En Bloc Total Vertebrectomy of the Thoracic and Lumbar Spine.

Background/Objectives: We evaluated the outcomes of patients undergoing en bloc total vertebrectomy at our institution within the last three decades. The aim of our study was to analyse the oncological and neurological outcomes and the changes over time. Methods: We included 22 consecutive patients treated with a total vertebrectomy at our institution between January 1990 and December 2022. The standard follow-up protocol for sarcoma patients was performed. Early complications were defined as complications within the first three months postoperatively. Local recurrence was defined as the reoccurrence of a tumour at least four months after surgery. Adequate statistical methods were applied to evaluate the survival rates and the influence of potential risk factors. A p-value of <0.05 was considered statistically significant. Results: From 1990 to 2010, five total vertebrectomies were performed each decade, whereas twelve patients underwent the procedure in the period from 2010 to 2022. The mean follow-up period was 101.25 months (±112; 2-339). The one-, five- and ten-year overall survival rates were 91% (CI = (0.79; 1.00)), 59% (CI = (0.37; 0.81)) and 51% (CI = (0.27; 0.75)), respectively. For soft tissue tumours, the average overall survival was 6.2 years, whereas, for bone sarcomas, it was 13.6 years. None of the patients with wide surgical margins developed local recurrence. Complications necessitating revision procedures occurred in 54% of all cases. Conclusions: A total vertebrectomy is a highly demanding procedure, requiring accurate patient selection, meticulous preoperative planning and a highly collaborative interdisciplinary team. Adequate surgical treatment seems to be indispensable when aiming for curative treatment. Owing to the rarity of the indications, this procedure should be restricted to large tumour centres.

Domain adaptation strategies for 3D reconstruction of the lumbar spine using real fluoroscopy data.

In this study, we address critical barriers hindering the widespread adoption of surgical navigation in orthopedic surgeries due to limitations such as time constraints, cost implications, radiation concerns, and integration within the surgical workflow. Recently, our work X23D showed an approach for generating 3D anatomical models of the spine from only a few intraoperative fluoroscopic images. This approach negates the need for conventional registration-based surgical navigation by creating a direct intraoperative 3D reconstruction of the anatomy. Despite these strides, the practical application of X23D has been limited by a significant domain gap between synthetic training data and real intraoperative images. In response, we devised a novel data collection protocol to assemble a paired dataset consisting of synthetic and real fluoroscopic images captured from identical perspectives. Leveraging this unique dataset, we refined our deep learning model through transfer learning, effectively bridging the domain gap between synthetic and real X-ray data. We introduce an innovative approach combining style transfer with the curated paired dataset. This method transforms real X-ray images into the synthetic domain, enabling the in-silico-trained X23D model to achieve high accuracy in real-world settings. Our results demonstrated that the refined model can rapidly generate accurate 3D reconstructions of the entire lumbar spine from as few as three intraoperative fluoroscopic shots. The enhanced model reached a sufficient accuracy, achieving an 84% F1 score, equating to the benchmark set solely by synthetic data in previous research. Moreover, with an impressive computational time of just 81.1 ms, our approach offers real-time capabilities, vital for successful integration into active surgical procedures. By investigating optimal imaging setups and view angle dependencies, we have further validated the practicality and reliability of our system in a clinical environment. Our research represents a promising advancement in intraoperative 3D reconstruction. This innovation has the potential to enhance intraoperative surgical planning, navigation, and surgical robotics.

Two-stage revision for periprosthetic joint infection after hip and knee arthroplasty.

Aims: Histology is widely used for diagnosis of persistent infection during reimplantation in two-stage revision hip and knee arthroplasty, although data on its utility remain scarce. Therefore, this study aims to assess the predictive value of permanent sections at reimplantation in relation to reinfection risk, and to compare results of permanent and frozen sections. Methods: We retrospectively collected data from 226 patients (90 hips, 136 knees) with periprosthetic joint infection who underwent two-stage revision between August 2011 and September 2021, with a minimum follow-up of one year. Histology was assessed via the SLIM classification. First, we analyzed whether patients with positive permanent sections at reimplantation had higher reinfection rates than patients with negative histology. Further, we compared permanent and frozen section results, and assessed the influence of anatomical regions (knee versus hip), low- versus high-grade infections, as well as first revision versus multiple prior revisions on the histological result at reimplantation. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), chi-squared tests, and Kaplan-Meier estimates were calculated. Results: Overall, the reinfection rate was 18%. A total of 14 out of 82 patients (17%) with positive permanent sections at reimplantation experienced reinfection, compared to 26 of 144 patients (18%) with negative results (p = 0.996). Neither permanent sections nor fresh frozen sections were significantly associated with reinfection, with a sensitivity of 0.35, specificity of 0.63, PPV of 0.17, NPV of 0.81, and accuracy of 58%. Histology was not significantly associated with reinfection or survival time for any of the analyzed sub-groups. Permanent and frozen section results were in agreement for 91% of cases. Conclusion: Permanent and fresh frozen sections at reimplantation in two-stage revision do not serve as a reliable predictor for reinfection.

The influence of biological DMARDs on aseptic arthroplasty loosening: a retrospective cohort study.

OBJECTIVE: To investigate whether biological DMARDs affect the risk of aseptic loosening after total hip/knee arthroplasty (THA/TKA) in patients with RA. METHODS: We retrospectively identified all patients suffering from RA who underwent THA/TKA at our academic centre between 2002 and 2015 and linked them with an existing prospective observational RA database at our institution. The risk of aseptic loosening was estimated using radiological signs of component loosening (RCL). A time-dependent Cox regression analysis was used to compare the risk of implant loosening between patients treated with traditional DMARDS and biological DMARDs, or alternately both over time. RESULTS: A total of 155 consecutive total joint arthroplasties (TJAs) (103 TKA vs 52 THA) was retrospectively included in the study. Mean age at implantation was 59 ± 13 years. Mean follow-up time was 69 ± 43 months. Overall, 48 (31%) TJAs showed signs of RCL, with 28 (27.2%) RCLs occurring after TKA compared with 20 after THA (38.5%). A significant difference regarding the incidence of RCL between the traditional DMARDs group (39 cases of RCL, 35%) and the biological DMARDs group (nine cases of RCL, 21%) (P = 0.026) was observed using the log-rank test. This was also true when using a time-dependent Cox regression with therapy as well as arthroplasty location (hip vs knee) as variables (P = 0.0447). CONCLUSION: Biological DMARDs may reduce the incidence of aseptic loosening after TJA in patients with RA compared with traditional DMARDs. This effect seems to be more pronounced after TKA than THA.

Early postoperative laboratory parameters are predictive of initial treatment failure in acute septic arthritis of the knee and shoulder joint.

Septic arthritis is an orthopedic emergency potentially causing irreversible joint damage. However, the predictive value of potential risk factors such as early postoperative laboratory parameters remains uncertain. We investigated risk factors for initial surgical treatment failure using data from 249 patients (194 knees, 55 shoulders) treated for acute septic arthritis between 2003 and 2018. Necessity for further surgical intervention was defined as primary outcome. Demographic data, medical history, initial and postoperative laboratory parameters, Charlson Comorbidity Index (CCI), and Kellgren and Lawrence classification were collected. Two scoring systems were developed as tools for failure risk estimation after initial surgical irrigation and debridement. More than one intervention was necessary in 26.1% of cases. Treatment failure occurred significantly more often for those with longer symptom duration (p = 0.003), higher CCI grades (p = 0.027), Kellgren-Lawrence grade IV (p = 0.013), shoulder arthroscopy (p = 0.010), positive bacterial culture results (p < 0.001), slow postoperative CRP decline until day three (p = 0.032) and five (p = 0.015), reduced WBC-decline (p = 0.008), and lower hemoglobin (p < 0.001). Scores for third and fifth postoperative day achieved AUCs of 0.80 and 0.85, respectively. This study identified risk factors for treatment failure in patients with septic arthritis, suggesting that early postoperative laboratory parameters can guide further treatment.

Do Elevated Serum C-Reactive-Protein Levels Excuse Delayed Surgery for Femoral Neck Fractures?

In elderly patients with femoral neck fractures, preoperative serum C-reactive protein (CRP) values might be elevated due to active infections. Although there are limited data on CRP as a predictor of periprosthetic joint infection (PJI), out of concern, this could lead to delayed surgery. Therefore, we aim to investigate whether elevated serum-CRP levels justify delayed surgery for femoral neck fractures. A retrospective analysis was performed of the records of patients undergoing arthroplasty who were found to have an elevated CRP level of 5 mg/dL or more between January 2011 to December 2020. The patients were stratified to three groups, according to initial serum CRP levels at a cut off of 5 mg/dL and the time between admission and surgery (<48 vs. ≥48 h after admission). This study revealed that the patients with elevated serum CRP levels and delayed surgery showed a worse survival rate and significantly more postoperative complications than the patients on whom surgery was performed immediately. There were no significant differences in terms of PJI and prolonged wound healing in the inter-group comparison. Therefore, delays to surgery on the basis of elevated CRP values offer no benefits to patients with femoral neck fractures.

The accelerated waning of immunity and reduced effect of booster in patients treated with bDMARD and tsDMARD after SARS-CoV-2 mRNA vaccination.

Objectives: This study aimed to assess the duration of humoral responses after two doses of SARS-CoV-2 mRNA vaccines in patients with inflammatory joint diseases and IBD and booster vaccination compared with healthy controls. It also aimed to analyze factors influencing the quantity and quality of the immune response. Methods: We enrolled 41 patients with rheumatoid arthritis (RA), 35 with seronegative spondyloarthritis (SpA), and 41 suffering from inflammatory bowel disease (IBD), excluding those receiving B-cell-depleting therapies. We assessed total anti-SARS-CoV-2 spike antibodies (Abs) and neutralizing Ab titers 6 months after two and then after three doses of mRNA vaccines compared with healthy controls. We analyzed the influence of therapies on the humoral response. Results: Patients receiving biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) showed reduced anti-SARS-CoV-2 S Abs and neutralizing Ab titers compared with HC or patients receiving conventional synthetic (cs)DMARDs 6 months after the first two vaccination doses. Anti-SARS-CoV-2 S titers of patients with b/tsDMARDs declined more rapidly, leading to a significant reduction in the duration of vaccination-induced immunity after two doses of SARS-CoV-2 mRNA vaccines. While 23% of HC and 19% of patients receiving csDMARDs were without detectable neutralizing Abs 6 months after the first two vaccination doses, this number was 62% in patients receiving b/tsDMARDs and 52% in patients receiving a combination of csDMARDs and b/tsDMARDs. Booster vaccination led to increased anti-SARS-CoV-2 S Abs in all HC and patients. However, anti-SARS-CoV-2 S Abs after booster vaccination was diminished in patients receiving b/tsDMARDs, either alone or in combination with csDMARDs compared to HC. Conclusion: Patients receiving b/tsDMARDs have significantly reduced Abs and neutralizing Ab titers 6 months after mRNA vaccination against SARS-CoV-2. This was due to a faster decline in Ab levels, indicating a significantly reduced duration of vaccination-induced immunity compared with HC or patients receiving csDMARDs. In addition, they display a reduced response to a booster vaccination, warranting earlier booster vaccination strategies in patients under b/tsDMARD therapy, according to their specific Ab levels.

Nifurtimox induces apoptosis of neuroblastoma cells in vitro and in vivo.

Neuroblastoma is the most common extracranial solid tumor in children and, when disseminated, carries a poor prognosis. Even with aggressive combinations of chemotherapy, surgery, autologous bone marrow transplant, and radiation, long-term survival remains at 30% and new therapies are needed. Recently, a patient with neuroblastoma who acquired Chagas disease was treated with nifurtimox with subsequent reduction in tumor size. The effect of nifurtimox on the neuroblastoma cell lines CHLA-90, LA1-55n, LA-N2, SMS-KCNR, and SY5Y was examined. Nifurtimox decreased cell viability in a concentration-dependent manner. Cell morphology, terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling assay, and caspase-3 activation indicate that cell death was primarily due to apoptosis. Nifurtimox also suppressed basal and TrkB-mediated Akt phosphorylation, and the cytotoxicity of nifurtimox was attenuated by a tyrosine hydroxylase inhibitor (alpha-methyl-tyrosine). Nifurtimox killed catecholaminergic, but not cholinergic, autonomic neurons in culture. In vivo xenograft models showed inhibition of tumor growth with a histologic decrease in proliferation and increase in apoptosis. These results suggest that nifurtimox induces cell death in neuroblastoma. Therefore, further studies are warranted to develop nifurtimox as a promising new treatment for neuroblastoma.

Prolyl hydroxylase inhibitors delay neuronal cell death caused by trophic factor deprivation.

Nerve growth factor (NGF) serves a critical survival-promoting function for developing sympathetic neurons. Following removal of NGF, sympathetic neurons undergo apoptosis characterized by the activation of c-Jun N-terminal kinases (JNKs), up-regulation of BH3-only proteins including BcL-2-interacting mediator of cell death (BIM)(EL), release of cytochrome c from mitochondria, and activation of caspases. Here we show that two small-molecule prolyl hydroxylase inhibitors frequently used to activate hypoxia-inducible factor (HIF) - ethyl 3,4-dihydroxybenzoic acid (DHB) and dimethyloxalylglycine (DMOG) - can inhibit apoptosis caused by trophic factor deprivation. Both DHB and DMOG blocked the release of cytochrome c from mitochondria after NGF withdrawal, whereas only DHB blocked c-Jun up-regulation and phosphorylation. DHB, but not DMOG, also attenuated the induction of BIM(EL) in NGF-deprived neurons, suggesting a possible mechanism whereby DHB could inhibit cytochrome c release. DMOG, on the other hand, was substantially more effective at stabilizing HIF-2alpha and inducing expression of the HIF target gene hexokinase 2 than was DHB. Thus, while HIF prolyl hydroxylase inhibitors can delay cell death in NGF-deprived neurons, they do so through distinct mechanisms that, at least in the case of DHB, are partly independent of HIF stabilization.

Embryonic sympathoblasts transiently express TrkB in vivo and proliferate in response to brain-derived neurotrophic factor in vitro.

BACKGROUND: Nerve growth factor and neurotrophin-3 are involved in the development of sympathetic neurons; however, whether brain derived neurotrophic factor also plays a role is not known. The purpose of this study was to determine whether BDNF and its receptor, TrkB, are expressed during the development of paravertebral sympathetic ganglia in vivo and to determine the effect of BDNF in vitro. RESULTS: As neural crest cells coalesce to form sympathetic ganglia, TrkB-positive cells are seen in both chicken and mouse embryos. In chicken embryos, TrkB-expressing cells first appear at Hamburger-Hamilton Stage (St) 27 and they co-express HNK-1, confirming that they are migrating neural crest cells. The TrkB-positive cells lack neural markers at this stage; however, they migrate with other neurally differentiating cells that are TrkA and TrkC-positive. By St. 29/30, TrkB-positive cells begin to express the neural specific markers Hu C/D and Islet-1; eventually, all TrkB positive cells commence neural differentiation. By St. 34, TrkB and TrkC staining are lost. BDNF transcript expression parallels that of TrkB. In the mouse, TrkB-positive cells surround newly formed sympathetic ganglia and a small number of TrkB positive cells that co-express tyrosine hydroxylase are seen within ganglia between E13.5-15. In cell culture, many cells from St. 29-30 chicken lumbar sympathetic ganglia express neural markers and are dividing, indicating that they are sympathoblasts. Sympathoblasts and neurons require both nerve growth factor and neurotrophin-3 for survival. BDNF increases the number of cells expressing neural markers in culture by increasing number of cells that incorporate bromodeoxyuridine. In contrast, most TrkB-positive sympathetic cells in vivo are not actively proliferating between E6-E8. CONCLUSION: Developing paravertebral sympathetic ganglia in avian and murine embryos contain a subpopulation of sympathoblasts that transiently express TrkB and ultimately commence neuronal differentiation. These TrkB expressing sympathoblasts are not actively dividing in vivo; yet, when placed in vitro, will divide in response to BDNF. This suggests that the availability of BDNF in vivo fails to reach a threshold necessary to induce proliferation. We suggest that excess TrkB stimulation of sympathoblasts in vivo may lead to the genesis of neuroblastoma.

NGF deprivation-induced gene expression: after ten years, where do we stand?

Nerve growth factor (NGF) is required for the survival of developing sympathetic and sensory neurons. In the absence of NGF, these neurons undergo protein synthesis-dependent apoptosis. Ten years have gone by since the first reports of specific genes being upregulated during NGF deprivation-induced cell death. Over the last decade, a few additional genes (DP5, Bim, SM-20) have been added to a list that began with cyclin D1 and c-jun. In this chapter, we discuss the evidence that these genes act as regulators of neuronal cell death. We also suggest a hypothesis for how one gene, SM-20, may function to suppress a self-protection mechanism in NGF-deprived neurons.

SM-20, EGL-9, and the EGLN family of hypoxia-inducible factor prolyl hydroxylases.

Key to the transduction of signals from the environment to the cell nucleus are enzymes that post-translationally modify proteins. Modifications such as protein phosphorylation have long been known to regulate protein interactions, stability, and localization, as well as enzyme activity. Recent investigations into how cells respond to varying oxygen levels have identified a new mechanism for regulating signal transduction involving the post-translational hydroxylation of proline. The enzymes that catalyze this reaction comprise a novel family of prolyl hydroxylases, which include a growth-factor-responsive and cell-death-related protein (SM-20) in mammals, and a protein (EGL-9) in C. elegans important for normal egg laying.

Induction of SM-20 in PC12 cells leads to increased cytochrome c levels, accumulation of cytochrome c in the cytosol, and caspase-dependent cell death.

Sympathetic neurons deprived of nerve growth factor (NGF) release cytochrome c into the cytosol and undergo caspase-dependent cell death through a process that requires de novo gene expression. Expression of the SM-20 gene increases after NGF withdrawal, and ectopic SM-20 expression induces cell death in NGF-maintained neurons. To further evaluate the mechanism by which SM-20 promotes cell death, we developed a PC12-derived cell line in which SM-20 expression can be induced by addition of doxycycline to the culture medium. Induction of SM-20 in either undifferentiated or NGF-differentiated cells resulted in cell death. Cell death was accompanied by an increase in caspase activity and was inhibited by the caspase inhibitor zVAD-FMK. Analysis of cytochrome c in cytosolic and mitochondria-enriched subcellular fractions revealed that induction of SM-20 led to the accumulation of cytochrome c in the cytosol. Surprisingly, SM-20 expression also resulted in a selective increase in the total amount of cytochrome c protein. Thus, induction of SM-20 expression appears to affect both the amount and subcellular localization of cytochrome c in PC12 cells. These results suggest that SM-20 promotes caspase-dependent cell death through a mechanism involving cytochrome c.