Adequate joint line restoration and good preliminary clinical outcomes after total knee arthroplasty using the Flexion First Balancer technique.

INTRODUCTION: Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). Factors which could possibly contribute to this dissatisfaction are a decreased posterior condylar offset (PCO) and subsequent joint line elevation which leads to mid-flexion instability. The Flexion First Balancer (FFB) technique aims to adequately restore the medial PCO and thereby reconstruct the medial native joint line to its pre-disease height. METHODS: A retrospective cohort of 59 patients operated using the FFB technique was analyzed and matched with a historic measured resection (MR) cohort of 59 patients. Groups were matched for age, gender, BMI and ASA classification. Joint line and PCO changes as well as patient reported outcome measurement scores (PROMs) were evaluated at one year [1.0 - 1.6] postoperatively. RESULTS: Radiographic evaluation revealed no changes in joint line height in the FFB group, whereas an elevation in joint line was seen in the MR group (p = 0.002). The PCO increased after surgery in both group without any statistically significant differences. Evaluation of PROMs found no differences between the two groups for total OKS and KOOS scores, nor in re-operation or complication rates. CONCLUSION: The FFB technique seems to be a safe technique to use in TKA and reconstructs the pre-disease joint line in contrast to the MR technique. The clinical outcomes were comparable between both groups.

Serial casting for elbow flexion contractures in neonatal brachial plexus palsy.

PURPOSE: The objective of this study was to evaluate the effectiveness of serial casting of elbow flexion contractures in neonatal brachial plexus palsy. METHODS: A prospective consecutive cohort study was performed with a median follow-up of 5 years. Forty-one patients with elbow flexion contractures ≥ 30° were treated with serial casting until the contracture was ≤ 10°, for a maximum of 8 weeks. Range of motion, number of recurrences and patient satisfaction were recorded and analyzed using Wilcoxon signed-rank and Cox regression tests. RESULTS: Passive extension increased from a median of -40° (IQR -50 to -30) to -15° (IQR -10 to -20, p < 0.001). Twenty patients showed 37 recurrences. The baseline severity of passive elbow extension had a hazard ratio of 0.93 (95% CI 0.89 to 0.96, p < 0.001) for first recurrence. Median patient satisfaction was moderate. Four patients showed loss of flexion mobility and in two patients serial casting had to be prematurely replaced by night splinting due to complaints. CONCLUSION: Serial casting improved elbow flexion contractures, although recurrences were frequent. The severity of elbow flexion contracture is a predictor of recurrence. We recommend more research on muscle degeneration and determinants involved in elbow flexion contractures to improve treatment strategies and prevent side-effects.

Local injection of autologous bone marrow cells to regenerate muscle in patients with traumatic brachial plexus injury: a pilot study.

OBJECTIVES: Traumatic brachial plexus injury causes severe functional impairment of the arm. Elbow flexion is often affected. Nerve surgery or tendon transfers provide the only means to obtain improved elbow flexion. Unfortunately, the functionality of the arm often remains insufficient. Stem cell therapy could potentially improve muscle strength and avoid muscle-tendon transfer. This pilot study assesses the safety and regenerative potential of autologous bone marrow-derived mononuclear cell injection in partially denervated biceps. METHODS: Nine brachial plexus patients with insufficient elbow flexion (i.e., partial denervation) received intramuscular escalating doses of autologous bone marrow-derived mononuclear cells, combined with tendon transfers. Effect parameters included biceps biopsies, motor unit analysis on needle electromyography and computerised muscle tomography, before and after cell therapy. RESULTS: No adverse effects in vital signs, bone marrow aspiration sites, injection sites, or surgical wound were seen. After cell therapy there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase in myofibre diameter (p = 0.007), a 50% increase in satellite cells (p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p < 0.001) was shown. CT analysis demonstrated a 48% decrease in mean muscle density (p = 0.009). Motor unit analysis showed a mean increase of 36% in motor unit amplitude (p = 0.045), 22% increase in duration (p = 0.005) and 29% increase in number of phases (p = 0.002). CONCLUSIONS: Mononuclear cell injection in partly denervated muscle of brachial plexus patients is safe. The results suggest enhanced muscle reinnervation and regeneration. Cite this article: Bone Joint Res 2014;3:38-47.

Relationship between the functional exon 3 deleted growth hormone receptor polymorphism and symptomatic osteoarthritis in women.

BACKGROUND: Several studies suggest a role of the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis in the pathophysiology of primary osteoarthritis (OA). A common polymorphism of the GH receptor (exon 3 deletion, d3-GHR) is associated with increased GH/IGF-1 activity. OBJECTIVE: To study associations between the d3-GHR polymorphism and symptomatic OA. METHODS: In the GARP (Genetics, osteoARthritis and Progression) study, we compared the d3-GHR polymorphism between OA patients and controls. GARP patients were genotyped for seven single nucleotide polymorphisms encompassing the d3-GHR gene, using rs4590183 as proxy for d3-GHR (pairwise r(2)=1). Binary logistic regression models with robust SEs were performed, stratified by sex. For replication, rs4590183 was tested in three additional cohorts. Fixed- and random-effects combined analyses were performed. RESULTS: In female GARP patients with severe familial OA, d3-GHR was associated with OA (adjusted OR 1.36 (95% CI 1.01 to 1.83), p=0.043), independently of age and body mass index. Combined analysis of all studies showed suggestive evidence for association between d3-GHR and OA (OR=1.17 (95% CI 1.04 to 1.30), p=0.008). Evidence was strongest in hip OA cases, without any evidence for heterogeneity. CONCLUSIONS: In women, the d3-GHR polymorphism was associated with symptomatic OA, especially at the hip site.

Developing core sets for patients with obstetricbrachial plexus injury based on the International Classificationof Functioning, Disability and Health.

BACKGROUND: Symptoms of obstetric brachial plexus injury (OBPI) vary widely over the course of time and from individual to individual and can include various degrees of denervation, muscle weakness, contractures, bone deformities and functional limitations. To date, no universally accepted overall framework is available to assess the outcome of patients with OBPI. The objective of this paper is to outline the proposed process for the development of International Classification of Functioning, Disability and Health (ICF) Core Sets for patients with an OBPI. METHODS: The first step is to conduct four preparatory studies to identify ICF categories important for OBPI: a) a systematic literature review to identify outcome measures, b) a qualitative study using focus groups, c) an expert survey and d) a cross-sectional, multicentre study. A first version of ICF Core Sets will be defined at a consensus conference, which will integrate the evidence from the preparatory studies. In a second step, field-testing among patients will validate this first version of Core Sets for OBPI. DISCUSSION: The proposed method to develop ICF Core Sets for OBPI yields a practical tool for multiple purposes: for clinicians to systematically assess and evaluate the individual's functioning, for researchers to design and compare studies, and for patients to get more insight into their health problems and their management.