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Frontiers in Endocrinology 2022Investigating the causal relationship between rheumatoid arthritis (RA) and atlantoaxial subluxation (AAS) and identifying and quantifying the role of C-reactive protein...
OBJECTIVE
Investigating the causal relationship between rheumatoid arthritis (RA) and atlantoaxial subluxation (AAS) and identifying and quantifying the role of C-reactive protein (CRP) as a potential mediator.
METHODS
Using summary-level data from a genome-wide association study (GWAS), a two-sample Mendelian randomization (MR) analysis of genetically predicted rheumatoid arthritis (14,361 cases, and 43,923 controls) and AAS (141 cases, 227,388 controls) was performed. Furthermore, we used two-step MR to quantitate the proportion of the effect of c-reactive protein-mediated RA on AAS.
RESULTS
MR analysis identified higher genetically predicted rheumatoid arthritis (primary MR analysis odds ratio (OR) 0.61/SD increase, 95% confidence interval (CI) 1.36-1.90) increased risk of AAS. There was no strong evidence that genetically predicted AAS had an effect on rheumatoid arthritis risk (OR 1.001, 95% CI 0.97-1.03). The proportion of genetically predicted rheumatoid arthritis mediated by C-reactive protein was 3.7% (95%CI 0.1%-7.3%).
CONCLUSION
In conclusion, our study identified a causal relationship between RA and AAS, with a small proportion of the effect mediated by CRP, but a majority of the effect of RA on AAS remains unclear. Further research is needed on additional risk factors as potential mediators. In clinical practice, lesions of the upper cervical spine in RA patients need to be given more attention.
Topics: Humans; Arthritis, Rheumatoid; Atlanto-Axial Joint; C-Reactive Protein; Cervical Vertebrae; Genome-Wide Association Study; Joint Dislocations; Joint Instability
PubMed: 36589832
DOI: 10.3389/fendo.2022.1054206 -
The Cochrane Database of Systematic... May 2019Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more...
BACKGROUND
Acute anterior shoulder dislocation, which is the most common type of dislocation, usually results from an injury. Subsequently, the shoulder is less stable and is more susceptible to re-dislocation or recurrent instability (e.g. subluxation), especially in active young adults. After closed reduction, most of these injuries are treated with immobilisation of the injured arm in a sling or brace for a few weeks, followed by exercises. This is an update of a Cochrane Review first published in 2006 and last updated in 2014.
OBJECTIVES
To assess the effects (benefits and harms) of conservative interventions after closed reduction of traumatic anterior dislocation of the shoulder. These might include immobilisation, rehabilitative interventions or both.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro and trial registries. We also searched conference proceedings and reference lists of included studies. Date of last search: May 2018.
SELECTION CRITERIA
We included randomised or quasi-randomised controlled trials comparing conservative interventions with no treatment, a different intervention or a variant of the intervention (e.g. a different duration) for treating people after closed reduction of a primary traumatic anterior shoulder dislocation. Inclusion was regardless of age, sex or mechanism of injury. Primary outcomes were re-dislocation, patient-reported shoulder instability measures and return to pre-injury activities. Secondary outcomes included participant satisfaction, health-related quality of life, any instability and adverse events.
DATA COLLECTION AND ANALYSIS
Both review authors independently selected studies, assessed risk of bias and extracted data. We contacted study authors for additional information. We pooled results of comparable groups of studies. We assessed risk of bias with the Cochrane 'Risk of bias' tool and the quality of the evidence with the GRADE approach.
MAIN RESULTS
We included seven trials (six randomised controlled trials and one quasi-randomised controlled trial) with 704 participants; three of these trials (234 participants) are new to this update. The mean age across the trials was 29 years (range 12 to 90 years), and 82% of the participants were male. All trials compared immobilisation in external rotation (with or without an additional abduction component) versus internal rotation (the traditional method) following closed reduction. No trial evaluated any other interventions or comparisons, such as rehabilitation. All trials provided data for a follow-up of one year or longer; the commonest length was two years or longer.All trials were at some risk of bias, commonly performance and detection biases given the lack of blinding. Two trials were at high risk of selection bias and some trials were affected by attrition bias for some outcomes. We rated the certainty of the evidence as very low for all outcomes.We are uncertain whether immobilisation in external rotation makes a difference to the risk of re-dislocation after 12 months' or longer follow-up compared with immobilisation in internal rotation (55/245 versus 73/243; risk ratio (RR) 0.67, 95% confidence interval (CI) 0.38 to 1.19; 488 participants; 6 studies; I² = 61%; very low certainty evidence). In a moderate-risk population with an illustrative risk of 312 per 1000 people experiencing a dislocation in the internal rotation group, this equates to 103 fewer (95% CI 194 fewer to 60 more) re-dislocations after immobilisation in external rotation. Thus this result covers the possibility of a benefit for each intervention.Individually, the four studies (380 participants) reporting on validated patient-reported outcome measures for shoulder instability at a minimum of 12 months' follow-up found no evidence of a clinically important difference between the two interventions.We are uncertain of the relative effects of the two methods of immobilisation on resumption of pre-injury activities or sports. One study (169 participants) found no evidence of a difference between interventions in the return to pre-injury activity of the affected arm. Two studies (135 participants) found greater return to sports in the external rotation group in a subgroup of participants who had sustained their injury during sports activities.None of the trials reported on participant satisfaction or health-related quality of life.We are uncertain whether there is a difference between the two interventions in the number of participants experiencing instability, defined as either re-dislocation or subluxation (RR 0.84, 95% CI 0.62 to 1.14; 395 participants, 3 studies; very low certainty evidence).Data on adverse events were collected only in an ad hoc way in the seven studies. Reported "transient and resolved adverse events" were nine cases of shoulder stiffness or rigidity in the external rotation group and two cases of axillary rash in the internal rotation group. There were three "important" adverse events: hyperaesthesia and moderate hand pain; eighth cervical dermatome paraesthesia; and major movement restriction between 6 and 12 months. It was unclear to what extent these three events could be attributed to the treatment.
AUTHORS' CONCLUSIONS
The available evidence from randomised trials is limited to that comparing immobilisation in external versus internal rotation. Overall, the evidence is insufficient to draw firm conclusions about whether immobilisation in external rotation confers any benefit over immobilisation in internal rotation.Considering that there are several unpublished and ongoing trials evaluating immobilisation in external versus internal rotation, the main priority for research on this question consists of the publication of completed trials and the completion and publication of ongoing trials. Meanwhile, evaluation of other interventions, including rehabilitation, is warranted. There is a need for sufficiently large, good-quality, well-reported randomised controlled trials with long-term follow-up. Future research should aim to determine the optimal immobilisation duration, precise indications for immobilisation, optimal rehabilitation interventions, and the acceptability of these different interventions.
Topics: Adult; Conservative Treatment; Female; Humans; Immobilization; Joint Instability; Male; Randomized Controlled Trials as Topic; Shoulder Dislocation
PubMed: 31074847
DOI: 10.1002/14651858.CD004962.pub4 -
Neurology India 2012Atlanto-axial dislocations (AADs) may be classified into four varieties depending upon the direction and plane of the dislocation i.e. anteroposterior, rotatory,... (Review)
Review
Atlanto-axial dislocations (AADs) may be classified into four varieties depending upon the direction and plane of the dislocation i.e. anteroposterior, rotatory, central, and mixed dislocations. However, from the surgical point of view these are divided into two categories i.e. reducible (RAADs) and irreducible (IAADs). Posterior fusion is the treatment of choice for RAAD. Transarticular screw fixation with sub-laminar wiring is the most stable& method of posterior fusion. Often, IAAD is due to inadequate extension in dynamic X-ray study which may also be due to spasm of muscles. If the anatomy at the occipito-atlanto-axial region {O-C1-C2; O: occiput, C1: atlas, C2: axis} is normal on X-ray, the dislocation should be reducible. In case congenital anomalies at O-C1-C2 and IAAD are seen on flexion/extension studies of the cervical spine, the C1-C2 joints should be seen in computerized tomography scan (CT). If the C1-C2 joint facet surfaces are normal, the AAD should be reducible by cervical traction or during surgery by mobilizing the joints. The entity termed "dolichoodontoid" does not exist. It is invariably C2-C3 (C3- third cervical vertebra) fusion which gives an appearance of dolichoodontoid on plain X-ray or on mid-saggital section of magnetic resonance imaging (MRI) or CT scan. The central dislocation and axial invagination should not be confused with basilar invagination. Transoral odontoidectomy alone is never sufficient in cases of congenital IAAD, adequate generous three-dimensional decompression while protecting the underlying neural structures should be achieved. Chronic post-traumatic IAAD are usually Type II odontoid fractures which get malunited or nonunited with pseudoarthrosis in dislocated position. All these dislocations can be reduced by transoral removal of the offending bone, callous and fibrous tissue.
Topics: Atlanto-Axial Joint; Cervical Vertebrae; Humans; Joint Dislocations
PubMed: 22406773
DOI: 10.4103/0028-3886.93582 -
Proceedings of the Royal Society of... Sep 1961
Topics: Axis, Cervical Vertebra; Cervical Atlas; Child; Fractures, Bone; Humans; Infant; Joint Dislocations
PubMed: 14476765
DOI: No ID Found -
Clinics (Sao Paulo, Brazil) Nov 2013The aim of this study was to review the literature on cervical spine fractures. (Review)
Review
OBJECTIVES
The aim of this study was to review the literature on cervical spine fractures.
METHODS
The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.
RESULTS
Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.
CONCLUSIONS
Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.
Topics: Cervical Vertebrae; Female; Humans; Joint Dislocations; Male; Medical Illustration; Spinal Fractures
PubMed: 24270959
DOI: 10.6061/clinics/2013(11)12 -
Orthopaedics & Traumatology, Surgery &... Feb 2023Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be... (Review)
Review
Elbow fracture is frequent in children, and often requires surgery. There are many potential sequelae: neurovascular, ligamentous and osseous. Some are liable to be overlooked, due to young age and the cartilaginous nature of the joint. There is little bone remodeling in the elbow and displacement fracture, and especially supracondylar or lateral condyle fracture, has to be corrected rigorously, notably in older children. In case of lateral tilt in fracture of the neck of the radial head, on the other hand, remodeling is effective. Deformity in cubitus varus and cubitus valgus leads to neurological lesions and instability. Treatment should be early, with adapted surgery in expert hands. Post-traumatic stiffness is rare. Early intensive physiotherapy is unsuited to children and could worsen the stiffness due to inflammation. Lateral condyle non-union is a classic complication of fracture. Simple percutaneous screwing is a useful option. The equivalent in the medial epicondyle is well-tolerated, and simple monitoring now suffices. Late posterolateral rotational instability is a poorly known complication. It should be considered in case of cubitus varus that becomes painful after a long asymptomatic course. Radiocapitellar subluxation is seen on X-ray. Residual radial head dislocation after primary treatment (Monteggia lesion) responds well to the Bouyala technique of ulnar flexion osteotomy associated to annular ligament repair, without requiring ligament reconstruction.
Topics: Child; Humans; Elbow Fractures; Fractures, Bone; Elbow Joint; Ulna; Joint Dislocations
PubMed: 36302449
DOI: 10.1016/j.otsr.2022.103454 -
Asian Journal of Surgery Dec 2023
Topics: Humans; Joint Dislocations; Cervical Vertebrae
PubMed: 37657978
DOI: 10.1016/j.asjsur.2023.08.162 -
Orthopaedics & Traumatology, Surgery &... Feb 2013This review describes bone and nerve injury mechanisms during a femoral head fracture-dislocation and outlines a novel classification system that uses computed... (Review)
Review
This review describes bone and nerve injury mechanisms during a femoral head fracture-dislocation and outlines a novel classification system that uses computed tomography scanning (CT scan) to help determine how to best treat these fractures in an emergency setting or in chronic cases. A series of 55 cases with CT scan performed in the emergency department (ED) and an average follow-up of 9 years (range 3-13) was used as a basis to develop the classification system; this system takes into account the size of the fragments and any associated acetabular wall or femoral neck fractures. The suggested course of action is based on the CT scan results after the hip joint is reduced. Conservative treatment is indicated every time the head fragments and any potential acetabular wall fragments are properly reduced and there are no foreign bodies (37.7%). Osteochondral head fragments below the fovea must be removed (36.3%). Fragments that are one-third or one-quarter of the head size can either be removed (7.2%) or reduced and fixed (5.4%). A novel medial approach is described that provides minimally invasive access to the anterior-inferior part of the femoral head, which should extend the indications for preservation of one-third head fragments. If the femoral neck is also fractured or a one-half head fragment exists in elderly patients, a total hip replacement should be considered right way (9%). At the latest follow-up, osteoarthritis was present in 43.7% of cases, but was mostly well tolerated - 94% of patients had a WOMAC score between 80 and 100 with signs of osteoarthritis visible on radiographs. Paradoxically, avascular necrosis (9%) is due to small head fractures. The results of our series are compared with the few series that have been published since CT scanning has been systematically used in the ED.
Topics: Femur Head; Hip Fractures; Hip Injuries; Humans; Joint Dislocations
PubMed: 23357042
DOI: 10.1016/j.otsr.2012.11.007 -
The Bone & Joint Journal Nov 2013Dislocation is one of the most common causes of patient and surgeon dissatisfaction following hip replacement and to treat it, the causes must first be understood.... (Review)
Review
Dislocation is one of the most common causes of patient and surgeon dissatisfaction following hip replacement and to treat it, the causes must first be understood. Patient factors include age greater than 70 years, medical comorbidities, female gender, ligamentous laxity, revision surgery, issues with the abductors, and patient education. Surgeon factors include the annual quantity of procedures and experience, the surgical approach, adequate restoration of femoral offset and leg length, component position, and soft-tissue or bony impingement. Implant factors include the design of the head and neck region, and so-called skirts on longer neck lengths. There should be offset choices available in order to restore soft-tissue tension. Lipped liners aid in gaining stability, yet if improperly placed may result in impingement and dislocation. Late dislocation may result from polyethylene wear, soft-tissue destruction, trochanteric or abductor disruption and weakness, or infection. Understanding the causes of hip dislocation facilitates prevention in a majority of instances. Proper pre-operative planning includes the identification of patients with a high offset in whom inadequate restoration of offset will reduce soft-tissue tension and abductor efficiency. Component position must be accurate to achieve stability without impingement. Finally, patient education cannot be over-emphasised, as most dislocations occur early, and are preventable with proper instructions.
Topics: Age Factors; Arthroplasty, Replacement, Hip; Clinical Competence; Comorbidity; Hip Dislocation; Hip Prosthesis; Humans; Patient Education as Topic; Postoperative Complications; Prosthesis Design; Radiography; Recurrence; Reoperation; Risk Factors; Sex Factors
PubMed: 24187356
DOI: 10.1302/0301-620X.95B11.32645 -
Orthopaedics & Traumatology, Surgery &... May 2017Benefits of femoral offset restoration during total hip arthroplasty should be the reduction of bearing surfaces wear, implant loosening and dislocation rates. Modular... (Review)
Review
UNLABELLED
Benefits of femoral offset restoration during total hip arthroplasty should be the reduction of bearing surfaces wear, implant loosening and dislocation rates. Modular neck stems ensure offset customization but fretting corrosion and catastrophic failures are well-documented complications. Since clinical evidences are needed to substantiate the effectiveness of femoral offset restoration and promote modular neck choice, we systematically reviewed the literature to ascertain whether femoral offset itself has a proven clinical influence: (1) on bearing surfaces wear, (2) implant loosening, (3) and dislocation rates. A systematic literature screening was conducted to find papers dealing with the influence of femoral offset on wear, dislocation and loosening, including articles with conventional radiographic femoral offset assessment and with comparative design. Observational studies, case reports, instructional course lectures, cadaveric and animal studies as well as biomechanical studies, letters to the editor, surgical techniques or technical notes were all excluded. No limits about publication date were supplied but only papers in English were taken into account. Data were extracted into an anonymous spreadsheet. Offset values, dislocation rates, wear rates, follow-up and surgical approaches were all detailed. Ten manuscripts were finally selected. A statistically significant correlation between femoral offset restoration and the reduction of conventional ultrahigh-molecular-weight polyethylene wear was found in two out of three papers investigating this issue, but no correlations were found between femoral offset and dislocation rates or implant loosening. Femoral offset modification influences ultrahigh-molecular-weight polyethylene liners wear, but no correlation was found with dislocation rates or implant loosening. Advantages on wear can be counterbalanced by the use of hard bearing surfaces or highly cross-linked polyethylene liners, besides the availability of larger femoral heads improving implant stability further reduces the importance of femoral offset restoration by means of modularity. We believe that efforts in restoring femoral offset during total hip arthroplasty do not translate into tangible clinical profits and consequently, we do not advise the routinely usage of modular neck stems in total hip arthroplasty.
LEVEL OF EVIDENCE
level III, systematic review of case-control studies.
Topics: Arthroplasty, Replacement, Hip; Biomechanical Phenomena; Femur Head; Hip Prosthesis; Humans; Joint Dislocations; Polyethylenes; Prosthesis Design; Prosthesis Failure
PubMed: 28159679
DOI: 10.1016/j.otsr.2016.12.013