Ankle osteoarthritis commonly involves sagittal malalignment with anterior translation of the talus relative to the tibia. Total ankle arthroplasty has become an increasingly popular treatment for patients with symptomatic ankle osteoarthritis. However, no comprehensive study has been conducted on the outcomes of total ankle arthroplasty for osteoarthritis with preoperative sagittal malalignment. The purpose of this study was to evaluate the effect of anterior translation of the talus on outcomes of three-component total ankle arthroplasty.
One hundred and four osteoarthritic ankles in 104 patients who underwent three-component total ankle arthroplasty were included in this study. The 104 ankles were divided into 2 groups: ankles with anteriorly translated talus (50 ankles), and ankles with non-translated talus (54 ankles). Clinical and radiographic outcomes were assessed in both groups. The mean follow-up duration was 42.8 ± 17.9 months (range, 24 to 95 months).
Forty-six (92%) of 50 ankles with anterior translation of the talus showed relocation of the talus within the mortise at 6 months, and 48 (96%) ankles were relocated at 12 months after total ankle arthroplasty. But, 2 (4%) ankles were not relocated until the final follow-up. The AOFAS scores, ankle range of motion, and radiographic outcomes showed no significant difference between the two groups at the final follow-up (p > 0.05 for each).
In majority of cases, the anteriorly translated talus in osteoarthritic ankles was restored to an anatomical position within 6 months after successful three-component total ankle arthroplasty. The clinical and radiographic outcomes in the osteoarthritic ankles with anteriorly translated talus group were comparable with those in non-translated talus group.
Osteoarthritis; Total ankle arthroplasty; Three-component prosthesis; Anterior translation of the talus
Non-specific chronic back pain (CBP) is often accompanied by psychological trauma, but treatment for this associated condition is often insufficient.
Nevertheless, despite the common co-occurrence of pain and psychological trauma, a specific trauma-focused approach for treating CBP has been neglected to date. Accordingly, eye movement desensitization and reprocessing (EMDR), originally developed as a treatment approach for posttraumatic stress disorders, is a promising approach for treating CBP in patients who have experienced psychological trauma.
Thus, the aim of this study is to determine whether a standardized, short-term EMDR intervention added to treatment as usual (TAU) reduces pain intensity in CBP patients with psychological trauma vs. TAU alone.
The study will recruit 40 non-specific CBP patients who have experienced psychological trauma. After a baseline assessment, the patients will be randomized to either an intervention group (n = 20) or a control group (n = 20). Individuals in the EMDR group will receive ten 90-minute sessions of EMDR fortnightly in addition to TAU. The control group will receive TAU alone. The post-treatment assessments will take place two weeks after the last EMDR session and six months later.
The primary outcome will be the change in the intensity of CBP within the last four weeks (numeric rating scale 0–10) from the pre-treatment assessment to the post-treatment assessment two weeks after the completion of treatment.
In addition, the patients will undergo a thorough assessment of the change in the experience of pain, disability, trauma-associated distress, mental co-morbidities, resilience, and quality of life to explore distinct treatment effects. To explore the mechanisms of action that are involved, changes in pain perception and pain processing (quantitative sensory testing, conditioned pain modulation) will also be assessed.
The statistical analysis of the primary outcome will be performed on an intention-to-treat basis. The secondary outcomes will be analyzed in an explorative, descriptive manner.
This study adapts the standard EMDR treatment for traumatized patients to patients with CBP who have experienced psychological trauma. This specific, mechanism-based approach might benefit patients.
This trial has been registered with ClinicalTrials.gov (NCT01850875).
Eye movement desensitization and reprocessing; EMDR; Non-specific chronic back pain; Psychological trauma; Randomized controlled trial; Study protocol
Previous reviews of the diagnostic performances of physical tests of the hip in orthopedics have drawn limited conclusions because of the low to moderate quality of primary studies published in the literature. This systematic review aims to build on these reviews by assessing a broad range of hip pathologies, and employing a more selective approach to the inclusion of studies in order to accurately gauge diagnostic performance for the purposes of making recommendations for clinical practice and future research. It specifically identifies tests which demonstrate strong and moderate diagnostic performance.
A systematic search of Medline, Embase, Embase Classic and CINAHL was conducted to identify studies of hip tests. Our selection criteria included an analysis of internal and external validity. We reported diagnostic performance in terms of sensitivity, specificity, predictive values and likelihood ratios. Likelihood ratios were used to identify tests with strong and moderate diagnostic utility.
Only a small proportion of tests reported in the literature have been assessed in methodologically valid primary studies. 16 studies were included in our review, producing 56 independent test-pathology combinations. Two tests demonstrated strong clinical utility, the patellar-pubic percussion test for excluding radiologically occult hip fractures (negative LR 0.05, 95% Confidence Interval [CI] 0.03-0.08) and the hip abduction sign for diagnosing sarcoglycanopathies in patients with known muscular dystrophies (positive LR 34.29, 95% CI 10.97-122.30). Fifteen tests demonstrated moderate diagnostic utility for diagnosing and/or excluding hip fractures, symptomatic osteoarthritis and loosening of components post-total hip arthroplasty.
We have identified a number of tests demonstrating strong and moderate diagnostic performance. These findings must be viewed with caution as there are concerns over the methodological quality of the primary studies from which we have extracted our data. Future studies should recruit larger, representative populations and allow for the construction of complete 2×2 contingency tables.
Physical examination/physical tests; Hip/Hip joint; Diagnosis; Sensitivity and specificity; Predictive values; Likelihood ratios; Systematic review; Orthopedics
Uric acid (UA) may protect muscle function from oxidative damage due to reactive oxygen species through its powerful antioxidant capacity. However, several studies have demonstrated that hyperuricemia is closely related to systemic inflammation and has oxidant properties effects, both of which may increase the risk of muscle strength loss. The purpose of this study was to examine the association of serum UA concentration with grip strength and leg extension power in adult men.
This study is a cross-sectional survey in which 630 Japanese male employees aged 30 years and older participated. Five hundred and eighty-six subjects participated in the measurement of grip strength, and 355 subjects participated in the measurement of leg extension power. Blood samples were obtained for serum UA analysis.
After adjustment for potential confounders, grip strength differed significantly between participants with and those without hyperuricemia (geometric mean and 95% confidence interval [CI]: 40.3 [39.2–41.3] kg vs. 41.9 [41.3–42.5] kg; P = 0.01). In addition, serum UA levels (quartiles) showed an inverted J-shaped curve with grip strength (mean and 95% CI: Q1, 41.6 [40.6–42.6] kg; Q2, 42.2 [41.2–43.2] kg; Q3, 41.8 [40.8–42.8] kg; Q4, 40.4 [39.3–41.4] kg; P for quadratic trend = 0.05). The results in the leg extension power group were similar to those observed in the grip strength group.
This population-based cross-sectional study shows for the first time that hyperuricemia is associated with poor muscle strength. Moreover, the results indicate an inverted J-shaped association between serum UA quartiles and muscle strength.
Grip strength; Leg extension power; Antioxidant; Reactive oxygen species; Inflammation
Diabetes mellitus is associated with tendinopathy or tendon injuries. However, the mechanism underlying diabetic tendinopathy is unclear. The purpose of this study was to examine the effects of high glucose concentrations on the activity and expression of matrix metalloproteinases, type I collagen, and type III collagen in tendon cells.
Tendon cells from rat Achilles tendons were treated with 6 mM, 12 mM, and 25 mM glucose, and then cell proliferation was evaluated by the 3-[4,5-Dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay. Messenger RNA (mRNA) expression of MMP-2, MMP-8, MMP-9, and MMP-13 and type I and type III collagen was assessed by quantitative real-time polymerase chain reaction (PCR). The enzymatic activity of MMP-2 and MMP-9 was measured by gelatin zymography.
The MTT assay results showed that the glucose concentration did not affect tendon cell proliferation. The results of the real-time PCR assay revealed that the mRNA expression of MMP-9 and MMP-13 was up-regulated by treatment with 25 mM glucose, whereas the mRNA expression of type I and III collagen was not affected. Gelatin zymography showed that 25 mM glucose increased the enzymatic activity of MMP-9.
High glucose concentration up-regulates the expression of MMP-9 and MMP-13 in tendon cells, which may account for the molecular mechanisms underlying diabetic tendinopathy.
Glucose; Matrix metalloproteinase; Tendon
Anterior bone grafts are used as struts to reconstruct the anterior column of the spine in kyphosis or following injury. An incomplete fusion can lead to later correction losses and compromise further healing. Despite the different stabilizing techniques that have evolved, from posterior or anterior fixating implants to combined anterior/posterior instrumentation, graft pseudarthrosis rates remain an important concern. Furthermore, the need for additional anterior implant fixation is still controversial. In this bench-top study, we focused on the graft-bone interface under various conditions, using two simulated spinal injury models and common surgical fixation techniques to investigate the effect of implant-mediated compression and contact on the anterior graft.
Calf spines were stabilised with posterior internal fixators. The wooden blocks as substitutes for strut grafts were impacted using a “pressfit” technique and pressure-sensitive films placed at the interface between the vertebral bone and the graft to record the compression force and the contact area with various stabilization techniques. Compression was achieved either with posterior internal fixator alone or with an additional anterior implant. The importance of concomitant ligament damage was also considered using two simulated injury models: pure compression Magerl/AO fracture type A or rotation/translation fracture type C models.
In type A injury models, 1 mm-oversized grafts for impaction grafting provided good compression and fair contact areas that were both markedly increased by the use of additional compressing anterior rods or by shortening the posterior fixator construct. Anterior instrumentation by itself had similar effects. For type C injuries, dramatic differences were observed between the techniques, as there was a net decrease in compression and an inadequate contact on the graft occurred in this model. Under these circumstances, both compression and the contact area on graft could only be maintained at high levels with the use of additional anterior rods.
Under experimental conditions, we observed that ligamentous injury following type C fracture has a negative influence on the compression and contact area of anterior interbody bone grafts when only an internal fixator is used for stabilization. Because of the loss of tension banding effects in type C injuries, an additional anterior compressing implant can be beneficial to restore both compression to and contact on the strut graft.
Graft compression; Anterior fixation; Posterior fixation; Spine biomechanics
Physical activity is known to benefit many physiological processes, including bone turnover. There are; however, currently no clinical guidelines regarding the most appropriate type, intensity and duration of activity to prevent bone loss.
To help address this gap in the literature, we performed a retrospective analysis of data from the Canadian Multicentre Osteoporosis Study (CaMos), a prospective cohort of 9423 adult patients, to determine the relationship between the amount of regular daily physical activity performed and bone mineral density. A total of 1169 female participants aged 75 and over provided information regarding their daily activity levels, including the amount of time spent each week performing physical activity at varying levels of intensity. Multiple and linear regression analyses were used to determine the effect of increasing amounts of this regular physical activity on bone mineral density.
The results indicate that a step increase in the amount of physical activity performed each day resulted in a positive effect on bone mineral density at the hip, Ward’s triangle, trochanter and femoral neck (B = 0.006 to 0.008, p < 0.05). Possible confounding factors such as the use of anti-resorptive therapy, body mass index and age were included in the analysis and suggested that age had a negative effect on bone density while body mass index had a positive effect. Anti-resorptive therapy provided a protective effect against loss of bone density.
The data indicate that a step increase in the amount of daily activity, using simple, daily performed tasks, can help prevent decreases in post-menopausal bone mineral density.
Osteoporosis; Physical activity; Bone mineral density; Post-menopausal
To explore the patients’ experiences during the three decades following repair of a nerve injury in the forearm and its consequences for daily life. Strategies that were used to facilitate adaptation were also investigated.
Fifteen participants with a complete median and/or ulnar nerve injury repaired in the ages from 13–20 years were interviewed using a semi-structured interview guide. The median follow-up time was 31 years (range 23–40). The participants were asked to describe the past and present symptoms of the injured hand, the consequences of the injury for daily life, personal qualities and support from others. In addition, they were asked to describe strategies used to facilitate adaptation. The interviews were subjected to content analysis.
The nerve injury lead to sensory and motor deficits in the injured hand, as well as sensitivity to cold and secondary back problems. Emotional reactions to trauma and symptoms related to post-traumatic stress disorder were described, as well as how they managed to cope with such reactions. There was a noticeable impact on education, leisure, professional or domestic life for some, while others could continue by changing e.g. their performance pattern. The participants’ life roles and relations were also affected. Both emotion- and problem-based strategies were used to manage challenges in daily life.
The present qualitative study can help us to provide the patient with honest and realistic information about what to expect after a nerve injury at forearm level, without eliminating hope. Emotional reactions to trauma should be identified and dealt with. In addition, health-care professionals can promote a variety of coping mechanisms to facilitate daily living for the injured patients.
Peripheral nerve injury; Outcome; Consequences; Adaptation; Adolescence; Qualitative study
To describe changes in health-related quality of life (HRQoL) of postmenopausal women with osteoporosis treated with teriparatide for up to 18 months and followed-up for a further 18 months, and to assess the influence of recent prior and incident fractures.
The European Forsteo Observational Study (EFOS) is an observational, prospective, multinational study measuring HRQoL using the EQ-5D. The primary objective was to assess changes in HRQoL during 36 months in the whole study population. A secondary post-hoc analysis examined fracture impact on HRQoL in four subgroups classified based on recent prior fracture 12 months before baseline and incident clinical fractures during the study. Changes from baseline were analysed using a repeated measures model.
Of the 1581 patients, 48.4% had a recent prior fracture and 15.6% of these patients had an incident fracture during follow-up. 10.9% of the 816 patients with no recent prior fracture had an incident fracture. Baseline mean EQ-VAS scores were similar across the subgroups. In the total study cohort (n = 1581), HRQoL (EQ-VAS and EQ-5D index scores) improved significantly from baseline to 18 months and this improvement was maintained over the 18-month post-teriparatide period. Improvements were seen across all five EQ-5D domains during teriparatide treatment that were maintained after teriparatide was discontinued. Subjects with incident clinical fractures had significantly less improvement in EQ-VAS than those without incident fractures. Recent prior fracture did not influence the change in EQ-VAS during treatment.
EFOS is the first longitudinal study in women with severe postmenopausal osteoporosis in the real world setting to show a substantial improvement in HRQoL during teriparatide treatment that was sustained during subsequent treatment with other medications. The increase in HRQoL was lower in the subgroups with incident fracture but was not influenced by recent prior fracture. The results should be interpreted in the context of the design of an observational study.
EQ-5D; Fracture; Osteoporosis; Quality of life; Teriparatide
Ectopic expression of BMP-2, BMP-4 and BMP-7 was observed in clinical samples of tendinopathy and collagenase-induced (CI) tendon injury rat model. TDSCs isolated from the CI model showed increased non-tenogenic differentiation potential and hence altered fate compared to the TDSCs isolated from the healthy animals (HT) but the mechanism is unclear. We hypothesized that sensitization of the BMP/Smad pathway in TDSCs (CI) might account for this difference. This study aimed to compare the activation state of the BMP/Smad pathway at basal level and upon BMP-2 stimulation in TDSCs (CI) and TDSCs (HT).
Collagenase or saline was injected into the patellar tendon of rats for 2 weeks. TDSCs (CI) and TDSCs (HT) were then isolated from the patellar tendon. The mRNA and protein expression of BMPs and BMP receptors in TDSCs (CI) and TDSCs (HT) were analysed. TDSCs from both sources were treated with rhBMP-2 and the expression of phosphorylated and total Smad1/5/8 was examined.
Except for the mRNA levels of Bmp7 and Bmpr2, there were significant higher mRNA and protein expression of BMPs and BMP receptors in TDSCs (CI) compared to TDSCs (HT). TDSCs (CI) showed higher basal expression of total Smad1/5/8 but similar basal level of phosphorylated Smad1/5/8 compared to TDSCs (HT). TDSCs (CI) exhibited higher total and phosphorylated Smad1/5/8 upon BMP-2 stimulation.
The sensitization of the BMP/Smad pathway in TDSCs (CI) might account for their higher non-tenogenic differentiation potential and hence altered fate. It also provided further support of BMPs and the BMP/Smad signaling pathway in the pathogenesis of tendinopathy.
Tendinopathy; Tendon-derived stem/progenitor cells; BMP/Smad signaling; Collagenase-induced tendon injury
Despite the emerging use of treadmills integrated with pressure platforms as outcome tools in both clinical and research settings, published evidence regarding the measurement properties of these new systems is limited. This study evaluated the within– and between–day repeatability of spatial, temporal and vertical ground reaction force parameters measured by a treadmill system instrumented with a capacitance–based pressure platform.
Thirty three healthy adults (mean age, 21.5 ± 2.8 years; height, 168.4 ± 9.9 cm; and mass, 67.8 ± 18.6 kg), walked barefoot on a treadmill system (FDM–THM–S, Zebris Medical GmbH) on three separate occasions. For each testing session, participants set their preferred pace but were blinded to treadmill speed. Spatial (foot rotation, step width, stride and step length), temporal (stride and step times, duration of stance, swing and single and double support) and peak vertical ground reaction force variables were collected over a 30–second capture period, equating to an average of 52 ± 5 steps of steady–state walking. Testing was repeated one week following the initial trial and again, for a third time, 20 minutes later. Repeated measures ANOVAs within a generalized linear modelling framework were used to assess between–session differences in gait parameters. Agreement between gait parameters measured within the same day (session 2 and 3) and between days (session 1 and 2; 1 and 3) were evaluated using the 95% repeatability coefficient.
There were statistically significant differences in the majority (14/16) of temporal, spatial and kinetic gait parameters over the three test sessions (P < .01). The minimum change that could be detected with 95% confidence ranged between 3% and 17% for temporal parameters, 14% and 33% for spatial parameters, and 4% and 20% for kinetic parameters between days. Within–day repeatability was similar to that observed between days. Temporal and kinetic gait parameters were typically more consistent than spatial parameters. The 95% repeatability coefficient for vertical force peaks ranged between ± 53 and ± 63 N.
The limits of agreement in spatial parameters and ground reaction forces for the treadmill system encompass previously reported changes with neuromuscular pathology and footwear interventions. These findings provide clinicians and researchers with an indication of the repeatability and sensitivity of the Zebris treadmill system to detect changes in common spatiotemporal gait parameters and vertical ground reaction forces.
Gait analysis; Walking; Measurement; Repeatability; Precision; Reproducibility
It seems appropriate to assume, that for a full and strong global shoulder function a normally innervated and active deltoid muscle is indispensable. We set out to analyse the size and shape of the deltoid muscle on MR-arthrographies, and analyse its influence on shoulder function and its adaption (i.e. atrophy) for reduced shoulder function.
The fatty infiltration (Goutallier stages), atrophy (tangent sign) and selective myotendinous retraction of the rotator cuff, as well as the thickness and the area of seven anatomically defined segments of the deltoid muscle were measured on MR-arthrographies and correlated with shoulder function (i.e. active abduction). Included were 116 patients, suffering of a rotator cuff tear with shoulder mobility ranging from pseudoparalysis to free mobility. Kolmogorov-Smirnov test was used to determine the distribution of the data before either Spearman or Pearson correlation and a multiple regression was applied to reveal the correlations.
Our developed method for measuring deltoid area and thickness showed to be reproducible with excellent interobserver correlations (r = 0.814–0.982).
The analysis of influencing factors on active abduction revealed a weak influence of the amount of SSP tendon (r = −0.25; p < 0.01) and muscle retraction (r = −0.27; p < 0.01) as well as the stage of fatty muscle infiltration (GFDI: r = −0.36; p < 0.01). Unexpectedly however, we were unable to detect a relation of the deltoid muscle shape with the degree of active glenohumeral abduction. Furthermore, long-standing rotator cuff tears did not appear to influence the deltoid shape, i.e. did not lead to muscle atrophy.
Our data support that in chronic rotator cuff tears, there seems to be no disadvantage to exhausting conservative treatment and to delay implantation of reverse total shoulder arthroplasty, as the shape of deltoid muscle seems only to be influenced by natural aging, but to be independent of reduced shoulder motion.
Rotator cuff tear; Pseudoparalysis; Deltoid muscle; Myotendinous retraction
Current tendon repair techniques do not provide sufficient tensile strength at the repair site, and thus early active motion rehabilitation after tendon repair is discouraged. To enhance the post-operative tensile strength, we proposed and tested an internal fixation technique using a polycaprolactone (PCL) biofilm. PCL was chosen for its good biocompatibility, excellent mechanical strength, and an appropriate degradation time scale.
PCL biofilms were prepared by a modified melt-molding/leaching technique, and the physical and mechanical properties and in vitro degradation rate were assessed. The pore size distribution of the biofilm and the paratenon of native tendons were observed using scanning electron microscopy. Next, we determined whether this biofilm could enhance the tensile strength of repaired tendons. We performed tensile tests on rabbit Achilles tendons that were first lacerated and then repaired: 1) using modified Kessler suture combined with running peripheral suture (‘control’ group), or 2) using biofilm to wrap the tendon and then fixation with sutures (‘biofilm’ group). The influence of different repair techniques on tendon tensile strength was evaluated by mechanical testing.
The novel biofilm had supple texture and a smooth surface. The mean thickness of the biofilm was 0.25 mm. The mean porosity of the biofilm was 45.3%. The paratenon of the rabbit Achilles tendon had pores with diameters ranging from 1 to 9 μm, which were similar to the 4–12 μm diameter pores in the biofilm cross-section. The weight loss of the biofilms at 4 weeks was only 0.07%. The molecular weight of PCL biofilms did not change after immersion in phosphate buffered saline for 4 weeks. The failure loads of the biofilm were similar before (48 ± 9 N) and after immersion (47 ± 7 N, P > 0.1). The biofilm group had ~70% higher mean failure loads and 93% higher stiffness compared with the control group.
We proposed and tested an internal fixation technique using a PCL biofilm to enhance tendon repair. Internal fixation with the biofilm followed by standard suturing can significantly increase the tensile strength of tendon repair sites. This technique has the potential to allow active motion rehabilitation during the early post-operative period.
Tendon injury; Internal fixation; Biomechanics; Microstructure
In instrumented posterolateral fusion reduction of a spondylolisthesis is appealing on theoretical grounds since this may lead to indirect decompression of the entrapped nerve roots. However, there is no consensus in the literature whether a beneficial effect of reduction on outcome can be expected. The objective of the current study was to evaluate whether a correlation between the extent of listhesis reduction and clinical improvement could be established.
From two ongoing prospective studies 72 patients with a single-level instrumented posterolateral lumbar fusion for low-grade spondylolisthesis (isthmic/degenerative 51/21) were evaluated. Radiographs and clinical outcome scores were available at baseline, 6 weeks and 1 year after surgery. Changes in neuroforaminal morphology were measured on calibrated radiographs. These changes in radiographic parameters were correlated to clinical outcome (Visual Analogue Score (VAS) leg pain, Oswestry Disability Index (ODI)). Fusion status was assessed on Computed Tomography-scan at one year.
A mean spondylolisthesis of 25 percent was reduced to 15 percent at 6 weeks with some loss of reduction to 17 percent at one year. The VAS and ODI significantly improved at both time intervals after surgery (p < 0.001). No significant correlations could be established between the extent of slip reduction and improvement in VAS or ODI (Pearson’s correlation −0.2 and 0.07 respectively at one year); this also accounted for the other radiographic parameters. A fusion rate of 64 percent was seen on CT-scan.
Clinical outcome was not related to the obtained radiographic reduction of the slipped vertebra in patients with a lumbar fusion for low grade spondylolisthesis. Loss of reduction or non-union on CT-scans had no effect on the clinical outcome. Reduction of a low-grade spondylolisthesis in spinal fusion is appealing, however, there is no evidence that it positively affects clinical outcome on the short term.
Slip reduction; Low-grade spondylolisthesis; Neuroforaminal morphology; Clinical outcome; Posterolateral lumbar fusion; Radiographs
Anterior cervical discectomy with interbody fusion cages is considered the standard surgical procedure in patients with cervical disc herniation. However, PEEK or metal cages have some undesirable imaging characteristics, leading to a search for alternative materials not creating artifacts on images; silicon nitride ceramic. Whether patients treated with silicon nitride ceramic cages have similar functional outcome as patients treated with PEEK cages is not known. We present the design of the CASCADE trial on effectiveness of ceramic cages versus PEEK cages in patients with cervical disc herniation and/or osteophytes.
Patients (age 18–75 years) with monoradicular symptoms in one or both arms lasting more than 8 weeks, due to disc herniation and/or osteophytes, are eligible for the trial. The study is designed as a randomized controlled equivalence trial in which patients are blinded to the type of cage for 1 year. The total follow-up period is 2 years. The primary outcome measure is improvement in the Neck and Disability Index (NDI). Secondary outcomes measures include improvement in arm pain and neck pain (VAS), SF-36 and patients' perceived recovery. The final elements of comparison are perioperative statistics including operating time, blood loss, length of hospital stay, and adverse events. Lateral plane films at each follow-up visit and CT scan (at 6 months) will be used to judge fusion and the incidence of subsidence. Based on a power of 90% and assuming 8% loss to follow-up, 100 patients will be randomized into the 2 groups. The first analysis will be conducted when all patients have 1 year of follow-up, and the groups will be followed for 1 additional year to judge stability of outcomes.
While the new ceramic cage has received the CE Mark based on standard compliance and animal studies, a randomized comparative study with the golden standard product will provide more conclusive information for clinicians. Implementation of any new device should only be done after completion of randomized controlled effectiveness trials.
Anterior cervical discectomy and fusion; Silicon nitride; Polyetheretherketone; PEEK; Interbody spacers; Randomized controlled trial; Herniated disc
In the field of rehabilitation, patients are supposed to be experts on their own lives, but the patient’s own desires in this respect are often not reported. Our objectives were to describe the patients’ desires regarding functional improvements before and after total hip arthroplasty (THA).
Sixty-four patients, 34 women and 30 men, with a mean age of 65 years, were asked to describe in free text which physical functions they desired to improve. They were asked before surgery and at three and 12 months after surgery. Each response signified one desired improvement. The responses were coded according to the International Classification of Functioning, Disability and Health (ICF) to the 1st, 2nd and 3rd category levels. The frequency of the codes was calculated as a percentage of the total number of responses of all assessments times and in percentage of each time of assessment.
A total of 333 responses were classified under Part 1 of the ICF, Functioning and Disability, and 88% of the responses fell into the Activities and Participation component. The numbers of responses classified into the Activities and Participation component were decreasing over time (p < 0.001). The categories of Walking (d450), Moving around (d455), and Recreation and leisure (d920) included more than half of the responses at all the assessment times. At three months after surgery, there was a trend that fewer responses were classified into the Recreation and leisure category, while more responses were classified into the category of Dressing (d540).
The number of functional improvements desired by the patients decreased during the first postoperative year, while the content of the desires before and one year after THA were rather consistent over time and mainly concerned with the ability to walk and participate in recreation and leisure activities. At three months, however, there was a tendency that the patients were more concerned about the immediate problems with putting on socks and shoes.
Arthroplasty, Replacement, Hip; Rehabilitation; Desires; Functional improvement; ICF
To explore whether risk factors for neurophysiologically confirmed carpal tunnel syndrome (CTS) differ from those for sensory symptoms with normal median nerve conduction, and to test the validity and practical utility of a proposed definition for impaired median nerve conduction, we carried out a case–control study of patients referred for investigation of suspected CTS.
We compared 475 patients with neurophysiological abnormality (NP+ve) according to the definition, 409 patients investigated for CTS but classed as negative on neurophysiological testing (NP-ve), and 799 controls. Exposures to risk factors were ascertained by self-administered questionnaire. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by logistic regression.
NP+ve disease was associated with obesity, use of vibratory tools, repetitive movement of the wrist or fingers, poor mental health and workplace psychosocial stressors. NP-ve illness was also related to poor mental health and occupational psychosocial stressors, but differed from NP+ve disease in showing associations also with prolonged use of computer keyboards and tendency to somatise, and no relation to obesity. In direct comparison of NP+ve and NP-ve patients (the latter being taken as the reference category), the most notable differences were for obesity (OR 2.7, 95 % CI 1.9-3.9), somatising tendency (OR 0.6, 95% CI 0.4-0.9), diabetes (OR 1.6, 95% CI 0.9-3.1) and work with vibratory tools (OR 1.4, 95% CI 0.9-2.2).
When viewed in the context of earlier research, our findings suggest that obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand are causes of impaired median nerve function. In addition, sensory symptoms in the hand, whether from identifiable pathology or non-specific in origin, may be rendered more prominent and distressing by hand activity, low mood, tendency to somatise, and psychosocial stressors at work. These differences in associations with risk factors support the validity of our definition of impaired median nerve conduction.
Carpal tunnel syndrome; Nerve conduction; Case–control; Obesity; Vibration; Occupation; Psychosocial; Somatising tendency; Upper limb disorders
We have previously proposed that sensory nerve conduction (SNC) in the median nerve should be classed as abnormal when the difference between conduction velocities in the little and index fingers is > 8 m/s. In a prospective longitudinal study, we investigated whether this case definition distinguished patients who were more likely to benefit from surgical treatment.
We followed up 394 patients (response rate 56%), who were investigated by a neurophysiology service for suspected carpal tunnel syndrome. Information about symptoms, treatment and other possible determinants of outcome was obtained through questionnaires at baseline and after follow-up for a mean of 19.2 months. Analysis focused on 656 hands with numbness, tingling or pain at baseline. Associations of surgical treatment with resolution of symptoms were assessed by Poisson regression, and summarised by prevalence rate ratios (PRRs) and associated 95% confidence intervals (95% CIs).
During follow-up, 154 hands (23%) were treated surgically, and sensory symptoms resolved in 241 hands (37%). In hands with abnormal median SNC, surgery was associated with resolution of numbness, tingling and pain (PRR 1.5, 95% CI 1.0-2.2), and of numbness and tingling specifically (PRR 1.8, 95% CI 1.3-2.6). In contrast, no association was apparent for either outcome when median SNC was classed as normal.
Our definition of abnormal median SNC distinguished a subset of patients who appeared to benefit from surgical treatment. This predictive capacity gives further support to its validity as a diagnostic criterion in epidemiological research.
Carpal tunnel syndrome; Neurophysiology; Case definition; Validity; Surgery; Outcome
To inform the clinical management of patients with suspected carpal tunnel syndrome (CTS) and case definition for CTS in epidemiological research, we explored the relation of symptoms and signs to sensory nerve conduction (SNC) measurements.
Patients aged 20–64 years who were referred to a neurophysiology service for investigation of suspected CTS, completed a symptom questionnaire (including hand diagrams) and physical examination (including Tinel’s and Phalen’s tests). Differences in SNC velocity between the little and index finger were compared according to the anatomical distribution of symptoms in the hand and findings on physical examination.
Analysis was based on 1806 hands in 908 patients (response rate 73%). In hands with numbness or tingling but negative on both Tinel’s and Phalen’s tests, the mean difference in SNC velocities was no higher than in hands with no numbness or tingling. The largest differences in SNC velocities occurred in hands with extensive numbness or tingling in the median nerve sensory distribution and both Tinel’s and Phalen’s tests positive (mean 13.8, 95% confidence interval (CI) 12.6-15.0 m/s). Hand pain and thumb weakness were unrelated to SNC velocity.
Our findings suggest that in the absence of other objective evidence of median nerve dysfunction, there is little value in referring patients of working age with suspected CTS for nerve conduction studies if they are negative on both Tinel’s and Phalen’s tests. Alternative case definitions for CTS in epidemiological research are proposed according to the extent of diagnostic information available and the relative importance of sensitivity and specificity.
Epidemiology; Evidence-based medicine; Hand; Nerve compression syndromes; Wrist
A health promotion intervention was developed for inflammatory arthritis patients, based on goal management. Elevated levels of depression and anxiety symptoms, which indicate maladjustment, are found in such patients. Other indicators of adaptation to chronic disease are positive affect, purpose in life and social participation. The new intervention focuses on to improving adaptation by increasing psychological and social well-being and decreasing symptoms of affective disorders. Content includes how patients can cope with activities and life goals that are threatened or have become impossible to attain due to arthritis. The four goal management strategies used are: goal maintenance, goal adjustment, goal disengagement and reengagement. Ability to use various goal management strategies, coping versatility and self-efficacy are hypothesized to mediate the intervention’s effect on primary and secondary outcomes. The primary outcome is depressive symptoms. Secondary outcomes are anxiety symptoms, positive affect, purpose in life, social participation, pain, fatigue and physical functioning. A cost-effectiveness analysis and stakeholders’ analysis are planned.
The protocol-based psycho-educational program consists of six group-based meetings and homework assignments, led by a trained nurse. Participants are introduced to goal management strategies and learn to use these strategies to cope with threatened personal goals. Four general hospitals participate in a randomized controlled trial with one intervention group and a waiting list control condition.
The purpose of this study is to evaluate the effectiveness of a goal management intervention. The study has a holistic focus as both the absence of psychological distress and presence of well-being are assessed. In the intervention, applicable goal management competencies are learned that assist people in their choice of behaviors to sustain and enhance their quality of life.
Nederlands Trial Register = NTR3606, registration date 11-09-2012.
Adjustment; Self-management; Psychological well-being; Depression; Chronic disease; Adaptation; Threatened goals; Rheumatoid arthritis; Coping; Positive psychology
The primary aim of this study was to investigate the association between BMI and musculoskeletal symptoms in interaction with physical workload. In addition, it was aimed to obtain insight into whether overweight and obesity are associated with an increase in occurrence of symptoms and/or decrease in recovery from symptoms.
Based on a large working population sample (n = 44,793), using the data from The Netherlands Working Conditions Survey (NWCS), logistic regression analyses were carried out to investigate the association between BMI and musculoskeletal symptoms, with adjustment for potential confounders. Longitudinal data from the Netherlands Working Conditions Cohort Study (NWCCS) of 7,909 respondents was used for the second research aim (i.e., to investigate the transition in musculoskeletal symptoms).
For high BMI an increased 12-month prevalence of musculoskeletal symptoms was found (overweight: OR 1.13, 95% CI: 1.08-1.19 and obesity: OR 1.28, 95% CI: 1.19-1.39). The association was modified by physical workload, with a stronger association for employees with low physical workload than for those with high physical workload. Obesity was related to developing musculoskeletal symptoms (OR 1.37, 95% CI: 1.05-1.79) and inversely related to recovery from symptoms (OR 0.76, 95% CI: 0.59-0.97).
BMI was associated with musculoskeletal symptoms, in particular symptoms of the lower extremity. Furthermore, the association differed for employees with high or low physical workload. Compared to employees with normal weight, obese employees had higher risk for developing symptoms as well as less recovery from symptoms. This study supports the role of biomechanical factors for the relationship between BMI and symptoms in the lower extremity.
Musculoskeletal disorders; Overweight/obesity; Physical workload; Worker population
Cardiac conduction disturbances are common in spondyloarthropathies such as ankylosing spondylitis (AS). Whether their occurrence can be linked to signs and symptoms of rheumatic disease activity is an unsettled issue addressed in this study.
In this cross-sectional study patients with AS according to modified New York criteria but without psoriasis, inflammatory bowel disease, dementia, pregnancy, other severe diseases such as malignancy and difficulties in answering questionnaires were invited; and 210 participated (120 men), mean age 49 years (SD 13; range: 16–77). Questionnaires, physical examination, ECG, and laboratory tests were performed at the same visit.
Cardiac conduction disturbances were common and diagnosed in 10-33%, depending on if conservative or less conservative predefined criteria were applied. They consisted mostly of 1st degree atrio-ventricular block and prolonged QRS duration, but one patient had a pacemaker and 7 more had complete bundle branch blocks. Conduction abnormalities were associated mainly with age, male gender and body weight, and not with laboratory measures of inflammation or with Bath Ankylosing Spondylitis Disease Activity Index. Neither were they associated with the presence of HLA B27, which was found in 87% of all patients; the subtype B270502 dominated in all patients.
Cardiac conduction abnormalities are common in AS, but not associated with markers of disease activity or specific B27 subtypes. Even relatively mild conduction system abnormalities might, however, indirectly affect morbidity and mortality.
Ankylosing spondylitis; Spondyloarthritis; Heart disease; Inflammation; Disease activity; HLA B27
Previous studies in patients with hip and knee osteoarthritis (OA) have advocated the relevance of assessing the number of painful joint sites, other than the primary affected joint, in both research and clinical practice. However, it is unclear whether joint-pain comorbidities can simply be summed up.
A total of 401 patients with hip or knee OA completed questionnaires on demographic variables and joint-pain comorbidities. Rasch analysis was performed to evaluate whether a sum score of joint-pain comorbidities can be calculated.
Self-reported joint-pain comorbidities showed a good fit to the Rasch model and were not biased by gender, age, disease duration, BMI, or patient group. As a group, joint-pain comorbidities covered a reasonable range of severity levels, although the sum score had rather low reliability levels suggesting it cannot discriminate well among patients.
Joint-pain comorbidities, in other than the primary affected joints, can be summed into a joint pain comorbidity score. Nevertheless, its use is discouraged for individual decision making purposes since its lacks discriminative power in patients with minimal or extreme joint pain.
Hip or knee osteoarthritis; Joint-pain comorbidities; Rasch analysis; Sum score; Validity
Mitochondrion has an important role in the osteoarthritis (OA) pathology. We have previously demonstrated that the alteration of the mitochondrial respiratory chain (MRC) contributes to the inflammatory response of the chondrocyte. However its implication in the process of cartilage destruction is not well understood yet. In this study we have investigated the relationship between the MRC dysfunction and the regulation of metalloproteases (MMPs) in human normal chondrocytes in culture.
Human normal chondrocytes were isolated from human knees obtained form autopsies of donors without previous history of rheumatic disease. Rotenone, 3-Nitropropionic acid (NPA), Antimycin A (AA), Sodium azide and Oligomycin were used to inhibit the activity of the mitochondrial complexes I, II, III, IV and V respectively. The mRNA expression of MMPs -1, -3 and -13 was studied by real time PCR. The intracellular presence of MMP proteins was evaluated by western blot. The liberation of these proteins to the extracellular media was evaluated by ELISA. The presence of proteoglycans in tissue was performed with tolouidin blue and safranin/fast green. Immunohistochemistry was used for evaluating MMPs on tissue.
Firstly, cells were treated with the inhibitors of the MRC for 24 hours and mRNA expression was evaluated. An up regulation of MMP-1 and -3 mRNA levels was observed after the treatment with Oligomycin 5 and 100 μg/ml (inhibitor of the complex V) for 24 hours. MMP-13 mRNA expression was reduced after the incubation with AA 20 and 60 μg/ml (inhibitor of complex III) and Oligomycin. Results were validated at protein level observing an increase in the intracellular levels of MMP-1 and -3 after Oligomycin 25 μg/ml stimulation [(15.20±8.46 and 4.59±1.83 vs. basal=1, respectively (n=4; *P<0.05)]. However, AA and Oligomycin reduced the intracellular levels of the MMP-13 protein (0.70±0.16 and 0.3±0.24, respectively vs. basal=1). In order to know whether the MRC dysfunction had an effect on the liberation of MMPs, their levels were evaluated in the supernatants. After 36 hours of stimulation, values were: MMP-1=18.06±10.35 with Oligomycin 25 μg/ml vs. basal=1, and MMP-3=8.49±4.32 with Oligomycin 5 μg/ml vs. basal=1 (n=5; *P<0.05). MMP-13 levels in the supernatants were reduced after AA 60 μg/ml treatment (0.50±0.13 vs. basal=1) and Oligomycin 25 μg/ml (0.41±0.14 vs. basal=1); (n=5; *P<0.05). The treatment of explants with Oligomycin, showed an increase in the positivity of MMP-1 and -3. Explants stimulated with AA or Oligomycin revealed a decrease in MMP-13 expression. Proteoglycan staining demonstrated a reduction of proteoglycan levels in the tissues treated with Oligomycin.
These results reveal that MRC dysfunction modulates the MMPs expression in human normal chondrocytes demonstrating its role in the regulation of the cartilage destruction.