Jonathan H. Lee

Hylan Versus Corticosteroid Versus Placebo for Treatment of Basal Joint Arthritis: A Prospective, Randomized, Double-Blinded Clinical Trial

PURPOSE Conservative, nonsurgical therapies for basal joint osteoarthritis, such as thumb spica splinting and intra-articular corticosteroid injections, remain the mainstays for symptomatic treatment. This study compares intra-articular hylan, corticosteroid, and placebo injections with regard to pain relief, strength, symptom improvement, and metrics of manual function in a randomized, controlled, double-blinded study. METHODS Sixty patients with basal joint arthritis were randomized to receive 2 intra-articular hylan injections 1 week apart, 1 placebo injection followed by 1 corticosteroid injection 1 week later, or 2 placebo injections 1 week apart. Patients were evaluated at 2, 4, 12, and 26 weeks and assessed with Visual Analog Scale pain scores, strength measures, difference scores, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and range of motion measurements. RESULTS All groups reported pain relief at 2 weeks. The steroid and placebo groups had significantly less pain at week 4 compared with baseline, but this effect disappeared by week 12. Only hylan injections continued to provide pain relief at 12 and 26 weeks compared with baseline. There were no significant differences in pain between groups at any time. At 12 and 26 weeks, the hylan group had improved grip strength compared with baseline, whereas the steroid and placebo groups were weaker. At 4 weeks, the steroid group reported in the difference score a greater improvement in symptoms (68%) compared with the hylan (44%) and placebo (50%) groups. Whereas at 26 weeks the hylan group reported the largest improvement in symptoms (68%), this was not statistically different from the placebo (47%) and steroid (58%) groups. There were no significant differences in Disabilities of the Arm, Shoulder, and Hand scores or range of motion among the groups. There were no complications from any injection. CONCLUSIONS There were no statistically significant differences among hylan, steroid, and placebo injections for most of the outcome measures at any of the follow-up time points. However, based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values, hylan injections should be considered in the management of basal joint arthritis of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Perfusion abnormalities in subchondral bone associated with marrow edema, osteoarthritis, and avascular necrosis

Abstract:  Bone marrow edema is seen in osteoarthritis, avascular necrosis, and other clinical conditions including the bone marrow edema syndrome. Bone marrow edema is associated with bone pain and may be related to the pathophysiology of osteoarthritis. Our hypothesis is that bone marrow edema is associated with a reduction in perfusion in subchondral bone, which contributes to focal and segmental bone necrosis and cartilage breakdown. We further hypothesize that altered fluid dynamics in subchondral bone comprise part of the physicochemical environment to which osteocytes are highly sensitive and alter their cytokine expression profile in response to changes in fluid flow, pressure, and oxygen gradients. We have used contrast‐enhanced magnetic resonance imaging with Gd‐DTPA to characterize changes in subchondral bone perfusion in two relevant and related models—the Dunkin–Hartley guinea pig model of osteoarthritis and human bone marrow edema associated with osteoarthritis and avascular necrosis. Pharmacokinetic modeling was used to extract dynamic parameters of perfusion. Representative time‐intensity curves are derived, which characterize normal bone and bone with marrow edema. Dynamic contrast‐enhanced magnetic resonance imaging may be a useful tool for the early diagnosis of bone perfusion abnormalities and may be used to characterize marrow edema associated with a number of clinical conditions. This technique may also shed light on the pathophysiology of subchondral perfusion in osteoarthritis and avascular necrosis.

Imageless Computer Navigation in Total Knee Arthroplasty Provides Superior Short Term Functional Outcomes: A Meta-Analysis

Computer navigation in total knee arthroplasty (TKA) is intended to produce more reliable results, but its impact on functional outcomes has not been firmly demonstrated. Literature searches were performed for Level I randomized trials that compared TKA using imageless computer navigation to those performed with conventional instruments. Radiographic and functional outcomes were extracted and statistically analyzed. TKA performed with computer navigation was more likely to be within 3° of ideal mechanical alignment (87.1% vs. 73.7%, P < .01). Navigated TKAs had a higher increase in Knee Society Score at 3-month follow-up (68.5 vs. 58.1, P = .03) and at 12-32 month follow-up (53.1 vs. 45.8, P < .01). Computer navigation in TKA provides more accurate alignment and superior functional outcomes at short-term follow-up.

Subchondral fluid dynamics in a model of osteoarthritis: use of dynamic contrast-enhanced magnetic resonance imaging

OBJECTIVE The hypothesis of this study is that changes in fluid dynamics in subchondral bone bear a functional relationship to bone remodeling and cartilage breakdown in osteoarthritis (OA). We have utilized dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) to extract kinetic parameters of bone perfusion at various stages in the development of OA in the Dunkin-Hartley guinea pig. DESIGN Animals of four different ages (6, 9, 12 and 15 months), representing various stages in the development of OA, were studied. All animals underwent DCE MRI and perfusion data were analyzed based on the Brix two-compartment pharmacokinetic model. Regions of interest were studied at the medial and lateral tibial plateaus and compared to histological-histochemical scores of articular cartilage and subchondral bone plate thickness. RESULTS A decrease in perfusion as well as outflow obstruction was observed in animals between 6 and 9 months of age, only in the medial tibial plateau subchondral bone. The eventual cartilage and bone lesions of OA occurred also in the medial tibia. Changes in perfusion occurred in the lateral tibia but not until OA lesions were established. Kinetic parameters of inflow were unchanged in both the medial and lateral plateaus. CONCLUSIONS DCE MRI can be used to extract kinetic information on bone perfusion in an animal model of OA. The signal enhancement in subchondral bone temporally precedes and spatially localizes at the same site of the eventual bone and cartilage lesions. Time-intensity curves suggest outflow obstruction as an underlying mechanism.

Assessment of Bone Perfusion with Contrast-Enhanced Magnetic Resonance Imaging

Osteoarthritis and avascular necrosis are common clinical entities with unknown origins. Recently, vascular changes were implicated in the pathogenesis of both conditions. This article discusses the use of novel noninvasive imaging techniques as a means of assessing bone perfusion and quantifying differences seen in osteoarthritis and avascular necrosis. Review of our human data suggests that the MRI contrast dye is retained for longer periods of time, suggesting decreased perfusion out of regions of osteoarthritis and avascular necrosis. Use of such a noninvasive measure of assessing bone perfusion could be useful in the diagnosis, prevention, and treatment of not only osteoarthritis and avascular necrosis but also other entities that affect the musculoskeletal system.

Long-Term Follow-Up of Basal Joint Resection Arthroplasty of the Thumb With Transfer of the Abductor Pollicis Brevis Origin to the Flexor Carpi Radialis Tendon

PURPOSE To investigate the long-term functional and clinical outcomes of a tendon transfer during basal joint interposition arthroplasty for osteoarthritis of the basal joint of the thumb, in which the origin of the abductor pollicis brevis (APB) and opponens pollicis is transferred to the flexor carpi radialis tendon, in order to increase the abduction moment arm of the thumb and provide dynamic stabilization of the base of the first metacarpal. METHODS We observed 22 patients, who received basal joint interposition arthroplasty with APB and opponens pollicis tendon transfer, over an average of 9 years (range, 3-20 years). Subjective outcome measures included patient satisfaction scores, visual analog scale scores for pain, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Clinical evaluations included thumb range of motion, grip strength, and pinch strength. RESULTS At an average follow-up of 9 years, 95% of patients (21 out of 22) subjectively scored the procedure as good or excellent and reported improvement in activities of daily living. Mean visual analog scale pain score was 4.4 at rest and 7.8 with activity (out of 100), and mean DASH score was 13.3 (out of 100). Average grip strength of the operated hand was equal to that of the contralateral hand, and lateral and tip pinch strengths were 79% and 93%, respectively, of the contralateral hand. No intraoperative or early postoperative complications were reported, although 1 patient whose procedure was performed as treatment for failed silastic arthroplasty reported metacarpal instability at 9-year follow-up (DASH score of 22). CONCLUSIONS Basal joint arthroplasty with APB and opponens pollicis tendon transfers provides excellent long-term results for carpometacarpal thumb osteoarthritis. The procedure is safe, with a low complication rate. Its success has long-term durability as measured by patient satisfaction, functional outcome measures, range of motion, and strength. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Aggravation of inflammatory response by costimulation with titanium particles and mechanical perturbations in osteoblast- and macrophage-like cells

The interface between bone tissue and metal implants undergoes various types of mechanical loading, such as strain, compression, fluid pressure, and shear stress, from daily activities. Such mechanical perturbations create suboptimal environments at the host bone-implant junction, causing an accumulation of wear particles and debilitating osseous integration, potentially leading to implant failure. While many studies have focused on the effect of particles on macrophages or osteoprogenitor cells, differential and combined effects of mechanical perturbations and particles on such cell types have not been extensively studied. In this study, macrophages and osteoprogenitor cells were subjected to physiological and superphysiological mechanical stimuli in the presence and absence of Ti particles with the aim of simulating various microenvironments of the host bone-implant junction. Macrophages and osteoprogenitor cells were capable of engulfing Ti particles through actin remodeling and also exhibited changes in mRNA levels of proinflammatory cytokines under certain conditions. In osteoprogenitor cells, superphysiological strain increased proinflammatory gene expression; in macrophages, such mechanical perturbations did not affect gene expression. We confirmed that this phenomenon in osteoprogenitor cells occurred via activation of the ERK1/2 signaling pathway as a result of damage to the cytoplasmic membrane. Furthermore, AZD6244, a clinically relevant inhibitor of the ERK1/2 pathway, mitigated particle-induced inflammatory gene expression in osteoprogenitor cells and macrophages. This study provides evidence of more inflammatory responses under mechanical strains in osteoprogenitor cells than macrophages. Phagocytosis of particles and mechanical perturbation costimulate the ERK1/2 pathway, leading to expression of proinflammatory genes.

Arthroscopic Wrist Anatomy

Arthroscopic wrist anatomy is best learned from cadaveric bioskills first, and reinforced through experience. Correlating focal clinical findings with arthroscopic anatomy, both normal and pathologic, can expand the clinician’s understanding and nuanced-interpretation of presenting complaints. Wrist arthroscopy has been shown to be more effective and predictable than all but the most sophisticated MRI and has an added benefit of real-time assessment of dynamic instability and partial cartilage lesions. Visualizing wrist pathology with the arthroscope is often more reliable than a physical examination or imaging studies such as MRI, arthrography, or plain radiographs. It is essential to alternate viewing and instrumentation portals to properly view normal and abnormal anatomy from various angles. Once arthroscopic wrist anatomy is understood and mastered, the surgeon can best plan and perform treatment based on the patient’s internal wrist pathology.

The Combination of the Tunnel View and Weight-Bearing Anteroposterior Radiographs Improves the Detection of Knee Arthritis

Imaging used for the evaluation of knee pain has historically included weight-bearing anteroposterior (AP), lateral, and sunrise radiographs. We wished to evaluate the utility of adding the weight-bearing (WB) posteroanterior (PA) view of the knee in flexion. We hypothesize that (1) the WB tunnel view can detect radiographic osteoarthritis (OA) not visualized on the WB AP, (2) the combination of the AP and tunnel view increases the radiographic detection of OA, and (3) this may provide additional information to the clinician evaluating knee pain. We retrospectively reviewed the WB AP and tunnel view radiographs of 100 knees (74 patients) presenting with knee pain and analyzed for evidence of arthritis. The combination of the WB tunnel view and WB AP significantly increased the detection of joint space narrowing in the lateral (p < 0.001) and medial (p = 0.006) compartments over the AP view alone. The combined views significantly improved the identification of medial subchondral cysts (p = 0.022), sclerosis of the lateral tibial plateau (p = 0.041), and moderate-to-large osteophytes in the medial compartment (p = 0.012), intercondylar notch (p < 0.001), and tibial spine (p < 0.001). The WB tunnel view is an effective tool to provide additional information on affected compartments in the painful knee, not provided by the AP image alone.