Clinical investigations to evaluate high-risk orthopaedic devices: a systematic review of the peer-reviewed medical literature

Purpose

The objective of this systematic review was to give an overview of clinical investigations regarding hip and knee arthroplasty implants published in peer-reviewed scientific medical journals before entry into force of the EU Medical Device Regulation in May 2021.

Methods

We systematically reviewed the medical literature for a random selection of hip and knee implants to identify all peer-reviewed clinical investigations published within 10 years before and up to 20 years after regulatory approval. We report study characteristics, methodologies, outcomes, measures to prevent bias, and timing of clinical investigations of 30 current implants. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

We identified 2912 publications and finally included 151 papers published between 1995 and 2021 (63 on hip stems, 34 on hip cups, and 54 on knee systems). We identified no clinical studies published before Conformité Européene (CE)-marking for any selected device, and no studies even up to 20 years after CE-marking in one-quarter of devices. There were very few randomized controlled trials, and registry-based studies generally had larger sample sizes and better methodology.

Conclusion

The peer-reviewed literature alone is insufficient as a source of clinical investigations of these high-risk devices intended for life-long use. A more systematic, efficient, and faster way to evaluate safety and performance is necessary. Using a phased introduction approach, nesting comparative studies of observational and experimental design in existing registries, increasing the use of benefit measures, and accelerating surrogate outcomes research will help to minimize risks and maximize benefits.

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

Comparison of dual-mobility cup and unipolar cup for prevention of dislocation after revision total hip arthroplasty

Background and purpose - Revision total hip arthroplasty (THA) is associated with higher dislocation rates than primary THA. We compared the risk of dislocation within 6 months and all-cause re-revision during the whole study period using either the dual-mobility cup or the unipolar cup. Methods - We used a prospective hospital registry-based cohort including all total and cup-only revision THAs performed between 2003 and 2013. The cups used were either dual-mobility or unipolar; the choice was made according to the preference of the surgeon. 316 revision THAs were included. The mean age of the cohort was 69 (25-98) years and 160 THAs (51%) were performed in women. The dual-mobility group (group 1) included 150 THAs (48%) and the mean length of follow-up was 31 (0-128) months. The unipolar group (group 2) included 166 THAs (53%) and the mean length of follow-up was 52 (0-136) months. Results - The incidence of dislocation within 6 months was significantly lower with the dual-mobility cup than with the unipolar cup (2.7% vs. 7.8%). The unadjusted risk ratio (RR) was 0.34 (95% CI: 0.11-1.02) and the adjusted RR was 0.28 (95% CI: 0.09-0.87). The number of patients needed to treat with a dual-mobility cup in order to prevent 1 case of dislocation was 19. The unadjusted incidence rate ratio for all-cause re-revision in the dual-mobility group compared to the unipolar group was 0.6 (95% CI: 0.3-1.4). Interpretation - Use of a dual-mobility rather than a unipolar cup in revision THA reduced the risk of dislocation within 6 months.

Impact of noise in holography with extended references in the low signal regime

Signal-to-noise ratio is a key factor in lensless imaging, particularly for low diffraction signal experiments in the single shot regime. We present our recent study of the noise impact on holography with extended references. Experimental data have been measured in single shot acquisition using an intense coherent soft X-ray high harmonic source. The impact of hardware and software noise under various detection conditions is discussed. A final comparison between single shot and multi-shot regimes is given.

Fourier transform holography with high harmonic spectra for attosecond imaging applications

We demonstrate a method of using a Fourier holographic technique to utilize attosecond soft x-ray pulses to image nanometer-scale objects. A discrete frequency comb of laser-generated high-order harmonics, yielding a train of attosecond pulses, has been used to record spatially and spectrally resolved images. The individual wavelengths were also combined to form a single image, albeit with lower spatial resolution, demonstrating the applicability of the method to using isolated attosecond pulses with continuous bandwidths.

Impact of wave front and coherence optimization in coherent diffractive imaging

We present single shot nanoscale imaging using a table-top femtosecond soft X-ray laser harmonic source at a wavelength of 32 nm. We show that the phase retrieval process in coherent diffractive imaging critically depends on beam quality. Coherence and image fidelity are measured from single-shot coherent diffraction patterns of isolated nano-patterned slits. Impact of flux, wave front and coherence of the soft X-ray beam on the phase retrieval process and the image quality are discussed. After beam improvements, a final image reconstruction is presented with a spatial resolution of 78 nm (half period) in a single 20 fs laser harmonic shot.

An analysis of the GLVQ algorithm

Generalized learning vector quantization (GLVQ) has been proposed in as a generalization of the simple competitive learning (SCL) algorithm. The main argument of GLVQ proposal is its superior insensitivity to the initial values of the weights (code vectors). In this paper we show that the distinctive characteristics of the definition of GLVQ disappear outside a small domain of applications. GLVQ becomes identical to SCL when either the number of code vectors grows or the size of the input space is large. Besides that, the behavior of GLVQ is inconsistent for problems defined on very small scale input spaces. The adaptation rules fluctuate between performing descent and ascent searches on the gradient of the distortion function.

Kinetics of in vitro lipolysis of human very low-density lipoprotein by lipoprotein lipase

BACKGROUND AND AIM

An initial step in the catabolism of triglyceride-rich lipoprotein involves the hydrolysis of the triglyceride moiety by lipoprotein lipase (LPL). As differences in the lipolytic behaviour of very low-density lipoprotein (VLDL) particles have been observed, it is possible that different VLDL particles have a different affinity to the enzyme, which means that their fate may partially depend on the LPL-mediated hydrolysis of their triglyceride content. Our aim was to determine whether variation in VLDL chemical composition affects their properties as a substrate for LPL.

METHODS AND RESULTS

Isolated VLDL was incubated in vitro with bovine LPL to determine substrate affinity. Under optimal assay conditions, free fatty acids were measured and the kinetic indicators for in vitro triglyceride hydrolysis (Km and Vmax) were calculated. VLDL cholesterol (VLDL-C), VLDL-apoB and the cholesterol/triglyceride ratio were assessed and the triglyceride/protein and triglyceride/apoB ratios were calculated as lipoprotein size estimators. VLDL-C, VLDL-apoB and the VLDL-C/triglyceride ratio positively correlated with Km: r = 0.52, p < 0.01; r = 0.52, p < 0.03; r = 0.69, p < 0.001 respectively. No correlation was found between the VLDL-triglyceride/protein or the VLDL-triglyceride/apoB ratios and Km (r = -0.20, and -0.06 respectively, p = not significant). Of the subjects' anthropometric characteristics, only the waist/hip ratio significantly correlated with Km: r = 0.63, p < 0.01.

CONCLUSIONS

In the present study, we investigated the substrate function of VLDL particles in vitro. Enzyme affinity seems to be associated with cholesterol-triglyceride content or the number of VLDL particles rather than particle size. It may be expected that VLDL with a low cholesterol/triglyceride ratio will be efficiently lypolised by LPL, thus leading to the formation of a smaller particle with atherogenic potential.

In vitro susceptibility of Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium avium against some quinolones

The in vitro susceptibility of Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium avium to ciprofloxacin, norfloxacin and ofloxacin was studied by the agar dilution method. All strains of Mycobacterium fortuitum were inhibited by 2 mg/ml or less of these antimicrobial agents. Concentrations higher than achievable blood levels were necessary to inhibit Mycobacterium chelonae and Mycobacterium avium.