Exploring the Potential of Lateral Wedge Insoles in Alleviating Bone Marrow Lesions in End-Stage Knee Osteoarthritis: A Preliminary Case Report.

The efficacy of lateral wedge insoles (LWIs) in patients with end-stage knee osteoarthritis (OA) is unclear. A 43-year-old male underwent two anterior cruciate ligament reconstructions in his right knee and was later diagnosed with end-stage knee OA. An LWI combining arch support with a lateral heel wedge was fabricated for this patient and used over 12 months. As a result, after 12 months, the bone marrow lesion (BML), as measured by the magnetic resonance imaging Osteoarthritis Knee Score (MOAKS), was downgraded from grade 2 to grade 1. The use of LWI in a patient with end-stage knee OA showed lower co-contraction ratios in knee muscles even after 12 months. The results provide preliminary evidence suggesting the use of LWI in patients with end-stage knee OA has potential benefits for reducing BML.

A Lateral Fracture Line Affects Femoral Trochanteric Fracture Instability and Swing Motion of the Intramedullary Nail: A Biomechanical Study.

Background: An unstable trochanteric femoral fracture is a serious injury, with a 1-year mortality rate of 5.4% to 24.9%, for which there is currently no standard treatment method. The lag screw insertion site is one of the primary contact areas between the cortical bone and an intramedullary nail. We hypothesized that a posterolateral fracture causes intramedullary nail instability when the posterolateral fracture line interferes with lag screw insertion. The purpose of the present study was to investigate the effect of posterolateral fracture line morphology on intramedullary nail stability by simulating unstable trochanteric femoral fractures with a posterolateral fracture fragment. Methods: Eighteen custom-made synthetic osteoporotic bone samples were used in the present study. Nine samples had a posterolateral fracture line interfering with the lag screw insertion hole (Fracture A), and the other 9 had a fracture line 10 mm away from the hole (Fracture B). Cyclic loading (750 N) was applied to the femoral head 1,500 times. Movement of the end cap attached to the intramedullary nail was recorded. The amplitudes of motion in the coronal plane (coronal swing motion), sagittal plane (sagittal swing motion), and axial plane (total swing motion) were evaluated. The change in the neck-shaft angle was evaluated on photographs that were made before and after the test. Medial cortical displacement was measured before and after the test. Results: Two Fracture-A samples were excluded because the amplitude of sagittal swing motion was too large. The mean values for coronal, sagittal, and total swing motion were 1.13 ± 0.28 mm and 0.51 ± 0.09 mm (p < 0.001), 0.50 ± 0.12 mm and 0.46 ± 0.09 mm (p = 0.46), and 1.24 ± 0.24 mm and 0.69 ± 0.11 mm (p < 0.001) for Fractures A and B, respectively. The mean neck-shaft angle change was -8.29° ± 2.69° and -3.56° ± 2.35° for Fractures A and B, respectively (p = 0.002). The mean displacement of the medial cortex was 0.38 ± 1.12 mm and 0.12 ± 0.37 mm for Fractures A and B, respectively (p = 0.57). Conclusions: This study showed that an unstable trochanteric femoral fracture with a posterolateral fracture line that interferes with the lag screw insertion holes is a risk factor for increased intramedullary nail instability.

Bone marrow-derived fibroblast migration via periostin causes irreversible arthrogenic contracture after joint immobilization.

Joint contracture causes distressing permanent mobility disorder due to trauma, arthritis, and aging, with no effective treatment available. A principal and irreversible cause of joint contracture has been regarded as the development of joint capsule fibrosis. However, the molecular mechanisms underlying contracture remain unclear. We established a mouse model of knee joint contracture, revealing that fibrosis in joint capsules causes irreversible contracture. RNA-sequencing of contracture capsules demonstrated a marked enrichment of the genes involved in the extracellular region, particularly periostin (Postn). Three-dimensional magnetic resonance imaging and immunohistological analysis of contracture patients revealed posterior joint capsule thickening with abundant type I collagen (Col1a2) and POSTN in humans. Col1a2-GFPTG ; Postn-/- mice and chimeric mice with Col1a2-GFPTG ; tdTomatoTG bone marrow showed fibrosis in joint capsules caused by bone marrow-derived fibroblasts, and POSTN promoted the migration of bone marrow-derived fibroblasts, contributing to fibrosis and contracture. Conversely, POSTN-neutralizing antibody attenuated contracture exacerbation. Our findings identified POSTN as a key inducer of fibroblast migration that exacerbates capsule fibrosis, providing a potential therapeutic strategy for joint contracture.

Protocol for the RETHINK study: a randomised, double-blind, parallel-group, non-inferiority clinical trial comparing acetaminophen and NSAIDs for treatment of chronic pain in elderly patients with osteoarthritis of the hip and knee.

INTRODUCTION: In patients with chronic pain, oral analgesics are essential treatment options to manage pain appropriately, improve activities of daily living abilities and achieve a higher quality of life (QOL). It is desirable to select analgesics for elderly patients based on comparative data on analgesic effect and risk of adverse events; however, there are few comparative studies so far. The purpose of this study is to determine whether the efficacy and safety of acetaminophen are non-inferior to non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of chronic pain associated with osteoarthritis of the hip and knee in elderly patients. METHODS AND ANALYSIS: This study is a multicentre, randomised controlled, double-blind, parallel-group study to compare the analgesic effect and adverse events between acetaminophen or NSAIDs (loxoprofen or celecoxib). A total of 400 elderly patients with osteoarthritis of the hip and knee will be recruited from five institutions in Japan. Patients of 65 years or older with osteoarthritis-related pain will be registered and randomly assigned to acetaminophen, loxoprofen or celecoxib with 2:1:1 allocation. The primary endpoint is change in the Brief Pain Inventory (BPI) item 3 (worst pain) score from baseline to week 8. The secondary endpoints are BPI item 3 score change from baseline to week 4, health-related QOL measured by Short Form-8 Health Survey, and occurrence of adverse events including gastrointestinal disorders and abnormal liver function. Data will be analysed in accordance with a predefined statistical analysis plan. ETHICS AND DISSEMINATION: This study protocol was approved by the Kyushu University Hospital Certified Institutional Review Board for Clinical Trials on 28 January 2021 (KD2020004) and the chief executive of each participating hospital. The results of the study will be submitted to international peer-reviewed journals, and the main findings will be presented at international scientific conferences. TRIAL REGISTRATION NUMBER: jRCTs071200112.

"But it feels swollen!": the frequency and clinical characteristics of people with knee osteoarthritis who report subjective knee swelling in the absence of objective swelling.

INTRODUCTION: There are complex interactions between pain and perceptions of the painful body part in musculoskeletal disorders, and disruption of various body representations in people with chronic pain. OBJECTIVES: The purpose of this study was to investigate how frequently people with knee osteoarthritis (OA) complain of swelling without objective evidence of swelling, and describe the clinical characteristics of this population. METHODS: Forty-six people with knee OA (68.1 ± 8.8 years) participated in this cross-sectional study. Subjective and objective swelling was evaluated by knee-specific body perception questionnaire and ultrasonography, respectively. Pain intensity, disability, pain-related beliefs, 2-point discrimination threshold, and quadriceps muscle strength were also evaluated. RESULTS: Approximately 1/3 of participants (n = 15) had subjective feelings of knee swelling in the absence of objective swelling (S only). Fifteen participants had both subjective and objective knee swelling (S + O group) and 16 had neither subjective nor objective knee swelling (No S/O group). Participants in the S only group had similar pain or disability as those in the S + O group but had more severe pain or disability than those with in the No S/O group. Those in the S only group also had larger 2-point discrimination distance threshold at the medial knee (impaired tactile acuity) than those in the S + O group and had more dysfunctional pain catastrophizing and pain-related self-efficacy than both other groups. CONCLUSION: Our results suggest that about 30% of people with knee OA perceive swelling of the knee in the absence of any objective swelling and that this is accompanied by severe pain and functional disability. Considering altered body image of the knee may reveal relevant treatment-based subgroups in people with knee OA.

Risk factors for excessive postoperative sliding of femoral trochanteric fracture in elderly patients: A retrospective multicenter study.

INTRODUCTION: The application of a load on the internal fixation of a trochanteric fracture exerts a moment along the lag screw, causing the proximal bone fragment to slide along the lag screw, allowing contact between the proximal and distal bone fragments, which promotes healing. However, excessive sliding is related to poor postoperative outcomes. We aimed to identify the risk factors for excessive sliding. MATERIALS AND METHODS: We conducted a multicenter retrospective study including 115 trochanteric fractures sustained through low-energy trauma in 19 male and 96 female patients aged 60 years or older (mean age: 82.9 years) between September 2013 and December 2014. We measured the postoperative sliding distance after osteosynthesis using a sliding hip screw or intramedullary nailing, and classified participants with ≥8 mm of sliding into the excessive sliding group (ESG) and with <8 mm into non-ESG. Finally, we investigated the risk factors of excessive postoperative sliding. RESULTS: Fifty participants were classified into the ESG and 65 participants into the non-ESG. Female sex (p = 0.0264), an A3 fracture type (p = 0.0003), greater tip-apex distance (p = 0.0250), and poor reduction in either the anteroposterior or lateral radiographic views (p = 0.0156) were identified as risk factors for excessive sliding by multivariate regression analysis. CONCLUSIONS: Female sex, an unstable fracture type, a greater tip-apex distance, and a poor reduction, in either the anteroposterior or lateral views, are associated with excessive postoperative sliding. Therefore, surgery should aim to achieve good reduction and stabilization from both radiographic views.

Identifying participants with knee osteoarthritis likely to benefit from physical therapy education and exercise: A hypothesis-generating study.

BACKGROUND: The purpose of this investigation was to undertake a hypothesis-generating study to identify candidate variables that characterize people with knee osteoarthritis who are most likely to experience a positive response to exercise. METHODS: One hundred and fifty participants with knee osteoarthritis participated in this observational, longitudinal study. All participants received a standard exercise intervention that consisted of 20-min sessions two to three times a week for three months. The classification and regression tree methodology (CART) was used to develop prediction of positive clinical outcome. Positive pain and disability outcomes (dependent variables) were defined as an improvement in pain intensity by >50% or an improvement of five or more on the Oxford knee score, respectively. The predictor variables considered included age, sex, body mass index, knee osteoarthritis severity (Kellgren/Lawrence grade), pain duration, use of medication, range of knee motion, pain catastrophizing, self-efficacy and knee self-perception. RESULTS: Fifty-five participants (36.6%) were classified as responders for pain intensity and 36.6% were classified as responders for disability. The CART model identified impairments in knee self-perception and knee osteoarthritis severity as the discriminators for pain intensity reduction following exercise. No variables predicted reduction of disability level following exercise. CONCLUSIONS: Such findings suggest that both body perception and osteoarthritis severity may play a role in treatment outcome with exercise. It also raises the possibility that those with higher levels of disrupted body perception may need additional treatment targeted at restoring body perception prior to undertaking exercise. SIGNIFICANCE: Regardless age, sex, body mass index, pain duration, use of medication, knee range of motion, pain catastrophizing and self-efficacy, participants with knee osteoarthritis who report low levels of body perception disruption (a FreKAQ score ≦ 17) and minimal structural changes (KL grade I) demonstrate significantly better outcomes from exercise therapy than other participants.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing.

PURPOSE: Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic. METHODS: The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15 years. The characteristics of the primary fractures and treatment course were evaluated. RESULTS: Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277 days, and in 5 of the 6 patients refractures occurred within 6 months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%). CONCLUSIONS: Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

[Bone disease with pain. Tibial plateau fracture].

Fractures that involve the proximal tibia affect knee kinematics and stability. Especially tibial prateau fractures are intra-articular injuries, impair not only metaphyseal bone but articular cartilage, meniscus and ligament. Basically the ideal treatment for tibial plateau fractures should be an anatomic reduction with stable fixation allowing weight bearing training and an early range of motion exercise, it is the reason that the indication of conservative treatment is limited. Open rudection and bone grafting followed by a buttress plate fixation is a general treatment for tibial plateau fracture. I have tried to use the arthroscopic technique for selected cases. Utilizing arthroscopic assist, accurate diagnosis and treatment of any associated joint pathology was possible, and an anatomical reduction was obtained. The aim of surgical treatment of tibial plateau fracture is to restore a congruity of joint by anatomical reduction of articular surface, and to achieve enough stability permitting early pain free range of motion training. Finally, the goal of treatment is to preserve normal knee function and to prevent developing post-traumatic arthrosis in the future.

Spontaneous osteonecrosis of the lateral femoral condyle of the knee: a report of 11 cases.

BACKGROUND: Spontaneous osteonecrosis (SON) of the lateral femoral condyle of the knee joint is very rare and there have been only a few articles about this condition. MATERIALS: We reviewed data for 11 patients (7 men, 4 women) with unusual SON of the lateral femoral condyle of the knee. The average age of patients at onset was 61.9 years (range 47-76 years). No patient had underlying disease or had undergone steroid therapy, although one underwent lateral meniscectomy. RESULTS: According to Aglietti's radiographic classification, three patients had stage 1 disease, two had stage 2 disease, three had stage 3 disease, one had stage 4 disease, and two had stage 5 at first examination. The average alignment of affected limbs on standing was 5.9 degrees valgus (range 0 degrees -11 degrees ). Although the osteonecrotic lesion was seen on the lateral side, the mechanical axis passed the medial compartment in three patients. Six patients were treated conservatively and the remaining five required surgery, which consisted of lateral unicompartmental knee arthroplasties. CONCLUSION: The pathology of the necrosis of the lateral femoral condyle was considered to be different from that of the medial femoral condyle regarding clinical features, limb alignment, and radiographic findings.

Recurrent hemarthrosis after knee joint arthroplasty: etiology and treatment.

This study reports the results for 10 patients with recurrent hemarthrosis after knee joint arthroplasty. The average interval between arthroplasty and the first instance of hemarthrosis was at 26 months, and the average number of hemarthroses per patient was 3.8. In 3 patients, the bleeding responded to simple conservative measures. The remaining 7 needed surgery; there were 6 arthroscopic synovectomies and 1 polyethylene revision. Impingement of the proliferative synovium was observed in only 2 patients during surgical intervention. In the 2 patients in whom arthroscopic management was successful, another procedure with an electric coagulator, in addition to a formal synovectomy, was performed. The use of a coagulator may be helpful for direct coagulation when arthroscopic management is selected, although open synovectomy is curative in most cases.

Anatomical analysis of the femoral condyle in normal and osteoarthritic knees.

It is important to understand anatomical feature of the distal femoral condyle for treatment of osteoarthritic knees. Detailed measurement of the femoral condyle geometry, however, has not been available in osteoarthritic knees including valgus deformity. This study evaluated femoral condyle geometry in 30 normal knees, 30 osteoarthritic knees with varus deformity, and 30 osteoarthritic knees with valgus deformity using radiographs and magnetic resonance imaging (MRI). In radiographic analysis in the coronal plane, the femoral joint angle (lateral angle between the femoral anatomic axis and a tangent to femoral condyles) was 83.3 degrees in the normal knees, 83.8 degrees in the varus knees, and 80.7 degrees in the valgus knees. In MRI analysis in the axial plane, the posterior condylar tangent showed 6.4 degrees of internal rotation relative to the transepicondylar axis in the normal knees, 6.1 degrees in the varus knees, and 11.5 degrees in the valgus knees. These results suggested that there was no hypoplasia of the medial condyle in the varus knees, but the lateral condyle in the valgus knees was severely distorted. Surgeons should take this deformity of the lateral femoral condyle into account when total knee arthroplasty is performed for a valgus knee.