Management of complications of mega-implants following treatment of primary and periprosthetic fractures of the lower extremities

In recent years, indications for implanting mega-implants were established in managing major bone defects linked to revision arthroplasty due to loosening, periprosthetic fractures, re-implantation following periprosthetic joint infection, non-union following fractures as well as complex intraarticular primary fractures. This study was conducted to discuss and analyze the strategy of diagnosis and management of complications following the use of mega-implants in treating primary and periprosthetic fractures of the lower extremities. This is a monocentric retrospective study. Patients aged ≥ 18 years who underwent implantation of a megaendoprosthesis due to periprosthetic or primary fractures of the lower extremity between January 2010 and February 2023 were identified from the authors' hospital information system. We identified 96 patients with equal numbers of fractures (71 periprosthetic fractures and 25 primary fractures). 90 cases out of 96 were investigated in this study. The drop-out rate was 6.25% (six cases). The average follow-up period was 22 months (1 to 8 years) with a minimum follow-up of 1 year. The diagnosis of complications was provided on the basis of subjective symptoms, clinical signs, radiological findings and laboratory investigations such as C-reactive protein, leucocyte count and the microbiological findings. The indications for implantations of modular mega-implants of the lower extremities were periprosthetic fractures (65 cases/72.22%) and primary fractures (25 cases/27.78%). Pathological fractures due to malignancy were encountered in 23 cases (25.56%), in one case due to primary tumor (1.11%) and 22 cases due to metastatic lesions (24.44%). Two cases (2.22%) presented with primary intraarticular fractures with severe osteoporosis and primary arthrosis. In all cases with malignancy staging was performed. Regarding localization, proximal femur replacement was encountered in 60 cases (66.67%), followed by distal femur replacement (28 cases/31.11%) and total femur replacement (2 cases/2.22%). The overall complication rate was 23.33% (21 complications in 21 patients). The most common complication was dislocation which was encountered in nine cases (10%), all following proximal femoral replacement (9 cases out of 60, making 15% of cases with proximal femoral replacement). The second most common complication was infection (six cases, 6.67%), followed by four aseptic loosenings (4.44%), further intraoperative periprosthetic fracture in one case (1.11%) and a broken implant in one case (1.11%). We noticed no cases with wear and tear of the polyethylene components and no cases of disconnections of the modular components. Mega-endoprostheses enable versatile management options in the treatment of primary and periprosthetic fractures of the lower extremities. The rate of complications such as loosening, implant failure, dislocation and infection are within an acceptable range in this preliminary analysis. However, implantation of mega-endoprostheses must be strictly indicated due the limited salvage options following surgery.

Beam-pointing verification using x-ray pinhole cameras on the 60-beam OMEGA laser

On the OMEGA laser system, the beam-pointing accuracy is verified by irradiating a 4 mm diameter Au-coated spherical target with ∼23 kJ of laser energy. Up to ten x-ray pinhole cameras record the x-ray emission from all 60-beam spots. A new set of algorithms has been developed to improve the accuracy of the pointing evaluation. An updated edge-finding procedure allows one to infer the center of the sphere with subpixel accuracy. A new approach was introduced to back-propagate the pixel locations on the 2D image to the 3D surface of the sphere. A fast Fourier transform-based de-noising method significantly improves the signal-to-noise of the data. Based on the beam-pointing analysis, hard-sphere calculations of the laser-drive illumination uniformity on the target surface and the decomposition of the illumination distribution into lower order modes (1-10) are evaluated.

3D Simulations Capture the Persistent Low-Mode Asymmetries Evident in Laser-Direct-Drive Implosions on OMEGA

Spherical implosions in inertial confinement fusion are inherently sensitive to perturbations that may arise from experimental constraints and errors. Control and mitigation of low-mode (long wavelength) perturbations is a key milestone to improving implosion performances. We present the first 3D radiation-hydrodynamic simulations of directly driven inertial confinement fusion implosions with an inline package for polarized crossed-beam energy transfer. Simulations match bang times, yields (separately accounting for laser-induced high modes and fuel age), hot spot flow velocities and direction, for which polarized crossed-beam energy transfer contributes to the systematic flow orientation evident in the OMEGA implosion database. Current levels of beam mispointing, imbalance, target offset, and asymmetry from polarized crossed-beam energy transfer degrade yields by more than 40%. The effectiveness of two mitigation strategies for low modes is explored.

Investigation of an apodized imaged Hartmann wavefront sensor

Quantitative wavefront measurements are demonstrated using a Hartmann mask re-imaged onto a camera. The wavefront is reconstructed using standard algorithms applied to the difference of beamlet centroids determined from fluence distributions obtained for two different longitudinal locations of the mask. The wavefront of the optical wave in the object plane is measured independently of imaging-system collimation. Apodization obtained with spatially dithered distributions of small transparent or opaque pixels improves the measurement accuracy by reducing the spatial-frequency content of the mask holes. Simulations and experiments demonstrate the excellent accuracy of this diagnostic over a wide range of parameters, making it suitable, for example, to characterize laser systems.

Single-shot high-resolution characterization of optical pulses by spectral phase diversity

The concept of spectral phase diversity is proposed and applied to the temporal characterization of optical pulses. The experimental trace is composed of the measured power of a plurality of ancillary optical pulses derived from the pulse under test by adding known amounts of chromatic dispersion. The spectral phase of the pulse under test is retrieved by minimizing the error between the experimental trace and a trace calculated using the known optical spectrum and diagnostic parameters. An assembly composed of splitters and dispersive delay fibers has been used to generate 64 ancillary pulses whose instantaneous power can be detected in a single shot with a high-bandwidth photodiode and oscilloscope. The diagnostic is experimentally shown to accurately characterize pulses from a chirped-pulse-amplification system when its stretcher is detuned from the position for optimal recompression. Pulse-shape reconstruction for pulses shorter than the photodetection impulse response has been demonstrated. Various investigations of the performance with respect to the number of ancillary pulses and the range of chromatic dispersion generated in the diagnostic are presented.

Demonstration of large-aperture tiled-grating compressors for high-energy, petawatt-class, chirped-pulse amplification systems

Two large-aperture tiled-grating (1.5 m) compressors, each consisting of four sets of tiled-grating assemblies, have been built for the OMEGA EP high-energy petawatt-class laser system. The techniques used for tiling individual tiled-grating assemblies and for optimizing the overall performance of a tiled-grating compressor are described. Both compressors achieved subpicosecond pulse duration without tiling-induced temporal degradation. A ray-tracing model predicted that the static wavefront of the grating tiles dominated focal-spot degradations when submicroradian tiling accuracy is achieved. The tiled-grating compressors delivered a tighter focal spot compared with subaperture grating compressors with single central tiles.

Large-aperture grating tiling by interferometry for petawatt chirped-pulse-amplification systems

A tiled-grating assembly with three large-scale gratings is developed with real-time interferometric tiling control for the OMEGA EP Laser Facility. An automatic tiling method is achieved and used to tile a three-tile grating assembly with the overall wavefront reconstructed. Tiling-parameters sensitivity and focal-spot degradation from all combined tiling errors are analyzed for a pulse compressor composed of four such assemblies.

Tumor necrosis factor receptors (Tnfr) in mouse fibroblasts deficient in Tnfr1 or Tnfr2 are signaling competent and activate the mitogen-activated protein kinase pathway with differential kinetics

To dissect tumor necrosis factor receptor (Tnfr)-1 (CD120a) and Tnfr2 (CD120b)-dependent signal transduction pathways, primary fibroblasts isolated from inguinal adipose tissue of wild type (wt), tnfr1(o), tnfr2(o), and tnfr1(o)/tnfr2(o) mice were studied. The mitogen-activated protein kinases Erk1 and Erk2 were found to be tyrosine-phosphorylated and activated by Tnf treatment in all wt, tnfr1(o), and tnfr2(o) fibroblasts; the activation was down-regulated 60 min after the start of steady state Tnf treatment. Distinct kinetics of Erk1 and Erk2 activation were detected; the Tnfr1-mediated activation of Erk1 and Erk2 started more slowly and persisted for more prolonged times as compared with Tnfr2 activation. Raf-1, Raf-B, Mek-1, Mek kinase, and p90(rsk) kinases were also shown to be activated independently in a distinct time-dependent pattern through the two Tnf receptors. In addition, both Tnfr1 and Tnfr2 mediated independently the activation of the transcription factor Ap-1 albeit with parallel activation kinetics. In contrast, Tnfr1 exclusively mediated activation of NF-kappaB and fibroblast proliferation; however, Tnfr2 enhanced proliferation triggered through Tnfr1. These findings indicate distinct but also overlapping roles of Tnfr1 and Tnfr2 in primary mouse fibroblasts and suggest different regulation mechanisms of signal transduction pathways under the control of both Tnf receptors.

[Doppler sonography of testicular circulation following reconstruction of inguinal hernia]

The use of pre- and postoperative testicular Doppler ultrasound examination in groin hernia repair is evaluated in 50 patients operated by the technique of Shouldice. The etiological differentiation between ischemic orchitis and testicular necrosis is based on the monitoring of testicular perfusion. The technique is presented in detail. Preoperatively the arterial supply could be examined in 45 of 50 patients and the venous flow in 41 patients. The postoperative arterial flow was found in all and the venous flow in 47 patients. Our results revealed the Doppler sonography as a suitable technique for postoperative semiquantitative examination of testicular perfusion. It should be employed in all cases of postoperative testicular pain. A mandatory use of the Doppler technique to obtain an indication for operative revision has still to be discussed.