Articular mobility in an African population

No significant links between somatognosia, stereognosia, and hypermobility: sensory processing unlikely to drive common complaints in hypermobile population

BACKGROUND

Previous research has demonstrated impaired proprioception and poorer responses to tactile deep pressure, visual-tactile integration, and vestibular stimuli in individuals with generalized hypermobility, potentially leading to sensory processing issues. Therefore, we aimed to explore the influence of hypermobility on somatognosia and stereognosia.

METHODS

Forty-six participants were assessed using the Beighton score and categorized into three groups: non-hypermobile (n = 20), symptomatic hypermobile (n = 13), and asymptomatic hypermobile (n = 13). Somatognosia was evaluated using the shoulder width test in the vertical plane and pelvic width test in the vertical and horizontal planes. Stereognosia was assessed with Petrie's test. Spearman's rank correlation coefficient was examined the relationship between the Beighton score and measures of somatognosia and stereognosia. An unpaired t-test was used to compare variables between hypermobile (both symptomatic and asymptomatic) and non-hypermobile individuals, while a one-way ANOVA was used to compare data between the three groups.

RESULTS

No significant relationship was observed between Beighton scores and measures of somatognosia and stereognosia. The t-test revealed no statistically significant differences between hypermobile and non-hypermobile groups in the shoulder width, two pelvic widths, and Petrie's tests (all p ≥ 0.105). Similarly, one-way ANOVA showed no statistically significant differences between the three groups across these tests (all p ≥ 0.177).

CONCLUSIONS

The results indicate that somatognosia and stereognosia are not significantly related to the Beighton score and do not significantly differ between the groups studied. These sensory processing functions are unlikely to contribute to the common complaints reported by hypermobile individuals.

CLINICAL TRIAL NUMBER

Not applicable.

Autism in the context of joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes: A systematic review and prevalence meta-analyses

Increasing research suggests a link between autism spectrum disorders and joint hypermobility, hypermobility spectrum disorders, and Ehlers-Danlos syndromes. However, no study systematically examined the available literature about the relationship between these conditions. A systematic literature search was conducted to identify studies (a) examining the link between autism, joint hypermobility, hypermobility spectrum disorders or Ehlers-Danlos syndrome, and (b) reporting the frequency of autism spectrum disorders in people with joint hypermobility, hypermobility spectrum disorders or Ehlers-Danlos syndrome, or vice versa. Prevalence meta-analyses were performed. Twenty articles met the inclusion criteria. Twelve studies explored joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome in autistic people. Six explored autism spectrum disorders/autistic traits in people with hypermobility spectrum disorders/Ehlers-Danlos syndrome. Two studies examined autism spectrum disorders in relatives of patients with hypermobility spectrum disorders/Ehlers-Danlos syndrome, and two explored autistic traits and joint hypermobility in non-clinical samples. Out of 15 studies examining the association between autism spectrum disorders/autistic traits and joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome, 12 reported significant results. The overall prevalence of joint hypermobility in autistic individuals was 22.3%, but it was higher (31%) when only studies assessing joint hypermobility clinically (excluding self-reports) were considered. The overall prevalence of hypermobility spectrum disorders/Ehlers-Danlos syndrome in autistic samples was 27.9%, but 39% if hypermobility spectrum disorders/Ehlers-Danlos syndrome were assessed clinically. Despite the heterogeneity of studies, these results suggest an association between autism and joint hypermobility/hypermobility spectrum disorders/Ehlers-Danlos syndrome that should be confirmed in further research.Lay abstractIncreasing research suggests a link between autism spectrum disorders (ASD) and joint hypermobility (JH), hypermobility spectrum disorders (HSD), and Ehlers-Danlos syndromes (EDS). However, no study systematically examined the available literature about the relationship between these conditions. To fill this gap, we conducted a systematic literature search to identify studies: (a) examining the link between autism, JH, HSD, or EDS, and (b) reporting the frequency of ASD in people with JH, HSD, or EDS, or vice versa. Prevalence meta-analyses were performed. Twenty articles met the inclusion criteria. Twelve studies explored JH/HSD/EDS in autistic people. Six explored ASD/autistic traits in people with HSD/EDS. Two studies examined ASD in relatives of patients with HSD/EDS, and two explored autistic traits and JH in non-clinical samples. Out of 15 studies examining the association between ASD/autistic traits and JH/HSD/EDS, 12 reported significant results. The overall prevalence of JH in autistic individuals was 22.3%, but it was higher (31%) when only studies assessing JH clinically (excluding self-reports) were considered. The overall prevalence of HSD/EDS in autistic samples was 27.9%, but 39% if HSD/EDS were assessed clinically. Despite the heterogeneity of studies, these results suggest an association between autism and JH/HSD/EDS that should be confirmed in further research.

Managing hypermobility spectrum disorder in a psychiatric setting

This case highlights the intersection of psychiatric symptoms and hypermobility spectrum disorder (HSD) in a woman in her 20s with multiple comorbidities, including postural orthostatic tachycardia syndrome, chronic pain and obstructive sleep apnoea. The patient had been unresponsive to conventional psychiatric treatments for anxiety and panic attacks. On recognition of HSD, a multidisciplinary approach, including propranolol for autonomic dysfunction, pregabalin for pain and anxiety, and lisdexamfetamine for cognitive impairment, significantly improved her condition. Early identification and tailored management of HSD in psychiatric settings can optimise treatment outcomes by addressing both physical and psychiatric symptoms. This case underscores the need for psychiatrists to incorporate physical health assessments into their diagnostic processes when treating complex psychiatric presentations.

Age not a primary risk factor for ACL injury-A comprehensive review of ACL injury and reinjury risk factors confounded by young patient age

Revision surgery after anterior cruciate ligament reconstruction (ACL-R) is hypothesized to be the result of an interplay between factors associated with the anatomy, physiological characteristics and environment of the patient. The multifactorial nature of revision ACL-R risk is difficult to quantify, and evidence regarding the independent roles of potentially important variables is inconsistent throughout the literature. Young patient age is often cited as one of the most prominent risk factors for reinjury after ACL-R. However, the association between a non-modifiable variable such as patient age and revision ACL-R risk is likely to be a spurious correlation due to the confounding effect of more important variables. From the perspective of healthcare professionals aiming to mitigate revision ACL-R risk through targeted interventions, awareness of factors like generalized joint hypermobility, bone morphology, muscle strength imbalances, and genetic factors is critical for the individualized risk assessment of patients with ACL injury. The aim of this current concepts article is to raise awareness of the essential anatomical, physiological, and activity-related risk factors associated with ACL injury and reinjury risk that are likely captured and confounded by patient age. LEVEL OF EVIDENCE: Level V.

Effect of testosterone treatment during puberty in boys with Klinefelter syndrome (The TIPY Study): protocol for a nationwide randomised, double-blinded, placebo-controlled study

INTRODUCTION

Klinefelter syndrome (KS) is a genetic condition characterised by the presence of an extra X chromosome in males (47,XXY). KS is associated with various phenotypic characteristics in adult life, including infertility, hypogonadism and increased risk of type II diabetes, cardiovascular disease and osteoporosis. Additionally, individuals with KS often experience mental health challenges and functional impairments that significantly impact their quality of life. Currently, testosterone replacement therapy (TRT) in adolescence is considered the first-line treatment by some physicians for patients with KS and biochemical signs of hypogonadism. However, comprehensive evidence on its effectiveness in preventing typical phenotypic traits associated with KS remains limited, and, currently, no evidence-based recommendations for TRT in this population exist. We therefore aim to evaluate the effects of two years of TRT during puberty in boys with KS. The primary endpoint is to monitor changes in body fat percentage. Secondary endpoints include changes in pubertal development and virilisation, growth and body proportions, bone mineralisation, muscle strength, lipid and glucose metabolism, systemic inflammation, methylation, fertility and effects on the cognitive and psychopathological features of KS.

METHODS AND ANALYSIS

The TIPY study is a multicentre, national, randomised, double-blind, placebo-controlled intervention study. Participants will be recruited from four tertiary paediatric endocrine units in Denmark that manage boys with KS. Participants will be randomised to treatment with transdermal placebo or transdermal testosterone (Androgel; Besins Healthcare, Paris, France) with dose titration every 3 months based on individual measurements of serum concentrations of testosterone. Dose titration will be conducted by a single physician to ensure free testosterone remains between +1 and +3 SD for age.Thorough clinical and biochemical evaluation will be performed at baseline, after 12 months and 24 months. Additional visits for minor evaluations will occur every 3 months. Neuropsychological assessment will be conducted at baseline and after 24 months of treatment.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Helsinki Declaration. The study has been approved by the Danish National Medical Research Ethics Committee and the Danish Medicines Agency (Clinical trials information system number 2023-505854-16-00). Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT06294990.

Does total hip arthroplasty benefit patients with minimal radiological osteoarthritis?

Aims

The effectiveness of total hip arthroplasty (THA) for patients with no or minimal radiological signs of osteoarthritis (OA) is unclear. In this study, we aimed to: 1) assess the outcome of such patients; 2) identify patient comorbidities and CT or MRI findings which predicted outcome; and 3) compare their outcome to the expected outcome of THA for hip OA.

Methods

Adult patients undergoing THA for hip pain, with no or minimal radiological features of OA (Tönnis grading scale ≤ 1), were identified from a consecutive series of 1,925 THAs. Exclusion criteria were: inflammatory arthritis; osteonecrosis of the femoral head; prior trauma or infection; and patients without minimum one-year follow-up and patient-reported outcome measures (PROMs). The primary outcome measure was the Oxford Hip Score (OHS). Secondary outcome measures were EuroQol-visual analogue scale (EQ-VAS), University of California and Los Angeles (UCLA) scale, and patient satisfaction on a validated three-point 'better', 'same', or 'worse' scale.

Results

A total of 107 patients with a median age of 41 years (IQR 18 to 73) were included, with mean follow-up of 6.0 years (SD 3.1). All patients underwent a diagnostic hip injection as a decision aid. Median postoperative OHS was 34 (IQR 28 to 42), with 36 patients (33%) achieving a patient-acceptable symptom state (OHS ≥ 42), lower than THA patients in international registries (40 to 43 points). Secondary outcomes were UCLA of 6 (4 to 8) and EQ-VAS of 73 (51 to 80); 91/102 patients (89%) felt 'better' and would 'undergo surgery again'. Patients with chronic pain syndrome or hypermobility had lower OHS than patients without comorbidities (-6 points, p < 0.006). Overall, 84 patients had a CT and 34 patients an MRI. Patients with subchondral cysts (OHS 42 (37 to 45) vs 35 (26 to 36); p = 0.014) or joint space narrowing on CT (OHS 42 (IQR 37 to 44) vs 35 (26 to 36); p = 0.022) had higher function.

Conclusion

Despite high satisfaction levels, patients undergoing THA with minimal or no radiological OA had lower postoperative function than typical THA patients. We recommend obtaining low-dose CT imaging and a diagnostic hip injection to aid decision-making.

The ankle instability severity score. A simple preoperative score to select patients for ankle ligament repair or reconstruction Surgery

BACKGROUND

Currently, there is no established preoperative clinical tool for determining whether to opt for surgical reconstruction or repair in cases of chronic ankle instability.

HYPOTHESIS

This study aimed to develop a predictive score for the likelihood of instability recurrence after surgical repair.

PATIENTS AND METHODS

A multicenter case-control study was conducted, comparing patients who experienced recurrence of instability after surgical repair of the lateral ankle ligament (ATFL) to those who did not experience recurrence within 2 years post-surgery. Preoperative risk factors associated with instability recurrence at the 2-year mark were identified. Utilizing these datas along with existing literature, the Ankle Instability Severity Score (AISS) for predicting the risk of recurrence after ATFL repair was formulated. Subsequently, this score was calculated for all patients in the study cohort to evaluate its predictive capability.

RESULTS

Gender (p = 0.03), age (p = 0.02), BMI (p = 0.02), and participation in pivot sports (p = 0.04) were identified as risk factors for recurrence. The 9-point AISS score was applied to the patient cohort. When the score was three or lower, the recurrence rate after ATFL repair stood at 10.6% (OR 0.11 [0.04;0.28], p < 0.001). Conversely, if the score exceeded five, the recurrence rate was substantially higher at 80.0% (OR 11.9 [1.67;237.0], p = 0.03). Using ROC analysis, a threshold value of AISS score at 3.5 (sensitivity = 77.4%, specificity = 72.8%, AUC = 0.78) was identified to develop a instability recurrence after surgical repair.

DISCUSSION

This study introduces the AISS score, which relies on straightforward preoperative criteria to assist in deciding whether patients with chronic ankle instability should undergo ligament repair surgery or explore alternative treatment options.

LEVEL OF EVIDENCE

IV; retrospective study.

Neural processes linking joint hypermobility and anxiety: key roles for the amygdala and insular cortex

BACKGROUND

Anxiety symptoms are elevated among people with joint hypermobility. The underlying neural mechanisms are attributed theoretically to effects of variant connective tissue on the precision of interoceptive representations contributing to emotions.

AIM

To investigate the neural correlates of anxiety and hypermobility using functional neuroimaging.

METHOD

We used functional magnetic resonance neuroimaging to quantify regional brain responses to emotional stimuli (facial expressions) in people with generalised anxiety disorder (GAD) (N = 30) and a non-anxious comparison group (N = 33). All participants were assessed for joint laxity and were classified (using Brighton Criteria) for the presence and absence of hypermobility syndrome (HMS: now considered hypermobility spectrum disorder).

RESULTS

Participants with HMS showed attenuated neural reactivity to emotional faces in specific frontal (inferior frontal gyrus, pre-supplementary motor area), midline (anterior mid and posterior cingulate cortices) and parietal (precuneus and supramarginal gyrus) regions. Notably, interaction between HMS and anxiety was expressed in reactivity of the left amygdala (a region implicated in threat processing) and mid insula (primary interoceptive cortex) where activity was amplified in people with HMS with GAD. Severity of hypermobility in anxious, compared with non-anxious, individuals correlated with activity within the anterior insula (implicated as the neural substrate linking anxious feelings to physiological state). Amygdala-precuneus functional connectivity was stronger in participants with HMS, compared with non-HMS participants.

CONCLUSIONS

The predisposition to anxiety in people with variant connective tissue reflects dynamic interactions between neural centres processing threat (amygdala) and representing bodily state (insular and parietal cortices). Correspondingly, interventions to regulate amygdala reactivity while enhancing interoceptive precision may have therapeutic benefit for symptomatic hypermobile individuals.

Halo traction evaluation of craniocervical instability in hereditary connective tissue disorder patients: Case series

INTRODUCTION

Craniocervical instability (CCI) is a condition commonly found in patients with connective tissue disorders such as Ehlers-Danlos Syndrome (EDS), leading to various symptoms. Assessing patients for surgical fusion as a treatment for CCI is challenging due to the complex nature of EDS-related symptoms. This study aimed to evaluate the role of pre-fusion halo-vest traction in alleviating symptoms and determining suitable candidates for fusion surgeries.

METHODS

EDS patients (n = 21) with neurological symptoms underwent insertion of halo-vest traction between 2019 and 2024. Patients completed a CCI Questionnaire before and after the halo-vest traction, reporting symptoms related to headache, vision, hearing, equilibrium, and function. Symptom groups were assigned scores based on patient responses, with one point for each affirmative answer. Before and after scores were analyzed using paired Student's t-test. Patients experiencing over 50 % improvement in the majority of symptoms were considered for definitive fusion surgery. 16 out of 21 patients subsequently underwent fusion for CCI.

RESULTS

The average age of the patients was 35 years, with a female-to-male ratio of 20:1, consistent with existing literature. Significant improvements were observed in various symptom groups after halo-vest traction, including headache (57 % improvement, p < 0.001), brainstem functions (71 % improvement, p < 0.001), cerebellar functions (55 % improvement, p < 0.001), hearing (63 % improvement, p < 0.001), motor functions (51 % improvement,p < 0.001), vision (60 % improvement, p < 0.001), cardiovascular functions (46 % improvement, p < 0.05), sensory and pain (53 % improvement, p < 0.001), high cortical functions (54 % improvement, p < 0.001), GI functions (52 % improvement, p < 0.05), bladder functions (52 % improvement, p < 0.05), and Modified Karnofsky score (30 % improvement, p < 0.05).

CONCLUSION

Halo-vest traction proved to be a simple and effective method for evaluating patients for surgery while providing symptomatic relief in EDS-related CCI cases. It allows surgeons to monitor patients with a now post halo stable craniocervical junctions (CCJ) before committing to surgery.

Primary Anterior Cruciate Ligament Reconstruction Performed With Hamstring Tendon Autograft Leads to an Over 4 Times Greater Rate of Second Anterior Cruciate Ligament Rupture After Return to Sport in Patients With Generalized Joint Hypermobility Compared With Bone-Patellar Tendon-Bone Autograft

PURPOSE

To examine the rate of (1) second anterior cruciate ligament (ACL) rupture (graft rupture or contralateral ACL rupture) and (2) graft rupture alone in patients with generalized joint hypermobility (GJH) at 12 months, at 24 months, and at the longest available time (LAT) following return to sport (RTS) after ACL reconstruction depending on graft choice, that is, hamstring tendon (HT) autograft or bone-patellar tendon-bone (BPTB) autograft.

METHODS

Data were extracted from a rehabilitation registry that comprised patients who had undergone ACL reconstruction between 2014 and 2022. Patients with GJH aged between 16 and 50 years who had minimum 24-month follow-up following RTS after ACL reconstruction with HT autograft (GJH-HT) or BPTB autograft (GJH-BPTB) were included. A Cox proportional hazard regression model was used to examine the rate of (1) second ACL rupture (graft rupture or contralateral ACL rupture) and (2) graft rupture alone at 12 months, at 24 months, and at the LAT after RTS.

RESULTS

This study included 82 patients (54 in the GJH-HT group and 28 in the GJH-BPTB group), of whom 72.0% were female patients, and the average age was 22.7 ± 7.4 years. The proportion of second ACL ruptures was greater in the GJH-HT group than in the GJH-BPTB group at 12 months (11 of 54 [20.4%] vs 0 of 28 [0%], P = .013), at 24 months (13 of 54 [24.1%] vs 1 of 28 [3.6%], P = .028), and at the LAT (16 of 54 [29.6%] vs 2 of 28 [7.1%], P = .024) after RTS. The rate of second ACL rupture was greater in the GJH-HT group than in the GJH-BPTB (hazard ratio = 4.98, P = .032) at the LAT after RTS. The proportion of patients with graft rupture was greater in the GJH-HT group than in the GJH-BPTB group at 12 months (8 of 54 [14.8%] vs 0 of 28 [0%], P = .046), at 24 months (10 of 54 [18.5%] vs 0 of 28 [0%], P = .013), and at the LAT (12 of 54 [22.2%] vs 0 of 28 [0%], P = .006) after RTS.

CONCLUSIONS

An over 4 times greater rate of second ACL rupture after RTS was reported for patients with GJH who underwent ACL reconstruction with HT autograft compared with BPTB autograft. Patients with GJH who were treated with BPTB autograft for ACL reconstruction did not experience graft rupture after RTS.

LEVEL OF EVIDENCE

Level III, retrospective study.

The Association of Genetic Variants Within the Type XII Collagen and Tenascin C Genes with Knee Joint Laxity Measurements

BACKGROUND/OBJECTIVES

Types I, V, and XI collagen gene variants have been reported to associate with measurements of knee joint laxity and/or absolute knee ligament length changes. Type XII collagen and tenascin C are also ligament structural proteins whose expression is regulated by mechanical loading. This study investigated whether COL12A1 and TNC variants are associated with knee laxity and/or ligament length changes.

METHODS

Genu recurvatum, anterior-posterior tibial translation, external-internal tibial rotation, and ligament length changes were measured in 128 healthy participants. They were genotyped for COL12A1 (rs970547) and TNC (rs1061494, rs2104772, rs1138545).

RESULTS

Both the COL12A1 AA and TNC rs1061494 TT genotypes were associated with decreased external (p = 0.007, p = 0.010) and internal (p = 0.025, p = 0.002) rotation, as well as slack (p = 0.033, p = 0.014), in the dominant leg. Both genotypes, together with sex, weight, and/or COL1A1 genotypes, explained 26% and 32% of the variance in external and internal rotation, respectively. The TNC genotype, sex, and BMI explained 23% of the variance in slack. The COL12A1 AA and the TNC rs1061494 TT genotypes were associated with smaller changes in the MCL (aMCL: COL12A1 p = 0.009, TNC p = 0.045; iMCL: COL12A1 p = 0.004, TNC p = 0.043; pMCL: COL12A1 p = 0.003, TNC p = 0.067; aDMCL: COL12A1 p = 0.007, TNC p = 0.020; pDMCL: COL12A1 p = 0.007, TNC p = 0.023) and/or LCL (COL12A1 p = 0.652, TNC p = 0.049) lengths within the dominant knee. The TNC rs1061494 CC genotype was associated with larger changes in the non-dominant anterior (p = 0.021) and posterior (p < 0.001) ACL bundle lengths.

CONCLUSIONS

These findings suggest that COL12A1 and TNC variants are associated with internal-external tibial rotation and knee ligament length changes in healthy individuals.

Comorbidities and neurosurgical interventions in a cohort with connective tissue disorders

Background

Connective tissue disorders (CTDs) are a heterogeneous group of disorders often presenting with a variety of comorbidities including musculoskeletal, autonomic, and immune dysfunction. Some CTDs such as hypermobile Ehlers-Danlos syndrome (hEDS), which is one of the most common, have been associated with neurological disorders requiring surgical intervention. The frequency of these comorbidities in these populations and their subsequent requirement for neurosurgical intervention remains unclear.

Methods

Based on our initial experience with this population, we investigated the presentation rates of specific comorbidities and neurosurgical interventions in a cohort of individuals referred to our institution for evaluation and neurosurgical management of issues secondary to diagnosed or suspected CTDs from 2014 to 2023. Primary diagnoses were made by referring physicians or institutions based on clinical presentation and standard-of-care criteria. We evaluated relationships between diagnoses and surgical interventions by multivariate correlation and intersection plots using the UpSetR package.

Results

Of 759 individuals, we excluded 42 based on incomplete data. From the remaining (total cohort, N = 717), 460 (64%) individuals were diagnosed with hEDS, 7 were diagnosed with a CTD other than hEDS, and 250 lacked a formal CTD diagnosis. We found that individuals with hEDS had a higher frequency of certain comorbidities, such as Mast Cell Activation Disorder and Postural Orthostatic Tachycardia Syndrome, and neurosurgical intervention compared to individuals without a CTD diagnosis (unaffected). Of the total cohort, 426 (59%) were diagnosed with Chiari I Malformation, which shared a significant overlap with hEDS. Of those who elected to undergo surgery (n = 612), 61% required craniocervical fusion (CCF). Notably, of the 460 individuals diagnosed with hEDS, 404 chose surgical intervention, of which, 73% required CCF for craniocervical instability.

Conclusion

In this retrospective study of individuals referred to our institution for evaluation of CTDs potentially requiring neurosurgical intervention, we defined the frequency of presentation of specific comorbidities that we commonly encountered and revealed the rate at which they required neurosurgical intervention.

Provocation of brachial plexus and systemic symptoms during the elevated arm stress test in individuals with myalgic encephalomyelitis/chronic fatigue syndrome or idiopathic chronic fatigue

BACKGROUND

We have noted that some adolescents and young adults with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) report difficulty with arms-overhead activities, suggestive of brachial plexus dysfunction or thoracic outlet syndrome (TOS). In the TOS literature, diagnostic maneuvers focus on the provocation of upper limb symptoms (arm fatigue and heaviness, paresthesias, neck and upper back pain), but not on elicitation of systemic symptoms.

OBJECTIVES

To estimate the proportion of patients with fatiguing illness who experience local and systemic symptoms during a common maneuver used in evaluating TOS-the elevated arm stress test (EAST).

METHODS

Patients were eligible for this retrospective study if they had been referred to the Johns Hopkins Chronic Fatigue Clinic between January 2020 and July 2023 and (a) reported difficulty maintaining arms-overhead postures, (b) were evaluated with an abbreviated one-minute EAST, and (c) had not undergone surgery in the upper limb, neck, or skull base. Modified EAST procedure: patients sat with their arms in a "hands up" or "candlestick" position while opening and closing their hands every 2-3 s repeatedly for 1 min, rather than the customary 3 min. The test was considered abnormal for local symptoms if the participant experienced pain, fatigue, heaviness, paresthesias, warmth or tremulousness in the upper limb, shoulder, neck, head, or upper back. The test was considered abnormal for systemic symptoms if the participant experienced overall fatigue, cognitive fogginess, lightheadedness, racing heart, diaphoresis, dyspnea, overall warmth, or nausea.

RESULTS

Of 154 patients evaluated during the study period, 64 (42%) met the eligibility criteria (61/64 female, median age 18 years [range, 13 to 50]). Of the 64, 50 (78%) had ME/CFS, 13 (20%) had idiopathic chronic fatigue with associated orthostatic intolerance (OI), and one had idiopathic chronic fatigue without OI. Of the 64, 58% had evidence of joint hypermobility. Local symptoms were provoked by EAST in 62/64 (97%) within a median of 20 s. During EAST, 26/64 (41%) reported systemic symptoms (1 had only systemic but no upper limb symptoms), most commonly lightheadedness (19%) and generalized fatigue (11%).

CONCLUSIONS

Even with an abbreviated test duration, the EAST maneuver provoked local and systemic symptoms in a substantial proportion of patients with chronic fatigue, OI, and ME/CFS who had reported difficulty with arms-overhead postures. Further studies are needed to explore the prevalence of brachial plexus or TOS symptoms in unselected individuals with ME/CFS or OI, and the proportion with systemic symptoms during and after EAST.

Phenotypic Presentation of Children with Joint Hypermobility: Preclinical Signs

INTRODUCTION

Joint hypermobility (JH) is mobility beyond the normal range of motion. JH can be an isolated finding or a characteristic of a syndrome. Characteristics related to the sitting position with atypical body positions, such as sitting in splits (S), with the foot on the head (F), in W (W), in a concave shape (C), episodes of dislocations, and subluxations, suggest impacts on body mechanics since childhood, with damage to the conformation of the joints.

OBJECTIVES

Identify preclinical signs of JH, in addition to Beighton Score (BS), through signs that are easily recognized early by pediatricians and family members to avoid possible joint deformities in the future.

METHODS

The medical records of 124 children (59.7% girls) between one and nine years old were analyzed. JH was assessed using the BS, a history of luxations/subluxations, and the concave (C), "W", "splits" (S), and foot (F) on head sitting positions.

RESULTS

The concave sitting position was the most common, followed by W, F, and S in decreasing order. A total of 52.4% of the children had BS > 6, with a higher prevalence among girls (60.8%) compared to boys (40.0%); a difference statistically significant (p = 0.024, Fisher's exact test). Thirty-two patients (27.4%) had luxations/subluxations with the higher scores.

CONCLUSIONS

Sitting in S, F, W, and C positions are preclinical phenotypic characteristics of JH, easily identified by pediatricians and family members to prevent possible joint deformities. BS ≥ 6 is more frequently observed in all positions. The majority of the total sample has BS > 6, with a significant female gender influence. Among those with a history of occasional joint dislocations and subluxations, half of them have the highest BS scores.

Safety and performance of a novel synthetic biomimetic scaffold for iliac crest defect reconstruction during surgical treatment of pelvic girdle pain: a first-in-human trial

INTRODUCTION

Surgical treatment of pelvic girdle pain (PGP) involves arthrodesis of sacroiliac (SI) and pubic symphysis joints. Fusion of pubic symphysis involves the implantation of an autologous iliac crest tricortical graft harvested from the iliac crest. The objective was to assess the safety of a novel synthetic graft substitute (b.Bone) for iliac crest reconstruction and to evaluate the results of PGP surgical treatment.

SOURCES OF DATA

Consecutive participants undergoing pelvic fusion and requiring iliac crest reconstruction were enrolled and followed-up for 12 months in a prospective first-in-human clinical investigation. Adverse events were documented, and health-related quality of life was evaluated using EuroQol-5D-5L questionnaire. Iliac crest defect healing was evaluated by the Modified Lane and Sandhu radiological scoring system. In addition, relevant published peer-reviewed scientific articles identified from PubMed.

AREAS OF AGREEMENT

The EQ-5D-5L scores improved steadily reaching the highest point at 365 days. By 365 days complete healing of the bone defect was observed.

AREAS OF CONTROVERSY

The management of PGP remains challenging with mixed results reported in the literature.

GROWING POINTS

While there is lack of consensus on how to manage PGP, the present study shows improved outcomes at one year following surgery. The synthetic b.Bone scaffold is a safe option with good healing outcomes for iliac crest defect reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

Although b.Bone synthetic scaffold found to be safe, further studies reporting on surgical treatment of PGP are required to confirm the findings in comparative trials.

Does high body mass index increase the risk of shoulder instability surgery? The LUXE prospective cohort study on 227 recurrent anterior shoulder instability

Background

The aim of this study was to determine whether body mass index (BMI) plays a role in overall morbidity following shoulder instability surgery and whether some surgical techniques are BMI-sensitive.

Methods

A prospective, multicenter database was created that included the following three surgical techniques: arthroscopic Bankart (AB), arthroscopic Bankart with remplissage (ABR), and Open Latarjet (OL). Patient data (demographic, strength, laxity and functional outcomes (Disability of the Arm, Shoulder, and Hand [QuickDASH]; Western Ontario Shoulder Instability Index; and QuickDASH Pain subscore) were compared at enrollment and last postoperative follow-up. Functional outcomes, complications, and postoperative outcomes were compared between the different groups and then subdivided by BMI. Follow-up radiographs were evaluated for graft position and complications for all patients who underwent OL.

Results

A total of 227 patients (164 men, 63 women) were included with at least 1-year follow-up (3.3y AB (n = 126), 4.5y ABR (n = 34), and 3y OL (n = 62)). At baseline, patients with high BMI (37(17%)) had significantly worse QuickDASH Pain subscores (2.9 ± 1.0, P value <.05) and QuickDASH (46.8 ± 21.6, P value < .001) scores compared to all other BMI groups. All BMI groups had similar QuickDASH (P value .22) and Western Ontario Shoulder Instability Index (P value .69) scores at last follow-up. Complication rates for patients with high BMI were significantly higher in ABR compared to AB (P value .042) and so were reoperation rates in patients with high BMI after OL compared to patients with high BMI after ABR (9.5%, P value .049).

Conclusion

Patients with high BMI showed significantly worse baseline functional scores but no difference was found in postoperative functional scores between BMI groups. Complication rates were significantly higher in patients with high BMI following ABR compared to AB, and so were reoperation rates in patients with high BMI undergoing Latarjet compared to AB.

Surgical management of severe planovalgus foot deformity in children with generalised joint hypermobility

BACKGROUND

This study aimed to evaluate the outcomes of calcaneal lengthening osteotomy (CLO) and double arthrodesis of the talonavicular and calcaneocuboid joints (DA) for correcting planovalgus foot deformity exclusively in patients with generalised joint hypermobility.

METHODS

We retrospectively reviewed 29 feet in 17 consecutive patients who underwent either CLO or DA. The mean age at surgery was 11.3 ± 2.3 years, and the mean follow-up duration was 7.7 ± 3.2 years. Preoperative and final follow-up radiographs and dynamic foot-pressure measurements were analysed.

RESULTS

Both operations significantly improved the radiographic parameters, except for the lateral talocalcaneal angle in the CLO group. Pedobarographic study demonstrated an elevation of the medial longitudinal arch and an improved foot-pressure distribution after both surgeries. The plantar pressure in the lateral forefoot significantly increased only in the DA group, while the pressures exerted on the medial forefoot and hindfoot and the arch index improved only in the CLO group.

CONCLUSIONS

Both CLO and DA effectively improve the foot alignments of the deformity in patients with generalised joint hypermobility. However, differences were observed in the changes in the lateral talocalcaneal angle and plantar pressure distribution between the two procedures.

LEVEL OF EVIDENCE

Therapeutic Level III.

Is Generalized Joint Hypermobility Associated with Chronic Painful Temporomandibular Disorders in Young Adults? A Cross-Sectional Study

Background/Objectives: Generalized joint hypermobility (GJH) is a common condition characterized by an increased range of motion across multiple joints. Previous studies have suggested a possible association between GJH and temporomandibular disorders (TMDs). This study aimed to assess the prevalence of GJH in a Portuguese population of young university adults and to explore the relationship between GJH, temporomandibular joint (TMJ) symptoms/clinical findings, chronic painful TMDs, and chronic painful TMDs subtypes (myalgia, arthralgia, or combined myalgia and arthralgia). Methods: A cross-sectional study was carried out in Oporto university institutions, involving 1249 students (18-25 years). GJH was assessed using the Beighton score cut-off ≥ 4. TMJ symptoms and clinical findings were collected using the Research Diagnostic Criteria for TMD protocol, as well as TMD diagnoses. Univariate and multivariate analyses were carried out to examine the associations between GJH and the variables of interest. Results: The overall prevalence of GJH was 41.9%, with females exhibiting a significantly higher likelihood of GJH (p < 0.001). A statistically significant association was found between GJH and TMJ clicking (p < 0.05). Although no overall association was found between GJH and chronic painful TMDs, GJH was significantly associated with the combined diagnosis of myalgia and arthralgia (p < 0.05). Conclusions: The results suggest that GJH may be associated with the more complex subtypes of chronic painful TMDs. However, due to the small size effect of this association, future longitudinal studies with large samples using GJH broader diagnostic criteria are essential to elucidate the relationship between GJH and painful TMDs in asymptomatic nonsyndromic joint hypermobility populations.

Uncovering the alterations in extrinsic foot muscle mechanical properties and foot posture in fibromyalgia: a case-control study

OBJECTIVES

The aim of the study was to evaluate foot posture and the mechanical properties of extrinsic foot muscles in fibromyalgia.

METHODS

Patients with fibromyalgia (n = 86) and age- and gender-matched controls (n = 41) were included in the study. Foot Posture Index (FPI), Beighton and Brighton criteria were used to evaluate static foot posture, joint hypermobility, and benign joint hypermobility syndrome (BJHS), respectively. Tonus, elasticity, and stiffness of the extrinsic foot muscles including gastrocnemius medialis, tibialis anterior, and peroneus longus were measured by the MyotonPRO® device. Foot function, quality of life, and physical activity level were assessed by the Foot Function Index (FFI), Short Form-36 (SF-36), and the International Physical Activity Questionnaire-Short Form (IPAQ-SF), respectively.

RESULTS

The frequency of abnormal foot posture in the fibromyalgia and control groups was 68.6% versus 39%, respectively; and neutral foot posture was approximately twice as prevalent in the control group compared to the fibromyalgia group (p = 0.006). Pronated foot posture was the most common abnormality in fibromyalgia (61.6%) and observed in 85.5% of the patients with joint hypermobility and in 87.1% of those meeting BJHS criteria. The elasticity of peroneus longus at rest and the elasticity of tibialis anterior in the standing position were significantly different between the fibromyalgia group and the control group [1.08 (0.22) vs. 1.02 (0.25), p = 0.037 and 0.92 (0.29) vs. 0.87 (0.24), p = 0.011, respectively]. Regarding the fibromyalgia group, no difference was detected among foot posture groups in terms of myotonometric data.

CONCLUSIONS

Pronation foot posture is common in fibromyalgia with a much higher frequency in fibromyalgia patients with hypermobility. In daily clinical practice for fibromyalgia, particular attention should be given to foot alignment.

Arthroscopic retrograde disimpaction of reverse Hill-Sachs lesions in acute posterior shoulder dislocation type A2 leads to good clinical outcome and close to anatomic reconstruction of the articular surface of the humeral head

BACKGROUND

Posterior shoulder dislocation frequently results in a centrally located impression fracture of the anterior humeral head, known as reverse Hill-Sachs lesion (RHSL). Depending on its size and location, the RHSL can lead to engagement with the posterior glenoid rim and subsequently redislocation of the shoulder joint. The objective of this study was to present the clinical and radiologic outcomes of anatomic reconstruction of the humeral articular surface using arthroscopically assisted disimpaction in patients with acute posterior shoulder dislocation and an engaging RHSL.

METHODS

As part of a retrospective analysis, 9 shoulders in 9 patients (1 female, 8 males) with engaging RHSL following acute posterior shoulder dislocation (type A2 according to the ABC classification) who underwent arthroscopically assisted disimpaction of the RHSL between 2016 and 2023 were identified. Eight patients were included, because 1 patient refused to participate. In all patients, a radiologic analysis of the RHSL was accomplished on preoperative and postoperative cross-sectional imaging including the alpha, beta, and gamma angle as well as depth measurements. The clinical examination included an assessment of the active range of motion, instability tests, and patient-reported outcome measures, such as the Western Ontario Shoulder Instability (WOSI) Index, the Constant Score, and the Subjective Shoulder Value (SSV).

RESULTS

The mean follow-up period for all 8 patients was 34.4 ± 38 months (range: 6-102 months). The mechanisms of injury included falls (n = 6), traffic accident (n = 1), and convulsive episode (n = 1). The average time from injury to surgery was 6.8 ± 4.7 days (range: 2-16). Patient-reported outcomes at the final follow-up indicated an average WOSI Index of 77.8% ± 17%, a mean Constant Score of 88.3 ± 11 points, and a mean SSV of 87% ± 16%. None of the patients experienced recurrent dislocations during the follow-up period. Post-traumatically, the mean absolute defect depth was 8.4 ± 2.2 mm and the mean gamma angle was 115.8° ± 13°. In the radiologic follow-up, the RHSL depth measurements showed a significant reduction in the mean defect depth from 8.4 ± 2 mm to 1.2 ± 1 mm resulting in an average reduction of the RHSL by 7.1 mm (P < .001). In 3 of the 8 patients (37.5%), the RHSL was not identifiable any more at follow-up and in 5 patients barely identifiable.

CONCLUSION

Arthroscopically assisted disimpaction of acute RHSLs leads to close to anatomic reduction of RHSL, achieving a stable shoulder and good clinical outcomes.

Biomechanical determinants of rheumatoid arthritis severity and excess cardiovascular disease: common origins of two complex diseases

OBJECTIVES

The determinants of rheumatoid arthritis (RA) severity and excess cardiovascular disease (CVD) are incompletely understood. Biomechanical factors are known to influence RA severity. Articular stiffness correlates with arterial and skin stiffness. This study explored the hypothesis that constitutional stiffness is a common determinant of RA severity and excess CVD.

METHODS

Fifty-eight patients with anti-CCP antibody (ACPA) positive RA and 57 controls were enrolled noting age, sex, body mass index, alcohol and tobacco exposure, Shared Epitope status and in RA disease duration, disease activity, ACPA titre and radiographic damage. Severe RA was defined as radiographic progression >1.3 mSharp points/year or requiring biological disease-modifying antirheumatic drugs (bDMARDs). Articular stiffness (Beighton Score and right 5th metacarpophalangeal (MCP) joint stress-strain responses), carotid-femoral pulse wave velocity and skin extensibility (percent increase distance two dots with manual traction dorsum right hand) were assessed.

RESULTS

Right 5th MCP stiffness correlated with Beighton Score and with arterial and skin stiffness. High radiographic rate was associated with greater MCP articular (t test p 0.014), arterial (p 0.044) and, in RA <5 years duration, greater skin stiffness (p 0.002) with similar trends in subjects requiring bDMARDs. In RA, arterial stiffness correlated with age (ß p<0.005), articular (ß p<0.001) and skin stiffness (ß p 0.037) and inversely with alcohol consumption (p 0.035).

CONCLUSIONS

Articular, arterial and skin stiffness correlated with each other and with RA severity. As skin is not affected by RA, this association suggests that constitutional stiffness might be a common determinant of RA and CVD. Prospective studies of at-risk preclinical and early RA are required to determine if this relationship is causal.

TRIALS REGISTRATION NUMBER

ACTRN12617000170325.

Synthetic suture tape for medial patellofemoral ligament reconstruction is an effective treatment for complex paediatric patellofemoral instability

PURPOSE

To assess the outcomes of medial patellofemoral ligament (MPFL) reconstruction using synthetic suture tape in paediatric patients with patellofemoral instability (PFI).

METHODS

This ambispective comparative study, conducted from 2014 to 2022, included paediatric patients who underwent MPFL reconstruction with synthetic suture tape and had a minimum follow-up of 1 year. Pre- and postoperative clinical and functional outcomes, patient satisfaction and complications were assessed.

RESULTS

The study comprised 22 patients (29 knees), with a median age at surgery of 14.4 years (interquartile range [IQR] 10.9-16.7) and a median follow-up of 46.5 months (24.7-66). Notably, 13 knees (44.8%) had open growth plates at the time of surgery. The cohort included patients with Down syndrome (3 patients), Ehlers-Danlos (2), arthrogryposis (1), generalized joint hypermobility (8) and previous unsuccessful PFI surgeries (8). Concomitant procedures were performed on 16 knees. Postoperatively, improvements were observed in all but one patient, who reported residual pain. There were two other complications: one suture-tape rupture and one surgical wound infection. Functional scores significantly improved: Kujala, +14 points (7-29) (p < 0.001); IKDC, +10.5 points (5.2-25.3) (p < 0.001); Tegner, +2 points (0-4) (p < 0.001); Lysholm, +15 points (0-37.5) (p < 0.001). Most patients achieved excellent outcomes by Crosby-Insall criteria (21 patients, 72.4%) and reported high satisfaction (23 patients, 79.3%).

CONCLUSIONS

MPFL reconstruction using synthetic suture tape is a viable and effective treatment for paediatric patients with PFI, particularly for those with connective tissue disorders, generalized joint hypermobility or past surgical failures, significantly enhancing clinical and functional outcomes with an acceptable complication rate.

LEVEL OF EVIDENCE

Level IV.

Do standardization of the procedure reduce measurement variability of the sonographic anterior drawer test of the ankle?

BACKGROUND

In quantitative ankle stress sonography, different examiners use different techniques, which may cause measurement variability. This study aimed to clarify whether standardizing stress sonography techniques reduces variability in the quantitative measurement of anterior talofibular ligament length change.

METHODS

Fourteen examiners with a mean ultrasound experience of 8.7 years participated in this study. Each examiner performed stress ultrasonography of the ankle using their preferred method on one patient with an intact anterior talofibular ligament (Patient 1) and on two patients with chronic ankle instability (Patient 2 and 3). Changes in the ligament length between the resting and stressed positions were determined. A consensus meeting was then conducted to standardize the sonographic technique, which was used by the examiners during a repeat stress sonography on the same patients. The variance and measured values were compared between the preferred and standardized techniques using F-tests and paired t-tests, respectively.

RESULTS

At a consensus meeting, a sonographic technique in which the examiner pushed the lower leg posteriorly against the fixed foot was adopted as the standardized technique. In Patient 1, the change in the anterior talofibular ligament length was 0.4 (range, -2.3-1.3) mm and 0.6 (-0.6-1.7) mm using the preferred and standardized techniques, respectively, with no significant difference in the variance (P = 0.51) or the measured value (P = 0.52). The length changes in Patient 2 were 2.0 (0.3-4.4) mm and 1.7 (-0.9-3.8) mm using the preferred and standardized techniques, respectively. In Patient 3, the length changes were 1.4 (-2.7-7.1) mm and 0.7 (-2.0-2.3) mm. There were no significant differences between the techniques in either patient group.

CONCLUSION

Variability in the quantitative measurement of ankle stress sonography was not reduced despite the standardization of the technique among examiners. Hence, comparing the measured values between different examiners should be avoided.

The relationship between Beighton score and biomechanical risk factors among adolescent, female volleyball players

OBJECTIVE

To investigate the relationship between Beighton score and biomechanical risk factors, such as knee valgus, in female, adolescent volleyball players.

DESIGN

Cross-sectional study.

SETTING

Biomechanics laboratory.

PARTICIPANTS

25 adolescent, club-level female volleyball athletes (14.5 ± 1.8 years) were tested between September 2021-November 2021.

MAIN OUTCOME MEASURES

Participants were asked to perform a double-leg vertical jump (DLVJ), a single-leg squat (SLS), and a single-leg drop landing (SLDL). Peak coronal plane angles during the DLVJ, SLS, and SLDL were computed. Spearman correlations were performed to identify significant relationships between Beighton score and biomechanical variables.

RESULTS

Peak knee valgus was found to be moderately correlated to Beighton score during the DLVJ-Land (r = 0.487, p = 0.014), SLDL (r = 0.478, p = 0.016), and SLS (r = 0.439, p = 0.028) tasks.

CONCLUSIONS

Overall, adolescent volleyball players with higher Beighton scores tended to exhibit a greater peak knee valgus, suggesting that such athletes could benefit from a targeted neuromuscular training or injury prevention program.

Study on the balance and gait characteristics of subjects with generalized joint hypermobility residing in high-altitude using wearable devices: a cross-sectional study

PURPOSE

To investigate the characteristics of balance and gait functions in Generalized Joint Hypermobility (GJH) subjects residing in high-altitude areas.

METHODS

This study included 61 university students (28 with GJH and 33 healthy controls) all from the high-altitude region of Linzhi, Tibet Autonomous Region. The Riablo™ wearable intelligent rehabilitation assessment and training system was used to assess static balance (with eyes open and closed) and gait function (during flat walking) in both groups.

RESULTS

Compared to healthy subjects, GJH subjects exhibited significantly impaired balance, indicated by an increased distance of the center of pressure position from the ideal center of gravity(EO: P = 0.007, EC: P = 0.031) and greater amplitude of center of pressure displacements (EO: P = 0.043, EC: P = 0.032). Gait velocity(P = 0.007), stride length(P = 0.012), and swing stance phase of the gait cycle(P = 0.046) were significantly reduced in GJH subjects compared to healthy subjects. A significant increase in the flat-foot phase of the gait cycle(P = 0.022) was observed in GJH subjects compared to healthy subjects.

CONCLUSION

The current study demonstrated that GJH subjects residing in high-altitude areas exhibit impairments in balance and gait, providing a basis for training and prevention strategies tailored for this population. And this study used the wearable intelligent rehabilitation evaluation and training system in high-altitude areas, providing methodological references for scientific research on balance and gait function under non laboratory conditions.

TRIAL REGISTRATION

Controlled Trials No.102772023RT133, Registered 13 October 2023.

The Effect of Attention Focus Instructions on Strength and Balance in Subjects With Generalized Joint Hypermobility

This study aims to examine the effects of different attention focuses on muscle strength and balance performance in individuals with Generalized Joint Hypermobility (GJH). This randomized crossover trial included 32 individuals with GJH whose Beighton score was greater than 5. Subjects performed each task under external attentional focus, internal attentional focus, and neutral attentional focus condition. Knee extensor muscle strength was measured using the Isokinetic Dynamometer. Postural stability was evaluated using the Biodex Balance System, while dynamic balance was assessed using the Y Balance Test. The main effects of attentional focus on the outcomes were analyzed using repeated measures ANOVA and post-hoc corrections with a 95% confidence interval. Subjects produced significantly higher quadriceps peak torque during external focus instruction and internal focus instruction compared to neutral condition (p = .006). Postural stability performance were found to be better during external attention focus compared to the internal focus of attention and the neutral group (p = .008). In addition, an increase in Y balance composite score was observed during external condition compared to internal condition and neutral condition (p < .001). Whether internal or external, the use of attentional focus may be beneficial for optimal force production during training in individuals with GJH. External attention focus enabled better postural stability and dynamic balance performances.

Impact of a Pilates intervention on physical function in children with generalised joint hypermobility and chronic musculoskeletal pain: A single-case experimental design

AIM

To assess the impact of a Physiotherapist-led Pilates Intervention for school aged children with Generalised Joint Hypermobility (GJH) on pain, physical function and Health Related Quality of Life (HRQoL).

METHODS

Three children aged 8-12 years with GJH participated in an 8 week Physiotherapist-led Pilates Intervention within a single-case experimental design (multiple baseline design). Repeated measures were collected during baseline, intervention, withdrawal and follow-up, for: (i) pain, (ii) physical function as measured by muscle strength, postural control, fatigue and activity levels and (iii) HRQoL.

RESULTS

Within the intervention phase, two children showed reduced fatigue and one child improved in muscle group strength of hip abduction (gluteus medius) and scapula adduction/rotation (rhomboideus major/minor) and HRQoL. No improvements were seen in pain or postural control. Within the early withdrawal phase all children showed improved strength for at least two muscle groups and one child showed reduced fatigue, pain (worst in last week) and improved postural control (functional reach lateral).

CONCLUSIONS

Pilates may provide an effective intervention for children with GJH to reduce fatigue and improve muscle strength and HRQoL. Limited conclusions can be made regarding pain and postural control. Further research with a longer Pilates duration is needed to confirm the dose and benefits for this population.

Osteoarthritis After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Contributing Factors and Potential Treatments

Anterior cruciate ligament (ACL) injuries result in abnormal knee motion and long-term joint degradation. ACL reconstruction (ACLR) is done with the aim of restoring normal knee kinematics and slowing the joint degradation process. It does appear that this inevitably happens and can be impacted by a multitude of factors. The aim of this review was to examine the factors that influence the progression of osteoarthritis (OA) after ACLR and examine possible treatments that can aid in slowing that progression. A systematic review was conducted by searching all levels of evidence for all studies in English that assessed risk factors for developing OA after ACL reconstruction, had a minimum follow-up of 10 years, and used radiographical outcomes to measure the presence of OA. Studies on trial treatments to reduce osteoarthritis after ACL reconstruction were also included. It was found that among the factors associated with an increased risk of post-ACLR OA are meniscal lesions, meniscectomy, increased age at the time of ACLR, increased time from injury to surgery, male sex, reduced range of motion, smaller thigh girth, graft complications, and failure. Additionally, in performing the ACLR, anteromedial femoral tunnel placement, higher graft tension, and following guidelines for performing anatomic ACLR have been shown to reduce the risk of OA as well. Patients should be adequately counselled on their risk pre-operatively for informed decision-making. Surgeons should also be aware of potential risk factors and how they can be mitigated.

The relationship between joint hypermobility and patellar instability: A systematic review

Introduction

Hypermobility describes the movement of joints beyond normal limits. Whether hypermobility predisposes to patellar instability is yet to be established. We aimed to determine if joint hypermobility leads to an increased risk of patellar instability, and to evaluate outcomes of treatment for patellar instability in those who exhibit hypermobility.

Methods

Published and unpublished literature databases were searched to September 7, 2023. Studies comparing prevalence of patellar dislocation/differences in treatment outcomes in patients with and without hypermobility were included.

Results

We identified 18 eligible studies (4,391 patients). The evidence was low in quality. A case series on 82 patients found that there was a relationship between generalised joint laxity and patellar instability. This was corroborated by a study comparing 104 patients with patellar dislocation to 110 patients without. Prevalence of generalised joint laxity was six time higher in the former (64.4% vs 10.9%, p < 0.001).Five studies found surgical intervention aimed at correcting patellar dislocation in patients with idiopathic hypermobility led to satisfactory outcomes. There was conflicting evidence regarding if hypermobile patients have worse outcomes than non-hypermobile patients following medial patellofemoral ligament reconstruction (MPFLR) in two studies. In addition, this procedure had a 19.1% failure rate in patients with Ehlers Danlos Syndrome (EDS), with hypermobility associated with a higher failure rate (p = 0.03). One study showed the type of graft used made no difference in outcome scores or re-dislocation rates (p > 0.5). Another study had 7/31 (22.6%) autografts which failed, compared to 2/16 allografts (12.5%) (p = 0.69).

Conclusion

Joint hypermobility is a risk factor for patellar instability. Identification of at-risk groups may aid prevention of dislocations and allow for appropriate treatment. Patients with EDS experience poor outcomes following patellar stabilization surgery, with post-operative monitoring required.

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity

BACKGROUND

To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL).

METHODS

From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0.

RESULTS

The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up.

CONCLUSION

Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Comparison of Terminal Elbow Extension between Humans and Baboons (Papio anubis)

It is assumed that hyperextension of the elbow joint beyond 0° in humans is due to local ligament and other soft tissue laxity. The common extant old-world olive baboon (Papio anubis), with a quadrupedal gait, commonly has a mild elbow joint flexion contracture. This study compares anatomic and functional roles of the olecranon-coronoid notch angle of the proximal ulna and the anterior direction of its opening on terminal elbow extension in humans and baboons. Active terminal elbow extension was measured in 211 elbows of skeletally mature humans using the neutral zero method. Passive elbow extension and radiographs were performed on 60 extremities of 30 anesthetized baboons. The mean olecranon-coronoid notch angle for humans and baboons was 22.2 ± 6.0° and 11.3 ± 3.2°, respectively (P < 0.001). Mixed effect regression analysis showed that the magnitude of the angle was a significant predictor of terminal elbow extension (P < 0.001) when accounting for species. Also, the causal mediation analysis showed that 18% of the difference in terminal elbow extension between species could be attributed to the olecranon-coronoid notch angle (P < 0.001). Anatomic dissection of 16 baboon arms showed that sectioning of all the anterior soft tissue structures increased mean terminal elbow extension from -18.2 ± 5.9° to -7.1 ± 6.0° and that further elbow extension was blocked primarily by the intact humeroulnar joint. The size of the notch angle and the positioning of its anterior proximal opening played a significant role in deciding terminal elbow extension in both species.

Unravelling the genetic landscape of cervical insufficiency: Insights into connective tissue dysfunction and hormonal pathways

BACKGROUND

The intricate molecular pathways and genetic factors that underlie the pathophysiology of cervical insufficiency (CI) remain largely unknown and understudied.

METHODS

We sequenced exomes from 114 patients in Latvia and Lithuania, diagnosed with a short cervix, CI, or a history of CI in previous pregnancies. To probe the well-known link between CI and connective tissue dysfunction, we introduced a connective tissue dysfunction assessment questionnaire, incorporating Beighton and Brighton scores. The phenotypic data obtained from the questionnaire was correlated with the number of rare damaging variants identified in genes associated with connective tissue disorders (in silico NGS panel). SKAT, SKAT-O, and burden tests were performed to identify genes associated with CI without a priori hypotheses. Pathway enrichment analysis was conducted using both targeted and genome-wide approaches.

RESULTS

No patient could be assigned monogenic connective tissue disorder neither genetically, neither clinically upon clinical geneticist evaluation. Expanding our exploration to a genome-wide perspective, pathway enrichment analysis replicated the significance of extracellular matrix-related pathways as important contributors to CI's development. A genome-wide burden analysis unveiled a statistically significant prevalence of rare damaging variants in genes and pathways associated with steroids (p-adj = 5.37E-06). Rare damaging variants, absent in controls (internal database, n = 588), in the progesterone receptor (PGR) (six patients) and glucocorticoid receptor (NR3C1) (two patients) genes were identified within key functional domains, potentially disrupting the receptors' affinity for DNA or ligands.

CONCLUSION

Cervical insufficiency in non-syndromic patients is not attributed to a single connective tissue gene variant in a Mendelian fashion but rather to the cumulative effect of multiple inherited gene variants highlighting the significance of the connective tissue pathway in the multifactorial nature of CI. PGR or NR3C1 variants may contribute to the pathophysiology of CI and/or preterm birth through the impaired progesterone action pathways, opening new perspectives for targeted interventions and enhanced clinical management strategies of this condition.

Fascia lata allograft: a suitable alternative in ligamentous reconstruction for chronic elbow instability?

Background

Up to now, there is no gold standard concerning the optimal graft choice in the surgical therapy of chronic elbow instability. As donor site morbidity represents a rare (1%-4%) but severe complication of graft harvest, using an allograft seems favorable. Fascia lata mimics the anatomy through its fan-shaped configuration of the ligamentous complex of the elbow joint, making it questionable for use as a graft. The aims of the study are (1) to evaluate the biomechanical suitability of fascia lata allograft and (2) to compare clinical and radiological outcome between ligament reconstruction of the lateral collateral ligament complex using either FiberTape augmented triceps autograft or FibreTape augmented fascia lata allograft.

Methods

Biomechanical testing of fascia lata was performed using a 10 kN uniaxial test system with a 1 kN load cell. The retrospective cohort study evaluated all patients who received a ligament reconstruction of the elbow due to chronic instability with allogenic fascia lata or autologous triceps tendon. Exclusion criteria were any type of coexisting fracture or nerval injury. Demographic parameters, patient-reported outcome parameters and radiological stability parameters (sonography and fluoroscopy) were evaluated.

Results

Tensile testing of 39 fascia lata allografts revealed an ultimate load of 234.8 ± 23.1 N and ultimate strength of 33.4 ± 4.4 MPa. Twenty one patients were included in the clinical substudy (57.1% men, 42.9% women, age 41.0 ± 12.2 years, body mass index 24.9 ± 4.1 kg/m2) with average follow-up of 21.6 ± 17.1 months. No significant differences were found concerning pain level, patient-reported outcome measures, or range of motion, between fascia lata and triceps group. There was also no difference concerning sonographic stability of lateral ulnar collateral ligament between the 2 groups (P = .14). One revision occurred in fascia lata allograft group and 2 in triceps autograft group due to graft elongation.

Conclusion

Currently, there is no clinical evidence demonstrating the superiority of either autograft or allograft tissue. Due to its demonstration of sufficient biomechanical properties, fascia lata allograft seems an appropriate treatment option for ligamentous reconstruction of chronic elbow instability.

Recurrent patellar dislocation: personalised therapy or operative treatment? The REPPORT randomised trial protocol

INTRODUCTION

Recurrent patellar dislocation is a debilitating musculoskeletal condition, affecting mainly adolescents and adults under the age of 30. It can persist for many decades, causing pain and cartilage and soft-tissue damage, potentially leading to osteoarthritis. Recurrent patellar dislocation can be managed with physiotherapy or surgery. However, it is not known which treatment is most effective.

METHODS AND ANALYSIS

Recurrent Patellar Dislocation: Personalised Therapy or Operative Treatment (REPPORT) is a pragmatic, multicentre, two-arm, superiority, randomised controlled trial. It will compare the clinical and cost-effectiveness of an initial management strategy of personalised, phased and progressive rehabilitation, termed personalised knee therapy versus surgery for recurrent patellar dislocation.The trial's target sample size is 276 participants who will be recruited from approximately 20 sites across the UK. Participants will be randomly allocated to the two treatment groups via a central computer-based minimisation system. Treatment allocation will be in a 1:1 ratio, stratified by age, presence of patella alta and recruitment site.The primary outcome is participant-reported function using the Knee injury and Osteoarthritis Outcome 4-domain score at 18 months post randomisation. Health economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data including patellar instability, health utility, work/education status, satisfaction with social roles and treatment, health resource use and adverse events will be collected at 6, 12, 18 and 24 months. Analysis will be on an intention-to-treat basis and reported in-line with the Consolidated Standards of Reporting Trials statement.

ETHICS AND DISSEMINATION

The trial was approved by the East Midlands-Nottingham 2 Research Ethics Committee on 30 March 2023.Results will be disseminated via peer-reviewed publications, presentations at national and international conferences, in lay summaries, and using the REPPORT website and social media channels.

TRIAL REGISTRATION NUMBER

ISRCTN17972668.

Development, validation, and psychometric analysis of Foot and Ankle Flexibility Index (FAFI)

AIM

To develop a new tool for identifying joint hypermobility of the paediatric foot and ankle, based on a dichotomous scoring system utilising the Lower Limb Assessment Score (LLAS), to separate the foot and ankle items.

MATERIAL AND METHODS

A total of 205 children, aged between 5 and 10 years, participated in a cross-sectional study. The new tool Foot and Ankle Flexibility Index (FAFI) was predicated upon the last 7 items of LLAS, which are specific to the foot and ankle. The internal consistency was measured with Cronbach's test. Kappa statistics with 95% CI were calculated to verify the level of inter-rater and intra-rater agreement for the FAFI.

RESULTS

Cronbach's alpha returned 0.82. The correlations between items returned a mean of 0.59 (range: 0.43-0.74). The discrimination score on the ROC curve (4 points) showed that the model can be used to identify children with joint hypermobility of the foot and ankle. Inter-rater reliability was largely good (ICC = 0.89). Excellent intra-rater reliability was found (ICC = 0.96) CONCLUSIONS: This study identified high reliability between evaluators, and high sensitivity and specificity, for a new reliable and valid tool for the identification of foot and ankle joint hypermobility.

Behavioural, developmental and psychological characteristics in children with germline PTEN mutations: a carer report study

BACKGROUND

PTEN is primarily known as a tumour suppressor gene. However, research describes higher rates of difficulties including intellectual disability and difficulties relating to autism spectrum conditions (ASCs) in people with germline PTEN mutations. Other psychological characteristics/experiences are less often reported and are explored in this study.

METHODS

The parents of 20 children with PTEN mutations completed an online survey exploring adaptive behaviour, ASC-associated behaviours, anxiety, mood, hypermobility, behaviours that challenge, sensory experiences, quality of life and parental wellbeing. Published normative data and data from groups of individuals with other genetic neurodevelopmental conditions were used to contextualise findings.

RESULTS

Overall levels of adaptive behaviour were below the 'typical' range, and no marked relative differences were noted between domains. Higher levels of ASC-related difficulties, including sensory experiences, were found in comparison with 'typically developing' children, with a possible peak in restrictive/repetitive behaviour; ASC and sensory processing atypicality also strongly correlated with reported joint hypermobility. A relative preservation of social motivation was noted. Anxiety levels were found to be elevated overall (and to relate to sensory processing and joint hypermobility), with the exception of social anxiety, which was comparable with normative data. Self-injurious behaviour was common.

CONCLUSIONS

Results suggest a wide range of possible difficulties in children with PTEN mutations, including elevated anxiety. Despite elevated ASC phenomenology, social motivation may remain relatively strong. Firm conclusions are restricted by a small sample size and potential recruitment bias, and future research is required to further explore the relationships between such characteristics.

Single-Leg Heel Raise Capacity is Lower, and Perceived Ankle Instability is Greater, in Dancers and Athletes With Posterior Ankle Impingement Syndrome

OBJECTIVE

To compare clinical assessment findings between elite athletic populations with and without a clinical diagnosis of posterior ankle impingement syndrome (PAIS).

DESIGN

Cross-sectional case-control study.

SETTING

Elite ballet and sport.

PARTICIPANTS

Ten male and female professional ballet dancers and athletes with a clinical diagnosis of PAIS and were matched for age, sex, and activity to 10 professional ballet dancers and athletes without PAIS.

INDEPENDENT VARIABLES

Posterior ankle pain on body chart and a positive ankle plantarflexion pain provocation test.

MAIN OUTCOME MEASURES

Single-leg heel raise (SLHR) endurance test, range of motion testing for weight-bearing ankle dorsiflexion, passive ankle plantarflexion, and first metatarsophalangeal joint dorsiflexion, and Beighton score for generalized joint hypermobility. Participants also completed the Cumberland Ankle Instability Tool (CAIT) questionnaire.

RESULTS

The group with PAIS achieved significantly fewer repetitions on SLHR capacity testing ( P = 0.02) and were more symptomatic for perceived ankle instability according to CAIT scores ( P = 0.004).

CONCLUSIONS

Single-leg heel raise endurance capacity was lower, and perceived ankle instability was greater in participants with PAIS. The management of this presentation in elite dancers and athletes should include the assessment and management of functional deficits.

Recurrent Pediatric Thumb Carpometacarpal Joint Dislocation Due to Generalized Joint Laxity Successfully Treated With Ligament Reconstruction: A Case Report

Acute traumatic dislocation without fractures of the thumb carpometacarpal (CMC) joint is extremely rare in children. Treatment options, such as closed reduction with casting or pinning and open reduction with primary ligament repair, remain controversial. Here, we report the first case of an 11-year-old boy with recurrent left thumb CMC joint dislocation due to idiopathic generalized hyperjoint laxity, even after primary open reduction with capsular ligament repair of the thumb CMC joint, eventually treated with Eaton-Littler's ligament reconstruction. Intraoperatively, a drill hole was made in the base of the first metacarpal bone while carefully preventing growth plate injury. Primary ligament reconstruction of the thumb CMC joint may be considered in pediatric cases with systemic hyperjoint laxity or recurrent thumb CMC joint dislocation. In such cases, Eaton-Littler's ligament reconstruction is recommended for thumb CMC joint stability because two prime stabilizers of the dorsoradial ligament and the volar anterior oblique ligament (AOL) are appropriately reconstructed by a half-slip of the flexor carpi radialis tendon.

Hypermobility Among Adolescents and the Association With Spinal Deformities: A Large Cross-Sectional Study

INTRODUCTION

Adolescent idiopathic scoliosis and Scheuermann kyphosis are common spinal deformities (SD) among adolescents. The potential link between hypermobility and SD is a topic of debate. We aimed to investigate the prevalence of hypermobility and its association with SD.

METHODS

A cross-sectional analysis of records of 17-year-old subjects who were recruited into mandatory military service was conducted. Study population comprised 1,220,073 subjects. Prevalence rates were calculated for hypermobility and different categories of SD by severity, studying the strength of the association between hypermobility and SD.

RESULTS

Of 1,220,073 subjects, 0.0111% exhibited hypermobility. Spinal deformities were identified in 10.5% of subjects. Specifically, 7.9% had mild SD, 2.4% had moderate SD, and 0.1% had severe SD. The overall association between hypermobility and SD showed an odds ratio of 2.31 (P < 0.001). Subgroup analyses revealed ORs of 1.226 (P = 0.041) for mild deformities, 5.783 (P < 0.001) for moderate deformities, and 4.01 (P = 0.002) for severe deformities. The association was stronger for moderate and severe SD.

CONCLUSIONS

This study establishes a notable association between hypermobility and SD among adolescents. The findings highlight the importance of understanding this relationship, which could contribute to advancements in comprehending SD development. Additional research is warranted to expand upon these findings.

Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions

Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.

The strength of balance: Strength and dynamic balance in children with and without hypermobility

BACKGROUND

Generalized Joint hypermobility (GJH) is predominantly non-symptomatic. In fact, individuals with joint flexibility usually perform better than their non-hypermobile counterparts during physical activities. Notwithstanding, strength and balance are essential to maintain the control of the extra range of motion during activities and to prevent musculoskeletal complications. There are limited and conflicting pieces of evidence in literature regarding the association between strength and balance in children with GJH.

OBJECTIVES

The purpose of this study was to examine differences in functional strength, dynamic balance, proprioception, and isometric strength in children with and without joint hypermobility and determine the association between strength outcomes and dynamic balance.

METHOD

A cross-sectional study was conducted among children aged 6 to 11. Hypermobility was determined using the Beighton Score, with scores ≥6 representing hypermobility. Functional strength was assessed with the Functional Strength Measure (FSM), isometric strength was determined with a handheld dynamometer (HHD), the Y-Balance Test (YBT) was used to assess dynamic balance and the Wedges test to measure proprioception.

RESULTS

This study included 588 participants (age: 7.97 ± 1.3 years; height: 128±10.1 cm; mass: 27.18 ± 7.98 kg). 402 children were classified as having normal mobility and 186 as being hypermobile. Hypermobile children had better functional strength in the lower extremities than children with normal range mobility but lower reach distance in the YBT. No differences in proprioception, functional strength of the upper extremity or isometric strength in the hands were found. However, isometric lower extremity force was less in hypermobile children than children with normal range mobility. Irrespective of their joint mobility, a fair significant correlation existed between total Y-balance distance and FSM items r = 0.16-0.37, p = 0.01. Correlations between total Y-balance distance and isometric strength of knee and ankle muscles ranged between r = 0.26-0.42, p = 0.001.

CONCLUSION

Hypermobile joints seem to co-occur with lower extremity isometric strength, more functional strength in the lower extremities and less reaching distance in dynamic balance. The opposing direction of the results on functional and isometric strength tests highlights the importance of the type of outcome measures used to describe the association of strength and the range of motion.

Influence of the Menstrual Cycle and Training on the Performance of a Perturbed Single-Leg Squatting Task in Female Collegiate Athletes

Background

Anterior cruciate ligament (ACL) injuries often occur when an athlete experiences an unexpected disruption, or perturbation, during sports. ACL injury rates may also be influenced by the menstrual cycle.

Purpose

To determine whether training adaptations to knee control and muscle activity during a perturbed single-leg squatting (SLS) task depend on menstrual cycle phase in female athletes.

Study Design

Controlled laboratory study.

Methods

A total of 21 healthy female collegiate athletes (current or former [<3 years]) who competed in 9 different sports performed an SLS task in which they attempted to match their knee position (user signal) to a target signal. The protocol consisted of a 9-condition pretest, 5 sets of 3 training trials, and a 9-condition posttest. One perturbation was delivered in each condition by altering the resistance of the device. Sagittal knee control (absolute error between the target signal and user signal) was assessed using a potentiometer. Muscle activity during perturbed squat cycles was normalized to maximal activation and to corresponding muscle activity during unperturbed squat cycles (%unperturbed) within the same test condition. Athletes performed the protocol during a distinct menstrual cycle phase (early follicular [EF], late follicular [LF], midluteal [ML]). Two-way mixed analysis of variance was used to determine the effects of the menstrual cycle and training on knee control and muscle activity during task performance. Venous blood was collected for hormonal analysis, and a series of health questionnaires and anthropometric measures were also assessed to determine differences among the menstrual cycle groups.

Results

After training, athletes demonstrated better knee control during the perturbed squat cycles (lower absolute error, P < .001) and greater soleus feedback responses to the perturbation (%unperturbed, P = .035). Better knee control was demonstrated in the ML phase versus the EF phase during unperturbed and perturbed squat cycles (P < .039 for both). Quadriceps activation was greater in the ML phase compared with the EF and LF phases, both immediately before and after the perturbation (P < .001 for all).

Conclusion

Athletes learned to improve knee control during the perturbed performance regardless of menstrual cycle phase. The best knee control and greatest quadriceps activation during the perturbed squatting task was found in the ML phase.

Clinical Relevance

These findings may correspond to a lower incidence of ACL injury in the luteal phase and alterations in exercise performance across the menstrual cycle.

Chronic Pain and Joint Hypermobility: A Brief Diagnostic Review for Clinicians and the Potential Application of Infrared Thermography in Screening Hypermobile Inflamed Joints

Joint hypermobility syndromes, particularly chronic pain associated with this condition, including Hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD), present diagnostic challenges due to their multifactorial origins and remain poorly understood from biomechanical and genomic-molecular perspectives. Recent diagnostic guidelines have differentiated hEDS, HSD, and benign joint hypermobility, providing a more objective diagnostic framework. However, incorrect diagnoses and underdiagnoses persist, leading to prolonged journeys for affected individuals. Musculoskeletal manifestations, chronic pain, dysautonomia, and gastrointestinal symptoms illustrate the multifactorial impact of these conditions, affecting both the physical and emotional well-being of affected individuals. Infrared thermography (IRT) emerges as a promising tool for joint assessment, especially in detecting inflammatory processes. Thermal distribution patterns offer valuable insights into joint dysfunctions, although the direct correlation between pain and inflammation remains challenging. The prevalence of neuropathies among hypermobile individuals accentuates the discordance between pain perception and thermographic findings, further complicating diagnosis and management. Despite its potential, the clinical integration of IRT faces challenges, with conflicting evidence hindering its adoption. However, studies demonstrate objective temperature disparities between healthy and diseased joints, especially under dynamic thermography, suggesting its potential utility in clinical practice. Future research focused on refining diagnostic criteria and elucidating the underlying mechanisms of hypermobility syndromes will be essential to improve diagnostic accuracy and enhance patient care in this complex and multidimensional context.

Is joint hypermobility linked to self-reported non-recovery from COVID-19? Case-control evidence from the British COVID Symptom Study Biobank

Objectives

This study sought to explore whether generalised joint hypermobility (GJH, a common marker of variant connective tissue) was a risk factor for self-reported non-recovery from COVID-19 infection.

Design

Prospective observational study.

Setting

COVID Symptom Study Biobank (https://cssbiobank.com/) UK.

Participants

Participants were surveyed in August 2022. 3064 (81.4%) reported at least one infection with COVID-19. These individuals self-reported on recovery and completed a self-report questionnaire to detect GJH (Hakim and Grahame 5-part questionnaire, 5PQ).

Main outcome measures

The primary outcome was the presence of self-reported non-recovery from COVID-19 infection at the time of the survey. Additional outcomes included scores on 5PQ and self-reported fatigue level (Chalder Fatigue Scale).

Results

The presence of GJH was not specifically associated with reported COVID-19 infection risk per se. However, it was significantly associated with non-recovery from COVID-19 (OR 1.43 (95% CI 1.20 to 1.70)). This association remained after sequential models adjusting for age, sex, ethnic group, education level and index of multiple deprivation (OR 1.33 (95% CI 1.10 to 1.61)) and further adjustment for vaccination status and number of vaccinations (OR 1.33 (95% CI 1.10 to 1.60)). Additionally, including in a model adjusting for all covariates, hypermobility significantly predicted higher fatigue levels (B=0.95, SE=0.25, t=3.77, SE, p=0.002). Fatigue levels mediated the link between GJH and non-recovery from COVID-19 (estimate of indirect effect=0.18, 95% bootstrapped CI 0.08 to 0.29).

Conclusions

Individuals with GJH were approximately 30% more likely not to have recovered fully from COVID-19 infection at the time of the questionnaire, and this predicted the fatigue level. This observation is clinically important through its potential impact for understanding and identifying sub-phenotypes of long COVID for screening and personalised targeted interventions. More generally, greater awareness of GJH and its extra-articular associations is needed for effective patient stratification and implementation of personalised medicine.

Outcomes of an All-Soft Tissue Fixation Technique for Reconstruction of the Medial Patellofemoral Complex Using Double-Bundle Quadriceps Tendon Autograft for Recurrent Patellar Dislocation in Skeletally Immature Patients

Background

Patellar fracture, femoral physis injury, and recurrent instability are concerning complications in medial patellofemoral ligament (MPFL) reconstruction (MPFLR) techniques for recurrent patellar dislocation in children and adolescents.

Purpose

To evaluate the outcomes of an anatomic all-soft tissue fixation technique for reconstruction of the medial patellofemoral complex (MPFC) using a double-bundle quadriceps tendon (QT) autograft for recurrent patellar dislocation in skeletally immature patients.

Study Design

Case series; Level of evidence, 4.

Methods

This retrospective study involved 24 skeletally immature patients (24 knees; 16 women and 8 men; age range, 9.5-15 years) with recurrent patellar dislocation who underwent MPFC reconstruction using a double-bundle QT autograft between September 2018 and January 2021. Only soft tissue suture fixation was used on the femoral and patellar sides of the 2 bundles of the QT. Radiographs, computed tomography, and magnetic resonance imaging were used to evaluate physeal status, lower limb alignment, patellar height and tilt, trochlear morphology, tibial tubercle-trochlear groove distance, and any associated knee pathology. Functional outcomes were assessed with the Kujala score, the visual analog scale (VAS) for pain, and the grading system of Insall et al.22.

Results

The mean follow-up time was 40 ± 9.6 months (range, 28-56 months). At the final follow-up, the Kujala and VAS pain scores showed a significant improvement versus preoperative scores (P < .001), and the passive lateral patellar glide showed a significant reduction (P < .001). All patients had negative apprehension and J signs. Of the 24 patients, 23 regained full range of motion, while 1 patient had a knee flexion deficit. The patellar tilt angle improved significantly at the final follow-up (P < .001). There was no patellar fracture, femoral physis injury, or recurrence of patellar dislocation. According to the grading system of Insall et al, the results were excellent in 15 knees (62.5%), good in 8 knees (33.3%), fair in 1 knee (4.2%), and no knees showed poor results.

Conclusion

Reconstruction of the MPFC using a double-bundle QT autograft with an all-soft tissue fixation technique was an effective method for treating patellar instability in skeletally immature patients.

A Retrospective Study of the Presentation, Diagnosis, Management, and Outcomes of 27 Patients with Osteogenesis Imperfecta at a Single Center in Türkiye

BACKGROUND This retrospective study aimed to evaluate the presentation, diagnosis, management, and outcomes of 27 patients diagnosed with osteogenesis imperfecta at a single center in Türkiye between January 2011 and January 2020. MATERIAL AND METHODS We analyzed data from the medical records of 27 patients with osteogenesis imperfecta admitted to Çukurova University Faculty of Medicine, Department of Orthopedics and Traumatology, between January 2011 and January 2020. The data included the clinical examination notes of the cases classified according to the Sillence and Shapiro systems, age, sex, parental consanguinity, genetic analysis (DNA isolation) results, the number and localization of past fractures, treatment methods, complications, hypermobility, and ambulation scoring. RESULTS The mean age of the patients (n=13 male, n=14 female) was 10.4±7.4 years, ranging from 3 to 39 years. Almost half (n=15, 55.6%) had consanguineous parents. The patients had 131 fractures during the 9 years between January 2011 and January 2020, with the femur being the most commonly fractured bone; 13 patients (48.15%) received surgical and conservative treatments, while the remaining 14 underwent only conservative treatments. The results revealed a strong association between the number of fractures and the types of genetic mutations (P=0.004). CONCLUSIONS Study findings indicate that the type of genetic mutation was not significantly correlated with the risk of treatment complications in osteogenesis imperfecta cases. Nevertheless, the study reveals a noteworthy association between the type of mutation and the number of surgeries required. Specifically, patients with the COL1A1 mutation needed more surgeries.

Present but Ignored: Physical Condition and Health-Related Quality of Life in College-Aged Females with Generalized Joint Hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is prevalent among young adults, necessitating effective monitoring of musculoskeletal health, particularly among college-aged females. This study aimed to identify physical fitness and health-related quality of life (HR-QoL) characteristics associated with GJH.

METHODS

A total of 67 participants were assessed: 26 with GJH (mean age 20.06, SD 1.2 years), and 41 without (mean age 20.15, SD 2.2 years). Assessments included hypermobility, anthropometric data, foot posture, balance, flexibility, strength, and HR-QoL. We used the Mann-Whitney test for two independent samples, categorical variables were analyzed with Cramer's V test. The results indicated that participants with GJH exhibited inferior balance and back muscle static strength endurance but greater flexibility compared to those without GJH. Significant differences were observed in foot posture. However, handgrip strength, explosive strength, and abdominal muscle static strength endurance did not differ significantly between groups. No significant differences were observed in HR-QoL components between the two groups. In conclusion, there appears to be a link between GJH and increased flexibility, impaired balance, reduced back muscle static strength endurance, and altered posture of both feet.

Chronic anterior shoulder instability with bone loss: a practical approach

The stability of the glenohumeral joint, known for its remarkable mobility, relies on several factors, including the congruency of the joint's bones and the integrity of capsulolabral structures, encompassing the labrum, the capsule, and the glenohumeral ligaments. In cases of anterior shoulder instability, bone lesions are a common occurrence, most frequently involving glenoid bone loss and Hill-Sachs lesions. When both glenoid and humeral bone lesions coexist, the isolated Bankart procedure has exhibited a significant rate of failure. In such instances, the Latarjet procedure, especially when bone loss is present, retains its position as the gold standard, thanks to its consistent success in both short- and long-term outcomes. Recent advancements in research have explored alternative strategies to address bone loss, including the Remplissage procedure for humeral bone deficits and the use of bone block grafts to manage glenoid bone lesions, with a focus on achieving more anatomical techniques. However, it's crucial to recognize that, beyond bone loss, a multitude of intrinsic and extrinsic factors come into play when determining the most suitable treatment. The patient's profile, including factors like constitutional laxity and activity level, must be carefully considered in the decision-making process. The Latarjet procedure maintains its esteemed status as a benchmark in the field, thanks to its consistent excellence in both short- and long-term results. This article seeks to provide insights into the roles and placement of various surgical techniques within the context of chronic anterior shoulder instability, taking into account the intricate interplay of factors that influence treatment decisions.

An investigation of sensory processing skills in toddlers with joint hypermobility

BACKGROUND

Children with Generalized Joint Hypermobility (GJH) may have a motor developmental delay in the early period and subluxation, fatigue, autonomic dysfunction, and pain arising from ligaments and other soft tissues in advanced ages. Additionally, there is a loss of proprioceptive sensation in children and adults with GJH.

AIMS

This study aimed to evaluate sensory processing skills in toddlers with GJH.

STUDY DESIGN

A cross-sectional study.

SUBJECTS

Fifty-eight children aged between 12 and 14 months were included in the study. These children were divided into two groups: with and without GJH (31 with GJH and 27 without GJH).

OUTCOME MEASURES

The sensory processing skills of the children in the study were evaluated with the Test of Sensory Functions in Infants (TSFI).

RESULTS

The scores in the subtests of TSFI in response to tactile deep pressure, adaptive motor functions, visual-tactile integration, and response to vestibular stimuli were higher in favor of children without GJH (p < 0.05). The total TSFI score was higher in the group without GJH (p < 0.05).

CONCLUSIONS

Sensory processing problems were found in toddlers with GJH. Sensory motor development should be evaluated in children with GJH, and an appropriate early intervention program should be planned.