INTRODUCTION:Primary musculoskeletal extranodal non-Hodgkin lymphoma is a rare presentation and account for 5% of all primary extranodal non-Hodgkin lymphomas. Treatment uses a combination of chemotherapy and radiotherapy with good prognosis in unifocal manifestation. We report an unusual case of primary musculoskeletal extranodal lymphoma presenting as a soft tissue swelling around the wrist.CASE REPORT:A 75 year old lady was referred to the Orthopaedic Outpatients Department with a painless, slowly growing mass on the dorsum of the right wrist. Clinical examination revealed a 6 X 9 cm round painless mass on the dorsum of the distal radius adherent to both the underlying structures and skin. MRI of the wrist showed a large mass causing extensive osteolysis of the distal radius and extending proximally with abnormal replacement of the marrow. The patient was brought to theatre for biopsy and subsequent histopathological examination confirmed a B-cell non-Hodgkin lymphoma. The patient was referred to the Haematology Service for further treatment and follow-up. She received chemotherapy and radiotherapy with satisfactory results.CONCLUSION:Lymphoma presenting as a soft tissue mass is relatively uncommon and can easily be confused with a wide variety of inflammatory conditions, more common neoplasias as well as infectious diseases (tuberculosis). Though rare, extranodal lymphoma should be regularly included in the differential diagnosis of mass lesions.

We present an unusual case of a chronic, irreducible intra-articular dislocation of the patella in an elderly nursing home resident. The patient had been unable to weight bear for 3 weeks. Radiographs in the emergency department (ED) confirmed the intra-articular dislocation with the superior pole lodged in the intercondylar notch. She underwent two failed closed reduction attempts and subsequently required an open reduction under general anaesthesia.

Aim of the study: It is important to reduce potential wound complications in total hip and total knee arthroplasty procedures. The purpose of this study was to compare the jubilee dressing method to a standard adhesive dressing.Method: 124 patients (62 total hip replacements and 62 total knee replacements) were randomly selected to have either a standard adhesive dressing or jubilee method dressing. The number of dressing changes, incidence of blistering, leakage, appearance of inflammation, infection rate and the average stay in hospital was recorded for each patient.Results: The jubilee dressing significantly reduced the rate of blistering, leakage and number of dressing changes when compare to a traditional adhesive dressing (p < 0.05). The rate of inflammation and average length of stay in hospital was not significantly different between the two groups.Conclusion: The authors recommend the use of this dressing for total hip and total knee arthroplasty procedures due to the associated lower complication rate. (C) 2012 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

Introduction: After total knee arthroplasty (TKA) patients develop marked asymmetrical quadriceps femoris (QFM) weakness due to neurological activation deficits and muscle atrophy; this is associated with a slow (type I) to fast (type II) shift in myosin heavy chain (MHC) expression. Preoperative resistance training (prehabilitation) has been shown to improve strength and function after TKA however is considered costly and labour intensive. Neuromuscular electrical stimulation (NMES) offers the potential for unsupervised training, although its role in prehabilitation has not been investigated. Aims: Determine changes in myosin heavy chain (MHC) mRNA expression following preoperative NMES. Evaluate the ability of NMES prehabilitation to improve strength and functional recovery post-TKA. Methods: Randomised control efficacy study applying NMES to the affected QFM for 20 min, 5 days/week, for 8 weeks pre-TKA. Isometric QFM strength was determined dynametrically and muscle cross-sectional area (CSA) calculated from MRI axial images. Function was assessed with a walk test, stair-climb test, and chair-rise test. Real-time PCR analysed MHC mRNA expression. All evaluations were performed at baseline and preoperatively with strength, CSA and function also tested at 6 and 12 weeks post-TKA. Results: Patients scheduled for TKA were recruited and randomised into control (n=9) or NMES (n=5) groups. Only the NMES group increased strength (27.8%; p=0.05) and CSA (7.4%; p=0.013) preoperatively. MHC type II mRNA decreased by 42% (p=0.078) indicating a fast to slow fibre shift. Function also improved in the NMES group (stair climb [p=0.006]; chair rise [p=0.018]). While all patients deteriorated after surgery, only the NMES group had notable strength gain from 6 to 12 weeks (53%; p=0.011) with associated functional recovery (stair-climb, p=0.017; chair-rise, p=0.01; walking speed, p=0.014). There were differences seen between the groups at 3 months post-TKA: stair climb (61.6%, p=0.04) and chair rise (28.4%, p=0.013). There was greater muscle atrophy seen in the controls than the NMES group post-TKA when compared to baseline (12.1% [p=0.034] versus 3.7% [ns]). Conclusions: This study has shown that 8 weeks preoperative quadriceps strengthening using home-based NMES can safely and effectively attenuate the extent and duration of QFM weakness and atrophy after primary TKA. This translates into significantly faster functional recovery thereby expediting a return to normal activities.

Introduction: Quadriceps femoris muscle (QFM) weakness has been associated with the development and progression of knee osteoarthritis, primarily due to arthrogenic muscle inhibition. Neuromuscular electrical stimulation (NMES) devices cause muscle contraction by circumventing these neural inhibitory feedback pathways. While it has been proposed this occurs in a reversed pattern of muscle fibre recruitment, the molecular mechanisms have not been clearly elucidated. Methods: This randomised control efficacy study applied NMES to the affected QFM for 20 min, 5 days a week, for 8 weeks. Strength was assessed dynometrically and function determined using validated measures (timed stair climb, chair rise and 25 metre walk tests). A quantitative polymerase chain reaction (PCR) method measured quantities of types I, IIa, and IIx myosin heavy chain (MHC) mRNA of muscle specimens taken from vastus lateralis of the affected QFM. Expression of genetic markers associated with muscle wasting (MAFbx and MURF-1; E3 muscle specific ligases of the ubiquitin proteasome pathway) and muscle anabolic states (IGF-1) were also determined. Statistical analysis was performed using ANOVA’s and independent t-test’s where appropriate. Results: Sixteen patients (10 women and 6 men) with radiologically severe knee OA were recruited and randomised into a control (n=6) or intervention (n=10) group. Groups were similar in terms of age (64.8 ± 11.0 vs. 64.6 ± 7.6; mean ± SD) and BMI (31.8 ± 6.1 vs.30.7 ± 2.9). There were significant improvements in function (stair climb [p Conclusions: The use of an 8 week NMES program produces significant quadriceps strength gain with associated functional improvements in subjects with severe knee OA. Expression of muscle atrophy markers did not change significantly; however increased IGF-1 expression could potentially inhibit further muscle atrophy. Of the 3 MHC mRNA isoforms, only MHC-IIx demonstrated a change in response to NMES. These results would indicate NMES induces early quadriceps strength gain by a predominantly neurological adaptation.

BACKGROUND:Supervised preoperative muscle strengthening programmes (prehabilitation) can improve recovery after total joint arthroplasty but are considered resource intensive. Neuromuscular electrical stimulation (NMES) has been shown to improve quadriceps femoris muscle (QFM) strength and clinical function in subjects with knee osteoarthritis (OA) however it has not been previously investigated as a prehabilitation modality. METHODS:This pilot study assessed the compliance of a home-based, NMES prehabilitation programme in patients undergoing total knee arthroplasty (TKA). We evaluated its effect on preoperative and postoperative isometric quadriceps femoris muscle (QFM) strength, QFM cross-sectional area (CSA) and clinical function (subjective and objective). Seventeen subjects were recruited with 14 completing the study (NMES group n = 9; Control group n = 5). RESULTS:Overall compliance with the programme was excellent (99%). Preoperative QFM strength increased by 28% (p > 0.05) with associated gains in walk, stair-climb and chair-rise times (p < 0.05). Early postoperative strength loss (approximately 50%) was similar in both groups. Only the NMES group demonstrated significant strength (53.3%, p = 0.011) and functional recovery (p < 0.05) from 6 to 12 weeks post-TKA. QFM CSA decreased by 4% in the NMES group compared to a reduction of 12% in the control group (P > 0.05) at 12 weeks postoperatively compared to baseline. There were only limited associations found between objective and subjective functional outcome instruments. CONCLUSIONS:This pilot study has shown that preoperative NMES may improve recovery of quadriceps muscle strength and expedite a return to normal activities in patients undergoing TKA for OA. Recommendations for appropriate outcome instruments in future studies of prehabilitation in TKA have been provided.

Introduction: Quadriceps femoris (QF) atrophy has been associated with the development of knee OA and is a major cause of functional limitations in affected individuals. TKA reliably reduces pain but improvements in function are less predictable and deficits may persist for up to 2 years post-operatively. Patients undergoing elective surgery are routinely optimized medically but we hypothesized that pre-operative strength and fitness improvements would also enhance outcome. Objectives: To determine the effect of a 6 week lower limb strengthening programme on post-operative QF strength and CSA, pain and functional scores. To determine changes in Myosin Heavy Chain (MHC) isoform, hypertrophy marker IGF-1 and atrophy markers MuRF-1 and MAFbx. Methods: 20 volunteers currently awaiting TKA were randomly assigned to a control [C] or intervention [I] group. [I] completed a 6 week home based, supervised exercise programme. Post-operatively all patients completed a standard inpatient physiotherapy routine. Assessments were completed at baseline (T=0), T=6 weeks (just prior to operation) and 3 months post-operatively (T=18 weeks). Assessments included isokinetic dynamometry; MRI QF CSA and American Knee Society scores. A percutaneous muscle biopsy of the vastus lateralis muscle was also performed at T=0 and T=6 under local anaesthesia. Results: At baseline there were no significant differences in parameters between groups. At T=18, [I] showed an 86% difference in QF peak torque above controls (P=0.003). CSA also improved by 6% versus a drop of 2.5% in [C] (P=0.041). Both groups showed improvements in Knee society function scores but [I] improved by 13 points more than [C] (P=0.044). MHC IIa mRNA expression increased by 40% whilst IIx decreased by 60% representing a shift to a less fatigable fibre type (P=0.05 and 0.028 respectively). IGF-1, MuRF-1 and MAFbx mRNA levels did not change significantly in either group. Conclusion: To our knowledge we have documented for the first time post-operative benefits by using a pre-operative training programme in TKA. This was manifest by continued rise in quadriceps peak torque, CSA and improved Knee society functional scores. We have also demonstrated the preservation of muscle plasticity in knee OA and suggest that factors other than known hypertrophy and atrophy pathways may be responsible.

Quadriceps femoris muscle (QFM) weakness is associated with the development of knee osteoarthritis (OA). Neuromusclar electrical stimulation (NMES) circumvents neural inhibition causing muscle contraction, however there is little reported data demonstrating its role in knee OA. Our aim was to evaluate the effectiveness of a NMES program in patients with knee OA. Sixteen patients (10 women, 6 men) with severe knee OA were randomised into control (n=6) or intervention (n=10) groups. These were similar in terms of age (64.8 ± 11.0 vs. 64.6 ± 7.6; mean ± SD) and BMI (31.8 ± 6.11 vs.30.7 ± 2.9). NMES was applied using a garment-based stimulator for 20 min/day, 5 d/wk for 8 weeks. Isokinetic and isometric QFM strength were determined at baseline, and weeks 2, 5, and 8 using a dynomometer. Functional assessments involved a 25 metre timed walk test (TWT), timed stair-climb test (SCT), and timed chair-rise test (CRT) at baseline and week 8. Subjects recorded NMES session duration in a log book while the device also recorded total treatment time. Function significantly improved in the NMES group as determined by the timed SCT (p The use of a portable home-based NMES program produced significant QFM strength gain with associated improvement in function in patients with severe knee OA. Compliance was excellent overall.

Background: Quadriceps femoris muscle (QFM) weakness has been implicated in the development of knee osteoarthritis (OA) as well as predicting functional ability after TKA. Preoperative strengthening (prehabilitation) may be facilitated by applying neuromuscular electrical stimulation (NMES) to the affected QFM using a garment-based portable stimulator. Methods: Single blind, randomised control efficacy study with NMES applied to the affected QFM for 20 min, 5 days a week, for 8 weeks pre-TKA. Isokinetic and isometric strength was assessed at baseline, week 2, week 5 and immediately pre-op. Function was assessed using a 25 metre timed walk test (TWT), timed stair-climb test (SCT), and timed chair-rise test (CRT) at baseline and pre-op. Results: 13 patients (8 women and 5 men) scheduled for TKA for knee OA were recruited and randomised into a control (n=5) or intervention (n=8) group. Groups were similar in terms of age (65.5 ± 6.8 vs. 61.8 ± 9.0; mean ± SD) and BMI (29.7 ± 2.1 vs.33.2 ± 5.6). There was an improvement in SCT (p Conclusion: The use of a portable home-based NMES program for 8 weeks results in significant strength gains with associated improvements in function in patients scheduled for TKA for knee OA.