Background and purposeTotal knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA.Patients and methods86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score.ResultsThe baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred.InterpretationTibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3–6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up.

Extracellular vesicles (EVs) function in intercellular signaling by transporting different membrane and cytosolic molecules, including hyaluronan (HA) and its synthesis machinery. As both EVs and HA are abundant in synovial fluid, we hypothesized that HA synthesized in synovial membrane would be carried on the surface of EVs. Synovial fluid (n = 15) and membrane samples (n = 5) were obtained from knee surgery patients. HA concentrations were analyzed in synovial fluid and HA and its synthesis machinery were examined with histochemical stainings in synovial membrane. To assess the size distribution of EVs in synovial fluid and to visualize HA on EVs, nanoparticle tracking analysis (NTA), confocal laser scanning microscopy (CLSM) and transmission electron microscopy (TEM) were utilized. The average HA concentration in synovial fluid was 2.0 ± 0.21 mg/ml without significant differences between the patients with trauma/diagnostic arthroscopy and primary or post-traumatic osteoarthritis. Positive stainings of HA synthases (HAS1-3), HA and its receptor CD44 in synovial cells indicated active HA secretion in synovial membrane. According to NTA, EVs were abundant in synovial fluid and their main populations were ≤300 nm in diameter after differential centrifugation. There were no significant differences in the EV counts between the patients with primary or post-traumatic osteoarthritis. TEM verified that HA-positive particles detected by CLSM were lipid membrane vesicles surrounded by a HA coat. Our results provide the first in vivo evidence that human synovial fluid contains HA-positive EVs, one source of which presumably is the long HAS-positive protrusions of synovial fibroblasts. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1960-1968, 2016.

Total knee arthroplasty (TKA) is known to lead to a reduction in periprosthetic bone mineral density (BMD). In theory, this may lead to migration, instability and aseptic loosening of the prosthetic components. Bisphosphonates inhibit bone resorption and may reduce this loss in BMD. We hypothesised that treatment with bisphosphonates and calcium would lead to improved BMD and clinical outcomes compared with treatment with calcium supplementation alone following TKA. A total of 26 patients, (nine male and 17 female, mean age 67 years) were prospectively randomised into two study groups: alendronate and calcium (bisphosphonate group, n = 14) or calcium only (control group, n = 12). Dual energy X-ray absorptiometry (DEXA) measurements were performed post-operatively, and at three months, six months, one, two, four, and seven years post-operatively. Mean femoral metaphyseal BMD was significantly higher in the bisphosphonate group compared with controls, up to four years following surgery in some areas of the femur (p = 0.045). BMD was observed to increase in the lateral tibial metaphysis in the bisphosphonate group until seven years (p = 0.002), and was significantly higher than that observed in the control group throughout (p = 0.024). There were no significant differences between the groups in the central femoral metaphyseal, tibial medial metaphyseal or diaphyseal regions of interest (ROI) of either the femur or tibia. Bisphosphonate treatment after TKA may be of benefit for patients with poor bone quality. However, further studies with a larger number of patients are necessary to assess whether this is clinically beneficial.

Anomalies of fatty acid (FA) metabolism characterize osteoarthritis (OA) and rheumatoid arthritis (RA) in the knee joint. No previous study has investigated the synovial fluid (SF) FA manifestations in these aging-related inflammatory diseases in the shoulder. The present experiment compared the FA alterations between the shoulder and knee joints in patients with end-stage OA or end-stage RA. SF samples were collected during glenohumeral or knee joint surgery from trauma controls and from OA and RA patients (n = 42). The FA composition of SF total lipids was analyzed by gas chromatography with flame ionization and mass spectrometric detection and compared across cohorts. The FA signatures of trauma controls were mostly uniform in both anatomical locations. RA shoulders were characterized by elevated percentages of 20:4n-6 and 22:6n-3 and with reduced proportions of 18:1n-9. The FA profiles of OA and RA knees were relatively uniform and displayed lower proportions of 18:2n-6, 22:6n-3 and total n-6 polyunsaturated FAs (PUFAs). The results indicate location- and disease-dependent differences in the SF FA composition. These alterations in FA profiles and their potential implications for the production of PUFA-derived lipid mediators may affect joint lubrication, synovial inflammation and pannus formation as well as cartilage and bone degradation and contribute to the pathogeneses of inflammatory joint diseases.

Background and purpose: Manipulation under anesthesia (MUA) is considered to be effective in treating stiffness after total knee arthroplasty (TKA). However, not all patients achieve a satisfactory range of motion (ROM) after MUA. This retrospective study determined the outcome of MUA and identified the factors affecting it.Patients and methods: The final sample consisted of 150 MUAs performed on 145 patients. The parameters of interest were ROM and Knee Society Score (KSS) or Oxford Knee Score (OKS). The associations of preoperative, perioperative, and postoperative risk factors with gain in flexion and flexion at post-MUA follow-up (an average of 2 months after MUA) were analyzed using multivariable regression model.Results: The mean of 26° (95% CI 23–29) gain in flexion and the mean of 3° (CI 2–4) gain in extension were noticed at post-MUA follow-up when compared with the ROM preceding MUA. The mean post-MUA-FU flexion was 99° (CI 97–102) and the mean post-MUA-FU extension deficit was 4° (CI 2–5). KSS (121 vs. 129) and OKS (29 vs. 28) were similar before and after MUA. The early timing of MUA was associated with better gain in flexion –0.04 (CI –0.08 to –0.01), while we found no association between the timing of MUA and flexion after MUA –0.004 (CI –0.03 to 0.03). High BMI was associated with better gain in flexion 0.8 (CI 0.2–1.5).Interpretation: We found that ROM improved substantially after MUA. The gain in flexion decreased as the time between TKA and MUA increased.