Gait oscillation analysis during gait and stair-stepping in elder patients with knee osteoarthritis.

BACKGROUND: Evaluation of knee and lower limb function alone is not sufficient to assess gait. For accurate assessment of gait abnormality, gait oscillation should also be measured. The goal of this analysis was to assess the influence of the knee joint on gait oscillation during gait and stair-stepping in patients with osteoarthritis of the knee. METHODS: In 33 patients diagnosed with knee osteoarthritis and 33 healthy adults as the control group, we examined acceleration (anterior and lateral directions) and gait barycentric factors (single-support phase and ratio of center of gravity maximum values) during gait and stair-stepping. RESULTS: Acceleration in the anterior direction in the sacral region was greater in healthy adults than in osteoarthritis (OA) patients during gait and stair-down. Acceleration in the anterior direction in the dorsal vertebral region was greater in OA patients than in healthy adults during (up and down) stair-stepping. Acceleration in the lateral direction in the sacral region was greater in healthy adults than in OA patients during stair-up. Acceleration in the lateral direction in the dorsal vertebral region was greater in OA patients than in healthy adults during stair-stepping. The single-support phase was close to 1 for gait and stair-stepping in healthy adults and OA patients. The single-support time was largely the same for gait and stair-stepping in healthy adults. On the other hand, the single-support time was longer for stair-stepping than for gait in OA patients. The ratio of the center of gravity maximum values was greater for the sacral region than for the dorsal vertebral region. There was a significant difference in the stair-stepping ratio of the center of gravity maximum values between healthy adults and OA patients for the sacral region. CONCLUSION: We considered that knee OA influenced acceleration in the anterior and lateral direction in the dorsal vertebral and the ratio of the center of gravity maximum values on gait oscillation.

Kinematic analysis of posterior-stabilized total knee arthroplasty during standing up from and sitting down on a chair.

BACKGROUND: Total knee arthroplasty is effective to regain quality of life. Standing up from and sitting down on a chair and stair stepping motion are important in daily living. We previously reported in vivo kinematics of this implant during a stepping exercise. The purpose of this analysis was to assess in vivo knee motion during standing up from and sitting down on a chair and determine the motion pattern in patients with the unique knee prosthesis. METHODS: A total of 15 patients implanted with Bi-Surface PS were assessed during standing up from and sitting down on a chair. The Bi-Surface PS knee is a posterior-cruciate substitute prosthesis with a unique ball-and-socket joint in the mid-posterior portion of the femoral and tibial components. Patients were examined during standing up from and sitting down on a chair using a two-dimensional to three-dimensional registration technique. RESULTS: During standing up from and sitting down on a chair from minimum to 30° knee flexion, anterior femoral translation was slight. From 30° knee flexion to maximum flexion, the kinematic pattern was a medial pivot and rollback. CONCLUSIONS: This study demonstrated that the knee motion kinematic patterns observed in this study were not similar to normal knee kinematics and derived from the unique design of the Bi-Surface PS.

The Role of Complete Suprapatellar Plicae.

Shelf syndrome mainly affects younger people, often athletes. Cases of complete suprapatellar plica syndrome are rare. Arthroscopic inspection is necessary to diagnose complete suprapatellar plicae. The patients' symptoms improve after removal of the plicae. Our technique is an easy, completely arthroscopic procedure that has yielded good clinical outcomes in patients who have complete suprapatellar plicae. Although cases of complete suprapatellar plica syndrome are rare, it should be considered in patients with moderate knee pain.

In vivo kinematics of a unique posterior-stabilized knee implant during a stepping exercise.

BACKGROUND: Stair-stepping motion is important in daily living, similar to gait. Knee prostheses need to have even more superior performance and stability in stair-stepping motion than in gait. The purpose of this analysis was to estimate in vivo knee motion in stair stepping and determine if this unique knee prosthesis function as designed. METHODS: A total of 20 patients with Bi-Surface posterior-stabilizing (PS) implants were assessed. The Bi-Surface PS knee is a posterior-cruciate substitute prosthesis with a unique ball-and-socket joint in the mid-posterior portion of the femoral and tibial components. Patients were examined during stair-stepping motion using a 2-dimensional to 3-dimensional registration technique. RESULTS: The kinematic pattern in step up was a medial pivot, in which the level of anteroposterior translation was very small. In step down, the kinematic pattern was neither a pivot shift nor a rollback. From minimum to maximum flexion, anterior femoral translation occurred slightly. CONCLUSIONS: In this study, this unique implant had good joint stability during stair stepping. The joint's stability during stair stepping was affected by the design of the femorotibial joint rather than post/cam engagement or the ball-and-socket joint.

Knee Arthritis Without Other Joint Symptoms in the Elderly With Seronegative Elderly Onset Rheumatoid Arthritis.

Elderly onset Rheumatoid arthritis (EORA) has important clinical distinctions when compared with younger onset RA (YORA). In knee arthritis of elderly patients, infection, crystal-induced arthritis or EORA should be suspected if elevation of CRP in the preoperative examination and turbid joint effusion in their knee joint are found. Furthermore, if joint swelling and effusion remain after performing total knee arthroplasty (TKA), the infection after TKA, implant debris-related arthritis and EORA should be considered. However, it is difficult to diagnose patients as EORA if Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) are negative. The differential diagnosis is very important.

Gait parameters in women with bilateral osteoarthritis after unilateral versus sequential bilateral total knee arthroplasty.

PURPOSE: To compare gait parameters in women after unilateral total knee arthroplasty (TKA) versus sequential bilateral TKA to determine the need for sequential TKA. METHODS: 35 women aged 60 to 74 (mean, 70) years with bilateral varus knee osteoarthritis (OA) underwent unilateral (n=23) or sequential bilateral (n=12) TKA by a single surgeon. All patients underwent unilateral TKA; 12 patients then underwent sequential TKA after 3 to 6 months of the first TKA. Gait parameters (step length, step width, gait velocity, single support phase value, and the maximum centre of gravity ratio) were compared before and after TKA, and between patients with unilateral versus bilateral TKA. RESULTS: Patients with sequential bilateral TKA had more severe OA in their contralateral knee than patients with unilateral TKA. In patients with unilateral and sequential bilateral TKA respectively, the mean step width differed at postoperative one month (12.9 vs. 19.1, p<0.01) and 3 months (11.9 vs. 16, p=0.03), and the mean maximum centre of gravity ratio differed at postoperative 3 months (2.43 vs. 1.75, p=0.02), whereas the mean step length, mean gait velocity, and mean single support phase values did not differ significantly between groups. CONCLUSION: After unilateral TKA, contralateral TKA may not be necessary in some patients whose gait has improved.

Venous thromboembolism after total joint arthroplasty: results from a Japanese multicenter cohort study.

INTRODUCTION: Real-world evidence of the effectiveness of pharmacological thromboprophylaxis for venous thromboembolism (VTE) is limited. Our objective was to assess the effectiveness and safety of thromboprophylactic regimens in Japanese patients undergoing joint replacement in a real-world setting. METHOD: Overall, 1,294 patients (1,073 females and 221 males) who underwent total knee arthroplasty (TKA) and 868 patients (740 females and 128 males) who underwent total hip arthroplasty (THA) in 34 Japanese national hospital organization (NHO) hospitals were enrolled. The primary efficacy outcome was the incidence of deep vein thrombosis (DVT) detected by mandatory bilateral ultrasonography up to post-operative day (POD) 10 and pulmonary embolism (PE) up to POD28. The main safety outcomes were bleeding (major or minor) and death from any cause up to POD28. RESULTS: Patients undergoing TKA (n = 1,294) received fondaparinux (n = 360), enoxaparin (n = 223), unfractionated heparin (n = 72), anti-platelet agents (n = 45), or no medication (n = 594). Patients undergoing THA (n = 868) received fondaparinux (n = 261), enoxaparin (n = 148), unfractionated heparin (n = 32), anti-platelet agents (n = 44), or no medication (n = 383). The incidence rates of sonographically diagnosed DVTs up to POD10 were 24.3% in patients undergoing TKA and 12.6% in patients undergoing THA, and the incidence rates of major bleeding up to POD28 were 1.2% and 2.3%, respectively. Neither fatal bleeding nor fatal pulmonary embolism occurred. Significant risk factors for postoperative VTE identified by multivariate analysis included gender (female) in both TKA and THA groups and use of a foot pump in the TKA group. Only prophylaxis with fondaparinux reduced the occurrence of VTE significantly in both groups. Propensity score matching analysis (fondaparinux versus enoxaparin) showed that the incidence of DVT was lower (relative risk 0.70, 95% confidence interval (CI) 0.58 to 0.85, P = 0.002 in TKA and relative risk 0.73, 95% CI 0.53 to 0.99, P = 0.134 in THA) but that the incidence of major bleeding was higher in the fondaparinux than in the enoxaparin group (3.4% versus 0.5%, P = 0.062 in TKA and 4.9% versus 0%, P = 0.022 in THA). CONCLUSIONS: These findings indicate that prophylaxis with fondaparinux, not enoxaparin, reduces the risk of DVT but increases bleeding tendency in patients undergoing TKA and THA. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry: UMIN000001366. Registered 11 September 2008.

Unusual appearance of an osteochondral lesion accompanying medial meniscus injury.

An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance.

Collagen expression in various degenerative meniscal changes: an immunohistological study.

PURPOSE. To examine changes in acid mucopolysaccharides and collagen expression during meniscal degeneration, tearing, and repair, using menisci excised from knee joint surgeries. METHODS. Menisci excised from 23 patients aged 15 to 80 years who underwent meniscal surgery for flap and bucket handle tears (n=11) and total knee arthroplasty (TKA) for osteoarthritis (n=12) were examined histologically. Staining images were converted to greyscale images to measure the mean grey levels, which indicated densitometry. Comparisons were made between acutely injured menisci and menisci with and without degeneration (from patients with osteoarthritis) in terms of acid mucopolysaccharides, collagen types I, II, and III expression. RESULTS. In menisci with no degeneration, acid mucopolysaccharides, collagen types I and II were expressed throughout the entire meniscus except for the circulating area. Collagen type III was intensely expressed at the exterior peripheral border and on the surface. During progression of meniscal degeneration, the expression of acid mucopolysaccharides increased, and the expression of collagen types I, II, and III decreased. In acutely injured menisci, collagen types II and III disappeared first, followed by collagen type I, resulting in the abrogation of fibre construction. CONCLUSION. In normal menisci, acid mucopolysaccharides and collagen types I, II, and III were well-balanced, and meniscal function was maintained. When the limits of repair were exceeded, the meniscus tissue deteriorated owing to the disappearance of collagen types II and III and a decrease in collagen type I, resulting in the abrogation of meniscus fabric construction.

Shelf syndrome of the knee in elderly people: a report of three cases.

Shelf syndrome occurs mainly in younger people (particularly athletes) and rarely in elderly people. We report on 3 elderly patients with a medial synovial plica causing severe pain and locked knees. They had had no symptoms in their early or middle life. After removal of the shelf, the symptoms improved considerably. Although shelf syndrome is rare in the elderly, it should be suspected whenever severe pain and a locked knee are present.

Intra-articular synovial cyst of the knee joint: a case report.

Synovial cysts occur secondary to injury, mucinous degeneration or tumours. We report a patient with snapping of the knee joint caused by a synovial cyst located near the patellofemoral joint which developed as a result of minor trauma.

Resection arthroplasty combined with a muscle graft to treat refractory post-total knee arthroplasty infections.

For refractory post-total knee arthroplasty infections, resection arthroplasty combined with muscle grafting has been conducted to control the infection while preserving the infected limb. Resection arthroplasty was conducted on 9 patients (10 knees) with post-total knee arthroplasty refractory infection. All infections were brought under control. Seven patients were pain free, and mild pain persisted in 2 after walking and during locomotion. The average range of knee motion was 67 degrees. The mean discrepancy in leg length was 5.2 cm. There was no recurrence of infection in any patient. The function of each knee was accepted. Resection arthroplasty combined with muscle transfer is an effective method if the individuals desire to preserve the affected limbs for religious or cosmetic reasons and wish to regain the ability to move their knees.

Effect of progestins with different glucocorticoid activity on bone metabolism.

OBJECTIVE: Progestins are commonly prescribed for hormone replacement therapy (HRT) and contraception. However, the effects of progestins on bone metabolism remain unclear and are often controversial. DESIGN AND PATIENTS: This study was conducted to test the hypothesis that progestins with no significant glucocorticoid activity may be a better choice for HRT to achieve increased beneficial effects on bone metabolism than progestins with strong glucocorticoid activity. A total of 104 postmenopausal women aged 50-75 years with osteoporosis were allocated randomly to three groups: (1) conjugated oestrogen plus medroxyprogesterone acetate (HRT-MPA, with significant glucocorticoid activity); (2) conjugated oestrogen plus norethisterone (HRT-NET, with no significant glucocorticoid activity); and (3) control (no treatment). MEASUREMENTS: Vertebral X-rays and bone mineral density (BMD) at distal 1/3 radius were assessed at baseline and every 6 months during the 2-year study period, along with markers of bone turnover. The occurrence of new nonvertebral fractures was identified by X-ray. RESULTS: After the 2-year treatment, mean BMD changes relative to baseline in the HRT-MPA, HRT-NET and control groups were 1.6%, 2.3% and -1.9%, respectively. In addition, the rate of increase in HRT-NET was significantly greater than that in HRT-MPA (P = 0.019). The incidence of new fractures during the 2-year treatment in the control group was 26% (9/34). HRT-NET treatment significantly inhibited the occurrence of new fractures (RR 0.14, 95% CI 0.02-0.93, P = 0.04), while HRT-MPA treatment failed to show a statistically significant reduction (RR 0.41, 95% CI 0.14-1.24, P = 0.11). Both HRT-MPA and HRT-NET treatments significantly decreased serum osteocalcin levels by 29.4% and 23.5%, respectively, after 6 months of treatment, with the decrease in HRT-MPA being significantly greater than that in HRT-NET (P = 0.042). CONCLUSIONS: These findings suggest that progestins with no significant glucocorticoid activity may be a better choice for HRT, resulting in increased beneficial effects on bone metabolism compared with progestins with strong glucocorticoid activity.

The use of frame fixation in the management of open distal extensor mechanism avulsion fracture in a dislocated knee.

An avulsion fracture of the tibial tubercle is a common injury in traffic accident. If the fracture is closed, then a comparatively good prognosis can be expected through reinforcement of the bone via osteosynthesis and the use of artificial ligaments. In this case, an open wound was observed in the tibial tubercle, and the wound was so polluted that the healing process was significantly delayed. It was therefore difficult to provide simultaneous surgical treatment and so three operations were required to perform the reconstruction of the extensor mechanism. The reconstruction of extensor mechanism and the frame fixation between the patella and tibia was performed. Six months after the injury, the patient was able to walk without aid, had a range of movement from 5 degrees to 130 degrees , and did not show any indications of ADL disorder. Using this method of frame fixation between the patella and tibia proved to be an effective technique for the reconstruction of the open knee extension mechanism injury.

Juvenile rheumatoid arthritis manifesting in only limping due to flexion contraction of the knee.

Juvenile rheumatoid arthritis (JRA) is a relatively uncommon condition. The damage to the cartilaginous tissue is often irreversible and responsible for much of the morbidity. Timely diagnosis and appropriate aggressive treatment of patients improve quality of life and outcome. A reported case of JRA is presented in which limping associated with flexion contraction of the knee developed without any systemic symptoms. Magnetic resonance imaging and arthroscopic examination were helpful with early diagnosis. Aspirin was effective. There have been no recurrence to date.

Atypical tenosynovial giant cell tumor of the extensor hallucis longus tendon.

We present a case of atypical giant cell tumor of the tendon sheath originating from the extensor hallucis longus tendon. The tumor contained multiple nodules and overlay the tendon 16 cm. Magnetic resonance imaging was the most useful preoperative investigation and showed the characteristic appearance of giant cell tumor of the tendon sheath, thus allowing local excision to be planned and executed. We discuss how local recurrence of this tumor could be prevented.

Locked knee caused by intraarticular ganglion.

Intraarticular ganglion cyst arising from the cruciate ligament is difficult to diagnose by clinical symptom. In our case, Cyst attached anteriorly to posterior cruciate ligament, and limited both flexion and extension of knee. The cyst was excised in a piecemeal fashion arthroscopically. Knee pain and limitation in knee motion disappeared by the day after surgery. We hypothesize that reason of restriction of extension is impingement between anterior cruciate ligament and intracondylar, and reason of restriction of flexion is stimulation nerve ending in the synovial membrane stretched with knee motion.

A giant rheumatoid nodule.

Subcutaneous rheumatoid nodules occur commonly in advanced cases of rheumatoid arthritis and are the most common extra-articular lesion of this disease. We present a case of a very unusual giant rheumatoid nodule that developed on the lateral side of a knee. The case was devoid of systemic symptoms of arthritis and the lesion was limited to a rheumatoid nodule. The nodule was successfully treated by surgical excision. However, other new nodules developed in her hand. Her clinical course has not been satisfactory.

Effects of basic fibroblast growth factor on the repair of large osteochondral defects of articular cartilage in rabbits: dose-response effects and long-term outcomes.

Articular cartilage possesses a limited capacity for self-renewal. The regenerated tissue often resembles fibrocartilage-like tissue rather than hyaline cartilage, and degeneration of the articular surface eventually occurs. The purpose of this study was to investigate the effect of basic fibroblast growth factor (bFGF) on the healing of full-thickness articular cartilage defects. bFGF (0, 10, 50, 100, 250, 500, or 1000 ng) was mixed with collagen gel and implanted into full-thickness articular cartilage defects drilled into rabbit knees. The repaired tissue was examined grossly and histologically, and was evaluated with the use of a grading scale at 4, 12, 24, and 50 weeks. At 4 weeks, treatment with 100 ng of bFGF had greatly stimulated cartilage repair both grossly and histologically in comparison with untreated defects (those filled with plain collagen gel). The average total scores on the histological grading scale were significantly better for the defects treated with bFGF than for the untreated defects. These improvements were evident as long as 50 weeks postoperatively, although slight deterioration was noted in the repaired cartilage. Immunohistochemical staining for type II collagen showed that this cartilage-specific collagen was diffusely distributed in the repaired tissue at 50 weeks. These findings suggest that bFGF may be a practical and important candidate for use in cartilage repair.

Patellar tendon rupture and marked joint instability after total knee arthroplasty.

BACKGROUND: Patellar tendon rupture is a rare complication of total knee arthroplasty (TKA). Multiple repair methods have been described in the literature. METHODS: A 66-year-old woman suffered a patellar tendon re-rupture and marked joint instability within 6 months after revision TKA. She underwent re-revision TKA and extensor mechanism reconstruction with femoral quadriceps tendon and augmentation by a Leeds-Keio ligament. RESULT: It was fairly difficult to acquire a satisfactory range of motion as well as gain in knee extension capacity by eliminating the extension lag. CONCLUSION: Patellar tendon ruptures after TKA should be repaired as soon as they are recognized.