The outcome of total ankle replacement: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis of modern total ankle replacements (TARs) to determine the survivorship, outcome, complications, radiological findings and range of movement, in patients with end-stage osteoarthritis (OA) of the ankle who undergo this procedure. We used the methodology of the Cochrane Collaboration, which uses risk of bias profiling to assess the quality of papers in favour of a domain-based approach. Continuous outcome scores were pooled across studies using the generic inverse variance method and the random-effects model was used to incorporate clinical and methodological heterogeneity. We included 58 papers (7942 TARs) with an interobserver reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98. The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean American Orthopaedic Foot and Ankle Society score changed from 40 (95% CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The mean total range of movement improved from 23° (95% CI 19 to 26) to 34° (95% CI 26 to 41) (p = 0.01). Our study demonstrates that TAR has a positive impact on patients' lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement. However, the quality of evidence is weak and fraught with biases and high quality randomised controlled trials are required to compare TAR with other forms of treatment such as fusion.

A trabecular metal tibial component in total knee replacement in patients younger than 60 years: a two-year radiostereophotogrammetric analysis.

We compared the performance of uncemented trabecular metal tibial components in total knee replacement with that of cemented tibial components in patients younger than 60 years over two years using radiostereophotogrammetric analysis (RSA). A total of 22 consecutive patients (mean age 53 years, 33 to 59, 26 knees) received an uncemented NexGen trabecular metal cruciate-retaining monobloc tibial component and 19 (mean 53 years, 44 to 59, 21 knees) a cemented NexGen Option cruciate-retaining modular tibial component. All the trabecular metal components migrated during the initial three months and then stabilised. The exception was external rotation, which did not stabilise until 12 months. Unlike conventional metal-backed implants which displayed a tilting migration comprising subsidence and lift-off from the tibial tray, most of the trabecular metal components showed subsidence only, probably due to the elasticity of the implant. This pattern of subsidence is regarded as being beneficial for uncemented fixation.

The occurrence of accessory immunologic cells in bone induction.

The differentiating tissues in fracture healing and in demineralized bone-powder-induced (DBP) bone formation were investigated with monoclonal antibodies with respect to the occurrence of Ia-positive cells, macrophages, and lymphocytes with interleukin-2 receptors (IL-2). Ia refers to molecules on the cell surface belonging to Class II of the major histocompatibility complex and is specific for the species and the individual. In both types of granulation tissues (fracture healing and following DBP implantation), the mesenchymal cells from the surrounding musculature were accompanied by large numbers of Ia-positive cells and common macrophages. The occurrence of IL-2 receptors was sparse in fracture healing but rich in DBP induction, probably because of its immunogenic properties, though weak. On Day 7, almost all existing cells in DBP induction were Ia-positive, signifying an immunologic effector phase apparently directed to the remaining still-passive bone powder in the periphery, while the central part of the inserted bone powder was producing cartilaginous cells and matrix. The presence of accessory immunologic cells in fracture healing is perhaps due to a surveillance function (a standard response on injury), but the cell differentiation might also be dependent on the active mediators emitted from Ia-positive cells and macrophages. This investigation strengthens the concept that induced bone development occurs in experimental fracture healing.

The implantation of demineralized fracture matrix yields more new bone formation than does intact matrix.

The inductive capacity of demineralized/lyophilized bone matrix prepared from fractured tibia ends in rats at different intervals after fracture was compared with matrix from the opposite, intact tibia. Fracture matrix and normal matrix cut in longitudinal strips were implanted in the gluteal muscles of 47 rats and were harvested after 15, 30, and 50 days. Staining was performed with hematoxylin-eosin, toluidine blue, and by monoclonal antibodies against Ia-antigen and collagen II. In comparison to the normal matrix, the fracture matrix brought about a more rapid bone formation counted as mineralization after 30 days and formation of ossicles after 30 and 50 days. Matrix from eight-day-old fracture was the most potent inductor compared to matrix from the other post-fracture intervals (one, five, and 11 days). Typical for the responding cells surrounding the implanted matrix was the abundant occurrence of cells carrying Ia-antigen. The cells penetrating the matrix formed pseudopods and could therefore be characterized as dendritic cells. The higher inductive capacity of fracture matrix might have some importance for the formation of the inductive enchondral callus in normal fracture healing.

The cartilaginous fracture callus in rats.

The right tibia was broken manually in 56 rats weighing 100 g; the fracture was stabilized with an intramedullary steel wire. Groups of rats were killed after 3-30 days. The fracture with its surrounding musculature was dissected out and immediately frozen to -70 degrees C. Cryostat sections of the fracture region were stained with hematoxylin/eosin, toluidine blue, and immunoenzymatically with collagen II antibodies. Another series of 30 fractured rats were killed after 1-15 days, and the fractures were examined histologically after decalcification with EDTA. Two types of callus were observed. The periosteal-endosteal callus started as proliferation of pre-osteoblasts without inflammatory cells on Day 1 and developed bone trabeculae from Day 3 until Days 8-10, but not thereafter. The cartilaginous callus was formed by condensation of fibroblast-like mesenchymal cells mixed with inflammatory cells outside the periosteal callus and started on Day 5 at the fracture fragments denuded of periosteum. The cells differentiating to cartilage seemed to migrate from the surrounding musculature and its newly formed vessels. The enchondral bone formation started close to the periosteal callus from which vessels were piercing into the then hypertrophic and mineralized chondrocytes on Day 11. We conclude that the bridging callus is formed by fundamentals of periosteal callus derived from predetermined cells and the bridge of enchondrally formed bone trabeculae by cells migrating from outside.

Traumatic hemarthrosis in stable knees.

A thorough arthroscopic examination was performed in 90 consecutive patients with sprained knee injuries with hemarthrosis, but without signs of instability or fracture. The source of bleeding was found in all but five joints. Thirty-nine injuries were tears of the cruciate ligament, only three of which were complete tears. Fourteen injuries were (osteo)chondral fractures and six were meniscal lesions. The remainder bled from the synovium or meniscal attachments. The arthroscopic examination resulted in an altered course of treatment in few, if any, of these patients.

Stability tests in knee ligament injuries.

For 182 knee joints with ligamentous injuries confirmed at surgery the records contained a complete and documented stability examination. In anterior cruciate ligament injuries the Lachman test and the anterior drawer sign were of similar value with regard to the frequency of false negatives - they missed half of the injuries - but their accuracy improved when they were repeated under anesthesia. The pivot shift was useful only under anesthesia. The medial collateral ligament injuries were usually detected because of valgus instability, also without anesthesia. The stability tests done with the patient under anesthesia are sufficiently reliable for making decisions about knee ligament surgery.

T-lymphocyte subsets and HLA-DR-expressing cells in the osteoarthritic synovialis.

Rheumatoid and osteoarthritic synovial membranes biopsied at operations were analysed in frozen sections with an immunohistochemical monoclonal antibody technique. It is evident from this investigation that immunocompetent inflammatory cells such as HLA-DR-expressing non-T cells and T cells in general occur even in the osteoarthritic synovial membrane, though to a lesser degree than in rheumatoid arthritis. In about half of the osteoarthritic synovial membranes these T cells were clustered in follicle-like formations. In both diseases, most of the T cells were helper/inducer T cells whereas cytotoxic/suppressor T cells occur sparsely and almost exclusively in rheumatoid arthritis.

Chronic calcaneal pain in athletes: entrapment of the calcaneal nerve?

In 11 heels in 10 athletes with chronic heel pain unrelieved by conservative therapy, the symptoms and physical findings caused a suspicion of entrapment of the calcaneal branches of the tibial nerve. The nerves were, therefore, surgically decompressed. No macroscopic signs of compression of the nerves were noted, but an entrapment of the anterior calcaneal branch could occur where the nerve passes between the tight and rigid edge of the deep fascia of the abductor hallucis and the medial edge of the os calcis. Followup of 58 months after surgery revealed that 10 of the 11 heels were asymptomatic and the patients had resumed athlete participation after an average of 5 weeks.

The effect of heat and stretching on the range of hip motion*.

Flexion, abduction, and external rotation of the hip joint were recorded in 30 volunteers randomized into three groups of 10. The measurements were taken before, immediately after, and 30 minutes after treatment of heat, stretching and a combination of heat plus stretching. Heat only did not improve the range of motion of the hip joint. Stretching increased flexion and external rotation, and heat plus stretching in combination gave the greatest increase in flexion motion, and also significantly increased abduction. External rotation after stretching treatment, and flexion and abduction after heat plus stretching treatment were still significantly increased after 30 minutes.J Orthop Sports Phys Ther 1984;6(2):110-115.

Apophysitis of the olecranon. A report of four cases.

Apophysitis of the olecranon is described in one girl and three boys from 9 to 13 years of age. The symptoms were pain and tenderness and radiography showed fragmentation. The symptoms improved and disappeared with rest.

The effect of stretching on the range of motion of the ankle joint in badminton players*.

The range of motion in the ankle joints were studied in two groups of badminton players during their training season. In one group, the exercise program consisted of tip-toe raising, whereas in the other group stretching exercise was added. The range of motion in the ankle joint in badminton players did not deviate from that of a control group. Both programs, stretching as well as regular exercise, increased the range of motion by approximatively 5 degrees during a 12-week period. No lengthening of the gastrocnemius muscle could be measured under maximal dorsiflexion from 30-35'. Too short or too tight a calf muscle does not explain the high incidence of Achilles tendon rupture and Achilles tendon pain in badminton players.J Orthop Sports Phys Ther 1983;5(2):74-77.

Osmium tetroxide in antigen-induced arthritis: failure to inhibit joint destruction.

Antigen induced arthritis (AIA) was elicited in 28 adult rabbits using ovalbumin. All animals developed an intensive monarthritis manifested by local heat and swelling. Two, 7 and 21 days later, respectively, 0.3 ml of 1 per cent OsO4 was injected into the arthritic knees of three groups of 9 rabbits. The rabbits were killed 1, 3 and 6 months later. No modifying influence on the severe to complete cartilage destruction was evident. One group of 8 rabbits received only OsO4 and the cartilage of these animals remained intact after 6 months.

Papain-induced mitosis of chondrocytes in adult joint cartilage: an experimental study in full-grown rabbits.

When diluted papain is injected intra-articularly into the knee joints of adult rabbits, slowing progressing, degenerative changes develop in the articular cartilage. After intravenous injection of crude papain no significant degenerative changes are found. With the aid of radioactive thymidine, it is possible to demonstrate that the chondrocytes recover their ability to divide before any degenerative changes can be found. At the same time the matrix loses its staining properties with Safranin-O and toluidine blue.

Late results of ankle fusion.

Forty-four ankle joint fusions performed in the period 1950-1972 at the Department of Orthopedic Surgery, Malmö General Hospital, were evaluated. Thirty-one patients were re-examined. The mean follow-up time was 12.3 years (6.4-28 years). Two-thirds of the patients were much better or better than before operation, but still a lot of problems existed. Two-thirds of the patients had some kind of pain localized to the subtalar region. Three out of four patients had to use special footwear. The rate of forefoot deformities was not increased. In conclusion, patients with ankle fusion often have persistent trouble; therefore technical and clinical development of total ankle joint replacement seems to be indicated.

Effect of osmium tetroxide and 198Au in normal and arthritic rabbit knee joints.

Antigen-induced arthritis (AIA) was induced in adult rabbit knee joints, using ovalbumin as antigen. After 4 weeks, intra-articular injections of 0.3 ml 1% osmium tetroxide or 100 muCi 198Au were given. The same injections were also given to normal animals. The animals were observed for up to 12 weeks. In the normal animals, no affection of articular cartilage could be seen by light microscopy. In the arthritic animals, however, severe destruction of articular cartilage was seen. The degree of destruction in the osmium tetroxide-treated animals was similar to or even worse than that of the controls, whereas the 198Au-treated animals showed a lesser degree of destruction than both controls and osmium tetroxide-treated animals. Autoradiograms, using 3H-thymidine, showed affection articular cartilage in all groups, i.e. both normal and arthritic.