Ankle joint distraction is a promising alternative treatment for patients with severe haemophilic ankle arthropathy.

INTRODUCTION: Haemophilic ankle arthropathy (HAA) causes major morbidity. When conservative treatment fails, major surgical interventions are indicated. An alternative treatment to maintain joint mobility and postpone these interventions is desired. AIM: To gather prospective data on clinical/structural changes after ankle joint distraction (AJD) in HAA. METHODS: This study includes patients with severe HAA insufficiently responding to conservative treatment. AJD was performed during 8-10 weeks by use of an external frame. Questionnaires, physical examination and radiology were used to evaluate pain, function and structural changes before and 6, 12, 24 and 36 months after distraction. Mixed effect models were used for analysis. RESULTS: This study includes eight cases (21-53 years). The fixed effects estimates of the visual analogue score (0-10) improved from 7.5 at baseline to 3.4 (p = .023) 3 years after distraction. The Haemophilia Activities List (HAL, 0-100) for basic/complex lower extremities functions improved from respectively 29.6 and 31.5 to 54.3 (p = .015) and 50.7 (p = .031). Joint mobility was maintained. Magnetic resonance imaging (MRI) showed thickened cartilage and reduced bone marrow oedema and subchondral cysts. Pin tract infections (n = 6) were effectively treated and no adverse bleeding events occurred. At 3-year follow-up, in none of the patients the originally indicated arthrodesis was performed. CONCLUSION: This first prospective study showed that AJD in HAA results in decreased pain, improved function and decreased arthropathy-related MRI findings in the majority of patients for prolonged time. Although the study population is small and follow-up is relatively short, AJD may be promising to postpone invalidating interventions and might be a breakthrough treatment.

Five-Year Follow-up of Knee Joint Distraction: Clinical Benefit and Cartilaginous Tissue Repair in an Open Uncontrolled Prospective Study.

Objective In end-stage knee osteoarthritis, total knee arthroplasty (TKA) may finally become inevitable. At a relatively young age, this comes with the risk of future revision surgery. Therefore, in these cases, joint preserving surgery such as knee joint distraction (KJD) is preferred. Here we present 5-year follow-up data of KJD. Design Patients ( n = 20; age <60 years) with conservative therapy resistant tibiofemoral osteoarthritis considered for TKA were treated. Clinical evaluation was performed by questionnaires. Change in cartilage thickness was quantified on radiographs and magnetic resonance images (MRI). The 5-year changes after KJD were evaluated and compared with the natural progression of osteoarthritis using Osteoarthritis Initiative data. Results Five-years posttreatment, patients still reported clinical improvement from baseline: ΔWOMAC (Western Ontario and McMaster Universities Arthritis Index) +21.1 points (95% CI +8.9 to +33.3; P = 0.002), ΔVAS (visual analogue scale score) pain -27.6 mm (95%CI -13.3 to -42.0; P < 0.001), and minimum radiographic joint space width (JSW) of the most affected compartment (MAC) remained increased as well: Δ +0.43 mm (95% CI +0.02 to +0.84; P = 0.040). Improvement of mean JSW (x-ray) and mean cartilage thickness (MRI) of the MAC, were not statistically different from baseline anymore (Δ +0.26 mm; P = 0.370, and Δ +0.23 mm; P = 0.177). Multivariable linear regression analysis indicated that KJD treatment was associated with significantly less progression in mean and min JSW (x-ray) and mean cartilage thickness (MRI) compared with natural progression (all Ps <0.001). Conclusions KJD treatment results in prolonged clinical benefit, potentially explained by an initial boost of cartilaginous tissue repair that provides a long-term tissue structure benefit as compared to natural progression. Level of evidence, II.

Tissue structure modification in knee osteoarthritis by use of joint distraction: an open 1-year pilot study.

BACKGROUND: Modification of joint tissue damage is challenging in late-stage osteoarthritis (OA). Few options are available for treating end-stage knee OA other than joint replacement. OBJECTIVES: To examine whether joint distraction can effectively modify knee joint tissue damage and has the potential to delay prosthesis surgery. METHODS: 20 patients (<60 years) with tibiofemoral OA were treated surgically using joint distraction. Distraction (~5 mm) was applied for 2 months using an external fixation frame. Tissue structure modification at 1 year of follow-up was evaluated radiographically (joint space width (JSW)), by MRI (segmentation of cartilage morphology) and by biochemical markers of collagen type II turnover, with operators blinded to time points. Clinical improvement was evaluated by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS) pain score. RESULTS: Radiography demonstrated an increase in mean and minimum JSW (2.7 to 3.6 mm and 1.0 to 1.9 mm; p<0.05 and <0.01). MRI revealed an increase in cartilage thickness (2.4 to 3.0 mm; p<0.001) and a decrease of denuded bone areas (22% to 5%; p<0.001). Collagen type II levels showed a trend towards increased synthesis (+103%; p<0.06) and decreased breakdown (-11%; p<0.08). The WOMAC index increased from 45 to 77 points, and VAS pain decreased from 73 to 31 mm (both p<0.001). CONCLUSIONS: Joint distraction can induce tissue structure modification in knee OA and could result in clinical benefit. No current treatment is able to induce such changes. Larger, longer and randomised studies on joint distraction are warranted.

[Trends in the number of knee and hip arthroplasties: considerably more knee and hip prostheses due to osteoarthritis in 2030]. / Trends in aantallen knie- en heupartroplastieken: de vraag naar knie- en heupprotheses blijft voorlopig toenemen.

OBJECTIVE: To predict the future number of knee and hip arthroplasties due to osteoarthritis (OA) in the Netherlands based on historical trends and demographic projections. DESIGN: Data analysis and model calculations. METHOD: Two future projections were based on age and sex-specific number of hospital admissions for the placement of total knee or hip prostheses due to OA between 1995 and 2005; data were obtained from the Dutch National Medical Registration (LMR). The demographical projection was based on the incidence of arthroplasty in 2005 combined with demographic predictions from Statistics Netherlands regarding the time period between 2005 and 2030. The trend projection used the trend in the age and sex-specific incidence of surgery between 1995 and 2005. RESULTS: Between 1995 and 2005, the annual number of knee arthroplasties in patients with a primary diagnose of OA increased from 4,916 to 14,565, an increase of 196%. The total number of hip arthroplasties increased from 13,785 to 20,715, an increase of 50%. The demographical projection suggests that the number of total hip arthroplasties will increase to 31,731 by 2030, an increase of 53%, and the number of knee arthroplasties to 22,183. The trend projection suggests that the numbers may increase to 51,680 for the hip (+149%) and to 57,893 for the knee (+297%). CONCLUSION: The increase in the number of knee and hip arthroplasties due to OA will probably continue in the coming 20 years. The following developments will probably contribute to this: demographical changes, the increase in overweight, improved long-term outcomes of arthroplasty, more active lifestyle of the elderly and the increasing number of orthopaedic surgeons.

Lower limb deformity due to failed trauma treatment corrected with the Ilizarov technique: factors affecting the complication rate in 52 patients.

BACKGROUND AND PURPOSE: Failed treatment of fractures may be corrected by the Ilizarov technique but complications are common. In 52 patients with compromised healing of femoral and tibial fractures, the results of secondary reconstruction with Ilizarov treatment were investigated retrospectively in order to identify the factors that contribute to the risk of complications. METHODS: 52 consecutive patients was analyzed. The median interval between injury and secondary reconstruction was 3 (0.1-27) years. The patients had failed fracture treatment resulting in bone defects, pseudarthrosis, infection, limb length discrepancy (LLD) caused by bone consolidation after bone loss, malunion, soft-tissue loss, and stiff joints. Most patients had a combination of these deformities. The results were analyzed by using logistic regression in a polytomous universal mode (PLUM) logistic regression model. RESULTS: The median treatment time was 9 (4-30) months, and the obstacle and complication rate was 105% per corrected bone segment. In 2 patients treatment failed, which resulted in amputation. In all other patients healing of nonunion could be established, malunion could be corrected, and infections were successfully treated. The statistical analysis revealed that relative bone loss of the affected bone was the only predictor for occurrence of complications. From these data, we constructed a simple graph that shows the relationship between relative bone loss of the affected bone and risk of complications. INTERPRETATION: Relative bone loss of the affected bone segment is the main predictor of complications after Ilizarov treatment of previously failed fracture treatment. The visualization of the analysis in a simple graph may assist comparison of the complication rates in the literature.

The canine 'groove' model of osteoarthritis is more than simply the expression of surgically applied damage.

OBJECTIVE: Recently a new canine model of osteoarthritis (OA; the 'groove' model) has been described. This model is based on surgically applied mechanical damage of the articular cartilage followed by transient forced loading of the affected joint. Ten weeks after surgery this model shows characteristics of OA, mimicking human OA. To establish whether the observed characteristics of degeneration in this model represent the surgically applied damage, or are the results of progressive features of OA, we evaluated this 'groove' model shortly after surgery. METHODS: In 20 female Beagle dogs, articular cartilage of the weight-bearing areas of the femoral condyles in the right knee was damaged without affecting the underlying bone. After surgery dogs were let out on a patio 5 days/week for 4 h/day. The dogs were forced to load the experimental joint by fixing the contralateral control limb to the trunk 3 days/week. The severity of OA was evaluated at 3 (n = 10) or 10 weeks (n = 10) after surgery. Synovial inflammation, cartilage damage and cartilage matrix turnover were determined. RESULTS: Ten weeks after surgery osteoarthritic features were found, as described previously. Proteoglycan (PG) synthesis, percentage release of newly formed PG, and that of total amount of PG were enhanced, whereas PG content was significantly diminished (all P < 0.05). Importantly, 3 weeks after surgery these characteristics of OA were not yet evident. CONCLUSIONS: The present results clearly show that the characteristics observed 10 weeks after induction of joint degeneration in the groove model are not just the expression of the surgically applied damage but are the result of progressive features of (experimental) OA.

Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is one of the most prevalent and disabling chronic conditions affecting the elderly. Its etiology is largely unknown, but age is the most prominent risk factor. The current study was designed to test whether accumulation of advanced glycation end products (AGEs), which are known to adversely affect cartilage turnover and mechanical properties, provides a molecular mechanism by which aging contributes to the development of OA. METHODS: The hypothesis that elevated AGE levels predispose to the development of OA was tested in the canine anterior cruciate ligament transection (ACLT) model of experimental OA. Cartilage AGE levels were enhanced in young dogs by intraarticular injections of ribose. This mimics the accumulation of AGEs without the interference of other age-related changes. The severity of OA was then assessed 7 weeks after ACLT surgery in dogs with normal versus enhanced AGE levels. RESULTS: Intraarticular injections of ribose enhanced cartilage AGE levels approximately 5-fold, which is similar to the normal increase that is observed in old dogs. ACLT surgery resulted in more-pronounced OA in dogs with enhanced AGE levels. This was observed as increased collagen damage and enhanced release of proteoglycans. The attempt to repair the matrix damage was impaired; proteoglycan synthesis and retention were decreased at enhanced AGE levels. Mankin grading of histology sections also revealed more-severe OA in animals with enhanced AGE levels. CONCLUSION: These findings demonstrate increased severity of OA at higher cartilage AGE levels and provide the first in vivo experimental evidence for a molecular mechanism by which aging may predispose to the development of OA.