Efficacy of intra-articular hyaluronan (Synvisc®) for the treatment of osteoarthritis affecting the first metatarsophalangeal joint of the foot (hallux limitus): study protocol for a randomised placebo controlled trial

<p>Abstract</p> <p>Background</p> <p>Osteoarthritis of the first metatarsophalangeal joint (MPJ) of the foot, termed <it>hallux limitus</it>, is common and painful. Numerous non-surgical interventions have been proposed for this disorder, however there is limited evidence for their efficacy. Intra-articular injections of hyaluronan have shown beneficial effects in case-series and clinical trials for the treatment of osteoarthritis of the first metatarsophalangeal joint. However, no study has evaluated the efficacy of this form of treatment using a randomised placebo controlled trial. This article describes the design of a randomised placebo controlled trial to evaluate the efficacy of intra-articular hyaluronan (Synvisc^®) to reduce pain and improve function in people with hallux limitus.</p> <p>Methods</p> <p>One hundred and fifty community-dwelling men and women aged 18 years and over with hallux limitus (who satisfy inclusion and exclusion criteria) will be recruited.</p> <p>Participants will be randomised, using a computer-generated random number sequence, to receive a single intra-articular injection of up to 1 ml hyaluronan (Synvisc^®) or sterile saline (placebo) into the first MPJ. The injections will be performed by an interventional radiologist using fluoroscopy to ensure accurate deposition of the hyaluronan in the joint. Participants will be given the option of a second and final intra-articular injection (of Synvisc^®or sterile saline according to the treatment group they are in) either 1 or 3 months post-treatment if there is no improvement in pain and the participant has not experienced severe adverse effects after the first injection. The primary outcome measures will be the pain and function subscales of the Foot Health Status Questionnaire. The secondary outcome measures will be pain at the first MPJ (during walking and at rest), stiffness at the first MPJ, passive non-weightbearing dorsiflexion of the first MPJ, plantar flexion strength of the toe-flexors of the hallux, global satisfaction with the treatment, health-related quality of life (assessed using the Short-Form-36 version two questionnaire), magnitude of symptom change, use of pain-relieving medication and changes in dynamic plantar pressure distribution (maximum force and peak pressure) during walking. Data will be collected at baseline, then 1, 3 and 6 months post-treatment. Data will be analysed using the intention to treat principle.</p> <p>Discussion</p> <p>This study is the first randomised placebo controlled trial to evaluate the efficacy of intra-articular hyaluronan (Synvisc^®) for the treatment of osteoarthritis of the first MPJ (hallux limitus). The study has been pragmatically designed to ensure that the study findings can be implemented into clinical practice if this form of treatment is found to be an effective treatment strategy.</p> <p>Trial registration</p> <p>Australian New Zealand Clinical Trials Registry: ACTRN12607000654459</p

Demographics of extra-articular calcaneal fractures: Including a review of the literature on treatment and outcome

Introduction: Extra-articular calcaneal fractures represent 25-40% of all calcaneal fractures and an even higher percentage of up to 60% is seen in children. A disproportionately small part of the literature on calcaneal fractures involves the extra-articular type. The aim of this study was to investigate the incidence of extra-articular calcaneal fractures in a Level 1 trauma centre, define the distribution of the various types of fractures and compare patient demographics between extra- and intra-articular calcaneal fractures. In addition the literature was reviewed for the most common types of extra-articular calcaneal fractures with regard to incidence, treatment and clinical outcome. Methods: The radiological records between 2003 and 2005 were reviewed for intra- and extra-articular calcaneal fractures. Patient gender-distribution and age were compared. A literature search was conducted for the treatment of extra-articular calcaneal fractures. Results: In this 3-year study period a total of 49 patients with 50 extra-articular calcaneal fractures and 91 patients with 101 intra-articular fractures were identified. The median age for the first group was 32.7 years, and for the second group 40.3 years; P = 0.04. Male predominance was significantly less pronounced for extra-articular (63%) compared with intra-articular fractures (79%; P = 0.04). Conclusion: One-third of all calcaneal fractures are extra-articular. Significant differences exist between the intra- and extra-articular groups, in terms of lower age and male-female ratio. The literature study shows inconsistencies in treatment options, but most extra-articular fractures are well manageable conservatively

Recent developments in podiatric prescribing in the UK and Australia

Commentary pape

Role of self and foreign antigenic determinants in allogeneic and self-restricted cytotoxic t cell recognition.

Murine spleen cells were sensitized in vitro to H-2 disparate allogeneic spleen cells and assayed on syngeneic target cells conjugated with the trinitrophenyl (TNP)-self or the fluorescein isothiocyanate (FITC)-self haptens, or on syngeneic target cells expressing the male H-Y antigen (H-Y self). The results indicated that allo-induced cytotoxic T lymphocytes (CTL) contained effectors that lysed both hapten-self but not H-Y self targets. Furthermore, it was demonstrated that separate populations of those allogeneic CTL were responsible for the lysis of TNP-self and FITC-self targets. This study also showed that cytotoxic effectors generated against the H-Y antigen with lytic activity equal to or greater than that of an allogeneically induced CTL response were unable to lyse hapten-self targets. These findings provide the first evidence that H-2 alloantigens may be unique in their ability to induce effectors that lyse hapten-conjugated autologous targets. These observations are discussed with respect to the self and foreign antigenic determinants involved in allogeneic and self-restricted CTL models

H-2-linked genetic control of murine cell-mediated lympholysis to autologous cells modified with high and low concentrations of fluor- escein isothiocyanate.

Spleen cells from H-2 k, H-2 d, and H-2 b mice were compared for their ability to generate primary in vitro cytotoxic responses to syngeneic cells modified with fluorescein isothiocyanate (FITC). All strains tested so far generated effector cells which specifically lysed FITC—but not TNP—self targets. Effector activity of H-2 b cells was weaker than that of H-2 kand H-2 d cells. H-2 b spleen cells did not respond to syngeneic stimulating cells modified with low concentrations of FITC, whereas H-2 k and H-2 d cells generated effector activity even when stimulated by syngeneic cells modified with low concentrations of FITC. The cytotoxic response generated by H-2 d spleen cells to FITC-self was equivalent to the response of H-2 k mice. Further studies using ( H-2 k × H-2 b)F 1 responding cells and F 1-modified stimulating cells indicated that the F 1 cells generated preferential cytotoxic activity in association with H-2 k compared with H-2 b self products. The results of this study indicate that H-2-linked genetic factors control the ability of inbred mouse strains to generate cytotoxic effector cells to FITC-self. Therefore, although H-2 k and H-2 b strains are respective high and low CTL responders to TNP, FITC, and other haptens, the present study demonstrates that H-2 d as well as H-2 k mice are high responders to FITC