Journal of Orthopaedic Surgery and Research - Most viewed articles

Septic arthritis in patients with rheumatoid arthritis

Abdulaziz Al-Ahaideb — 2008-07-29

There is an increasing number of rheumatoid patients who get septic arthritis. Chronic use of steroids is one of the important predisposing factors. The clinical picture of septic arthritis is different in immunocompromised patients like patients with rheumatoid arthritis. The diagnosis and management are discussed in this review article.

Diagnosis of periprosthetic infection following total hip arthroplasty – evaluation of the diagnostic values of pre- and intraoperative parameters and the associated strategy to preoperatively select patients with a high probability of joint infection

2008-07-21

Background: The correct diagnosis of a prosthetic joint infection (PJI) is crucial for adequate surgical treatment. The detection may be a challenge since presentation and preoperative tests are not always obvious and precise. This prospective study was performed to evaluate a variety of pre- and intraoperative investigations. Furthermore a detailed evaluation of concordance of each preoperative diagnosis was performed, together with a final diagnosis to assess the accuracy of the pre-operative assumption of PJI. Methods: Between 01/2005 and 02/2007, a prospective analysis was performed in 50 patients, who had a two stage revision because of assumed PJI. Based on clinical presentation, radiography, haematological screening, or early failure, infection was assumed and a joint aspiration was performed. Depending upon these findings, a two stage revision was performed, with intra-operative samples for culture and histological evaluation obtained. Final diagnosis of infection was based upon the interpretation of the clinical presentation and the pre- and intraoperative findings. Results: In 37 patients a positive diagnosis of PJI could be made definitely. The histopathology yielded the highest accuracy (0.94) in identification of PJI and identified 35 of 37 infections (sensitivity 0.94, specificity 0.94, positive-/negative predictive value 0.97/0.86). Intra-operative cultures revealed sensitivities, specificities, positive-/negative predictive values and accuracy of 0.78, 0.92, 0.96, 0.63 and 0.82. These values for blood screening tests were 0.95, 0.62, 0.88, 0.80, and 0.86 respectively for the level of C-reactive protein, and 0.14, 0.92, 0.83, 0.29 and, 0.34 respectively for the white blood-cell count. The results of aspiration were 0.57, 0.5, 0.78, 0.29, and 0.54. Conclusion: The detection of PJI is still a challenge in clinical practice. The histopathological evaluation emerges as a highly practical diagnostic tool in detection of PJI. Furthermore, we found a discrepancy between the pre-operative suspicion of PJI and the final post-operative diagnosis, resulting in a slight uncertainty in whether loosening is due to bacterial infection or not. The variation in accuracy of the single tests may influence the detection of PJI. Level of Evidence: Diagnostic Level I.

Virtual interactive musculoskeletal system (VIMS) in orthopaedic research, education and clinical patient care

2007-03-08

The ability to combine physiology and engineering analyses with computer sciences has opened the door to the possibility of creating the "Virtual Human" reality. This paper presents a broad foundation for a full-featured biomechanical simulator for the human musculoskeletal system physiology. This simulation technology unites the expertise in biomechanical analysis and graphic modeling to investigate joint and connective tissue mechanics at the structural level and to visualize the results in both static and animated forms together with the model. Adaptable anatomical models including prosthetic implants and fracture fixation devices and a robust computational infrastructure for static, kinematic, kinetic, and stress analyses under varying boundary and loading conditions are incorporated on a common platform, the VIMS (Virtual Interactive Musculoskeletal System). Within this software system, a manageable database containing long bone dimensions, connective tissue material properties and a library of skeletal joint system functional activities and loading conditions are also available and they can easily be modified, updated and expanded. Application software is also available to allow end-users to perform biomechanical analyses interactively. Examples using these models and the computational algorithms in a virtual laboratory environment are used to demonstrate the utility of these unique database and simulation technology. This integrated system, model library and database will impact on orthopaedic education, basic research, device development and application, and clinical patient care related to musculoskeletal joint system reconstruction, trauma management, and rehabilitation.

Tissue specific characteristics of cells isolated from human and rat tendons and ligaments

N Scutt, CG Rolf and A Scutt — 2008-07-24

Background: Tendon and ligament injuries are common and costly in terms of surgery and rehabilitation. This might be improved by using tissue engineered constructs to accelerate the repair process; a method used successfully for skin wound healing and cartilage repair. Progress in this field has however been limited; possibly due to an over-simplistic choice of donor cell. For tissue engineering purposes it is often assumed that all tendon and ligament cells are similar despite their differing roles and biomechanics. To clarify this, we have characterised cells from various tendons and ligaments of human and rat origin in terms of proliferation, response to dexamethasone and cell surface marker expression. Methods: Cells isolated from tendons by collagenase digestion were plated out in DMEM containing 10% fetal calf serum, penicillin/streptomycin and ultraglutamine. Cell number and collagen accumulation were by determined methylene blue and Sirius red staining respectively. Expression of cell surface markers was established by flow cytometry. Results: In the CFU-f assay, human PT-derived cells produced more and bigger colonies suggesting the presence of more progenitor cells with a higher proliferative capacity. Dexamethasone had no effect on colony number in ACL or PT cells but 10 nM dexamethasone increased colony size in ACL cultures whereas higher concentrations decreased colony size in both ACL and PT cultures. In secondary subcultures, dexamethasone had no significant effect on PT cultures whereas a stimulation was seen at low concentrations in the ACL cultures and an inhibition at higher concentrations. Collagen accumulation was inhibited with increasing doses in both ACL and PT cultures. This differential response was also seen in rat-derived cells with similar differences being seen between Achilles, Patellar and tail tendon cells. Cell surface marker expression was also source dependent; CD90 was expressed at higher levels by PT cells and in both humans and rats whereas D7fib was expressed at lower levels by PT cells in humans. Conclusion: These data show that tendon & ligament cells from different sources possess intrinsic differences in terms of their growth, dexamethasone responsiveness and cell surface marker expression. This suggests that for tissue engineering purposes the cell source must be carefully considered to maximise their efficacy.

Clinical effects of Garcinia kola in knee osteoarthritis

2008-07-30

Objectives. Over the past years, there has been a growing number of knee osteoarthritis (KOA) patients who are not willing to comply with long-term non-steroidal anti-inflammatory drugs (NSAID) treatment and wish to use herbal anti- rheumatic medicine. This study assessed the clinical effects of Garcinia kola (GK) in KOA patients. Patients and Methods. Prospective randomized, placebo controlled, double blind, clinical trial approved by the institutional medical ethics review board and written informed consent obtained from each patient. All KOA patients presenting at the Obafemi Awolowo University Teaching Hospital complex were recruited into the study. The patients were grouped into four (A=Placebo, B=Naproxen, C=Garcinia kola, D=Celebrex). The drugs and placebo were given twice a day per oral route. Each dose consisted of 200mg of G. kola, Naproxen (500mg), Celebrex (200mg) and Ascorbic acid (100mg). The primary outcome measure over six weeks study period was the change in mean WOMAC pain visual analogue scales (VAS). Secondary outcome measures included the mean change in joint stiffness and physical function (mobility/walking). Results: 143 patients were recruited, 84 (58.7%, males - 24, females - 60) satisfied the selection criteria and completed the study. The effect of knee osteoarthritis bilateralism among the subjects was not significant on their outcome (p>0.05). The change in the mean WOMAC pain VAS after six weeks of G. kola was significantly reduced compared to the placebo (p<0.001). Multiple comparisons of the mean VAS pain change of G. kola group was not lowered significantly against the naproxen and celebrex groups ( p>0.05). The onset of G. kola symptomatic pain relief was faster than the placebo (p<0.001). However, it was slower than the active comparators (p>0.05). The duration of therapeutic effect of Garcinia kola was longer than the placebo (p>0.001). G. kola period of effect was less than naproxen and celebrex (p<0.001). G. kola subjects had improved mean change mobility/walking after six weeks better than the control group(p<0.001).The mean change in mobility of the G. kola group when compared to the active comparators was not significantly better (p<0.05). The mean change of knee joint stiffness (p<0.001) and the change of mean WOMAC score (p<0.001) were improved on Garcinia kola as compared to the placebo. The mid term outcome of eleven Garcinia kola subjects after cessation of use had a mean pain relief period of 17.27+/-5.15 days (range: 9-26 days). There was no significant cardiovascular, renal or drug induced adverse reaction to Garcinia kola. Conclusions: Garcinia kola appeared to have clinically significant analgesic /anti-inflammatory effects in knee osteoarthritis patients. Garcinia kola is a potential osteoarthritis disease activity modifier with good mid term outcome. Further studies are required for standardization of dosages and to determine long-term effects.

Subacromial impingement in patients with whiplash injury to the cervical spine

Ali Abbassian and Grey E Giddins — 2008-06-27

Background: Impingement syndrome and shoulder pain have been reported to occur in a proportion of patients following whiplash injuries to the neck. In this study we aim to examine these findings to establish the association between subacromial impingement and whiplash injuries to the cervical spine.Methods and resultsWe examined 220 patients who had presented to the senior author for a medico-legal report following a whiplash injury to the neck. All patients were assessed for clinical evidence of subacromial impingement. 56/220 patients (26%) had developed shoulder pain following the injury; of these, 11/220 (5%) had clinical evidence of impingement syndrome. Only 3/11 patients (27%) had the diagnosis made prior to evaluation for their medico-legal report. In the majority, other clinicians had overlooked the diagnosis. The seatbelt shoulder was involved in 83% of cases (p < 0.03). Conclusion: After a neck injury a significant proportion of patients present with shoulder pain, some of whom have treatable shoulder pathology such as impingement syndrome. The diagnosis is, however, frequently overlooked and shoulder pain is attributed to pain radiating from the neck resulting in long delays before treatment. It is important that this is appreciated and patients are specifically examined for signs of subacromial impingement after whiplash injuries to the neck. Direct seatbelt trauma to the shoulder is one possible explanation for its aetiology.

A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation

S Raymond Golish, Jason A Oliviero, Eric I Francke and Mark D Miller — 2008-07-16

Background: Non-operative management of midshaft clavicle fractures is standard; however, surgical management is increasing. The purpose of this study is to compare the biomechanical performance of plate versus intramedullary fixation in cyclic bending for matched pairs of cadaveric clavicles. We hypothesized that the biomechanical properties are similar. Methods: Eight sets of matched clavicles with vertical, midshaft osteotomies were prepared from fresh, frozen cadavers. A 3.5 mm dynamic compression plate or a 3.8 or 4.5 mm intramedullary device were used for fixation. Clavicles were loaded in a four-point bend at 6 different loads for 3000 cycles at 1 Hz starting with 180 N and increasing by 180 N with sampling at 2 Hz. Failure was defined as 10 mm of displacement or catastrophic construct failure prior to 10 mm of displacement. Results: Between constructs, there was a significant difference with large effect size in displacement at fixed loads of 180 N (P = 0.001; Cohen's d = 1.85), 360 N (P = 0.033; Cohen's d = 1.39), 540 N (P = 0.003; Cohen's d = 0.73) and 720 N (P = 0.018; Cohen's d = 0.72). There was a significant difference with large effect size in load at fixed displacements of 5 mm (P = 0.001; Cohen's d = 1.49), 7.5 mm (P = 0.011; Cohen's d = 1.06), and 10 mm (P = 0.026; Cohen's d = 0.84). Conclusion: Plate constructs are superior in showing less displacement at fixed loads and greater loads at fixed displacements over a broad range of loads and displacements with cyclic four-point bending. The clinical relevance is that plate fixation may provide a stronger construct for early rehabilitation protocols that focus on repetitive movements in the early pre-operative period.

Extensor-tendons reconstruction using autogenous palmaris longus tendon grafting for rheumatoid arthritis patients

2008-04-24

Background: The purpose of the study is to retrospectively review the clinical outcome of our study population of middle-aged RA patients who had suffered extensor-tendon rupture. We reported the outcome of autogenous palmaris tendon grafting of multiple extensor tendons at wrist level in 14 middle-aged rheumatoid patients. Methods: Between Feb. 2000 to Feb. 2004, thirty-six ruptured wrist level extensor tendons were reconstructed in fourteen rheumatoid patients (11 women and three men) using autogenous palmaris longus tendon as a free interposition graft. In each case, the evaluation was based on both subjective and objective criteria, including the range of MCP joint flexion after surgery, the extension lag at the metacarpophalangeal joint before and after surgery, and the ability of the patient to work.Results and DiscussionThe average of follow-up was 54.1 months (range, 40 to 72 months). The average range of MCP joint flexion after reconstruction was 66°. The extension lag at the metacarpophalangeal joint significantly improved from a preoperative mean of 38° (range, 25°–60°) to a postoperative mean of 16° (range, 0°–30°). Subjectively all patients were satisfied with the clinical results, and achieved a return to their level of ability before tendon rupture. We found good functional results in our series of interposition grafting using palmaris longus to reconstruct extensor tendon defects in the rheumatoid patients. Conclusion: Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall function. Early aggressive treatment of extensor tendon reconstruction using autogenous palmaris longus tendon as a free interposition graft in the rheumatoid wrist is another viable option to achieve good clinical functional result.

Acromioclavicular joint dislocation: a comparative biomechanical study of the palmaris-longus tendon graft reconstruction with other augmentative methods in cadaveric models

Guntur E Luis, Chee-Khuen Yong, Deepak A Singh, S Sengupta and David SK Choon — 2007-11-27

Background: Acromioclavicular injuries are common in sports medicine. Surgical intervention is generally advocated for chronic instability of Rockwood grade III and more severe injuries. Various methods of coracoclavicular ligament reconstruction and augmentation have been described. The objective of this study is to compare the biomechanical properties of a novel palmaris-longus tendon reconstruction with those of the native AC+CC ligaments, the modified Weaver-Dunn reconstruction, the ACJ capsuloligamentous complex repair, screw and clavicle hook plate augmentation.HypothesisThere is no difference, biomechanically, amongst the various reconstruction and augmentative methods.Study DesignControlled laboratory cadaveric study. Methods: 54 cadaveric native (acromioclavicular and coracoclavicular) ligaments were tested using the Instron machine. Superior loading was performed in the 6 groups: 1) in the intact states, 2) after modified Weaver-Dunn reconstruction (WD), 3) after modified Weaver-Dunn reconstruction with acromioclavicular joint capsuloligamentous repair (WD.ACJ), 4) after modified Weaver-Dunn reconstruction with clavicular hook plate augmentation (WD.CP) or 5) after modified Weaver-Dunn reconstruction with coracoclavicular screw augmentation (WD.BS) and 6) after modified Weaver-Dunn reconstruction with mersilene tape-palmaris-longus tendon graft reconstruction (WD. PLmt). Posterior-anterior (horizontal) loading was similarly performed in all groups, except groups 4 and 5. The respective failure loads, stiffnesses, displacements at failure and modes of failure were recorded. Data analysis was carried out using a one-way ANOVA, with Student's unpaired t-test for unpaired data (S-PLUS statistical package 2005). Results: Native ligaments were the strongest and stiffest when compared to other modes of reconstruction and augmentation except coracoclavicular screw, in both posterior-anterior and superior directions (p < 0.005).WD.ACJ provided additional posterior-anterior (P = 0. 039) but not superior (p = 0.250) stability when compared to WD alone.WD+PLmt, in loads and stiffness at failure superiorly, was similar to WD+CP (p = 0.066). WD+PLmt, in loads and stiffness at failure postero-anteriorly, was similar to WD+ACJ (p = 0.084).Superiorly, WD+CP had similar strength as WD+BS (p = 0.057), but it was less stiff (p < 0.005).Conclusions and Clinical RelevanceModified Weaver-Dunn procedure must always be supplemented with acromioclavicular capsuloligamentous repair to increase posterior-anterior stability. Palmaris-Longus tendon graft provides both additional superior and posterior-anterior stability when used for acromioclavicular capsuloligamentous reconstruction. It is a good alternative to clavicle hook plate in acromioclavicular dislocation.

Unusual patterns of Monteggia fracture-dislocation

2006-11-03

Background: High-energy trauma may result in uncommon open injuries around the elbow joint. The management of these injuries can be difficult.Case descriptionFourteen patients were treated between 1999 and 2003 and their injuries consisted of Monteggia fracture-dislocations combined with segmental fractures of the ulna or fractures of the forearm bones and/or various more complex trauma such as neural injuries, bone comminution and severe soft tissue injuries around the elbow. Eight of them (57%) were multiply injured with severe additional injuries. All patients underwent surgery within first 4–6 hours. Internal fixation, external fixation or a combination of both methods were used to stabilize fractures while open wounds had secondary closure. Results: Additional operations were required in 6 patients. The functional results according to the Mayo Elbow Performance Index were excellent or good in eleven patients, and fair or poor in the remaining three. The patients with fair and poor results had suffered from severe neural and soft tissue trauma and/or multiple fractures of the upper extremity. Conclusion: These injuries should be treated as an emergency. The surgeon should apply any available method that can provide stability to the bone fragments and safe handling of the soft tissues giving priority to internal fixation of the fractures. Severe osseous, soft tissue and neural trauma affect the functional results of the elbow region.