Bulletin of the NYU hospital for joint diseases最新文献

Hip resurfacing arthroplasty has been developed as an alternative to traditional total hip arthroplasty, in an effort to minimize the loss of native bone in young patients with symptomatic hip osteoarthritis. Femoral neck fracture following hip resurfacing is a unique complication; several risk factors are associated with this complication, including female gender. In the present study, we used finite element models of the proximal femur to simulate stresses across the femoral neck in pelvis models with varying widths. This analysis demonstrated an increase in hip reaction forces as the width of the pelvis increases, a condition that simulates a resurfacing condition in a female pelvis. This difference in peak stress on the femoral neck may explain the increased incidence of femoral neck fractures seen in female patients following hip resurfacing.

Background: Traditional surgical treatment of isthmic spondylolisthesis is posterior-lateral fusion, but the addition of anterior surgery has been explored. The purpose of this study was to evaluate the surgical and clinical outcomes of anterior-posterior surgical treatment for low-grade isthmic spondylolisthesis.

Methods: Retrospectively, we enrolled 23 consecutive patients (mean age of 50) who underwent surgical treatment for low grade isthmic spondylolisthesis. The mean follow-up was 10 months. Basic demographic and radiographic data was collected. Pre- and post-surgical clinical surveys (VAS, ODI, and SF-36) were collected.

Results: All 23 patients underwent anterior interbody fusion with a femoral ring allograft or ICBG in combination with posterior lumbar decompression and fusion with instrumentation. The average slip percentage decreased from 23.2% to 19.0% (p = 0.24) while slip angle increased from 9.8° to 17.9° (p < 0.001) and average disc height decreased from 1.9 cm to 0.80 cm (p < 0.001). VAS scores decreased from 7.1 to 2.4 (p < 0.001), ODI scores decreased from 52.5 to 28.1 (p < 0.001), and SF-36 scores increased in the Physical Component Scale (PCS) from 29.5 to 42.6 (p < 0.001).

Conclusion: In our study, patients demonstrated an improvement in the ODI as well the physical component scores of the SF-36, thus having a good clinical outcome.

Intraarticular coronal fracture of the femoral condyle is rare, and an isolated medial Hoffa fracture in a child is extremely rare. To our knowledge, such a case has not yet been reported in the literature. Early diagnosis and prompt treatment are essential for a good long-term outcome. We report a case of 12-year-old male who suffered a traffic accident and sustained an isolated medial Hoffa fracture. Open reduction was performed using a subvastus approach and the joint surface congruity restored and secured by two large fragment partially threaded screws placed from anterior to posterior in the epiphysis. At the 36-month follow-up, the fracture was united, and the patient had full extension and approximately 130° flexion of knee. There was no varus or valgus instability or limb length discrepancy. This case highlights the importance of early diagnosis and prompt treatment in the form of epiphyseal fixation for the management of these fractures in skeletally immature individuals.

In osteonecrosis (ON) of the hip, interruption of angiogenesis is a pathological process that may lead to impairment of the nutrient supply, cell death, and the collapse of bone. However, the process of angiogenesis in ON is not well understood. The purpose of this study was to investigate the expression of vascular endothelial growth factor (VEGF) in human mesenchymal stem cells (MSCs) in vitro. Cultured MSCs obtained from the hips of normal, ON, and osteoarthritic (OA) patients all expressed VEGF-A. Furthermore, MSCs from normal stem cells also expressed VEGF-B, but its expression had a tendency to increase in those stem cells from ON and OA patients, while VEGF-C was absent in all of the stem cells. However, VEGF-D expression consistently decreased in MSCs from ON patients, but increased in stem cells from OA donors over that of control cells. In addition, placental growth factor (PGF), which has a similar function as VEGF, was expressed in MSCs, and the levels were similar in MSCs from normal, ON, and OA donors. The results suggest that ON and OA are associated with aberrant VEGF-D expression.

Since the main objective of therapies in rheumatology is not only to improve the patient condition but also to prevent a further disability and because of the emergence of new and very effective therapies, the outcome measures used to evaluate treatments in rheumatology have been revisited. The major changes are that in addition to the concept of improvement (achievement of a relevant level of change), other concepts have been recognized as important, such as status (achievement of an acceptable condition), onset of action (the quickest is the better), and sustainability. In order to evaluate these concepts, new tools have been recently elaborated (for example, the ACR-EULAR remission criteria in rheumatoid arthritis) and several statistical approaches can be used for an optimal presentation of the data observed in clinical trials (in particular to assess the concepts of onset of action and sustainability).

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder affecting multiple organ systems, joints, ligaments, and bones and commonly involves the cervical spine. Chronic synovitis may result in bony erosion and ligamentous laxity that result in instability and subluxation. Anterior atlantoaxial subluxation (AAS) is the most frequently occurring deformity, due to laxity of the primary and secondary ligamentous restraints. Additional manifestations of RA include cranial settling, subaxial subluxation, or a combination of these. Although clinical findings can be confounded by the severity of multifocal joint and systemic involvement, a careful history is critical to identify symptoms of cervical disease; serial physical examination is the best noninvasive diagnostic tool. Thorough physical and neurologic examinations should be performed in all patients and serial functional assessments charted. Radiographs of the cervical spine with lateral flexion-extension dynamic views should be obtained periodically and used to "clear" the cervical spine before elective surgery requiring general anesthesia. Advanced imaging, such as magnetic resonance imaging (MRI) or myelography and computed tomography (CT), may be necessary to evaluate the neuraxis. Early initiation of pharmacotherapy may slow progression of rheumatoid cervical disease. Operative intervention before the onset of advanced myelopathy results in improved outcomes compared to the surgical stabilization of patients whose conditions are more advanced. A multidisciplinary approach involving rheumatology, surgery, and rehabilitation is beneficial to optimize outcomes.

Over the last decade, reverse total shoulder arthroplasty has gained significant popularity due to its ability to address difficult reconstructive shoulder problems that could not be adequately treated in the past. The concept of the reverse shoulder prosthesis was introduced in the 1970s, but the initial attempts were associated with high complication and implant failure rates. The pioneering work of Paul Grammont (shifting the center of rotation medially and distally) and the development of the DELTA prosthesis have been fundamental to all subsequent reverse shoulder arthroplasty systems. These semiconstrained prostheses utilize the deltoid to improve function and stability of the shoulder joint by coupling a convex glenoid with a concave humeral component. Modern generations of reverse shoulder prosthesis continue to evolve on the fundamentals of Grammont. Though results of these new prosthesis demonstrate promising outcomes, many controversies and challenges continue to be refined. An historical review of the evolution of reverse shoulder arthroplasty is presented, as well as the currently expanding indications for its application.

The use of musculoskeletal ultrasound (MSKUS) has increased in a variety of rheumatic conditions, particularly rheumatoid arthritis (RA). MSKUS complements the physical examination by allowing for superior visualization of synovitis and erosive changes compared to conventional radiography and provides detail comparable or supplementary to magnetic resonance imaging (MRI). This modality is also less expensive than MRI and CT scans, without claustrophobia or other contraindications, while uniquely providing dynamic, rather than static imaging. A growing body of literature for MSKUS in RA is contributing significantly to the understanding of diagnostic and prognostic utility, longitudinal assessment, and disease remission. Furthermore, scoring systems focusing on the patient level rather than individual joints have been developed, allowing for simplification of exams while still retaining accuracy and utility. The combination of these advances has led to increased use of MSKUS in RA in the realm of research as well as at the bedside and in the clinic.

Three years after the approval of the interleukin 6 (IL-6) receptor antibody tocilizumab in the U.S. for the treatment of rheumatoid arthritis, data has continued to accumulate that can help guide its use for this indication. In particular, the structural benefit of therapy, previously shown in Japanese studies, has been confirmed in non-Japanese populations. Additional studies have identified markers, such as high titer rheumatoid factor, that may be associated with greater clinical response to this agent. While registry data with this therapy have not yet become available, more detailed analyses of clinical trial data have helped clarify the risk for certain toxicities, including infection and gastrointestinal perforation. Importantly, data have become available supporting the use of tocilizumab in diseases other than adult RA. Large clinical trials in systemic juvenile inflammatory arthritis have led to the approval of tocilizumab for this indication, and preliminary data suggests benefit in adult onset Still's disease. Finally, there is interest in the potential of IL-6 inhibition in other diseases, although meaningful data has not yet become available.