Ankle joint distraction is a promising alternative treatment for patients with severe haemophilic ankle arthropathy

INTRODUCTION

Haemophilic ankle arthropathy (HAA) causes major morbidity. When conservative treatment fails, major surgical interventions are indicated. An alternative treatment to maintain joint mobility and postpone these interventions is desired.

AIM

To gather prospective data on clinical/structural changes after ankle joint distraction (AJD) in HAA.

METHODS

This study includes patients with severe HAA insufficiently responding to conservative treatment. AJD was performed during 8-10 weeks by use of an external frame. Questionnaires, physical examination and radiology were used to evaluate pain, function and structural changes before and 6, 12, 24 and 36 months after distraction. Mixed effect models were used for analysis.

RESULTS

This study includes eight cases (21-53 years). The fixed effects estimates of the visual analogue score (0-10) improved from 7.5 at baseline to 3.4 (p = .023) 3 years after distraction. The Haemophilia Activities List (HAL, 0-100) for basic/complex lower extremities functions improved from respectively 29.6 and 31.5 to 54.3 (p = .015) and 50.7 (p = .031). Joint mobility was maintained. Magnetic resonance imaging (MRI) showed thickened cartilage and reduced bone marrow oedema and subchondral cysts. Pin tract infections (n = 6) were effectively treated and no adverse bleeding events occurred. At 3-year follow-up, in none of the patients the originally indicated arthrodesis was performed.

CONCLUSION

This first prospective study showed that AJD in HAA results in decreased pain, improved function and decreased arthropathy-related MRI findings in the majority of patients for prolonged time. Although the study population is small and follow-up is relatively short, AJD may be promising to postpone invalidating interventions and might be a breakthrough treatment.

Five-Year Follow-up of Knee Joint Distraction: Clinical Benefit and Cartilaginous Tissue Repair in an Open Uncontrolled Prospective Study

Objective In end-stage knee osteoarthritis, total knee arthroplasty (TKA) may finally become inevitable. At a relatively young age, this comes with the risk of future revision surgery. Therefore, in these cases, joint preserving surgery such as knee joint distraction (KJD) is preferred. Here we present 5-year follow-up data of KJD. Design Patients ( n = 20; age <60 years) with conservative therapy resistant tibiofemoral osteoarthritis considered for TKA were treated. Clinical evaluation was performed by questionnaires. Change in cartilage thickness was quantified on radiographs and magnetic resonance images (MRI). The 5-year changes after KJD were evaluated and compared with the natural progression of osteoarthritis using Osteoarthritis Initiative data. Results Five-years posttreatment, patients still reported clinical improvement from baseline: ΔWOMAC (Western Ontario and McMaster Universities Arthritis Index) +21.1 points (95% CI +8.9 to +33.3; P = 0.002), ΔVAS (visual analogue scale score) pain -27.6 mm (95%CI -13.3 to -42.0; P < 0.001), and minimum radiographic joint space width (JSW) of the most affected compartment (MAC) remained increased as well: Δ +0.43 mm (95% CI +0.02 to +0.84; P = 0.040). Improvement of mean JSW (x-ray) and mean cartilage thickness (MRI) of the MAC, were not statistically different from baseline anymore (Δ +0.26 mm; P = 0.370, and Δ +0.23 mm; P = 0.177). Multivariable linear regression analysis indicated that KJD treatment was associated with significantly less progression in mean and min JSW (x-ray) and mean cartilage thickness (MRI) compared with natural progression (all Ps <0.001). Conclusions KJD treatment results in prolonged clinical benefit, potentially explained by an initial boost of cartilaginous tissue repair that provides a long-term tissue structure benefit as compared to natural progression. Level of evidence, II.

[Trends in the number of knee and hip arthroplasties: considerably more knee and hip prostheses due to osteoarthritis in 2030]

OBJECTIVE

To predict the future number of knee and hip arthroplasties due to osteoarthritis (OA) in the Netherlands based on historical trends and demographic projections.

DESIGN

Data analysis and model calculations.

METHOD

Two future projections were based on age and sex-specific number of hospital admissions for the placement of total knee or hip prostheses due to OA between 1995 and 2005; data were obtained from the Dutch National Medical Registration (LMR). The demographical projection was based on the incidence of arthroplasty in 2005 combined with demographic predictions from Statistics Netherlands regarding the time period between 2005 and 2030. The trend projection used the trend in the age and sex-specific incidence of surgery between 1995 and 2005.

RESULTS

Between 1995 and 2005, the annual number of knee arthroplasties in patients with a primary diagnose of OA increased from 4,916 to 14,565, an increase of 196%. The total number of hip arthroplasties increased from 13,785 to 20,715, an increase of 50%. The demographical projection suggests that the number of total hip arthroplasties will increase to 31,731 by 2030, an increase of 53%, and the number of knee arthroplasties to 22,183. The trend projection suggests that the numbers may increase to 51,680 for the hip (+149%) and to 57,893 for the knee (+297%).

CONCLUSION

The increase in the number of knee and hip arthroplasties due to OA will probably continue in the coming 20 years. The following developments will probably contribute to this: demographical changes, the increase in overweight, improved long-term outcomes of arthroplasty, more active lifestyle of the elderly and the increasing number of orthopaedic surgeons.

Long-term psychosocial functioning after Ilizarov limb lengthening during childhood

BACKGROUND AND PURPOSE

Few studies have been concerned with the patient's perception of the outcome of limb lengthening. We describe the psychological and social functioning after at least 2 years of follow-up in patients who had had a leg length discrepancy and who had undergone an Ilizarov limb lengthening procedure.

PATIENTS AND METHODS

Self-esteem and perceived competence were measured in 37 patients (aged 17-30 years) both preoperatively and at a mean follow-up of 7 (2-14) years. At follow-up, health-related quality of life, functioning at school, daily activities, and treatment-related experiences were measured, and also retrospectively for the preoperative period.

RESULTS

Preoperative and follow-up scores for self-esteem were similar. Overall perceived competence scores at follow-up were comparable to that of a healthy normal population. Patients' perceived athletic competence was lower and their perceived level of behavioral conduct was higher. At follow-up, patients had more positive appraisal of their physical appearance. Most health-related quality of life scores were not significantly different to those of the healthy normal population, apart from a reduced gross motor function, less vitality, and more pain. Patients with a remaining leg length inequality (LLI) of more than 2 cm had lower quality of life scores for gross motor function, sleep, pain, vitality, and depressive feelings.

INTERPRETATION

At an average of 7 years after an Ilizarov limb lengthening procedure, patients still have physical restraints, but they appear to have normal psychosocial functioning, self-esteem, and perceived competence. These patients have quality of life scores comparable to those of norm groups, apart from a reduced gross motor function, less vitality and more pain. Residual LLI of more than 2 cm remains important even after long-term follow-up; these patients report lower quality of life.

Lower limb deformity due to failed trauma treatment corrected with the Ilizarov technique: factors affecting the complication rate in 52 patients

BACKGROUND AND PURPOSE

Failed treatment of fractures may be corrected by the Ilizarov technique but complications are common. In 52 patients with compromised healing of femoral and tibial fractures, the results of secondary reconstruction with Ilizarov treatment were investigated retrospectively in order to identify the factors that contribute to the risk of complications.

METHODS

52 consecutive patients was analyzed. The median interval between injury and secondary reconstruction was 3 (0.1-27) years. The patients had failed fracture treatment resulting in bone defects, pseudarthrosis, infection, limb length discrepancy (LLD) caused by bone consolidation after bone loss, malunion, soft-tissue loss, and stiff joints. Most patients had a combination of these deformities. The results were analyzed by using logistic regression in a polytomous universal mode (PLUM) logistic regression model.

RESULTS

The median treatment time was 9 (4-30) months, and the obstacle and complication rate was 105% per corrected bone segment. In 2 patients treatment failed, which resulted in amputation. In all other patients healing of nonunion could be established, malunion could be corrected, and infections were successfully treated. The statistical analysis revealed that relative bone loss of the affected bone was the only predictor for occurrence of complications. From these data, we constructed a simple graph that shows the relationship between relative bone loss of the affected bone and risk of complications.

INTERPRETATION

Relative bone loss of the affected bone segment is the main predictor of complications after Ilizarov treatment of previously failed fracture treatment. The visualization of the analysis in a simple graph may assist comparison of the complication rates in the literature.

Growth rate after limb deformity correction by the Ilizarov method with or without knee joint distraction: lengthening in 30 children followed for at least 2 years

BACKGROUND AND PURPOSE

Growth inhibition and stimulation have both been reported after juvenile limb lengthening. Distraction of a joint usually suspends and unloads the growth plate and may stimulate growth. We investigated the influence of knee joint distraction on the speed of growth after limb lengthening. METHODS In a retrospective study, growth patterns were analyzed in 30 children mean 61 (24-109) months after limb lengthening with the Ilizarov method, each child having more than 2 years of remaining growth. In 14 patients with knee joint instability, the knee was bridged over during lengthening for joint stabilization. Whether or not joint bridging and distraction would affect patterns of growth of the lengthened limb by unloading the growth plate was evaluated with a repeated measurements analysis of variance.

RESULTS

After lengthening procedures, the proportionate leg-length discrepancy was found to decrease in 16 children, suggesting increased growth rate in the lengthened limbs. A statistically significantly faster growth rate was seen in 8 of 14 patients with knee distraction as compared to patients with single bone frame configurations.

INTERPRETATION

Further research is required to investigate whether growth stimulation is due to the surgical technique and whether joint distraction should be recommended during limb lengthening in growing children.

The canine 'groove' model of osteoarthritis is more than simply the expression of surgically applied damage

OBJECTIVE

Recently a new canine model of osteoarthritis (OA; the 'groove' model) has been described. This model is based on surgically applied mechanical damage of the articular cartilage followed by transient forced loading of the affected joint. Ten weeks after surgery this model shows characteristics of OA, mimicking human OA. To establish whether the observed characteristics of degeneration in this model represent the surgically applied damage, or are the results of progressive features of OA, we evaluated this 'groove' model shortly after surgery.

METHODS

In 20 female Beagle dogs, articular cartilage of the weight-bearing areas of the femoral condyles in the right knee was damaged without affecting the underlying bone. After surgery dogs were let out on a patio 5 days/week for 4 h/day. The dogs were forced to load the experimental joint by fixing the contralateral control limb to the trunk 3 days/week. The severity of OA was evaluated at 3 (n = 10) or 10 weeks (n = 10) after surgery. Synovial inflammation, cartilage damage and cartilage matrix turnover were determined.

RESULTS

Ten weeks after surgery osteoarthritic features were found, as described previously. Proteoglycan (PG) synthesis, percentage release of newly formed PG, and that of total amount of PG were enhanced, whereas PG content was significantly diminished (all P < 0.05). Importantly, 3 weeks after surgery these characteristics of OA were not yet evident.

CONCLUSIONS

The present results clearly show that the characteristics observed 10 weeks after induction of joint degeneration in the groove model are not just the expression of the surgically applied damage but are the result of progressive features of (experimental) OA.

Clinical benefit of joint distraction in the treatment of ankle osteoarthritis

Irrespective of underlying mechanisms, the structural changes after joint distraction and the efficacy during several years validate the concept of joint distraction in the treatment of osteoarthritis. Therefore, joint distraction in the case of severe ankle osteoarthritis at relatively young age may be a treatment of choice. In the light of increased aging, and the limited life span of an endoprosthesis, evaluation of joint distraction in the case of knee and hip osteoarthritis is justified.

Joint distraction as an alternative for the treatment of osteoarthritis

Irrespective of underlying mechanisms, the long-term efficacy of joint distraction in the treatment of severe ankle osteoarthritis at young age validates the concept of joint distraction in the treatment of osteoarthritis. Therefore, joint distraction in the case of severe ankle osteoarthritis may be a treatment of choice. This opens the possibility to study joint distraction as a treatment for other joints. Because knee osteoarthritis is much more common, it is a much greater social and economic problem. Beneficial effects of joint distraction in the case of ankle osteoarthritis, and specifically in the treatment of more common forms of osteoarthritis such as severe knee and hip osteoarthritis, may therefore have a great impact, especially in view of the increasing age of our population.