A randomized controlled clinical and radiological trial about outcomes of navigation-assisted TKA compared to conventional TKA: long-term follow-up

PURPOSE

Well balanced knees with good alignment are essential for a well-functioning TKA with long survival of its implants. This prospective randomized study comparing navigation-assisted TKA and conventional TKA reported the clinical and radiological outcomes at a follow-up of 9 years. The purpose of this study was to compare the clinical and radiological outcomes for patients who underwent navigation-assisted TKA or conventional TKA after long-term follow-up.

METHODS

A total of 80 patients (88 knees) were available for physical and radiological examination 9 years after TKA. Clinical outcomes were evaluated using HSS, WOMAC, and KS function and pain scores. And radiological outcomes of the component loosening and its survivorship during 9-year follow-up were also evaluated.

RESULTS

There were no significant differences in the field of clinical outcomes between the two groups. In terms of radiological outcomes, the navigation group had fewer alignment outliers (7.3 vs 20 %, p = 0.006). Although the clinical outcomes showed no differences between the two groups, the survival rate was slightly better in the navigation group than in the conventional group without statistical significance (best-case scenario 100 vs 95.3 %, n.s., worst-case scenario 95.6 vs 88.4 %, n.s.).

CONCLUSION

Navigation-assisted TKA produced better alignment outcomes and better survival rates than conventional instruments although some of the differences were not statistically significant.

LEVEL OF EVIDENCE

I.

Comparison of two different S-1 plus cisplatin dosing schedules as first-line chemotherapy for metastatic and/or recurrent gastric cancer: a multicenter, randomized phase III trial (SOS)

BACKGROUND

Five-weekly S-1 plus cisplatin (SP5) is one of the standard first-line regimens for advanced gastric cancer (GC), proven in a Japanese phase III study. To enhance the dose intensity of cisplatin, 3-weekly S-1 plus cisplatin (SP3) was developed.

PATIENTS AND METHODS

This multicenter, randomized, open-label, phase III study evaluated whether SP3 (S-1 80 mg/m(2)/day on days 1-14 and cisplatin 60 mg/m(2) on day 1) was noninferior/superior to SP5 (S-1 80-120 mg/day on days 1-21 and cisplatin 60 mg/m(2) on day 1 or 8) in terms of progression-free survival (PFS). Chemotherapy-naive patients with metastatic, recurrent gastric or gastroesophageal junction adenocarcinoma were randomized 1 : 1 to receive either SP3 or SP5. The trial is registered at ClinicalTrials.gov (NCT00915382).

RESULTS

Between February 2009 and January 2012, 625 patients were randomized at 42 sites in Korea and Japan. With a median follow-up duration of 32.4 months (range, 13.3-48.6 months) in surviving patients, SP3 was not only noninferior but also superior to SP5 in terms of PFS [median 5.5 versus 4.9 months; hazard ratio (HR) = 0.82; 95% confidence interval (CI) 0.68-0.99; P = 0.0418 for superiority). There was no difference in overall survival (OS) between the groups (median 14.1 versus 13.9 months; HR = 0.99; 95% CI 0.81-1.21; P = 0.9068). In patients with measurable disease, the response rates were 60% in the SP3 arm and 50% in the SP5 arm (P = 0.065). Both regimens were generally well tolerated, but grade 3 or higher anemia (19% versus 9%) and neutropenia (39% versus 9%) were more frequent in SP3.

CONCLUSIONS

SP3 is superior to SP5 in terms of PFS. However, since the improvement in PFS was only slight and there was no difference in OS, both SP3 and SP5 can be recommended as first-line treatments for patients with advanced GC.

Delayed-type hypersensitivity reaction to piperacillin/tazobactam in a patient with an infected total knee replacement

We describe a patient who developed a delayed-type hypersensitivity reaction to piperacillin/tazobactam in the cement beads and a spacer inserted at revision of total replacement of the left knee. We believe that this is the first report of such a problem. Our experience suggests that a delayed-type hypersensitivity reaction should be considered when a mixture of antibiotics such as piperacillin/tazobactam has been used in the bone cement, beads or spacer and the patient develops delayed symptoms of pain or painful paraesthesiae, fever, rash and abnormal laboratory findings in the absence of infection. The diagnosis was made when identical symptoms were induced by a provocation challenge test.

The complications of high tibial osteotomy: closing- versus opening-wedge methods

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m(2)), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis. The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy. Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity.

The effect of anteroposterior laxity on the range of movement and knee function following a cruciate-retaining total knee replacement

The amount of anteroposterior laxity required for a good range of movement and knee function in a cruciate-retaining total knee replacement (TKR) continues to be debated. We undertook a retrospective study to evaluate the effects of anteroposterior laxity on the range of movement and knee function in 55 patients following the e-motion cruciate-retaining TKR with a minimum follow-up of two years. The knees were divided into stable (anteroposterior translation, < or = 10 mm, 38 patients) and unstable (anteroposterior translation, > 10 mm, 17) groups based on the anteroposterior laxity, measured using stress radiographs. We compared the Hospital for Special Surgery (HSS) scores, the Western Ontario MacMasters University Osteoarthritis (WOMAC) index, weight-bearing flexion, non-weight-bearing flexion and the reduction of flexion under weight-bearing versus non-weight-bearing conditions, which we referred to as delta flexion, between the two groups at the final follow-up. There were no differences between the stable and unstable groups with regard to the mean HHS and WOMAC total scores, as well as weight-bearing and non-weight-bearing flexion (p = 0.277, p = 0.082, p = 0.095 and p = 0.646, respectively). However, the stable group had a better WOMAC function score and less delta flexion than the unstable group (p = 0.011 and p = 0.005, respectively). Our results suggest that stable knees with laxity < or = 10 mm have a good functional outcome and less reduction of flexion under weight-bearing conditions than unstable knees with laxity > 10 mm following an e-motion cruciate-retaining TKR.

Cordycepin inhibits IL-1beta-induced MMP-1 and MMP-3 expression in rheumatoid arthritis synovial fibroblasts

OBJECTIVE

MMP is a key enzyme in the degradation of extracellular matrices, and its expression plays important roles in inflammatory diseases. Cordycepin (3'-deoxyadenosine), a bioactive compound of Cordyceps militaris, has been shown to exhibit many pharmacological activities, such as anti-cancer, anti-inflammatory and anti-infection activities. In this study, we aimed at the inhibitory effect of cordycepin on IL-1beta-induced MMP-1 and MMP-3 expression as well as the molecular basis using RA synovial fibroblasts (RASFs).

METHODS

RASFs were isolated from synovial tissue obtained from 12 patients with RA and cultured in monolayer. Expression of MMP-1 and MMP-3 was evaluated using western blotting and real-time PCR. Chemokines were analysed by ELISA. The phosphorylation of mitogen-activated protein kinase was measured by western blotting. Electrophoretic mobility shift assay was performed to evaluate binding activities of DNA to nuclear factor-kappaB (NF-kappaB) and activator protein-1 (AP-1).

RESULTS

Cordycepin inhibited IL-1beta-induced MMP-1 and MMP-3 expressions in RASFs in a dose-dependent manner. Among various chemokines [such as monocyte chemoattractant protein-1 (MCP-1), GRO-alpha, regulated upon activation, normal T-cell expressed and presumably secreted (RANTES) and epithelial neutrophil activating peptide 78 (ENA-78)], cordycepin specifically blocked IL-1beta-induced ENA-78 production in RASF. Moreover, cordycepin significantly inhibited IL-1beta-induced p38/JNK and AP-1 activation, but not extracellular signal-regulated kinase (ERK) and NF-kappaB activation.

CONCLUSIONS

Cordycepin is a potent inhibitor of IL-1beta-induced chemokine production and MMP expression and strongly blocks the p38/JNK/AP-1 signalling pathway in RASFs.

Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty

This study was undertaken to compare the clinical and radiological results achieved using navigation-assisted minimally invasive surgery (NA-MIS) and conventional (CON) techniques in 42 bilateral total knee arthroplasty (TKA) patients with a minimum follow-up of one year. Clinical evaluations were performed using range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores (pain, functional, and total) at 3, 6 and 9 months and one year postoperatively. Patients' subjective preferences and radiological indices, including mechanical axis and coronal inclinations of the prostheses, were compared at one year postoperatively. NA-MIS TKA yielded better HSS and WOMAC total scores than CON TKA up to six months, and a better WOMAC pain score up to 9 months. However, these differences were not significant at one year postoperatively. ROM was comparable in both groups at all times, but more patients preferred the NA-MIS side to the CON side. Radiological results showed no differences in mean values between the two surgical groups, although the NA-MIS group contained fewer outliers than the CON group. In conclusion, NA-MIS TKA was associated with better clinical results up to 6 or 9 months after surgery, giving more accurate leg alignment than CON TKA.

Effectiveness of raloxifene on bone mineral density and serum lipid levels in post-menopausal women with low BMD after discontinuation of hormone replacement therapy

OBJECTIVE

To evaluate the effect of raloxifene on bone mineral density (BMD) and serum lipid levels in post-menopausal women who had discontinued hormone replacement therapy (HRT).

METHODS

Thirty-four post-menopausal women with low BMD who had taken 60 mg of raloxifene daily for 12 months after discontinuing HRT were evaluated retrospectively. Information about their demographics, fracture history, BMD, lipid profiles and adverse events were collected from medical records and intranet database. The outcome measures were changes in the spine (L2-L4) and femur BMD, serum lipid concentrations, fracture rate and tolerability.

RESULTS

The post-menopausal women had a significant increase in their spine (L2-L4) and femur BMD from their baseline BMD [spine, 2.9 +/- 4.6% (P < 0.001); femur, 3.0 +/- 6.6% (P = 0.01)]. Serum low-density lipoprotein (LDL) cholesterol was significantly reduced by 22.6% below baseline after 12 months (P = 0.007). No fractures were observed during therapy. Raloxifene was well tolerated. The most common adverse event was hot flash, which was generally mild.

CONCLUSIONS

Raloxifene increases BMD at important skeletal sites, and lowers LDL cholesterol with tolerable adverse events.

Diarylheptanoids with free radical scavenging and hepatoprotective activity in vitro from Curcuma longa

Assay-guided fractionation of the EtOAc soluble fraction of the rhizomes of Curcuma longa furnished three DPPH free radical scavenging diarylheptanoids, curcumin (1), demethoxycurcumin (2), and bisdemethoxycurcumin (3). Compounds 1-3 showed the DPPH radical scavenging effects with IC(50) values of 2.8, 39.2, 308.7 microM, respectively. L-Ascorbic acid and resveratrol as positive controls exhibited IC(50) values of 22.5 and 25.0 microM, respectively. Compounds 1-3 showed significant hepatoprotective effects on tacrine-induced cytotoxicity in human liver-derived Hep G2 cells. The EC(50) values of 1-3 are 86.9, 70.7, and 50.2 microM, respectively. Silybin (EC(50) = 69.0 microM) and silychristin (EC(50) = 82.7 microM) were used as positive controls.

Bakuchiol: a hepatoprotective compound of Psoralea corylifolia on tacrine-induced cytotoxicity in Hep G2 cells

Bioassay-guided fractionation of the H(2)O extract of the seeds of Psoralea corylifolia furnished one hepatoprotective compound, bakuchiol (1), together with two moderately active compounds, bakuchicin (2) and psoralen (3), on tacrine-induced cytotoxicity in human liver-derived Hep G2 cells. The EC(50) values of compounds 1 - 3 are 1.0, 47.0, 50.0 microg/ml, respectively. Silymarin as a positive control showed the EC(50) value with 5.0 microg/ml.

Clinical and radiographic outcome of femoral head fractures: 30 patients followed for 3-10 years

The aim of this study was to evaluate the outcome of 30 femoral head fractures. We modified Pipkin's classification into 4 types: I (5 cases) small fracture of head distal to fovea centralis, which was too small or too fragmented to be fixed with screws; II (18 cases), larger fracture of head distal to fovea centralis; III (4 cases), large fracture of head proximal to fovea centralis, and IV (3 cases), comminuted fracture of head. Excision of the head fragment was done in all 5 cases of type I and in 9 type II fractures. Fixation of the head fragment was performed in 9 type II and in all 4 type III cases. The femoral head was replaced in all 3 type IV fractures. After a mean follow-up of 3-10 years, the clinical outcome, according to Epstein et al.'s critieria, were excellent in 7, good in 15, fair in 4 and poor in 1, except in type IV, and the radiographic outcome was excellent in 15, good in 7, fair in 4 and poor in 1. On the basis of our findings, we conclude that excision of the small fragment is a good choice of treatment in type 1. Early accurate reduction with stable internal fixation in type II or III permits bony union. Arthroplasty seems to be indicated in type IV.

Failure after core decompression in osteonecrosis of the femoral head

In a retrospective study of 39 hips with osteonecrosis of the femoral head treated with core decompression we evaluated the extent of the necrotic area, the Ficat stage and the location of the lesion. The extent of the necrotic lesion was classified into three categories: mild, less than 15%; moderate, 15-30%; and severe, more than 30%. In 14 mild cases core decompression failed in 2, whereas there were 4 failures out of 7 moderate cases and 16 failures out of 19 severe cases. The extent and location of the necrotic portion as well as the Ficat stage can be used as predictors for the result of core decompression in osteonecrosis of the femoral head.

Aseptic synovitis after meniscal repair using the biodegradable meniscus arrow

We report a case of aseptic synovitis in a 19-year-old man. The synovitis of the left knee developed 13 months after meniscal repair using the biodegradable Meniscus Arrow (Bionx Inc, Malvern, PA). Histologic examination revealed chronic nonspecific synovitis and birefringent materials. Immunohistochemical tests were positive in lysozyme, alpha-1-antitrypsin, and alpha-1-antichymotrypsin. After arthroscopic synovectomy, pain and swelling of the knee joint were relieved and the patient's range of motion fully recovered. We have found no previous report of aseptic synovitis accompanying meniscal repair using the biodegradable Meniscus Arrow.

Inhibitory effects of butanol fraction of the aqueous extract of Forsythia koreana on the nitric oxide production by murine macrophage-like RAW 264.7 cells

The aim of this study was to investigate the effect of butanol fraction of the aqueous extract of Forsythia koreana fruits on the nitric oxide (NO) production and inducible nitric oxide synthesis (iNOS) gene expression in murine macrophage-like RAW 264.7 cells. Butanol fraction alone affected neither NO production nor iNOS gene expression in macrophage-like RAW 264.7 cells. However, the butanol fraction inhibited NO production and iNOS gene expression in RAW 264. 7 cells stimulated with interferon-gamma (IFN-gamma) and lipopolysaccharide (LPS). These findings suggest that inhibition of NO production by this butanol fraction in RAW 264.7 cells stimulated with IFN-gamma plus LPS was due to the suppression of iNOS gene expression.

Genetically engineered transgenic plants with the domain 1 sequence of tobacco mosaic virus 126 kDa protein gene are completely resistant to viral infection

In many plant RNA viruses, Domains 1, 2 and 3 are conserved in replicase proteins. In order to examine the interference of viral replication by the Domain 1 sequence, we generated transgenic plants transformed with DNA corresponding to the Domain 1 sequence of the TMV 126 kDa protein. This DNA sequence includes the TMV RNA from nucleotides 1 to 2,149, which comprises both the 5'-untranslated and methyl transferase region. The transgenic plants obtained showed complete resistance to TMV infection. The presence of the Domain 1 sequence in the plants completely prevented local necrosis in Nicotiana tabacum cv. Xanthi nc, and any systemic development of symptoms in Nicotiana tabacum Xanthi upon TMV inoculation. Most transgenic plants sustained the conferred resistance even under TMV inoculum concentrations up to as high as 1,000 microg/ml. To detect any accumulation of TMV coat protein or viral RNA in infected transgenic plants, immunochemical tests and Northern blot analyses were carried out. Neither viral RNA or coat protein was detectable in the systemic leaves of the completely resistant transgenic plants, whereas they were accumulated in large quantities in all of the control plants. Because of the conservation of Domain 1 in many plant RNA viruses, the acquisition of resistance to virus infection using the Domain 1 sequence appears to be a very effective strategy for breeding of viral resistant plants.

Biomechanical test comparing the load to failure of the biodegradable meniscus arrow versus meniscal suture

The biodegradable Meniscus Arrow (Bionx, Blue Bell, PA) is a newly introduced method for repair of meniscal injury. However, because of a lack of studies, there is still little understanding of its biomechanical behavior. Biomechanical test was carried out to evaluate the load to failure and failure modes of the Meniscus Arrow and to compare the results with those of three traditionally used methods. Thirty-five lateral menisci obtained from Yorkshire pigs were incised longitudinally, simulating a peripheral longitudinal tear, and were repaired by means of Meniscus Arrows (one-point and two-point fixation), as well as with the techniques of knot-end, horizontal, and vertical suture using No. I PDS II monofilament suture. Tensile strength testing was performed according to each repair method with the Instron tensometer (Model No. 5569; Instron, Canton, MA) and its results were analyzed using a computerized statistical program. The average maximal tensile strengths were 113.9 +/- 14.6 N in vertical suture, 75.1 +/- 18.4 N in horizontal suture, 53.9 +/- 6.4 N in knot-end suture, 38.3 +/- 4.3 N in one-point fixation Meniscus Arrow repair, and 56.5 +/- 3.5 N in two-point fixation Meniscus Arrow repair. The initial failure strength for two-point fixation Meniscus Arrow repair is comparable to that of a knot-end suture. Following the results of this study, meticulous caution should be taken when meniscal tears are repaired with Meniscus Arrows.

Below knee stump reconstruction by turn-up technique. Report of 2 cases

In cases of persistent recurrence of tumor or intractable infection affecting the proximal half of the tibia, knee disarticulation or short below knee amputation is sometimes inevitable. If the knee joint is lost, rehabilitation is very difficult and sometimes impossible to attain in terms of active normal daily living. A new technique was designed for reconstruction of the stump following below knee amputation after en bloc resection of the proximal 2/3 of the tibia that included turn-up of the distal composite graft to 180 degrees and rigid fixation. It was applied to 2 cases. The followup showed excellent results in both cases.

The intraoperative evaluation of the neurosensory function of the anterior cruciate ligament in humans using somatosensory evoked potentials

Most of the investigation of the properties of the anterior cruciate ligament (ACL) has focused on its biomechanical functions. There has been increasing interest in the study of the possible neuroreceptor function of the ACL and its role in providing important proprioceptive feedback. Anatomic and histologic studies in humans have shown the presence of neuroreceptors within the anterior cruciate ligament. Indirect evidence exists that proprioception is diminished in the ACL-deficient knee. However, direct evidence in humans of the actual origin of the afferent impulses from within the ACL itself is lacking. Measurement of direct electrical afferent activity, occurring on stimulation of the ACL, should provide this evidence. Somatosensory evoked potentials (SEP) measure the electric potentials evoked in the cerebral cortex upon stimulation of a peripheral neuroreceptor. Carried by the posterior columns of the spinal cord, they reflect activity of the proprioceptive fibers. During arthroscopic procedures performed on nine patients, the normal ACL was stimulated by the use of electrodes applied to the femoral end, midsubstance, and tibial end, and cortical potentials thus evoked were recorded. In all cases, SEPs were recorded at the cerebral cortex upon stimulation of the ACL. The greatest potentials were reported upon stimulation of the midsubstance of the ligament. These findings provide direct evidence for, and strongly support the presence of, active proprioceptive receptors within the intact anterior cruciate ligament of the human knee.

Bent plate fixation in combined intertrochanteric and subtrochanteric fractures of the femur

Twenty-five combined intertrochanteric and subtrochanteric fractures of the femur (Type IV of Kyle's or Type V of Seinsheimer's classification) were treated with a bent plate and followed up through union (average: 2 years). All of the patients received immediate supplementary bone grafting and additional external supports. All but one of the fractures united between 3 and 6 months. Complications were: delayed union (1 case), which was treated by bone graft, trochanteric bursitis (3), and mild coxa vara (2). Anatomical reduction of scattered fragments and its maintenance through bony union were achieved in all cases. The bent plate provided excellent fixation in combined intertrochanteric and subtrochanteric fracture of the femur, and could be a successful alternative for these combined fractures.