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Development of the musculoskeletal system requires precise integration of muscles, tendons and bones. The molecular mechanisms involved in the differentiation of each of these tissues have been the focus of significant research; however, much less is known about how these tissues are integrated into a functional unit appropriate for each body position and role. Previous reports have demonstrated crucial roles for Hox genes in patterning the axial and limb skeleton. Loss of Hox11 paralogous gene function results in dramatic malformation of limb zeugopod skeletal elements, the radius/ulna and tibia/fibula, as well as transformation of the sacral region to a lumbar phenotype. Utilizing a Hoxa11eGFP knock-in allele, we show that Hox11 genes are expressed in the connective tissue fibroblasts of the outer perichondrium, tendons and muscle connective tissue of the zeugopod region throughout all stages of development. Hox11 genes are not expressed in differentiated cartilage or bone, or in vascular or muscle cells in these regions. Loss of Hox11 genes disrupts regional muscle and tendon patterning of the limb in addition to affecting skeletal patterning. The tendon and muscle defects in Hox11 mutants are independent of skeletal patterning events as disruption of tendon and muscle patterning is observed in Hox11 compound mutants that do not have a skeletal phenotype. Thus, Hox genes are not simply regulators of skeletal morphology as previously thought, but are key factors that regulate regional patterning and integration of the musculoskeletal system.
MRI plays a critical role in all orthopaedic practices. A basic working knowledge of the most commonly used pulse sequences in musculoskeletal imaging and the appearance of normal tissues on those sequences is critical to confident MRI interpretation. The orthopaedic surgeon should be familiar with appropriate use of intravenous and intra-articular contrast and its limitations. Concepts key to MRI interpretation include image contrast and resolution, signal, noise, and pulse sequence. Recent advances in anatomic and functional imaging highlight the robust potential of MRI for musculoskeletal evaluation. As MRI technology evolves, the orthopaedic surgeon must stay current on these technologic advances to use this tool to its fullest potential.
PURPOSE - The cause of snapping in trigger finger is not clearly understood. The purpose of this study was to investigate the influence of stiffness of the first annular pulley on snapping in trigger finger patients with sonoelastography, a new technique for quantitative assessment of the stiffness of soft tissues.
METHODS - We first studied 20 healthy volunteers (all women, aged 24-78 y) to define the change of stiffness with aging and with specific fingers. We then studied 10 digits of 9 patients (all women, aged 60-78 y) with trigger finger that involved middle or ring fingers. Thickness and stiffness were evaluated by sonoelastography. Stiffness was estimated by strain ratio of subcutaneous fat to the pulley (F/P strain ratio). The patients were treated with corticosteroid injection, and the measurement was repeated 3 weeks later.
RESULTS - In the healthy volunteers, both thickness and F/P strain ratio showed a positive correlation with age. There was no difference between the middle and ring fingers. In trigger finger patients, the pulley thicknesses of the affected finger and the adjacent normal finger before corticosteroid injection were 0.99 ± 0.19 mm and 0.60 ± 0.14 mm (mean ± SD), respectively. The F/P strain ratios of the affected finger and the adjacent normal finger before the injection were 4.2 ± 1.3 and 2.4 ± 0.63, respectively. Three weeks after the injection, snapping disappeared in all patients, the pulley thickness decreased to 0.61 ± 0.15 mm, and the F/P strain ratio decreased to 2.5 ± 0.68. The cross-sectional area for flexor tendons within the pulley did not change after the injection.
CONCLUSIONS - Increased stiffness and thickening of the A1 pulley are considered to be causes for snapping in trigger finger, and corticosteroid injection can alleviate snapping by changing these 2 features.
Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Anterior cruciate ligament graft choice is controversial, with no evidence-based consensus available to guide decision making. The study design was evidence-based medicine systematic review of randomized controlled trials evaluating patellar tendon versus hamstring tendon autografts. A literature review identified 9 randomized controlled trials comparing patellar tendon and hamstring tendon autografts. An evidence-based systematic review was performed. Objective and subjective outcomes of interest included surgical technique, rehabilitation, instrumented laxity, isokinetic strength, patellofemoral pain, return to preinjury activity, and Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee-1991 scores. Additional surgery, graft failure, and complications were reviewed. Slight increased laxity on arthrometer testing was seen in the hamstring population in 3 of 7 studies. Pain with kneeling was greater for the patellar tendon population in 4 of 4 studies. Only 1 of 9 studies showed increased anterior knee pain in the patellar tendon group. Frequency of additional surgery seemed to be related to the fixation method and not graft type. No study reported a significant difference in graft failure between patellar tendon and hamstring tendon autografts. Objective differences (range of motion, isokinetic strength, arthrometer testing) were not detected between groups in the majority of studies, suggesting that their sensitivity to detect clinical outcomes may be limited. Increased kneeling pain in the patellar tendon group was seen consistently in the studies evaluated. Subjective differences in anterior knee pain or return-to-activity level were not consistently observed in these studies. With numbers available, failure rates were not significantly different between groups. These findings suggest that graft type may not be the primary determinant for successful outcomes after anterior cruciate ligament surgery.
The healing responses of the anterior cruciate ligament and the patellar tendon differ markedly. The anterior cruciate ligament fails to heal, whereas the patellar tendon heals slowly. The basis of these differences is unknown. Since cellular proliferation is a critical element of healing, we investigated the response to explants of anterior cruciate ligament and patellar tendon from sheep knees to platelet-derived growth factor-AB and transforming growth factor beta 1 as a function of time and dose. Explants cultured for 48, 72, and 96 hours with transforming growth factor beta 1 (0-100 ng/ml) or platelet-derived growth factor-AB (0-200 ng/ml) were radiolabeled for the final 24 hours with [3H]thymidine, and DNA synthesis was quantified as trichloroacetic acid-precipitable radioactivity normalized to dry tissue weight. Statistical analyses (analysis of variance) showed that transforming growth factor beta 1 induced a significant proliferative response in the anterior cruciate ligament at 96 hours with equivalent responses at 10, 50, and 100 ng/ml, whereas the patellar tendon only responded to one condition, 10 ng/ml at 96 hours. Conversely, the patellar tendon had a significant dose-dependent response to platelet-derived growth factor-AB at 72 and 96 hours, whereas the anterior cruciate ligament showed no proliferative response to platelet-derived growth factor-AB. The minimal response of anterior cruciate ligament to platelet-derived growth factor-AB could explain, at least in part, the poor repair capacity of this tissue. The response of the anterior cruciate ligament to transforming growth factor beta suggests that exogenous transforming growth factor beta may promote initial healing. Although growth factors have the potential to modulate soft-tissue repair, tissue responses in tendons and ligaments may vary at different anatomic sites.