Perioperative complications following total joint replacement

Exosomes From Human Urine-Derived Stem Cells Encapsulated Into PLGA Nanoparticles for Therapy in Mice With Particulate Polyethylene-Induced Osteolysis

Background: Periprosthetic osteolysis is the primary reason for arthroplasty failure after total joint replacement because of the generation of wear particles and subsequent bone erosion around the prosthesis, which leads to aseptic loosening. Periprosthetic osteolysis is often treated with revision surgery because of the lack of effective therapeutic agents. As key messengers of intercellular interactions, exosomes can be independently used as therapeutic agents to promote tissue repair and regeneration. In this study, we fabricated poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) that carry exosomes derived from human urine stem cells (USC-Exos) and explored their effects on polyethylene-induced osteolysis. Methods: USCs were identified by multipotent differentiation and flow cytometry analyses. USC-Exos were isolated and identified by transmission electron microscopy (TEM), dynamic light scattering (DLS), and western blotting. PLGA microspheres containing USC-Exos were fabricated to synthesize NPs using the mechanical double-emulsion method. The obtained NPs were characterized in terms of stability, toxicity, exosome release, and cell uptake. Then, these NPs were implanted into the murine air pouch model, and their effects on polyethylene-induced osteolysis were evaluated by microcomputed tomography (micro-CT) and histological analyses. Results: The average NP diameter was ~282 ± 0.4 nm, and the zeta potential was -2.02 ± 0.03 mV. After long-term storage at room temperature and 4°C, the NP solution was stable without significant coaggregation. In vitro release profiles indicated sustained release of exosomes for 12 days. In vivo, injection of NPs into the murine air pouch caused less osteolysis than that of USC-Exos, and NPs significantly reduced bone absorption, as indicated by histology and micro-CT scanning. Conclusion: Our findings suggest that USC-Exo-based PLGA NPs can prevent particulate polyethylene-induced osteolysis and bone loss.

Perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty

Knee osteoarthritis is a common arthritic disease which mainly affects the elderly (≥65 years old) population. As a result of the cartilage degeneration, it can cause a significant amount of pain and functional limitation. In patients who are refractory to conservative management, total knee arthroplasty is being utilised as the last resort in management. In this review, we discuss the perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty.

Outcome of Ceramic-on-Ceramic Total Hip Arthroplasty with 4th Generation 36 mm Head Compared to that with 3rd Generation 28 mm Head by Propensity Score Matching

BACKGROUND

With the development of 4th generation ceramic bearing, the large ceramic head is available for ceramic-on-ceramic total hip arthroplasty (THA). This retrospective study aimed to compare the outcomes of ceramic-on-ceramic THA with 4th generation 36 mm head to those with 3rd generation 28 mm head using propensity score matching.

METHODS

We retrospectively reviewed the results of 133 ceramic-on-ceramic THAs with 4th generation 36 mm ceramic head in 129 patients and 133 ceramic-on-ceramic THAs identified from 405 ceramic-on-ceramic THAs with 3rd generation 28 mm head by propensity score matching. There were 83 males and 50 females in both groups with a mean age of 55 years. There was no significant difference in other demographic features except for follow-up period (4.2 years in the 36 mm group and 6.4 years in the 28 mm group, p < 0.001). Clinical and radiological results and occurrence of complication were compared between the two groups.

RESULTS

Harris Hip Score was increased significantly from 46.4 to 92.1 in the 36 mm group and from 46.7 to 93.6 in the 28 mm group. No loosening or osteolysis was observed in the 36 mm group. However, one hip showed radiologic sign of loosening in the 28 mm group. As for complication, postoperative dislocation was more frequent in the 28 mm group (6 in the 28 mm group vs. 0 in the 36 mm group, p = 0.03). Otherwise, there was no significant difference in other results including inguinal pain, squeaking or ceramic fracture.

CONCLUSION

Ceramic-on-ceramic THA with 4th generation 36 mm head significantly reduced postoperative dislocation rate without increasing the rate of inguinal pain, squeaking, or ceramic fracture compared to that with 3rd generation 28 mm head.

Effect of nursing intervention via a chatting tool on the rehabilitation of patients after Total hip Arthroplasty

Background

Nursing intervention following discharge is a long-term rehabilitation process that is essential for improving hip joint function and quality of life in affected patients. This study aimed to assess the effect of nursing intervention via WeChat on the rehabilitation of patients after total hip arthroplasty (THA).

Methods

We conducted a retrospective analysis of 232 patients who underwent THA at our hospital from January 2013 to October 2015. Of the 232 patients, 114 received nursing intervention via telephone (Group A), and 118 received nursing intervention via WeChat (Group B). Furthermore, the Harris hip score and Short-Form 36 (SF-36) health survey score were used to evaluate hip joint function and quality of life in patients in the two groups at discharge and 1, 3 and 6 months following discharge. Moreover, the functional independence measure was applied to assess the recovery of joint function in the patients.

Results

No significant difference was observed in the Harris hip score and the SF-36 health survey score between the two groups at discharge and 1 month following discharge (p > 0.05). However, the Harris hip score and SF-36 health survey score were lower in group A than in group B at 3 and 6 months following discharge (p < 0.05). Furthermore, no obvious difference was observed in terms of functional independence between the two groups at discharge (p > 0.05). However, more individuals were completely independent in group B than in group A at 1, 3 and 6 months following discharge (p < 0.05).

Conclusions

Nursing intervention via WeChat can improve the effect of rehabilitation after THA and promote the recovery of joint function in patients.

Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty

OBJECTIVES

To test the feasibility of a telephone-based intervention that prepares family caregivers to recognize delirium symptoms and how to communicate their observations to healthcare providers.

DESIGN

Mixed-method, pre-post quasi-experimental design.

SETTING

A Midwest Veterans Affairs Medical Center and a nonprofit health system.

PARTICIPANTS

Forty-one family caregiver-older adult dyads provided consent; 34 completed the intervention.

INTERVENTION

Four telephone-based education modules using vignettes were completed during the 3 weeks before the older adult's hospital admission for elective hip or knee replacement. Each module required 20 to 30 minutes.

MEASUREMENTS

Interviews were conducted before the intervention and 2 weeks and 2 months after the older adult's hospitalization. A researcher completed the Confusion Assessment Method (CAM) and a family caregiver completed the Family Version of the Confusion Assessment Method (FAM-CAM) 2 days after surgery to assess the older adults for delirium symptoms.

RESULTS

Family caregivers' knowledge of delirium symptoms improved significantly from before the intervention to 2 weeks after the intervention and was maintained after the older adult's hospitalization. They also were able to recognize the presence and absence of delirium symptoms in the vignettes included in the intervention and in the older adult after surgery. In 94% of the cases, the family caregiver rating on the FAM-CAM approximately 2 days after the older adult's surgery agreed with the researcher rating on the CAM. Family caregivers expressed satisfaction with the intervention and stated that the information was helpful.

CONCLUSION

Delivery of a telephone-based intervention appears feasible. All family caregivers who began the program completed the four education modules. Future studies evaluating the effectiveness of the educational program should include a control group.

An assessment of data and methodology of online surgeon scorecards

OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

Metal ions as inflammatory initiators of osteolysis

Osteolysis and aseptic loosening currently contribute 75 % of implant failures. Furthermore, with over four million joint replacements projected to be performed in the United States annually, osteolysis and aseptic loosening may continue to pose a significant morbidity. This paper reviews the osteolysis cascade leading to osteoclast activation and bone resorption at the biochemical level. Additionally, the metal ion release mechanism from metallic implants is elucidated. Even though metal ions are not the predominating initiator of osteolysis, they do increase the concentration of key inflammatory cytokines that stimulate osteoclasts and prove to be a contributor to osteolysis and aseptic loosening. Osteolysis is a competitive mechanism among a number of biological reactions, which includes debris release, macrophage and osteoclast activation, an inflammatory response as well as metal ion release. Pharmacological therapy for component loosening has also been reviewed. A non-surgical treatment of osteolysis has not been found in the literature and thus may become an area of future research. Even though this research is warranted, comprehensively understanding the immune response to orthopedic implants and their metallic ions, and thus, creating improved prostheses appears to be the most cost-effective approach to decrease the morbidity related to osteolysis and to design implants with greater longevity. The ionic forms, cytokines, toxicity, gene expression, biological effects, and hypersensitivity responses of metallic elements from metal implants are summarized as well.

REGENERATIVE ENGINEERING: APPROACHES TO LIMB REGENERATION AND OTHER GRAND CHALLENGES

The clinical grand challenge to regenerate complex tissue and organ systems call for a paradigm shift that requires a transdisciplinary approach. The field of regenerative engineering puts forward a Convergence approach to create a regenerative toolbox to move beyond individual tissue repair to the regeneration of complex tissues and organ systems. Here we discuss the regenerative tool box currently under development to address grand opportunities in complex tissue/organ regeneration.

Rational design of nanofiber scaffolds for orthopedic tissue repair and regeneration

This article reviews recent significant advances in the design of nanofiber scaffolds for orthopedic tissue repair and regeneration. It begins with a brief introduction on the limitations of current approaches for orthopedic tissue repair and regeneration. It then illustrates that rationally designed scaffolds made up of electrospun nanofibers could be a promising solution to overcome the problems that current approaches encounter. The article also discusses the intriguing properties of electrospun nanofibers, including control of composition, structures, orders, alignments and mechanical properties, use as carriers for topical drug and/or gene sustained delivery, and serving as substrates for the regulation of cell behaviors, which could benefit musculoskeletal tissue repair and regeneration. It further highlights a few of the many recent applications of electrospun nanofiber scaffolds in repairing and regenerating various orthopedic tissues. Finally, the article concludes with perspectives on the challenges and future directions for better design, fabrication and utilization of nanofiber scaffolds for orthopedic tissue engineering.