Long-term survival and failure analysis of anatomical stemmed and stemless shoulder arthroplasties

AIMS

The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up.

METHODS

A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted.

RESULTS

The ROM (p < 0.001), CS (p < 0.001), and DASH score (p < 0.001) showed significant improvements after shoulder arthroplasty for both implants. There were no differences between the groups treated with stemmed or stemless shoulder prosthesis with respect to the mean CS (79.2 (35 to 118) vs 74.4 (31 to 99); p = 0.519) and DASH scores (11.4 (8 to 29) vs 13.2 (7 to 23); p = 0.210). The ten-year unadjusted cumulative survival rate was 95.3% for the stemmed anatomical shoulder prosthesis and 91.5% for the stemless shoulder prosthesis and did not differ between the treatment groups (p = 0.251). The radiological evaluation of the humeral components in both groups did not show loosening of the humeral implant. The main reason for revision for each type of arthroplasties were complications related to the glenoid.

CONCLUSION

The use of anatomical stemless shoulder prosthesis yielded good and reliable results and did not differ from anatomical stemmed shoulder prosthesis over a mean period of ten years. The differences in periprosthetic humeral bone adaptations between both implants have no clinical impact during the follow-up. Cite this article: Bone Joint J 2021;103-B(7):1292-1300.

Surgical site, gender, and place of residence influence the time to resume driving after total joint arthroplasty

BACKGROUND

For a large proportion of the population, especially those residing in the countryside, the use of a car for daily activities is indispensable. Following a TKA or THA procedure, the overseeing physician will usually recommend refraining from driving, sometimes up to 12 weeks after surgery with a major social and economical impact on patient's life.

OBJECTIVE

Considering the legal stipulations in Germany regarding fitness to drive a motor vehicle, the aim of this study is to determine the time point when patients after total knee arthroplasty (TKA) or total hip arthroplasty (THA) take up driving again postoperatively. Further, we assessed the replaced joint, side, gender, place of residence and physician's recommendations influencing the patient in making the decision to start driving again.

METHODS

92 eligible participants, contained within the frame of a prospective experimental observational study, were contacted via telephone 12 weeks after surgery and interviewed using a structured questionnaire. The answers were statistically analysed using SPSS® Version 26 for Windows.

RESULTS

Male participants resumed driving between the 6th and 7th week post-surgery, female participants resumed driving between the 8th and 9th week post-surgery. For 58.6% of patients the reason for the first post-operative use of a vehicle was medical: the journey to physical therapy or to a doctor's appointment. There were statistically significant differences regarding operated side, gender and place of residence. TKA impaired patients the most. Patients recovering from a TKA drove considerably later. Patients recovering from a right sided TKA had an increased risk (9 times) not to become an "early driver". Female patients who underwent TKA had an increased risk by a factor of 21 of becoming a "late driver". In the ageing population, surgeons, physical therapists and rehabilitation professionals need to consider new approaches in providing options for patients' mobility. Interestingly, there is a different need for early use of own vehicle in rural regions whereas in cities patients start driving later. There are clear differences between gender and surgical site.

CONCLUSIONS

The rehabilitation following a right sided TKA proved a challenge with regard to the reuptake of driving. This should be taken into account when planning the course of therapy for patients who are driving regulary. Female patients could benefit from special training.

TRIAL REGISTRATION

retrospectively registered, DRKS00018693 https://www.drks.de/drks_web/navigate.do?navigationId=trial . HTML&TRIAL_ID=DRKS00018693.

Chondrocytes From Osteoarthritic and Chondrocalcinosis Cartilage Represent Different Phenotypes

Basic calcium phosphate (BCP)-based calcification of cartilage is a common finding during osteoarthritis (OA) and is directly linked to the severity of the disease and hypertrophic differentiation of chondrocytes. Chondrocalcinosis (CC) is associated with calcium pyrophosphate dihydrate (CPPD) deposition disease in the joint inducing OA-like symptoms. There is only little knowledge about the effect of CPPD crystals on chondrocytes and the signaling pathways involved in their generation. The aim of this study was to investigate the chondrocyte phenotype in CC cartilage and the effect of CPPD crystals on chondrocytes. Cartilage samples of patients with CC, patients with severe OA, and healthy donors were included in this study. The presence of CC was evaluated using standard X-ray pictures, as well as von Kossa staining of cartilage sections. OA severity was evaluated using the Chambers Score on cartilage sections, as well as the radiological Kellgren–Lawrence Score. Patients with radiologically detectable CC presented calcification mainly on the cartilage surface, whereas OA patients showed calcification mainly in the pericellular matrix of hypertrophic chondrocytes. OA cartilage exhibited increased levels of collagen X and matrix metalloproteinase 13 (MMP13) compared with CC and healthy cartilage. This observation was confirmed by qRT-PCR using cartilage samples. No relevant influence of CPPD crystals on hypertrophic marker genes was observed in vitro, whereas BCP crystals significantly induced hypertrophic differentiation of chondrocytes. Interestingly, we observed an increased expression of p16 and p21 in cartilage samples of CC patients compared with OA patients and healthy controls, indicating cellular senescence. To investigate whether CPPD crystals were sufficient to induce senescence, we incubated chondrocytes with BCP and CPPD crystals and quantified senescence using β-gal staining. No significant difference was observed for the staining, but an increase of p16 expression was observed after 10 days of culture. Primary chondrocytes from CC patients produced CPPD crystals in culture. This phenotype was stabilized by mitomycin C-induced senescence. Healthy and OA chondrocytes did not exhibit this phenotype. BCP and CPPD crystals seem to be associated with two different chondrocyte phenotypes. Whereas BCP deposition is associated with chondrocyte hypertrophy, CPPD deposition is associated with cellular senescence.

Quantitative imaging of bone remodeling in patients with a unicompartmental joint unloading knee implant (ATLAS Knee System)-effect of metal artifacts on a SPECT-CT-based quantification

Background

SPECT-CT using radiolabeled phosphonates is considered a standard for assessing bone metabolism (e.g., in patients with osteoarthritis of knee joints). However, SPECT can be influenced by metal artifacts in CT caused by endoprostheses affecting attenuation correction. The current study examined the effects of metal artifacts in CT of a specific endoprosthesis design on quantitative hybrid SPECT-CT imaging.

The implant was positioned inside a phantom homogenously filled with activity (955 MBq ^99mTc). CT imaging was performed for different X-ray tube currents (I = 10, 40, 125 mA) and table pitches (p = 0.562 and 1.375). X-ray tube voltage (U = 120 kVp) and primary collimation (16 × 0.625 mm) were kept constant for all scans. The CT reconstruction was performed with five different reconstruction kernels (slice thickness, 1.25 mm and 3.75 mm, each 512 × 512 matrix). Effects from metal artifacts were analyzed for different CT scans and reconstruction protocols. ROI analysis of CT and SPECT data was performed for two slice positions/volumes representing the typical locations for target structures relative to the prosthesis (e.g., femur and tibia). A reference region (homogenous activity concentration without influence from metal artifacts) was analyzed for comparison.

Results

Significant effects caused by CT metal artifacts on attenuation-corrected SPECT were observed for the different slice positions, reconstructed slice thicknesses of CT data, and pitch and CT-reconstruction kernels used (all, p < 0.0001). Based on the optimization, a set of three protocols was identified minimizing the effect of CT metal artifacts on SPECT data. Regarding the reference region, the activity concentration in the anatomically correlated volume was underestimated by 8.9–10.1%. A slight inhomogeneity of the reconstructed activity concentration was detected inside the regions with a median up to 0.81% (p < 0.0001). Using an X-ray tube current of 40 mA showed the best result, balancing quantification and CT exposure.

Conclusion

The results of this study demonstrate the need for the evaluation of SPECT-CT protocols in prosthesis imaging. Phantom experiments demonstrated the possibility for quantitative SPECT-CT of bone turnover in a specific prosthesis design. Meanwhile, a systematic bias caused by metal implants on quantitative SPECT data has to be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40658-021-00360-z.

MMP-9 mediated Syndecan-4 shedding correlates with osteoarthritis severity

OBJECTIVE

Osteoarthritis (OA) is a degenerative joint disease inducing the degradation of the articular cartilage. Syndecan-4 (Sdc4) is a heparan sulfate proteoglycan, expressed under inflammatory conditions and by chondrocytes during OA. Little is known about Sdc4 shedding and its regulation in OA. Therefore, we investigated the regulation of Sdc4 shedding and underlying shedding mechanisms under OA conditions.

DESIGN

Articular cartilage, serum, synovial fluid and synovial membrane from OA patients with different radiological severity were analyzed. ELISA, RT-qPCR and IHC for Sdc4, MMP-2 and -9 were performed. MMP inhibitors and siRNA were evaluated for their effect on Sdc4 shedding by ELISA and on IL-1 signaling by western blot (pERK/ERK).

RESULTS

Shed Sdc4 was increased in synovial fluid of OA patients, but not in the serum and is a good predictor (AUC = 0.72) for OA severity with a sensitivity of 67.5% and specificity 65.2%. MMP-9, but not MMP-2, was increased in cartilage and synovial membrane at mRNA levels and in the synovial fluid at protein levels. Shed Sdc4 correlated with the amount of MMP-9 in synovial fluid. Further, the inhibition and knock-down of MMP-9 decreased the amount of shed Sdc4 in vitro. Increased Sdc4 shedding resulted in less phosphorylation of ERK upon IL-1β stimulation.

CONCLUSION

Shed Sdc4 might be a good prognostic biomarker for OA mediated cartilage degradation. MMP-9 seems to be the relevant sheddase for Sdc4 under OA conditions, desensitizing chondrocytes towards IL-1 signaling.

Unwillingly traumatizing: is there a psycho-traumatologic pathway from general surgery to postoperative maladaptation?

BACKGROUND

Surgery may possibly be undermined by psychologic, psychiatric and psychosomatic problems, as long as these problems interfere with a patient's capacity to cope with surgery adaptively. Recent studies have shown that interpersonal trauma, e.g. abuse or neglect, and its correlates are involved in the adaptation to surgery. This observation is heuristically coherent, given the respective traumatization is an interpersonal event occurring in a relationship. Notably, surgery inevitably leads to the violation of physical boundaries within a doctor-patient relationship. Based on the principles of psycho-traumatologic thinking, such a constellation is deemed qualified to activate posttraumatic symptoms in the traumatized.

METHOD

The present topical review summarizes the respective findings which point to a subgroup of patients undergoing surgery, in whom difficulty bearing tension and confiding in others may cause adaptive problems relevant to surgery. Although this theorizing is empirically substantiated primarily with respect to total knee arthroplasty (TKA), a pubmed-research reveals psychopathologic distress to occur prior to surgery beyond TKA. Likewise, posttraumatic distress occurs in large numbers in the context of several operations, including cardiac, cancer and hernia surgery.

CONCLUSION

Aspects of psychological trauma may be linked to the outcomes of general surgery, as well, e.g. biliary, hernia or appendix surgery. The mechanisms possibly involved in this process are outlined in terms of a hierarchical organization of specific anxiety and negative affect as well as in terms of psychodynamics which imply the unconscious action of psychologic defenses at their core.

IMPLICATIONS

Not least, we encourage the screening for trauma and its correlates including defenses prior to general surgery in order to identify surgical candidates at risk of, e.g. chronic postoperative pain, before the operation.

Retrieval study of commercially available knee implant coatings TiN, TiNbN and ZrN on TiAl6V4 and CoCr28Mo6

BACKGROUND

Coated implant components for total knee arthroplasties are primarily used for metal-sensitive patients and are offered by different manufacturers. However, there is only little knowledge with respect to their coating design and supposed superior tribological performance. Our aim was to compare retrieved coated implants by identifying present damages, critical factors influencing the coating durability and their correlation to the clinical performance.

MATERIALS AND METHODS

28 retrieved knee endoprostheses from nine different manufacturers were analyzed for potential surface defects as well as the coating strategy for each manufacturer. The coating designs were investigated on preserved regions with regard to substrate and coating material, layer thickness and roughness using scanning electron microscopy and confocal microscopy. Furthermore, the mechanical properties and adhesive strength of the layer were evaluated by nanoindentation and scratch testing. The friction performance of the coatings against ultra-high molecular weight polyethylene (UHMWPE) was investigated in a tribological test. In addition, clinical data were collected and evaluated for all patients.

RESULTS

Our cohort of 28 retrieved knee endoprostheses exhibited different damage patterns in the articulating area with an incidence of 79% for discoloration and 21% for coating delamination. All coatings presented droplets, macropores and pinholes in preserved areas, which can be attributed to the coating and post-polishing processes. Interestingly, the adhesive strength was significantly increased by 60.4% for titanium nitride coatings on TiAl6V4 alloy in comparison to CoCr28Mo6 substrates. The friction behavior of titanium nitride coatings against UHMWPE is similar to uncoated CoCr28Mo6 alloy and lowest for the ZrN multi-layer coating with a reduction of 14%.

DISCUSSION

This study shows that manufacturing related coating deposition defects can cause wear due to adhesive failure and corrosion underneath the coating layers. Adhesive strength was identified as a critical factor for coating durability. Minor adhesive strength was present on CoCr28Mo6 cast alloy in comparison to good adhesion of Ti-based coatings on TiAl6V4 wrought alloy. Based on our findings, this is consistent to higher prevalence rates of CoCr28Mo6/TiNbN coatings for gross delamination and pitting damage with increasing implantation time.

The effect of TNF-α on osteoblasts in metal wear-induced periprosthetic bone loss

Aims

This study aimed to examine the effects of tumour necrosis factor-alpha (TNF-α) on osteoblasts in metal wear-induced bone loss.

Methods

TNF-α immunoexpression was examined in periprosthetic tissues of patients with failed metal-on-metal hip arthroplasties and also in myeloid MM6 cells after treatment with cobalt ions. Viability and function of human osteoblast-like SaOs-2 cells treated with recombinant TNF-α were studied by immunofluorescence, terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling (TUNEL) assay, western blotting, and enzyme-linked immunosorbent assay (ELISA).

Results

Macrophages, lymphocytes, and endothelial cells displayed strong TNF-α immunoexpression in periprosthetic tissues containing metal wear debris. Colocalization of TNF-α with the macrophage marker CD68 and the pan-T cell marker CD3 confirmed TNF-α expression in these cells. Cobalt-treated MM6 cells secreted more TNF-α than control cells, reflecting the role of metal wear products in activating the TNF-α pathway in the myeloid cells. While TNF-α did not alter the immunoexpression of the TNF-receptor 1 (TNF-R1) in SaOs-2 cells, it increased the release of the soluble TNF-receptor 1 (sTNF-R1). There was also evidence for TNF-α-induced apoptosis. TNF-α further elicited the expression of the endoplasmic reticulum stress markers inositol-requiring enzyme (IRE)-1α, binding-immunoglobulin protein (BiP), and endoplasmic oxidoreductin1 (Ero1)-Lα. In addition, TNF-α decreased pro-collagen I α 1 secretion without diminishing its synthesis. TNF-α also induced an inflammatory response in SaOs-2 cells, as evidenced by the release of reactive oxygen and nitrogen species and the proinflammatory cytokine vascular endothelial growth factor.

Conclusion

The results suggest a novel osteoblastic mechanism, which could be mediated by TNF-α and may be involved in metal wear debris-induced periprosthetic bone loss.

Cite this article: Bone Joint Res 2020;9(11):827–839.

Evaluation of the standard procedure for the treatment of periprosthetic joint infections (PJI) in Germany - results of a survey within the EndoCert initiative

BACKGROUND

The periprosthetic joint infection (PJI) is a severe complication in the field of arthroplasty. Despite the rising number of primary joint replacements, no unified therapeutic standard has been established for the treatment of PJI yet.

METHODS

A survey on the principles of treatment of PJI in Germany was conducted. A total of 515 EndoProthetikZentren (EPZ) were included, resulting in a response rate of 100%.

RESULTS

For early infections 97.6% of the centers use prosthesis-preserving procedures (DAIR). A one-stage exchange was implemented by less than 50% of the centers. If implemented, this treatment entails a prior selection of patients for a successful treatment. The two-stage exchange is performed in all centers, and most centers proceed with the implantation of a cemented spacer between stages. 75% of the centers proceed with a center-based concept for the treatment of PJI.

CONCLUSION

The aim of a uniform PJI standard at the centers has not yet been fully achieved. Further improvements within the certification were initiated. The most relevant treatment options in Germany are displayed. The two-stage revision with a cemented spacer is the most widely implemented treatment. This exposition of principles could help for the further development of standardized treatment guidelines and definitions.

Tofacitinib and Baricitinib Are Taken up by Different Uptake Mechanisms Determining the Efficacy of Both Drugs in RA

Background: Rheumatoid arthritis (RA) is a systemic autoimmune disease in which synovial fibroblasts (SF) play a key role. Baricitinib and Tofacitinib both act intracellularly, blocking the ATP-binding side of JAK proteins and thereby the downstream signalling pathway via STAT-3. Therefore, we investigated the role of organic cation transporters (OCTs) in Baricitinib and Tofacitinib cellular transport. Methods: OCT expression was analysed in SF isolated from RA and osteoarthritis (OA) patients, as well as peripheral blood mononuclear cells. The interaction of Baricitinib and Tofacitinib with OCTs was investigated using quenching experiments. The intracellular accumulation of both drugs was quantified using LC/MS. Target inhibition for both drugs was tested using Western blot for phosphorylated JAK1 and STAT3 upon stimulation with IL-6. Results: MATE-1 expression increased in OASF compared to RASF. The other OCTs were not differentially expressed. The transport of Baricitinib was not OCT dependent. Tofacitinib; however, was exported from RASF in a MATE-1 dependent way. Tofacitinib and Baricitinib showed comparable inhibition of downstream signalling pathways. Conclusion: We observed different cellular uptake strategies for Baricitinib and Tofacitinib. Tofacitinib was exported out of healthy cells due to the increased expression of MATE1. This might make Tofacitinib the favourable drug.

BCP crystals promote chondrocyte hypertrophic differentiation in OA cartilage by sequestering Wnt3a

OBJECTIVE

Calcification of cartilage with basic calcium phosphate (BCP) crystals is a common phenomenon during osteoarthritis (OA). It is directly linked to the severity of the disease and known to be associated to hypertrophic differentiation of chondrocytes. One morphogen regulating hypertrophic chondrocyte differentiation is Wnt3a.

METHODS

Calcification and sulfation of extracellular matrix of the cartilage was analysed over a time course from 6 to 22 weeks in mice and different OA grades of human cartilage. Wnt3a and ß-catenin was stained in human and murine cartilage. Expression of sulfation modulating enzymes (HS2St1, HS6St1) was analysed using quantitative reverse transcription PCR (RT-PCR). The influence of BCP crystals on the chondrocyte phenotype was investigated using quantitative RT-PCR for the marker genes Axin2, Sox9, Col2, MMP13, ColX and Aggrecan. Using western blot for β-catenin and pLRP6 we investigated the activation of Wnt signalling. The binding capacity of BCP for Wnt3a was analysed using immunohistochemical staining and western blot.

RESULTS

Here, we report that pericellular matrix sulfation is increased in human and murine OA. Wnt3a co-localised with heparan sulfate proteoglycans in the pericellular matrix of chondrocytes in OA cartilage, in which canonical Wnt signalling was activated. In vitro, BCP crystals physically bound to Wnt3a. Interestingly, BCP crystals were sufficient to induce canonical Wnt signalling as assessed by phosphorylation of LRP6 and stabilisation of β-catenin, and to induce a hypertrophic shift of the chondrocyte phenotype.

CONCLUSION

Consequently, our data identify BCP crystals as a concentrating factor for Wnt3a in the pericellular matrix and an inducer of chondrocyte hypertrophy.

Bisphosphonates inhibit surface-mediated osteogenesis

Bisphosphonates (BPs) target osteoclasts, slowing bone resorption thus providing rationale to support osseointegration. However, BPs may negatively affect osteoblasts, impairing peri-implant bone formation. The goal of this study was to assess the effects BPs have on surface-mediated osteogenesis of osteoblasts. MG63 cells were cultured on 15-mm grade 2 titanium disks: smooth, hydrophobic-microrough, or hydrophilic-microrough (Institut Straumann AG, Basel, Switzerland). Tissue culture polystyrene (TCPS) was used as a control. At confluence, cells were treated with 0, 10^-8 , 10^-7 , and 10^-6 M of alendronate, zoledronate, or ibandronate for 24 hr. Sprague Dawley rats were also treated with 1 μg/kg/day ibandronate or phosphate-buffered saline control for 5 weeks. Calvarial osteoblasts (rat osteoblasts [rOBs]) were isolated, characterized, and cultured on surfaces. Osteogenic markers in the media were quantified using ELISAs. BP treatment reduced osteocalcin, osteoprotegerin, osteopontin, bone morphogenetic protein-2, prostaglandin E₂ , transforming growth factor β1, interleukin 10, and vascular endothelial growth factor in MG63 cells. The effect was more robust on rough surfaces, and higher concentrations of BPs stunted production to TCPS/PT levels. Ibandronate conditioned rOBs produced less osteogenic markers similar to direct BP treatment. These results suggest that BP exposure jeopardizes the pro-osteogenic response osteoblasts have to microstructured surfaces. Their effects persist in vivo and negatively condition osteoblast response in vitro. Clinically, BPs could compromise osseointegration.

The Genetic Variations Associated With Time to Aseptic Loosening After Total Joint Arthroplasty

BACKGROUND

Total joint arthroplasty (TJA) is one of the most frequent surgical procedures performed in modern hospitals, and aseptic loosening is the most common indication for revision surgeries. We conducted a systemic exploration of potential genetic determinants for early aseptic loosening.

METHODS

Data from 423 patients undergoing TJA were collected and analyzed. Three analytical groups were formed based on joint arthroplasty status. Group 1 were TJA patients without symptoms of aseptic loosening of at least 1 year, group 2 were patients with primary TJA, and group 3 were patients receiving revision surgery because of aseptic loosening. Genome-wide genotyping comparing genotype frequencies between patients with and without aseptic loosening (group 3 vs groups 1 and 2) was conducted. A case-control association analysis and linear modeling were applied to identify the impact of the identified genes on implant survival with time to the revision as an outcome measure.

RESULTS

We identified 52 single-nucleotide polymorphisms (SNPs) with a genome-wide suggestive P value less than 10^-5 to be associated with the implant loosening. The most remarkable odds ratios (OR) were found with the variations in the IFIT2/IFIT3 (OR, 21.6), CERK (OR, 12.6), and PAPPA (OR, 14.0) genes. Variations in the genotypes of 4 SNPs-rs115871127, rs16823835, rs13275667, and rs2514486-predicted variability in the time to aseptic loosening. The time to aseptic loosening varied from 8 to 16 years depending on the genotype, indicating a substantial effect of genetic variance.

CONCLUSION

Development of the aseptic loosening is associated with several genetic variations and we identified at least 4 SNPs with a significant effect on the time for loosening. These data could help to develop a personalized approach for TJA and loosening management.

The Pain Paradox of Borderline Personality and Total Knee Arthroplasty (TKA): Recruiting Borderline Personality Organization to Predict the One-Year Postoperative Outcome

Background

TKA is a common treatment for arthropathies of the knee; however, its results are compromised by psychosocial equivalents of pain: prior research suggests persistent pain and dysfunction after TKA not only to be linked to psychological symptoms such as depression or anxiety but also to psychodynamic determinants of borderline personality, namely borderline personality organization. Osteoarthritis (OA) and Rheumatoid arthritis (RA), the main indications for TKA, are themselves linked to personality factors and disorders, e.g. borderline. The present study investigates the influence of borderline personality organization (BPO) on the outcomes of TKA one year postoperatively.

Methods

We studied 144 patients scheduled for primary TKA before and after the operation using the IPO-16 and the WOMAC for the assessment of knee pain and function.

Results

Non-parametric correlations were found between primitive defenses and knee-pain, not function. Linear regression showed prediction of knee pain and knee function by the preoperative WOMAC scores (p<0.01), whereas there was additional prediction of knee-pain by gender (p=0.03) and primitive defenses (p=0.04).

Discussion

The results suggest a psychodynamic mechanism of maladaptation after TKA apparently representing the bodily manifestations of fundamental psychic defenses.

Reactive oxygen/nitrogen species (ROS/RNS) and oxidative stress in arthroplasty

The interplay between implant design, biomaterial characteristics, and the local microenvironment adjacent to the implant is of utmost importance for implant performance and success of the joint replacement surgery. Reactive oxygen and nitrogen species (ROS/RNS) are among the various factors affecting the host as well as the implant components. Excessive formation of ROS and RNS can lead to oxidative stress, a condition that is known to damage cells and tissues and also to affect signaling pathways. It may further compromise implant longevity by accelerating implant degradation, primarily through activation of inflammatory cells. In addition, wear products of metallic, ceramic, polyethylene, or bone cement origin may also generate oxidative stress themselves. This review outlines the generation of free radicals and oxidative stress in arthroplasty and provides a conceptual framework on its implications for soft tissue remodeling and bone resorption (osteolysis) as well as implant longevity. Key findings derived from cell culture studies, animal models, and patients' samples are presented. Strategies to control oxidative stress by implant design and antioxidants are explored and areas of controversy and challenges are highlighted. Finally, directions for future research are identified. A better understanding of the host-implant interplay and the role of free radicals and oxidative stress will help to evaluate therapeutic approaches and will ultimately improve implant performance in arthroplasty.

In vivo corrosion and damages in modular shoulder prostheses

Wear and corrosion at taper junctions of orthopaedic endoprostheses remain of great concern and are associated with adverse clinical reactions. Whereas tribocorrosion of hip tapers was extensively investigated, there is only little knowledge regarding the clinical performance of modular total shoulder prostheses. This retrieval study evaluated 35 modular taper junctions of anatomical shoulder explants using stereomicroscopy, confocal microscopy, as well as optical and scanning electron microscopy to determine the damage modes as well as the effects of taper topography and alloy microstructure. Among all humeral head tapers, 89% exhibited material degradation. Different overlapping wear mechanisms were identified such as plastic deformation, adhesive material transfer, microploughing, and fretting damage. Only CoCrMo cast alloy heads showed a susceptibility to electrochemically dominated fretting in comparison to CoCrMo wrought alloy. Moreover, corundum blasted stem tapers show a significantly increased incidence rate for microploughing. To date, this is the most comprehensive study on the damage types of modular taper junctions of anatomical shoulder arthroplasty proving the existence of fretting even on less weight-bearing implants. This study revealed critical fretting factors, such as the surface finish and the alloy type that are essential for the development of countermeasures that avoid any taper corrosion.

Bone biology in postnatal Wistar rats following hypoxia-reoxygenation

Hypoxia response pathways have a central role in normal and abnormal bone biology but the effect of systemic hypoxia-reoxygenation on bone is not clear. Following hypoxic exposure, aberrant synthesis, folding and trafficking of proteins has been reported to occur, which can result in endoplasmic reticulum (ER) stress and may finally cause cell death. This study aimed to examine the effect of systemic hypoxia-reoxygenation injury on bone biology in postnatal rats. Immunoexpression of HIF-1α and VEGF was upregulated in femurs of newborn Wistar rats in response to systemic hypoxia-reoxygenation. Along with that, increased apoptosis of osteoblast precursors, osteoblasts, osteocytes and endothelial cells was observed in comparison to femurs of control animals by transmission electron microscopy, TUNEL staining and immunoexpression of cleaved caspase-3. The viability of osteoclasts was not affected. After hypoxia-reoxygenation, ER stress was observed in the osteoblasts and osteocytes as indicated by dilatation of the ER and enhanced immunoexpression of the ER stress marker GRP78. Localisation of collagen α1 immunoreaction was widespread in the bone matrix of control femurs but was confined to the osteoblasts and osteocytes in response to hypoxia-reoxygenation. In support of these findings, in vitro work showed reduced viability of osteoblast-like SaOs-2 cells and upregulation of GRP78 protein expression in them by western blotting following exposure to hypoxia. This suggests that systemic hypoxia-reoxygenation may disturb bone biology in postnatal Wistar rats by inducing ER stress and apoptosis in osteoblasts and osteocytes, without affecting the viability of osteoclasts. More in-depth research is needed to confirm causality between ER stress and apoptosis of osteoblasts and osteocytes.

Characteristics of different cathodic arc deposition coatings on CoCrMo for biomedical applications

Coatings of endoprostheses are used to improve the tribological performance of arthroplasties. A major challenge for the successful use of these coatings, however, is a stable layer adhesion, a smooth surface, as well as a reduction in droplet formation during the coating process. Explants with commercially available coatings were investigated to assess surface/layer defects and adhesion properties. For the investigation of new coatings, we used cathodic arc deposition (Arc-PVD) to generate TiN, ZrN similar to the currently commercially available coatings and three different diamond like carbon (DLC) coatings on CoCrMo substrate. All surface coatings were mechanically specified by measuring roughness, coating thickness, abrasive wear and critical loads. A friction wear test was modified using an UHMWPE counterpart with a contact pressure of 10 MPa to compare different coatings in one tribological test setup. Calf serum was used as lubricant. The commercially used coatings on the retrieved explants show several defects and the critical load for coating failure varied widely. All produced surface coatings showed an increased surface roughness after coating compared to uncoated samples, which was due to droplet formation, especially in the DLC coatings. A diamond post-polishing process was performed to reduce the surface roughness and reach the ISO standard of R_a < 50 nm. The ZrN and TiN coatings exhibited a decreased friction after removing of the droplets in comparison to uncoated CoCrMo samples, indicating that the post-polishing process might be a useful tool to ameliorate the tribological performance. The friction coefficient for all tested DLC layers was more than two times increased compared to the CoCrMo samples. The use of hard/soft bearings with DLC coated endoprostheses seems to be not advantageous.

Periprosthetic hypoxia as consequence of TRPM7 mediated cobalt influx in osteoblasts

The reasons for the high number of loosened metal-on-metal (MoM) hip implants are still not fully understood. Hypoxia-inducible factor 1 (HIF-1) mediated signaling pathways, which normally modulate tissue metabolism under hypoxic circumstances, could be triggered by metallic wear debris and influence bone metabolism favoring osteolysis. This may lead to early loosening of the orthopedic implants. Immunhistochemical staining of periprosthetic tissues of failed artificial hip implants showed that the concentration of HIF-1α in the surrounding tissues of failed MoM hip implants was significantly higher in comparison to failed metal-on-polyethylene (MoP) hip implants and osteoarthritic tissues. Therefore, we examined the Co²⁺ -uptake mechanisms and the influence of Co²⁺ uptake on HIF-1α stabilization. Based on cobalt mediated quenching effects, calcium imaging experiments using fura-2 showed a concentration-dependent cobalt influx in MG-63 cells, which could be inhibited by the unspecific TRPM7 channel inhibitor 2-APB (20 μM) and TRPM7 specific siRNA. Western blots confirmed a dose dependent increase of HIF-1α upon stimulation with Co²⁺ . This effect could be abrogated by inhibition of cobalt influx using 2-APB. This study shows that chemical hypoxia originating from HIF-1α upregulation within the periprosthetic tissue is related to cobalt wear debris and highlights TRPM7 as an important key mediator in this context. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1806-1813, 2019.

Ionic cobalt but not metal particles induces ROS generation in immune cells in vitro

Total joint replacement is one of the most successful procedures in orthopedic surgery today. However, metal implant materials undergo wear and corrosion processes. Generated particles and ions can cause a variety of cellular reactions. Cobalt-containing alloys are used frequently in implant materials. Some studies suggest that cobalt exhibits potential cytotoxic effects, for example, via generation of reactive oxygen species (ROS). To further elucidate the effects of cobalt on human cells, we determined cell viability and cytosolic and mitochondrial superoxide formation after incubation of either ions or particles with different cells. MM-6 and Jurkat cell lines were treated for 24, 48 and 72 h with either CoCrMo particles or cobalt ions (supplied as CoCl₂ ). A total of 24 h exposure of both forms of cobalt did not induce cell death using terminal deoxynucleotidyl transferase (TUNEL) and trypan blue assay. Interestingly, the formation of superoxide (O₂ ^.- ) is evoked mainly by ionic CoCl₂ but not cobalt particles. Cobalt alloy particles are likely to even suppress O₂ ^.- formation in mitochondria in both used cell lines. Furthermore, we did not observe any effect of cobalt particles on O₂ ^.- formation in peripheral blood mononuclear cells (PBMCs) from healthy donors. We also found that the O₂ ^- formation by CoCl₂ within mitochondria is a generalized effect for all cell types used, while the formation of superoxide in cytosolic compartment is cell-type dependent. In summary, our data suggest that cobalt ions specifically induce the formation of O₂ ^.- , whereas the cobalt particles were better tolerated. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1246-1253, 2019.

What Is the Role of Diagnostic and Therapeutic Sonication in Periprosthetic Joint Infections?

BACKGROUND

Periprosthetic joint infection (PJI) is one of the most dreaded complications in joint replacement surgery. Diagnosis and treatment can be difficult and biofilms are of major concern due to their low susceptibility toward antibiotics.

METHODS

This review focuses on the use of sonication as an evolving diagnostic and adjunct treatment modality in the context of PJI. Therapeutic application of sonication is discussed separately for its (i) direct action on bacteria, (ii) synergistic effects with antibiotics, and (iii) effects on release of antibiotics from bone cement.

RESULTS

Used as a diagnostic tool, sonication shows promising results with respect to sensitivity and specificity when compared to conventional methods, notably after previous administration of antibiotics. As an adjunct treatment modality, the chemical, physical, and mechanical effects of sonication are primarily driven by cavitation and recognized as the main cause for bactericidal effects but the exact underlying mechanisms have not been identified yet. Sonication alone does not have the ability to completely eradicate biofilms but synergistic effects when used in conjunction with antibiotics have been reported. There is also evidence for enhanced antibiotic release from bone cement.

CONCLUSION

Sonication is as an evolving modality in the context of PJIs. As a diagnostic tool, it has not been introduced in routine clinical practice and sonication as a treatment modality in PJIs is still in an experimental stage. Factors such as frequency, pressure, chemical activity, intensity, and exposure time need to be evaluated for optimal application of sonication and may also improve study comparison.

Targeting β-catenin dependent Wnt signaling via peptidomimetic inhibitors in murine chondrocytes and OA cartilage

OBJECTIVE

The canonical Wnt signaling pathway has been shown to be involved in regulating chondrocyte hypertrophic differentiation during Osteoarthritis (OA). The aim of this study was to test the therapeutic potential of two stapled peptide canonical Wnt inhibitors - SAH-Bcl9 and StAx-35R - in preventing Wnt induced cartilage changes in OA.

METHODS

Primary neonatal murine chondrocytes and cartilage explants from OA patients undergoing total joint replacement for knee OA, were used for microscopy to determine matrix and cell penetrating capacity of fluorescein isothiocyanate FITC-tagged SAH-Bcl9 and StAx-35R peptides. T cell factor/lymphoid enhancer-binding factor (TCF/LEF) reporter assays were used to monitor the inhibition of Wnt3a induced β-catenin signaling by each peptide. Changes in chondrocyte phenotypic marker gene expression were analyzed by qRT PCR.

RESULTS

Both peptides localized intercellular in primary murine chondrocytes and cartilage explants. They inhibited Wnt3a induced TCF/LEF promoter activity in primary murine chondrocytes. Both inhibitors did not rescue Wnt3a altered expression of chondrocyte phenotypic genes (Sox9, Col2a1, Acan) and hypertrophy marker gene (Col10a1) at high doses (100 ng/ml). Upon application of 10 ng/ml Wnt3a, StAx-35R partially reversed the Wnt effect on Sox9 and Col2a1 gene expression. Both peptides, however, reversed the downregulation of SOX9 and aggrecan (ACAN), and decrease of COL10A1 gene expression in preserved human OA cartilage explants.

CONCLUSION

These data indicate that blockade of canonical Wnt signaling might be a therapeutic strategy to treat early OA cases and protect further cartilage degradation by preventing chondrocyte hypertrophic differentiation.

The effect of irrigation time and type of irrigation fluid on cartilage surface friction

It is known that fluid irrigation used during arthroscopic procedures causes a wash-out of lubricating substances from the articular cartilage surface and leads to increased friction. It was the goal of this study to investigate whether this effect depends on the time of irrigation and type of fluid used. Rabbit hind legs were used for the tests. The knees were dissected and the friction coefficient of the femoral cartilage measured against glass in a boundary lubrication state. To determine the influence of irrigation time and fluid, groups of 12 knees received either no irrigation (control), 15, 60 or 120min of irrigation with lactated Ringer's solution or 60min of irrigation with normal saline or a sorbitol/mannitol solution. The time of irrigation had a significant effect on the static and kinetic coefficient of friction (CoF), as had the type of fluid. Longer irrigation time with Ringer's solution was associated with increased friction coefficients (relative increase of the kinetic CoF compared to the control after 15, 60 and 120min: 16%, 76% and 88% respectively). The sorbitol/mannitol solution affected the static and kinetic CoF significantly less than either Ringer's or normal saline. The washout of lubricating glycoproteins from the cartilage surface and the associated increase of friction can be effectively influenced by controlling the time of irrigation and type of fluid used. The time of exposure to the irrigation fluid should be as short as possible and monosaccharide solutions might offer a benefit compared to salt solutions in terms of the resultant friction.