Reconstruction of the medial patellofemoral ligament through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation.

PURPOSE: The present study aimed to assess the clinical efficacy and imaging results of reconstruction of the medial patellofemoral ligament through a double bundle of single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation. METHODS: Twenty-three patients with recurrent patellar dislocation, including ten males and 13 females, with 23 knee joints were enrolled according to the relevant criteria. Reconstruction of the medial patellofemoral ligament was performed through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity. Knee function was evaluated using visual analog scale (VAS) score, International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner score, and Kujala score at pre- and postoperative stages. Patellar stability was assessed by CT scans measuring tibial tuberosity-trochlear groove (TT-TG) distance, lateral patella displacement (LPD), congruence angle (CA), and patellar tilt angle (PTA). RESULTS: All 23 patients were effectively followed up for 13-28 months (mean: 21.91 ± 4.14 months). At the last follow-up, the postoperative VAS score, IKDC score, Lysholm score, Tegner score, and Kujala score of 23 patients were 1.13 ± 0.82, 87.35 ± 3.17, 90.22 ± 1.28, 4.35 ± 0.65, and 89.26 ± 1.96, respectively, as compared to the preoperative values of 5.91 ± 1.13, 30.96 ± 5.09, 30.30 ± 2.98, 1.26 ± 0.62, and 27.87 ± 3.46, respectively, and these differences were statistically significant (P < 0.001). At the last follow-up, the postoperative TT-TG, LPD, CA, and PTA values of the 23 patients were 8.80 ± 1.85 mm, 6.01 ± 1.77 mm, 11.32 ± 6.18°, and 9.35 ± 2.88°, respectively, compared to the preoperative values of 18.77 ± 1.74 mm, 14.90 ± 4.07 mm, 37.82 ± 5.71°, and 23.58 ± 3.24°, respectively, and the differences were statistically significant (P < 0.001). No relevant complications were observed in the 23 patients. CONCLUSIONS: Reconstruction of the medial patellofemoral ligament through a double bundle of a single patellar tract and quadriceps tendons combined with medial displacement of lateral hemi-tibial tuberosity for treating low-grade recurrent patella dislocation showed satisfactory medium-term efficacy, and further investigations are required to confirm the long-term efficacy of this approach.

[Augmenting locking plate with autologous bone graft for the treatment of nonunion of long bone fracture in the lower extremity with retaining of the original intramedullary nail].

OBJECTIVE: To explore clinical effect of attaching locking plate with bone grafting based on retaining the original intramedullary nail in treating non-union after intramedullary nail fixation of long shaft fractures of lower limbs. METHODS: A retrospective study was conducted on 20 patients treated with non-union fractures after intramedullary nailing of long shaft fractures of lower limbs from June 2015 to June 2020. All patients were treated with the original intramedullary nailing and bone grafting from the iliac bone, and were underwent open reduction plate internal fixation and bone grafting for old fractures. Among them, 14 were males and 6 were females, aged from 35 to 56 years old with an average of (42.2±9.6) years old. Nine patients were femoral shaft fracture and 11 patients were tibial shaft fracture. According to characteristics of fracture end nonunion, 6 patients were stable/atrophic, 9 patients were unstable/large, and 5 patients were unstable/atrophic. The nonunion time ranged from 8 to 12 months with an average of(9.8±2.0) months after the initial surgery. Visual analogue scale (VAS), knee range of motion, bone healing time, complications and fracture-end healing were recorded before and at the latest follow-up. RESULTS: All patients were followed up for 18 to 48 months with an average of (36.3±10.5) months. The incision of all patients were healed at stageⅠwithout complications such as infection or internal fixation ruptur. Healing time of femur and tibia was (8.5±2.6) months and (9.5±2.2) months. Knee joint motion increased from preoperative (101.05±8.98) ° to postoperative (139.35±8.78) ° at the latest follow-up (t=-12.845, P<0.001). VAS decreased from preoperative (5.15±1.72) to postoperative (0.75±0.96) at the latest follow-up (t=11.186, P<0.001). CONCLUSION: On the basis of retaining the original intramedullary nail, the addition of locking plate internal fixation and autogenous iliac bone grafting have advantages of simple operation, less trauma, fewer complications and high fracture healing rate. It is one of the effective surgical schemes for the treatment of nonunion after intramedullary nail fixation of long bone fracture of lower extremity.

The efficacy and safety of tranexamic acid in rheumatoid arthritis patients undergoing simultaneous bilateral total knee arthroplasty: a multicenter retrospective study.

BACKGROUND: The efficacy and safety of tranexamic acid (TXA) in reducing blood loss following total knee arthroplasty (TKA) in patients with osteoarthritis have been widely confirmed. However, there is still a paucity of the evidences regarding the effectiveness of TXA in patients with rheumatoid arthritis (RA). The purpose of the study is to explore the efficacy and safety of intravenous TXA on blood loss and transfusion risk following simultaneous bilateral TKA (SBTKA) in patients with RA. METHODS: As a multicenter retrospective study, a total of 74 patients diagnosed with RA who underwent SBTKA were assigned into TXA group (15 mg/kg intravenous TXA before skin incision, n = 50) and control group (no TXA use, n = 24). The primary outcomes were total blood loss (TBL) and intraoperative blood loss (IBL). The secondary outcomes were hemoglobin (Hb) and hematocrit (Hct) drop on postoperative day 3, transfusion rate and volume, ambulation time, length of stay, hospitalization expenses and the incidence of complications. RESULTS: The mean TBL, IBL and transfusion volume in TXA group were significantly lower than those in control group. The Hb and Hct drop on postoperative day 3 in control group were higher than those in TXA group (p<0.05). The similar trend was detected on transfusion rate, ambulation time and length of stay. The incidence of complications and hospitalization expenses did not differ significantly between the two groups (p>0.05). CONCLUSIONS: TXA could effectively reduce blood loss, decrease transfusion risk, shorten ambulation time and length of stay following SBTKA in patients with RA, without increasing the risk of complications.

Pathogenesis of acquired heterotopic ossification: Risk factors, cellular mechanisms, and therapeutic implications.

Heterotopic ossification (HO), including hereditary and acquired HO, is the formation of extraskeletal bone in skeletal muscle and surrounding soft tissues. Acquired HO is often caused by range of motion, explosion injury, nerve injury or burns. Severe HO can lead to pain and limited joint activity, affecting functional rehabilitation and quality of life. Increasing evidence shows that inflammatory processes and mesenchymal stem cells (MSCs) can drive HO. However, explicit knowledge about the specific mechanisms that result in HO and related cell precursors is still limited. Moreover, there are no effective methods to prevent or reduce HO formation. In this review, we provide an update of known risk factors and relevant cellular origins for HO. In particular, we focus on the underlying mechanisms of MSCs in acquired HO, which follow the osteogenic program. We also discuss the latest therapeutic value and implications for acquired HO. Our review highlights the current gaps in knowledge regarding the pathogenesis of acquired HO and identifies potential targets for the prevention and treatment of HO.

Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty.

BACKGROUND: Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA. METHODS: We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared. RESULTS: The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05). CONCLUSION: Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.

The effect of body mass index on blood loss and complications in simultaneous bilateral total hip arthroplasty: A multicenter retrospective study.

BACKGROUND: The effect of body mass index (BMI) on blood loss in simultaneous bilateral total hip arthroplasty (SBTHA) was still undetermined. The purpose of the study was to evaluate the blood loss, transfusion and incidence of complications in normal, overweight, and obese patients undergoing SBTHA. METHODS: A total of 344 patients following SBTHA were enrolled into this study. The patients were assigned into three groups on the basis of their BMI, including normal (BMI 18.0-24.9 kg/ m2), overweight (BMI 25.0-29.9 kg/ m2), or obese group (BMI ≥ 30.0 kg/ m2). The primary outcome was total blood loss (TBL), and secondary outcomes were intraoperative blood loss, drain volume, ratio of TBL and patient's blood volume (PBV), transfusion rate and volume, hemoglobin and hematocrit drop, length of stay, expenses, and complications. RESULTS: The PBV and TBL increased significantly along with the elevated BMI (p < 0.001; p = 0.019, respectively). There was no significant difference in intraoperative blood loss, drain volume, transfusion volume, length of stay, expenses, or incidence of complications among the three groups. In addition, the transfusion rate in normal group was higher than that in overweight (58.3% vs 39.6%, p = 0.001) and obese group (58.3% vs 31.9%, p = 0.001). The maximum hemoglobin drop in obese group was the highest (p = 0.001). CONCLUSION: Obesity could increase perioperative blood loss but not increase transfusion risk in the setting of SBTHA. Conversely, obese and overweight patients maybe have lower transfusion need compared with normal patients because of more blood volume. In addition, obesity did not affect the incidence of complications.

Evaluation of Accuracy of Preoperative Planning of the Femurofibular Angle in Open-Wedge High Tibial Osteotomy for Mild Medial Knee Osteoarthritis.

OBJECTIVE: The purpose of this study was to evaluate the usefulness of preoperative planning of the femurofibular angle (FFA) in medial open-wedge high tibial osteotomy (OWHTO) for mild medial knee osteoarthritis. METHODS: Thirty-two patients (32 knees) with mild medial knee OA were retrospectively reviewed. The patients underwent preoperative planning of the FFA for OWHTO. For preoperative planning, a full-length weight-bearing X-ray photograph of the lower limb was opened within Adobe Photoshop Software, and a targeted corrective mechanical axis line of the lower limb and its intersecting point at the lateral tibial plateau surface was drawn using rectangle selection and filling tools. A frame, which encircled the tibia and fibula, was created around the predicted osteotomy plane and then rotated until the ankle center was on the targeted mechanical axis line. Subsequently, a distal femoral condyle line and a proximal fibula axis line were drawn, and the angle between the two lines was measured and defined as the femurofibular angle (FFA). During biplane OWHTO, the preoperatively determined FFA was used to complete the correction of the mechanical axis. During follow-up, the postoperative mechanical weight-bearing line (WBL) of the lower limb, the mechanical femorotibial angle (mFTA), and the FFA were measured and compared with the preoperatively determined values. RESULTS: The mechanical WBL shifted from a preoperative value of 25.36 ± 5.02% to a postoperative value of 56.19 ± 0.10% from the medial border along the mediolateral width of the tibial plateau, and it was 56.57 ± 0.08% at the final follow-up (P < 0.01). The preoperatively determined value was 56.25%, and no significant difference was found compared with postoperative week-one and final follow-up values (P > 0.05). The mFTA was corrected from a preoperative varus of 4.02 ± 0.63° to a postoperative week-one valgus of 2.37 ± 0.28°, and it had a valgus of 2.48 ± 0.39° at the final follow-up (P < 0.01). No significant difference in the valgus was found compared with the postoperative week-one, final follow-up and preoperatively determined valgus of 2.34 ± 0.26° (P > 0.05). The postoperative week-one and final follow-up FFAs were 90.34 ± 1.53° and 90.33 ± 1.52°, respectively, and no significant difference was found compared with the preoperatively determined value of 90.12 ± 1.72° and the intraoperative setting value of 90.25 ± 1.67° (P > 0.05). All corrected values were within the acceptable range of preoperative planning. CONCLUSION: Preoperative planning of the FFA may be useful in OWHTO for patients with mild medial knee OA. Satisfactory correction of the postoperative targeted mechanical axis line of the lower limb can be obtained.

Inhibitory properties of Chinese Herbal Formula SanHuang decoction on biofilm formation by antibiotic-resistant Staphylococcal strains.

The aim of this study was to explore the effect of Chinese herbal SanHuang decoction (SH) on biofilm formation of antibiotic-resistant Staphylococci on titanium surface, and to explore its mechanism. Biofilm-forming ATCC 35984, ATCC 43300 and MRSE 287 were used in this study. The MICs of SH and vancomycin against Staphylococci were determined by the broth microdilution method. Six groups were designed, namely control group (bacteria cultured with medium), 1/8MIC SH group (1MIC SH was diluted by 1/8 using TSB or saline), 1/4MIC SH group, 1/2MIC SH group, 1MIC SH group and vancomycin group (bacteria cultured with 1MIC vancomycin). The inhibitory effect on bacterial adhesion and biofilm formation were observed by the spread plate method, CV staining, SEM, and CLSM. Real-time PCR was performed to determine the effect of SH on the expression levels of ica AD and ica R gene in ATCC 35984 during the biofilm formation. The strains were found to be susceptible to SH and vancomycin with MIC of 38.75 mg/ml and 2.5 µg/ml, respectively. SH with 1 MIC and 1/2 MIC could inhibit the bacteria adhesion, showing only scattered adhesion from SEM. CLSM showed that SH with 1 MIC and 1/2 MIC inhibited the biofilm formation. The quantitative results of the spread plate method and CV staining showed that there was significant differences between the SH groups (P < 0.05). Further, with an increase in SH concentration, the inhibitory effect became more obvious when compared with control group. Among the groups, vancomycin had the strongest inhibitory effect on bacterial adhesion and biofilm formation (P < 0.01). With an increase in SH concentration, the expression levels of ica AD decreased, and the expression of ica R increased correspondingly (P < 0.05). In conclusions, SH can inhibit the biofilm formation of antibiotic-resistant Staphylococci. Its probable mechanistic activity may be through the inhibition of polysaccharide intercellular adhesin synthesis by down-regulating the expression of ica AD gene.

[Clincal observation of non-absorbable suture cerclage combined with patella claw fixation for treatment of inferior patella fractures].

OBJECTIVE: To investigate the effectiveness of non-absorbable suture cerclage combined with patella claw fixation for the treatment of inferior patella fractures. METHODS: Between September 2016 and January 2019, 22 patients with inferior patella fractures were treated. There were 12 males and 10 females, with a mean age of 49.1 years (range, 32-67 years). The causes of injury were traffic accident in 8 cases, falling in 12 cases, and other causes in 2 cases. The interval from injury to operation was 3-7 days (mean, 4.4 days). For the operation, 3 or 4 longitudinal tunnels were drilled backward from the surface of the proximal fracture fragment with Kirschner wires; under the guidance of lumbar puncture needles and steel wires, non-absorbable suture passed through the tunnels and encircled the inferior fracture fragment, then tighten to achieve a satisfactory reduction of the fracture; finally, the patella claw was used to strengthen the fixation. During the follow-up, complications were observed, maximum motion range of the knee joint was measured, X-ray examination was performed and fracture healing time was recorded. The knee function was evaluated according to Böstman scores. RESULTS: All the 22 patients were followed up 12-36 months (mean, 19.4 months). No infection, joint stiffness, bone nonunion, loss of reduction, or displacement of internal fixation occurred. All fractures were clinically healed, and the bone healing time was 2-3 months (mean, 2.6 months). At last follow-up, the maxium motion range of knee joint was 130°-135°, with an average of 132.6°. The Böstman score of the affected knee was 28-30 (mean, 29.2). All cases were graded as excellent results. CONCLUSION: Non-absorbable suture cerclage combined with patella claw fixation for inferior patella fractures has the advantages of simple operation, reliable fixation, and few complications, and the clinical results are satisfactory.

Susceptibility of Mature Staphylococcus Biofilms to Chinese Herbal Decoction Sanhuang Jiedu: An In Vitro Study.

BACKGROUND: External socking and washing with the Chinese herbal Sanhuang Jiedu decoction (SHJD) can effectively control local limb infections with bone and implant exposure. However, the antibiofilm activities of this decoction in vitro have not yet been investigated. Therefore, the aim of this study was to examine the effects and characteristics of SHJD on the mature biofilms of multidrug-resistant staphylococci on a titanium surface. METHODS: Biofilm-forming methicillin-resistant Staphylococcus epidermidis ATCC 35984 and S. aureus ATCC 43330, and non-biofilm-forming S. epidermidis ATCC 12228 were selected as the experimental strains. The mature biofilms were prepared on titanium surfaces. The five experimental groups were based on dilution concentrations (DC) of SHJD: the control group (biofilm incubated with 0.85% NaCl solution), the SHJD (DC:1/8) group (initial SHJD solution was diluted 1/8), the SHJD (DC:1/4) group, the SHJD (DC:1/2) group, and the SHJD (DC:1/1) group (initial SHJD solution). The effects of SHJD on the mature biofilms were observed with the bacterial spread plate method, crystal violet (CV) staining, scanning electron microscopy, and confocal laser scanning microscopy. RESULTS: After culture in tryptic soy broth for 72 h, ATCC 43300 and ATCC 35984 produced mature biofilms and ATCC 12228 did not. The optical density value of ATCC 12228 was 0.11 ± 0.02, significantly lower than that of ATCC 35984 (0.42 ± 0.05) or ATCC 43300 (0.41 ± 0.03) (P < 0.05). The mature biofilms of ATCC 43300 and ATCC 35984 clearly disintegrated when incubated for 12-24 h with SHJD (DC:1/1) or SHJD (DC:1/2), showing only scattered bacterial adhesion. In the SHJD (DC:1/4) group, although many residual bacterial colonies still clustered together, presenting a biofilm structure, it was very looser than that in the SHJD (DC:1/8) group in which the biofilm was similar to that in the control group. For ATCC 12228, only colony adhesion was observed, and the number of colonies decreased as the concentration of SHJD or the culture period increased. The quantitative results for the bacterial spread plate and CV staining showed significant differences between the SHJD groups (P < 0.05). CONCLUSION: SHJD has antibiofilm activity against multidrug-resistant Staphylococcus strains. It weakens or disrupts already-formed mature biofilms on titanium surfaces in a concentration- and incubation time-dependent manner.

[Arthroscopic reconstruction of medial patellofemoral ligament combined with medial displacement of lateral hemitibial tuberosity for treatment of recurrent dislocation of patella].

OBJECTIVE: To observe the effectiveness of arthroscopic reconstruction of medial patellofemoral ligament (MPFL) with a single bundle of autogenous half peroneal longus tendon, and medial displacement of lateral hemitibial tuberosity for the treatment of recurrent dislocation of patella. METHODS: Retrospectively analyse the clinical data of 24 patients (24 knees) with recurrent patellar dislocation with tibial tuberosity-trochlear groove distance (TT-TG) values more than 15 mm who were admitted between September 2014 and September 2018. Of which 7 were male and 17 were female; aged 16-35 years old with an average of 25.8 years. The disease duration ranged from 15 to 46 months, with an average of 26.7 months. All patients had a history of knee trauma, and a positive result of apprehension test on the affected knee. All patients underwent the surgery of arthroscopic reconstruction of MPFL with a single bundle of autogenous half peroneal longus tendon, and medial displacement of lateral hemitibial tuberosity. Before and after operation, Kujala score was used to evaluate patellofemoral joint function, Lysholm score was used to evaluate knee joint function; CT and MRI were used to measure and compare the changes of congruence angle (CA), patellar tilt angle (PTA), and lateral patella displacement (LPD) in order to evaluate patella stability. RESULTS: All incisions healed by first intention, and no infection or neurovascular injury occurred. Deep vein thrombosis of the lower extremities occurred in 2 cases at 4 and 7 days after operation respectively, and the thrombosis disappeared after symptomatic treatment. All the 24 patients were followed up 12-14 months (mean, 12.9 months). During follow-up, no patellar dislocation reoccurred in the affected knee. At last follow-up, the apprehension test was negative in every patients. The TT-TG, CA, PTA, and LPD were significantly improved when compared with those before operation ( P<0.05). The Kujala score and Lysholm score at 1 month and last follow-up were significantly better than those before operation, and the above scores at last follow-up were significantly better than those at 1 month after operation ( P<0.05). According to Lysholm score, the patients' knee joint functions were excellent in 13 cases, good in 10 cases, and fair in 1 case, and the excellent and good rate was 95.8%. CONCLUSION: Arthroscopic reconstruction of MPFL with a single bundle of autogenous half peroneal longus tendon combined with medial displacement of lateral hemitibial tuberosity has the advantages of minimal invision and reliable effectiveness. It can be used as one of the effective surgical methods for the treatment of recurrent dislocation of patella.

Arthroscopic pie-crusting release of the posteromedial complex of the knee for surgical treatment of medial meniscus injury.

BACKGROUND: An arthroscopic narrow posteromedial gap of the knee may cause failure of a meniscus operation. The posteromedial complex (PMC) of the knee, including the posterior part of the medial collateral ligament (MCL) and the posterior oblique ligament (POL), has a restrictive effect on the opening of the posteromedial gap of the knee in the half-extension position. Thus, we evaluated the radiological and clinical results of pie-crusting release of the PMC for arthroscopic meniscal surgery in tight knees. METHODS: Sixty patients with posterior injury of the medial meniscus were reviewed. All patients accepted arthroscopic pie-crusting release of the PMC. Fourty patients accepted meniscoplasty, and 20 patients accepted meniscal suturing. To evaluate the arthroscopic opening of the medial gap in 20° half-extension under 11-kg valgus stress, the width of the medial space before and after release were measured. During follow-up, the medial stability was evaluated by radiographic measurements of the joint space width (JSW) in 20° half-extension. Magnetic resonance imaging (MRI) was conducted to evaluate healing of the MCL and meniscus. Knee functions were evaluated using VAS (visual analogy score), Lysholm, IKDC (International Knee Documentation Committee) and Tegner scoring systems. RESULTS: In all patients, meniscus operations were performed without iatrogenic cartilage injury. After PMC release, the arthroscopic width of the medial space was 5.7 ± 0.5 mm, larger than that before release (2.5 ± 0.5 mm, p < 0.01). The follow-up time was 21.93 ± 7.04 months, there was no residual valgus laxity of the knee. The radiographic JSW was 5.97 ± 0.8 mm preoperatively, 9.2 ± 1.1 mm in the 1st week postoperatively, and 6.1 ± 0.9 mm by the 3rd postoperative month, showing no differences between preoperative and 3 months postoperative measurement (p > 0.05). For sutured meniscus, MRI showed healing in 15 patients while five had two-grade abnormal signals. VAS, Lysholm, IKDC and Tegner scores were 1.80 ± 0.51, 80.08 ± 3.74, 82.17 ± 4.64 and 5.48 ± 0.59, respectively, showing significant differences compared with the preoperative scores (5.57 ± 0.69, 48.17 ± 4.22, 51.42 ± 4.02 and 3.20 ± 0.68, respectively, p< 0.01). CONCLUSIONS: Pie-crusting release of the PMC can increase the posteromedial space and improve the visual field of the knee under arthroscopy, while neither causing no residual valgus instability of the knee nor affecting the clinical outcome at the final follow-up.

Pre-operative simulation using a three-dimensional printing model for surgical treatment of old and complex tibial plateau fractures.

To investigate the clinical efficacy of pre-operative simulation using a three-dimensional (3D) printing model for surgical treatment of old and complex tibial plateau fractures. Forty-two patients with old and complex tibial plateau fractures were retrospectively reviewed from January 2014 to January 2018, which were divided into a conventional planning group (n = 22) and a planning with 3D printing group (n = 20). In the planning with 3D printing group, preoperative equal-ratio fracture models prepared using the 3D printing technique were used to perform pre-operative simulation and guide the real surgical operation. In the conventional planning group, the operation was performed based on pre-operative computed tomography (CT) images. Surgery duration, blood loss and the number of fluoroscopy during operations were recorded. During follow-up, the quality of fracture reduction and complications were also recorded. Knee functions were evaluated using the hospital for special surgery (HSS) scoring system. The operation time, blood loss and the number of fluoroscopy during operation in the planning with 3D printing group were less than that in the conventional planning group (P < 0.01). All patients were followed up for mean of 24.38 ± 7.62 months. The rate of excellent fracture reduction in the planning with 3D printing group and conventional planning group was 75% and 45.45%, respectively (P = 0.05). The complication rate was 15% in the planning with 3D printing group and 31.82% in the conventional planning group. At the final follow-up evaluation, the mean HSS score was 86.05 ± 7.67 in the planning with 3D printing group and 79.09 ± 6.75 in the conventional planning group (P = 0.003). The rate of excellent results in the planning with 3D printing group was 70% and in the conventional planning group was 45.45% (P = 0.083). In conclusion, pre-operative simulation using a 3D printing model may be helpful for the treatment of old and complex tibial plateau fractures, which may be conducive to the pre-operative planning and to making the surgical procedure accurate and personalized. However, its clinical effectiveness need to be further assessed by a prospective randomized-controlled study.

[Arthroscopic cyst removal and wire-guided suture for the treatment of lateral meniscal cyst of knee joint].

OBJECTIVE: To explore clinical effect of arthroscopic cyst removal and wire-guided suture for the treatment of lateral meniscal cyst of knee joint. METHODS: From July 2014 to December 2017, 33 patients with lateral meniscal cyst of knee joint were treated by arthroscopic cysts removal and wire-guided suture, including 13 males and 20 females, aged from 20 to 55 years old with an average age of(36.23 ±2.30) years old, the courses of disease ranged from 3 to 14 months with an average of(4.60±0.83) months; Preoperative MRI examination was clear diagnosed. There were 14 cysts on anterior horn, 18 cysts on meniscal body and 1 cyst on posterior horn;all cysts were solitary, and 3 of them were multilocular. Lysholm score and GLASOW score of knee joint function and clinical efficacy were observed before and after operation at 6 months. RESULTS: All patients were followed up form 6 to 24 months with an average of (7.5±1.2) months. Preoperative symptoms disappeared or significantly alleviated, and all incisions were healed by intention without complication and neurovascular injury. MRI showed meniscal tear areas and cystic defective areas healed, cyst was not recurrenced, healing time ranged form 8 to 12 weeks with an average of (9.6±1.6) weeks, and patients recovered their daily life and exercise. There was significant difference in Lysholm score before operation (61.12±4.35) and after operation at 6 momths(91.32±3.36)(t=46.11, P<0.01);according to GLASOW assessment, 31 patients with excellent recovery, and 2 good. CONCLUSIONS: Arthroscopic cyst removal and wire-guided suture for the treatment of lateral meniscal cyst of knee joint could reserve meniscus, repair injury of meniscus, recover knee joint function after operation, and is worth popularizing.

How to accurately determine the distal femoral valgus cut angle in the valgus knee arthroplasty.

PURPOSE: Distal femoral resection in total knee arthroplasty (TKA) is commonly performed using intramedullary jigs with a pre-operatively planned valgus cut angle (VCA). For valgus knees with lateral femoral condyle hypoplasia, the method of determining the accurate VCA has not been clarified. The aim of the present study is to introduce a method that can accurately determine the distal femoral VCA in the valgus knee arthroplasty. METHODS: Twenty patients with valgus deformity caused by lateral femoral condylar hypoplasia underwent primary TKA with individually measured VCA. The VCA was defined as the acute crossing angle of the anatomical and mechanical axes of the femur on a pre-operative X-ray film, and the two axes almost always crossed at the distal femoral diaphysis, but not the centre of the knee as generally described. The entry point of the femoral intramedullary guide rod was determined on the extension of the femoral anatomical axis and was usually medial to the centre of the knee. According to the pre- and post-operative X-ray films, the mechanical lateral distal femoral angle (mLDFA), and coronal alignment of the femoral components were measured. The post-operative knee pain and function were evaluated using the Visual Analog Scale and Knee Society Score, respectively. RESULTS: The mean VCA measured according to the above method was 6.4° ± 1.0° (4.7-8.2°), and the femoral entry point was located at a mean distance of 7.4 ± 2.1 mm (4.5-10.9 mm) medial to the centre of the knee joint. The mean mLDFA before and after operation was 77.4° ± 5.7° (74-82°) and 88.4° ± 1.7° (86-90°), respectively, showing a statistically significant difference (P < 0.01). CONCLUSIONS: The deformity of the distal femoral diaphysis is quite various in different valgus knees. The VCA and the femoral entry point should be determined individually for each case. The application of the current method resulted in good post-operative mechanical axis alignment and clinical results after TKA. LEVEL OF EVIDENCE: Level IV.

Krüppel-Like Factor 2 Regulates Degradation of Type II Collagen by Suppressing the Expression of Matrix Metalloproteinase (MMP)-13.

BACKGROUND/AIMS: Krüppel-like factor 2 (KLF2) plays an essential role in the inhibition of endothelial cell and macrophage activation during the inflammatory process. However, the roles of KLF2 in chondrocytes and the pathological progression of osteoarthritis (OA) remain unknown. The aim of this study was to investigate the function of KLF2 in the inhibition of cartilage matrix destruction in chondrocytes. METHODS: RT-PCR and western blot analysis was used to determine the expression of KLF2 in human chondrocytes. Luciferase assay, ELISA assay and MMP-13 enzymatic activity assays were used to investigate the effects of KLF2 in regulating MMP-13 expression. Western blot analysis was used to examine the effects of KLF2 in suppressing degradation of type Ⅱ collagen. RESULTS: KLF2 is expressed in primary chondrocytes and is downregulated in OA chondrocytes. Expression of KLF2 in primary chondrocytes was reduced in response to IL-1ß. Overexpression of KLF2 robustly inhibited IL-1ß-induced MMP-13 expression. Conversely, knockdown of KLF2 markedly exacerbated MMP-13 expression. Mechanistically, KLF2 could suppress the activation of MMP-13 promoter. However, knockdown of KLF2 could promote the activation of MMP-13 promoter. Importantly, overexpression of KLF2 ameliorated the degradation of type Ⅱ collagen while silencing of KLF2 exacerbated the degradation of type Ⅱ collagen induced by IL-1ß. CONCLUSIONS: KLF2 may be a potential therapeutic target for OA treatment.

Photodynamic inactivation of fibroblasts and inhibition of Staphylococcus epidermidis adhesion and biofilm formation by toluidine blue O.

Treating skin and soft tissue infections of severe limb traumas can be challenging. Crucial concerns focus on inhibiting biofilm formation by antibiotic­resistant bacteria, and preventing scar formation by fibroblastic hyperproliferation. The local use of toluidine blue O (TBO)­mediated photodynamic therapy (PDT) may be a promising strategy for treating such lesions. The present study used Staphylococcus epidermidis (strain ATCC 35984) to assess the effects of TBO­PDT on bacterial adherence and biofilm formation, using confocal laser scanning microscopy (CLSM), tissue culture plating (TCP) and scanning electron microscopy (SEM). Primary human fibroblast cells were used to evaluate the cytotoxicity of TBO­PDT using the 3­(4,5­dimethylthiazol­2­yl)­2,5­diphenyltetrazolium bromide (MTT) assay and CLSM. Six different treatment groups were investigated: Medium only [tryptone soy broth (TSB) or Dulbecco's modified Eagle's medium (DMEM)]; red light control (light dose, 30 J/cm2); TBO group (50 mM TBO); TBO­PDT1 (TBO irradiated with 10 J/cm2); TBO­PDT2 (TBO irradiated with 20 J/cm2); and TBO­PDT3 (TBO irradiated with 30 J/cm2). The results of the S. epidermidis adhesion assay indicated that the TSB, light and TBO groups exhibited significant bacterial adherence, compared with the TBO­PDT groups. Analysis of biofilm formation revealed significant light dose­dependent differences between the TBO­PDT groups and the TSB, light, and TBO groups. Furthermore, SEM indicated fewer colony masses in the TBO­PDT groups compared with the control groups. The MTT assay for fibroblastic cell toxicity demonstrated ~1.1, 4.6, 14.5, 29.7 and 43.4% reduction in optical density for the light, TBO, TBO­PDT1, TBO­PDT2 and TBO­PDT3 groups, respectively, compared with the DMEM control group. There was no difference in toxicity between the light and control groups, however, there were significant differences among the TBO­PDT groups. Finally, alterations in fibroblast morphology and cell spreading were revealed by CLSM, following TBO­PDT treatment. TBO­PDT inhibited bacterial adhesion and biofilm formation, and exhibited significant cytotoxic effects on human fibroblasts. These results indicate that the local use of TBO­PDT in limb lesions may be a useful treatment method for inhibiting bacterial biofilm formation and fibroblastic hyperproliferation, which may prevent infectious hypertrophic scar formation.

[Double-plate fixation via combined approaches for the treatment of old tibial plateau fractures of Schatzker type IV].

OBJECTIVE: To explore the clinical efficacy of double-plate fixation for the treatment of old tibial plateau fractures with Schatzker type IV through anterior midline and posteromedial approaches. METHODS: From July 2013 to July 2015, 15 patients with old tibial plateau fractures were treated with internal fixation using locking reconstructive plate for the posteromedial fragment and anatomical locking plate for anteromedial fragment through antero midline and posteromedial approaches. There were 9 males and 6 females, with an average age of 49.2 years old (ranged, 21 to 61 years old). Eight patients had injured in the left side and 7 in the right side. According to Schatzker classification, all patients were type IV. The mean interval from injury to operation was 26.5 days (ranged, 21 to 65 days). The main clinical symptoms before operation were knee joint swelling, pain, deformity and limitation of motion. The X-ray and CT confirmed the fracture type. The indexes such as tibial plateau tibial shaft angle (TPA), femoral tibial angle (FTA) and posterior slope angle (PSA) were compared between immediate postoperation and final follow-up using postoperative X-ray film. The knee functions were evaluated using the HSS (Hospital for Special Surgery) knee score system. RESULTS: Two patients had incision complications which healed by correct treatment, 1 patient had traumatic arthritis. All patients were followed up for mean 16.6 months (ranged, 13 to 24 months). No infections, deep venous thrombosis, implant loosening and breakage, fragment displacement, plateau surface collapse and bone nonunion found. The bone union time ranged from 3 to 8 months (mean 6.07 months) after operation. The average immediate postoperative value of TPA, FTA and PSA were(86.81±1.67)°, (168.00±3.29)° and(10.20±1.47)° respectively; and(86.47±1.67)°, (168.53±3.03)° and (10.54±1.21)° respectively at the final follow-up evaluation, showing no statistical differences(P>0.05). According to the HSS score system, 26.33±3.86 in pain, 20.00±1.79 in function, 16.00±1.55 in range of motion, 8.67±0.94 in muscle strength, 8.53±1.67 in flexion deformity, 9.33±0.94 in joint stability, and the total mean score was 88.86±8.92. The outcomes were excellent in 10 cases, good in 4, and fair in 1. CONCLUSIONS: Double-plate fixation via combined anterior midline and posteromedial approaches is an ideal surgical method for old tibial plateau fractures with Schatzker IV type, showing satisfactory exposure, reliable reduction and fixation, and benefiting for early functional exercise. The short-term clinical results was satisfactory.

Clinical results of treatment using a modified K-wire tension band versus a cannulated screw tension band in transverse patella fractures: A strobe-compliant retrospective observational study.

It was a retrospective case-control study. The aim of this study was to explore the clinical efficacy and complication of treatment using a modified Kirschner wire tension band (MKTB) or a cannulated screw tension band (CSTB) in transverse patellar fractures.In total, 55 patients with transverse patellar fractures were retrospectively reviewed and divided into 2 groups according to the surgical technique: 29 patients were in the MKTB group and 26 patients in the CSTB group. B[Latin Small Letter o with Caron]stman's clinical grading scale, including range of movement (ROM), pain, ability to work, atrophy of quadriceps femoris, assistance in walking, effusion, giving way, and stair-climbing, was used to evaluate the clinical results. Complications including painful hardware, implant loosening or breakage, and bone nonunion were also assessed.Both groups were evaluated at the final follow-up before removing implant in the MKTB group. The B[Latin Small Letter o with Caron]stman's score of ROM, pain, atrophy of quadriceps femoris, and effusion were all higher in the CSTB group than in the MKTB group (P < 0.05). Twelve patients in the MKTB group underwent implant removal, and the score of ROM, pain, and effusion were higher than before removing implant (P < 0.05), but there was no difference compared to the CSTB group (P > 0.05). Seventeen patients achieved excellent results, 9 had good results, and 3 reported fair results in the MKTB group; the CSTB group had excellent results in 22 patients and good results in 4 patients, showing a significant difference in the excellent rate between the 2 groups (P = 0.021). Total B[Latin Small Letter o with Caron]stman scores in the MKTB and CSTB groups (26.96 ±â€Š4.47 and 29.42 ±â€Š1.47, respectively) were significantly different (P = 0.01). Total scores in the MKTB group after removing implant were higher than those before removing implant (P = 0.001), and similar to those in the CSTB group (P = 0.224). Eleven patients in the MKTB group reported painful hardware, including 4 cases of implant loosening.CSTB achieves better clinical results than MKTB, meanwhile avoiding the problems of painful hardware and implant loosening. Functional limitation caused by hardware pain was commonly seen in the MKTB group, and removing implant after fracture healing improved knee function.

Inhibited Bacterial Adhesion and Biofilm Formation on Quaternized Chitosan-Loaded Titania Nanotubes with Various Diameters.

Titania nanotube-based local drug delivery is an attractive strategy for combating implant-associated infection. In our previous study, we demonstrated that the gentamicin-loaded nanotubes could dramatically inhibit bacterial adhesion and biofilm formation on implant surfaces. Considering the overuse of antibiotics may lead to the evolution of antibiotic-resistant bacteria, we synthesized a new quaternized chitosan derivative (hydroxypropyltrimethyl ammonium chloride chitosan, HACC) with a 27% degree of substitution (DS; referred to as 27% HACC) that had a strong antibacterial activity and simultaneously good biocompatibility with osteogenic cells. Titania nanotubes with various diameters (80, 120, 160, and 200 nm) and 200 nm length were loaded with 2 mg of HACC using a lyophilization method and vacuum drying. Two standard strain, methicillin-resistant Staphylococcus aureus (American Type Culture Collection 43300) and Staphylococcus epidermidis (American Type Culture Collection 35984), and two clinical isolates, S. aureus 376 and S. epidermidis 389, were selected to investigate the bacterial adhesion at 6 h and biofilm formation at 24, 48, and 72 h on the HACC-loaded nanotubes (NT-H) using the spread plate method, confocal laser scanning microscopy (CLSM), and scanning electron microscopy (SEM). Smooth titanium (Smooth Ti) was also investigated and compared. We found that NT-H could significantly inhibit bacterial adhesion and biofilm formation on its surface compared with Smooth Ti, and the NT-H with 160 nm and 200 nm diameters had stronger antibacterial activity because of the extended HACC release time of NT-H with larger diameters. Therefore, NT-H can significantly improve the antibacterial ability of orthopedic implants and provide a promising strategy to prevent implant-associated infections.