The human model in the development of osteoarthritis after anterior cruciate ligament rupture and reconstruction: an observational study

The natural history of the anterior cruciate ligament (ACL) deficient knee is the development of premature osteoarthritis. However, several issues require further investigation: which is the optimal time interval from the injury to perform an ACL reconstruction (ACLR)? How is the articular cartilage and menisci influenced at this time and how do these structures respond after ACLR? What is the potential contribution of novel magnetic resonance imaging modalities for the detection of chondral lesions prior to surgery as well as a non-invasive follow-up tool? Last but not least, what occurs in the biochemical and molecular environment of the chondrocyte of the ACL deficient knee and what is the significance of the time elapsed from injury for the development of premature osteoarthritis of the knee?A total of 109 patients who underwent an ACLR from 2009 till 2011 were evaluated clinically, 3.0 T magnetic resonance imaging morphological sequences were applied and articular cartilage samples were harvested and molecularly tested. The incidence of higher grade(III and IV) chondral lesions is much higher in patients who were submitted to ACLR 12 or more months after the knee injury, compared with patients who received an ACLR in an acute (within 3 months) or sub acute fashion (3 to 12 months). The superiority of arthroscopy versus 3.0T MRI regarding the detection of chondral lesions is indisputable, nevertheless the introduction of novel sequences could facilitate a more reliable non-invasive method of detecting and grading articular cartilage lesions.Furthermore, our study demonstrated an increased expression of inflammatory, catabolic and apoptotic agents from the chondrocytes of the ACL deficient knee and a correlation with the time from injury, thus enhancing the cartilage degradation. These metabolic alterations are similar to those implicated in the pathogenesis of osteoarthritis, suggesting that pharmaceutical factors influencing cartilage homeostasis could lead to more effective treatment strategies of posttraumatic arthritis.In the last section, clinical and imaging data at 3.0 T MRI from 29 patients at mean 2 years follow-up are demonstrated. Despite the high level of satisfaction of the patients as deflected at the self -assessment questionnaires and clinical evaluation, 65% of the patients presented a chondral lesion (almost double compared with baseline). The greatest increase in the progression of lesions concerned the lateral femoral condyle, followed by patella and medial femoral condyle, suggesting that knee kinematics are not fully restored after ACLR. Surgery protected the meniscal integrity but did not seem to have a chondroprotective effect, even in the group of patients with intact menisci at the time of ACLR. Thus, extended in vivo and in vivo embiomechanical studies are further required to optimize surgical techniques and resemble the natural ACL anatomy.Η φυσική ιστορία του γόνατος μετά από ρήξη ΠΧΣ είναι η ανάπτυξη πρώιμης οστεοαρθρίτιδας. Ωστόσο υπάρχουν ζητήματα που χρήζουν περαιτέρω διερεύνησης από τη βιβλιογραφία: ποιος είναι ο κατάλληλος χρόνος για τη χειρουργική αποκατάσταση του προσθίου χιαστού; πώς επηρεάζεται ο αρθρικός χόνδρος και οι μηνίσκοι στο διάστημα αυτό και πώς εξελίσσονται οι βλάβες αυτές με το χρόνο, μετά την αποκατάσταση του ΠΧΣ; ποια μπορεί να είναι η συμβολή των νέων απεικονιστικών μεθόδων στην ανίχνευση των χόνδρινων βλαβών πριν το χειρουργείο, αλλά και ως αναίμακτη μέθοδος follow up; Τέλος, πώς διαμορφώνεται το μοριακό-βιοχημικό περιβάλλον του χονδροκυττάρου μετά από την στροφική κάκωση του γόνατος και τι ρόλο παίζει ο χρόνος ως το χειρουργείο στην ανάπτυξη πρώιμης οστεοαρθρίτιδας;Επιχειρήθηκε η τριπλή προσέγγιση 109 ασθενών μετά από ρήξη προσθίου χιαστού, μέσω της κλινικής αξιολόγησης, απεικόνισης του γόνατος με μαγνητική τομογραφία 3.0 Τesla και λήψης δείγματος χόνδρου για μοριακή ανάλυση. Φαίνεται ότι οι πιθανότητες ανάπτυξης υψηλού βαθμού χόνδρινων βλαβών (3ου και 4ου) είναι πολύ υψηλότερες σε ασθενείς που χειρουργούνται σε διάστημα μεγαλύτερο των 12 μηνών από την αρχική κάκωση, σε σχέση με άτομα που χειρουργούνται ως 3 μήνες ή από 3 ως 12 μήνες από τον τραυματισμό. H υπεροχή της αρθροσκόπησης έναντι της μαγνητικής τομογραφίας 3.0 Τesla ως προς την ανίχνευση χόνδρινων βλαβών είναι αδιαμφισβήτητη, ωστόσο η εισαγωγή νέων ακολουθιών ίσως να οδηγήσει σε μια πιο αξιόπιστη μη-επεμβατική δυνατότητα ανίχνευσης και ταξινόμησης των χόνδρινων βλαβών. Επίσης, η μελέτη μας κατέδειξε ότι τα χονδροκύτταρα μετά από ρήξη ΠΧΣ παράγουν φλεγμονώδεις, καταβολικούς και αποπτωτικούς, παράγοντες και τα αυξημένα επίπεδα έκφρασης αυτών των παραγόντων σχετίζονται με τον χρόνο από την κάκωση του γόνατος, συμβάλλοντας στην αποδόμηση του αρθρικού χόνδρου. Οι μεταβολές αυτές προσομοιάζουν αυτές που επισυμβαίνουν στο γόνατο κατά την ανάπτυξη οστεοαρθρίτιδας, υποδεικνύοντας ότι πιθανώς ο συνδυασμός παραγόντων υπεύθυνων για την ομοιόσταση του χόνδρου και της κατάλληλης χειρουργικής παρέμβασης, να οδηγήσει σε πιο αποτελεσματικές θεραπείες για την μετατραυματική οστεοαρθρίτιδα. Τέλος, παρουσιάζονται στοιχεία από τη μετεγχειρητική παρακολούθηση 29 ασθενών, τόσο κλινικά, όσο και απεικονιστικά με ΜΤ 3Τ. Παρά τα υψηλά επίπεδα ικανοποίησης των ασθενών, όπως αντικατοπτρίζονται στα σκορ αυτό-αξιολόγησης και στην κλινική εξέταση, στο 65% των ασθενών ανιχνεύτηκαν χόνδρινες βλάβες (σχεδόν διπλασιάστηκαν σε σχέση με τις προεγχειρητικές). Η μεγαλύτερη αύξηση αφορούσε τον έξω μηριαίο κόνδυλο και ακολούθησε η επιγονατίδα και ο έσω μηριαίος κόνδυλος, υποδεικνύοντας ότι η κινηματική του γόνατος δεν αποκαθίσταται πλήρως μετά από συνδεσμοπλαστική ΠΧΣ. Η ανακατασκευή ΠΧΣ φαίνεται να έχει προστατευτικό ρόλο όσον αφορά τους μηνίσκους, αλλά όχι και τον αρθρικό χόνδρο, ακόμα και στην ομάδα ασθενών που είχε ακέραιους μηνίσκους προεγχειρητικά. Πιο εκτεταμένες in vitro και in vivo εμβιομηχανικές μελέτες απαιτούνται για τη βελτιστοποίηση των χειρουργικών τεχνικών και την προσέγγιση της φυσιολογικής ανατομίας του ΠΧΣ

Pediatric Terrible Triad Elbow Fracture Dislocations: Report of 2 Cases

An elbow dislocation associated with radial head and coronoid process fractures, the terrible triad injury, has an unpredictable outcome in adults and is rare in children. We present 2 such injuries in children, 1 combined with an olecranon fracture, and both with good early clinical outcomes. However, in 1 of the 2 cases, avascular necrosis of the proximal radius was evident on radiographs. Copyright (C) 2013 by the American Society for Surgery of the Hand. All rights reserved

Surgical treatment of hip fractures: factors influencing mortality

Background: Data for osteoporotic hip fractures in Greece is limited and little is known upon the meaning of family support during the postoperative/rehabilitation period. Objective: To identify the factors influencing the mortality after hip fractures in the elderly, the effect of rehabilitation and family support in the post-fracture course, and the impact of these fractures on the family of the injured elderly. Methods: We conducted an observational study of 218 consecutive patients older than 60 years of age, who underwent surgical management of a unilateral hip fracture at a tertiary hospital of Central Greece, with follow-up contacts at 30 days, 3 months and one year. Demographic characteristics, pre- and post-fracture residential and functional status, assessment of basic activities of daily living (ADL), co-morbidities, type and mechanism of fracture and hospitalization data as well as the modification of activities of the patients' relatives were recorded. Results: Fifteen patients (6.9%) died during hospitalization; thirty-nine (17.9%) died within one year of fracture. The factors that were predictive of in-hospital, 30-days and one-year mortality, based on multivariate analysis, were male sex, advanced age >85 and Charson index >3. There was a significant association between delayed surgery (>48 hours) and increased in-hospital mortality. The percentage of patients assessed as ADL A or B at baseline, decreased form 84% preoperatively to 50.4% one year postoperatively. Only one-third of patients walking without aid before the fracture returned to the previous state. Family members modified their activities in 48% of cases to assist their relatives with a hip fracture. Conclusions: One-year mortality in patients with hip fractures was 17.9%. Surgical delay (>48 hours) increased inhospital mortality. Comorbidities >3, male sex, and advanced age increased the risk of in-hospital and post-discharge mortality during the 1st year. Twelve months postoperatively, half of patients walking without aid before the fracture returned to the previous state. Despite the beneficial effect of family support, the lack of organized rehabilitation programs and geriatric units are potential negative factors for patients' functional outcome. In addition, 48% of patients' relatives changed their daily activities to assist their relatives

Molecular changes indicative of cartilage degeneration and osteoarthritis development in patients with anterior cruciate ligament injury Pathophysiology of musculoskeletal disorders

Background: Anterior cruciate ligament (ACL) tear is considered a risk factor for osteoarthritis development. The purpose of our study was to investigate the expression levels of the apoptotic enzyme caspase 3, pro-inflammatory cytokines interleukin-1β (IL-1β) and interleukin-6 (IL-6) and degrading enzyme matrix metalloproteinase 13 (MMP-13), all indicative of cartilage degeneration and osteoarthritis development in patients' chondrocytes after ACL rupture. Methods: We investigated the correlation between grade of cartilage degradation and time from injury or patients' age. IL-1β, IL-6 and MMP-13 mRNA expression levels were investigated in normal (n = 4) and chondrocytes from patients with ACL rupture (n = 33) using real-time polymerase chain reaction (PCR). Moreover, MMP-13 and caspase-3 protein expression levels were evaluated by western blot analysis. Trend analysis and correlation coefficient were performed to derive the relations between gene expression (MMP13, IL-6, IL-1β) and grading of cartilage defects and between gene expression (MMP13, IL-6, IL-1β) and patients' age, respectively. Results: Correlations were established between grade of cartilage degradation and time from injury. MMP-13, IL-6, IL-1β and caspase 3 expression levels were significantly upregulated in chondrocytes from ACL-deficient knee compared to normal. Among the patients with ACL-deficient knees, a significant upregulation of MMP-13 was observed in patients with ACL-rupture > 18 months from the time of injury to arthroscopy compared to patients with ACL-injury up to 18 months, whereas IL-6 and IL-1β expression was higher in chondrocytes from patients with more than 10 months ACL injury compared to those that underwent surgery within the first 10 months after injury. Νο association was observed between IL-1β, IL-6 and MMP-13 expression levels and cartilage defects or patients' age. Conclusion: Our results showed that increased levels of apoptotic, inflammatory and catabolic factors in chondrocytes are associated with time from injury and could contribute to cartilage degradation and osteoarthritis development after ACL rupture. © 2016 Papathanasiou et al

Co-design of diversified cropping systems in the Mediterranean area

International audienceHighlights: • We combined SWOT analysis and co-design workshops to study diversification options. • The approach was applied in five case studies in the Mediterranean basin. • Intercropping was seen as the most promising solution in most case studies. • New cereal-based rotations included legume species, or rapeseed. • New systems provided a partial solution to local environmental and economic threats.Abstract: Agriculture today faces opposing challenges: reducing its environmental impacts while feeding a growing population and adapting to climate change. Diversification of cropping systems has been proposed as a solution to address these issues and promote sustainable and resilient agricultural systems. While alternatives have been proposed by research and development, changing the agricultural systems remains a huge challenge. Engaging local actors when considering those changes is important for their successful implementation. While co-designing with stakeholders is gaining interest in the scientific community, approaches that consider varying local contexts remain uncommon. In this study, our aim was to co-design, during workshops with local stakeholders, diversification options in five case studies located in the Mediterranean countries of Algeria, France, Greece, and Spain. Prior to the co-design process, we conducted a SWOT/PESTLE analysis in each case study to analyze the local context of current and potential agricultural systems. Our hypothesis was that co-designed systems would differ between case studies, according to their environmental, social and political contexts leading to fine-tuned locally ad hoc systems. Options for intercropping and diversifying rotations were considered for both cerealbased systems and vine systems. Additionally, these options included adapted management practices for cereal-based systems and more innovative diversification, such as photovoltaic panels or agroforestry, for vine systems. While some of these options could serve as adaptations to climate change, they may not be sufficient to address future climate conditions. Interestingly, we did not observe significant differences among the system options designed for the various case studies, even though the local contexts were very different. Indeed, options only partially addressed the issues identified by stakeholders: primarily, economic and environmental threats. This study points to the advantage of participatory research in diverse contexts along with cross-case analyses, and to the need to consider the future of these Mediterranean regions, where crop diversification is limited by water deficit. To foster the transition next steps should consider assessing experimentally these systems with farmers to stimulate learning, while considering market possibilities