Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution.

PURPOSE: Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment. METHODS: A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). RESULTS: Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198). CONCLUSION: The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating. LEVEL OF EVIDENCE: Retrospective comparative study, Level IV.

Biologically Derived Neoproteoglycans for Profiling Protein-Glycosaminoglycan Interactions.

Glycosaminoglycans (GAGs) are a class of highly negatively charged membrane-associated and extracellular matrix polysaccharides involved in the regulation of myriad biological functions, including cell adhesion, migration, signaling, and differentiation, among others. GAGs are typically attached to core proteins, termed proteoglycans (PGs), and can engage >500 binding proteins, making them prominent relays for sensing external stimuli and transducing cellular responses. However, their unique substructural protein-recognition domains that confer their binding specificity remain elusive. While the emergence of glycan arrays has rapidly enabled the profiling of ligand specificities of a range of glycan-binding proteins, their adaptation for the analysis of GAG-binding proteins has been considerably more challenging. Current GAG microarrays primarily employ synthetically defined oligosaccharides, which capture only a fraction of the structural diversity of native GAG polysaccharides. Augmenting existing array platforms to include GAG structures purified from tissues or produced in cells with engineered glycan biosynthetic pathways may significantly advance the understanding of structure-activity relationships in GAG-protein interactions. Here, we demonstrate an efficient and tunable strategy to mimic cellular proteoglycan architectures by conjugating biologically derived GAG chains to a protein scaffold, defined as neoproteoglycans (neoPGs). The use of a reactive fluorogenic linker enabled real-time monitoring of the conjugation reaction efficiency and tuning of the neoPG valency. Immobilization of the reagents on a 96-well array platform allowed for efficient probing of ligand binding and enzyme-substrate specificity, including growth factors and the human sulfatase 1. The neoPGs can also be used directly as soluble probes to evaluate GAG-dependent growth factor signaling in cells.

Comminuted periprosthetic distal femoral fractures have greater postoperative extension malalignment.

INTRODUCTION: Comminution is a significant aspect of periprosthetic distal femoral fracture characterization and may influence post-surgical outcomes. Existing classification systems that guide treatment decisions do not take into account comminution and current literature is unclear on which surgical approach is optimal. We hypothesize that fractures with comminution will have poorer quality post-reduction alignment, especially with a lateral approach. MATERIALS AND METHODS: 37 study patients were identified with billing codes designating a distal femoral periprosthetic fracture. A retrospective chart review was performed to categorize fractures by absence or presence of comminution and medial parapatellar versus lateral surgical approach. These patients underwent an imaging evaluation for the primary outcome of reduction quality including the anatomic lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). Differences in radiographic outcomes were analyzed with Wilcoxon/Kruskal-Wallis tests, and analysis by approach was through Fisher's exact test. RESULTS: Patients with comminuted fractures had significantly greater extension of the fragment (PDFA = 95.4° vs 90.0°, p = 0.018) and similar coronal alignment (LDFA = 85.3° vs 86.3°, p = 0.83) of the knee compared to non-comminuted fractures after surgical reduction. This difference was more prominent amongst those treated with a lateral approach (PDFA = 96.1° vs 89.4°, p = 0.032) than with a medial approach (PDFA = 93.7° vs 91.5°, p = 0.41) (Table 1). DISCUSSION: Current classification systems and treatment guidelines for periprosthetic distal femoral fractures do not adequately address several issues that may influence treatment outcomes, especially comminution. Comminuted fractures had greater post-reduction extension malalignment, falling outside the recommended PDFA range of 87-90°, especially with a lateral approach. Consideration should be given to surgical approach and techniques to reduce excessive extension when treating comminuted periprosthetic distal femoral fractures.

Spatially controlled glycocalyx engineering for growth factor patterning in embryoid bodies.

Growth factor (GF) patterning in stem cell spheroids, such as embryoid bodies (EBs), has been sought to guide their differentiation and organization into functional 3D tissue models and organoids. Current approaches relying on exposure of EBs to gradients of GFs suffer from poor molecular transport in the spheroid microenvironment and from high cost of production and low stability of recombinant GFs. We have developed an alternative method for establishing GF gradients in EBs utilizing stem cell surface engineering with membrane-targeting heparan sulfate-glycomimetic co-receptors for GFs. We have capitalized on the ability of amphiphilic lipid-functionalized glycopolymers with affinity for FGF2 to assemble into nanoscale vesicles with tunable dimensions and extracellular matrix penetrance. Upon size-dependent diffusion into EBs, the vesicles fused with the plasma membranes of stem cells, giving rise to concentric gradients of cells with enhanced FGF2-binding. The extracellular matrix-assisted cell surface remodeling process described is the first example of spatially-targeted glycocalyx engineering in multicellular systems to control GF localization. The glycopolymer structure, vesicle dimensions, and remodeling conditions determine the level of FGF2 adhesion and gradient slope. The increased chemical and thermal stability of the synthetic glycomimetics and the tunability of their GF-binding profile, which is defined by their glycosylation and may be extended to other recombinant or endogenous morphogens beyond FGF2, further increase the versatility of this method.

Embryonic Stem Cell Engineering with a Glycomimetic FGF2/BMP4 Co-Receptor Drives Mesodermal Differentiation in a Three-Dimensional Culture.

Cell surface glycans, such as heparan sulfate (HS), are increasingly identified as co-regulators of growth factor signaling in early embryonic development; therefore, chemical tailoring of HS activity within the cellular glycocalyx of stem cells offers an opportunity to control their differentiation. The growth factors FGF2 and BMP4 are involved in mediating the exit of murine embryonic stem cells (mESCs) from their pluripotent state and their differentiation toward mesodermal cell types, respectively. Here, we report a method for remodeling the glycocalyx of mutant Ext1-/- mESCs with defective biosynthesis of HS to drive their mesodermal differentiation in an embryoid body culture. Lipid-functionalized synthetic HS-mimetic glycopolymers with affinity for both FGF2 and BMP4 were introduced into the plasma membrane of Ext1-/- mESCs, where they acted as functional co-receptors of these growth factors and facilitated signal transduction through associated MAPK and Smad signaling pathways. We demonstrate that these materials can be employed to remodel Ext1-/- mESCs within three-dimensional embryoid body structures, providing enhanced association of BMP4 at the cell surface and driving mesodermal differentiation. As a more complete understanding of the function of HS in regulating development continues to emerge, this simple glycocalyx engineering method is poised to enable precise control over growth factor signaling activity and outcomes of differentiation in stem cells.