Bovine and human endometrium-derived hydrogels support organoid culture from healthy and cancerous tissues.

Organoid technology has provided unique insights into human organ development, function, and diseases. Patient-derived organoids are increasingly used for drug screening, modeling rare disorders, designing regenerative therapies, and understanding disease pathogenesis. However, the use of Matrigel to grow organoids represents a major challenge in the clinical translation of organoid technology. Matrigel is a poorly defined mixture of extracellular matrix proteins and growth factors extracted from the Engelbreth-Holm-Swarm mouse tumor. The extracellular matrix is a major driver of multiple cellular processes and differs significantly between tissues as well as in healthy and disease states of the same tissue. Therefore, we envisioned that the extracellular matrix derived from a native healthy tissue would be able to support organoid growth akin to organogenesis in vivo. Here, we have developed hydrogels from decellularized human and bovine endometrium. These hydrogels supported the growth of mouse and human endometrial organoids, which was comparable to Matrigel. Organoids grown in endometrial hydrogels were proteomically more similar to the native tissue than those cultured in Matrigel. Proteomic and Raman microspectroscopy analyses showed that the method of decellularization affects the biochemical composition of hydrogels and, subsequently, their ability to support organoid growth. The amount of laminin in hydrogels correlated with the number and shape of organoids. We also demonstrated the utility of endometrial hydrogels in developing solid scaffolds for supporting high-throughput, cell culture-based applications. In summary, endometrial hydrogels overcome a major limitation of organoid technology and greatly expand the applicability of organoids to understand endometrial biology and associated pathologies.

Role of the prorenin receptor in endometrial cancer cell growth.

Endometrial cancer is the most diagnosed gynecological malignancy. Despite numerous scientific advances, the incidence and mortality rate of endometrial cancer continues to rise. Emerging evidence suggests a putative role of the (pro)renin receptor ((P)RR), in the ontogenesis of endometrial cancer. The (P)RR is implicated in breast cancer and pancreatic carcinoma pathophysiology by virtue of its role in proliferation, angiogenesis, fibrosis, migration and invasion. Thus, we aimed to investigate the functional role of the (P)RR in human endometrial cancer. We employed an siRNA-mediated knockdown approach to abrogate (P)RR expression in the endometrial epithelial cell lines; Ishikawa, AN3CA and HEC-1-A and examined cellular proliferation and viability. We also carried out a sophisticated proteomic screen to explore potential pathways via which the (P)RR is acting in endometrial cancer physiology. These data confirmed that the (P)RR is critical for endometrial cancer development, contributing to both its proliferative capacity and in the maintenance of cell viability. This is likely mediated through proteins such as MGA, SLC4A7, SLC7A11 or DHRS2, which were reduced following (P)RR knockdown. These putative protein interactions/pathways, which rely on the presence of the (P)RR, are likely to contribute to endometrial cancer progression and could therefore, represent several novel therapeutic targets for endometrial cancer.

Acute hypoxia-reoxygenation and vascular oxygen sensing in the chicken embryo.

Fetal/perinatal hypoxia is one of the most common causes of perinatal morbidity and mortality and is frequently accompannied by vascular dysfunction. However, the mechanisms involved have not been fully delineated. We hypothesized that exposure to acute hypoxia-reoxygenation induces alterations in vascular O2 sensing/signaling as well as in endothelial function in the chicken embryo pulmonary artery (PA), mesenteric artery (MA), femoral artery (FA), and ductus arteriosus (DA). Noninternally pipped 19-day embryos were exposed to 10% O2 for 30 min followed by reoxygenation with 21% O2 or 80% O2 Another group was constantly maintained at 21% O2 or at 21% O2 for 30 min and then exposed to 80% O2 Following treatment, responses of isolated blood vessels to hypoxia as well as endothelium-dependent (acetylcholine) and -independent (sodium nitroprusside and forskolin) relaxation were investigated in a wire myograph. Hypoxia increased venous blood lactate from 2.03 ± 0.18 to 15.98 ± 0.73 mmol/L (P < 0.001) and reduced hatchability to 0%. However, ex vivo hypoxic contraction of PA and MA, hypoxic relaxation of FA, and normoxic contraction of DA were not significantly different in any of the experimental groups. Relaxations induced by acetylcholine, sodium nitroprusside, and forskolin in PA, MA, FA, and DA rings were also similar in the four groups. In conclusion, exposure to acute hypoxia-reoxygenation did not affect vascular oxygen sensing or reactivity in the chicken embryo. This suggests that direct effects of acute hypoxia-reoxygenation on vascular function does not play a role in the pathophysiology of hypoxic cardiovascular injury in the perinatal period.

Patellar complications in single versus double tunnel medial patellofemoral ligament reconstruction.

PURPOSE: Hamstring graft fixation on the patellar side during medial patellofemoral ligament (MPFL) reconstruction is usually with transosseous tunnels and can frequently lead to further problems. The aim of our study was to compare and analyse patellar complications in single patellar tunnel versus double tunnel hamstring graft fixation. METHODS: Twenty-nine knees with MPFL reconstructions (group S) in which the hamstring tendon graft was transfixed using a suspensory fixation method in a single tunnel drilled across the patella were analysed in comparison with 29 knees (group D) with interference fixation of the graft through two tunnels drilled up to a predetermined depth in the patella. Primary outcome measured was any patellar complication like anterior knee pain and patella fracture. Secondary outcomes assessed were future functional instability and failure of reconstruction. RESULTS: Anterior knee pain was noted in six patients in group S, of which three patients had removal of the irritating metalwork on the patella. In all, nine surgical interventions were needed in six patients in this group. Three patients in group D complained of knee pain, but no one in this group needed any further surgical interventions ( p value 0.02). Symptomatic instability requiring revision surgery or realignment surgery was required in two patients in the group S and none in group D. No patellar fractures were seen in either group. CONCLUSION: Our study showed increasing problems with single tunnel patellar fixation, with more reoperation and failure rates compared to double tunnel fixation. The evidence supports the move towards anatomical double bundle MPFL reconstructions.

Comparative study of autograft harvested from contra lateral proximal tibia versus the iliac crest for operative management of depressed tibial plateau fractures.

Our study evaluates differences in fracture healing, clinical outcome and donor site morbidity between iliac crest bone graft and contra lateral proximal tibial bone graft utilized for internal fixation of displaced tibial plateau fractures. In 34 patients requiring bone grafting, iliac crest was utilized in 16 cases and proximal tibia in the remaining 18. Fracture union was achieved in all patients in either group at a mean period of 14 weeks with no difference in the functional knee scores between the groups. The iliac crest group showed significantly higher visual analogue pain scores in the immediate post-operative period and greater donor site complications like superficial wound infection, incisional hernia and chronic pain compared to the proximal tibial group. Contra lateral proximal tibia offers a viable alternative to iliac crest as a donor site for bone graft with adequacy of graft quantity, ease of graft harvest and lesser donor site morbidity.

Acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts.

PURPOSE: To review the outcome of acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts in 15 patients. METHODS: Records were reviewed for 3 men and 12 women aged 31 to 72 (mean, 53) years who underwent acetabular revision with bone grafting and cementation for aseptic loosening at a mean of 12.4 (range, 6.6-20.3) years after primary Charnley low-friction hip arthroplasty with superolateral structural bulk autografts from the femoral head for dysplastic hip (n=14) or bone loss secondary to acetabular fracture (n=1). RESULTS: After a mean follow-up of 6.7 (range, 1.1-14.5) years, the mean Merle d'Aubigné and Postel score improved from 8.55 to 16.5. Bridging trabeculae was noted in 10 hips and graft remodelling in 5 hips. Five hips had ectopic ossification of Brooker grade 1 to 2. The mean hip centre of rotation was 21.6 (range, 16.2-30.6) mm. Two women required re-revision for aseptic loosening of the acetabulum after 8.5 and 6.6 years. The first one underwent re-revision with solid allograft for superolateral deficiency of the acetabulum. The second one underwent re-revision with solid and morselised bone allografts for loosened acetabulum. One patient had superior migrationof the acetabulum for 9 mm at year 2, but it was asymptomatic. One patient had a dislocation that was reduced with manipulation under anaesthesia. Threepatients had trochanteric non-union and presented with lateral thigh pain and tenderness, but no further surgery was performed. CONCLUSION: The medium-term outcome of acetabular revision with bone grafting and cementation is satisfactory. Repeat bone grafting is required to restore the anatomic acetabular position and bone loss secondary to acetabular loosening.

Outcomes of dual-mobility acetabular cup for instability in primary and revision total hip arthroplasty.

BACKGROUND: The concept of a dual-mobility hip socket involves the standard femoral head component encased in a larger polyethylene liner, which in turn articulates inside a metal shell implanted in the native acetabulum. The aim of this study was to assess outcomes from using a Serf Novae(®) Dual Mobility Acetabular cup (Orthodynamics Ltd, Gloucestershire, UK) to address the problem of instability in primary and revision total hip arthroplasty (THA). MATERIALS AND METHODS: A retrospective review was carried out of all hip arthroplasties performed in a District General Hospital utilising the dual-mobility socket from January 2007 to December 2012. Clinical and radiological outcomes were analysed for 44 hips in 41 patients, comprising 20 primary and 24 revision THA. The average age of the study group was 70.8 years (range 56-84 years) for primary and 76.4 years (range 56-89 years) for revision arthroplasty. Among the primary THA, always performed for hip osteoarthritis or in presence of osteoarthritic changes, the reasons to choose a dual mobility cup were central nervous system problems such as Parkinson's disease, stroke, dementia (10), hip fracture (5), failed hip fracture fixation (2), severe fixed hip deformity (2) and diffuse peripheral neuropathy (1). The indications for revisions were recurrent dislocation (17), aseptic loosening with abductor deficiency (4), failed hemiarthroplasty with abductor deficiency (2) and neglected dislocation (1). RESULTS: At a mean follow-up of 22 months (range 6-63 months), none of the hips had any dislocation, instability or infection and no further surgical intervention was required. Radiological assessment showed that one uncemented socket in a revision arthroplasty performed for recurrent dislocation had changed position, but was stable in the new position. The patient did not have complications from this and did not need any surgical intervention. CONCLUSIONS: Even though postoperative hip stability depends on several factors other than design-related ones, our study shows promising early results for reducing the risk of instability in this challenging group of patients undergoing primary and revision hip arthroplasty. LEVEL OF EVIDENCE: IV.

Bacterial communities in the rumen of Holstein heifers differ when fed orchardgrass as pasture vs. hay.

The rich and diverse microbiota of the rumen provides ruminant animals the capacity to utilize highly fibrous feedstuffs as their energy source, but there is surprisingly little information on the composition of the microbiome of ruminants fed all-forage diets, despite the importance of such agricultural production systems worldwide. In three 28-day periods, three ruminally-cannulated Holstein heifers sequentially grazed orchardgrass pasture (OP), then were fed orchardgrass hay (OH), then returned to OP. These heifers displayed greater shifts in ruminal bacterial community composition (determined by automated ribosomal intergenic spacer analysis and by pyrotag sequencing of 16S rRNA genes) than did two other heifers maintained 84 d on the same OP. Phyla Firmicutes and Bacteroidetes dominated all ruminal samples, and quantitative PCR indicated that members of the genus Prevotella averaged 23% of the 16S rRNA gene copies, well below levels previously reported with cows fed total mixed rations. Differences in bacterial community composition and ruminal volatile fatty acid (VFA) profiles were observed between the OP and OH despite similarities in gross chemical composition. Compared to OP, feeding OH increased the molar proportion of ruminal acetate (P = 0.02) and decreased the proportion of ruminal butyrate (P < 0.01), branched-chain VFA (P < 0.01) and the relative population size of the abundant genus Butyrivibrio (P < 0.001), as determined by pyrotag sequencing. Despite the low numbers of animals examined, the observed changes in VFA profile in the rumens of heifers on OP vs. OH are consistent with the shifts in Butyrivibrio abundance and its known physiology as a butyrate producer that ferments both carbohydrates and proteins.

A study of biplanar crossed pin construct in the management of displaced pediatric supracondylar humeral fractures.

PURPOSE: Study of a biplanar crossed pin construct by two crossed Kirschner wires in the management of displaced extension type supracondylar humeral fractures in children. METHODS: Sixty-four patients with such fractures were included and treated according to the study protocol: after achieving closed reduction under general anesthesia with fluoroscopic control, two crossed Kirschner wires of equal diameter were inserted percutaneously. The first lateral wire tracts from the posterolateral corner of the epicondyle to the anteromedial cortex proximally. Then, the medial wire is inserted from the anteromedial corner of the epicondyle to the posterolateral cortex proximally after crossing the fracture site. Thus, a biplanar crossed pin construct was achieved, as each wire had two separate fixation points and the crossed construct was achieved not only in the coronal plane but also in the sagittal plane. Every effort was made to get this construct right at the very first attempt without repetition. RESULTS: Two patients were lost to follow-up during the first postoperative year. The mean follow-up for the remaining 62 patients was 14.5 months (range 6-24 months). At the final follow-up, using Flynn's overall modified classification, the clinical result was considered to be satisfactory in 60 (96.8 %) patients and unsatisfactory with poor result in two (3.2 %) patients. Technical error was thought to be the cause of the poor results. There were no postoperative neural or vascular complications. CONCLUSION: A biplanar crossed pin construct achieved by two Kirschner wires crossed in the coronal and sagittal planes is efficient to stabilize a displaced extension type supracondylar fracture of the humerus in children.

Severe metallosis owing to intraprosthetic dislocation in a failed dual-mobility cup primary total hip arthroplasty.

We report a case of extensive metallosis owing to an intraprosthetic dislocation of a dual-mobility cup after a primary total hip arthroplasty. A 70-year-old man was referred to us from another center with a painful right hip 3 years after the arthroplasty. Initial investigations were suspicious of osteolysis secondary to metallosis with the characteristic "bubble sign" visualized on plain radiographs. At the revision procedure, widespread black staining of soft tissues and bone was noted. The polyethylene liner had dislodged leading to erosion of the metal socket by the prosthetic head. Histopathology examination of periprosthetic tissue confirmed metallosis. To our knowledge, this is the first reported case of severe metallosis owing to a known complication of dual-mobility sockets.

Percutaneous elastic intramedullary nailing of metacarpal fractures: surgical technique and clinical results study.

BACKGROUND: We reviewed our results and complications of using a pre-bent 1.6 mm Kirschner wire (K-wire) for extra-articular metacarpal fractures. The surgical procedure was indicated for angulation at the fracture site in a true lateral radiograph of at least 30 degrees and/or in the presence of a rotatory deformity. METHODS: A single K-wire is pre-bent in a lazy-S fashion with a sharp bend at approximately 5 millimeters and a longer smooth curve bent in the opposite direction. An initial entry point is made at the base of the metacarpal using a 2.5 mm drill by hand. The K-wire is inserted blunt end first in an antegrade manner and the fracture reduced as the wire is passed across the fracture site. With the wire acting as three-point fixation, early mobilisation is commenced at the metacarpo-phalangeal joint in a Futuro hand splint. The wire is usually removed with pliers post-operatively at four weeks in the fracture clinic. RESULTS: We studied internal fixation of 18 little finger and 2 ring finger metacarpal fractures from November 2007 to August 2009. The average age of the cohort was 25 years with 3 women and 17 men. The predominant mechanism was a punch injury with 5 diaphyseal and 15 metacarpal neck fractures. The time to surgical intervention was a mean 13 days (range 4 to 28 days). All fractures proceeded to bony union. The wire was extracted at an average of 4.4 weeks (range three to six weeks). At an average follow up of 8 weeks, one fracture had to be revised for failed fixation and three superficial wound infections needed antibiotic treatment. CONCLUSIONS: With this simple and minimally invasive technique performed as day-case surgery, all patients were able to start mobilisation immediately. The general outcome was good hand function with few complications.

Closed retrograde retrieval of the distal broken segment of femoral cannulated intramedullary nail using a ball-tipped guide wire.

BACKGROUND: Extracting broken segments of intramedullay nails from long bones can be an operative challenge, particularly from the distal end. We report a case series where a simple and reproducible technique of extracting broken femoral cannulated nails using a ball-tipped guide wire is described. This closed technique involves no additional equipment or instruments. MATERIALS AND METHODS: Eight patients who underwent the described method were included in the study. The technique involves using a standard plain guide wire passed through the cannulated distal broken nail segment after extraction of the proximal nail fragment. The plain guide wire is then advanced distally into the knee joint carefully under fluoroscopy imaging. Over this wire, a 5-millimeter (mm) cannulated large drill bit is used to create a track up to the distal broken nail segment. Through the small knee wound, a ball-tipped guide wire is passed, smooth end first, till the ball engages the end of the nail. The guide wire is then extracted along with the broken nail through the proximal wound. RESULTS: The method was successfully used in all eight patients for removal of broken cannulated intramedullary nail from the femoral canal without any complications. All patients underwent exchange nailing with successful bone union in six months. None of the patients had any problems at the knee joint at the final follow-up. CONCLUSION: We report a technique for successful extraction of the distal fragment of broken femoral intramedullary nails without additional surgical approaches.

Radiation exposure during in-situ pinning of slipped capital femoral epiphysis hips: does the patient positioning matter?

Multiple radiographic images may be necessary during the standard procedure of in-situ pinning of slipped capital femoral epiphysis (SCFE) hips. This procedure can be performed with the patient positioned on a fracture table or a radiolucent table. Our study aims to look at any differences in the amount and duration of radiation exposure for in-situ pinning of SCFE performed using a traction table or a radiolucent table. Sixteen hips in thirteen patients who were pinned on radiolucent table were compared for the cumulative radiation exposure to 35 hips pinned on a fracture table in 33 patients during the same time period. Cumulative radiation dose was measured as dose area product in Gray centimeter2 and the duration of exposure was measured in minutes. Appropriate statistical tests were used to test the significance of any differences. Mean cumulative radiation dose for SCFE pinned on radiolucent table was statistically less than for those pinned on fracture table (P<0.05). The mean duration of radiation exposure on either table was not significantly different. Lateral projections may increase the radiation doses compared with anteroposterior projections because of the higher exposure parameters needed for side imaging. Our results showing decreased exposure doses on the radiolucent table are probably because of the ease of a frog leg lateral positioning obtained and thereby the ease of lateral imaging. In-situ pinning of SCFE hips on a radiolucent table has an additional advantage that the radiation dose during the procedure is significantly less than that of the procedure that is performed on a fracture table.

Perioperative bridging anticoagulation therapy in at-risk patients undergoing elective arthroplasty surgery.

We investigated the efficacy and safety of a standardized periprocedural anticoagulation bridging regimen that was instituted for patients who were on long-term oral anticoagulation therapy and were admitted for elective lower limb arthroplasty. Over a 3-month period, from March to June 2007, 15 inpatients who required temporary interruption of oral anticoagulation therapy in order to undergo elective orthopedic surgery were included in the study. All patients had bridging anticoagulation therapy instituted as per a standardized hospital protocol adapted from a British Orthopaedic Association publication. Patients were followed up prospectively during their inpatient stay. One operation was canceled, and 1 operating theatre list was rescheduled to delay a procedure because of nonadherence to the protocol. There were 2 cases of excessive surgical wound bruising, which caused additional morbidity and delayed discharge. One patient died from a cause unrelated to anticoagulation. Lack of proper knowledge of the bridging therapy protocol and improper communication between the medication prescribing and dispensing staff were the most important areas of concern. Given our study results, we believe that patient information and staff education are the key elements in successful implementation of a perioperative bridging anticoagulation protocol in elective arthroplasty.

Functional salvage of a mangled lower limb using custom-made endoprosthetic replacement.

Functional salvage of a severely injured extremity is a challenge for the patient and the treating surgeon. We report a case of a woman presenting with severely injured lower limb and bone loss, which was managed using a custom-made endoprosthetic replacement for successful functional outcome. Despite being complicated by bone loss, nerve injury and infection; a planned staged surgical treatment and rehabilitation have resulted in satisfactory outcome. At 3-year follow-up, the functional score according to the Musculoskeletal Tumor Society-International Symposium on Limb Salvage System was 70% and the Toronto Extremity Salvage Score was 62%. Endoprosthetic replacements may have a limited role in managing selected patients with mangled extremity and can lead to a good functional outcome to these patients.

Manipulation under anaesthesia for stiffness following knee arthroplasty.

INTRODUCTION: Stiffness following knee arthroplasty is a frustrating complication and a significantly disabling problem. We present our experience of knee stiffness requiring manipulation under anaesthesia (MUA) as the first line of treatment following partial or total knee arthroplasty. PATIENTS AND METHODS: All stiff knees requiring MUA over a 6-month period from March to August 2007 were retrospectively analysed from theatre records and case notes. Data were collected regarding demographics, range of knee motion before and after manipulation and at subsequent follow-up. Complications of the procedure and outcomes were also analysed. RESULTS: Twenty-one patients (11 female, 10 male) underwent MUA. The average age was 62 years (range, 56-80 years). Sixteen primary and 3 revision total knee replacements underwent manipulation, as did one medial unicompartmental replacement and one patellofemoral arthroplasty. General anaesthesia with good muscle relaxation was used in all but one patient. The mean duration between arthroplasty and MUA was 13.2 weeks (range, 6-32 weeks). The range of knee movement improved from a mean range of 10.4-71.2 degrees in the pre-MUA period to 2.1-94.0 degrees post-MUA and at follow-up was 2.3-91.9 degrees . The mean arc of motion improved from 60.2 degrees (range, 40-80 degrees ) pre-MUA to 91.9 degrees (range, 45-120 degrees ) post-MUA. The mean improvement in the arc of motion was 31.6 degrees (P < 0.001). At an average follow-up of 3 months (range, 6 weeks to 8 months), the mean arc of motion was 90.4 degrees (range, 40-120 degrees ). The mean improvement in knee movement from the pre-MUA at the follow-up was 30.2 degrees (P < 0.001). One patient failed to gain any improvement from MUA. There were no complications noted from the procedure. CONCLUSIONS: MUA has a role in the treatment of early stiffness with excellent immediate outcomes. We advocate that MUA should be the first line of management for stiff knee arthroplasties after failed physiotherapy.

Medium-term results of patellofemoral joint arthroplasty.

The results of a multi-surgeon, multi-implant series of patellofemoral joint arthroplasties performed over a ten year period are presented. All patellofemoral joint arthroplasties performed from 1997 to 2006 were retrospectively reviewed using case notes, radiographs and clinic appointments until their latest follow-up period. One hundred and one arthroplasties in 91 patients were followed up for an average period of 48 months (range 6-96 months). The average age was 57 years with female patients thrice as common as male patients. There were 5 (5%) complications with 1 deep infection and 4 stiff knees. Thirty five subsequent procedures were performed in 28 patients including arthroscopic debridement in 18, arthroscopic lateral retinacular release in 8, tibial tuberosity transfer in 3, manipulation for stiffness in 2, and revision to total knee arthroplasty in 4 patients (3 for progression of tibiofemoral osteoarthritis and 1 for infection). The necessity of further surgeries in one third of the study group suggests that close follow-up of these patients is needed to address any concerns that can be easily resolved.