The validity of using administrative claims data in total joint arthroplasty outcomes research.

The purpose of this study was to evaluate concordance between administrative and clinical diagnosis and procedure codes for revision total joint arthroplasty (TJA). Concordance between administrative and clinical records was determined for 764 consecutive revision TJA procedures from 4 hospitals. For revision total hip arthroplasty, concordance between clinical diagnoses and administrative claims was very good for dislocation, mechanical loosening, and periprosthetic joint infection (all kappa > 0.6), but considerably lower for prosthetic implant failure/breakage and other mechanical complication (both kappa < 0.25). Similarly, for revision total knee arthroplasty diagnoses, concordance was very good for periprosthetic fracture, periprosthetic joint infection, mechanical loosening, and osteolysis (all kappa > 0.60), but much lower for implant failure/breakage and other mechanical complication (both kappa < 0.24). Concordance for TJA-specific procedure codes was very good only for revision total knee arthroplasty patellar component revisions and tibial insert exchange procedures. Total (all-component) revisions were overcoded for hips (00.70) and undercoded for knees (00.80). Improved clinical documentation and continued education are needed to enhance the value of these codes.

Identification of peptide antagonists to glycoprotein Ibalpha that selectively inhibit von Willebrand factor dependent platelet aggregation.

GPIbalpha is an integral membrane protein of the GPIb-IX-V complex found on the platelet surface that interacts with the A1 domain of von Willebrand factor (vWF-A1). The interaction of GPIbalpha with vWF-A1 under conditions of high shear stress is the first step in platelet-driven thrombus formation. Phage display was used to identify peptide antagonists of the GPIbalpha-vWF-A1 interaction. Two nine amino acid cysteine-constrained phage display libraries were screened against GPIbalpha revealing peptides that formed a consensus sequence. A peptide with sequence most representative of the consensus, designated PS-4, was used as the basis for an optimized library. The optimized selection identified additional GPIbalpha binding peptides with sequences nearly identical to the parent peptide. Surface plasmon resonance of the PS-4 parent and two optimized synthetic peptides, OS-1 and OS-2, determined their equilibrium dissociation GPIbalpha binding constants ( K Ds) of 64, 0.74, and 31 nM, respectively. Isothermal calorimetry corroborated the K D of peptide PS-4 with a resulting affinity value of 68 nM. An ELISA demonstrated that peptides PS-4, OS-1, and OS-2 competitively inhibited the interaction between the vWF-A1 domain and GPIbalpha-Fc in a concentration-dependent manner. All three peptides inhibited GPIbalpha-vWF-mediated platelet aggregation induced under high shear conditions using the platelet function analyzer (PFA-100) with full blockade observed at 150 nM for OS-1. In addition, OS-1 blocked ristocetin-induced platelet agglutination of human platelets in plasma with no influence on platelet aggregation induced by several agonists of alternative platelet aggregation pathways, demonstrating that this peptide specifically disrupted the GPIbalpha-vWF-A1 interaction.

Characterization of an alternative splice variant of human nucleoside triphosphate diphosphohydrolase 3 (NTPDase3): a possible modulator of nucleotidase activity and purinergic signaling.

Nucleoside triphosphate diphosphohydrolase 3 (NTPDase3) is a cell surface, membrane-bound enzyme that hydrolyzes extracellular nucleotides, thereby modulating purinergic signaling. An alternatively spliced variant of NTPDase3 was obtained and analyzed. This alternatively spliced variant, termed "NTPDase3beta", is produced through the use of an alternative terminal exon (exon 11) in place of the terminal exon (exon 12) in the full-length NTPDase3, now termed "NTPDase3alpha". This results in an expressed protein lacking the C-terminal cytoplasmic sequence, the C-terminal transmembrane helix, and apyrase conserved region 5. The cDNA encoding this truncated splice variant was detected in a human lung library by PCR. Like the full-length NTPDase3alpha, the alternatively spliced NTPDase3beta was expressed in COS cells after transfection, but only the full-length NTPDase3alpha is enzymatically active and properly trafficked to the plasma membrane. However, when the truncated NTPDase3beta was co-transfected with full-length NTPDase3alpha, there was a significant reduction in the amount of NTPDase3alpha that was properly processed and trafficked to the plasma membrane as active enzyme, indicating that the truncated form interferes with normal biosynthetic processing of the full-length enzyme. This suggests a role for the NTPDase3beta variant in the regulation of NTPDase3 nucleotidase activity, and therefore the control of purinergic signaling, in those cells and tissues expressing both NTPDase3alpha and NTPDase3beta.

Metal-on-metal total hip arthroplasty with large heads may prevent early dislocation.

UNLABELLED: Postoperative dislocation is one of the major causes of morbidity and failure of total hip arthroplasty. We reviewed 327 patients (377 hips) retrospectively with varying diagnoses and indications but all of whom received large-diameter metal-on-metal prostheses. Two surgical approaches were used: the anterolateral abductor splitting (342 procedures) and a mini-incision posterior approach (35 procedures). Average age at time of surgery was 55.9 years and average followup was 4.0 months. There were 346 (91.8%) primary procedures, 15 (4.0%) conversion procedures, and 16 (4.2%) revisions or reimplantations. The most common preoperative diagnoses included osteoarthritis (250 hips; 66.3%) and avascular necrosis (46 hips; 12.2%). There were 62 (16.4%) patients with high-risk diagnoses for dislocation. The status in terms of postoperative dislocation was known for all patients. During the short followup period, there were no dislocations. Use of large-diameter femoral heads and metal-on-metal articulations decreases the risk of dislocations, making their use a viable choice for primary and revision procedures. LEVEL OF EVIDENCE: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Isolated liner exchange using the anterolateral approach is associated with a low risk of dislocation.

UNLABELLED: Authors of reports on the outcome of isolated liner exchange for osteolysis and wear have reported high dislocation rates. Twenty-six patients (27 hips) with a minimum of 2 years of followup had isolated liner exchange for wear and osteolysis done using the abductor splitting anterolateral approach. The mean followup was 41 months. The average age at time of surgery was 51 years. Preoperative Harris hip scores averaged 70, and increased to 82 at the most recent followup. We observed improvements in pain and functional scores. The average operating time was 82 minutes, and the average blood loss was 255 mL. Only three (12%) patients required transfusion. No components were rerevised for aseptic loosening, and one patient (one hip) had a dislocation (3.7%). Isolated liner exchange for osteolysis and wear done using the anterolateral approach has a lower risk of dislocation than previously reported and provides substantial improvements in pain, function, and Harris hip score. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Structure and protein design of a human platelet function inhibitor.

Hematophagous arthropods secrete a salivary apyrase that inhibits platelet activation by catabolizing ADP released from damaged tissues and blood cells. We report the X-ray crystal structures of a human enzyme of the soluble apyrase family in its apo state and bound to a substrate analog. The structures reveal a nucleotide binding domain comprising a five-blade beta propeller, binding determinants of the substrate and the active site, and an unusual calcium binding site with a potential regulatory function. Using a comparative structural biology approach, we were able to redesign the human apyrase so as to enhance its ADPase activity by more than 100-fold. The engineered enzyme is a potent inhibitor of platelet aggregation and may serve as the basis for the development of a new class of antithrombotic agents.

Cloning, expression, and characterization of a soluble calcium-activated nucleotidase, a human enzyme belonging to a new family of extracellular nucleotidases.

The salivary apyrases of blood-feeding arthropods are nucleotide-hydrolyzing enzymes implicated in the inhibition of host platelet aggregation through the hydrolysis of extracellular adenosine diphosphate. A human cDNA homologous to the apyrase cDNA of the blood-feeding bed bug was identified, revealing an open reading frame encoding a 371-amino acid protein. A cleavable signal peptide generates a secreted protein of 333 residues with a predicted core molecular mass of 37,193 Da. Expression in COS-1 cells produced a secreted apyrase in the cell media. The ADPase and ATPase activities were dependent upon calcium, with a pH optimum between pH 6.2 and 7.2. Interestingly, the preferred substrate was not ADP, as might be expected for an enzyme modulating platelet aggregation, but rather UDP, followed by GDP, UTP, GTP, ADP, and ATP. The nucleotidase did not hydrolyze nucleoside monophosphates. Size-exclusion chromatography and Western blot analysis revealed a molecular mass of approximately 34-37 kDa. Treatment of the enzyme with peptide N-glycosidase F indicated that the protein is glycosylated. Northern analysis identified the transcript in a range of human tissues, including testis, placenta, prostate, and lung. No traditional apyrase-conserved regions or nucleotide-binding domains were identified in this human enzyme, indicating membership in a new family of extracellular nucleotidases.