Toe dactylitis in patients with spondyloarthropathy: assessment by magnetic resonance imaging

OBJECTIVE: To investigate using magnetic resonance imaging (MRI) the part played by flexor and extensor tenosynovitis and synovitis of the metatarsophalangeal (MTP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in producing the "sausage-like" aspect of spondyloarthropathy (SpA) toe dactylitis. METHODS: Twelve sausage-like toes and corresponding contralateral toes of 7 consecutive patients meeting Amor criteria for SpA were studied by MRI. RESULTS: All dactylitic toes showed fluid collections in the flexor synovial sheaths on MRI. Due to the sheath distension the plantar bone to skin distance was significantly increased (p < 0.05) in the dactylitic toes compared to normal contralateral toes. Peritendinous soft tissues were not involved since these were significantly thicker (p < 0.05) in normal toes. Extensor synovial sheaths were involved in only 4 dactylitic toes. Of the 36 joints of the 12 dactylitic toes only 2 MTP joints showed capsule distension. Considering MRI as the "gold standard", examination showed 100% sensitivity and specificity for flexor sheath involvement but lacked sensitivity for extensor synovial sheaths and showed a low specificity for joint capsule distension. CONCLUSION: Like finger dactylitis, toe dactylitis may also be due to flexor tenosynovitis and synovitis of MTP, PIP, and DIP joints may not be a required condition for sausage-shaped appearance. Extensor tenosynovitis may be present in addition to flexor tenosynovitis. Physical examination is a sufficient method for diagnosing toe dactylitis.     

M-CAVI, a neoadjuvant carboplatin-based regimen for the treatment of T2-4N0M0 carcinoma of the bladder

Dupuytren's disease is a proliferative fibroplasia that can lead to a significant contracture of the metacarpophalangeal (MCP) and interphalangeal (IP) joints, causing a functional disability. Surgical excision of the Dupuytren's tissue and release of the contracted joints may be necessary to restore function. Most patients require hand therapy postoperatively. Postoperative complications have been reported at 17%. These include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). The hand therapist plays a vital role in the early detection and treatment of many of these complications.     

Transvenous "snare-assisted" coil occlusion of patent ductus arteriosus

We have used the "S" Quattro Turbo to treat four neglected dorsal interphalangeal joint dislocations. At an average follow up period of 45 months, there was a mean increase in the range of movement of the PIP joints by 74 degrees and of the IP joint of the thumb or DIP joints by 45 degrees. We recommend this technique for treating dorsal dislocations of the interphalangeal joints of more than 3 weeks duration.     

Gouty arthritis in nodal osteoarthritis

OBJECTIVE: To analyze the clinical features and identify factors associated with the development of gouty arthritis in nodal osteoarthritis (OA). METHODS: Thirty-two consecutive patients (21 women and 11 men, mean age 75.8 years) with both nodal OA and crystal proven acute gout and/or tophi of distal/proximal interphalangeal (DIP/PIP) joints were studied between 1986 and 1994. RESULTS: Tophi of DIP and/or PIP joints were present in 29 (90%) patients; alone in 9 and together with acute DIP or PIP gouty arthritis in 20. Three patients had acute DIP or PIP gouty episodes but no digital tophi. Mean pretreatment serum urate was 614.9 +/- 163.2 (range 422-1088 mumol/l). Risk factors for gout included diuretic use (81%), renal failure (59%), hypertension (66%), alcoholism (22%), prophylactic low dose ASA (20%), and a positive family history (16%) of patients. CONCLUSION: The coexistence of gouty arthritis in nodal OA is important to recognize and treat, particularly in elderly women with renal failure, hypertension, or cardiac failure who are receiving longterm diuretic therapy.     

Magnetic resonance imaging protocol optimization for evaluation of hyaline cartilage in the distal interphalangeal joint of fingers

RATIONALE AND OBJECTIVES: To identify a single magnetic resonance imaging (MRI) protocol that will provide optimal signal-to-noise ratio, resolution, and image contrast with minimal susceptibility artifacts and that will allow clear delineation and visualization of cartilage, fluid, bone, tendons, and ligaments within the distal interphalangeal (DIP) joint of the human hand. METHODS: A highly optimized 2.4 T MRI system was constructed from a 31-cm horizontal bore magnet, using a solenoid radiofrequency coil. This was used to study the DIP joints of 16 healthy, asymptomatic volunteers. RESULTS: A range of image contrast protocols were explored, including spin-echo T1 and T2, field echo, chemical shift suppression to give water only images, and magnetization transfer. Susceptibility variations were explored by changing the field strength from 0.6 to 2.4 T. A spin-echo protocol with TR = 1500 msec and TE = 30 msec can routinely produce images with resolution 0.075 x 0.150 for a slice thickness of 1 mm in 13 minutes. That protocol can visualize simultaneously compact and trabecular bone, two layers of cartilage, synovial fluid, and synovium within the joint, tendons and ligaments, and the volar plate. CONCLUSIONS: Although the contrast is not fully optimized for any one tissue, the spin echo protocol (TR = 1500, TE = 30) provides sagittal MR images, which clearly delineate the major structures of interest within the DIP joint, and which will be used in future studies to compare changes in the DIP joint because of aging or osteoarthritis. Experience gained by applying the above methods to a total of 16 healthy, asymptomatic volunteers has enabled a single sequence to be identified, which although not optimized for any one tissue, nevertheless visualized simultaneously and clearly delineated compact and trabecular bone, two layers of cartilage, synovial fluid, and synovium within the joint.     

Integrated radiation hybrid and yeast artificial chromosome map of chromosome 9p

OBJECTIVES: To determine concentrations of chondroitin sulphate (CS) and keratan sulphate (KS) epitopes, glycosaminoglycans (GAGs) and hyaluronan (HA) in knee synovial fluid (SF) from normal subjects and patients with osteoarthritis (OA) or rheumatoid arthritis (RA), to test whether these variables may be used as markers of the OA process. METHODS: OA was subdivided into large joint OA (LJOA), nodal generalised OA (NGOA), and OA with calcium pyrophosphate crystal deposition (CPA). Clinical assessment of inflammation (0-6) was undertaken on OA and RA knees. Knee SF was examined by enzyme linked immunosorbent assay for: CS epitopes, using monoclonal antibodies 3-B-3 and 7-D-4; KS epitope using monoclonal antibody 5-D-4; and HA, using biotinylated HA binding region of cartilage proteoglycan. Total sulphated GAGs were measured by dye binding with 1:9 dimethylmethylene blue. RESULTS: Increased SF 3-B-3 concentrations and 3-B-3/GAG ratio were found in OA, compared with RA or normal knees, with higher 3-B-3 and 3-B-3/GAG in LJOA and NGOA than in CPA. SF 7-D-4 and 7-D-4/GAG were reduced in RA, compared with normal and OA; SF 5-D-4 was reduced in OA compared with normal. GAG and HA concentrations were decreased in both OA and RA. No correlations with radiographic scores were observed, but SF 7-D-4 was lower in 'inflamed' compared with 'non-inflamed' RA and OA knees. In patients with bilateral samples there were strong correlations between right and left knees for all SF variables. CONCLUSIONS: Changed concentrations of SF CS and KS can be detected in OA with a profile that differs from that seen in RA. Clinical subgrouping and local joint inflammation may influence these measures, supporting different pathogenesis within OA subgroups and requirement for careful patient characterisation in SF studies.     

Persistence of decreased T-helper cell function in industrial workers 20 years after exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin

OBJECTIVE: To evaluate the distribution of mepivacaine hydrochloride after distal interphalangeal (DIP) joint injection in horses. DESIGN: Prospective, uncontrolled study. ANIMALS: 10 adult horses. PROCEDURE: 30 minutes before euthanasia, 8 ml of 2% mepivacaine hydrochloride was injected into the dorsal pouch of a forelimb DIP joint. Synovial tissue from the DIP joint and podotrochlear (navicular) bursa and bone tissue from the medullary cavity of the distal sesamoid (navicular) bone were taken from both forelimbs immediately after death. All synovial and bone specimens were analyzed for tissue concentration of mepivacaine by high-performance liquid chromatography. Synovial tissue and bone specimen concentrations from the injected forelimb were compared with corresponding specimens from the noninjected forelimb. All synovial tissue and bone specimen concentrations were compared with an estimated effective tissue concentration of mepivacaine (0.3 microgram/mg) for local anesthesia. RESULTS: Specimen concentrations of mepivacaine from the injected forelimb were significantly greater (P < 0.05) than those in the corresponding tissues of the contralateral noninjected forelimb. All DIP joint and navicular bursa synovial tissue specimens from the injected forelimb had greater than the estimated effective tissue concentration of mepivacaine for local anesthesia. Of the 10 navicular bone specimens from the injected forelimb, 4 were higher and 2 were within 20% of the estimated effective tissue concentration of mepivacaine for local anesthesia. CONCLUSIONS: Mepivacaine hydrochloride deposited into the DIP joint should anesthetize pain arising from navicular bursa synovia and may decrease pain arising from the medullary cavity of the navicular bone. CLINICAL RELEVANCE: DIP joint injection of mepivacaine hydrochloride is not specific for DIP joint pain.     

Shaping of the cat paw for food taking and object manipulation: an X-ray analysis

The kinematics of the cat distal forelimb during food-taking were analysed to obtain information on the movement processes within the paw before and during object taking in a species without monosynaptic corticomotoneuronal projections. The behaviour was investigated with two tests: either the table test (TT, food offered on a table located at ground level in a reaching distance of 22 and 28 cm) or the horizontal test (HT, food offered in a small container located at shoulder level, height 18-25 cm, reaching distance 6-12 cm). In five animals, the changes in configuration and the conjoint actions of the wrist, the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were assessed with three-dimensional X-ray cinematography (time resolution 20 ms, spatial resolution 1 mm) and video analysis. While approaching the target, the digits were first extended and subsequently abducted. This 'preshaping' consisted of combined angular changes in the MCP and PIP joints, thereby attaining an adequate grip aperture. Each cat used a stable strategy, but different cats used different strategies. In the TT, preshaping involved an MCP extension and a PIP flexion. In the HT, predominant extension of the MCP, predominant extension of the PIP, or a combination of both were used, followed by MCP flexion and PIP flexion. The grip aperture started to decrease before object contact, earlier in the TT, later in the HT. Grasping was achieved by flexion of first the PIP and later the MCP. The X-ray analysis gave evidence for individuated digit movements. Correlation analysis of the angular position of the joints between the different phalanges showed that digits 3 and 4 acted in concert, as did digits 2 and 5, but with clear independence between the different pairs. Furthermore, the different phalanges served different purposes during the grasp. Digits 3, 4 established object contact, digits 2, 5 were mainly used to stabilize the paw onto the surface. The cat distal forelimb displays a refined movement repertoire during the preshaping and grasping phase of food-taking. During the preshaping phase, the kinematics resembled in some aspects the situation in humans. The results demonstrate the ability of the polysynaptic projections from the cortico-motoneuronal system to organize differentiated distal limb movements, including individuated movements of the digits.     

Local hemodynamics, permeability, and oxygen metabolism during acute inflammation of innervated or denervated isolated equine joints

OBJECTIVES: To determine oxygen metabolism, permeability, and blood flow in isolated joints in response to interleukin 1beta (IL-1beta) and contribution of innervation. SAMPLE POPULATION: One metacarpophalangeal (MCP) joint of 24 adult horses. PROCEDURE: The MCP joint was isolated for 6 hours in a pump-perfused, auto-oxygenated, innervated or denervated preparation. Isolated joints were assigned to the following 4 groups: control, control-denervated, inflamed, and inflamed-denervated, and inflammation was induced by intra-articular injection of IL-1beta. Circuit arterial and venous pressures, flows, and blood gas tensions, synovial fluid production, and intra-articular pressure were measured. Total vascular resistance; oxygen delivery, consumption, and extraction ratio (ER); and permeability surface area product were calculated. Synovial membrane blood flow was determined at 0, 60, and 330 minutes. Synovial membrane wet-to-dry ratio was obtained, and permeability to macromolecules was determined by intra-articular injection of Evans blue albumin and fluorescein isothiocyanate-conjugated dextran. RESULTS: Oxygen delivery and synovial membrane blood flow progressively increased but were not different among groups. Oxygen consumption and ER significantly increased in inflamed joints, as did intraarticular pressure and synovial fluid production. Inflamed joints had greater wet-to-dry ratio. Albumin permeability significantly increased in the villous synovial membrane of the inflamed groups, and dextran permeability was increased in the innervated groups, with a trend toward increased permeability in inflamed groups. CONCLUSION: Inflammation significantly increased oxygen demand, which was initially met by increased ER. Permeability to small molecules was increased with inflammation; innervation increased permeability to large molecules. Use of an isolated joint model enabled documentation of the physiologic responses of the joint to acute inflammation.     

Large index-fingertip forces are produced by subject-independent patterns of muscle excitation

Are fingertip forces produced by subject-independent patterns of muscle excitation? If so, understanding the mechanical basis underlying these muscle coordination strategies would greatly assist surgeons in evaluating options for restoring grasping. With the finger in neutral ad- abduction and flexed 45 degrees at the MCP and PIP, and 10 degrees at DIP joints, eight subjects attempted to produce maximal voluntary forces in four orthogonal directions perpendicular to the distal phalanx (palmar, dorsal, lateral and medial) and in one direction collinear with it (distal). Forces were directed within 4.7 +/- 2.2 degrees (mean +/- S.D.) of target and their magnitudes clustered into three distinct levels (p < 0.05; post hoc pairwise RMANOVA). Palmar (27.9 +/- 4.1 N), distal (24.3 +/- 8.3 N) and medial (22.9 +/- 7.8 N) forces were highest, lateral (14.7 +/- 4.8 N) was intermediate, and dorsal (7.5 +/- 1.5 N) was lowest. Normalized fine-wire EMGs from all seven muscles revealed distinct muscle excitation groups for palmar, dorsal and distal forces (p < 0.05; post hoc pairwise RMANOVA). Palmar force used flexors, extensors and dorsal interosseous; dorsal force used all muscles; distal force used all muscles except for extensors; medial and lateral forces used all muscles including significant co-excitation of interossei. The excitation strategies predicted to achieve maximal force by a 3-D computer model (four pinjoints, inextensible tendons, extensor mechanism and isometric force models for all seven muscles) reproduced the observed use of extensors and absence of palmar interosseous to produce palmar force (to regulate net joint flexion torques), the absence of extensors for distal force, and the use of intrinsics (strong MCP flexors) for dorsal force. The model could not predict the interossei co-excitation seen for medial and lateral forces, which may be a strategy to prevent MCP joint damage. The model predicts distal force to be most sensitive to dorsal interosseous strength, and palmar and distal forces to be very sensitive to MCP and PIP flexor moment arms, and dorsal force to be sensitive to the moment arm of and the tension allocation to the PIP extensor tendon of the extensor mechanism.     

Evaluation of sodium hyaluronate therapy in induced septic arthritis in the horse

This study was conducted to determine the efficacy of sodium hyaluronate (SH) with antibiotic therapy and joint lavage for reducing acute inflammatory and degenerative changes induced by septic arthritis. Septic arthritis was induced in six adult horses by inoculating the tarsocrural joints with 1 x 10(4) colony-forming units of Staphylococcus aureus. When clinical signs appeared, trimethoprim-sulphamethoxazole (30 mg/kg bodyweight [bwt] daily) and phenylbutazone (4.4 mg/kg bwt sid) were administered and continued until termination of the study (Treatment Day 18). Twenty-four hours post inoculation, all joints were lavaged with sterile lactated Ringer's solution. Following lavage, one joint of each horse was injected with 10 mg of SH, and the contralateral joint served as the control. Sodium hyaluronate treated joints showed significant reductions in lameness, tarsal circumference and synovial fluid protein and WBC concentrations. The synovial membrane of the SH-treated joints contained less cellular infiltrate, less granulation tissue formation and retained a more normal villous structure compared with controls. The total glycosaminoglycan loss from the articular cartilage in the SH treated joints was consistently less than that from the control joints; however, this difference was not statistically significant. Sodium hyaluronate with joint lavage appears to be more beneficial than lavage alone for treatment of septic arthritis.     

The effects of high-dose methotrexate on the development of cartilage lesions in a lapine model of osteoarthrosis

To determine whether systemic administration of methotrexate (MTX) can prevent joint destruction in experimental osteoarthrosis (OA) in rabbits, the disorder was induced unilaterally in the knee joints of 40 rabbits by partial medial meniscectomy and sectioning of the medial collateral and both cruciate ligaments. A sham operation (arthrotomy only) was performed in another four animals. Effects on the cartilage of the femoral condyles were studied after 6 and 12 weeks. Twelve weeks after induction, femoral and tibial osteophyte formation was demonstrated on radiographs in all cases. Marked cartilage damage was found histologically (median Mankin score 10 vs 1 for non-operated controls; P < 0.05, Wilcoxon test). Cartilage proteoglycan (GAG) content (dye binding assay) was reduced in operated joints [63 +/- 8 (mean +/- SEM) vs 75 +/- 6 micrograms chondroitin sulfate/mg cartilage wet weight], and the leukocyte count in the joints was elevated (226 +/- 14 vs 7 +/- 3 leukocytes per microliter joint aspirate after injection of 0.5 ml saline solution; both P < 0.05, Wilcoxon test). The rate of GAG synthesis was unchanged (ex vivo labelling with 35S-sulfate). Treatment with MTX (30 mg x kg body weight-1 x week-1 i.m., starting 12 h postoperatively) reduced cartilage damage (median Mankin score 8 vs 10 for placebo, P < 0.05, Mann-Whitney U-test), but had no significant effect on the other parameters tested. No significant MTX effects were observed on cartilage from nonoperated joints. Our data indicate that MTX may have a limited therapeutic effect in experimental OA in the rabbit.     

Effects of 0.05% chlorhexidine lavage on the tarsocrural joints of horses

In six horses, a 0.05% solution of chlorhexidine diacetate was used to lavage one tarsocrural joint; the contralateral control joint was lavaged with lactated Ringer's solution. Horses were evaluated daily for lameness. Synovial fluid samples were collected on days 1, 4, and 8 for determination of protein concentration, total and differential leukocyte counts, and mucin clot formation. After death on day 8, synovium and osteochondral samples were collected from the tarsocrural joints for examination of morphology and proteoglycan staining. Lavage with chlorhexidine solution caused lameness that was reduced but still evident at day 8. Synovial protein concentration was significantly increased by chlorhexidine lavage; the greatest increase occurred on day 1. Joint lavage increased synovial leukocyte counts on day 1, primarily by increasing polymorphonuclear (PMN) cell counts. Although total synovial leukocyte counts returned to normal by day 4, PMN cell counts remained elevated through day 8; PMN cell counts for chlorhexidine-lavaged joints were typically twice that of control joints. Chlorhexidine lavage caused synovial ulceration, inflammation, and abundant fibrin accumulation. Consistent differences in proteoglycan staining were not detected between control and chlorhexidine-lavaged joints. Joint lavage with 0.05% chlorhexidine diacetate, the lowest known bactericidal concentration, is not recommended for equine joints.     

Changes in biochemical markers of joint tissue metabolism in a randomized controlled trial of glucocorticoid in early rheumatoid arthritis

OBJECTIVE: To determine the effects of low-dose prednisolone on joint tissue metabolism in early rheumatoid arthritis (RA). METHODS: In addition to a range of biochemical markers of cartilage, bone and synovial tissue turnover, levels of pro-matrix metalloproteinase 3 (pro-MMP-3), pro-MMP-1, and cytidine deaminase (CD) were measured in serum from 79 of 128 patients with early RA who took part in the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study. Serum concentrations of joint tissue metabolites on treatment and off treatment were compared using Student's t-test. RESULTS: Levels of the keratan sulfate epitope, 5D4, and glycosaminoglycan (GAG) were similar on and off treatment. However, the levels of synovium-derived markers, hyaluronate (HA) and N-propeptide of type III procollagen (PIIINP), were reduced by 23.9% (P < 0.01) and 25.2% (P < 0.001), respectively, during treatment with prednisolone. Serum osteocalcin (OC) was reduced by 25.8% (P < 0.001), while the levels of CD and pro-MMP-3 increased by 31.2% (P < 0.01) and 53.7% (P < 0.001) during prednisolone treatment compared with the off-treatment period. CONCLUSION: Low-dose prednisolone had no significant effect on markers of cartilage turnover (GAG, 5D4) in early RA, suggesting that early erosions do not involve cartilage surfaces. The reduction in the markers of bone turnover (OC) and synovial tissue turnover (HA and PIIINP) support the general view that prednisolone reduces synovitis and suppresses bone turnover.     

Posterior tilting of the tibial component decreases femoral rollback in posterior-substituting knee replacement: a computer simulation study

The extensor tendons of the fingers and toes form part of the capsule of the interphalangeal joint and press against the proximal phalanx during flexion. Previous work on the fingers has shown that there is a "sesamoid" fibrocartilage on the deep surface of each tendon that labels immunohistochemically for a variety of glycosaminoglycans and collagens. However, we know little about the molecular composition of the tendon in the toes. This question is of special interest, because the mechanics of the interphalangeal joints differ in the upper and lower limbs-the toes balance the forefoot, distribute load during the gait cycle, and transmit the pull of larger muscles. This means that their extensor tendons are more often under higher tension than those in the fingers. Here, we report the presence of an equivalent fibrocartilage and compare its immunolabelling characteristics in all the toes. Six forefeet were removed from elderly cadavers, and the interphalangeal (IP) joints were fixed in 90% methanol. The extensor tendon and its enthesis were dissected out from the IP joint of the big toe and from the proximal interphalangeal (PIP) joint of all lesser toes, decalcified, cryosectioned, and immunolabelled with a panel of monoclonal and polyclonal antibodies for type I, II, III, and VI collagens; chondroitin 4 and 6 sulphates; and dermatan and keratan sulphate. Antibody binding was detected with the Vectastain ABC Elite avidin-biotin-peroxidase kit (Vector Laboratories, Burlingame, CA). The extensor tendon in all the toes had a metachromatic, sesamoid fibrocartilage on its deep surface that immunolabelled for all glycosaminoglycans and for type I, III, and VI collagens. Labelling for type II collagen was seen in the sesamoid fibrocartilage of all toes but was particularly characteristic of the 2nd through 5th toes. The immunolabelling patterns of the enthesis fibrocartilage were similar in all toes and to results reported previously for fingers. The normal occurrence of type II collagen in the sesamoid fibrocartilage of the 2nd through 5th toes is in contrast to our published data on the fingers. The finding can be related to the more constant loading of the tendon in the toes. The greater prominence of type II collagen in the sesamoid fibrocartilage of the 2nd through 5th toes could be related to a difference in joint position during walking between the 1st toe and the 2nd through 5th toes--the PIP joints of the latter are usually more flexed than the IP joint of the former.     

Effects of 6alpha-methylprednisolone acetate on an equine osteochondral fragment exercise model

OBJECTIVE: To determine effects of intra-articularly administered 6alpha-methylprednisolone acetate (MPA) in exercised horses with carpal osteochondral fragmentation. ANIMALS: 18 horses: 3 groups of 6 each. PROCEDURE: An osteochondral (chip) fragment was created in 1 randomly chosen middle carpal joint of each horse. Polyionic fluid (PF) was injected into both middle carpal joints of horses in the control group. In horses of the MPA-control group, MPA was injected into the middle carpal joint without an osteochondral fragment; a similar volume of PF was injected into the contralateral middle carpal joint. In the MPA-treated group of horses, 100 mg of MPA was injected into the middle carpal joint containing the osteochondral fragment; a similar volume of PF was injected into the contralateral joint. Injections were administered on postsurgical days 14 and 28, and horses were exercised on a high-speed treadmill for 8 weeks, starting on postsurgical day 15. RESULTS: Clinical improvement in degree of lameness was not associated with MPA administration. Joints that contained an osteochondral fragment and were treated with MPA had lower prostaglandin E2 concentration in synovial fluid, and lower scores for intimal hyperplasia and vascularity in synovial membrane, compared with PF-treated joints. However, articular cartilage erosion and morphologic lesions suggested possible deleterious effect of intra-articular MPA administration. CONCLUSIONS: Some beneficial effects of MPA administration on synovial fluid and synovial membrane were identified; however, the deleterious findings contrast with those associated with triamcinolone acetonide used in a similar model, but agree with other results of MPA administration in normal and abnormal joints.     

Two-year prospective, randomized trial comparing an innovative twice-a-week progestin regimen with a continuous combined regimen as postmenopausal hormone therapy

OBJECTIVE: To determine the relationship between matrix metalloproteinases (MMPs), their inhibitors, and the turnover of matrix molecules in articular cartilage from patients with osteoarthritis (OA). METHODS: Synovial fluid samples were collected from the knees of 54 patients with OA. Radiographic evaluations and magnetic resonance imaging were performed on the knees of 34 OA patients to classify the stage of the disease. Biochemical analyses and immunoassays were used to measure the concentrations of MMP-1, MMP-3, tissue inhibitor of metalloproteinases 1 (TIMP-1), TIMP-2, the disaccharide of hyaluronic acid, the proteoglycan glycosaminoglycan disaccharides of chondroitin 4-sulfate (delta di-CS4) and chondroitin 6-sulfate (delta di-CS6), the 846 epitope on chondroitin sulfate of cartilage proteoglycan aggrecan (putative biosynthetic marker), the keratan sulfate (KS) epitope of aggrecan (putative degradation marker), and the C-propeptide of cartilage type II procollagen (CPII) (biosynthetic marker). RESULTS: The concentration of TIMP-1 was directly correlated with the levels of MMP-1 and MMP-3 (both were also correlated with each other), confirming earlier results. There was an inverse correlation between the delta di-CS6:delta di-CS4 ratio and the concentration of MMP-3. The level of delta di-CS6 was correlated with that of the KS epitope, and to a lesser degree, with that of the 846 epitope (the latter was also correlated with the level of delta di-CS4). The concentration of TIMP-1 correlated with that of the 846 epitope, whereas TIMP-2 levels correlated with those of CPII. There were significantly lower concentrations of delta di-CS6, delta di-CS4, the 846 epitope, and CPII in synovial fluid from patients with late-stage OA. CONCLUSION: These observations suggest a link between proteolysis and inhibitor concentrations in OA cartilage. Production of TIMPs appears to be individually linked to the synthesis of specific cartilage molecules. The reduction in the amount of cartilage-matrix structural components suggests that there is a measurable loss of cartilage in the late stages of the disease, as suggested previously. The resultant composition of the cartilage suggests that the loss may primarily involve "resident" molecules originally present in healthy cartilage.     

Total anterior teno-arthrolysis. Report of 72 cases

This report describes a new technique for treatment of the chronically flexed fingers which applies in particular to fingers previously operated on several times and now presenting cutaneous, tendinous and joint problems. It consists in releasing the entire flexor apparatus through a full length lateral digital incision and a sub periosteal dissection. The volar plates of PIP and DIP are released as a whole with the flexor apparatus. The extended finger and flexor apparatus then are allowed to heal in a new relationship. Straightening of the finger is always possible. The range of motion is maintained or increased. This technique can also be used in stiff PIP joints and in certain serious forms of Dupuytren's contracture. 56 cases are reviewed with 78% with good or fair results.     

Characterization of multijoint finger stiffness: dependence on finger posture and force direction

The two-dimensional static stiffness of the index finger was measured with the interphalangeal joints in flexed and extended postures. The stiffness of the relaxed finger was compared with the stiffness when voluntary force was exerted in different directions. The finger stiffness was found to be anisotropic, with the direction of greatest stiffness being approximately parallel to the proximal phalange of the finger. This direction was relatively unaffected by finger posture or direction of finger force. Finger stiffness was more anisotropic when the interphalangeal joints were extended than flexed. The stiffness was most anisotropic when the interphalangeal joints were extended and force was being exerted in the direction of pointing, while it was least anisotropic when the interphalangeal joints were flexed and force was being exerted in directions normally associated with pinching and tapping actions. The stiffness of the individual finger joints was computed and the relation between stiffness and joint torque was examined. Previous studies, which examined single finger joints in isolation, had found that joint stiffness varied in a linear fashion with net joint torque. In contrast, we did not find a monotonic relation between joint stiffness and net joint torque, which we attributed to the need to vary the amount of cocontraction of antagonistic muscles when controlling the direction of finger force.