Joint hypermobility in adults referred to rheumatology clinics

Predisposing Anatomy for Thoracic Outlet Syndrome and Functional Outcomes after Supraclavicular Thoracic Outlet Decompression in Athletes

Purpose

This study aims to examine predisposing anatomic factors and subsequent post-decompression functional outcomes among high-intensity athletes with thoracic outlet syndrome (TOS).

Materials and Methods

A single-institution retrospective review was performed on a prospective database of patients with TOS from 2018 to 2023 who had undergone operative decompression for TOS. Demographics, TOS characteristics, predisposing anatomy, operative details, and postoperative outcomes were examined. The primary outcome was postoperative return to sport. Secondary outcomes included vascular patency.

Results

A total of 13 patients who were engaged in high-demand athletic activity at the time of their diagnosis were included. Diagnoses included 8 (62%) patients with venous TOS, 4 (31%) patients with neurogenic TOS, and 1 (8%) patient with arterial TOS. Mixed vascular and neurogenic TOS was observed in 3 (23%) patients. The mean age of the cohort was 30 years. Abnormal scalene structure was observed in 12 (92%) patients, and abnormal bone structures were noted in 4 (27%) patients; 2 (15%) with cervical ribs and 3 (23%) patients with clavicular abnormalities. Prior ipsilateral upper extremity trauma was reported in 4 (27%) patients. Significant joint hypermobility was observed in 8 (62%) patients with a median Beighton score of 6. Supraclavicular cervical and/or first rib resection with scalenectomy was performed in all patients. One case of postoperative pneumothorax was treated non-operatively. Ten (77%) patients returned to sport. Duplex ultrasonography showed subclavian vein patency in all 8 patients with venous TOS and wide patency with no drop in perfusion indices in the patient with arterial TOS.

Conclusion

Athletes with TOS who required operative intervention had a high incidence of musculoskeletal aberrations and joint hypermobility. Supraclavicular decompression was associated with a high success rate, with overall good functional outcomes and good likelihood of patients returning to preoperative high-intensity athletics.

Upslope walking increases anterior tibial translation deficiency in patients with generalized joint hypermobility

BACKGROUND

Generalized joint hypermobility (GJH) is a highly prevalent disease that frequently affects the knee joint. The current literature has conflicting results about whether patients with GJH had knee kinematics deficiency during gait. This could be because most of the testing environment (level walking) was gentle and low-demanding for patients when studying their knee kinematics. With a high-demanding knee function and sagittal firm structure requirement, upslope walking was thought to stimulate sagittal knee kinematics deficiency in patients with GJH.

RESEARCH QUESTIONS

However, only little investigation reported whether upslope walking could stimulate knee kinematic deficiency or not. We hypothesize that upslope walking can increase sagittal knee kinematic deficiency between GJH subjects and healthy controls.

METHODS

A three-dimensional motion analysis was conducted to explore whether upslope walking could stimulate sagittal knee kinematic deficiency in patients with GJH. A total of 44 patients with GJH and 44 healthy controls were recruited. Subjects walked on both level and upslope (15%) conditions when the kinematic data were collected. SPM1D analysis was taken to explore the differences between groups.

RESULTS

Our results showed that upslope walking could significantly increase knee flexion angle and anterior tibial translation in both GJH patients and healthy controls (p < 0.05). The increments of anterior tibial translation (values in upslope walking minus values in level walking) of GJH patients were greater than those of healthy controls (magnitude varying from 2.5 to 2.9 mm during 0-3% gait cycles (GC), p = 0.034; 1.4-2.9 mm during 93-100%GC, p = 0.012).

SIGNIFICANCES

The findings partially confirmed our hypothesis and suggested that upslope walking could increase anterior tibial translation deficiency in patients with GJH. Upslope walking may be a practical motion task in studying the weakness of knee kinematics of GJH subjects for researchers and scholars. Patients with GJH may face a more challenging knee kinematic environment than healthy controls in up-sloped activities.

Association between the Beighton Score and Stress Ultrasonographic Findings of the Anterior Talofibular Ligament in Healthy Young Women: A Cross-Sectional Study

The Beighton score (BS) is widely used to evaluate generalized joint laxity. However, the association between the BS and lateral ankle laxity is unclear. This study compared the ultrasonographic (US) findings of the anterior talofibular ligament (ATFL) between high- (≥6) and low- (≤3) BS groups of healthy young women. The ATFL lengths of healthy young women were measured in the stress and nonstress positions using the previously reported technique from March 2021 to January 2022. The ATFL ratio (ratio of stress to nonstress ATFL length) was used as an indicator of lateral ankle laxity. The anterior drawer test (ADT) was performed. The correlation between the BS and US findings was also examined. A total of 20 (high-BS group) and 61 (low-BS group) subjects with a mean age of 23.8 ± 1.0 years were included. The high-BS group showed a higher grade of ADT than the low-BS group. No significant differences were found in the nonstress and stress ATFL lengths and ATFL ratio (1.10 ± 0.05 vs. 1.09 ± 0.05, p = 0.19) between the groups. No correlation was found between the BS and US findings. In conclusion, this study did not detect significant differences in the US findings of the ATFL between the high- and low-BS groups.

Bone Block Grafting for Posterior Instability After Anatomical Total Shoulder Arthroplasty: A Case Report

CASE

A 60-year-old woman with avascular necrosis of the right humeral head underwent anatomical total shoulder arthroplasty (TSA); however, recurrent posterior dislocation occurred 13 months postoperatively. We performed bone block grafting of an autologous iliac crest to the posterior glenoid and posterior capsular plication, after which satisfactory postoperative shoulder function without residual joint instability was achieved.

CONCLUSION

The presented case had recurrent posterior dislocation after TSA without any abnormal findings in the prosthetic components. Posterior bone block grafting with capsular plication should be considered a viable option for posterior instability after anatomical TSA.

Nutritional Implications of Patients with Dysautonomia and Hypermobility Syndromes

PURPOSE OF REVIEW

Dysautonomia and hypermobility syndrome are two distinct but often overlapping clinical conditions that are recognized for their complex multiorgan system afflictions. The purpose of this review is to investigate dietary strategies to reduce symptoms and augment quality of life in this growing patient population.

RECENT FINDINGS

There is increasing evidence supporting dietary modifications to include food rich in probiotics and prebiotics, along with fiber supplements to reduce gastrointestinal symptoms. Adequate salt and fluid intake may reduce orthostatic hypotension symptoms. Dietary supplements may help with osteoarticular, musculoskeletal, and fatigue symptoms. Individualized diet strategies and supplements can reduce the multiorgan system symptoms observed in dysautonomia and hypermobility syndrome.

Clinical management of benign joint hypermobility syndrome: a case series

BACKGROUND

Benign Joint Hypermobility Syndrome (BJHS) is a relatively prevalent condition of the spectrum of heritable connective tissue disorders, with musculoskeletal, visceral and psychological manifestations. The conservative management of the musculoskeletal symptomatology must be modified for optimal effectiveness and minimal sequelae.

PURPOSE

To provide an overview of the presentation, assessment, chiropractic management, and outcomes of patients with BJHS.

STUDY DESIGN

Case series.

DISCUSSION

Recognizing joint hypermobility as a significant contributing factor in patients presenting with musculoskeletal complaints is often challenging. The lack of awareness of BJHS may delay the diagnosis as well as effective management. Manual therapy should be used judiciously; active exercise is an essential element of care. We provide an overview of the presentations, assessment, chiropractic management, and outcomes of three patients with BJHS. Future clinical trials are necessary to determine effective clinical management strategies for patients with BJHS.

Relationship of joint hypermobility with low Back pain and lumbar spine osteoarthritis

BACKGROUND

Chronic low back pain (cLBP) affects millions of Americans and costs billions. Studies suggest a link between cLBP and joint hypermobility.

METHODS

We conducted cross-sectional primary analyses of joint hypermobility and cLBP, lumbar spine osteoarthritis (OA), and lumbar facet joint OA (FOA) in 3 large studies-the Generalized Osteoarthritis Study, Genetics of Generalized Osteoarthritis Study, and Johnston County Osteoarthritis Project (total n = 5072). Associations of joint hypermobility and Beighton trunk flexion with cLBP and lumbar OA were estimated using separate adjusted logistic regression models. Adjusted pooled odds ratios (pORs) and 95% confidence intervals (CIs) were then summarized-using random effect univariate, multivariate crude, and adjusted models-and heterogeneity was determined (I² statistic).

RESULTS

In univariate models, hypermobility was associated with symptomatic FOA (pOR = 0.64 [95% CI 0.44, 0.93]) but this result was not found in the multivariate models. In multivariate adjusted models, hypermobility was not significantly associated with cLBP and lumbar OA, but trunk flexion was inversely associated with cLBP (pOR = 0.40 [95% 0.26, 0.62]), spine OA (pOR = 0.66 [95% CI 0.50, 0.87]), symptomatic spine OA (pOR = 0.39 [95% CI 0.28, 0.53]), and symptomatic FOA (pOR = 0.53 [95% CI 0.37, 0.77]). Generally, between-study heterogeneity was moderate-high.

CONCLUSIONS

Hypermobility was not associated with cLBP or lumbar OA. The inverse association of trunk flexion with cLBP and lumbar OA may indicate a role for a flexible spine in avoiding or managing these conditions.

Fibromyalgia as a Predictor of Increased Postoperative Complications, Readmission Rates, and Hospital Costs in Patients Undergoing Posterior Lumbar Spine Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

The aim of this study was to identify whether a concomitant diagnosis of fibromyalgia (FM) influences postoperative complications, readmission rates or cost following primary 1 to 2 level lumbar fusions in an elective setting.

SUMMARY OF BACKGROUND DATA

Patients with FM often are limited by chronic lower back pain, many of whom will seek operative treatment. No previous study has evaluated whether patients with a concomitant diagnosis of FM have more complications following spine surgery.

METHODS

Medicare data (2005-2014) from a national database was queried for patients who underwent primary 1 to 2 level posterolateral lumbar spine fusion for degenerative lumbar pathology. Thirty- and 90-day postoperative complication rates, readmission rates, and treatment costs were queried. To reduce confounding, FM patients were matched with a control cohort of non-FM patients using patient demographics, treatment modality, and comorbid conditions, and then analyzed by multivariable logistic regression.

RESULTS

Within the first 30-day postoperative, acute post hemorrhagic anemia (odds ratio [OR]: 2.58; P < 0.001) and readmission rates were significantly higher in FM patients compared to controls. There was no significant difference in wound related complications within first 30-days (0.19% vs. 0.23%; P = 0.520) or with length of stay (3.60 vs. 3.53 days; P = 0.08). Within 90-day postoperative, FM patients had higher rates of pneumonia (OR: 3.73; P < 0.001) and incurred 5.31% more in hospital charges reimbursed compared to the control cohort.

CONCLUSION

Primary 1 to 2 level lumbar fusions performed on FM patients have higher rates of postoperative anemia, pneumonia, cost of care, and readmission compared to match controls. FM patients and surgeons should be aware of these increased risks in an effort to control hospital costs and potential complications.

LEVEL OF EVIDENCE

3.

Thoracic Outlet Syndrome: Biomechanical and Exercise Considerations

Thoracic outlet syndrome (TOS) describes a group of disorders that are due to a dynamic compression of blood vessels or nerves, between the clavicle and first rib or cervical vertebral nerve roots. Individuals with TOS typically experience upper limb pain, numbness, tingling, or weakness that is exacerbated by shoulder or neck movement. The causes of TOS vary, and can include abrupt movements, hypertrophy of the neck musculature, and anatomical variations in which the brachial plexus roots pass through this musculature, edema, pregnancy, repeated overhead motions, the blockage of an artery or vein, or abnormal posture. To understand the complexity of this condition, an analysis of shoulder anatomy and mechanics are needed to help describe limitations and the subsequent pathophysiology of TOS. Several treatment options are available, including surgery, medications, and exercise. A comprehensive study of shoulder anatomy and biomechanics, and knowledge of the benefits of exercise, may help clinicians and healthcare practitioners determine the most appropriate treatment plan for an individual with TOS.

Range of Ankle Dorsiflexion in a Group of Adults with Ligamentous Laxity

BACKGROUND

Ligamentous or joint laxity is a clinical entity characterized by increased joint mobility beyond the range of motion regarded as normal, and joint mobility is an effective indicator of the degree of laxity. We examined the influence of ligamentous laxity on the range of ankle dorsiflexion with the knee flexed and extended, comparing lax adults with a control (nonlax) group.

METHODS

The sample comprised 400 individuals: 200 in the control group (mean ± SD age, 32.49 ± 11.06 years) and 200 in the lax group (mean ± SD age, 29.82 ± 9.40 years). The Beighton criteria were applied to each participant to diagnose laxity or nonlaxity, and sex, age, and angle range of bilateral dorsiflexion with the knee extended and flexed were recorded.

RESULTS

The mean ± SD dorsiflexion range with the knee straight was 16.14° ± 5.29° left ankle and 21.21° ± 4.93° right ankle in the lax group and 12.94° ± 4.17° left ankle and 17.08° ± 4.40° right ankle in the control group. The respective values with the knee flexed were 15.84° ± 5.31° and 21.21° ± 4.80° in the lax group and 12.95° ± 3.95 and 17.23° ± 4.25° in the control group.

CONCLUSIONS

In this sample, ankle dorsiflexion range in the lax group was 4° bigger than that in the control group in both knee positions.

Impact of Generalized Joint Laxity on Plantar Loading Patterns in Young Females

BACKGROUND

Generalized joint laxity is often associated with gait deviations. The aim of this study was to investigate the static and dynamic loading pattern of the foot with increasing joint mobility and to discuss the potential impact of this condition on the plantar loading patterns.

METHODS

Seventy female participants between ages of 18 and 30 were included in this cross-sectional survey. The Beighton-Horan Joint Mobility Index scores were assessed and participants divided into 3 categories: no hypermobility (NH) group, scores 0 to 2; moderate hypermobility (MH) group, scores 3 to 4; distinct hypermobility (DH) group, scores 5 to 9. Pedobarographic analysis was performed both in static and walking conditions. Dynamic foot loading examined in 10 anatomic zones. Contact areas of forefoot, midfoot, and rearfoot were recorded.

RESULTS

In the dynamic pedobarographic analysis, individuals with distinct joint hypermobility displayed higher peak pressure and maximum force values under the hallux, compared with other groups ( P < .05). The maximum force value of the second metatarsal was higher in the DH group than in the MH group ( P < .05).

CONCLUSION

Our study results suggest that plantar loading pattern differs with increasing degrees of the hypermobility score.

CLINICAL RELEVANCE

Differences in plantar loading parameters in people with severe joint mobility scores may be useful in interpreting the foot pathologies of these individuals.

Sense of extension force and angle of the knee joint are correlated between two generations of men

Numerous motor abilities depend on the activity of proprioceptors, which has been suggested to be genetically determined. To test this hypothesis, the control of torque generated by knee extensors and knee position was studied in 30 father-son pairs both before and immediately after running. After stabilisation of the participant in a sitting position, the knee joint of his dominant leg was flexed to 90°, and the maximal voluntary torque (MVT) of the dominant knee extensors under static conditions was measured. The participant then tried five times to produce 50% of the MVT. Next, the participant extended the knee to 45° five times without visual control. Significant correlations between the reproducibility of successive trials for groups of fathers and their sons were found. The correlation coefficients for the repeatability of the knee extension torque were 0.69 (confidence interval [CI] = 0.45-0.84; P < 0.01) and 0.75 (CI = 0.54-0.87; P < 0.01) before and after the fatiguing exercise, respectively, whereas the coefficient for the reproducibility of positioning the knee was 0.49 (CI = 0.16-0.72; P < 0.01) after the fatiguing exercise. Our results indicate a significant influence of hereditary factors on the control of limb torque and position.

Joint hypermobility and oligoarticular juvenile idiopathic arthritis: What relationship?

AIM

Oligoarticular onset juvenile idiopathic arthritis (oJIA) is characterised by a prevalent lower limb involvement, antinuclear antibodies (ANA) positivity and high risk of anterior uveitis. As we observed that oJIA patients frequently present with joint hypermobility (JH), we investigated whether there was a relationship between oJIA and JH.

METHODS

Our series consisted of children with oJIA, as defined by the International League of Associations for Rheumatology criteria, for whom complete clinical data of at least 2 years' duration were available. Clinical and laboratory data, collected at disease onset and at the last follow-up, included: sex, age, presence of JH according to the Beighton score, disease activity, presence of uveitis, ANA, treatment and outcome.

RESULTS

A total of 274 oligoarticular JIA patients (224 female, 50 male; mean age: 11.5) followed on average for 6.6 years, entered the study. The mean age at disease onset was 4.9 years, ANA were positive in 83.9% and uveitis occurred in 20.8%. JH was present in 70.8% of cases at onset, in 44.5% at the last evaluation. JH was more frequent in females (73.7%) than in males (58.0%) (P = 0.028). Uveitis was less frequent in hypermobile children both at diagnosis (17.5 vs. 28.7%, P = 0.037) and during overall disease course (23.7 vs. 36.3%, P = 0.034). Of 163 subjects with at least 5-year follow-up, the full clinical remission rate was significantly higher in JH patients (50.5%) than in those without JH (42.3%; P = 0.042).

CONCLUSION

In patients with oligoarticular JIA, JH is more frequent than in healthy subjects, uveitis less frequent and the long-term outcome better.

Postural balance control in women with generalized joint laxity

Objectives

This study aims to investigate the potential relationship between joint laxity and postural balance by using tetra-ataxiometric posturography (Tetrax®).

Patients and methods

A total of 69 healthy volunteers were included in the study and classified into three groups based on their hypermobility severity determined with Beighton-Horan hypermobility index scores. Of those, 29 participants were non-hypermobile, 13 participants were mildly hypermobile and remaining 27 patients had severe hypermobility. Postural control of the participants was evaluated by using the Tetrax® device in eight different positions. The stability index, Fourier index, weight distribution index, and synchronization index scores of each participant were recorded.

Results

We found that the participants with severe hypermobility exhibited significantly higher stability index scores while the position of the head is extended and rotated right. The weight distribution index on elastic surfaces was impaired in non-hypermobile and severely hypermobile participants. We observed that the Fourier Index scores were higher at a higher-medium frequency (0.5-1 Hz) in participants with severe hypermobility. There was no difference between the groups in terms of synchronization index scores.

Conclusion

These findings suggest that severely hypermobile individuals have a decreased postural stability in head-extended and head- rotated positions when compared to individuals who are non-hypermobile. This increased instability may lead to an increased risk of musculoskeletal injuries, especially in sports that require extension and rotation movements of the head.

The impact of generalized joint laxity (GJL) on the posterior neck pain, cervical disc herniation, and cervical disc degeneration in the cervical spine

BACKGROUND CONTEXT

Generalized joint laxity (GJL) can have a negative impact on lumbar spine pathology, including low back pain, disc degeneration, and disc herniation, but the relationship between GJL and cervical spine conditions remains unknown.

PURPOSE

To investigate the relationship between GJL and cervical spine conditions, including the prevalence of posterior neck pain (PNP), cervical disc herniation (CDH), and cervical disc degeneration (CDD), in a young, active population.

STUDY DESIGN

Retrospective 1:2 matched cohort (case-control) study from prospectively collected data PATIENT SAMPLE: Of a total of 1853 individuals reviewed, 73 individuals with GJL (study group, gruop A) and 146 without GJL (control group, Group B) were included in the study according to a 1:2 case-control matched design for age, sex, and body mass index.

OUTCOME MEASURE

The primary outcome measure was the prevalence and intensity of PNP at enrollment based on a visual analogue scale score for pain. The secondary outcome measures were (1) clinical outcomes as measured with the neck disability index (NDI) and 12-item short form health survey (SF-12) at enrollment, and (2) radiological outcomes of CDH and CDD at enrollment.

METHODS

We compared baseline data between groups. Descriptive statistical analyses were performed to compare the 2 groups in terms of the outcome measures.

RESULTS

The prevalence and intensity of PNP were significantly greater in group A (patients with GJL) than in group B (patients without GJL) (prevalence: p=.02; intensity: p=.001). Clinical outcomes as measured with NDI and SF-12 did not differ significantly between groups. For radiologic outcomes, the prevalence of CDD was significantly greater in group A than in group B (p=.04), whereas the prevalence of CDH did not differ significantly between groups (p=.91).

CONCLUSIONS

The current study revealed that GJL was closely related to the prevalence and intensity of PNP, suggesting that GJL may be a causative factor for PNP. In addition, GJL may contribute to the occurrence of CDD, but not CDH. Spine surgeons should screen for GJL in patientswith PNP and inform patients of its potential negative impact on disc degeneration of the cervical spine.

Alterations in neuromuscular function in girls with generalized joint hypermobility

Background

Generalized Joint Hypermobility (GJH) is associated with increased risk of musculoskeletal joint pain. We investigated neuromuscular performance and muscle activation strategy.

Methods

Girls with GJH and non-GJH (NGJH) performed isometric knee flexions (90°,110°,130°), and extensions (90°) at 20 % Maximum Voluntary Contraction, and explosive isometric knee flexions while sitting. EMG was recorded from knee flexor and extensor muscles.

Results

Early rate of torque development was 53 % faster for GJH. Reduced hamstring muscle activation in girls with GJH was found while knee extensor and calf muscle activation did not differ between groups. Flexion-extension and medial-lateral co-activation ratio during flexions were higher for girls with GJH than NGJH girls.

Conclusions

Girls with GJH had higher capacity to rapidly generate force than NGJH girls which may reflect motor adaptation to compensate for hypermobility. Higher medial muscle activation indicated higher levels of medial knee joint compression in girls with GJH. Increased flexion-extension co-activation ratios in GJH were explained by decreased agonist drive to the hamstrings.

Maxillofacial prosthetic rehabilitation for esophageal and laryngeal laxity due to the hypermobility syndrome: A clinical report

Laryngeal and esophageal laxity resulting from a connective tissue disease can lead to severe pain and functional impairment. This clinical report describes a patient with such significant neck pain that it prevented her from speaking; it also caused pain with deglutition. Maxillofacial prosthetic rehabilitation with an external laryngeal and esophageal support significantly reduced the patient's pain and restored normal speaking and deglutition functions. This clinical report describes the design and fabrication of a support to stabilize the patient's laryngeal and esophageal structures to her midline.

Plantar pressure patterns in women affected by Ehlers-Danlos syndrome while standing and walking

This study aims to quantitatively characterize plantar pressure distribution in women affected by Ehlers-Danlos syndrome of the hypermobile type (EDS-HT) to verify the existence of peculiar patterns possibly related to postural anomalies or physical and functional lower limb impairments typical of this disease. A sample of 26 women affected by EDS-HT (mean age 36.8, SD 12.0) was tested using a pressure platform in two conditions, namely static standing and walking. Raw data were processed to assess contact area and mean and peak pressure distribution in rearfoot, midfoot and forefoot. Collected data were then compared with those obtained from an equally numbered control group of unaffected women matched for age and anthropometric features. The results show that, in both tested conditions, women with EDS-HT exhibited significantly smaller forefoot contact areas and higher peak and mean pressure than the control group. No differences in the analyzed parameters were found between right and left limb. The findings of the present study suggest that individuals with EDS-HT are characterized by specific plantar pressure patterns that are likely to be caused by the morphologic and functional foot modification associated with the syndrome. The use of electronic pedobarography may provide physicians and rehabilitation therapists with information useful in monitoring the disease's progression and the effectiveness of orthotic treatments.

Children with generalised joint hypermobility and musculoskeletal complaints: state of the art on diagnostics, clinical characteristics, and treatment

INTRODUCTION

To provide a state of the art on diagnostics, clinical characteristics, and treatment of paediatric generalised joint hypermobility (GJH) and joint hypermobility syndrome (JHS).

METHOD

A narrative review was performed regarding diagnostics and clinical characteristics. Effectiveness of treatment was evaluated by systematic review. Searches of Medline and Central were performed and included nonsymptomatic and symptomatic forms of GJH (JHS, collagen diseases).

RESULTS

In the last decade, scientific research has accumulated on all domains of the ICF. GJH/JHS can be considered as a clinical entity, which can have serious effects during all stages of life. However research regarding the pathological mechanism has resulted in new potential opportunities for treatment. When regarding the effectiveness of current treatments, the search identified 1318 studies, from which three were included (JHS: n = 2, Osteogenesis Imperfecta: n = 1). According to the best evidence synthesis, there was strong evidence that enhancing physical fitness is an effective treatment for children with JHS. However this was based on only two studies.

CONCLUSION

Based on the sparsely available knowledge on intervention studies, future longitudinal studies should focus on the effect of physical activity, fitness, and joint stabilisation. In JHS and chronic pain, the effectiveness of a multidisciplinary approach should be investigated.

Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity

PURPOSE

The reproductive hormone relaxin acts to loosen pelvic ligaments in preparation for childbirth and is thought to be a mediator of joint laxity. The purpose of this study was to evaluate the correlation of serum relaxin with radiographic laxity at the trapezial-metacarpal joint and with generalized joint laxity.

METHODS

We enrolled 289 healthy subjects prospectively. Participants completed a demographic questionnaire and were examined for generalized joint hypermobility using the Beighton-Horan scale. Stress radiographs of the trapezial-metacarpal joint were obtained in 163 subjects (56%). Blood samples were collected, and serum relaxin was measured for 287 subjects using enzyme-linked immunosorbent assay for human relaxin-2.

RESULTS

The mean serum relaxin level among all subjects was 1.84 pg/mL (range, 0-45.25 pg/mL). Relaxin was not detectable in 166 of 287 samples, whereas the mean serum relaxin level among the 121 subjects with a detectable relaxin level (of 287 total relaxin samples) was 4.37 pg/mL (range, 0.46-45.25 pg/mL). Mean trapezial-metacarpal subluxation ratio scores were higher among those with a detectable relaxin level compared to those without a detectable relaxin level (0.34 vs 0.30 pg/mL). The average Beighton-Horan laxity score was 1.8 (range, 0-9). There was no correlation between generalized joint laxity measures and serum relaxin levels.

CONCLUSIONS

In a large volunteer population, we demonstrated a relationship between circulating relaxin and trapezial-metacarpal joint laxity. However, we were unable to show a direct link between serum relaxin and generalized joint laxity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Collagen gene variants previously associated with anterior cruciate ligament injury risk are also associated with joint laxity

Background:

Genetic association studies demonstrate a relationship between several collagen gene variants and anterior cruciate ligament (ACL) injury, yet the mechanism of these relationships is still unclear. Joint laxity is a heritable trait; increased magnitudes of anterior knee laxity (AKL), genu recurvatum (GR), and general joint laxity (GJL) have been consistently associated with a greater risk of ACL injury. Joint laxity may constitute an important intermediate phenotype for the genetic association with ACL injury that can be measured clinically.

Hypothesis:

To determine if genetic variants within the COL1A1, COL5A1, and COL12A1 genes, previously associated with ACL injury, were also associated with greater magnitudes of AKL, GR, and GJL.

Study Design:

Descriptive laboratory study.

Methods:

Blood samples and measures of AKL, GR, and GJL were obtained from 124 (50 male, 74 female) healthy, recreationally active subjects. Genomic DNA was extracted from the blood samples and genotyped for single-nucleotide polymorphisms previously examined relative to ACL injury. Univariate analyses of variance compared the magnitude of each laxity variable across the 3 genotypes for each single-nucleotide polymorphism in both sex-combined and sex-specific models.

Results:

Specific genotypes were associated with greater GR in all subjects. Some genotypes were associated with greater magnitudes of GR, AKL, and GJL in females only.

Conclusions:

Gene variants previously associated with ACL injury risk were in large part also associated with joint laxity. Sex-specific genetic associations with joint laxity were consistent with those previously reported for ACL injury.

Clinical Relevance:

These data provide insight into potential pathways through which genotypic variants in collagen genes have the potential to alter ligament structure and behavior and, thus, ACL injury risk.

Primary total knee arthroplasty in patients with fibromyalgia

No data on the results of total knee arthroplasty (TKA) in patients with fibromyalgia have been published. The purposes of this study were to review a cohort of patients with fibromyalgia undergoing TKA to determine the level of postoperative pain and satisfaction with the surgery, the incidence of postoperative surgical complications, and revision rates and their relationship to TKA design. One hundred ten patients with fibromyalgia (141 knees) who underwent primary TKA between 1990 and 2001 were studied. The average age was 64 years (range, 39-86 years), and the average follow-up was 7 years (range, 2-16 years). Forty-five knees were cruciate retaining, and 96 had a posterior stabilized design. Clinical outcome was assessed using the Knee Society Knee Score and satisfaction regarding the results of the procedure. Postoperative surgical complications and reoperations were obtained from the registry. Sixty-two patients (44%) continued with some pain after TKA. Eighty-five patients (82%) were satisfied with the results. The most common complications were arthrofibrosis and symptomatic instability. The revision rate was 6% (8 knees). Survivorship free from revision at 7 years was 89% for cruciate retaining knees and 98% for posterior stabilized knees. Patients with fibromyalgia undergoing primary TKA have a high prevalence of complications and pain. Despite continued pain, the majority of patients were satisfied with the results and reported improvements after TKA. This data should be used to counsel patients with fibromyalgia preoperatively regarding limited goals with respect to pain relief and suggests that a multimodal individualized treatment program may be necessary to achieve optimal outcomes in patients with fibromyalgia.

The role of the elastic fiber system in the pathogenesis of osteoarthritis and knee joint laxity

Osteoarthritis (OA) is a disease of synovial joints in which all articular structures are affected. Evidence suggests that a decreased density in the elastic fiber concentration of the knee capsule is associated with joint hypermobility, a condition associated with OA. However, there is no study that shows a direct relationship between the elastic fiber system and knee OA. The purpose of this study is to determine if there is a correlation between the elastic fiber density in medial (MCL) and lateral (LCL) collateral ligaments and the severity of OA. The elastic fiber concentration in MCL and LCL were examined in cadaver knees (n = 10; 4 M, 6 F). The elastic fiber density, measured as the concentration of elastic fibers per unit area, was correlated with the severity of OA, which was graded on a 0-16 scale using histologic and macroscopic markers. Among all subjects, elastic fiber concentrations between MCL (mean 15.49% ± 2.49) and LCL (mean 13.93 ± 3.63) showed a significant difference (P = 0.023). There were no inter-gender differences between the elastic fiber concentration in either MCL or LCL. Among all subjects, the severity of OA was found to be correlated negatively with the elastic fiber concentration in both MCL (r = -0.693, P ≤ 0.05) and LCL (r = -0.718, P ≤ 0.05). This is the first study to show a correlation between the elastic fiber system and knee OA.

Electromyographic activity of pelvic and lower limb muscles during postural tasks in people with benign joint hypermobility syndrome and non hypermobile people. A pilot study

Benign joint hypermobility syndrome (BJHS) is associated with the early development of certain degenerative conditions, which may be associated with altered muscle activity. This pilot study compared muscle activation patterns during postural tasks between people with BJHS who do not have pain and people with normal flexibility (control group). Sixteen subjects aged 22-45 years (8 with BJHS) were selected from a population recruited to a larger study. Electromyographic activity of erector spinae (ES), gluteus medius (GM), and lower limb (rectus femoris (RF), semitendinosus (ST), tibialis anterior (TA) and gastrocnemius lateralis) muscles was assessed, and chosen based on the muscles being tested in the larger study. Subjects carried out 30 s of quiet standing (QS) and one-leg standing (OLS), both with eyes open (EO) and eyes closed (EC). Both groups had significantly more TA activity, and control subjects had significantly more GM activity, during OLS EC compared with QS. GM activity was not significantly different between groups. Compared with the BJHS group, control subjects had significantly less ST activation overall, significantly more ES activity during OLS EC and significantly less RF-ST co-contraction during QS. This study has noted differences in muscle activation patterns between pain-free hypermobile people and control subjects, specifically involving muscles surrounding the pelvis and hip. This pilot data suggests that strategies for stabilising the body during balancing tasks may be relevant to injury risk in people with BJHS. While results need to be verified with a larger subject sample, this study is important in developing new treatments for hypermobile people.

Joint hypermobility and anxiety: the state of the art

Joint hypermobility (JH) is considered a common benign, hereditary, overlap, connective tissue disorder with a prevalence in the general population of about 10% in European populations and 25% in other ethnic groups. JH shows an association with mitral valve prolapse and fibromyalgia. However, the most significant and important association between joint hypermobility syndrome (JHS) and any other disorder from a clinical point of view is with panic disorder. This article summarizes all published studies on JHS and anxiety, analyzing the main results and limitations. An overview of the etiologic explanation of the association between JH and anxiety, with special focus on genetic findings, is also included. The most relevant conclusions are the following: JHS is more prevalent in individuals with panic disorder/agoraphobia, and patients with JHS present with greater prevalence of panic disorder/agoraphobia. In addition, there is an association between JHS severity and severity of anxiety, and mitral valve prolapse plays a secondary role in the association between JHS and anxiety. New fields of research based on these data are suggested.

Incidence of joint hypermobility syndrome in a military population: impact of gender and race

BACKGROUND

Joint hypermobility syndrome is defined by abnormal laxity in multiple joints in association with symptomatic joint pain. Previous studies in small populations suggest a predominance of female gender and nonwhite race among those diagnosed with hypermobility syndrome.

QUESTIONS/PURPOSES

We investigated the epidemiology of joint hypermobility in a large military population, presuming this syndrome would be less prevalent in this specialized population but that demographic analysis would reveal risk factors for this rare condition.

METHODS

We queried the Defense Medical Epidemiology Database by race, gender, military service, and age for the years 1998 to 2007 using the International Classification of Diseases, 9th Revision code 728.5 (hypermobility syndrome).

RESULTS

We identified 790 individuals coded for joint hypermobility syndrome among a population at risk of 13,779,234 person-years for a raw incidence rate of 0.06 per 1000 person-years. Females had a higher incidence rate for joint hypermobility syndrome compared with males. Racial stratification showed service members of white race had higher rates of joint hypermobility syndrome compared with service members categorized as black and "other."

CONCLUSIONS

In a large, established military database it appears joint hypermobility syndrome is a rare condition within the young, active population we studied and female gender is the most important risk factor.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Motor competence and physical activity in 8-year-old school children with generalized joint hypermobility

OBJECTIVE

Because the criteria used for diagnosing between generalized joint hypermobility (GJH) and musculoskeletal complaints, as well as relations between GJH and an insufficient motor development and/or a reduced physical activity level differ, the prevalence of GJH varies considerably. The aim of this study was to survey the prevalence of GJH defined by a Beighton score at >or=4, >or=5, or >or=6 positive tests of 9 and benign joint hypermobility syndrome (BJHS) in Danish primary school children at 8 years of age. A second aim was to compare children with and without GJH and BJHS regarding motor competence, self-reported physical activity, and incidence of musculoskeletal pain and injuries.

METHODS

A cross-sectional study of 524 children in the second grade from 10 public schools was performed. A positive response rate was obtained for 416 (79.4%) children, and 411 (78.4%) children were clinically examined and tested for motor competence, whereas questionnaire response to items comprising musculoskeletal pain and injuries, in addition to daily level and duration of physical activity, corresponded to 377 (71.9%) children.

RESULTS

In total, 29% of the children had GJH4, 19% had GJH5, 10% had GJH6, and 9% had BJHS, with no gender difference. There was no difference in daily level and duration of physical activity and in frequency of musculoskeletal pain and injuries between those with and without GJH. Children with >or=GJH5 as well as with >or=GJH6 performed better in the motor competence tests.

CONCLUSION

Motor competence and physical activity are not reduced in primary school children at 8 years of age with GJH or BJHS. It is recommended that a potential negative influence on the musculoskeletal system over time, as a result of GJH, be investigated by longitudinal studies.

Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders

The aim of this study was to analyze whether generalized joint hypermobility (GJH) is a risk factor for temporomandibular disorders (TMD). We examined 895 subjects (20-60 yr of age) in a population-based cross-sectional sample in Germany for GJH according to the Beighton classification and for TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD). After controlling for the effects of age, gender, and general joint diseases using multiple logistic regression analyses, hypermobile subjects (with four or more hypermobile joints on the 0-9 scale) had a higher risk for reproducible reciprocal clicking as an indicator for disk displacement with reduction (Odds Ratio (OR) = 1.68) compared with those subjects without hypermobile joints. Concurrently, subjects with four or more hypermobile joints had a lower risk for limited mouth opening (< 35 mm; OR = 0.26). The associations between GJH and reproducible reciprocal clicking or limited mouth opening were statistically significant in a trend test. No association was observed between hypermobility and myalgia/arthralgia (RDC/TMD Group I/IIIa). In conclusion, GJH was found to be associated with non-painful subtypes of TMD.

Inverse association of general joint hypermobility with hand and knee osteoarthritis and serum cartilage oligomeric matrix protein levels

OBJECTIVE

Extensive joint hypermobility, lower serum cartilage oligomeric matrix protein (COMP) levels, and early-onset osteoarthritis (OA) are phenotypes of inherited pseudoachondroplasia and multiple epiphyseal dysplasia. However, few studies have evaluated the association between articular hypermobility and primary OA. We undertook the present study to evaluate this association and to test the hypothesis that COMP levels are associated with hypermobility in patients with OA and individuals without OA.

METHODS

Two separate cohorts were available for analysis, the CARRIAGE (CARolinas Region Interaction of Aging Genes and Environment) extended family and a subset of the GOGO (Genetics of Generalized Osteoarthritis) sibpair cohort. In the CARRIAGE family, we performed hand and knee examinations and hypermobility evaluations (Beighton criteria) and obtained sera for measurement of COMP and hyaluronan (HA). Data on COMP and HA levels and extensive joint radiographic and hypermobility data were also available for the GOGO cohort.

RESULTS

The prevalence of hypermobility was 13% in the CARRIAGE family and 5% in the GOGO cohort. In the CARRIAGE family, hypermobility was associated with a significantly reduced prevalence of hand (especially proximal interphalangeal joint) and knee OA and lower mean serum COMP levels, both in the total cohort and in non-hand-OA subgroups. These results were further validated in the GOGO subsets without radiographic OA, in which hypermobility was also associated with a significantly reduced mean serum COMP level (P < 0.0001 adjusted for age). Serum HA levels did not differ in relation to hypermobility in either cohort.

CONCLUSION

The present results indicate that there is an inverse relationship between hypermobility and hand and knee OA, and that hypermobility is associated with lower serum COMP levels. Genetic variations of the COMP gene may account for some subgroups of benign joint hypermobility.

Hypermobility and the hypermobility syndrome

Hypermobile joints by definition display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS). JHS is an under recognised and poorly managed multi-systemic, hereditary connective tissue disorder, often resulting in a great deal of pain and suffering. The condition is more prevalent in females, with symptoms frequently commencing in childhood and continuing on into adult life. This paper provides an overview of JHS and suggested clinical guidelines for both the identification and management of the condition, based on research evidence and clinical experience. The Brighton Criteria and a simple 5-point questionnaire developed by Hakim and Grahame, are both valid tools that can be used clinically and for research to identify the condition. Management of JHS frequently includes; education and lifestyle advice, behaviour modification, manual therapy, taping and bracing, electrotherapy, exercise prescription, functional rehabilitation and collaborative working with a range of medical, health and fitness professionals. Progress is often slow and hampered by physical and emotional setbacks. However with a carefully considered management strategy, amelioration of symptoms and independent functional fitness can be achieved.

Gender differences exist in osteoarthritic gait

BACKGROUND

Knee osteoarthritis is 2-3 times more prevalent in females than males. Biomechanical differences in gait may play a role in this gender predisposition. The purpose of this study was to determine if there are gender-based biomechanical differences in the gait patterns of people with knee osteoarthritis.

METHODS

Three-dimensional gait analysis was performed on healthy (18 males and 24 females) subjects and patients with moderate knee osteoarthritis (24 males and 15 females). Kinematics and kinetics at the hip, knee and ankle were calculated. Variables including anthropometrics, stride characteristics, strength, pain, stiffness, function and radiographic disease severity were also quantified. Multivariate statistical techniques and analysis of variance were used to test for main disease effects, main gender effects and disease vs. gender interactions.

FINDINGS

A significant interaction effect between gender and disease was found in the knee flexion angle and the knee moments in the sagittal, frontal and transverse planes. In each of these measures the females exhibited different biomechanics with osteoarthritis, while the osteoarthritic males maintained the same biomechanics as healthy males. This interaction between gender and osteoarthritis was not associated with differences in anthropometrics, stride characteristics, strength, pain, stiffness, function or radiographic disease severity between the populations.

INTERPRETATION

This study has found gait pattern differences between the genders in the osteoarthritic patients that were not apparent in the healthy subjects. This suggests that the biomechanics associated with knee osteoarthritis are gender dependent. Therefore, gender specific design of biomechanical interventions to slow the progression of osteoarthritis should be explored.

Measuring knee joint laxity: a review of applicable models and the need for new approaches to minimize variability

Knee joint laxity can result from soft tissue injury, such as a ligament tear, or from genetic factors such as joint hypermobility syndrome and various forms of Ehlers-Danlos Syndrome. The location of a subject's passive knee laxity along a continuous spectrum is dependent on the mechanical properties of the existing structures, and the increased motion that often follows joint injury. At a threshold along the spectrum, a patient will be at risk for joint instability and further injury to joint structures. Links between instability and laxity may be better understood if laxity can be reliably and accurately quantified. Current measures of laxity have not been compared to a 'gold standard' in all cases, and when they have, were found to overestimate the laxity values. This is attributed to soft tissue deformation. Consequently, a noninvasive measure of laxity with improved accuracy and repeatability would be useful clinically and in the research sector. In this review, current clinical measures of laxity are critiqued, criteria for a measure of laxity are identified, and three theoretical models of knee laxity are outlined. These include contact, lumped parameter, and finite element models, with emphasis on applicability, strengths, and limitations of each. The long term goal is to develop a model and method able to differentiate subjects along a spectrum of laxity, and understand the functional implications of altered joint integrity. This would allow careful scrutiny of clinical interventions aimed at improving joint health and provide a valuable research tool to study joint injury, healing, and degeneration.

Calcific tendinitis: natural history and association with endocrine disorders

A retrospective, observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Of the patients, 73 (71.6%) were women and 29 (28.4%) were men. Compared with population prevalences, significant levels of endocrine disorders were found. We compared 66 patients (62 women [93.9%] and 4 men [6.1%]; mean age, 50.3 years) (81 shoulders) with associated endocrine disease with 36 patients (11 women [30.6%] and 25 men [69.4%]); mean age, 52.4 years) (44 shoulders) without endocrine disease. The endocrine cohort was significantly younger than the non-endocrine cohort when symptoms started (mean, 40.9 years and 46.9 years, respectively), had significantly longer natural histories (mean, 79.7 months compared with 47.1 months), and had a significantly higher proportion who underwent operative treatment (46.9% compared with 22.7%). Disorders of thyroid and estrogen metabolism may contribute to calcific tendinitis etiology. Classifying calcific tendinitis into type I (idiopathic) and type II (secondary or endocrine-related) aids prognosis and management.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

Variability in tendon and knee joint biomechanics among inbred mouse strains

Hereditary factors are thought to be responsible for impaired tendon function and joint laxity. The present study investigated the genotypic variability of knee laxity and stiffness and tendon mechanical and geometric properties among 16-week-old female A/J, C57BL/6J (B6), and C3H/HeJ (C3H) inbred mice. In one group of mice, knee mechanics were quantified using a custom loading apparatus enabling translation of the tibia against a stationary femur. In a second group, flexor digitorum longus and Achilles tendons from the left hind limb underwent biomechanical testing, while those of the contralateral limb were analyzed histologically for determination of cross-sectional area. Our results demonstrate that tendon and joint mechanics varied significantly among the inbred mouse strains, indicating that biomechanical properties are genetically determined. A/J mouse knees exhibited greater laxity (p < 0.001) and lower stiffness (p < 0.001) compared to those of the B6 and C3H mice. The genotypic differences in whole joint properties were similar to those of the tendons' structural biomechanical traits. Although body mass did not differ (p > 0.2) among the three strains, significant genotypic differences were found at the whole tendon, material quality, and morphological levels of the tissue hierarchy. Furthermore, genetic regulation of tendon mechanical properties varied with anatomic site. Patterns of genotypic differences in tendon size were not consistent with those of biomechanical properties, suggesting that unique combinations of structural and compositional factors contribute to tendon growth, adaptation, and development. Therefore, the three inbred strains constitute a useful experimental model to elucidate genetic control of structure-function relationships in normal and healing tendons and ligaments.

The frequency of hypermobility and its relationship with clinical findings of fibromyalgia patients

The etiology and pathogenic mechanisms of fibromyalgia (FM) are unknown. A number of studies have suggested that there was a link between hypermobility and FM. In this study, we aimed to expose the frequency of hypermobility in FM patients and its relation with clinical findings. For this reason, 236 women (118 FM women as study group and 118 healthy women as control group) were enrolled in the study. Joint hypermobility was evaluated in the participants by using Beighton scoring system. The rate of joint hypermobility among FM patients (Beighton score of at least 4 or more) was found to be higher than the control group (46.6 vs 28.8%). This result was also statistically meaningful (p<0.05). In addition, the mean Beighton score of FM group was observed to be higher than the control (3.68 vs 2.55, p<0.001). Although not reaching statistical difference (p>0.05), more severe clinical findings were observed in FM patients with hypermobility when compared with ones without.

Clinical study of hereditary disorders of connective tissues in a Chilean population: joint hypermobility syndrome and vascular Ehlers-Danlos syndrome

OBJECTIVE

To demonstrate the high frequency and lack of diagnosis of joint hypermobility syndrome (JHS) and the seriousness of vascular Ehlers-Danlos syndrome (VEDS).

METHODS

Two hundred forty-nine Chilean patients with hereditary disorders of the connective tissues (CTDs) and 64 control subjects were evaluated for the diagnoses of JHS and VEDS using the validated Brighton criteria, as compared with the traditional Beighton score. In addition, the presence of blue sclera was determined, with the degree of intensity graded as mild, moderate, or marked.

RESULTS

The frequency of hereditary CTDs was 35%, with diagnoses of JHS in 92.4% of subjects, VEDS in 7.2%, and osteogenesis imperfecta in 0.4%. The Beighton score proved to be insufficient for the diagnosis of JHS (35% of subjects had a negative score), whereas the Brighton criteria yielded positive findings (a diagnosis of JHS) in 39% of control subjects. Blue sclera was frequent, being identified in 97% of JHS patients and 94% of VEDS patients. Moderate osteopenia/osteoporosis was observed in 50% of patients with VEDS and 26% of those with JHS. Dysautonomia, dyslipidemia, and scoliosis were more frequent in VEDS patients than in JHS patients. The typical JHS facial appearance and the "hand holding the head sign" were identified. Raynaud's phenomenon was extremely rare in JHS patients (2%). Ruptured uterus and cerebral aneurysm occurred in 12% and 6% of VEDS patients, respectively. Spontaneous pneumothorax was more frequent in VEDS patients (11%) than in JHS patients (0.9%).

CONCLUSION

JHS is very frequent but usually undiagnosed. The Beighton score is an insufficient method for JHS diagnosis. We recommend that physicians learn to recognize the typical facial features of JHS and be able to identify blue sclera. We also propose that validated hypermobility criteria be routinely used. Further research is needed to determine why the prevalence of JHS is so high in Chile.

Hypermobility syndrome increases the risk for low bone mass

Few studies on the benign joint hypermobility syndrome suggest a tendency toward osteopenia, but there are conflicting results. We assessed bone mineral density in pre-menopausal women with hypermobility. Twenty-five consecutive Caucasian women diagnosed with benign hypermobility syndrome by Beighton score and 23 age- and sex-matched controls were included in the study. Age, menarch age, number of pregnancies, duration of lactation, physical activity and calcium intake were questioned according to European Vertebral Osteoporosis Study Group (EVOS) form. All subjects were pre-menopausal and none of them were on treatment with any drugs effecting bone metabolism or had any other systemic disease. No statistically significant difference was found for body mass index, menarch age, number of pregnancies, duration of lactation, calcium intake, calcium score and physical activity score between the two groups. Total femoral and trochanteric bone mineral density and t and z scores were significantly lower in hypermobile patients compared to the control group. Ward's triangle and femoral neck z scores were also found to be significantly low in hypermobile patients (p<0.05). Significant negative correlations were found between the Beighton scores and trochanteric BMD, t and z scores (r=-0.29, r=-0.30, and r=-0.32) in hypermobility patients. Low bone mass was more frequently found among subjects with hypermobility (p=0.03). Hypermobility was found to increase the risk for low bone mass by 1.8 times (95% confidence interval 1.01-3.38). Our study suggests that pre-menopausal women with joint hypermobility have lower bone mineral density when compared to the controls and hypermobility increases the risk for low bone mass.

Severe thoracic kyphosis in the older patient in the absence of vertebral fracture: association of extreme curve with age

BACKGROUND AND PURPOSE

Limited data exist on the natural history of thoracic kyphosis in elderly patients. The purpose of this study was to determine the statistical distribution of the thoracic kyphotic angle (TKA) measurement in older patients without vertebral body abnormalities when compared with a young population.

METHODS

The TKA was measured by Cobb angle on digital lateral chest radiographs in 90 patients >65 years of age, 60 patients 51-65 years of age, 67 patients 36-50 years of age, and 63 patients 18-35 years of age. Patients with vertebral compression, vertebral body angulation, congenital anomaly, or significant scoliosis were excluded.

RESULTS

In patients >65 years of age, average TKA was 41.9 degrees , but the distribution was unexpectedly bimodal, with a low mode at 28.3 degrees and an upper mode at 51.5 degrees (P < .001). Elderly women and men independently demonstrated a bimodal TKA distribution. Two-thirds of elderly women and half of elderly men had a TKA >40 degrees (upper mode). In young patients, average TKA was 26.8 degrees . In middle-aged patients, TKA was intermediate and nonbimodal.

CONCLUSION

The TKA distribution in elderly patients (>65 years) without vertebral body abnormality is unexpectedly bimodal (non-normal distribution) with a subpopulation of patients significantly more affected by extreme kyphosis. Extreme thoracic kyphosis therefore occurs independently in a large subset of people, in the absence of vertebral wedge compression. The development of extreme thoracic kyphosis might contribute to excess biomechanical stress in the spine and may identify a population at risk for future vertebral compression fracture in particular at the thoracolumbar junction.

Relationship of radiographic and clinical variables to pinch and grip strength among individuals with osteoarthritis

OBJECTIVE

Little is known about how specific radiographic features are related to hand strength in osteoarthritis (OA). This study examined associations of radiographic variables with pinch and grip strength among individuals with radiographic hand OA.

METHODS

Participants (n = 700, 80% female, mean age 69 years) were part of a study on the genetics of generalized OA. All had bilateral radiographic hand OA. Linear models were used to examine associations of grip and pinch strength with 1) OA in joint groups (proximal interphalangeal, metacarpophalangeal [MCP], carpometacarpal [CMC]), 2) OA in rays (first through fifth), and 3) summed Kellgren/Lawrence (K/L) grades for severity of OA in all joints. Adjusted models controlled for age, sex, hand pain, chondrocalcinosis, and hand hypermobility. Mixed models accounted for clustering within families.

RESULTS

In bivariate analyses, all joint groups, all rays, and total summed K/L grades were significantly negatively associated with grip and pinch strength (P < 0.05). In adjusted models, the only joint group significantly associated with grip strength was the CMCs, and only OA in the MCP joint was significantly associated with pinch strength (P < 0.05). The only ray significantly associated with grip strength (P < 0.05) was ray 1, and no individual rays were significantly associated with pinch strength. A higher summed K/L grade was significantly associated with both lower grip strength and lower pinch strength.

CONCLUSION

Among individuals with radiographic hand OA, increasing radiographic severity is associated with reduced grip and pinch strength, even when controlling for self-reported pain. Individuals with radiographic OA in specific locations (CMC joints, MCP joints, and ray 1) may be at particular risk for reduced hand strength.