Seasonal Transcriptome Profiling of Susceptible and Tolerant Citrus Cultivars to Citrus Huanglongbing

Citrus huanglongbing (HLB) caused by 'Candidatus Liberibacter asiaticus' (CLas) is the most devastating citrus disease worldwide. Most commercial citrus cultivars are susceptible to HLB, with a few more tolerant exceptions such as 'LB8-9' Sugar Belle mandarin. Transcriptomic analyses have been widely used to investigate the potential mechanisms for disease susceptibility, resistance, or tolerance. Previous transcriptomic studies related to HLB mostly focused on single time point data collection. We hypothesize that changes in day length and temperature throughout the seasons have profound effects on citrus-CLas interactions. Here, we conducted RNA-seq analyses on HLB-susceptible Valencia sweet orange and HLB-tolerant mandarin 'LB8-9' in winter, spring, summer, and fall. Significant variations in differentially expressed genes (DEGs) related to HLB were observed among the four seasons. For both cultivars, the highest number of DEGs were found in the spring. CLas infection stimulates the expression of immune-related genes such as NBS-LRR, RLK, RLCK, CDPK, MAPK pathway, reactive oxygen species (ROS), and PR genes in both cultivars, consistent with the model that HLB is a pathogen-triggered immune disease. HLB-positive mandarin 'LB8-9' trees contained higher concentrations of maltose and sucrose, which are known to scavenge ROS. In addition, mandarin 'LB8-9' showed higher expression of genes involved in phloem regeneration, which might contribute to its HLB tolerance. This study shed light on the pathogenicity mechanism of the HLB pathosystem and the tolerance mechanism against HLB, providing valuable insights into HLB management.

Citrus Huanglongbing is a pathogen-triggered immune disease that can be mitigated with antioxidants and gibberellin

Huanglongbing (HLB) is a devastating disease of citrus, caused by the phloem-colonizing bacterium Candidatus Liberibacter asiaticus (CLas). Here, we present evidence that HLB is an immune-mediated disease. We show that CLas infection of Citrus sinensis stimulates systemic and chronic immune responses in phloem tissue, including callose deposition, production of reactive oxygen species (ROS) such as H2O2, and induction of immunity-related genes. The infection also upregulates genes encoding ROS-producing NADPH oxidases, and downregulates antioxidant enzyme genes, supporting that CLas causes oxidative stress. CLas-triggered ROS production localizes in phloem-enriched bark tissue and is followed by systemic cell death of companion and sieve element cells. Inhibition of ROS levels in CLas-positive stems by NADPH oxidase inhibitor diphenyleneiodonium (DPI) indicates that NADPH oxidases contribute to CLas-triggered ROS production. To investigate potential treatments, we show that addition of the growth hormone gibberellin (known to have immunoregulatory activities) upregulates genes encoding H2O2-scavenging enzymes and downregulates NADPH oxidases. Furthermore, foliar spray of HLB-affected citrus with gibberellin or antioxidants (uric acid, rutin) reduces H2O2 concentrations and cell death in phloem tissues and reduces HLB symptoms. Thus, our results indicate that HLB is an immune-mediated disease that can be mitigated with antioxidants and gibberellin.

Candidatus Liberibacter: From Movement, Host Responses, to Symptom Development of Citrus Huanglongbing

Candidatus Liberibacter spp. are fastidious α-proteobacteria that cause multiple diseases on plant hosts of economic importance, including the most devastating citrus disease: Huanglongbing (HLB). HLB was reported in Asia a century ago but has since spread worldwide. Understanding the pathogenesis of Candidatus Liberibacter spp. remains challenging as they are yet to be cultured in artificial media and infect the phloem, a sophisticated environment that is difficult to manipulate. Despite those challenges, tremendous progress has been made on Ca. Liberibacter pathosystems. Here, we first reviewed recent studies on genetic information of flagellar and type IV pili biosynthesis, their expression profiles, and movement of Ca. Liberibacter spp. inside the plant and insect hosts. Next, we reviewed the transcriptomic, proteomic, and metabolomic studies of susceptible and tolerant plant genotypes to Ca. Liberibacter spp. infection and how Ca. Liberibacter spp. adapt in plants. Analyses of the interactions between plants and Ca. Liberibacter spp. imply the involvement of immune response in the Ca. Liberibacter pathosystems. Lastly, we reviewed how Ca. Liberibacter spp. movement inside and interactions with plants lead to symptom development.

Molecular signatures between citrus and Candidatus Liberibacter asiaticus

Citrus Huanglongbing (HLB), also known as citrus greening, is one of the most devastating citrus diseases worldwide. Candidatus Liberibacter asiaticus (CLas) is the most prevalent strain associated with HLB, which is yet to be cultured in vitro. None of the commercial citrus cultivars are resistant to HLB. The pathosystem of Ca. Liberibacter is complex and remains a mystery. In this review, we focus on the recent progress in genomic research on the pathogen, the interaction of host and CLas, and the influence of CLas infection on the transcripts, proteins, and metabolism of the host. We have also focused on the identification of candidate genes for CLas pathogenicity or the improvements of HLB tolerance in citrus. In the end, we propose potentially promising areas for mechanistic studies of CLas pathogenicity, defense regulators, and genetic improvement for HLB tolerance/resistance in the future.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Patients with elevated triglyceride and cholesterol serum levels have a prolonged survival in amyotrophic lateral sclerosis

Weight loss is a common phenomenon and an independent prognostic factor in amyotrophic lateral sclerosis (ALS). Several potential causal mechanisms, including intrinsic hypermetabolism and deficient food intake, have been discussed. We investigated the influence of fasting serum glucose, cholesterol, and triglyceride levels at time of diagnosis on survival in ALS. Serum cholesterol (LDL, HDL, and LDL/HDL ratio), triglycerides, and glucose were investigated in 488 patients (age of onset = 57.6 ± 12.6 years) in relation to survival and revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALS-FRS) data. High serum levels of both fasting cholesterol and triglycerides had a significantly positive effect on survival (p < 0.05). We found a median prolonged life expectancy by 14 months for patients with serum triglyceride levels above the median of 1.47 mmol/l. The results suggest that the lipid metabolism and the nutritional status of ALS patients are important prognostic factors. These parameters should be thoroughly monitored during the clinical management of these patients. In case of progressive loss of body weight, a diet rich in lipids and calories should be considered. However, the final decision whether a lipid-rich diet should be recommended to ALS patients can only be based on a double-blind placebo-controlled interventional trial. Our results further imply that lipid-lowering drugs, e.g., statins, should be applied carefully in ALS patients although individual risk considerations must be made.

[Reconstruction of osteochondral defects with a stem cell-based cartilage-polymer construct in a small animal model]

AIM

Mesenchymal stem cells have a high therapeutic potential for the reconstruction of articular cartilage defects. In this study, a cartilage-polymer construct using mesenchymal stem cells from trabecular bone and a polylactic acid polymer was fabricated with a press-coating technique. We investigated whether cells from human trabecular bone fragments have the same chondrogenic differentiation potential as mesenchymal stem cells derived from bone marrow and whether it is possible to reconstruct an osteochondral lesion in the nude rat with the fabricated construct.

METHOD

Cells were obtained from the femoral head of patients undergoing total hip arthroplasty. The fabrication of the constructs was performed by centrifugation of 1.5x10(6) cells to a cell pellet which was then placed in a polymer block. The fabricated cell constructs were cultivated for 3 weeks in a serum-free medium, supplemented with transforming growth factor beta1. Every third day, the chondrogenic differentiation was analysed using chondrogenic and osteogenic marker genes. After three weeks the constructs were implanted into 5 mm osteochondral defects of the knee joint of nude rats. After 4 and 12 weeks histochemical and immunohistochemical analyses were performed.

RESULTS

At the end of the culture period the constructs showed a proteoglycan-rich extracellular matrix with the expression of collagen types II, IX and X as well as aggrecan und COMP (cartilage oligomeric matrix protein). No osteogenic markers except collagen type I could be detected. The analysis of the in vivo experiment showed a good defect filling with a reconstructed cartilage surface along with increasing resorption of the polymer.

CONCLUSION

We have shown that it is possible to fabricate cartilage-polymer constructs from trabecular bone-derived cells, and that the cells have the same chondrogenic differentiation potential as mesenchymal stem cells derived from bone marrow. With the fabricated cartilage-polymer construct it is possible to reconstruct an osteochondral defect in the knee joint of the nude rat.

[A novel questionnaire to assess activity in patients after hip arthroplasties]

BACKGROUND

Until now, the activity of the lower limb could only be exactly measured with expensive electronic pedometers. The aim of this study was to develop a feasible questionnaire to measure the activity of patients after arthroplasty.

METHODS

The "Daily Activity Questionnaire" (DAQ) was developed in several steps and the evaluation was carried out in three groups of patients with osteoarthritis of the hip (160 patients and 855 investigated days). The psychometric characteristics were verified.

RESULTS

The retest reliability (ICC) of the DAQ is in a range comparable to the electronic pedometer StepWatch. The testing of the criterion validity showed high correlations between the StepWatch and the DAQ (r=0.743).

CONCLUSION

Because of its high correlations to the load changes actually performed, the DAQ is especially suited to answer arthroplasty-related questions. In all patient groups, projected load changes between 1.8 and 2.4 million per year were found, which by far exceed the generally accepted test standards for endoprostheses.

Cementless acetabular reconstruction and structural bone-grafting in dysplastic hips. Surgical technique

BACKGROUND

Studies of acetabular reconstruction with use of cement and bulk bone graft have demonstrated increasing rates of cup failure in patients with dysplastic hips seven years after total hip arthroplasty. Comparable data on the long-term results of bulk bone-grafting done in conjunction with cementless implants are limited. The aim of this study was to review the clinical and radiographic results of autologous bulk bone-grafting in conjunction with a cementless cup.

METHODS

From 1987 to 1992, forty-seven patients (forty women and seven men, with an average age of 50.4 years) who had developmental dysplasia of the hip underwent fifty-six total hip arthroplasties and received a structural graft in combination with a cementless Harris-Galante type-I cup. All patients were followed prospectively. In fifty-five hips, implant migration was measured with single-image radiographic analysis.

RESULTS

After an average duration (and standard deviation) of 10.2 +/- 2.9 years, three patients (four hips) had died. In the surviving patients, four implants had been revised and two had radiographic evidence of loosening. With use of revision and loosening as end points, the eleven-year survival rates were 91.6% and 88.9%, respectively. Of the fifty implants that had no loosening, fourteen had measurable cup migration, thirty-five had no migration, and one implant could not be measured. All migrations but one were progressive. With loosening used as the end point, the survival rate at eleven years was 100% for the implants with no migration; however, the survival rate for the cups that had migrated was 69.3% (p = 0.0012).

CONCLUSIONS

The eleven-year survival rate for the spherical press-fit cups in combination with bulk bone-grafting is satisfactory, given the complexity of these reconstructions. However, the difference between the survival of the implants that had migrated and those that had not was significant. We expect that the thirteen implants with progressive acetabular migration at the time of the latest follow-up are at risk for loosening, which will increase the revision rate for this series in the coming years.

Proposal for a histopathological consensus classification of the periprosthetic interface membrane

AIMS

The introduction of clearly defined histopathological criteria for a standardised evaluation of the periprosthetic membrane, which can appear in cases of total joint arthroplasty revision surgery.

METHODS

Based on histomorphological criteria, four types of periprosthetic membrane were defined: wear particle induced type (detection of foreign body particles; macrophages and multinucleated giant cells occupy at least 20% of the area; type I); infectious type (granulation tissue with neutrophilic granulocytes, plasma cells and few, if any, wear particles; type II); combined type (aspects of type I and type II occur simultaneously; type III); and indeterminate type (neither criteria for type I nor type II are fulfilled; type IV). The periprosthetic membranes of 370 patients (217 women, 153 men; mean age 67.6 years, mean period until revision surgery 7.4 years) were analysed according to the defined criteria.

RESULTS

Frequency of histopathological membrane types was: type I 54.3%, type II 19.7%, type III 5.4%, type IV 15.4%, and not assessable 5.1%. The mean period between primary arthroplasty and revision surgery was 10.1 years for type I, 3.2 years for type II, 4.5 years for type III and 5.4 years for type IV. The correlation between histopathological and microbiological diagnosis was high (89.7%), and the inter-observer reproducibility sufficient (85%).

CONCLUSION

The classification proposed enables standardised typing of periprosthetic membranes and may serve as a tool for further research on the pathogenesis of the loosening of total joint replacement. The study highlights the importance of non-infectious, non-particle induced loosening of prosthetic devices in orthopaedic surgery (membrane type IV), which was observed in 15.4% of patients.

Cementless acetabular reconstruction and structural bone-grafting in dysplastic hips

BACKGROUND

Studies of acetabular reconstruction with use of cement and bulk bone graft have demonstrated increasing rates of cup failure in patients with dysplastic hips seven years after total hip arthroplasty. Comparable data on the long-term results of bulk bone-grafting done in conjunction with cementless implants are limited. The aim of this study was to review the clinical and radiographic results of autologous bulk bone-grafting in conjunction with a cementless cup.

METHODS

From 1987 to 1992, forty-seven patients (forty women and seven men, with an average age of 50.4 years) who had developmental dysplasia of the hip underwent fifty-six total hip arthroplasties and received a structural graft in combination with a cementless Harris-Galante type-I cup. All patients were followed prospectively. In fifty-five hips, implant migration was measured with single-image radiographic analysis.

RESULTS

After an average duration (and standard deviation) of 10.2 +/- 2.9 years, three patients (four hips) had died. In the surviving patients, four implants had been revised and two had radiographic evidence of loosening. With use of revision and loosening as end points, the eleven-year survival rates were 91.6% and 88.9%, respectively. Of the fifty implants that had no loosening, fourteen had measurable cup migration, thirty-five had no migration, and one implant could not be measured. All migrations but one were progressive. With loosening used as the end point, the survival rate at eleven years was 100% for the implants with no migration; however, the survival rate for the cups that had migrated was 69.3% (p = 0.0012).

CONCLUSIONS

The eleven-year survival rate for the spherical press-fit cups in combination with bulk bone-grafting is satisfactory, given the complexity of these reconstructions. However, the difference between the survival of the implants that had migrated and those that had not was significant. We expect that the thirteen implants with progressive acetabular migration at the time of the latest follow-up are at risk for loosening, which will increase the revision rate for this series in the coming years.

Anterior cruciate ligament constructs fabricated from human mesenchymal stem cells in a collagen type I hydrogel

BACKGROUND

Disruptions of the anterior cruciate ligament (ACL) of the knee joint are common and are currently treated using ligament or tendon grafts. In this study, we tested the hypothesis that it is possible to fabricate an ACL construct in vitro using mesenchymal stem cells (MSC) in combination with an optimized collagen type I hydrogel, which is in clinical use for autologous chondrocyte transplantation (ACT).

METHODS

ACL constructs were molded using a collagen type I hydrogel containing 5 x 10(5) MSC/mL and non-demineralized bone cylinders at each end of the constructs. The constructs were kept in a horizontal position for 10 days to allow the cells and the gel to remodel and attach to the bone cylinders. Thereafter, cyclic stretching with 1 Hz was performed for 14 days (continuously for 8 h/day) in a specially designed bioreactor.

RESULTS

Histochemical analysis for H and E, Masson-Goldner and Azan and immunohistochemical analysis for collagen types I and III, fibronectin and elastin showed elongated fibroblast-like cells embedded in a wavy orientated collagenous tissue, together with a ligament-like extracellular matrix in the cyclic stretched constructs. No orientation of collagen fibers and cells, and no formation of a ligament-like matrix, could be seen in the non-stretched control group cultured in a horizontal position without tension. RT-PCR analysis revealed an increased gene expression of collagen types I and III, fibronectin and elastin in the stretched constructs compared with the non-stretched controls.

DISCUSSION

In conclusion, ACL-like constructs from a collagen type I hydrogel, optimized for the reconstruction of ligaments, and MSC have been fabricated. As shown by other investigators, who analyzed the influence of cyclic stretching on the differentiation of MSC, our results indicate a ligament-specific increased protein and gene expression and the formation of a ligament-like extracellular matrix. The fabricated constructs are still too weak for animal experiments or clinical application and current investigations are focusing on the development of a construct with an internal augmentation using biodegradable fibers.

[Long-term results of uncemented Parhofer-Mönch screw rings]

AIM

The aim of this study was an analysis of the long-term behaviour and implant migration of the Parhofer-Mönch-screw cup seen in patients between 1982 and 1991.

METHOD

92 cups (m : f = 53 : 39, mean age 53 +/- 7 years) were included mainly prospectively. After 118 +/- 45 months all patients were examined clinically and radiologically. Digital migration analysis was performed using the single-film X-ray analysis (Einbildröntgenanalyse, EBRA).

RESULTS

5 patients had died. 32 cups were revised, in 7 patients a loosening of the cup was suspected. The 10-year-survival was 71.4 %. In 53 of 81 analysed cups a migration of more than 1 mm was shown, 28 cups did not migrate. In comparison to these stable implants the survival of migrated cups was significantly inferior.

CONCLUSION

The 10-year-survival and the high rate of implant migration document the poor results of the PM cup. In spite of an extraordinary primary stability, the failure of secondary osseointegration represents the main cause of loosening in this type of cup.

Fabrication of homogeneously cross-linked, functional alginate microcapsules validated by NMR-, CLSM- and AFM-imaging

Cross-linked alginate microcapsules of sufficient mechanical strength can immunoisolate cells for the long-term treatment of hormone and other deficiency diseases in human beings. However, gelation of alginate by external Ba(2+) (or other divalent cations) produces non-homogeneous cross-linking of the polymeric mannuronic (M) and guluronic (G) acid chains. The stability of such microcapsules is rather limited. Here, we show that homogeneous cross-linking can be achieved by injecting BaCl(2) crystals into alginate droplets before they come into contact with external BaCl(2). The high effectiveness of this crystal gun method is demonstrated by confocal laser scanning microscopy and by advanced nuclear magnetic resonance imaging. Both techniques gave clear-cut evidence that homogeneous cross-linkage throughout the microcapsule is only obtained with simultaneous internal and external gelation. Atomic force microscopy showed a very smooth surface topography for microcapsules made by the crystal gun method, provided that excess Ba(2+) ions were removed immediately after gelation. In vitro experiments showed greatly suppressed swelling for crystal gun microcapsules. Even alginate extracted from Lessonia nigrescens (highly biocompatible) yielded microcapsules with long-term mechanical stability not hitherto possible. Encapsulation of rat islets, human monoclonal antibodies secreting hybridoma cells and murine mesenchymal stem cells transfected with cDNA encoding for bone morphogenetic protein (BMP-4) revealed that injection of BaCl(2) crystals has no adverse side effects on cell viability and function. However, the release of low-molecular weight factors (such as insulin) may be delayed when using alginate concentrations in the usual range.

Ultrafast dephasing of surface plasmon excitation in silver nanoparticles: influence of particle size, shape, and chemical surrounding

By combination of two special methods, i.e., persistent spectral hole burning and laser assisted nanoparticle preparation, the dephasing time T2 of surface plasmon excitation in silver nanoparticles was systematically investigated. A strong dependence of T2 on the plasmon energy is found which reflects the relevance of interband damping and makes necessary a precise control of the particle shape when measuring T2. The influence of the reduced dimension on the dephasing dynamics was observed as a decrease of T2 with shrinking particle size. In addition, for silver nanoparticles on quartz substrates, a considerable amount of chemical interface damping was observed.

Formation of cartilage matrix proteins by BMP-transfected murine mesenchymal stem cells encapsulated in a novel class of alginates

Proliferation and differentiation of wild-type, BMP-2 and BMP-4 transfected cells of C3H10T1/2, a mouse mesenchymal stem cell line that can differentiate into chondrocytes, were studied under monolayer (2D-) and encapsulation (3D-) conditions. Cells were encapsulated in a novel class of alginate. The alginate was of clinical grade (CG) because of complete removal of mitogenic and cytotoxic contaminants by chemical means. Compared to commercial alginates used so far for encapsulation it was characterized by ultra-high viscosity (UHV; viscosity of a 0.1% w/v solution of about 20 cP). In contrast to monolayer cultures, proliferation of cells was prevented when the cells were encapsulated in UHV/CG alginate at the same suspension density. As revealed by immunohistochemistry and quantitative RT-PCR, transfected and wild-type monolayer cells showed synthesis of type I collagen after transfer into differentiation medium, while culture in an alginate scaffold resulted in an upregulation of type II collagen and other hyaline cartilage proteins. BMP-4 transfected cells produced considerably more type II collagen than BMP-2 transfected and wild-type cells. BMP-4 transfected cells were also characterized by type I collagen production up to Day 10 and exhibited transient alkaline phosphatase activity levels that were much higher than the peak values observed for the other two cell lines. The coincidence of the ALP peak values with downregulation of type I collagen in BMP-4 transfected cells suggested that C3H10T1/2 cells differentiate into chondrocytes via a chondroprogenitor-like cell.

[Standardized testing of skeletal implant surfaces with an osteoblast cell culture system. IV. Specific gene expression during differentiation]

Successful osseointegration of an implant depends on the properties of the material of which it is made. A standardized cell culture system for the assessment of the biological effect of material surfaces has already been described. In the present study, this system has been extended to include the quantitative analysis of the material-dependent osteoblast gene expression. Human foetal osteoblasts (hFOB 1.19) were cultured for 3 weeks on titanium surfaces of varying roughness, and on surfaces of chromium-cobalt-molybdenum alloy (CrCoMo). Using a real time RT-PCR technique, expressions of alkaline phosphatase, collagen 1 and osteocalcin were determined as parameters of osteoblast differentiation. In comparison with CrCoMo, differentiation was accelerated on titanium. While the smooth titanium surface leads to earlier cell growth, the rough surface induces more prolonged and stronger cell proliferation. Our results confirm at the molecular level the excellent clinical biocompatibility of titanium surfaces. The real-time RT-PCR provides a new method for the quantitative assessment of material-dependent osteoblastic differentiation.

A novel class of amitogenic alginate microcapsules for long-term immunoisolated transplantation

In the light of results of clinical trials with immunoisolated human parathyroid tissue Ba2+-alginate capsules were developed that meet the requirements for long-term immunoisolated transplantation of (allogeneic and xenogeneic) cells and tissue fragments. Biocompatibility of the capsules was achieved by subjecting high-M alginate extracted from freshly collected brown algae to a simple purification protocol that removes quantitatively mitogenic and cytotoxic impurities without degradation of the alginate polymers. The final ultra-high-viscosity, clinical-grade (UHV/CG) product did not evoke any (significant) foreign body reaction in BB rats or in baboons. Similarly, the very sensitive pERK assay did not reveal any mitogenic impurities. Encapsulated cells also exhibited excellent secretory properties under in vitro conditions. Despite biocompatible material, pericapsular fibrosis is also induced by imperfect capsule surfaces that can favor cell attachment and migration under the release of material traces. This material can interact with free end monomers of the alginate polymers under formation of mitogenic advanced glycation products. Smooth surfaces, and thus topographical biocompatibility of the capsules (visualized by atomic force microscopy), can be generated by appropriate crosslinking of the UHV/CG-alginate with Ba2+ and simultaneous suppression of capsule swelling by incorporation of proteins and/or perfluorocarbons (i.e., medically approved compounds with high oxygen capacity). Perfluorocarbon-loaded alginate capsules allow long-term non-invasive monitoring of the location and the oxygen supply of the transplants by using 19F-MRI. Transplantation studies in rats demonstrated that these capsules were functional over a period of more than two years.

The influence of pore geometry in cp Ti-implants--a cell culture investigation

Biocompatibility testing of differently structured titanium implants was performed using an in vitro test system of a newly established human fetal osteoblastic cell line (hFOB 1.19). Cell adhesion of osteoblastic cells on the different porous geometries and the suitability of a copper vapor laser system for surface structuring was tested with the following parameters: cell-number, cell viability, alkaline phosphatase expression. The analysis of the cell culture results demonstrated that 25 microm and 200 microm porous geometries showed similar or even better results than the negative control of polystyrene; there was no sign of toxic effects. However, the 100 microm porous geometry showed an impressive negative influence on the calculated parameters. The reason for this effect is unclear. The series with 50 microm, 300 microm, 400 microm and 500 microm showed a comparable, intermediate effect on the cell culture with respect to the different parameters. However, the results were worse than with the 25 and 200 microm porous geometry. In conclusion, the 25 microm and 200 microm porous geometry seems to have the most positive effect on the human osteoblastic cell line hFOB 1.19.

[Standardized testing of bone implant surfaces with an osteoblast cell culture cyste. III. PVD hard coatings and Ti6Al4V]

The effect of titanium-based PVD coatings and a titanium alloy on the proliferation and differentiation of osteoblasts was investigated using a standardised cell culture system. Human fetal osteoblasts (hFOB 1.19) were cultured on titanium-niobium-nitride ([Ti,Nb]N), titanium-niobium-oxy-nitride coatings ([Ti,Nb]ON) and titanium-aluminium-vanadium alloy (Ti6Al4V) for 17 days. Cell culture polystyrene (PS) was used as reference. For the assessment of proliferation, the numbers and viability of the cells were determined, while alkaline phosphatase activity, collagen I and osteocalcin synthesis served as differentiation parameters. On the basis of the cell culture experiments, a cytotoxic effect of the materials can be excluded. In comparison with the other test surfaces, [Ti,Nb]N showed greater cell proliferation. The [Ti,Nb]N coating was associated with the highest level of osteocalcin production, while all other differentiation parameters were identical on all three surfaces. The test system described reveals the influence of PVD coatings on the osteoblast differentiation cycle. The higher oxygen content of the [Ti,Nb]ON surface does not appear to have any positive impact on cell proliferation. The excellent biocompatibility of the PVD coatings is confirmed by in vivo findings. The possible use of these materials in the fields of osteosynthesis and articular surfaces is still under discussion.

Experimental photodynamic laser therapy for rheumatoid arthritis with a second generation photosensitizer

Photodynamic laser therapy has been shown to be a new method for the treatment of synovitis in various animal models. Its principle is the accumulation of a photosensitizing drug in the inflamed synovium which is destroyed by photoactivation of the drug. In the present animal study we demonstrate the effect of a second-generation photosensitizer and suggest a concept for light dosimetry within the joint. We used 38 inbred rabbits for the IgG-induced arthritis model; 2 mg/kg of the benzoporphyrin derivative monoacid ring-A (BPD-MA) Verteporfin were administered 3 h before irradiation, which was performed using a 690-nm diode laser coupled to quartz glass fiber with a cylinder diffusor tip at a total light energy of either 180 or 470 J. During irradiation specific fluorescence of BPD-MA was monitored using a spectroscopy unit. The effect of the photodynamic laser therapy was documented grossly and histologically after 1 week. Within the 470 J-group a complete necrosis of the inflamed synovium was observed. The bradytrophic structures of the joint, however, remained unchanged. Throughout the 180 J-group the extent of necrosis was minor. During irradiation the tissue fluorescence of BPD-MA showed a dose-dependent decrease. Using BPD-MA as a photosensitizer a highly selective and minimal invasive synoviorthesis can be performed. At a dose of 2 mg/kg the histological effect depends on the light dose. For optimum efficacy a total energy of 470 J seems favorable. Online fluorescence detection can be used to monitor the effect of light administration. For dosimetry therefore an online tissue fluorescence detection may represent a technical solution.

[5- to 8-year results of total hip endoprosthesis implantation with the Müller straight shaft prosthesis (cemented TiAlNb shaft)]

The aim of this study was to obtain mid-term results after total hip arthroplasty (THA) with cemented titanium stems. In all, 184 patients with a total of 202 THAs (cemented titanium stem) were clinically and radiologically examined after an average follow-up of 6 years (5-8). The recruitment was 86%. The Harris score was determined clinically. Radiologically, the directly postoperative radiographs were compared to the control radiographs according to the recommendations of Gruen et al. and Johnston et al. In 2 cases (1%) septical complications appeared after 2 years, which were treated in two-stage surgery. To date, revisions after loosening have been carried out in 3 cases (1.5%). This is equivalent to a revision rate of 2.5%. Three further cases showed evidence of loosening in more than 5 radiolucent lines (RLL), according to Gruen, making close-meshed controls necessary. Clinically, in all of the 6 cases of aseptic loosening, the Harris score remained above 80 points. In 36 cases, more than one RLL, compared to the postoperative radiographs, was ascertained and mainly found in zones 1, 7, 8, and 14. Substantial subsidence or varus could only be observed in one case. The clinical results in the Harris score were good or excellent in 78% and satisfactory in 20%. With an average of 75 at the time of follow-up, the age of the patients was, according to the indication that only patients above age 60 are to receive cemented-stem prostheses, clearly advanced. The body weight was significantly higher (82 kg; d = 2.4) in those 6 patients having evident RLL, than in patients without RLL. The ratio body weight to surface of the stem was especially different (1.5 kg/cm2 versus 1 kg/cm2; P < 0.005) in the two groups. This did not apply to sex or activity of the patient, size or kind of stem, Harris score, ectopic ossification, or body weight index. The biggest possible stem should be implanted. Not all cemented titanium stem prostheses are necessarily affected with a high rate of loosening at a mid-term follow-up.

[Cytotoxicity study of high gold content Degutan surfaces of various degrees of roughness with fibroblasts (BALB 3T3) and osteoblasts (hFOB 1.19)]

The cytotoxicity of Degutan surfaces with different degrees of roughness, and the effect of surface structures on osteoblast proliferation and differentiation, was investigated with standardised cell culture systems. Fibroblast cell lines (BALB/3T3) and osteoblast cell lines (hFOB 1.19) were used. The number and variability of the cells were determined for assessment of proliferation and alkaline phosphatase activity, collagen I and osteocalcin production were used as parameters for differentiation. In the early phase, the largest numbers of cells and greatest proliferation were measured on polished Degutan surfaces. In the late phase, however, larger numbers of cells and a greater degree of proliferation were to be seen on sandblasted and sandblasted/heat-treated Degutan surfaces. No differences were found for collagen I, osteocalcin production or alkaline phosphatase activity. Neither the osteoblasts nor the fibroblasts revealed a toxic effect of Degutan. The results for osteoblast differentiation correlate with recent studies on identical structured titanium surfaces. In view of the immeasurable amount of ion release, Degutan may be considered an ideal model for an inert material surface.

Photodynamic therapy for rheumatoid arthritis?

BACKGROUND AND OBJECTIVE

The only early surgical therapy of rheumatoid arthritis is synovectomy. But even an arthroscopic synovectomy is restricted to more or less big joints. It has been shown recently that for smaller joints a laser synovectomy is possible but more time-consuming than with mechanical instruments. An alternative method may be photodynamic therapy.

STUDY DESIGN/MATERIALS AND METHODS

In this study, possible photodynamic effects of Chloroquine, Methotrexate, Piroxicam, and Sodium Morrhuate were examined using a cell culture model of human synovial fibroblasts from patients having rheumatoid arthritis.

RESULTS

Incubation with Chloroquine or Methotrexate and subsequent laser irradiation at a wavelength of 351 nm resulted in an at least twenty-fold enhanced cytotoxicity.

CONCLUSION

Both substances therefore may serve for a photodynamic therapy of rheumatoid arthritis.

[TNF-alpha secretion by human macrophage-like cells in response to wear particles and its modification by drugs]

Tumour necrosis factor (TNF) is considered to be the initiator protein of particle disease leading to aseptic loosening of endoprostheses. The aim of the present study was to investigate the TNF response of the macrophage-like cells (MLC) to the periprosthetic particles typically found during revision surgery. For this purpose, particles of polyethylene (PE), pure titanium (Ti), chromium (Cr), cobalt (Co), alumina ceramic (Al2O3) and zirconium dioxide (ZrO2) were used. Additionally, the therapeutic effect of non-steroidal and steroidal drugs, biphosphonates and pentoxyfylline on PE particles was investigated with the aim of differentiating drugs with, from those without, a positive effect on aseptic loosening.

METHOD

In an established macrophage model (Rader et al. 1999), THP1 cells (human monocytic cell line) were differentiated over a period of five days in the presence of vitamin D3 and GM-CSF in macrophage-like cells (MLC). To obtain a TNF profile of the different materials, 10(6) MLC were incubated with each of a range of different particle concentrations. For drug testing purposes 80 x 10(8) PE particles, which evoked a maximum TNF response, were applied together with increasing drug concentrations in the same manner. The supernatant was then investigated for TNF secretion using ELISA.

RESULTS

It was found that the greatest TNF response was provoked by Co and PE particles, and was 25 and 23 times as high, respectively, in comparison with control. The smallest TNF secretion was seen with Al2O3 (4 x control) and ZrO2 (5 x control). At the recommended dose, non-steroidal anti-inflammatory drugs (NSAIDs) produced no decrease in TNF secretion. The biphosphonates, etidronate and ibendronate significantly reduced the TNF response of the PE-stimulated macrophages (by 1/7 and 1/5, respectively). Therapeutic doses of pentoxyfylline also led to a decrease of 1/5 in maximum TNF release.

CONCLUSION

Ceramic articulating surfaces are superior to metal/metal or PE/PE matings in terms of the biological effects of their wear particles. At therapeutic doses, NSAIDs have no beneficial effect on the process of aseptic loosening. Certain biphosphonates and pentoxyfylline have a positive effect on aseptic loosening.

[Standardized testing of bone implant surfaces with an osteoblast cell culture system. II. Titanium surfaces of different degrees of roughness]

The effect of titanium surfaces with different degrees of roughness on osteoblast proliferation and differentiation was investigated using a standardised cell culture system. Human foetal osteoblasts (hFOB 1.19) were cultured on polished (Ti pol), sandblasted (Ti sb) and sandblasted/heat treated (Ti sb-ht) titanium surfaces for 17 days. Cell culture quality polystyrene (Ps) was used as a control. Cell number and viability were determined for assessment of proliferation. Alkaline phosphatase activity, collagen I and osteocalcin production were measured as parameters for osteoblast differentiation. In the early phase, higher proliferation values were measured on Ti pol. However, on Ti sb and Ti sb-ht higher proliferation was found in the late phase. The activity of the early differentiation marker alkaline phosphatase was higher on Ti pol. No differences were seen for the late differentiation parameters collagen I and osteocalcin. The test system permits the influence of the surface structure on the dynamics of the osteoblast development cycle to be determined. The larger surface area of rough materials leads to an initially delayed, but then prolonged cell proliferation. This model correlates with recent in vivo findings, and confirms the use of rough surfaces for implants in direct contact with bone, even at the cellular level.

[Standardized tests of bone implant surfaces with an osteoblast cell culture system. I. Orthopedic standard materials]

The effect of standard orthopaedic materials on proliferation and differentiation of osteoblasts was examined using a standardised cell culture system. Osteoblasts hFOB 1.19 were cultured on stainless steel (SS), a chromium-cobalt-molybdenum alloy (CrCoMb) and commercially pure titanium (cpTi) for 12 days. Cell culture polystyrene (PS) was used as a reference. Cell numbers and cell viability were used as parameters of proliferation. Cell differentiation was assessed using alkaline phosphatase activity, collagen I and osteocalcin production. The parameters of proliferation showed earlier maximum values on PS and cpTi, while proliferation was delayed on SS and CrCoMb. The highest values of differentiation were found on cpTi. The development of alkaline phosphatase activity showed two peaks reflecting apoptosis and redifferentiation. The cell culture system hFOB 1.19 is thus suitable for revealing differences in proliferation and differentiation of osteoblasts on standard orthopaedic materials. The results correlate with previous in vivo findings. Using this system, the dynamic effect of the material surface on the differentiation process of osteoblasts can be demonstrated.

[Experiences with an ankle joint motion device in prevention of thrombosis in patients after total endoprosthesis knee replacement]

PURPOSE

Thromboprophylaxis with heparins after total joint replacement is well accepted. The aim of this prospective randomized study was to evaluate the thrombo-prophylactical efficiency of an ankle joint moving device (Artroflow) after total knee arthroplasty.

METHOD

In this prospective study 160 patients were examined who had undergone total knee arthroplasty (TKA). All of the 160 patients received Enoxaparin 1 x 40 mg subcutaneously per day. In addition to this, 90 patients received Artroflow three times a day for 30 minutes. The passive movements of the ankle joint lead to an emptying of the foot and calf veins. Except for the daily routine, we performed physical examination and ultrasound in colour, compression and duplex technique one day before surgery and at the 7th and 14th day after surgery. If a thrombosis was suspected, an ascending phlebography was carried through.

RESULTS

The overall thrombosis rate was 6.3% (n = 10). 11.4% (n = 70) deep vein thromboses (DVT) could be observed in the group without Artroflow. Thrombosis occurred in the group with Artroflow in 2 cases (2.2%, n = 90). A statistical difference was found between the two patient groups (p < 0.05, Chi-Square-test). One patient was excluded from the study because of pain in the ankle joint at the fourth day of treatment.

CONCLUSION

In addition to heparins, this ankle joint moving device can be recommended as a physical way to prevent DVTs in the thromboprophylaxis of total knee arthroplasty.

Low-molecular-weight heparin and partial thromboplastin time-adjusted unfractionated heparin in thromboprophylaxis after total knee and total hip arthroplasty

Thromboprophylaxis with heparins after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is well established. The aim of this study was to compare low-molecular-weight heparin (enoxaparin) with partial thromboplastin time (PTT)-adjusted, unfractionated heparin (heparin sodium). In a prospective study of THA and TKA 246 patients, physical examination and compression and duplex ultrasound were performed 1 day before and 7 and 14 days after surgery. One hundred thirty patients received 40 mg enoxaparin subcutaneously once per day. One hundred sixteen patients received 5,000 IU heparin sodium subcutaneously 3 times daily. As the PTT did not reach 40 seconds, the heparin sodium dosage was increased to 7,500 IU 3 times daily. The overall thrombosis rate was 4% (n = 10). In the enoxaparin group, the rate was 2.9% of the 70 THAs and 10% of the 60 TKAs. Thrombosis also occurred in the group that received heparin sodium: 1.8% of the THAs and 1.7% of the TKAs. For TKA, the difference between the 2 heparin groups was statistically significant. In the thromboprophylaxis of TKA, PTT-adjusted unfractionated heparins are superior to fixed doses of low-molecular-weight heparins.

Migration of the uncemented Harris-Galante acetabular cup: results of the einbildroentgenanalyse (EBRA) method

Seventy primary total hip arthroplasties using the Harris-Galante acetabular cup (Zimmer, Warsaw, IN) were prospectively examined. Over the entire period of 65.4+/-7.8 months, radiologic migration analysis was performed using the Einbildroentgenanalyse (EBRA) method at an accuracy of 1 mm. Although there was clinically no suspicion of prosthetic loosening in any case, in 8 implants (11.4%) migration of more than 1 mm was observed. Cranial migration occurred in 3 cases (1.1, 1.3 and 1.6 mm), medial migration in 3 cases (1.1, 1.1, and 2.9 mm), and lateral migration in 2 cases (1.1 and 1.1 mm). In the other 62 cases, however, no migration was traceable. Compared with measurements of other implant systems by means of the EBRA method published recently by other groups, the migration rate of the Harris-Galante cup was without exception lower and provided excellent midterm implant stability.

[Results of hip joint boring in femur head necrosis in the adult--4 to 18 years follow-up]

INTRODUCTION

Without primary fracture of femoral cortex in femoral head necrosis, 85% of cases have a collapse of the femoral head without treatment after 2 years. It was the aim of this retrospective study to examine the long term outcome of patients having undergone femoral head decompression.

METHODS

The clinical evaluation was done by the Harris Score. A.p. pictures of the pelvis as well as Lauenstein X-rays were taken as radiographic evaluation. These were compared to the preoperative radiographs, computer-tomographies, szintigrams and MRIs according to the classification of Ficat et al. (1980) and to that of Steinberg et al. (1984).

RESULTS

62 cases of femoral head necrosis in 52 patients were followed. 12 cases received a varic osteotomy in addition to the decompression of the femoral head. The average follow up period was 90 months postoperatively. 11 cases had received a total hip arthroplasty (THA) and in three cases there was an indication for a THA after follow up examination. The mean interval between femoral head decompression and THA was 7.1 years. 40 cases (65%) ha a Harris Score over 75 points corresponding to a good to excellent clinical result.

CONCLUSION

Femoral head decompression remains an important operation to preserve the structural integrity. It is indicated in cases without subchondral.

[Possibilities for interpreting digital migration analysis of cement-free PM total hip endoprostheses]

PURPOSE

Aim of this study was the validation of a digital measurement device for hip implants.

METHODS

From 43 patients with a minimum of four subsequent roentgenograms 246 roentgenograms of PM-shafts (an average 5.72/shaft) and 142 roentgenograms of PM-cups (an average 6.45/cup) were digitized on a DiagnostiX 2048 basis station (Pace Systems, Germany). Modified Sutherland/Nunn methods were chosen for measuring purposes. Regression analysis was done and the results were correlated to implant loosening.

RESULTS

Concerning the total vertical migration of the cup there is a significant (p < 0.04) difference between the loosened components (6.02 +/- 2.59 mm) and the fixed cups (2.26 +/- 2.89 mm). The average annual vertical migration rate of the stem shows a highly significant difference (p < 0.007) when comparing loosened stems (0.82 +/- 0.43 mm, total migration 4.78 +/- 2.89 mm) and fixed ones (0.20 +/- 0.54 mm, total migration 1.72 +/- 3.02 mm)

CONCLUSIONS

Using the regression analysis and a sufficient number of pictures the system allows us to give migration values that make loosening likely. However for the single implant an individual prognosis of loosening is not possible.

Real time monitoring of laser-induced thermal changes in cartilage in vitro by using snapshot FLASH

Snapshot FLASH imaging has been applied to study the spatial and temporal spreading of thermal changes caused by a Holmium:YAG laser in patella cartilage in vitro at 7 T. The temperature dependence of the proton resonance frequency was used to demonstrate the thermal energy deposition. A series of cartilage images, with a time resolution of 512 ms and a spatial resolution of 400 x 200 microm, showed dynamic changes of the temperature-related image phase in the regions irradiated by the laser.

Mutagenic effects of the Excimer laser using a fibroblast transformation assay

For over 10 years fiber-guided laser systems have been used in arthroscopic surgery. The possibility of a mutagenic risk by the use of lasers has not been sufficiently repudiated, especially for the Excimer laser at a wavelength of 308 nm, which is close to the absorption spectrum of DNA. The aim of this study therefore was to approximate the mutagenic risk of UV-laser wavelengths using an in vitro transformation assay. BALB/3T3 fibroblasts were irradiated with Excimer laser wavelengths of 248 nm and 308 nm. The resulting transformation rates were compared to those of untreated cells and to cells that were subjected to an x-ray dose of 1 Gy. Pulse energy, frequency, and irradiation time were varied over a wide range, from sublethal fluences to total cell death. Furthermore, the effect of repeated irradiation (split-dose) was analyzed. The results for the 248 nm irradiation showed a highly significant transformation rate (P < 10(-9)). In contrast, results for the 308 nm irradiation were not at all significant (P < .18). The transformation rate of cells that were treated with x-rays was increased exponentially compared with the controls. Although an increased transformation rate was found after 248 nm irradiation, that of the wavelength 308 nm was not enhanced. The study therefore shows that the use of the Excimer wavelength 308 nm in arthroscopic procedures does not imply a specific mutagenic risk.

Photodynamic laser therapy for rheumatoid arthritis. Cell culture studies and animal experiments

The introduction of arthroscopic techniques has improved the surgical therapy of rheumatoid arthritis. The additional application of the holmium:yttrium aluminum garnet (Ho:YAG) laser likewise holds great promise by providing complete hemorrhagic control. Unfortunately, a minimally invasive solution for use in smaller joints has not yet emerged. The present study describes the possible treatment of these joints by means of photodynamic laser therapy. Cell culture studies with human synovial fibroblasts obtained from patients with rheumatoid arthritis have demonstrated a cytotoxic effect after administration of Photosan-3 as a photosensitizer and subsequent laser irradiation at 630 nm. for the in vivo studies, IgG-induced arthritis in rabbits, which is histologically consistent with the proliferative phase of rheumatoid arthritis, was used as the animal model. The histologic picture following photodynamic laser therapy with Photosan-3 revealed complete synovial destruction which also extended to the border of the subjacent joint capsule. In contrast, bradytrophic structures, e.g. cartilage. menisci, and ligaments, remained unchanged at both the macroscopic and microscopic levels. Therefore, photodynamic laser therapy can be considered a new method in the surgical treatment of inflammatory disease of the synovial membrane. It has the advantage of being minimally invasive, while offering a high degree of efficacy and selectivity.

[A new osteoblast cell culture system for standardized testing of biomaterials]

For in vitro testing of new biomaterials cultured fibroblasts are employed. In the case of the agar diffusion test survival of cells is involved in the presence of the material to be tested. Further statements on the biological effects of a biomaterial require the use of cell cultures adapted to the tissue concerned and the underlying problem being investigated. In the present study, an osteoblast cell culture system with which implant surfaces in contact with bone can be tested as required by the relevant standards is described. Test bodies made of titanium, polystyrene or copper were used in the conventional agar diffusion test, and were also overgrown with fibroblasts or a cell line of foetal human osteoblasts. For the agar diffusion test, the test criterion was the extent of the inhibition area on staining with neutral red, while for the overgrowth, the mean cell diameter and the number of cells was employed. The phenotype of the osteoblast cell line was determined immunohistochemically by means of alkaline phosphatase or immunohistologically by means of collagen I and osteocalcin. Calcification was demonstrated using the v. Kossa stain. In the case of the osteoblasts, a differentiation of a collagen I and alkaline phosphatase-positive phenotype over an osteocalcin-positive phenotype to an increase in calcium deposition was shown. As in the case of the agar diffusion test, direct overgrowth also revealed no cytotoxic effect for titanium and polystyrene. In contrast, a cytotoxic effect consisting in a decrease in the number of cells and also a left shift in the size distribution was observed for copper. The standard deviations of the individual tests were less for overgrowth than for the agar diffusion test. The culture system for osteoblast cells thus meets the criteria of the EN/DIN 30993-5 in terms of the quality and accuracy of the results obtained. In addition to excluding direct cytotoxicity, this test system offers a new possibility of examining the influence of the material on cell growth. Consequently, it permits a repeatable examination of proliferation and differentiation of the osteoblasts on each material surface.

[Experimental bases for photodynamic laser therapy in chronic polyarthritis]

The principle of photodynamic laser therapy (PDT) for chronic polyarthritis consists in specifically concentrating a drug (photosensitizer) in the synovium. Subsequent activation of the photosensitizer by means of laser leads to a cytotoxic effect. The practicability of PDT was first shown in cell cultures of human synovial fibroblasts. For further tests an animal model consisting of IgG-induced arthritis in rabbits was used. In this model, concentration of the photosensitizer in the synovial lining cells, in the media of arteries and in the lymphoid infiltrate was seen. After laser irradiation there was total selective demarcation of the synovium. In contrast, bradytrophic tissues such as cartilage, meniscus and ligament structures were changed neither macroscopically nor microscopically. In the animal model PDT combines high selectivity with minimal invasiveness and can be used in small joints. PDT thus offers ideal preconditions for future minimal invasive treatment of chronic inflammatory joint diseases.

[Magnetic resonance imaging and temperature measurement in cartilage following laser therapy]

The aim of this study was the dynamic measurement, with magnetic resonance imaging, of temperature in cartilage irradiated by laser. Fresh specimens, each with chondromalacia grade II and III, were irradiated with a Holmium:YAG laser under MRI control. Temperature was measured by means of the proton-shift method, which allows high temporal and spatial resolution. With this method a maximum increase in temperature of 35 degrees was found after irradiation with 1.0 J and 10 Hz for 5 s at a distance of 1 mm. In no case at all was an increase in temperature of more than 10 degrees observed in the cartilage adjacent to the subchondral bone. These results exclude the possibility of significant thermal damage from laser treatment as described.