Bone scan in the patellofemoral pain syndrome

Summary Eighty patients who complained of retropatellar pain underwent evaluation by bone scintigraphy, intraosseous pressure determination, radiography, arthroscopy and physical diagnostic tests. The bone scans showed that 48% of the painful knees had an increased uptake compared with 9% for the normal joints. A highly significant correlation was evident between an increased uptake and established chondromalacia. For the diagnosis of a high pressure patella, radiography was only 7% sensitive (6/88), compared with 44% (39/88) for bone scintigraphy and 78% for the clinical sustained flexion test. The positive predictive value of a bone scan for detecting a high pressure patella was 0.72 (39/54). The best predictor was a positive sustained flexion test with a predictive value of 0.85 (69/81).

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Résumé Dix-huit malades se plaignant de douleurs rétro-patellaires ont été examinés par scintigraphie, mesure de la pression intra-osseuse, radiographie, arthroscopie et tests cliniques. La scintigraphie a montré que 48% des genoux douloureux présentaient une hyperfixation contre 9% des articulations normales. Il existait une corrélation évidente, hautement significative, entre l'hyperfixation et la chondropathie rotulienne. Pour le diagnostic d'hyperpression intrapatellaire, la radiographie n'était démonstrative que dans 7% des cas (6/88) alors que la scintigraphie l'était dans 44% (30/88) et le test clinique de «flexion prolongée» dans 78%. La valeur d'une scintigraphie positive en faveur du diagnostic d'hyperpression intra-patellaire est de 0.72 (39/54). L'élément le plus fiable est la positivité du test de flexion prolongée qui a une valeur prédictive de 0.85 (69/81).

     

杜仲及其有效成分治疗膝骨关节炎的作用机制研究现状

膝骨关节炎（KOA）是中老年常见的退行性关节疾病,发病率随着人口老龄化程度加深及肥胖人群增加而不断增加,严重影响患者健康及日常生活。目前采用的非甾体类抗炎药、软骨保护类药物、阿片类镇痛药等对症治疗手段作用有限,且药物不良反应明显。杜仲是治疗KOA常用且有效的中药之一,但其作用机制和药效物质基础尚未明确,限制了其在临床更为广泛的运用。杜仲在KOA治疗领域的有效成分主要为环烯醚萜类（京尼平苷、杜仲苷/桃叶珊瑚苷）、木脂素类（松脂醇二葡萄糖苷）、黄酮类（槲皮素、紫云英苷、黄芩素、金丝桃苷、山柰酚）、苯丙素类（绿原酸）、杜仲多糖等化合物,他们主要通过丝裂原活化蛋白激酶、核转录因子-κB、磷脂酰肌醇3-激酶/蛋白激酶B及等Janus激酶1/信号转导和转录激活因子3等信号通路,来调节炎性因子水平、抗氧化应激反应、保护软骨细胞、平衡细胞外基质合成与降解等,控制KOA病情进展。该文对杜仲及其有效成分在KOA治疗方面的作用机制进行了综述,以期为KOA新药研发提供理论依据。     

中药调控膝骨关节炎相关信号通路的研究进展

随着中医药对膝骨关节炎（KOA）研究的不断深入,现代学者发现诸多中药可从分子层面干预信号通路延缓膝骨关节炎的进展。文中所述中药及其活性成分在干预膝骨关节炎的机制中与信号通路有着密切关系。中药及有效成分可在不同信号通路的传导下调控相应的靶向分子水平,抑制软骨炎性因子、细胞凋亡、软骨基质降解及促进软骨细胞自噬,以达到减轻滑膜炎性水肿和延缓软骨退变的目的。现对国内外中药干预KOA的研究进行系统性总结：黄芩素等可通过阻断磷脂酰肌醇3-激酶/蛋白激酶B（PI3K/Akt）信号通路,减少软骨细胞炎性因子、凋亡及促进自噬;山茱萸新苷Ⅰ等成分降低Janus激酶2/信号转导和转录激活因子3（JAK2/STAT3）通路磷酸化活性改善滑膜炎症、延缓软骨基质退变;丹酚酸A等中药活性成分可通过抑制核转录因子-κB（NF-κB）通路磷酸化,减轻炎症与软骨基质降解;大黄素等有效成分可降低Wnt/β-连环蛋白（Wnt/β-catenin）通路活性,抑制胶原蛋白与蛋白多糖分解;肉豆蔻苷等通过阻断p38丝裂原活化蛋白激酶（p38 MAPK）信号传导,抑制细胞凋亡;木通皂苷D等可增强核因子E₂相关因子2/血红素加氧酶1（Nrf2/HO-1）通路活性,抑制软骨细胞氧化应激;牛膝总皂苷等通过增强转化生长因子-β（TGF-β）/Smad信号传导,减少软骨基质降解;藏红花素通过激发河马/Yes相关蛋白（Hippo/YAP）活性抑制软骨炎症与凋亡因子增加;川芎嗪阻断Notch通路改善软骨细胞形态与异常;齐墩果酸等通过发挥雌激素信号通路,减轻软骨基质破坏与退变。以上总结旨在为今后开展KOA临床与实验研究提供借鉴。     

Dietary Interventions with Polyphenols in Osteoarthritis: A Systematic Review Directed from the Preclinical Data to Randomized Clinical Studies

Osteoarthritis (OA) is the most common form of arthritis and a major cause of limited functionality and thus a decrease in the quality of life of the inflicted. Given the fact that the existing pharmacological treatments lack disease-modifying properties and their use entails significant side effects, nutraceuticals with bioactive compounds constitute an interesting field of research. Polyphenols are plant-derived molecules with established anti-inflammatory and antioxidant properties that have been extensively evaluated in clinical settings and preclinical models in OA. As more knowledge is gained in the research field, an interesting approach in the management of OA is the additive and/or synergistic effects that polyphenols may have in an optimized supplement. Therefore, the aim of this review was to summarize the recent literature regarding the use of combined polyphenols in the management of OA. For that purpose, a PubMed literature survey was conducted with a focus on some preclinical osteoarthritis models and randomized clinical trials on patients with osteoarthritis from 2018 to 2021 which have evaluated the effect of combinations of polyphenol-rich extracts and purified polyphenol constituents. Data indicate that combined polyphenols may be promising for the treatment of osteoarthritis in the future, but more clinical trials with novel approaches in the identification of the in-between relationship of such constituents are needed.     

Impact of Sarcopenia and Obesity on Gait Speed After Total Knee Replacement

ObjectivesOlder adults with sarcopenic obesity have a higher risk of experiencing mobility difficulty. Additionally, sarcopenia and obesity are closely associated with knee osteoarthritis. This study investigated the associations of sarcopenia, obesity, and in combination of both with walking disability during postoperative rehabilitation in older adults with knee osteoarthritis who underwent total knee replacement.DesignA retrospective cohort study.Setting and ParticipantsFrom a rehabilitation center database, we retrospectively selected and investigated 482 older patients with knee osteoarthritis who had undergone total knee replacement and received postoperative rehabilitation.MethodsSarcopenia was identified in accordance with the diagnostic criteria established by the Asian Working Group for Sarcopenia and obesity was defined as body mass index ≥ 30 kg/m². Accordingly, patients were classified into four body composition groups, namely sarcopenic obese, sarcopenic, obese, and normal (reference group). After total knee replacement, all patients attended monthly follow-up admission during the postoperative rehabilitation. Gait speed was measured before surgery and monthly after total knee replacement. A gait speed cutoff of 1.0 m/s was used to identify postoperative walking disability. Kaplan–Meier curve analysis was performed to measure the probability of experiencing postoperative walking disability among the groups. Cox multivariate regression models were established to calculate the hazard ratios of postoperative walking disability.ResultsCompared with the reference group, the sarcopenic, obese, and sarcopenic obese groups appeared to have a higher probability of experiencing postoperative walking disability (all P < .001). The sarcopenic obese group were likely to have the highest risk of experiencing postoperative walking disability (adjusted hazard ratio = 3.89).Conclusions and ImplicationsSarcopenia or obesity alone may independently exert negative effects on postoperative gait speed. The participants with sarcopenic obesity were likely to have the highest risk of experiencing walking disability following total knee replacement. The findings may serve as a reference for clinicians developing rehabilitation strategies to optimize walking ability after total knee replacement, especially those preoperatively diagnosed as having sarcopenic obesity.     

Prior Pelvic Osteotomy Affects the Outcome of Subsequent Total Hip Arthroplasty

BackgroundAlthough pelvic osteotomy (PO) is an important surgical procedure that can alleviate symptoms and potentially slow progression of osteoarthritis in patients with development dysplasia of the hip, some patients eventually require conversion to total hip arthroplasty (THA). This study aimed to determine the outcome of conversion THA in patients with prior PO.MethodsForty nine patients with a history of prior PO who underwent conversion THA at a single institution were matched at a 1:3 ratio based on the date of surgery, age, gender, and body mass index with 147 developmental dysplasia of the hip patients who underwent primary THA without prior PO. A retrospective chart review was performed to compare outcomes at a minimum follow-up of 2 years.ResultsPatients with prior PO required more supplemental screw fixation for the acetabular component (59.2% vs 38.1%, P = .016), more autologous bone grafting (24.5% vs 11.6%, P = .048), had a longer mean operative time (106.0 vs 79.8 minutes, P < .001), and greater estimated blood loss (350.0 vs 206.8 mL, P = .015). Patients with prior PO had smaller cup version angle (26.0° vs 29.0°, P = .012) and greater discrepancy in the limb length (10.3 vs 7.26 mm, P = .041). Eight hips (16.3%) with prior PO and 6 (4.1%) without osteotomy required reoperation (P = .008). There was no difference in outcome scores at the latest follow-up.Conclusion: THA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.ConclusionTHA after prior PO is technically demanding, leading to longer operative times, greater blood loss, and variation in implant placement. Although functional outcomes are similar, THA after a prior PO is more likely to require reoperation.     

Alignment in Medial Fixed-Bearing Unicompartmental Knee Arthroplasty: The Limb Has a Leg Up on the Component

BackgroundTo assess how implant alignment affects unicompartmental knee arthroplasty (UKA) outcome, we compared tibial component alignment of well-functioning UKAs against 2 groups of failed UKAs, revised for progression of lateral compartment arthritis (“Progression”) and aseptic loosening (“Loosening”).MethodsWe identified 37 revisions for Progression and 61 revisions for Loosening from our prospective institutional database of 3351 medial fixed-bearing UKAs performed since 2000. Revision cohorts were matched on age, gender, body mass index, and postoperative range of motion with “Successful” unrevised UKAs with minimum 10-year follow-up and Knee Society Score ≥70. Tibial component coronal (TCA) and sagittal (TSA) plane alignment was measured on postoperative radiographs. Limb alignment was quantified by hip-knee-ankle (HKA) angle on long-leg radiographs. In addition to directly comparing groups, a multivariate logistic regression examined how limb and component alignments were associated with UKA revision.ResultsIn the Progression group, component alignment was similar to the matched successes (TCA 3.6° ± 3.5° varus vs 5.1° ± 3.5° varus, P = .07; TSA 8.4° ± 4.4° vs 8.8° ± 3.6°, P = .67), whereas HKA angle was significantly more valgus (0.3° ± 3.6° valgus vs 4.4° ± 2.6° varus, P < .001). Loosening group component alignment was also similar to the matched successes (TCA 6.1° ± 3.7° varus vs 5.9° ± 3.1° varus, P = .72; TSA 8.4° ± 4.6° vs 8.1° ± 3.9°, P = .68), and HKA was significantly more varus (6.1° ± 3.1° varus vs 4.0° ± 2.7° varus, P < .001). Using a multivariate logistic regression, HKA angle was the most significant factor associated with revision (P < .001).ConclusionIn this population of revised UKAs and long-term successes, limb alignment was a more important determinant of outcome than tibial component alignment.Level of EvidenceLevel III case-control study.     

Role of high tibial osteotomy in medial compartment osteoarthritis of the knee: Indications,surgical technique and outcomes

Knee osteoarthritis (OA) is the most common joint disorder worldwide. In particular, primary knee OA often presents with a varus malalignment. This increases the loads going through the medial compartment resulting in cartilage degeneration and symptomatic arthritis. High tibial osteotomy (HTO) is the workhorse surgical procedure for treating medial knee OA. When performed precisely in the hands of an experienced surgeon, HTO can delay or avoid knee arthroplasty. Of note, outcomes of knee arthroplasty are at best unpredictable in patients of younger age. Hence, there is a growing need for joint preservation procedures for younger patients presenting with knee OA, of which HTO is one. Through this article, the authors of whom all are joint preservation surgeons with a special interest in osteotomy hope to share from their experience as well as the available literature on the indications, perioperative planning, surgical technique, outcomes as well as pearls and pitfalls of HTO.     

A short-term radiological and clinical comparison between the bi-cruciate and cruciate retaining total knee arthroplasty A retrospective case controlled study

PurposeThe aim of this study was to provide a short term comparison in radiological and clinical outcome between Bi-Cruciate Retaining (BCR)- and Cruciate Retaining (CR) Total Knee Arthroplasty (TKA).MethodsThe cohort consists of 122 patients undergoing a TKA with PSI, equally distributed over the BCR- and CR-TKA group. Perioperative conditions were observed and radiological images were analysed pre-, 6-weeks, and 1-year postoperative to quantify alignment differences between BCR- and CR-TKA. Preoperatively predicted templates were compared with the implanted size to determine predictive value. In addition mean range of motion and revision rates were determined in both groups.ResultsNo significant difference was observed in amount of outliers in component alignment between BCR- and CR-TKA. Outliers of the Hip-Knee-Ankle-Axis (HKA-axis) occurred significantly more frequent (P = 0.009) in the BCR-group (37.7%) compared to CR-TKA (18.0%). No clinically relevant differences regarding the predictive sizing of implant components was obtained. No significant differences were observed in revision rates (P = 1.000) and ROM (p = 0.425) between the BCR-groep and CR-group at 2-years FU.ConclusionThis study illustrates that although the HKA-axis was not fully restored, bi-cruciate retaining surgical technique for BCR-TKA is safe and effective with comparable radiological and clinical outcome as CR TKA. Randomized controlled trials with longer follow up on the HKA-axis alignment and clinical parameters are needed to confirm the presented results and should focus on possible cut off values concerning leg axis in order to define in what patients a BCR-TKA can safely be used.Level of evidence IVRetrospective Case Controlled Study.     

Management of knee and hip osteoarthritis: an opportunity for the Canadian chiropractic profession

Knee and hip osteoarthritis (OA) place a significant burden on the Canadian health system and are a major public health challenge. This brief commentary discusses the recently published Osteoarthritis Research Society International guideline and the American College of Rheumatology guideline for the management of OA. Special attention has been given to the role of manual therapy, exercise, and patient education for the treatment of knee and hip OA. This article also reviews the Good Life with osteoArthritis in Denmark (GLA:D^®) treatment program for knee and hip OA and the implementation of this program in Canada. Lastly, the authors discuss the opportunity for the Canadian chiropractic profession to embrace treatment programs like GLA:D^® and take an active role in the strengthening of the Canadian health system from a musculoskeletal perspective.