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Crozier D, Gray JM, Maltas JA, Bonomo RA, Burke ZDC, Card KJ, Scott JG. The evolution of diverse antimicrobial responses in vancomycin-intermediate Staphylococcus aureus and its therapeutic implications. bioRxiv 2024:2023.11.30.569373. [PMID: 38077036 PMCID: PMC10705500 DOI: 10.1101/2023.11.30.569373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Staphylococcus aureus causes endocarditis, osteomyelitis, and bacteremia. Clinicians often prescribe vancomycin as an empiric therapy to account for methicillin-resistant S. aureus (MRSA) and narrow treatment based on culture susceptibility results. However, these results reflect a single time point before empiric treatment and represent a limited subset of the total bacterial population within the patient. Thus, while they may indicate that the infection is susceptible to a particular drug, this recommendation may no longer be accurate during therapy. Here, we addressed how antibiotic susceptibility changes over time by accounting for evolution. We evolved 18 methicillin-susceptible S. aureus (MSSA) populations under increasing vancomycin concentrations until they reached intermediate resistance levels. Sequencing revealed parallel mutations that affect cell membrane stress response and cell-wall biosynthesis. The populations exhibited repeated cross-resistance to daptomycin and varied responses to meropenem, gentamicin, and nafcillin. We accounted for this variability by deriving likelihood estimates that express a population's probability of exhibiting a drug response following vancomycin treatment. Our results suggest antistaphylococcal penicillins are preferable first-line treatments for MSSA infections but also highlight the inherent uncertainty that evolution poses to effective therapies. Infections may take varied evolutionary paths; therefore, considering evolution as a probabilistic process should inform our therapeutic choices.
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Burke ZDC, Hart CM, Kelley BV, Mamouei Z, Blumstein GW, Hamad C, Hori K, Cevallos N, Villalpando C, Truong N, Turkmani A, Ralston M, Kavanaugh A, Tenorio E, Kauvar LM, Li A, Prunet N, Stavrakis AI, Bernthal NM. Monoclonal Antibody Disrupts Biofilm Structure and Restores Antibiotic Susceptibility in an Orthopedic Implant Infection Model. Antibiotics (Basel) 2023; 12:1490. [PMID: 37887191 PMCID: PMC10604051 DOI: 10.3390/antibiotics12101490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Bacterial biofilms on orthopedic implants are resistant to the host immune response and to traditional systemic antibiotics. Novel therapies are needed to improve patient outcomes. TRL1068 is a human monoclonal antibody (mAb) against a biofilm anchoring protein. For assessment of this agent in an orthopedic implant infection model, efficacy was measured by reduction in bacterial burden of Staphylococcus aureus, the most common pathogen for prosthetic joint infections (PJI). Systemic treatment with the biofilm disrupting mAb TRL1068 in conjunction with vancomycin eradicated S. aureus from steel pins implanted in the spine for 26 of 27 mice, significantly more than for vancomycin alone. The mechanism of action was elucidated by two microscopy studies. First, TRL1068 was localized to biofilm using a fluorescent antibody tag. Second, a qualitative effect on biofilm structure was observed using scanning electron microscopy (SEM) to examine steel pins that had been treated in vivo. SEM images of implants retrieved from control mice showed abundant three-dimensional biofilms, whereas those from mice treated with TRL1068 did not. Clinical Significance: TRL1068 binds at high affinity to S. aureus biofilms, thereby disrupting the three-dimensional structure and significantly reducing implant CFUs in a well-characterized orthopedic model for which prior tested agents have shown only partial efficacy. TRL1068 represents a promising systemic treatment for orthopedic implant infection.
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Affiliation(s)
- Zachary D. C. Burke
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Christopher M. Hart
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Benjamin V. Kelley
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Zeinab Mamouei
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Gideon W. Blumstein
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Christopher Hamad
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Kellyn Hori
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Nicolas Cevallos
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Christina Villalpando
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Nicole Truong
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Amr Turkmani
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Micah Ralston
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Aaron Kavanaugh
- Orthopedic Hospital Research Center, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA (K.H.)
| | - Edgar Tenorio
- Trellis Bioscience, Inc., Redwood City, CA 94063, USA
| | | | - Alan Li
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA 90095, USA
| | - Nathanael Prunet
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA 90095, USA
| | - Alexandra I. Stavrakis
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
| | - Nicholas M. Bernthal
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (C.M.H.); (B.V.K.)
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Burke ZDC, Lazarides AL, Gundavda MK, Griffin AM, Tsoi KM, Ferguson PC, Wunder JS. Open Versus Core Needle Biopsy in Lower-Extremity Sarcoma: Current Practice Patterns and Patient Outcomes. J Bone Joint Surg Am 2023; 105:57-64. [PMID: 37466581 DOI: 10.2106/jbjs.22.01259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Historically, open biopsy (OB) was the gold standard for sarcoma diagnosis. Core needle biopsy (CNB) has become increasingly common. There are limited data evaluating how the type of biopsy impacts definitive surgical resection or postoperative outcomes. The aims of this study were to (1) characterize current international biopsy practice patterns, and (2) evaluate how the type of biopsy performed impacts the resection surgery, infection risk, oncological complications, and patient-reported functional outcome scores. METHODS This study was a preplanned secondary analysis of the prospective, multicenter PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. Patients with a benign diagnosis, metastatic disease, or no biopsy prior to surgery were excluded. Prospectively collected demographic, biopsy, surgical, and outcome variables were analyzed, and differences between patients undergoing OB and CNB were assessed. Parametric and nonparametric tests were used to compare variables between groups, and the Cox proportional hazards method was used to compare infection-related and oncological outcomes at 1 year. Median functional outcome scores at 1 year were compared. RESULTS Four hundred and sixty-four patients met the inclusion criteria. Data were collected from 48 sarcoma centers in 12 countries. CNB was the more utilized biopsy modality overall (57.5%). OB was more common in the U.S. and Canada. The median operative time was significantly longer for patients who underwent OB (324 versus 260 minutes; p < 0.001). Significantly more skin (p < 0.001) and fascial tissue (p < 0.001) were excised in the OB group, which also had a lower rate of primary closure (86.3% versus 92.9%; p = 0.03). There were no differences in surgical site infection or oncological outcomes between the groups at 1-year follow-up. CONCLUSIONS CNB was the more common biopsy modality in the PARITY study in most countries. However, OB was more common in the U.S. and Canada. Patients undergoing OB had longer operative times, more excised tissue, and lower rates of primary closure, but this did not translate to differences in infection rates or oncological outcomes, including local recurrence. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Zachary D C Burke
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alexander L Lazarides
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
- Department of Sarcoma, Moffitt Cancer Center, Tampa, Florida
| | - Manit K Gundavda
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
- Division of Orthopaedic Oncology, Centre for Bone and Joint Cancer, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Anthony M Griffin
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
| | - Kim M Tsoi
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
| | - Peter C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
| | - Jay S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Sinai Health System, Toronto, Ontario, Canada
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Gundavda MK, Lazarides AL, Burke ZDC, Focaccia M, Griffin AM, Tsoi KM, Ferguson PC, Wunder JS. Is a radiological score able to predict resection-grade chondrosarcoma in primary intraosseous lesions of the long bones? Bone Joint J 2023; 105-B:808-814. [PMID: 37391201 DOI: 10.1302/0301-620x.105b7.bjj-2022-1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Aims The preoperative grading of chondrosarcomas of bone that accurately predicts surgical management is difficult for surgeons, radiologists, and pathologists. There are often discrepancies in grade between the initial biopsy and the final histology. Recent advances in the use of imaging methods have shown promise in the ability to predict the final grade. The most important clinical distinction is between grade 1 chondrosarcomas, which are amenable to curettage, and resection-grade chondrosarcomas (grade 2 and 3) which require en bloc resection. The aim of this study was to evaluate the use of a Radiological Aggressiveness Score (RAS) to predict the grade of primary chondrosarcomas in long bones and thus to guide management. Methods A total of 113 patients with a primary chondrosarcoma of a long bone presenting between January 2001 and December 2021 were identified on retrospective review of a single oncology centre's prospectively collected database. The nine-parameter RAS included variables from radiographs and MRI scans. The best cut-off of parameters to predict the final grade of chondrosarcoma after resection was determined using a receiver operating characteristic curve (ROC), and this was correlated with the biopsy grade. Results A RAS of ≥ four parameters was 97.9% sensitive and 90.5% specific in predicting resection-grade chondrosarcoma based on a ROC cut-off derived using the Youden index. Cronbach's α of 0.897 was derived as the interclass correlation for scoring the lesions by four blinded reviewers who were surgeons. Concordance between resection-grade lesions predicted from the RAS and ROC cut-off with the final grade after resection was 96.46%. Concordance between the biopsy grade and the final grade was 63.8%. However, when the patients were analyzed based on surgical management, the initial biopsy was able to differentiate low-grade from resection-grade chondrosarcomas in 82.9% of biopsies. Conclusion These findings suggest that the RAS is an accurate method for guiding the surgical management of patients with these tumours, particularly when the initial biopsy results are discordant with the clinical presentation.
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Affiliation(s)
- Manit K Gundavda
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Centre for Bone & Joint/Cancer - Bone and Soft Tissue Tumours, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
| | - Alexander L Lazarides
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Department of Sarcoma, Mofitt Cancer Centre, Tampa, Florida, USA
| | - Zachary D C Burke
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Sarcoma Program, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Marco Focaccia
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
- Orthopaedic Oncology Unit, IRCCS Instituto Orthopedico Rizzoli, Bologna, Italy
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Kim M Tsoi
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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Lazarides AL, Burke ZDC, Gundavda MK, Novak R, Ghert M, Wilson DA, Rose PS, Wong P, Griffin AM, Ferguson PC, Wunder JS, Houdek MT, Tsoi KM. How Do the Outcomes of Radiation-Associated Pelvic and Sacral Bone Sarcomas Compare to Primary Osteosarcomas following Surgical Resection? Cancers (Basel) 2022; 14:cancers14092179. [PMID: 35565308 PMCID: PMC9104334 DOI: 10.3390/cancers14092179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 02/05/2023] Open
Abstract
Radiation-associated sarcoma of the pelvis and/or sacrum (RASB) is a rare but challenging disease process associated with a poor prognosis. We hypothesized that patients with RASB would have worse surgical and oncologic outcomes than patients diagnosed with primary pelvic or sacral bone sarcomas. This was a retrospective, multi-institution, comparative analysis. We reviewed surgically treated patients from multiple tertiary care centers who were diagnosed with a localized RASB. We also identified a comparison group including all patients diagnosed with a primary localized pelvic or sacral osteosarcoma/spindle cell sarcoma of bone (POPS). There were 35 patients with localized RASB and 73 patients with POPS treated with surgical resection. Patients with RASB were older than those with POPS (57 years vs. 38 years, p < 0.001). Patients with RASB were less likely to receive chemotherapy (71% for RASB vs. 90% for POPS, p = 0.01). Seventeen percent of patients with RASB died in the perioperative period (within 90 days of surgery) as compared to 4% with POPS (p = 0.03). Five-year disease-specific survival (DSS) (31% vs. 54% p = 0.02) was worse for patients with RASB vs. POPS. There was no difference in 5-year local recurrence free survival (LRFS) or metastasis free survival (MFS). RASB and POPS present challenging disease processes with poor oncologic outcomes. Rates of perioperative mortality and 5-year DSS are worse for RASB when compared to POPS.
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Affiliation(s)
- Alexander L. Lazarides
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Zachary D. C. Burke
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Manit K. Gundavda
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Rostislav Novak
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON L8V 1C3, Canada;
| | - David A. Wilson
- Department of Orthopaedic Surgery, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Peter S. Rose
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (P.S.R.); (M.T.H.)
| | - Philip Wong
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada;
| | - Anthony M. Griffin
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Peter C. Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Jay S. Wunder
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
| | - Matthew T. Houdek
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (P.S.R.); (M.T.H.)
| | - Kim M. Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto Musculoskeletal Oncology Unit, Sinai Health System, Toronto, ON M5S 1A8, Canada; (A.L.L.); (Z.D.C.B.); (M.K.G.); (R.N.); (A.M.G.); (P.C.F.); (J.S.W.)
- Correspondence:
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Zoller SD, Hegde V, Burke ZDC, Park HY, Ishmael CR, Blumstein GW, Sheppard W, Hamad C, Loftin AH, Johansen DO, Smith RA, Sprague MM, Hori KR, Clarkson SJ, Borthwell R, Simon SI, Miller JF, Nelson SD, Bernthal NM. Evading the host response: Staphylococcus "hiding" in cortical bone canalicular system causes increased bacterial burden. Bone Res 2020; 8:43. [PMID: 33303744 PMCID: PMC7728749 DOI: 10.1038/s41413-020-00118-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/22/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Extremity reconstruction surgery is increasingly performed rather than amputation for patients with large-segment pathologic bone loss. Debate persists as to the optimal void filler for this "limb salvage" surgery, whether metal or allograft bone. Clinicians focus on optimizing important functional gains for patients, and the risk of devastating implant infection has been thought to be similar regardless of implant material. Recent insights into infection pathophysiology are challenging this equipoise, however, with both basic science data suggesting a novel mechanism of infection of Staphylococcus aureus (the most common infecting agent) into the host lacunar-canaliculi network, and also clinical data revealing a higher rate of infection of allograft over metal. The current translational study was therefore developed to bridge the gap between these insights in a longitudinal murine model of infection of allograft bone and metal. Real-time Staphylococci infection characteristics were quantified in cortical bone vs metal, and both microarchitecture of host implant and presence of host immune response were assessed. An orders-of-magnitude higher bacterial burden was established in cortical allograft bone over both metal and cancellous bone. The establishment of immune-evading microabscesses was confirmed in both cortical allograft haversian canal and the submicron canaliculi network in an additional model of mouse femur bone infection. These study results reveal a mechanism by which Staphylococci evasion of host immunity is possible, contributing to elevated risks of infection in cortical bone. The presence of this local infection reservoir imparts massive clinical implications that may alter the current paradigm of osteomyelitis and bulk allograft infection treatment.
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Affiliation(s)
- Stephen D Zoller
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Zachary D C Burke
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Howard Y Park
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Chad R Ishmael
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Gideon W Blumstein
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - William Sheppard
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Christopher Hamad
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Amanda H Loftin
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Daniel O Johansen
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
| | - Ryan A Smith
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Marina M Sprague
- Department of Internal Medicine, University of California, Los Angeles, 757 Westwood Plaza, Suite 7501, Los Angeles, CA, 90095, USA
| | - Kellyn R Hori
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Samuel J Clarkson
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Rachel Borthwell
- David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Scott I Simon
- Department of Biomedical Engineering, University of California, Davis, Davis, CA, 95616, USA
| | - Jeff F Miller
- California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA, 90095, USA
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, University of California, Los Angeles, 90095, USA
| | - Scott D Nelson
- Department of Pathology, University of California, Los Angeles, 1250 16th St Suite 3450, Santa Monica, CA, 90404, USA
| | - Nicholas M Bernthal
- Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA, 90404, USA.
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Bernthal NM, Ishmael CR, Burke ZDC. Management of Pigmented Villonodular Synovitis (PVNS): an Orthopedic Surgeon’s Perspective. Curr Oncol Rep 2020; 22:63. [DOI: 10.1007/s11912-020-00926-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bernthal NM, Burke ZDC, Hegde V, Upfill-Brown A, Chen CJ, Hwang R, Eckardt JJ. Long-term follow-up of all-polyethylene tibial components when used for oncological endoprosthetic reconstruction. Bone Joint J 2020; 102-B:170-176. [PMID: 32009432 DOI: 10.1302/0301-620x.102b2.bjj-2019-0535.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We aimed to examine the long-term mechanical survivorship, describe the modes of all-cause failure, and identify risk factors for mechanical failure of all-polyethylene tibial components in endoprosthetic reconstruction. METHODS This is a retrospective database review of consecutive endoprosthetic reconstructions performed for oncological indications between 1980 and 2019. Patients with all-polyethylene tibial components were isolated and analyzed for revision for mechanical failure. Outcomes included survival of the all-polyethylene tibial component, revision surgery categorized according to the Henderson Failure Mode Classification, and complications and functional outcome, as assessed by the Musculoskeletal Tumor Society (MSTS) score at the final follow-up. RESULTS A total of 278 patients were identified with 289 all-polyethylene tibial components. Mechanical survival was 98.4%, 91.1%, and 85.2% at five, ten and 15 years, respectively. A total of 15 mechanical failures were identified at the final follow-up. Of the 13 all-polyethylene tibial components used for revision of a previous tibial component, five (38.5%) failed mechanically. Younger patients (< 18 years vs > 18 years; p = 0.005) and those used as revision components (p < 0.001) had significantly increased rates of failure. Multivariate logistic regression modelling showed revision status to be a positive risk factor for failure (odds ratio (OR) 19.498, 95% confidence interval (CI) 4.598 to 82.676) and increasing age was a negative risk factor for failure (OR 0.927, 95% CI 0.872 to 0.987). Age-stratified risk analysis showed that age > 24 years was no longer a statistically significant risk factor for failure. The final mean MSTS score for all patients was 89% (8.5% to 100.0%). CONCLUSION The long-term mechanical survivorship of all-polyethylene tibial components when used for tumour endoprostheses was excellent. Tumour surgeons should consider using these components for their durability and the secondary benefits of reduced cost and ease of removal and revision. However, caution should be taken when using all-polyethylene tibial components in the revision setting as a significantly higher rate of mechanical failure was seen in this group of patients. Cite this article: Bone Joint J. 2020;102-B(2):170-176.
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Affiliation(s)
- Nicholas M Bernthal
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Zachary D C Burke
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Alexander Upfill-Brown
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Clark J Chen
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Richard Hwang
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
| | - Jeffrey J Eckardt
- Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, University of California, Santa Monica, California, USA
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Bernthal NM, Upfill-Brown A, Burke ZDC, Ishmael CR, Hsiue P, Hori K, Hornicek F, Eckardt JJ. Long-term follow-up of custom cross-pin fixation of 56 tumour endoprosthesis stems: a single-institution experience. Bone Joint J 2019; 101-B:724-731. [PMID: 31154850 DOI: 10.1302/0301-620x.101b6.bjj-2018-0993.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIMS Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique. PATIENTS AND METHODS A review of 658 consecutive, prospectively collected cemented endoprosthetic reconstructions for oncological diagnoses at a single centre between 1980 and 2017 was performed. A total of 51 patients were identified with 56 endoprosthetic implants with cross-pin fixation, 21 of which were implanted following primary resection of tumour. Locations included distal femoral (n = 36), proximal femoral (n = 7), intercalary (n = 6), proximal humeral (n = 3), proximal tibial (n = 3), and distal humeral (n = 1). RESULTS The median follow-up was 132 months (interquartile range (IQR) 44 to 189). In all, 20 stems required revision: eight for infection, five for structural failure, five for aseptic loosening, and two for tumour progression. Mechanical survivorship at five, ten, and 15 years was 84%, 78%, and 78%, respectively. Mechanical failure rate varied by location, with no mechanical failures of proximal femoral constructs and distal femoral survivorship of 82%, 77%, and 77% at five, ten, and 15 years. The survivorship of primary constructs at five years was 74%, with no failure after 40 months, while the survivorship for revision constructs was 89%, 80%, and 80% at five, ten, and 15 years. CONCLUSION The rate of mechanical survivorship in our series is similar to those reported for other methods of reconstruction for short diaphyseal segments, such as compressive osseointegration. The mechanical failure rate differed by location, while there was no substantial difference in long-term survival between primary and revision reconstructions. Overall, custom cross-pin fixation is a viable option for endoprosthetic reconstruction of short metaphyseal segments with an acceptable rate of mechanical failure. Cite this article: Bone Joint J 2019;101-B:724-731.
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Affiliation(s)
- N M Bernthal
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - A Upfill-Brown
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Z D C Burke
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - C R Ishmael
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - P Hsiue
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - K Hori
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - F Hornicek
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - J J Eckardt
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, California, USA
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10
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Stavrakis AI, Patel AD, Burke ZDC, Loftin AH, Dworsky EM, Silva M, Bernthal NM. The role of chairman and research director in influencing scholarly productivity and research funding in academic orthopaedic surgery. J Orthop Res 2015; 33:1407-11. [PMID: 25940983 DOI: 10.1002/jor.22919] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/27/2015] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine what orthopaedic surgery department leadership characteristics are most closely correlated with securing NIH funding and increasing scholarly productivity. Scopus database was used to identify number of publications/h-index for 4,328 faculty, department chairs (DC), and research directors (RD), listed on departmental websites from 138 academic orthopaedic departments in the United States. NIH funding data was obtained for the 2013 fiscal year. While all programs had a DC, only 46% had a RD. Of $54,925,833 in NIH funding allocated to orthopaedic surgery faculty in 2013, 3% of faculty and 31% of departments were funded. 16% of funded institutions had a funded DC whereas 65% had a funded RD. Department productivity and funding were highly correlated to leadership productivity and funding(p< 0.05). Mean funding was $1,700,000 for departments with a NIH-funded RD, $104,000 for departments with an unfunded RD, and $72,000 for departments with no RD. These findings suggest that orthopaedic department academic success is directly associated with scholarly productivity and funding of both DC and RD. The findings further highlight the correlation between a funded RD and a well-funded department. This does not hold for an unfunded RD.
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Affiliation(s)
- Alexandra I Stavrakis
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, 90404, California
| | - Ankur D Patel
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
| | - Zachary D C Burke
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
| | - Amanda H Loftin
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
| | - Erik M Dworsky
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
| | - Mauricio Silva
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
| | - Nicholas M Bernthal
- UCLA Santa Monica Orthopaedic Center, 1250 16th Street, Suite 2100, Santa Monica, 90404, California
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Burke ZDC, Jabaji Z, de Virgilio C. Cold, Painful Right Lower Extremity. Surgery 2015. [DOI: 10.1007/978-1-4939-1726-6_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Burke ZDC, Chen JB, Conceicao C, Hoffman RM, Miller LT, Taela A, DeUgarte DA. Evaluation of preoperative and intraoperative red blood cell transfusion practices at Maputo Central Hospital, Mozambique. Transfusion 2013; 54:42-8. [PMID: 23692441 DOI: 10.1111/trf.12252] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 04/02/2013] [Accepted: 04/05/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate preoperative and intraoperative blood transfusion practices in Hospital Central (Maputo, Mozambique) and estimate the number of potentially avoidable transfusions. STUDY DESIGN AND METHODS A retrospective cohort study was performed. Age, comorbidities, hemoglobin (Hb), the potential for blood loss, and units of red blood cell (RBC) transfusions were recorded. Preoperative transfusions were evaluated to determine whether they met criteria established by the Mozambican Ministry of Health as well as proposed guidelines based on more restrictive protocols. Avoidable blood transfusions were defined as those preoperative transfusions that were not indicated based on these guidelines. Multivariate logistic regression was used to identify factors that predicted transfusion. RESULTS A total of 205 patients (age range, 0.1-86 years) underwent surgery in the main operating room during the 2-week study period. Overall, 35 (17%) patients received 68 transfusions. Of these, 36 transfusions were given preoperatively and 32 were given intraoperatively. Thirty-six percent of preoperative transfusions were avoidable according to national guidelines. Ninety-two percent were avoidable using more restrictive guidelines. The primary predictors of preoperative blood transfusion were lower Hb (odds ratio [OR], 0.390/1 g/dL; p < 0.0001) and the potential for blood loss (OR, 3.73; p = 0.0410). CONCLUSIONS Adherence to existing Hb thresholds recommended by national blood transfusion guidelines could significantly reduce the number of transfusions and the association risk of transfusion-transmissible infections. Adoption of more restrictive guidelines is recommended to further improve blood transfusion utilization and further reduce the transmission risk of human immunodeficiency virus and hepatitis.
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Affiliation(s)
- Zachary D C Burke
- UCLA Center for World Health and Program in Global Health Education, David Geffen School of Medicine at UCLA, Los Angeles, California; Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
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