Publications by authors named "Srihatach Ngarmukos"

37 Publications

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial.

Knee 2021 Sep 15;33:1-10. Epub 2021 Sep 15.

Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: Ultrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.

Methods: Seventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.

Results: There was no difference in pain score during movement between the groups (mean difference -0.48 [-1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.

Conclusions: The SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.
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http://dx.doi.org/10.1016/j.knee.2021.08.024DOI Listing
September 2021

The analgesic efficacy of anterior femoral cutaneous nerve block in combination with femoral triangle block in total knee arthroplasty: a randomized control trial.

Korean J Anesthesiol 2021 Jun 29. Epub 2021 Jun 29.

Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: Ultrasound-guided femoral triangle block (FTB) can provide motor-sparing anterior knee analgesia. However, it may not completely anesthetize the anterior femoral cutaneous nerve (AFCN). We hypothesized that an AFCN block (AFCNB) in combination with a FTB would decrease pain during movement in the immediate 12-hour postoperative compared with a FTB alone.

Methods: Eighty patients scheduled to undergo total knee arthroplasty (TKA) were randomized to receive either FTB alone (FTB group) or AFCNB with FTB (AFCNB + FTB group) as a part of the multimodal analgesic regimen. The primary outcome was pain during movement 12 hours postoperatively. Secondary outcomes included numeric rating scale (NRS) pain scores, incidence of surgical incision site pain, intravenous morphine consumption, immediate functional performance, patient satisfaction, and length of hospital stay.

Results: The NRS pain scores on movement 12 hours postoperatively were significantly lower in patients of AFCNB + FTB group compared to those in patients of FTB group (mean difference, -2.02 [95% confidence interval: -3.14, -0.89], P < 0.001). Incidence of pain at the site of surgical incision in 24 hours postoperatively and morphine consumption in 48 hours postoperatively were significantly lower (P < 0.001) and quadriceps muscle strength at 0 degree immediately after the surgery was significantly greater in patients of AFCNB + FTB group (P = 0.04).

Conclusions: The addition of ultrasound-guided AFCNB to FTB provided more effective analgesia and decreased opioid requirement compared to FTB alone after TKA and may enhance immediate functional performance on the day of surgery.
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http://dx.doi.org/10.4097/kja.21120DOI Listing
June 2021

Upregulation of antigen presentation function and inflammation in chondrocytes by induction of proteoglycan aggrecan peptides (P16-31 and P263-280).

Clin Exp Rheumatol 2021 Jun 8. Epub 2021 Jun 8.

Immunology Division, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, and Skeletal Disorders Research Unit, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand.

Objectives: A central hallmark of osteoarthritis (OA) is cartilage destruction. Chondrocytes not only control cartilage metabolism, but are capable of immunogenic responses. The role of chondrocytes in the pathogenesis of OA is still unclear. In this study, we aimed to determine the immunological role of chondrocytes in response to proteoglycan aggrecan (PG) peptides.

Methods: Human chondrocytes were isolated from cartilage of knee OA patients undergoing knee arthroplasty and stimulated with proteoglycan aggrecan peptides in the presence of IFNγ. Antigen presentation markers, co-stimulatory molecules, cytokine production, gene expression and antigen presentation to T cells were evaluated.

Results: Our results show that IFNγ was required for the expression of MHC class I and II. However, stimulation with PG peptides P16-31 and P263-280, but not P2379-2394, increased expression level of co-stimulatory molecules (CD80 and CD86) and IL-6, IL-8 and TNFα production. This upregulation was seen in chondrocytes to nearly comparable levels of professional antigen-presenting cells. A similar pattern of gene expression was observed between P16-31 and P263-280 peptide stimulation on chondrocytes and this was different from P2379-2394 peptide treatment. Co-culture with autologous T cells revealed signi cant proliferation of cells when stimulating with the P263-280 peptides.

Conclusions: Our study shows that human chondrocytes display unique features of antigen presentation. Their ability to process certain proteoglycan aggrecan peptides, in which these molecules are synthesised by the cartilage themselves render the possibility of a role for "self-antigens" in the immunopathogenesis of OA.
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June 2021

The infrapatellar fat pad produces interleukin-6-secreting T cells in response to a proteoglycan aggrecan peptide and provides dominant soluble mediators different from that present in synovial fluid.

Int J Rheum Dis 2021 Jun 18;24(6):834-846. Epub 2021 May 18.

Immunology Division, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Objective: The purpose of this study was to investigate the effects of osteoarthritis (OA) peripheral blood mononuclear cell (PBMC) -stimulating proteoglycan aggrecan peptides on T cells present in infrapatellar fat pads (IPFPs) and synovial tissues, and to correlate these findings with mediators present in synovial fluid of OA patients.

Methods: We tested for interleukin-6 (IL-6) -producing T cells in IPFPs of patients with knee OA using ELISPOT. Cytokine and cytotoxic mediator production from OA PBMCs, IPFPs, synovial tissues, and synovial fluids in response to proteoglycan aggrecan peptides were quantified by cytometric bead array. Patterns of cytokine and cytotoxic mediator production were analyzed and compared.

Results: T cells from IPFPs elicited strong responses towards the p263-280 peptide by secreting IL-6. In addition, there was a trend that the p263-280 peptide stimulated higher production of cytokines/cytotoxic mediators than other proteoglycan aggrecan peptides, although this was not statistically significant. In patients with knee OA, a group of cytotoxic mediators (sFas, perforin, granzyme A, and granulysin) and IL-6 were detectable at high levels from the synovial fluid. In addition, inflammation in patients with knee OA was more pronounced in joint-surrounding tissues than levels in circulating peripheral blood.

Conclusion: Our data suggest that T cells responding to the p263-280 peptide contribute to the secretion of various soluble mediators that are found within the synovial fluid. We also identified potential new candidates that may serve as biomarkers of knee OA.
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http://dx.doi.org/10.1111/1756-185X.14126DOI Listing
June 2021

Analgesic efficacy of infiltration between the popliteal artery and capsule of the knee (iPACK) block added to local infiltration analgesia and continuous adductor canal block after total knee arthroplasty: a randomized clinical trial.

Reg Anesth Pain Med 2020 11 23;45(11):872-879. Epub 2020 Aug 23.

Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: A combination of motor-sparing analgesia with local infiltration analgesia (LIA) and continuous adductor canal block (CACB) may improve postoperative pain and functional recovery for total knee arthroplasty (TKA). We hypothesized that the addition of a novel technique for posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (iPACK) block, to LIA with CACB would reduce opioid requirements.

Methods: In this double-blinded randomized controlled trial, 72 patients were assigned to receive either LIA with CACB (LIA+CACB group) or iPACK block with LIA and CACB (iPACK+LIA+CACB group). The primary outcome was cumulative postoperative intravenous morphine consumption within 24 hours. The secondary outcomes included numerical rating scale pain scores, incidence of posterior knee pain, performance test results, patient satisfaction, length of stay, and adverse events.

Results: Morphine consumption within 24 hours postoperatively showed no significant intergroup difference (LIA+CACB; 1.31±1.85 mg vs iPACK+LIA+CACB; 0.61±1.25 mg, p=0.08). There were no clinically significant differences in the overall pain scores between the groups. The lower Timed Up and Go test scores on postoperative days 1 and 2, along with a shorter duration of hospitalization, were found in the iPACK+LIA+CACB group (p<0.05).

Conclusion: The addition of an iPACK block to the LIA and CACB does not reduce the postoperative opioid consumption nor improve analgesia. However, it may improve immediate functional performance and reduce the length of hospitalization after TKA.

Trial Registration Number: TCTR20180702001.
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http://dx.doi.org/10.1136/rapm-2020-101396DOI Listing
November 2020

Adductor Canal Block Combined With iPACK (Interspace Between the Popliteal Artery and the Capsule of the Posterior Knee) Block vs Periarticular Injection for Analgesia After Total Knee Arthroplasty: A Randomized Noninferiority Trial.

J Arthroplasty 2021 01 2;36(1):122-129.e1. Epub 2020 Jul 2.

Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: The combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen.

Methods: Seventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority.

Results: Adjusted mean differences, (ACB + iPACK) - (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were -0.66 (-1.86, 0.54) and -0.19 (-1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group.

Conclusions: ACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance.

Level Of Evidence: Therapeutic level I.
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http://dx.doi.org/10.1016/j.arth.2020.06.086DOI Listing
January 2021

Motor-sparing effect of iPACK (interspace between the popliteal artery and capsule of the posterior knee) block versus tibial nerve block after total knee arthroplasty: a randomized controlled trial.

Reg Anesth Pain Med 2020 04 4;45(4):267-276. Epub 2020 Feb 4.

Orthopaedics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Background And Objective: An ultrasound-guided anesthetic technique targeting the interspace between the popliteal artery and capsule of the posterior knee (iPACK) can provide posterior knee analgesia with preserved motor function after total knee arthroplasty (TKA). This study compared the peroneal nerve motor-sparing effects of iPACK block and tibial nerve block (TNB) when combined with local infiltration analgesia (LIA) and continuous adductor canal block (CACB).

Methods: In this study, 105 patients scheduled for elective TKA were randomized to receive proximal iPACK block (iPACK1), distal iPACK block (iPACK2), or TNB, along with spinal anesthesia, modified LIA, and CACB. The primary outcome was the incidence of common peroneal nerve (CPN) motor blockade. Secondary outcomes included CPN sensory function, tibial sensorimotor function, posterior knee pain, pain score, intravenous morphine requirement, timed up-and-go test, quadriceps muscle strength, range of motion, length of hospital stay, patient satisfaction, and adverse events.

Results: The incidence of CPN motor blockade was significantly higher in the TNB group than in the iPACK1 (p=0.001) and iPACK2 (p=0.001) groups, but was not significant between the iPACK1 and iPACK2 groups (p0.76). Tibial nerve motor function was more preserved in the iPACK1 and iPACK2 groups than in the TNB group (p<0.001 and p<0.001, respectively). Complete CPN and tibial sensorimotor blockade were not observed in the iPACK2 group. Posterior knee pain score was significantly higher in the iPACK1 group than in other groups during the 24-hour postoperative period (p=0.001).

Conclusions: Compared with TNB, iPACK1 and iPACK2 preserved CPN and tibial nerve motor function to a greater extent. However, iPACK2 did not demonstrate complete CPN and tibial nerve motor blockade while maintaining effective posterior knee pain relief.

Trial Registration Number: TCTR20180206002.
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http://dx.doi.org/10.1136/rapm-2019-100895DOI Listing
April 2020

Relationships between blood leukocyte mitochondrial DNA copy number and inflammatory cytokines in knee osteoarthritis.

J Zhejiang Univ Sci B 2020 Jan.;21(1):42-52

Department of Biochemistry, Osteoarthritis and Musculoskeleton Research Unit, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Chulalongkorn University, Bangkok 10330, Thailand.

Osteoarthritis (OA) is a degenerative articular disorder manifested by cartilage destruction, subchondral sclerosis, osteophytes, and synovitis, resulting in chronic joint pain and physical disability in the elderly. The purpose of this study was to investigate mitochondrial DNA copy number (mtDNA) and inflammatory cytokines in primary knee OA patients and healthy volunteers. A total of 204 knee OA patients and 169 age-matched healthy volunteers were recruited. Their relative blood leukocyte mtDNA was assessed by quantitative real-time polymerase chain reaction (qRT-PCR), and ten inflammatory cytokines in their plasma were detected by multiplex immunoassay. Blood leukocyte mtDNA in the OA group was significantly lower than that in the control group. Leukocyte mtDNA in the control group was negatively correlated with their age (r=-0.380, P<0.0001), whereas mtDNA in the OA group was positively correlated with their age (r=0.198, P<0.001). Plasma interleukin-4 (IL-4) and IL-6 were significantly higher in the knee OA group than in the control group. The plasma IL-6 level was positively correlated with blood leukocyte mtDNA in the OA group (r=0.547, P=0.0014). IL-5 showed as a major factor (coefficient 0.69) in the second dimension of principle components analysis (PCA)-transformed data and was significantly higher in the OA group (P<0.001) as well as negatively correlated with mtDNA (r=-0.577, P<0.001). These findings suggest that elevation of plasma IL-4 and IL-6 and a relative reduction in mtDNA might be effective biomarkers for knee OA. IL-5 is a plausible factor responsible for decreasing blood leukocyte mtDNA in knee OA patients.
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http://dx.doi.org/10.1631/jzus.B1900352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964998PMC
November 2020

Blood leukocyte LINE-1 hypomethylation and oxidative stress in knee osteoarthritis.

Heliyon 2019 May 24;5(5):e01774. Epub 2019 May 24.

Department of Biochemistry, Osteoarthritis and Musculoskeleton Research Unit, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.

Aim: Joints inflammation is one of the most pathologic processes leading to the development of osteoarthritis (OA), possibly leading to genomic instability. LINE-1 is transposable elements, and alterations in LINE-1 methylation induced by 8-hydroxy-2'-deoxyguanosine (8-OHdG) can cause genomic instability contributing to OA development. Herein, the present study examined associations between LINE-1 methylation, 8-OHdG, and knee OA severity.

Methods: LINE-1 methylation levels were measured in 104 knee OA patients and 96 healthy controls by quantitative combined bisulfite restriction analysis. 8-OHdG was investigated by ELISA. The knee OA severity was appraised by questionnaires (VAS, WOMAC, KOOS, and lequesne index) and radiological severity based on the grading of Kellgren and Lawrence (KL) standard criteria.

Key Findings: Blood leukocyte LINE-1 methylation levels were significantly lower in knee OA patients than in healthy controls. Interestingly, individuals with LINE-1 hypomethylation were significantly associated with an elevated risk of knee OA. Linear regression analysis revealed that LINE-1 methylation was independently associated with KL grading of knee OA. Furthermore, plasma 8-OHdG levels in OA cases were not significantly different from those in healthy volunteers, whereas synovial fluid 8-OHdG values were considerably higher than in paired plasma specimens of the OA subjects.

Significance: This study demonstrated that LINE-1 hypomethylation in blood leukocytes was associated with increased risk and radiographic severity of knee OA, and increased synovial fluid 8-OHdG levels were observed in knee OA patients. Collectively, LINE-1 hypomethylation and elevated 8-OHdG could emerge as biomarkers indicating the severity of knee OA and may take a possible part in the pathological process of knee OA.
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http://dx.doi.org/10.1016/j.heliyon.2019.e01774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536726PMC
May 2019

Optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study.

Korean J Anesthesiol 2019 10 30;72(5):486-494. Epub 2019 Apr 30.

Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: This study aimed to determine the optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK), using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the level of ABTN forming a popliteal plexus would mainly spread throughout the popliteal fossa without contacting the tibial or peroneal nerves.

Methods: The anatomical study included 30 soft cadavers. Ultrasound-guided dye injection was performed in legs of 10 cadavers after identifying the position of the ABTN and surrounding structures, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided injection in the iPACK. All patients also received continuous adductor canal block. Sensorimotor function of the tibial and common peroneal nerves was determined.

Results: In the distal portion of the popliteal fossa, the tibial nerve and popliteal vessels ran superficially and closely together. The trajectory of ABTN ran lateral to the popliteal vasculature, forming a plexus towards the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In the clinical study, no patients experienced complete motor or sensory blocks.

Conclusions: We described a modified iPACK technique injection at the level of the ABTN forming the popliteal plexus, and it may constitute an optional anesthetic regimen to promote early ambulation following TKA.
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http://dx.doi.org/10.4097/kja.19060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781212PMC
October 2019

Plasma and Joint Fluid Glypican-3 Are Inversely Correlated with the Severity of Knee Osteoarthritis.

Cartilage 2021 10 4;12(4):505-511. Epub 2019 Apr 4.

Department of Biochemistry, Osteoarthritis and Musculoskeleton Research Unit, Vinai Parkpian Orthopaedic Research Center, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.

Objective: Glypican-3 possesses a possible action in regulation of bone growth and development implicated in osteoarthritis (OA) pathology. Therefore, this study aimed to investigate glypican-3 in plasma and synovial fluid of knee OA patients and to determine the possible association between glypican-3 levels and radiographic severity.

Design: A total of 80 knee OA patients and 80 healthy controls were recruited. Glypican-3 levels in plasma and synovial fluid were measured using enzyme-linked immunosorbent assay. The severity of knee OA was assessed by radiographic grading according to the Kellgren-Lawrence classification. Relative mRNA expression of glypican-3 in 10 inflamed synovial tissues from OA patients and 10 noninflamed synovial controls was quantified using real-time polymerase chain reaction.

Results: Plasma glypican-3 levels were significantly lower in OA patients than in healthy controls ( = 0.03), whereas synovial fluid glypican-3 levels were remarkably greater than in paired plasma samples of OA patients ( < 0.001). Subsequent analysis demonstrated that plasma and synovial fluid glypican-3 levels were inversely associated with the radiographic severity of knee OA ( = -0.691, < 0.001; = -0.646, < 0.001, respectively). Furthermore, there was a positive relationship between plasma and synovial fluid glypican-3 levels in knee OA patients ( = 0.515, < 0.001). Additionally, overexpression of glypican-3 mRNA was observed in inflamed synovium of OA patients ( = 0.021).

Conclusions: The present study revealed that plasma and synovial glypican-3 levels were negatively associated with radiographic severity of knee OA. Glypican-3 could emerge as a potential biomarker for reflecting the severity of knee OA and might play a plausible role in the pathophysiology of degenerative joint disease.
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http://dx.doi.org/10.1177/1947603519841679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461156PMC
October 2021

Opioid-Sparing Analgesia and Enhanced Recovery After Total Knee Arthroplasty Using Combined Triple Nerve Blocks With Local Infiltration Analgesia.

J Arthroplasty 2019 02 13;34(2):295-302. Epub 2018 Oct 13.

Department of Orthopaedics, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.

Background: Peripheral nerve block and local infiltration analgesia (LIA) have an increasing role as part of multimodal analgesia for enhanced recovery after total knee arthroplasty (TKA). We hypothesized that the combination of obturator nerve block (ONB) and tibial nerve block (TNB) would reduce pain and opioid consumption more than ONB or TNB alone when combined with continuous adductor canal block and LIA.

Methods: Ninety patients were recruited into the study and received spinal anesthesia, LIA, and continuous adductor canal block. They were further randomized to receive either an ONB (group 1), a TNB (group 2), or both (group 3). The primary outcome was total morphine consumption over the postoperative 24 hours. The secondary outcomes included visual analog scale scores, time to first and total dosage of rescue analgesia, Timed Up and Go test, range of motion, muscle strength test, hospital stay, and patient satisfaction.

Results: Eighty-nine patients completed analysis. The median total morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR] 0-4) in group 3, 4 mg (IQR 2-8) in group 2, and 6 mg (IQR 6-14) in group 1 (P < .001). Posterior knee pain during the first 24 hours postoperatively was significantly lower in group 3 than in group 1 (P = .006). The ability to ambulate and quadriceps strength were significantly better in group 3 than in the other groups.

Conclusion: The combination of triple nerve block was superior to double nerve block in improving analgesia and functional outcomes in the immediate postoperative period after total knee arthroplasty, when combined with LIA.
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http://dx.doi.org/10.1016/j.arth.2018.10.009DOI Listing
February 2019

Functional and T Cell Receptor Repertoire Analyses of Peripheral Blood and Infrapatellar Fat Pad T Cells in Knee Osteoarthritis.

J Rheumatol 2019 03 15;46(3):309-317. Epub 2018 Oct 15.

From the Medical Microbiology Interdisciplinary Program, Graduate School, Chulalongkorn University; Immunology Division, Department of Microbiology, Faculty of Medicine, Chulalongkorn University; Department of Orthopedics, Faculty of Medicine, Chulalongkorn University; Center of Excellence in Immunology and Immune-mediated Diseases, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Objective: Osteoarthritis (OA) is a condition that features inflammation and immune responses of innate and adaptive immunity. The role of T cells in knee OA pathogenesis is still unclear. Our aim was to characterize T cell functions and their clonality in patients with knee OA in peripheral blood (PB) and infrapatellar fat pads (IPFP).

Methods: We isolated T cells from PB and IPFP of patients with knee OA and PB of healthy individuals and determined soluble mediators produced from these cells. In addition, we performed a clonal analysis of activated CD8+ T cells and compared the T cell receptor β-variable gene chain (TRBV) usages between T cells in PB and IPFP of patients with knee OA.

Results: Our results suggest that in patients with knee OA, circulating T cells possess a more "cytotoxic" profile or rather impaired cytokine production, but the knee microenvironment allows for these T cells to produce proinflammatory cytokines [interleukin (IL)-1β, IL-6, tumor necrosis factor], IL-17, and interferon-γ within IPFP. Activated CD8+ IPFP T cells carry different repertoire distribution from those present in PB of patients with knee OA. Shared TRBV usage of activated CD8+ IPFP T cells among the 3 patients with knee OA was also observed.

Conclusion: Our study describes the nature of T cells in knee OA that may be due to "unhealthy" aging or other factors that drive healthy aging T cells into a state of imbalance, thus contributing to the pathogenesis of knee OA.
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http://dx.doi.org/10.3899/jrheum.170775DOI Listing
March 2019

Circulating and Synovial Fluid Heat Shock Protein 70 Are Correlated with Severity in Knee Osteoarthritis.

Cartilage 2020 07 19;11(3):323-328. Epub 2018 Jul 19.

Department of Orthopaedics, Osteoarthritis and Musculoskeleton Research Unit, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.

Objective: Heat shock proteins are molecules rapidly produced under conditions of environmental stress, and involve in protecting the cells structural integrity and function. Osteoarthritis (OA) is a chronic destructive disorder of the joints manifested by the ongoing deterioration and loss of articular cartilage. The present study aimed to analyze circulating and synovial heat shock protein (Hsp70) values in knee osteoarthritis patients and healthy controls and to determine their relationship with the radiographic grading of the severity of knee OA.

Design: Seventy-two subjects with knee OA and 30 control participants were recruited. Circulating and joint fluid Hsp70 values were quantified by commercially available enzyme-linked immunosorbent assay.

Results: Circulating Hsp70 was markedly higher in knee OA patients compared with that of healthy volunteers ( = 0.01). Correspondingly, synovial fluid Hsp70 was 3-fold greater than paired circulating Hsp70 samples ( < 0.001). Further analysis revealed that circulating and joint fluid Hsp70 values were significantly related with the radiographic severity of knee OA ( = 0.413, < 0.001 and = 0.658, < 0.001, respectively). Subsequently, circulating Hsp70 value was directly associated with joint fluid Hsp70 value ( = 0.704, < 0.001).

Conclusions: Circulating and synovial Hsp70 levels were positively correlated with the radiographic severity of knee OA. Hsp70 could represent a potential biochemical marker for predicting the severity and may play a fundamental part in the pathogenic mechanism of knee OA.
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http://dx.doi.org/10.1177/1947603518790075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298593PMC
July 2020

Does Adductor Canal Block Have a Synergistic Effect with Local Infiltration Analgesia for Enhancing Ambulation and Improving Analgesia after Total Knee Arthroplasty?

Knee Surg Relat Res 2018 Jun;30(2):133-141

Department of Anesthesiology, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Purpose: We compared a single-injection adductor canal block (ACB) with or without local infiltration analgesia (LIA) for accelerating functional recovery and reducing postoperative pain after total knee arthroplasty (TKA).

Materials And Methods: Sixty-two patients undergoing TKA with simple spinal analgesia and ACB were randomized to receive either LIA (group A+L) or placebo LIA (group A). Postoperative visual analog scale (VAS) score for pain, Timed Up and Go (TUG) test and quadriceps strength, total dosage of rescue analgesia, time to first rescue analgesia, and adverse events were serially evaluated from postoperative day 1 to 3 months.

Results: There were no differences between both groups in pre- and postoperative VAS, TUG test, quadriceps strength 2 days, 3 days, 2 weeks, 6 weeks, and 3 months postoperatively. There were no differences in Knee Society clinical and function scores at 6 months and 1 year. However, group A+L had a significantly longer time for postoperative rescue analgesia (491 minutes vs. 143 minutes, p=0.04) with less patients requiring rescue analgesia during 6 hours after surgery (16.7% vs. 43.3%, p=0.024). Both groups had similarly high rates of patient satisfaction with low adverse event rates.

Conclusions: Combined ACB and LIA in TKA enhanced early ambulation with reduced and delayed rescue analgesia.
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http://dx.doi.org/10.5792/ksrr.17.088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990237PMC
June 2018

Vitamin D Supplementation Improves Quality of Life and Physical Performance in Osteoarthritis Patients.

Nutrients 2017 Jul 26;9(8). Epub 2017 Jul 26.

Vinai Parkpian Orthopaedic Research Center, Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand.

(1) : Lower levels of serum 25-hydroxyvitamin D (25(OH)D) are common in osteoarthritis (OA) patients. However, the effect of vitamin D supplementation on muscle strength and physical performance remains unclear. This study will investigate the effects of vitamin D₂ supplementation on muscle strength and physical performance in knee OA patients; (2) : One hundred and seventy-five primary knee OA patients with low levels of serum 25(OH)D (<30 ng/mL) received 40,000 IU vitamin D₂ (ergocalciferol) per week for six months. Body composition, muscle strength, physical performance, serum 25(OH)D level, leptin, interlukin-6 (IL-6), parathyroid hormone (PTH), protein carbonyl, and metabolic profile were analyzed; (3) : Baseline mean serum 25(OH)D levels in knee OA patients was 20.73 ng/mL. Regarding baseline vitamin D status, 58.90% of patients had vitamin D insufficiency, and 41.10% had vitamin D deficiency. After vitamin D₂ supplementation for six months, mean serum 25(OH)D level was 32.14 ng/mL. For post-supplementation vitamin D status, 57.10% of patients had vitamin D sufficiency and 42.90% had vitamin D insufficiency. From baseline to six months, there was a significant increase in mean serum 25(OH)D level ( < 0.001), while mean LDL cholesterol ( = 0.001), protein carbonyl ( = 0.04), and PTH ( = 0.005) all significantly decreased. Patient quality of life (SF-12) and pain (visual analog scale, VAS) both improved significantly from baseline to the six-month time point ( = 0.005 and = 0.002, respectively). Knee OA patients demonstrated significant improvement grip strength and physical performance measurements after vitamin D₂ supplementation ( < 0.05); (4) : Vitamin D₂ supplementation for six months reduced oxidative protein damage, decreased pain (VAS), improved quality of life, and improved grip strength and physical performance in osteoarthritis patients.
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http://dx.doi.org/10.3390/nu9080799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579593PMC
July 2017

Effect of vitamin E on oxidative stress level in blood, synovial fluid, and synovial tissue in severe knee osteoarthritis: a randomized controlled study.

BMC Musculoskelet Disord 2017 Jun 29;18(1):281. Epub 2017 Jun 29.

Department of Orthopaedics, Faculty of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Background: This study was performed to evaluate the antioxidative and anti-inflammatory effects of vitamin E on oxidative stress in the plasma, synovial fluid, and synovial tissue of patients with knee osteoarthritis.

Methods: Seventy-two patients with late-stage knee osteoarthritis scheduled for total knee arthroplasty were randomized to take oral placebo (Group A) or 400 IU of vitamin E (Group B) once a day for 2 months before undergoing surgery. The blood levels of endpoints indicating oxidative stress or antioxidant capacity, Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score (WOMAC), and adverse effects were compared before and after the intervention between the two groups. At surgery, these redox endpoints and histological findings were compared between the synovial fluid and synovial tissue.

Results: In blood samples, the pre-intervention of oxidative stress and antioxidative capacity were not different between Group A and Group B. In post-intervention blood samples, the Malondialdehyde (Group A 1.34 ± 0.10, Group B 1.00 ± 0.09, p < 0.02), Alpha tocopherol (Group A 15.92 ± 1.08, Group B 24.65 ± 1.47, p < 0.01) and Trolox equivalent antioxidant capacity (Group A 4.22 ± 0.10, Group B 5.04 ± 0.10, 0 < 0.01) were significantly different between Group A and Group B. In synovial fluid samples, the Malondialdehyde (Group A 1.42 ± 0.12, Group B 1.06 ± 1.08, p 0.01), Alphatocopherol (Group A 4.51, Group B 7.03, p < 0.01), Trolox equivalent antioxidant capacity (Group A, 1.89 ± 0.06, Group B 2.19 ± 0.10) were significantly different between Group A and Group B. The pre-intervention WOMAC score and KSS score were not different between Group A and Group B. The post-intervention WOMAC score was significantly improved in all categories in Group B (Pain: Group A 27.26 ± 0.89, Group B 19.19 ± 1.43, p < 0.01; Stiffness: Group A 8.23 ± 0.79, Group B 5.45 ± 0.73, p 0.01; Function: Group A 94.77 ± 4.22, Group B 72.74 ± 6.55, p < 0.01). The post-intervention KSS score was significantly improved in all categories in Group B (Clinical: Group A 25.31 ± 14.33, Group B 33.52 ± 16.96, p < 0.01; Functional: Group A 41.43 ± 16.11, Group B 51.61 ± 19.60, p 0.02). Significantly fewer synovial tissue cells were stained with nitrotyrosine and hematoxylin-eosin in Group B than in Group A. There were no differences in adverse effects or surgical complications between the groups.

Conclusion: Vitamin E is an effective antioxidant that can improve clinical symptoms and reduce oxidative stress conditions in patients with late-stage knee osteoarthritis.

Trial Registration: This research project had been approved for registration at Thai Clinical Trials Registry (TCTR) since 2016-08-28 11:26:32 (Retrospective registered). The TCTR identification number is TCTR20160828001 .
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http://dx.doi.org/10.1186/s12891-017-1637-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5492918PMC
June 2017

Elevated serum leptin levels are associated with low vitamin D, sarcopenic obesity, poor muscle strength, and physical performance in knee osteoarthritis.

Biomarkers 2017 Dec 19;22(8):723-730. Epub 2017 Apr 19.

a Department of Biochemistry, Faculty of Medicine , Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society , Bangkok , Thailand.

Context: The associations between serum leptin, vitamin D status, sarcopenic obesity, muscle strength and physical performance in osteoarthritis (OA) remain uncertain.

Objective: To analyse the relationships between serum leptin, vitamin D status, muscle strength and physical performance in OA patients.

Methods: A total of 208 knee OA patients were enrolled. Serum leptin, vitamin D, muscle strength and physical performance were evaluated.

Results: OA patients with sarcopenic obesity had significantly higher serum leptin levels than those with non-sarcopenic obesity. In addition, knee OA patients with sarcopenic obesity displayed low grip strength and poor physical performance. Furthermore, high serum leptin was negatively associated with vitamin D and physical performance.

Conclusions: Serum leptin levels were correlated with low vitamin D, reduced muscle strength and functional impairment, suggesting that serum leptin might serve as a biomarker reflecting physical performance in OA patients.
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http://dx.doi.org/10.1080/1354750X.2017.1315615DOI Listing
December 2017

Immune Mediators in Osteoarthritis: Infrapatellar Fat Pad-Infiltrating CD8+ T Cells Are Increased in Osteoarthritic Patients with Higher Clinical Radiographic Grading.

Int J Rheumatol 2016 14;2016:9525724. Epub 2016 Dec 14.

Immunology Division, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence in Immunology and Immune-Mediated Diseases, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Osteoarthritis is a condition of joint failure characterized by many pathologic changes of joint-surrounding tissues. Many evidences suggest the role of both innate and adaptive immunity that interplay, resulting either in initiation or in progression of osteoarthritis. Adaptive immune cells, in particular T cells, have been demonstrated to play a role in the development of OA in animal models. However, the underlying mechanism is yet unclear. Our aim was to correlate the frequency and phenotype of tissue-infiltrating T cells in the synovial tissue and infrapatellar fat pad with radiographic grading. Our results show that CD8+ T cells are increased in osteoarthritic patients with higher radiographic grading. When peripheral blood CD8+ T cells were examined, we show that CD8+ T cells possess a significantly higher level of activation than its CD4+ T cell counterpart ( < 0.0001). Our results suggest a role for CD8+ T cells and recruitment of these activated circulating peripheral blood CD8+ T cells to the knee triggering local inflammation within the knee joint.
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http://dx.doi.org/10.1155/2016/9525724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5192329PMC
December 2016

Area of Skin Numbness After Total Knee Arthroplasty: Does Minimally Invasive Approach Make Any Difference From Standard Approach?

J Arthroplasty 2016 11 15;31(11):2499-2503. Epub 2016 Apr 15.

Faculty of Medicine, Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand.

Background: Skin numbness after total knee arthroplasty (TKA) was reported in relation to injury of the infrapatellar branch of saphenous nerve (IPBSN).

Methods: Phase I study: A nonrandomized and nonconsecutive selection of 30 patients undergoing unilateral TKA, using minimally invasive surgery approach, and 30 patients having standard approach were included. Area of skin numbness was periodically evaluated and compared until 1-year follow-up (FU). Phase II study: we dissected 15 normal cadaveric knees and followed the course and distribution of IPBSN.

Results: Twenty-nine predominantly female patients in each group completed 1-year FU with no differences in demographic data. Both the groups had significantly improved Knee Society Score clinical and function scores with no statistical differences. The numb areas in both the groups similarly decreased from 2 weeks (51.7 cm vs 51.1 cm) to 1 year (2.1 cm vs 2.4 cm) with similar percentages of no skin numbness at 1 year (69% vs 65%). The IPBSN branched from saphenous nerve before exiting the adductor canal and ran longitudinally and obliquely. It was found as a single nerve in 20%, a 2-branch nerve in 67% and a 3-branch nerve in 13%. All branches crossed the knee midline between superior patellar pole and tibial tubercle.

Conclusion: Clinical study showed that TKA using minimally invasive surgery approach provided similar area of skin numbness to standard approach. Numbness area gradually decreased at serial FUs in both the groups. The cadaveric study demonstrated that the IPBSN consistently gave no branch passing the knee midline above superior patellar pole.
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http://dx.doi.org/10.1016/j.arth.2016.04.002DOI Listing
November 2016

Spontaneous acetabular periprosthetic fracture in a patient continuously having zoledronic acid.

Clin Orthop Surg 2014 Sep 5;6(3):358-60. Epub 2014 Aug 5.

Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Zoledronic acid has been used for prevention of osteolytic and osteoblastic bone metastasis. This case report illustrates an undesirable consequence from prolonged usage of zoledronic acid in bone metastasis prevention. Periprosthetic acetabular fracture in a patient treated with zoledronic acid for 7 years was reported. The clinical presentation, radiographic and pathological results were described. This is a rare complication after total hip arthroplasty which should not be ignored especially in patients who received long term bisphosphonate.
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http://dx.doi.org/10.4055/cios.2014.6.3.358DOI Listing
September 2014

Relationship of plasma and synovial fluid vascular endothelial growth factor with radiographic severity in primary knee osteoarthritis.

Int Orthop 2014 May 3;38(5):1099-104. Epub 2013 Dec 3.

Inter-department Program of Biomedical Sciences, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand.

Purpose: Recent evidence suggests that angiogenesis and inflammation contribute to the development and progression of osteoarthritis (OA). The purpose of this study was to investigate vascular endothelial growth factor (VEGF) levels in plasma and synovial fluid of patients with knee OA and to determine the relationship of VEGF levels with disease severity in knee OA.

Methods: A total of 100 subjects were enrolled in this study (80 knee OA patients and 20 healthy controls). Plasma and synovial fluid VEGF levels were analysed using enzyme-linked immunosorbent assay. VEGF expressions in synovial membrane and articular cartilage samples were assessed using immunohistochemistry.

Results: VEGF level in synovial fluid of knee OA patients was tenfold higher than that in paired plasma (P < 0.001). Both plasma and synovial fluid VEGF exhibited a positive correlation with radiographic severity (r = 0.454 and r = 0.727, P < 0.001, respectively). VEGF expression was highly detectable in synovial lining cells and articular chondrocytes of knee OA patients.

Conclusions: VEGF levels in both plasma and synovial fluid were positively correlated with the severity of knee OA. Therefore, VEGF may be useful for monitoring OA severity and could play a substantial role in the development and progression of knee OA.
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http://dx.doi.org/10.1007/s00264-013-2192-yDOI Listing
May 2014

Accuracy of computer-assisted total knee arthroplasty related to extra-articular tibial deformities.

Comput Aided Surg 2013 ;18(5-6):166-71

Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University , Bangkok , Thailand.

Objective: To compare the accuracy of postoperative mechanical alignment in computer-assisted total knee arthroplasties (CAS-TKA) related to various degrees of extra-articular tibial deformity.

Methods: We performed CAS-TKA on 30 knee models in which extra-articular proximal tibial deformities were preset to have malalignments ranging from 30° of varus to 30° of valgus. The knees were assigned to two groups, designated Group A (knees with ≤ 15° preoperative malalignment) and Group B (knees with > 15° preoperative malalignment), and the postoperative mechanical alignment in the two groups was compared using a computer-assisted surgery (CAS) system. Resected bone pieces from the distal femurs and proximal tibias were measured with a digital Vernier caliper and the results compared with the CAS calculations to evaluate the execution accuracy of the bone resection.

Results: There was no outlier in either group when a ± 3° deviation from neutral mechanical alignment was set as the acceptance criterion. Interestingly, Group B showed significantly more outliers when the acceptance criterion was a deviation of ± 2° (26.67%, p = 0.0317) or ± 1° (6.67%, p = 0.0007) from neutral alignment. There was no statistical difference between the groups in terms of the execution accuracy of the bone resection.

Discussion: The CAS-TKA approach provided significantly less alignment accuracy in tibia with greater preoperative frontal deformity, despite there being no outliers beyond ± 3°.
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http://dx.doi.org/10.3109/10929088.2013.840803DOI Listing
June 2014

Contemporary pain management in total knee arthroplasty.

J Med Assoc Thai 2012 Oct;95 Suppl 10:S238-44

Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Pain management has become a very important part of postoperative care for total knee arthroplasty patients. Contemporary pain control has evolved from high-dose opioid in the past to state-of-the-art multimodal regimens. These include multiple non-opioid medication such as NSAIDs, COX-2 inhibitors, and gabapentinoid, and novel anesthetic techniques such as preemptive analgesia and ultrasound-guided peripheral nerve blocks. Another method which is gaining popularity is intraarticular injection of anesthetic cocktail during surgery. Pre-op education can also help patients cope with their pain better.
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October 2012

Gap changes after popliteus-tendon resection in PS-TKA: a cadaveric study in Thai female knees.

Knee 2012 Oct 11;19(5):597-600. Epub 2011 Aug 11.

Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Bangkok 10330, Thailand.

Popliteus-tendon injury during total knee arthroplasty (TKA) may result in imbalanced soft-tissue tension; however, it is unclear whether complete popliteus-tendon resection is a factor which contributes to knee instability following TKA. We performed an isolated complete resection of the popliteus tendon during a standard posterior stabilised TKA (PS-TKA) in 14 normal knees of Thai female cadavers and measured gap differences in both knee flexion and extension. In addition, we measured the distance from the femoral attachment of the popliteus tendon to the femoral condyles including the distance from the most distal femoral attachment of the popliteus tendon to the distal lateral femoral condyle (DFa-DLFC), and the distance from the most posterior femoral attachment of the popliteus tendon to the posterior lateral femoral condyle (PFa-PLFC). After completion of bone cuts, static flexion and extension gaps were measured with a tension of 98 N under intact and complete tendon resection, respectively. The mean DFa-DLFC and PFa-PLFC distances were 8.9 mm (range, 6.4-10.5mm) and 11.5mm (range, 9.5-14.0mm), respectively. Of 14 cadaveric knees, 35.7% had a DFa-DLFC distance <9 mm. Flexion and extension gaps significantly increased in both medial and lateral sides after complete popliteus resection with a similar mean increased value of 1.85 mm. The clinical evaluation of gap changes after popliteus resection on knee stability should be further investigated. A routine 9-mm distal femoral bone cut may injure the popliteus tendon during TKA conducted on small knees.
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http://dx.doi.org/10.1016/j.knee.2011.06.017DOI Listing
October 2012

Relationship of serum IL-6, C-reactive protein, erythrocyte sedimentation rate, and knee skin temperature after total knee arthroplasty: a prospective study.

Int Orthop 2011 Jan 21;35(1):31-5. Epub 2010 Feb 21.

Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.

Knee osteoarthritis is a common cause of severe pain and functional limitation. Total knee arthroplasty is an effective procedure to relieve pain, restore knee function, and improve quality of life for patients with end stage knee arthritis. The aim of this study was to investigate the inflammatory process in patients with primary knee osteoarthritis before surgery and in subsequent periods following total knee arthroplasty. A prospective study of 49 patients undergoing primary total knee replacements was conducted. The patients were evaluated by monitoring serum interleukin-6 (IL-6), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), knee skin temperature, and clinical status. Measurements were carried out preoperatively and postoperatively on day one and at two, six, 14, and 26 weeks during follow-up review in the knee clinic. The serum IL-6 and CRP were elevated on the first postoperative day but fell to preoperative values at two weeks postoperatively. Both returned to within the normal range by six weeks postoperatively. In addition, the postoperative ESR showed a slow rise with a peak two weeks after surgery and returned to the preoperative level at 26 weeks postoperatively. The difference in skin temperature between operated and contralateral knees had a mean value of +4.5°C at two weeks. The mean value decreased to +3.5°C at six weeks, +2.5°C at 14 weeks, and +1.0°C at 26 weeks. The difference in skin temperature decreased gradually and eventually there was no statistically significant difference at 26 weeks after surgery. A sustained elevation in serum IL-6, CRP, ESR, and skin temperature must raise the concern of early complication and may suggest the development of postoperative complication such as haematoma and/or infection.
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http://dx.doi.org/10.1007/s00264-010-0973-0DOI Listing
January 2011

Dickkopf-1 (Dkk-1) in plasma and synovial fluid is inversely correlated with radiographic severity of knee osteoarthritis patients.

BMC Musculoskelet Disord 2010 Nov 10;11:257. Epub 2010 Nov 10.

Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: Osteoarthritis (OA) is a common degenerative joint disease causing pain, stiffness, reduced motion, swelling, crepitus, and disability. Dickkopf-1 (Dkk-1) is a critical mediator of osteoblastogenesis and regulates the joint remodeling. The aim of this study was to examine plasma and synovial fluid Dkk-1 levels of patients with primary knee OA and to investigate their relationship with disease severity.

Methods: Thirty-five patients aged 55-83 years with knee OA and 15 healthy individuals were recruited into this study. Disease severity was determined using weight-bearing anteroposterior radiographs of the affected knee. The radiological grading of OA in the knee was performed according to the Kellgren-Lawrence grading system. Dkk-1 levels in both plasma and synovial fluid were evaluated using enzyme-linked immunosorbent assay.

Results: The average concentration of circulating Dkk-1 in the knee OA patients was remarkably lower than that of healthy controls (396.0 ± 258.8, 95%CI 307.1-484.9 vs 2348.8 ± 2051.5, 95%CI 1164.3-3533.3 pg/ml, p < 0.0001). Dkk-1 levels in synovial fluid were significantly lower than in paired plasma samples (58.6 ± 31.8, 95%CI 47.7-69.6 vs 396.0 ± 258.8, 95%CI 307.1-484.9 pg/ml, p < 0.001). Furthermore, both plasma and synovial fluid Dkk-1 levels were inversely correlated with radiographic severity (r = -0.78, p < 0.001 and r = -0.42, p = 0.01, respectively). Plasma Dkk-1 levels were also significantly correlated with synovial fluid Dkk-1 levels (r = 0.72, p < 0.001).

Conclusions: Dkk-1 levels in plasma and synovial fluid are inversely related to the severity of joint damage in knee OA. Dkk-1 could serve as a biochemical marker for determining disease severity and might play a potential role in the pathogenesis of the degenerative process of OA.
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http://dx.doi.org/10.1186/1471-2474-11-257DOI Listing
November 2010

The early results of gender-specific total knee arthroplasty in Thai patients.

Knee 2011 Dec 30;18(6):483-7. Epub 2010 Oct 30.

Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Bangkok 10330, Thailand.

We prospectively evaluated a consecutive series of 314 patients (265 females and 49 males) who underwent unilateral TKA and received an average of 2 years of follow-up. In all patients, a standard (STD) or a gender-specific (GS) femoral component was selected based on the presentation of intra-operative medio-lateral overhanging of the femoral cutting guide over the femoral condyle. There were no significant differences in the pre-operative parameters of both groups. At the last follow-up, both STD and GS groups had similarly improved KS clinical scores (92.9 vs. 92.1 points), function scores (89.5 vs. 89.7 points) and ROM (133.5° vs. 134.1°) with no difference in the rate of lateral retinacular release. The overall percentage of the GS component selection was 52.5% (165/314) and was significantly higher in female patients than male patients (60.8% vs. 8.2%, p<0.0001). In addition, selected GS prostheses increased significantly with increasing femoral size (25% for size C, 53% for size D, 86% for size E, and 100% for size F, respectively). There were no complications or early loosening related to the GS prosthesis. The mean post-operative limb alignment was 5.5° of the anatomical valgus with no difference between groups. We concluded that the GS femoral component did not provide better clinical outcomes than the standard femoral component; however, it provided surgical ease to minimize prosthesis overhanging in patients with narrow femoral condyles.
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http://dx.doi.org/10.1016/j.knee.2010.10.005DOI Listing
December 2011

High-flexion TKA in patients with a minimum of 120 degrees of pre-operative knee flexion: outcomes at six years of follow-up.

Int Orthop 2011 Sep 24;35(9):1321-6. Epub 2010 Oct 24.

Department of Orthopaedics, Chulalongkorn University, Bangkok 10330, Thailand.

We prospectively evaluated outcomes of high-flexion total knee arthroplasty in 165 patients who had advanced arthritis with a minimum 120-degree pre-operative knee flexion, with a mean follow-up of 77 months. Patients were divided into two groups according to their ability to perform full-range (heel-to-buttock) pre-operative knee flexion (group A) and the inability to do so (group B). The overall clinical rating was "excellent" in 96% of patients and "good" in 4% of patients. Mean maximum knee flexion decreased from 137.9° to 134.8°, with no statistical difference between pre- and post-operative knee flexion. However, patients in group A had significantly decreased knee flexion (146.2° vs. 135.0°, p < 0.001), whereas patients in group B exhibited no change in knee flexion (133.7° vs. 134.7°, p = 0.14). We found that 14.7%, 36.5% and 43.0% of the studied patients could engage in kneeling, Thai polite style sitting and cross-legged sitting, respectively, with no significant differences between groups A and B. The survival rates for any reoperation and prosthesis-related problem (such as early loosening) at six years were 98.3% and 100%, respectively. At six-year follow-up in patients with well preserved pre-operative knee flexion, the high-flexion knee prosthesis provided a favourable outcome without improving knee flexion.
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http://dx.doi.org/10.1007/s00264-010-1140-3DOI Listing
September 2011
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