No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA.

BACKGROUND: Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained. QUESTIONS/PURPOSES: We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery. METHODS: Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism. RESULTS: With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction. CONCLUSION: The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen. LEVEL OF EVIDENCE: Level III, therapeutic study.

Single Use Instruments for Implanting a Contemporary Total Knee Arthroplasty System Are Accurate, Efficient, and Safe.

BACKGROUND: Single use instruments (SUI) is a potential mechanism to improve efficiency and reduce cost in total knee arthroplasty (TKA). New technology requires patient safety and surgical accuracy. A multi-center study of SUI vs reusable mechanical instrumentation (RUI) for a TKA system compared implant placement accuracy and operating room (OR) efficiency. METHODS: Four surgeons implanted 88 primary TKAs, N = 44 RUI and N = 44 SUI. Accuracy was measured radiographically at 3 months. The primary endpoint was non-inferiority of absolute value of mechanical axis alignment. Radiographic endpoints, OR times, and adverse events were also evaluated. RESULTS: Seventy-five subjects completed the study (41 SUI/34 RUI). The primary endpoint non-inferiority of SUI vs RUI was met, with no significant difference between SUI and RUI in most radiographic parameters (distal femoral varus-valgus, proximal tibial varus-valgus, tibial slope, or subjects within 3° of target); there was a slight difference in femoral component flexion angle (P = .015). SUI and RUI mean (SD) OR set-up times were 18.8 (10.03) and 26.7 (6.93) (P <.001), and surgical times (first incision to last stitch) were 64.6 (16.95) and 60.5 (19.01) (P = .295), respectively. Differences in OR clean-down and anesthesia were not significant. There were no revisions, and there was no significant difference in the number of reported adverse events. CONCLUSION: SUI resulted in similar accuracy of implant placement to RUI with decreased OR set-up time and no increase in adverse events. These results support the safety and efficacy of SUI for performing TKA. Further analysis of potential economic and technical advantages is warranted.

Editorial Commentary: Revising a Failed Osteochondral Allograft-Further Down the Rabbit Hole We Go .

Fresh osteochondral allografting has gained popularity as a useful technique for managing difficult cartilage repair problems and, in revision situations, is a treatment of choice when other procedures such as microfracture, osteochondral autograft transfer, and cell-based therapies fail. However, it is a challenge when an allograft fails. Absent substantial progression of osteoarthritis, revising with another allograft results in a reasonable chance of "success" (but a high likelihood of further surgery along the way). Thus, in the setting of a failed osteochondral allograft, sometimes the best option is to keep going further down the rabbit hole and revise a failed allograft with an allograft.

Knee Injury and Osteoarthritis Outcome Score has higher responsiveness and lower ceiling effect than Knee Society Function Score after total knee arthroplasty.

PURPOSE: To compare the following subjective scoring instruments: the Knee Society Function (KS-F) Score and Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients who underwent total knee arthroplasty (TKA) by assessing standard metrics related to the utility of each instrument, including responsiveness, ceiling effect, and distribution of scores. METHODS: Patients undergoing TKA for osteoarthritis (n = 82) were evaluated pre-operatively and post-operatively at a median time of 1 year (range 0.7-3.6 years) using the KS-F score and KOOS. Responsiveness, the ability of a tool to measure change over time, was evaluated by computing the standardized response mean. Ceiling effects were determined by calculating the percentage of patients who attained the best-possible score. RESULTS: The KOOS scale had higher standardized response mean than KS-F scale in the majority of subsections (except sports and recreation). The KOOS had a lower ceiling effect in the majority of subsections (except pain) and was significantly lower on the symptoms and quality of life subscales (both p < 0.05). Scores were not normally distributed for either KS-F or KOOS scales. CONCLUSIONS: Since the KOOS scale had a higher responsiveness and a lower ceiling effect, it appears to be a superior outcome tool versus the KS-F scale when evaluating the outcomes of TKA patients. LEVEL OF EVIDENCE: Diagnostic Study, Level I.

Lateral Opening-wedge Distal Femoral Osteotomy: Pain Relief, Functional Improvement, and Survivorship at 5 Years.

BACKGROUND: Distal femoral varus osteotomy may be used to treat valgus knee malalignment or to protect a knee compartment in which cartilage restoration surgery (such as osteochondral or meniscus allografting) has been performed. Medial closing-wedge osteotomy has demonstrated good success in treatment of osteoarthritis in published series, but few studies have evaluated distal femoral lateral opening-wedge osteotomy in terms of correction of deformity, pain and function, and survivorship. QUESTIONS/PURPOSES: (1) Does lateral opening-wedge osteotomy lead to accurate correction? (2) What pain and function levels do patients experience after lateral opening-wedge osteotomy? (3) What are the nonunion, complication, and reoperation rates after lateral opening-wedge osteotomy? METHODS: Between 2000 and 2010, we performed 40 distal femoral osteotomies. Two knees (two patients) underwent a medial closing-wedge osteotomy and were excluded from the present study. Thirty-eight knees (97%) in 36 patients were lateral opening-wedge varus-producing osteotomies; of those, 31 knees (82%) in 30 patients had followup at a minimum of 2 years (mean, 5 years; SD, 2; range, 2-12 years) and comprised the study population. The indications for osteotomy included symptomatic lateral compartment arthritis with clinical valgus deformity or a cartilage or meniscal defect in the lateral compartment with clinical valgus alignment. The study population was stratified into two groups based on reason for osteotomy: patients with isolated symptomatic lateral compartment arthritis (arthritis group; 19 knees [61%]) and patients who underwent joint preservation procedures including osteochondral allograft transplantation or meniscal allograft transplantation (joint preservation group; 12 knees [39%]). Data collection from our institution's osteotomy database included patient demographics, lower extremity coronal alignment, and operative details. Pain and function were measured preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score. Time to radiographic union, complications, and reoperations were recorded. RESULTS: Twenty-one of 31 knees had postoperative radiographic data available for review. Of these, seven of 15 knees in the arthritis group and three of six knees in the joint preservation group were within the correction goal of ± 3° from neutral mechanical alignment. In the arthritis group, the mean IKDC total score improved from 47 (SD, 15) preoperatively to 67 (SD, 10) postoperatively. In the joint preservation group, the mean IKDC total score improved from 36 (SD, 12) preoperatively to 62 (SD, 18) postoperatively. One nonunion occurred in the arthritis group. No postoperative complications were experienced. Ten knees in the arthritis group and six knees in the joint preservation group had additional surgery after the osteotomy, consisting primarily of hardware removal, arthroscopy for cartilage-related conditions, or conversion to arthroplasty. Survivorship at 5 years, with conversion to arthroplasty as the endpoint, was 74% in the arthritis group and 92% in the joint preservation group. CONCLUSIONS: Lateral opening-wedge distal femoral osteotomy was less accurate in correction of valgus deformity than expected, but the procedure was associated with improved knee pain and function scores. Our clinical and radiographic results are comparable to published series evaluating medial closing-wedge distal femoral osteotomy. Achieving our desired correction of ± 3° from neutral alignment was clinically difficult. An improved method of preoperative templating and refinement of the intraoperative technique may improve this. Future studies with more patients and longer followup will provide clarity on this topic. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Accuracy of A Handheld Accelerometer-Based Navigation System for Femoral and Tibial Resection in Total Knee Arthroplasty.

Restoration of mechanical axis in total knee arthroplasty (TKA) is correlated with improved implant survivorship. We assessed the accuracy and required surgical time using a hand-held accelerometer-based navigation system for TKA. Data collected on 53 patients included assembly, resection, and tourniquet times. Implant alignment and mechanical axis were measured on radiographs. Femoral alignment was 0.29° ± 2.2° varus. Tibial alignment was 0.09° ± 1.4° valgus. Postoperative mechanical axis was 0.2° ± 2.1° varus. Malalignment rates for the femur, tibia, and axis were 13%, 3.8%, and 17%, respectively. Average time for pinning and navigating was 3.6 minutes for the femur and 2.6 minutes for the tibia; mean tourniquet time was 62 minutes. This navigation system accurately re-established mechanical axis without increasing surgical time.

Tibial Slope is Highly Variable in Patients Undergoing Primary Total Knee Arthroplasty: Analysis of 13,546 Computed Tomography Scans.

The purpose of this study was to retrospectively measure with computed tomography (CT) the posterior tibial slope (PTS) to establish the average anatomy and the incidence of outliers in patients undergoing total knee arthroplasty (TKA). Our cohort included 13,546 arthritic patients: 8241 (61%) female; 5305 (39%) male. The average PTS angle was 7.2°±3.7° (range, -5° to 25°). The average of PTS angle of the males was 7.17°±3.82° and females was 7.24°±3.57°. A significant number of patients 35.0% (4149) were identified outliers in PTS. 1568 (11.6%) patients' PTS angle was less than 4°, 2581 (19.1%) patients' PTS angle was more than 10°. These data can be useful to determine optimum techniques and methodology to perform more accurate TKA.

Variability in Distal Femoral Anatomy in Patients Undergoing Total Knee Arthroplasty: Measurements on 13,546 Computed Tomography Scans.

Proper mechanical and rotational alignment plays an important role in achieving the success of the total knee arthroplasty (TKA). The purpose of the present study was to retrospectively determine with computed tomography (CT) the distal femoral valgus angle (DFVA) and femoral rotation angle (FRA). Our cohort included 13,546 CT scans of patients undergoing TKA. The average DFVA was 5.7 ± 2.3° (range from 1 to -16°) with 13.8% of patients identified as outliers. The distal FRA angle average was 3.3 ± 1.5° (range from -3 to 11°) with 2.8% of patients identified as outliers. These data can be useful in making orthopedic surgeons aware of the variability of femoral anatomy. Using the same cutting angle may lead to malposition of the femoral component.

Participation in Sports or Recreational Activities After Osteochondral Allograft Transplantation of the Talus.

BACKGROUND: Fresh osteochondral allograft (OCA) transplantation is a viable treatment option for osteochondral defects of the talus. However, sufficient data are not available on patients' participation in sports or recreational activities after the procedure. PURPOSE: To assess whether patients undergoing OCA transplantation of the talus participated in sports or recreational activities postoperatively. STUDY DESIGN: Case series; level of evidence, 4. METHODS: A total of 36 ankles in 34 patients underwent OCA transplantation of the talus. At a mean follow-up of 9.2 years, information on participation in sports or recreational activities pre- and postoperatively was obtained, as well as postoperative pain, function, and satisfaction. RESULTS: The mean age at the time of surgery was 36.1 years (range, 20.5-57.7 years), and 50% of patients were men. The mean graft size was 3.6 cm2 (range, 1-7.2 cm2) or 41.1% of the talar dome. Before the injury, 63.9% of patients (23/36 ankles) reported being highly competitive athletes or well trained and frequently sporting; 36.1% of patients (13/36 ankles) reported sometimes sporting or were nonsporting. Also, 66.7% of patients (24/36 ankles) were able to participate in sports or recreational activities after OCA transplantation and 50% (18/36 ankles) were still participating in sports or recreational activities at the latest follow-up. In a subset of well-trained or highly competitive athletes, 73.9% (17/23 ankles) were able to return to sports or recreational activities at any point after OCA transplantation, and 65.2% (15/23 ankles) were still participating at the latest follow-up. Further surgery occurred in 16.7% of patients (6/36 ankles). Graft survivorship was 94.3% at 5 years and 85.3% at 10 years. There was a significant improvement in the mean Olerud-Molander Ankle Scores, and the mean Foot and Ankle Ability Measure scores were high postoperatively. Moreover, 79.4% of patients (27/34 ankles) were either satisfied or extremely satisfied with the allograft surgery. CONCLUSION: Fresh OCA transplantation is a reasonable surgical option for osteochondral defects of the talus for young, active patients who have failed previous operative management or have massive defects.

Treatment of osteochondral injuries of the humeral head using fresh osteochondral allograft transplantation.

Background: Large osteochondral lesions of the humeral head can result from locked posterior dislocations, avascular necrosis, and osteochondritis dissecans. Fresh osteochondral allograft (OCA) transplantation is a treatment option for young patients with focal osteochondral defects of the humeral head. The purpose of this case series was to assess graft survivorship, subjective patient-reported outcomes, and satisfaction among 7 patients who underwent OCA transplantation of the humeral head. Methods: We identified 7 patients who underwent humeral head OCA transplantation between 2008 and 2017. A custom questionnaire including the American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDash), Likert satisfaction, and reoperations was mailed to each patient. Clinical failure was defined as further surgery that involved removal of the allograft. Results: Median follow-up duration was 10 years (range, 4.6 to 13.5 years) with a median age of 21.6 years (range, 18.5 to 43.5 years). Most patients (86%) reported improved function and reduced pain. At the final follow-up, 71% of patients reported ongoing problems with their shoulder including pain, stiffness, clicking/grinding, limited range of motion, and instability. Return to recreational activities was high at 86% but 43% expressed limitations with activity due to their shoulder. Overall satisfaction was high at 71% with mean American Shoulder and Elbow Surgeons and QuickDASH scores at 62.4 and 29.2, respectively. Reoperation after OCA occurred in 1 patient (14%). Conclusion: Among this case series of 7 patients who underwent OCA transplantation of the humeral head, patient satisfaction was high at 10-year follow-up and most returned to recreational activity although most also had persistent shoulder symptoms.

Subchondral Bone Alignment in Osteochondral Allograft Transplants for Large Oval Defects of the Medial Femoral Condyle: Comparison of Lateral versus Medial Femoral Condyle Donors.

OBJECTIVE: Supply-demand mismatch of medial femoral condyle (MFC) osteochondral allografts (OCAs) remains a rate-limiting factor in the treatment of osteochondral defects of the femoral condyle. Surface contour mapping was used to determine whether a contralateral lateral femoral condyle (LFC) versus ipsilateral MFC OCA differs in the alignment of donor:native subchondral bone for large osteochondral defects of the MFC. DESIGN: Thirty fresh-frozen human femoral condyles were matched by tibial width into 10 groups of 3 condyles (MFC recipient, MFC donor, and LFC donor) each for 3 cartilage surgeons (90 condyles). The recipient MFC was imaged using nano-computed tomography scan. Donor oval grafts were harvested from each matched condyle and transplanted into a 17 mm × 36 mm defect created in the recipient condyle. Following the first transplant, the recipient condyle was imaged and superimposed on the native condyle nano-CT scan. The donor plug was removed and the process repeated for the other donor. Surface height deviation and circumferential step-off height deviation were compared between native and donor subchondral bone surfaces for each transplant. RESULTS: There was no statistically significant difference in mean subchondral bone surface deviation (LFC = 0.87 mm, MFC = 0.76 mm, P = 0.07) nor circumferential step-off height (LFC = 0.93 mm, MFC = 0.85 mm, P = 0.09) between the LFC and MFC plugs. There were no significant differences in outcomes between surgeons. CONCLUSIONS: There were no significant differences in subchondral bone circumferential step-off or surface deviation between ipsilateral MFC and contralateral LFC oval-shaped OCAs for 17 mm × 36 mm defects of the MFC.

Outcomes After Osteochondral Allograft Transplantation of the Medial Femoral Condyle in Patients With Varus and Nonvarus Alignment.

BACKGROUND: Fresh osteochondral allograft (OCA) transplantation is an effective technique for the treatment of focal chondral and osteochondral defects in the knee. Coronal-plane malalignment leads to increased contact forces within a compartment and subsequently the cartilage repair site and may lead to higher failure rates. However, the magnitude of the effect of coronal-plane malalignment on graft survivorship and clinical outcomes has not been well characterized. PURPOSE: To evaluate how varus malalignment affects graft survival and patient-reported outcomes after isolated OCA transplantation of the medial femoral condyle (MFC). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 70 patients (74 knees) who underwent primary OCA transplantation of the MFC between 2005 and 2019 were identified from a prospectively collected single-surgeon cartilage registry with a minimum 2-year follow-up. Coronal-plane alignment was evaluated utilizing standing hip-to-ankle radiographs. OCA failure, defined as removal of the graft or conversion to arthroplasty, and reoperations were recorded. Patient-reported outcomes were obtained preoperatively and postoperatively using the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, modified Merle d'Aubigné-Postel score, and overall patient satisfaction score. RESULTS: The mean mechanical tibiofemoral angle for patients with varus alignment was 3.9° of varus (range, 1.1° to 8.9°) and for patients with nonvarus alignment it was 0.02° of valgus (range, 3.6° varus to 4.6° valgus). Graft survivorship was 95.3% in the varus group and 95.8% in the nonvarus group (P = .918) at 5 years postoperatively. Reoperations after OCA transplantation occurred in 14.0% of the varus group and 22.6% of the nonvarus group (P = .336). The mean International Knee Documentation Committee total score improved from 45.2 preoperatively to 74.8 at latest follow-up in the varus group and from 40.5 preoperatively to 72.3 at latest follow-up in the nonvarus group. Patient satisfaction was >85%. CONCLUSION: Patients undergoing isolated OCA transplantation of the MFC had high rates (>90%) of graft survivorship and significant improvements in pain and function. Patients with mild preexisting varus malalignment were found to have no difference in the failure rate or clinical outcomes compared with patients with nonvarus alignment.

Elevated Lipid Metabolites in Stored Clinical OCA Media Correlate With Chondrocyte Death.

BACKGROUND: A major limitation of osteochondral allografts (OCA) is the deterioration of cartilage health associated with cell death during prolonged storage. However, little is known about the mechanisms that contribute to chondrocyte death during storage. PURPOSE/HYPOTHESIS: This study aimed to determine whether bioactive lipid metabolites accumulate in the storage media of OCA and whether they are associated with a loss of chondrocyte viability during prolonged storage. It was hypothesized that free fatty acids (FFAs) would accumulate over time in the storage media of OCA and adversely affect cartilage health during storage. STUDY DESIGN: Controlled laboratory study. METHODS: A group of 21 (n = 6-8 OCA/treatment group) fresh human hemicondylar OCA tissues and media were analyzed after 7, 28, and 68 days of prolonged cold (4°C) storage. Targeted mass spectrometry analysis was used to quantify bioactive FFAs, as well as primary (lipid hydroperoxide [ROOH]) and secondary (malondialdehyde) lipid oxidation products. Chondrocyte viability was measured using a fluorescence-based live/dead assay and confocal microscopy. RESULTS: The concentration of all targeted fatty acid metabolites in storage media was significantly increased with increased cold storage time (P < .05). ROOH was significantly higher on day 28 of cold storage. No difference in secondary ROOH products in storage media was observed. Chondrocyte viability significantly declined in both the en face and the vertical cross-sectional analysis with increased cold storage time and inversely correlated with fatty acid metabolites (P < .05). CONCLUSION: It is well established that elevated levels of certain FFAs and lipid oxidation products can alter cell function and cause cell death via lipotoxicity and other mechanisms. This work is the first to identify elevated levels of FFA metabolites and primary oxidation lipid products in the storage media from clinical OCA. The concentrations of FFA metabolites were measured at levels (>100 µM) known to induce cell death and were directly correlated with chondrocyte viability. CLINICAL RELEVANCE: These findings provide important targets for understanding why cartilage health declines during cold storage, which can be used to optimize media formulations and improve graft health.

'On Table' Versus 'Off Table' Direct Anterior Approach Total Hip Arthroplasty: Is There a Difference?

Background: The purpose of this study was to evaluate whether there were differences in patient-reported outcomes, operative times, satisfaction scores, and complications between patients undergoing total hip arthroplasty (THA) performed through a direct anterior approach on a specialized traction table or a regular operating room table. Methods: Patients who underwent a direct anterior approach THA on a specialized table or a regular table with a minimum 1-year follow-up were included. Patient-reported outcome measures and THA satisfaction were recorded. Demographics, complications, and operative times (both in-room and surgical time) were evaluated. Three hundred twenty-two patients were included with 217 (67.4%) undergoing anterior THA on the specialized table and 105 (32.6%) on a regular table. Results: Outcome measures were similar at 4 months and 1 year postoperatively. Average operative time was 87 minutes (range, 50-160) and 90 minutes (range, 35-197) for the specialized table and regular table groups (P = .314). Average total in room time was 123 minutes (range, 87-201) and 120 minutes (range, 62-255) for the specialized table and regular table groups (P = .564). Satisfaction rates between groups did not differ (P = .564). No differences were found in complication rates at 4 months (P = .814) or 1 year (P = .547). Conclusions: This study shows that the direct anterior approach for THA can be safely and efficiently performed on either a specialized traction table or a regular table. Surgeons should continue to utilize the approach and set-up they are most comfortable with to achieve an optimal outcome for the patient.

PI3 kinase δ is a key regulator of synoviocyte function in rheumatoid arthritis.

Class I phosphoinositide 3 kinase (PI3K) δ is a promising therapeutic target for rheumatoid arthritis (RA) because of its contribution to leukocyte biology. However, its contribution in fibroblasts has not been studied as a mechanism that contributes to efficacy. We investigated the expression and function of PI3Kδ in synovium and cultured fibroblast-like synoviocytes (FLS). Immunohistochemistry demonstrated that PI3Kδ is highly expressed in RA synovium, especially in the synovial lining. Using quantitative PCR and Western blot analysis, we found that PI3Kδ mRNA and protein expression is higher in RA than in osteoarthritis (OA) synovium. PI3Kδ was also expressed in cultured FLS, along with PI3Kα and PI3Kß, whereas PI3Kγ was not detectable. PI3Kδ mRNA expression was selectively induced by inflammatory cytokines tumor necrosis factor (TNF) and interleukin-1 (IL-1) but not by growth factors platelet-derived growth factor (PDGF) and transforming growth factor ß (TGFß). The use of inhibitors that block individual PI3K isoforms, including the novel selective PI3Kδ inhibitor INK007, showed that PI3Kδ is required for PDGF- and TNF-induced Akt activation. PI3Kδ inhibition also diminished PDGF-mediated synoviocyte growth and sensitized cells to H(2)O(2)-induced apoptosis. These data are the first documentation of increased PI3Kδ expression in both RA synovium and cultured synoviocytes. Furthermore, these are the first data demonstrating that PI3Kδ is a major regulator of PDGF-mediated fibroblast growth and survival via Akt. Thus, targeting PI3Kδ in RA could modulate synoviocyte function via anti-inflammatory and disease-altering mechanisms.

Do fresh osteochondral allografts successfully treat femoral condyle lesions?

BACKGROUND: Fresh osteochondral allograft transplantation is an increasingly common treatment option for chondral and osteochondral lesions in the knee, but the long-term outcome is unknown. QUESTIONS/PURPOSES: We determined (1) pain and function, (2) frequency and types of reoperations, (3) survivorship at a median of 13.5 years, and (4) predictors of osteochondral allograft failure in the distal femur. METHODS: We evaluated 122 patients (129 knees) who underwent osteochondral allograft transplantation of the femoral condyle. Mean age was 33 years and 53% were male. Clinical evaluation included the modified Merle d'Aubigné-Postel (18-point), IKDC, and Knee Society function (KS-F) scores. We defined graft failure as revision osteochondral allografting or conversion to arthroplasty. We determined whether patient characteristics or attributes of the graft influenced failure. Minimum followup was 2.4 years (median, 13.5 years); 91% had more than 10 years of followup. RESULTS: Mean modified Merle d'Aubigné-Postel score improved from 12.1 to 16, mean IKDC pain score from 7.0 to 3.8, mean IKDC function score from 3.4 to 7.2, and mean KS-F score from 65.6 to 82.5. Sixty-one knees (47%) underwent reoperations. Thirty-one knees (24%) failed at a mean of 7.2 years. Survivorship was 82% at 10 years, 74% at 15 years, and 66% at 20 years. Age of more than 30 years at time of surgery and having two or more previous surgeries for the operated knee were associated with allograft failure. CONCLUSIONS: Followup of femoral condyle osteochondral allografting demonstrated durable improvement in pain and function, with graft survivorship of 82% at 10 years.

Osteochondral Allografts for Large Oval Defects of the Medial Femoral Condyle: A Comparison of Single Lateral Versus Medial Femoral Condyle Oval Grafts Versus 2 Overlapping Circular Grafts.

BACKGROUND: Studies have demonstrated the acceptability of using a contralateral nonorthotopic lateral femoral condyle (LFC) graft for a circular medial femoral condyle (MFC) osteochondral defect up to 20 to 25 mm in diameter. Larger oblong defects can now be managed using either overlapping circle grafts or a single oblong-shaped osteochondral allograft (OCA). PURPOSE: To determine if an oblong contralateral nonorthotopic LFC OCA can attain an acceptable surface contour match compared with an oblong ipsilateral MFC OCA or an overlapping circle technique for large oblong defects of the MFC. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 120 fresh-frozen human femoral condyles were matched by tibial width into 30 groups of 4 condyles (1 recipient MFC, 3 donor condyles). The recipient MFC was initially imaged using nano-computed tomography (nano-CT). A 17 × 36-mm oblong defect was created in the recipient MFC. Overall, 3 donor groups were formed: MFC oblong, LFC nonorthotopic oblong, LFC or MFC overlapping circles. After each transplant, the recipient condyle underwent nano-CT and was digitally reconstructed, which was superimposed on the initial nano-CT scan of the native recipient condyle. Dragonfly 3D software was used to determine the root mean square (RMS) of both the surface height deviation and the circumferential step-off height deviation between the native and donor cartilage surfaces for each graft. RESULTS: RMS surface height deviations were as follows: 0.59 mm for MFC oblong grafts, 0.58 mm for LFC oblong grafts, and 0.78 mm for overlapping circle grafts. The MFC and LFC oblong grafts had significantly less surface height deviation than the overlapping circle grafts (P = .004 and P = .002, respectively). RMS step-off height deviations were as follows: 0.68 mm for MFC oblong grafts, 0.70 mm for LFC oblong grafts, and 0.85 mm for overlapping circle grafts. The MFC and LFC oblong grafts had significantly less step-off height deviation than the overlapping circle grafts (P < .001 and P = .002, respectively). The majority of this difference was on the medial segment of the overlapping circle grafts. CONCLUSION: Oblong ipsilateral MFC OCAs and oblong contralateral nonorthotopic LFC OCAs produced a significantly better surface contour match to the native MFC than overlapping circle grafts for oblong defects 17 × 36 mm in size. CLINICAL RELEVANCE: Size-matched contralateral nonorthotopic LFC grafts are acceptable for MFC defects, which may allow for a quicker match, earlier patient care, and less wastage of valuable donor tissue.

Direct Anterior Approach to Total Hip Arthroplasty Improves the Likelihood of Return to Previous Recreational Activities Compared with Posterior Approach.

Total hip arthroplasty offers relief and functional improvement, with the rate of direct anterior approach (DAA) increasing compared with the posterior approach (PA). This study aimed to assess the effect of surgical approach on return to recreational activity after total hip arthroplasty. Total hip arthroplasty performed for primary or posttraumatic osteoarthritis were identified; 100 DAA patients were matched with 100 PA patients on age, sex, diagnosis, and surgical year. Patients were mailed a recreational activity survey, Harris Hip Function, and Hip disability and Osteoarthritis Outcome Score questionnaires. Two hundred surveys were mailed, 130 (65%) responded (66 DAA and 64 PA) and were included. The mean follow-up was 2.5 years for the DAA group and 2.3 years for the PA group (P = 0.256). Among DAA patients, 51% returned to activity within 6 months, compared with 44% of PA patients (P = 0.360). Among those who returned to activity, 71% in the DAA group tried their main presurgery sport, compared with 53% in the PA group (P = 0.019). Twenty-eight percent of DAA patients and 4% of PA patients reported the surgical approach influenced their return to activity (P = 0.001). Outcome scores were clinically similar between groups. Objective data did not favor one approach over the other.

Fresh Osteochondral and Chondral Allograft Preservation and Storage Media: A Systematic Review of the Literature.

BACKGROUND: Storage procedures and parameters have a significant influence on the health of fresh osteochondral allograft (OCA) cartilage. To date, there is a lack of agreement on the optimal storage conditions for OCAs. PURPOSE: To systematically review the literature on (1) experimental designs and reporting of key variables of ex vivo (laboratory) studies, (2) the effects of various storage solutions and conditions on cartilage health ex vivo, and (3) in vivo animal studies and human clinical studies evaluating the effect of fresh OCA storage on osteochondral repair and outcomes. STUDY DESIGN: Systematic review; Level of evidence, 5. METHODS: A systematic review was performed using the PubMed, Embase, and Cochrane databases. The inclusion criteria were laboratory studies (ex vivo) reporting cartilage health outcomes after prolonged storage (>3 days) of fresh osteochondral or chondral tissue explants and animal studies (in vivo) reporting outcomes of fresh OCA. The inclusion criteria for clinical studies were studies (>5 patients) that analyzed the relationship of storage time or chondrocyte viability at time of implantation to patient outcomes. Frozen, cryopreserved, decellularized, synthetic, or tissue-engineered grafts were excluded. RESULTS: A total of 55 peer-reviewed articles met the inclusion criteria. Ex vivo studies reported a spectrum of tissue sources and storage solutions and conditions, although the majority of studies lacked complete reporting of key variables, including storage solution formula and environmental conditions. The effect of various conditions (eg, temperature) and storage solutions on cartilage health were inconsistent. Although 60% of animal models suggest that storage time may influence outcomes and 80% indicate inferior outcomes with frozen OCA as compared with fresh OCA, 75% of clinical studies report no correlation between storage time and outcomes. CONCLUSION: Given the variability in experimental designs and lack of reporting across studies, it is still not possible to determine optimal storage conditions, although animal studies suggest that storage time and chondrocyte viability influence osteochondral repair outcomes. A list of recommendations was developed to encourage reporting of key variables, such as media formulation, environmental factors, and methodologies used. High-quality clinical data are needed to investigate the effects of storage and graft health on outcomes.

Are immediate postoperative X-Rays valuable in evaluating complications of primary total hip arthroplasty?

PURPOSE: This study aimed to investigate the complications of primary total hip arthroplasty based on immediate postoperative X-rays. The overall quality and cost of X-rays were assessed. METHODS: The institutional database was queried to identify all patients who underwent total hip arthroplasty in a single institution between January 1, 2018, and December 31, 2018. Immediate postoperative X-rays were reviewed to identify the complications such as periprosthetic fractures, dislocation, and fixation failure. The quality and cost of X-ray were assessed. The complications were categorized as "known" and "unknown" according to the intraoperative fluoroscopic results. RESULTS: A total of 518 total hip arthroplasties were included in this study. Based on intraoperative fluoroscopy, periprosthetic fractures were found in 10 (2%) THAs. Compared to the X-rays taken immediately after surgery, 9 periprosthetic fractures (recorded as "known") were found and 1 was not (recorded as "unknown"). There was no significant difference between intraoperative fluoroscopy and X-rays (P > 0.05). Of the 518 X-rays, 225 (43%) were of suboptimal quality. The cost of a single portable pelvic X-ray was $647. CONCLUSION: In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. The X-rays are often of suboptimal quality, have minimal clinical utility, and are less cost-effective.