Clinical efficacy of greater trochanter osteotomy with tension wire fixation in total hip arthroplasty for Crowe type IV developmental dysplasia of the hip.

OBJECTIVE: The choice of osteotomy in joint replacement surgery for Crowe type IV developmental dysplasia of the hip (DDH) is a challenging and controversial procedure. In this study, we compared the clinical efficacy of a combination of greater trochanter osteotomy and tension wire fixation with that of subtrochanteric osteotomy. METHODS: We performed 15 primary total hip arthroplasty (THA) procedures between January 2016 and July 2020 on 13 patients with a combination of greater trochanter osteotomy and tension wire fixation (the GTT group) and 12 THA procedures in 11 patients using subtrochanteric osteotomy (the STO group). The mean follow-up was 2.8 years (range 2.2-4.5 years) in the GTT group and 2.6 years (range 2.5-4.3 years) in the STO group. Clinical scores and radiographic results were evaluated during the final follow-up for the 15 hips in the GTT group and 12 hips in the STO group. RESULTS: Postoperative Harris hip scores, implant position, and the surgery time did not differ between the treatment groups. There were no differences in preoperative leg length discrepancy LLD (P = 0.46) and postoperative LLD (P = 0.56) between the two groups. Bone union occurred within 6 months after surgery in 12 hips in the GTT group (92.3%) and in 9 hips (81.8%) in the STO group. One case in the GTT group and two cases in the STO group had nonunion, and additionally, there was one case of postoperative nerve injury in the STO group, while no symptoms of nerve damage were observed in the GTT group. CONCLUSION: The GTT method demonstrated many advantages and reliable clinical results for Crowe type IV DDH patients undergoing THA. This is a surgical method that warrants further development and promotion clinically.

Efficacy of Diosmin in Reducing Lower-Extremity Swelling and Pain After Total Knee Arthroplasty: A Randomized, Controlled Multicenter Trial.

BACKGROUND: Many patients experience lower-extremity swelling following total knee arthroplasty (TKA), which impedes recovery. Diosmin is a semisynthetic flavonoid that is often utilized to treat swelling and pain caused by chronic venous insufficiency. We aimed to evaluate the efficacy and safety of diosmin in reducing lower-extremity swelling and pain as well as in improving functional outcomes following TKA. METHODS: This study was designed as a randomized, controlled multicenter trial and conducted in 13 university-affiliated tertiary hospitals. A total of 330 patients undergoing TKA were randomized to either receive or not receive diosmin postoperatively. The diosmin group received 0.9 g of diosmin twice per day for 14 consecutive days starting on the day after surgery, whereas the control group received neither diosmin nor a placebo postoperatively. The primary outcome was lower-extremity swelling 1, 2, 3, and 14 days postoperatively. The secondary outcomes were postoperative pain assessed with use of a visual analogue scale, Hospital for Special Surgery score, range of knee motion, levels of the inflammatory biomarkers C-reactive protein and interleukin-6, and complications. RESULTS: At all postoperative time points, diosmin was associated with significantly less swelling of the calf, thigh, and upper pole of the patella as well as with significantly lower pain scores during motion. However, no significant differences in postoperative pain scores at rest, Hospital for Special Surgery scores, range of motion, levels of inflammatory biomarkers, or complication rates were found between the diosmin and control groups. CONCLUSIONS: The use of diosmin after TKA reduced lower-extremity swelling and pain during motion and was not associated with an increased incidence of short-term complications involving the outcomes studied. However, further studies are needed to continue exploring the efficacy and safety of diosmin use in TKA. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Oct4 facilitates chondrogenic differentiation of mesenchymal stem cells by mediating CIP2A expression.

Bone development and cartilage formation require strict modulation of gene expression for mesenchymal stem cells (MSCs) to progress through their differentiation stages. Octamer-binding transcription factor 4 (Oct4) expression is generally restricted to developing embryonic pluripotent cells, but its role in chondrogenic differentiation (CD) of MSCs remains unclear. We therefore investigated the role of Oct4 in CD using a microarray, quantitative real-time polymerase chain reaction, and western blotting. The expression of Oct4 was elevated when the CD of cultured MSCs was induced. Silencing Oct4 damaged MSC growth and proliferation and decreased CD, indicated by decreased cartilage matrix formation and the expression of Col2a1, Col10a1, Acan, and Sox9. We found a positive correlation between the expression of CIP2A, a natural inhibitor of protein phosphatase 2A (PP2A) and that of Oct4. Cellular inhibitor of PP2A (CIP2A) expression gradually increased after CD. Overexpression of CIP2A in MSCs with Oct4 depletion promoted cartilage matrix deposition as well as Col2a1, Col10a1, Acan, and Sox9 expression. The chondrogenic induction triggered c-Myc, Akt, ERK, and MEK phosphorylation and upregulated c-Myc and mTOR expression, which was downregulated upon Oct4 knockdown and restored by CIP2A overexpression. These findings indicated that Oct4 functions as an essential chondrogenesis regulator, partly via the CIP2A/PP2A pathway.

Fibrin Glue-Kartogenin Complex Promotes the Regeneration of the Tendon-Bone Interface in Rotator Cuff Injury.

OBJECTIVE: Rotator cuff injury healing is problematic because the tendon-bone junction often forms cicatricial tissues, rather than fibrocartilage, which leads to mechanical impairment and is prone to redamage. Kartogenin (KGN) is a newly discovered small molecule compound which can induce cartilage formation through chondrogenesis of endogenous mesenchymal stem cells. METHODS: In this study, we used KGN with fibrin glue (FG) to repair the rotator cuff injury by promoting the formation of fibrocartilage at the tendon to bone interface. Firstly, we assessed the release rate of KGN from the FG-KGN complex and then created a rabbit rotator cuff tendon graft-bone tunnel model. The rabbits received saline, FG-KGN, or FG injections onto the tendon to bone interface after injury. Shoulder tissues were harvested at 6 and 12 weeks, and the sections were stained with HE and Safranin O/Fast green. The samples were assessed by histologic evaluation and biomechanical testing. Synovial mesenchymal stem cells derived from the synovial tissue around the rotator cuff were harvested for western blotting and qRT-PCR analysis. RESULTS: KGN was released rapidly from the FG-KGN complex during first 4 hrs and followed by a slow release until 7 days. The tendon graft-bone interface in the control (saline) group and the FG group was filled with scar tissue, rather than cartilage-like tissue, and only a small number of chondrocytes were found at the adjacent bone surface. In the FG-KGN group, the tendon to bone interface was fully integrated and populated by chondrocytes with proteoglycan deposition, indicating the formation of fibrocartilage-like tissues. At 12 weeks, the maximum tensile strength of the FG-KGN group was significantly higher than that of the FG and control groups (P < 0.01). The RNA expression levels of tendinous genes such as Tenascin C and the chondrogenic gene Sox-9 were substantially elevated in SMSCs treated with the FG-KGN complex compared to the other two groups. CONCLUSION: These results indicated that fibrin glue is an effective carrier for KGN, allowing for the sustained release of KGN. The FG-KGN complex could effectively promote the regeneration and formation of fibrocartilage tissue of the tendon-bone interface in the rabbit rotator cuff tendon graft-bone tunnel model.

Exosomes from Kartogenin-Pretreated Infrapatellar Fat Pad Mesenchymal Stem Cells Enhance Chondrocyte Anabolism and Articular Cartilage Regeneration.

OBJECTIVE: To evaluate the effect of Kartogenin-pretreated exosomes derived from infrapatellar fat pad mesenchymal stem cells on chondrocyte in vitro and articular cartilage regeneration in vivo. METHODS: Infrapatellar fat pad mesenchymal stem cells (IPFP-MSCs) were isolated from rabbits to harvest exosomes. After identification of mesenchymal stem cells and exosomes, rabbit chondrocytes were divided into three groups for further treatment: the EXO group (chondrocytes treated with exosomes isolated from infrapatellar fat pad mesenchymal stem cells), KGN-EXO group (chondrocytes treated with exosomes isolated from infrapatellar fat pad mesenchymal stem cells pretreated with KGN), and control group. After processing and proliferation, phenotypic changes of chondrocytes were measured. In the in vivo study, 4 groups of rabbits with articular cartilage injury were treated with KGN-EXO, EXO, IPFP-MSCs, and control. Macroscopic evaluation and histological evaluation were made to figure out the different effects of the 4 groups on cartilage regeneration in vivo. RESULTS: The proliferation rate of chondrocytes in the EXO or KGN-EXO group was significantly higher than that in the control group (P < 0.05). The qRT-PCR results showed that the expression of Sox-9, Aggrecan, and Col II was the highest in the KGN-EXO group compared with the EXO group and the control group (P < 0.05). The results of Western blot were consistent with the results of qRT-PCR. In vivo, the cartilage defects in the KGN-EXO group showed better gross appearance and improved histological score than those in IPFP-MSC groups, EXO groups, and control groups (P < 0.05). At 12 weeks, the defect site in the KGN-EXO group was almost completely repaired with a flat and smooth surface, while a large amount of hyaline cartilage-like structures and no obvious cracks were observed. CONCLUSION: Our study demonstrates that the exosomes isolated from infrapatellar fat pad mesenchymal stem cells pretreated with KGN have potent ability to induce chondrogenic differentiation of stem cells, effectively promoting the proliferation and the expression of chondrogenic proteins and genes of chondrocytes. The KGN-EXO can also promote the repair of articular cartilage defects more effectively, which can be used as a potential therapeutic method in the future.

MiR-146a-5p promotes IL-1ß-induced chondrocyte apoptosis through the TRAF6-mediated NF-kB pathway.

OBJECTIVE: This study aimed to explore the role of the miR-146a-5p/TRAF6/NF-KB axis in chondrocyte apoptosis. METHODS: Transcriptome sequencing for microRNA expression in control and osteoarthritic cartilage was performed. Bioinformatic analysis was performed to identify the target genes of miR-146a-5p, and subsequently, Gene Ontology (GO) terms and KEGG pathways were identified. Furthermore, protein-protein interactions were analyzed to identify the hub regulatory gene of miR-146a-5p. MiR-146a-5p mimic, inhibitor and the corresponding negative control were constructed, and the apoptosis rates were measured in the transfected groups by flow cytometry, TUNEL staining and Western blot. Potential miRNA-target interactions were identified by dual-luciferase reporter assay. RESULTS: The microRNA array demonstrated that miR-146a-5p was significantly upregulated in osteoarthritic tissues, which was further confirmed by PCR analysis. Compared with the control group, IL-1ß significantly decreased the viability of chondrocytes, while coculture with miR-146a-5p inhibitor rescued the IL-1ß-induced inhibition of chondrocyte viability. Western blot results also identified the proapoptotic effects of miR-146a-5p. Bioinformatic analysis results revealed that miR-146a-5p targeted 159 potential genes, and TRAF6 was the hub gene among the 159 genes. The relative expression of TRAF6 was significantly decreased in the IL-1ß-induced group. When siTRAF6 was added, apoptosis was significantly increased. Luciferase reporter assays showed that luciferase activity of the TRAF6 3'-UTR reporter was decreased in chondrocytes after transfection with the miR-146a-5p mimic. CONCLUSIONS: This work showed that miR-146 induces chondrocyte apoptosis by targeting the TRAF6-mediated NF-KB signaling pathway, and miR-146 may be a potential target for OA treatment.

Cross-Cultural Adaptation and Validation of the Simplified Chinese Version of the Lower Extremity Functional Scale.

PURPOSE: The purpose of this study was to cross-culturally adapt and validate the Simplified Chinese version of the Lower Extremity Functional Scale (SC-LEFS). METHODS: The original English version of the Lower Extremity Functional Scale was translated and cross-culturally adapted into Simplified Chinese according to international guidelines. The SC-LEFS and 36-Item Short-Form Health Survey were administered to 213 patients with lower extremity musculoskeletal disorders. Psychometric properties including internal consistency, test-retest reliability, content validity, and construct validity were tested. RESULTS: There were no floor or ceiling effects for the SC-LEFS. The scale had high values for internal consistency (Cronbach α = 0.97) and test-retest reliability (intraclass correlation coefficient = 0.97). Corrected item-total correlations for every item ranged from 0.67 to 0.89. And the item-level content validity index (I-CVI) for each item ranged from 0.78 to 1.00. Principal component analysis revealed a one-factor structure. Nine of ten prior hypotheses were confirmed, which further supports good construct validity within the SC-LEFS. CONCLUSION: The SC-LEFS has high internal consistency, good test-retest reliability and content validity, convergent construct validity, and a one-factor structure. Thus, it could be regarded as a reliable and valid tool to assess activity limitations in Chinese patients with lower extremity musculoskeletal disorders.

Improved accumulation of TGF-ß by photopolymerized chitosan/silk protein bio-hydrogel matrix to improve differentiations of mesenchymal stem cells in articular cartilage tissue regeneration.

Articular cartilage regeneration is a challenging process due to its inadequate ability of self-recovering biological mechanisms. The progresses of cartilage tissue engineering is supported to overwhelmed the repairing difficulties and degenerative diseases. The main goal of the present study is to design biomaterials with suitable physico-chemical, mechanical and biological properties for the carrier of growth factor and improving differentiation of mesenchymal stem cell into damaged cartilage tissues. Herein, TGF-ß loaded hydrogel network was prepared through the chemical interactions between vinyl group of natural polymers. Fourier-transform infrared spectroscopy results show the characteristic peaks at 3074 cm-1, 1713 cm-1, and 810 cm-1, which confirm the existence of the vinyl group and successful formation of maleoyl functionalized Chitosan (MCh). The obtained MCh was freely dissolved in the distilled water up to 8% (w/v). X-ray photoelectron spectroscopy survey spectral results show a peak at 289.0 eV which revealed that the OCO and DS were 1.2% and also evidenced the methacryl substitution of Silk fibroin (SF) nanoformulations. The weight loss and mechanical test were analyzed and the results showed that MSF acts as a foremost crosslinking point with MCh through the reaction between the methacrylate groups of MSF and maleoyl groups of MCh which led to enhancing the density and improved the compressive strength. The maximum drug release activity was recorded in the TGF-ß loaded MCh@MSF hydrogel compared to bare MCh hydrogel. Further, the TGF-ß loaded MCh@ MSF hydrogel exhibited the cell viability percentage nearly at 79-102% for MC3T3-E1 and 88-104% for BMDSCs. Similarly, the TGF-ß loaded MCh@MSF exhibited the highest inhibitory activity against E. coli (83%) than S. aureus (67%). Overall, this study concluded the TGF-ß loaded MCh@MSF showed better biocompatibility and could be utilized in the field of cartilage tissue engineering.

[CONDITIONS OF SYNOVIAL MESENCHYMAL STEM CELLS DIFFERENTIATING INTO FIBROCARTILAGE CELLS].

OBJECTIVE: To explore the conditions of synovial derived mesenchymal stem cells (SMSCs) differentiating into the fibrocartilage cells by using the orthogonal experiment. METHODS: The synovium was harvested from 5 adult New Zealand white rabbits, and SMSCs were separated by adherence method. The flow cytometry and multi-directional differentiation method were used to identify the SMSCs. The conditions were found from the preliminary experiment and literature review. The missing test was carried out to screen the conditions and then 12 conditions were used for the orthogonal experiment, including transforming growth factor ß1 (TGF-ß1), bone morphogenic protein 2 (BMP-2), dexamethasone (DEX), proline, ascorbic acid (ASA), pyruvic acid, insulin + transferrin + selenious acid pre-mixed solution (ITS), bovin serum albumin (BSA), basic fibroblast growth factor (bFGF), intermittent hydraulic pressure (IHP), bone morphogenic protein 7 (BMP-7), and insulin-like growth factor (IGF). The L60 (212) orthogonal experiment was designed using the SPSS 18.0 with 2 level conditions and the cells were induced to differentiate on the small intestinal submucosa (SIS)-3D scaffold. The CD151+/CD44+ cells were detected with the flow cytometry and then the differentiation rate was recorded. The immumohistochemical staining, cellular morphology, toluidine blue staining, and semi-quantitative RT-PCR examination for the gene expressions of sex determining region Y (SRY)-box 9 gene (Sox9), aggrecan gene (AGN), collagen type I gene (Col I), collagen type II gene (Col II), collagen type IX gene (Col IX) were used for result confirmation. The differentiation rate was calculated as the product of CD151/CD44+ cells and cells with Col I high expression. The grow curve was detected with the DNA abundance using the PicoGreen Assay. The visual observation and the variances analysis among the variable were used to evaluate the result of the orthogonal experiment, 1 level interaction was considered. The q-test and the least significant difference (LDS) were used for the variance analysis with a type III calibration model. The test criteria (a) was 0.05. RESULTS: The cells were certified as SMSCs, the double-time of the cells was 28 hours. During the differentiation into the fibrocartilage, the volume of the SIS-3D scaffold enlarged double every 5 days. The scaffolds were positively stained by toluidine blue at 14 days. The visual observation showed that high levels of TGF-ß1 and BMP-7 were optimum for the differentiation, and BMP-7 showed the interaction with BMP-2. The conditions of DEX, ASA, ITS, transferrin, bFGF showed decreasing promotional function by degrees, and the model showed the perfect relevance. P value was 0.000 according to the variance analysis. The intercept analysis showed different independent variables brought about variant contribution; the TGF-ß1, ASA, bFGF, IGF, and BMP-7 were more remarkable, which were similar to the visual observation. CONCLUSION: In the process of the SMSCs differentiation into the fibrocartilage, the concentrations of TGF-ß1, ASA, bFGF, and IGF reasonably can improve the conversion rate of the fibrocartilage cells. The accurate conditions of the reaulatory factor should be explored further.

[PERIOPERATIVE BLOOD MANAGEMENT STRATEGIES FOR JOINT ARTHROPLASTY].

OBJECTIVE: To summarize the perioperative blood management strategies for joint arthroplasty. METHODS: The literature concerning preoperative, intraoperative, and postoperative blood management was reviewed and summarized. RESULTS: At present, a variety of blood management and conservation strategies are available. Preoperative strategies include iron supplementation, erythropoietin (EPO), and preoperative autologous donation (PAD). Intraoperative options include acute normovolemic hemodilution (ANH), antifibrinolytics, and the use of a tourniquet. Postoperative strategies include the use of reinfusion systems and guided transfusion protocols. Preoperatively, administration of either simple EPO or a combination of EPO and PAD can be efficacious in anemic patients. Intraoperatively, tourniquet use and tranexamic acid can effectively control bleeding. Postoperatively, appropriate transfusion indications can avoid unnecessary blood transfusions. CONCLUSION: Perioperative blood management strategies for joint arthroplasty should be integrated for the individual patient using a variety of ways to reduce perioperative blood loss and blood transfusion, and promote the rehabilitation of patients.

[In vitro differentiation of synovial-derived mesenchymal stem cells infected by adenovirus vector mediated by bone morphogenetic protein 2/7 genes into fibrocartilage cells in rabbits].

OBJECTIVE: To investigate the feasibility of rabbit synovial-derived mesenchymal stem cells (SMSCs) differentiating into fibrocartilage cells by the recombinant adenovirus vector mediated by bone morphogenetic protein 2/7 (BMP-2/7) genes in vitro. METHODS: SMSCs were isolated and purified from 3-month-old New Zealand white rabbits [male or female, weighing (2.1 +/- 0.3) kg]; the morphology was observed; the cells were identified with immunocytological fluorescent staining, flow cytometry, and cell cycles. The adipogenic, osteogenic, and chondrogenic differentiations were detected. The recombinant plasmid of pAdTrack-BMP-2-internal ribosome entry site (IRES)-BMP-7 was constructed and then was used to infect SMSCs. The cell DNA content and the oncogenicity were tested to determine the safety. Then infected SMSCs were cultured in incomplete chondrogenic medium in vitro. Chondrogenic differentiation of infected SMSCs was detected by RT-PCR, immunofluorescent staining, and toluidine blue staining. RESULTS: SMSCs expressed surface markers of stem cells, and had multi-directional potential. The transfection efficiency of SMSCs infected by recombinant plasmid of pAdTrack-BMP-2-IRES-BMP-7 was about 70%. The safety results showed that infected SMSCs had normal double time, normal chromosome number, and normal DNA content and had no oncogenicity. At 21 days after cultured in incomplete chondrocyte medium, RT-PCR results showed SMSCs had increased expressions of collegan type I and collegan type II, particularly collegan type II; the expressions of RhoA and Sox-9 increased obviously. Immunofluorescent staining and toluidine blue staining showed differentiation of SMSCs into fibrocartilage cells. CONCLUSION: It is safe to use pAdTrack-BMP-2-IRES-BMP-7 for infecting SMSCs. SMSCs infected by pAdTrack-BMP-2-IRES-BMP-7 can differentiate into fibrocartilage cells spontaneously in vitro.