Articular cartilage loss in long-standing immobilisation of interphalangeal joints
Summary
Articular cartilage changes are observed in stiff joints where parts of a joint surface are not in contact with opposing cartilage. The unused cartilage surface becomes irregular, fissured and covered by a capillary network. Later defects in the matrix become filled by connective tissue and a vascular proliferation invades the cartilage margin and erodes subchondral bone, to which the overlying joint capsule becomes adherent. The changes resemble those in experimental animals, and their pathology and clinical significance are discussed.
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Cited by (17)
This report presents a case of post-burn palmar contracture with flexion contracture of thumb of 20-year duration. The contracture was released and the raw area was covered with split thickness skin graft. Only one ‘K’ wire in soft tissue was needed to keep all the fingers straight and immobilized, suggestive of intermetacarpal ligamentous contracture. A static night splint was given to maintain the correction. Complete range of movement was achieved in a month with the combination of dynamic splinting and physiotherapy. It was interesting to note that even 20 years of contracted position did not render the metacarpophalangeal joints completely stiff and useless. Probable reasons are discussed.
Extent and direction of joint motion limitation after prolonged immobility: An experimental study in the rat
1999, Archives of Physical Medicine and RehabilitationObjectives: To test the hypotheses that contractures progress at different rates in relation to the time after immobilization, that immobilization in flexion leads to loss of extension range of motion, and that joints of sham-operated animals are better controls than the contralateral joint of experimental animals.
Study Design: Experimental, controlled study in which 40 adult rats had one knee joint immobilized at 135° of flexion for up to 32 weeks and 20 animals underwent a sham procedure. At intervals of 2, 4, 8, 16, and 32 weeks, 8 experimental and 4 sham-operated animals were killed and their knee motion measured in flexion and extension.
Results: In the experimental group, the range of motion decreased in the first 16 weeks of immobility at an average rate of 3.8° per week (p < .0001) to reach 61.1° of restriction. A plateau was then observed from which the contracture did not progress further. The loss in range of motion occurred in extension, not in flexion.
Conclusion: This study defined an acute stage of contractures starting at the onset of immobility and lasting 16 weeks, during which the range of motion was progressively restricted, and a chronic stage during which no additional limitation was detected. The loss in motion was attributed to posterior knee structures not under tension during immobilization in flexion. Contrary to the hypothesis, the contralateral joint was validated as a control choice for range-of-motion experiments.
Management of Proximal Interphalangeal Joint Fractures Using a New Dynamic Traction Splint and Early Active Movement
1992, Journal of Hand TherapyThis paper introduces a newly designed dynamic traction splint for the management of digital intea-articular fractures. These fractures, particularly when involving comminution of the joint surface, often result in limitation of hand function due to joint stiffness, tendon adhesion, and chronic pain. Fourteen patients with intea-articular fractures were studied. Thirteen cases involved the proximal interphalangeal joint of the finger and one case involved the interphalangeal joint of the thumb. The splint, a compact, lateral-hinge type, was designed to apply dynamic traction to the fracture. Follow-up at 7 months (range 2 to 19 months) demonstrated functional, pain-free movement. The mean total arc of active motion was 80° in the proximal interphalangeal joints of the fingers and 60° in the interphalangeal joint of the thumb. Radiologic examination demonstrated remodeling of the articular surfaces with maintenance of joint space. The results, when compared with those of other treatment methods, support the use of this splint and treatment program for the management of difficult intea-articular fractures.
The effects of continuous passive motion on the temporomandibular joint after surgery. Part I. Appliance design and fabrication
1989, Oral Surgery, Oral Medicine, Oral PathologyThe application of continuous passive motion (CPM) to synovial joints immediately after orthopedic surgery stimulates the regeneration of articular tissue, eliminates adhesions, prevents joint stiffness, reduces pain, and is well tolerated by patients. This article reviews the development of CPM in animal studies and its subsequent clinical applications to patients after orthopedic surgery. It seems likely that CPM applied to the temporomandibular joint after surgery would result in similar advantages to patients. We identify the criteria for the function, patient acceptability, and safety of a CPM appliance to be used on the temporomandibular joint. The first prototype is described and redesigned in a second model that meets the necessary criteria for testing on patients.
The effects of immobilization on the rabbit temporomandibular joint
1985, Journal of Oral and Maxillofacial SurgeryWhile the effects of immobilization of joints covered with hyaline cartilage have been widely studied, the effects on the fibrous tissue-covered temporomandibular joint have not been studied as extensively. This study was designed to determine the short-term effects of immobilization on the rabbit temporomandibular joint. Nineteen rabbits were placed in maxillomandibular fixation. The temporomandibular joints were studied histologically after periods of from ten to 28 days. Significant thinning was observed as early as after ten days, as was degeneration of the cartilage. Degeneration became progressively more severe as the duration of the immobilization increased. Reparative events began appearing after 28 days. These findings suggest that although initially immobilization produces destructive changes, the changes may well be reversible.
Fixed post-traumatic flexion-contractures of digits. Review of thirty-three cases
1983, Annales de Chirurgie de la MainLe doigt en crochet séquelle de plaies digito-palmaires est un doigt habituellement multi-opéré. Il peut apparaître même sans section initiale des tendons fléchisseurs (18 % des cas), mais le blocage des tendons fléchisseurs y est constant. Il s'accompagne, dans tous les cas, d'une rétraction cutanée de la face palmaire du doigt, et dans la moitié des cas, d'une rétraction capsulo-ligamentaire de l'articulation interphalangienne proximale. Cette atteinte articulaire apparaît sans corrélation statistique avec l'ancienneté du crochet. Nous avons fait une analyse rétrospective de 33 cas de doigts en crochet associant une rétraction cutanée au blocage en flexion des tendons fléchisseurs à la suite d'un traumatisme de la face palmaire du doigt. Nous avons utilisé une méthode d'appréciation objective des résultats, classant le secteur de mobilité actif post-opératoire des articulations interphalangiennes proximales en trois groupes par rapport au secteur de mobilité fonctionnelle de chaque doigt. Le pronostic est lié à l'âge du patient : après 27 ans environ, la probabilité d'échec opératoire est de 78 % alors qu'avant cet âge, elle est de 25 %. Le pronostic semble également lié au doigt atteint : les doigts radiaux ont statistiquement un meilleur pronostic (65 % de résultats favorables) que les doigts cubitaux (31 % de résultats favorables). L'existence d'une lésion nerveuse collatérale associée ne semble pas un facteur réel de mauvais pronostic. Toutes ces notions peuvent permettre de mesurer les indications opératoires et d'avertir le patient du risque d'échec, qui est globalement important (39 % de résultats défavorables), même si la moitié de ceux-ci reste discutable en tant qu'échecs. Le nombre d'interventions antérieures n'a pas d'influence notable sur le pronostic et l'amputation n'est donc pas la seule solution à proposer à un doigt en crochet multi-opéré. Sur le plan thérapeutique, il a fallu pratiquer une arthrolyse interphalangienne proximale dans la moitié des cas, sans que ce geste entraîne une raideur fonctionnellement gênante. Quant au recouvrement cutané, il nous est apparu que le lambeau hétérodigital donne des résultats statistiquement comparables à ceux des plasties locales homodigitales. Les indications des lambeaux hétérodigitaux doivent donc demeurer limitées aux cas où l'état cicatriciel du doigt en crochet ne permet pas d'y prélever sans risque le lambeau cutané de couverture qui reste indispensable dans tous les cas.
A fixed post-traumatic flexion contracture of a finger is usually secondary to multiple previous operations. We have observed that a former flexor tendon laceration is not constant and is missing in 18 % of our cases. The flexor tendons are, nevertheless, always involved in the contracture. A volar skin contracture was present in all cases, but only in half of them was noted a retraction of the volar components of the PIP joint. This articular involment has no statistical correlation with the time elapsed from the onset of the contracture. We have reviewed 33 cases of post-traumatic flexions contractures of the digits all secondary to volar trauma. In every case there was at least a flexor tendon adhesion and skin contracture. They have all been submitted to both objective and statistical analysis. Results have been evaluated by comparison between the normal functional range of motion for each digit and the actual post-operative active range of motion. On the basis of our study we conclude that : the age of the patient is an important prognostic factor. We obtained 75 % satisfactory results in patients younger than 27 years, but only 22 % in the older group. Good results are more easily obtained in radial (65 %) than ulnar digits (31 %). While the authors rated 39 % of the results bad, half of the patients in this group were satisfied with the result. A volar PIP joint release has been necessary in half of the cases with no significant secondary joint stiffness. A skin flap is necessary to cover the cutaneous defect secundary to the release. There is no statistically significant advantage to cross finger flaps. Therefore we feel that local flaps are indicated except in the cases where local scar tissues would not make it feasible. The prognosis is independant of the number of previous operations and of associated nerve lesions. Therefore amputation is not the only solution for a multi-operated finger fixed in flexion.