evaluation of prophylactic treatments to prevent post-traumatic joint

Efird W, Kellam P, et al. J Orthop Res. 2014;32(11):1520-4.
doi: 10.1002/jor.22700.

Take Home Message: Three agents that target different aspects of
the inflammatory pathways decreased joint stiffness after joint trauma in rats.

Arthrofibrosis and joint stiffness are problems for many patients
who experience serious joint trauma, and so far no prophylactic treatments for joint
stiffness have been identified.  Without a
preventative option, many patients must undergo surgical intervention to treat
the stiffness after it occurs. Identifying a safe and effective prophylaxis to
alter the inflammatory pathways and prevent joint stiffness in susceptible
patients is an ideal conservative therapy option. The purpose of this animal study
was to examine three therapeutic agents to assess prophylactic treatment (i.e. prevention)
of arthrofibrosis by inhibiting components in the inflammatory process. The
researchers used montelukast, a
leukotriene inhibitor, forskolin, a transforming
growth factor-beta1 blocker, and triamcinolone acetonide, a
corticosteroid. Surgery was performed on 48 male rats; the right patella was
laterally dislocated and repaired with a pro-inflammatory suture and
immobilized in full flexion.  The rats were placed into four treatment groups
after surgery including the control group that received no prophylaxis.
 The montelukast group received 3.75 mg/kg/day in their food. The
forskolin and corticosteroid group received two injections. The forskolin and corticosteroid
groups received injections one day and four days after the operation. Two weeks
after the surgery, the rats were euthanized and the researchers used
radiographs to measure the femorotibial angle. During the femorotibial angle measurement,
the joint capsule was intact but both cruciate ligaments and the posterior
joint capsule had been cut. All animals who received an intervention showed
less contracture than the control group. The corticosteroid group had less
contracture than the montelukast and forskolin groups, developing only a 7°
loss of extension. The corticosteroid group formed less contracture than all
other groups. In conclusion, all three interventions caused reductions in joint
stiffness, but the corticosteroid was the most effective agent.

This study highlights the possibility that targeting inflammatory
pathways may reduce the risk of post-traumatic joint stiffness.  Animals in
the corticosteroid group formed the least amount of contracture but experienced
unwanted weight loss as a side effect.  A human dose of triamcinolone
acetonide would be small enough to avoid these potential adverse effects. Now
that we see evidence that we can reduce post-traumatic joint stiffness with
these interventions, it would be useful to see more studies that help us understand
dose-response interactions to achieve a greater decrease in joint contracture.
 It may be pertinent for athletes seeking treatment for joint stiffness to
have either forskolin or montelukast perfected as a treatment option in humans,
to avoid unnecessary use of corticosteroids. It may also be informative if
future studies examine how these interventions influence healing after various
types of injury. Implementing these drug therapies effectively may lead to
fewer patients underging surgical intervention to decrease joint contracture
and stiffness following joint trauma.

Questions for Discussion: Do you know any other treatments that
would be effective to decrease joint contractures and joint stiffness? Have any
of your patients used these similar drug therapies to prevention joint

Written by: Kristin Gibson and Daniel Clark
Reviewed by: Kim Pritchard
Related Posts

Efird, W., Kellam, P., Yeazell, S., Weinhold, P., & Dahners, L. (2014). An evaluation of prophylactic treatments to prevent post traumatic joint stiffness Journal of Orthopaedic Research, 32 (11), 1520-1524 DOI: 10.1002/jor.22700