Press-fit metal-backed rotating patella: seven- to 14-year followup

Patellar polyethylene spinout after low-contact stress, high-congruity, mobile-bearing patellofemoral arthroplasty

A low-contact stress, high-congruity, mobile-bearing patellofemoral joint arthroplasty decreases the contact force in the patellofemoral joint, theoretically reducing patellar polyethylene wear and increasing implant longevity. This article describes the case of a 47-year-old obese woman who presented with pain and loss of extension after a low-contact stress, high-congruity, mobile-bearing patellofemoral joint arthroplasty. Radiographs revealed dislocation (ie, spinout) of the patellar polyethylene. Patellar polyethylene spinout is a rare complication of metal-backed, mobile-bearing patellar resurfacing. Theoretically, patellar polyethylene spinout in low-contact stress, high-congruity, mobile-bearing patellofemoral arthroplasty is related to implant design and the placement of the metal base plate. Ultimately, the articulation of low-contact stress, high-congruity, mobile-bearing patellofemoral arthroplasty may be too congruent to resist the forces of the patellofemoral joint, particularly in patients who are obese, and the patellar rotation allowed by this articulation may not be sufficient for all patients. Should patellar spinout occur, replacement of the polyethylene is not sufficient to correct the problem; hence, revision of the patellar and trochlear components is required because it remains unclear whether failure is secondary to patellar or trochlear design deficiencies.

Management of the deficient patella in revision total knee arthroplasty

There are a number of options available to manage the patella when revising a failed total knee arthroplasty. If the previous patellar component is well-fixed, undamaged, not worn, and compatible with the femoral revision component, then it can be retained. When a patellar component necessitates revision and is removed with adequate remaining patellar bone stock, an onlay-type all-polyethylene cemented implant can be used. Management of the patella with severe bony deficiency remains controversial. Treatment options for the severely deficient patella include the use of a cemented all-polyethylene biconvex patellar prosthesis, patellar bone grafting and augmentation, patellar resection arthroplasty (patelloplasty), performing a gull-wing osteotomy, patellectomy, or the use of newer technology such as a tantalum (trabecular metal) patellar prosthesis. Severe patellar bone deficiency is a challenging situation because restoration of the extensor mechanism, proper patellar tracking, and satisfactory anatomic relationships with the femoral and tibial components are critical for an optimal clinical outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

De novo myofibrillogenesis in C2C12 cells: evidence for the independent assembly of M bands and Z disks

We studied the distribution of the giant sarcomeric protein obscurin during de novo myofibrillogenesis in C(2)C(12) myotubes to learn when it is integrated into developing sarcomeres. Obscurin becomes organized first at the developing M band and later at the mature Z disk. Primordial M bands consisting of obscurin, myomesin, and M band epitopes of titin assemble before adult fast-twitch sarcomeric myosin is organized periodically and nearly concurrently with primitive Z disks, which are composed of alpha-actinin and Z disk epitopes of titin. Z disks and M bands can assemble independently at spatially distant sites. As sarcomerogenesis proceeds, these structures interdigitate to produce a more mature organization. Fast-twitch muscle myosin accumulates in the myoplasm and assembles into A bands only after Z disks and M bands assume their typical interdigitated striations. The periodicities of M bands remain constant at approximately 1.8 microm throughout sarcomerogenesis, whereas distances between Z disks increase from approximately 1.1 microm in early sarcomeres to approximately 1.8 microm in more mature structures. Our findings indicate for the first time that primitive M bands self-assemble independently of Z disks, that obscurin is a component of these primitive M bands in skeletal muscle cells, and that A bands assemble only after M bands and Z disks integrate into maturing sarcomeres.

Obscurin regulates the organization of myosin into A bands

Obscurin is a giant sarcomeric protein composed of adhesion modules and signaling domains. It surrounds myofibrils at the level of the Z disk and the M line. To study the role of obscurin during myofibrillogenesis, we used adenovirus-mediated gene delivery to overexpress part of its COOH terminus in primary cultures of postnatal day 1 (P1) skeletal myotubes. Examination of the subcellular distribution of a number of sarcomeric proteins revealed that the organization of myosin into A bands was dramatically reduced. Myosin assembled into A bands normally in mock- or control-infected P1 myotubes. Overexpression of the COOH terminus of obscurin did not affect the organization of other sarcomeric markers, including actin, alpha-actinin, titin, and myomesin. Assembly of myomesin into nascent M lines in treated myotubes suggests that these structures can form independently of A bands. Immunoblot analysis indicated that there was a small ( approximately 20%) but consistent decrease in the amount of myosin expressed in cells infected with the COOH terminus of obscurin. Coimmunoprecipitation experiments in which we used adult skeletal muscle homogenates demonstrated that obscurin exists in a complex with myosin. Thus our findings suggest that the COOH-terminal region of obscurin interacts with sarcomeric myosin and may play a critical role in its ability to assemble into A bands in striated muscle.

Patellar options in revision total knee arthroplasty

There are numerous options that need to be considered by the surgeon at the time of revision total knee arthroplasty (TKA). One needs to consider the reason for the revision, the type of patella in place, and the length of time the patella has been in place. The surgeon also needs to consider the status of the patellar bone stock, the stability of the patellar component (well-fixed or loose), and the component type (cemented or metal-backed). Assuming that the existing prosthesis is not metal-backed and has minimal PE wear, then it is preferable to retain a well-fixed all-PE cemented patellar button. However, if the button is metal-backed, then it probably is best to remove the button and replace it with an all-PE domed patellar component. Assuming more than 8 mm of patellar bone stock is remaining, it usually is best to cement an all-PE dome-shaped patella. However, if less than 8 mm is remaining, then that patient can be left with a patelloplasty, recognizing that this individual is going to continue with a high likelihood of anterior knee pain, subluxation, and poor functional results. In that situation, it may be preferable to consider a bone stock augmentation.