26Postoperative diagnosis and outcome in patients with revision arthroplasty for aseptic loosening.

BACKGROUND: The most common cause of implant failure is aseptic loosening (AL), followed by prosthetic joint infection (PJI). This study evaluates the incidence of PJI among patients operated with suspected AL and whether the diagnosis of PJI was predictive of subsequent implant failure including re-infection, at 2 years of follow up. METHODS: Patients undergoing revision hip or knee arthroplasty due to presumed AL from February 2009 to September 2011 were prospectively evaluated. A sonication fluid of prosthesis and tissue samples for microbiology and histopathology at the time of the surgery were collected. Implant failure include recurrent or persistent infection, reoperation for any reason or need for chronic antibiotic suppression. RESULTS: Of 198 patients with pre-and intraoperative diagnosis of AL, 24 (12.1 %) had postoperative diagnosis of PJI. After a follow up of 31 months (IQR: 21 to 38 months), 9 (37.5 %) of 24 patients in the PJI group had implant failure compared to only 1 (1.1 %) in the 198 of AL group (p < 0.0001). Sensitivity of sonicate fluid culture (>20 CFU) and peri-prosthetic tissue culture were 87.5 % vs 66.7 %, respectively. Specificities were 100 % for both techniques (95 % CI, 97.9-100 %). A greater number of patients with PJI (79.1 %) had previous partial arthroplasty revisions than those patients in the AL group (56.9 %) (p = 0.04). In addition, 5 (55.5 %) patients with PJI and implant failure had more revision arthroplasties during the first year after the last implant placement than those patients with PJI without implant failure (1 patient; 6.7 %) (RR 3.8; 95 % CI 1.4-10.1; p = 0.015). On the other hand, 6 (25 %) patients finally diagnosed of PJI were initially diagnosed of AL in the first year after primary arthroplasty, whereas it was only 16 (9.2 %) patients in the group of true AL (RR 2.7; 95 % CI 1.2-6.1; p = 0.03). CONCLUSIONS: More than one tenth of patients with suspected AL are misdiagnosed PJI. Positive histology and positive peri-implant tissue and sonicate fluid cultures are highly predictive of implant failure in patients with PJI. Patients with greater number of partial hip revisions for a presumed AL had more risk of PJI. Early loosening is more often caused by hidden PJI than late loosening.

Analysis of the bone microRNome in osteoporotic fractures.

Osteoporosis causes important morbidity among elderly individuals. Fragility fractures, and especially hip fractures, have a particularly negative impact on the patients' quality of life. The role of epigenetic mechanisms in the pathogenesis of many disorders is increasingly recognized, yet little is known about their role in non-malignant bone disorders such as osteoporosis. The aim of this study was to explore the expression of miRNAs in patients with osteoporotic hip fractures. Trabecular bone samples were obtained from the femoral heads of patients undergoing replacement surgery for osteoporotic hip fractures and non-fracture controls with hip osteoarthritis. Levels of 760 miRNA were analyzed by real-time PCR. Thirteen miRNAs showed nominally significant (p < 0.05) differences between both groups. Six miRNAs (miR-187, miR-193a-3p, miR-214, miR518f, miR-636, and miR-210) were selected for the replication stage. These miRNAs were individually analyzed in a larger group of 38 bone samples. At this stage, we confirmed statistically significant differences across groups for mir-187 and miR-518f. The median relative expression levels of miR-187 were 5.3-fold higher in the non-fracture group (p = 0.002). On the contrary, miR-518f was preferentially expressed in bones from osteoporotic patients (8.6-fold higher in fractures; p = 0.046). In this first hypothesis-free study of the bone microRNome we found two miRNAs, miR-187, and miR-518f, differentially regulated in osteoporotic bone. Further studies are needed to elucidate the mechanisms involved in the association of these miRNAs with fractures.

Wnt-related genes and large-joint osteoarthritis: association study and replication.

Osteoarthritis (OA) has a strong genetic component, and experimental evidence suggests the involvement of the Wnt pathway in its pathogenesis. Hence, we explored the association of common single nucleotide polymorphisms (SNPs) related to the Wnt pathway with hip and knee OA. Seventy-eight SNPs were analyzed in 606 patients undergoing joint replacement and in 680 control subjects. SNPs were located in WNT1, WNT10A, WNT16, DVL2, FZD5, BCL9, SFRP1, TCF7L1 and SFRP4 genes. SNPs significantly associated with OA were genotyped in an independent group of 369 patients and 407 controls. One SNP in WNT10A, rs3806557, was associated with hip OA in men (OR 0.65, 95% CI 0.46-0.93; p = 0.017), but the association was not confirmed in the replication phase. The TCF7L1 polymorphism rs11547160 was also associated with hip OA in the discovery set, but not in the replication set. Similarly, the SFRP4 SNP rs1052981 was associated with knee OA in women with OR of 2.73 (95% CI 1.29-5.8; p = 0.006), but the association was not replicated. The BCL9 polymorphism rs2353525 was associated with knee OA in women, both in the unadjusted and in the age- and BMI-adjusted analysis (OR 2.01; 95% CI 1.34-2.98; p = 0.0006). A similar, but not statistically significant, trend was observed in the replication phase. In the combined analysis, OR was 3.13 (1.34-7.28; p = 0.009). These data suggest that some SNPs of genes related to the Wnt pathway and, specifically BCL9, influence the genetic predisposition to osteoarthritis of the large joints in a sex- and joint-specific way.

Aromatase expression in osteoarthritic and osteoporotic bone.

OBJECTIVE: Estrogen deprivation is a central mechanism in the development of osteoporosis with aging. Results from recent studies also suggest the involvement of estrogens in the pathophysiology of osteoarthritis (OA). Aromatization of androgenic precursors in peripheral tissue is the main source of estrogens in postmenopausal women and in men. However, the importance of aromatase expression in bone is a subject of controversy. This study was undertaken to determine aromatase expression in bone samples from patients with hip fracture and patients with OA. METHODS: We studied 104 patients with hip fracture (n = 60) or primary hip OA (n = 44). Aromatase expression was determined in trabecular bone samples from the femoral neck and in osteoblast cultures grown by the primary explant technique (n = 62), using real-time reverse transcriptase-polymerase chain reaction. RESULTS: Aromatase RNA was detected in bone samples at levels similar to those found in adipose tissue. Transcript levels were significantly lower in bone tissue samples obtained from patients with OA than in those obtained from patients with fracture (P = 0.00001). Likewise, primary cultures of osteoblast cells from OA patients revealed lower aromatase expression than those of cells from fracture patients (P = 0.012). Results were independent of age or sex differences. CONCLUSION: Our findings indicate that the aromatase gene is expressed in bone tissue in high amounts, similar to those found in adipose tissue, but transcript levels are lower in tissue samples and osteoblast cultures from patients with OA than in those from patients with hip fracture. Since estrogens may help to prevent local cartilage degradation, it can be speculated that such a reduced expression of aromatase could facilitate the development of OA.