Legg-Calvé-Perthes disease in hemophilia: incidence and etiologic considerations

A review of hip radiographs of patients with severe hemophilia showed Legg-Calvé-Perthes disease in four of 63 patients examined before the era of specific treatment. In another series of 44 patients receiving prophylactic treatment, there was no evidence of Legg-Calvé-Perthes disease. A case report of a boy with severe hemophilia with hip joint bleeding that caused joint capsule distention and greatly increased intracapsular pressure is presented. Based on our findings, and previously published results, we suggest that Legg-Calvé-Perthes disease in hemophilia is caused by increased intracapsular pressure secondary to hemarthrosis.     

CT scans and lipohaemarthrosis in hip fractures

Computed tomography was performed on 40 patients with recent hip trauma. Radiographs of 25 showed a fracture of the femoral neck with slight displacement; 24 of these had intra-articular fluid and 20 had a lipohaemarthrosis on the CT scan. In 15 patients, radiographs at the time of admission were normal but suspicion of fracture remained. A fracture was later verified in five patients, four of whom had lipohaemarthrosis on admission. In the remaining 10 patients no fracture could be detected; only one patient had a hip joint effusion but no free fat. Thus all 24 patients with lipohaemarthrosis had an intracapsular fracture of the hip. We suggest CT for patients with hip trauma and negative radiographs. The presence of a lipohaemarthrosis of the hip strongly suggests an intra-articular fracture of either the femoral neck or the acetabulum.     

Conventional radiography in transient synovitis of the hip in children

Conventional radiography was performed at diagnosis and at follow-up 5 to 9 months later in 70 children with transient synovitis of the hip. Twenty-four of the patients also had CT examination at diagnosis. The cartilaginous and osseous reaction in the conventional antero-posterior radiographs was studied as was the relation between the radiographic and CT findings concerning fat planes, joint effusion, and position of the hip joint. At diagnosis there was significant increase in the medial joint space and at follow-up examination there was significant increase in medial and cranial joint space, metaphyseal width and acetabular roof width. There was a correlation of a bulging lateral 'capsular fat plane' to the position of abduction in the affected hip which explains the asymmetry in the lateral fat plane observed in these patients.     

Prospective comparison of hip fracture treatment: 856 cases followed for 4 months in The Netherlands and Sweden

In a prospective multicenter study 1115 hip fracture patients were registered in Rotterdam (The Netherlands), Sundsvall and Lund (Sweden). The patients had similar background parameters with a mean age of 78 years, about half of them living alone and just above 80 percent coming from independent living

For cervical fracture, hemiarthroplasty was the predominating treatment in Rotterdam (n 169), whereas osteosynthesis was used in Sundsvall (screws n 135) and Lund (hook-pins n 148). The mean (median) hospitalization time was 32 (20) days in Rotterdam, 16 (12) days in Sundsvall, and 17 (10) days in Lund. Discharge to independent living varied from 53 percent in Lund to 72 percent in Sundsvall. Functional outcome (walking ability and ADL capacity) was at 4 months similar in all groups, but at 2 weeks was lower in Rotterdam. Mortality at 2 weeks / 1 month 14 months was in Rotterdam 4/9/20, in Sundsvall 2/4/13, and in Lund 01311 0 percent.

Trochanteric fractures were treated by screwplate in Rotterdam (n 146) and Lund (n 78), and by Ender nails in Sundsvall (n 11 7). The mean (median) hospitalization time was in Rotterdam 39 (29) days, in Sundsvall 24 (1 5) days and in Lund 19 (11) days. Discharge to independent living varied from 41 percent in Lund to 57 percent in Sundsvall. Functional outcome was similar between the groups. Mortality at 2 weeks / 1 month 14 months was in Rotterdam 2/6/14, in Sundsvall 611 2/19 and in Lund 12/12/18 percent.

Thus, our study has shown that it is possible to perform a prospective multicenter study involving different European countries. The functional out- come after 4 months was very consistent between the centers studied, irrespective of choices made concerning operation method and rehabilitation routines. However, a difference in mortality within these first postoperative months was found, which seems attributable to the operation procedure.     

Open-wedge osteotomy by hemicallotasis or the closed-wedge technique for osteoarthritis of the knee. A randomised study of 50 operations

We describe the results of 50 operations carried out on 46 patients with medial osteoarthritis of the knee of Ahlb?ck grade 1 to 3. Patients were randomised either to a closed-wedge high tibial osteotomy (HTO) or an open-wedge procedure based on the hemicallotasis technique (HCO). Their median age was 55 years (38 to 68). The preoperative median hip-knee-ankle (HKA) angle was 171 degrees (164 to 176) in the HTO group and 173 degrees (165 to 179) in the HCO group. After six weeks, the median HKA angle was 185 degrees (176 to 194) in the HTO group and 184 degrees (181 to 188) in the HCO group. In the HTO group, seven patients were within the range of 182 degrees to 186 degrees compared with 21 in the HCO group (p < 0.001). One year later, ten HTO patients were within this range while the HKA angulation in the HCO group was unchanged. At two years the numbers were 11 and 18, respectively. We evaluated the clinical results on the Hospital for Special Surgery, Lysholm and Wallgren-Tegner activity scores, and patients completed part of the Nottingham Health Profile questionnaire. An impartial observer at the two-year follow-up concluded that all scores had improved, but found no clinical differences between the groups.     

Moderate varus/valgus malalignment after total knee arthroplasty has little effect on knee function or muscle strength: 91 patients assessed after 1 year

Background and purpose — Postoperative muscle strength and component alignment are important factors affecting functional results after total knee arthroplasty (TKA). We are not aware of any studies that have investigated the relationship between them. We therefore investigated whether coronal malalignment of the mechanical axis and/or of individual implant components would affect knee muscle strength and function 1 year after TKA surgery.Patients and methods — We included 120 consecutive osteoarthritis (OA) patients admitted for TKA. Preoperative active range of motion (ROM) of the knee, patient age, sex, and BMI were recorded and the Knee Society score (KSS) and knee joint extensor/flexor muscle strength were assessed. At 1-year follow-up, the mechanical and coronal component alignment was measured from a postoperative long standing radiograph, and ROM, KSS, and muscle strength measurements were taken in 91 patients. Functional outcome and muscle strength measurements were compared between normally aligned and malaligned TKA groups.Results — 29 of 91 TKAs were malaligned, i.e. they deviated more than 3° from the neutral mechanical axis. 18 femoral components and 15 tibial components were malaligned. Before surgery, the malaligned and normally aligned groups were similar regarding sex distribution, BMI, ROM, KSS, and muscle strength. At the 1-year follow-up, the differences between the groups regarding knee joint function and muscle strength were small, not statistically significant, and barely clinically relevant.Interpretation — Moderate varus/valgus malalignment of the mechanical axis or of individual components has no relevant clinical effect on function or muscle strength 1 year after TKA surgery.Failure to restore limb alignment in total knee arthroplasty (TKA) increases the risk of revision (Jeffery et al. 1991, Ritter et al. 1994 and 2011, Berend et al. 2004), but the effect of accurate postoperative alignment on TKA function is controversial (Lotke and Ecker 1977, Choong et al. 2009, Fang et al. 2009, Longstaff et al. 2009, Huang et al. 2012).Huang et al. (2012) reported that TKAs with a coronal alignment within 3° from the neutral axis had better function and quality of life at 5-year follow-up than TKAs that deviated more than 3° from neutral alignment. Other studies comparing computer-assisted TKA with conventional TKA surgery have not been able to correlate malalignment with inferior functional outcomes (Spencer et al. 2007, Kamat et al. 2009, Kim et al. 2009, Burnett and Barrack 2013).Patients with greater preoperative muscle strength have been reported to have faster recovery and better functional outcome after TKA (Mizner et al. 2005, Yoshida et al. 2008). However, full recovery of muscle strength after TKA is uncommon (Berth et al. 2002, Valtonen et al. 2009, Maffiuletti et al. 2010, Vahtrik et al. 2012).It is plausible that failure to restore the mechanical axis restoration results in inferior muscle function. Sogabe et al. (2009) found different cross-sectional areas in the quadriceps muscles with different knee alignments. They suggested that knees with varus or valgus deformation should have poorer muscle function compared to normally aligned knees. However, we have not been able find any studies investigating muscle strength after TKA in relation to component alignment and mechanical axis restoration.We investigated whether coronal malalignment of the mechanical axis and/or of individual implant components would affect knee muscle strength and function 1 year after TKA surgery.     

Combination injuries 2. The risk of pulp necrosis in permanent teeth with subluxation injuries and concomitant crown fractures

Abstract – Background: The reported risk of pulp necrosis (PN) is generally low in teeth with subluxation injuries. A concomitant crown fracture may increase the risk of PN in such teeth. Aim: To analyse the influence of a concomitant trauma‐related infraction, enamel‐, enamel–dentin‐ or enamel–dentin–pulp fracture on the risk of PN in permanent teeth with subluxation injury. Material and Methods: The study included 404 permanent incisors with subluxation injury from 289 patients (188 male, 101 female). Of these teeth, 137 had also suffered a concomitant crown fracture. All the teeth were examined and treated according to a standardized protocol. Statistical Analysis: The risk of PN was analysed separately for teeth with immature and mature root development by the Kaplan–Meier method, the log‐rank test and Cox regression analysis. The level of significance was set at 5%. Risk factors included in the analysis were gender, patient age, crown fracture type, mobility and response to an electric pulp test (EPT) at the initial examination. Results: Teeth with immature root development: The risk of PN was increased in teeth with a concomitant enamel fracture (log‐rank test: P = 0.002), enamel–dentin fracture (log‐rank test: P < 0.0001), enamel–dentin–pulp fracture (log‐rank test: P < 0.0001) and in teeth with no response to EPT at the initial examination [hazard ratio: 21 (95% confidence interval, CI: 2.5–172.5), P = 0.005]. Teeth with mature root development: the risk of PN was increased in teeth with an enamel–dentin fracture [hazard ratio: 12.2 (95% CI: 5.0–29.8), P < 0.0001], infraction [hazard ratio: 5.1 (95% CI: 1.2–21.4) P = 0.04] and in teeth with no response to EPT at the initial examination [hazard ratio: 8 (95% CI: 3.3–19.5), P < 0.0001]. Conclusion: A concomitant crown fracture and no response to EPT at the initial examination may be used to identify teeth at increased risk of PN following subluxation injury.     

DNA methylation is altered in B and NK lymphocytes in obese and type 2 diabetic human

Objective

Obesity is associated with low-grade inflammation and the infiltration of immune cells in insulin-sensitive tissues, leading to metabolic impairment. Epigenetic mechanisms control immune cell lineage determination, function and migration and are implicated in obesity and type 2 diabetes (T2D). The aim of this study was to determine the global DNA methylation profile of immune cells in obese and T2D individuals in a cell type-specific manner.

Material and methods

Fourteen obese subjects and 11 age-matched lean subjects, as well as 12 T2D obese subjects and 7 age-matched lean subjects were recruited. Global DNA methylation levels were measured in a cell type-specific manner by flow cytometry. We validated the assay against mass spectrometry measures of the total 5-methylcytosine content in cultured cells treated with the hypomethylation agent decitabine (r = 0.97, p < 0.001).

Results

Global DNA methylation in peripheral blood mononuclear cells, monocytes, lymphocytes or T cells was not altered in obese or T2D subjects. However, analysis of blood fractions from lean, obese, and T2D subjects showed increased methylation levels in B cells from obese and T2D subjects and in natural killer cells from T2D patients. In these cell types, DNA methylation levels were positively correlated with insulin resistance, suggesting an association between DNA methylation changes, immune function and metabolic dysfunction.

Conclusions

Both obesity and T2D are associated with an altered epigenetic signature of the immune system in a cell type-specific manner. These changes could contribute to the altered immune functions associated with obesity and insulin resistance.