Whole-genome sequencing in prenatally detected congenital malformations: prospective cohort study in clinical setting

OBJECTIVE

To investigate the diagnostic yield of trio whole-genome sequencing (WGS) in fetuses with various congenital malformations referred to a tertiary center for prenatal diagnosis.

METHODS

In this prospective study, 50 pregnancies with different congenital malformations, negative for trisomies and causative copy-number variants, were analyzed further with fetal-parental trio WGS analysis. Parents were eligible for inclusion if they accepted further investigation following the detection of isolated or multiple malformations on prenatal ultrasound. Cases with isolated increased nuchal translucency, gamete donation or multiple pregnancy were excluded. WGS with the Illumina Inc. 30× polymerase-chain-reaction-free short-read sequencing included analysis of single-nucleotide variants, insertions and deletions, structural variants, short tandem repeats and copy-number identification of SMN1 and SMN2 genes.

RESULTS

A molecular diagnosis was achieved in 13/50 (26%) cases. Causative sequence variants were identified in 12 genes: FGFR3 (n = 2), ACTA1 (n = 1), CDH2 (n = 1), COL1A2 (n = 1), DHCR7 (n = 1), EYA1 (n = 1), FBXO11 (n = 1), FRAS1 (n = 1), L1CAM (n = 1), OFD1 (n = 1), PDHA1 (n = 1) and SOX9 (n = 1). The phenotypes of the cases were divided into different groups, with the following diagnostic yields: skeletal malformation (4/9 (44%)), multisystem malformation (3/7 (43%)), central nervous system malformation (5/15 (33%)) and thoracic malformation (1/10 (10%)). Additionally, two cases carried variants that were considered potentially clinically relevant, even though they were assessed as variants of uncertain significance, according to the guidelines provided by the American College of Medical Genetics and Genomics. Overall, we identified a causative or potentially clinically relevant variant in 15/50 (30%) cases.

CONCLUSIONS

We demonstrate a diagnostic yield of 26% with clinical WGS in prenatally detected congenital malformations. This study emphasizes the benefits that WGS can bring to the diagnosis of fetal structural anomalies. It is important to note that causative chromosomal aberrations were excluded from our cohort before WGS. As chromosomal aberrations are a well-known cause of prenatally detected congenital malformations, future studies using WGS as a primary diagnostic test, including assessment of chromosomal aberrations, may show that the detection rate exceeds the diagnostic yield of this study. WGS can add clinically relevant information, explaining the underlying cause of the fetal anomaly, which will provide information concerning the specific prognosis of the condition, as well as estimate the risk of recurrence. A genetic diagnosis can also provide more reproductive choice for future pregnancies. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Leaving no one behind: Defining and implementing an integrated life course approach to vaccination across the next decade as part of the immunization Agenda 2030

Strategic Priority 4 (SP4) of the Immunization Agenda 2030 aims to ensure that all people benefit from recommended immunizations throughout the life-course, integrated with essential health services. Therefore, it is necessary for immunization programs to have coordination and collaboration across all health programs. Although there has been progress, immunization platforms in the second year of life and beyond need continued strengthening, including booster doses and catch-up vaccination, for all ages, and recommended vaccines for older age groups. We note gaps in current vaccination programs policies and achieved coverage, in the second year of life and beyond. In 2021, the second dose of measles-containing vaccine (MCV2), given in the second year of life, achieved 71% global coverage vs 81% for MCV1. For adolescents, 60% of all countries have adopted human papillomavirus vaccines in their vaccination schedule with a global coverage rate of only 12 percent in 2021. Approximately 65% of the countries recommend influenza vaccines for older adults, high-risk adults and pregnant women, and only 25% recommended pneumococcal vaccines for older adults. To achieve an integrated life course approach to vaccination, we reviewed the evidence, gaps, and strategies in four focus areas: generating evidence for disease burden and potential vaccine impact in older age groups; building awareness and shifting policy beyond early childhood; building integrated delivery approaches throughout the life course; and identifying missed opportunities for vaccination, implementing catch-up strategies, and monitoring vaccination throughout the life course. We identified needs, such as tailoring strategies to the local context, conducting research and advocacy to mobilize resources and build political will. Mustering sufficient financial support and demand for an integrated life course approach to vaccination, particularly in times of COVID-19, is both a challenge and an opportunity.

Diagnostic yield using whole-genome sequencing and in-silico panel of 281 genes associated with non-immune hydrops fetalis in clinical setting

OBJECTIVE

To investigate the diagnostic yield of clinical whole-genome sequencing (WGS) in prenatally diagnosed non-immune hydrops fetalis (NIHF).

METHODS

This was a retrospective study of 23 fetuses with prenatally diagnosed NIHF, negative for trisomies and copy-number variants, referred for analysis by WGS with an in-silico panel of 281 genes associated with hydrops fetalis. Due to identification of a high proportion of causative variants in the HRAS gene in the main cohort, Sanger sequencing of HRAS was performed in a replication cohort, consisting of 24 additional fetuses with NIHF that were negative for trisomies and copy-number variants and had not undergone WGS.

RESULTS

Of the 23 fetuses in the main cohort, a molecular diagnosis was achieved in 12 (52.2%). Pathogenic or likely pathogenic variants were identified in seven genes: HRAS (n = 5), RIT1 (n = 2), FOXP3 (n = 1), GLB1 (n = 1), MAP2K1 (n = 1), PTPN11 (n = 1) and RASA1 (n = 1). The inheritance pattern of the 12 causative variants was autosomal dominant in 10 cases (HRAS, MAP2K1, PTPN11, RASA1, RIT1), autosomal recessive in one (GLB1) and X-linked recessive in one (FOXP3). Of the 24 fetuses in the replication cohort, a pathogenic variant in HRAS was identified in one, resulting in an overall frequency of causative HRAS variants of 12.8% (6/47) in our two cohorts.

CONCLUSIONS

We demonstrate a diagnostic yield of 52% with clinical WGS in NIHF using an in-silico panel of 281 genes. However, the high diagnostic yield may be attributed to the small sample size and possible over-representation of severe phenotypes in the included fetuses. Bearing in mind that chromosomal abnormalities were excluded in our cohorts, a detection rate of up to 75% is possible in prenatally diagnosed NIHF when WGS analysis includes calling of chromosomal aberrations. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Tailored intervention with peer-to-peer as a tool to promote childhood vaccination in migrants

Background

A tailored intervention about childhood vaccination in Stockholm, Sweden, has focused on different activities with the aim to improve vaccination confidence and in particular Measles, Mumps and Rubella (MMR) vaccination coverage. The intervention included provided peer education focusing on vaccination information, the vaccine-preventable diseases, child development and communication skills in Somali and Swedish language and for the peers to further inform other parents in their communities.

Aim

This study aims to explore peers’ experiences of the interventions and their role to promote vaccination confidence.

Methods

This study follows a qualitative methodology with in-depth interviews and the data collection is ongoing. The study participants consist of seven peers who participated in the program. The interviews aimed to explore how the peers used the training in real life. All interviews conducted were tape-recorded and transcribed verbatim in order to facilitate deep content analysis. The analysis followed a content analysis, by first coding the data and then developing categories and emerging themes.

Results

Preliminary findings show that peers expressed the importance of having a training that equipped them with knowledge and confidence to discuss fact-based information with hesitant parents. The peers shared that after the training they had several opportunities to talk about childhood vaccinations in particular MMR vaccination with other parents. Some peers took an active role in reaching other parents by utilising the film and the cards to facilitate their dialogue. Other also acknowledged that when they could not answer a specific question, they encouraged the parents to address the query with the child health clinic nurses.

Conclusions

The use of a peer-to-peer concept to increase vaccination confidence provides additional forums for parents to dialogue about their concerns and receive correct vaccination information.

Key messages

Tailored interventions in close collaboration with communities are crucial for sustainable improvements of vaccination acceptance and coverage. The peer-to-peer concept provides a new arena to reach vaccination hesitant parents and can complement the communication on vaccination from health care provides.

Tailored communication intervention in a Somali community, Sweden, to improve vaccine confidence

Background

Sweden sustains a high and stable vaccination coverage for measles-mumps-rubella (MMR) vaccination (>96%) but despite a high national coverage, there may be local gaps. One example is a Stockholm suburb hosting a population with largely Somali origin that since 1998 has showed low MMR vaccine rates (70%). A baseline study using the Tailoring Immunisation Programme (TIP), child health clinics (CHC) nurses reported poor communication with vaccine hesitant parents who worried that the MMR vaccine may cause autism. Following, a tailored intervention with emphasis on strong and preferred oral communication was designed to address parentś concerns and, seminars to reinforce nurses in improving their encounter with parents.

Methods

The intervention was developed using the TIP guide including an adapted version of the Behaviour Change Wheel model, it included communication tools (films, videos), public seminars in Somali on MMR vaccine, vaccine-preventable diseases and autism, and training of peer parent group. CHC nurses were given tailored seminars with updated information on vaccines with emphasis on how to communicate with vaccine hesitant parents.

Results

Preliminary results suggest that the tools implemented have been well received by all stakeholders and a positive trend in vaccination coverage has been observed. Parents have engaged actively, 32 parents completed the peer-to-peer training and all nurses attended the seminars. Preliminary data of qualitative interviews with 11 nurses indicates that increased knowledge strengthened their confidence to meet the parents and address vaccine hesitancy. The films and information materials facilitated the nursés communication with parents.

Conclusions

Tailored communication interventions need to be tested, implemented and evaluated as tools to motivate change in parental attitudes and to strengthened health care providers role aiming to increase vaccine acceptance and resilience in the immunisation programmes.

Key messages

Tailored communication intervention on vaccination need to be implemented and evaluated as tools to motivate changes in attitudes and behaviours regarding vaccine acceptance. Tailored interventions has been positively received by all target groups and a positive trend in vaccination coverage has been observed.

Serious complications due to acute rhinosinusitis in children up to five years old in Stockholm, Sweden - Still a challenge in the pneumococcal conjugate vaccine era

OBJECTIVES

The aim of this study was to analyze the rate of admissions, the rate of serious complications (postseptal orbital complications and surgery) and the bacterial etiology of acute rhinosinusitis in hospitalized children under five years old in Stockholm County, eight years after the introduction of the pneumococcal conjugate vaccine (PCV). The secondary aim was to compare this period with the period four years prior to the vaccine's introduction.

METHODS

This was a population-based, descriptive observational study with retrospectively collected data from 1 July 2008 to 30 June 2016 in Stockholm County. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed and compared to the pre-PCV period of 2003-2007.

RESULTS

A total of 215 children were admitted, for a yearly incidence of 18.8 per 100 000 children (22.8 for boys, 14.6 for girls). Computer tomography-verified postseptal orbital complications occurred in 29 cases (13.5%) and surgery was necessary in nine (4.2%). Pathogens other than Streptococcus pneumoniae were found in the cases with postseptal complication or surgery (Streptococcus pyogenes in four, Haemophilus influenzae in three and Staphylococcus aureus in one case). In comparison to the four years pre-PCV, the incidence of admission decreased from 43.81 to 20.31 and 17.45 per 100 000/year for the two four-year periods after vaccine introduction. The incidence of CT-verified postseptal complication increased slightly from 1.51 to 2.34 and 2.74 per 100 000/year. The incidence of surgeries increased marginally but continued to be very low, from 0.22 to 0.54 and 1.03 per 100 000/year.

CONCLUSIONS

Complications due to acute rhinosinusitis in children living in Stockholm County continues to be very rare after the introduction of pneumococcal vaccine. Hospitalization has decreased for children under five years old after PCV introduction, but the incidence or postseptal complications and surgery in the same population increased slightly. Predominantly bacteria other than Streptococcus pneumoniae was found. There is a need of larger studies to determine trends, and a need of prospective studies to elucidate the bacterial etiology, of serious complications due to acute rhinosinusitis in children.

Most preschool children hospitalised for acute rhinosinusitis had orbital complications, more common in the youngest and among boys

AIM

This study established the incidence of acute rhinosinusitis and related orbital complications in tertiary care in Stockholm County and surveyed the clinical outcomes.

METHODS

This was a population-based, retrospective, observational study, from July 1, 2003 to June 30, 2007, of the hospital admissions records of 213 children up to five years old, with a diagnosis of sinusitis and related complications.

RESULTS

Preseptal cellulitis was present in 171 of the 213 admissions, which equated to an incidence of orbital complications due to acute rhinosinusitis of 36 per 100 000 people per year (95% confidence interval 26-49). Postseptal complications occurred in seven cases. The incidence rate ratio for hospitalisation of children less than two years old with rhinosinusitis compared with children aged 2-5 years was 2.8 (95% confidence interval 1.8-4.4). The incidence among boys was 53 per 100 000 people per year and 36 per 100 000 people per year for girls, and the incidence rate ratio was 1.5 (95% confidence interval 1.0-2.3). The most common bacterial finding was Streptococcus pneumoniae.

CONCLUSION

Most children hospitalised for acute rhinosinusitis had an orbital complication, and this was more common in children under the age of two years and boys. Severe postseptal complications were rare.

Identification of new TRIP12 variants and detailed clinical evaluation of individuals with non-syndromic intellectual disability with or without autism

The ubiquitin pathway is an enzymatic cascade including activating E1, conjugating E2, and ligating E3 enzymes, which governs protein degradation and sorting. It is crucial for many physiological processes. Compromised function of members of the ubiquitin pathway leads to a wide range of human diseases, such as cancer, neurodegenerative diseases, and neurodevelopmental disorders. Mutations in the thyroid hormone receptor interactor 12 (TRIP12) gene (OMIM 604506), which encodes an E3 ligase in the ubiquitin pathway, have been associated with autism spectrum disorder (ASD). In addition to autistic features, TRIP12 mutation carriers showed intellectual disability (ID). More recently, TRIP12 was postulated as a novel candidate gene for intellectual disability in a meta-analysis of published ID cohorts. However, detailed clinical information characterizing the phenotype of these individuals was not provided. In this study, we present seven novel individuals with private TRIP12 mutations including two splice site mutations, one nonsense mutation, three missense mutations, and one translocation case with a breakpoint in intron 1 of the TRIP12 gene and clinically review four previously published cases. The TRIP12 mutation-positive individuals presented with mild to moderate ID (10/11) or learning disability [intelligence quotient (IQ) 76 in one individual], ASD (8/11) and some of them with unspecific craniofacial dysmorphism and other anomalies. In this study, we provide detailed clinical information of 11 TRIP12 mutation-positive individuals and thereby expand the clinical spectrum of the TRIP12 gene in non-syndromic intellectual disability with or without ASD.

Detailed molecular and clinical characterization of three patients with 21q deletions

We have investigated three patients with 21q deletions, two with developmental delay, dysmorphic features and internal organ malformations, and one with cognitive function within the normal range but with some deficits in gross and fine motor development. All aberrations were characterized by array-comparative genomic hybridization (array-CGH). In addition, extensive fluorescence in situ hybridization (FISH) mapping on metaphase chromosomes and mechanically stretched chromosomes was performed on patient 1 who had an extremely complex intrachromosomal rearrangement with 16 breakpoints, four deletions and four duplications. Patients 2 and 3 had interstitial deletions comprising 21q21.1-21q22.11 and 21q11.2-21q21.3, respectively. Partial deletions of 21q are rare and these patients display a highly variable phenotype depending on the size and position of the deletion. A review of the literature identified 38 cases with pure 21q deletions. Twenty-three of these had reliable mapping data. The combined information of present and previous cases suggests that the ITSN1 gene is involved in severe mental retardation in patients with 21q deletion. In addition, a critical region of 0.56 Mb containing four genes, KCNE1, DSCR1, CLIC6 and RUNX1, is associated with severe congenital heart defects, and deletions of the most proximal 15-17 Mb of 21q is associated with mild or no cognitive impairment, but may lead to problems with balance and motor function.

Analysis of the distribution and frequency of trisomy 7 in vivo in synovia from patients with osteoarthritis and pigmented villonodular synovitis

Osteoarthritis (OA) and pigmented villonodular synovitis (PVNS) are disorders associated with trisomy 7. The aim of the present study was to determine the frequency and distribution of the cells with +7 in vivo by analyzing sections of paraffin-embedded synovia from patients affected by OA, PVNS, other forms of synovitis [hemorragic synovitis (HS) and chronic synovitis (CS)], and from individuals without joint disease. Fluorescence in situ hybridization (FISH), using a centromeric probe for chromosome 7, showed that the mean frequency of trisomic nuclei in 5-microm sections was highest in PVNS (9.0%), followed by CS (5.9%), OA (5.6%), and HS (4.6%), whereas trisomic nuclei were rare (0.7%) in normal tissue. When 8-microm sections were studied, the frequencies of trisomic cells in OA and control synovia increased to 6.7% and 1.5%, respectively. Trisomic nuclei were found in all cases, including those for which cytogenetic analysis of short-term cultures had not disclosed any trisomic cells. Overall, the trisomic cells were scattered within the tissue. However, small clusters of cells with +7 were found in three cases. By hematoxylin-eosin staining of the slides used for FISH analysis it could be shown that the clustered trisomic cells were proliferating synoviocytes within villous extensions of the synovial membrane.

The patella in total knee arthroplasty: resurfacing or nonresurfacing of patella

Data from the Swedish Knee Arthroplasty Registry were analyzed to compare bi- and tricompartmental knee arthroplasties carried out in patients operated on for arthrosis in 1990-1996. Of the 16,607 primary arthroplasties that were carried out there were 5,139 with patellar replacement in the primary procedure and 10,928 without. By April 1998, 280 revisions were performed, 250 of these cases were analyzed in this study. Patella-related complications were commonly the reason for early revision: in 99 of the 168 knees with a primary bicompartmental procedure and in 36 of the 82 knees with a primary tricompartmental procedure. This presentation merely analyzes the extent of patellar problems in knee arthroplasty, as a detailed analysis of the causes of this common problem is not possible using data from a national multicenter study.

The tumor-associated gene HMGIC is expressed in normal and osteoarthritis-affected synovia

Chromosomal rearrangements involving chromosome bands 12q13-15 are very frequent findings in benign solid tumors, and recently, the primary molecular target for these aberrations was identified as the gene HMGIC. However, mutations in this gene have also been observed in nonneoplastic tissues. In a previous study, we reported breakpoints within HMGIC of synovia affected by osteoarthritis (OA) in two cases with 12q15 aberrations. To analyze further the role of HMGIC in this disease, we have performed cytogenetic, fluorescent in situ hybridization (FISH), RNA, and protein expression analyses on synovial samples from patients with OA and individuals without signs of the disorder. Cytogenetic analysis of short-term cultured cells revealed clonal 12q13-15 aberrations in 2/36 cases of OA synovia and no rearrangement in any of the five controls. With FISH analysis, it was shown that the chromosomal breakpoints in the two aberrant cases were located outside the HMGIC locus. In contrast, at RNA and protein expression analyses, OA-affected as well as normal synovia displayed transcription and translation of the gene. We also analyzed whether immunoreactivity for HMGIC was associated with the proliferation-specific antigen Ki-67, but no correlation between the staining patterns of these proteins was observed. From the results of the present study, it is evident that expression of HMGIC cannot simply be considered a sign of neoplasia or an effect of proliferation.

Trisomy 7 accumulates with age in solid tumors and non-neoplastic synovia

Trisomy 7 is a common finding in benign and malignant solid tumors, in several non-neoplastic lesions (for example, osteoarthritis and rheumatoid arthritis), and in apparently normal tissues as well, suggesting that the occurrence of +7 might be associated with factors other than the disease process itself. To find out whether the frequency of +7 varies with a patient's age, we cytogenetically analyzed short-term-cultured synovial samples from elderly persons without signs of arthritis and from young patients affected by juvenile chronic arthritis (JCA). In normal synovia, gain of a chromosome 7 was present as a clonal change in five of 10 cases and in single cells in four of the five remaining cases. In synovia from patients with JCA, cells with +7 were detected in only one of nine cases, representing the oldest patient in the series. Furthermore, we reviewed the cytogenetic literature on tumors of the brain, breast, colon, kidney, lung, skin, thyroid, and upper aerodigestive tract. In the majority (six of eight) of these tumor types, the frequency of cases displaying a clone with +7 as the sole aberration increased with age. Taken together, the results presented here suggest that the acquisition of trisomy 7 in some neoplastic and non-neoplastic tissues might be associated with age rather than with disease. The finding of a completely different frequency distribution in two of the tumor types (tumors of the brain and the thyroid gland), however, emphasizes the heterogeneity of +7 and indicates that other, possibly tissue-specific, factors might influence the occurrence of this mutation.

Polyclonal expansion of cells with trisomy 7 in synovia from patients with osteoarthritis

Trisomy 7 as the single chromosome aberration has been found in a variety of neoplasms and in normal tissue in the proximity of tumors, as well as in non-neoplastic lesions. Recently, we described a nonrandom pattern of chromosome aberrations, in particular, a gain of chromosome 7, in synovia, cartilage, and osteophytes from patients with osteoarthritis. To study the clonal origin of trisomy 7 in osteoarthritis, multiple synovial samples were collected from five women, all of whom were informative heterozygotes with regard to the X-linked human androgen receptor gene (AR). From each case, three to four independent cell cultures were initiated. Trisomic cell populations were subcloned from the individual cultures, and it was established whether or not the same allele of AR was inactivated in trisomic cells from different parts of the same joint. The finding of a polyclonal X-inactivation pattern in two of the cases provides strong evidence that gain of an extra copy of chromosome 7 occurs independently in multiple cells.

The introduction period of unicompartmental knee arthroplasty is critical: a clinical, clinical multicentered, and radiostereometric study of 251 Duracon unicompartmental knee arthroplasties

One hundred twenty-eight consecutive knees were operated on with the Duracon unicompartmental knee arthroplasty. Of 111 knees, followed 3 years (range, 1-6 years), 109 knees were satisfactory. Two knees were revised because of progression of osteoarthritis and inexplicable pain. Radiostereometric analysis in 49 knees showed a migration of 0.6 mm after 2 years. The magnitude of migration was lower in comparison with published series. In a multicenter study comprising 4 other hospitals, there were 8 revisions in 123 operated knees. The reasons were loosening, subsidence, or fracture. These revisions were within 1 year and mostly related to operative technique. Unicompartmental knee arthroplasty is a demanding procedure that needs special experience and includes a risk of early failures during the introduction of a system.

Bilateral proprioceptive defects in patients with a unilateral anterior cruciate ligament reconstruction: a comparison between patients and healthy individuals

Proprioception of the knee was measured in 20 patients with reconstructed anterior cruciate ligaments and in 19 age-matched controls. The mean time from surgery was 2 years. Three tests of proprioception were used: (a) threshold to detection of passive motion from 20 and 40 degrees toward flexion and extension, (b) active reproduction of a 30 degrees passive angle change, and (c) visual reproduction of a 30 degrees passive angle change. The aim was a complete, bilateral, proprioceptive evaluation of patients who had undergone reconstruction of the anterior cruciate ligament. As compared with those in the control group, the knees with reconstructed anterior cruciate ligaments had a higher threshold to detection of passive motion in the extension trials from 20 and 40 degrees (p = 0.0003 and 0.04, respectively) and in the flexion trials from 20 and 40 degrees (p = 0.004 and 0.0008, respectively). When the uninjured knees of the patients were compared with those in the control group, higher values for threshold to detection of passive motion were found in the flexion trials from 20 degrees (p = 0.002) and 40 degrees (p = 0.02). Thus, decreased proprioceptive ability was present in some measurements of these patients after reconstructive surgery, not only in injured knees but also in uninjured knees, as compared with the reference group. The functional relevance of these findings was not investigated in this study, but the results suggest that bilateral proprioceptive considerations should be made when evaluating prognostic factors, treatment, and risk of contralateral knee injury in patients with reconstructed anterior cruciate ligaments.

Rehabilitation following acute anterior cruciate ligament injuries--a 12-month follow-up of a randomized clinical trial

The efficacy of two non-operative rehabilitation programs was studied in a consecutive randomized controlled clinical trial of 100 patients after 12 months subsequent to an acute anterior cruciate ligament (ACL) injury. Follow up of randomization to two training models was evaluated after 3 and 12 months: A self-monitored training program (SM) of traditional mobility and muscle strength training of the injured leg was compared to a supervised (SV) training model exercising postural function in closed kinetic-chains. Nearly 50% of the patients in the SM group required supervision after 6 weeks. An intention-to-treat analysis was performed and showed significantly better values in most of the results of the supervised group at 3 and 12 months. An alternative analysis of subgroups showed a significant difference between transferred male patients and original SV male patients at 3 months but not at 12 months, indicating the importance of initial guiding after an ACL injury. No such difference was observed in the female patients.

Total meniscectomy in adolescence. A thirty-year follow-up

We have carried out a prospective, longitudinal 30-year review of 95 adolescents who underwent total meniscectomy in one knee, and have compared the results with those observed 13 years earlier. All the medical records were scrutinised. Of the 63 patients reviewed clinically, 47 reported decreased sporting activity, although subjective satisfaction rose by 3% to 71%. The scores on the WOMAC osteoarthritis index differed significantly between patients grouped by subjective global assessment. Satisfactory function scores increased from 48% to 60%. In the 53 patients consenting to bilateral radiography of the knee, the incidence of narrowing of the articular cartilage in the operated knee increased significantly between the reviews (19% to 36%). Progression of degenerative change paralleled reduction in activity. Outcome measures were best after medial, intermediate after lateral and worst after double meniscectomy.

Total meniscectomy in adolescence

We have carried out a prospective, longitudinal 30-year review of 95 adolescents who underwent total meniscectomy in one knee, and have compared the results with those observed 13 years earlier. All the medical records were scrutinised. Of the 63 patients reviewed clinically, 47 reported decreased sporting activity, although subjective satisfaction rose by 3% to 71%. The scores on the WOMAC osteoarthritis index differed significantly between patients grouped by subjective global assessment. Satisfactory function scores increased from 48% to 60%. In the 53 patients consenting to bilateral radiography of the knee, the incidence of narrowing of the articular cartilage in the operated knee increased significantly between the reviews (19% to 36%). Progression of degenerative change paralleled reduction in activity. Outcome measures were best after medial, intermediate after lateral and worst after double meniscectomy.

Hydroxyapatite-enhanced tibial prosthetic fixation

Sixty-two knees (60 patients) were randomized to four noncemented groups. In Groups 1, 3, and 4, the bone cuts were made with a cooled saw blade. In Group 1, 15 patients were operated on with the porous coated Osteonic 7000 tibial component. In Group 2, 15 patients were operated on with the same tibial component as in Group 1 but with the use of a standard saw blade. In Group 3, 16 patients were operated on with the hydroxyapatite-coated Osteonic tibial component, and in Group 4, 16 patients were operated on with the hydroxyapatite Duracon tibial component. All patients were followed up clinically and with roentgenstereometric analysis. There were no differences among the groups regarding clinical outcome. One knee was revised (Group 2) after 1 year because of loosening of the tibial component. The maximum migration at 1 year was 1.7 mm in Group 1, 1.9 mm in Group 2, 1.3 mm in Group 3, and 1 mm in Group 4. At the 2-year followup, the migrations were 1.8 mm, 1.5 mm, 1.4 mm, and 1 mm in Groups 1, 2, 3, and 4, respectively. The inducible displacement that occurred at 1 year was 0.6 mm in Group 1, 0.5 mm in Group 2, 0.4 mm in Group 3, and 0.4 mm in Group 4. The hydroxyapatite coating had a strong positive effect on the tibial component fixation. No prosthesis in the hydroxyapatite groups showed continuous migration.

Proprioception in people with anterior cruciate ligament-deficient knees: comparison of symptomatic and asymptomatic patients

STUDY DESIGN

Nonrandomized prospective study.

OBJECTIVE

To evaluate proprioception in 2 groups of patients with anterior cruciate ligament (ACL) deficiency who had different severity of symptoms.

BACKGROUND

Defective proprioception has previously been found in patients with ACL-deficient knees. It has been suggested that sensory receptors of the ACL and other knee joint ligaments contribute to proprioception and knee joint function and stability.

METHODS AND MEASURES

A total of 17 patients with ACL deficiency (mean [SD] age, 28.8 +/- 5.6 years; range, 22-39 years) with few, if any, symptoms were compared with 20 patients with ACL deficiency (mean [SD] age, 26.6 +/- 6.1 years; range, 18-39 years) having instability and episodes of giving way. The groups were compared with each other and with an age-matched reference group of 19 nonimpaired subjects. Their mean (SD) age was 25.6 +/- 3.7 years (range, 20-37 years). Three tests of proprioception were used: threshold to detection of passive motion from 2 starting positions (20 degrees and 40 degrees of knee flexion) toward flexion and extension, active reproduction of a 30 degrees passive angle change, and visual reproduction of a 30 degrees passive angle change. The Wilcoxon rank sum test was used for between-group comparisons.

RESULTS

Symptomatic patients had higher threshold to detection of passive motion in their injured side in the flexion trial from 20 degrees (median of 1.5 degrees vs median of 0.5 degree) and in the extension trial from 40 degrees (median of 1.0 degree vs median of 0.5 degree) than the asymptomatic patients. No differences were found in the other threshold tests, active or visual reproduction tests.

CONCLUSIONS

Patients with severe symptoms related to ACL deficiency were found to have inferior proprioceptive ability in some measurements compared with patients with a good knee function. The findings indicate that proprioceptive deficits might influence the outcome of an ACL injury treated nonoperatively.

Changes in osseous correction after proximal tibial osteotomy: radiostereometry of closed- and open-wedge osteotomy in 33 patients

33 patients (22 men), median age 54 (40-68) years, with medial gonarthrosis grades 1-3, were treated by closed-wedge osteotomy (high tibial osteotomy = HTO, n 16) or open-wedge osteotomy by hemicallotasis (hemicallotasis osteotomy = HCO, n 19). 2 patients were operated on bilaterally. The patients were studied by RSA (radiostereometric analysis) for measuring 3-D changes in the correction achieved. In the HTO group the RSA measurements were obtained at the time of plaster removal, 1 month later and 1 year after surgery. In the HCO group, the RSA measurements were performed at the time of removal of the external fixator, 1 month later and 1 year after surgery. After removal of the fixation, HTO was associated with increased medial/lateral and distal translation of the proximal segment, compared to HCO. In addition, the tibial plateau rotated more around the longitudinal axis of the tibia after HTO.

Proprioceptive defects after an anterior cruciate ligament rupture -- the relation to associated anatomical lesions and subjective knee function

A disturbed proprioception has been described in patients with an anterior cruciate ligament (ACL) deficient knee. The relation to demographic data and to different commonly associated anatomical lesions, as well as to subjective knee function, was prospectively studied in 16 consecutive patients after an acute knee ligament injury. All patients had a complete rupture of the ACL, but variable associated anatomical lesions. The threshold to detect a passive motion, as a measure of their proprioceptive ability, was registered repeatedly during the first year after injury. Four of the patients had consistently severe and persistent deficits at 1, 2 and 8 months. These four individuals had more chondral lesions and a lower subjective rating of their knee function than the remaining patients. In the whole group there were significant correlations between the recorded thresholds and associated chondral lesions, meniscal lesions and the subjective rating of knee function. We found no significant relation between age, gender, activity level, grade of mechanical laxity increase or a medial collateral ligament rupture, and the proprioceptive recordings. Thus, morphological lesions other than a rupture of the ACL seem to contribute to the proprioceptive deficits after a knee ligament injury, and the patients' ability to detect a passive motion showed a relation to subjective knee function from the time of injury onwards.

Tourniquet release for hemostasis increases bleeding. A randomized study of 77 knee replacements

We conducted a prospective, randomized study of 77 primary knee replacement operations on 75 patients (52 women), with a mean age of 71 years, to evaluate the effect of tourniquet release for hemostasis on blood loss and transfusion requirements. The operations were all done with spinal anesthesia and the use of a midline skin incision and medial parapatellar approach. In group I, the tourniquet was released for hemostasis before the wound was closed. In group 2, the tourniquet was first released after the wound was closed and a compressive dressing had been applied. The total intra- and postoperative blood losses were, on average, 858 mL (SD 443) in group I and 589 mL (347) in group 2 (p = 0.01). The median units of blood given and the postoperative decreases in hemoglobin values were similar in both groups. In a subgroup of 45 cementless prostheses, the 25 patients with prostheses allocated to group 1 lost 1022 mL (397) blood, compared to 646 mL (333) by the 20 patients with prostheses in group 2 (p = 0.01). Our findings speak against the efficacy of tourniquet release for hemostasis in knee replacement surgery.

Open-wedge osteotomy by hemicallotasis or the closed-wedge technique for osteoarthritis of the knee

We describe the results of 50 operations carried out on 46 patients with medial osteoarthritis of the knee of Ahlbäck grade 1 to 3. Patients were randomised either to a closed-wedge high tibial osteotomy (HTO) or an open-wedge procedure based on the hemicallotasis technique (HCO). Their median age was 55 years (38 to 68). The preoperative median hip-knee-ankle (HKA) angle was 171° (164 to 176) in the HTO group and 173° (165 to 179) in the HCO group. After six weeks, the median HKA angle was 185° (176 to 194) in the HTO group and 184° (181 to 188) in the HCO group. In the HTO group, seven patients were within the range of 182° to 186° compared with 21 in the HCO group (p < 0.001). One year later, ten HTO patients were within this range while the HKA angulation in the HCO group was unchanged. At two years the numbers were 11 and 18, respectively.

We evaluated the clinical results on the Hospital for Special Surgery, Lysholm and Wallgren-Tegner activity scores, and patients completed part of the Nottingham Health Profile questionnaire. An impartial observer at the two-year follow-up concluded that all scores had improved, but found no clinical differences between the groups.

Hemicallotasis open-wedge osteotomy for osteoarthritis of the knee

We studied the complications after open-wedge osteotomy by hemicallotasis in 308 consecutive patients, most of whom had osteoarthritis of the knee. The participating surgeons, who worked at 17 hospitals, used their discretion in selecting patients, operating techniques and external fixators. The general complications included 11 cases of deep-vein thrombosis (4%), six of nonunion (2%) and one of septic arthritis of the knee. There were technical complications in 13 patients (4%). In 157 patients (51%) pin-site infections were recorded; of these, 96% were minor and responded to wound toilet and antibiotic treatment. A total of 18 revision procedures was carried out.

Hemicallotasis open-wedge osteotomy for osteoarthritis of the knee. Complications in 308 operations

We studied the complications after open-wedge osteotomy by hemicallotasis in 308 consecutive patients, most of whom had osteoarthritis of the knee. The participating surgeons, who worked at 17 hospitals, used their discretion in selecting patients, operating techniques and external fixators. The general complications included 11 cases of deep-vein thrombosis (4%), six of nonunion (2%) and one of septic arthritis of the knee. There were technical complications in 13 patients (4%). In 157 patients (51%) pin-site infections were recorded; of these, 96% were minor and responded to wound toilet and antibiotic treatment. A total of 18 revision procedures was carried out.

Failure of partial cementation to achieve implant stability and bone ingrowth: a long-term roentgen stereophotogrammetric study of tibial components

Thirty patients with gonarthrosis were operated on with the PCA primary total knee prosthesis and had the tibial component fixed to the bone by partial cementation. In the first two groups of patients, cementation was by a peripheral rim of high and low-viscosity cement, respectively. In the third group, the pegs were cemented with the low-viscosity cement. Follow-up was performed with use of clinical parameters and roentgen stereophotogrammetric analysis. Clinically, the series was successful apart from a problem with tibial component wear, necessitating revision in five patients. At 8 years, the mean Hospital for Special Surgery score was 81 points. Venn-diagram scores revealed four failures and three acceptable cases; the remaining cases were satisfactory. Apart from one loose patellar component, there was no mechanical loosening. Roentgen stereophotogrammetric analysis showed that the tibial components moved relative to the bone; this indicated fibrous tissue fixation, which was corroborated histologically in two patients. The objective, to achieve bone ingrowth, was thus not successfully met. Radiolucent lines were consistently seen, and their size correlated with the migration as measured by roentgen stereophotogrammetric analysis. Furthermore, five continuously migrating prostheses showed significantly larger radiolucent zones than the prostheses that migrated only initially, and they were less well bonded to the bone at 1 year. In conclusion, partial cementation does not appear to be a way to achieve bone ingrowth in porous-coated implants under load.

Open-wedge osteotomy by hemicallotasis or the closed-wedge technique for osteoarthritis of the knee. A randomised study of 50 operations

We describe the results of 50 operations carried out on 46 patients with medial osteoarthritis of the knee of Ahlbäck grade 1 to 3. Patients were randomised either to a closed-wedge high tibial osteotomy (HTO) or an open-wedge procedure based on the hemicallotasis technique (HCO). Their median age was 55 years (38 to 68). The preoperative median hip-knee-ankle (HKA) angle was 171 degrees (164 to 176) in the HTO group and 173 degrees (165 to 179) in the HCO group. After six weeks, the median HKA angle was 185 degrees (176 to 194) in the HTO group and 184 degrees (181 to 188) in the HCO group. In the HTO group, seven patients were within the range of 182 degrees to 186 degrees compared with 21 in the HCO group (p < 0.001). One year later, ten HTO patients were within this range while the HKA angulation in the HCO group was unchanged. At two years the numbers were 11 and 18, respectively. We evaluated the clinical results on the Hospital for Special Surgery, Lysholm and Wallgren-Tegner activity scores, and patients completed part of the Nottingham Health Profile questionnaire. An impartial observer at the two-year follow-up concluded that all scores had improved, but found no clinical differences between the groups.

Rearrangement of the neoplasia-associated gene HMGIC in synovia from patients with osteoarthritis

The occurrence of clonal chromosome aberrations in short-term cultures from synovia, osteophytes, and cartilage from patients with osteoarthritis (OA) was recently reported. Among these aberrations, a recurrent involvement of chromosome bands 12q13-15 in structural rearrangements was detected in both synovia and osteophytes. Chromosomal abnormalities of 12q13-15 are frequent among malignant and benign mesenchymal tumors, and it was recently demonstrated that the molecular target in these neoplasms is the HMGIC gene. In this study, we show by fluorescence in situ hybridization that HMGIC was disrupted by rearrangements of 12q15 in synovia from two patients with OA. The finding of HMGIC rearrangement in a lesion that is not traditionally regarded as neoplastic not only widens the spectrum of disorders that may be associated with altered function of this gene, but also provides further support for the notion that genetically rearranged cell populations are part of the OA process.

Major bone transplantation in total knee arthroplasty: a 2- to 9-year radiostereometric analysis of tibial implant stability

Eight total knee arthroplasties involving major bone grafting to repair noncontained defects of the proximal tibia were studied. In all knees, autologous bone was used. Cement was used for implant fixation. At follow-up evaluation 5 years after surgery, 7 knees had excellent results, and 1 had fair results; the mean Hospital for Special Surgery score was 84. Radiostereometric analysis showed a mean migration of 0.5 mm (range, 0.2-1.5 mm). None of the knees in which major structural autologous bone grafting was used showed increased micromotion of the adjacent tibial implant.

Frequent complications in distal femoral osteotomy: a retrospective 8 year multicenter follow-up

A total of 32 distal femoral osteotomies performed between 1971 and 1993 were evaluated, with a follow-up of 8 (2-23) years. Indications were lateral gonarthrosis in 23 cases (group I), and there were a variety of other indications in 9 cases (group 2). Twenty-six of the patients were submitted to revision surgery. Eleven operations were performed as a result of complications, such as pseudarthrosis (5), deep infection (3), and stiff knee (3). The remaining 16 were removals of fixation devices and they were not considered complications. Clinical results were evaluated based on different clinical scores (HSS, Lysholm, and Tegner) and NHP (Nottingham Health Profile), and there were 10 cases with good or excellent results. Results were better if the postoperative HKA angle (Hip-Knee-Ankle) was within 0-8 degrees of varus. As accuracy of correction is of importance, and serious complications frequent, it is important to entrust cases such as these to the care of surgeons with a good knowledge of the surgical technique.

Early rehabilitation of acute anterior cruciate ligament injury--a randomized clinical trial

The efficacy of a 6-week rehabilitation program was evaluated in 100 consecutive patients, age 15-42 years, with acute anterior cruciate ligament (ACL) injury. Arthroscopy revealed associated lesions in 82% of the patients. Except for resections on menisci with large and unstable lesions, no surgery was performed. The patients were randomly assigned to supervised training or self-monitored training after instruction.

RESULTS

At the 6-week follow-up there was no difference between the groups with regard to pain at rest, pain during walking, or experience of giving-way episodes, Tegner activity level of Lysholm knee score. Only 2 of the 100 patients were observed without joint mobility restriction. The only significant difference between the groups was the improvement of muscle function in men in the supervised training group.

CONCLUSION

Six weeks' rehabilitation is too short a time period from original injury to obtain normal mobility and restored knee function.

Prevention of deep vein thrombosis in knee arthroplasty. Preliminary results from a randomized controlled study of low molecular weight heparin vs foot pump compression

BACKGROUND

We evaluated in a randomized controlled study the possibility to use foot pump mechanical compression compared to routine LMWH as prophylaxis against deep vein thrombosis during knee arthroplasty.

METHODS

Forty patients were included in this preliminary report. Eleven patients withdrew, usually during the early phase of the study.

RESULTS

Among the 29 patients completing a venography, 27% in the compression group and none in the LMWH group had a DVT. This difference was statistically significant (p<0.05). One further patient in the compression group died from pulmonary embolism 17 days postoperatively.

CONCLUSIONS

With the present study protocol, mechanical foot pump compression failed to be as efficient as LMWH prophylaxis.

Open wedge tibial osteotomy by callus distraction in gonarthrosis. Operative technique and early results in 36 patients

Proximal tibial osteotomy is indicated in cases of medial gonarthrosis with varus deformity in the active, younger patient. We report our experience of the hemicallotasis technique in 36 patients and the early clinical results after a median follow-up of 14 (11-16) months. The median patient age was 54 (33-64) years. The median hip-knee-ankle (HKA) angle was 172 (161-179) degrees preoperatively, 184 (178-187) degrees after completed correction and 183 (175-190) degrees at follow-up. The median fixation time was 88 (61-146) days. Complications were minor. Superficial pin-site inflammation/infections occurred in one fifth of the pins. The HSS score increased from a median 71 preoperatively to 94 at follow-up, the Lysholm score from 56 to 91 and the Tegner activity score from 6 to 10. The Nottingham Health Profile showed significant improvements as regards pain and physical mobility.

Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy: a matched radiostereometric study

To assess migration of the tibial component we used roentgen stereophotogrammetric analysis in 40 patients who had had a total knee arthroplasty after failure of a closing wedge osteotomy and compared them with 40 matched patients after primary total knee arthroplasty. We found no difference in migration over time or in the tendency for continuous migration between the two groups. There were no differences in alignment or position of the knee prosthesis or in the clinical outcome. Our findings show that revision of a failed high tibial osteotomy to a total knee arthroplasty is effective.

Fixation of the tibial component of total knee arthroplasty after high tibial osteotomy

To assess migration of the tibial component we used roentgen stereophotogrammetric analysis in 40 patients who had had a total knee arthroplasty after failure of a closing wedge osteotomy and compared them with 40 matched patients after primary total knee arthroplasty.

We found no difference in migration over time or in the tendency for continuous migration between the two groups. There were no differences in alignment or position of the knee prosthesis or in the clinical outcome.

Our findings show that revision of a failed high tibial osteotomy to a total knee arthroplasty is effective.

Early inducible displacement of tibial components in total knee prostheses inserted with and without cement: a randomized study with roentgen stereophotogrammetric analysis

The fixation of tibial components randomized to insertion with or without cement in twenty-six knees was examined for inducible displacement at six weeks and one year postoperatively with use of roentgen stereophotogrammetric analysis. Furthermore, migration was studied during the first two postoperative years. Inducible displacement was found in all knees at both the six-week and the one-year follow-up examination, but no differences were detected with respect to the type of fixation (p > 0.05). All tibial components migrated for as long as one year postoperatively, after which most stabilized. No difference was found between the groups with respect to migration during the first two years postoperatively (p > 0.05), with the exception of subsidence of the component, which was found to be 0.0+/-0.1 millimeter (mean and standard error of the mean) for the components inserted with cement and 0.5+/-0.1 millimeter for the components inserted without cement (p < 0.01). Migration after one year was the same for both groups. We found a relationship between inducible displacement at six weeks and at one year as well as one between inducible displacement and migration at one year. To our knowledge, the present study is the first in which the micromotion of an interference-fit prosthesis was found to be similar to that of a device inserted with cement. The results of the present study emphasize the importance of the initial prosthetic fixation.

Simultaneous measurements of sagittal knee laxity with an external device and radiostereometric analysis

We obtained simultaneous measurements of sagittal knee laxity in 12 consecutive patients after reconstruction of the anterior cruciate ligament (ACL), using the Stryker laxity tester and radiostereometric analysis (RSA). The mean anteroposterior (AP) displacement when a 90 N load was applied in both directions was 5.3 +/- 2.7 mm with RSA and 9.8 +/- 1.6 mm with the external device (p < 0.001). The corresponding measurements at a load of 180 N were 5.7 +/- 2.4 mm and 13.8 +/- 3.7 mm, respectively (p < 0.001). More than 50% of the sagittal knee movement, as measured by the external device at a load of 180 N, was not true femorotibial displacement of the joint but was due to soft-tissue deformation.