A method used to evaluate knee osteoarthritis secondary to ligament reconstruction

Serious ligament injuries of the knee always involve early secondary arthritic lesion. Surgical reconstruction of the injured ligaments can partially prevent the degenerative process. Nonetheless, surgical trauma may, in turn, cause articular lesion. The authors suggest and discuss a new method used to evaluate knee osteoarthritis occurring after ligament reconstruction, which may be of use to an objective opinion based on long-term results. What makes this method original is that it is based on a comparison of radiographic parameters observed during examinations of the injured knee at the time of surgery and at follow-up.

Kashin-Beck disease

The article describes the history, clinical picture and anatomopathological changes of Kashin-Beck disease with reference to the stages of the disease which are at present agreed upon. Specific reference is made to the occurrence of the disease in Tibet. An overview is given of the different proposed etiologies.

How much physical activity is good for health?

Research studies over the past several decades confirm the health benefits of regular physical activity, a concept with foundations in antiquity. The effects of activity on certain individual health conditions, the precise dose of activity that is required for specific benefits, the role (if any) of intensity of effort, and the elucidation of biological pathways whereby activity contributes to health are topics for further research. Although details remain to be clarified, it is now clear that regular physical activity reduces the risk of morbidity and mortality from several chronic diseases and increases physical fitness, which leads to improved function. Table 3 outlines the relationship of activity to several diseases, a judgment on the strength of the evidence, and a rough determination of the amount of research extant. Results from clinical exercise studies and epidemiological investigations can be integrated into a consistent and coherent theory of healthful physical activity. However, some differences between these two research streams need to be reconciled. Exercise physiologists have generally recommended relatively intensive activity and a formal approach to exercise prescription. The epidemiological studies suggest a linear dose-response relationship, at least up to a point, between physical activity and health and functional effects. These data support public health recommendations directed toward the most sedentary and unfit stratum of the population and emphasize doing at least moderate physical activity. If this group of adults would accumulate 30 minutes of walking per day (or the equivalent energy expenditure in other activities), they would receive clinically significant health benefits. An important point is that it does not matter what type of physical activity is performed: Sports, planned exercise, household or yard work, or occupational tasks are all beneficial. The key factor is total energy expenditure; if that is constant, improvements in fitness and health will be comparable. There are probably 40 million adults in the US whose sedentary habits place them at considerably increased risk of morbidity and mortality from several diseases. These same individuals also are more likely to have functional limitations, especially as they move into the later years of life. The sizable independent relative risk for impaired health in sedentary persons, and the large number at risk, leads to a substantial public health burden. This problem deserves continued and increased attention by physicians and other health professionals, scientists, and the public health establishment.

Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study

OBJECTIVE

To evaluate the effect of weight loss in preventing symptomatic knee osteoarthritis in women.

DESIGN

Cohort analytic study.

SETTING

The Framingham Study, based on a sample of a defined population.

PATIENTS

Women who participated in the Framingham Knee Osteoarthritis Study (1983 to 1985): Sixty-four out of 796 women studied had recent-onset symptomatic knee osteoarthritis (knee symptoms plus radiographically confirmed osteoarthritis) were compared with women without disease.

MEASUREMENTS

Recalled date of symptom onset was used as the incident date of disease. Historical weight was defined as baseline body mass index up to 12 years before symptom onset. Change in body mass index was assessed at several intervals before the current examination. Odds ratios assessing the association between weight change and knee osteoarthritis were adjusted for age, baseline body mass index, history of previous knee injury, habitual physical activity level, occupational physical labor, smoking status, and attained education.

RESULTS

Weight change significantly affected the risk for the development of knee osteoarthritis. For example, a decrease in body mass index of 2 units or more (weight loss, approximately 5,1 kg) over the 10 years before the current examination decreased the odds for developing osteoarthritis by over 50% (odds ratio, 0.46; 95% Cl, 0.24 to 0.86; P = 0.02). Among those women with a high risk for osteoarthritis due to elevated baseline body mass index (greater than or equal to 25), weight loss also decreased the risk (for 2 units of body mass index, odds ratio, 0.41; P = 0.02). Weight gain was associated with a slightly increased risk for osteoarthritis, which was not statistically significant.

CONCLUSION

Weight loss reduces the risk for symptomatic knee osteoarthritis in women.

Inhibition of estradiol-induced early osteoarthritic changes by tamoxifen

Previous studies on osteoarthritic changes induced by intraarticular injections of estradiol benzoate (EB) suggest estrogen as a risk factor in the development of knee osteoarthritis (OA). The present study observed the anti-arthritic effects of tamoxifen (TMX). Oophorectomized rabbits were subjected to intraarticular injections of vehicle control, EB, TMX, or EB/TMX for 3 weeks. The cartilage changes were assessed by light and scanning electron microscopic examination, enzyme histochemical analysis, and the amount of alcian blue stain binding to glycosaminoglycans. EB injections resulted in cell necrosis, chondrocyte clonings, and pittings, whereas the vehicle control, TMX, and EB/TMX-injected groups showed no histologic abnormalities. Histochemical analysis showed that the numbers of lactate dehydrogenase (LDH)-reactive chondrocytes in the EB-injected group were significantly reduced when compared to other groups (p less than 0.001). The injections of EB/TMX significantly reduced the chondrocyte numbers in the lateral superficial layer (p less than 0.05), compared with the vehicle injection. TMX-injected group revealed slight although insignificant decreases in chondrocyte numbers. The amount of alcian blue stains, representing the relative amount of proteoglycans, significantly decreased only in the superficial layer of the EB- and EB/TMX-injected groups (p less than 0.05). TMX, when concurrently injected with EB, antagonized the chondrodestructive effects of estradiol at the early stage of knee OA in rabbits. The results suggest the potential therapeutic use of TMX at the early stage of OA.

Rheumatic disease in a Philippine village. II: a WHO-ILAR-APLAR COPCORD study, phases II and III

Many difficulties were encountered in a population survey of rheumatic complaints in a remote village area in the Philippines affecting the reliability of estimates of population prevalence. In phase I, a simple questionnaire identified 269 adults out of 950 who had rheumatic symptoms. In Phase II, 234 or 87% of positive respondents were requestioned using a more detailed pro forma. There were 196 with peripheral joint pain, 67 with neck pain and 137 with back pain. One third attributed their symptoms to work and 127 subjects had to stop work because of their complaints. Disability, including an inability to carry loads, affected nearly 1.8% of the population. Questions designed to detect rheumatoid arthritis and gout were not satisfactorily answered. Of those with complaints, 82% indicated that they still required help for their symptoms. In phase III, 166 subjects were medically examined. Osteoarthritis of the knee was found in 25 and 17 had Heberden's nodes. There were 16 with epicondylitis; 16 had rotator cuff pain and 35 had levator scapulae insertion pain. Three of these and three others had neck or shoulder swellings related to carrying loads on poles. Definite rheumatoid arthritis was diagnosed in two subjects and gout in five. No case of ankylosing spondylitis was identified. Thus, rheumatic complaints were common in this rural community and were frequently severe enough to cause disability and loss of time from work. Health worker education is required on how to handle these problems.

Chiari osteotomy in the adult: a long-term follow-up study

For almost 20 years the Chiari pelvic displacement osteotomy has been used as a method of providing cover to the femoral head in cases of acetabular dysplasia. The osteotomy is one of a number of procedures that have been used in an attempt to prevent the early development of secondary osteo-arthritis and the need for total hip replacement. More recently, the operation has been undertaken in cases where there is already some arthritic change. This long-term review of 18 Chiari operations shows that the procedure was successful in cases of acetabular dysplasia where there was minimal subluxation of the femoral head (i.e. with Shenton's line still intact). In more advanced cases where there was significant subluxation (i.e. with Shenton's line broken by more than 1 mm) and even early arthritic changes, the results were poor. It is concluded that the operation may be of value as an almost 'prophylactic' procedure but that it is of no value as a so-called 'salvage' procedure.

Epidemiology and genetics of osteoarthritis

Osteoarthritis is the most common of the arthropathies. Previous population-based epidemiologic studies have estimated the prevalence of osteoarthritis by age, gender, race, and site in many populations. Cross-sectional and retrospective data from these prevalence surveys have been analyzed to identify possible risk factors for the development of osteoarthritis at specific sites. Data from prospective population-based epidemiologic studies including the Framingham Osteoarthritis Study, the Tecumseh Community Health Study, the National Health and Nutrition Examination Survey I Epidemiologic Followup Study, and the Baltimore Longitudinal Study of Aging are being analyzed to estimate the incidence of osteoarthritis by age, gender, and site, and the prognosis of subjects with osteoarthritis at specific sites in terms of morbidity and mortality, as well as to confirm the association of risk factors with the development and progression of osteoarthritis by site. Additionally, the application of techniques of molecular biology to the study of the genetics of familial osteoarthritis has identified hereditary defects in type II collagen that appear to predispose to the early development of osteoarthritis in affected family members. Results of these studies highlight opportunities for the primary and secondary prevention of osteoarthritis.

Effect of sodium hyaluronate on prevention of osteoarthritis

The changes in the surface of articular cartilage of femoral condyle from rabbits were evaluated after degenerative changes were made by the technique advocated by Hulth. The medial collateral and both cruciate ligaments were excised, and a medial menisectomy was done. Then the right knee joint was injected with 1 ml of Na-hyaluronate gel every two weeks. The animals were sacrificed at two, four, six, eight, or sixteen weeks postoperatively. After sacrifice, the medial femoral condyle was excised and prepared for the light microscopic and scanning electron microscopic study. At eight to sixteen weeks, there were chondrocyte clones with clefts to the radial zone and increased loss of the height of articular cartilage on the control side; but, on the experimental side there was a significant delay and lessening of the arthritic response. The biocompatibility and the protective effect of joint degeneration of this device make this material a valuable adjuvant in the treatment of osteoarthritis and the traumatized joints.

Amelioration of lapine osteoarthritis by treatment with glycosaminoglycan-peptide association complex (Rumalon)

The chondroprotective potential of glycosaminoglycan-peptide association complex (GP-C) was examined in the medial meniscectomy model of lapine osteoarthritis (OA). Prophylactic treatment with increasing doses of intramuscular GP-C (0.05-0.5 ml/kg) caused a significant reduction in OA lesion area and histologic scores, and the effect on disease activity appeared to be dose related. The DNA and uronic acid contents of OA tissue were unaffected by prophylactic treatment with GP-C. However, levels of hydroxyproline in OA cartilage increased to near control levels with prophylactic treatment. Cartilage levels of active and total metalloproteinases that digest proteoglycans were elevated in rabbits with OA; prophylactic treatment with low-dose GP-C (0.05 ml/kg) produced a significant reduction in active, but not total, enzyme. Cartilage levels of tissue inhibitor of metalloproteinases in animals with OA were comparable with control levels, but rose with increasing doses of GP-C. We also investigated GP-C as a therapeutic treatment in animals that had already developed OA lesions. Carbon black retention and histologic score returned to near-normal after therapeutic treatment with GP-C. Uronic acid and hydroxyproline levels were decreased in OA cartilage. Therapeutic treatment with GP-C had no statistically significant effect on uronic acid levels, but was associated with increased hydroxyproline content in the cartilage. The changes in metalloproteinase and metalloproteinase inhibitor were similar to those found in the studies of prophylactic treatment. The findings in this animal model may help explain some of the beneficial effects of GP-C in human OA.

In vivo protective effects of prophylactic treatment with tiaprofenic acid or intraarticular corticosteroids on osteoarthritic lesions in the experimental dog model

We examined the in vivo effects of prophylactic intraarticular corticosteroid injections and nonsteroidal antiinflammatory drugs (NSAID) (tiaprofenic acid) oral administration on cartilage lesions of osteoarthritis (OA) and osteophyte formation in 18 dogs in which the anterior cruciate ligament had been sectioned. Six of the dogs received no treatment; 5 had 3 injections of 5 mg triamcinolone hexacetonide at 0, 4 and 8 weeks postsurgery; and 7 were treated orally with 5 mg/kg/day tiaprofenic acid. The untreated dogs developed cartilage lesions on the tibial plateaus and femoral condyles with prominent osteophytes on both lateral and medial condyles. The number and size of the osteophytes were significantly reduced in the triamcinolone treated dogs (p less than 0.0001). Moreover, both triamcinolone and tiaprofenic acid treated groups showed a decrease in the grade and size of tibial plateau lesions, compared to the untreated dogs. There was a similar and statistically significant decrease in lesion size when the treated dogs (about 50 mm2) were compared to the untreated dogs (77 mm2). Histological studies revealed that both drugs also significantly decreased the severity of OA structural changes of the cartilage on both femoral condyles and tibial plateaus, although the response to triamcinolone was more pronounced. Our data confirm the effectiveness of prophylactic treatment with corticosteroids and tiaprofenic acid in preventing the progression of OA lesions in the dog model.

Is osteoarthritis a preventable disease?

Since most of the pathophysiological steps of the initiation of osteoarthritis are not understood, its prevention can only mean decreasing or abolishing its risk factors. Excess mechanical stresses certainly can be minimized by correcting developmental or acquired anatomical or functional defects, probably by decreasing occupational or sports hazards and perhaps by avoiding overweight. Effective control of chondrolytic/inflammatory episodes is a promising prospect. Opposing the effects of age remains a remote expectation.

Recent advances in animal models for evaluating chondroprotective drugs

While a variety of animal models have been described to evaluate the effects of antiarthritic and chondroprotective drugs on cartilage metabolism, most cannot be said to truly reproduce the temporal changes that occur in human osteoarthritis (OA). Total meniscectomy is a common orthopedic procedure in humans and frequently leads to OA in later years. We investigated the effects of unilateral medial meniscectomy in sheep knee joints subjected to moderate regular exercise. Morphological and biochemical studies of joint cartilage after 6 months revealed slowly progressive changes similar to those seen in early OA, characterized by cartilage fibrillation, chondrocyte hypertrophy, matrix proliferation and marginal osteophyte formation. The proteoglycans synthesized contained more chondroitin-4-sulphate than chondroitin-6-sulfate.

Epidemiology of osteoarthritis: current concepts and new insights

Osteoarthritis (OA) is the most common of the arthropathies. Previous epidemiologic studies have described the prevalence of OA by age, gender and site in many populations. Cross sectional and retrospective data from these prevalence surveys have been analyzed to identify possible risk factors for the development of OA. Data from prospective epidemiologic studies including the Framingham Study, Tecumseh Community Health Study, and the Baltimore Longitudinal Study of Aging are being analyzed to estimate the incidence of OA by age, gender and site, and confirm the association of risk factors with the development and progression of OA. Results of these studies provide potential opportunities for the primary and secondary prevention of OA.

Prevention in orthopedics

Cogent data indicate a continuous increase in the incidence of orthopedic disease and trauma. Primary and secondary preventive measures should, when applicable, be recommended by the orthopedic profession to decision makers in the community, and should be reinforced by the health care programs.

[Objectives to be assigned to the various proposed treatments (NSAID, analgesics, preventive or curative fundamental treatments). Which type of patients for which type of clinical trials]

Short term symptomatic treatment concerns, above all, painful, active osteoarthritis. Long term treatment prevents or slows down the destruction of cartilage and is assessed by radiological measurement of the joint space in the hip and knee. This must also be combined with a clinical criterion based on a functional pain index and the quality of the patient's life. Interphalangeal osteoarthritis, excluding root arthrosis of the thumb, is a good model and the preventive effect of treatment can be assessed from the extension of interphalangeal involvement. In the lower limbs, osteoarthritis of the hip in its idiopathic form (with overall superior or supra-external narrowing) and minor dysplasias were selected. Internal femorotibial osteoarthritis is suitable for evaluating a drug's effect in protecting cartilage. Other varieties are reserved for symptomatic treatments.

[Pharmacologic studies on the antidegenerative effect of ademetionine in experimental arthritis in animals]

A standardized pharmacological model of biochemically induced osteoarthritis in the knee joint of laboratory animals was used for the study of a possible antidegenerative effect of ademetionine (S-adenosyl-methionine, active substance of Gumbaral) in-vivo. Four days after the initial induction of osteoarthritis by 2 intraarticular injections of 0.6 mg sodium iodoacetate into the left knee joint of adult hens, the therapy started with once-weekly intraarticular doses of 0.5 mg, 1.0 mg and 2.0 mg ademetionine over a period of 14 weeks. Quantitative monitoring of the intensity and progression of osteoarthritis was performed every 2 weeks by joint space measurements, topographic-radiological evaluations, and by a macroscopic post-mortem assessment of the joint cartilage and bone. These objective analytical parameters clearly demonstrated that weekly intraarticular doses of 1.0 mg ademetionine significantly reduced the intensity of degenerative processes compared to the placebo (saline) treated joints. The antidegenerative effect of doses of 0.5 mg or 2.0 mg ademetionine were less pronounced and of no statistical significance. Our findings indicate an interesting therapeutic potency of ademetionine in experimental osteoarthritis and confirm the positive clinical observations as well as in-vitro results with this new drug by other researchers.

Experimental osteoarthritis in guinea-pigs

Cartilage degeneration was induced in the hind knees of guinea-pigs by surgery. Partial medial meniscectomy induced rapidly progressing lesions whereas the lesions induced by section of the lateral collateral ligament with or without section of the medial collateral ligament developed later and progressed more slowly. In all cases the lesions were first seen focally on the medial tibial plateau where they extended both laterally and deeper into the cartilage. Later, lesions appeared on the medial femoral condyle and meniscus, and eventually also on cartilage in the lateral joint compartment. During the later stages, these models had many features of human osteoarthritis. The appearance and progression of spontaneous lesions in the hyaline cartilage of the hind knees of young guinea-pigs first reported by Bendele and Hulman (1988) has been confirmed. Extra ascorbic acid added to the drinking water had a slight chondroprotective effect on the development of spontaneous lesions but gave no significant protection against the development of lesions induced by lateral collateral ligament section.

Evidence for the involvement of interleukin 1 in human osteoarthritic cartilage degradation: protective effect of NSAID

Our study demonstrates for the first time the presence, in situ, of interleukin 1 (IL-1) in human osteoarthritic (OA) synovium as well as in cartilage. In vitro IL-1 was found to significantly increase the catabolism of proteoglycan macromolecules and to stimulate the metalloprotease activity in human OA cartilage explants. Tiaprofenic acid, a nonsteroidal antiinflammatory drug belonging to the propionic acid class, reduced both the proteoglycan catabolism (26 micrograms/ml, 6.3 +/- 1.4%; 2.6 micrograms/ml, 7.1 +/- 1.4%) and metalloprotease activity (26 micrograms/ml, 1.1 +/- 0.3 units/mg wet weight; 2.6 micrograms/ml, 1.1 +/- 0.2 units/mg wet weight) induced by IL-1 (10.2 +/- 2.3%; 1.7 +/- 0.4 units/mg wet weight). The effect of tiaprofenic acid was reversed by a pharmacological dose of either PGE2 or dibutyryl cAMP.

[Meniscus plasty of the discoid cartilage of the knee joint. Report of 32 cases]

During the time period from 1982 to 1987, 32 patients, 17 females and 15 males, aging 14 to 47, had their lateral discoid menisci reshaped operatively into nearly normal configuration. Final results of the treatment were both subjectively and objectively satisfactory confirmed at the time of re-examinations, 3 to 48 months (25 pts. had been over one year) after operation. Reshaping the discoid meniscus not only brought about normal pattern of it, got rid of symptoms and signs caused by the discoid meniscus-itself, but also by eliminating the horizontal shearing force produced by non-physiological motion of the discoid meniscus, reasonably prevent, at least delay the development of osteoarthritis of that joint.

[Methods of evaluating chondroprotective treatment]

A chondroprotective therapy is a basic treatment of osteo-arthritis aimed at stopping pathological processes involved in articular cartilage degradation. Assessing the clinical benefit of such treatment is difficult, as it is related to individual characteristics (primary or secondary osteo-arthritis, anatomical location and/or evolutive stage), to the duration of treatment and to the efficacy criteria utilized. Whether this assessment can be made in a single patient or requires studies of patient populations is debated.

[A program of prevention of dysplastic arthrosis (general principles)]

The authors put forward a program of prevention of dysplastic arthrosis which is presented in graphic form with textual description. It has been worked out on the basis of the formerly elaborated conceptual model "Dysplasia of the joint-dysplastic arthrosis" and it is a complex of general medical prophylactic measures oriented towards the elimination of mutagenous environmental factors, i.e. towards prevention of morbidity and towards the treatment-and-rehabilitation orthopaedic measures directed at reduction of the risk of development of dysplastic arthrosis in the conditions of dysplastic lesion of the joint (prevention of the disease). The conditions necessary for carrying out this program are supposed to be: a diagnostic algorithm providing for revealing dysplastic lesions already at the preclinical stage; thorough quantitative and qualitative characteristics of the dysplastic process providing for planning of correct surgical interventions; prognostic evaluations presuming a probability of evolution of the dysplastic process and its outcome; and a system of stage-by-stage diagnostic and treatment-and-rehabilitation measures providing for achievement of the effect expected in each particular case. Three groups of surgical interventions have been pointed out: prophylactic, which are performed on the dysplastic joint in case of absence of dystrophic changes; therapeutic, which are performed in case of presence of reversible dystrophic changes (e.g. chondromalation at stages I and II); and palliative, which only result in temporary stabilization of the arthrosis process, i.e. leading to improvement.

Does smoking protect against osteoarthritis?

While studying knee osteoarthritis (OA) in the first Health and Nutrition Examination Survey, we unexpectedly found a protective association between smoking and OA. After adjustment for age, sex, and weight, smokers had a significantly lower rate of OA than did nonsmokers, and heavier smokers were less likely to have the disease than were light smokers. To test this association in a separate study and see if it was due to confounding factors, we looked at the Framingham Osteoarthritis Study, a study of elderly members of the Framingham Heart Study cohort. We evaluated whether the presence of knee OA in 1983-1985 was related to smoking status at the first Framingham examination, 36 years earlier. Subjects who had been smokers at examination 1 had a lower rate of OA (190 of 679, 28%) than did nonsmokers (276 of 736, 37.5%). In an analysis adjusted for age, sex, and weight, heavy smokers had a modestly lower risk of developing knee OA than did nonsmokers (relative risk 0.81). Also, the adjusted risk of severe OA was less in heavy smokers than in nonsmokers (relative risk 0.73). The negative association with OA persisted when we examined the average cigarette consumption over the first 10 years of the Framingham study. Furthermore, after controlling for age, sex, weight, knee injury history, sports activity history, physical activity level, coffee and alcohol consumption, and weight change after examination 1, and after modeling weight and age in a nonlinear manner, smoking remained a significant protector against later knee OA. It appears that smoking or some unidentified factor correlated with smoking modestly protects against the development of knee OA.

The beneficial outcomes of the arthritis self-management course are not adequately explained by behavior change

Evaluation of the Arthritis Self-Management Course revealed significant positive changes in the practice of behaviors that were taught and in health outcomes. However, utilizing a variety of statistical techniques, we were able to demonstrate only weak associations between changes in behavior and changes in health status. This suggests the need to examine the mechanisms by which health education affects health status.

Preventive aspects of mobility and functional disability

Among bone and joint diseases, frequent causes of disability include (a) fractures from falls and osteoporosis, (b) osteoarthritis of hips, knees, and lumbar spine, (c) painful feet, (d) back pain, and (e) intractable rheumatoid arthritis. Risk factors for falling may arise from factors intrinsic to the patient and from hazards in the environment. The prevention and management of osteoporosis are controversial. Most experts endorse the use of estrogens in postmenopausal women and the need for continuing physical activity, particularly walking, in both elderly men and women. To preserve independent living, conservative management of osteoarthritis of hip, knee, and low back consists of properly balancing rest, non-weight-bearing exercises, and the use of walking aids. In rheumatoid arthritis, the clinician should emphasize (a) exercises to maintain range of motion and (b) muscle strength, both to prevent flexion contractures and to maintain the ability to carry on activities of daily living.

Early functional treatment of supination-eversion stage-II ankle fractures: preliminary results

The preliminary results of early functional treatment of 30 patients with a grade-II supination-eversion fracture of the ankle according to Lauge-Hansen are discussed. The treatment of all patients consisted of splint immobilization for one week, followed by the application of a functional brace (Push Brace Medium) and immediate full weight bearing and functional training. All fractures healed without complications. Ankle function, radiographic findings and anamnestic complaints were monitored. The loss of ankle function diminished to 3.2 degrees +/- 4.9 degrees plantar flexion and to 1.7 degrees +/- 5.3 degrees dorsal flexion after one year follow up, none of the patients had significant complaints of pain or swelling. Radiography showed consolidation with callus formation in all cases. The grade-II supination-eversion fracture is a stable fracture which allows early functional treatment with the support of a Push Brace Medium. This results in an inexpensive, simple and comfortable therapy. A prospective randomized clinical trial is necessary to show the advantages of functional treatment over cast immobilization. Long-term follow-up will have to ascertain the theoretic risk of posttraumatic osteo-arthritis.

Glutaraldehyde-cross-linked meniscal allografts: clinical, gross, and histological results

Osteoarthritic changes in the knee are often a late result of total meniscectomy. In cases of total resection, availability of a prosthetic meniscus might limit development of these changes. The objective of this research was to evaluate a glutaraldehyde-cross-linked medial meniscus as a morphologically and biologically compatible prosthesis in a canine model. Medial and lateral menisci were harvested from donor dogs, frozen in saline, and cross-linked with glutaraldehyde. Five host animals were selected and matched with donors. Glutaraldehyde-cross-linked medial menisci were implanted bilaterally in the stifle joints and one glutaraldehyde cross-linked lateral meniscus was implanted subcutaneously. Clinical results showed asymptomatic limb and joint usage during the 12 postoperative weeks. Gross and histological evaluations indicated acceptable biocompatibility. The subcutaneous implants were encapsulated with a thin fibrous tissue capsule that was only mildly inflamed. Within the joints, the anterior attachment and periphery were maintained in position by their sutures; however, there was dehiscence of the posterior suture in all cases. The articulating surfaces of the implants were intact. There was an initial loss in the quantity of proteoglycans following glutaraldehyde treatment, with significant recovery after implantation into the joints. There were significant degenerative changes (loss of proteoglycans and fibrillation) in the articular cartilage on the femoral condyle and tibial plateau most likely a result of the posterior attachment failure. It was concluded that glutaraldehyde-cross-linked meniscal allografts showed an acceptable degree of histocompatibility. However, failure of the posterior attachment interfered with testing the efficacy of the prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Quantitative study of experimental osteoarthritic lesions in the rabbit. Value for the study of anti-osteoarthritis drugs]

Section of the anterior cruciate ligament of the right knee was performed in 20 rabbits which were sacrificed 3 months later. During that time, 10 animals were treated with a proteino-polysaccharide compound. The importance of cartilage destruction was evaluated by measuring the articular surfaces and the surface of the fissured areas using an automatic image analyzer; osteophytes were measured by a volumetric study. The percentage of the fissured areas appears to be without correlation with the osteophytosis, the increase of the water content or the decrease of glycosaminoglycans following the procedure. In animals which were treated, the extent of the fissure is significantly reduced but the biochemical and histometric modifications are not too different from those of the reference group.

The effect of glycosaminoglycan polysulfuric acid ester on articular cartilage in experimental osteoarthritis: effects on morphological variables of disease severity

The effects of the semisynthetic glycosaminoglycan polysulfuric acid ester on the development of osteoarthritis (OA) in a meniscectomy model in rabbits were investigated. Prophylactic treatment by both an intramuscular and intraarticular regimen for 11 weeks after meniscectomy caused amelioration or total prevention of erosions evaluated by gross and histologic variables. Treatment for 4 to 8 weeks of erosions (already developed in animals 12 weeks after operation) also caused amelioration of erosions. Controls included animals with OA treated with saline injection. Knees from age matched normal controls for each of the experimental groups were studied in the same manner. It is concluded that glycosaminoglycan polysulfuric acid ester retarded development of erosions and influenced favorably the histological severity of lesions already formed in this experimental model of OA.

Triamcinolone hexacetonide protects against fibrillation and osteophyte formation following chemically induced articular cartilage damage

Although corticosteroids have been shown to cause articular cartilage degeneration, recent studies of experimentally induced osteoarthritis indicate that under certain conditions they may protect against cartilage damage and osteophyte formation. The present study examines the in vivo effect of triamcinolone hexacetonide on the degeneration of articular cartilage which occurs following intraarticular injection of sodium iodoacetate. Three weeks after a single injection of iodoacetate into the knees of guinea pigs, ipsilateral femoral condylar cartilage exhibited fibrillation, loss of staining with Safranin O, depletion of chondrocytes, and prominent osteophytes. In striking contrast, when triamcinolone hexacetonide was injected into the ipsilateral knee 24 hours after the intraarticular injection of iodoacetate, fibrillation was noted in only 1 of 6 samples, osteophytes were much less prominent, pericellular staining with Safranin O persisted, and cell loss was less extensive. Knees of animals which received only one-tenth as much intraarticular triamcinolone hexacetonide after the iodoacetate injection also exhibited marked reduction in size and extent of osteophytes. However, the degree of fibrillation, loss of Safranin O staining, and chondrocyte depletion was similar to that observed in animals injected with iodoacetate but not treated with intraarticular steroid. No apparent morphologic or histochemical changes were observed after intraarticular injection of the steroid preparation alone. Thus, triamcinolone hexacetonide produced a marked, dose-dependent protective effect in this model of chemically induced articular cartilage damage.

The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions

A framework for organizing health services data is presented that subdivides the spectrum of health information into subgroups that constitute a logical progression from quantifying the burden of illness, through identifying its likely causes, to validating interventions that prevent or ameliorate it and evaluating their efficiency, to monitoring the application of these interventions and coming full-circle to determine whether the burden of illness has been reduced.

Rotational acetabular osteotomy for the dysplastic hip

A circumacetabular osteotomy of the acetabulum was initially done at the University of Tokyo Hospital by one of us (H. T.) in 1968. This procedure, which rotates the acetabulum, was designed to correct a dysplastic acetabulum in adolescents and adults. The surgical exposure combines both an anterior and a posterior approach. Between 1974 and 1982 this operation was performed on 103 patients (120 hips) with acetabular dysplasia, some showing early degenerative arthritis. The forty-five hips (forty-one patients) that form the basis of this report were followed for three years to eight years and ten months (average, four years and six months). Thirty hips showed only acetabular dysplasia, and fifteen were in the early stage of degenerative arthritis. The ages of the patients at the time of operation ranged from eleven to forty-two years, the majority being in the second or third decade of life. All of the forty-five hips had a preoperative center-edge angle of 10 degrees or less, but most of them had a nearly normal value after surgery. In the majority of the hips either limp or pain with exertion, or both, had disappeared, and a satisfactory range of motion had been restored.

Immobilization ameliorates chemically-induced articular cartilage damage

We have previously shown that immobilization protects against the development of mechanically-induced osteoarthritis following-anterior cruciate ligament transection in dogs. Herein, we examine the effect of immobilization of the leg on the chemically-induced degeneration of femoral articular cartilage caused by intraarticular injection of iodoacetate in guinea pigs. One week after the injection, cartilage from animals which were not immobilized exhibited a decrease in Safranin O staining and a 10-20% reduction in the number of chondrocytes. Three weeks after injection, cell death and loss of Safranin O staining had progressed, and surface fibrillation and osteophytes had developed. Articular cartilage from the contralateral (uninjected) knees of guinea pigs which received iodoacetate, and from knees of animals which were immobilized for 1 week but did not receive iodoacetate, was histologically and histochemically normal. However, specimens from 2 of 4 untreated knees which were immobilized for 3 weeks showed a reduction in Safranin O staining. Immobilization of the knee did not alter the loss of Safranin O staining seen after intraarticular iodoacetate injection, but did reduce the depletion of chondrocytes (P less than 0.05). Furthermore, neither osteophytes nor fibrillation developed in any of the animals which were constrained after iodoacetate injection. Thus, immobilization was clearly protective in this model of chemically-induced cartilage injury.

Innominate osteotomy in the management of residual congenital subluxation of the hip in young adults

The application of innominate osteotomy (IO) to persistent subluxation of the hip in adults is limited. Indeed, a relatively small percentage of such adults, particularly those in the fourth and fifth decades of life, meet the precise indications and essential prerequisites for IO. Nevertheless, in most carefully selected young adults in up to and including the fifth decade of life, IO has proved successful. The objective of IO is to prevent degenerative processes in adults with only potential arthritis, seeking arrest or even reversal of the progression of degenerative disease. IO is applicable only to adults who have arthritis in its earliest stages. Achievement of these objectives is dependent on adherence to the exact indications, prerequisites, and contraindications as well as to the details of the surgical technique as described.

Meniscal function and the importance of meniscal regeneration in preventing late medical compartment osteoarthrosis

The medial meniscus was totally removed in 22 patients who were followed up for more than ten years. Preservation of the meniscal rims enhances regeneration. There was no evidence of medial compartment damage in 91% of the patients by arthroscopic examination at ten years' follow-up examination. This finding suggests that meniscal rim regeneration can protect the joint from osteoarthrotic changes. Late medial compartment osteoarthrosis following medial meniscectomy in an otherwise normal knee is probably avoidable if surgical and postoperative treatment are designed to enhance regeneration of the meniscal rim.

Immobilization of the knee prevents osteoarthritis after anterior cruciate ligament transection

The effect of immobilization of the knee in flexion on the development of osteoarthritis was studied in dogs that had undergone transection of the anterior cruciate ligament. Knees of dogs that were permitted ad libitum ambulation in a pen for 12 weeks after transection of the ligament showed osteophytes and fibrillation and a decrease in proteoglycan (uronic acid) content, although thickness of the articular cartilage was normal. Proteoglycan synthesis was 80% greater (P less than 0.01) than that in cartilage from the contralateral knee, and more than twice the normal proportion of the total proteoglycans was present in the medium of cultures of cartilage from the unstable knee (P less than 0.01). Similarly, the proportion of total tissue proteoglycans extracted with 0.4M guanidinium chloride was 3 times greater than normal (P less than 0.01). In contrast, osteophytes were not seen when the leg was immobilized in flexion immediately after transection of the ligament, and the articular surface remained intact. The cartilage became atrophic, however, and its proteoglycan content (uronic acid) was diminished; proteoglycan synthesis was decreased to 61% of the level in cartilage from the contralateral knee, although proteoglycan extractability was normal. Knee cartilage from these legs that were immobilized after transection, therefore, resembled that from dogs whose leg had been immobilized without cruciate ligament transection. In cartilage from all operated and/or immobilized joints the proportion of proteoglycans that interacted with hyaluronic acid in vitro was diminished, because of a defect in the hyaluronate-binding region of the proteoglycan.

Royal College Lecture, prevention of arthritis through preservation of cartilage

In the face of current enthusiasm for total replacement of joints, we must not forget that much degenerative arthritis is preventable. Three causes of iatrogenic damage to articular cartilage are pressure necrosis, obliterative degeneration and drug-induced degeneration. Our experiments with continuous passive motion have shown striking beneficial effects on the healing and regeneration of cartilage. We are beginning to test this clinically at knee, elbow and finger joints with encouraging results.