Phenotype-considered kinematically aligned total knee arthroplasty for windswept-deformity-associated osteoarthritis: surgical strategy and clinical outcomes.

BACKGROUND: Windswept deformity (WSD) in relation to advanced osteoarthritis (OA) presents a significant surgical challenge in total knee arthroplasty (TKA). The primary goal of this study is to investigate the Prevalance of WSD associated osteoarthritis who have undergone total knee arthroplasty. The secondary goal is to explore the causes of WSD and its association with spinal deformity or leg length discrepancy in these patients. Finally, we evaluate the surgical outcomes of phenotype-considered kinematically aligned TKA (KA-TKA) in treating patients with WSD. METHODS: A review was conducted on data from 40 knees of 33 WSD patients who underwent phenotype-considered KA-TKA from August 2016 to December 2020. Patient demographics, associated diseases, preoperative and postoperative knee alignment angles, range of motion (ROM), Oxford Knee Score (OKS), and Knee Society Score (KSS) were collected and analyzed. Subgroup analysis for comparing the results between valgus and varus knees were also performed. RESULTS: Within the studied cohort of WSD patients, a substantial 64% displayed concomitant coronal spinal imbalance and 21% evidenced leg length discrepancy. Postoperative improvements were notable in knee alignments, ROM, OKS, and KSS following the application of the phenotype-considered KA-TKA approach. There were significant differences in the knee alignment angles, including mHKA, LDFA, and MPTA, between the valgus and varus side of knees (P = 0.018). However, no statistically significant difference were observed in the functional scores, comprising ROM, OKS, and KSS, between valgus and varus knees. CONCLUSIONS: A high percentage of patients with WSD exhibited coronal spinal imbalance and leg length discrepancy. Phenotype-considered KA-TKA effectively provided alignment targets for the treatment of both varus and valgus knees in patients with WSD, achieving excellent short-term outcomes and acceptable knee alignment.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty.

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Comparison of implant failure rates of different plates for midshaft clavicular fractures based on fracture classifications.

BACKGROUNDS: The aim of our study was to investigate failure rates of reconstruction plate and non-reconstruction plate, and find the best strategy for implant selection for different fracture types for midshaft clavicular fractures. PATIENTS AND METHODS: Two hundred twenty-six consecutive patients with midshaft clavicular fractures who received open reduction and plate fixation during Jan 2012 to July 2017 were reviewed. The correlations between implant failure rates and risk factors including demographic data, fracture classifications, and implant types were analyzed. RESULTS: AO/OTA fracture classification and plate types are the most important factors affecting implant failure for midshaft clavicular fractures. Reconstruction plate had a significantly higher failure rate (53%) than that of non-reconstruction plates (3%) in comminuted midshaft clavicular (AO/OTA 15-2C) fractures (P value < 0.01). However, the difference was not significant in AO/OTA 15-2A and 2B classifications. CONCLUSION: Patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates had very high implant failure rates compared to non-reconstruction plates. We suggested that patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates need more protection and more frequent follow-up in the postoperative period.

Biomechanical Analysis of Implanted Clavicle Hook Plates With Different Implant Depths and Materials in the Acromioclavicular Joint: A Finite Element Analysis Study.

Clinical implantation of clavicle hook plates is often used as a treatment for acromioclavicular joint dislocation. However, it is not uncommon to find patients that have developed acromion osteolysis or had peri-implant fracture after hook plate fixation. With the aim of preventing complications or fixation failure caused by implantation of inappropriate clavicle hook plates, the present study investigated the biomechanics of clavicle hook plates made of different materials and with different hook depths in treating acromioclavicular joint dislocation, using finite element analysis (FEA). This study established four parts using computer models: the clavicle, acromion, clavicle hook plate, and screws, and these established models were used for FEA. Moreover, implantations of clavicle hook plates made of different materials (stainless steel and titanium alloy) and with different depths (12, 15, and 18 mm) in patients with acromioclavicular joint dislocation were simulated in the biomechanical analysis. The results indicate that deeper implantation of the clavicle hook plate reduces stress on the clavicle, and also reduces the force applied to the acromion by the clavicle hook plate. Even though a clavicle hook plate made of titanium alloy (a material with a lower Young's modulus) reduces the force applied to the acromion by the clavicle hook plate, slightly higher stress on the clavicle may occur. The results obtained in this study provide a better reference for orthopedic surgeons in choosing different clavicle hook plates for surgery.

Trochanter stabilising plate improves treatment outcomes in AO/OTA 31-A2 intertrochanteric fractures with critical thin femoral lateral walls.

BACKGROUND: For AO/OTA 31-A2 fractures (A2 fractures) treated with dynamic hip screw (DHS), postoperative lateral wall fracture (PLWF) is thought to be a major cause of femoral medialisation and reoperation. Though trochanter stabilising plate (TSP) had been reported to have a good effect in preventing femoral medialization, its effects and indication in A2 fractures remain controversial. We hypothesized that TSP may improve treatment outcomes in patients with high risk of postoperative lateral femoral wall fractures. The purpose of this study was to investigate (1) the main risk factors predictive of PLWF in A2 fractures and, (2) whether TSP can improve treatment outcomes in patients with high risk of PLWF. METHODS: Two hundred and fifty-two A2 fractures treated with DHS or DHS and TSP (DHS-TSP) during January 2000 and June 2013 were enrolled in this study. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for PLWF in 205 patients who were treated with DHS alone. The risk factor found to be associated with PLWF was utilized to include 171 patients who were at high risk of PLWF. Standard univariate and multivariate analyses were performed to evaluate the effect of TSP on treatment outcomes. RESULTS: Lateral wall thickness was found to be the main risk factor for PLWF in A2 fractures. A lateral wall thickness of 2.24 cm was found to be the best cutoff point to determine which patients were at high risk for PLWF. In 171 patients with a lateral wall thickness less than 2.24 cm, patients treated with DHS-TSP had significantly decreased lag screw sliding distances, PLWF rate, and reoperation rate (P=0.028, <0.001 and P=0.003, respectively) compared to the corresponding values of those treated with DHS alone. In the multivariate analysis, TSP decreased the reoperation rate by 13 times compared to that of patients who were treated with DHS alone. CONCLUSION: Lateral wall thickness is the main risk factor for PLWF in A2 fractures treated with DHS. Use of TSP in A2 fractures with critical thin lateral wall thickness <2.24 cm can significantly decrease the lag screw sliding distances, PLWF rate and reoperation rate.

Outcomes of arthroscopic double-bundle PCL reconstruction using the LARS artificial ligament.

The purpose of this study was to assess the outcomes of posterior cruciate ligament (PCL) reconstruction using the Ligament Augmentation and Reconstruction System (LARS) (JK Orthomedic Ltd, Dollard-des-Ormeaux, Quebec, Canada) artificial ligament. Compared with older artificial ligaments, the LARS, which has been used in Europe for 15 years, is more resistant to wear and tear, has satisfactory torsional fatigue resistance, and has good biocompatibility. The current is study included 38 double-bundle PCL reconstructions using the LARS artificial ligament in 38 patients. Mean patient age was 32.6 years, and mean time from injury to surgery was 6 months. Mean follow-up was 37 months (range, 30-68 months). The study endpoint was 2-year follow-up. Mean Tegner score improved from 3.4 ± 0.6 preoperatively to 6.0 ± 1.4 postoperatively (P<.001), and mean Lysholm score improved from 70.0 ± 11.0 pre-operatively to 91.7 ± 5.5 postoperatively (P<.001). Knee laxity decreased significantly postoperatively (P<.001), and no differences existed at 1- and 2-year follow-up. After surgery using the Y-type LARS artificial ligament, knee function and stability improved. Using the LARS artificial ligament for double-bundle reconstruction of the PCL avoids donor-site morbidity and disease transmission. The complication rate is low, and the results appear to be stable with time and comparable with those obtained with other grafts. Double-bundle PCL reconstruction with the LARS artificial ligament may be an alternative treatment option.

Peptidoglycan enhances IL-6 production in human synovial fibroblasts via TLR2 receptor, focal adhesion kinase, Akt, and AP-1- dependent pathway.

Peptidoglycan (PGN), the major component of the cell wall of Gram-positive bacteria, activates the innate immune system of the host and induces the release of cytokines and chemokines. We investigated the signaling pathway involved in IL-6 production stimulated by PGN in rheumatoid arthritis synovial fibroblasts. PGN caused concentration- and time-dependent increases in IL-6 production. PGN-mediated IL-6 production was attenuated by TLR2 small interfering RNA and nucleotide-binding oligomerization domain 2 small interfering RNA. Pretreatment with PI3K inhibitor (Ly294002 and wortmannin), Akt inhibitor, and AP-1 inhibitor (tanshinone IIA) also inhibited the potentiating action of PGN. PGN increased the focal adhesion kinase (FAK), PI3K, and Akt phosphorylation. Stimulation of rheumatoid arthritis synovial fibroblast cells with PGN increased the accumulation of phosphorylated c-Jun in the nucleus, AP-1-luciferase activity, and c-Jun binding to the AP-1 element on the IL-6 promoter. PGN mediated an increase in the accumulation of phosphorylated c-Jun in the nucleus, AP-1-luciferase activity, and c-Jun binding to AP-1 element was inhibited by Ly294002, Akt inhibitor, and FAK mutant. Our results suggest that PGN increased IL-6 production in human synovial fibroblasts via the TLR2 receptor/FAK/PI3K/Akt and AP-1 signaling pathway.

Involvement of AdipoR receptor in adiponectin-induced motility and alpha2beta1 integrin upregulation in human chondrosarcoma cells.

Chondrosarcoma is a type of highly malignant tumor with a capacity to invade locally and cause distant metastasis. Chondrosarcoma shows a predilection for metastasis to the lungs. Adiponectin is a protein hormone secreted predominantly by differentiated adipocytes and is involved in energy homeostasis. However, the effect of adiponectin on migration activity in human chondrosarcoma cells is mostly unknown. We found that adiponectin increased the migration and expression of alpha2beta1 integrin in human chondrosarcoma cells. The protein and messenger RNA expression of adiponectin receptor (AdipoR1 and AdipoR2) in chondrosarcoma patients and chondrosarcoma cell lines were significantly higher than the normal cartilage. Moreover, primary chondrosarcoma and chondrosarcoma cell lines (SW1353 and JJ012) were more invasive than normal chondrocytes. Adiponectin-mediated migration and integrin expression was attenuated by 5'-adenosine monophosphate-activated protein kinase (AMPK) small interfering RNA and an AMPK inhibitor (Ara A and compound C). Activation of p38 and nuclear factor-kappa B (NF-kappaB) pathways after adiponectin treatment was demonstrated, and adiponectin-induced expression of integrins and migration activity was inhibited by the specific inhibitor and mutant of p38 and NF-kappaB cascades. This study showed for the first time that adiponectin mediates the migration of human chondrosarcoma cells. One mechanism underlying adiponectin-directed migration was transcriptional upregulation of alpha2beta1 integrin and activation of AdipoR receptor, AMPK, p38 and NF-kappaB pathways.

Leptin induces IL-8 expression via leptin receptor, IRS-1, PI3K, Akt cascade and promotion of NF-kappaB/p300 binding in human synovial fibroblasts.

Leptin, the adipocyte-secreted hormone that centrally regulates weight control, is known to function as an immunomodulatory regulator. We investigated the signaling pathway involved in IL-8 production caused by leptin in both rheumatoid arthritis synovial fibroblasts (RASF) and osteoarthritis synovial fibroblasts (OASF). RASF and OASF expressed the long (OBRl) and short (OBRs) isoforms of the leptin receptor. Leptin caused concentration- and time-dependent increases in IL-8 production. Leptin-mediated IL-8 production was attenuated by OBRl receptor antisense oligonucleotide, JAK2 inhibitor or STAT3 small interference RNA (siRNA). Transfection with insulin receptor substrate (IRS)-1 siRNA or dominant-negative mutant of p85 and Akt or pretreatment with phosphatidylinositol 3-kinase inhibitor (Ly294002 and wortmannin), Akt inhibitor, NF-kappaB inhibitor (PDTC) and NF-kappaB inhibitor peptide also inhibited the potentiating action of leptin. Stimulation of RASF with leptin activated IkappaB kinase alpha/beta (IKK alpha/beta), p65 phosphorylation at Ser(276), p65 translocation from the cytosol to the nucleus, and kappaB-luciferase activity. Moreover, pretreatment with p300 inhibitor (curcumin) also blocked IL-8 expression. The binding of p65 to the NF-kappaB elements, as well as the recruitment of p300 and the enhancement of histone H3 acetylation on the IL-8 promoter was enhanced by leptin, which was inhibited by wortmannin, Akt inhibitor or IRS-1 siRNA. These results suggest that leptin increased IL-8 production in synovial fibroblast via the OBRl/JAK2/STAT3 pathway, as well as the activation of IRS1/PI3K/Akt/NF-kappaB-dependent pathway and the subsequent recruitment of p300.