Krüppel-like factor 4 promotes the proliferation and osteogenic differentiation of BMSCs through SOX2/IGF2 pathway.

OBJECTIVES: Human bone marrow mesenchymal stem cells (BMSCs) have multi-lineage differentiation potential and have been widely researched in regenerative medicine. The purpose of this research was to explore whether Krüppel-like factor 4 (KLF4) can regulate the osteogenic differentiation of BMSCs. METHODS: We transfected human BMSCs with KLF4 overexpression plasmid and si-KLF4 to study the effects of KLF4. We performed cell proliferation assay, flow cytometry and Alizarin Red staining on BMSCs. Quantitative real-time PCR and western blot was performed to determined mRNA and protein expression of osteogenic differentiation markers, KLF4, SOX2 and IGF2. Bone defect animal model was created and the adenovirus containing KLF4 overexpression or knockdown plasmid was injected. Finally, HE staining was performed on tibia to assess the new bone formation. RESULTS: Our results showed that KLF4 promotes not only the growth of BMSCs, but also their osteogenic differentiation. Also, it mediated these effects through SOX2/IGF2 signaling pathway. In addition, KLF4 overexpression could increase the bone regeneration in in-vivo model, whereas KLF4 knockdown decreased the bone regeneration. CONCLUSIONS: KLF4 regulates BMSC's osteogenic differentiation via SOX2/IGF2 pathway.

Posterior Locking Plate Fixation of Bartonícek Type IV Posterior Malleolar Fracture: A Focus on Die-Punch Fragment Size.

Die-punch fragments refer to articular cartilage and subchondral bone embedded in cancellous bone as part of an intra-articular fracture. Bartonícek type IV posterior malleolar fractures with associated die-punch fragments are rare, and the appropriate surgical approach remains unclear. We determined outcomes, and the effect of die-punch fragment size on outcomes, for 32 patients with Bartonícek type IV posterior malleolar fractures with die-punch fragments between January 2015 and December 2017. Mean follow-up for all patients was 23.8 (range 20.0-30.0) months. At the final follow-up visit, mean ankle dorsal extension was 24.6° and plantar flexion was 40.0°; American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 88.6 ± 4.3; visual analog scale weightbearing pain score was 1.5 ± 0.6; and Bargon traumatic arthritis score was 0.8 ± 0.4. There were no severe complications. We divided patients into a small-fragment (≤3 mm) group (n = 12) and large-fragment (>3 mm) group (n = 20). The Bargon scores at final follow-up were 0.5 and 1, respectively (P=.02). There were no statistically significant differences between the 2 groups for the other outcome scores at various time intervals. The posterolateral approach with distal locking plate internal fixation for Bartonícek type IV posterior malleolar fractures with die-punch fragments can result in excellent anatomical reduction of the collapsed articular surface and the displaced fragment from the tibial plafond, recovery of articular surface congruity, and maintenance of joint stability. Die-punch fragment size may not impact clinical and functional outcomes but may contribute to post-traumatic arthritis.

The CT morphological characteristics and the clinical management strategy of posterior malleolar fractures with talar subluxation.

BACKGROUND: The optimal clinical treatment and the computed tomography (CT) morphological characteristics of posterior malleolar fractures (PMF) with talar subluxation remain inconclusive. Clinically, both plate screws and lag screws are widely used to fix posterior malleolar fragments using a direct or indirect approach. We sought to summarize the morphological characteristics and modified classification on the basis of CT and the intraoperative strategy for posterior talar subluxation in PMF. METHODS: Retrospectively, 46 adult PMF patients with subluxations of the talus were recruited as the study cohort. According to its morphological features, PMF with subluxation of the talus can be divided mainly into two types using this modified classification: a complete fracture (the single-fragment type) and PMF with two-angled fracture fragments (the double-fragment type). The cohort's demographic information, classifications, fracture morphology, fixation methods, pain levels, and functional scores were recorded for both fracture types. RESULTS: The average values of the depths and heights of the posterior malleolar fragments were (29.1±7.3) mm for the single-fragment type and (17.9±4.2) mm for the double-fragment type. There was a significant difference in the mean values between the two types (P < 0.05). Posterior plate fixation was suitable for the single-fragment type, while antero-posterior and postero-anterior (AP-PA) lag screws fixations were made available for the double-fragment type. Both methods achieved good results. No significant differences were found in terms of sex, age, body mass index (BMI), side, Haraguchi classification, Bartonícek and Rammelt classification, Visual Analog Scale (VAS) scores, or American Orthopedic Foot & Ankle Society scores (AOFAS) when comparing the single-/double-fragment type groups after the mid-term follow-up (P > 0.05). CONCLUSION: According to the injury mechanism and the morphological characteristics of the fractures, the proposed improved classification system for PMF with subluxation of the talus based on the injury mechanism and the fracture morphology can provide guidance for surgical management strategies and achieve optimal outcomes.

Treatment of nonunion after femoral neck fracture with valgus intertrochanteric osteotomy: a case report with 18-year follow-up.

We herein report the long-term effect of valgus intertrochanteric osteotomy for nonunion after femoral neck fracture. In this report, we describe our experience using valgus intertrochanteric osteotomy to treat nonunion after femoral neck fracture in a 20-year-old woman. The patient was discharged from the hospital 10 days after the operation, the internal fixation device was removed 1 year after the operation, and the patient was then followed up for 18 years. Valgus intertrochanteric osteotomy can effectively treat nonunion after adductive femoral neck fracture.

Efficacy and safety of local infiltration analgesia for pain management in total knee and hip arthroplasty: A meta-analysis of randomized controlled trial.

BACKGROUND: Local infiltration analgesia (LIA) has become popular in postoperative pain relief after total hip arthroplasty (THA) or total knee arthroplasty (TKA). The aim of this meta-analysis was to compare the efficacy and safety of LIA with intrathecal morphine and epidural analgesia after THA and TKA. METHODS: A systematic article search was performed from PubMed, Embase, and Web of Science databases, up to February 21, 2019. The main outcomes included visual analog scale for assessment of pain, morphine equivalent consumption, length of hospital stay, and adverse events. The data were calculated using weight mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (95% CIs). RESULTS: Eleven studies with a total of 707 patients met the inclusion criteria and were included in this meta-analysis. LIA provided better pain control than other 2 techniques at 24-hour (WMD = 10.61, 95% CI: 3.36-17.87; P = .004), 48-hour (WMD = 16.0, 95% CI: 8.87-23.13; P < .001), and 72-hour (WMD = 11.31, 95% CI: 3.78-18.83; P < .001). Moreover, LIA had similar morphine consumption and duration of hospital stay with intrathecal morphine and epidural analgesia. There was significantly lower incidence of adverse events with LIA than with the other 2 techniques. CONCLUSION: LIA provided better postoperative pain control and less adverse events than intrathecal morphine and epidural analgesia after THA and TKA.

Risk Factors for Surgical Site Infection After Spinal Surgery: A Systematic Review and Meta-Analysis Based on Twenty-Seven Studies.

BACKGROUND: The present meta-analysis was conducted to explore and identify the risk factors for surgical site infection (SSI) after spinal surgery based on qualified studies and to gain insight into the management of SSI among patients undergoing spinal surgery. METHODS: We searched the following electronic databases, PubMed, the Cochrane Library, and the Embase database, updated to May 2018, to identify eligible studies according to the index words with associated publications. The odds ratios and 95% confidence intervals were used to analyze the main outcomes. RESULTS: We found 27 studies with a total of 2175 patients in the SSI group and 41,536 patients in the control group for the present meta-analysis. The pooled results revealed that the risk factors for SSI included diabetes, obesity, hypertension, ≥3 hours operative time, and transfusion. In addition, no significant association was found between SSI and the following risk factors: female gender, age >60 years, smoking habit, bone autograft, bone allograft, prophylactic antibiotics, and steroid therapy. CONCLUSIONS: Our findings provide evidence that diabetes, obesity (body mass index >30 kg/m2), hypertension, ≥3 hours operative time, and transfusion have a strong association with a remarkable increase in the risk of SSI after spinal surgery. In conclusion, more high-quality trials with larger sample sizes and long-term randomized controlled trials are warranted to confirm the risk factors for SSI among patients undergoing spinal surgery.