Aims

The aim of this study was to evaluate whether achieving medial joint opening, as measured by the change in the joint line convergence angle (∆JLCA), is a better predictor of clinical outcomes after high tibial osteotomy (HTO) compared with the mechanical axis deviation, and to find individualized targets for the redistribution of load that reflect bony alignment, joint laxity, and surgical technique.

Stem cells are known to have low levels of intracellular reactive oxygen species (ROS) and high levels of glutathione. ROS are thought to interact with several pathways that affect the transcription machinery required for stem cell differentiation, and are critical for maintaining stem cell function. In this study, we are developing a new fluorescent probe that rapidly and reversibly reacts with glutathione (GSH), the most abundant non-protein thiol in living cells that acts as an antioxidant and redox regulator.

Multipotent perivascular progenitor cells derived from human ESCs (hESC-PVPCs): Differentiated ESCs as embryoid bodies in the presence of BMP4 to induce mesoderm differentiation followed by a simple cell selection strategy using attachment of single cells onto collagen-coated dishes. Differential gene expression profiling was performed among H9 hESCs, EBs induced by BMP4 and naturally selected CD140B+CD44+ population at Day 7 (PVPCs). Colony-forming assay: GSHhigh and GSHlow PVPCs were plated on 10-cm tissue culture-treated polystyrene dishes in triplicate in growth medium and cultured for 14 days. Transwell migration assay: GSHhigh and GSHlow PVPCs at passage 4 were resuspended at 1 × 10⁶/mL in the migration medium and seeded in the upper chamber. The following human recombinant SDF-1 and PDGF-AA proteins were used as chemoattractants in the lower compartment.

Probe-GSH conjugate shows shifts in fluorescence excitation and emission spectra that enables ratiometric measurement of GSH levels. Using these properties, stem cells can be purified by FACS-based technology according to intracellular GSH level. We are developing a protocol both for comparing GSH level in stem cell from different culture conditions and for preparing stem cells with high-GSH level . Our results reveal that GSHhigh PVPC purified by FACS show increased colony forming ability compared with that GSHlow PVPC, indicating that intracellular GSH contributes to the maintenance of stemness. Moreover, transplantation of GSHlow PVPC is more effective than that of GSHlow PVPC for cartilage regeneration in osteochondral defect.

This technique enable FACS-based sorting of stem cells according to intracellular GSH levels and thus investigation of functional role of GSH (high antioxidant capacity) in the stem cell maintenance and chondrogenic differentiation.

Purpose

Management and outcomes of fungal periprosthetic joint infection (PJI) remain unclear due to its rarity. Although two-stage exchange arthroplasty is considered a treatment of choice for its chronic features, there is no consensus for local use of antifungal agent at the 1st stage surgery. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer in two-stage exchange arthroplasty against chronic fungal PJIs after total knee arthroplasty (TKA).

Background

Rotational alignment is important for the long-term success and good functional outcome of total knee arthroplasty (TKA). While the surgical transepicondylar axis (sTEA) is the generally accepted landmark on the distal femur, a precise and easily identifiable anatomical landmark on the tibia has yet to be established. Our aim was to compare five axes on the proximal tibia in normal and osteoarthritic (OA) knees to determine the best landmark for determining rotational alignment during TKA.

Buechel and Pappas invented a modified version of LCS RP system (Co-Cr) with light material (Titanium), axial rotation limiting bar and improved conformity. The purpose of this prospective randomized study was to compare the minimum 3-year clinical outcomes including lightness, preference, and instability between the Co-Cr implant system and the Titanium implant system in bilateral total knee arthroplasty.

We prospectively enrolled 108 patients and 20 patients were lost to follow-up. Therefore, 88 patients (176 knees; mean age, 69.9±6.0years) were included in the study. The range of motion and clinical scores such as Knee Society score (KSS), Hospital for Special Surgery score (HSS) and Western Ontario and McMaster University (WOMAC) scores were measured preoperatively and postoperatively. At each follow-up, patients also complete a Likert scale questionnaire regarding subjective pain, lightness, left-right side preference (naturalness and satisfaction) and subjective instability.

There were no significant differences in all preoperative variables between two groups (p>.05). Mean follow-up period was 46.3±8.8 (36 to 72) months. The mean weight of Titanium implants was three times lighter than that of Co-Cr implants (133.9g versus 390.1g, p<.01). At the minimum of 3-year follow-up, there were no significant differences in pain, range of motion (ROM), clinical scores including KSS, HSS, and WOMAC between both groups. Also, the study showed no significant differences with subjective pain, lightness, preference (convenience, naturalness, and satisfaction), and subjective instability between the Co-Cr protheses and the Titanium protheses (p>.05).

No differences in clinical outcomes as well as subjective side-to-side differences between the Co-Cr prostheses and the Titanium prostheses were observed in the minimum 3-year follow-up. This implies that patients do not feel differently with two different weighted implants in mid-term follow-up.

Introduction

The purpose of this study was to determine whether the patient's perceived outcome and speed of recovery differs between a posterior cruciate ligament (PCL) substituting (cam-post type) and PCL sacrificing (ultracongruent polyethylene) total knee arthroplasty (TKA).

The long-term outcome and survivorship of TKA in Asian countries have been reported to be excellent, comparable to Western countries. However, increased knee flexion is required for many daily activities in Asian cultures, which remains a major problem to be resolved. High-flexion TKA designs have been introduced to improve flexion after TKA and to allow a high degree of flexion in a safe manner. However, several biomechanical studies have shown that high-flexion designs have a greater risk for the loosening of the femoral component compared to the conventional TKA designs. We evaluated the implant survival and the mid-term clinical and radiological outcomes of Asian patients who had undergone high-flexion TKA and assessed whether high-flexion activities increased the risk of premature failure.

We prospectively followed 72 Nexgen LPS-flex fixed TKA in 47 patients implanted by a single surgeon between March 2003 and September 2004. Five patients (6 knees) expired during follow-up. A Kaplan-Meier survivorship analysis using revision surgery as the end point was used to determine the probability of survival for the cohort and the equality of survival between two subgroups who could perform high-flexion activities or not. Median follow-up was 6.5 (0.9–8.6) years.

Twenty-five patients (33 knees) received a revision for aseptic loosening of the femoral component at a mean of 3.5 years (range, 0.9–7.8 years). According to the Kaplan-Meier survivorship analysis, the probabilities of survival without revision for aseptic loosening are 66.7% and 51.8% at 5 and 8 years, respectively. The 8-year cumulative survivorship is lower (30.6%) when squatting, kneeling, or sitting cross-legged could be achieved than if none of these activities were possible (78.3%). In the surviving knees, non-progressive radiolucent lines were observed around the femoral component of 12 patients (15 knees) and one tibial component.

The overall mid-term high-flex implant survival of our Asian cohort is lower than that of the conventional and other high-flexion designs. This unacceptable high rate of femoral component loosening is strongly associated with postoperative high flexion activities.

The purpose of this study was to validate the usefulness of SPECT/CT as an evaluation method for determining treatment and prognosis for patellofemoral cartilage lesions, based on MRI and arthroscopic findings.

From August 2009 to February 2010, SPECT/CT was performed on 80 patients (24 male and 56 female, average 53.3 years old) with chronic anterior knee pain who had no degenerative changes or patellar malalignment on plain radiographs. Radioisotope uptake findings on patellofemoral joint from SPECT/CT were classified into three grades by one nuclear medicine specialist. In the patients who demonstrated poor improvements after conservative treatments, MRI and arthroscopy were performed. Patellofemoral cartilage conditions under arthroscopic finding (ICRS grades) were compared with SPECT/CT grading.

In all cases, there were increased uptakes on patellofemoral joints. Eighteen cases showed low uptake (Group 1), 22 cases showed medium uptake (Group 2) and 40 cases high uptake (Group 3). At the follow-up examination after mean 1.7 months, 16 cases of Group 1 (89%), 14 cases of Group 2 (64%) and 28 cases of Groups3 (70%) responded positively to the conservative treatments. For those 22 cases showing poor improvement, MRI and arthroscopy were done. Damage or thinning of patellofemoral cartilage, subchondral cyst, edema and fissuring were observed in every case that underwent MRI. Every arthroscopic case was found that there was patellofemoral cartilage damage. Each of ICRS grade I and grade II was found in 2 cases from Group 1. Two cases of grade II, 4 cases of grade III, and 2 cases of grade IV were found in Group 2. Two cases of grade II, 4 cases of grade III, and 6 cases of grade IV were found in Group 3. There was significant difference in the success rate of conservative treatment between SPECT/CT grade 1 and 2 or 3. And there was significant association between SPECT/CT grade and ICRS grade (P=0.034).

SPECT/CT could be a useful modality in determining the treatment and prognosis for patellofemoral cartilage lesions compared with MRI and arthroscopic findings.

Primary total knee arthroplasty is associated with considerable blood loss, and allergenic blood transfusions are frequently necessary. Because of the cost and risks of allogenic blood transfusions, the autologous drainage blood reinfusion technique has been developed as an alternative. A number of studies have compared reinfusion techniques with standard suction drainage, but few reports compared with no drain use. We analyzed early results after primary total knee arthroplasty using autologous drainage blood reinfusion and no drain.

We selected 30 patients who underwent primary total knee arthroplasty using no drain between November 2005 and March 2006 and matched for age and gender with 30 patients who underwent primary total knee arthroplasty using autologous drainage blood reinfusion technique between January 2003 and October 2005. All operations were done under pneumatic tourniquet and meticulous hemostasis was performed after deflation of the tourniquet. We have retrospectively reviewed the preoperative data (age, gender, body mass index, diagnosis, history of the knee surgery, infection and anticoagulant therapy, and medical cormorbidities) and the postoperative data (hemoglobin, hematocrit and platelet during hospitalization, the amount of allogenic blood transfusion and narcotics, complications, rehabilitation process, and clinical scores).

All preoperative and postoperative variables except the postoperative second and seventh days hemoglobin and 2nd day hematocrit showed no significant differences between two groups. The hemoglobin and hematocrit also showed no significant differences at the postoperative fourteenth day.

The autologous drainage blood reinfusion method in primary total knee arthroplasty does not have significant clinical benefit over no-drain method with regards to allogenic blood transfusions, narcotics uses, the incidence of complications and rehabilitation processes.

Wound complication including superficial infection is a concern after total knee arthroplasties (TKA) in diabetics. However, influence of glycoregulation before TKA has not been investigated in relationship to wound healing. Our hypothesis was that glycated hemoglobin (HbA1C), since it reflects long-term regulation of blood glucose, might be associated with incidence of wound complications after TKA in diabetic patients.

We retrospectively reviewed 167 TKAs performed in 115 patients with diabetes mellitus between January 2001 and March 2007. All patients were diagnosed as type II DM and osteoarthritis. A wound complication was defined as a hematoma, bulla, drainage or superficial infection. Stepwise multivariate logistic regression was used to identify which variables had a significant effect on the risk of wound complications. Variables considered were age, gender, body mass index, histories of previous knee surgery, comorbidities, duration of diabetes, the methods of diabetes treatment, complications of diabetes, preoperative HbA1c level, operation time, antibiotics-impregnated cement use, the amount of blood transfusion, and postoperative blood glucose level.

The overall incidence of wound complications was 6.6% (n=11) including superficial infection in 1.8% (n=3), hematoma or bullae in 3.6% (n=6), and drainage in 1.8% (n=3). There were seven cases (4.2%) of deep infection. A multivariate logistic regression revealed that independent risk factors for the development of wound complications were preoperative HbA1C ≥ 8% (odds ratio 6.074, 95% confidence interval 1.119–32.971) and operation time (odds ratio 1.013, 95% confidence interval 1.000–1.026).

Poorly controlled hyperglycemia before surgery may increase the incidence of wound complications among diabetic patients receiving total knee arthroplasties. The correlation of glycemic control and wound complications may assist in the preoperative evaluation and selection of time for surgery.

To evaluate the radiographic mid-to long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem.

Among 27 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 36 months to 10 years, 3 months (mean, 76.6 months). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis.

Radiographic analysis showed very stable stem initially. 27 stems showed minimal subsidence (less than 0.005m) and 1 stem showed moderate subsidence (about 0.008m) in the cement. But there was no mechanical failure and subsidence at the composite-femur interface. Evidence of cortical and trabecular remodeling were observed in all cases. No radiolucent line or osteolysis were found in the follow-up period. There were 4 proximal femoral cracks and 1 distal femoral splitting during operation.

The result of cemented stem revision with the use of impacted cancellous allograft was good mid-to long-term. And femoral bone stock deficiency may be reconstructed successfully.