Effects of fondaparinux on wound drainage after total hip and knee arthroplasty.

BACKGROUND: The purpose of this investigation was to determine the effects of fondaparinux on postoperative wound drainage, length of hospital stay (LOS) and rate of surgical site infection in total joint patients. METHODS: 117 patients undergoing total joint arthroplasty treated with fondaparinux for venous thromboembolism (VTE) prophylaxis were prospectively studied. RESULTS: The average time to a dry wound was 3.4 days, with an average LOS of 3.77 days. Perioperative complications included 2 cases each of superficial cellulitis, deep vein thrombosis, and pulmonary embolism; there were no cases of deep infection. Multi-variate analysis showed increased patient BMI increased LOS (p = 0.0169). CONCLUSION: Fondaparinux is an effective drug for VTE prophylaxis in total joint arthroplasty with wound drainage and LOS comparable to historical controls of enoxaparin, warfarin, and rivaroxaban.

Calculating the Position of the Joint Line of the Knee Using Anatomical Landmarks.

Restoration of the joint line of the knee during primary and revision total knee arthroplasty is a step that directly influences patient outcomes. In revision total knee arthroplasty, necessary bony landmarks may be missing or obscured, so there remains a lack of consensus on how to accurately identify and restore the joint line of the knee. In this study, 50 magnetic resonance images of normal knees were analyzed to determine a quantitative relationship between the joint line of the knee and 6 bony landmarks: medial and lateral femoral epicondyles, medial and lateral femoral metaphyseal flares, tibial tubercle, and proximal tibio-fibular joint. Wide variability was found in the absolute distance from each landmark to the joint line of the knee, including significant differences between the sexes. Normalization of the absolute distances to femoral or tibial diameters revealed reliable spatial relationships to the joint line of the knee. The joint line was found to be equidistant from the lateral femoral epicondyle and the proximal tibio-fibular joint, representing a reproducible point of reference for joint line restoration. The authors propose a simple 3-step algorithm that can be used with magnetic resonance imaging, computed tomography, or radiography to reliably determine the anatomical location of the joint line of the knee relative to the surrounding bony anatomy. [Orthopedics. 2016; 39(6):381-386.].

Anemia versus transfusion: does blood conservation increase the risk of complications?

Orthopedic trauma patients are routinely transfused for anemia even when asymptomatic at rest, despite there being relatively little scientific evidence as to what level of anemia can be safely tolerated. Some surgeons prefer a more liberal approach, transfusing to keep hemoglobin (Hgb) levels at 7.0 g/dL or higher; others prefer a more conservative approach, allowing Hgb levels to drop below 7.0 g/dL. We conducted a study to determine if a more conservative approach might put patients at higher risk of complications of severe anemia. We retrospectively reviewed the cases of 104 patients who were treated by a single surgeon at a level I academic trauma center and who were followed up for at least 1 year. Patients (ages 18-50 years) were divided into 2 groups by lowest Hgb level before first transfusion-under 7.0 g/dL and 7.0 g/dL or higher-and then by whether they had been transfused. Logistic regression analysis was performed. The primary outcome was postoperative complication. There was no increased risk of complication related to anemia (P = .3). However, there was a significant risk of complication related to transfusion (P < .01). Furthermore, there was a dose-dependent effect with each unit transfused (P = .02). In young, healthy, asymptomatic orthopedic trauma patients, a more conservative transfusion strategy (vs a more liberal strategy) did not appear to carry higher risk.

Effect of day of the week of primary total hip arthroplasty on length of stay at a university-based teaching medical center.

Length of hospital stay (LHS) after primary total hip arthroplasty (THA) constitutes a critical outcome measure, as prolonged LHS implies increased resource expenditure. Investigations have highlighted factors that affect LHS after THA. These factors include advanced age, medical comorbidities, obesity, intraoperative time, anesthesia technique, surgical site infection, and incision length. We retrospectively analyzed the effect of day of the week of primary THA on LHS. We reviewed the surgery and patient factors of 273 consecutive patients who underwent THA at our institution, a tertiary-care teaching hospital. There was a 15% increase in LHS for patients who underwent THA on Thursday versus Monday when controlling for other covariates that can affect LHS. Other statistically significant variables associated with increased LHS included American Society of Anesthesiologists grade, transfusion requirements, and postoperative complications. The day of the week of THA may be an independent variable affecting LHS. Institutions with reduced weekend resources may want to perform THA earlier in the week to try to reduce LHS.

Cartilage oligomeric matrix protein and its binding partners in the cartilage extracellular matrix: interaction, regulation and role in chondrogenesis.

Thrombospondins (TSPs) are widely known as a family of five calcium-binding matricellular proteins. While these proteins belong to the same family, they are encoded by different genes, regulate different cellular functions and are localized to specific regions of the body. TSP-5 or Cartilage Oligomeric Matrix Protein (COMP) is the only TSP that has been associated with skeletal disorders in humans, including pseudoachondroplasia (PSACH) and multiple epiphyseal dysplasia (MED). The pentameric structure of COMP, the evidence that it interacts with multiple cellular proteins, and the recent reports of COMP acting as a 'lattice' to present growth factors to cells, inspired this review of COMP and its interacting partners. In our review, we have compiled the interactions of COMP with other proteins in the cartilage extracellular matrix and summarized their importance in maintaining the structural integrity of cartilage as well as in regulating cellular functions.

Subtrochanteric Fracture following Removal of a Porous Tantalum Implant.

Osteonecrosis of the hip accounts for about 10% of all total hip arthroplasty cases and presents a significant challenge for those patients with and without femoral head collapse. Subtrochanteric femur fractures have been reported with numerous types of proximal femoral implants. Care must be taken to avoid penetrating the lateral cortex of the proximal femur inferior to the distal border of the lesser trochanter. Core decompression requires a 3 mm to 20 mm defect in the lateral femoral cortex. Subtrochanteric femur fractures are a well-known complication of core decompression as well. We present a case of a subtrochanteric fracture following the removal of a porous tantalum implant.

The pros and cons of using larger femoral heads in total hip arthroplasty.

With the introduction of improved bearing surfaces for total hip arthroplasty (THA) has come a reintroduction of larger femoral heads with the promise of reducing the rate of hip instability and increasing hip range of motion (ROM). The size of femoral heads used for THA ranges from 22 to 40 mm, and even larger heads are used for hip resurfacing. With accurately positioned components, larger heads reduce the hip instability rate and theoretically increase hip ROM. However, for any given bearing surface, the volumetric wear rate is higher for larger heads than for smaller heads, which potentially jeopardizes the long-term survival of these reconstructions. In this article, we review the evidence for use of larger femoral heads with respect to stability, ROM, impingement, wear rate, bearing surfaces, and future directions.

Identification of the landmark registration safe zones during total knee arthroplasty using an imageless navigation system.

Incorrect registration during computer assisted total knee arthroplasty (CA-TKA) leads to malposition of implants. Our aim was to evaluate the tolerable error in anatomic landmark registration. We incorrectly registered the femoral epicondyles, femoral and tibial centers, as well as the malleoli and documented the change in angulation or rotation. We found that the distal femoral epicondyles were the most difficult anatomic landmarks to register. The other bony landmarks were more forgiving. Identification of the distal femoral epicondyles has a high inter-observer and intra-observer variability. Our observation that there is less than 2mm of safe zone in the anterior or posterior direction during registration of the medial and lateral epicondyles may explain the inability of CA-TKA to improve upon the outcomes of conventional TKA.

c-Maf Transcription Factor Regulates ADAMTS-12 Expression in Human Chondrogenic Cells.

OBJECTIVE: ADAMTS (a disintegrin and metalloproteinase with thrombospondin type-1 motif) zinc metalloproteinases are important during the synthesis and breakdown of cartilage extracellular matrix. ADAMTS-12 is up-regulated during in vitro chondrogenesis and embryonic limb development; however, the regulation of ADAMTS-12 expression in cartilage remains unknown. The transcription factor c-Maf is a member of Maf family of basic ZIP (bZIP) transcription factors. Expression of c-Maf is highest in hypertrophic chondrocytes during embryonic development and postnatal growth. We hypothesize that c-Maf and ADAMTS-12 are co-expressed during chondrocyte differentiation and that c-Maf regulates ADAMTS-12 expression during chondrogenesis. DESIGN: Promoter analysis and species alignments identified potential c-Maf binding sites in the ADAMTS-12 promoter. c-Maf and ADAMTS-12 co-expression was monitored during chondrogenesis of stem cell pellet cultures. Luciferase expression driven by ADAMTS-12 promoter segments was measured in the presence and absence of c-Maf, and synthetic oligonucleotides were used to confirm specific binding of c-Maf to ADAMTS-12 promoter sequences. RESULTS: In vitro chondrogenesis from human mesenchymal stem cells revealed co-expression of ADAMTS-12 and c-Maf during differentiation. Truncation and point mutations of the ADAMTS-12 promoter evaluated in reporter assays localized the response to the proximal 315 bp of the ADAMTS-12 promoter, which contained a predicted c-Maf recognition element (MARE) at position -61. Electorphoretic mobility shift assay confirmed that c-Maf directly interacted with the MARE at position -61. CONCLUSIONS: These data suggest that c-Maf is involved in chondrocyte differentiation and hypertrophy, at least in part, through the regulation of ADAMTS-12 expression at a newly identified MARE in its proximal promoter.

The Oncogene LRF Stimulates Proliferation of Mesenchymal Stem Cells and Inhibits Their Chondrogenic Differentiation.

OBJECTIVE: The oncogene leukemia/lymphoma-related factor (LRF) enhances chondrosarcoma proliferation and malignancy. This study aimed to investigate the roles of LRF in chondrogenic differentiation of primary human bone marrow-derived mesenchymal stem cells (BMSCs). DESIGN: LRF was overexpressed in BMSC by lentiviral transduction. Chondrogenic differentiation of BMSC was induced by high-density pellet culture. Western blotting and real-time polymerase chain reaction were used to investigate changes in protein and mRNA levels, respectively, during chondrogenesis. Safranin-O staining, immunohistochemistry, and glycoaminoglycan contents were used to assess cartilage matrix deposition. BMSC proliferation was determined by mitochondrial dehydrogenase activity and cell counting. Cell cycle profiling was performed by flow cytometry. RESULTS: LRF overexpression effectively inhibited protein and mRNA expression of chondrocyte markers and cartilage matrix deposition during chondrogenesis of BMSC. Endogenous LRF expression was constitutively high in undifferentiated BMSC but remained low in primary articular chondrocytes. Endogenous LRF protein was downregulated in a time-dependent manner during chondrogenesis. BMSCs overexpressing LRF had higher proliferation rates and cell population in the S phase. LRF suppressed p53 expression during chondrogenesis and this might prevent differentiating chondrocytes from entering a quiescent state. CONCLUSION: Our data showed that LRF is important for stimulating stem cell proliferation and cell cycle progression. It is known that LRF is highly expressed in the mouse limb buds prior to overt chondrogenesis; thus, LRF might function to prevent premature chondrogenic differentiation of stem cells.

Failure of a constrained acetabular liner without reinforcement ring disruption.

Several risk factors for dislocation after total hip arthroplasty (THA) have been identified including operative-, patient-, and implant-related factors. The following case report describes the dislocation of a revision THA without disruption of the constrained liner or containment ring. The possible mechanisms leading to this type of failure include lever-out impingement and poor abductor function, or tension secondary to prior surgery. Dislocation without disruption of containment ring has not been described for the Pinnacle Acetabular Cup with the Enhanced Stability Constrained Liner (DePuy Orthopaedics, Warsaw, Indiana).

The oncogene LRF is a survival factor in chondrosarcoma and contributes to tumor malignancy and drug resistance.

Chondrosarcoma is a form of malignant skeletal tumor of cartilaginous origin. The non-malignant form of the disease is termed chondroma. Correctly distinguishing between the two forms is essential for making therapeutic decisions. However, due to their similar histological appearances and the lack of a reliable diagnostic marker, it is often difficult to distinguish benign tumors from low-grade chondrosarcoma. Therefore, it is necessary to search for a potential marker that has diagnostic and prognostic values in chondrosarcoma. In this study, we demonstrated by immunohistochemistry that elevated leukemia/lymphoma-related factor (LRF) expression was associated with increased malignancy in human chondrosarcoma tissue microarrays. Moreover, siRNA depletion of LRF drastically reduced proliferation of chondrosarcoma cell lines and effectively induced senescence in these cells. This could be attributed to the observation that LRF-depleted cells were arrested at the G(1) phase, and had increased p53 and p21 expression. Moreover, LRF depletion not only drastically reduces the cellular migration and invasion potentials of chondrosarcoma cells but also sensitized these cells to the apoptosis-inducing chemotherapeutic agent doxorubicin. We conclude that LRF is a survival factor in chondrosarcomas and its expression correlates with tumor malignancy and chemoresistance. Our data implicate the potential role of LRF as both a diagnostic marker and therapeutic target for chondrosarcomas.

Identification of a 3Kbp mechanoresponsive promoter region in the human cartilage oligomeric matrix protein gene.

Expression of chondrocyte-specific genes is regulated by mechanical force. However, despite the progress in identifying the signal transduction cascades that activate expression of mechanoresponsive genes, little is known about the transcription factors that activate transcription of mechanoresponsive genes. The DNA elements that confer mechanoresponsiveness within a cartilage gene promoter have yet to be identified. We have established an experimental system to identify the DNA elements and transcription factors that mediate the mechanoresponse of a promoter to nominal compressive stress in primary human chondrocytes and stem cells in a three-dimensional culture system. Our results demonstrate that the proximal 3 Kb of the human cartilage oligomeric matrix protein promoter is sufficient to mediate a mechanoresponse in human articular chondrocytes and stem cells, and that the magnitude of mechanoresponse correlates to the regulation of the endogenous gene at the RNA and protein level. This information is critical to understanding how mechanical force regulates the transcriptional activation of cartilage genes in three-dimensional culture.

The application of minimally invasive surgical techniques. Part I: total hip arthroplasty.

Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If satisfactory alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

The application of minimally invasive surgical techniques. Part II: total knee arthroplasty.

Traditional surgical approaches often involve making large skin incisions and extensively dissecting healthy tissue to access diseased anatomy. Obviously more desirable is to make smaller incisions and more focused dissections and achieve the same postsurgical outcomes. Minimally invasive surgery (MIS) is gaining popularity in many orthopedic fields, but MIS techniques are not without risk. Continued use of these techniques is a topic of debate. If alignment is satisfactory with MIS, and if the complication rates of MIS are similar to those of traditional approaches, it seems sensible to consider the less invasive approaches to enable earlier patient recovery and improve cosmesis. Skeptics claim that there is no advantage in using MIS over time-tested approaches and are concerned that MIS approaches are being implemented before being properly subjected to peer review.

Applying computer-assisted navigation techniques to total hip and knee arthroplasty.

Appropriate implant alignment is a major goal of total joint arthroplasty. Obtaining appropriate alignment typically involves making intraoperative decisions in response to visual and tactile feedback. Integrated computer-based systems provide the option of continuous real-time feedback and offer the potential to decrease intraoperative errors while enhancing the surgical learning experience. Computer-assisted orthopedic surgery helps the surgeon perform both intraoperative and postoperative technical audits of implant alignment. Improving implant alignment can be correlated with improved long-term clinical outcomes. However, despite emerging data, many surgeons remain wary of computer-assisted orthopedic surgery.

Current management options for osteonecrosis of the femoral head: part 1, diagnosis and nonoperative management.

Osteonecrosis of the femoral head is a multifactorial disease that can result in significant clinical morbidity and affects patients of any age, including young and active patients. Late sequelae of femoral head osteonecrosis include femoral head collapse and subsequent degeneration of the hip joint. A high index of suspicion and improved radiographic evaluation allow orthopedic surgeons to identify this disease at an earlier stage. Current management options for hip osteonecrosis have results that vary according to patient population and disease stage. Modifications of older techniques, as well as emerging technologies, have led to the development of management strategies that may be able to alter the course of femoral head osteonecrosis.

Enhanced activity of transforming growth factor ß1 (TGF-ß1) bound to cartilage oligomeric matrix protein.

Cartilage oligomeric matrix protein (COMP) is an important non-collagenous cartilage protein that is essential for the structural integrity of the cartilage extracellular matrix. The repeated modular structure of COMP allows it to "bridge" and assemble multiple cartilage extracellular matrix components such as collagens, matrilins, and proteoglycans. With its modular structure, COMP also has the potential to act as a scaffold for growth factors, thereby affecting how and when the growth factors are presented to cell-surface receptors. However, it is not known whether COMP binds growth factors. We studied the binding interaction between COMP and TGF-ß1 in vitro and determined the effect of COMP on TGF-ß1-induced signal transduction in reporter cell lines and primary cells. Our results demonstrate that mature COMP protein binds to multiple TGF-ß1 molecules and that the peak binding occurs at slightly acidic pH. These interactions were confirmed by dual polarization interferometry and visualized by rotary shadow electron microscopy. There is cation-independent binding of TGF-ß1 to the C-terminal domain of COMP. In the presence of manganese, an additional TGF-ß-binding site is present in the TSP3 repeats of COMP. Finally, we show that COMP-bound TGF-ß1 causes increased TGF-ß1-dependent transcription. We conclude that TGF-ß1 binds to COMP and that TGF-ß1 bound to COMP has enhanced bioactivity.

Total hip arthroplasty in above-knee amputees: a case report.

There are previous case reports in the literature that describe total knee and total hip arthroplasty (THA) in below-knee amputees, but we could find no case reports on above-knee amputees (AKAs) who have severe osteoarthritis of the hip. We present a case involving an AKA who developed severe osteoarthritis of the ipsilateral hip. Out patient underwent THA with a satisfactory postoperative outcome. Technical considerations for AKAs undergoing THA are also reviewed.