Indicators and medical tests to identify lower limb swelling causes after total knee arthroplasty: a Delphi study with multidisciplinary experts.

BACKGROUND: Lower limb swelling after total knee arthroplasty (TKA) hinders surgical effectiveness. The poor results of studies on swelling interventions are due to the lack of a classification of swelling causes through appropriate medical tests. A gold standard is missing. This study aimed to clarify the causes of TKA postoperative swelling and how to identify them through indicators and medical tests by consulting a wide range of experts from multiple disciplines. METHOD: The Delphi method was used. A first draft of the index was prepared based on a systematic search of the literature. A total of 11 experts from several disciplines were invited to evaluate the rationality of the indicators and suggest modifications. After two rounds of consultation, the experts reached a consensus, and the consultation was stopped. RESULTS: The response rate of the 11 experts was 100%, and the authoritative Cr was 0.896. Kendall's W values for opinion coordination of the two rounds of consultation were 0.262 and 0.226, respectively (P < 0.001). Among the final indicators, there were 4 primary indicators for swelling cause classification (inflammatory response, poor venous return, joint hematoma, muscle damage, and healing), 19 secondary and 19 tertiary indicators. CONCLUSION: The indications obtained by systematic literature review and multidisciplinary expert consultation are reliable and scientific. Multiple causes of lower extremity swelling after TKA were identified. Blood test indicators can reflect an inflammatory response, suggest poor venous return, and reflect muscle damage and healing progress. Ultrasound scans are needed to identify underlying thrombotic or valvular problems, joint hematomas, and muscle damage. These tests help clinicians and researchers determine the cause of swelling after TKA and take appropriate management.

Exploring expectations of Chinese patients for total knee arthroplasty: once the medicine is taken, the symptoms vanish.

BACKGROUND: Preoperative expectations of total knee arthroplasty (TKA) outcomes are important determinants of patient satisfaction. However, expectations of patients in different countries are affected by cultural background. The general goal of this study was to describe Chinese TKA patients' expectations. METHODS: Patients scheduled for TKA were recruited in a quantitative study(n = 198). The Hospital for Special Surgery Total Knee Replacement Expectations Survey Questionnaire was used for survey TKA patients' expectations. Descriptive phenomenological design was used for the qualitative research. Semi-structured interviews were conducted with 15 TKA patients. Colaizzi's method was used for interview data analysis. RESULTS: The mean expectation score of Chinese TKA patients was 89.17 points. The 4 highest score items were walk short distance, remove the need for walker, relieve pain and make knee or leg straight. The 2 lowest score items were employed for monetary reimbursement and sexual activity. Five main themes and 12 sub-themes emerged from the interview data, including multiple factors raised expectations, expectations of physical comfort, expect various activities back to normal, hope for a long joint lifespan, and expect a better mood. CONCLUSIONS: Chinese TKA patients reported a relatively high level of expectations, and differences across cultures result in different expectation points than other national populations, requiring adjustment of items when using assessment tools across cultures. Strategies for expectation management should be further developed. LEVEL OF EVIDENCE: Level IV.

Comparison of 3D Printing Rapid Prototyping Technology with Traditional Radiographs in Evaluating Acetabular Defects in Revision Hip Arthroplasty: A Prospective and Consecutive Study.

OBJECTIVE: To compare rapid prototyping technology (RP tech) in revision total hip arthroplasty (RTHA) with traditional examination methods and to see how they are different in evaluating acetabular anatomy and designing surgical procedure. METHODS: From February 2014 to March 2018, 43 RTHA patients with complex acetabulum defects were enrolled in this prospective study regardless of age or gender. Incomplete and unclear data were excluded. Three types of radiographic examination were performed on each patient before the revision surgery. Four groups of evaluations were designed: (i) X-ray; (ii) computed tomography (CT-scan); (iii) RP tech; and (iv) CT-aided RP tech. Discrepancies between preoperative radiographic analysis and intra-operative findings were separately compared by a team of surgeons. Premade surgical plans based on each evaluation method were compared with the final surgical procedure. The compliance of anatomic evaluation and surgical plan-design based on 3D RP tech and traditional radiographs were ranked manually by a of team surgeons into: (i) complete accordance; (ii) general accordance; and (iii) undetermined structure/procedure. The difference in ranks between RP tech and traditional radiographic methods were analyzed with a nonparametric Kruskal-Wallis test. P < 0.05 was considered significant. Multiple adjustments were taken for the statistical tests level according to the Bonferroni method. RESULTS: For anatomic analysis, the accordance in four groups of evaluating methods differed from each other (P < 0.05) except for the comparison of RP tech and CT-aided RP tech. RP tech displayed better anatomic evaluating accuracy than traditional methods (X-ray and CT) with the "complete accordance" rates of these groups being 88.37%, 4.65% and 27.91%, respectively. But CT-aided RP tech did not improve accuracy significantly compared with using RP tech individually, although the value seems high in the CT-aided RP group with the "complete accordance" rate of 95.35%. For surgery design, RP tech significantly showed better applicable surgical design compared with X-ray and CT (P < 0.05), and the "complete accordance" rates were 88.37%, 6.98% and 23.26%, but no significant difference was observed between RP tech and CT-aided RP tech, and the "complete accordance" rate of CT-aided RP tech group was 97.67%. RP tech showed remarkable improvement in bone defect assessment and surgical plan design. CONCLUSION: Using RP technology improved both sensibility and accuracy in acetabular defect evaluation with better locating and evaluating efficiency compared with X-ray and CT-scans. It also improved surgical schedule designing in complex acetabular defecting revision surgery. In particularly complex cases, CT aided RP tech may increase the accuracy of RP tech.

Erythropoietin enhances meniscal regeneration and prevents osteoarthritis formation in mice.

Osteoarthritis (OA) is a leading cause of pain and disability, and knee is the most commonly afflicted joint. Meniscal tear due to injury or degeneration is an established factor for OA pathogenesis. Previous studies have demonstrated that meniscectomy does not reduce the OA incidence. We hypothesized that enhancing meniscal regeneration may prevent OA formation and progression. We first investigated the developmental pattern of mouse meniscus. Knee joint samples were collected at embryonic stages as well as after birth for histological and immunohistochemical studies. The results showed that meniscal cells underwent active proliferation and apoptosis at embryonic day 19.5 and Day 1 after birth. Collagen I (Col-1) is a major type of matrix protein in matured meniscus. Meniscal cells isolated from 3-month-old mice were used to examine the effect of selected factors on the molecules related to cell proliferation, angiogenesis, inflammation, extracellular matrix proteins and matrix degradation enzymes. Overall assessment indicated that EPO had optimal effect on meniscal regeneration. An organ culture system of mouse meniscus was established to test the effect of EPO on in vitro cultured menisci. EPO upregulated the expression of Col-1, Col-2 and VEGF-A, and downregulated the expression of MMP-13. Finally, we established a mouse model of meniscus injury induced OA (MIO), and mice were subjected to PBS or EPO treatments. The results demonstrated that EPO enhanced meniscal repair and prevented OA formation. EPO may become an effective Disease Modifying Osteoarthritis Drug and may be used for early treatment for meniscal injury to prevent OA progression.

Does mobile-bearing have better flexion and axial rotation than fixed-bearing in total knee arthroplasty? A randomised controlled study based on gait.

OBJECTIVE: To analyse the 6 degrees of freedom of the knee and gait data of patients with medial knee osteoarthritis before and after fixed-bearing (FB) and mobile-bearing (MB) total knee arthroplasty (TKA) â€‹and examine the influence of TKA on gait characteristics and the difference between FB and MB prosthesis. We also sought to explore the prosthesis options available for TKA in these patients. METHODS: Thirty patients who underwent TKA at the Department of Orthopedics at our hospital from June to October 2017 were included. All patients had a lower limb mechanical axis (hip-knee-ankle angle) of less than 180° which were regarded as genu varum knees and had medial knee osteoarthritis. Patients were randomised divided into the FB group â€‹and the MB group according to the knee prosthesis implanted. An infrared navigation three-dimensional portable knee motion analysis system (Opti-Knee®, Shanghai Innomotion, Inc.) was used to acquire data on the 6 degrees of freedom of both knees when walking on flat ground before and after surgery (angle of tibia relative to femur parameters: flexion-extension, internal rotation-external rotation, abduction-adduction; displacement parameters: anterior-posterior, proximal-distal, medial-lateral). Postoperative follow-up efficacy was assessed using the Oxford Knee Score system. RESULTS: There were significant differences in the maximum values of the internal/external rotation and flexion/extension angle between patients post-TKA and the healthy population, p values were 0.007 and <0.001,respectively. The postoperative maximum values of genu varum and internal rotation in both FB [(-9.49 â€‹± â€‹5.99°), (-5.77 â€‹± â€‹3.42°), respectively] and MB [(-9.64 â€‹± â€‹4.83°), (-7.54 â€‹± â€‹4.51°), respectively] groups were lower than the preoperative ones [FB (-15.13 â€‹± â€‹6.78°), (-8.28 â€‹± â€‹4.83°); MB (-13.28 â€‹± â€‹3.98°), (-9.46 â€‹± â€‹4.99°), respectively] (p â€‹≤ â€‹0.001), while the postoperative maximum values of flexion angle and anterior displacement in both FB [(46.11 â€‹± â€‹4.14°), (0.71 â€‹± â€‹0.35 â€‹cm), respectively] and MB [(49.33 â€‹± â€‹3.98°), (0.75 â€‹± â€‹0.89 â€‹cm), respectively] groups were larger than the preoperative ones [FB (43.15 â€‹± â€‹3.77°), (0.26 â€‹± â€‹0.74 â€‹cm); MB (44.62 â€‹± â€‹5.92°), (0.33 â€‹± â€‹0.79°), respectively] (p â€‹≤ â€‹0.001). The postoperative range of flexion/extension angle in both FB (40.13 â€‹± â€‹4.14°) and MB (45.82 â€‹± â€‹3.76°) groups was significantly larger than the preoperative one [FB (36.17 â€‹± â€‹6.07°), MB (37.09 â€‹± â€‹3.93°), respectively] (p â€‹≤ â€‹0.001). There were also significant increases in range of anterior-posterior displacement in the FB group (0.85 â€‹± â€‹0.32 â€‹cm) postoperatively compared with the preoperative one (0.71 â€‹± â€‹0.92 â€‹cm) (p â€‹= â€‹0.016) â€‹and significant increases in range of medial-lateral displacement (0.64 â€‹± â€‹0.73 â€‹cm) in the MB group postoperatively compared with the preoperative one (0.52 â€‹± â€‹0.91 â€‹cm) (p â€‹= â€‹0.025). The mean flexion/extension angle of the MB group was significantly greater than the FB group after surgery in both the stance phase and the swing phase (p â€‹< â€‹0.001). There were significant differences in postoperative knee axial rotation during the gait cycle between the MB and FB groups (p â€‹= â€‹0.028) â€‹and that postoperative internal rotation of the tibia relative to the femur increased in the MB group. The Oxford Knee Score at the last follow-up visit about 7.5 months after surgery was 15.6 â€‹± â€‹1.3 and 15.1 â€‹± â€‹1.1 points for FB and MB groups, respectively. This difference was not significant (p â€‹= â€‹0.428). CONCLUSIONS: TKA can make the parameters of knee gait characteristics closer to the normal population. Medial knee osteoarthritis patients who received a MB prosthesis in TKA had better joint flexion function and axial rotation than the FB one. However, there is insufficient evidence to suggest that the MB prosthesis is a better option for patients with medial knee osteoarthritis. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: To date, no consensus for prosthesis selection in TKA has been established. This study found significant differences in joint flexion/extension angle and internal/external rotation during gait post-TKA surgery in medial knee osteoarthritis patients who received different prostheses. This will provide some references for prosthesis selection for a large number of genu varum patients in clinical practice.

Clinical Applications of 3-Dimensional Printing Technology in Hip Joint.

Three-dimensional (3D) printing is a digital rapid prototyping technology based on a discrete and heap-forming principle. We identified 53 articles from PubMed by searching "Hip" and "Printing, Three-Dimensional"; 52 of the articles were published from 2015 onwards and were, therefore, initially considered and discussed. Clinical application of the 3D printing technique in the hip joint mainly includes three aspects: a 3D-printed bony 1:1 scale model, a custom prosthesis, and patient-specific instruments (PSI). Compared with 2-dimensional image, the shape of bone can be obtained more directly from a 1:1 scale model, which may be beneficial for preoperative evaluation and surgical planning. Custom prostheses can be devised on the basis of radiological images, to not only eliminate the fissure between the prosthesis and the patient's bone but also potentially resulting in the 3D-printed prosthesis functioning better. As an alternative support to intraoperative computer navigation, PSI can anchor to a specially appointed position on the patient's bone to make accurate bone cuts during surgery following a precise design preoperatively. The 3D printing technique could improve the surgeon's efficiency in the operating room, shorten operative times, and reduce exposure to radiation. Well known for its customization, 3D printing technology presents new potential for treating complex hip joint disease.

Changes in Alignment of Ipsilateral Knee on Computed Tomography after Total Hip Arthroplasty for Developmental Dysplasia of the Hip.

OBJECTIVE: To assess the changes in alignment of ipsilateral knee joint after total hip arthroplasty (THA) for patients with developmental dysplasia of the hip (DDH). METHODS: Thirty-four patients with DDH (38 hips) who underwent THA between February and December 2008 were included in the study: 4 men and 30 women with a mean age of 56.2 years. According to Crowe classification, 11 patients were grade I, 12 were grade II, 9 were grade III, and 6 were grade IV. Computed tomography scans were performed from the anterior superior iliac spine to the tibial tubercle before surgery and at last follow-up. Femoral anteversion angle, leg lengthening, and knee alignment, including patellar tilt angle, lateral patellar displacement, and tibiofemoral rotation angle, were measured on computed tomography scans, and their relationships were analyzed. RESULTS: The mean follow-up period was 51.5 months (range, 39-70 months). There were no intraoperative fractures, and no infections occurred during the follow-up period. One patient developed deep venous thrombosis and another suffered from femoral nerve palsy. The mean preoperative Harris Hip Score was 48.9 ± 7.5 and improved to 91.2 ± 8.3 by the last follow-up (P < 0.001). There was no sign of prosthetic loosening in all hips. Postoperatively, mean leg lengthening was 26.08 ± 21.81 mm (P < 0.001), femoral anteversion decreased 9.03° ± 12.80° (P < 0.001), and patellar tilt, lateral patellar displacement, and tibiofemoral rotation increased by 3.58° ± 4.96° (P < 0.001), 1.78 ± 3.36 mm (P = 0.002), and 2.56° ± 3.37° (P < 0.001), respectively. Postoperative increase in patellar tilt and lateral patellar displacement had significant linear relationships with the decrease in femoral anteversion (r = 0.621, P < 0.001 and r = 0.437, P = 0.0037, respectively). These results revealed that patellofemoral alignment would change more with the decrease in femoral anteversion. Postoperative increase in external rotation of the tibia had significant positive linear relationships with leg lengthening (r = 0.34, P = 0.037) and the decrease in femoral anteversion (r = 0.693, P < 0.001). These results revealed that the external rotation of the proximal tibia would increase with the leg lengthening or the decrease of femoral anteversion. Postoperative changes in patellar tilt and lateral patellar displacement had no significant linear relationships with leg lengthening (P = 0.795 and P = 0.082, respectively). CONCLUSIONS: Total hip arthroplasty for DDH could induce changes in alignment of ipsilateral patellofemoral and tibiofemoral joints, with increases in patellar tilt and displacement, and increases in external rotation of the tibia. These secondary alterations still existed at medium-term follow-up after surgery, which should be considered during THA for patients with DDH. Extended follow-up is necessary to evaluate long-term changes in the knee joint.

[Study of mtDNA 12S rRNA A1555G, GJB2, GJB3 gene mutation in Uighur and Han people with hereditary nonsyndromic hearing loss in Xinjiang].

OBJECTIVE: To study mtDNA, GJB2, GJB3 and determine gene mutation situs and frequency in Uighur and Han people with hereditary nonsyndromic hearing loss, and to compare the differences of gene mutation situs and frequency between Uighur and Han people. METHODS: Blood samples were obtained from 93 patients (43 Uygur and 50 Han) with hereditary non-syndromic hearing loss and 110 normal people (56 Uygur and 54 Han). Genomic DNA was extracted from isolated leukocytes, and amplified by polymerase chain reaction (PCR). PCR products of GJB3 were sequenced directly; while PCR products of mitochondrial DNA 12S rRNA A1555G point mutations were analyzed by PCR-Alw26I digestion, and positive ones were further sequenced. GJB2 genes of 83 patients (43 Uygur and 40 Han) with hereditary non-syndromic hearing loss and 98 normal people (46 Uygur and 52 Han) were directly sequenced. RESULTS: Among GJB3 genes of 93 patients, 2 cases of 33C-T, 2 cases of of 766G-A, 7 cases of 357C-T, and 4 cases of 798C-T were detected. Mitochondrial DNA 12SrRNA A1555G mutation was detected in 8 patients (2 Uygur and 6 Han). Nine kinds of base changes of GJB2 were detected: 109G-A, 233-235delC, 79G-A, 196G-A, 341A-G, 564G-A, 380G-A, 71G-A, and 35delG. In the control group, detected GJB3 mutations included 4 cases of 357C-T, 5 cases of 798C-T, and 2 cases of 93C-T; while 9 kinds of base changes of GJB2 were detected: 341A-G, 380G-A, 457G-A, 79-GA, 109G-A, 281A-G, 21G-T, 171G-T, and 368C-A. For mtDNA 12SrRNA A1555G, the difference between study group of and control group of Han people was statistically significant (P < 0.05). For GJB2 mutation 79G-A, the difference between study group and control group was statistically significant (P < 0.05) in both Uygur and Han people; while for GJB2 mutation 341A-G, the difference in study group between Uygur and Han people was statistically significant (P < 0.05). And for GJB3 mutation 798C-T, the difference was statistically significant both between study group and control group, and between Uygur and Han people (P < 0.05). CONCLUSIONS: In Xinjiang, mutation rate was high for mtDNA 12SRNA A1555G. while GJB3 gene mutations were not the main cause of the hereditary nonsyndromic hearing loss. There were certain ethnic and geographical characteristics of GJB2and GJB3 mutations.