The Effect of Smoking on Endothelial Dysfunction in Autosomal Dominant Polycystic Kidney Disease Patients with Preserved Renal Function

BackgroundIn autosomal dominant polycystic kidney disease (ADPKD), endothelial dysfunction (ED) is common and occurs much earlier than kidney function impairment. The impact of smoking on ED in ADPKD patients has not been previously studied. The aim of this study was to investigate the potential contribution of smoking habits to ED and subclinical atherosclerosis in these patients.MethodsThis case-control study included 54 ADPKD patients with preserved renal function and 45 healthy control subjects. ED was assessed using ischemia-induced forearm flow-mediated dilatation (FMD). Carotid intima-media thickness (CIMT) was measured from 10 mm proximal to the right common carotid artery. Clinical demographic characteristics and laboratory data were recorded for the patients and control group. Regression analysis was used to determine independent associations of ED and CIMT.ResultsFMD was significantly lower in the ADPKD patients (19.5 ± 5.63 vs. 16.56 ± 6.41, p = .018). Compared with nonsmoker ADPKD patients, smoker patients had significantly lower FMD values (18.19 ± 6.52 vs. 13.79 ± 5.27, p = .013). In multiple regression analysis, age (β = –0.294, 95% CI: −0.392: −1.96, p = .001) for FMD and smoking (β  =  1.328, 95% CI: 0.251, 2.404, p = .017) for CIMT were independent predictors.ConclusionsPatients with ADPKD had more impaired endothelial function and subclinical atherosclerosis compared with control subjects. Smoking may increase the risk of subclinical atherosclerosis in ADPKD patients.     

Left Ventricular Hypertrophy Is More Prevalent in Type B than Type A Aortic Dissection

Objectives: Several factors determining differences between types A and B aortic dissection (AD) have been reported; however, little data exist examining their differences in left ventricular hypertrophy (LVH). We compared the prevalence of LVH in patients with types A and B AD.Methods: We retrospectively analyzed 334 patients with acute AD (227 type A; 107 type B). Concentric hypertrophy (CH; increased left ventricular mass index [LVMI] and relative wall thickness [RWT]) is one of four types of left ventricular (LV) geometry thought to be most associated with hypertension. We compared LVMI and the prevalence of CH in patients with types A or B AD. Multivariate logistic regression analyses of variables associated with type B AD were performed.Results: Comparing type A and B AD, LVMI (95 ± 26 vs.107 ± 28, p <0.001) and prevalence of CH (26% vs. 44%, p = 0.001) were higher in type B AD. In multivariate analysis, CH was an independent factor associated with type B AD (odds ratio: 2.62, confidence interval: 1.54–4.47, p <0.001).Conclusions: Our data suggested LVH was more prevalent in type B than in type A AD. Considering LVH usually results from hypertension, patients with type B AD may be more affected by hypertension than those with type A.     

Association between red blood cell distribution width and non-valvular atrial fibrillation in hemodialysis patients: a single-center Chinese population study

BackgroundRed blood cell distribution width (RDW) has emerged as a prognostic marker of atrial fibrillation (AF) in various clinical settings. However, the relationship by which RDW was linked to AF in hemodialysis (HD) patients was not clear. We sought to reveal the relationship between RDW and AF occurrence in HD patients.MethodsWe enrolled 170 consecutive maintenance HD patients, including 86 AF patients and 84 non-AF patients. All participants’ medical history and detailed clinical workup were recorded before the first dialysis session of the week. Electrocardiography, laboratory and transthoracic echocardiography examination indices were compared between the AF group and non-AF group. Multivariable logistic regression analysis was performed to identify the independent predictors of AF occurrence in HD patients.ResultsThere were all paroxysmal AF patients in AF group. Compared to the non-AF group, patients with AF group had a significantly older age (61.0 ± 1.48 vs. 49.71 ± 1.79, p < 0.001), lower BMI (24.3 ± 4.11 vs. 25.8 ± 3.87, p < 0.05), higher RDW (15.10 ± 0.96 vs. 14.26 ± 0.82, p < 0.001) and larger LAD (39.87 ± 3.66 vs. 37.68 ± 5.08, p < 0.05). Multivariable logistic regression analyses demonstrated that values of age (OR: 1.030, 95%CI: 1.004-1.057, per one- year increase), BMI (OR: 0.863, 95%CI: 0.782–0.952, per 1 kg/m² increase), RDW (OR: 2.917, 95%CI: 1.805–4.715, per 1% increase) and LAD (OR: 1.097, 95%CI: 1.004–1.199, per 1 mm increase) were independently associated with AF occurrence (p < 0.05, respectively). The best cutoff value of RDW to predict AF occurrence was 14.65% with a sensitivity of 68.6% and a specificity of 72.6%.ConclusionsThe increased RDW was significantly associated with the paroxysmal AF occurrence in HD patients.     

A Comparative Study of a New Retractor‐Assisted WILTSE TLIF,MIS‐TLIF,and Traditional PLIF for Treatment of Single‐Level Lumbar Degenerative Diseases

ObjectivesTo compare the clinical efficacy of a new retractor‐assisted Wiltse transforaminal lumbar interbody fusion (TLIF), minimally invasive TLIF (MIS‐TLIF), and traditional posterior lumbar interbody fusion (PLIF) in treating single‐level lumbar degenerative diseases.MethodsA retrospective study was conducted by analyzing the clinical and imaging data of consecutive patients with single‐level lumbar degenerative diseases who underwent the new retractor‐assisted Wiltse TLIF, MIS‐TLIF, or traditional PLIF. This study enrolled 87 concurrent patients between June 2016 and December 2019 (Wiltse TLIF 29 cases; MIS‐TLIF 28 cases; PLIF 30 cases). The three groups were compared for perioperative indicators (including intraoperative blood loss, postoperative drainage volume, operation time, intraoperative fluoroscopy time, bedridden time), creatine kinase (CK), visual analog score (VAS), Oswestry disability index (ODI), Japanese Orthopaedic Association (JOA) score, intervertebral fusion rate, muscle atrophy, and fatty infiltration (including ratio of multifidus atrophy and ratio of lean‐to‐total cross‐sectional area [CSA]).ResultsIntraoperative blood loss (F = 62.628, p < 0.001), postoperative drainage volume (F = 72.048, p < 0.001), and bedridden time (χ² = 62.289, p < 0.001) were significantly lower in the MIS‐TLIF and Wiltse groups than in the PLIF group. The operative and intraoperative radiation times of the MIS‐TLIF group were significantly longer than those of the Wiltse and PLIF groups. The CK concentration in the Wiltse and MIS‐TLIF groups were significantly lower than those in the PLIF group 1 day (F = 9.331, p < 0.001) and 3 days after surgery (F = 15.967, p < 0.001). The PLIF group''s back pain VAS score was higher than those of the Wiltse and MIS‐TLIF groups. The PLIF group had a higher ODI 6 months (F = 3.282, p = 0.042) and 12 months (F = 5.316, p = 0.007) after surgery and a lower JOA score than the Wiltse and MIS‐TLIF groups 6 months (F = 3.234, p = 0.044) and 12 months (F = 3.874, p = 0.025) after surgery. The ratio of multifidus atrophy in the PLIF group (41.70 ± 8.84%) was significantly higher than those of the Wiltse group (24.13 ± 6.82%) and the MIS‐TLIF group (22.35 ± 5.03%). The ratio of lean‐to‐total CSA in the PLIF group was lower than those of the Wiltse and MIS‐TLIF groups after surgery (F = 8.852, p < 0.001). MIS‐TLIF group showed longer operation time (169.11 ± 29.38 min) and intraoperative fluoroscopy time (87.61 ± 3.13 s) than the Wiltse group.ConclusionWiltse TLIF assisted by the new retractor is a more convenient and minimally invasive surgical method than the traditional PLIF and MIS‐TLIF methods, which are linked to a long learning curve and long operation and fluoroscopy time.     

Reduction in Bone Volume Resection with a Newer Posterior Stabilized Total Knee Arthroplasty Design

Background

Posterior stabilized total knee arthroplasty requires an intercondylar notch to accommodate the cam housing that articulates with the tibial post to create femoral rollback required for deep flexion. The volume of bone resected for the intercondylar notch varies with implant design, and newer designs may accommodate high flexion with less bone resection.

Questions/Purposes

This study aims to analyze the bone volume and density resected from the intercondylar notch for three posterior stabilized implants from a single company: a Posterior Stabilized (PS) system, a Hi-Flex system (HF), and a rounded new box-reamer (RB) system and to further assess whether the newer RB with a cylindrical cutting tool would preserve more native bone.

Materials and Methods

Using a computer model, the PS, HF, and RB femoral components were digitally implanted into CT scans of 19 cadaver femurs. Nine cadavers were fit with a size 4 implant, six with size 3, and four with a size 2. The volume of intercondylar bone resected digitally for femoral preparation was measured. Bone density was measured by CT scans in Hounsfield units (HU). A paired t test was used to compare the mean volume of bone resected for each implant.

Results

For the size 4 femurs, the newer RB design removed 8% less intercondylar bone than the PS design (7,832 ± 501 vs. 8,547 ± 377 mm³, p < 0.001) and 28% less bone than the HF design (7,832 ± 501 vs. 10,897 ± 444 mm³, p < 0.001). The average HU for size 4 femurs for RB design was 427 ± 72 (PS = 399 ± 69, p < 0.001; HF = 379 ± 66, p < 0.001). For the size 3 femurs, the RB design removed 12% less intercondylar bone than the PS (6,664 ± 786 vs. 7,516 ± 648 mm³, p < 0.001) and 27% less bone than the HF (6,664 ± 786 vs. 9,078 ± 713 mm³, p < 0.001). HU for size 3 femurs for the RB design was 452 ± 70 (PS = 422 ± 53, p < 0.1; HF = 410 ± 59, p < 0.01). For the size 2 femurs, the RB design removed 5% less intercondylar bone than the PS (5,730 ± 552 vs. 6,009 ± 472 mm³, p < 0.01) and 22% less bone than the HF (5,730 ± 552 vs. 7,380 ± 532 mm³, p < 0.001). HU for size 2 femurs for the RB design was 430 ± 48 (PS = 408 ± 55, p < 0.01; HF = 385 ± 56, p < 0.01).

Conclusions

The newer RB design removes less bone from the intercondylar notch than the classic PS and HF designs in all sizes tested. The bone-conserving cuts incorporated into this newer implant design appear to preserve native bone without compromising design objectives.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9340-1) contains supplementary material, which is available to authorized users.     

Medium Activity Prevents Periprosthetic Bone Mass Loss in the Medial Metaphyseal Region of the Tibia after Posterior‐Stabilized TKA: A 5‐Year Follow‐up Study of 110 Knees

ObjectiveThe bone mass around the prosthesis plays an important role in the stability of the prosthesis. This study aimed to assess the effect of postoperative activity on bone mineral density (BMD) in the proximal tibia 5 years after total knee arthroplasty (TKA). To provide a scientific guidance for postoperative functional exercise.Methods110 patients underwent unilateral primary TKA were divided into three groups based on the University of California Los Angeles (UCLA) activity scale: low activity group (LA group, UCLA = 4, 5); medium activity group (MA group, UCLA = 6, 7); and high activity group (HA group, UCLA = 8, 9). The primary observation was a comparison of the BMD and BMD change percentage (ΔBMD (%)) in the periprosthetic tibia among the LA, MA and HA groups at 1 year, 3 years and 5 years. The secondary observations were radiographic evaluation (prosthetic stability, periprosthetic fractures, aseptic loosening and periprosthetic joint infection) and clinical evaluation (Knee Society Score (KSS), visual analogue score scores and range of motion (ROM)). A one‐way ANOVA was used to compare the clinical scores and BMD among the three groups.ResultsThe BMD of medial region decreased by 10.80%, 12.64%, 13.61% at 1, 3, and 5 years respectively; these were 5.72%, 6.26%, 7.83% in lateral region and 1.42%, 1.78%, 3.28% in diaphyseal region. For medial metaphyseal region, the BMD of the MA group was significantly greater than that of the LA and HA groups at 1 and 3 years (108.9 ± 5.2 vs. 106.1 ± 6.69 vs. 105.4 ± 5.2 and 108.5 ± 6.0 vs. 101.2 ± 6.76 vs. 103.0 ± 6.8, P < 0.01 and P < 0.001), and the BMD changes (ΔBMD (%)) in the MA group were significantly smaller than those in the LA and HA groups (8.75 ± 5.36 vs. 11.92 ± 5.49 vs. 12.70 ± 5.21 and 9.11 ± 5.11 vs. 16.04 ± 4.79 vs. 14.82 ± 4.26, P < 0.01 and P < 0.001).Regarding secondary observations, all of the prostheses were assessed as stable, without periprosthetic fractures, aseptic loosening and periprosthetic joint infection. Regarding KSS scores, there was no significant difference among the three groups. However, the VAS and ROM of the HA group were better than those of the MA and LA groups (1.65 ± 0.79 vs. 2.63 ± 0.77 vs. 3.00 ± 1.17, p < 0.001, and 111.90 ± 9.17 vs. 110.20 ± 6.78 vs. 102.90 ± 8.48, P < 0.001).ConclusionMedium activity prevented periprosthetic bone loss in the medial metaphyseal region of the tibia after posterior‐stabilized TKA, and moderate‐intensity exercise is recommended for patients after TKA to reduce periprosthetic bone loss.     

Patellofemoral Joint after Opening Wedge High Tibial Osteotomy: A Comparative Study of Uniplane versus Biplane Osteotomies

ObjectiveTo the best of our knowledge, there has been no comparative study of changes in radiographic parameters in the sagittal plane between biplane opening wedge high tibial osteotomy (OWHTO) with plate fixation and uniplane OWHTO with spacer implantation. The aim of the study was to compare sagittal radiographs between the procedures of biplane and uniplane OWHTOs in patients with genu varum and to investigate the impact on the patellofemoral joint.MethodsA retrospective study of 71 patients (58.0 ± 5.0 years of age, 58 females and 13 males) with varus‐aligned medial compartment knee osteoarthritis treated with OWHTO was performed during the period from January 2016 to February 2019. Thirty‐three patients underwent biplane osteotomy with plate fixation (biplane group), and 38 patients underwent uniplane osteotomy with absorbable wedged spacer fixation (uniplane group). Independent t tests were used to compare the two groups according to the preoperative and postoperative radiographic parameters of hip‐knee‐ankle (HKA) angle, posterior tibial slope (PTS), tibial tubercle prominence (TTP), Caton–Deschamps (CD) index, and Blackburne–Peel (BP) index. During the last follow‐up assessment, patients were asked to rate their patellofemoral joint status using the Samsung Medical Center (SMC) patellofemoral (PF) scoring system. The visual analog scale (VAS) was also used to rate knee joint pain when walking.ResultsThere was no significant difference between the two groups in any of the demographic, clinical, or radiological characteristics at baseline (p > 0.05). Comparisons of postoperative sagittal radiographic parameters between patients in the uniplane group and patients in the biplane group showed significant differences in the PTS (13.4° vs 16.6°, t = 4.465, p < 0.001), TTP (9.0 mm vs 4.2 mm, t = 7.950, p < 0.001), and CD index (0.81 vs 0.70, t = 4.035, p < 0.001). At the final follow‐up assessment (minimum, 2 years), the SMC PF function score was significantly lower in patients in the uniplane group than in patients in the biplane group (27.8 vs. 32.1, t = 2.458, p = 0.016), but there were no significant differences in the SMC PF pain score or VAS score (p > 0.05).ConclusionThe essential difference in the postoperative sagittal radiographic changes between biplane and uniplane OWHTO was the tibial tubercle prominence, indicating the posterior displacement of the tibial tubercle. Uniplane OWHTO may yield better function of the patellofemoral joint compared to biplane OWHTO.     

Borderline Developmental Dysplasia of the Hip: A Risk Factor Predicting the Development and Poor Prognosis after Core Decompression for Idiopathic Osteonecrosis of the Femoral Head

ObjectiveIt is unclear whether idiopathic osteonecrosis of the femoral head (ONFH) is associated with borderline developmental dysplasia of the hip (BDDH). This study aimed to compare the incidence of BDDH between patients with idiopathic ONFH and matched control subjects and determine the influence of BDDH on poor prognosis after core decompression (CD).MethodsWe retrospectively examined 78 consecutive patients (111 hips) with idiopathic ONFH undergoing CD and 1:2 matched with 156 control subjects (222 hips). The anteroposterior pelvic radiographs were used to measure the acetabular anatomical parameters and divide included subjects into BDDH or non‐BDDH group. The incidence of BDDH and acetabular anatomical parameters were compared between patients with idiopathic ONFH and matched controls. Clinical outcomes, such as Harris Hip Score (HHS), progression of collapse, and conversion to total hip arthroplasty (THA), were compared between patients with BDDH and without BDDH in the idiopathic ONFH group, with a mean follow‐up of 72.1 ± 36.6 months.ResultsPatients with idiopathic ONFH had a significantly higher incidence of BDDH than matched controls (29.7% vs 12.2%, p < 0.001). Less acetabular coverage was also found in patients with idiopathic ONFH than in matched controls as demonstrated by lower CEA (28.5° ± 4.7° vs 33.1° ± 5.7°, p < 0.001), AHI (82.4 ± 5.0 vs 86.3 ± 5.4, p < 0.001), ADR (299.6 ± 28.4 vs 318.8 ± 31.3, p < 0.001), and a higher sharp angle (40.0° ± 3.4° vs 37.4° ± 3.7°, p < 0.001). In patients with idiopathic ONFH, the BDDH group had a significantly lower mean HHS at the last follow‐up (83.5 ± 17.4 vs 91.6 ± 9.7, p = 0.015) with a different score distribution (p = 0.004), and a lower 5‐year survival rate with both clinical failure (66.7%, 95% CI 52.4%–84.9% vs 83.7%, 95% CI 75.2%–93.1%; p = 0.028) and conversion to THA (74.6%, 95% CI 60.7%–91.6% vs 92.1%, 95% CI 85.6%–99.0%; p = 0.008) as the endpoints than the non‐BDDH group.ConclusionThe incidence of BDDH was significantly higher in patients with idiopathic ONFH than matched controls, and idiopathic ONFH patients who underwent CD with BDDH had lower mean HHS as well as 5‐year survival rate than those without BDDH. Therefore, BDDH should be considered a risk factor predicting the development of idiopathic ONFH as well as poor prognosis after CD.     

Anti-phospholipase A2 receptor antibodies directly induced podocyte damage in vitro

BackgroundThe pathogenesis of primary membranous nephropathy (MN) involves the antibodies against antigens on the cell surface of podocytes, with the majority of M-type phospholipase A2 receptor (PLA2R), and a profound podocyte dysfunction. The effects of anti-PLA2R antibodies directly to the podocytes remain unclear.MethodsAnti-PLA2R antibodies from patients with PLA2R-associated MN were affinity-purified using a column coupled with recombinant human PLA2R protein. Their effects on conditionally immortalized human podocytes were assessed by apoptosis assays, cellular calcium detection, wound healing assay, and immunofluorescent staining. Proteomics analysis was performed by LC-MS/MS and on PANTHER database.ResultsThe stimulation by anti-PLA2R antibodies could induce early-stage apoptosis of podocytes (MFI of Annexin V = 104.3 ± 19.2 vs. 36.7 ± 7.6, p = 0.004). The increase of calcium concentration in podocytes (MFI = 3309.3 ± 363.6 vs. 1776.3 ± 212.7, p = 0.015) might attribute to the endoplasmic reticulum calcium efflux. The expression of calcium/calmodulin-dependent protein kinase IV (CaMK4) was also increased (MFI = 134.4 ± 9.8 vs. 105.3 ± 10.1, p = 0.011). Proteomics results suggested that anti-PLA2R antibody treatment led to damage on cellular structure, and produced functional disorders on protein binding, actin filament binding, and microtubule motor activity. The staining of F-actin on foot process was reduced (MFI = 27.3 ± 2.8 vs. 47.5 ± 1.0, p = 0.001) and the motility and adherence capacity of podocytes were reduced (number of migrated cells = 44.7 ± 3.1 vs. 53.3 ± 4.9, p = 0.001) after incubation with anti-PLA2R antibodies.ConclusionThese data indicate that anti-PLA2R antibodies may directly induce podocyte damage independent of the complement system, which expands the mechanism of anti-PLA2R antibodies on MN.     

Analysis of the Effect of Antibiotic Bone Cement in the Treatment of Diabetic Foot Ulcer through Tibia Transverse Transport

ObjectiveTo explore the efficacy of antibiotic bone cement (ABC) combined with the modified tibial transverse transport (mTTT) on the treatment of severe diabetic foot with infection.MethodsA retrospective cohort study was conducted of 243 patients with TEXAS grade 3/4 stage D diabetic foot ulcers from December 2016 to December 2019. A total of 115 patients treated with mTTT were classified as the mTTT group (78 male and 37 female, mean age: 70.4 ± 6 years) and 128 patients who were treated with ABC combined with mTTT were in the ABC + mTTT group (89 male and 39 female, mean age: 68.9 ± 8 years). Follow‐up records during treatment and 6 months after surgery were collected, including the time required for white blood cells (WBC) and C‐reactive protein (CRP) to return to normal range, wound healing time, pain visual analog scale (VAS), ankle‐brachial index (ABI), foot skin temperature, transcutaneous oxygen pressure measurement (TcPO₂), complications, and other indicators. Normally distributed data were compared using the independent sample t‐test, non‐normally distributed data were analyzed by one‐way ANOVA analysis of variance.ResultsThere were 128 cases in the ABC + mTTT group (89 male and 39 female, mean age: 68.9 ± 8 years) treated with ABC and mTTT, and 115 cases in the TTT group (78 male and 37 female, mean age: 70.4 ± 6 years) treated with mTTT alone. The time required for WBC and CRP to return to the normal range and wound healing time in the ABC + mTTT group were significantly shorter than those in the mTTT group (12.9 ± 4.6 vs. 22.6 ± 1.6 days, t = 3.979, p < 0.001; 25.3 ± 1.3 vs. 31.3 ± 2.3 days, t = 4.261, p = 0.001; 11.9 ± 3.8 vs. 15.9 ± 3.9 days, t = 4.539, p < 0.001). There were no significant intergroup differences in the foot skin temperature, VAS score, ABI, and TcPO₂ (t = 0.349, 0.542, 0.765, 0.693 while all p > 0.05).ConclusionAlthough the application of ABC with mTTT for treatment of diabetic foot ulcers did not affect the wound healing time and ankle blood supply in the mid‐term, it could control ulcer infection faster and accelerate wound healing.     

Posterior Pelvic Tilt in the Standing Position Might Be Associated with Collapse Progression in Post‐Collapse Stage Osteonecrosis of the Femoral Head

ObjectiveExcessive pelvic tilt has been reported to impair the biomechanical loading of the hip joint. However, the influence of pelvic tilt in osteonecrosis of the femoral head (ONFH) remains unclear. This study aims to assess whether sagittal pelvic posture in the standing position correlates with progression of femoral head collapse in post‐collapse stage ONFH.MethodsThis is a single‐center retrospective study. We investigated 107 patients (107 hips; 73 males and 34 females; mean age, 48 years) diagnosed with Association of Research Circulation Osseous (ARCO) stage III ONFH at the first visit and who subsequently underwent surgical treatment in our institution from July 2016 to December 2020. The sagittal pelvic posture in the standing position before surgery was quantified as the angle formed by the anterior pelvic plane and the vertical z‐axis in the sagittal view (APP angle). An APP angle <0° indicated posterior pelvic tilt. Progression of femoral head collapse was calculated as collapse speed. The following factors potentially associated with collapse speed were evaluated by exploratory data analysis followed with multiple linear regression analysis: sex, age, BMI, etiology, pelvic incidence, contralateral hip condition, time interval between the first visit and surgery, size of necrotic lesion, location of necrotic lesion, and APP angle.ResultsAs ONFH progressed from ARCO stage IIIA to stage IV, APP angle decreased significantly and continuously (stage IIIA, −0.2° ± 5.5°; stage IIIB, −3.7° ± 5.8°; stage IV, −7.1° ± 6.4°). The factors significantly associated with collapse speed were size of necrotic lesion (p = 0.0079), location of necrotic lesion (p = 0.0190), and APP angle (p < 0.0001). APP angle showed a negative correlation with collapse speed (r = −0.40, p < 0.0001). After stratifying by size of necrotic lesion (<50% and ≥50% involvement) and location of necrotic lesion (JIC type C1 and C2), a significant negative correlation was observed between APP angle and collapse speed in each group (JIC type C1 with <50% involvement, r = −0.69, p < 0.0001; JIC type C1 with ≥50% involvement, r = −0.58, p = 0.0475; JIC type C2 with <50% involvement, r = −0.51, p = 0.0124; JIC type C2 with ≥50% involvement, r = −0.39, p = 0.0286).ConclusionsOur results suggest that posterior pelvic tilt in the standing position occurred as ONFH progressed from ARCO stage IIIA to stage IV, which might be associated with progression of femoral head collapse in ONFH.     

Mid‐Term Outcomes of Navigation‐Assisted Primary Total Knee Arthroplasty Using Adjusted Mechanical Alignment

ObjectiveThe adjusted mechanical alignment (aMA) technique is an extension of conventional mechanical alignment (MA), which has rarely been reported. The purpose of this study was to evaluate mid‐term outcomes of navigation‐assisted total knee arthroplasty (TKA) using aMA.MethodsThis retrospective cohort study enrolled 63 consecutive patients (77 knees) who underwent navigation‐assisted TKA using aMA between September 2017 and October 2019. Fifty‐two consecutive patients (61 knees) who underwent TKA using MA during the same period were assessed as the controlled group. The demographic data and perioperative data were recorded. The parameters of resection and soft tissue balance including tibia resection angle, frontal femoral angle, axial femoral angle, joint line translation, medial and lateral gap in extension and flexion position were recorded. Radiographic parameters and functional scores including the Hospital for Special Surgery (HSS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Forgotten Joint Score‐12 (FJS‐12) were evaluated. Surgery‐related complications were recorded. The average follow‐up was 3.5 years, with a minimum of 2.4 years.ResultsThe frontal femoral angle was 2.55° ± 1.08° in aMA group versus 0.26° ± 0.60° in MA group (p < 0.001). The axial femoral angle was 3.07° ± 2.23° external in aMA group versus 2.30° ± 1.70° in MA group (p = 0.027). The lateral flexion gap was wider in the aMA group, with a mean of 0.71 mm more laxity (p = 0.001). Postoperative coronal alignment was 177.03° ± 1.82° in aMA group versus 178.14° ± 1.69° in MA group (p < 0.001). The coronal femoral component angle was 92.62° ± 2.78° in aMA group versus 90.85° ± 2.01° in MA group (p < 0.001). Both aMA‐TKA and MA‐TKA achieved satisfactory mid‐term clinical outcomes. However, the HSS scores at 1 month postoperatively were significantly higher using aMA than using MA (p < 0.001).ConclusionNavigation‐assisted TKA using aMA technique obtained satisfactory mid‐term clinical outcomes. The aMA technique aims to produce a biomimetic wider lateral flexion‐extension gap and minimize releases of soft tissues, which might be associated with better early clinical outcomes than MA technique.     

Health-related quality of life outcomes in adolescent Scheuermann’s kyphosis patients treated with posterior spinal fusion: A comparison with age- and sex-matched controls

Purpose:To assess the health-related quality of life and radiographic outcomes of surgically treated adolescent Scheuermann’s kyphosis patients after minimum of 2-year follow-up and to compare the health-related quality of life with age- and sex-matched healthy controls.Methods:Twenty-two consecutive adolescents (mean age = 16.7 years) undergoing posterior spinal fusion for Scheuermann’s kyphosis were included and matched by age and sex with two healthy controls. The health-related quality of life was evaluated using the Scoliosis Research Society-24 questionnaire. Radiographic parameters were measured for comparison preoperatively and at 6 months and 2-year follow-ups. The health-related quality of life parameters were compared with healthy controls at 2 years of follow-up.Results:The mean maximal thoracic kyphosis improved from 79° (range = 75°–90°) to 55° (range = 45°–75°) (p < 0.001), and the mean lumbar lordosis was reduced from 71° (range = 51°–107°) to 52° (range = 34°–68°) (p < 0.001) after 2 years postoperatively. Incidence of proximal junctional kyphosis (PJK) was 18%. The scores of the Scoliosis Research Society-24 improved, with statistical significance observed in pain and self-image domains from preoperative to 2-year follow-up (p = 0.002 in both domains). The self-image and function were significantly lower in the operated patients at their 2-year follow-up visit compared to controls (p = 0.023 for self-image and p < 0.001 for function).Conclusion:Instrumented posterior spinal fusion improves the health-related quality of life of Scheuermann’s kyphosis patients during the 2-year follow-up. The greatest improvement is observed in pain and self-image domains. The health-related quality of life in pain and activity domains reaches the level of healthy individuals, while function and self-image remain at a statistically lower level.     

Reduced left ventricular contractility,increased diastolic operant stiffness and high energetic expenditure in patients with severe aortic regurgitation without indication for surgery

Open in a separate window OBJECTIVESRecent mortality studies showed worse prognosis in patients (ARNS) with severe aortic regurgitation and preserved ejection fraction (EF) not fulfilling the criteria of current guidelines for surgery. The aim of our study was to analyse left ventricular (LV) systolic and diastolic function and mechanical energetics to find haemodynamic explanations for the reduced prognosis of these patients and to seek a new concept for surgery. METHODSGlobal longitudinal strain (GLS) and echo-based single-beat pressure–volume analyses were performed in patients with ARNS (LV end-diastolic diameter <70 mm, EF >50%, GLS > −19% n = 41), with indication for surgery (ARS; n = 19) and in mild hypertensive controls (C; n = 20). Additionally, end-systolic elastance (LV contractility), stroke work and total energy (pressure–volume area) were calculated.RESULTSARNS demonstrated significantly depressed LV contractility versus C: end-systolic elastance (1.58 ± 0.7 vs 2.54 ± 0.8 mmHg/ml; P < 0.001), despite identical EF (EF: 59 ± 6% vs 59 ± 7%). Accordingly, GLS was decreased [−15.7 ± 2.7% (n = 31) vs −21.2 ± 2.4%; P < 0.001], end-diastolic volume (236 ± 90 vs 136 ± 30 ml; P < 0.001) and diastolic operant stiffness were markedly enlarged, as were pressure–volume area and stroke work, indicating waste of energy. The correlation of GLS versus end-systolic elastance was good (r = −0.66; P < 0.001). ARNS and ARS patients demonstrated similar haemodynamic disorders, whereas only GLS was worse in ARS.CONCLUSIONSARNS patients almost matched the ARS patients in their haemodynamic and energetic deterioration, thereby explaining poor prognosis reported in literature. GLS has been shown to be a reliable surrogate for LV contractility, possibly overestimating contractility due to exhausted preload reserve in aortic regurgitation patients. GLS may outperform conventional echo parameters to predict more precisely the timing of surgery.     

Spatial Bridge Locking Fixator versus Traditional Locking Plates in Treating AO/OTA 32‐A3.2 Fracture: Finite Element Analysis and Biomechanical Evaluation

ObjectiveTo compare the biomechanical behaviors of the spatial bridge locking fixator (SBLF), single locking plate (SP), and double locking plate (DP) for AO/OTA 32‐A3.2 fractures using finite element analysis and biomechanical tests.MethodsAxial loading of 700 N was conducted on the AO/OTA 32‐A3.2 model via finite element analysis. The von Mises stress and the interfragmentary movement (IFM) were comparatively analyzed in the three configurations above. On the mechanical tester, axial and torsional loading of 30 synthetic femurs (five specimens of each configuration for each test at random) was performed, and the interfragmentary movement, torsion angle, stiffness, and ultimate load were recorded and analyzed.ResultsThe finite element analysis (FEA) results showed that the von Mises stress of the spatial bridge locking fixator (SBLF) was lower than that of the single locking plate (SP) and higher than that of the double locking plate (DP). At 700 N, the axial IFMs were 0.15–0.38 mm (SBLF), 0.03–0.84 mm (SP), and 0.02–0.07 mm (DP). The biomechanical experiment indicated that the axial interfragmentary movements (IFMs) were 0.44 ± 0.23 mm (SBLF), 1.02 ± 0.40 mm (SP), and 0.07 ± 0.07 mm (DP) (p < 0.001). The axial IFM of the SBLF group had the highest probability (79.26%) of falling within the ideal range (0.2–0.8 mm), and the SP and DP groups had probabilities of 27.10% and 3.14%, respectively. The axial stiffness in the SBLF group (1586 ± 130 N/mm) was significantly lower than that in the DP group (10,264 ± 2671 N/mm) (p < 0.001) but greater than that in the SP group (725 ± 178 N/mm) (p = 0.396). The range of axial loads to ultimate failure was 3385–4527 N (SBLF), 3377–4664 N (SP), and 3780–4804 N (DP). The shear motion of the fracture end was 0.35 ± 0.14 mm (SBLF), 0.16 ± 0.10 mm (SP), and 0.08 ± 0.04 mm (DP) (p < 0.001). The torsional stiffness was 1.68 ± 0.14 Nm/degree (SBLF), 2.32 ± 0.29 Nm/degree (SP) (SBLF&SP, p < 0.001), and 3.53 ± 0.73 Nm/degree (DP) (SBLF&DP, p < 0.001).ConclusionsThe SBLF structure may exhibit a better biomechanical performance compared with the SP and DP in providing the best quantity and more symmetrical interfragmentary movement for AO/OTA 32‐A3.2 fractures.     

Hip Preservation or Total Hip Arthroplasty? A Retrospective Case–Control Study of Factors Influencing Arthroplasty Decision‐Making for Patients with Osteonecrosis of the Femoral Head in China

ObjectiveAt present, there is no consensus or guidance on indications for osteonecrosis of the femoral head (ONFH) patients to receive hip arthroplasty (THA) treatment. This study aims to explore the factors that influence the decision‐making for THA in patients with ONFH, and to provide references for clinical decision for ONFH patients to be indicated for THA or hip preservation.MethodsThis retrospective case–control study involved data for ONFH patients from July 2016 to October 2021 from the China Osteonecrosis of the Femoral Head Database (CONFHD). The patients with ONFH, and unilateral hip affected at the first visit were divided into THA group and non‐THA group according to if they had undergone THA treatment. The differences between the two groups of patients in terms of gender, age at the time of consultation, body mass index (BMI), etiology, onset side, association research circulation osseous (ARCO) stage, hip joint function, visual analog scale (VAS), etc. were analyzed. Multivariate binomial logistic regression analysis was then applied to evaluate the risk factors of ONFH patients who underwent THA during the first visit.ResultsA total of 640 patients were recruited for analysis, including 209 cases from the THA group and 431 cases from the non‐THA group. The results of univariate analysis showed that the two groups of patients were significantly different in the following six indicators: age (59 vs. 46, Z = −9.58, p < 0.001), duration of disease (78 vs. 17, Z = –16.14, p < 0.001), gender composition (χ² = 8.09, p = 0.004), disease etiology (χ² = 33.04, p < 0.001), ARCO stage (χ² = 334.86, p < 0.001), flexion of hip joint (χ² = 172.33, p < 0.001). However, the comparison between the two groups on VAS (Z = –0.82, p = 0.41), BMI (Z = –1.35, p = 0.18), and onset side (χ² = 1.53, p = 0.22) did not obviously differ. The results regression analysis showed that the age at the time of consultation, duration of disease, ARCO stage, and the hip joint function affected the decision making if the patients should undergo THA. The results of receiver operating characteristic curve (ROC) analysis showed that aforementioned indicators were satisfactory in predicting whether patients with ONFH would be treated with THA. The regression model using the above four indicators as comprehensive indicators has satisfactory performance in predicting whether to perform THA, and the area under the curve (AUC) is 93.94%.ConclusionThese factors such as age, duration of disease, ARCO stage, and hip flexion function should be considered comprehensively before making decisions to perform THA or not in our clinical practice.     

Hypotensive Anesthesia Combined with Tranexamic Acid Reduces Perioperative Blood Loss in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Cohort Study

ObjectiveTo assess the efficacy and safety of hypotensive anesthesia (HA) combined with tranexamic acid (TXA) for reducing perioperative blood loss in simultaneous bilateral total hip arthroplasty (SBTHA).MethodsIn this retrospective cohort study, a total of 183 eligible patients (15 females and 168 males, 44.01 ± 9.29 years old) who underwent SBTHA from January 2015 to September 2020 at our medical center were enrolled for analysis. Fifty‐nine patients received standard general anesthesia (Std‐GA group), the other 85 and 39 patients received HA with an intraoperative mean arterial pressure between 70 and 80 mmHg (70–80 HA group) and below 70 mmHg (<70 HA group), respectively. TXA was administrated to all patients. Perioperative blood loss (total, dominant, and hidden), transfusion rate and volume, hemoglobin and hematocrit reduction, duration of operation and anesthesia, length of hospitalization, range of hip motion as well as postoperative complications were collected from hospital''s electronic records and compared between groups.ResultsAll patients were followed for more than 3 months. Total blood loss in the two HA groups (1390.25 ± 595.67 ml and 1377.74 ± 423.46 ml, respectively) was significantly reduced compared with that in Std‐GA group (1850.83 ± 800.73 ml, P < 0.001). Both dominant and hidden blood loss were dramatically decreased when HA was applied (both P < 0.001). Accordingly, the transfusion rate along with volume in 70–80 HA group (14.1%, 425.00 ± 128.81 ml) and <70 HA group (12.8%, 340.00 ± 134.16 ml) were reduced in comparison with those in Std‐GA group (37.3%, 690.91 ± 370.21ml; P = 0.001 and P = 0.014, respectively). The maximal hemoglobin and hematocrit reduction in both HA groups were significantly less than those in Std‐GA group (both P < 0.001). Of note, 70–80 and <70 HA groups exhibited comparable efficacy with no significant differences between them. Besides, significant difference in duration of surgery was found among groups (P = 0.044 and P < 0.001), while no differences in anesthesia time and postoperative range of hip motion were observed. Regarding complications, the incidence of both acute kidney injury and postoperative hypotension in <70 HA group was significantly higher than that in 70–80 HA and Std‐GA groups (P = 0.014 and P < 0.001). Incidence of acute myocardial injury was similar among groups (P = 0.099) and no other severe complications or mortality were recorded.ConclusionThe combination of HA with a mean arterial pressure (MAP) of 70–80 mmHg and TXA could significantly reduce blood loss and transfusion during SBTHA, in addition to shortening operation time and length of hospitalization, and with no increase in complications.     

Chronic kidney disease recognition amongst physicians and advanced practice providers

ObjectiveChronic kidney disease is a worldwide public health issue, with increasing prevalence resulting in high morbidity and mortality. As a result, recognizing and treating it early can lead to improved outcomes. We hypothesized that some providers might be more comfortable making this diagnosis than others.MethodsRetrospective study of 380 patients with chronic kidney disease seen between 2012 and 2016 in an outpatient setting.ResultsThree hundred and sixteen patients were treated by physicians and sixty-four by advanced practice providers. Chronic kidney disease was identified by the primary care providers in 318 patients (83.6%). Patients recognized with chronic kidney disease were older, 76 ± 8.8 vs 72 ± 7.45 years, p = 0.001; had lower GFR, 37 [29, 46] vs 57 [37, 76] ml/min/1.73 m², p < 0.0001 and were more likely to be seen by a physician compared to an advanced practice provider: 272/316 (86%) vs 46/64 (71.8%), p = 0.008. In multivariate analyses, care by a physician, OR = 2.27 (1.13–4.58), p = 0.02 was associated with increased recognition of chronic kidney disease. On the other hand, higher GFR was associated with decreased diagnosis of chronic kidney disease, OR = 0.95 (0.93–0.96), p < 0.0001.ConclusionThe odds of chronic kidney disease recognition were higher amongst physicians in comparison to non-physician providers.     

Extended Fixation for Paprosky Type III Acetabular Defects in Revision Total Hip Arthroplasty with a Minimum Follow‐Up of 2 Years

ObjectiveRevision of total hip arthroplasty for patients with severe acetabular bone defects is challenging. This study aims to report the minimum 2 years outcome of the iliac extended fixation technique in patients with Paprosky type III acetabular defects.MethodsFifty‐seven revision total hip arthroplasty patients were retrospectively reviewed who underwent reconstruction with the concept of iliac extended fixation from 2014 to 2017 in our hospital. We proposed a new concept of “iliac extended fixation” in revision total hip arthroplasty as fixation extending superiorly 2 cm beyond the original acetabular rim with porous metal augments, which was further classified into intracavitary and extracavitary fixation. Patients were assessed using the Harris Hip Score and the Western Ontario and McMaster Universities Osteoarthritis Index Score. Radiographs and patient‐reported satisfaction were assessed.ResultsAt an average follow‐up of 63 months (range 25–88 months), the postoperative Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly improved at the last follow‐up (p < 0.001). The center of rotation was significantly improved (p < 0.05). Fifty‐three (93.0%) patients were satisfied with the outcome. The extracavitary iliac extended fixation group had higher rate of osteointegration in zone 1A (the superior lateral zone) than the intracavitary iliac extended fixation group (82.3% vs 55.0%, p = 0.015), and significantly more horizontal screws fixation (5.1 ± 24.7° vs 42.3 ± 36.8°, p < 0.001).ConclusionIntracavitary and extracavitary iliac extended fixation with porous metal augments and cementless cups are effective in reconstructing severe superior acetabular bone defects. The difference in screw direction might reflect the different biomechanics of augment fixation.     

A pilot study of thiamin and folic acid in hemodialysis patients with cognitive impairment

ObjectiveThis study aimed to explore the effectiveness of thiamin and folic acid supplementation on the improvement of the cognitive function in patients with maintenance hemodialysis.MethodIn the present study, we randomly assigned patients undergoing hemodialysis who had the Montreal Cognitive Assessment (MoCA) score lower than 26 to treatment group (n = 25, thiamin 90 mg/day combined with folic acid 30 mg/day) or control group (n = 25, nonintervention). All subjects were followed up for 96 weeks. The primary outcome was the improvement of the MoCA score. The secondary outcomes included homocysteine level, survival and safety.ResultsPatients in treatment group had an increase of the MoCA score from 21.95 ± 3.81 at baseline to 25.68 ± 1.96 at week 96 (p < 0.001, primary outcome), as compared with the MoCA score from 20.69 ± 3.40 to 19.62 ± 3.58 in control group. Thiamin combined with folic acid treatment also resulted in lower level of serum homocysteine in treatment group compare with control group at week 96 (p < 0.05, secondary outcome). 3 patients and 9 patients died during follow-up period in treatment and control group respectively (p = 0.048). The proportion of adverse events in treatment group was significantly lower than that in control group.ConclusionHemodialysis patients with cognitive impairment treated with thiamin and folic acid had a significant improvement in MoCA score.