Prenatal cortisol exposure impairs adrenal function but not glucose metabolism in adult sheep

Adverse environmental conditions before birth are known to programme adult metabolic and endocrine phenotypes in several species. However, whether increments in fetal cortisol concentrations of the magnitude commonly seen in these conditions can cause developmental programming remains unknown. Thus, this study investigated the outcome of physiological increases in fetal cortisol concentrations on glucose-insulin dynamics and pituitary-adrenal function in adult sheep. Compared with saline treatment, intravenous fetal cortisol infusion for 5 days in late gestation did not affect birthweight but increased lamb body weight at 1-2 weeks after birth. Adult glucose dynamics, insulin sensitivity and insulin secretion were unaffected by prenatal cortisol overexposure, assessed by glucose tolerance tests, hyperinsulinaemic-euglycaemic clamps and acute insulin administration. In contrast, prenatal cortisol infusion induced adrenal hypo-responsiveness in adulthood with significantly reduced cortisol responses to insulin-induced hypoglycaemia and exogenous adrenocorticotropic hormone (ACTH) administration relative to saline treatment. The area of adrenal cortex expressed as a percentage of the total cross-sectional area of the adult adrenal gland was also lower after prenatal cortisol than saline infusion. In adulthood, basal circulating ACTH but not cortisol concentrations were significantly higher in the cortisol than saline-treated group. The results show that cortisol overexposure before birth programmes pituitary-adrenal development with consequences for adult stress responses. Physiological variations in cortisol concentrations before birth may, therefore, have an important role in determining adult phenotypical diversity and adaptability to environmental challenges.

The BioPoly Partial Resurfacing Knee Implant Provides Beneficial Clinical Outcomes: A Concise Follow-up, at 5 Years, of a Previous Report

Abstract

We previously conducted a single-arm, prospective study in which 31 patients (mean age [and standard deviation], 42.5 ± 11.3 years) with cartilage lesions were treated with use of the BioPoly Partial Resurfacing Knee Implant. Treatment outcomes were compared with those reported for the standard of care, microfracture. We found that the mean KOOS (Knee injury and Osteoarthritis Outcome Score) Quality of Life score at 5 years in the BioPoly cohort was noninferior to (p = 0.004), and indeed greater than (p = 0.021), that in the microfracture cohort. The BioPoly cohort demonstrated improvement in the mean scores for all KOOS domains at every postoperative time point (p < 0.025). The mean score for the visual analog scale (VAS) for pain significantly improved (p < 0.025) at all time points up to 4 years and trended toward significant improvement at 5 years (p = 0.027). This study indicated that the BioPoly implant was safe, provided significant improvement starting at 6 months and continuing to 5 years, and provided greater improvement than microfracture for some outcome measures.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Outcomes of Hip and Knee Fungal Periprosthetic Joint Infections: A Retrospective Cohort Study

BACKGROUND

Fungal infections are a rare cause of periprosthetic joint infection (PJI), identified in 1% of all of these cases. Outcomes are not well-established due to small cohort sizes in the published literature. The aims of this study were to establish the patient demographics and infection-free survival of patients presenting to 2 high-volume revision arthroplasty centers who had fungal infection of either a hip or knee arthroplasty. We sought to identify risk factors for poor outcomes.

METHODS

A retrospective analysis was performed of patients at 2 high-volume revision arthroplasty centers who had confirmed fungal PJI of the total hip arthroplasty (THA) and total knee arthroplasty (TKA). Consecutive patients treated between 2010 and 2019 were included. Patient outcomes were classified as infection eradication or persistence. A total of 67 patients who had 69 fungal PJI cases were identified. There were 47 cases involving the knee and 22 of the hip. Mean age at presentation was 68 years (THA mean 67, range 46 to 86) (TKA mean 69, range, 45 to 88). A history of sinus or open wound was present in 60 cases (89%) (THA 21 cases, TKA 39 cases). The median number of operations prior to the procedure at which fungal PJI was identified was 4 (range, 0 to 9), THA 5 (range, 3 to 9), and TKA 3 (range, 0 to 9).

RESULTS

At a mean follow-up 34 months (range, 2 to 121), remission rates were 11 of 24 (45%) and 22 of 45 (49%) for hip and knee, respectively. There were 7 TKA (16%) and 1 THA cases (4%) that failed treatment resulting in amputations. During the study period, 7 THA and 6 TKA patients had died. Two deaths were directly attributable to PJI. Patient outcome was not associated with the number of prior procedures, patient comorbidities, or organisms.

CONCLUSION

Eradication of fungal PJI is achieved in less than half of patients, and outcomes are comparable for TKA and THA. The majority of patients who have fungal PJI present with an open wound or sinus. No factors were identified that increase the risk of persistent infection. Patients who have fungal PJI should be informed of the poor outcomes.

A new oral model of free fatty acid kinetics to assess lipolysis in subjects with and without type 2 diabetes

Assessing free fatty acids (FFAs) kinetics and the role of insulin and glucose on FFA lipolysis and disposal may improve our understanding of the pathogenesis of type 2 diabetes (T2D). Some models have been proposed to describe FFA kinetics during an intravenous glucose tolerance test and only one during an oral glucose tolerance test. Here, we propose a model of FFA kinetics during a meal tolerance test and use it to assess possible differences in postprandial lipolysis in individuals with type 2 diabetes (T2D) and individuals with obesity without type 2 diabetes (ND). We studied 18 obese ND and 16 T2D undergoing three meal tolerance tests (MTT) on three occasions (breakfast, lunch, and dinner). We used plasma glucose, insulin, and FFA concentrations collected at breakfast to test a battery of models and selected the best one based on physiological plausibility, ability to fit the data, precision of parameter estimates, and the Akaike parsimony criterion. The best model assumes that the postprandial suppression of FFA lipolysis is proportional to the above basal insulin, while FFA disposal is proportional to FFA concentration. It was used to compare FFA kinetics in ND and T2D along the day. The maximum lipolysis suppression occurred significantly earlier in ND than T2D (39 ± 6 min vs. 102 ± 13 min, 36 ± 4 min vs. 78 ± 11 min, and 38 ± 6 min vs. 84 ± 13 min, P < 0.01, at breakfast, lunch, and dinner, respectively), making lipolysis significantly lower in ND than T2D. This is mainly attributable to the lower insulin concentration in the second group. This novel FFA model allows to assess lipolysis and insulin antilipolytic effect in postprandial conditions.NEW & NOTEWORTHY In this study, we propose a new mathematical model able to quantify postprandial FFA kinetics and adipose tissue insulin sensitivity in both subjects with obesity without type 2 diabetes (ND) and subjects with type 2 diabetes (T2D). Results show that the slower postprandial suppression of lipolysis in T2D contributes to the higher free fatty acid (FFA) concentration that, in turn, may contribute to hyperglycemia.

Ischial screw fixation can prevent cup migration in 3D-printed custom acetabular components for complex hip reconstruction

INTRODUCTION

Custom acetabular components have become an established method of treating massive acetabular bone defects in hip arthroplasty. Complication rates, however, remain high and migration of the cup is still reported. Ischial screw fixation (IF) has been demonstrated to improve mechanical stability for non-custom, revision arthroplasty cup fixation. We hypothesize that ischial fixation through the flange of a custom acetabular component aids in anti-rotational stability and prevention of cup migration.

METHODS

Electronic patient records were used to identify a consecutive series of 49 custom implants in 46 patients from 2016 to 2022 in a unit specializing in complex joint reconstruction. IF was defined as a minimum of one screw inserted into the ischium passing through a hole in a flange on the custom cup. The mean follow-up time was 30 months. IF was used in 36 cups. There was no IF in 13 cups. No difference was found between groups in age (68.9 vs. 66.3, P = 0.48), BMI (32.3 vs. 28.2, P = 0.11) or number of consecutively implanted cups (3.2 vs. 3.6, P = 0.43). Aseptic loosening with massive bone loss was the primary indication for revision. There existed no difference in Paprosky grade between the groups (P = 0.1). 14.2% of hips underwent revision and 22.4% had at least one dislocation event.

RESULTS

No ischial fixation was associated with a higher risk of cup migration (6/13 vs. 2/36, X² = 11.5, P = 0.0007). Cup migration was associated with an increased risk for all cause revision (4/8 vs. 3/38, X² = 9.96, P = 0.0016, but not with dislocation (3/8 vs. 8/41, X² = 1.2, P = 0.26).

CONCLUSION

The results suggest that failure to achieve adequate ischial fixation, with screws passing through the flange of the custom component into the ischium, increases the risk of cup migration, which, in turn, is a risk factor for revision.

889 Management of Paediatric Appendicitis During the First Wave of COVID-19: Comparison of Our Centre to National Practice

Aim

Our hospital took part in a multi-centre prospective cohort study “the CASCADE study” investigating the management and early outcomes of children with appendicitis in the UK and Ireland during the first wave of the COVID-19 pandemic (1). The aim of this study was to compare our local outcomes to those at a national level.

Method

This was a prospective cohort study with data collected from 01/04/2020 to 31/05/2020. Primary outcome was treatment strategy for appendicitis. Secondary outcomes were duration of symptoms, ultrasound findings, rate of simple vs perforated appendicitis and complications.

Results

Overall, only a minority (2/24 [8%]) were initially treated non-operatively, with both proceeding to appendicectomy due to pain. Remaining children (24/26 [92%]) were primarily treated with appendicectomy. All were performed laparoscopically with no conversions to open. Ultrasound was performed for most children (23/26 [88%]) which accurately identified appendicitis (22/23 [95%]) and negative appendicectomy rate of zero. Rates of complex appendicitis were not higher than expected (10/26 [38%]) but had a longer duration of symptoms (median 66.0h [IQR21.5] vs 30.0h [27.2], p = 0.008) and more complications (4 vs 1). Post-operative length of stay was significantly shorter for simple appendicitis than complicated (median 1.0d [IQR0.0] vs 4.0 [IQR2.8], p = 0.001).

Conclusions

Practice in our centre contrasts with the CASCADE study's National findings where 39% were treated non-operatively, only 48% of appendicectomies were performed laparoscopically, only 53% of children had diagnostic imaging and negative appendicectomy rate was 4.5%. Rates of complications for simple and complex appendicitis were similar, but post-operative length of stay shorter in our centre.

18 The Impact of Social Deprivation on TNM Staging of Non-Melanoma Skin Cancers: An Initial Review

Aim

Over 150,000 cases of non-melanoma skin cancer (NMSC) are diagnosed per year in the UK [1], with greatest incidence in less deprived socioeconomic groups [2]. The association between social deprivation and melanoma staging has been reported [3], however is not as well considered in Basal or Squamous Cell Carcinomas (BCCs/SCCs).

Method

A pilot review of 200 NMSC excision biopsies completed at a single hospital was undertaken. Specimens were identified via the histopathology database and included all excising specialities and anatomical locations. Registered postcodes were categorised into a decile via the English Indices of Deprivation 2019 database (1= most deprived, 10= least deprived). Tumour staging was identified from the histopathology report.

Results

200 specimens were reviewed including 9 deprivation deciles ranging from Decile 2 to Decile 10. Decile 6 was the most common decile, incorporating 20% of all specimens. pT1 BCCs were the most commonly excised lesion at 68.5%, pT3 BCCs and SCCs were least commonly excised (1.5% of specimens each). Increased proportions of pT2 BCCs and SCCs occurred in less deprived deciles, contrasting with pT3 BCCs which clustered in Deciles 6 and 7. pT3 SCCs comprised 11.1% of excised lesions in Decile 4, the greatest proportion outside of pT1 lesions.

Conclusions

This initial review suggests that the distribution of NMSC staging is not even across social deprivation levels. Increased proportions of pT2 staged lesions occurred in less deprived cohorts. Further expansion of the dataset is justified to assess the degree to which social deprivation may affect NMSC stage at excision.

The KSHV ORF20 Protein Interacts with the Viral Processivity Factor ORF59 and Promotes Viral Reactivation

Upon Kaposi's Sarcoma-associated herpesvirus (KSHV) lytic reactivation, rapid and widespread amplification of viral DNA (vDNA) triggers significant nuclear reorganization. As part of this striking shift in nuclear architecture, viral replication compartments are formed as sites of lytic vDNA production along with remarkable spatial remodeling and the relocalization of cellular and viral proteins. These viral replication compartments house several lytic gene products that coordinate viral gene expression, vDNA replication, and nucleocapsid assembly. The viral proteins and mechanisms that regulate this overhaul of the nuclear landscape during KSHV replication remain largely unknown. KSHV's ORF20 is a widely conserved lytic gene among all herpesviruses, suggesting it may have a fundamental contribution to the progression of herpesviral infection. Here, we utilized a promiscuous biotin ligase proximity labeling method to identify the proximal interactome of ORF20, which includes several replication-associated viral proteins, one of which is ORF59, the KSHV DNA processivity factor. Using coimmunoprecipitation and immunofluorescence assays, we confirmed the interaction between ORF20 and ORF59 and tracked the localization of both proteins to KSHV replication compartments. To further characterize the function of ORF20, we generated an ORF20-deficient KSHV and compared its replicative fitness to that of wild-type virus. Virion production was significantly diminished in the ORF20-deficient virus as observed by supernatant transfer assays. Additionally, we tied this defect in viable virion formation to a reduction in viral late gene expression. Lastly, we observed an overall reduction in vDNA replication in the ORF20-deficient virus, implying a key role for ORF20 in the regulation of lytic replication. Taken together, these results capture the essential role of KSHV ORF20 in progressing viral lytic infection by regulating vDNA replication alongside other crucial lytic proteins within KSHV replication compartments. IMPORTANCE Kaposi's Sarcoma-associated herpesvirus (KSHV) is a herpesvirus that induces lifelong infection, and as such, its lytic replication is carefully controlled to allow for efficient dissemination from its long-term reservoir and for the spread of the virus to new hosts. Viral DNA replication involves many host and viral proteins, coordinating both in time and space to successfully progress through the viral life cycle. Yet, this process is still not fully understood. We investigated the role of the poorly characterized viral protein ORF20, and through proximity labeling, we found that ORF20 interacts with ORF59 in replication compartments and affects DNA replication and subsequent steps of the late viral life cycle. Collectively, these results provide insights into the possible contribution of ORF20 to the complex lytic DNA replication process and suggest that this highly conserved protein may be an important modulator of this key viral mechanism.

Clinical Outcome of Free Latissimus Dorsi Flaps for Coverage of Soft Tissue Defects in Multiply Revised Total Knee Arthroplasties

BACKGROUND

Multiply revised total knee arthroplasties (TKAs) may present with large anterior soft tissue defects, which can be challenging to reconstruct. In the rare cases where local flaps are insufficient, we use free latissimus dorsi (LD) myocutaneous flaps to achieve soft tissue coverage. This study looked to determine implant survivorship, infection status, and patient-reported outcomes of patients undergoing simultaneous revision TKA and LD flaps in a tertiary unit.

METHODS

This was a retrospective study of 18 consecutive patients who had revision TKA and free LD flap reconstruction. Twelve were male and the median age was 65 years (range, 35-83). Patients had undergone a median of 4 previous arthroplasty procedures (range, 3-6). Median follow-up was 49 months (range, 18 to 110). The primary outcome was revision-free implant survival. Secondary outcomes included soft tissue integrity, Oxford Knee Score, and EuroQol 5-domain score at latest follow-up.

RESULTS

At latest follow-up, 14 of 18 patients had maintained their implant. Seven patients were infection-free, 7 were on suppressive antibiotics with the implant in situ, and 4 had undergone above-knee amputation. Five-year implant survival was 75% (95% confidence interval, 46-90). At median follow-up (49 months), mean Oxford Knee Score was 13.4 (range, 2-35) and mean EuroQol 5-domain index was 0.071 (range:-0.427 to 0.747).

CONCLUSION

LD free flap is a viable option for limb salvage in patients with large anterior soft tissue defects following multiple revisions of TKA. However, functional outcomes can be poor and there is a significant risk of ongoing infection and amputation in this complex patient cohort.

Magnetic Nanoparticle and Exosomal Therapeutic (M-NEXT) Effects on HIV-Associated Neurotoxicity

The human immunodeficiency virus (HIV) envelope glycoprotein protein 120 (gp120) induces neurotoxicity associated with HIV-associated neurocognitive disorders (HAND). Mechanism of Gp120-mediated neurotoxicity is primarily apoptosis. Currently, there are no therapeutics that address gp120 neurotoxicity. A biocompatible, efficacious therapeutic that easily crosses the blood-brain barrier (BBB) is needed to treat neuronal toxicity observed in HIV-infected individuals. Magnetic nanoparticles (MNPs) have successfully delivered anti-HIV agents across in vitro BBB transwell model. However, MNPs at high doses may damage cells. Exosomal extracellular vesicles (xEVs) are endogenous nanocarriers capable of crossing the BBB. Unlike MNPs, xEVs interact with cells in a paracrine or juxtracrine manner, lacking long-range site specificity. Here we investigated the efficacy of an MNP and xEV-coupled therapeutic (M-NEXT) as a nanocarrier for targeted delivery of anti-HIV fusion agent across the BBB to inhibit HIV-gp120 associated neuropathology. M-NEXT consisting of MNPs encapsulated within xEV carrying T20 peptide on the surface was synthesized and characterized via zeta potential, dynamic light scattering, and TEM imaging. Preliminary efficacy studies using SH-SY5Y cocultured with the in vitro BBB model showed that the M-NEXT-T20-fusion peptide protected neurons from HIV gp120-mediated neurotoxicity. Additionally, BBB integrity and permeability assessed via trans-endothelial resistance (TEER) and a Dextran-FITC transport assay was unaffected. SH-SY5Y viability measured by XTT assay was not significantly modulated by M-NEXT. In summary, preliminary findings support M-NEXT as effective nanocarriers for delivery of anti-HIV gp120 associated neurotoxicity agents.

Implementing Digitalised Lean Manufacturing Training in a UK Engine Manufacturing Centre During the SARS-CoV2 Pandemic of 2020

This paper examines a novel way of training Lean Manufacturing Systems and Tools utilising an Industry 4.0 methodology during the SARS-COVID2 Pandemic of 2020. Currently, it is challenging for the Integrated Production Systems Team, responsible for carrying out training on the Lean principles, to undertake the training safely and without the risk of possible disease transmission. This is due to the usual close quarters training carried out in the Engine Manufacturing Centre. Schools, Colleges and Universities have adapted and utilised technology and moved to an Industry 4.0 digitalised approach to learning and development. This is therefore an opportunity for manufacturing to follow suit and create digitised solutions to training and development opportunities, to ensure that the employees within the manufacturing facility have adequate knowledge on the Lean principles.

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

BACKGROUND

The burden of knee replacement prosthetic joint infection (KR PJI) is increasing. KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions.

AIM

To provide guidelines for surgeons and units treating KR PJI.

METHODS

Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.

RESULTS

Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT. This document outlines practice guidelines for units providing a KR PJI service and sets out: CONCLUSIONS: KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.

Infected prosthetic knee replacement: What to do and what not to do

This article is an expansion of a lecture given in the British Orthopaedic Association (BOA) Congress in Liverpool in 2019 as part of a symposium on infected knee replacement. It is designed to provide pointers and advice to surgeons on how these patients can be referred, investigated, and managed. The management of periprosthetic infection necessitates many decisions to be made to provide the patient with the best advice and treatment. This is a discussion of the philosophies of periprosthetic knee infection. It is not a definitive guide nor a metanalysis of scientific papers. These are the subjective views of the author and generalise decision making. All decisions should remain tailored to the patient's needs.

1059 Sleep Parameters In People With Type 2 Diabetes With And Without Insomnia Symptoms

Introduction

There is an increasing awareness of the high prevalence of insomnia symptoms in people with type 2 diabetes (T2D). Past studies have demonstrated the importance of measuring sleep parameters in both averages and variabilities using subjective and objective methods. Thus, we aimed to compare the averages and variability of sleep parameters in people with T2D with and without insomnia symptoms.

Methods

Actigraph measurements and sleep diaries were used in 59 participants to assess sleep parameters, including sleep efficiency (SE), sleep latency, total sleep time, and wake after sleep onset over seven nights. Validated instruments were used to assess the symptoms of depression, anxiety, and pain. Circular data were used to describe the distribution of bed distribution with SE as a magnitude for both groups. Mann Whitney U test was utilized to compare averages and variability of sleep parameters between the two groups. Multivariable general linear model to control for demographic and clinical variables. For the secondary aim, multiple linear regression tests were utilized to assess the association between averages and variability values for both groups.

Results

SE was found to be lower in average and higher in variability for participants with T2D and insomnia symptoms, than those with T2D only subjectively and objectively. SE variability was also the only sleep parameter higher in people with T2D and insomnia symptoms, with psychological symptoms potentially playing a role in this difference. We observed that people in T2D+Insomnia tend to go to bed earlier compared to the T2D only group based on objective measures, but no difference was observed between groups in subjective measures. The only significant relationship in both objective and subjective measures was between the averages and variability of SE.

Conclusion

Our findings suggest a discrepancy between subjective and objective measures in only average of total sleep time, as well as agreement in measures of variability in sleep parameters. Also, the relationship between averages and variabilities suggested the importance of improving SE to minimize its variability. Further research is warranted to investigate the complex relationship between sleep parameters and psychological factors in people with T2D and insomnia symptoms.

Support

None

Bioengineered Exosomal Extracellular Vesicles in Cancer Therapeutics

Liquid or blood-based biopsy is a less invasive and more efficient method in which to clinicians can identify diagnostic, prognostic, and therapeutic responsive biomarkers in cancer patients. Circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), RNAs, proteins, metabolites, and extracellular vesicles (EVs) are all potential biomarkers found in liquid biopsies. All nucleated cells including healthy, virally infected, and cancer cells release EVs. Since the early 1980s, evidence has mounted to support the pathophysiological role of EVs in cancer. Here we focus on the smallest of the EV, the exosome, and their clinical relevance as nanotherapeutics for cancers. Exosomes obtained from tumors have been reported to promote and/or facilitate malignancy of cancers especially in terms of metastatic potential. Exosomal EVs have also contributed to the development of therapeutic resistance. Recent studies demonstrate that intrinsic and bioengineered exosomes can serve as effective therapeutic agents that disrupt cancer progression. Here we review the current literature regarding the utilization of bioengineered exosomes for therapeutics to treat prevalent cancers such as melanoma, glioma, breast, pancreatic, hepatic, cervical, prostate, and colon cancers. Overall, studies reviewed show that bioengineered exosomes are effective and promising for targeted cancer therapy.

The uncrossed-doubled patellar tendon: A novel imaging finding

A spectrum of anatomic variants of the conventional single patellar tendon have been described however a double patellar tendon is a highly rare finding, which has only been described once before where a cross-over tendon morphology was illustrated. We report the case of a 46-year-old man with a 3 month history of left knee pain who was found to have an incidental double patellar tendon without cross-over, with one deep bundle demonstrating a more conventional patellar tendon course, paralleled by a second anatomically-distinct superficial bundle of differing morphology coursing anterolateral to the deep conventional bundle, explicitly connecting patella to tibial tuberosity. A comprehensive understanding of the anatomic variations of the patellar tendon is essential for both radiologist and clinician to deliver safe clinical practice. We present a rare case of an uncrossed-doubled patellar tendon, which to our knowledge, has never been reported.

57 Non-targeted metabolomic profiles within the uterine milieu of porcine pregnancies containing populations of uniform or diverse spherical, ovoid, or tubular conceptuses during initiation of embryo elongation

Alterations in the signalling of critical molecular factors within the uterine milieu result in deficiencies in embryo elongation, leading directly to embryonic loss as well as delayed elongation. The objective of this study was to identify metabolites within the uterine environment from populations of uniform and diverse porcine conceptuses as they transition between spherical, ovoid, and tubular conceptuses during the initiation of embryo elongation. White crossbred gilts (n=38) were bred at standing oestrus (designated Day 0) and again 24h later and randomly assigned to collection group. At Day 9, 10, or 11 of gestation, reproductive tracts were collected immediately following harvest and flushed with 40mL of RPMI-1640 media. Conceptus morphologies were assessed from each pregnancy to assign to 1 of 5 treatment groups based on these morphologies: (1) uniform spherical (n=8); (2) diverse spherical and ovoid (n=8); (3) uniform ovoid (n=8); (4) diverse ovoid and tubular (n=8); and (5) uniform tubular (n=6). Subsequently uterine flushings from these pregnancies were submitted for non-targeted profiling by gas chromatography-mass spectrometry (GC-MS) and ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) techniques. Raw spectral data were processed using the XCMS package in R (R Foundation for Statistical Computing, Vienna, Austria) and features were clustered using RAMclustR. Unsupervised multivariate principal component analysis was performed in R using pcamethods package, and univariate ANOVA was performed in R with a Benjamini-Hochberg false discovery rate adjustment. Principal component analysis of the GC-MS and UPLC-MS data identified 153 and 104 metabolites, respectively. Of the identified metabolites, 51 and 71 metabolites from the GC-MS and UPLC-MS analysis, respectively, corresponded to known compounds. After false discovery rate adjustment of the GC-MS and UPLC-MS data, 38 and 59 metabolites from the GC-MS and UPLC-MS analysis, respectively, differed (P&lt;0.05) in uterine flushings from pregnancies for the 5 conceptus stages. Some metabolites were greater (P&lt;0.05) in abundance for uterine flushings containing earlier stage conceptuses (i.e. spherical) such as uric acid, tryptophan, 5-hydroxy-L-tryptophan, and L-tryosine. In contrast, some metabolites were greater (P&lt;0.05) in abundance for uterine flushings containing later stage conceptuses (i.e. tubular) such as creatinine, serine, isovaleryl-I-carnitine, and lauric diethaolamide. These data illustrate several putative metabolites that change within the uterine milieu as porcine embryos transition between spherical, ovoid, and tubular conceptuses. Funding was provided by USDA-NIFA-AFRI Grant no. 2017-67015-26456.

Real-time determination of enantiomeric and isomeric content using photoelectron elliptical dichroism

The fast and accurate analysis of chiral chemical mixtures is crucial for many applications but remains challenging. Here we use elliptically-polarized femtosecond laser pulses at high repetition rates to photoionize chiral molecules. The 3D photoelectron angular distribution produced provides molecular fingerprints, showing a strong forward-backward asymmetry which depends sensitively on the molecular structure and degree of ellipticity. Continuously scanning the laser ellipticity and analyzing the evolution of the rich, multi-dimensional molecular signatures allows us to observe real-time changes in the chemical and chiral content present with unprecedented speed and accuracy. We measure the enantiomeric excess of a compound with an accuracy of 0.4% in 10 min acquisition time, and follow the evolution of a mixture with an accuracy of 5% with a temporal resolution of 3 s. This method is even able to distinguish isomers, which cannot be easily distinguished by mass-spectrometry.

Partial Resurfacing of the Knee with the BioPoly Implant: Interim Report at 2 Years

Background:

Current treatments for focal chondral and osteochondral lesions of the femoral condyle have been associated with variable outcomes. We conducted a clinical trial of the BioPoly RS Partial Resurfacing Knee Implant to address this unmet need.

Methods:

We performed a single-arm, prospective study in which 33 patients with focal cartilage lesions affecting the femoral condyle were managed with the BioPoly RS Partial Resurfacing Knee Implant. Knee injury and Osteoarthritis Outcome Score (KOOS) scores, a visual analog scale (VAS) for pain, the Short Form-36 (SF-36) physical component score , and the Tegner activity score were used to assess outcomes preoperatively and at 6 months, 1 year, and 2 years postoperatively. The KOOS outcomes at 2 years were compared with historical outcomes following microfracture treatment.

Results:

We found significant and clinically meaningful improvements in the KOOS scores, VAS pain score, and SF-36 physical component score (p < 0.025) when the values at all 3 postoperative time points were compared with the preoperative scores, and we also found significant improvements when the Tegner activity score at 2 years was compared with the preoperative score (p < 0.025). More than half of the cohort of patients had had a previous failure of cartilage-repair procedures. No significant differences were detected between younger patients (≤40 years) and older patients (>40 years). When compared with historical microfracture data, the BioPoly RS Implant demonstrated significantly superior KOOS scores for quality of life and sports.

Conclusions:

The present study indicated that the BioPoly RS Partial Resurfacing Knee Implant is safe, that it resulted in significantly improved knee function by 6 months, and that this improvement was sustained for 2 years regardless of patient age. The BioPoly RS Knee Implant allows return to a higher level of sporting activity than microfracture. Additional long-term follow-up is needed to determine the long-term effects of the device.

Level of Evidence:

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial

IMPORTANCE

For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven.

OBJECTIVE

To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion.

DESIGN, SETTING, AND PARTICIPANTS

A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013.

INTERVENTIONS

Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]).

MAIN OUTCOMES AND MEASURES

Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%).

RESULTS

Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20).

CONCLUSIONS AND RELEVANCE

Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN33288337.

A systematic review and meta-analysis of premature mortality in bipolar affective disorder

OBJECTIVE

To review and complete meta-analysis of studies estimating standardised mortality ratios (SMRs) in bipolar affective disorder (BPAD) for all-cause and cause-specific mortalities.

METHOD

Cause-specific mortality was grouped into natural and unnatural causes. These subgroups were further divided into circulatory, respiratory, neoplastic and infectious causes, and suicide and other violent deaths. Summary SMRs were calculated using random-effects meta-analysis. Heterogeneity was examined via subgroup analysis and meta-regression.

RESULTS

Systematic searching found 31 studies meeting inclusion criteria. Summary SMR for all-cause mortality = 2.05 (95% CI 1.89-2.23), but heterogeneity was high (I(2) = 96.2%). This heterogeneity could not be accounted for by date of publication, cohort size, mid-decade of data collection, population type or geographical region. Unnatural death summary SMR = 7.42 (95% CI 6.43-8.55) and natural death = 1.64 (95% CI 1.47-1.83). Specifically, suicide SMR = 14.44 (95% CI 12.43-16.78), other violent death SMR = 3.68 (95% CI 2.77-4.90), deaths from circulatory disease = 1.73 (95% CI 1.54-1.94), respiratory disease = 2.92 (95% CI 2.00-4.23), infection = 2.25 (95% CI 1.70-3.00) and neoplasm = 1.14 (95% CI 1.10-1.21).

CONCLUSION

Despite considerable heterogeneity, all summary SMR estimates and a large majority of individual studies showed elevated mortality in BPAD compared to the general population. This was true for all causes of mortality studied.

Muscle atrophy and metal-on-metal hip implants: a serial MRI study of 74 hips

BACKGROUND AND PURPOSE

Muscle atrophy is seen in patients with metal-on-metal (MOM) hip implants, probably because of inflammatory destruction of the musculo-tendon junction. However, like pseudotumors, it is unclear when atrophy occurs and whether it progresses with time. Our objective was to determine whether muscle atrophy associated with MOM hip implants progresses with time.

PATIENTS AND METHODS

We retrospectively reviewed 74 hips in 56 patients (32 of them women) using serial MRI. Median age was 59 (23-83) years. The median time post-implantation was 83 (35-142) months, and the median interval between scans was 11 months. Hip muscles were scored using the Pfirrmann system. The mean scores for muscle atrophy were compared between the first and second MRI scans. Blood cobalt and chromium concentrations were determined.

RESULTS

The median blood cobalt was 6.84 (0.24-90) ppb and median chromium level was 4.42 (0.20-45) ppb. The median Oxford hip score was 34 (5-48). The change in the gluteus minimus mean atrophy score between first and second MRI was 0.12 (p = 0.002). Mean change in the gluteus medius posterior portion (unaffected by surgical approach) was 0.08 (p = 0.01) and mean change in the inferior portion was 0.10 (p = 0.05). Mean pseudotumor grade increased by 0.18 (p = 0.02).

INTERPRETATION

Worsening muscle atrophy and worsening pseudotumor grade occur over a 1-year period in a substantial proportion of patients with MOM hip implants. Serial MRI helps to identify those patients who are at risk of developing worsening soft-tissue pathology. These patients should be considered for revision surgery before irreversible muscle destruction occurs.

Gait assessment as a functional outcome measure in total knee arthroplasty: a cross-sectional study

Background

The aim of the study was to assess gait in total knee arthroplasty (TKA) patients, using a technique that can to be used on a routine basis in a busy orthopaedic clinic.

Methods

A total of 103 subjects were recruited: 29 pre-op TKA patients; 17 TKA patients at 8 weeks post-op; 28 TKA patients at 52 weeks post-op; and 29 age-matched controls. Inertial measurement units (IMUs) were used to assess gait. Limb segment angles, knee angle and temporal parameters of gait were calculated. Specific gait parameters were quantified, and data analysed using MANOVA and discriminant analysis.

Results

The gait of TKA patients as a group was only slightly improved at 12 months when compared with the pre-operative group, and both groups were significantly different to controls in several variables. Knee flexion range in stance was the most important variable in discriminating between patients and controls; knee flexion range in swing was the only variable that showed a significant difference between pre- and post-operative patients. When considered individually, only 1/29 patient was within the normal range for this variable pre-operatively, but 9/28 patients were within the normal range 12 months post-operatively.

Conclusions

Even after 12 months after surgery, many TKA patients have not improved their gait relative to pre-operative patients. Routine gait assessment may be used to guide post-operative rehabilitation, and to develop strategies to improve mobility of these patients.

Functional outcome following primary total knee arthroplasty cannot be predicted using the initial post-operative radiograph

Obtaining standardised post-operative radiographs following total knee arthroplasty is common practice. Little is known regarding how measurements taken from the initial post-operative radiograph correlate to functional outcome. The initial post-operative radiographs for 110 primary total knee arthroplasties were reviewed retrospectively. Femoral and tibial component alignment was measured by two independent consultant radiologists. Functional outcome was assessed by the Oxford Knee Score pre-operatively and one year post-operatively. Correlation was determined by Pearson correlation analysis. There was no significant correlation between the radiographic measurements with the one year post-operative Oxford Knee Score nor was there significant correlation with the difference in pre-operative and post-operative scores. The initial post-operative radiograph cannot be used as a tool to reliably predict functional outcome at one year.

A new approach to managing patients with problematic metal hip implants: the use of an Internet-enhanced multidisciplinary team meeting: AAOS exhibit selection

BACKGROUND

Over one million patients worldwide are estimated to have a metal-on-metal hip arthroplasty. To improve the management of these patients and reduce surgeon uncertainty regarding decision-making, we designed an Internet-enhanced multidisciplinary team (iMDT) working approach.

METHODS

From August 2012 to April 2014, the iMDT discussed 215 patients with 266 metal-on-metal hip arthroplasties. Of these, 236 primary arthroplasties (132 hip resurfacing and 104 total hip) were analyzed. The remaining thirty cases involved problematic revised hips and were therefore excluded. The possible recommendations of the iMDT were monitoring, further investigation, or surgery. The concordance between the recommendation and the actual management was used to assess the usefulness of this approach in reducing uncertainty in surgeon-level decision-making.

RESULTS

The median Oxford Hip Score was 35 (range, 4 to 48), and median cobalt and chromium levels in whole blood were 3.54 ppb (range, 0.18 to 161.46 ppb) and 3.17 ppb (range, 0.20 to 100.67 ppb), respectively. Magnetic resonance imaging revealed abductor muscle atrophy in ninety-two (39%) of the hips and a pseudotumor in eighty (34%). The iMDT recommended monitoring of 146 (61.9%) of the hips, further investigation of thirty (12.7%), and surgery in sixty (25.4%). The actual outcome was concordant with the recommendation in 211 (91.7%) of the hips.

CONCLUSIONS

Our iMDT approach to the metal-on-metal hip burden combines the tacit knowledge of an expert panel, regulatory guidance, and up-to-date evidence to improve decision-making among surgeons. The high level of concordance between the recommendation and the actual outcome, combined with the feasibility of the methods used, suggest that this method effectively reduces uncertainty among surgeons and may lead to improved patient outcomes.

Outcomes of infected revision knee arthroplasty managed by two-stage revision in a tertiary referral centre

BACKGROUND

A two-stage revision remains the gold standard to eradicate deep infection in total knee arthroplasty. Higher failure rates are associated with a number of factors including poly-microbial infections, multiresistant organisms and previous operations. The aims are to investigate [1] the overall success rate of a two-stage revision for infections in TKA, [2] the outcome of repeat two-stage revisions in recurrent infections and [3] the factors affecting the outcomes of such cases.

METHODS

We present the outcomes of a consecutive, retrospective case series of 51 periprosthetic joint infections managed with a two-stage revision knee arthroplasty over a three year period.

RESULTS

Forty-six (90%) of 51 were referred from other hospitals. Infection was successfully eradicated in 24 (65%) of 37 patients undergoing an initial two-stage procedure. Following a failed two-stage revision, a repeat two-stage revision was performed in 19 patients eradicating infection in 8 (42%). A third two-stage was performed in five of these patients eradicating infection in three with an average follow-up of 43 months. Multidrug resistance was present in 69%, and 47% of the patients were infected with multiple organisms. All unsuccessful outcomes involved at least one multidrug-resistant organism compared to 43% in the successful cohort (P=0.0002). Serological markers prior to a second-stage procedure were not significantly different between successful and unsuccessful outcome groups.

CONCLUSION

Single or multiple two-stage revisions can eradicate infection despite previous failed attempts. In this series, failure is associated with multidrug resistance, previous failed attempts to eradicate infection and a less favourable host response.

Evidence from Raman spectroscopy of a putative link between inherent bone matrix chemistry and degenerative joint disease

OBJECTIVE

Osteoarthritis (OA) is a common debilitating disease that results in degeneration of cartilage and bone in the synovial joints. Subtle changes in the molecular structure of the subchondral bone matrix occur and may be associated with cartilage changes. The aim of this study was to explore whether the abnormal molecular changes observed in the matrix of OA subchondral bone can be identified with Raman spectroscopy.

METHODS

Tibial plateaus from patients undergoing total knee replacement for OA (n = 10) were compared with healthy joints from patients undergoing leg amputation (n = 5; sex- and laterality-matched) and with non-OA cadaveric knee specimens (n = 5; age-matched). The samples were analyzed with Raman spectroscopy, peripheral quantitative computed tomography, and chemical analysis to compare changes in defined load-bearing sites in both the medial and lateral compartments.

RESULTS

OA subchondral bone matrix changes were detected by Raman spectroscopy. Within each cohort, there was no spectral difference in bone matrix chemistry between the medial and lateral compartments, whereas a significant spectral difference (P < 0.001) was observed between the non-OA and OA specimens. Type I collagen chain ratios were normal in the non-OA specimens but were significantly elevated in the OA specimens.

CONCLUSION

In comparing the results of Raman spectroscopy with those obtained by other standard techniques, these findings show, for the first time, that subchondral bone changes, or inherent differences, exist in both the medial and lateral (beneath intact cartilage) compartments of OA knees. The development of Raman spectroscopy as a screening tool, based on molecular-specific modifications in bone, would facilitate the identification of clinical disease, including early molecular changes.

Custom-made cement-linked mega prostheses: a salvage solution for complex periprosthetic femoral fractures

Periprosthetic femoral fractures with long stem implants, poor bone stock and loosening pose a considerable surgical challenge. We describe a reconstruction technique using a custom-made mega-prosthesis, cement-linked to the femoral stem of a well-fixed existing implant. Clinical and radiological outcomes were assessed at our tertiary referral centre. There were 15 patients with a periprosthetic femoral fracture: 5 proximal and 10 distal femoral arthroplasties linked to existing femoral stems. The survival rate was 93.3% at a mean follow-up of 5.3 years (0.5-19.3) with 1 revision. We present a salvage technique with good intermediate-term outcomes for highly selected patients with complex periprosthetic femoral fractures, as another option to conventional fixation methods. Specifically, it allows immediate weight bearing and avoids some of the morbidity of total femoral arthroplasty or amputation.

Abstract P2-03-05: Relationship between 64Cu-DOTA-trastuzumab positron emission tomography uptake and assessment of HER2 by immunohistochemistry in women with advanced breast cancer

Background: We have utilized 64Cu-DOTA-trastuzumab with PET imaging to assess the in vivo expression of HER2 in women with advanced breast cancer. We have demonstrated that a preadministered dose of trastuzumab 45 mg prior to injection of 64Cu-DOTA-trastuzumab resulted in a 75% decrease in the hepatic uptake of Cu-64, resulting in improved image quality.

Methods: Patients with biopsy confirmation of recurrent disease located outside the breast and axilla considered for study. Complete staging workup included CT of the chest, abdomen, and pelvis, bone scintigraphy and 18F FDG PET. At least 1 non-hepatic site of metastasis that was &gt; 2 cm separate from the biopsy site was also required. HER2 status was assessed by both IHC and FISH. Index lesions were identified on CT imaging. After the first two patients, all patients received a cold dose of 45mg of trastuzumab immediately prior to 64Cu-DOTA-trastuzumab to decrease liver uptake. 64Cu-DOTA-trastuzumab PET imaging was performed at 24 and 48 hours. Uptake on 64Cu-DOTA-trastuzumab was correlated with HER2 status by IHC and FISH.

Results: Fifteen women have undergone 64Cu-DOTA-trastuzumab PET imaging and quantitative image analysis. 10 patients were HER2+ (7 IHC 3+, 3 IHC 2+/FISH+), 3 patients were IHC 2+/FISH-, and 2 patients were IHC 1+. Tumor uptake by 64Cu-DOTA-trastuzumab PET max SUV was higher in HER2+ positive than HER2- patients (1.9-fold higher on day1, p&lt;0.02, and 1.7-fold higher on day2, p&lt;0.05). However, the lowest max SUV was in a HER2+ patient (HER2 2+/FISH+), demonstrating considerable heterogeneity.

Conclusion: 64Cu-DOTA-trastuzumab PET correlates with HER2+ status. However, due to high within and between patient variability, 64Cu-DOTA-trastuzumab PET imaging could potentially enrich for HER2+ patients that respond to HER2-targeted therapy, and could also suggest some HER2- patients that may benefit from HER2-targeted therapy. This hypothesis needs to be further explored in patients undergoing HER2-targeted therapy. This work was supported by the Department of Defense grant # BC095002.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-03-05.

Abstract P2-05-10: 64Cu-DOTA-trastuzumab positron emission tomography imaging of HER2 in women with advanced breast cancer

Background: We propose to utilize64Cu-DOTA-trastuzumab with PET imaging to assess the in vivo expression of HER2 in women with advanced breast cancer. We hypothesized that the uptake of HER2 in normal tissues compromises the quality of radiographic images and that the pre-administration of trastuzumab prior to injection of64Cu-DOTA-trastuzumab would improve image quality. Two different doses of cold trastuzumab (5 mg and 50 mg) were tested. Once the dose of cold trastuzumab was established in women with documented HER2 positive metastatic disease, we initiated a second study of64Cu-DOTA-trastuzumab PET imaging in women whose cancers were HER2 1+ and 2+ by immunohistochemical staining.

Methods: Patients with biopsy confirmation of recurrent disease located outside the breast and axilla considered for study. Complete staging workup included CT of the chest, abdomen, and pelvis, bone scintigraphy and18F FDG PET. At lease 1 non-hepatic site of metastasis that was &gt; 2 cm separate from the biopsy site was also required. HER2 status was assessed by both IHC and FISH. In the first study all patients were required to have HER2 positive disease and could not have received anti-HER therapy for &gt; 2 months. Immediately prior to injection of64Cu-DOTA-trastuzumab, a cold dose of either 5 mg or 50 mg of trastuzumab was administered.64Cu-DOTA-trastuzumab PET imaging was performed at 24 and 48 hours.

Results: Eight women with HER2 positive metastatic breast cancer have undergone64Cu-DOTA-trastuzumab PET imaging: 2 received a pre-64Cu-DOTA-trastuzumab PET dose of 5 mg trastuzumab and 6 received 50 mg.64Cu-DOTA-trastuzumab PET effectively visualized and provided uptake measurements for presumably HER2+ metastatic lesions in bone, liver, lung and, to a lesser degree, lymph nodes. The 50 mg dose resulted in approximately 75% decrease in liver uptake of64Cu and improved the visualization of hepatic metastasis. We have initiated the second phase of the study utilizing the pre-administration of 50 mg trastuzumab in women with HER2 1+ and 2 + disease. To date we have imaged one patient.

Conclusion:64Cu-DOTA-trastuzumab PET imaging is feasible and image quality is improved with the pre-administration of 50 mg trastuzumab. Enrollment of women with IHC 1+ and 2+ disease continues. This work was supported by the Department of Defense grant # 1024511.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-05-10.

Delayed sciatic nerve palsy following resurfacing hip arthroplasty caused by metal debris

The rapid rise in the incidence of failed metal-on-metal hip articulations in recent years has led to many patients requiring complex revision surgery. These failed metal prostheses may produce local metallic debris, which promotes both local and systemic adverse effects. We report an unusual case of failed metal-on-metal resurfacing hip arthroplasty presenting with ipsilateral buttock pain and foot drop 6 months after surgery. After thorough investigations, the metal-on-metal bearing was revised to a metal-on-polyethylene total hip replacement. This resulted in marked improvement in the systemic symptoms, inflammatory marke and metal ion levels postoperatively. However, neither clinical nor neurophysiological sciatic nerve recovery followed. The patient eventually required tendon transfer surgery for her persistent foot drop.

Custom rotating-hinge primary total knee arthroplasty in patients with skeletal dysplasia

Patients with skeletal dysplasia are prone to developing advanced osteoarthritis of the knee requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure owing to the deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We retrospectively reviewed the outcome of 11 TKRs performed in eight patients with skeletal dysplasia at our institution using the Stanmore Modular Individualised Lower Extremity System (SMILES) custom-made rotating-hinge TKR. There were three men and five women with mean age of 57 years (41 to 79). Patients were followed clinically and radiologically for a mean of seven years (3 to 11.5). The mean Knee Society clinical and function scores improved from 24 (14 to 36) and 20 (5 to 40) pre-operatively, respectively, to 68 (28 to 80) and 50 (22 to 74), respectively, at final follow-up. Four complications were recorded, including a patellar fracture following a fall, a tibial peri-prosthetic fracture, persistent anterior knee pain, and aseptic loosening of a femoral component requiring revision. Our results demonstrate that custom primary rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, with a satisfactory range of movement and improved function. It compensates for bony deformity and ligament deficiency and reduces the likelihood of corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than with primary TKR in the general population.

Primary sarcoma of the anterior cruciate ligament - a case report

Clear cell sarcoma of tendons and aponeuroses (CCSTA) is a rare, aggressive soft tissue malignancy, which is found in intimate association with tendon, aponeurosis or fascia. It has not previously been reported in association with intraarticular ligaments. We report the first case of an intraarticular CCSTA, in this case of the anterior cruciate ligament and describe the diagnostic and treatment challenges of intraarticular tumours of the knee.

Bizarre parosteal osteochondromatous proliferation of bone: clinical management of a series of 22 cases

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora's lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.