Differentiation of patented crystalline glucosamine sulfate from other glucosamine preparations will optimize osteoarthritis treatment.

Symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) are recommended for the medium- to long-term management of knee osteoarthritis (OA) due to their abilities to control pain, improve function and delay joint structural changes. Among SYSADOAs, evidence is greatest for the patented crystalline glucosamine sulfate (pCGS) formulation (Mylan). Glucosamine is widely available as glucosamine sulfate (GS) and glucosamine hydrochloride (GH) preparations that vary substantially in molecular form, pharmaceutical formulation and dose regimen. Only pCGS is given as a highly bioavailable once-daily dose (1500 mg), which consistently delivers the plasma levels of around 10 µmol/L required to inhibit interleukin-1-induced expression of genes involved in the pathophysiology of joint inflammation and tissue destruction. Careful consideration of the evidence base reveals that only pCGS reliably provides a moderate effect size on pain that is higher than paracetamol and equivalent to non-steroidal anti-inflammatory drugs (NSAIDs), while non-crystalline GS and GH fail to reach statistical significance for pain reduction. Chronic administration of pCGS has disease-modifying effects, with a reduction in need for total joint replacement lasting for 5 years after treatment cessation. Pharmacoeconomic studies of pCGS demonstrate long-term reduction in additional pain analgesia and NSAIDs, with a 50% reduction in costs of other OA medication and healthcare consultations. Consequently, pCGS is the logical choice, with demonstrated medium-term control of pain and lasting impact on disease progression. Physician and patient education on the differentiation of pCGS from other glucosamine formulations will help to improve treatment selection, increase treatment adherence, and optimize clinical benefit in OA.

Percutaneous release of the A1 pulley using a modified Kirschner wire: a cadaveric study.

PURPOSE. To evaluate the outcome of percutaneous release of the A1 pulley in 40 cadaveric fingers using a modified Kirschner wire. METHODS. A 2.5-mm-diameter Kirschner wire measuring >12 cm in length was used. One end of the wire was sharpened into a 'J' shape using a grinder. The J-shaped tip featured a blunt, elongated lower tip, a sharp J-shaped curve, and a blunt upper tip. Completeness of A1 pulley release and injuries to the A2 pulley, flexor tendon, and neurovascular structures were evaluated in 40 cadaveric fingers. RESULTS. Complete release of the A1 pulley was achieved in 8 index, 7 middle, 8 ring, and 8 little fingers, whereas incomplete release of the distal part was noted in 2 index, 2 middle, 2 ring, and one little fingers; release was missed in one middle and one little fingers. Injury to the A2 pulley was noted in 2 index fingers; the injury was minimal and limited to the proximal 2 mm of the A2 pulley. There was no flexor tendon or digital nerve injury in any finger. CONCLUSION. Percutaneous release of the A1 pulley using a modified Kirschner wire achieved complete release in 78% of cadaveric fingers, which is comparable to that using a specially manufactured push knife.

Femoral head-neck diameter and ratio in Thais: a cadaveric study.

OBJECTIVE: To report the femoral head and neck diameter in both coronal and sagittal planes, the femoral head-neck ratio, and the difference between sex in a normal Thai population. MATERIAL AND METHOD: One hundred two femoral bones without visible previous disease or deformity of the head, neck, and shaft that included 50 male donors and 52 female donors, with an average age of 58.8 years (range 25 to 85) were included in the present study. The measurement of the femoral head and neck diameters was performed by using Vernier calipers (scale 150 x 0.02 mm). RESULTS: The mean head and neck diameters in coronal and sagittal planes in male and female are 45.25, 45.23, 40.28, 40.13 mms (p = 0.000), and 30.80, 25.65, 27.79, 22.08 mms (p = 0.000), respectively. The head-neck ratio in each plane in both male and female are 1.47, 1.45 (p = 0.257), and 1.77, 1.83 (p = 0.016), respectively. CONCLUSION: The very small average diameter of femoral head, especially in Thai females, should warn surgeons to carefully consider and then, perform hip resurfacing arthroplasty to avoid early complication from neck notching and mal-position. The head-neck ratio of the present study group is high enough to anticipate that postoperative anterior impingement of the neck and acetabulum or limiting hip flexion is unlikely to occur.

Uni-condyle high tibial osteotomy for malunion of medial plateau fracture: surgical technique and case report.

High tibial osteotomy (HTO) is a surgical procedure to re-align varus or valgus mal-alignment of the knee. Medial opening wedge HTO is a surgical treatment of choice for knee varus mal-alignment with many advantages over lateral closing wedge HTO. However, the opening of the medial wedge alters the plane of the lateral tibial plateau, especially when the correction angle is large, which may be the cause of early arthritic changes of the lateral compartment. Many recent studies reported the changes in medial posterior slope after medial opening wedge HTO, which affected the biomechanics of the knee. This report presents uni-condyle HTO, a new surgical technique that corrects alignment of medial tibial plateau in both coronal and sagittal plane without affecting the plane of lateral tibial plateau.

The relationship of anteroposterior, transepicondylar and posterior condylar axis of the femur: a Thai cadaveric study using digital measurement.

OBJECTIVE: To study the normal relationship of the anteroposterior (AP), transepicondylar (TE) and posterior condylar (PC) axis of cadaveric femoral bones using digital technology and special computer program. MATERIAL AND METHOD: Digital image of distal femur of 100 cadaveric bones of both sides and both sexes were taken using a special stand and clamp to ensure the same view and same distance from bone to camera. All still images were transferred into a specially developed computer program, then reference points were located by two observers, and were done twice at one week interval. The program reported the angle between AP-TE, AP-PC and TE-PC axes automatically. The data was then analyzed. RESULTS: The age of donor cadaveric bones ranged from 22 to 58 years (average 45.61 +/- 7.73). The AP-TE, AP-PC and TE-PC angles were 92.43 +/- 2.07, 86.65 +/- 1.85 and 5.79 +/- 1.26, respectively. The correlation coefficients of intra-observer reliability in observer 1 were 0.89, 0.87 and 0.91; in observer 2 were 0.92, 0.90 and 0.87. The correlation coefficients of inter-observer reliability were 0.81, 0.82 and 0.80. Limit agreement tests of AP-TE, AP-PC and TE-PC were 90.59%, 92. 57% and 96.03%, in that order. CONCLUSION: Using digital technology, the normal relationship of AP, TE and PC axes of femur from cadaveric bone could be more accurately studied comparing with the previous studies performing measurement on plain film, CT scan or MRI using goniometer.

The invention of new anterior spinal instrumentation prototype: a structural analysis of KKU expandable cage.

OBJECTIVE: Report the invention and structural analysis of the new model of anterior spinal instrumentation (KKU expandable cage) that is expandable for space filling after vertebral body resection while simultaneously stabilize the upper vertebra with the lower vertebra, to tolerate the thoracolumbar physiologic load and augment the interbody arthrodesis of the spine. MATERIAL AND METHOD: The new model of expandable anterior spinal instrumentation, named KKU expandable cage, was invented and designed using the computer. The structural property of this instrumentation was tested and analyzed using the computer based structural analysis software. RESULTS: The KKU expandable cage made out of 316L stainless steel is 0.0301044 kg in mass and 3.76305 x 10(-6) m3 for volume. The outer diameter of the device is 23 mm and the height can expand from 20 mm to 35 mm for space filling after thoracolumbar vertebrectomy. The stress in the device after applying the maximal thoracolumbar physiologic compression load (1250N) is between 11692.7 N/m2 to 94.7266 x 10(6) N/m2, less than compression strength of the 316L stainless steel (170 x 10(6) N/m2). CONCLUSION: The stainless steel 316 L KKU expandable cage for anterior spinal instrumentation can withstand the maximal thoracolumbar physiologic compression load without failure whereas its expandable property enable it to fill and fit in the space reaching the height of 35 mm. Therefore, the insertion of this device into a space after thoracolumbar or lumbar corpectomy or vertebrectomy for the vertebral osteomyelitis or vertebral metastasis is appropriate. The device can also stabilize the spine and tolerate the maximal physiologic compression load of the thoracolumbar vertebrae. Therefore, the device helps decrease the need for bone graft or bone substitute in these patients.

Reliability of the Roland - Morris Disability Questionnaire (Thai version) for the evaluation of low back pain patients.

OBJECTIVE: To determine the reliability of the Thai version of the Roland - Morris disability questionnaire in low back pain patients. MATERIAL AND METHOD: To develop Thai version of the Roland - Morris disability questionnaire and test it in 120 low back pain patients. Reliability of the Thai version of the Roland - Morris disability questionnaire was assessed by internal consistency using Cronbach's alpha coefficient. RESULTS: The overall Cronbach's alpha coefficient of the scale was 0.83. The Cronbach's alpha coefficient of each question in the Thai version of the Roland - Morris disability questionnaire exceeded 0.7 (range, 0.71- 0.93). The Cronbach's alpha coefficient tested in acute or chronic low back pain patients whether they have back pain only or back pain with radiculopathy which also exceeded 0.7 (range, 0.83-0.87). CONCLUSION: The Thai version of the Roland - Morris disability questionnaire is a reliable tool for assessing functional disability of low back pain in Thai patients.

Reliability of the medical outcomes study short-form survey version 2.0 (Thai version) for the evaluation of low back pain patients.

OBJECTIVES: To determine the reliability of Thai version of the medical outcomes study short-form survey version 2.0 (SF-36V2) in low back pain patients. MATERIAL AND METHOD: The authors developed the Thai version of the Medical Outcomes Study Short-Form Survey version 2.0 (SF-36V2) and tested it in 100 low back pain patients. Reliability of the Thai version of SF-36V2 was assessed by internal consistency using Chronbach's alpha coefficient and item-scale correlation. RESULTS: The authors demonstrated that the Chronbach's alpha coefficient of the physical health and mental health summary scales were 0.93 and 0.92 respectively. The Chronbach's alpha coefficient of eight scales in the Thai version of the SF-36V2 ranging was 0.72 - 0.94. The Chronbach's alpha coefficient tested in acute or chronic low back pain patients whether they have back pain only or back pain with radiculopathy ranging was 0.72-0.93. The item correlation coefficient for the 35 items within the eight health aspects ranged from 0.43 to 0.8. CONCLUSION: The Thai version of the Medical Outcomes Study Short-Form Survey version 2.0 (SF-36V2) is a reliable tool for assessing functional disability of low back pain in Thai patients.

Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: There is uncertainty as to whether supplemental oral nonsteroidal anti-inflammatory medication improves the effectiveness of steroid injections in the treatment of de Quervain disease. We tested the hypothesis that there are no significant differences in the success rates when this condition is treated with triamcinolone injection with or without supplemental oral nimesulide. METHODS: In a randomized, double-blind trial, 160 patients with de Quervain disease received an injection of 10 mg of triamcinolone acetonide and either 200 mg of oral nimesulide for seven days (eighty patients) or placebo tablets for seven days (eighty patients). An independent, blinded evaluator assessed the primary outcomes (tenderness, pain, and the result on the Finkelstein test) at three weeks after injection. Adverse reactions were assessed, and probabilities of recurrence for both groups were compared. Factors possibly predictive of disease recurrence were also assessed. RESULTS: The success rate after one injection was 67% in the nimesulide group and 68% in the placebo group. The overall success rates after single or multiple injections with a mean follow-up of 13.6 months were 95% for both groups. No significant differences were noted with respect to the success rates (p = 0.69) or pain scores after treatment (p = 0.11). The most common adverse reactions to triamcinolone injection and nimesulide were pain after injection and dyspepsia, respectively. The symptoms of de Quervain disease recurred in 33% of the patients in the nimesulide group and in 37% of those in the placebo group. The median time of recurrence was at the fifth month in the nimesulide group and at the fourth month in the placebo group. The recurrence of symptoms was significantly (p = 0.01) related to the presence of crepitation (relative risk, 2.13; 95% confidence interval, 1.19 to 3.80). CONCLUSIONS: Supplemental oral administration of the nonsteroidal anti-inflammatory drug nimesulide does not improve the effectiveness of a single injection of triamcinolone acetonide in the treatment of de Quervain disease. Patients with crepitation in the first dorsal compartment during thumb extension or abduction are at increased risk for recurrence of this disease. LEVEL OF EVIDENCE: Therapeutic study, Level I-1b (randomized controlled trial [no significant difference but narrow confidence intervals]).

The midpedicular and interpedicular distance of thoracolumbar vertebrae.

OBJECTIVES: 1. To introduce the measurement of the midpedicular distance (MPD) as an alternative to the interpedicular distance (IPD). 2. To measure the IPD and MPD of T11, T12, L1 and L2 vertebrae on anteroposterior (AP) plain film of the normal spine. 3. To study the relationship of the IPD and MPD of T11 to L2 of the normal spine. STUDY DESIGN: Thoracolumbar AP plain film of 89 subjects (39 males, 50 females) with an average age of 47.6 years (range 21-78 years) from the roentgenographic files were included. Both the IPD and MPD of T11, T12, L1 and L2 were measured by two observers. The mean difference of IPD and MPD at these four levels were compared by using a one-way ANOVA. The relationship of the IPD and MPD measured from the T11 to L2 levels were evaluated using the simple linear regression model. RESULTS: The mean IPD was progressively wider (p = 0.000) from the T11 to L1 level, but no significant difference (p = 0.308) was found between the mean IPDs of L1 and L2. The mean MPD of each level was significantly different from the others (p = 0.000) except the mean MPDs of T12 and L1 (p = 1.000). Both the IPD and MPD had a statistically significant linear relationship with the level of the vertebrae from T11 to L2 (p = 0.000) with the coefficients of determination (R2) of 0.39 and 0.28, respectively. CONCLUSION: More care should be taken in clinical practice when measuring the IPD of a fractured vertebra relative to those of adjacent lower levels in order to determine whether or not widening has occurred, especially IPD L1 vis-à-vis IPD L2. MPD measurement has no advantage over the IPD measurement but is a useful alternative when a comparison of the pedicular distance of L1 and L2 is needed.