The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. A prospective, randomized, multicenter study

BACKGROUND

Total knee arthroplasty is associated with major postoperative blood loss of approximately 800 to 1200 milliliters, and blood transfusion is frequently required. With the increased concern about the risks of blood transfusion, various methods of blood conservation in orthopaedic surgery have been studied. The most appropriate solution, however, is to reduce the loss of blood during and after an operation. The present prospective, controlled, randomized study was designed to evaluate the hemostatic efficacy of the use of fibrin tissue adhesive in patients managed with total knee arthroplasty.

METHODS

Fifty-eight patients who were scheduled to have a total knee arthroplasty were randomly divided into two groups: a control group, in which the standard means of hemostasis were applied, and a treatment group, in which the standard means to control local bleeding were applied and a fibrin tissue adhesive was sprayed on the internal aspects of the operative field before skin closure. All operations were performed in a bloodless field with use of a pneumatic tourniquet. All patients received low-molecular-weight heparin as thromboprophylaxis twelve hours before the operation and every twelve hours postoperatively. Blood loss during the operation was evaluated by measuring the volume in the suction apparatus and by estimating the amount of lost blood in the swabs at the end of the operation. The apparent postoperative lost blood was determined by measuring the volume in the suction-drain bottles. All blood transfusions were recorded.

RESULTS

The mean apparent postoperative blood loss (and standard deviation) in the fibrin-tissue-adhesive group was 360+/-287.7 milliliters compared with 878+/-403.0 milliliters in the control group, with a mean difference of 518 milliliters (p<0.001). The decrease in the level of hemoglobin was 25+/-10 grams per liter in the treatment group compared with 37+/-12 grams per liter in the control group (p<0.001). Sixteen patients (55 percent) in the control group required a blood transfusion and eight (28 percent) required two units of blood, whereas only five (17 percent) of the patients in the fibrin-tissue-adhesive group required a blood transfusion and only one (3 percent) required two units (p = 0.004). The number of adverse events was comparable between the two groups. None of the adverse events were considered to be related to the use of fibrin tissue adhesive. One death, which was due to massive pulmonary embolism, was reported in the control group. No seroconversion was reported at three and six months after the operation.

CONCLUSION

The use of fibrin tissue adhesive in total knee arthroplasty seems to be an effective and safe means with which to reduce blood loss and blood-transfusion requirements. Furthermore, the importance of these findings was enhanced by a significant reduction in blood loss, in the postoperative decrease in the level of hemoglobin, and in blood-transfusion requirements despite preoperative thromboprophylaxis with low-molecular-weight heparin.

T-cell exhaustion and residency dynamics inform clinical outcomes in hepatocellular carcinoma

BACKGROUND & AIMS

Despite recent translation of immunotherapies into clinical practice, the immunobiology of hepatocellular carcinoma (HCC), in particular the role and clinical relevance of exhausted and liver-resident T cells remain unclear. We therefore dissected the landscape of exhausted and resident T cell responses in the peripheral blood and tumor microenvironment of patients with HCC.

METHODS

Lymphocytes were isolated from the blood, tumor and tumor-surrounding liver tissue of patients with HCC (n = 40, n = 10 treated with anti-PD-1 therapy). Phenotype, function and response to anti-PD-1 were analyzed by mass and flow cytometry ex vivo and in vitro, tissue residence was further assessed by immunohistochemistry and imaging mass cytometry. Gene signatures were analyzed in silico.

RESULTS

We identified significant enrichment of heterogeneous populations of exhausted CD8+ T cells (TEX) in the tumor microenvironment. Strong enrichment of severely exhausted CD8 T cells expressing multiple immune checkpoints in addition to PD-1 was linked to poor progression-free and overall survival. In contrast, PD-1 was also expressed on a subset of more functional and metabolically active CD103+ tissue-resident memory T cells (TRM) that expressed few additional immune checkpoints and were associated with better survival. TEX enrichment was independent of BCLC stage, alpha-fetoprotein levels or age as a variable for progression-free survival in our cohort. These findings were in line with in silico gene signature analysis of HCC tumor transcriptomes from The Cancer Genome Atlas. A higher baseline TRM/TEX ratio was associated with disease control in anti-PD-1-treated patients.

CONCLUSION

Our data provide information on the role of peripheral and intratumoral TEX-TRM dynamics in determining outcomes in patients with HCC. The dynamics between exhausted and liver-resident T cells have implications for immune-based diagnostics, rational patient selection and monitoring during HCC immunotherapies.

LAY SUMMARY

The role of the immune response in hepatocellular carcinoma (HCC) remains unclear. T cells can mediate protection against tumor cells but are frequently dysfunctional and exhausted in cancer. We found that patients with a predominance of exhausted CD8+ T cells (TEX) had poor survival compared to patients with a predominance of tissue-resident memory T cells (TRM). This correlated with the molecular profile, metabolic and functional status of these cell populations. The enrichment of TEX was independently associated with prognosis in addition to disease stage, age and tumor markers. A high TRM proportion was also associated with better outcomes following checkpoint therapy. Thus, these T-cell populations are novel biomarkers with relevance in HCC.

Female pelvic anatomy: MR assessment of variations during the menstrual cycle and with use of oral contraceptives

Magnetic resonance (MR) imaging was performed on 21 women in different phases of the menstrual cycle, nine who used oral contraceptives and 12 who did not. Sagittal images in a dual spin-echo sequence were obtained to assess conspicuity and dimensions of the corpus uteri, cervix, vagina, and their component tissues. The endometrium, junctional zone, myometrium, cervical canal, fibrous stroma, and vaginal canal were seen in all cases and the vesicovaginal septum, rectovaginal septum, and levator ani in 90%, 86%, and 100%, respectively. The uterus was retrodisplaced in 19% of the women. In the nonpill group, endometrial width was significantly larger (P less than .025) in the secretory phase (mean, 5 mm) than in the follicular phase (3.1 mm). In the pill-using group, endometrial width was 1.1 mm in both phases, significantly smaller than in the nonpill group (P less than .025, follicular; P less than .0005, secretory). Junctional zone width was significantly smaller in the pill-using group (P less than .005). Qualitatively, the myometrium was relatively brighter on second echo images in the pill-using group, compatible with known edema that occurs with use of oral contraceptives. MR can reliably demonstrate gynecologic structure and anatomic changes that occur during the menstrual cycle and with use of oral contraceptives.

Distal transfer of the greater trochanter in cox vara

Seven patients (nine hips) who suffered from coxa vara were treated by distal transfer of the greater trochanter. The operation eliminated or markedly diminished the preoperative Trendelenburg sign, thus improving gait. In three patients (four hips) operated upon at the aged of 9 and 12 years, the initial coxa vara was converted into an almost normal valgus kemoral neck. There was one poor result due to technical failure.

Auditory biofeedback in spastic diplegia

Using a simple auditory feedback device that produces a continuous buzzing signal on heel contact, we studied the effects of augmented auditory biofeedback on the gait of four spastic diplegic children. The purpose of the biofeedback was to attempt to increase dorsiflexion at heel strike without causing other compensatory changes at the knee and hip, which might lead to crouch gait. We measured velocity, stride length, and thigh, knee, and ankle angles at the heel strike, midswing, and toe-off phases of gait. Four subjects, aged 5-8 years, were given a standard gait training program, supplemented with biofeedback two times per week in a clinical setting and 1 h daily in a home program over an 8-week period. Three computer video gait analyses of the sagittal plane were conducted without biofeedback in the pre- and posttraining conditions and twice with biofeedback over the course of treatment. We performed linear regression analysis of joint angles at heel strike, midswing, and toe-off as a function of days into the study for each patient. Angle-angle diagrams for a test subject before, during, and after treatment indicate changes toward a normal gait pattern with biofeedback. The linear regression analysis showed a statistically significant (p less than 0.01) shift toward dorsiflexion at heel strike with repeated exposure to biofeedback. A compensatory crouch gait was not induced. The linear regression analyses for hip and knee angles were not statistically significant (p greater than 0.25), indicating a disassociation of movement among hip, knee, and ankle.

Neoantigens as potential vaccines in hepatocellular carcinoma

Background

Neoantigens, new immunogenic sequences arising from tumor mutations, have been associated with response to immunotherapy and are considered potential targets for vaccination. Hepatocellular carcinoma (HCC) is a moderately mutated tumor, where the neoantigen repertoire has not been investigated. Our aim was to analyze whether tumors in HCC patients contain immunogenic neoantigens suitable for future use in therapeutic vaccination.

Methods

Whole-exome sequencing and RNAseq were performed in a cohort of fourteen HCC patients submitted to surgery or liver transplant. To identify mutations, single-nucleotide variants (SNV) originating non-synonymous changes that were confirmed at the RNA level were analyzed. Immunogenicity of putative neoAgs predicted by HLA binding algorithms was confirmed by using in vitro HLA binding assays and T-cell stimulation experiments, the latter in vivo, by immunizing HLA-A*02.01/HLA-DRB1*01 (HHD-DR1) transgenic mice, and in in vitro, using human lymphocytes.

Results

Sequencing led to the identification of a median of 1217 missense somatic SNV per patient, narrowed to 30 when filtering by using RNAseq data. A median of 13 and 5 peptides per patient were predicted as potential binders to HLA class I and class II molecules, respectively. Considering only HLA-A*02.01- and HLA-DRB1*01-predicted binders, 70% demonstrated HLA-binding capacity and about 50% were immunogenic when tested in HHD-DR1 mice. These peptides induced polyfunctional T cells that specifically recognized the mutated but not the wild-type sequence as well as neoantigen-expressing cells. Moreover, coimmunization experiments combining CD8 and CD4 neoantigen epitopes resulted in stronger CD8 T cell responses. Finally, responses against neoantigens were also induced in vitro using human cells.

Conclusion

These results show that mutations in HCC tumors may generate immunogenic neoantigens with potential applicability for future combinatorial therapeutic strategies.

Fracture healing in rabbits after osteotomy using the CO2 laser

Fracture healing was studied in 28 rabbits after their femurs had been osteomized using the carbon dioxide laser. Twenty rabbits whose femurs were osteotomized by means of a Gigli saw served as the control group. Fracture healing was initially delayed in the laser cut femurs, yet after 60 days no significant difference between the groups could be detected. The initial delay was caused by thermal damage to the laser cut bone edges. Further fragmentation of the damaged bone occurred during the immediate postoperative period.

Gaucher disease--the orthopaedic aspect. Report of seven cases

Seven patients with Gaucher type 1 disease are presented: five female and two male. The orthopaedic problems encountered were: avascular necrosis of both femoral heads in two girls, bilateral bone infarctions of the femurs in all three girls, complicated by staphylococcal osteomyelitis of the right femur in one girl and by pathological fractures of both femurs in another girl, osteonecrosis of both humeral heads in one male adult patient, osteonecrosis of the femoral heads in two further adults (male and female), and a pathological fracture of the fourth lumbar vertebra in another adult woman with concomitant humeral head involvement. The patient with osteonecrosis of the humeral head was treated with a total shoulder arthroplasty, and the two patients with osteonecrosis of the femoral heads were treated with total hip arthroplasties, with satisfactory intermediate and long-term results.

Spatio-temporal diffusion of dynamic PET images

Positron emission tomography (PET) images are corrupted by noise. This is especially true in dynamic PET imaging where short frames are required to capture the peak of activity concentration after the radiotracer injection. High noise results in a possible bias in quantification, as the compartmental models used to estimate the kinetic parameters are sensitive to noise. This paper describes a new post-reconstruction filter to increase the signal-to-noise ratio in dynamic PET imaging. It consists in a spatio-temporal robust diffusion of the 4D image based on the time activity curve (TAC) in each voxel. It reduces the noise in homogeneous areas while preserving the distinct kinetics in regions of interest corresponding to different underlying physiological processes. Neither anatomical priors nor the kinetic model are required. We propose an automatic selection of the scale parameter involved in the diffusion process based on a robust statistical analysis of the distances between TACs. The method is evaluated using Monte Carlo simulations of brain activity distributions. We demonstrate the usefulness of the method and its superior performance over two other post-reconstruction spatial and temporal filters. Our simulations suggest that the proposed method can be used to significantly increase the signal-to-noise ratio in dynamic PET imaging.

Total hip arthroplasty revision using the press-fit CLS Spotorno cementless stem. Twenty-four hips followed between 1987 and 1998

A retrospective study of uncemented femoral revision for loosening after total hip arthroplasty was conducted for the period 1987-1998. The study included 24 hips in 22 patients (7 men, 15 women). The revision procedure consisted of the replacement of the loose hip prosthesis using the CLS (Protek) press-fit stem. Patients were followed for a mean duration of 4.5 years. The mean interval between the primary operation and the revision was 10 years (range 2-16 years). Using the Merle D'Aubigné hip score and radiographic findings, a favorable outcome was noted in 20 hips. We suggest that the femoral revision procedure using the uncemented Spotorno stem is a very useful method of correction of loosening after total hip replacement.

Blood levels of active metabolites of vitamin D3 in fracture repair in humans. A preliminary report

Blood levels of the active metabolites of vitamin D3, 25-hydroxycholecalciferol [25(OH)D3], 1,25-dihydroxycholecalciferol [1,25(OH)2D3] and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in seven patients. Two subjects suffered from delayed union of tibial fractures; one showed a delayed union after a proximal tibial osteotomy; one patient suffered from bilateral femoral neck fractures, of which one failed to unite and the other united late; two patients had multiple fractures that united normally; and one patient exhibited staged bilateral femoral neck fractures whose occurrence was separated by a short interval and which united without undue delay. The blood levels of 25(OH)D3 were within the normal range. A relative decrease in 24,25(OH)2D3 values was noted in all patients, whereas in three subjects the decrease was absolute, to non-detectable levels. A decrease in 1,25(OH)2D3 levels was noted in only two patients. We postulate that these changes reflect the consumption of these metabolites during healing at the fracture site.

The total condylar knee prosthesis: a review of 71 operations

Seventy-one operations are reviewed, in which knees were replaced with the total condylar prosthesis. The follow-up period ranged between 1 and 7 years, with an average of 3.25 years. Osteoarthritis was diagnosed preoperatively in 53 knees and rheumatoid arthritis in 18. The results obtained in cases of osteoarthritis were better than those in cases of rheumatoid arthritis. The prognosis was adversely affected by obesity, preoperative flexion contracture of 30 degrees or more, wound-healing problems, wound infection, and postoperative manipulation under general anesthesia. The overall results were excellent in 48% of cases (34 knees), good in 28% (20 knees), fair in 11.3% (eight knees), and poor in 4.3% (three knees). Failure was experienced in 8.4% of cases (six knees).

Peritonitis in a neonate due to Cyberlindnera fabianii, an ascomycetic yeast

The ascomycetous yeast Cyberlindera fabianii is not only present in the environment, but is also occasionally pathogenic. Especially, neonates seem to be prone to infection. Here, we describe a case of peritoneal infection of a neonate after congenital heart surgery. The correct identification of this peculiar species is made by MALDI-TOF and especially by molecular biology methods, whereas the standard biochemical identification methods fail.The neonate with a hypoplastic left heart syndrome had a Norwood palliation followed by transient ECMO therapy for 3 days. The patient developed a renal insufficiency, so that peritoneal dialysis was initiated. After a few days, a peritoneal infection due to C. fabianii emerged. The proper source of this rare and particular yeast remains obscure. In spite of a reasonable antimycotic therapy, the patient developed a capillary leak syndrome and died finally in septic shock with multiorgan failure. One reason is probably that the yeast population, which was highly susceptible to all common antimycotic drugs at the beginning of therapy with fluconazole (and for a short period with caspofungin and liposomal amphotericin B), became rapidly resistant.

Acetabular supporting ring in total hip replacement

A series of 14 total hip arthroplasties with a Müller acetabular supporting ring including 3 primary and 11 revision arthroplasties is reviewed. This device was used in cases of acetabular bone deficiency, and bone graft was added in 11 cases. The mean length of follow-up was 39.9 months. Twelve patients had good or satisfactory results, while two operations failed. These results indicate that the acetabular supporting ring is a useful implant in cases with acetabular bone stock deficiency.

Computerized tomography in the diagnosis and treatment of osteoid osteoma

Thirteen cases of osteoid osteoma demonstrated with computerized tomography are reported. Twelve patients underwent definitive surgery and were relieved of their symptoms. The histological examination confirmed the preoperative diagnosis in 11 cases. Six lesions were located in the proximal femur, three in the neck of the talus, two in the proximal tibia, and one each in the proximal humerus and the calcaneus. Radionuclide technetium 99m MDP scans were performed in 11 cases and showed an increased uptake in the vicinity of the lesions. Computerized tomography showed the precise location of the nidus, thus helping in the preoperative planning of the surgical approach and enabling us to perform a precise and economic resection.

Bone grafting in total hip replacement for acetabular protrusion. A review of 11 operations

In 11 total hip replacement operations performed on nine patients with acetabular protrusion, the deficient acetabulum was reinforced with a bone graft from the femoral head in ten operations and in one from the greater trochanter and the femoral medullary canal. Acetabular meshes were used in two operations and a fine wire mesh in one. At follow-up, averaging 18 (8-28) months postoperatively, a solid bone socket for the acetabular component had formed in all hips without evidence of loosening or infection.

Adaptive Subsets Limit the Anti-Tumoral NK-Cell Activity in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a global health burden with increasing incidence, poor prognosis and limited therapeutic options. Natural killer (NK) cells exhibit potent anti-tumoral activity and therefore represent potential targets for immunotherapeutic approaches in HCC treatment. However, the anti-tumoral activity of NK cells in HCC associated with different etiologies, and the impact of the heterogeneous NK cell subset, e.g., adaptive and conventional subsets, are not understood in detail. By comparatively analyzing the NK-cell repertoire in 60 HCC patients, 33 liver cirrhosis patients and 36 healthy donors (HD), we show in this study that the NK-cell repertoire is linked to HCC etiology, with increased frequencies of adaptive NK cells in Hepatitis B virus (HBV)-associated HCC. Adaptive NK cells exhibited limited anti-tumoral activity toward liver cancer cells; however, this was not a result of a specific NK-cell impairment in HCC but rather represented an intrinsic feature, since the characteristics of circulating and intra-tumoral adaptive NK cells were conserved between HD, HCC and liver cirrhosis patients. Hence, the expansion of adaptive NK cells with reduced anti-tumoral activity, detectable in HBV-associated HCC, may have implications for tumor surveillance and therapy.

Active metabolites of vitamin D in patients with coxarthrosis and with aseptic loosening of total hip endoprostheses

The blood levels of the active metabolites of vitamin D--25-hydroxycholecalciferol (25(OH)D), 1,25 dihydroxycholecalciferol (1,25(OH)2D), and 24,25 dihydroxycholecalciferol (24,25(OH)2D)--were determined in 15 patients suffering from arthrosis of the hip and in 13 patients with aseptic loosening of total hip endoprostheses. Normal values were found in all but one patient with aseptic loosening, in whom 24,25(OH)2D was not detectable. The difference between the two groups of patients was not statistically significant.

Tear of the anterior cruciate ligament as a late complication of meniscectomy

During the years 1973-5 we performed 190 meniscectomies. We report 4 cases of tears of the anterior cruciate ligament after meniscectomy. Although this complication is mentioned in the literature, very few orthopaedic surgeons are familiar with it.

Blood levels of vitamin D metabolites in gonarthrosis

The blood levels of the active metabolites of vitamin D3 25-hydroxycholecalciferol [25(OH)D3]. 1,25-dihydroxycholecalciferol [1,25(OH)2D3], and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in 27 patients suffering from arthrosis of the knee, including 4 patients with non-insulin-dependent diabetes mellitus. The blood level of 24,25-dihydroxycholecalciferol was found to be significantly lower in patients with gonarthrosis than in patients with coxarthrosis. With the exclusion of the diabetic patients, the mean value for this metabolite was lower than in the coxarthrosis group, but the difference was not significant statistically.

The inverted Y approach to the talus and ankle joint

A case of a comminuted fracture of the body of the talus and the medial malleolus is reported. The inverted Y approach was used to expose the talus and ankle joint, facilitating reduction and internal fixation.

Lateral patellar release and bone grafting of the tibial plateau in total condylar knee arthroplasties. A technical note

In a review of 50 primary total condylar knee arthroplasties in 25 female and in 14 male patients the factors affecting the necessity of lateral patellar release and bone grafting of the medial tibial plateau were established. Lateral patellar release was performed in 18 of 33 arthroplasties in female patients, in only two of 17 operations in male patients, and on all but one of the knees with preoperative valgus deformity. Bone grafting of the medial tibial plateau was necessary mainly in small knees, i.e., for six of 18 small prostheses in contrast to one of 15 standard-sized implants in female patients and in none of the operated knees in males.

Disruption of the symphysis pubis and fatigue fractures of the pelvis in a patient with rheumatoid arthritis. A case report

A 40-year-old woman, who suffered from severe rheumatoid arthritis causing avascular necrosis of the femoral head and protrusio acetabuli of the right hip, developed a severe spontaneous disruption of the symphysis pubis concomitant with a stress fracture of the left ilium adjacent to the left sacroiliac joint. After successful total hip arthroplasty, the symphysiolysis improved, but a new stress fracture of the left superior pubic ramus developed. Fourteen months after operation both stress fractures are healed. Altered hip and pelvic girdle mechanics acting on osteoporotic bone may account for this sequence of events.