The development and validation of a patient-reported questionnaire to assess outcomes of elbow surgery

We developed a questionnaire to assess patient-reported outcome after surgery of the elbow from interviews with patients. Initially, 17 possible items with five response options were included. A prospective study of 104 patients (107 elbow operations) was carried out to analyse the underlying factor structure, dimensionality, internal and test-retest reliability, construct validity and responsiveness of the questionnaire items. This was compared with the Mayo Elbow performance score clinical scale, the Disabilities of the Arm, Shoulder and Hand questionnaire, and the Short-Form (SF-36) General Health Survey. In total, five questions were considered inappropriate, which resulted in the final 12-item questionnaire, which has been referred to as the Oxford elbow score. This comprises three unidimensional domains, 'elbow function', 'pain' and 'social-psychological'; with each domain comprising four items with good measurement properties. This new 12-item Oxford elbow score is a valid measure of the outcome of surgery of the elbow.

The use of a patient-based questionnaire (the Oxford Shoulder Score) to assess outcome after rotator cuff repair

INTRODUCTION

It is increasingly important for surgeons to monitor the outcome of their practice for the purpose of audit. The main difficulty has been the lack of appropriate methods of assessing outcome. Outcome has traditionally been assessed by clinical means which can be inaccurate, irreproducible and subject to surgeon bias. In addition, the perspective of the patient and surgeon may differ with respect to outcome and interest has grown in patient-based scoring systems. The Oxford Shoulder Score (OSS) is one such patient-based scoring system. The main aim of this study was to assess whether a patient-based questionnaire, in this case the OSS, could be effectively used to audit outcome from shoulder surgery. A secondary aim was to assess the value of gathering outcome information by post.

PATIENTS AND METHODS

A total of 24 patients (14 male; median age 59 years; age range, 43-73 years) who had completed a pre-operative OSS questionnaire and had undergone rotator cuff repair were included in the study. Participants were assessed postoperatively at regular intervals using the OSS at hospital visits and by postal questionnaire.

RESULTS

The completion level for the OSS was 97% and the response rate to the postal questionnaire was 96%. At 3 months' post-surgery, 21 of 24 patients had improved; at final review (16-37 months), 23 patients had improved following surgery. The OSS was observed to be a robust tool for the quantitative assessment and tracking of patient outcomes after surgery.

CONCLUSIONS

This study shows the value of using a postal questionnaire to follow-up patients after surgery and demonstrates the successful use of a patient-based questionnaire to audit the outcome from shoulder surgery.

Chronic musculoskeletal pain and arthritis: impact, attitudes and perceptions

The aim of this study was to assess the prevalence, management and impact on quality of life of chronic musculoskeletal pain in Ireland by comparing the attitudes and perceptions of sufferers to those of general practice doctors (GPs). A telephone survey was conducted with 498 people with chronic musculoskeletal pain (screened from a total of 3323) and 150 GPs selected randomly from the medical register. The survey was based on a structured questionnaire that asked about the impact of CMP, usual management and perceived benefits and risks of treatment. Chronic musculoskeletal pain, including arthritis, affected one in six of the people screened for the survey. 25% of those surveyed have never consulted a doctor about their condition and many others will have waited up to two years before seeking help. 67% of respondents reported that pain caused significant reduction in their quality of life (measured using the SF-12 scale). The survey also indicated that people with chronic musculoskeletal pain have misconceptions about their condition, treatment options and side effects and patients rarely receive written information from their GP on these subjects. Chronic musculoskeletal pain, including arthritis is common and significantly reduces quality of life in Ireland. People delay seeking medical help, despite being in constant/daily pain. Written information is sparse and misperceptions relating to treatment are common. Improved awareness and valid information may lead to better care for people suffering from CMP in Ireland.

The assessment of early osteoarthritis

Treatment strategies for osteoarthritis most commonly involve the removal or replacement of damaged joint tissue. Relatively few treatments attempt to arrest, slow down or reverse the disease process. Such options include peri-articular osteotomy around the hip or knee, and treatment of femoro-acetabular impingement, where early intervention may potentially alter the natural history of the disease. A relatively small proportion of patients with osteoarthritis have a clear predisposing factor that is both suitable for modification and who present early enough for intervention to be deemed worthwhile. This paper reviews recent advances in our understanding of the pathology, imaging and progression of early osteoarthritis.

Understanding pain in osteoarthritis

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.

The pathology of frozen shoulder

We treated 22 patients with a diagnosis of primary frozen shoulder resistant to conservative treatment by manipulation under anaesthetic and arthroscopic release of the rotator interval, at a mean time from onset of 15 months (3 to 36). Biopsies were taken from this site and histological and immunocytochemical analysis was performed to identify the types of cell present. The tissue was characterised by the presence of fibroblasts, proliferating fibroblasts and chronic inflammatory cells. The infiltrate of chronic inflammatory cells was predominantly made up of mast cells, with T cells, B cells and macrophages also present. The pathology of frozen shoulder includes a chronic inflammatory response with fibroblastic proliferation which may be immunomodulated.

The use of the Oxford hip and knee scores

The Oxford hip and knee scores have been extensively used since they were first described in 1996 and 1998. During this time, they have been modified and used for many different purposes. This paper describes how they should be used and seeks to clarify areas of confusion.

Genetic influences in the aetiology of anteromedial osteoarthritis of the knee

We report a study of 112 patients with primary anteromedial osteoarthritis of the knee and their families. Sibling risk was determined using randomly selected single siblings. Spouses were used as controls. The presence of symptomatic osteoarthritis was determined using an Oxford knee score of ≥ 29 supported by a Kellgren and Lawrence radiological score of II or greater.

Using Fisher’s exact test we found that there was a significant increased risk of anteromedial osteoarthritis (OA) relative to the control group (p = 0.031). The recurrence risk of anteromedial OA to siblings was 3.21 (95% confidence interval 1.12 to 9.27).

These findings imply that genetic factors may play a major role in the development of anteromedial OA of the knee.

In vivo measurement of tissue metabolism in tendons of the rotator cuff

We have undertaken an in vivo assessment of the tissue metabolism and cellular activity in torn tendons of the rotator cuff. Cellular oxygen consumption was measured in 13 patients undergoing mini-open repair of small, medium, large and massive full-thickness tears. Measurements were also taken from three control patients who were undergoing open stabilisation of the shoulder with grossly normal tendons. The level of oxygen and nitrous oxide was measured amperometrically using silver needle microelectrodes at the apex of the tear and 1.5 cm from its edge. With nitrous oxide indicating the degree of perfusion, oxygen consumption was calculated at each location to reflect cellular activity.

All of the torn tendons had lower levels of cellular activity than the control group. This activity was lower still in the tissue nearest to the edge of the tear with the larger tears showing the lowest activity. This indicated reduced levels of tissue metabolism and infers a reduction in tendon viability.

Our findings suggest that surgical repair of torn tendons of the rotator-cuff should include the more proximal, viable tissue, and may help to explain the high rate of re-rupture seen in larger tears.

Construction and validation of a quality of life questionnaire for neuromuscular disease (INQoL)

BACKGROUND

Because there is no muscle disease specific measure of quality of life (QoL), we wanted to develop and validate an individualized muscle disease specific measure of QoL for adults suitable for both clinical and research use.

METHODS

A literature review exploring QoL and its measurement resulted in the development of a theoretical model of QoL. This was used alongside qualitative interviews (n = 41) and a postal survey (n = 252) to design a questionnaire. The psychometric properties, validity (n = 95), reliability (n = 40), and responsiveness (n = 25) of the scale were assessed.

RESULTS

The Individualized Neuromuscular Quality of Life questionnaire (INQoL) consists of 45 questions within 10 sections. Four of these focus on the impact of key muscle disease symptoms (weakness, locking [i.e., myotonia], pain, and fatigue), five look at the impact (degree and importance of impact) muscle disease has on particular areas of life, and one section asks about the positive and negative effects of treatment. The questionnaire is structured to allow for variations in the individual characteristics that influence quality of life. Psychometric evaluation established construct validity and test-retest reliability. A preliminary assessment of responsiveness was obtained.

CONCLUSIONS

The Individualized Neuromuscular Quality of Life is a validated muscle disease specific measure of quality of life developed from the experiences of patients with muscle disease and can be used for individuals or large samples.

Pathology of the torn rotator cuff tendon. Reduction in potential for repair as tear size increases

We have studied cellular and vascular changes in different stages of full thickness tears of the rotator cuff. We examined biopsies from the supraspinatus tendon in 40 patients with chronic rotator cuff tears who were undergoing surgery and compared them with biopsies from four uninjured subscapularis tendons. Morphological and immunocytochemical methods using monoclonal antibodies directed against leucocytes, macrophages, mast cells, proliferative and vascular markers were used. Histological changes indicative of repair and inflammation were most evident in small sized rotator cuff tears with increased fibroblast cellularity and intimal hyperplasia, together with increased expression of leucocyte and vascular markers. These reparative and inflammatory changes diminished as the size of the rotator cuff tear increased. Marked oedema and degeneration was seen in large and massive tears, which more often showed chondroid metaplasia and amyloid deposition. There was no association between the age of the patient and the duration of symptoms. In contrast, large and massive tears showed no increase in the number of inflammatory cells and blood vessels. Small sized rotator cuff tears retained the greatest potential to heal, showing increased fibroblast cellularity, blood vessel proliferation and the presence of a significant inflammatory component. Tissue from large and massive tears is of such a degenerative nature that it may be a significant cause of re-rupture after surgical repair and could make healing improbable in this group.

Zebrafish circadian clocks: cells that see light

In the classical view of circadian clock organization, the daily rhythms of most organisms were thought to be regulated by a central, 'master' pacemaker, usually located within neural structures of the animal. However, with the results of experiments performed in zebrafish, mammalian cell lines and, more recently, mammalian tissues, this view has changed to one where clock organization is now seen as being highly decentralized. It is clear that clocks exist in the peripheral tissues of animals as diverse as Drosophila, zebrafish and mammals. In the case of Drosophila and zebrafish, these tissues are also directly light-responsive. This light sensitivity and direct clock entrainability is also true for zebrafish cell lines and early-stage embryos. Using luminescent reporter cell lines containing clock gene promoters driving the expression of luciferase and single-cell imaging techniques, we have been able to show how each cell responds rapidly to a single light pulse by being shifted to a common phase, equivalent to the early day. This direct light sensitivity might be related to the requirement for light in these cells to activate the transcription of genes involved in DNA repair. It is also clear that the circadian clock in zebrafish regulates the timing of the cell cycle, demonstrating the wide impact that this light sensitivity and daily rhythmicity has on the biology of zebrafish.

The management of knee pain in primary care: factors associated with consulting the GP and referrals to secondary care

OBJECTIVES

To investigate the treatment of knee pain in primary care and the factors associated with consulting general practitioners (GPs) and referrals to specialist services.

METHODS

Individuals with knee pain were identified through postal questionnaires sent to patients aged 50 and over from two GP practices in southeast London. Patients with knee pain were then invited to the department, where demographic, clinical and service use data were collected. Participants also completed measures of pain, function, handicap and illness beliefs.

RESULTS

From the 2940 questionnaires that were sent out, the response rate was 34%. Of these, 49% reported experiencing knee pain in the previous 12 months. Two hundred and thirty-one patients with knee pain attended the department. One hundred and thirty-four (58%) had seen their GP about their knee pain, with 50 (37%) referred on to specialist services. Compared with non-consulters, consulters had more severe disease and higher levels of disability and handicap, and believed the condition was more severe and had major consequences on their lives. Those referred to specialist care had higher levels of handicap and also believed the condition was more severe, with major consequences on their lives, than those not referred.

CONCLUSION

In this sample nearly half of those who reported knee pain had not seen their GP and were self-managing their condition. A mixture of physical, social and psychological factors predicted visits to GPs and rates of referral to secondary care. Patient perceptions about knee pain were important predictors of both consultations and referrals, highlighting the need to address both physical and psychosocial factors in relation to help-seeking.

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey

OBJECTIVE

To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis.

DESIGN

Cross-sectional survey.

SETTING

National survey in the UK.

PARTICIPANTS

Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months.

MAIN OUTCOME MEASURES

Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy.

RESULTS

Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14-3.02], concerns about medication (OR 1.49, 95% CI 1.01-2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44-0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38-2.43), side effects (HR 3.69, 95% CI 2.74-4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48-3.30). For both daily (HR 1.53, 95% CI 1.1-2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17-3.07), practical difficulties taking bisphosphonate medication-in particular, too frequent dosing-were associated with nonpersistence.

CONCLUSIONS

Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.

Does increasing the grades of the knee osteoarthritis line drawing atlas alter its clinimetric properties?

OBJECTIVES

To (a) develop further logically derived line drawing atlases (LDAs) for grading radiographic knee osteoarthritis (OA); and (b) determine which is superior using metrological criteria.

METHODS

A series of LDAs (-3 to +3, -4 to +4, and -5 to +5) were produced by (a) incorporating additional grades for osteophyte and joint space width (JSW) above the 0-3 pilot LDA, over an equivalent range of disease; and (b) adding negative grades for JSW. 121 sets of bilateral knee radiographs (standing, anteroposterior plus flexed skyline), plus serial views of 68 tibiofemoral joints (TFJs) and 36 patellofemoral joints were scored twice by one observer for each LDA. Minimum JSW of 50 radiograph sets was directly measured and awarded a categorical grade dependent upon the boundaries of each LDA grade. Time taken to grade 30 randomly selected knee radiograph sets was measured.

RESULTS

Intraobserver reproducibility was similar for all LDAs, (weighted kappa: JSW = 0.85-0.87; osteophyte = 0.77-0.79), with no deterioration with increasing grades. Criterion validity favoured the -5 to +5 LDA, which was also quickest to use. All atlases showed similar responsiveness (standardised response mean: medial TFJ JSW = 0.78-0.83; medial femoral osteophyte = 0.61-0.73), with most sites compromised by small sample size, little change in score, and high variation between subjects.

CONCLUSIONS

A set of LDAs was created illustrating the full range of normality/abnormality likely to be encountered in a community study of knee pain or OA. Despite superior validity and equivalent reproducibility, improved responsiveness of the -5 to +5 LDA was not confirmed.

Genetic influences in the aetiology of tears of the rotator cuff

From a retrospective, cohort study of 205 patients diagnosed with full-thickness tears of the rotator cuff, we determined, using ultrasound, the prevalence of such tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full-thickness tears in siblings versus controls was 2.42 (95% CI 1.77 to 3.31). The relative risk of symptomatic full-thickness tears in siblings versus controls was 4.65 (95% CI 2.42 to 8.63).

The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full-thickness tears of the rotator cuff.

Musculoskeletal pain in Europe: its impact and a comparison of population and medical perceptions of treatment in eight European countries

OBJECTIVES

To describe the impact of musculoskeletal pain (MP); to compare management of MP by the population and by primary care physicians; and to identify misconceptions about treatment.

METHODS

5803 people with MP and 1483 primary care physicians, randomly selected, in eight European countries were interviewed by telephone. A structured questionnaire was used to ask about usual management of MP and perceived benefits and risks of treatment. Current health status (SF-12) was also assessed.

RESULTS

From primary care physicians' perceptions, MP appears to be well managed. All presenting patients are offered some form of treatment, 90% or more doctors are trying to improve patients' quality of life, and most are aware and concerned about the risks of treatment with NSAIDs. From a population perspective, up to 27% of people with pain do not seek medical help and of those who do, several wait months/years before seeing a doctor. 55% or fewer patients who have seen a doctor are currently receiving prescription treatment for their pain. Communication between doctors and patients is poor; few patients are given information about their condition; and many have misconceptions about treatment.

CONCLUSIONS

Management of MP is similar across eight European countries, but there is discordance between physician and patient perspectives of care. Some people with pain have never sought medical help despite being in constant/daily pain. Those who do seek help receive little written information or explanation and many have misperceptions about the benefits and risks of treatment that limit their ability to actively participate in decisions about their care.

Arthroplasty of the elbow in haemophilia

Total elbow replacement can be a valuable option for the treatment of the elbow in haemophilia where there are associated arthropathic changes. We describe the outcome of seven elbow replacements in five consecutive patients with severe haemophilia A (native factor levels < 1%) at a mean of 42 months (25 to 65) after operation. All the patients had excellent relief of pain and improvement in function. One failure was due to infection in an immunocompromised patient with both HIV and Hepatitis C antibodies who was on anti-retroviral chemotherapy. The implant was revised at 30 months in a one-stage procedure and showed no evidence of loosening or infection 35 months later.

UK community prevalence of knee chondrocalcinosis: evidence that correlation with osteoarthritis is through a shared association with osteophyte

OBJECTIVES

(1) To estimate the prevalence of chondrocalcinosis (CC) in the community and to characterise its compartmental distribution within the knee. (2) To investigate the associations between CC and individual radiographic features of osteoarthritis (OA) at the tibiofemoral joint (TFJ) and patellofemoral joint (PFJ).

METHODS

From three community questionnaire studies investigating the prevalence of knee pain, standing anteroposterior and skyline radiographs were obtained on 1727 subjects (1084 women, 643 men; mean age 63.7; 999 (58%) with knee pain). A single observer recorded the presence and site of CC and graded osteophyte and joint space narrowing (JSN) using a line atlas. "OA" was globally defined as the presence of definite osteophyte and definite JSN. Minimum joint space width (JSW) was measured to 0.1 mm with a metered dial caliper

RESULTS

(1) The crude prevalence of CC was 7.0% (95% confidence interval (CI) 5.8 to 8.2). This showed a strong association with age. The age adjusted odds ratio (aOR) for CC in women v men was 0.79 (95% CI 0.52 to 1.12). The age, sex, and knee pain standardised estimate for those aged >40 in Nottingham, UK was 4.5%. Patellofemoral CC was seen in only nine cases, all with tibiofemoral CC. (2) The age-sex aOR for the association between CC and OA was 2.08 at the PFJ (1.38 to 3.12) and 2.00 (1.11 to 3.60) at the TFJ. There was no association between measured JSW and CC at either the PFJ or TFJ. Both total osteophyte score and total number of sites with osteophyte were positively associated with CC; aOR for the upper quartile was 2.40 (1.48 to 3.90) and 1.94 (1.15 to 3.26), respectively. An association between CC and diuretic use was also demonstrated (aOR=2.07, 1.02 to 4.19).

CONCLUSIONS

In this large UK community study the age, sex, and knee pain adjusted prevalence of CC was 4.5%. There was a strong age association, but no sex predisposition. Patellofemoral CC was uncommon. An association between OA and CC was confirmed, but this appears to operate through an association with osteophyte rather than JSN. The new association between CC and diuretic use might theoretically be explained by diuretic induced hypomagnesaemia.

Minimum solid area models applied to the prediction of Young's modulus for cancellous bone

In developing models for the mechanical behavior of cancellous bone, accurate prediction of Young's modulus as a function of the pore fraction and morphology is a requirement. Previous workers have suggested models which provide good statistical fits, but most of these models are highly idealized, with no treatment of the actual morphology of the porosity. In the field of engineering ceramics, simple minimum solid area models have been developed over the past four decades to describe the mechanical properties of porous structural ceramics. This paper applies these models to data for cancellous bone, and it is shown that one, developed specifically for high porosity materials, gives realistic predictions of tissue modulus and a good statistical fit to well-established data. This model should prove to be useful in biomechanical analyses involving cancellous bone tissue.

Development of a symptom specific health status measure for patients with chronic cough: Leicester Cough Questionnaire (LCQ)

BACKGROUND

Chronic cough is a common condition which has a significant impact on quality of life. Assessment and management are hampered by the absence of well validated outcome measures. The development and validation of the Leicester Cough Questionnaire (LCQ), a self-completed health related quality of life measure of chronic cough, is presented.

METHODS

Patients with chronic cough were recruited from outpatient clinics. The development of the LCQ consisted of three phases: phase 1 (item generation); phase 2 (item reduction, allocation of items to domains and validation of questionnaire); phase 3 (repeatability and responsiveness testing of final version of questionnaire).

RESULTS

Phase 1: Literature review, multidisciplinary team meeting and 15 structured interviews with chronic cough patients generated 44 items (LCQ1) with a 7 point Likert response scale. Phase 2: 104 chronic cough outpatients completed the LCQ1 along with an importance rating for each item. The clinical impact factor method was used for item reduction to 19 items (LCQ2: final version). These items were divided into three domains (physical, psychological and social) following expert opinion. Internal reliability, as assessed using Cronbach's alpha coefficients, varied between 0.79 and 0.89. Concurrent validity was high when the LCQ2 (n=56) was compared with a cough visual analogue score (r=-0.72). There was a moderate relationship with response to the St George's Respiratory Questionnaire (r=-0.54) and SF36 total score (r=0.46). Phase 3: Two week repeatability (n=24) was high with intraclass correlation coefficients for domains varying between 0.88 and 0.96. Responsiveness in nine patients whose cough was successfully treated varied within domains from an effect size of 0.84 to 1.75.

CONCLUSION

The LCQ is a valid, repeatable 19 item self-completed quality of life measure of chronic cough which is responsive to change. It should be a useful tool in clinical trials and longitudinal studies.

An avian model of limb deviation induced by periosteal surgery

A model of limb deviation induced by hemi-circumferential periosteal stripping of the distal tibiotarsus of domestic chicks is described. This model has been developed to study the effects of periosteal stripping on the cellular, mechanical, vascular, and biochemical status of the immature bone and growth plate. It is hoped that such studies may further elucidate the mechanisms involved in altered bone growth following periosteal stripping techniques which are used in human and equine orthopaedics for the management of leg length discrepancies and angular limb deformities respectively (Auer and Martens 1980, Warrell and Baker 1987). Hemi-circumferential periosteal stripping of the left distal tibiotarsus of 28-day-old chicks resulted in significant change in metaphyseal-diaphyseal angle with time, compared to both the controls and the untreated right legs (P<0.0001). This model of limb deviation developed rapidly and consistently, and the procedures were well tolerated by the birds over the short survival time (maximum 28 days).

A comparative study of outcome in myositis and other musculoskeletal disorders assessed using the Nottingham health profile

OBJECTIVE

This study evaluated the comparative impact of myositis and other musculoskeletal disorders on general health using the Nottingham health profile (NHP) as a generic measure of health status.

METHODS

A prospective observational study of 113 females with myositis, 142 females with rheumatoid arthritis, 45 females with spinal osteoporosis and 96 females with knee osteoarthritis.

RESULTS

All mean NHP section scores were higher in myositis and other musculoskeletal disorders compared to population mean values. Section scores for energy and social isolation were high in myositis compared to all other disorders. Scores for physical disability in myositis were similar to RA. Pain scores were higher in RA and OA compared to myositis. Backwards linear regression models explained 26-42% of the variation in energy and social isolation scores. Emotion and physical section scores were the major determinants and the pattern was similar in all disorders. Disease duration and age had little effect.

CONCLUSIONS

Myositis is not simply a disease with physical problems but has wide ranging effects on social and emotional well being. Until disease-specific instruments are available, a generic measure like the NHP can be used to assess problems other than muscle pain and loss of strength.

Localised deposition of amyloid in tears of the rotator cuff

Age-related localised deposition of amyloid in connective tissue has been found in degenerative articular and periarticular tissue. Biopsies of the supraspinatus tendon of 28 patients undergoing repair of the rotator cuff were analysed histologically for the presence of localised deposition of amyloid. There was a long history of impingement in 20 patients, and eight patients had suffered an acute traumatic tear with no preceding symptoms. Localised deposition of amyloid identified by Congo Red staining was detected in 16 samples (57%). Amyloid was present in 14 (70%) of the degenerative tears, but in only two (25%) of the acute tears. Immunohistochemical staining showed that the amyloid deposits were positive for P component, but negative for κ and λ light chains, prealbumin, and β2 microglobulin. Critical electrolyte staining revealed highly-sulphated glycosaminoglycans at sites of deposition of amyloid. The presence of localised deposition of amyloid in tears of the rotator cuff is likely to represent irreversible structural changes. These findings support the theory that impingement and tears are due to intrinsic degenerative changes within the tendons of the rotator cuff.

Localised deposition of amyloid in tears of the rotator cuff

Age-related localised deposition of amyloid in connective tissue has been found in degenerative articular and periarticular tissue. Biopsies of the supraspinatus tendon of 28 patients undergoing repair of the rotator cuff were analysed histologically for the presence of localised deposition of amyloid. There was a long history of impingement in 20 patients, and eight patients had suffered an acute traumatic tear with no preceding symptoms. Localised deposition of amyloid identified by Congo Red staining was detected in 16 samples (57%). Amyloid was present in 14 (70%) of the degenerative tears, but in only two (25%) of the acute tears. Immunohistochemical staining showed that the amyloid deposits were positive for P component, but negative for kappa and lambda light chains, prealbumin, and beta2 microglobulin. Critical electrolyte staining revealed highly-sulphated glycosaminoglycans at sites of deposition of amyloid. The presence of localised deposition of amyloid in tears of the rotator cuff is likely to represent irreversible structural changes. These findings support the theory that impingement and tears are due to intrinsic degenerative changes within the tendons of the rotator cuff.

Arthroscopy of the elbow for loose bodies

This retrospective study confirms the benefit of arthroscopic removal of loose bodies from the elbow, and documents the accuracy of history and plain radiographs. In contrast to previous reports, patients with a diagnosis of osteoarthritis had a similar outcome to those with an alternative diagnosis.

The sintering and mechanical behavior of hydroxyapatite with bioglass additions

There is increasing interest in the potential of composites of hydroxyapatite with phosphate- or silicate-based bioactive glasses, and certain of these glass additions have been found, in previous work, to aid densification and form a mechanically-reinforced, bioactive material; in particular, large improvements in flexural strength and fracture toughness were obtained through the addition of small amounts of phosphate glass. Less is known about the mechanical behavior of HA/bioglass composites, although in vivo studies by other workers have shown encouraging biological results. In this investigation, the sintering behavior, mechanical properties, and microstructure of composites of HA with up to 50 wt % glass, were analyzed. X-ray diffraction showed the phase composition of sintered composites with up to 5 wt % added bioglass to be non-stoichiometric HA with alpha-TCP or beta-TCP. Phase analysis of composites containing higher glass additions was impracticable due to peak broadening and overlap, although reaction products, at the highest glass additions and sintering temperatures, may include wollastonite-2M and beta-Na2Ca4(PO4)2SiO4. Sintered density, and mechanical properties other than fracture toughness, showed no significant improvement over HA.

The relationship between surface topography and contact in the elbow joint: development of a two-dimensional geometrical model in the coronal plane

One of the first stages in developing an accurate biomechanical representation of the elbow joint is to model realistically the geometry of the joint. In particular, given the complex anatomy of the articular surfaces, the relationship between surface topography and joint contact must be fully understood in order to model the contact conditions. As the joint articulates, the location and size of the contacts between the mating surfaces change, altering the distribution and magnitude of load transmission. In this paper, a geometric model of the anatomical elbow joint in the coronal plane is described. The contours of the articulating surfaces are represented algebraically by a series of connecting lines and circular arcs. It is shown that the location and size of the contact between the surfaces change significantly due to small changes in the topography of one or more of the mating surfaces. The surface topography-joint contact relationship is modelled for a number of different clinical conditions for the joint. The model is relevant to clinical studies of joint degeneration and to the design of prosthetic components for the elbow joint.

Recurrent instability of the elbow in the Ehlers-Danlos syndrome. A report of three cases and a new technique of surgical stabilisation

We present three cases of recurrent instability of the elbow in association with the Ehlers-Danlos syndrome. The pattern of instability has not previously been reported. We describe our procedure for achieving stability using a bone graft to the olecranon fossa which gave a functional range of movement.

Interobserver and intraobserver variation in classification systems for fractures of the distal humerus

We assessed the inter- and intraobserver variation in classification systems for fractures of the distal humerus. Three orthopaedic trauma consultants, three trauma registrars and three consultant musculoskeletal radiologists independently classified 33 sets of radiographs of such fractures on two occasions, each using three separate systems.

For interobserver variation, the Riseborough and Radin system produced ‘moderate’ agreement (kappa = 0.513), but half of the fractures were not classifiable by this system. For the complete AO system, agreement was ‘fair’ (kappa = 0.343), but if only AO type and group or AO type alone was used, agreement improved to ‘moderate’ and ‘substantial’, respectively (kappa = 0.52 and 0.66). Agreement for the system of Jupiter and Mehne was ‘fair’ (kappa = 0.295). Similar levels of intraobserver variation were found.

Systems of classification are useful in decision-making and evaluation of outcome only if there is agreement and consistency among observers. Our study casts doubt on these aspects of the systems currently available for fractures of the distal humerus.

Interobserver and intraobserver variation in classification systems for fractures of the distal humerus

We assessed the inter- and intraobserver variation in classification systems for fractures of the distal humerus. Three orthopaedic trauma consultants, three trauma registrars and three consultant musculoskeletal radiologists independently classified 33 sets of radiographs of such fractures on two occasions, each using three separate systems. For interobserver variation, the Riseborough and Radin system produced 'moderate' agreement (kappa = 0.513), but half of the fractures were not classifiable by this system. For the complete AO system, agreement was 'fair' (kappa = 0.343), but if only AO type and group or AO type alone was used, agreement improved to 'moderate' and 'substantial', respectively (kappa = 0.52 and 0.66). Agreement for the system of Jupiter and Mehne was 'fair' (kappa = 0.295). Similar levels of intraobserver variation were found. Systems of classification are useful in decision-making and evaluation of outcome only if there is agreement and consistency among observers. Our study casts doubt on these aspects of the systems currently available for fractures of the distal humerus.

End-stage coxarthrosis and gonarthrosis. Aetiology, clinical patterns and radiological features of idiopathic osteoarthritis

OBJECTIVES

To determine and compare the aetiological background, clinical patterns and radiological features of idiopathic osteoarthritis (OA) of the hip and the knee warranting arthroplasty.

METHODS

A total of 402 Caucasians consecutively undergoing total hip replacement (THR) or total knee replacement (TKR) for idiopathic OA at a major centre was surveyed.

RESULTS

Previous joint injury was more common in the TKR group (P < 0.0001). However, both groups manifested a mixed occupational background, body mass indices similar to the general population and a predominance of females (F:M = 1.3-1.4:1). The TKR group had a significantly younger age of symptom onset (56 yr) than the THR group (61 yr) but both groups had a tendency to bilateral arthroplasty (33%), nodal involvement (54-59%), a significant excess of right-sided replacements (1.8:1, THR; 2.2:1, TKR) and similar levels of pre-operative pain and disability. Up to 40% of hips manifested acetabular dysplasia and 10% possible previous slipped upper femoral epiphyses. Eighty-five per cent with end-stage coxarthrosis or gonarthrosis had an identical pattern of radiographic disease contralaterally.

CONCLUSIONS

Our data suggest the importance of a constitutional tendency to idiopathic, end-stage OA, a disorder traditionally associated with environmental factors leading to 'wear and tear'.

Linkage analysis of chromosome 2q in osteoarthritis

BACKGROUND

In independent linkage studies chromosome 2q11-q24 and chromosome 2q23-35 have previously been implicated as regions potentially harbouring susceptibility loci for osteoarthritis (OA).

OBJECTIVE

To test chromosome 2q for linkage to idiopathic osteoarthritis.

METHODS

Using a cohort of 481 OA families that each contained at least one affected sibling pair with severe end-stage disease (ascertained by hip or knee joint replacement surgery), we conducted a linkage analysis of chromosome 2q using 16 polymorphic microsatellite markers at an average spacing of one marker every 8.5 cM.

RESULTS

Our results provide suggestive evidence for a locus at 2q31 with a maximum multipoint logarithm of the odds score (MLS) of 1.22 which increased to 2.19 in those families concordant for hip-only disease (n = 311). This suggestive linkage was greater in male-hip families (MLS = 1.57, n = 71) than in female-hip families (MLS = 0.71, n = 132).

CONCLUSIONS

Chromosome 2q is likely to contain at least one susceptibility locus for OA.

Linkage analysis of candidate genes as susceptibility loci for osteoarthritis-suggestive linkage of COL9A1 to female hip osteoarthritis

OBJECTIVE

To examine 11 candidate genes as susceptibility loci for osteoarthritis (OA).

METHODS

A total of 481 families have been ascertained in which at least two siblings have had joint replacement surgery of the hip, or knee, or hip and knee for idiopathic OA. Each candidate gene was targeted using one or more intragenic or closely linked microsatellite marker. The linkage data were analysed unstratified and following stratification by sex and by joint replaced (hip or knee).

RESULTS

The analyses revealed suggestive linkage of the type IX collagen gene COL9A1 (6q12-q13) to a subset of 132 families that contained affected females who were concordant for hip OA (female-hip) with a P-value of 0.00053 and logarithm of the odds (LOD) score of 2.33 [corrected P-value of 0. 0016, corrected LOD score of 1.85].

CONCLUSIONS

COL9A1 may therefore be a susceptibility locus for female hip OA. In addition, there was weak evidence of linkage to HLA/COL11A2 (6p21.3) in female hip OA with a corrected P-value of 0.016.

Association analysis of the vitamin D receptor gene, the type I collagen gene COL1A1, and the estrogen receptor gene in idiopathic osteoarthritis

OBJECTIVE

Evidence has accumulated supporting a role for genes in the etiology of osteoarthritis (OA). Several candidates have been targeted as potential susceptibility loci including genes that are involved in the regulation of bone density. Genetic association analysis has suggested a role for the vitamin D receptor gene (VDR) and the estrogen receptor gene (ER) in susceptibility. Such findings must be tested in additional independent cohorts. We tested for association of these 2 genes, plus a third gene implicated in bone density, COL1A1, with idiopathic OA.

METHODS

A case-control cohort of 371 affected probands and 369 unaffected spouses was used. Association was tested using 4 intragenic single nucleotide polymorphisms (SNP), one each for the VDR and COL1A1 genes, and 2 for the ER gene. The VDR and ER SNP are the same SNP that have been associated with OA. All 4 SNP affect restriction enzyme sites and were genotyped using polymerase chain reaction and enzyme digestion. Allele and genotype distributions for each SNP were compared between cases and controls and analyzed using Fisher's exact test.

RESULTS

There was no evidence of association of the VDR or the ER gene SNP to OA. There was weak evidence of association of the COL1A1 SNP in female cases (p = 0.017), reflected by a difference in the distribution of genotypes at this SNP between female cases and controls (p = 0.027). However, when corrected for multiple testing, these results were not significant.

CONCLUSION

If the VDR, ER, or COL1A1 genes do encode predisposition to OA then the 4 SNP tested are not associated with major susceptibility alleles at these 3 loci.

A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain

OBJECTIVE

To determine the clinical efficacy of sclerosing injections in patients with chronic low back pain.

METHODS

Randomized, double-blind, placebo-controlled trial of three, once weekly injections of dextrose-glycerine-phenol with lignocaine vs saline plus lignocaine in patients with mechanical back pain of more than 6 months' duration. All patient assessments were performed blind by an experienced physiotherapist. The injections to the ligaments of the L4-5 and L5-S1 lumbar motion segments were given by an orthopaedic physician experienced in the technique, blinded to the nature of the injection solution according to a standard protocol. Demographic and clinical data, the short-form McGill Pain Questionnaire, the modified Somatic Pain Questionnaire, the Zung Depression Inventory, Oswestry Disability Scale and the modified Schober method of measuring spinal flexion were undertaken at 0, 1, 3 and 6 months.

RESULTS

Seventy-four patients [mean (S.D.) age 45(11) yr, female:male ratio 1:1, median pain duration >10 yr] were recruited and there were no drop-outs over the study period. There were no statistically significant differences in patient characteristics between the placebo and treatment groups at baseline or for any measure at follow-up.

CONCLUSIONS

Three, weekly sclerosant injections alone may not be effective treatment in many patients with undifferentiated chronic back pain. Patient selection and combination with other treatment modalities may be factors in determining treatment success.

Suggestive linkage of the parathyroid receptor type 1 to osteoporosis

We have investigated the role of 23 candidate genes in the control of bone mineral density (BMD) by linkage studies in families of probands with osteoporosis (lumbar spine [LS] or femoral neck [FN] BMD T score < -2.5) and low BMD relative to an age- and gender-matched cohort (Z score < -2.0). One hundred and fifteen probands (35 male, 80 female) and 499 of their first- or second-degree relatives (223 males and 276 females) were recruited for the study. BMD was measured at the LS and FN using dual-energy X-ray absorptiometry and expressed as age- and gender-matched Z scores corrected for body mass index. The candidate genes studied were the androgen receptor, type I collagen A1 (COLIA1), COLIA2, COLIIA1, vitamin D receptor (VDR), colony-stimulating factor 1, calcium-sensing receptor, epidermal growth factor (EGF), estrogen receptor 1 (ESR1), fibrillin type 1, insulin-like growth factor 1, interleukin-1 alpha (IL-1alpha), interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-11 (IL-11), osteopontin, parathyroid hormone (PTH), PTH-related peptide, PTH receptor type 1 (PTHR1), transforming growth factor-beta 1, and tumor necrosis factors alpha and beta. Sixty-four microsatellites lying close to or within these genes were investigated for linkage with BMD. Using the program MapMaker/Sibs there was suggestive evidence of linkage between BMD and PTHR1 (maximum LOD score obtained [MLS] 2.7-3.5). Moderate evidence of linkage was also observed with EGF (MLS 1.8), COLIA1 (MLS 1.7), COLIIA1/VDR (MLS 1.7), ESR1 (MLS 1.4), IL-1alpha (MLS 1.4), IL-4 (MLS 1.2), and IL-6 (MLS 1.2). Variance components analysis using the program ACT, correcting for proband-wise ascertainment, also showed evidence of linkage (p </= 0.05) at markers close to or within the candidate genes IL-1alpha, PTHR1, IL-6, and COLIIA1/VDR. Further studies will be required to confirm these findings, to refine the location of gene responsible for the observed linkage, and to screen the candidate genes targeted at these loci for mutations.