Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes.

BACKGROUND: Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates. MATERIALS AND METHODS: Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically. RESULTS: Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group). CONCLUSIONS: CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

Minimally invasive osteosynthesis of distal tibial fractures using anterolateral locking plate: Evaluation of results and complications.

PURPOSE: Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on ante- rolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. METHODS: This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing. RESULTS: Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm). CONCLUSION: The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.

Histoid Leprosy Presenting with Keloid Like Lesions.

A 42 year old male presented with multiple, discrete, hyperpigmented, firm, non elastic, non tender papules and plaques on the posterior trunk of 5 months duration, resembling keloid. The patient had also a few skin colored papules on the anterior trunk and face. The sensations over the skin lesions were intact. The patient had glove and stocking type of anesthesia and bilaterally thickened, non tender peripheral nerve trunks. The slit skin smear for acid fast bacilli from the ear lobes, skin lesions and normal skin were highly positive for Mycobacterium leprae. A skin biopsy showed a well defined collection of spindle shaped histiocytes in the dermis packed with acid fast bacilli. We are presenting here a case of histoid leprosy presenting with keloid like lesions, probably the rarest presentation of histoid leprosy.

On-table reconstruction and fixation of Mason type III radial head fractures.

PURPOSE: To evaluate the functional and radiological outcome of comminuted radial head fractures, which were not amenable for classical open reduction with internal fixation, treated by on-table reconstruction and fixation using low profile plates. METHODS: We reviewed 6 patients of Mason type III radial head fractures treated by on-table reconstruction technique between 2011 and 2013. There were 5 men and 1 woman with a mean age of 35 years (range 25-46 years). All surgeries were carried out at our tertiary care level 1 trauma centre within a mean of 3 days (range 1-8 days) from date of injury using on-table reconstruction technique. The functional outcome was measured using elbow functional rating index described by Broberg and Morrey and the patient-based Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. RESULTS: The mean follow-up period was 25 months. The average elbow flexion was 135°(range 125°-140°) and theaverage flexion contracture was 5°(range 0-10°). The average supination and pronation was 75°(range 70°-80°) and 70°(range 65°-82°) respectively. According to Broberg and Morrey scoring system, the average score was 90 points (range 75-100). The mean DASH score was 2.49 points. CONCLUSION: On-table reconstruction and fixation of comminuted radial head fractures using low profile plates is a reasonable option. The reconstructed radial head acts as spacer and provides reasonably good results and no surgical intervention is required for asymptomatic nonunion of these fractures regardless of the radiological findings.

The clinical and radiological evaluation of the use of an allograft-prosthesis composite in the treatment of proximal femoral giant cell tumours.

Giant cell tumour is the most common aggressive benign tumour of the musculoskeletal system and has a high rate of local recurrence. When it occurs in proximity to the hip, reconstruction of the joint is a challenge. Options for reconstruction after wide resection include the use of a megaprosthesis or an allograft-prosthesis composite. We performed a clinical and radiological study to evaluate the functional results of a proximal femoral allograft-prosthesis composite in the treatment of proximal femoral giant cell tumour after wide resection. This was an observational study, between 2006 and 2012, of 18 patients with a mean age of 32 years (28 to 42) and a mean follow-up of 54 months (18 to 79). We achieved excellent outcomes using Harris Hip Score in 13 patients and a good outcome in five. All allografts united. There were no complications such as infection, failure, fracture or resorption of the graft, or recurrent tumour. Resection and reconstruction of giant cell tumours with proximal femoral allograft-prosthesis composite is a better option than using a prosthesis considering preservation of bone stock and excellent restoration of function. A good result requires demanding bone banking techniques, effective measures to prevent infection and stability at the allograft-host junction.

Characterization of Solanum tuberosum multicystatin and the significance of core domains.

Potato (Solanum tuberosum) multicystatin (PMC) is a unique cystatin composed of eight repeating units, each capable of inhibiting cysteine proteases. PMC is a composite of several cystatins linked by trypsin-sensitive (serine protease) domains and undergoes transitions between soluble and crystalline forms. However, the significance and the regulatory mechanism or mechanisms governing these transitions are not clearly established. Here, we report the 2.2-Šcrystal structure of the trypsin-resistant PMC core consisting of the fifth, sixth, and seventh domains. The observed interdomain interaction explains PMC's resistance to trypsin and pH-dependent solubility/aggregation. Under acidic pH, weakening of the interdomain interactions exposes individual domains, resulting in not only depolymerization of the crystalline form but also exposure of cystatin domains for inhibition of cysteine proteases. This in turn allows serine protease-mediated fragmentation of PMC, producing ∼ 10-kD domains with intact inhibitory capacity and faster diffusion, thus enhancing PMC's inhibitory ability toward cysteine proteases. The crystal structure, light-scattering experiments, isothermal titration calorimetry, and site-directed mutagenesis confirmed the critical role of pH and N-terminal residues in these dynamic transitions between monomer/polymer of PMC. Our data support a notion that the pH-dependent structural regulation of PMC has defense-related implications in tuber physiology via its ability to regulate protein catabolism.

Developmentally linked changes in proteases and protease inhibitors suggest a role for potato multicystatin in regulating protein content of potato tubers.

The soluble protein fraction of fully developed potato (Solanum tuberosum L.) tubers is dominated by patatin, a 40 kD storage glycoprotein, and protease inhibitors. Potato multicystatin (PMC) is a multidomain Cys-type protease inhibitor. PMC effectively inhibits degradation of patatin by tuber proteases in vitro. Herein we show that changes in PMC, patatin concentration, activities of various proteases, and their gene expression are temporally linked during tuber development, providing evidence that PMC has a role in regulating tuber protein content in vivo. PMC was barely detectable in non-tuberized stolons. PMC transcript levels increased progressively during tuberization, concomitant with a 40-fold increase in PMC concentration (protein basis) as tubers developed to 10 g fresh wt. Further increases in PMC were comparatively modest (3.7-fold) as tubers developed to full maturity (250 g). Protease activity declined precipitously as PMC levels increased during tuberization. Proteolytic activity was highest in non-tuberized stolons and fell substantially through the 10-g fresh wt stage. Cys-type proteases dominated the pre-tuberization and earliest stages of tuber development. Increases in patatin transcript levels during tuberization were accompanied by a notable lag in patatin accumulation. Patatin did not begin to accumulate substantially on a protein basis until tubers had reached the 10-g stage, wherein protease activity had been inhibited by approximately 60%. These results indicate that a threshold level of PMC (ca. 3 microg tuber(-1), 144 ng mg(-1) protein) is needed to favor patatin accumulation. Collectively, these results are consistent with a role for PMC in facilitating the accumulation of proteins in developing tubers by inhibiting Cys-type proteases.

Characterization of Solanum tuberosum multicystatin and its structural comparison with other cystatins.

Potato (Solanum tuberosum) multicystatin (PMC) is a crystalline Cys protease inhibitor present in the subphellogen layer of potato tubers. It consists of eight tandem domains of similar size and sequence. Our in vitro results showed that the pH/PO(4)(-)-dependent oligomeric behavior of PMC was due to its multidomain nature and was not a characteristic of the individual domains. Using a single domain of PMC, which still maintains inhibitor activity, we identified a target protein of PMC, a putative Cys protease. In addition, our crystal structure of a representative repeating unit of PMC, PMC-2, showed structural similarity to both type I and type II cystatins. The N-terminal trunk, alpha-helix, and L2 region of PMC-2 were most similar to those of type I cystatins, while the conformation of L1 more closely resembled that of type II cystatins. The structure of PMC-2 was most similar to the intensely sweet protein monellin from Dioscorephyllum cumminisii (serendipity berry), despite a low level of sequence similarity. We present a model for the possible molecular organization of the eight inhibitory domains in crystalline PMC. The unique molecular properties of the oligomeric PMC crystal are discussed in relation to its potential function in regulating the activity of proteases in potato tubers.

Extraction of RNA from fresh, frozen, and lyophilized tuber and root tissues.

A method for isolating transcriptionally competent RNA from fresh, frozen, and lyophilized plant storage tissues containing high levels of starch and phenolics is described. The protocol avoids the use of guanidium salts, which often lead to the formation of a viscous gel during extraction of high starch-containing tissues, and instead uses a borate-Tris buffer in combination with high concentrations of NaCl, Na2SO3, and sodium dodecyl sulfate in the extraction medium. RNA was extracted from fresh, frozen, and lyophilized tissues of potato tubers, storage roots of sweet potato, radish, and turnip, and rhizomes of ginger. The yield of RNA from potato tubers averaged 281 microg g fresh weight(-1) and 1584 microg g dry weight(-1) from frozen and lyophilized samples, respectively. A260/A230 ratios of potato RNA extracts were 2.2 or greater, indicating minimal contamination by polyphenols and carbohydrates. Similarly, A260/A280 ratios exceeded 1.9, demonstrating minimal contamination of the RNA by tuber protein. While A260/A280 ratios of extracts from the other plant species were somewhat lower than those for potato (average = 1.56 and 1.80 for fresh and lyophilized samples, respectively), A260/A230 ratios averaged more than 2.0, and the RNA extracted from fresh and lyophilized samples of all species was intact, as demonstrated by denaturing agarose-formaldehyde gel electrophoresis. The protocol yielded RNA suitable for downstream molecular applications involving reverse transcription-polymerase chain reaction from all five species. Transcriptionally competent RNA was also recovered from lyophilized potato tuber tissue stored for 6 years (ambient temperature) by a simple modification to the protocol involving extraction in cold acetone. Lyophilization can thus be used to preserve RNA in high starch- and phenolic-containing plant tissues for studies on gene expression.

Phase I and pharmacologic study of a 3-hour infusion of paclitaxel followed by cisplatinum and 5-fluorouracil in patients with advanced solid tumors.

A Phase I and pharmacological study of paclitaxel administered as an outpatient, 3-h i.v. infusion just before a 5-day regimen of daily cisplatinum (CP) and a continuous infusion of 5-fluorouracil (5-FU) was performed in patients with advanced solid tumors. A secondary objective was to determine the objective response rate to this regimen. Forty-two patients were enrolled and were evaluable for toxicities. Eighteen patients were previously untreated, whereas the rest had received prior treatment with radiation (J. H. Schiller et al., J. Clin. Oncol., 12: 241-248, 1994), chemotherapy (M. J. Kennedy et al., Clin. Cancer Res., 4: 349-356, 1998), or both modalities (J. H. Schiller et al., J. Clin. Oncol., 12: 241-248, 1994). The paclitaxel dose was escalated from 100-135-170-200-225 to 250 mg/m2, whereas i.v. 5-FU and CP doses were fixed at 1.0 g/m2/day continuous infusion and 20 mg/m2/day, respectively, daily for 5 days. Granulocyte colony-stimulating factor (G-CSF; 5 microg/kg/day) was administered s.c. from day 6, routinely after 250 mg/m2 dose of paclitaxel or after a lower dose of paclitaxel if ANC <500/microl or febrile neutropenia was observed. Patients were treated every 28 days. Plasma and urine samples were collected to determine the pharmacokinetics of paclitaxel. In previously untreated patients, the maximally tolerated dose of paclitaxel in the drug regimen was determined to be 170 mg/m2 without and 250 mg/m2 with G-CSF support. At the higher dose level, mucositis and thrombocytopenia were dose-limiting. In previously treated patients, these toxicities were observed at all dose levels of paclitaxel > or =135 mg/m2. With increasing doses of paclitaxel, a disproportionate increase in the peak concentrations, as well as the area under plasma concentration time-curve, was seen. This nonlinearity was due to saturable total body clearance and volume of distribution of paclitaxel (P < 0.001). The apparent plasma elimination half-life was unaffected by the dose of paclitaxel. CP and 5-FU had no apparent effect on the metabolism of paclitaxel. Among 32 patients evaluable for response, 22 demonstrated an objective response, including five complete remissions. Therefore, a regimen of 3-h infusion of 250 mg/m2 paclitaxel before CP and FU is tolerable with G-CSF (as above) support in previously untreated patients. The regimen also seems to be highly active against breast and esophageal cancers.

Dexamethasone induction of taxol metabolism in the rat.

This study examined the effect of dexamethasone (DEX), 100 mg/kg/day for 3 days, on [3H]taxol metabolism in liver microsomes and hepatocytes of male and female Sprague-Dawley rats. In control rats, two isomeric monohydroxylated metabolites, M1 and M2, were formed. The formation of both metabolites was 2-3 times greater in the male than in the female animals. After DEX treatment, M1 increased 2.6-fold in the male animals and 6.5-fold in the female animals. This was accompanied by similar increases in hepatic cytochrome P4503A protein and testosterone 6 beta-hydroxylation. Three additional metabolites (U1, U2, and U3) were formed in the DEX-treated animals only. Isolation of these metabolites from rat hepatocyte incubates by reversed-phase HPLC permitted structure identification of U2 and U3, using tandem MS. The mass spectrum of U3 was consistent with deacetylation of taxol, whereas the mass spectrum of U2 was consistent with deacetylation of the monohydroxylated taxol metabolite M2. A comparison of HPLC and MS data for U3 with those of standard 10-deacetyltaxol suggested that the site of deacetylation might be the 4-position of the taxane ring. Preliminary observations indicate that the deacetylation is caused by a DEX-inducible cytochrome P450.

Taxol metabolism and disposition in cancer patients.

The objective of this study was to determine the metabolic fate and disposition of taxol in cancer patients. Five patients received 225 or 250 mg/m2 of taxol together with 100 microCi of [3H]taxol as a 3-hr infusion, followed by cisplatin and 5-fluorouracil. Urine, feces, and blood samples were collected for 120 hr and analyzed for total radioactivity, taxol, and metabolites by reversed-phase HPLC and tandem MS. Total urinary excretion was 14.3 +/- 1.4% (SE) of the dose, with unchanged taxol and an unknown polar metabolite as the main excretion products. Total fecal excretion was 71.1 +/- 8.2%, with 6 alpha-hydroxytaxol being the largest component by far. Unchanged taxol and four other metabolites could also be identified from fecal extracts. The plasma area under the curve for unchanged taxol was 20.5 +/- 2.3 microM.hr and that for total taxol metabolites was 14.2 +/- 4.5 microM.hr. The half-life of total metabolites (5.6 +/- 0.4 hr), however, greatly exceeded that of unchanged taxol (2.9 +/- 0.3 hr). Thus, at 5-hr posttaxol infusion, the plasma concentrations of the five metabolites together exceeded the taxol concentration by 2.4-fold. The findings from this study should be of importance as a guide to further therapeutic evaluation of this drug.

Cytochrome P450 3A-mediated human liver microsomal taxol 6 alpha-hydroxylation.

The antitumor drug taxol was metabolized to one major (6 alpha-hydroxytaxol) and two minor metabolites by human liver microsomes. A 10-fold interindividual variability with a Vmax of 1.16 +/- 0.85 nmol/hr/mg of microsomal protein and a Km of 18.0 +/- 12.2 microM was observed for taxol 6 alpha-hydroxylation (mean +/- S.D.; n = 6). The NADPH-dependency and the inhibitory effect of carbon monoxide and piperonyl butoxide on taxol metabolism indicated the involvement of cytochrome P450 (CYP) monooxygenases. Chemical inhibition studies pointed to the CYP 3A subfamily as being responsible for taxol 6 alpha-hydroxylation. However, although some CYP 3A substrates were inhibitory (midazolam, 17 alpha-ethinyl estradiol, quercetin, verapamil and testosterone), others were not (troleandomycin, erythromycin and cyclosporin A). The inhibition was found to be competitive with low Ki values for midazolam (10.5 microM) and 17 alpha-ethinyl estradiol (4.5 microM). Taxol 6 alpha-hydroxylation correlated well with the metabolism of 17 alpha-ethinyl estradiol (r = 0.874; P < .05) and midazolam (r = 0.954; P < .01) in the same livers. Rabbit anti-rat CYP 3A1 antibodies, which cross-react with human CYP 3A isoforms, were inhibitory of taxol 6 alpha-hydroxylation. Although the evidence from these experiments supported the CYP 3A mediation of taxol 6 alpha-hydroxylation, the lack of effect of some inhibitors combined with the inability of a human CYP 3A4 transfected cell line to metabolize taxol point to a CYP 3A isoform other than 3A4. The findings in this study could prove clinically useful for the prediction of potential drug interactions, both inhibitory and inductive of taxol metabolism.

Taxol metabolism in rat hepatocytes.

Metabolism of the anticancer drug taxol was investigated in freshly isolated rat hepatocytes. Two main metabolites were separated by reversed-phase HPLC and shown by tandem mass spectrometry to be monohydroxylated metabolites. Kinetic studies revealed apparent Km values of 68 and 61 microM with identical Vmax values for the two metabolites. Verapamil and midazolam, but not phenacetin, showed concentration-dependent inhibition of taxol metabolism with both metabolites being affected equally. The IC50 was about 100 microM for verapamil and 25 microM for midazolam. These observations demonstrate for the first time in vitro metabolism of taxol and suggest that the metabolism may be subject to potentially important interactions with numerous other drugs.

Binding of taxol to human plasma, albumin and alpha 1-acid glycoprotein.

The binding of taxol to human plasma and to individual plasma proteins was studied by equilibrium dialysis. Taxol was found to bind extensively (about 95%) without a significant difference between healthy volunteers and cancer patients. At clinically relevant concentrations (0.1-6 microM), the binding was found to be concentration independent, indicating nonspecific hydrophobic binding. Human serum albumin and alpha 1-acid glycoprotein were found to contribute about equally to the binding, with a minor contribution from lipoproteins. None of the drugs commonly coadministered with taxol (dexamethasone, diphenhydramine, ranitidine, doxorubicin, 5-fluorouracil and cisplatin) altered the binding of taxol significantly. The protein binding of taxol was found to dramatically decrease the red blood cell uptake of taxol.