Impact of chronic kidney disease on outcomes after total joint arthroplasty: a meta-analysis and systematic review.

OBJECTIVE: Comorbidities in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) may compromise outcomes with increased hospital stays, re-admission, and mortality rates. We aimed to determine whether chronic kidney disease (CKD) affects post-operative outcomes of patients undergoing total joint arthroplasty (TJA). METHODS: To identify studies for this review and meta-analysis, two independent reviewers searched PubMed, Cochrane, EMBASE, and Google Scholar until April 1, 2019, and identified additional studies by manual search of reference lists. Prospective or retrospective studies with quantitative outcomes for patients undergoing TJA were selected. Outcomes were compared between patients with underlying CKD stage ≥ 3 or eGFR < 60 mL/min/1.73 m2 versus mild/non-CKD as controls. Main endpoints were mortality, re-operation, and re-admission rates. RESULTS: Among 59 studies reviewed, 19 meeting the eligibility criteria were included, providing data of 2,141,393 patients. After THA or TKA, CKD was associated with higher mortality risk than non-CKD (pooled OR 2.20, 95%CI = 1.90 to 2.54; P < 0.001); no significant differences were seen in re-operation between CKD and non-CKD patients (pooled OR 1.26, 95%CI = 0.84 to 1.88; P = 0.266); and CKD patients had higher any-cause re-admission rates (pooled OR = 1.57, 95%CI = 1.27 to 1.94, P < 0.001). CONCLUSION: Underlying CKD predicts adverse outcomes after elective TJA with increased risk of mortality, re-admission, surgical site infection, and perioperative transfusion. Findings of this review and meta-analysis highlight CKD as a critical contributor to complications after TJA and may be helpful to surgeons when advising patients about associated risks of TJA.

Role of LncRNA TUG1 in intervertebral disc degeneration and nucleus pulposus cells via regulating Wnt/ß-catenin signaling pathway.

OBJECTIVE: To investigate the role of TUG1 in intervertebral disc degeneration (IDD) and human nucleus pulposus cells (NPCs) via regulating Wnt/ß-catenin pathway. METHODS: The study collected nucleus pulposus (NP) tissue samples from 30 patients with lumbar disc herniation (LDH) (Case group) and 18 patients with lumbar spine trauma (Control group). NPCs induced by TNF-α in vitro were divided into Blank, Vector, TUG1, TUG1-siRNA, XAV-939, TUG1 + XAV-939 groups. qRT-PCR was used to detect the expression of TUG1 and ECM-related genes, Western blot to determine the expression of Wnt/ß-catenin pathway and apoptosis-related proteins, and ELISA to measure the expression of ECM-related proteins. The apoptosis was detected by TUNEL and Annexin V-FITC/PI double-staining. The proliferation and senescence were tested by CCK-8 and SA-ß-gal staining respectively. RESULTS: TUG1 was upregulated in patients with IDD, which was positively related to Wnt and ß-catenin. Besides, TUG1, Wnt1 and ß-catenin were greatly increased in the NPCs after TNF-α induction. Compared with the Blank group, TUG1-siRNA and XAV-939 can appreciably down-regulate the expressions of Wnt1, ß-catenin, Caspase-3, Bax, MMP3 and ADAMTS5, up-regulate the expression of Bcl-2, Aggrecan and COL2A1, inhibit the apoptosis and senescence, and promote cell proliferation; however, the TUG1 group had the completely opposite results. CONCLUSION: Silencing TUG1 may not only protect human NPCs from TNF-α-induced apoptosis and senescence, but also promote cell proliferation by blocking Wnt/ß-catenin pathway, which provides a theoretical basis for the clinical treatment of IDD.

A national snapshot of the impact of clinical depression on post-surgical pain and adverse outcomes after anterior cervical discectomy and fusion for cervical myelopathy and radiculopathy: 10-year results from the US Nationwide Inpatient Sample.

Depression is associated with poorer outcomes in a wide spectrum of surgeries but the specific effects of depression in patients undergoing cervical spine surgery are unknown. This study aimed to evaluate the prevalence and impact of pre-surgical clinical depression on pain and other outcomes after surgery for cervical degenerative disc disease using a national representative database. Data of patients with cervical myelopathy and radiculopathy were extracted from the 2005-2014 US Nationwide Inpatient Sample (NIS) database. Included patients underwent anterior discectomy and fusion (ACDF). Acute or chronic post-surgical pain, postoperative complications, unfavorable discharge, length of stay (LOS) and hospital costs were evaluated. Totally 215,684 patients were included. Pre-surgical depression was found in 29,889 (13.86%) patients, with a prevalence nearly doubled during 2005-2014 in the US. Depression was independently associated with acute or chronic post-surgical pain (aOR: 1.432), unfavorable discharge (aOR: 1.311), prolonged LOS (aOR: 1.152), any complication (aOR: 1.232), respiratory complications/pneumonia (aOR: 1.153), dysphagia (aOR: 1.105), bleeding (aOR: 1.085), infection/sepsis (aOR: 1.529), and higher hospital costs (beta: 1080.640) compared to non-depression. No significant risk of delirium or venous thrombotic events was observed in patients with depression as compared to non-depression. Among patients receiving primary surgery, depression was independently associated with prolonged LOS (aOR: 1.150), any complication (aOR:1.233) and postoperative pain (aOR:1.927). In revision surgery, no significant associations were found for prolonged LOS, any complication or pain. In conclusion, in the US patients undergoing ACDF, pre-surgical clinical depression predicts post-surgical acute or chronic pain, a slightly prolonged LOS and the presence of any complication. Awareness of these associations may help clinicians stratify risk preoperatively and optimize patient care.

Protective effects of ginsenoside Rg3 on TNF-α-induced human nucleus pulposus cells through inhibiting NF-κB signaling pathway.

This work aims to evaluate the effect of ginsenoside Rg3 on the apoptosis, proliferation, extracellular matrix (ECM) metabolism and oxidative stress-induced damage of human nucleus pulposus cells (NPCs) induced by TNF-α. The human NPCs were divided into Control, TNF-α, TNF-α + low Rg3, TNF-α + medium Rg3 and TNF-α + high Rg3 groups. Annexin V-FITC/PI, CCK-8 and flow cytometry were used to detect the apoptosis, proliferation, and cell cycle of NPCs, respectively. The expressions of ECM-related molecules were determined by qRT-PCR, ELISA and Western blotting. NF-κB p65 pathway and apoptosis-related proteins were evaluated by Western blotting, and the production of reactive oxygen species (ROS) was detected by DCFH-DA assay. Compared with Control group, NPCs in the TNF-α group had elevated proportion of apoptotic cells with up-regulation of Bax and Caspase-3 and down-regulation of Bcl-2. Besides, TNF-α inhibited proliferation and arrested cell cycle at G1 of NPCs. Moreover, human NPCs induced by TNF-α presented the increase in the expressions of ECM degrading genes (MMP3 and ADAMTS5), the content of ROS and malondialdehyde (MDA), and the expression of NF-κB/p65 in nucleus, but showed the decrease in the expression of ECM synthesis genes (Aggrecan and COL2A1) and the activity of superoxide dismutase (SOD) and glutathione peroxidase (GSH-PX). However, NPCs treated by both TNF-α and Rg3 demonstrated a certain degree of reversal in the above indexes, which became increasingly evident with the up-regulation of Rg3 concentration. Ginsenoside Rg3 may exert the effect of attenuating TNF-α-induced NPCs impairment via blocking the NF-κB signaling pathway.

[Effect of Bryan cervical disc replacement on cervical curvature and replacement segment in treating cervical spondylosis].

OBJECTIVE: To investigate the effect of Bryan cervical disc replacement on cervical curvature and replacement segment in the treatment of cervical spondylosis, and analyze its clinical efficacy. METHODS: Forty-nine patients underwent Bryan artificial cervical disc replacement from August 2010 to August 2013 were retrospectively analyzed. There were 26 males and 23 females, aged from 27 to 66 years old with an average of 48.5 years. Including 21 cases of nerve root type, 16 cases of spinal cord type, 12 cases of mixed type. And 21 cases were single segment replacement, 28 cases were double segments replacement. Preoperative and postoperative pain was compared using visual analogue scale(VAS);cervical function was observed by Japanese Orthopedic Association Scores (JOA) and Neck Disability Index (NDI);cervical lordosis curvature, function spinal unit(FSU) curvature, activities of replacement and adjacent segment, FSU activity were measured by cervical X-rays. Clinical effects were evaluated by the Odom method. RESULTS: All the patients were followed up for 18.5 to 37.3 months with an average of 33.1 months. Pvoperative VAS, JOA, NDI scores were 7.08±1.55, 5.2±1.9, 39.96±7.06 before operation, 3.76±2.33, 13.20±1.20, 25.20±6.64 at 3 months after operation, and 2.80±1.50, 14.3±1.6, 24.24±7.89 at the last follow-up. Patients at three months and the last follow-up after operation were obviously improved in their VAS, JOA, and NDI scores (P<0.05). There was no significant difference between the scores at last follow-up and 3 months after operation. Cervical lordosis changed from (10.64±4.26)° preoperatively to (13.68±4.56) ° at the last follow-up;the FSU curvature from (5.40±0.41) °to (9.92±2.00) °at the last follow-up (P<0.05). The range of motion of the cervical spine preoperatively, 3 month postoperatively, and at the last follow-up were(70.84±6.17)°, (60.00±6.58)°, (71.48±4.61)°; FSU activities were(12.00±0.49)°, (9.36±0.26)°, (12.52±0.33)°;the activities of replacement segment were (10.48±0.67)°, (7.24±0.34)°, (9.28±0.36)°;the activities of upper segment of replacement were (10.52±0.60)°, (8.60±0.30)°, (10.44±0.43)°;the activities of lower segment of replacement were (8.48±0.40)°, (6.56±0.36)°, (9.60±0.39)°;there were significant differences in above items preoperatively and 3 months postoperatively(P<0.05); and there were no significant difference preoperatively and at the last follow-up(P>0.05). Pharyngeal discomfort and hoarseness occurred in 5 cases, and were recovered within 2 weeks after operation;heterotopic ossification occurred in 1 case at 6 months after operation;displacement of prosthesis occurred in 1 case at 12 months after operation. Based on Odom standard to evaluate the clinical outcome, 20 cases obtained excellent results, with 27 good, 2 general. CONCLUSIONS: Bryan artificial cervical disc replacement not only generate good clinical effects, but may also restore the cervical lordosis and FSU curvature, while retaining the activities of replacement segment, and restoring overall cervical biomechanical functions.

Effects of Chinese herbal formula Erxian decoction for treating osteoporosis: a systematic review.

PURPOSE: The aim is to systematically assess the effectiveness and safety of Chinese herbal formula Erxian decoction (EXD) for treating osteoporosis. MATERIALS AND METHODS: Six databases were searched from inception through September 17, 2016, without language restriction. All randomized controlled trials of EXD for osteoporosis were included. One or more outcome measures including fracture, change in bone mineral density (BMD), pain symptom improvement, bone biochemical markers, quality of life, adverse event or adverse drug reaction were evaluated. Study selection, data extraction, quality assessment, and data analyses were conducted according to Cochrane standards. RESULTS: Eight trials including 644 patients investigated the effects of EXD in the treatment of osteoporosis. The methodological quality of the included trials was generally low. The meta-analysis from two trials showed favorable effects of EXD in improving BMD of lumbar spine (mean difference [MD]: 0.05 [0.03, 0.06]; I2=0%; P<0.00001) and BMD of femoral great trochanter (MD: 0.06 [0.02, 0.10]; I2=59%; P=0.005) compared with caltrate tablets. The other meta-analysis from two trials showed beneficial effects of EXD plus caltrate tablets and calcitriol in improving BMD of femoral neck (MD: 0.04 [0.00, 0.09]; I2=56%; P=0.04), the level of calcium (MD: 0.20 [0.15, 0.24]; I2=0%; P<0.00001), and phosphorus (MD: -0.28 [-0.39, -0.17]; I2=68%; P<0.00001) compared with caltrate tablets and calcitriol alone. The adverse drug reactions of EXD were mainly slight gastrointestinal symptoms. CONCLUSION: The study provides suggestive evidence of the superiority of EXD monotherapy or combination therapy over basic supplements for treating osteoporosis. However, the evidence remains weak. More rigorously designed and measured, randomized double-blind, placebo-controlled trials with larger sample size are needed to verify the current conclusions.

Cervical anterior hybrid technique with bi-level Bryan artificial disc replacement and adjacent segment fusion for cervical myelopathy over three consecutive segments.

This study aimed to assess the preliminary clinical efficacy and feasibility of the hybrid technique for multilevel cervical myelopathy. Considering the many shortcomings of traditional treatment methods for multilevel cervical degenerative myelopathy, hybrid surgery (bi-level Bryan artificial disc [Medtronic Sofamor Danek, Memphis, TN, USA] replacement and anterior cervical discectomy and fusion) should be considered. Between March 2006 and November 2012, 108 patients (68 men and 40 women, average age 45years) underwent hybrid surgery. Based on the Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), and Odom's criteria, the clinical symptoms and neurological function before and after surgery were evaluated. Mean surgery duration was 90minutes, with average blood loss of 30mL. Mean follow-up duration was 36months. At the final follow-up, the mean JOA (± standard deviation) scores were significantly higher compared with preoperative values (15.08±1.47 versus 9.18±1.22; P<0.01); meanwhile, NDI values were markedly decreased (12.32±1.03 versus 42.68±1.83; P<0.01). Using Odom's criteria, the clinical outcomes were rated as excellent (76 patients), good (22 patients), fair (six patients), and poor (four patients). These findings indicate that the hybrid method provides an effective treatment for cervical myelopathy over three consecutive segments, ensuring a good clinical outcome.

Multivariate analysis of risk factors for predicting supplementary posterior instrumentation after anterolateral decompression and instrumentation in treating thoracolumbar burst fractures.

BACKGROUND: Although anterolateral decompression and instrumentation has several advantages in treating thoracolumbar burst fractures, the risk factors for supplementary posterior instrumentation are still unclear. METHODS: We retrospectively reviewed 238 patients who underwent anterolateral decompression and instrumentation for single-level thoracolumbar burst fractures from January 2010 and March 2012. The influences of several potential risk factors that might affect supplementary posterior instrumentation were assessed using univariate and multivariate analyses. RESULTS: Twenty seven patients who developed worsening back pain without neurological deterioration after the anterolateral approach treatment need further posterior instrumentation fixation. The univariate analysis showed that age, disruption of the posterior longitudinal ligament complex (PLC), and fracture level were the risk factors for supplementary posterior instrumentation. However, age and integrity of the PLC were the independent risk factors for supplementary posterior instrumentation by multivariate analyses. CONCLUSIONS: Supplemental posterior instrumentation was necessary in 11.3% of cases following anterolateral decompression and instrumentation in the present study. Older age and disruption of the PLC were the independent risk factors in prediction of supplementary posterior instrumentation in treating thoracolumbar burst fractures.

[Clinical study of a cervical anterior Hybrid technique with posterior longitudinal ligament retained for cervical spondylosis].

OBJECTIVE: To explore the clinical effects and significances of a cervical anterior Hybrid technique with posterior longitudinal ligament retained in treating cervical spondylosis. METHODS: The clinical data of 138 patients with cervical spondylosis underwent cervical anterior Hybrid surgery were retrospectively analyzed from March 2009 to March 2013. There were 52 males and 86 females,the age ranged from 36 to 58 years old with an average of 45.3 years. Course of disease was from 3 to 16 months. Cervical spondylosis classification included 22 cases with nerve root type, 68 cases with myelopathic type, 48 cases with mixed type. All patients were treated with the primary Hybrid surgery and their cervical posterior longitudinal ligaments were retained in anterior decompression. JOA score and image examination were used to evaluate clinical effect, and image examination included range of motion of the replacement segment, range of motion of the whole cervical spine, the sagittal diameter of the spinal cord before and after operation. RESULTS: All operations were successful and operation time was 60 to 125 min (averaged 90.6 min), perioperative bleeding was 10 to 60 ml (averaged 30.1 ml). All patients were followed up from 12 to 48 months with an average of 22.2 months. All pathological segments obtained fully decompression, reserved posterior longitudinal ligament had no obvious hypertrophy, proliferation and calcification. The prosthesis had good location and the incision healed well without complications. Upper limbs root symptoms were completely relieved in the patients with cervical spondylotic radiculopathy, muscle strengths and sensations got different recovery in the patients with cervical spondylotic myelopathy. JOA score was increased from preoperative 8.62±1.22 to final follow-up 14.26±1.47 (P<0.05). Artificial intervertebral discs were stabilized in the patients, the replacement segment and range of motion of whole cervical spine were respectively (14.2± 5.6)° and (33.8±10.3)°, there was no significant differences between preoperative and postoperative (P>0.05). Spinal cord sagittal diameter was increased from preoperative (5.2±1.3) mm to postoperative (8.8±0.5) mm (P<0.05). CONCLUSION: Anterior cervical Hybrid surgery with posterior longitudinal ligament retained can achieve fully decompression and good clinical efficacy, we recommend retaining the normal posterior longitudinal ligament in surgery as complete as possible.