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The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral discogenic pain through the analysis of clinical data and finite element modelling (FEM).

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This study examined whether systemic administration of melatonin would have different effects on osseointegration in ovariectomized (OVX) rats, depending on whether this was administered during the day or night.

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Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are curettage or subperiosteal resection to extra periosteal wide resection followed by bone transport. Materials and Methods. A total of 18 patients were treated between 2010 – 2020; 12 patients came with pain and 6 with pain and deformity. All patients were treated by Ilizarov technique. Age ranges from 4–14 years. 12 patients by enbloc excision and bone transportation and 6 patients were treated by osteotomy at the true apex of the deformity by introducing the k/wires in the medullary cavity with stable fixation by Ilizarov device. The longest duration for bone transport was 16 weeks (14–20 weeks) for application, after deformity correction was 20 weeks. We have never used any kind of bone grafts. Results. All the 18 patients were treated successfully by Ilizarov compression distraction device. The patients with localized tibial pathology with deformity had the shortest period on the Ilizarov apparatus, 14 weeks. Conclusions. Preservation and bone regeneration by distraction histogenesis constitutes a highly conservative limb saving surgery. Patients with bone defects of <10 cm, a great deal of preserved healthy tissue and good prognosis are good candidates for these methods

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The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck.

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The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years.

Background. Spastic muscles of patients with cerebral palsy (CP) are considered structurally as shortened muscles, that produce high force in short muscle lengths. Yet, previous intraoperative studies in which muscles’ forces are measured directly as a function of joint angle showed consistently that spastic knee flexor muscles produce a low percentage of their maximum force in flexed knee positions. They also showed effects of epimuscular myofascial force transmission (EMFT): simultaneous activation of different muscles elevated target muscle's force. However, quantification of spastic muscle's force - muscle-tendon unit length (l. MTU. ) data during gait is lacking. Aim. Combining intraoperative experiments with participants’ musculoskeletal models developed based on their gait analyses, we aimed to test the following hypotheses: activated spastic semitendinosus (ST) muscle (1) operates at short l. MTU. 's during gait, forces are (2) low at short l. MTU. 's and (3) increase by co-activating other muscles. Methods. Ten limbs of seven children with CP (GMFCS-II) were tested. Pre-surgery, gait analyses were conducted. Intraoperatively, isometric spastic ST distal forces were measured in ten hip-knee joint angle combinations, in two conditions: (i) activation of the ST individually and (ii) simultaneously with the gracilis, biceps femoris, and rectus femoris muscles endorsing EMFT. In OpenSim, gait_2392 model was used for each limb to (a) calculate l. MTU. per each hip and knee angle combination and the gait relevant l. MTU. range, and (b) analyze gait relevant spastic muscle force - l. MTU. data. Two-way ANOVA was used to compare the patients’ l. MTU. to those of the seven age-matched typically developing (TD) children. l. MTU. values were normalized for the participants’ thigh length. (a) was used to test hypothesis (1) and (b) to test hypotheses (2) and (3): in condition (i), the percent of peak force exerted at the shortest l. MTU. calculated per limb was used as a metric for (2). In condition (ii), mean percent change in muscle force calculated within gait-relevant l. MTU. range was used as a metric for (3). Results. Modeling showed that l. MTU. of spastic ST during gait is shorter on average by 14.1% compared to TD. The ST active force at the shortest gait-relevant l. MTU. was 68.6 (20.6)% (39.9–99.2%) of the peak force. Simultaneous activation of other muscles caused substantial increases in force (minimally by 11.1%, up to several folds, with an exception for one limb). Therefore, only the first and third hypotheses were confirmed. Conclusion. The modeling showed in concert with the clinical considerations that spastic ST may be a shortened muscle that produces high force in short muscle lengths. However, this contrasts intraoperative data, which shows only low forces in flexed knee positions. Note that, the model does not distinguish the muscle-belly and tendon lengths. Therefore, it cannot isolate shorter muscle length and how this compares to the data of TD children remains unknown. Yet, the effects of co-activation of other muscles shown intraoperatively to cause an increase of the spastic ST's force are observed also in muscle force - l. MTU. data characterizing gait. Therefore, if indeed spastic ST produces high forces in short muscle-belly lengths alone, elevated forces due to co-activation of other muscles may be considered as a contributor to the patients’ pathological gait. Otherwise, such EMFT effect may be the main determinant of the pathological condition

Aims. Dystrophic calcification (DC) is the abnormal appearance of calcified deposits in degenerating tissue, often associated with injury. Extensive DC can lead to heterotopic ossification (HO), a pathological condition of ectopic bone formation. The highest rate of HO was found in combat-related blast injuries, a polytrauma condition with severe muscle injury. It has been noted that the incidence of HO significantly increased in the residual limbs of combat-injured patients if the final amputation was performed within the zone of injury compared to that which was proximal to the zone of injury. While aggressive limb salvage strategies may maximize the function of the residual limb, they may increase the possibility of retaining non-viable muscle tissue inside the body. In this study, we hypothesized that residual dead muscle tissue at the zone of injury could promote HO formation. Methods. We tested the hypothesis by investigating the cellular and molecular consequences of implanting devitalized muscle tissue into mouse muscle pouch in the presence of muscle injury induced by cardiotoxin. Results. Our findings showed that the presence of devitalized muscle tissue could cause a systemic decrease in circulating transforming growth factor-beta 1 (TGF-β1), which promoted DC formation following muscle injury. We further demonstrated that suppression of TGF-β signalling promoted DC in vivo, and potentiated osteogenic differentiation of muscle-derived stromal cells in vitro. Conclusion. Taken together, these findings suggest that TGF-β1 may play a protective role in dead muscle tissue-induced DC, which is relevant to understanding the pathogenesis of post-traumatic HO. Cite this article: Bone Joint Res 2020;9(11):742–750

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The purpose of this study was to identify the changes in untreated long head of the biceps brachii tendon (LHBT) after a rotator cuff tear and to evaluate the factors related to the changes.

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In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy.

Rapidly progressive osteoarthritis of the hip (RPOH) is an unusual subset of osteoarthritis. It is characterized by rapid joint space loss, chondroly­sis, and sometimes marked femoral head and acetabular destruction as a late finding. The exact pathogenetic mechanism is unknown. Potential causes of RPOH include subchondral insufficiency fracture resulting from osteoporosis, increasing posterior pelvic tilt as a mechanical factor, and high serum levels of matrix metalloproteinase (MMP)-3 as biological factors. This study was aimed to identify some markers that associate with the destructive process of RPOH by analyzing the proposed pathological factors of the disease, MMP-3, pelvic tilt, and osteoporosis. Of female patients who visited our hospital with hip pain from 2012 through 2018, this study enrolled female patients with sufficient clinical records including the onset of hip pain, age and body mass index (BMI) at the onset, a series of radiographs during the period of >12 months from the onset of hip pain, and hematological data of MMP-3 and C-reactive protein (CRP). We found the hip joints of 31 patients meet the diagnostic criteria of RPOH, chondrolysis >two mm in one year, or 50% joint space narrowing in one year. Those patients were classified into two groups, 17 and 14 patients with and without subsequent femoral head destruction in one year shown by computed tomography, respectively. Serum MMP-3 and CRP were measured with blood samples within one year after the hip pain onset. The cortical thickness index (CTI) as an indicator of osteoporosis and pelvic tilt parameters were evaluated on the initial anteroposterior radiograph of the hip. These factors were statistically compared between the two groups. This study excluded male patients because RPOH occurs mainly in elderly females and the reference intervals of MMP-3 are different between males and females. There was no difference in age at onset or bone mass index between the RPOH patients with and without subsequent femoral head destruction. Serum levels of MMP-3 were significantly higher in the RPOH patients with the destruction (152.1 ± 108.9 ng/ml) than those without the destruction (66.8 ± 27.9 ng/ml) (P = 0.005 by Mann-Whitney test). We also found increased CRP in the patients with femoral head destruction (0.725 ± 1.44 mg/dl) compared with those without the destruction (0.178 ± 0.187 mg/dl) (P = 0.032 by Mann-Whitney test). No difference in the duration between the hip pain onset and the blood examination was found between the two groups. There was no significant difference in CTI or pelvic tilt between the two groups. The pathological condition that may increase serum MMP-3 and CRP could be involved in femoral head destruction after chondrolysis of the hip in patients with RPOH

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Femoroacetabular impingement (FAI) is a potential cause of hip osteoarthritis (OA). The purpose of this study was to investigate the expression profile of matrix metalloproteinases (MMPs) in the labral tissue with FAI pathology.

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Patients with metabolic syndrome (MetS) are known to be at increased risk of postoperative complications, but it is unclear whether MetS is also associated with complications after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Here, we perform a systematic review and meta-analysis linking MetS to postoperative complications in THA and TKA.

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Restoring the pre-morbid anatomy of the proximal humerus is a goal of anatomical shoulder arthroplasty, but reliance is placed on the surgeon’s experience and on anatomical estimations. The purpose of this study was to present a novel method, ‘Statistical Shape Modelling’, which accurately predicts the pre-morbid proximal humeral anatomy and calculates the 3D geometric parameters needed to restore normal anatomy in patients with severe degenerative osteoarthritis or a fracture of the proximal humerus.

Heterotopic ossification (HO) is the formation of bone at extra-skeletal sites. Genetic diseases, traumatic injuries, or severe burns can induce this pathological condition and can lead to severe immobility. While the mechanisms by which the bony lesions arise are not completely understood, intense inflammation associated with musculoskeletal injury and/or highly invasive orthopaedic surgery is thought to induce HO. The incidence of HO has been reported between 3% and 90% following total hip arthroplasty. While the vast majority of these cases are asymptomatic, some patients will present decreased range of motion and painful swelling around the affected joints leading to severe immobility. In severe cases, ectopic bone formation may be involved in implant failure, leading to costly and painful revision surgery. The effects of surgical-related intraoperative risk factors for the formation of HO can also play a role. Prophylactic radiation therapy, and anti-inflammatory and biphosphonates agents have shown some promise in preventing HO, but their effects are mild to moderate at best and can be complicated with adverse effects. Irradiation around surgery could decrease the incidence of HO. However, high costs and the risk of soft tissue sarcoma inhibit the use of irradiation. Increased trials have demonstrated that nonsteroidal anti-inflammatory drugs (NSAID) are effective for the prevention of HO. However, the risk of gastrointestinal side effects caused by NSAID has drawn the attention of surgeons. The effect of the selective COX-2 inhibitor, celecoxib, is associated with a significant reduction in the incidence of HO in patients undergoing THA. Bone morphogenetic proteins (BMP) such as BMP2 identified another novel druggable target, i.e., the remote application of apyrase (ATP hydrolyzing agent) in the burn site decreased HO formation and mitigated functional impairment later. The question is if apyrase can be safely administered through other, such as systematical, routes. While the systemic treatments have shown general efficacy and are used clinically, there may be great benefit obtained from more localised treatment or from more targeted inhibitors of osteogenesis or chondrogenesis. In the surgical setting, prophylaxis for HO is regularly indicated due to the considerable risk of functional impairment. Heterotopic ossification is a well-known complication of total hip arthroplasty, especially when the direct lateral approach is used. Possible intraoperative risks are the size of incision, approach, duration of surgery and gender that can be associated with higher rates of HO or increase of the severity of HO. Like inflammation and tissue damage/ischemia are likely to be the key in the formation of HO, kindness to the soft tissues, tissue preserving surgery, pulse lavage to remove bone inducing factors and avoiding damage to all tissues should be erased as a comorbidity. Incision length, tissue dissection and subsequent localised trauma and ischemia, blood loss, anesthetic type and length of surgery may all contribute to the local inflammatory response. Data suggest that the surgeon may control the extent and nature of HO formation by limiting the incision length and if possible the length of the operation. Currently resection of HO is generally suggested after complete maturation (between 14–18 months), since earlier intervention is thought to predispose to recurrence. Reliable indicators of maturation of HO are diminishing activity on serial bone scans and/or decreasing levels of alkaline phosphatase. Although usually asymptomatic, heterotopic bone formation can cause major disability consisting of pain and a decreased range of motion in up to 7% of patients undergoing THA. Patients benefit from early resection of the heterotopic ossification with a proper and reliable postoperative strategy to prevent recurrence of HO with clinical implications

The primary objective of this study was to determine if paediatric proximal humerus fractures undergo significant displacement resulting in change in management. A retrospective analysis was performed on children who presented with proximal humeral fractures to our institution between 2009 and 2014. Patients were included if they were diagnosed with a fracture of the proximal humerus in the absence of an underlying bone cyst or pathological condition. Patients with open fractures, multiple fractures, neurologic, or vascular injuries were excluded. The primary endpoint was conversion to operative treatment after initial non-operative management. Secondary endpoints were a healed fracture with acceptable alignment at the final radiographic evaluation, as well as the number of follow-up radiographs obtained after the initiation of non-operative management. A decision to manage the fracture operatively at the initial presentation was made in 14 out of 239 patients. Of the 225 patients that were initially managed non-operatively, only 1 patient underwent subsequent surgical management. In this series, no non-unions, re-fractures, nor fracture-dislocations were identified. These data support that the majority of management decisions for paediatric proximal humeral fractures are made at the initial presentation. Once non-operative management is chosen, routine follow-up imaging rarely leads to any change in treatment

Introduction. Reverse shoulder prosthesis has been developed to treat the clinical and pathological condition noted as cuff tear arthropathy (CTA). The current models of reverse shoulder arthroplasty (RSA) expose the procedure to the risk of scapular notching, possibly leading to loosening of the glenoid. Aim. The purpose of this study was to report updated results at a minimum follow-up of four years of 25 patients underwent reverse shoulder arthroplasty between 2006 and 2010 with an eccentric 36-mm glenoid component (SMR Lima). Methods. Clinical and radiographic evaluation was performed preoperatively and at every year of follow-up. All patients were evaluated with MRI or CT scan preoperatively and with X-ray examinations postoperatively to evaluate the presence of inferior scapular notching. To value the clinical outcome the Constant score and VAS score have been evaluated preoperatively and every year of follow up. Results. Since the last report the mean Constant remain stable (63.11±8.92) and the mean VAS score decreased to 1.75±2.38 (p<0.005). Radiographs showed one case of grade 1 inferior scapular notching at 7-year follow-up. Notching didn't have any influence on clinical outcome. In two patients radiolucent lines were visible around the central peg or screws. No patient had glenoid baseplate loosening or baseplate failure. Conclusion. Satisfactory results have been achieved in the treatment of cuff-deficient shoulder conditions with reverse shoulder arthroplasty using an eccentric glenosphere at medium follow up. The patients have maintained their improved function with durable clinical and radiographic results at a minimum of four years

Introduction. Knee osteoarthritis (OA) is a major contributor to disability in seniors and affecting millions of people around the world. Its main problem and the biggest factor in the disability of patients is pain. Pain renders patient inactive and develops lower extremity muscle wasting and worsens patient status adversely. However no radical solution existed until now. Recently I discovered a very valid manipulative technique (Squeeze-hold) for OA knee. This study presents the one-year follow-up data (three cases) by this treatment. Methods. Subjects. The subjects were three severe knee OA patients who had their data collected for 12 months after having a treatment. Treatment (squeeze-hold): The lower limb muscles (all muscles attached to the knee joint) were squeezed and held by hand. Each squeeze was performed in linear sequence all the way through the lower limbs. The squeezes were held for 20 seconds. This treatment was performed on a weekly basis. Evaluation: The conditions of the OA were evaluated using a Kellgren-Lawrence Grading Scale. Visual analogue scale as indicator of pain and Japanese Knee Osteoarthritis Measure as indicator of the activity restriction were recorded every month for a year. Results. In all three cases, OA knee pain and ADL were gradually improved by sustained once-a-week treatment. The daily activities were gradually increased. After a year, the pain passed approximately away. In case 1 and 2, a limitation in ROM did not show a marked improvement and joint contracture remained. Discussion. Squeeze-hold therapy that is approach to lower-limb muscles relieved OA knee pain. It is suggested by the fact that lower-limb muscles is responsible for the pain. And the physical activity of knee OA patient increases with decreasing pain effected by Squeeze-hold therapy. This increase in physical activity provides increase in joint movement and it lead to improve articular metabolism. Cyclical loading increases chondrocyte activity. Additionally, It inhibits the release of matrix metalloproteinase, pro-inflammatory mediators and shear stress-induced nitric oxide that induces chondrocyte apoptosis. And further, this increased physical activity improves muscle-strengthening of the lower extremity. It is plausible that these effects may continuously lead to decreased pain and improved ADL. A primary pain in knee OA can be attributed to inflammation of knee joint capsule or within knee joint capsule. And the pain leads to muscular hypertonicity thereby a bigger secondary pain develops in the muscles. Decreased physical activity due to the pain worsens pathological condition to induce greater pain. By this means, there might be formed pain-deterioration chain. Squeeze-hold therapy reduces the myogenic pain and cut the pain-deterioration chain. However, ROM could not improve though the pain and ADL activity imploved. This treatment ought to be performed before the formation of articular contracture. The results indicate Squeeze-hold treatment for lower-limb muscles might improves OA knee pain and limited ADL. However, this study had only three cases. Further research efforts are needed to identify the adaptation to diverse clinical symptoms knee OA

Summary Statement. Applying appropriate upper limb regional-specific and joint-specific tools along with suitable psychologic tools provides an effective assessment of supportive, interventional, and treatment strategies in TE. Background. Tennis elbow (TE) is a painful pathologic condition with its origin in the common wrist extensor muscles at the lateral epicondyle. As the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting, with an annual incidence of 4 to 7 cases per 1000 patients in general practice (with a peak at 35 to 54 yrs of age), TE has considerable socioeconomic costs. As pain relief and improvement in functional performance are the 2 common aims of all treatment strategies, the importance of using appropriate tools for the assessment of pain and functional disability in TE is evident. In view of the high prevalence of TE, uncertainties about its treatment, and its substantial socioeconomic consequences, using more specific, patient-centred assessment tools is essential for providing more useful information on the level of pain and functional disability in TE. The Study aimed to: 1) compare pain and functional disability in tennis elbow (TE) patients with healthy controls; and 2) evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. Methods. Sixteen consecutive TE patients were recruited at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localised lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. Results. Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). Discussion. TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of “upper limb” and “psychologic” assessment tools