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PubMed1995

Hallux valgus correction with metatarsal osteotomy: effect of a lateral distal soft tissue procedure.

The purpose of this study was to compare the results of hallux valgus correction using a proximal metatarsal osteotomy with or without a lateral distal metatarsophalangeal soft tissue procedure. This procedure included release of the lateral joint capsule and transfer of the adductor tendon into the neck of the metatarsal. Two groups of patients were reviewed retrospectively. In the first group (17 patients and 25 feet), a proximal closing wedge osteotomy and an Akin osteotomy were performed. In the second group (22 patients and 31 feet), in addition to the osteotomies, the adductor tendon and lateral capsule were released from the sesamoid and the adductor tendon was sutured into the neck of the first metatarsal. Exostectomy and plication of the medial capsule were done in all cases. Physical examination at follow-up revealed significantly more first metatarsophalangeal stiffness in the second group. The average arc of motion was 62 degrees in the first group and 46 degrees in the second. Radiographically, however, results were significantly better in the second group. The average intermetatarsal angle was 9.6 degrees for group 1 and 6.1 degrees for group 2. The average hallux valgus angle was 15 degrees for group 1 and 10 degrees in group 2. Complications included three pin tract infections and four dorsal malunions. The lateral distal soft tissue procedure ensured a more reliable correction of the bunion deformity. However, it resulted in a significant amount of postoperative first metatarsophalangeal stiffness.

Adolescent↗
PubMed1996

The effect of nonablative laser energy on the ultrastructure of joint capsular collagen.

This study was designed to evaluate the effect of laser energy at nonablative levels on the ultrastructure of joint capsular collagen. The femoropatellar joint capsules of six mature New Zealand white rabbits were harvested immediately after death. Specimens were divided into three treatment groups (5, 10, and 15 watts) and one control group. Laser energy was applied using a holmium: YAG laser. Transmission electron microscopy showed significant ultrastructural alterations in collagenous architecture for all laser treatment groups, with increased fibril cross-sectional diameter for each of the treated groups. The fibrils began to lose their distinct edges and their periodical cross-striations at subsequently higher energy densities. A morphometric analysis showed that each subsequently higher laser energy caused a significant increase in collagen fibril diameter. Ultrastructural alteration of collagen fibril architecture caused by the thermal effect of laser energy is probably the dominant mechanism of laser-induced tissue shrinkage.

Animals↗
PubMed2005

Large extrasynovial intracapsular ganglia of the knee: a report of 3 cases.

PURPOSE: Intra-articular ganglia of the knee are rare and usually incidental findings of little clinical significance. Nevertheless some are large, symptomatic, and require treatment. We report on 3 patients with an intra-articular knee ganglion and an extrasynovial extension that was contained within the joint capsule. This seems to be a rare condition; a review of the English-language literature revealed no reports of similar cases. TYPE OF STUDY: Case series. METHODS: Three patients, 1 man and 2 women aged 27 to 40 years, presented with an almost identical history of anterior knee pain that had been treated conservatively for a long time as chondromalacia patellae. The symptoms, which were ill-defined, appeared to be deteriorating until a localized swelling appeared on the lateral side of the patella tendon in each case. On examination, a lateral meniscal cyst associated with an underlying meniscal tear was suspected. However, magnetic resonance imaging revealed a ganglion arising from the substance of the anterior cruciate ligament (case 1) and from the area of the tibial insertion of the anterior cruciate ligament (cases 2 and 3). All 3 ganglia extended anteriorly and then laterally over and in front of the lateral meniscus. The ganglia were approached through an anterior midline incision and lateral parapatellar arthrotomy, which allowed direct and easy access for complete excision. Histologic examination confirmed the diagnosis of a ganglion in all 3 cases. RESULTS: The postoperative course was uneventful in all patients with no signs of recurrence at 1 year (case 1), 2 years (case 2), and 3 years (case 3). CONCLUSIONS: Although the described condition seems very rare, we believe that it should be included in the differential diagnosis of cystic lesions about the knee joint. LEVEL OF EVIDENCE: Level IV, case series, no, or historical control group.

Adult↗
PubMed1994

Mitochondria in fine afferent nerve fibres of the knee joint in the cat: a quantitative electron-microscopical examination.

The distribution of mitochondria, their content and concentration (expressed as the ratio of the mean volume of mitochondria and the surface of the sensory axon) were determined in group-III and -IV nerve fibres innervating the knee joint capsule in the cat. Mitochondria mainly accumulated in axonal swellings ("beads") and end bulbs of the terminal branches. Between single nerve fibres, marked differences in the content and the concentration of mitochondria were obtained in proximal portions (inside of the perineurium) and in distal portions (unmyelinated sensory endings). In group-III nerve fibres, the mitochondrial concentration ranged from 0.005 to 0.030 microns 3/microns 2 (proximal portion) and from 0.016 to 0.080 microns 3/microns 2 (distal portion). In unmyelinated group-IV nerve fibres, the values also showed a broad variation ranging from 0.001 to 0.011 microns 3/microns 2 (proximal portion) and from 0.003 to 0.019 microns 3/microns 2 (distal portion). The wide range of mitochondrial concentrations may reflect different energy consumption during receptive processes: nerve fibres with a low mechanical threshold and a high probability of excitatory events may be rich in mitochondria, whereas fibres with a high mechanical threshold and a low probability of excitatory events may be poor in mitochondria.

Animals↗
PubMedDate not supplied

The effect of nonablative laser energy on joint capsular properties. An in vitro mechanical study using a rabbit model.

To evaluate the effect of laser energy at nonablative levels on the mechanical properties of joint capsular tissues, we tested the femoropatellar joint capsules of 12 mature New Zealand White rabbits. Specimens were divided into three treatment groups (5, 10, and 15 watts) and one control group. All specimens were first nondestructively mechanically tested to determine stiffness and viscoelastic properties and then treated with laser energy or served as a control. Shrinkage was recorded and mechanical testing was repeated. The application of laser energy resulted in 9%, 26%, and 38% reduction in capsular tissue length for the 5, 10, and 15 watt groups, respectively. Tissue shrinkage was significantly and strongly correlated with energy density. Laser energy caused a significant decrease in tensile stiffness only in the 10 and 15 watt groups. Laser energy did not change the relaxation properties at any energy density. This study demonstrates that significant capsular shrinkage can be achieved with the application of nonablative laser energy without detrimental effects to the viscoelastic properties of the tissue; although at higher energy densities, laser energy did lessen capsular stiffness properties. The results of this study should be interpreted with caution until in vivo studies are performed.

Analysis of Variance↗
PubMed2000

Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder.

BACKGROUND: Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder. METHODS: An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid. RESULTS: A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures. CONCLUSIONS: The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).

Adolescent↗
PubMed1995

The effect of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head.

The chevron osteotomy is one of the most widely used distal metatarsal osteotomies for the treatment of hallux valgus in adults. Because the osteotomy interrupts the intraosseous blood supply to the metatarsal head, there has always been a concern that the operation could produce osteonecrosis of the metatarsal head, particularly if the important extraosseous blood supply was also damaged. We used latex injection and a modified Spalteholz technique in cadaveric specimens to demonstrate the effect of the chevron osteotomy, with and without lateral capsular release, on the vascular supply to the first metatarsal head. We found an extensive network of extraosseous vasculature to the metatarsal head both proximal and distal to the site of the osteotomy. Both of these vascular networks were preserved when the osteotomy was done properly. Also, an extensive plantar and plantar lateral network of vessels provided circulation to the head. Potential technical flaws in the performance of the osteotomy included cutting of the first dorsal metatarsal artery by overpenetration of the saw blade and incorrect placement of the proximal arms of the osteotomy inside the joint capsule. These technical errors, alone or in conjunction with extensive capsular stripping, can result in damage to the vessels that supply the metatarsal head.

Aged↗
PubMed2006

[Z-plasty for valgus deformity in total knee arthroplasty].

PURPOSE OF THE STUDY: Several options for treatment of valgus deformity in total knee arthroplasty (TKA) have been described. In 2002 the lateral approach to the valgus knee with Z-plasty of the articular capsule involving part of Hoffa's fat pad started to be used in our department. In this study the surgical technique, including steps for gradual deformity correction, is described and shortterm results are evaluated. MATERIAL: A total of 1136 TKAs were carried out in the period from 1994 to 2004; of these 131 (11 %) were performed on valgus knee. After a visit to the Schulthess Klinik and personal communication with Dr. med. T. Drobny, we began to use the lateral approach to the valgus knee, with Z-plasty of the articular capsule and involvement of Hoffa's fat pad. Forty-two patients (35 women and 7 men) were treated by this technique. The average age of this group was 71 years, and the average preoperative valgus deformity was 20.5 degrees. METHODS SURGICAL TECHNIQUE: A skin incision is made along the midline and, in its lower part, it is led toward the lateral border of the tibial tubercle. The joint capsule is incised in the superficial layer at about 2 cm lateral to the patella. Dissection of the superficial and deep layers of the capsule is made laterally, extending up to 4 cm. After joint exposure, the fat pad is separated from the medial attachment and preserved, on a lateral pedicle, with the patellar ligament. If needed, this flap can be used to close a defect in the distal articular capsule. By including both parts of the joint capsule produced by Z-plasty, medial transposition of the patella is achieved after suture. The deformity is corrected in a sequential manner according to its severity and the effect of release in each step, as follows: 1) Point incisions of the iliotibial band at a 5-cm distance above the articular fissure (piecrusting). 2) Subperiosteal elevation of the iliotibial band attachment from Gerdy's tubercle. 3) Release of the posterolateral capsule. 4) Subperiosteal release of the femoral attachment of the lateral collaterall ligament and dissection of the popliteal muscle. 5) Release of the lateral head of the gastrocnemius muscle. The evaluation of patients was based on the Knee Society Clinical Rating System. RESULTS: Using this surgical technique, correction of deformity was achieved in all patients. The knee axis after surgery improved to 6.6 degrees on the average. The more extensive dissection of lateral structures resulted in larger blood losses, which were on average 1150 ml, and the procedure also required a longer tourniquet application (55 min). The patients were followed up on average for 22 months. The Knee Score assessment in the whole group (42 knees) was on average 90.6 points, with 92.0, 93.3 and 87.9 for rating system categories A, B and C, respectively. The average range of motion was 0 to 118 degrees , and none of the patients reported femoropatellar problems. Revision surgery for hematoma was performed in one patient and puncture of the knee joint had to be done in several patients. Redress for postoperative motion restriction was carried out in three patients and one patient underwent repeat surgery for infection. DISCUSSION: The lateral approach with Z-plasty of the capsule and fat pad involvement provides maximal release of and access to the lateral structures, reduces the risk of insufficient blood supply of the patella and also resolves patellar subluxation. This technique thus allows us to reduce the probability of developing femoropatellar problems that are frequently responsible for poor TKA outcomes in the valgus knee. CONCLUSIONS: The technique described here is an effective approach to the valgus knee requiring total replacement. It provides good access to exposed lateral structures and, with the use of Z-plasty, permits correct alignment and tracking of the patella. In addition, it minimally interferes with blood supply to the patella and completely avoids problems associated with suture of the articular capsule.

Aged↗
PubMed2002

A dynamic model of the knee and lower limb for simulating rising movements.

A two-dimensional dynamical model of the human body was developed and used to simulate muscle and knee-ligament loading during a fast rising movement. The hip, ankle, and toes were each modeled as a simple hinge joint. Relative movements of the femur, tibia, and patella in the sagittal plane were described using a more detailed representation of the knee. The geometry of the model bones was adapted from cadaver data. Eleven elastic elements described the geometric and mechanical properties of the knee ligaments and joint capsule. The patella was assumed to be massless. Smooth hypersurfaces were constructed and used to calculate the position and orientation of the patella during a forward integration of the model. Each hypersurface was formed by applying the principle of static equilibrium to approximate patellofemoral mechanics during the simulation. The model was actuated by 22 musculotendinous units, each unit represented as a three-element muscle in series with tendon. A first-order process was assumed to model muscle excitation-contraction dynamics. Dynamic optimization theory was used to calculate the pattern of muscle excitations that produces a coordinated rising movement from an initial squatting position in minimum time. The calculations support the contention that squatting is a relatively safe exercise for rehabilitation following ACL reconstruction. ACL forces remain less than 20 N for the duration of the task.

Adult↗
PubMed2007

Primary frozen shoulder: global capsular stiffness versus localized contracture.

Stiffness in primary (idiopathic) frozen shoulders has been attributed to a global fibroplasia of the capsule despite the fact surgical release of the capsule at the rotator interval and of the coracohumeral ligament restores motion in almost all patients. Occurrence of vimentin, a cytocontractile protein known to be present in Dupuytren's contracture and in club-feet, has been reported in resection specimens of anterior capsular structures. We hypothesized vimentin would occur only in the anterior structures but fibroplasia would occur throughout the capsule. Tissues removed from four patients were stained with antibodies against vimentin, allowing us to confirm its presence in only in anterior capsular structures, supporting our first hypothesis contracture is due to a selective involvement of the anterior capsule. Staining the sections against types I and III collagen permitted the detection of both collagens in the anterior and the posterior capsular structures and thus confirmed our second hypothesis that fibroplasia involves the entire joint capsule. Therefore it seems, in patients with primary frozen shoulder, fibroplasia and contracture are two distinct processes.

Aged↗
PubMed2001

Thermal capsulorrhaphy for acute or chronic shoulder instability.

During the past two decades, arthroscopic procedures have been replacing traditional, more invasive orthopedic surgical procedures. As technology becomes more advanced, the opportunity to provide a greater number of minimally invasive surgical interventions continues to improve. Thermal modification of joint capsule and ligamentus tissues, a recent introduction to medical science, has been investigated extensively during the past six years. Arthroscopic thermal capsulorrhaphy is one such procedure, and it is performed on individuals with a history of joint instability. These patients now can be treated surgically without large incisions and significant shoulder joint trauma. The thermal unit in both monopolar and bipolar models has similar properties to those of the basic electrosurgical unit. Relatively low-temperature heat is directed to the supportive structures of the shoulder joint causing the tissues to expand. This tightens a previously stretched and attenuated shoulder capsule.

Arthroscopy↗
PubMed2006

Capsaicin receptor expression in the rat temporomandibular joint.

Experimentally, temporomandibular joint (TMJ) nerve units respond to capsaicin, which is used clinically to treat TMJ pain. However, the existence of capsaicin receptors in the TMJ has not previously been clearly demonstrated. Immunohistochemical analysis has revealed the presence of transient receptor potential vanilloid subtype 1 (TRPV1) expression in the nerves and synovial lining cells of the TMJ. TRPV1-immunoreactive nerves are distributed in the synovial membrane of the joint capsule and provide branches to the joint compartment. The disc periphery is supplied by TRPV1 nerves that are mostly associated with small arterioles, and occasional nerves penetrate to the synovial lining layer. Double immunofluorescence has shown that many TRPV1-immunoreactive nerves are labeled with neuropeptide calcitonin gene-related peptide, whereas few are labeled with IB4-lectin. The results provide evidence for the presence of TRPV1 in both nerves and synovial lining cells, which might thus be involved in the mechanism of nociception and inflammation in the TMJ.

Animals↗
PubMed1998

A biomechanical assessment of ligaments preventing dorsoradial subluxation of the trapeziometacarpal joint.

Degenerative arthritis of the trapeziometacarpal joint is commonly associated with ligament laxity and joint subluxation. Specifically, key pinch in an affected joint often results in dorsoradial joint subluxation. This study examined the role the 4 ligaments of the trapeziometacarpal joint play in preventing dorsoradial subluxation. Six fresh-frozen cadaver hands were dissected of all soft tissue to expose the joint capsule and ligaments of the trapeziometacarpal joint. Serial random sectioning of the intermetacarpal ligament, anterior oblique ligament, palmar oblique ligament, and dorsoradial collateral ligament (RCL) was performed. Dorsoradial displacement of the metacarpal shaft in relation to the trapezium was measured using a linear variable dimension transformer. In all 6 specimens, sectioning of the RCL resulted in the greatest dorsoradial subluxation of the metacarpal. The mean displacement due to sectioning of the RCL was 1.4 mm, compared with 0.08 mm for the intermetacarpal ligament, 0.06 mm for the anterior oblique ligament, and 0.2 mm for the palmar oblique ligament. The importance of the RCL in preventing dorsoradial subluxation may have clinical significance. This study suggests that repairing or reconstructing the RCL during ligament reconstruction of the trapeziometacarpal joint should be considered.

Biomechanical Phenomena↗
PubMed1992

The structure and function of the temporomandibular joint.

Although characterised by having a synovial membrane lining the nonarticulating surfaces within the joint capsule, in some ways the temporomandibular joint (TMJ) is an atypical joint. This paper highlights the differences between the TMJ and other movable joints with a description of the structure, innervation blood supply and musculature. Also included are details of how the TMJ moves--the effectors of movement and the various reflexes controlling movement of the joint.

Cartilage, Articular↗
PubMed2001

Neuropeptide Y changes the excitability of fine afferent units in the rat knee joint.

1. The aim of the present study was to examine the effects of the sympathetic co-transmitter Neuropeptide Y on primary afferent nerve fibres of the rat knee joint. The responses to passive joint rotations at defined torque were recorded from 41 slowly conducting afferent nerve fibres (0.9 - 18.8 m s(-1)) innervating the knee joint capsule. 2. About 70% of the joint afferents were significantly affected in their mechanosensitivity by topical application of Neuropeptide Y. Significant effects occurred at a concentration of 10 nM. 3. Decreased mechanosensitivity was observed in about 40% of nerve fibres, whereas 30% of the units increased the mechanosensitivity. In addition, in about 35% of the fibres resting activity was induced or increased. Neither the conduction velocity nor the mechanical threshold of the units correlated with the described effects of Neuropeptide Y. 4. NPY(13--36), a specific Y2-receptor agonist, only modulated the mechanosensitivity, with no effect on the resting activity. The effects on the mechanosensitivity were similar to Neuropeptide Y, i.e. increase and decrease of the response. 5. Studies with the Y1-agonist (Leu(31), Pro(34))-NPY showed that activation of the Y1-receptor predominantly resulted in an enhanced mechanosensitivity and an induction or increase of a resting activity. The opposite effect was observed by application of BIBP 3226 BS, a Y1-receptor antagonist. 6. In conclusion, these data indicate that Neuropeptide Y affects the excitability of sensory nerve fibre endings.

Animals↗
PubMed2000

Reconstruction of hip stability after proximal and total femur resections.

Dislocation is the most common complication after proximal and total femur endoprosthetic reconstruction. The current study describes a surgical technique of acetabular preservation and reconstruction of the joint capsule and abductor mechanism that recreates joint stability and avoids dislocation. Between 1980 and 1996, 57 patients underwent proximal or total femur resection with endoprosthetic reconstruction. Forty-six patients had primary sarcoma of bone, nine had other bone tumors, and two had metabolic bone disease. The acetabulum was spared and not resurfaced in all patients. Bipolar hemiarthroplasty was performed in 49 patients, and fixed unipolar hemiarthroplasty was performed in eight. Soft tissue reconstruction included Dacron tape capsulorrhaphy over the prosthetic neck, reattachment of the abductor mechanism to the prosthesis, and extracortical bone fixation. The average followup period was 6.5 years (range, 2-18.2 years). Dislocation occurred in only one (1.7%) patient, and aseptic prosthetic loosening occurred in three (5.3%) patients. Four patients with primary bone sarcoma had local recurrence, of whom one required amputation of the limb. The limb salvage rate was 98%. Eighty-one percent of the patients had a good to excellent functional outcome. Acetabular preservation, capsulorrhaphy, and reconstruction of the abductor mechanism recreate hip stability and avoid dislocation after proximal and total femur endoprosthetic reconstruction.

Adolescent↗
PubMedDate not supplied

Correction of patellar luxation by recession sulcoplasty in three foals.

Lateral luxation of the patella in four femoropatellar joints of three foals was repaired by recession sulcoplasty and medial imbrication of the joint. One foal was euthanatized because of septic arthritis caused by incisional dehiscence, and the other two foals were normal 2 years after surgery. Recession sulcoplasty combined with medial imbrication of the joint capsule resulted in a functional femoropatellar joint and should be considered in foals affected with lateral patellar luxation.

Animals↗
PubMedDate not supplied

Correlation of radiographic, necropsy and histologic findings in 8 dogs with elbow dysplasia.

Elbow dysplasia is osteoarthrosis/degenerative joint disease due to abnormal development of the elbow joint. The abnormal development is the result of specific inherited etiologies alone or in combination. This paper attempts to clarify the diagnosis of elbow dysplasia based on the presence of degenerative joint disease by correlating radiographic, necropsy, and histopathologic results using elbows from 8 German Shepherd dogs. All elbows had radiographic changes consistent with osteoarthrosis/degenerative joint disease which were identified best on the flexed medial-lateral projection. Radiographically, a specific diagnosis was made in seven elbows; ununited anconeal process (6) and osteochondrosis (1). At necropsy these lesions were confirmed plus 14 elbows were identified that had fragmented medial coronoid process (6), abnormally shaped medial coronoid processes or fissures in the articular cartilage of the medial coronoid process (8). Additionally, histopathologically there was proliferative synovitis at the radial notch of the ulna and degenerative changes on the proximal, nonarticular surface of the anconeal process at the site of insertion of the olecranon ligament and joint capsule. Therefore, for screening the elbow joint to identify elbow dysplasia, the recognition of osteoarthrosis/degenerative joint disease on an extreme flexed mediolateral radiograph appears to be sufficient.

Animals↗