The presence of a sinus tract is associated with reinfection after two-stage revision surgery for prosthetic hip joint infection: a case-control study.

BACKGROUND: Reinfection rates after two-stage revision (TSR) for prosthetic joint infection (PJI) range from 7.9 to 14%. Many factors, including sinus tracts, are associated with reinfection after this procedure. This study aimed to delineate whether the presence of sinus tract could increase reinfection rate after TSR and to investigate other potential risk factors for reinfection after TSR. METHODS: We conducted a case-control study by retrospectively reviewing patients who underwent TSR for prosthetic hip joint infection from 2002 to 2022. The case group included patients who developed reinfection after TSR, while the control group consisted of patients who did not experience reinfection. PJI and reinfection after TSR were defined based on Delphi-based international consensus criteria. Patient demographics, past medical history, clinical manifestations, laboratory results, interval between stages, microbiological culture results were collected. Univariate analyses were utilized to assess the effect of sinus tract on reinfection and to identify other risk factors for reinfection after TSR. RESULTS: Six patients with reinfection after TSR were included as the case group and 32 patients without reinfection were in the control group. Significant difference was observed in percentage of patients with sinus tracts between the two groups (67% in the case group versus 19% in the control group, p = 0.031, OR = 8.7). Significant difference was also found in percentage of patients with positive cultures of synovial fluid and synovium harvested during the first-stage revision between the two groups (100% in the case group versus 50% in the control group, p = 0.030). Additionally, patients in the case group had a significantly higher C-reactive protein (CRP) level prior to the second stage revision than that of patients in the control group (8.80 mg/L versus 2.36 mg/L, p = 0.005), despite normal CRP levels in all patients. CONCLUSIONS: Our study revealed that the presence of sinus tracts could significantly increase risk of postoperative reinfection after TSR. Positive cultures during the first stage revision and elevated CRP level prior to the second stage revision could also increase the risk of reinfection after TSR. Further studies with a larger sample size are required. TRIAL REGISTRATION: Retrospectively registered.

Bone marrow mesenchymal stem cells in treatment of peripheral nerve injury.

Peripheral nerve injury (PNI) is a common neurological disorder and complete functional recovery is difficult to achieve. In recent years, bone marrow mesenchymal stem cells (BMSCs) have emerged as ideal seed cells for PNI treatment due to their strong differentiation potential and autologous transplantation ability. This review aims to summarize the molecular mechanisms by which BMSCs mediate nerve repair in PNI. The key mechanisms discussed include the differentiation of BMSCs into multiple types of nerve cells to promote repair of nerve injury. BMSCs also create a microenvironment suitable for neuronal survival and regeneration through the secretion of neurotrophic factors, extracellular matrix molecules, and adhesion molecules. Additionally, BMSCs release pro-angiogenic factors to promote the formation of new blood vessels. They modulate cytokine expression and regulate macrophage polarization, leading to immunomodulation. Furthermore, BMSCs synthesize and release proteins related to myelin sheath formation and axonal regeneration, thereby promoting neuronal repair and regeneration. Moreover, this review explores methods of applying BMSCs in PNI treatment, including direct cell transplantation into the injured neural tissue, implantation of BMSCs into nerve conduits providing support, and the application of genetically modified BMSCs, among others. These findings confirm the potential of BMSCs in treating PNI. However, with the development of this field, it is crucial to address issues related to BMSC therapy, including establishing standards for extracting, identifying, and cultivating BMSCs, as well as selecting application methods for BMSCs in PNI such as direct transplantation, tissue engineering, and genetic engineering. Addressing these issues will help translate current preclinical research results into clinical practice, providing new and effective treatment strategies for patients with PNI.

Comparison of the safety and efficacy of three superficial skin closure methods for multi-layer wound closure in total knee arthroplasty: a multicenter, prospective, randomized controlled trial.

BACKGROUND: Good wound healing is critical to infection prophylaxis and satisfactory rehabilitation in Total Knee Arthroplasty (TKA). Currently, two techniques, i.e., barbed continuous subcuticular suture without skin adhesive or combined use skin adhesive (n-butyl-2) are being used for superficial wound closure of TKA. While a new skin adhesive (2-octyl) with self-adhesive mesh has been employed as an alternative to conventional surgical skin closure in TKA, its superiority, especially in reducing wound complications and improving wound cosmetic outcomes has not been investigated. This study aimed to compare 2-octyl, n-butyl-2, and no skin adhesive in terms of safety and efficacy in TKA superficial wound closure. METHODS: We conducted a multicenter, prospective, randomized controlled study in 105 patients undergoing primary TKA between May 2022 and October 2023. Each patient's knee was randomized to receive 2-octyl, n-butyl-2, or no skin adhesive skin closure with all using barbed continuous sutures in deep tissue. Wounds were followed 1, 3, 5 days, 2, 6 weeks, and 3 months after surgery. Wound discharge, complications, cosmetic outcomes, patient satisfaction, and wound-related costs were compared among these three methods. RESULTS: Wound discharge was less in 2-octyl group and n-butyl-2 group than in non-adhesive group at 1 day, with the discharge only being less in 2-octyl group than in the non-adhesive group at day 3 and day 5 days (P < 0.05). There was no statistical difference in the incidence of other wound complications among the groups (P > 0.05). The 2-octyl group achieved better cosmetic effects than the other two groups in 6 weeks and 3 months (P < 0.05). Compared to the non-adhesive group, 2-octyl group scored higher in overall patient satisfaction score in 2 weeks and incurred lower costs (P < 0.05). CONCLUSIONS: Skin closure in TKA using 2-octyl adhesive material showed superiority when compared to no skin adhesive or n-butyl-2, in reducing wound discharge, improving the cosmetic outcomes, without increasing wound complications. In addition, the use of 2-octyl yielded better patient satisfaction and also was less costly compared to no skin adhesive. Our study exhibited that 2-octyl was a safe and effective wound closure technique for patients undergoing TKA. TRIAL REGISTRATION: This study has been registered at Clinical Trials. Gov (No. ChiCTR210046442).

The Effect of the Morphology of the Femur and Acetabulum in Dysplastic Hips on the Selection of Arthroplasty Femoral Implants: A Computer Tomography-Based Study.

OBJECTIVES: Due to the technical challenges associated with femoral reconstruction in total hip arthroplasty for patients with developmental dysplasia of the hip (DDH), the exact indications for using femoral modular stems, despite their satisfactory clinical outcomes, remain poorly investigated. This study sought to assess the morphology of the femur and acetabulum, and to investigate the discriminative ability of femoral anteversion (FA), acetabular anteversion (AA), and combined anteversion (CA) on the selection of femoral modular stem in dysplastic hips. METHODS: Retrospective data were collected from multiple centers on a total of 230 cases who underwent THA due to DDH from January 1, 2020, to March 1, 2023. There were 46 males and 184 females, with an average age of 51.57 ± 14.87. Patients were stratified according to Crowe and Eftekhar classifications. FA, AA, and CA were measured using computed tomography (CT). The distribution of these indices in different grades of dysplastic hips was compared, and the correlation between these indices and the selection of femoral modular stem was analyzed. Receiver operating characteristic (ROC) and likelihood statistics were performed to investigate the discriminating and predictive value of each index in selecting modular stem. RESULTS: Two hundred and thirty hips were included in the study. FA increased as the subluxation percentage increased: type I, 21.5°; type II, 28.6°; type III, 34.9°; and type IV, 39.7°. AA was smaller in type I (16.9°) and higher in types II, III, and IV (18.9-22.6°). The area under the curve for the modular stem was 0.87 for FA, 0.86 for CA, and 0.65 for AA. The optimal cutoff values were FA > 32.6°, CA > 50.7°, and AA > 23.3°. CONCLUSION: Excessive AA and femoral anteversion FA were observed in Crowe types II, III, and IV cases. FA and CA demonstrated strong discriminative ability and predictive value in the selection of a modular stem. The best cutoff values were ≥32.6° for FA and ≥50.7° for CA in discriminating the use of modular stem. Surgeons may contemplate the use of a modular stem when the preoperative evaluation approaches the cutoff value.

Development and clinical validation of a deep learning-based knee CT image segmentation method for robotic-assisted total knee arthroplasty.

BACKGROUND: This study aimed to develop a novel deep convolutional neural network called Dual-path Double Attention Transformer (DDA-Transformer) designed to achieve precise and fast knee joint CT image segmentation and to validate it in robotic-assisted total knee arthroplasty (TKA). METHODS: The femoral, tibial, patellar, and fibular segmentation performance and speed were evaluated and the accuracy of component sizing, bone resection and alignment of the robotic-assisted TKA system constructed using this deep learning network was clinically validated. RESULTS: Overall, DDA-Transformer outperformed six other networks in terms of the Dice coefficient, intersection over union, average surface distance, and Hausdorff distance. DDA-Transformer exhibited significantly faster segmentation speeds than nnUnet, TransUnet and 3D-Unet (p < 0.01). Furthermore, the robotic-assisted TKA system outperforms the manual group in surgical accuracy. CONCLUSIONS: DDA-Transformer exhibited significantly improved accuracy and robustness in knee joint segmentation, and this convenient and stable knee joint CT image segmentation network significantly improved the accuracy of the TKA procedure.

PUFAs add fuel to Crohn's disease-associated AIEC-induced enteritis by exacerbating intestinal epithelial lipid peroxidation.

Polyunsaturated fatty acids (PUFAs) have been shown to exacerbate Crohn's disease (CD) by promoting lipid peroxidation (LPO) of intestinal epithelial cells (IECs). Dysbiosis of the gut microbiota may play a crucial role in this process. CD patients often exhibit an increased abundance of Escherichia coli (E. coli) in the gut, and the colonization of adherent-invasive E. coli (AIEC) is implicated in the initiation of intestinal inflammation in CD. However, the impact of AIEC on LPO remains unclear. In this study, we observed that AIEC colonization in the terminal ileum of CD patients was associated with decreased levels of glutathione peroxidase 4 (GPX4) and ferritin heavy chain (FTH) in the intestinal epithelium, along with elevated levels of 4-Hydroxynonenal (4-HNE). In vitro experiments demonstrated that AIEC infection reduced the levels of GPX4 and FTH, increased LPO, and induced ferroptosis in IECs. Furthermore, arachidonic acid (AA) and docosahexaenoic acid (DHA) supplementation in AIEC-infected IECs significantly aggravated LPO and ferroptosis. However, overexpression of GPX4 rescued AIEC-induced LPO and ferroptosis in IECs. Our results further confirmed that AIEC with AA supplementation, associated with excessive LPO and cell death in IECs, worsened colitis in the DSS mouse model and induced enteritis in the antibiotic cocktail pre-treatment mouse model in vivo. Moreover, treatment with ferrostatin-1, a ferroptosis inhibitor, alleviated AIEC with AA supplementation-induced enteritis in mice, accompanied by reduced LPO and cell death in IECs. Our findings suggest that AIEC, in combination with PUFA supplementation, can induce and exacerbate intestinal inflammation, primarily through increased LPO and ferroptosis in IECs.

Surgical Management and Outcome of Entero-Urinary Fistula Complicating Crohn's Disease: A Single Center Study.

BACKGROUND: Entero-urinary fistulas (EUF) are a rare complication of Crohn's disease (CD), observed in 1.6 to 7.7%. The management of EUF complicating CD is challenging. We aimed to report the outcome and surgical management of EUF in CD. METHODS: A retrospective chart review was performed in all CD patients with EUF who underwent surgery in our center between January 2012 and December 2021. Patient demographics, preoperative optimization, surgical management, postoperative complications, and follow-up information were collected from a prospectively maintained database. RESULTS: A total of 74 eligible patients were identified. The median interval between CD diagnosis and EUF diagnosis was 2 (0.08-6.29) years. Patients with EUF presented with pneumaturia (75.68%), urinary tract infections (72.97%), fecaluria (66.22%), and hematuria (6.76%). Fistulae originated most commonly from the ileum (63.51%), followed by the colon (14.86%), the rectum (9.46%), the cecum (2.70%), and multiple sites (9.46%). The EUF symptoms, weight, nutritional status, laboratory results were significantly improved after preoperative optimization. The absence of EUF symptoms was observed in 42 patients after the optimization and only 9 of which required bladder repair. However, 19 of 32 patients whose symptoms did not resolve required bladder repair (P = 0.001). Only 1 patient developed a bladder leakage in the early postoperative period and 3 patients experienced recurrent bladder fistula. CONCLUSIONS: Surgical management of EUF complicating CD is effective and safe, with a low rate of postoperative complication and EUF recurrence. Preoperative optimization, which is associated with the resolution of urinary symptoms and improved surgical outcomes, should be recommended.

Exosomal miR-103a-3p from Crohn's Creeping Fat-Derived Adipose-Derived Stem Cells Contributes to Intestinal Fibrosis by Targeting TGFBR3 and Activating Fibroblasts.

BACKGROUND AND AIMS: Mesenteric adipose tissue hypertrophy is a hallmark of Crohn's disease [CD], and creeping fat [CF] is unique to CD. Adipose-derived stem cells [ASCs] from inflammatory tissue exhibited altered biological functions. The role of ASCs isolated from CF in intestinal fibrosis and the potential mechanism remain unclear. METHODS: ASCs were isolated from CF [CF-ASCs] and disease-unaffected mesenteric adipose tissue [Ctrl-ASCs] of patients with CD. A series of in vitro and in vivo experiments were conducted to study the effects of exosomes from CF-ASCs [CF-Exos] on intestinal fibrosis and fibroblast activation. A micro-RNA microarray analysis was performed. Western blot, luciferase assay and immunofluorescence were performed to further detect the underlying mechanisms. RESULTS: The results indicated that CF-Exos promoted intestinal fibrosis by activating fibroblasts in a dose-dependent manner. They continuously promoted progression of intestinal fibrosis even after dextran sulphate sodium withdrawal. Further analysis showed that exosomal miR-103a-3p was enriched in CF-Exos and participated in exosome-mediated fibroblast activation. TGFBR3 was identified as a target gene of miR-103a-3p. Mechanistically, CF-ASCs released exosomal miR-103a-3p and promoted fibroblast activation by targeting TGFBR3 and promoting Smad2/3 phosphorylation. We also found that the expression of miR-103a-3p in diseased intestine was positively associated with the degree of CF and fibrosis score. CONCLUSION: Our findings show that exosomal miR-103a-3p from CF-ASCs promotes intestinal fibrosis by activating fibroblasts via TGFBR3 targeting, suggesting that CF-ASCs are potential therapeutic targets for intestinal fibrosis in CD.

Comparison of risk of complication between neuraxial anaesthesia and general anaesthesia for hip fracture surgery: a systematic review and meta-analysis.

BACKGROUND: Controversy remains over the choice of anaesthetic technique for patients undergoing surgery for hip fracture. AIM: The aim was to compare the risk of complication of neuraxial anaesthesia with that of general anaesthesia in patients undergoing hip fracture surgery. METHODS: This systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and was registered at PROSPERO (CRD42022337384). The study included eligible randomised controlled trials published before February 2022. Data synthesis was performed to compare the differences between general and neuraxial anaesthesia. Meta-regression analysis was performed to investigate the influence of the publication year. A subgroup analysis was performed based on patient age and the anaesthetic technique used. A grading of recommendations, assessment, development and evaluations assessment was performed to assess the quality of each outcome. RESULTS: Twenty randomised controlled trials and 4802 patients were included. Data synthesis revealed significant higher risk of acute kidney injury in the general anaesthesia group ( P =0.01). There were no significant differences between the two techniques in postoperative short-term mortality ( P =0.34), delirium ( P =0.40), postoperative nausea and vomiting ( P =0.40), cardiac infarction ( P =0.31), acute heart failure ( P =0.34), pulmonary embolism ( P =0.24) and pneumonia ( P =0.15). Subgroup analysis based on patient age and use of sedative medication did not reveal any significant differences. Meta-regression analysis of the publication year versus each adverse event revealed no statistically significant differences. CONCLUSION: A significantly higher risk of postoperative acute kidney injury was found in patients receiving general anaesthesia. This study revealed no significant differences in terms of postoperative mortality and other complications between general and neuraxial anaesthesia. The results were consistent across the age groups.

Long-Term clinical results of patellofemoral arthroplasty for isolated patellofemoral osteoarthritis.

OBJECTIVES: The aim of this study was to explore the clinical outcomes and long-term survival of patellofemoral arthroplasty in treatment of isolated patellofemoral osteoarthritis. METHODS: We retrospectively studied a total of 46 type Y-L-Q PFAs that were designed at our institution in 38 patients. Implant survivorship was analyzed with a follow-up of 18.9-29.6 years. Knee Society Score (KSS), Oxford Knee Score (OKS), and University of California Los Angeles activity scale (UCLA) were used to assess functional outcomes. RESULTS: The implant survivorship was 83.6% at 15 years, 76.8% at 20 years, and 59.4% at 25 years 14 PFAs in 12 patients were revised into total knee arthroplasty at 16.0 ± 6.7 years; 13 for progression of tibiofemoral osteoarthritis and one for polyethylene wear. The mean Knee Society Score objective scores and functional scores were 73.0 ± 17.5 (range, 49-95) and 56.4 ± 28.9 (range, 5-90), respectively. The mean Oxford Knee Score was 25.8 ± 11.5 (range, 8-44). CONCLUSION: Type Y-L-Q patellofemoral arthroplasty can be an effective method for treating isolated patellofemoral osteoarthritis with satisfactory survival.

Crohn's disease-associated AIEC inhibiting intestinal epithelial cell-derived exosomal let-7b expression regulates macrophage polarization to exacerbate intestinal fibrosis.

The interaction between adherent-invasive Escherichia coli (AIEC) and intestinal macrophages is implicated in the pathogenesis of Crohn's disease (CD). However, its role in intestinal fibrogenesis and the underlying molecular mechanisms are poorly understood. In addition, miRNAs such as let-7b may participate in AIEC-macrophage interactions. In this study, we identified that the colonization of AIEC in the ileum was associated with enhanced intestinal fibrosis and reduced let-7b expression by enrolling a prospective cohort of CD patients undergoing ileocolectomy. Besides, AIEC-infected IL-10-/- mice presented more severe intestinal fibrosis and could be improved by exogenous let-7b. Mechanistically, intestinal macrophages were found to be the main target of let-7b. Transferring let-7b-overexpressing macrophages to AIEC-infected IL-10-/- mice significantly alleviated intestinal fibrosis. In vitro, AIEC suppressed exosomal let-7b derived from intestinal epithelial cells (IECs), instead of the direct inhibition of let-7b in macrophages, to promote macrophages to a fibrotic phenotype. Finally, TGFßR1 was identified as one target of let-7b that regulates macrophage polarization. Overall, the results of our work indicate that AIEC is associated with enhanced intestinal fibrosis in CD. AIEC could inhibit exosomal let-7b from IECs to promote intestinal macrophages to a fibrotic phenotype and then contributed to fibrogenesis. Thus, anti-AIEC or let-7b therapy may serve as novel therapeutic approaches to ameliorate intestinal fibrosis.

What is the context?Adherent-invasive Escherichia coli (AIEC) plays an important role in the pathogenesis of Crohn's disease (CD) and has a strong association with intestinal fibrosis in animal models. However, how these bacteria contribute to intestinal fibrosis in CD patients is still unclear.The plasticity of macrophages is crucial in immune tolerance and tissue repair in the gastrointestinal tract, and the abnormal interaction between macrophages and gut bacteria triggers the fibrogenesis in the intestine.The association between the miRNA let-7b and fibrosis process has been widely reported in many tissues, except the intestine.What is new?AIEC colonization in the terminal ileum is associated with severe intestinal fibrosis in CD patients and the let-7b plays an anti-fibrotic role in intestinal fibrosis.Intestinal macrophages are the key modulator of AIEC-induced fibrosis and can be promoted to an antifibrotic phenotype through let-7b-targeted TGFßR1 inhibition.AIEC suppresses intestinal epithelial cell-derived exosomal let-7b to promote intestinal macrophages to a fibrotic phenotype, rather than a direct effect on macrophage regulation.What is the impact? Anti-AIEC and let-7b therapy may serve as potential therapeutic strategies to reduce intestinal fibrosis in CD in the future.

Total Hip Arthroplasty in the Nonparalytic Limb of Residual Poliomyelitis Patients: A Propensity Score Matched Study.

OBJECTIVE: Poliomyelitis is a rare neuromuscular disease that can cause hip osteoarthritis on the contralateral side due to an abnormal mechanical weight-bearing state, making some residual poliomyelitis patients candidates for total hip arthroplasty (THA). The aim of this study was to investigate the clinical outcome of THA in the nonparalytic limbs of these patients compared with those of non-poliomyelitis patients. METHODS: Patients treated between January 2007 and May 2021 were retrospectively identified in a single center arthroplasty database. Eight residual poliomyelitis cases that met the inclusion criteria were matched to non-poliomyelitis cases in a ratio of 1:2 based on age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (aCCI), surgeon, and operation date. The hip function, health-related quality of life, radiographic outcomes, and complications were analyzed with unpaired Student's t test, Mann-Whitney test, Fisher's exact test or analysis of covariance (ANCOVA). Survivorship analysis was determined using the Kaplan-Meier estimator analysis and Gehan-Breslow-Wilcoxon test. RESULTS: After a mean follow-up of about 5 years, patients with residual poliomyelitis had worse postoperative mobility outcomes(P < 0.05), but there was no difference in total modified Harris hip score (mHHS) or European quality of life-visual analogue scale (EQ-VAS) between the two groups (P > 0.05). There was no difference in radiographic outcomes or complications between the two groups, and patients had similar postoperative satisfaction (P > 0.05). No readmission or reoperation occurred in the poliomyelitis group (P > 0.05), but the postoperative limb length discrepancy (LLD) in the residual poliomyelitis group was greater than that in the control group (P < 0.05). CONCLUSION: Functional outcomes, health-related quality of life improvement were similarly significantly improved in the nonparalytic limb of residual poliomyelitis patients after THA compared with conventional osteoarthritis patients. However, the residual LLD and weak muscle strength of the affected side will still influence mobility, so residual poliomyelitis patients should be fully informed of this outcome before surgery.

Acetabular Diameter Assessment and Three-Dimensional Simulation for Acetabular Reconstruction in Dysplastic Hips.

BACKGROUND: This study aimed to investigate the relationship between acetabular width, three-dimensional (3D) simulation, and surgical results in total hip arthroplasty patients who have developmental dysplasia of the hip (DDH). METHODS: This retrospective study included 216 DDH cases. Inner and outer acetabular width (OAW) was measured at the plane passing through the center of acetabular fossa. 3D simulation and 2D standard templating were performed. The actual cup size and the use of augments during surgery were recorded. Association among the indices and their distribution in different types of DDH were analyzed. RESULTS: A difference of 13 to 14 millimeters (mm) was found between the inner acetabular width and actual cup size used in type II, III, and IV cases, while the difference was 0.2 to 3.6 mm for OAW. The accuracy of 2D templating and 3D simulation in predicting cup size was comparable in Crowe type I (86.5 versus 76%, P = .075), type II (72.7 versus 51.5%, P = .127), and type III (93.3 versus 66.7%, P = .169). The 3D simulation was significantly more accurate in Crowe type IV (89.1% versus 60.9%, P = .001). Augments and bone grafts were significantly more commonly used in type II (25%) than in the other types (0 to 6.5%). CONCLUSION: OAW more accurately predicted actual cup size than inner acetabular width. The supero-lateral acetabular bone defects in type II cases require additional attention. Compared with 2D templating, 3D simulation is more accurate in predicting actual cup size in dysplastic hips with severe deformity and may be recommended in these selected cases, especially for Crowe IV patients.

Computer Navigation Assisted Restricted Kinematic Alignment Improves Short-Term Outcomes in Total Knee Arthroplasty: An Ambispective Cohort Study.

OBJECTIVES: Mechanical alignment (MA)-total knee arthroplasty (TKA) has been challenged due to the excessive soft tissue release and the evidence of the clinical outcomes of computer assisted navigation is still limited. The aim of this ambispective cohort study was to: (i) investigate whether computer assisted navigation is capable to achieve restricted kinematic alignment (rKA)-TKA; and (ii) compare the short-term outcomes between rKA-TKA and MA-TKA. METHODS: We retrospectively included 41 patients diagnosed with osteoarthritis who received MA-TKA between April 2019 and January 2021 and 43 patients diagnosed with osteoarthritis who received rKA-TKA were included in the prospective cohort from January 2021 to September 2021. Demographical, peri-operative, and radiological data were collected and compared. Unpaired two-sample t-test for continuous variables and χ2 test for categorical variables were used to compare various measurements in two groups. The patient-reported outcome measures at baseline, 10 days (T1), and 6 months (T6) after surgery were statistically analyzed by generalized estimating equation (GEE) models. RESULTS: Fourty-one patients (45 knees) and 43 patients (48 knees) were included in the MA and the rKA group respectively. Three constitutional knee phenotypes (II, I, IV) were the commonest in our population. Navigation improved the surgical accuracy (1.5° vs 3.5°, p < 0.001) and precision (interquartile range 4.0 vs 2.0, p < 0.001) in the rKA group than the MA group. The changes in Knee Injury and Osteoarthritis Outcome Score 12 (KOOS12), EuroQol five-dimension questionnaire (EQ5D) from baseline to T1 and T6 for patients with on-target rKA were larger than on-target MA counterparts (26.053 vs 18.607, P < 0.001(KOOS12, T1) , 0.457 vs 0.367 p < 0.001(EQ5D, T1) ; 51.017 vs 46.896, P = 0.023(KOOS12, T6) , 0.606 vs 0.565, P = 0.01(EQ5D, T6) ). Patients with on-target rKA had better Forgotten Joint Score (FJS) at T1 (54.126 vs 40.965, P = 0.002) compared with on-target MA counterparts. CONCLUSIONS: Computer assisted navigation achieved the level of accuracy required by rKA-TKA. rKA-TKA offered significantly better short-term outcomes than MA-TKA.

Hypoxic ASCs-derived Exosomes Attenuate Colitis by Regulating Macrophage Polarization via miR-216a-5p/HMGB1 Axis.

BACKGROUND: Exosomes derived from mesenchymal stem cells have shown therapeutic effects for colitis. As a more clinically accessible resource, the therapeutic potential of exosomes from adipose-derived stem cells (ASCs) has not been fully elucidated, and whether hypoxia precondition could improve the therapeutic effect of ASC-derived exosomes in colitis remains elusive. METHODS: In this study, exosomes were derived from ASCs under normoxia (NExos) and hypoxia (HExos) and were identified by detecting their morphology, size distribution, and exosome surface markers. The concentration of inflammation-related cytokines was detected by ELISA, and macrophage phenotype-related genes were determined by quantitative reverse transcription-polymerase chain reaction (qRT-PCR), western blot, and immunofluorescence. A miRNA microarray sequencing analysis was conducted to confirm the differentially expressed miRNAs. Dextran sulfate sodium-induced colitis was employed as an in vivo assay. RESULTS: Administration of NExos alleviated inflammation by modulating the balance of macrophages both in cellular assays and in vivo experiments, and HExos showed higher therapeutic efficiency than NExos. The miR-216a-5p in HExos was significantly enriched and promoted macrophage M2 polarization through transfer to macrophages by exosomes. The miR-216a-5p was confirmed to target the 3'-UTR of HMGB1. Mechanistically, hypoxia-induced ASCs release miR-216a-5p in an exosomal way that induced macrophage M2 polarization by regulating the HMGB1/TLR4/NF-κB signaling pathway. CONCLUSIONS: Exosomal miR-216a-5p released from hypoxia-prime ASCs showed higher therapeutic efficiency than NExos in experimental colitis by promoting the M2 macrophage phenotype, which indicated that hypoxia prime may represent a promising approach to optimizing the function of ASC-derived exosomes.

Exosomal miR-216a-5p released from hypoxia-prime ASCs showed higher therapeutic efficiency than NExos in experimental colitis by promoting the M2 macrophage phenotype, which indicated that hypoxia prime may represent a promising approach to optimize the function of ASC-derived exosomes.

Total Knee Arthroplasty in Patients with Primary Sjögren's Syndrome: A Retrospective Case-Control Study Matched Patients without Rheumatic Diseases.

Background: The number of patients with primary Sjögren's syndrome (pSS) who require total knee arthroplasty (TKA) is expected to increase, and there are few studies describing their outcomes. This research was focused on the evaluation of a TKA cohort in pSS patients and to compare outcomes with those of matched individuals from the general population. Methods: From 2004 to 2020, we found 36 TKAs in 30 patients with pSS from the single-institution arthroplasty registry, and they were matched for age, gender, bilateral or unilateral surgery, American Society of Anesthesiologists (ASA) score, and year of surgery with 72 TKAs in 60 osteoarthritis patients without rheumatic diseases (1:2 ratio). Perioperative outcomes were obtained, and clinical evaluations were performed at the last follow-up. Results: After a mean six-year follow-up, both cohorts had similar knee function and health-related quality of life outcomes. The pSS group had more patients with post-operative anemia and hypoalbuminemia and more patients needing platelet transfusion. There were no significant differences in other complications, the rates of 90-day readmission, or overall revision. By multivariate analysis, the influencing factor for anemia in pSS patients was lower preoperative hemoglobin (OR = 0.334, 95% CI (0.125−0.889), p < 0.05). Conclusions: Our study demonstrated that pSS patients who received TKA could achieve comparable clinical outcomes to the general population. However, more attention should be paid to the perioperative hematological management of pSS patients who underwent TKA.

Obesity paradox among patients undergoing total knee arthroplasty: a retrospective cohort study.

BACKGROUND: Obesity has been recognized as the risk factor for postoperative complication for surgical patients. However, recent studies have showed protective effect of obesity in surgical and non-surgical patients. Our study is to examine the association of body mass index(BMI) with early postoperative complications in patients undergoing total knee arthroplasty. MATERIALS AND METHODS: All patients who had primary total knee arthroplasty between January 2014 and December 2019 were included. Medical records were retrospectively reviewed and BMI was categorized as underweight(BMI < 18.5), normal weight(18.5 < BMI < 24.9), overweight I(25 < BMI < 27.4), overweight II(27.5 < BMI < 29.9), obese I(30 < BMI < 34.9) and obese II(BMI ≥ 35). The association between BMI and occurrence of early postoperative complications was examined and logistic regression was used to calculate relationship between BMI and early postoperative complications. RESULTS: A total of 2969 patients were included in our analysis. The overall complication rate in patients undergoing total knee arthroplasty was 14.8%, with the highest complication being 22.2% in the underweight group, the second highest in the normal weight group(17.5%), the lowest in the overweight I(13.8%) and obese I(12.0%) group and then higher again in obese II group(16.7%). In multivariable analyses, overweight I (OR 0.737, 95% CI 0.559-0.972, P = 0.031) and obese I (OR 0.631, 95% CI 0.449-0.885, P = 0.008) were associated with lower risk of early postoperative complications after total knee arthroplasty. CONCLUSION: In this retrospective study, overweight and obese patients had a lower risk of early postoperative complications after total knee arthroplasty. Further studies are necessary to confirm and investigate the mechanism of obesity paradox in this surgical population. TRIAL REGISTRATION: This study had been registrated in www.chictr.org.cn on 25/10/2021 and the registration ID was ChiCTR2100052408.

Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method.

BACKGROUND: Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS: Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS: Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION: Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.

The Prevalence of Concomitant Skip Small Bowel Lesions in Crohn's Disease and Their Effects on Reoperation in Patients Undergoing Ileocolic Resection.

AIMS: Concomitant lesions in the small intestine are common in Crohn's disease (CD). This study aimed to detect the incidence of small bowel (SB) lesions in patients undergoing surgical resection for symptomatic ileocolic disease and whether concomitant SB lesions are associated with reoperation due to recurrent CD. METHODS: In this observational, historical cohort study, consecutive patients with CD undergoing primary ileocolic resection (ICR) from 2007 to 2019 were included. Clinical variables and intraoperative findings were extracted from a prospectively maintained database and analyzed by Cox proportional hazards regression models for identifying risk factors of reoperation. RESULTS: Of the 404 patients included, there were 202 (50%) patients having concomitant SB lesions, and 108 of them underwent concurrent surgical intervention for SB lesions whereas 94 did not. The presence of concomitant SB lesions was a risk factor for reoperation (p = 0.041). Subgroup analysis indicated that patients with concomitant uncomplicated SB lesions left in situ had a comparable rate of reoperation (p = 0.605) whereas patients having concomitant complicated SB lesions undergoing simultaneous surgical intervention showed a higher reoperation rate (P = 0.006) when compared with those without concomitant SB lesions. Interestingly, the adverse effects of concomitant SB lesions can be reversed in the setting of postoperative anti-TNF agents [HR 0.2; 95% CI (0.04-0.9); P=0.040]. CONCLUSIONS: Concomitant SB lesion(s), especially those complicated lesions, could be a risk factor for postoperative surgical recurrence in patients undergoing ICR. Active postoperative management strategies such as anti-TNF agents should be provided for these patients.

Surgical treatment of femoroacetabular impingement in a patient with Stickler syndrome: a case report.

Stickler syndrome is a multisystem connective tissue disorder caused by mutations in collagen genes that can present with craniofacial, ocular, audial, or skeletal abnormalities. Here, we report on a male patient with a COL2A1 missense mutation (c.647G>A; p.Gly216Asp). He complained of an out-toeing gait and restricted hip mobility. Radiographs showed broad and elongated femoral necks with coxa valga. An alpha angle of 119° and 96° for his left and right femur, respectively, and almost no femoral head-neck offset, suggested a femoroacetabular impingement. Considering the patient's unwillingness to receive a total hip replacement for his Tönnis grade 2 hips, we intended to establish impingement-free hips by causing minimizing trauma. Therefore, we performed an osteochondroplasty of femoral head-neck junction and gluteal muscle release without correcting coxa valgus through the surgical hip dislocation approach. The range of motion of his hips improved as the surgery restored the femoral head-neck offset. However, the patient experienced a sense of lower limb length disparity and hip instability, which might be caused by his uncorrected proximal femoral deformity. This case presents the previously unreported phenotypic features of a COL2A1 mutation G216D. Orthopedic surgeons should consider genetic disorders when confronting atypical abnormalities. Moreover, the primary deformity should be corrected in hip preservation surgeries. Insufficient deformity correction might contribute to unsatisfactory surgical outcomes.