Effectiveness and Safety of Transdermal Buprenorphine Versus Sustained-release Tramadol in Patients With Moderate to Severe Musculoskeletal Pain: An 8-Week, Randomized, Double-Blind, Double-Dummy, Multicenter, Active-controlled, Noninferiority Study.

OBJECTIVES: The aim of this noninferiority study was to investigate clinical effectiveness and safety of buprenorphine transdermal system (BTDS) in patients with moderate to severe musculoskeletal pain inadequately controlled with nonsteroidal anti-inflammatory drugs, compared with sustained-release tramadol tablets. MATERIALS AND METHODS: Eligible patients were randomized (1:1) to receive low-dose 7-day BTDS (5, 10, and 20 µg/h, maximum dosage of 20 µg/h) or sustained-release tramadol tablets (100 mg, maximum dosage of 400 mg/d) over an 8-week double-blind treatment period (3-week titration, 5-week maintenance). The primary endpoint was the difference in the visual analogue scale (VAS) pain scores from baseline to treatment completion. Noninferiority was assumed if the treatment difference on the VAS scale was within ±1.5 cm, this threshold indicating a clinically meaningful result. ClinicalTrials.gov identifier: NCT01476774. RESULTS: Two hundred eighty patients were randomized to BTDS (n=141) or to tramadol (n=139). Both treatments were associated with a significant reduction in pain by the end of the treatment. The least squares mean difference of the change from baseline in VAS scores between the BTDS and tramadol groups were 0.45 (95% confidence interval, -0.02 to 0.91), which was within the ±1.5 cm predefined threshold, indicating that the effectiveness of BTDS was not inferior to the effectiveness of sustained-release tramadol tablets. The incidence of adverse events was comparable between the 2 treatment groups. CONCLUSIONS: Our results suggest that BTDS is a good therapeutic option for patients experiencing chronic musculoskeletal pain of moderate to severe intensity that is insufficiently controlled by nonsteroidal anti-inflammatory drugs.

[Expression of cadherin-11 in rheumatoid arthritis synovium and its correlation with inflammation].

OBJECTIVE: To explore the pattern of cadherin-11 expression and its relationship with synovial inflammation in rheumatoid arthritis (RA), and study the regulatory effects of cytokines on cadherin-11 expression on RA fibroblast-like synoviocytes (RAFLS). METHODS: Synovium samples were obtained from 28 RA patients who were undergoing total knee replacement. After HE staining, synovitis score was determined according to Rooney's inflammation score system. The expression of cadherin-11 in RA synovium was semi-quantified by immunohistochemical staining, and its correlations with Rooney's inflammation score and systematic inflammatory markers were analyzed statistically. After induction with transforming growth factor ß (TGF-ß) or interleukin 17 (IL-17) at a series of concentrations, the expression of cadherin-11 on RAFLS was assessed by real time guantitative-PCR and Western blotting. RESULTS: There was no significant difference in cadherin-11 expression in RA synovium among different levels of C-reactive protein. Cadherin-11 in the lining and sublining layers were positively correlated with D-dimer, synovial lining layer hyperplasia, proliferating blood vessels, perivascular infiltration of lymphocytes, focal aggregation of lymphocytes and diffuse infiltration of lymphocytes; cadherin-11 in the lining layer was negatively correlated with interstitial fibrosis. TGF-ß or IL-17 stimulation could up-regulate cadherin-11 expression on RAFLS at mRNA and protein levels. CONCLUSION: The over-expression of cadherin-11 in RA was correlated with synovial lining layer hyperplasia, proliferating blood vessels and infiltration of lymphocytes. Cadherin-11 expression on RAFLS could be induced by TGF-ß and IL-17 induction.

[Clinical significance of arthritis treatment guidelines revealed by outpatients prescriptions].

OBJECTIVE: To investigate the current status of osteoarthritis medications of outpatients for arthritis treatment guidelines, and provide references for the promotion and popularization of traditional Chinese and western medicine in treatment of arthritis. METHODS: The outpatient prescriptions for the treatment of osteoarthritis from all the rheumatology and orthopedics specialists from 2007 February to May in Peking University People's Hospital were chosen and analyzed statistically. RESULTS: There were a total of 2 145 osteoarthritis prescription in this study, including 8 categories: joint lubricants, non-steroid anti-inflammatory drugs (NSAIDs), local anesthetics, cartilage protective agent, adrenal corticosteroids, vitamin AD, analgesic drugs and traditional Chinese medicine. The Chinese medicines were among the drugs with the most species amounted up to 35. The most common route of medication was oral administration (73.2%), which was used more in the department of rheumatology and immunology than in orthopedics. And in oral drugs, the biggest consumption was NSAIDs, accounting for 29.9%. There was no significantly difference between the rheumatology and orthopedic specialists when using non-specific cyclooxygenase (COX) inhibitors. But orthopedic specialists prescribed more COX-1 specific inhibitor than rheumatology specialists. CONCLUSION: Recently the arthritis treatment guidelines have been issued one after another. Many experts have already accepted the treatment of pain. However, in the implementation, the large differences still exist. The use of the Chinese medicine is still very chaotic; there are no clear-cut norms to be followed. Therefore, the implementation of the arthritis treatment guidelines and treatments of arthritis by traditional Chinese medicine are urgent to be standardized.

LTB4 can stimulate human osteoclast differentiation dependent of RANKL.

Our previous study showed that Leukotriene B4 can directly stimulate osteoclast differentiation independent of RANKL. In order to determine whether Leukotriene B4 could indirectly stimulate human osteoclast differentiation through increasing RANKL expression of rheumatoid arthritis fibroblast-like synoviocytes, we utilize the coculture model of rheumatoid arthritis fibroblast-like synoviocytes and monocyte, which were stimulated in the presence of 2.5 ng/ml M-CSF in the control group, 2.5 ng/ml M-CSF+10(-8)M LTB4 in the experimental group a, and 2.5 ng/ml M-CSF+10(-8)M LTB4+100 ng/ml OPG in the experimental group b. After culture for 3 weeks, the number of multinucleated TRAP staining positive osteoclast-like cells stained with TRAP was counted to evaluate the differentiation effect in each group. There was almost no osteoclast-like cell in the control group and the experimental group b. There were many osteoclast-like cells in the experimental group a. These results indicated that Leukotriene B4 is capable of inducing osteoclast differentiation by a RANKL-dependent mechanism.

[Mid-term therapeutic effect analysis of cementless total knee arthroplasty without patella replacement].

OBJECTIVE: To explore the flexibility and reliability of cementless total knee arthroplasty (TKA) without patella replacement through a retrospective study of the mid-term therapeutic effect of the treatment of the patients. METHODS: From June 1997 to March 2000, a consecutive series of 152 (152 knees) cementless TKA performed in Hessing-Stiftung was studied. Among them, there were 63 males and 89 females, with 70 left knees and 82 right knees. Their ages ranged from 51 years to 72 years, with an average of 59 years. There were 146 cases of osteoarthritis and 6 cases of traumatic arthritis. The course of the disease lasted for 1.0 years to 3.5 years. The EFK prostheses of German Plus company were used in all the cases. The HSS score before the operation was 41.5 +/- 12.3, and the average range of motion was 55 degrees (ranging from 30 degrees to 90 degrees). RESULTS: Five patients underwent anterior knee pain, and the pain was released after the appropriate treatment. No deep infection happened in all cases. A total of 145 patients (145 knees) were followed up for 5 years to 8 years. The HSS score was 87.5 +/- 8.2 at the end of the follow-up, showing significant difference (P < 0.05). The average range of motion was 95 degrees (ranging from 90 degrees to 110 degrees). Partial radiolucencies occurred at the tibia side in 18 knees 3 to 6 months after the operation. Among them, the width was less than 2 mm in 15 knees without symptom, and more than 2 mm in 3 knees. There were 2 of the 3 knees which were revised at the tibia side because of the aseptic loosing, while 1 patient had only mild pain in the knee during the follow-up, with no sign of loosing. CONCLUSION: The mid-term effect of cementless TKA is satisfactory. The ingrowth of femur and tibial bones is reliable. The early stage migration of the component is the main reason of loosing. Satisfying outcomes can also be achieved without patella replacement during TKA.

[One-stage revision operations for infection after hip arthroplasty].

OBJECTIVE: To disscuss the therapeutic method of the postoperative infection after hip arthroplasty and compare the results of one-stage revision and two-stage revision. METHODS: From January 1999 to December 2005, 15 cases of infection after hip arthroplasty were treated, including 10 males and 5 females, with a mean age of 63 years (54-71 years). The locations were left hip in 8 cases and right hip in 7 cases. The first operation was hip prosthesis replacement in 6 cases and tatol hip arthroplasty in 9 cases. Infection occurred after 1 month in 6 cases and after 6 months in 9 cases. The preoperative temperature and ruting blood test were normal, the mean erythrocyte sedimentation rate (ESR) was 61 mm/h (34-80 mm/h), mean C-reactive protein (CRP) was 11.7 mg/L (5.4-21.0 mg/L). The mean Harris score was 33 (25-40). The X-ray films showed that periosteal reaction, osteolysis and loosening of prosthesis occurred. The time from the first operation to revision operation was 1-41 months (mean 7.3 months). The results of bacterial culture were positive in 11 cases. One-stage revision was performed in 10 cases, two-stage revision was performed in 5 cases. RESULTS: Of 15 cases, 6 were classified as early postoperative infection, 9 cases as late chonic infection. The microorganism cultures results of joint aspiration or pus in sinus were positive in 11 cases and negative in 4 cases before operation and during operation; 8 had staphylococcus epidermids infection, 2 escherichia coli infection and 1 staphylococcus aureus infection. Incision of revision operation healed by first intention. No re-infection, swelling and tenderness occurred after 19 months (12-37 months) of follow-up. Pain of hip joint disappeared in 14 cases, and only 1 case had mild pain when walking. ESR and CRP after operation decreased to normal range. The mean Harris score increased significantly to 84.2 (79-92) after revision, showing significant difference when compared with that before operation (P < 0.05). CONCLUSION: For postoperative infection after total hip arthroplasty, it is still possible to have satisfactory clinical outcome by one-stage or two-stage revision as long as clear diaglosis and correct treatment can made.

[Influence of closed-box and open-box knee prosthesis on postoperative blood loss in patients undergoing total knee replacement].

OBJECTIVE: To study the influence of close-box and open-box knee prosthesis on postoperative blood loss in patients undergoing total knee replacement (TKR). METHODS: From June 2005 to December 2006, 108 patients with primary knee osteoarthritis were treated with TKR. Closed-box knee prosthesis was used in 54 patients (Group A), including unilateral (Group A1, n=27) and bilateral (Group A2, n=27). There were 7 males and 47 females, aged 41-76 years; and the disease course was 4-16 years. Open-box knee prosthesis was used in 54 patients (Group B), including unilateral (Group B1, n=27) and bilateral (Group B2, n=27). There were 8 males and 46 females, aged from 59-81 years; and the disease course was 8-26 years. The postoperative blood loss and perioperative blood loss were compared between groups. RESULTS: The postoperative blood loss was (890+/-352), (1,694-/+528), (1,068+/-386) and(2,065+/-622) mL in groups A1, A2, B1 and B2, respectively. There was no significant difference between groups A1 and B1 (P>0.05). There was significant difference between groups A2 and B2 (P<0.05). The total blood loss was (1,095+/-329), (2,082+/-594), (1,274+/-415) and (2,459+/-734) mL in groups A1, A2, B1 and B2, respectively. There was no significant difference between groups A1 and B1 (P>0.05). There was significant difference between groups A2 and B2 (P< 0.05). CONCLUSION: Closed-box knee prosthesis may play roles on reducing postoperative blood loss. The main influential factor for postoperative blood loss is operation techniques which includes reducing operation time and stanching thoroughly during operation.

Research on coagulation of unwashed shed blood after total knee replacement in Chinese patients.

To evaluate quality of unwashed but filtered wound shed blood through ConstaVac blood conservation system (Stryker Company) after total knee replacement, we selected 30 patients who underwent total knee replacement consecutively from July 2003 to July 2004 and received retransfusion of wound shed blood. Pre- and postoperative coagulative factors of peripheral vein blood and wound shed blood were measured, such as fibrinogen, AT-III, D-dimer, plasminogen, and PT, APTT were also measured. No clinical evidence of coagulation and DIC appeared in these patients. There is significant change of coagulative factors in unwashed but filtered wound shed blood and it may cause a potential risk of coagulopathy to retransfuse wound shed blood, but retransfusion of unwashed but filtered shed blood appeared to be relative safe clinically.

[Rotational landmarks and total knee arthroplasty in osteoarthritic knees].

OBJECTIVE: To investigate the rotational mismatch of total knee replacement with medial 1/3 of tibial tuberosity as bony landmark in osteoarthritic patients with varus or valgus deformity. METHODS: Axial images on computed tomography of 62 knees (including 55 varus deformities and 7 valgus deformities) in 32 Chinese osteoarthritic patients who had total knee arthroplasty were analyzed, compared with that of 10 healthy knees. On images of the distal femur, the angle between the lines of surgical epicondylar axis (SEA) and posterior condylar axis was measured as posterior condylar angle (PCA), and on images of the proximal tibia, a baseline for the anteriorposterior axis of each component was drawn based on the SEA for the femur and the medial 1/3 of the tibial tuberosity for the tibia. The angle between these lines (Angle a) was defined as the rotational mismatch between the components when they were aligned to the anatomic landmarks of each bone. RESULTS: The sulcus of medial epicondyle of femur could be identified on CT images of over 80% osteoarthritic knees; the median value of PCA was +2.36 degrees, with an individual variation of 0 degree to +7.5 degrees. Angle a was +6.45 +/- 3.68 degrees (range, 0 degree to +11.8 degrees) in 10 healthy knees, which increased significantly to +10.85 +/- 10.47 degrees (range, 0 degree to +28.1 degrees) in 55 varus knees (P < 0.05), which also increased significantly to +11.6 +/- 7.3 degrees (range, -6.5 degrees to +26.8 degrees) in 7 valgus knees (P < 0.05). CONCLUSION: With the medial 1/3 of the tibial tuberosity as the rotational landmark for the tibial component, there was a tendency to align the tibial component in external rotational position relative to the femoral component in knees with normal alignment, the rotational mismatch increased in Chinese osteoarthritic knees with varus and valgus deformity.

[Bioabsorbable interference screw for ligament reconstructions in the knee].

OBJECTIVE: To evaluate the clinical results of bioabsorbable interference screw in knee ligament reconstruction. METHODS: From April 2002 to August 2004, 39 patients with knee ligament injury were treated, including 33 males and 6 females with a median age of 25 years (15 to 65 years). The involved ligament included 29 anterior cruciate ligament of knee (ACL), 6 posterior cruciate ligament of knee (PCL), 4 combined ACL and PCL, 3 medial collateral or lateral collateral ligaments of knee point and 1 posterolateral complex injury of knee. All of patients underwent anatomic ligament reconstructions under arthroscopy or open surgery by autografts and fixation with bioabsorbable interference screw. RESULTS: All 34 patients were followed up 6 to 28 months (mean 13.7 months). The patients were evaluated by Lysholm knee functional scales, the knee scores were 43.6 +/- 13.4 before operation and 85.4 +/- 16.3 after operation, showing significant difference (P < 0.05). There was no limitation of range of motion and loosening of the screw. However, one case suffered from infection, and 3 cases suffered from effusion and synovitis after surgery and recovered after management. CONCLUSION: Bioabsorbable interference screw fixation is a reliable method in knee ligament reconstruction and is effective to restore knee joint stability.

[Quantification of expression of leukotriene B4 inducing tumor necrosis factor-alpha and interleukin-1beta at mRNA level in synovial membrane cells of rheumatoid arthritis by real-time quantitative PCR].

OBJECTIVE: To investigate quantification of expression of LTB4 inducing IL-1beta and TNF-alpha at mRNA level in synovial membrane cells of rheumatoid arthritis. METHODS: Primary cultured synovial cells from RA patients were treated with exogenous LTB4, MK-886 (inhibitor of 5-lipoxygenase activating protein) and Bestatin(inhibitor of leukotriene A4 hydrolase) in the presence of LIT respectively, expressions of TNF-alpha and IL-1beta were detected at mRNA level by Real-time Quantitative PCR. RESULTS: Expressions of basic TNF-alpha (TNF-alpha/GAPDH) and IL-beta (IL-beta/GAPDH) at mRNA level in primary cultured synovial cells were 0.02 +/- 0.00 and 0.16 +/- 0.01 respectively. LTB4 (10(-9) mol/L-10(-8) mol/L) was shown to induce dose-dependent increase of mRNA expression of TNF-alpha. (7-15 times) and IL-1beta (1 time) , endogenous product of LTB4 by LIT significantly increased mRNA expressions of TNF-alpha (145 times) and IL-1beta (12 times) respectively. LIT-treated synoviocytes with addition of MK-886 (5-LOX exciting protein FLAP inhibitor) (1-10 micromol/L) were inhibited to secrete LTB4 dose-dependently, following the markedly down-regulated expressions of TNF-alpha (15%-66%) and IL-1beta (41%-71%) at mRNA level . Bestatin(100 mg/L) could also remarkably diminish LTB4-induced mRNA expressions of TNF-alpha(86%) and IL-1beta (79%). CONCLUSION: LTB4 of synovial membrance cells in rheumatoid arthritis could induce expressions of TNF-alpha and IL-1beta at mRNA level, and their expression at mRNA level had been quantified successfully. It is a beneficial help to quantify all kinds of cytokines in methodology.

[Analysis of short-term results of post total knee arthroplasty using TC-Dynamic posterior stabilized prostheses].

OBJECTIVE: To assess the feasibility, safety, and validity of the TC-Dynamic posterior stabilized prostheses implanted in the total knee arthroplasty (TKA). METHODS: Twelve knees of 10 patients (the TC-Dynamic group) were followed up, who had been implanted with the TC-Dynamic posterior stabilized prostheses from September 2003 to March 2004. Preoperative KSS knee scores were 16.08 +/- 11.58, function scores 13.75 +/- 19.79, and the range of motion (ROM) of the knee 75.00 +/- 26.46 degrees. Meanwhile, 50 knees of 30 patients (the Scorpio group) were followed up, who had undergone TKA with the Scorpio posterior stabilized prostheses. Preoperative KSS knee scores were 19.48 +/- 9.67, function scores 3.16 +/- 19.82, and the ROM of the knee 80.80 +/- 22.82 degrees. The anteroposterior and lateral X-ray films of each knee were examined before and after operation. The statistical Z-test was used to analyze the differences between the 2 groups in the improvement of the KSS knee scores, function scores, and ROM after operation. RESULTS: The average of the 130 days' follow-up revealed that the patients implanted with the TC-Dynamic prostheses had an excellent result. In the TC-Dynamic group, the KSS knee scores were 88.83 +/- 4.04 with improved scores of 72.75 +/- 14.47 compared with those before operation; function scores were 79.17 +/- 5.15 with improved scores of 65.42 +/- 19.47; the ROM of the knee was 107.92 +/- 11.57 degrees with increased degrees of 32.92 +/- 32.22 degrees. Meanwhile, in the Scorpio group, the KSS knee scores were 85.68 +/- 7.36 with improved scores of 66.20 +/- 10.44 compared with those before operation; function scores were 71.40 +/- 12.70 with improved scores of 68.24 +/- 25.35; the ROM of the knee was 109.20 +/- 11.13 degrees with increased degrees of 28.40 +/- 26.41 degrees. There was no significant difference in the improvement of the KSS knee scores, function scores, and ROM after operation between the 2 groups (P > 0.01). All the X-ray films of the knees implanted with both the Scorpio prostheses and the TC-Dynamic prostheses were analyzed. No mal-alignment or lucent line with the prostheses was seen in all these X-ray films. CONCLUSION: The short-term follow-up indicates that the patients implanted with the TC-Dynamic prostheses have an excellent result. The TC-Dynamic prostheses with a scientific and proper design is more suitable for the Chinese. However, the long-term outcome of the patients implanted with the TC-Dynamic prostheses should be observed in a larger number of TKA operations. The basic surgical principles, including excision of both the cruciate ligaments and correction of the bone deformity with the proper balancing of the soft tissues in flexion and extension, are still crucial to successful TKA and to the long-term high survival rate of the knee prostheses.

[Relationship between anatomy of knee collateral ligament and geometry of posterior femoral condylar articular surface].

OBJECTIVE: To analyze the relationship between the collateral ligament attachment and the epicondylar axis with rotational alignment of the femoral component in the total knee arthroplasty(TKA). METHODS: Twenty normal cadaver knee joints were anatomized and 2 holes were drilled on the distal femur from the deep and superficial insertions of the medial collateral ligaments to the lateral condylar part, respectively. Then, all the knees were scanned by MRI on the sagittal plane, making the drilled hole located relatively to the posterior condylar joint surface on the axial plane, and the posterior condylar angle (PCA) and the condylar twist angle (CTA) were measured. RESULTS: The collateral ligament had the deep and superficial parts, and the deep part was strained during the knee flexing. PCA and CTA were 4.50 +/- 1.26 degrees and 7.10 +/- 0.30 degrees respectively, and there was a significant difference between them (P < 0.05), which were significantly greater than those reported abroad. On the sagittal plane, there was no significant difference between the radius of the posterior medial and lateral condylar circles (P > 0.05). The distance from the center of the posterior condylar circle to the deep insertion of the medial collateral ligament (MCL) (dl) was 4.22 +/- 0.20 mm, and the distance to the superficial insertion of MCL (d2) was 7.36 +/- 0.13 mm. The difference between dl and d2 was significant (P < 0.05). CONCLUSION: The center of the posterior condylar circle passes from the deep insertion of the collateral ligament, which can be regarded as a fixed flexion-extension axis of the knee. By releasing the different parts of the collateral ligaments, the balance of the flexion and extension gap can be obtained, and then varus, valgus or flexed contracture deformity of the knee can be realigned. Besides, the rotational orientation of the femoral prosthesis can be made by a reference to the epicondylar insertion of the collateral ligament.

[Early clinical outcome of total knee arthroplasty for flexion-contracture deformity knees of different degrees].

OBJECTIVE: To make a retrospective analysis on an early clinical outcome of total knee arthroplasty (TKA) for the knees with different degrees of flexion-contracture deformities. METHODS: Ninety-seven knees of 65 patients undergoing total knee arthroplasty with the Scorpion posterior-stabilized knee prosthesis from January 2000 to December 2003 were reviewed, including 51 osteoarthritis patients (74 knees) and 14 rheumatoid arthritis patients (23 knees). Thirty-three patients underwent unilateral TKA, and 32 patients underwent bilateral TKA. The average range of motion (ROM) before operation was 82.8 degrees (range, 5-140 degrees). According to the preoperative flexion-contracture degrees of the knees, these patients were divided into 2 groups, group A and group B. Group A consisted of the patients with flexion-contracture less than 20 degrees (range, 0-15 degrees), and group B consisted of the patients with flexion-contracture not less than 20 degrees (range, 20-60 degrees). In group A, the average flexion-contracture degree, ROM, KSS (knee society score), and function score were 10.7 +/- 8.0 degrees, 104.6 +/- 20.0 degrees, 29.1 +/- 18.0, and 32.6 +/- 20.7, respectively. But the corresponding data were much worse in group B than in group A, which were 28.2 +/- 7.8 degrees, 60.8 +/- 26.6 degrees, 12.1 +/- 13.2, and 26.8 +/- 18.1. All the operations were primary total knee arthroplasty, and they were performed by the same group of surgeons. The time for the prosthesis installed lasted for 25.6 minutes, and the average tourniquet time was 34.7 minutes. Three or four days after operation, the patients began the continuous passive motion (CPM) and active functional exercise of the knee. RESULTS: The patients were followed up for an average of 2 years and 7 months(range, 8 mon-3.5 yr). During the follow-up period, the average flexion-contracture degree, ROM, KSS, and function score in group A were 0.4 +/- 2.1 degrees, 108.6 +/- 19.0 degrees, 82.1 +/- 13.8, and 72.3 +/- 29.1, respectively; and the corresponding data in group B were 1.3 +/- 3.2 degrees, 98.6 +/- 16.40, 75.9 +/- 8.2, and 81.4 +/- 26.9, respectively. There was no significant difference between the 2 groups. No revision or deep infection was found. CONCLUSION: The curative effect is mainly determined by the surgeon's good operational skills, rich clinical experience, and familiarity with the prosthesis, and it is not influenced by severity of the knee flexion-contracture deformity. The knee ROM after TKA, which has a "toward middle ROM" phenomenon, is influenced by many clinical factors. It is very important for the patient to perform a functional exercise of the knee as early as possible after operation.

[Techniques of soft tissue balance in total knee arthroplasty of varus knee].

OBJECTIVE: To analyze formation of the varus angle of the knee due to osteoarthritis and to explore techniques of the soft tissue balance in the total knee arthroplasty(TKA). METHODS: One hundred patients with 145 varus knees (18 males, 25 varus knees; 82 females, 120 varus knees) underwent TKA from January 1999 to December 2003. Their ages averaged 62.4 years (range, 45-80 years), and their HSS(hospital of special surgery)scores were 38.0 +/- 3.2 points. Before operation,all the patients were measured in the alignment of the lower extremity, accurate bone-cutting was performed, and their static alignment was achieved. Then, the soft tissue release was made. The release performance consisted of 3 steps: release before the bone-cutting, release during the bone-cutting, and release after the bone-cutting. Release of the medial ligament and capsule, elimination of the osteophytes, and release of the lateral patellar retinaculum were more important. RESULTS: The varus angles in these patients were 9.2 +/- 3.1 degrees before operation. Among them, the varus angles caused by the soft tissue imbalance accounted for 53.2%, and caused by the bone structure accounted for 46.8%; and the latter caused by the tibia varus, 22.8%, and by the tibia plateau destruction, 24.0%. There was no significant difference between the varus angles caused by the soft tissue imbalance and the varus angles caused by the bone structure deformity (P > 0.05). According to the postoperative imaging studies, the correction degree for the varus angles by the bone-cutting was 4.3 degrees, which represented 27.9% of the total corrected angles, and the correction degree for the varus angles corrected by the soft tissue balance was 10.7 degrees, which represented 72.1% of the total corrected angles. The HSS scores were 87.0 +/- 4.5 points after operation, and the difference between preoperation and postoperation was significant. CONCLUSION: The varus knee due to osteoarthritis results from the varus angle in the bone structure and the angles caused by the imbalance of the collateral ligaments and the soft tissues around the knee. The latter causative factor is more important in the formation of the varus knee and should only be corrected through the soft tissue release. The more important part to be released is the attachments of the medial ligament and the posterior capsule. The release performance should be followed by the principles, i.e., step by step, tests at all the time, and avoidance of the excessive release.

LTB4 can directly stimulate human osteoclast formation from PBMC independent of RANKL.

Leukotriene B4, as a kind of 5-lipoxygenase metabolite of arachidonic acid, is known to influence osteoclast formation and bone resorption. In order to determine whether Leukotriene B4 could directly stimulate human osteoclast differentiation and activation independent of RANKL (ODF), three different concentrations of Leukotriene B4 (10(-9)M, 10(-8)M, 10(-7)M) were added to the culture of CD14+ monocyte fraction of peripheral blood mononuclear cell (PBMC) in the presence of macrophage colony-stimulating factor (M-CSF). Under these conditions, Leukotriene B4 could induce multinucleated cells, which were positive for Tartrate-resistant acidic phosphatase (TRAP) staining and capable of bone resorption. Addition of osteoprotegerin (OPG) to PBMC cultures does not abrogate osteoclast formation induced by LTB4. Osteoclastogenesis induced by Leukotriene B4 were dose-dependently increased and weaker than that of RANKL. These results indicated that Leukotriene B4, elevated in many inflammatory diseases, is directly capable of inducing osteoclast formation by a RANKL-independent mechanism.