Multidrug-resistant tuberculosis in children: A practical update on epidemiology, diagnosis, treatment and prevention

Pediatric multidrug-resistant tuberculosis (MDR-TB) remains a significant global problem, and there are numerous barriers preventing children with MDR-TB from being identified, confirmed with microbiologic tests, and treated with a safe, practical, and effective regimen. However, several recent advances in diagnostics and treatment regimens have the promise to improve outcomes for children with MDR-TB. We introduce this review with two cases that exemplify both the challenges in management of MDR-TB in children, but also the potential to achieve a positive outcome. More than 30,000 cases of MDR-TB per year are believed to occur in children but less than 5% are confirmed microbiologically, contributing to poorer outcomes and excess mortality. Rapid molecular-based testing that provides information on rifampin susceptibility is increasingly globally available and recommended for all children suspected of TB disease--but remains limited by challenges obtaining appropriate samples and the paucibacillary nature of most pediatric TB. More complex assays allowing better characterization of drug-resistant isolates are emerging. For children diagnosed with MDR-TB, treatment regimens have traditionally been long and utilize multiple drugs associated with significant side effects, particularly injectable agents. Several new or repurposed drugs including bedaquiline, delamanid, clofazimine and linezolid now allow most treatment regimens to be shorter and all-oral. Yet data to support short, all-oral, novel regimens for young children containing pretomanid remain insufficient at present, and there is a compelling need to conduct pediatric trials of promising therapeutics and MDR-TB treatment regimens.

Fourier-transform infrared spectroscopy imaging is a useful adjunct to routine histopathology to identify failure of polyethylene inlays in revision total hip arthroplasty

The use of highly crosslinked ultra-high molecular weight polyethylene (XLPE) has significantly reduced the volumetric wear of acetabular liners, thereby reducing the incidence of osteolysis. However, contemporary components tend to generate smaller wear particles, which can no longer be identified using conventional histology. This technical limitation can result in imprecise diagnosis. Here, we report on two uncemented total hip arthroplasty cases (~7 years in situ) revised for periprosthetic fracture of the femur and femoral loosening, respectively. Both liners exhibited prominent wear. The retrieved pseudocapsular tissue exhibited a strong macrophage infiltration without microscopically identifiable polyethylene particles. Yet, using Fourier-transform infrared micro-spectroscopic imaging (FTIR-I), we demonstrated the prominent intracellular accumulation of polyethylene debris in both cases. This study shows that particle induced osteolysis can still occur with XLPE liners, even under 10 years in situ. Furthermore, we demonstrate the difficulty of determining the presence of polyethylene debris within periprosthetic tissue. Considering the potentially increased bioactivity of finer particles from XLPE compared to conventional liners, an accurate detection method is required, and new histopathological hallmarks of particle induced osteolysis are needed. FTIR-I is a great tool to that end and can help the accurate determination of foreign body tissue responses.

Fretting and Tribocorrosion of Modular Dual Mobility Liners: Role of Design, Microstructure, and Malseating

BACKGROUND

Modular dual mobility (DM) bearings have a junction between a cobalt chrome alloy (CoCrMo) liner and titanium shell, and the risk of tribocorrosion at this interface remains a concern. The purpose of this study was to determine whether liner malseating and liner designs are associated with taper tribocorrosion.

METHODS

We evaluated 28 retrieved modular DM implants with a mean in situ duration of 14.6 months (range, 1 to 83). There were 2 manufacturers included (12 and 16 liners, respectively). Liners were considered malseated if a distinct divergence between the liner and shell was present on postoperative radiographs. Tribocorrosion was analyzed qualitatively with the modified Goldberg Score and quantitatively with an optical coordinate-measuring machine. An acetabular shell per manufacturer was sectioned for metallographic analysis.

RESULTS

There were 6 implants (22%) that had severe grade 4 corrosion, 6 (22%) had moderate grade 3, 11 (41%) had mild grade 2, and 5 (18.5%) had grade 1 or no visible corrosion. The average volumetric material loss at the taper was 0.086 ± 0.19 mm3. There were 7 liners (25%) that had radiographic evidence of malseating, and all were of a single design (P = .01). The 2 liner designs were fundamentally different from one another with respect to the cobalt chrome alloy type, taper surface finish, and shape deviations. Malseating was an independent risk factor for increased volumetric material loss (P = .017).

CONCLUSIONS

DM tribocorrosion with quantifiable material loss occurred more commonly in malseated liners. Specific design characteristics may make liners more prone to malseating, and the interplay between seating mechanics, liner characteristics, and patient factors likely contributes to the shell/liner tribocorrosion environment.

LEVEL OF EVIDENCE

Level III.

Has wrought Cobalt-Chromium-Molybdenum alloy changed for the worse over time?

BACKGROUND

Total hip arthroplasty (THA) failure due to tribocorrosion of modular junctions and resulting adverse local tissue reactions to corrosion debris have seemingly increased over the past few decades. Recent studies have found that chemically-induced column damage seen on the inner head taper is enabled by banding in the alloy microstructure of wrought cobalt-chromium-molybdenum alloy femoral heads, and is associated with more material loss than other tribocorrosion processes. It is unclear if alloy banding represents a recent phenomenon. The purpose of this study was to examine THAs implanted in the 1990s, 2000s, and 2010s to determine if alloy microstructure and implant susceptibility to severe damage has increased over time.

METHODS

Five hundred and forty-five modular heads were assessed for damage severity and grouped based on decade of implantation to serve as a proxy measure for manufacturing date. A subset of heads (n=120) was then processed for metallographic analysis to visualize alloy banding.

RESULTS

We found that damage score distribution was consistent over the time periods, but the incidence of column damage significantly increased between the 1990s and 2000s. Banding also increased from the 1990s to 2000s, but both column damage and banding levels appear to recover slightly in the 2010s.

CONCLUSION

Banding, which provides preferential corrosion sites enabling column damage, has increased over the last three decades. No difference between manufacturers was seen, which may be explained by shared suppliers of bar stock material. These findings are important as banding can be avoidable, reducing the risk of severe column damage to THA modular junctions and failure due to adverse local tissue reactions.

Retrieval of a Lane Plate 82 Years After Implantation: Case Report, Metallurgical Analysis, and Historical Review

Background

The Lane plate was one of the first widely used bone plates, utilized in the first decades of the twentieth century. Here we present the results of a retrieval analysis on a Lane plate, and a review of the history of these plates. Our patient underwent plating of her femur with a Lane plate in 1938. She developed a sciatic nerve palsy, managed surgically later that year by Dr. Arthur Steindler at the University of Iowa. Her femur healed, her nerve recovered, and she did well until 2020, at age 94, when she presented to the University of Iowa with a draining sinus that appeared to communicate with the plate. She underwent irrigation and debridement with hardware removal. The plate was sectioned, and its composition and structure characterized.

Methods

We retrieved hard copies of the patient's archived medical records from 1938, which document in detail the treatments performed by Dr. Steindler. The plate was analyzed using scanning electron microscopy (SEM) to characterize the surface of the plate. A cross section was taken from the plate, and the composition of the alloy was determined using energy dispersive x-ray spectroscopy (EDS). A review of the literature surrounding early plating techniques was conducted.

Results

Our patient recovered from her surgery and soon returned to her baseline state of health. Intraoperative cultures grew C. acnes. Analysis of the surface of the plate demonstrated significant corrosion, and the crystal structure seen on SEM suggested a strong alloy that is prone to corrosion. Analysis of the cross section with EDS demonstrated an alloy containing 94.9% iron, 1.7% aluminum, 1.2% chromium, and 1.1% manganese.

Conclusion

The Lane plate was introduced around 1907 by Sir William Arbuthnot Lane, a British surgeon, and was one of the first widely used devices for the plating of fractures. Given that this patient was likely one of the last to be treated with a Lane plate, this may be the final opportunity for such a retrieval analysis. Level of Evidence: IV.

Do total shoulder arthroplasty implants corrode?

BACKGROUND

Total shoulder arthroplasty (TSA) has become the gold-standard treatment to relieve joint pain and disability in patients with glenohumeral osteoarthritis who do not respond to conservative treatment. An adverse reaction to metal debris released due to fretting corrosion has been a major concern in total hip arthroplasty. To date, it is unclear how frequently implant corrosion occurs in TSA and whether it is a cause of implant failure. This study aimed to characterize and quantify corrosion and fretting damage in a single anatomic TSA design and to compare the outcomes to the established outcomes of total hip arthroplasty.

METHODS

We analyzed 21 surgically retrieved anatomic TSAs of the same design (Tornier Aequalis Pressfit). The retrieved components were microscopically examined for taper corrosion, and taper damage was scored. Head and stem taper damage was quantitatively measured with a non-contact optical coordinate-measuring machine. In selected cases, damage was further characterized at high magnifications using scanning electron microscopy. Energy-dispersive x-ray spectroscopy and metallographic evaluations were performed to determine underlying alloy microstructure and composition. Comparisons between groups with different damage features were performed with independent-samples t tests; Mann-Whitney tests and multivariate linear regression were conducted to correlate damage with patient factors. The level of statistical significance was set at P < .05.

RESULTS

The average material loss for head and stem tapers was 0.007 mm3 and 0.001 mm3, respectively. Material loss was not correlated with sex, age, previous implant, or time in situ (P > .05). We observed greater volume loss in head tapers compared with stem tapers (P = .002). Implants with evidence of column damage had larger volumetric material loss than those without such evidence (P = .003). Column damage aligned with segregation bands within the alloy (preferential corrosion sites). The average angular mismatch was 0.03° (standard deviation, 0.0668°), with negative values indicating distal engagement and positive values indicating proximal engagement. Implants with proximal engagement were significantly more likely to have column damage than those with distal engagement (P = .030).

DISCUSSION

This study has shown not only that the metal components of TSA implants can corrode but also that the risk of corrosion can be reduced by (1) eliminating preferential corrosion sites and (2) ensuring distal engagement to prevent fluid infiltration into the modular junction.

Non-ischaemic cardiomyopathy associated with elevated serum cobalt and accelerated wear of a metal-on-metal hip resurfacing

A man in his late 30s developed non-ischaemic cardiomyopathy due to systemic cobalt toxicity associated with accelerated bearing surface wear from metal-on-metal hip resurfacing implanted in the previous 6 years. Following revision arthroplasty, the patient regained baseline cardiac function. Cobalt-induced cardiomyopathy is a grave condition that deserves early consideration due to potentially irreversible morbidity. We present this case to increase awareness, facilitate early detection and emphasise the need for research into the diagnosis and management of at-risk patients.

Are Damage Modes Related to Microstructure and Material Loss in Severely Damaged CoCrMo Femoral Heads?

BACKGROUND

Fretting and corrosion in metal-on-polyethylene total hip arthoplasty (THA) modular junctions can cause adverse tissue reactions that are responsible for 2% to 5% of revision surgeries. Damage within cobalt-chromium-molybdenum (CoCrMo) alloy femoral heads can progress chemically and mechanically, leading to damage modes such as column damage, imprinting, and uniform fretting damage. At present, it is unclear which of these damage modes are most detrimental and how they may be linked to implant alloy metallurgy. The alloy microstructure exhibits microstructural features such as grain boundaries, hard phases, and segregation bands, which may enable different damage modes, higher material loss, and the potential risk of adverse local tissue reactions.

QUESTIONS/PURPOSES

In this study, we asked: (1) How prevalent is chemically dominated column damage compared with mechanically dominated damage modes in severely damaged metal-on-polyethylene THA femoral heads made from wrought CoCrMo alloy? (2) Is material loss greater in femoral heads that underwent column damage? (3) Do material loss and the presence of column damage depend on alloy microstructure as characterized by grain size, hard phase content, and/or banding?

METHODS

Surgically retrieved wrought CoCrMo modular femoral heads removed between June 2004 and June 2019 were scored using a modified version of the Goldberg visually based scoring system. Of the total 1002 heads retrieved over this period, 19% (190 of 1002) were identified as severely damaged, exhibiting large areas of fretting scars, black debris, pits, and/or etch marks. Of these, 43% (81 of 190) were excluded for metal-on-metal articulations, alternate designs (such as bipolar, dual-mobility, hemiarthroplasty, metal adaptor sleeves), or previous sectioning of the implant for past studies. One sample was excluded retroactively as metallurgical analysis revealed that it was made of cast alloy, yielding a total of 108 for further analysis. Information on patient age (57 ± 11 years) and sex (56% [61 of 108] were males), reason for removal, implant time in situ (99 ± 78 months), implant manufacturer, head size, and the CoCrMo or titanium-based stem alloy pairing were collected. Damage modes and volumetric material loss within the head tapers were identified using an optical coordinate measuring machine. Samples were categorized by damage mode groups by column damage, imprinting, a combination of column damage and imprinting, or uniform fretting. Metallurgical samples were processed to identify microstructural characteristics of grain size, hard phase content, and banding. Nonparametric Mann-Whitney U and Kruskal-Wallis statistical tests were used to examine volumetric material loss compared with damage mode and microstructural features, and linear regression was performed to correlate patient- and manufacturer-specific factors with volumetric material loss.

RESULTS

Chemically driven column damage was seen in 48% (52 of 108) of femoral heads, with 34% (37 of 108) exhibiting a combination of column damage and imprinting, 12% (13 of 108) of heads displaying column damage and uniform fretting, and 2% (2 of 108) exhibiting such widespread column damage that potentially underlying mechanical damage modes could not be verified. Implants with column damage showed greater material loss than those with mechanically driven damage alone, with median (range) values of 1.2 mm3 (0.2 to 11.7) versus 0.6 mm3 (0 to 20.7; p = 0.03). Median (range) volume loss across all femoral heads was 0.9 mm3 (0 to 20.7). Time in situ, contact area, patient age, sex, head size, manufacturer, and stem alloy type were not associated with volumetric material loss. Banding of the alloy microstructure, with a median (range) material loss of 1.1 mm3 (0 to 20.7), was associated with five times higher material loss compared with those with a homogeneous microstructure, which had a volume loss of 0.2 mm3 (0 to 4.1; p = 0.02). Hard phase content and grain size showed no correlation with material loss.

CONCLUSION

Chemically dominated column damage was a clear indicator of greater volume loss in this study sample of 108 severely damaged heads. Volumetric material loss strongly depended on banding (microstructural segregations) within the alloy. Banding of the wrought CoCrMo microstructure should be avoided during the manufacturing process to reduce volumetric material loss and the release of corrosion products to the periprosthetic tissue.

CLINICAL RELEVANCE

Approximately 30% of THAs rely on wrought CoCrMo femoral heads. Most femoral heads in this study exhibited a banded microstructure that was associated with larger material loss and the occurrence of chemically dominated column damage. This study suggests that elimination of banding from the alloy could substantially reduce the release of implant debris in vivo, which could potentially also reduce the risk of adverse local tissue reactions to implant debris.

On the Formation Mechanism of Column Damage Within Modular Taper Junctions

BACKGROUND

Column damage is a unique degradation pattern observed in cobalt-chromium-molybdenum (CoCrMo) femoral head taper surfaces that resemble column-like troughs in the proximal-distal direction. We investigate the metallurgical origin of this phenomenon.

METHODS

Thirty-two severely damaged CoCrMo femoral head retrievals from 7 different manufacturers were investigated for the presence of column damage and chemical inhomogeneities within the alloy microstructure via metallographic evaluation of samples sectioned off from the femoral heads.

RESULTS

Column damage was found to affect 37.5% of the CoCrMo femoral heads in this study. All the column-damaged femoral heads exhibited chemical inhomogeneities within their microstructures, which comprised of regions enriched or depleted in molybdenum and chromium. Column damage appears as a dissolution of the entire surface with preferential corrosion along the molybdenum and chromium depleted regions.

CONCLUSION

Molybdenum and chromium depleted zones serve as initiation sites for in vivo corrosion of the taper surface. Through crevice corrosion, the degradation spreads to the adjacent non-compositionally depleted areas of the alloy as well. Future improved alloy and processing recipes are required to ensure no chemical inhomogeneity due to segregation of solute elements are present in CoCrMo femoral heads.

Simultaneous Characterization of Implant Wear and Tribocorrosion Debris within Its Corresponding Tissue Response Using Infrared Chemical Imaging

Biotribology is one of the key branches in the field of artificial joint development. Wear and corrosion are among fundamental processes which cause material loss in a joint biotribological system; the characteristics of wear and corrosion debris are central to determining the in vivo bioreactivity. Much effort has been made elucidating the debris-induced tissue responses. However, due to the complexity of the biological environment of the artificial joint, as well as a lack of effective imaging tools, there is still very little understanding of the size, composition, and concentration of the particles needed to trigger adverse local tissue reactions, including periprosthetic osteolysis. Fourier transform infrared spectroscopic imaging (FTIR-I) provides fast biochemical composition analysis in the direct context of underlying physiological conditions with micron-level spatial resolution, and minimal additional sample preparation in conjunction with the standard histopathological analysis workflow. In this study, we have demonstrated that FTIR-I can be utilized to accurately identify fine polyethylene debris accumulation in macrophages that is not achievable using conventional or polarized light microscope with histological staining. Further, a major tribocorrosion product, chromium phosphate, can be characterized within its histological milieu, while simultaneously identifying the involved immune cell such as macrophages and lymphocytes. In addition, we have shown the different spectral features of particle-laden macrophages through image clustering analysis. The presence of particle composition variance inside macrophages could shed light on debris evolution after detachment from the implant surface. The success of applying FTIR-I in the characterization of prosthetic debris within their biological context may very well open a new avenue of research in the orthopedics community.

The Biomaterials of Total Shoulder Arthroplasty: Their Features, Function, and Effect on Outcomes

The materials that are used in total shoulder arthroplasty (TSA) implants have been carefully chosen in an attempt to minimize hardware-related complications. The 2 main metal alloys used in TSA implants are Ti-6Al-4V (titanium-aluminum-vanadium) and CoCrMo (cobalt-chromium-molybdenum). Ti alloys are softer than CoCr alloys, making them less wear-resistant and more susceptible to damage, but they have improved osseointegration and osteoconduction properties. Although controversial, metal allergy may be a concern in patients undergoing TSA and may lead to local tissue reaction and aseptic loosening. Numerous modifications to polyethylene, including cross-linking, minimizing oxidation, and vitamin E impregnation, have been developed to minimize wear and reduce complications. Alternative bearing surfaces such as ceramic and pyrolytic carbon, which have strong track records in other fields, represent promising possibilities to enhance the strength and the durability of TSA prostheses.

What Surgeons Need to Know About Adverse Local Tissue Reaction in Total Hip Arthroplasty

Adverse local tissue reactions (ALTRs) were first associated with patients with failed metal-on-metal surface replacements and total hip arthroplasty (THA). However, an increasing number of cases of ALTR in metal-on-polyethylene (MOP) THA patients is being reported. Clinically, ALTR appears as benign, aseptic masses or bursae in the periprosthetic tissues. Histopathologically, ALTRs are distinguished by an intense lymphocyte infiltrate, destruction of the synovial surfaces, widespread necrosis, and fibrin exudate. Tribocorrosion of modular junctions appears to be the cause of ALTR in MOP patients. The various tribocorrosion damage modes occurring at modular junctions produce metal ions and a diversity of particulates in relation to size, chemical composition, and structure. The mechanisms by which these various products of tribocorrosion lead to ALTR are still a matter of considerable research. This review clarifies what constitutes ALTR, its relationship to implant factors, and highlights current methods for diagnosis and management of patients with ALTR in the setting of MOP THA.

In Vitro Evidence for Cell-Accelerated Corrosion Within Modular Junctions of Total Hip Replacements

Corrosion at modular junctions of total hip replacement (THR) remains a major concern today. Multiple types of damage modes have been identified at modular junctions, correlated with different corrosion characteristics that may eventually lead to implant failure. Recently, within the head-taper region of the CoCrMo retrieval implants, cell-like features and trails of etching patterns were observed that could potentially be linked to the involvement of cells of the periprosthetic region. However, there is no experimental evidence to corroborate this phenomenon. Therefore, we aimed to study the potential role of periprosthetic cell types on corrosion of CoCrMo alloy under different culture conditions, including the presence of CoCrMo wear debris. Cells were incubated with and without CoCrMo wear debris (obtained from a hip simulator) with an average particle size of 119 ± 138 nm. Electrochemical impedance spectroscopy (EIS) was used to evaluate the corrosion tendency, corrosion rate, and corrosion kinetics using the media after 24 h of cell culture as the electrolyte. Results of the study showed that there was lower corrosion resistance (p < 0.02) and higher capacitance (p < 0.05) within cell media from macrophages challenged with particles when compared with the other media conditions studied. The potentiodynamic results were also in agreement with the EIS values, showing significantly higher corrosion tendency (low E_corr ) (p < 0.0001) and high I_corr (p < 0.05) in media from challenged macrophages compared with media with H₂ O₂ solution. Overall, the study provides in vitro experimental evidence for the possible role of macrophages in altering the chemical environment within the crevice and thereby accelerating corrosion of CoCrMo alloy. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:393-404, 2020.

Wear particles induce a new macrophage phenotype with the potential to accelerate material corrosion within total hip replacement interfaces

Evidence that macrophages can play a role in accelerating corrosion in CoCrMo alloy in total hip replacement (THR) interfaces leads to questions regarding the underlying cellular mechanisms and immunological responses. Hence, we evaluated the role of macrophages in corrosion processes using the cell culture supernatant from different conditions and the effect of wear particles on macrophage dynamics. Monocytes were exposed to CoCrMo wear particles and their effect on macrophage differentiation was investigated by comparisons with M1 and M2 macrophage differentiation. Corrosion associated macrophages (M_CA macrophages) exhibited upregulation of TNF-α, iNOS, STAT-6, and PPARG and down-regulation of CD86 and ARG, when compared to M1 and M2 macrophages. M_CA cells also secreted higher levels of IL-8, IL-1β, IL-6, IL-10, TNF-α, and IL-12p70 than M1 macrophages and/or M2 macrophages. Our findings revealed variation in macrophage phenotype (M_CA) induced by CoCrMo wear particles in generating a chemical environment that induces cell-accelerated corrosion of CoCrMo alloy at THR modular interfaces. STATEMENT OF SIGNIFICANCE: Fretting wear and corrosion within the implant's modular taper junction are prominent causes of implant failure, as they promote the release of corrosion products and subsequent development of adverse local tissue reactions. Being a multifactorial process, several in vitro models have been developed to recreate the in vivo corrosion process, often summarized as mechanically-assisted crevice corrosion. Considering the excellent corrosion properties of CoCrMo alloy, the severity of chemically-generated damage observed at the modular interface has been surprising and poorly understood. The aim of the current study is to provide a better understanding of macrophages and their plasticity at the THR taper interface when they encounter wear debris from CoCrMo alloy. This is a preliminary study along the path towards determining the mechanism(s) of CAC.

Fourier transform infrared spectroscopic imaging of wear and corrosion products within joint capsule tissue from total hip replacements patients

Implant debris generated by wear and corrosion is a prominent cause of joint replacement failure. This study utilized Fourier transform infrared spectroscopic imaging (FTIR-I) to gain a better understanding of the chemical structure of implant debris and its impact on the surrounding biological environment. Therefore, retrieved joint capsule tissue from five total hip replacement patients was analyzed. All five cases presented different implant designs and histopathological patterns. All tissue samples were formalin-fixed and paraffin-embedded. Unstained, 5 μm thick sections were prepared. The unstained sections were placed on BaF₂ windows and deparaffinized with xylene prior to analysis. FTIR-I data were collected at a spectral resolution of 4 cm^-1 using an Agilent Cary 670 spectrometer coupled with Cary 620 FTIR microscope. The results of study demonstrated that FTIR-I is a powerful tool that can be used complimentary to the existing histopathological evaluation of tissue. FTIR-I was able to distinguish areas with different cell types (macrophages, lymphocytes). Small, but distinct differences could be detected depending on the state of cells (viable, necrotic) and depending on what type of debris was present (polyethylene [PE], suture material, and metal oxides). Although, metal oxides were mainly below the measurable range of FTIR-I, the infrared spectra of tissues exhibited noticeable difference in their presence. Tens of micrometer sized polyethylene particles could be easily imaged, but also accumulations of submicron particles could be detected within macrophages. FTIR-I was also able to distinguish between PE debris, and other birefringent materials such as suture. Chromium-phosphate particles originating from corrosion processes within modular taper junctions of hip implants could be identified and easily distinguished from other phosphorous materials such as bone. In conclusion, this study successfully demonstrated that FTIR-I is a useful tool that can image and determine the biochemical information of retrieved tissue samples over tens of square millimeters in a completely label free, nondestructive, and objective manner. The resulting chemical images provide a deeper understanding of the chemical nature of implant debris and their impact on chemical changes of the tissue within which they are embedded.

What Factors Drive Taper Corrosion?

Adverse local tissue reactions to corrosion products can lead to total hip arthroplasty failure. Although this problem has been well known for more than 25 years, it has seemingly increased in frequency over the recent years. The occurrence of corrosion is multifactorial-depending on implant, patient, and surgeon factors. As of now, there is no "one-size-fits-all" solution to prevent corrosion in total hip arthroplasty devices. Thus, it is imperative to fully understand the exact mechanisms of modular junction corrosion to prevent premature implant failure. This review highlights a few key concepts that need to be explored to minimize the impact of corrosion. The key concepts include (1) the prevention of micromotion, (2) the role of implant alloy metallurgy in the corrosion process, (3) the in vivo generation of a corrosive environment, and (4) potential unanticipated problems.

Microbial diversity and nitrogen-metabolizing gene abundance in backyard food waste composting systems

AIMS

The microbial diversity of backyard compost piles is poorly understood compared to large-scale, highly regulated composting systems. The purpose of this study was the identification of the microbial community composition and associated change over time among three different backyard composting styles.

METHODS AND RESULTS

Food waste was composted in a household backyard compost bin, a small-scale aerated windrow or a semi-aerated static pile. Samples were obtained from each sequential phase of the composting process for 16s rRNA sequencing and relationships between temperature, moisture and microbial communities were examined. The Bacilli dominated in the early phases of composting then transitioned to Proteobacteria in the later stages. Different bacterial species increased and decreased dramatically in different composting systems and at different phases of the composting process. We performed qPCR to quantify gene abundance of nirS to profile the nitrogen-metabolizing bacteria present in each composting system. Gene abundance of nirS varied with temperature, but peaked during the cooling phase in the aerated windrow.

CONCLUSIONS

Although the phases of decomposition were not as distinct as large-scale regulated piles, the microbial diversity mirrored the appropriate phases. Interestingly, different backyard composting styles were marked by the predominance of certain bacterial species. In particular, nitrogen-metabolizing bacterial communities peaked in the later stages of decomposition.

SIGNIFICANCE AND IMPACT OF THE STUDY

A profile of the compost microbiome yields important clues about how differences in backyard food waste composting systems influence bacterial species that may facilitate or hinder nitrogen metabolism.

Healing bone lesion defects using injectable CaSO4 /CaPO4 -TCP bone graft substitute compared to cancellous allograft bone chips in a canine model

CaSO₄ /CaPO₄ -TCP bone graft substitute has been shown to be effective for treatment of bone lesion defects, but its mechanical, histological, and radiographic characteristics have not been studied in direct comparison with a conventional treatment such as cancellous allograft bone. Thirteen canines had a critical-size axial defect created bilaterally into the proximal humerus. CaSO₄ /CaPO₄ -TCP bone graft substitute (PRO-DENSE™, Wright Medical Technology) was injected into the defect in one humerus, and an equal volume of freeze-dried cancellous allograft bone chips was placed in the contralateral defect. The area fraction of new bone, residual graft, and fibrous tissue and the compressive strength and elastic modulus of bone within the defects were determined after 6, 13, or 26 weeks and correlated with radiographic changes. The data were analyzed using Friedman and Mann-Whitney tests. There was more bone in defects treated with the CaSO₄ /CaPO₄ -TCP bone graft substitute compared to defects treated with cancellous bone allograft at all three time points, and the difference at 13 weeks was significant (p = 0.025). The new bone was significantly stronger and stiffer in defects treated with the CaSO₄ /CaPO₄ -TCP bone graft substitute compared to defects treated with cancellous bone allograft at 13 (p = 0.046) and 26 weeks (p = 0.025). At 26 weeks, all defects treated with CaSO₄ /CaPO₄ -TCP bone graft substitute demonstrated complete healing with new bone, whereas healing was incomplete in all defects treated with cancellous allograft chips. The CaSO₄ /CaPO₄ -TCP bone graft substitute could provide faster and significantly stronger healing of bone lesions compared to the conventional treatment using freeze-dried cancellous allograft bone. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 107B: 408-414, 2019.

Alloy Microstructure Dictates Corrosion Modes in THA Modular Junctions

BACKGROUND

Adverse local tissue reactions (ALTRs) triggered by corrosion products from modular taper junctions are a known cause of premature THA failure. CoCrMo devices are of particular concern because cobalt ions and chromium-orthophosphates were shown to be linked to ALTRs, even in metal-on-polyethylene THAs. The most common categories of CoCrMo alloy are cast and wrought alloy, which exhibit fundamental microstructural differences in terms of grain size and hard phases. The impact of implant alloy microstructure on the occurring modes of corrosion and subsequent metal ion release is not well understood.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether (1) the microstructure of cast CoCrMo alloy varies broadly between manufacturers and can dictate specific corrosion modes; and whether (2) the microstructure of wrought CoCrMo alloy is more consistent between manufacturers and has low implications on the alloy's corrosion behavior.

METHODS

The alloy microstructure of four femoral-stem and three femoral-head designs from four manufacturers was metallographically and electrochemically characterized. Three stem designs were made from cast alloy; all three head designs and one stem design were made from wrought alloy. Alloy samples were sectioned from retrieved components and then polished and etched to visualize grain structure and hard phases such as carbides (eg, M₂₃C₆) or intermetallic phases (eg, σ phase). Potentiodynamic polarization (PDP) tests were conducted to determine the corrosion potential (E_corr), corrosion current density (I_corr), and pitting potential (E_pit) for each alloy. Four devices were tested within each group, and each measurement was repeated three times to ensure repeatable results. Differences in PDP metrics between manufacturers and between alloys with different hard phase contents were compared using one-way analysis of variance and independent-sample t-tests. Microstructural features such as twin boundaries and slip bands as well as corrosion damage features were viewed and qualitatively assessed in a scanning electron microscope.

RESULTS

We found broad variability in implant alloy microstructure for both cast and wrought alloy between manufacturers, but also within the same implant design. In cast alloys, there was no difference in PDP metrics between manufacturers. However, coarse hard phases and clusters of hard phases (mainly intermetallic phases) were associated with severe phase boundary corrosion and pitting corrosion. Furthermore, cast alloys with hard phases had a lower E_pit than those without (0.46 V, SD 0.042; 0.53 V, SD 0.03, respectively; p = 0.015). Wrought alloys exhibited either no hard phases or numerous carbides (M₂₃C₆). However, the corrosion behavior was mainly affected by lattice defects and banded structures indicative of segregations that appear to be introduced during bar stock manufacturing. Alloys with banding had a lower E_corr (p = 0.008) and higher I_corr (p = 0.028) than alloys without banding (-0.76 V, SD 0.003; -0.73 V, SD 0.009; and 1.14 × 10^-4 mA/cm², SD 1.47 × 10^-5; 5.2 × 10^-5 mA/cm², SD 2.57 × 10^-5, respectively). Alloys with carbides had a slightly higher E_corr (p = 0.046) than those without (-0.755 V, SD 0.005; -0.761 V, SD 0.004); however, alloys with carbides exhibited more severe corrosion damage as a result of phase boundary corrosion, hard phase detachment, and subsequent local crevice corrosion.

CONCLUSIONS

The observed variability in CoCrMo alloy microstructure of both cast and wrought components in this study appears to be an important issue to address, perhaps through better standards, to minimize in vivo corrosion. The finding of the banded structures within wrought alloys is especially concerning because it unfavorably influences the corrosion behavior independent of the manufacturer. The findings suggest that a homogeneous alloy microstructure with a minimal hard phase fraction exhibits more favorable corrosion behavior within the in vivo environment of modular taper junctions, thus lowering metal ion release and subsequently the risk of ALTRs to corrosion products. Also, the question arises if hard phases fulfill a useful purpose in metal-on-polyethylene bearings, because they may come with a higher risk of phase boundary corrosion and pitting corrosion and the benefit they provide by adding strength is not needed (unlike in metal-on-metal bearings).

CLINICAL RELEVANCE

Implant failure resulting from corrosion processes within modular junctions is a major concern in THA. Our results suggest that implant alloy microstructure is not sufficiently standardized and may also dictate specific corrosion modes and subsequent metal ion release.

Serum Metal Levels for Diagnosis of Adverse Local Tissue Reactions Secondary to Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty

BACKGROUND

Recently, corrosion at the head-neck junction in metal-on-polyethylene bearing surface total hip arthroplasty (THA) has been recognized as a cause of adverse local tissue reactions (ALTRs). Serum metal levels have been advocated as a tool for the diagnosis of ALTR; however, no prior studies have specifically examined their utility. The purpose of this study was to determine the optimal cutoff values for serum cobalt and chromium levels in diagnosing ALTR after metal-on-polyethylene bearing surface THA.

METHODS

We reviewed 447 consecutive patients with serum metal levels tested at our institution and identified 64 patients with a metal-on-polyethylene bearing who had axial imaging or underwent reoperation to confirm the presence or absence of ALTR. Receiver-operating characteristic curves were produced to identify cutoff thresholds to optimize sensitivity, and diagnostic test performance was characterized.

RESULTS

Forty-four of the 64 patients (69%) were positive for an ALTR. The best test for the diagnosis of ALTR was the serum cobalt level (area under the curve [AUC] = 99%). A threshold cutoff of ≥1.0 ng/mL had a sensitivity of 100%, specificity of 90%, positive predictive value (PPV) of 96%, and negative predictive value (NPV) of 100%. Serum chromium levels were also diagnostic (AUC = 87%). A threshold cutoff of ≥0.15 ng/mL had a sensitivity of 100%, specificity of 50%, PPV of 81%, and NPV of 100%. Finally, serum cobalt-to-chromium ratio was also helpful for diagnosis (AUC = 90%). A threshold cutoff value of 1.4 for the cobalt-to-chromium ratio offered a sensitivity of 93%, specificity of 70%, PPV of 87%, and NPV of 82%.

CONCLUSION

Measurement of serum cobalt level with a threshold value of 1.0 ng/mL in our experience is the best test for identifying the presence of ALTR in patients with a metal-on-polyethylene THA. Measurement of chromium level and the ratio of cobalt-to-chromium levels are also of value.

Mechanical, chemical and biological damage modes within head-neck tapers of CoCrMo and Ti6Al4V contemporary hip replacements

Total hip replacement (THR) failure due to mechanically assisted crevice corrosion within modular head-neck taper junctions remains a major concern. Several processes leading to the generation of detrimental corrosion products have been reported in first generation modular devices. Contemporary junctions differ in their geometries, surface finishes, and head alloy. This study specifically provides an overview for CoCrMo/CoCrMo and CoCrMo/Ti6Al4V head-neck contemporary junctions. A retrieval study of 364 retrieved THRs was conducted which included visual examination and determination of damage scores, as well as the examination of damage features using scanning electron microscopy. Different separately occurring or overlapping damage modes were identified that appeared to be either mechanically or chemically dominated. Mechanically dominated damage features included plastic deformation, fretting, and material transfer, whereas chemically dominate damage included pitting corrosion, etching, intergranular corrosion, phase boundary corrosion, and column damage. Etching associated cellular activity was also observed. Furthermore, fretting corrosion, formation of thick oxide films, and imprinting were observed which appeared to be the result of both mechanical and chemical processes. The occurrence and extent of damage caused by different modes was shown to depend on the material, the material couple, and alloy microstructure. In order to minimize THR failure due to material degradation within modular junctions, it is important to distinguish different damage modes, determine their cause, and identify appropriate counter measures, which may differ depending on the material, specific microstructural alloy features, and design factors such as surface topography. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1672-1685, 2018.

Does Surface Topography Play a Role in Taper Damage in Head-neck Modular Junctions?

BACKGROUND

There are increasing reports of total hip arthroplasty failure subsequent to modular taper junction corrosion. The surfaces of tapers are machined to have circumferential machining marks, resulting in a surface topography of alternating peaks and valleys on the scale of micrometers. It is unclear if the geometry of this machined surface topography influences the degree of fretting and corrosion damage present on modular taper junctions or if there are differences between modular taper junction material couples.

QUESTIONS/PURPOSES

(1) What are the differences in damage score and surface topography between CoCr/CoCr and CoCr/Ti modular junctions? (2) How are initial surface topography, flexural rigidity, taper angle mismatch, and time in situ related to visual taper damage scores for CoCr/CoCr couples? (3) How are initial surface topography, flexural rigidity, taper angle mismatch, and time in situ related to visual taper damage scores for CoCr/Ti couples?

METHODS

Damage on stem and head tapers was evaluated with a modified Goldberg score. Differences in damage scores were determined between a group of 140 CoCr/CoCr couples and 129 CoCr/Ti couples using a chi-square test. For a subgroup of 70 retrievals, selected at random, we measured five variables, including initial stem taper machining mark height and spacing, initial head taper roughness, flexural rigidity, and taper angle mismatch. All retrievals were obtained at revision surgeries. None were retrieved as a result of metal-on-metal failures or were recalled implants. Components were chosen so there was a comparable number of each material couple and damage score. Machining marks around the circumference of the tapers were measured using white light interferometry to characterize the initial stem taper surface topography in terms of the height of and spacing between machining mark peaks as well as initial head taper roughness. The taper angle mismatch was assessed with a coordinate measuring machine. Flexural rigidity was determined based on measurements of gross taper dimensions and material properties. Differences of median or mean values of all variables between material couples were determined (Wilcoxon rank-sum tests and t-tests). The effect of all five variables along with time in situ on stem and head taper damage scores was tested with a multiple regression model. With 70 retrievals, a statistical power of 0.8 could be achieved for the model.

RESULTS

Damage scores were different between CoCr/CoCr and CoCr/Ti modular taper junction material couples. CoCr/CoCr stem tapers were less likely to be mildly damaged (11%, p = 0.006) but more likely to be severely damaged (4%, p = 0.02) than CoCr/Ti stem tapers (28% and 1%, respectively). CoCr/CoCr couples were less likely to have moderately worn head tapers (7% versus 17%, p = 0.003). Stem taper machining mark height and spacing and head taper roughness were 11 (SD 3), 185 (SD 46), and 0.57 (SD 0.5) for CoCr/CoCr couples and 10 (SD 3), 170 (SD 56), and 0.64 (SD 0.4) for CoCr/Ti couples, respectively. There was no difference (p = 0.09, p = 0.1, p = 0.16, respectively) for either factor between material couples. Larger stem taper machining mark heights (p = 0.001) were associated with lower stem taper damage scores, and time in situ (p = 0.006) was associated with higher stem taper damage scores for CoCr/CoCr material couples. Stem taper machining marks that had higher peaks resulted in slower damage progression over time. For CoCr/Ti material couples, head taper roughness was associated with higher stem (p = 0.001) and head taper (p = 0.003) damage scores, and stem taper machining mark height, but not time in situ, was associated with lower stem taper damage scores (p = 0.007).

CONCLUSIONS

Stem taper surface topography was related to damage scores on retrieved head-neck modular junctions; however, it affected CoCr/CoCr and CoCr/Ti couples differently.

CLINICAL RELEVANCE

A taper topography of circumferential machining marks with higher peaks appears to enable slower damage progression and, subsequently, a reduction of the reported release of corrosion products. This may be of interest to implant designers and manufacturers in an effort to reduce the effects of metal release from modular femoral components.

Nanoscale surface modification by anodic oxidation increased bone ingrowth and reduced fibrous tissue in the porous coating of titanium-alloy femoral hip arthroplasty implants

Hip arthroplasty femoral stems coated with Ti6Al4V beads were treated by anodic oxidation in H₃ PO₄ for enhanced bioactivity and were studied in a 6-month canine model to determine the effects of the treated surface on the ingrowth of bone and soft tissues. The area fractions of bone, marrow, and fibrous tissue in the porous coating of seven treated and seven untreated control implants were determined using histomorphological techniques. The area fraction of bone within the porous coating was greater for anodic oxide treated (23.6 ± 8.3%) compared to control implants (l2.7 ± 4.7%) (p = 0.013), and there was less fibrous tissue in the treated implants (18.0 ± 9.5%) compared to the controls (33.1 ± 7.9%) (p = 0.006). XPS, XRD, TEM, and SEM analyses of the treated implants revealed a 400 nm-thick titanium oxide layer of low crystallinity with an undulating surface, populated with more than 25 nm-size pores per square micrometer. There was no detectable increase in serum titanium or in generation of particulates locally compared to the control implants. Micro and nanoscale surface modification by anodic oxidation increased bone ingrowth and reduced fibrous tissue, which may extend the longevity of fixation, limiting pathways for particle migration, and impeding the progression of osteolysis and aseptic loosening of arthroplasty components. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 283-290, 2017.

Successful long-term fixation and progression of osteolysis associated with first-generation cementless acetabular components retrieved post mortem

BACKGROUND

Primary cementless acetabular reconstruction has shown durable long-term fixation. Late failures secondary to aseptic loosening are rare but may occur in patients with previously well-fixed components. In the present study, the histopathological characteristics of postmortem specimens were correlated with wear damage and radiographic data in an attempt to better understand the long-term events in the periacetabular tissue around well-functioning devices.

METHODS

Seventeen primary cementless Harris-Galante I acetabular components with adjacent tissues were harvested after a mean of eleven years (range, four to twenty-five years) from patients whose implants were well functioning at the time of death. Undecalcified and paraffin sections were used to quantify the extent of bone and soft tissues within the porous coating and at the interface between the coating and the surrounding bone. Wear particles were identified with use of polarized light microscopy and energy-dispersive x-ray analysis. Bearing-surface volumetric wear and backside wear damage of the polyethylene liner were assessed.

RESULTS

All of the components were fixed by bone ingrowth (mean extent, 33% ± 21%). Particle-induced granulomas were present in the porous coating and along the interface and progressed through screw holes, ballooning into the retroacetabular bone in the longer-term specimens. Particles of femoral and acetabular origin were identified in the granulomas. Bearing-surface volumetric wear (mean, 41.6 mm3/year) increased with duration and correlated with increasing extent of granuloma in the porous coating and the increasing size of pelvic granulomas. Radiolucencies on radiographs correlated with the extent of bone and fibrous tissue ingrowth. Of the six pelvic granulomas that were identified histologically, only one was apparent on routine radiographs.

CONCLUSIONS

Acetabular fixation by bone ingrowth can be successful into the third decade after implantation. Osteolysis and secondary replacement of bone with particle-induced granuloma are commonly seen in the presence of excellent clinical function. Strategies designed to minimize bearing-surface wear and backside damage are important to maintain long-term bone ingrowth fixation.

Influence of pH on the tribocorrosion behavior of CpTi in the oral environment: synergistic interactions of wear and corrosion

Dental implants made of titanium alloys have been used as a predictable therapy approach to replace missing teeth. The oral environment subjects titanium implants to varying conditions like changes in pH, temperature, and saliva contamination leading to chemical corrosion together with mastication process.

OBJECTIVE

In this study, the combined effect of chemical corrosion and wear (so-called tribocorrosion) in the degradation of dental implant material (CpTi) under varying pH oral environment was investigated.

METHODS

Titanium (CpTi) discs were subjected to sliding tests in artificial saliva at varying pHs: 3.0, 6.0, and 9.0. A custom made tribocorrosion apparatus was used to perform the tests. The tribological system consisted of a ceramic ball of 28 mm diameter articulating against the flat face (titanium).

RESULTS

Electrochemical impedance spectroscopy results indicated an increase in electrochemical double layer capacitance (C(dl)) at pH 3.0 and 6.0 after sliding. Surprisingly, in the presence of tribological stresses, the measured current evolution was highest and fluctuated the most at pH 6.0. In addition, the greatest weight loss was measured at pH 6.0.

CONCLUSIONS

Despite reports of CpTi being electrochemically stable down to pH 2.0, this study suggests degradation peaks at near neutral pH values in the presence of motion. At pH 6.0, the passive film layer, typically protecting the surface of titanium may not be reformed cohesively, resulting in more tribocorrosion products at the surface, which are easily sheared off. These findings elevate concern with regard to dental implants because the average pH of the oral cavity is 6.3.

The metabolism of imiloxan hydrochloride in healthy male volunteers

1. The metabolism of imiloxan hydrochloride [(+-)-2-(1-ethyl-2-imidazoyl)methyl-1,4-benzodioxane hydrochloride], an alpha 2-adrenoceptor antagonist, was studied in four male volunteers given a 500 mg oral dose containing 0.48 MBq of the 14C-labelled material. Compound-related radioactivity was rapidly excreted chiefly in the urine within 24 h of dosing. 2. Metabolites derived by initial oxidation on either or both the benzodioxane and imidazoyl moieties followed by glucuronic acid and sulphate conjugation, and an N-glucuronide of imiloxan were tentatively identified in urine. 3. The major urinary metabolites, comprising some 37-41% of the dose, appeared to be +-2-(1-ethyl-2-imidazoyl)methyl-1,4-benzodioxane-6/7-sulphonic acid (19% of dose), [+-2-(1-ethyl-2-imidazoyl)methyl-1,4-benzodioxane- 6/7-ylium D-glucopyranoside]uronate (10-14% of dose), and a glucuronide conjugate of +-2-(1-ethyl-2-imidazoyl-4/5-hydroxy)methyl-1,4-benzodioxane (8% of dose).

Increased bone formation using calcium sulfate-calcium phosphate composite graft

Calcium phosphates (CaPO4) and faster-resorbing calcium sulfate (CaSO4) are successfully employed as synthetic bone grafts for treatment of contained defects. We used a canine critical-sized bone defect model to study an injectable CaSO4/CaPO4 composite graft that incorporated a matrix of CaSO4 and dicalcium phosphate dihydrate into which beta-tricalcium phosphate granules were distributed. The area fraction, ultimate compressive stress, and elastic modulus of restored bone and the relative rates of material resorption were compared between the CaSO4/CaPO4 composite graft and pure CaSO4 pellets and to normal canine bone. The area fraction of bone in stained sections and the ultimate compressive stress of the regenerated bone were greater using the CaSO4/CaPO4 composite graft compared to pure CaSO4 pellets after 13 and 26 weeks and were greater than normal bone. The elastic modulus of restored bone in defects treated with CaSO4/CaPO4 composite graft was greater than in defects treated with CaSO4 pellets after 26 weeks, but similar to specimens of normal bone. A small amount of CaSO4/CaPO4 composite graft and no CaSO4 pellets remained after 13 or 26 weeks. This novel CaSO4/CaPO4 composite holds promise for clinical applications where a strong, injectable, slower-resorbing, and biocompatible bone graft substitute would be advantageous.

Bone ingrowth through porous titanium granulate around a femoral stem: histological assessment in a six-month canine hemiarthroplasty model

The procedure of using of porous titanium granules for cementless fixation of a hip replacement femoral stem was studied in a hemiarthroplasty model in 10 canines for 6 months. A vibrating instrument was used to facilitate both the delivery and distribution of the irregularly shaped porous titanium granules into the femoral canal as well as the subsequent insertion of a titanium alloy stem into the intramedullary bed of granules. Histological examination revealed lamellar bone formation through the mantle of porous titanium granules in continuity with the surrounding cortex resulting in the formation of an integrated mantle of bone and titanium granulate around the prosthesis.

Drivers of professional mobility in the Northern Territory: dental professionals

INTRODUCTION

Attracting and retaining an efficient allied health workforce is a challenge faced by communities in Australia and overseas. High rates of staff turnover in the professional workforce diverts resources away from core business and results in the loss of valuable skills and knowledge. Understanding what attracts professionals to a particular place, and why they leave, is important for developing effective strategies to manage turnover and maximise workforce productivity. The Northern Territory (NT) faces particular workforce challenges, in part because of its geographic location and unusual demography. Do these factors require the development of a tailored approach to recruitment and retention? This article reports on a study undertaken to examine the motivations for coming to, staying in and leaving the NT for dental professionals, and the implications of results on workforce management practices.

METHODS

In 2006, dentists, dental specialists, dental therapists and dental hygienists who were working or had worked in the NT, Australia, in the recent past were surveyed to collect demographic and workforce data and to establish the relative importance of social and work-related factors influencing their migration decisions. Multivariate logistic regression models were generated to describe the demographic characteristics of dental professionals who stayed in the NT for more than 5 years and to analyse why dental professionals left. The analyses, based on a 42% response rate, explained 60-80% of the variation in responses.

RESULTS

Generally dental professionals who had stayed for more than 5 years were older, had invested in the purchase of homes and were more involved in social and cultural activities. Those who moved to the NT as a result of financial incentives or who had strong expectations that working in the NT would be an exciting, novel experience tended to stay for no more than 5 years, often leaving because they found the work environment too stressful. In contrast, those who stayed longer came because they had existing social networks and were familiar with the NT environment, staying primarily because they have enjoyed the NT lifestyle, particularly the sense of community and the opportunities available through living in smaller centres.

CONCLUSION

There are benefits in actively engaging newly recruited professionals and their families in social networks. Work related stress and departure was associated with administrative deficiencies within the management system. Despite the NT's unusual demographic profile, the factors influencing recruitment and retention are not markedly different from those reported elsewhere.

Local and systemic levels of tobramycin delivered from calcium sulfate bone graft substitute pellets

We asked if tobramycin-loaded calcium sulfate pellets could be used to maintain high local site antibiotic concentrations for an extended period with minimal systemic levels and without adverse effects on vital organs. Calcium sulfate pellets loaded with 10% tobramycin were implanted in contained medullary defects in the proximal humeri of canines. The number of pellets implanted was calculated to yield an equivalent human maximum prescribed dose, and 1.8-fold this dose. These doses converted to approximately 20 mg/kg, and 36 mg/kg, respectively, for the canine. Local and systemic tobramycin levels, pellet resorption, bone response, clinical pathology parameters, and histopathologic responses of potential target organs were analyzed to determine if there was any adverse response for a 28-day period. Serum tobramycin was elevated for less than one day while local levels remained elevated for at least 14 days, and in some animals, 28 days. Tobramycin delivered locally from calcium sulfate pellets had no apparent adverse effect on clinical pathology parameters or on any of the organs that were analyzed. In addition, bone formation and pellet resorption followed patterns typically seen with calcium sulfate materials.

Accumulation in liver and spleen of metal particles generated at nonbearing surfaces in hip arthroplasty

Systemic migration of metal particles generated at nonbearing surfaces rather than the intended primary bearing was studied in postmortem specimens from 30 patients with total hip arthroplasty. Using light and electron microscopy with x-ray microanalysis, submicrometer metal particles were identified within macrophages in the liver and/or the spleen in 11 of 15 patients with a revised arthroplasty and in 2 of 15 patients with primary hip arthroplasty. The macrophages formed focal aggregates in the organs without apparent toxicity. Fretting at ancillary fixation devices, loose components, and modular connections can generate a substantial volume of debris. These particles are in addition to those generated at the bearing surfaces, further increasing both the local and systemic particulate burdens. While all components can be associated with the distant spread of particles and metal ions, it is the environment of revision arthroplasty that provides the greatest potential for the generation and systemic dissemination of wear debris. The long-term effects of accumulated wear particles in the liver and spleen are unknown.

Effects of altered crystalline structure and increased initial compressive strength of calcium sulfate bone graft substitute pellets on new bone formation

A new, modified calcium sulfate has been developed with a different crystalline structure and a compressive strength similar to many calcium phosphate materials, but with a resorption profile only slightly slower than conventional surgical-grade calcium sulfate. A canine bilateral defect model was used to compare restoration of defects treated with the modified calcium sulfate compared to treatment using conventional calcium sulfate pellets after 6, 13, and 26 weeks. The modified calcium sulfate pellets were as effective as conventional calcium sulfate pellets with regard to the area fraction and compressive strength of newly formed bone in the treated bone defects. Mechanical testing demonstrated that the initial compressive strength of the modified material was increased nearly three-fold compared to that of conventional surgical-grade calcium sulfate. This increase potentially allows for its use in a broader range of clinical applications, such as vertebral and subchondral defects.

An injectable calcium sulfate-based bone graft putty using hydroxypropylmethylcellulose as the plasticizer

The addition of a plasticizer to synthetic bone graft substitutes can improve handling characteristics, injectability, and the ability to uniformly fill defects. Restoration of large medullary bone defects using an injectable calcium sulfate-based putty using hydroxypropylmethylcellose as the plasticizer was compared to conventional calcium sulfate paste in a canine model. Beginning 2 weeks following implantation, serial clinical and specimen radiographs demonstrated a similar progressive resorption of the implanted materials and replacement with new bone for both the putty and paste forms of calcium sulfate. The area fraction of new bone and remaining implant material in bone defects treated with the putty were not significantly different from defects treated with conventional calcium sulfate paste after 13 and 26 weeks. In addition to its handling characteristics, the putty was biocompatible and as effective as conventional calcium sulfate paste in achieving substantial bony restoration of a large, critical-size bone defect.

Estrogenic endocrine disruptive components interfere with calcium handling and differentiation of human trophoblast cells

During development, calcium (Ca) is actively transported by placental trophoblasts to meet fetal nutritional and the skeletal mineralization needs. Maternal exposure to estrogenic pesticides, such as 1,1-bis(p-chlorophenyl)-2,2,2-trichloroethane (DDT) and methoxychlor (MTC), has been shown to result in reproductive disorders and/or abnormal fetal development. In this study, we have examined the effects of exposure of trophoblastic cells to MTC and DTT, in comparison to 17beta-estradiol (E2) and diethylstilbestrol (DES), to test the hypothesis that cellular Ca handling is a target for these endocrine disruptive components. Treatment with DDT, MTC, DES, or E2 increased cellular Ca uptake, and the expression of trophoblast-specific human Ca binding protein (HCaBP) was down-regulated by both MTC and DDT. Treatment with MTC, DDT, and DES inhibited cell proliferation, induced apoptosis, and suppressed expression of several trophoblast differentiation marker genes. These effects were reversed by overexpression of metallothionein IIa, a gene highly responsive to cadmium and other metals. These results strongly suggest that trophoblast Ca handling functions are endocrinally modulated, and that their alteration by candidate endocrine disruptors, such as MTC and DDT, constitutes a possible pathway of the harmful effects of these components on fetal development.

Effect of cartilage oligomeric matrix protein on mesenchymal chondrogenesis in vitro

OBJECTIVE

Cartilage oligomeric matrix protein (COMP) mutations have been identified as responsible for two arthritic disorders, multiple epiphyseal dysplasia (MED) and pseudoachondroplasia (PSACH). However, the function of COMP in chondrogenic differentiation is largely unknown. Our investigation focuses on analyzing the function of normal COMP protein in cartilage biology.

METHODS AND RESULTS

To explore the function of COMP we make use of an in vitro model system for chondrogenesis, consisting of murine C3H10T1/2 mesenchymal cells maintained as a high-density micromass culture and stimulated with bone morphogenetic protein 2 (BMP-2). Under these culture conditions, C3H10T1/2 cells undergo active chondrogenesis in a manner analogous to that of embryonic limb mesenchymal cells, and have been shown to serve as a valid model system to investigate the mechanisms regulating mesenchymal chondrogenesis. Our results indicate that ectopic COMP expression enhances several early aspects of chondrogenesis induced by BMP-2 in this system, indicating that COMP functions in part to positively regulate chondrogenesis. Additionally, COMP has inhibitory effects on proliferation of cells in monolayer. However, at later times in micromass culture, ectopic COMP expression in the presence of BMP-2 causes an increase in apoptosis, with an accompanying reduction in cell numbers in the micromass culture. However, the remaining cells retain their chondrogenic phenotype.

CONCLUSIONS

These data suggest that COMP and BMP-2 signaling converge to regulate the fate of these cells in vitro by affecting both early and late stages of chondrogenesis.

Restoration of large bone defects using a hard-setting, injectable putty containing demineralized bone particles compared to cancellous autograft bone

An injectable, hard-setting, calcium sulfate-based putty containing demineralized bone matrix particles (AlloMatrix II, Wright Medical Technology, Inc, Arlington, Tenn) was compared to autogenous cancellous bone graft to evaluate healing in a canine model. Area fraction of new bone, modulus of elasticity, and compressive strength of new bone were evaluated, as was radiographic and histologic healing. Bilateral defects were created in the proximal humeri, and each defect was implanted with either the putty or autogenous bone according to a randomized schedule. Dogs were euthanized at 6, 13, and 26 weeks. The area fraction, modulus of elasticity, and compressive strength of newly formed bone was not significantly different between the putty and autogenous bone at 6, 13, or 26 weeks. The putty had excellent handling characteristics, was biocompatible, and was as effective as autograft bone in achieving near complete bony restoration of a large, critical-sized defect.

Osseous healing using injectable calcium sulfate-based putty for the delivery of demineralized bone matrix and cancellous bone chips

Three formulations of injectable calcium sulfate-based putties containing demineralized bone matrix (DBM), 50% DBM/50% cancellous bone (CB) chips, and 30% DBM/70% CB were studied in canines. Four humeral defects per dog were implanted with one of each of the putty formulations while the fourth defect was left untreated. After 6 weeks, the dogs were euthanized. Radiographs and histology showed that the area fraction of new bone in the defects was greater for the three putty formulations than the untreated defects. The area of residual cancellous bone graft remaining in the defects was <10% in both CB putties. Residual calcium sulfate was not apparent in any of the histological sections. We conclude that fast-resorbing calcium sulfate-based putties are effective delivery means of bone graft materials for the successful restoration of bony defects.

Healing of large defects treated with calcium sulfate pellets containing demineralized bone matrix particles

Calcium sulfate (OsteoSet, Wright Medical Technology, Inc, Arlington, Tenn) and calcium sulfate/demineralized bone matrix (DBM) pellets (OsteoSet DBM, Wright Medical Technology, Inc) have been evaluated preclinically in a bilateral medullary defect model of a canine humerus. In this model, both short (6 week) and long (26 week) time points have been evaluated. An analysis of bone response to the pellets was conducted using radiological, histological, mechanical, and quantification techniques. The calcium sulfate/DBM pellets exhibited more rapid trabecular bone remodeling as demonstrated by the absence of the ringlet bone structure typically seen with calcium sulfate pellets. We concluded that calcium sulfate and calcium sulfate/DBM pellets are both effective bone graft substitutes.

Filgrastim support during combination chemotherapy using cisplatin, doxorubicin, and cyclophosphamide to treat advanced or recurrent endometrial cancer: a clinical study and literature review

In a private practice setting, 16 patients with advanced or recurrent endometrial carcinoma received cisplatinum 50 mg/m2, doxorubicin 50 mg/m2, and cyclophosphamide 750 mg/m2 every three weeks. Growth factor support using filgrastim was initiated on the first cycle of therapy and each subsequent cycle. Sixteen patients were entered into the study with 13 being evaluable. No patient had previously received chemotherapy. The overall response rate was 54% with two complete responses (15%) and five partial responses (38%). Stable disease was seen in 46% of patients. Progression-free survival was observed to be a median of 8.5 months for a complete response, a median of 8.5 months for a partial response and a median of 7 months for stable disease. Fifteen percent of the patients and 3% of all chemotherapy cycles had febrile neutropenic events. There were no deaths due to myelotoxicity. Only one patient required a dose reduction due to neutropenia. Four of the 13 patients required dose reductions due to previous nadir thrombocytopenia. Grade 4 granulocytopenia occurred in 28% of treatment cycles and grade 3 granulocytopenia occurred in 12% of treatment cycles. The use of filgrastim (G-CSF) allowed patients to stay on therapy for an average of seven treatments. Neutropenia was not the dose-limiting toxicity from this dose-intense regimen.

Laminated multi-segment rib graft in anterior column reconstruction

Rib harvested during thoracotomy can be effectively used for anterior column reconstruction. An innovative technique is described to convert multiple individual rib segments into a robust single anterior column reconstruction graft using cortical screws.

The murine COMP (cartilage oligomeric matrix protein) promoter contains a potent transcriptional repressor region

OBJECTIVE

A subgroup of patients with pseudoachondroplasia (PSACH) and multiple epiphyseal dysplasia (MED) have been found to harbor mutations within the cartilage oligomeric matrix protein (COMP) gene. These two diseases are autosomal dominant disorders that are characterized by an early onset of osteoarthritis (OA). The COMP gene is expressed primarily in chondrocytes in articular cartilage as well as in tendon and ligament. Therefore, control over tissue specific COMP expression may be an important aspect in cartilage biology. To begin an analysis of the regulation of COMP expression, we have cloned, sequenced and characterized the entire genomic clone for mouse COMP that includes the COMP promoter.

METHODS AND RESULTS

The COMP coding region spans 19 exons over approximately 8.4 kb of DNA. The arrangement and size of the exons have a remarkable similarity to those of the human COMP genomic sequence, indicating a significant degree of genomic conservation. Analysis of a 453 basepair region of the putative COMP promoter reveals two strong transcriptional repressor elements located between position -356 and -304 and between -251 and -180, relative to the start site for transcription. These repressor elements down-regulate transcription from the promoter in a broad spectrum of cell lines. Removal of the repressor DNA sequence from the COMP promoter leads to significant enhancement in transcriptional activity, indicating that this region acts in a dominant manner to transcriptional activators located more proximal to the start site of transcription. This region also represses transcription when linked to a heterologous promoter.

CONCLUSIONS

This repressor region probably down-regulates transcription from the COMP promoter in vivo. It may help to repress transcription of COMP in non-cartilaginous tissues and/or may aid in the expression of COMP to the appropriate level in tissues such as cartilage, tendon and ligament.

Gene expression profiling following BMP-2 induction of mesenchymal chondrogenesis in vitro

OBJECTIVE

This study aims to apply gene expression profiling technology to gain insight into the molecular regulation of mesenchymal chondrogenesis.

METHODS

The experimental system consists of micromass cultures of C3H10T1/2 cells, a murine multipotential embryonic cell line, treated with the chondroinductive growth factor, bone morphogenetic factor-2 (BMP-2). In this system, chondrogenic differentiation characterized by both morphological changes and cartilage matrix gene expression has been shown to be completely dependent upon BMP-2 treatment and the high cell plating density of micromass cultures. To identify candidate genes that may have key functional roles in chondrogenesis, we have applied subtractive hybridization to isolate genes whose expression is significantly up- or down-regulated during chondrogenesis. RNA was isolated from micromass cultures treated with BMP-2 for 24 h and analysed for representational differences by means of a subtractive hybridization screening method.

RESULTS

Sixteen different genes were identified whose expression was up-regulated between two- and 12-fold by B,P-2, and twelve different genes were identified whose expression was down-regulated between two- and seven-fold by BMP-2.

CONCLUSIONS

The potential of this screening methodology to identify new BMP-2 regulated genes is suggested by the fact that a majority of the identified genes are indeed novel. Identification and characterization of these genes should provide insight as to how chondrogenesis is regulated and also should provide important new markers for the study of osteoarthritis.

A transcriptionally inactive E2F-1 targets the MDM family of proteins for proteolytic degradation

E2F-1-activated transcription promotes cell cycle progression and apoptosis. These functions are regulated by several factors including the E2F-1-binding protein MDM2 and the retinoblastoma protein pRb. Using a yeast two-hybrid screen we have identified the MDM2-related protein, MDMX, as an E2F-1-binding protein. In these studies we find that coexpression of MDMX with E2F-1 results in degradation of the MDMX protein. Although this proteolytic degradation can be blocked by the protease inhibitors bafilomycin A(1), N-acetyl-Leu-Leu-Norleu-AL, and N-acetyl-Leu-Leu-Met-AL, MDMX degradation is not inhibited by lactacystin, suggesting that degradation occurs by a proteasome-independent mechanism. Using an E2F-1 deletion mutant (E2F-1(180-437)) we show that E2F-1-targeted degradation of MDMX does not require the E2F-1 DNA binding domain and therefore is independent of E2F-1-driven transcription. We also find that this transcriptionally inactive E2F-1 mutant is capable of degrading the MDMX-related protein MDM2 and the MDMX isoform MDMX-S. Mapping of the E2F-1 C terminus reveals that neither a previously characterized C-terminal MDM2 binding domain nor the pRb binding domain on E2F-1 is required for MDMX and MDM2 degradation.

Leader protein of encephalomyocarditis virus binds zinc, is phosphorylated during viral infection, and affects the efficiency of genome translation

Encephalomyocarditis virus (EMCV) is the prototype member of the cardiovirus genus of picornaviruses. For cardioviruses and the related aphthoviruses, the first protein segment translated from the plus-strand RNA genome is the Leader protein. The aphthovirus Leader (173-201 amino acids) is an autocatalytic papain-like protease that cleaves translation factor eIF-4G to shut off cap-dependent host protein synthesis during infection. The less characterized cardioviral Leader is a shorter protein (67-76 amino acids) and does not contain recognizable proteolytic motifs. Instead, these Leaders have sequences consistent with N-terminal zinc-binding motifs, centrally located tyrosine kinase phosphorylation sites, and C-terminal, acid-rich domains. Deletion mutations, removing the zinc motif, the acid domain, or both domains, were engineered into EMCV cDNAs. In all cases, the mutations gave rise to viable viruses, but the plaque phenotypes in HeLa cells were significantly smaller than for wild-type virus. RNA transcripts containing the Leader deletions had reduced capacity to direct protein synthesis in cell-free extracts and the products with deletions in the acid-rich domains were less effective substrates at the L/P1 site, for viral proteinase 3Cpro. Recombinant EMCV Leader (rL) was expressed in bacteria and purified to homogeneity. This protein bound zinc stoichiometrically, whereas protein with a deletion in the zinc motif was inactive. Polyclonal mouse sera, raised against rL, immunoprecipitated Leader-containing precursors from infected HeLa cell extracts, but did not detect significant pools of the mature Leader. However, additional reactions with antiphosphotyrosine antibodies show that the mature Leader, but not its precursors, is phosphorylated during viral infection. The data suggest the natural Leader may play a role in regulation of viral genome translation, perhaps through a triggering phosphorylation event.

A dose-escalating study of weekly bolus topotecan in previously treated ovarian cancer patients

OBJECTIVE

Topotecan is an established topoisomerase I inhibitor for the treatment of relapsed ovarian cancer. Myelotoxicity and suboptimal patient convenience associated with daily topotecan, however, have prompted investigators to explore alternate regimens, including a weekly regimen of topotecan. The objective of this study was to determine the maximum tolerated dose (MTD) of topotecan given as a weekly bolus in previously treated ovarian cancer patients.

METHODS

Second- and third-line ovarian cancer patients with measurable disease or elevated cancer antigen 125 received weekly bolus topotecan intravenously starting at 1.5 mg/m(2). Topotecan was escalated in dose increments of 0.5 mg/m(2) every 21 days as tolerability allowed. Dose-limiting toxicity was defined as grade 3/4 neutropenia or thrombocytopenia.

RESULTS

Thirty-two of 35 patients were evaluable for safety and tolerability. No notable toxicity was observed with weekly topotecan doses < 4 mg/m(2). Additionally, there was an absence of dose-limiting myelotoxicity and thrombocytopenia with weekly topotecan. The MTD of weekly topotecan without the use of granulocyte colony-stimulating factor support was 4 mg/m(2), with grade 2 anemia, chronic fatigue, and grade 2 gastrointestinal toxicity limiting further dose escalation. Weekly topotecan also demonstrated antitumor activity at doses >2 mg/m(2).

CONCLUSIONS

The establishment of a well-tolerated, weekly regimen of topotecan (4 mg/m(2), with a maximum recommended dose of 6 mg/m(2)) provides the basis for further investigation in phase II studies of single-agent and combination regimens in previously treated ovarian cancer patients.

Transduction of a dominant-negative H-Ras into human eosinophils attenuates extracellular signal-regulated kinase activation and interleukin-5-mediated cell viability

Inhibition of eosinophil apoptosis by exposure to interleukin-5 (IL-5) is associated with the development of tissue eosinophilia and may contribute to the inflammation characteristic of asthma. Analysis of the signaling events associated with this process has been hampered by the inability to efficiently manipulate eosinophils by the introduction of active or inhibitory effector molecules. Evidence is provided, using a dominant-negative N17 H-Ras protein (dn-H-Ras) and MEK inhibitor U0126, that activation of the Ras-Raf-MEK-ERK pathway plays a determining role in the prolongation of eosinophil survival by IL-5. For these studies, a small region of the human immunodeficiency virus Tat protein, a protein transduction domain known to enter mammalian cells efficiently, was fused to the N-terminus of dn-H-Ras. The Tat-dn-H-Ras protein generated from this construct transduced isolated human blood eosinophils at more than 95% efficiency. When Tat-dn-H-Ras-transduced eosinophils were treated with IL-5, they exhibited a time- and dosage-dependent reduction in extracellular regulated kinase 1 and 2 activation and an inhibition of p90 Rsk1 phosphorylation and IL-5-mediated eosinophil survival in vitro. In contrast, Tat-dn-H-Ras did not inhibit CD11b up-regulation or STAT5 tyrosine phosphorylation. These data demonstrate that Tat dominant-negative protein transduction can serve as an important and novel tool in studying primary myeloid cell signal transduction in primary leukocytes and can implicate the Ras-Raf-MEK-ERK pathway in IL-5-initiated eosinophil survival.