Anatomic Total Shoulder Arthroplasty: Component Size Prediction with 3-Dimensional Pre-Operative Digital Planning

Background

The rate, complexity, and cost of total shoulder arthroplasty (TSA) continues to grow. Technology has advanced pre-operative templating. Reducing cost of TSA has positive impact for the patient, manufacturer, and hospital. The aim of this study was to evaluate the accuracy of implant size selection based on 3-D templating. Our hypothesis was that pre-operative templating would enable accurate implant prediction within one size.

Methods

Multicenter retrospective study of anatomic TSAs templated utilizing 3-D virtual planning technology. This program uses computed tomography (CT) scans allowing the surgeon to predict component sizes of the glenoid and humeral head and stem. Pre-operative templated implant size were compared to actual implant size at the time of surgery. Primary data analysis utilized unweighted Cohen's Kappa test.

Results

111 TSAs were analyzed from five surgeons. Pre-operative templated glenoid sizes were within one size of actual implant in 99% and exactly matched in 89%. For patients requiring a posterior glenoid augment (n = 14), 100% of implants were within one size of the template and 93% matched exactly. For stemless humeral components (n = 87) implanted, 98% matched the pre-operative template within one size with 79% exactly matched. For stemmed components (n = 24), 88% of cases were within one size of the preoperative plan and exactly matching in 83%. Humeral head diameter matched within one size of the pre-operative template in 84% of cases and exactly matched in 72%.

Conclusion

Pre-operative 3-D templating for TSAs can accurately predict glenoid and humeral component size. This study sets the groundwork for utilization of pre-operative 3-D templating as a potential method to reduce overall TSA costs by managing cost of implants, reducing inventory needs, and improving surgical efficiency.

Cytokine responses in nonlesional psoriatic skin as clinical predictor to anti-TNF agents

BACKGROUND

A major issue with the current management of psoriasis is our inability to predict treatment response.

OBJECTIVE

Our aim was to evaluate the ability to use baseline molecular expression profiling to assess treatment outcome for patients with psoriasis.

METHODS

We conducted a longitudinal study of 46 patients with chronic plaque psoriasis treated with anti-TNF agent etanercept, and molecular profiles were assessed in more than 200 RNA-seq samples.

RESULTS

We demonstrated correlation between clinical response and molecular changes during the course of the treatment, particularly for genes responding to IL-17A/TNF in keratinocytes. Intriguingly, baseline gene expressions in nonlesional, but not lesional, skin were the best marker of treatment response at week 12. We identified USP18, a known regulator of IFN responses, as positively correlated with Psoriasis Area and Severity Index (PASI) improvement (P = 9.8 × 10^-4) and demonstrate its role in regulating IFN/TNF responses in keratinocytes. Consistently, cytokine gene signatures enriched in baseline nonlesional skin expression profiles had strong correlations with PASI improvement. Using this information, we developed a statistical model for predicting PASI75 (ie, 75% of PASI improvement) at week 12, achieving area under the receiver-operating characteristic curve value of 0.75 and up to 80% accurate PASI75 prediction among the top predicted responders.

CONCLUSIONS

Our results illustrate feasibility of assessing drug response in psoriasis using nonlesional skin and implicate involvement of IFN regulators in anti-TNF responses.

Michigan Initiative for Anterior Cruciate Ligament Rehabilitation (MiACLR): A Protocol for a Randomized Clinical Trial

OBJECTIVE

Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR.

METHODS

This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging).

IMPACT

The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population.

Characterization of crumb rubber from end-of-life tyres for paving applications

Crumb rubber (CR) derived from grinding of end-of-life tyres (ELTs) may be successfully used as a bitumen modifier or as a supplementary component in the production of bituminous mixtures employed for the construction and maintenance of road pavements. However, CRs deriving from different sources and production processes yield effects on performance of corresponding paving mixtures under traffic loading and on gaseous emissions produced during laying on site which may change considerably depending upon their physical and chemical properties. In order to quantitatively assess the possible variability of CR characteristics, 16 samples were taken from 9 Italian and 2 foreign ELT processing plants. Investigation activities included field surveys, during which plants were examined in detail, and laboratory tests, which focused on physical and chemical characterization of CR. Based on the analysis of available technical information and experimental data, it was possible to find relationships between the peculiar characteristics of treatment cycles and corresponding CR properties.

Review of Italian experience on automotive shredder residue characterization and management

Automotive Shredder Residue (ASR) is a special waste that can be classified as either hazardous or non hazardous depending on the amount of hazardous substances and on the features of leachate gathered from EN12457/2 test. However both the strict regulation concerning landfills and the EU targets related to End-of-Life Vehicles (ELVs) recovery and recycling rate to achieve by 2015 (Directive 2000/53/EC), will limit current landfilling practice and will impose an increased efficiency of ELVs valorization. The present paper considers ELVs context in Italy, taking into account ASRs physical-chemical features and current processing practice, focusing on the enhancement of secondary materials recovery. The application in waste-to-energy plants, cement kilns or metallurgical processes is also analyzed, with a particular attention to the possible connected environmental impacts. Pyrolysis and gasification are considered as emerging technologies although the only use of ASR is debatable; its mixing with other waste streams is gradually being applied in commercial processes. The environmental impacts of the processes are acceptable, but more supporting data are needed and the advantage over (co-)incineration remains to be proven.

Automobile Shredder Residues in Italy: characterization and valorization opportunities

At the moment Automobile Shredder Residue (ASR) is usually landfilled worldwide, but European draft Directive 2000/53/CE forces the development of alternative solutions, stating the 95%-wt recovery of an End of Life Vehicle (ELV) weight to be fulfilled by 2015. This work describes two industrial tests, each involving 250-300 t of ELVs, in which different pre-shredding operations were performed. The produced ASR materials underwent an extended characterization and some post-shredding processes, consisting of dimensional, magnetic, electrostatic and densimetric separation phases, were tested on laboratory scale, having as main purpose the enhancement of ASR recovery/recycling and the minimization of the landfilled fraction. The gathered results show that accurate depollution and dismantling operations are mandatory to obtain a high quality ASR material which may be recycled/recovered and partially landfilled according to the actual European Union regulations, with particular concern for Lower Heating Value (LHV), heavy metals content and Dissolved Organic Carbon (DOC) as critical parameters. Moreover post-shredding technical solutions foreseeing minimum economic and engineering efforts, therefore realizable in common European ELVs shredding plants, may lead to multi-purposed (material recovery and thermal valorization) opportunities for ASR reuse/recovery.