后交叉韧带重建后翻修原因分析

目的 对后交叉韧带(PCL)重建失败原因进行分析.方法 回顾2001年11月至2007年5月8例PCL翻修病例,分析PCL重建失败的原因.结果 8例翻修手术中发现1例双束重建韧带的后内束断裂;7例单束重建者中4例重建的PCL已完全断裂、吸收,另3例重建韧带有部分连接性,但已明显松弛失用.8例患者中,1例双束重建的上下骨道位置正确,其他7例骨道位置均不正确,股骨端上骨道明显偏后,胫骨端下骨道位置明显偏上向前.8例均行一期翻修重建于术,其中应用自体半腱股薄肌腱移植物单束重建2例、双束重建1例、后内束重建1例,自体骨-髌腱-骨(B-T-B)单束重建2例,同种异体B-T-B单束与双束重建各1例.结论 PCL重建手术失败的原因与手术骨道位置异常有关.临床重建应注重选择正确骨道位置.     

Automated Objective Scoring of Histologically Apparent Cartilage Degeneration Using a Custom Image Analysis Program

Histologic assessment of cartilage degradation has traditionally involved semiquantitative techniques, the most commonly utilized being the Mankin scale. Such assessments depend on human observer subjectivity, and thus have drawn criticism on the basis of associated inter‐ and intraobserver variability. We report a newly developed computational image analysis procedure for fully automated and fully objective assessment of the Mankin scale. Image processing routines were developed in a widely used programming environment (Matlab®) to analyze cartilage degradation. One hundred and twenty‐five histology images incorporating a wide range of degradation features were analyzed by the algorithm and by seven observers experienced in cartilage histologic assessment. Based on random effects linear statistical models, the computer program performed well, showing a correlation of 0.88 between its Mankin scores and latent (average of human observers') image scores. Regarding the four subcomponents of the Mankin scale, computer program correlations with observer scores were best for surface defect and proteoglycan depletion, but less favorable for cellularity and tidemark invasion. While limitations exist with image processing techniques, the new algorithm provides an objective and automated method for analyzing cartilage histology sections, consistent with human observer grading. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 522–528, 2009     

Cellular and epigenetic features of a young healthy and a young osteoarthritic cartilage compared with aged control and OA cartilage

Osteoarthritis (OA) is generally a disease of the elderly population, but can occur in young patients in exceptional cases. This study compares the cellular and epigenetic features of primary old‐age OA with those of secondary OA in a 23‐year‐old patient with developmental dysplasia of the hip. In addition, control cartilage from a 14‐year‐old was compared with that from patients with a fracture of the neck of femur (#NOF) to establish to what extent the latter is a useful control for OA. Articular cartilage was obtained from discarded femoral heads after hip arthroplasty. MMP‐3, MMP‐9, MMP‐13, and ADAMTS‐4 were immunolocalized and the methylation status of specific promoter CpG sites was determined. Both primary and secondary OA were characterized by loss of aggrecan, formation of clones, and abnormal expression of the proteases that correlated with epigenetic DNA demethylation. The latter indicated that the abnormal expression of the cartilage‐degrading proteases was not due to a short‐term up‐regulation, but a heritable, permanent alteration in gene expression. Comparing cell densities in young and old control cartilage estimated an age‐related cell loss of ∼1% per year. In aged #NOF cartilage, some superficial‐zone chondrocytes expressed the proteases, but the majority of cells were immunonegative and their promoters were hypermethylated. The cellular and epigenetic features of the intermediate and deep zones of #NOF cartilage are thus similar to those of young healthy cartilage, justifying the use of #NOF cartilage as control cartilage for OA, providing the superficial zone is removed. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 593–601, 2009     

改良伸膝装置粘连松解术治疗膝关节伸直位僵直

伸膝装置粘连是下肢骨折、感染和膝关节滑膜病变的常见并发症,一般认为屈膝功能不足70°,对生活和步态有较大影响时,需手术治疗。自2002年,在收治的32例伸直型膝关节僵直患者膝关节松解过程中,联合股四头肌成形及由我们设计的膝内外侧支持带成形术治疗并术后应用CPM机锻炼,疗效满意,现将治疗情况及有关问题讨论报告如下。     

膝部复杂骨折的治疗

膝部复杂骨折是指股骨髁粉碎骨折和（或）胫骨髁粉碎骨折及合并干骺端和骨干分离的平台骨折,前者属AO／ASIF分类的C：、C,型,后者按Schatzker分类为Ⅳ、Ⅴ、Ⅵ型骨折,部分同时合并髌骨骨折和（或）交叉韧带、半月板损伤,此类骨折复杂,具有治疗困难、并发症多、致残率高等特点。自2002年1月至2007年9月共收治此类骨折41例,采用切开复位解剖钢板内固定、CPM锻炼、中药熏洗等综合方法治疗,疗效满意。     

Over-the-Counter Enzyme Supplements: What a Clinician Needs to Know

Over-the-counter (OTC) enzyme use is increasing in frequency in the United States. The numerous health benefit claims by manufacturers are leading to a surge in enzyme use for various conditions and symptoms. Clinicians need to help patients navigate this complex realm and make informed decisions about the use of OTC enzymes. This review focuses on key concepts for health care providers to understand the current evidence, risks, and benefits of OTC enzymes.     

Predicting discharge outcomes after total knee replacement using the Risk Assessment and Predictor Tool

Objective

To explore the use of the Risk Assessment and Predictor Tool (RAPT) as a pre-operative tool to predict postoperative discharge destination and length of stay for patients undergoing total knee replacement (TKR) in Singapore.

Participants and setting

A cohort of 569 patients undergoing primary TKR at the Singapore General Hospital were recruited prospectively from November 2009 to June 2010.

Intervention

All patients completed a modified RAPT questionnaire pre-operatively, and underwent standard clinical pathway guidelines for TKR throughout the study.

Main outcome measures

Actual discharge destination (ADDest) and length of stay (LOS).

Design

Total RAPT score and preferred discharge destination (PDD) were recorded pre-operatively, while ADDest and LOS were obtained immediately after discharge. Multivariable logistic regression and multivariable regression analysis were used to determine whether the RAPT items and score could predict the discharge outcomes.

Results

Total RAPT score was a significant predictor of LOS for patients following TKR (R = 0.24, P < 0.001); the higher the RAPT score, the longer the LOS. Total RAPT score was also a significant predictor of actual discharge to home [odds ratio (OR) 2.32, 95% confidence interval (CI) 1.11 to 4.85]. PDD was a significant predictor for LOS (R = 0.22, P < 0.001) and ADDest (R = 0.33, P < 0.001). Patients who chose to be discharged home were more likely to be directly discharged home (OR 9.79, 95% CI 5.07 to 18.89, P < 0.001).

Conclusion

Total RAPT score and PDD were significant predictors of ADDest and LOS for patients following TKR in Singapore. The ability to predict discharge outcomes following TKR could assist caregivers, healthcare professionals and administrators in optimising care and resource allocations for patients.     

A critical role for collagen II in cartilage matrix degradation: Collagen II induces pro‐inflammatory cytokines and MMPs in primary human chondrocytes

We report a process that results in the acceleration of matrix degradation in human articular cartilage, a phenomenon commonly observed in osteoarthritis (OA). The study was conducted by (1) examining the potential of collagen II in modulating the gene expression profile of primary human chondrocytes (PHCs), and (2) investigating the involvement of pro‐inflammatory signaling cascades. We first tested the collagen II‐dependent induction of pro‐inflammatory cytokines and matrix metalloproteinases (MMPs) in PHCs. PHCs were incubated with or without monomeric (i.e., nonfibrillar) collagen II. Cells were then analyzed by RT‐PCR for the expression of MMP1, MMP3, MMP13, MMP14, and IL‐1β. ELISA was used to quantify IL‐6 and IL‐8 release. To examine the influence of collagen II signaling, specifically the role of MAPK p38, a p38‐inhibitor was added prior to collagen treatment. Changes in IκB concentration were monitored by immunoblot analysis to detect NFκB signaling. Results indicated that incubation of PHCs with collagen II did produce a dose‐dependent induction of MMP1, MMP3, MMP13, MMP14, as well as cytokines IL‐1β, IL‐6, and IL‐8. At the same time, inhibition of p38 and IκB degradation revealed that collagen II‐dependent gene induction also involves MAPK p38 and NFκB signaling. Thus, we provide evidence for a collagen II‐dependent feed‐forward mechanism whereby collagen II induces first MMPs and pro‐inflammatory cytokines and then release of collagen II fragments from mature collagen II fibers. This, in turn, induces more pro‐inflammatory cytokines and MMPs, and the process is repeated, which results in the acceleration and perpetuation of cartilage matrix degradation. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:65–70, 2009     

Does loading influence the severity of cartilage degeneration in the canine Groove‐model of OA?

Many animal models are used to study osteoarthritis (OA). In these models the role of joint loading in the development of OA is not fully understood. We studied the effect of loading on the development of OA in the canine Groove‐model. In ten female beagle dogs OA was induced in one knee according to the Groove‐model. The animals were divided in groups with and without forced‐loading. Forced‐loading was achieved by fixing the contra‐lateral limb to the trunk 3 times a week for 4 hours. After 20 weeks joint tissues of all dogs were evaluated. Subjective evaluation revealed less movement with more loading in the forced‐loading‐group compared to the group without forced‐loading. In both groups induction of OA resulted in macroscopical and microscopical OA changes as well as alterations in cartilage metabolism characteristics for OA. Although differences were small, for some parameters they were statistically significant for the forced‐loading‐group. There were no differences between the contra‐lateral healthy joints of both groups. The present study demonstrates that in the Groove‐model intensified loading is not a prerequisite for the development of OA, although it adds to some extent to the severity of the OA. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:1332–1338, 2009