Major Criteria

• A Beighton score of 4/9 or greater (either currently or historically)
• Arthralgia for longer than 3 months in 4 or more joints

Minor Criteria

• A Beighton score of 1, 2 or 3/9 (0, 1, 2 or 3 if aged 50+)
• Arthralgia (> 3 months) in one to three joints or back pain (> 3 months), spondylosis, spondylolysis/spondylolisthesis.

• Dislocation/subluxation in more than one joint, or in one joint on more than one occasion.
• Soft tissue rheumatism. > 3 lesions (e.g. epicondylitis, tenosynovitis, bursitis).
• Marfanoid habitus (tall, slim, span/height ratio >1.03, upper: lower segment ratio less than 0.89, arachnodactyly [positive Steinberg/wrist signs].
• Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring.
• Eye signs: drooping eyelids or myopia or antimongoloid slant.
• Varicose veins or hernia or uterine/rectal prolapse.

The Diagnosis

The diagnois of Benign Joint Hypermobility is made if

Two major criteria are present

or

There is one major and two minor criteria present

or

Four minor criteria are present

Related posts:

1. Benign Joint Hypermobility Syndrome
2. Neuropathic Joint Disease or Charcot Joint in Children
3. Beighton Scale For Joint Hypermobility

The Beighton score is used for assessing the presence of hypermobility. However, it must be noted that the diagnosis of Hypermobility Syndrome or HMS should be made using the Brighton Criteria.

Beighton scoring is based on testing the simple movement or hypermovements if you want to call them

Passive Dorsiflexion of Little Finger 

In a normal individual, little finger cannot be extended beyond 90 degrees, even passively. Score 0

If the passive extension [dorsiflexion] reveals this movement beyond 90 degrees  – Score 1

Passive Dorsiflexion of Thumb

If thumb cannot be made to touch the flexor aspect of forearm – Score 0

If thumb can be made to touch the flexor aspect of forearm – Score 1

Hyperextension of left  elbow

In a most of individual the range of movement of elbow is 0-120 degrees. 0 signifies that arm can be made to straighten  but further movement is not possible. Any further extension movement of elbow would result in arm bending backward.

Some normal individual may have a slight backward bending movement. To look for a hypermobile joint a cut off point of 10 degrees is kept.

If elbow cannot be bent backwards is less than 10 degrees [has less than 10 degrees of extension - Score 0

If elbow can be bent backwards more than 10 degrees [has more than 10 degrees of extension] - Score 1

Hyperextension of Knee

The concept of elbow when applied to knee would provide scores of knee. In a normal individual the knee can not be straightened beyond 0 degrees. Further extension is known as hyperextension

 

Hyperextension of right knee beyond 10 degrees not present - Score 0

Hyperextension of right knee beyond 10 degrees present – Score 1

Trunk Flexion

Individual is not able to  rest the palms and hands on the floor with forward flexion [bending] of trunak with knees full extended – Score 0

Individual is able to rest the palms and hands on the floor with forward flexion [bending] of trunak with knees full extended – Score 1

 

Calculation of Score

The score is calculated by adding the scores of

• Both the thumbs
• Both the little fingers
• Both elbows
• Both knees
• One Trunk Movement

Maximum possible score thus becomes 9

4/9 score is considered significant.

Related posts:

1. Benign Joint Hypermobility Syndrome
2. What Is Joint Hypermobility?
3. Neuropathic Joint Disease or Charcot Joint in Children

The entity is different from the disorders that cause local joint hypermobility and generalized joint laxity, such as Marfan syndrome and Ehlers–Danlos syndrome.

Hypermobility not associated with systemic disease occurs in 4% to 13% of the people.

Hypermobility may occur in several different connective tissue disorders including Marfan syndrome, EDS, and osteogenesis imperfecta, Down syndrome, homocystinuria and hyperlysinemia.

Benign joint hypermobility syndrome has a strong genetic component with an autosomal dominant pattern.

Pathophysiology

Why do some people have symptoms with hypermobile joints. Four factors have been suggested -

• Shape of the ends of the bones resulting in joint wear and tear
• Impaired proprioreception
• Fatigue of surrounding tissues

Clinical Presentation

Pain in a hypermobile joint which may affect one or multiple joints is the most common symptom. This can occur at any age are often exacerbated by  physical activity.

Though it may occur in any joint but knee and ankle are most commonly involved.

Other symptoms that may occur are  are joint stiffness, myalgia, muscle cramps, and nonjoint limb pain.

There might be a history of double-jointedness or recurrent dislocations in the family.

Easy bruising, ligament or tendon rupture, congenital hip dysplasia, and temporomandibular joint dysfunction may be associated findings.

On physical examination, there might be pain in joints on manipulation.

Other assoicated findings that might be present are [Suggesting some connective tissue disorder]

• Scoliosis
• Pes planus
• Genu valgum
• Lordosis
• Marfanoid habitus
• Varicose veins
• Rectal or uterine prolapse
• Thin skin

People with hypermobility syndrome may develop other conditions caused by their unstable joints. These conditions include  frequent sprains, tendinitis, or bursitis when doing activities that would not affect the normal individual.

Diagnosis

Diagnosis of benign joint hypermobility syndrome is one of exclusion. Other causes like inflammatory, infectious, and autoimmune causes should be ruled out . Routine work up including  a complete blood cell count, erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibody test, serum complement  levels, and serum immunoglobulin levels should be done.

By rule all of these are within normal limits in benign joint hypermobility syndrome. Aspiration of joint in cases who have joint effusion shows a noninflammatory pattern from meniscal and cartilage irritation.

Determining the Beighton score which is a measure of generalized joint laxity is essential for diagnosis making. .A Beighton score of 4 or more points is considered indicative of generalized joint laxity. Brighton criteria which is based on Beighton score helps to establish diagnosis of benign joint hypermobility syndrome and also helps to distinguish it from other connective tissue disorders.

Treatment

Many individuals with joint hypermobility syndrome improve in adulthood. Treatments are individualized based on the manifestations.

The  treatment  of benign joint hypermobility syndrome consists of

• Lifestyle modification
• Change In Exercise Pattern
• Protection of jointsor
• Medication

Nonsteroidal anti-inflammatory drugs are used for pain control. Restraining from aggravating activities  can relieve the symptoms.

In long term, modification of activities that induce symptoms is part of the treatment. Vigorous and repetitive activities should be curtailed.

Patients need to be taught about the condition they have.. Overtraining, poor pacing, too maniy performances or athletic competitions, and focusing on joint flexibility rather than stability may all increase joint pain and the risk of injury.

They should be avoided. But it cannot be possible in all cases [for example athletes] and alternatives can be explored.

It is important that the individual with hypermobility remain extremely fit – even more so than the average individual – to prevent recurrent injuries. Regular exercise and physical therapy or hydrotherapy can reduce symptoms of hypermobility, because strong muscles help to stabilise joints.

Strengthening program to provide muscular stability and stabilization to the joint may be beneficial. Stretching techniques that are targeted to isolate tight muscles without stressing the surrounding joints may reduce symptoms.

Supportive splints along with appropriate footwear protect the joint, and supportive joint taping  can improve joint proprioception.

Related posts:

1. What Is Joint Hypermobility?
2. Brighton Criteria For Benign Joint Hypermobilty Syndrome
3. Beighton Scale For Joint Hypermobility

• Double jointedness
• Hypermobility syndrome
• Benign joint hypermobility syndrome
• Hyperlaxity

Hypermobile joint is a joint that can be stretched beyond what is called normal range is normal.

It could be due to

• Malaligned joints
• Joint with abnormal shape of articular surfaces
• Connective tissue disorder (such as  Ehlers-Danlos syndrome, Marfan syndrome)
• Abnormal joint proprioception

Hypermobility can run in families suggesting a genetic basis too.

Most of people with hypermobile joints do not have any problem but others especially those in sports may become prone to repeated joint injuries.

Hypermobility syndrome

When generalized  joint hypermobility is present with symptoms of muscle and joint pain, it is termed as Hypermobility syndrome.

Related posts:

1. Benign Joint Hypermobility Syndrome
2. Beighton Scale For Joint Hypermobility
3. Neuropathic Joint Disease or Charcot Joint in Children

This has been reported by a meta-anlysis conducted by Kym Hennessy and colleagues at Glasgow Caledonian University and published online December 12 in Arthritis Care & Research

The study involved analysis of 17 studies involving more than 700 patients. According to researchers, most of the studies they analyzed were not of high quality.

There was weak evidence for custom orthoses reducing pain and forefoot plantar pressures.

Evidence was inconclusive for foot function, walking speed, gait parameters and reducing angle progression in hallux abductovalgus [A condition where great toe starts moving in valgus and abduction -In other words, great toe starts pointing towards outer aspect of foot]

Overall, the researchers suggest that custom orthotics may help ease pain and elevated forefoot plantar pressures, but findings are inconclusive and a definitive randomized controlled trial is needed to establish the role of custom orthotics.

Source: Arthritis Care Res 2012 DOI: 10.1002/acr.21559

Related posts:

1. Drugs For Rheumatoid Arthritis Less Effective In Obese Patients
2. Xray of Bilateral Hands In Rheumatoid Arthritis Showing Dislocation of All Metacarpophalangeal Joints
3. Tocilizumab Inhibits Joint Damage In Rheumatoid Arthritis Not Adequately Controlled With Methotrexate

The articular surfaces are connected together by the following ligaments:

• Volar radioulnar ligament
• Dorsal radioulnar ligament
•  Articular disk (Triangular fibrocartilage)

Triangular fibrocartilage complex is ulnar continuation of distal radius & presents concave surface for articulation with lunate and triquetrium.

Distal Radio Ulnar Joint

Distal radio ulnar joint is involved in pronation and supination movements of the forearm. In pronation,  ulna assumes a small relative negative variance position, ulnar head moves dorsally, and volar ligaments become tight;

In supination,  ulna assumes a small relative positive variance position, ulnar head moves volarly, and dorsal ligaments become tight.

Related posts:

1. What is Ulnar Variance?
2. Anatomical Considerations In Treatment Of Distal Radius Fractures
3. Triangular Fibrocartilage Complex

Apart from this following patients can undergo arthrodesis are

• Painful stiffness of knee after infection, tuberculosis or injury
• Severe deformity in paralytic conditions
• Neuropathic arthropathy [Charcot joint]
• Malignancy around the knee.

The most frequent indication for knee arthrodesis at present is salvage of a failed total knee arthroplasty.

Position

• 0 to 15 degrees of flexion
• 5 to 8 degrees of valgus
• 10 degrees of external rotation

Techniques

Techniques in literature for this surgery and mainly classified on the basis of type of fixation

• External Fixation

• Internal Fixation

The amount and quality of bone, patient demands, quality of bone and surgeon’s experience are important factors for seleting a particular techinqe.

Compression Arthrodesis with External Fixation

It is done in knees with minimal bone loss and broad cancellous surfaces with adequate cortical bone to allow good bony apposition and compression.

Advantages of compression arthrodesis

• Good, stable compression across the fusion site
• Placecement of fixation proximal and distal to an infected or neuropathic joint.

Pin track problems, poor patient compliance, and the frequent need for early removal and cast immobilization are the usual disadvantages.
Arthrodesis with Iinternal fixation

Internal fixation could be by

• Intramedullary rod
• Plate fixation

Intramedullary Rod Fixation

Most appropriate when extensive bone loss does not allow compression. Examples are after tumor resection or failed total knee arthroplasty.

Advantages of intramedullary nailing are

• Immediate weight bearing
• Easier rehabilitation
• No pin track problem
• High fusion rate

Significant blood loss, more frequent major complications, and difficulty in obtaining correct alignment are  the problem faced with ineral fixation arthrodesis with intrameduallry rod.

Plate Fixation

Two long plates placed at right angles to each other have also been used in knee arthrodesis offering same benefits of internal fixation but require extensive surgical exposure and are contraindicated in infection.

Prognosis

Reported success rates of knee arthrodesis are 80% to 98% of patients.

Properly selected patients are satisfied especially with the decrease in pain.

Usual concerns of patients after successful aoutcome are

• Awkwardness of gait my cause public attention
• Difficulty riding public transportation
• Difficulty sitting in theaters and stadiums
• Difficulty getting up after a fall.

A proper preoperative conselling would reduce the anxiety faced in postoperative period.

A trial of preoperative long-leg immobilization can be done to make the patient assess himself  if he could manage after a fused knee.

Related posts:

1. What Is Arthrodesis?
2. Ankle Arthrodesis

Most common indication for performing this surgery is common indication is arthritis following injury to ankle also called post-traumatic arthritis.

Other indications are

• Rheumatoid arthritis
• Infection
• Neuromuscular disorders
• Failed total ankle arthroplasty.
• Bone tumors around the ankle

Before proceeding with arthrodesis, surgeon might give you a below knee cast to see if you are suitable candidate for arthrodesis.

Position

The optimal position for ankle fusion is

• 0 degrees of flexion
• 0 to 5 degrees of valgus
• 5 to 10 degrees of external rotation with slight posterior displacement of the talus.

Techniques & Approaches

Techniques are classified by approach used

Anterior

Ankle is approached from anterior [front] side with or without an additional small incision

Transmalleolar

This approach provides slightly better access to the posterior aspect of the ankle joint. Exposure is improved by medial and lateral transmalleolar osteotomies.

Posterior

The posterior approach can be used  in patients with compromised anterior skin from previous trauma or surgery.

And by method of fixation used:

External fixation

• Charnley fixation clamp
•  Calandruccio compression device
• Ring Fixator
• tubular externall fixators

Internal Fixation

Internal fixation has several theoratical advantages over external fixation

• Ease of insertion
• Patient convenience
• comparable rates of delayed union, malunion, nonunion, and infection
• Greater resistance to shear stress.

following modalities are used in internal fixation

• Cancellous screws – parallel or crossed
• Direct compression plates
• Kirschner wires
• Steinmann pins
• Intramedullary rods
• Lateral T-plate
• Posterior blade plate fixation.

Procedure

The procedure involves denuding the remaining articular cartilage and  making two parallel cuts, one through the distal tibia and one through dome of talus to resect a minimal amount of bone to allow apposition of large cancellous surfaces and translation of the talus posteriorly beneath the tibia.

Addition of bone grafting is said to increase fusion rate. Bone graft can be taken from tibia or either lateral or medial malleolus.

Arthroscopic Ankle Arthrodesis

Arthroscopically assisted ankle arthrodesis offers advantages of

• Quicker fusion because of the limited exposure and less extensive periosteal stripping
• Preservation of the overall contour of the ankle mortise, giving a better cosmetic result.

Prognosis

In general overall shortening generally is less than 1 cm and fusion rate is  80% to 90%.

Arthrodesis offers good pain relief but there is limited hindfoot motion resulting in difficult walking on uneven surfaces difficult.

Related posts:

1. What Is Arthrodesis?
2. Knee Arthrodesis

It can affect any joint in your body. But most commonly it is seen in following joints

• Hips
• Knees
• Hands
• Spine [also called spondylosis]

Following are the risk factors for this disease

Age

Age is the biggest risk factor. Osteoarthritis is more common in older individuals. It is rarely seen in persons younger than 40 years of age.

Gender

Women are more likely to develop osteoarthritis.

Obesity

Higher weight has been associated with higher risk of geting osteoarhtrits and this risk is more pronounced in case of knee OA.

Congenital Anomalies

Defective cartilage and other congenital joint problems may predispose to joint degeneration.

Arthropathies

Diseases like rheumatoid arthritis, gout and others that affect joints can cause the degenerative changes to occur.

Injury/Infection

A major injury to a joint may alter the joint anatomy and thus result in early degeneration. An infection may result in cartilage damage.

Repetitive Stress Injury

Repetitive stress injury occurs when the joint is subjected to repetitive forces regularly. It generally occurs in occupations that require repetitive use of the joints. For example typing or vibratoinal tools.

Related posts:

1. Varus Knees Have An Increased Risk For Development Of Osteoarthritis
2. New Method Developed For MRI To Detect Early Osteoarthritis In Knee
3. Why Does Osteoarthritis Occur-A Look Into Pathophysiology

The study was conducted by Dr. Mami Tama and colleagues in Nagasaki University.
In the study, MRI of wrists and finger joints of both hands were examined in 51 early-stage rheumatoid arthritis (RA) patients by both plain and Gd-DTPA enhanced MRI.

Synovitis, bone edema and bone erosion were considered as MRI-proven joint injury. A physical examination just before the MRI study was done by certified rheumatologist.

The presence of tender and/or swollen joints in the same fields as MRI was considered as joint injury on physical examination.
The association of MRI-proven joint injury with physical examination-proven joint injury was examined.

A total of 1110 sites were examined in the above mentioned patients.

MRI-proven joint injury was found in 521 sites whereas other 589 sites were normal.

Physical examination-proven joint injury was found in 305 sites which was significantly low as compared with MRI-proven joint injury.

Moreover, joint injury on physical examination was not found in 81.5 % of the sites where MRI findings were normal.

An association of the severity of MRI-proven joint injury with that of joint injury on physical examination was demonstrated.

The authors concluded that MRI is not only sensitive but accurate in reflect the joint injury in patients with early-stage RA.

DOI: 10.1002/acr.20395
The study suggests that MRI is a useful adjunct in the treatment of Rheumatoid arthrits.

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1. Smoking Causes Greater Risk For Rheumatoid Arthrits
2. Tocilizumab Inhibits Joint Damage In Rheumatoid Arthritis Not Adequately Controlled With Methotrexate
3. Drugs For Rheumatoid Arthritis Less Effective In Obese Patients