Nahum Halperin

Thigh muscle activity and anterior cruciate ligament insufficiency

The purpose of this study was to examine the dynamic relationship between the quadriceps femoris and hamstrings in anterior cruciate ligament (ACL) insufficiency. Thirty-five young active patients with an untreated complete tear of the ACL took part in the study. Using a KINCOM isokinetic dynamometer, the dynamic capacity of each muscle group at 30° in concentric and eccentric exertion in both the deficient and sound knee was measured. Findings demonstrated a significant reduction (P<0.05) in the torque produced by the deficient-side quadriceps compared to the sound side but no significant variations in the hamstring torque. Discussion of the findings considers a possible involvement of neurophysiological inhibition of the quadriceps as a cause for the observed weakness.

Anterior compartment syndrome of the thigh in athletes-indications for conservative treatment

Anterior compartment syndrome of the thigh resulting from blunt contusion without an accompanying fracture is rare. The treatment advocated for it by most authors has been surgical. However, because wound infection rates are high and loss of knee range of motion is frequent, we considered conservative treatment in selected patients. Six athletes who developed an anterior thigh compartment syndrome shortly after sustaining a blunt contusion to the quadriceps with an accompanying massive hematoma were studied prospectively. Tissue pressure, renal function, and creatinine phosphokinase (CPK) levels were closely monitored. Fasciotomy was not performed, despite sustained pressure elevations above 50 mm Hg. Neurologic function was not affected. At follow-up examination 1 year later, no limitation of joint motion nor weakness of the quadriceps were observed. Thus in selected young patients in whom an isolated anterior compartment syndrome of the thigh occurs, conservative treatment yielded results superior to fasciotomy.

Differences in gait patterns, pain, function and quality of life between males and females with knee osteoarthritis: a clinical trial

BackgroundThe aim of this study was to gain a deeper understanding of the gender differences in knee osteoarthritis (OA) by evaluating the differences in gait spatio-temporal parameters and the differences in pain, quality of life and function between males and females suffering from knee OA.Methods49 males and 85 females suffering from bilateral medial compartment knee OA participated in this study. Each patient underwent a computerized gait test and completed the WOMAC questionnaire and the SF-36 health survey. Independent t-tests were performed to examine the differences between males and females in age, BMI, spatio-temporal parameters, the WOMAC questionnaire and the SF-36 health survey.ResultsMales and females had different gait patterns. Although males and females walked at the same walking speed, cadence and step length, they presented significant differences in the gait cycle phases. Males walked with a smaller stance and double limb support, and with a larger swing and single limb support compared to females. In addition, males walked with a greater toe out angle compared to females. While significant differences were not found in the WOMAC subscales, females consistently reported higher levels of pain and disability.ConclusionThe spatio-temporal differences between genders may suggest underlying differences in the gait strategies adopted by males and females in order to reduce pain and cope with the loads acting on their affected joints, two key aspects of knee OA. These gender effects should therefore be taken into consideration when evaluating patients with knee OA.Trial RegistrationThe study is registered in the NIH clinical trial registration, protocol No. NCT00599729.

Shoulder girdle neoplasms mimicking frozen shoulder syndrome

Shoulder pain and immobility comprise a multifactorial disorder apparently affected by pain inhibiting joint motion. As the syndrome is very common, many patients do not undergo detailed imaging studies before treatment. This study compared a series of 7 patients in whom a neoplasm was the underlying cause for the stiff shoulder with a series of 50 patients with primary or secondary frozen shoulder. In addition to a detailed history being taken, the Disabilities of the Arm, Shoulder, and Hand (DASH) upper limb outcomes data collection questionnaire was completed and physical examination, radiography, ultrasonography, and bone scanning were performed in all cases. In the cases of tumor, the presenting symptom was a stiff shoulder without radiographic abnormality in 7 of 67 patients with shoulder girdle neoplasms who were seen at our musculoskeletal oncology clinic. The tumors included osteoid osteoma, osteoblastoma, metastatic carcinoma, chondrosarcoma, periosteal lipoma, and acute lymphoblastic lymphoma. The diagnosis was established in all cases by an area of focal isotope uptake demonstrated by a routine technetium 99 methylene diphosphonate bone scan. In a single case of metastatic colon carcinoma, the diagnosis could only be established by magnetic resonance imaging, as the radiographs were normal and the bone scan demonstrated diffuse uptake over the proximal humerus. The patients whose frozen shoulder was caused by an underlying tumor were significantly younger and had a lower fatigue/energy dimension score on the RAND Short Form-36 health survey. The most useful diagnostic test appears to be a discrete area of bony tenderness, present in 7 of 7 patients with tumor and in only 5 of 50 patients in the control group. Although an underlying tumor is a rare cause of frozen shoulder syndrome, the potential grave consequences of misdiagnosis and the possibility of performing an unnecessary and ineffective invasive procedure should prompt physicians to increased vigilance. In patients with discrete bony tenderness elicited by light tapping, a bone scan should be ordered and magnetic resonance imaging should be considered.

Concentric and eccentric torque variations of the quadriceps femoris in patellofemoral pain syndrome

The purpose of this study was to investigate the extent of torque reduction in the quadriceps femoris in subjects complaining of patellofemoral pain syndrome compared to subjects with sound knees. Fifty-five patients (21 women and 34 men) and 30 healthy subjects (15 women and 15 men) took part in this study. Using the KINCOM isokinetic dynamometer, quadriceps torque was assessed at 30°/s, 60°/s, and 120°/s, both in the concentric and eccentric modes. Findings demonstrated a significant (P < 0·01) reduction of between 30% and 40% in the patients when compared with the control group. This reduction was not speed or mode-specific. Men were stronger than women by a margin of 22% and 14% for the concentric and eccentric modes in the control group. Parallel figures for the patellofemoral pain syndrome group were 25% and 17%. Good to high correlations were found between peak and average torque in both groups. There were no significant differences between the muscles referring to the dominant versus the non-dominant legs of the control group.

Sex and Body Mass Index Correlate With Western Ontario and McMaster Universities Osteoarthritis Index and Quality of Life Scores in Knee Osteoarthritis

OBJECTIVE To examine the associations of sex, body mass index (BMI), and age with knee osteoarthritis (OA) symptomatic severity. DESIGN A cross-sectional retrospective analysis. SETTING Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Data were acquired from a stored database of a private therapy center. PARTICIPANTS Patients (N=1487) with symptomatic knee OA were evaluated. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES WOMAC questionnaire and SF-36. RESULTS BMI correlated significantly with worse knee OA symptoms for all WOMAC and SF-36 subcategories (all P ≤.001). Age correlated significantly with worse symptoms only for WOMAC function and SF-36 physical functioning (P=.001 and P=.009, respectively). A significant difference across BMI quintiles was found for all WOMAC and SF-36 subcategories (all P ≤.01). Women showed worse knee OA symptoms in all WOMAC and SF-36 subcategories (all P ≤.001). There was a significant interaction of sex by BMI in WOMAC pain and WOMAC function (P=.01 and P=.02, respectively). CONCLUSIONS Based on the results of this analysis, it can be concluded that women and patients with a higher BMI with knee OA are at a greater risk for worse symptoms.

Efficacy of methylsulfonylmethane supplementation on osteoarthritis of the knee: a randomized controlled study.

BackgroundPatients with osteoarthritis (OA) take a variety of health supplements in an attempt to reduce pain and improve function. The aim of this study was to determine the efficacy of methylsulfonylmethane (MSM) in treating patients with knee OA.MethodsThis study was a prospective, randomized, double-blind, controlled clinical trial. Forty nine men and women 45-90 (mean 68 ± SD 7.3) years of age with knee OA according to the American College of Rheumatology clinical criteria for OA of the knee and with radiographic confirmed knee OA were enrolled in the study and randomly assigned into 2 groups: One received MSM in doses of 1.125 grams 3 times daily for 12 weeks and the other received a placebo in the same dosing frequency. The primary outcomes were the WOMAC Osteoarthritis Index for pain, stiffness and physical function, the Aggregated Locomotor Function (ALF) test that evaluates each patients physical function, the SF-36 quality of life health survey and the visual-analogue-scale (VAS) for pain. The secondary outcomes were Knee Society Clinical Rating System for Knee Score (KSKS) and Function Score (KSFS). Patients were assessed at baseline, 6 weeks and 12 weeks. All continuous variables were tested by the Kolmogorov-Smirnov test for Normal distribution. Changes within the groups and differences between the groups were calculated by repeated measures of analysis (ANOVA) with one nested variable.ResultsThere were significant differences between treatment groups over time in WOMAC physical function (14.6 mm [CI: 4.3, 25.0]; p = 0.04) and in WOMAC total score (15.0 mm [CI: 5.1, 24.9]; p = 0.03). Treatment groups did not differ significantly in WOMAC pain (12.4 mm [CI: 0.0, 24.8]); p = 0.08) or WOMAC stiffness (27.2 mm [CI: 8.2, 46.2]; p = 0.08). There was a non-significant difference in SF-36 total score between treatment groups (11.6 [CI: 1.0, 22.1]; p = 0.54). A significant difference was found between groups in VAS for pain (0.7 s [CI: -0.9, 2.4]; p = 0.05). Secondary outcomes showed non-significant differences between the two groups.ConclusionsPatients with OA of the knee taking MSM for 12 weeks showed an improvement in pain and physical function. These improvements, however, are small and it is yet to be determined if they are of clinical significance.Trial RegistrationClinicalTrials.gov: NCT01188213

Correlation between single limb support phase and self-evaluation questionnaires in knee osteoarthritis populations

Purpose. To investigate the correlation between single limb support (SLS) phase (%% of gait cycle) and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 Health Survey) in patients with knee osteoarthritis (OA). Method. A prospective observational study was employed with 125 adults with bilateral medial compartment symptomatic knee OA who underwent a physical and radiographic evaluation. Velocity, step length and SLS were assessed by a computerised mat (GAITRite). Patients completed the WOMAC and SF-36 Health Survey questionnaires. Results. Statistical analysis examined the correlations between SLS and both questionnaires, between Kellgren & Lawrence (K&L) scores and both questionnaires and between SLS correlations and K&L correlations. We found significantly stronger correlations between SLS and WOMAC-pain, WOMAC-function, the SF-36 pain sub-category, velocity and step length than between K&L scores and these parameters (Pearsons r  ==  0.50 vs. 0.26, 0.53 vs. 0.34, 0.50 vs. 023, 0.81 vs. 0.33, 0.77 vs. 0.37, respectively; all p  <  0.05). Significant differences in SLS were found over WOMAC-pain, WOMAC-function and SF-36 overall score quartiles (p  <  0.05 for all). Conclusion. We recommend integrating SLS as an objective parameter in the comprehensive evaluation of patients with knee OA.

Abductor pollicis longus tendon arthroplasty of the trapezio-metacarpal joint: Surgical technique and results

Tendon interposition resection arthroplasty of the trapezium is a valuable tool in treating osteoarthrosis of the first carpometacarpal joint. A previously unreported modification of such an operation is described in which a part of the abductor pollicis longus tendon is used as an interposition material. This technique was employed in a series of thirty-nine thumbs. After a minimal follow-up period of 2 years, the results of the operation are graded excellent in 48% of the patients, good in 35%, and average in the rest. Grip strength, as well as pinch strength, is about three quarters of the normal average. No patient needed a further operation.

Symptomatic transient patellar ischemia following total knee replacement as detected by scintigraphy: A prospective, randomized, double-blind study comparing the mid-vastus to the medial para-patellar approach

The most advantageous surgical approach for total knee arthroplasty is not defined. The mid-vastus approach has been suggested to improve patient rehabilitation and prevent patellar devascularization. The following study assessed the changes in patellar vascularity as determined by bone scanning following total knee arthroplasty without lateral release or patellar replacement. A total of 30 patients were randomly allocated to either undergo a medial para-patellar approach or a midvastus approach. All patients underwent a pre-operative bone scan and another scan was performed 5-7 days later. The bone scans were compared to assess the intensity of patellar uptake. In 4/30 (13.5%) of subjects, evenly distributed among the two study groups, patellar ischemia was demonstrated by decreased radioisotope uptake. These subjects underwent a third bone scan 1 month later. The latter scan demonstrated similar uptake to the pre-operative scan. These patients continue to suffer from anterior knee pain and show a positive patellar grinding test, which were not found in other patients. The current study appears to indicate that transient patellar ischemia is relatively common following total knee arthroplasty, even when no lateral release is performed. The surgical approach does not seem to affect the frequency of patellar ischemia. This phenomenon might be related to clinical symptoms of anterior knee pain.