Long-Term Effects of AposTherapy in Patients with Osteoarthritis of the Knee: A Two-Year Followup.

Several biomechanics treatments for knee osteoarthritis (OA) have emerged with the goal of reducing pain and improving function. Through this, researchers have hoped to achieve a transition from the pathological gait patterns to coordinated motor responses. The purpose of the study was to determine the long-term effects of a therapy using a biomechanical device in patients with knee OA. Patients with knee OA were enrolled to active and control groups. The biomechanical device used in therapy (AposTherapy) was individually calibrated to each patient in the active group. Patients in the control group received standard treatment. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), Aggregated Locomotor Function (ALF), Short Form 36 (SF-36), and Knee Society Score assessments. The active and control groups were similar at the baseline (group difference in all scores P > 0.05). The active group showed a larger improvement over time between groups in all three WOMAC categories (F = 16.8, 21.7, and 18.1 for pain, stiffness, and function; all P < 0.001), SF-36 Physical Scale (F = 5.8; P = 0.02), Knee Society Knee Score (F = 4.3; P = 0.044 ), and Knee Society Function Score (F = 6.5; P = 0.014 ). At the two-year endpoint, the active group showed significantly better results (all P ≤ 0.001). The groups showed a difference of 4.9, 5.6, and 4.7 for the WOMAC pain, stiffness, and function scores, respectively, 10.8 s in ALF score, 30.5 in SF-36 Physical Scale, 16.9 in SF-36 Mental Scale, 17.8 in Knee Society Knee Score, and 25.2 in Knee Society Function Score. The biomechanical therapy examined was shown to significantly reduce pain and improve function and quality of life of patients with knee OA over the long term.

SPECT versus Planar Scintigraphy as a Clinical Aid in Evaluation of the Elderly with Knee Pain.

Chronic knee pain is a common complaint among the elderly and appears in 30%-40% of the population over the age of 65. This study was performed in order to evaluate correlation between clinical presentation of chronic knee pain and the imaging findings of SPECT and planar bone scintigraphy. Methods. We prospectively recruited 116 patients over the age of 50 who had neither knee surgery nor trauma. Patients were divided into symptomatic and asymptomatic groups. All patients were examined by an experienced orthopedic surgeon; on the same day imaging was performed. Statistical analysis was performed to correlate physical examination findings with planar scintigraphy and SPECT findings and blood pool images. Results. In symptomatic patients, planar scintigraphy correlated significantly (P < 0.01) with the presence of excessive joint fluid, synovial condensation, and decrease in range of motion as measured in extension and flexion and patellar grinding test. SPECT findings correlated with all of the above tests as well as with medial and patellofemoral joint tenderness. Conclusions. We believe a finding of tenderness at the medial articular crease or of the patellofemoral compartment of the knee should be considered an indication for the use of SPECT scintigraphy rather than planar scintigraphy.

Can single limb support objectively assess the functional severity of knee osteoarthritis?

There is a lack in objective measurements that can assess the symptoms of knee osteoarthritis (KOA). In a previous study it was shown that pain and function are in higher correlation with the single-limb support gait parameter than with radiographic KOA stage. Single limb support represents a phase in the gait cycle when the body weight is entirely supported by one limb, while the contra-lateral limb swings forward. The purpose of this study was to further examine the relationship between single-limb support and the level of pain and function in patients with KOA. 125 adults with bilateral KOA underwent a physical and radiographic evaluation, and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the SF-36 health survey. Patients walked barefoot at a self-selected speed on a computerized mat. Statistical analysis was used to divide the patients into quintiles based on single-limb support phase value and determine the differences in WOMAC and SF-36 scores between quintiles. Significant differences were found in WOMAC and SF-36 sub-category scores between the single-limb support quintiles. The means of the WOMAC-pain and WOMAC-function sub-categories decreased gradually over single-limb support quintiles (P<0.001), and the means of the SF-36 sub-categories increased gradually over the quintiles (P<0.001). Results show that single-limb support quintiles can help determine the level of pain, function and quality of life in patients with KOA. These results suggest that single-limb support quintiles may be added as an additional scale for generally assessing the symptomatic stage of KOA.

Sex and body mass index correlate with Western Ontario and McMaster Universities Osteoarthritis Index and quality of life scores in knee osteoarthritis.

OBJECTIVE: To examine the associations of sex, body mass index (BMI), and age with knee osteoarthritis (OA) symptomatic severity. DESIGN: A cross-sectional retrospective analysis. SETTING: Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Data were acquired from a stored database of a private therapy center. PARTICIPANTS: Patients (N=1487) with symptomatic knee OA were evaluated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: WOMAC questionnaire and SF-36. RESULTS: BMI correlated significantly with worse knee OA symptoms for all WOMAC and SF-36 subcategories (all P ≤.001). Age correlated significantly with worse symptoms only for WOMAC function and SF-36 physical functioning (P=.001 and P=.009, respectively). A significant difference across BMI quintiles was found for all WOMAC and SF-36 subcategories (all P ≤.01). Women showed worse knee OA symptoms in all WOMAC and SF-36 subcategories (all P ≤.001). There was a significant interaction of sex by BMI in WOMAC pain and WOMAC function (P=.01 and P=.02, respectively). CONCLUSIONS: Based on the results of this analysis, it can be concluded that women and patients with a higher BMI with knee OA are at a greater risk for worse symptoms.

Efficacy of methylsulfonylmethane supplementation on osteoarthritis of the knee: a randomized controlled study.

BACKGROUND: Patients with osteoarthritis (OA) take a variety of health supplements in an attempt to reduce pain and improve function. The aim of this study was to determine the efficacy of methylsulfonylmethane (MSM) in treating patients with knee OA. METHODS: This study was a prospective, randomized, double-blind, controlled clinical trial. Forty nine men and women 45-90 (mean 68 ± SD 7.3) years of age with knee OA according to the American College of Rheumatology clinical criteria for OA of the knee and with radiographic confirmed knee OA were enrolled in the study and randomly assigned into 2 groups: One received MSM in doses of 1.125 grams 3 times daily for 12 weeks and the other received a placebo in the same dosing frequency. The primary outcomes were the WOMAC Osteoarthritis Index for pain, stiffness and physical function, the Aggregated Locomotor Function (ALF) test that evaluates each patient's physical function, the SF-36 quality of life health survey and the visual-analogue-scale (VAS) for pain. The secondary outcomes were Knee Society Clinical Rating System for Knee Score (KSKS) and Function Score (KSFS). Patients were assessed at baseline, 6 weeks and 12 weeks. All continuous variables were tested by the Kolmogorov-Smirnov test for Normal distribution. Changes within the groups and differences between the groups were calculated by repeated measures of analysis (ANOVA) with one nested variable. RESULTS: There were significant differences between treatment groups over time in WOMAC physical function (14.6 mm [CI: 4.3, 25.0]; p = 0.04) and in WOMAC total score (15.0 mm [CI: 5.1, 24.9]; p = 0.03). Treatment groups did not differ significantly in WOMAC pain (12.4 mm [CI: 0.0, 24.8]); p = 0.08) or WOMAC stiffness (27.2 mm [CI: 8.2, 46.2]; p = 0.08). There was a non-significant difference in SF-36 total score between treatment groups (11.6 [CI: 1.0, 22.1]; p = 0.54). A significant difference was found between groups in VAS for pain (0.7 s [CI: -0.9, 2.4]; p = 0.05). Secondary outcomes showed non-significant differences between the two groups. CONCLUSIONS: Patients with OA of the knee taking MSM for 12 weeks showed an improvement in pain and physical function. These improvements, however, are small and it is yet to be determined if they are of clinical significance. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01188213.

Correlation between single limb support phase and self-evaluation questionnaires in knee osteoarthritis populations.

PURPOSE: To investigate the correlation between single limb support (SLS) phase (% of gait cycle) and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Health Survey) in patients with knee osteoarthritis (OA). METHOD: A prospective observational study was employed with 125 adults with bilateral medial compartment symptomatic knee OA who underwent a physical and radiographic evaluation. Velocity, step length and SLS were assessed by a computerised mat (GAITRite). Patients completed the WOMAC and SF-36 Health Survey questionnaires. RESULTS: Statistical analysis examined the correlations between SLS and both questionnaires, between Kellgren & Lawrence (K&L) scores and both questionnaires and between SLS correlations and K&L correlations. We found significantly stronger correlations between SLS and WOMAC-pain, WOMAC-function, the SF-36 pain sub-category, velocity and step length than between K&L scores and these parameters (Pearson's r = 0.50 vs. 0.26, 0.53 vs. 0.34, 0.50 vs. 023, 0.81 vs. 0.33, 0.77 vs. 0.37, respectively; all p < 0.05). Significant differences in SLS were found over WOMAC-pain, WOMAC-function and SF-36 overall score quartiles (p < 0.05 for all). CONCLUSION: We recommend integrating SLS as an objective parameter in the comprehensive evaluation of patients with knee OA.

The effect of hyaluronan injections into human knees on the number of bone and cartilage wear particles captured by bio-ferrography.

Osteoarthritis is characterized by degradation of cartilage and subchondral bone, releasing wear particles into the synovial fluid. Intra-articular injections of exogenous hyaluronan are often given to patients suffering from osteoarthritis in order to compensate for the reduction in the level of endogenous hyaluronan and to restore the rheological properties of the synovial fluid. The exact effect of these injections is still ambiguous. In this work bio-ferrography was used to capture magnetically labeled cartilage and bone debris from the synovial fluid in human knees before each of four injections (Euflexxa). The wear particles were counted and characterized microscopically and chemically. WOMAC, VAS, SF-36 and KS questionnaires indicated significant pain relief during the treatment, but suffered from inconsistency. Bio-ferrography showed a reduction in the concentration of both cartilage and bone particles, with a minimum after the third hyaluronan injection. The advantages of bio-ferrography as a primary assessment tool are discussed. The results indicate that while hyaluronan treatment may temporarily slow the wear rate to an extent beyond a placebo effect, it does not prevent joint degradation altogether.

A treatment applying a biomechanical device to the feet of patients with knee osteoarthritis results in reduced pain and improved function: a prospective controlled study.

BACKGROUND: This study examined the effect of treatment with a novel biomechanical device on the level of pain and function in patients with knee OA. METHODS: Patients with bilateral knee OA were enrolled to active and control groups. Patients were evaluated at baseline, at 4 weeks and at the 8-week endpoint. A novel biomechanical device was individually calibrated to patients from the active group. Patients from the control group received an identical foot-worn platform without the biomechanical elements. Primary outcomes were the WOMAC Index and ALF assessments. RESULTS: There were no baseline differences between the groups. At 8 weeks, the active group showed a mean improvement of 64.8% on the WOMAC pain scale, a mean improvement of 62.7% on the WOMAC function scale, and a mean improvement of 31.4% on the ALF scale. The control group demonstrated no improvement in the above parameters. Significant differences were found between the active and control groups in all the parameters of assessment. CONCLUSIONS: The biomechanical device and treatment methodology is effective in significantly reducing pain and improving function in knee OA patients.The study is registered at clinicaltrials.gov, identifier NCT00457132, http://www.clinicaltrials.gov/ct/show/NCT00457132?order=1.

APOS therapy improves clinical measurements and gait in patients with knee osteoarthritis.

BACKGROUND: The purpose of the study was to investigate the changes in gait patterns and clinical measurements following treatment with a novel biomechanical device on patients with knee osteoarthritis. METHODS: Forty six patients with bilateral knee osteoarthritis were analyzed. Patients completed a gait test, Western Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire and SF-36 Health Survey at baseline and after 12 weeks. The biomechanical device was individually calibrated to each patient at baseline to allow training under reduced pain. FINDINGS: Gait velocity, step length and single limb support improved significantly and toe out angle decreased significantly (10%, 6%, 1% and 2%, respectively). WOMAC-Pain and WOMAC-Function significantly decreased (26% and 34%, respectively), and SF-36 score significantly increased following the 12 weeks of treatment. INTERPRETATION: Our results suggest an overall improvement in the gait patterns, level of pain and level of function of patients with knee osteoarthritis following 12 weeks of treatment with the novel biomechanical device.

Magnetic isolation of particles suspended in synovial fluid for diagnostics of natural joint chondropathies.

Millions of people are stricken with the degenerative joint disease known as osteoarthritis. Osteoarthritis is associated with biochemical and mechanical processes, and is characterized by loss of articular cartilage and hypertrophy of bone. As cartilage and bone particles are released into the synovial fluid, a variety of biomarkers have been suggested for the analysis of this fluid. Here we have developed a method for isolating bone and cartilage wear particles suspended in the synovial fluid of the hip, knee and ankle joints of humans, based on specific magnetization of collagens I and II. Bio-ferrography is used to capture the particles on glass slides, allowing microscopic, chemical and statistical analyses. The relations between the level of the disease and the number, dimensions, shape and chemical composition of the particles were established. The method, which was found to be sensitive and reliable, can easily be extended to other applications, such as diagnosis of cancer and infectious diseases, determination of the efficacy of drugs or optimization of implants.

Differences in gait patterns, pain, function and quality of life between males and females with knee osteoarthritis: a clinical trial.

BACKGROUND: The aim of this study was to gain a deeper understanding of the gender differences in knee osteoarthritis (OA) by evaluating the differences in gait spatio-temporal parameters and the differences in pain, quality of life and function between males and females suffering from knee OA. METHODS: 49 males and 85 females suffering from bilateral medial compartment knee OA participated in this study. Each patient underwent a computerized gait test and completed the WOMAC questionnaire and the SF-36 health survey. Independent t-tests were performed to examine the differences between males and females in age, BMI, spatio-temporal parameters, the WOMAC questionnaire and the SF-36 health survey. RESULTS: Males and females had different gait patterns. Although males and females walked at the same walking speed, cadence and step length, they presented significant differences in the gait cycle phases. Males walked with a smaller stance and double limb support, and with a larger swing and single limb support compared to females. In addition, males walked with a greater toe out angle compared to females. While significant differences were not found in the WOMAC subscales, females consistently reported higher levels of pain and disability. CONCLUSION: The spatio-temporal differences between genders may suggest underlying differences in the gait strategies adopted by males and females in order to reduce pain and cope with the loads acting on their affected joints, two key aspects of knee OA. These gender effects should therefore be taken into consideration when evaluating patients with knee OA. TRIAL REGISTRATION: The study is registered in the NIH clinical trial registration, protocol No. NCT00599729.

Lumbar disk replacement with the ProDisc prosthesis.

Twenty-two ProDisc II prostheses (Spine Solutions, New York, New York) were implanted in 21 patients with degenerative disk disease at L5-S1 (19 disks) and L4-L5 (3 disks). After mean follow-up of 3.1 years (range, 17-49 months), pain intensity in all but 3 patients had improved from an average of 7.7 preoperatively to 4.6 postoperatively (P< .001) on a visual analog scale. Average Oswestry Disability Index score improved from 61 to 35 (P< .001). Radiographic reconstruction of the disk space height was achieved in all cases. Previous diskectomy at the implanted level and disk degeneration adjacent to previous fusion negatively influenced the results.

Deep vein thrombosis prevention in joint arthroplasties: continuous enhanced circulation therapy vs low molecular weight heparin.

Deep vein thrombosis prevention efficacy using a new, miniature, mobile, battery-operated pneumatic system (continuous enhanced circulation therapy [CECT] system) combined with low-dose aspirin was compared to enoxaparin. One hundred twenty-one patients who underwent total hip or knee arthroplasty were prospectively randomized into 2 groups. The study group was treated by the CECT system starting immediately after the induction of anesthesia. Postoperatively, a daily 100-mg aspirin tablet was added. The control group received 40 mg of enoxaparin per day. Bilateral venography was performed at the fifth to eight postoperative day. In the CECT group, as compared to the enoxaparin group, there was a significantly lower overall rate of DVT and proximal DVT. Safety profiles were similar in both groups. The combination of the CECT device with low-dose aspirin is more effective than enoxaparin in preventing deep-vein thrombosis after lower limb arthroplasties.

Complete paraplegia following gunshot injury without direct trauma to the cord.

STUDY DESIGN: A retrospective review of all patients with neurologic deficit following gunshot wounds that did not penetrate the spinal canal. OBJECTIVES: To evaluate the possibility that neurologic deficit following gunshot wounds is possible without direct trauma to the cord. SUMMARY OF BACKGROUND DATA: Gunshot injuries to the spine account for 13% to 17% of all spinal cord injuries and are likely to result in complete paraplegia. Neurologic deficit is the result of direct trauma to the nervous tissue by the bullet, bone, or disc fragments, which compress the cord. METHODS: The medical charts, radiographs, CT scans, and myelographies or MRIs of all patients admitted to our hospital with neurologic deficit secondary to gunshot wounds between 1977 and 2003 were reviewed. Twenty-six patients were identified: 15 with complete and 11 with incomplete paraplegia. In 19 patients, the spinal canal at the level of injury was explored and decompressed. RESULTS: In 3 patients with complete paraplegia at the thoracic level, CT scan, myelography (1 patient), MRI (2 patients), and operative exploration (2 patients) did not indicate any signs of canal compromise. Two were injured by low-velocity bullets passing through the vertebra (in 1 patient) and the posterior part of the lamina (in the second). The third was injured by high-velocity bullets with no signs on MRI of any injury to the vertebral column or spinal cord. At follow-up 4.1 years later, on average, none had any neurologic recovery. CONCLUSION: Neurologic deficit following gunshot wounds is possible even without violation of the spinal canal. It is most probably the result of the kinetic energy emitted by the bullet.

Gowers' sign in children with discitis of the lumbar spine.

Gowers' sign is pathognomonic in patients with Duchenne muscular dystrophy. These patients, when rising, 'climb up' their thighs using their hands in order to overcome the weakness of the pelvic girdle and paravertebral muscles. We report on four children in the age range of 3.3-8 years with disc space infection in the lumbar region, who demonstrated the sign in the early stages of the disease. Following treatment, Gowers' sign disappeared in all of these patients. We therefore conclude that the presence of Gowers' sign in small children must alert the examiner to the possibility of infection in the lumbar spine. These children use this maneuver in order to avoid painful motion of the lumbar spine.

Clinical presentation and anatomic position of L3-L4 disc herniation: a prospective and comparative study.

OBJECTIVE: A prospective, controlled cohort study was conducted to assess the anatomic transverse location and clinical presentation of L3-L4 disc herniation compared with lower lumbar levels. METHODS: This study prospectively identified 37 patients diagnosed with L3-L4 disc herniation (study group) and 52 patients diagnosed with L4-L5 and L5-S1 herniation (control group). The following clinical data were collected: age, femoral stretch test, motor strength, sensation, and deep tendon reflexes. The anatomic transverse location of the disc fragments was assessed by computed tomography or magnetic resonance imaging and was classified as either central, posterolateral, foraminal, or far lateral. RESULTS: The patients in the study group were older than the patients in the control group, and neurologic deficit was more common. The transverse location was foraminal and extraforaminal in 59% of the study group compared with 27% of the control group. These differences were statistically significant. CONCLUSIONS: The incidence of foraminal and far lateral disc herniation is significantly higher at the L3-L4 level compared with lower lumbar levels. When examining an older patient complaining of thigh pain, special attention should be given to the quadriceps strength, patellar reflex, and femoral stretch test. The L3-L4 foraminal and extraforaminal area should be assessed carefully.

Aspirin therapy and bleeding during proximal femoral fracture surgery.

To assess the effect of daily low-dose aspirin therapy on perioperative bleeding of patients operated on for proximal femoral fracture, we did a prospective case-control study. During 14 months, we followed up 104 patients, 39 of whom were taking aspirin before the injury. The bleeding was estimated by the number of blood units needed perioperatively, the change in hemoglobin values, and followup on complications and drain volume. The aspirin-treated group received an average of 0.5 units of blood more than the control group, postoperatively. This finding was statistically significant. The groups did not differ significantly in any other bleeding parameter. No major bleeding occurred in the patients. It is safe to do surgery for a proximal femoral fracture in patients who are taking aspirin.

Restoration of arthritic cartilage defects using autologous chondrocytes transplantation is superior to cartilage-paste graft in rabbits.

This study compared the articular cartilage repair potential of cultured chondrocytes transplantation with bone-cartilage paste-graft in the resurfacing of full-thickness defects without breaching of the subchondral bone plate in rabbit knees. A 5 x 5-mm articular cartilage defect was created in the patellar groove of the femur. Three months following creation, the defect was filled with cultured autologous chondrocytes (group 1) or bone-cartilage paste (group 2). A control group of untreated defects was followed for 1 year. The reparative tissue was analyzed macroscopically, histologically, and by immunohistochemistry 3-12 months post-transplantation. The surfaces of the reparative tissue in group 1 were smooth, and the defects were filled with reparative tissue that resembled hyaline cartilage. The composition of the repair tissue more closely resembled cartilage, as demonstrated by cartilage-specific stains. In contrast, the reparative tissue in group 2 was fibrous and exhibited markers of mesenchymal stem cells and bone formation. Transplantation of cultured chondrocytes into a full-thickness defect in the rabbit generates a biologic substitute tissue that resembles native articular cartilage with living cells capable of synthesizing the surrounding cartilage matrix. In contrast, analysis of the healing response to the paste-graft technique failed to show cartilage-like characteristics. This information may be clinically applicable to direct the use of these treatments in chondral injuries.

Symptomatic transient patellar ischemia following total knee replacement as detected by scintigraphy. A prospective, randomized, double-blind study comparing the mid-vastus to the medial para-patellar approach.

The most advantageous surgical approach for total knee arthroplasty is not defined. The mid-vastus approach has been suggested to improve patient rehabilitation and prevent patellar devascularization. The following study assessed the changes in patellar vascularity as determined by bone scanning following total knee arthroplasty without lateral release or patellar replacement. A total of 30 patients were randomly allocated to either undergo a medial para-patellar approach or a midvastus approach. All patients underwent a pre-operative bone scan and another scan was performed 5-7 days later. The bone scans were compared to assess the intensity of patellar uptake. In 4/30 (13.5%) of subjects, evenly distributed among the two study groups, patellar ischemia was demonstrated by decreased radioisotope uptake. These subjects underwent a third bone scan 1 month later. The latter scan demonstrated similar uptake to the pre-operative scan. These patients continue to suffer from anterior knee pain and show a positive patellar grinding test, which were not found in other patients. The current study appears to indicate that transient patellar ischemia is relatively common following total knee arthroplasty, even when no lateral release is performed. The surgical approach does not seem to affect the frequency of patellar ischemia. This phenomenon might be related to clinical symptoms of anterior knee pain.