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PubMed1996

New perspectives on osteoarthritis.

Osteoarthritis (OA) is the most common rheumatologic disease, afflicting tens of millions of U.S. citizens. It is not an inevitable consequence of aging; rather, it is a degenerative process acquired because of metabolic, mechanical, genetic, and other influences. It is characterized by progressive loss of cartilage and bony overgrowth. Because cartilage is not innervated, the pain of OA arises from secondary effects, such as joint capsule distention, stretching of periosteal nerve endings, and, possibly, synovial inflammation. Psychologic factors, including stress and depression, may influence the perception of pain by OA patients. The risk of OA apparently is not increased by normal joint use, but persons who participate in competitive sports or who play with abnormal or injured joints are at increased risk. Obesity increases OA risk, and weight loss has been found to decrease it. Some forms of premature OA appear to be inherited. The objective diagnosis of OA is made on the basis of radiography. However, many individuals with radiographic evidence of OA are asymptomatic in the affected joint. It is essential to ensure that pain in the affected joint is attributable to OA and not another cause. The management of OA should include physical medicine measures such as heat or cold therapy and often neglected environmental measures, such as reducing chair height and using shoe orthotics. Therapeutic exercise is beneficial for many patients and includes an initial warm-up with range of motion, muscle strengthening, and aerobic activity (such as swimming). A major question in the pharmacologic management of OA is whether nonsteroidal anti-inflammatory drugs (NSAIDs) are superior to analgesics in terms of symptomatic relief; studies indicate that they are not. The question is relevant because of the adverse effects of NSAID use, particularly in the elderly population.

Age Factors↗
PubMed1984

Irreducible dorsal dislocation of the distal interphalangeal joint of the finger.

Distal interphalangeal joint dislocations of the fingers are uncommon but easily reducible. Irreducible dislocations are quite rare and treatment of such a case is being reported here. Causes of irreducibility have been found to be: volar plate interposition, protrusion of the middle phalanx through the joint capsule, and flexor tendon displacement over the middle phalanx. When these situations occur open reduction is indicated.

Adult↗
PubMed2000

Morphology and functional roles of synoviocytes in the joint.

The joint capsule exhibits a unique cellular lining in the luminal surface of the synovial membrane. The synovial intimal cells, termed synoviocytes, are believed to be responsible for the production of synovial fluid components, for absorption from the joint cavity, and for blood/synovial fluid exchanges, but their detailed structure and function as well as pathological changes remain unclear. Two types of synoviocytes, macrophagic cells (type A cells) and fibroblast-like cells (type B cells) have been identified. Type A synoviocytes are non-fixed cells that can phagocytose actively cell debris and wastes in the joint cavity, and possess an antigen-presenting ability. These type A cells, derived from blood-borne mononuclear cells, can be considered resident macrophages (tissue macrophages) like hepatic Kupffer cells. Type B synoviocytes are characterized by the rich existence of rough endoplasmic reticulum, and dendritic processes which form a regular network in the luminal surface of the synovial membrane. Their complex three-dimensional architecture was first revealed by our recent scanning electron microscopy of macerated samples. The type B cells, which are proper synoviocytes, are involved in production of specialized matrix constituents including hyaluronan, collagens and fibronectin for the intimal interstitium and synovial fluid. The proliferative potentials of type B cells in loco are much higher than type A cells, although the transformation of subintimal fibroblasts into type B cells can not be excluded. In some mammals, type B cells show features suggesting endocrine and sensory functions, but these are not recognized in other species. The synoviocytes, which form a discontinuous cell layer, develop both fragmented basement membranes around the cells and junctional apparatus such as desmosomes and gap junctions. For an exact understanding of the mechanism of arthritis, we need to establish the morphological background of synoviocytes as well as their functions under normal conditions.

Animals↗
PubMed1989

The prevention and treatment of injuries to the shoulder in swimming.

The biomechanics of swimming cause considerable stress on the shoulder joint which may be accentuated by improper stretching or training techniques. The rotator cuff, and particularly the supraspinatus tendon, is at risk in repetitive overhead stroke activity. Arthritis in the shoulder is primarily centered at the acromioclavicular joint; degeneration may occur as a result of overuse or leverage of the scapuloclavicular mechanism, or from motion related to upward pressure at the undersurface of the acromion due to subluxation or instability of the glenohumeral joint. Instability of the glenohumeral joint is a major problem which may occur in itself or in combination with rotator cuff tendinitis. The glenohumeral joint is stabilised superiorly by a posterior superior sling consisting of the long biceps tendon, the superior joint capsule, and the coracoacromial and coracohumeral ligaments. An anterior inferior sling mechanism consisting of the inferior glenohumeral ligament and subscapularis musculotendinous unit provides significant stability if uninjured. Fragments of labral tissue may mechanically wedge into the joint also leading to symptoms of subluxation. If the humeral head is wedged or allowed to slip out of joint due to capsular incompetency, secondary rotator cuff 'impingement' may occur; this is particularly difficult to manage. Prevention of injury is best accomplished through a programme of flexibility and strengthening avoiding overuse.

Athletic Injuries↗
PubMed1989

Ultrasonographic evidence of hip synovitis in patients with rheumatoid arthritis.

One hundred non-operated hip joints in 50 adult patients with active rheumatoid polyarthritis were examined by ultrasonography as well as by clinical methods and X-ray. In 15 hip joints in 11 patients, ultrasonography indicated intra-articular effusion (a distance between the joint capsule and bone of more than 7 mm in 14 and a difference between the two sides of more than 1.5 mm for one hip). There were no subjective symptoms associated with five of these hip joints, the X-ray findings were normal for 11 hips, and careful clinical examination showed normal findings for one hip joint. The routine clinical examination used in the hospital had revealed pathological findings in only two of these hip joints. It is concluded that ultrasonography may reveal intra-articular effusion or synovitis in clinically and radiologically apparently normal hip joints of patients with active rheumatoid arthritis. The increase in pain and restricted motion was statistically significant in the hips for which ultrasonography indicated intra-articular effusion. Hips that appear pathological in ultrasonography are thus synovitis, and do not fall within the range of normal variation for healthy hip joints.

Adult↗
PubMed1990

Intracapsular and atmospheric pressure in the dynamics and stability of the hip. A biomechanical study.

A cadaver study was undertaken to evaluate (a) the relations between the rotation around the axis of the neck of the femur, intracapsular effusion, and intracapsular pressure; and (b) the importance of the atmospheric pressure in stabilizing the hip joint. The following conclusions were reached: (1) There is no increase in intracapsular pressure within the normal range of rotation ("flexion") around the axis of the neck of the femur. (2) Intracapsular fluid (e.g., blood, pus, synovial edema and/or free synovial fluid) decreases this pressureless range of rotation, a likely cause of pain and subsequently flexion contractures. (3) Joint stability is primarily maintained by the atmospheric pressure within the normal range of rotation. The joint capsule is tightened only in extreme extension or flexion and contributes to stability only in these positions. (4) The traction force needed to overcome the stabilizing effect of the atmospheric pressure and thus subluxate the adult joint is approximately 200 N, in a child less, proportional to the square of the diameter of the femoral head. We also propose that intracapsular fluid makes the joint potentially unstable, a prerequisite for unfavorable mechanical cartilage load. These findings have clinical implications in synovitis, septic and juvenile arthritis, congenital dislocation of the hip, arthroplasty, and trauma.

Adult↗
PubMedDate not supplied

Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management.

Multidirectional instability of the shoulder is a complex entity. Relatively few series of patients with this condition have been reported. Affected patients have global (anterior, inferior, and posterior) excessive laxity of the glenohumeral joint capsule and a rotator interval capsule defect. The onset of symptoms is frequently related to atraumatic events. The chief complaint is more often related to pain than to instability per se. Symptoms are mostly experienced within the midrange of glenohumeral motion. Because the contralateral shoulder is often equally lax and asymptomatic, it appears that factors in addition to excessive capsular laxity play a pathophysiologic role. These factors may include subtle losses of strength and/or neuromotor coordination of the rotator cuff and scapular stabilizing muscles, defective proprioceptive responses, and the absence of a limited joint volume. Most patients can be successfully treated nonoperatively with a specific exercise program. If a 6-month trial of nonoperative management fails, the patient is a candidate for surgical reconstruction. The most time-honored procedure is an open inferior capsular shift, which corrects excessive global laxity of the capsule and the rotator interval defect.

Arthroscopy↗
PubMed1997

Sensory innervation of the cat knee articular capsule and cruciate ligament visualised using anterogradely transported wheat germ agglutinin-horseradish peroxidase.

Wheat germ agglutinin-horseradish peroxidase conjugate (WGA-HRP) was injected into the dorsal root ganglia (L5-S1) of the cat and used as an anterograde tracer substance for intra-axonal labelling of peripheral nerve endings in joint capsule and cranial (anterior) cruciate ligament (CCL). We believed that the high specificity of WGA-HRP for neural tissue along with the high visibility of its reaction product could help resolve controversies concerning the sensory innervation of the cruciate ligaments. Substantial amounts of WGA-HRP were transported in tibial nerve axons to the level of the knee. However, using standard HRP histochemistry we found that the capsular tissue and ligament synovia disintegrated during the incubation reaction. This problem was avoided by air drying the tissue slices on glass slides prior to reaction. Abundant labelling occurred in the posterior capsule with dense filling of axons and terminal endings. Sensory endings displayed features consistent with Ruffini endings and pacinian corpuscles. Sensory endings were located throughout the CCL in its sagittal plane, in the subsynovial layers and between collagen fascicles. In each CCL we observed 5-17 ovoid and elongated endings with dense terminal arborisations. These endings were between 100 and 150 microns long, were encapsulated, and gave rise to 1 or 2 axons. Large (up to 1.5 mm in maximum extent) elongated regions of dense, inhomogeneous labelling were found in the body of several CCLs. These resembled Golgi tendon-like endings, with the exception of their large size. We conclude that anterograde transport of HRP to the knee is a useful technique for labelling mechanoreceptors and axons in knee tissue. However, recently developed immunohistochemical analysis of peripheral tissue using protein gene product 9.5 appears to be the method of choice and should be employed for further study of human and animal cruciate ligament innervation.

Animals↗
PubMed1999

A method of tracking donor cells after simulated autologous transplantation: a study using synovial cells of transgenic rats.

A transgenic rat was used as a transplantation donor to simulate autologous transplantation. The sex-matched transplantation between a female transgenic and a wild-type rat can theoretically be regarded as an autologous transplantation due to the genetic agreement of these rats except for the non-protein-producing transgenes. Transgene-containing synovial cells were tracked in the joint using this autologous transplantation model. The transgenes in the donor synovial cells were detected using in situ hybridization (ISH), while mitotic activities were simultaneously examined by immunodetection of 5-bromo-2'-deoxyuridine (BrdU). A defect was generated in the knee joint capsule of a Fischer 344 (wild-type) rat. The synovium of a transgenic rat was sutured to the defect of the wild-type rat in group 1 and was allowed to free float in the joint in group 2. A large number of BrdU-labeled, transgene-containing synovial cells were detected in both groups at 3 days. The number of these cells then decreased, but they could still be identified even at 4 weeks after autologous transplantation. These results indicated that transplanted synovial cells were viable in the joint for at least 4 weeks. Furthermore, the transgenic rat was shown to be an effective animal model for distinguishing the extrinsic from the intrinsic cells in the cellular intermixed tissues in vivo. The combined method of ISH for detecting transgene-containing cells and the immunohistochemistry of BrdU for detecting proliferating cells was also shown to be effective for tracking the viability of extrinsic cells after autologous transplantation.

Animals↗
PubMedDate not supplied

[Secondary flattening of the acetabular roof in children].

The primary "idiopathic" shallow acetabuli within the classical complex of CDH are confronted with the rare secondary "symptomatic" dysplasias of the acetabular roof. They are encountered mainly in connection with neuromuscular diseases and bad static conditions about the hip-joint. Nine cases with secondary flattening of the acetabular roof of unknown aetiology are presented, probably partially due to CDH, in connection with slight cerebral disturbances, mental and physical retardation, hypotonia of the muscles, with general constitutional laxity of joints as well as with acquired local loosening of the joint capsule due to treatment, and with insufficiency of the hip-abductors. As with the classical CDH one may observe in those cases a lateralization of the femoral head in the absence of an interposition in the joint; increasing subluxations due to joint instability with increasing shallow acetabuli may start from infancy, many years prior to puberty. If conservative treatment--not prolonged--fails and the findings are deteriorating acetabuloplasty is indicated prior to intertrochanteric adduction osteotomy during the growth-period.

Acetabulum↗
PubMed1979

Arthrography as a method of diagnosing tear of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb ("gamekeeper's thumb").

Arthrography of the metacarpo-phalangeal (MP) joint of the thumb was performed on 47 thumbs. The normal arthrographic appearance shows a closed joint space, whereas leakage of contrast material indicates tear of the joint capsule with or without an associated tear of a stabilizing ligament. Arthrographic demonstration of the heads of the adductor pollicis muscle was found to be specific for tear of the ulnar collateral ligament (UCL) of the MP joint, a tear which is commonly responsible for its instability. Arthrography is suggested as a safe and accurate diagnostic examination for the early detection of tears of the UCL of the MP joint.

Adolescent↗
PubMed2006

Magnetic resonance imaging changes of sacroiliac joints in patients with recent-onset inflammatory back pain: inter-reader reliability and prevalence of abnormalities.

To study the inter-reader reliability of detecting abnormalities of sacroiliac (SI) joints in patients with recent-onset inflammatory back pain by magnetic resonance imaging (MRI), and to study the prevalence of inflammation and structural changes at various sites of the SI joints. Sixty-eight patients with inflammatory back pain (at least four of the five following criteria: symptom onset before age 40, insidious onset, morning stiffness, duration >3 months, improvement with exercise--or three out of five of these plus night pain) were included (38% male; mean age, 34.9 years [standard deviation 10.3]; 46% HLA-B27-positive; mean symptom duration, 18 months), with symptom duration <2 years. A MRI scan of the SI joints was made in the coronal plane with the following sequences: T1-weighted spin echo, short-tau inversion recovery, T2-weighted fast-spin echo with fat saturation, and T1-spin echo with fat saturation after the administration of gadolinium. Both SI joints were scored for inflammation (separately for subchondral bone and bone marrow, joint space, joint capsule, ligaments) as well as for structural changes (erosions, sclerosis, ankylosis), by two observers independently. Agreement between the two readers was analysed by concordance and discordance rates and by kappa statistics. Inflammation was present in 32 SI joints of 22 patients, most frequently located in bone marrow and/or subchondral bone (29 joints in 21 patients). Readers agreed on the presence of inflammation in 85% of the cases in the right SI joint and in 78% of the cases in the left SI joint. Structural changes on MRI were present in 11 patients. Ten of these 11 patients also showed signs of inflammation. Agreement on the presence or absence of inflammation and structural changes of SI joints by MRI was acceptable, and was sufficiently high to be useful in ascertaining inflammatory and structural changes due to sacroiliitis. About one-third of patients with recent-onset inflammatory back pain show inflammation, and about one-sixth show structural changes in at least one SI joint.

Adult↗
PubMed1989

[Functional treatment of joint fractures].

The absence of functional load causes damage to different extents in various structures of the joint. Especially cartilage, joint capsule and ligaments are affected. Although operative functional treatment provides better prerequisites for avoiding such damage compared to conservative procedures, the results are not satisfactory in nearly 25% of the cases. Functional treatment of fractures of the joint by extension and continuous passive motion are suitable wherever operative reconstructions do not seem successful or have been proven to be superior as in fractures of the calcaneus.

Fracture Fixation↗
PubMed1987

Surgical findings in clenched-fist injuries.

A total of 191 patients (representing 194 skin lacerations) hospitalized for clenched-fist injuries were evaluated for deep structure involvement. Tendon, joint, cartilage, and/or bone were damaged in 75%. Tendon involvement occurred in 28 of 138 (20.3%), joint capsule violation in 99 of 146 (67.8%), free articular cartilage fragments in 8 of 139 (5.8%) and articular-bone indentations in 23 of 139 (16.5%). All patients with clenched-fist lacerations or puncture wounds over joints should be treated by surgical debridement and exploration of the deep structures, including the joint, at the time they first seek medical care.

Adolescent↗
PubMed2000

The sternoclavicular joint: variants of the discus articularis.

OBJECTIVE: To study the anatomy of the sternoclavicular joint, its discus and its variations.Design. Anatomical study (macroscopic dissection). BACKGROUND: Textbooks on manual therapy give different descriptions of the movements of this joint. These apparent contradictions could be due to poor understanding of the anatomy of this joint resulting in ignoring specific movement patterns under particular conditions. METHODS: Macroscopic dissection of 22 embalmed sternoclavicular joints. RESULTS: The sternoclavicular and the costoclavicular parts of the discus always were quite distinct in orientation, thickness, surface and consistency. The sternoclavicular part was attached to the dorso-cranial part of the extremitas sternalis claviculae by a broad insertion in which several small blood vessels are visible. This part is grossly vertical, thicker than the lateral part and has a fibrous aspect. The costoclavicular part of the discus is always thinner than the sternoclavicular part. Sometimes it is reduced to a fine translucent pellet or is perforated. Subsynovial vascular arcades run along the insertion of the discus on the joint capsule, both on sternal and on clavicular sides. The costosternal articular surface can be divided into a sternal and a costal segment, separated by a vascular zone. CONCLUSIONS: Findings suggest different functions of the distinct parts of the joint. The smooth aspect of the lateral segment of the costosternal articular surface and of the costoclavicular part of the discus could be an argument to consider a functionally distinct costoclavicular compartment. The insertion of the discus on the clavicula strongly suggests that small movements take place between clavicula and discus and that the discus itself is moved only when the increasing amplitude stretches this insertion. We hypothesise that all midrange movements take place between the convex inferior edge of the clavicula and the costoclavicular part of he discus and that larger elevation depression and pro- and retraction movement take place, respectively, between clavicula and discus or discus and sternum. In three specimens we observed a previously not described arterial ramus articularis originating from the left thyrocervical trunk.RelevanceThese findings might explain differences of the arthrokinematic behaviour of this joint between midrange and full range motions.

Dissection↗
PubMedDate not supplied

Midterm results of arthroscopic co-planing of the acromioclavicular joint.

BACKGROUND: There has been recent concern about long-term morbidity associated with arthroscopic co-planing of the acromioclavicular joint in the treatment of impingement syndrome. OBJECTIVE: The purpose of this study was to assess the results of the co-planing procedure, special attention being paid to acromioclavicular joint morbidity. METHODS: The study included 56 patients who were operated on by the senior author. Outcomes were evaluated both objectively and subjectively through physical examinations and telephone surveying. Each patient had subacromial decompression at the time of the index surgery. Other concomitant arthroscopic procedures included rotator cuff repair and labral debridement or repair. RESULTS: Average follow-up was 4 years (range, 2-7 years). Thirty-five (95%) of 37 patients had no subjective pain and no objective tenderness to direct palpation or compression of the acromioclavicular joint. The joint was not clinically hypermobile in comparison with that on the opposite side in any patient. In all, 95% of patients had good or excellent results in terms of the University of California at Los Angeles Shoulder Score. Of the 2 patients who did have pain and tenderness at the acromioclavicular joint, both had had multiple operations on their shoulders before the index procedure. Nineteen patients were not examined clinically but did complete a telephone survey; these 19 patients were not symptomatic at the acromioclavicular joint. CONCLUSIONS: To fully treat impingement syndrome, the surgeon should remove osteophytes under the lateral clavicle and medial acromion. With good technique, the surgeon can leave the anterior, posterior, and superior acromioclavicular joint capsule intact. We conclude that for appropriate clinical indications, beveling the inferior 20% to 25% of the clavicle to make it co-planar with the decompressed acromion is safe and is not an etiologic factor in acromioclavicular joint pain or instability.

Acromion↗
PubMed1983

[Characteristics of the topographical anatomical interrelations of the vertebral artery, muscles and connective tissue and neural formations in the area of the atlanto-occipital joint].

A topographical-anatomical investigation has been performed in the atlanto-occipital joint area by means of Pirogov's saw cuts and the histopographic section technique in 28 corpses of fetuses, newborns and mature persons. Peculiarities of interrelations between the vertebral artery, veins, muscles, nerves and the joint elements have been considered at the level of three horizontal and two sagittal planes made in the joint area. The vertebral artery and its venous plexus have been demonstrated to go in the nearest vicinity to the joint, the veins adhere the joint, and the common fascial vascular sheath entwines in the joint capsule. The proper occipital muscles situating here: the superior and inferior oblique muscles and the musculus rectus capitis posterior major press these vessels, as well as the anterior and posterior branches of the first cervical nerve, to the joint. These tight relations of the muscles, vertebral vessels and branches of the first cervical nerve create conditions for compression of the neuro-vascular formations in the atlanto-occipital joint area.

Adult↗