single traumatic events. Rotator cuff tears are seen throughout the range of skeletal maturity, often coexist with labral tears and typically are found in athletes.

PMID:

 

24473866

 

[PubMed - as supplied by publisher]

Advanced Age Diminishes Tendon-to-Bone Healing in a Rat Model of Rotator Cuff Repair

Abstract

BACKGROUND:Advanced patient age is associated with recurrent tearing and failure ofrotator cuff repairs clinically; however, basic science studies have not evaluated the influence of aging on tendon-to-bone healing after rotator cuff repair in an animal model.Hypothesis/ PURPOSE:This study examined the effect of aging on tendon-to-bone healing in an established rat model of rotator cuff repair using the aged animal colony from the National Institute on Aging of the National Institutes of Health. The authors hypothesized that normal aging decreases biomechanical strength and histologic organization at the tendon-to-bone junction after acute repair. STUDY DESIGN:Controlled laboratory study. METHODS:In 56 F344xBN rats, 28 old and 28 young (24 and 8 months of age, respectively), the supraspinatus tendon was transected and repaired. At 2 or 8 weeks after surgery, shoulder specimens underwent biomechanical testing to compare load-to-failure and load-relaxation response between age groups. Histologic sections of the tendon-to-bone interface were assessed with hematoxylin and eosin staining, and collagen fiber organization was assessed by semiquantitative analysis of picrosirius red birefringence under polarized light. RESULTS:Peak failure load was similar between young and old animals at 2 weeks after repair (31% vs 26% of age-matched uninjured controls, respectively; P > .05) but significantly higher in young animals compared with old animals 8 weeks after repair (86% vs 65% of age-matched uninjured controls, respectively; P < .01). Eight weeks after repair, fibroblasts appeared more organized and uniformly aligned in young animals on hematoxylin and eosin slides compared with old animals. Collagen birefringence analysis of the tendon-to-bone junction demonstrated that young animals had increased collagen fiber organization and similar histologic structure compared with age-matched controls (53.7 ± 2.4 gray scales; P > .05). In contrast, old animals had decreased collagen fiber organization and altered structure compared with age-matched controls (49.8 ± 3.1 gray scales; P < .01).Discussion:In a rat model of aging, old animals demonstrated diminished tendon-to-bone healing after rotator cuff injury and repair. Old animals had significantly decreased failure strength and collagen fiber organization at the tendon-to-bone junction compared with young animals. This study implies that animal age may need to be considered in future studies of rotator cuff repair in animal models. CLINICAL RELEVANCE:With increasing age and activity level of the population, the incidence of rotator cuff tears is predicted to rise. Despite advances in rotator cuff repair technique, the retear rate remains specifically high in elderly patients. The findings of this research suggest that aging negatively influences tendon-to-bone healing after rotator cuff repair in a validated animal model.

KEYWORDS:

aging, biomechanics, elderly, quasi-linear viscoelastic, rehabilitation, rotator cufftear, shoulder

PMID:

 

24500915

 

[PubMed - as supplied by publisher]

Patient adherence with postoperative restrictions after rotator cuff repair

Abstract

HYPOTHESIS:

This study aimed to measure self-reported patient adherence to postoperative restrictions after rotator cuff repair, to evaluate correlations between adherence and functional outcome, and to identify possible indicators of poor adherence. We believed that poor adherence would correlate with poor functional outcome.

METHODS:

Fifty consecutive patients undergoing repair for rotator cuff tears were included and instructed to wear an abduction brace for 6 weeks after surgery. Functional evaluations, including American Shoulder and Elbow Surgeons score, University of California-Los Angeles shoulder score, and Simple Shoulder Test, were made preoperatively and postoperatively. Patients commented on their adherence with a medical adherence measurement questionnaire.

RESULTS:

Average adherence was 88% (range, 59.2-100). There were no significant correlations between adherence and improvement in American Shoulder and Elbow Surgeons, University of California-Los Angeles, or Simple Shoulder Test scores after rotator cuff repair (P = .06245, .5891, and .7688). Of the patient demographics analyzed, only smoking status had a positive effect on adherence (P = .00432; coefficient, 9.867). All other demographics, including hand dominance, mechanism of injury, repair complexity, comorbidities, living status, employment status, and age, had no significant effect on self-measured adherence to postoperative restrictions (P = .7876, .5889, .6444, .4190, .0609, .4171, .5402).

CONCLUSIONS:

Patients' self-reported adherence did not correlate with shoulder outcome as measured on any of 3 functional outcome scores.

Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

KEYWORDS:

Adherence, demographics, functional outcome, indicators, physical therapy, postoperative, restriction, rotator cuff repair

PMID:

 

24581418

 

[PubMed - as supplied by publisher]

Female patients with late-onset legg-calvé-perthes disease are frequently gymnasts

BACKGROUND:

The cause of Legg-Calvé-Perthes disease (LCPD) is unknown. We have observed a relatively high prevalence of female gymnasts presenting with LCPD. The purpose of this study was to determine: (1) the percentage of LCPD patients exposed to high-level gymnastics training, (2) the demographics of this subset of patients, and (3) their clinical outcomes.

METHODS:

Several adolescent female gymnasts presented to our clinic with recent-onset LCPD. We reviewed our cases to discern the prevalence and treatment of the disorder in this patient cohort. From 1999 to 2010, 572 patients were evaluated for a diagnosis of LCPD at our tertiary referral center. Clinical records were retrospectively reviewed. Of those, 13 patients had a history of gymnastics participation with 8 patients (all females) having competitive participation.

RESULTS:

For females aged 10 years and older presenting with LCPD, 7 of 9 patients (78%) were involved in high-level competitive gymnastics. These patients had disease onset between 10 and 12 years of age (mean, 11 y). Competitive gymnasts represented 6.6% (8 of 120) of females with LCPD and 1.4% (8 of 572) of all patients evaluated with LCPD during the study period. Only 1 of 111 females below 10 years with LCPD participated in competitive gymnastics (χ, P<0.0001).Patients underwent a variety of treatments. Two patients underwent nonoperative treatment, and the remainder underwent surgical management. All 7 gymnasts had a Stulberg IV result. In the nongymnast group of females 10 years and older, there were 1 Stulberg III result and 1 Stulberg IV result.

CONCLUSIONS:

At our center, competitive gymnasts comprise >75% of the female patients over the age of 10 who presented with late-onset LCPD. Results in general were poor. Further studies are needed to explore the association between the physical demands of advanced gymnastic training and the development of LCPD in this subset of patients.

LEVEL OF EVIDENCE:

IV, case series.

PMID:

 

24065070

 

[PubMed - in process]

Two article for LCP

[Accuracy of proximal femur correction achieved with LCP paediatric hip plates].

Abstract

PURPOSE OF THE STUDY:

The aim of the study was to evaluate, in comparison with the pre-operative planning, the accuracy of proximal femur correction achieved with the use of locking compression paediatric hip plates (LCP) in children and adolescents and to assess pre- and post-operative complications.

MATERIAL AND METHODS:

A group of 52 patients in whom proximal femoral osteotomy using the LCP was performed on a total of 55 hips between September 2009 and February 2013 were retrospectively evaluated. The following diagnoses were treated: unstable hip in cerebral palsy, 18 operations; Legg-Calvé-Perthes disease, 10 operations; coxa vara of aetiology other than coxa vara adolescentium (CVA), eight operations; true CVA, six operations; femoral shortening by the Wagner method, six procedures; proximal femoral derotation osteotomy, four procedures; and post-traumatic pseudoarthrosis of the proximal femur, three operations.

RESULTS:

Compared with the pre-operative plan, the average deviation of the colodiaphyseal angle was 5.2° (1° to 11°) in 18 unstable hips; 4.7° (1° to 10°) in 10 cases of Legg-Calvé-Perthes disease; 4.5° (3° to 6°) in eight hips with coxa vara of aetiology other than CVA; 6.5° (2° to 13°) in six CVA hips; 4.5° (1° to 10°) in six cases of femoral shortening; 3.5° (1° to 5°) in four derotation osteotomies; and 3.7° (0° to 6°) in three corrections of pseudoarthrosis. In one patient, osteosynthesis failed due to screws being pulled out from the proximal fragment; re-osteosynthesis was carried out using a conventional angled blade plate.

DISCUSSION:

As in other international studies, our results confirmed a high accuracy of proximal femur correction with use of the LCP instrumentation. The reported higher time requirement for this technique seems to be related to the learning curve and, with more frequent use, will probably be comparable to the time needed for application of conventional hip angled plates.

CONCLUSIONS:

The up-to-date LCP fixation system using the principle of angular stability for correction of the proximal femur in children is a clear advancement and its higher costs are certain to be outweighed by its higher accuracy and thus better results.

PMID:

 

24119475

 

[PubMed - in process]

 

[Tönnis and Kalchschmidt triple pelvic osteotomy].

Abstract

OBJECTIVE:

With three precise osteotomies it is possible to move the acetabulum to achieve sufficient coverage in dysplastic hips.

INDICATIONS:

Main indication is a painful dysplastic hip. Other acetabular pathologies, such as retroversion can also be addressed. In recent years young patients with Legg-Calve-Perthes disease

CONTRAINDICATIONS:

Patients with an arthrosis (Tönnis level 2) and obesity often have poor results. Therefore the combination of these parameters should be seen as a contraindication.

SURGICAL TECHNIQUE:

The operation starts with the patient in a lateral decubitus position. The first incision is parallel to the sacrotuberal ligament. The gluteus maximus muscle is spread until the ligament itself with its bony connection at the tuber ischiadicum is visible. After putting two special retractors in the foramen obturatorium and one to the spina ischiadica, osteotomy of the os ischium is performed from the incisura ischiadica to the foramen obturatorium. For the next osteotomy the os pubis is approached and it should be performed subperiostally. The vasa and nervus obturatorius and femoralis should be protected. At the os ilium the abdominal muscles are separated from the iliac crest. The third osteotomy has a 90° angle and starts at the linea terminalis and leads just below the spina iliaca anterior superior iliac spine. The acetabulum can now be moved with a Schanz screw. At this point it is necessary to elevate the os pubis while moving the acetabulum laterally. This prevents a lateralization and reduces the distance at the iliac osteotomy. The osteosynthesis is performed with screws at the os ilium and also at the os pubis.

POSTOPERATIVE MANAGEMENT:

Patients are advised to avoid weight bearing for 12 weeks. In the first 6 weeks they are allowed to perform a maximum flexion of 60°.

RESULTS:

According to the Harris hip score 80.4 % of the patients showed good and very good results after 11.5 years. In cases with arthrosis and obesity a higher rate of poor results were found.

PMID:

 

24085351

 

[PubMed - in process]

 

Guided growth of the trochanteric apophysis combined with soft tissue release for Legg-Calve-Perthes disease

Abstract

During the initial fragmentation stage of Perthes disease, the principle focus is to achieve containment of the femoral head within the acetabulum. Whether by bracing, abduction casts, femoral and/or pelvic osteotomy, the goals are to maximize the range of hip motion and to avoid incongruity, hoping to avert subsequent femoro-acetabular impingement or hinge abduction. A more subtle and insidious manifestation of the disease relates to growth disturbance involving the femoral neck. We have chosen to tether the greater trochanteric physis, combined with a medial soft tissue release, as part of our non-osteotomy management strategy for select children with progressive symptomatology and related radiographic changes. In addition to providing containment, we feel that this strategy addresses potential long-range issues pertaining to limb length and abductor mechanics, while avoiding iatrogenic varus deformity caused by osteotomy. This is a retrospective review of 12 patients (nine boys, three girls), average age 7.3 years old (range 5.3-9.7), who underwent non-osteotomy surgery for Perthes disease. An eight-plate was applied to the greater trochanteric apophysis at the time of arthrogram, open adductor and iliopsoas tenotomy, and Petrie cast application. We compared clinical and radiographic findings at the outset to those at an average follow-up of 49 months (range 14-78 months). Six plates were subsequently removed; the others remain in situ. Eleven of twelve patients experienced improvement in pain, and alleviation of limp and Trendelenburg sign at latest follow-up. The majority had improved or maintained range of motion and prevention of trochanteric impingement demonstrated by near normalization of abduction. Neck-shaft angles, Shenton's line, extrusion index, center edge angles and trochanteric height did not change significantly. One patient underwent subsequent trochanteric distalization and no other patients have undergone subsequent femoral or periacetabular osteotomies. Leg length discrepancy worsened in four patients and was treated with contralateral eight-plate distal femoral epiphysiodesis. As a group the mean leg length discrepancy did not change significantly. There were no perioperative complications. six trochanteric plates were subsequently removed after an average of 43.7 months (range 28-69) due to irritation of hardware; the others remain in situ, pending further growth. We employed open adductor and iliopsoas tenotomy and Petrie cast application and guided growth of the greater trochanter as a means of redirecting the growth of the common proximal femoral chondroepiphysis. The accrued benefits of preventing relative trochanteric overgrowth with a flexible tether are the avoidance of iatrogenic varus and weakening of the hip abductors. The goals are to preserve abductor strength and avoid trochanteric transfer or intertrochanteric osteotomy.

PMID:

 

24563149

 

[PubMed - as supplied by publisher]