Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study.

BACKGROUND: Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties. METHODS: Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties. RESULTS: A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision. CONCLUSION: Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up.

PURPOSE: Patients with an upper brachial plexus lesion can suffer from dysfunction, joint deformities and instability of the shoulder. The goal of this study was to determine pain, shoulder function, patient satisfaction and muscle strength in shoulder arthrodesis in patients with an upper brachial plexus lesion more than 15 years after surgery. METHODS: We retrospectively studied 12 patients with a brachial plexus lesion of mean age 46 years (27-61). At a mean of 19.8 years (15.4-30.3) after shoulder arthrodesis, patient-reported outcome measures (PROMs), range of motion (e.g., active and passive), patient satisfaction, strength of the affected and non-affected side (e.g., maximum isometric strength in Newton in forward and retroflexion, ab- and adduction, internal and external rotation) and position of fusion were obtained. PROMS consisted of the Visual Analogue Scale (VAS; 0-100, 0 being painless) for pain and the Disabilities of the Arm, Shoulder and Hand Score (DASH; 0-100, 0 being the best score) for function. RESULTS: At latest follow-up, the median VAS pain score was 49 (0-96) and 0 for, respectively, the affected and unaffected side. The DASH was 15 (8-46), meaning a reasonable to good function of the upper extremity. Active and passive retroflexion was significantly different (p = 0.028). All subjects stated that in the same situation they would undergo a shoulder arthrodesis again. The unaffected side was significantly stronger in every direction. Arthrodesis showed position of fusion of 31° (12-70) abduction, 20° (10-50) forward flexion and 22° (- 14 to 58) internal rotation. The unaffected side was significantly (p ≤ 0.05) stronger in every movement direction. CONCLUSION: At a mean of 20 years after shoulder arthrodesis, patients with an upper brachial plexus lesion are still satisfied with a good to moderate functional improvement. LEVEL OF EVIDENCE III: A retrospective cohort study.

Physical activity after outpatient surgery and enhanced recovery for total knee arthroplasty.

PURPOSE AND HYPOTHESIS: The purpose of this study was to 'objectively' measure improvement of physical activity with the use of an activity monitor between patients who followed an enhanced recovery- or outpatient surgery pathway after total knee arthroplasty (TKA). It was hypothesized that both pathways will have comparable physical activity after TKA at 6-week follow-up. METHODS: This prospective observational comparative case study was designed to investigate activity parameters (e.g. physical activity, number of steps, sit-stand transfers) of two different pathways after 6 weeks with the use of a non-invasive triaxial accelerometer activity monitor. This study included 20 patients with a mean age of 65.5 years (SD 6.1) undergoing TKA who were allocated to follow one of the two pathways: enhanced recovery (n = 10) or outpatient surgery (n = 10). Patients were monitored for 4 days pre-, 4 days during and 4 days after 5 weeks postoperatively. Patient-reported outcome measures (PROMs) and range of knee motion were obtained pre- and 6 weeks postoperatively. RESULTS: The activity parameters recovered steeply during the first 4 postoperative days and continued to improve within both pathways (n.s.). Preoperative and during the first 4 days and 5 weeks postoperative, activity parameters were comparable (n.s.) between both pathways but did not reach preoperative levels of physical activity and range of motion (n.s.). PROMs improved within each pathway, and no difference between both pathways was observed (n.s.). CONCLUSIONS: This study demonstrates that the early physical activity parameters of patients after TKA, following the outpatient surgery pathway, were similar to patients who followed the standard enhanced recovery pathway. The activity monitor is an added value for a more detailed and objective analysis of the physical performance in patients after TKA. LEVEL OF EVIDENCE: III.

Wearable sensor-based measures of step-up transfers are supplementary to patient-reported outcome measures following total joint arthroplasty.

PURPOSE: This study investigated the longitudinal assessment of step-up performance in patients undergoing total joint arthroplasty (TJA) and correlation with subjective patient reported outcome measures (PROMs). METHODS: In this sub-analysis of the ADAPT study, PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Block step-up (BS) transfers were assessed by wearable-derived measures of time. 76 patients undergoing TJA were included. Subgroups were formed isolating the worst performing quartile (low functioning (LF)) from the high functioning (HF), and outcomes were compared. RESULTS: One-year post-surgery, WOMAC function demonstrated strong correlations to WOMAC pain (Pearson's r = 0.67-0.84) and moderate correlations to BS performance (Pearson's r = 0.31-0.54). Both WOMAC and BS significantly improved with a larger effect size for the HF subgroup (0.62 vs. 0.43; p < 0.05). Patients designated to the LF subgroup at 3 months had increased odds of representing the LF subgroup at 12 months (WOMAC = 19; BS = 4). WOMAC defined 18 LF patients at 12 months follow-up. BS performance identified 9 additional LF patients. CONCLUSIONS: WOMAC function scores seem pain dominated. Measures of BS performance allow assessment of otherwise hidden residual functional impairment. Lower functioning 3 months post-surgery is predictive of longer-term impairment.

Severe hip or knee osteoarthritis is a disabling condition which not only impacts patients' mobility but restricts quality of life due to constant pain and consequential lifestyle changes.Total joint arthroplasty (TJA) has developed into a successful intervention for patients with advanced hip or knee osteoarthritis.Some patients are dissatisfied after TJA due to residual functional impairment and the inclusion of performance-based tests in the post-operative evaluation and rehabilitation allows for the assessment of otherwise hidden residual impairment.Early detection of functional impairment using the repeated block step-up (BS) transfers allows to facilitate more targeted rehabilitation for better functional outcomes.

Prosthetic hip-associated cobalt toxicity: a systematic review of case series and case reports.

Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty. The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms. A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients. The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases). Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system. The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings. We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing. Level of Evidence: Level V, systematic review.

The Viking viewer for connectomics: scalable multi-user annotation and summarization of large volume data sets.

Modern microscope automation permits the collection of vast amounts of continuous anatomical imagery in both two and three dimensions. These large data sets present significant challenges for data storage, access, viewing, annotation and analysis. The cost and overhead of collecting and storing the data can be extremely high. Large data sets quickly exceed an individual's capability for timely analysis and present challenges in efficiently applying transforms, if needed. Finally annotated anatomical data sets can represent a significant investment of resources and should be easily accessible to the scientific community. The Viking application was our solution created to view and annotate a 16.5 TB ultrastructural retinal connectome volume and we demonstrate its utility in reconstructing neural networks for a distinctive retinal amacrine cell class. Viking has several key features. (1) It works over the internet using HTTP and supports many concurrent users limited only by hardware. (2) It supports a multi-user, collaborative annotation strategy. (3) It cleanly demarcates viewing and analysis from data collection and hosting. (4) It is capable of applying transformations in real-time. (5) It has an easily extensible user interface, allowing addition of specialized modules without rewriting the viewer.

Control of a mucosal challenge and prevention of AIDS by a multiprotein DNA/MVA vaccine.

Heterologous prime/boost regimens have the potential for raising high levels of immune responses. Here we report that DNA priming followed by a recombinant modified vaccinia Ankara (rMVA) booster controlled a highly pathogenic immunodeficiency virus challenge in a rhesus macaque model. Both the DNA and rMVA components of the vaccine expressed multiple immunodeficiency virus proteins. Two DNA inoculations at 0 and 8 weeks and a single rMVA booster at 24 weeks effectively controlled an intrarectal challenge administered 7 months after the booster. These findings provide hope that a relatively simple multiprotein DNA/MVA vaccine can help to control the acquired immune deficiency syndrome epidemic.

Femoral fit in ABG-II hip stems, influence on clinical outcome and bone remodeling: a radiographic study.

INTRODUCTION: In a consecutive series of 64 patients with an ABG-II stem, we analyzed whether the tightness of the fit of the prosthesis affected bone remodeling and if there was a relation between clinical and radiological results. MATERIALS AND METHODS: Radiographic analysis of bone remodeling in different Gruen zones was done. Bone density changes were graded as present or absent in the AP and lateral radiographs as compared with the previous sets of radiographs. Bone remodeling was compared to literature values of the ABG-I stem. Three stem levels were defined. The proximal level was set at the upper border of the lesser trochanter, the mid-stem level at halfway the stem and the distal level 1 cm above the tip of the prosthesis. Femoral fit was defined as tight when the ratio of the fit was >/=0.8 and as non-tight if the fit was <0.8. The incidence of thigh pain was scored using the Merle d'Aubigne (MdA) hip score. RESULTS: Proximal bone resorption in Gruen zone 1 was 26.6% and in zone 7, 34.4% compared to 48 and 45% for the ABG-I stem after 5 years. No correlation was found between femoral fit and radiological changes. Proximal and distal fit was significantly lower for patients with thigh pain than without thigh pain. Patients with a non-tight proximal fit produced significantly more varus (17/30 = 56.7%) than patients with a tight proximal fit (2/34 = 5.9%; P < 0.01). CONCLUSION: Femoral fit in ABG-II does not predict certain radiological changes, but less proximal bone resorption confirms the design changes from ABG-I to ABG-II. A non-tight proximal fit is correlated with varus position of the stem. Thigh pain is correlated with a poor fit and fill of the femoral stem.

The development of a model for in vitro testing of femoral stems in impaction bone grafting.

Comprehension of the biomechanical behaviour of orthopaedic implants is essential. This paper describes the development of an in vitro model to investigate the behaviour of femoral implants in the revision setting. The development of a femoral model and a bone graft substitute is described. The properties of human, bovine, ovine morselized bone graft, and a graft substitute were compared. On measuring hoop strain after impaction bone grafting there was no significant difference between the ovine bone graft and graft substitute with the size 1 Exeter stem. The results suggest that this bone graft substitute is a viable alternative for in vitro testing. The authors recommend the use of the graft substitute and the femoral model to predict femoral stem biomechanics.

Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck: a systematic review and meta-analysis of current generation hip stems.

AIMS: Our aim was to prepare a systematic review and meta-analysis to compare the outcomes of cemented and cementless hemiarthroplasty of the hip, in elderly patients with a fracture of the femoral neck, to investigate the mortality, complications, length of stay in hospital, blood loss, operating time and functional results. MATERIALS AND METHODS: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on randomised controlled trials (RCTs), studying current generation designs of stem only. The synthesis of results was done of pooled data, with a fixed effects or random effects model, based on heterogeneity. RESULTS: A total of five RCTs including 950 patients (950 hips) were included. Cementless stems were found to be associated with more complications compared with cemented stems (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.12 to 2.31, p = 0.01), especially implant-related complications (OR 3.15, 95% CI 1.55 to 6.41, p = 0.002). The operating time was shorter for cementless stems (weighted mean difference -9.96 mins, 95%CI -12.93 to -6.98, p < 0.001). The data on functional outcomes could not be pooled. There was no statistically significant difference for any other outcome between the two methods of fixation. CONCLUSION: In hemiarthroplasty of the hip using current generation stems, cemented stems result in fewer implant-related complications and similar mortality compared with cementless stems. Cite this article: Bone Joint J 2017;99-B:421-31.

Novel insights in the control of tetrapyrrole metabolism of higher plants.

Tetrapyrrole biosynthesis has been the subject of numerous studies over several decades. In recent years scientific interest in plant tetrapyrrole biosynthesis has included both genetical and biochemical elucidation of almost every enzymatic step of the pathway and has focused to an increasing extent on the regulatory mechanism of the entire metabolic pathway, but in particular of key steps, such as synthesis of 5-aminolevulinate, magnesium chelatase or protochlorophyllide oxidoreductase.

Roles of Tetratricopeptide Repeat Proteins in Biogenesis of the Photosynthetic Apparatus.

Biosynthesis of the photosynthetic apparatus is a complex operation, which includes the concerted synthesis and assembly of lipids, pigments and metal cofactors, and dozens of proteins. Research conducted in recent years has shown that these processes, as well as the stabilization and repair of this molecular machinery, are facilitated by transiently acting regulatory proteins, many of which belong to the superfamily of helical repeat proteins. Here, we focus on one of its families in photoautotrophic model organisms, the tetratricopeptide repeat (TPR) proteins, which participate in almost all of these steps and are crucial for biogenesis of the thylakoid membrane.

Validity of an inertial measurement unit to assess pelvic orientation angles during gait, sit-stand transfers and step-up transfers: Comparison with an optoelectronic motion capture system.

An inertial measurement unit (IMU) allows kinematic evaluation of human motion with fewer operational constraints than a gold standard optoelectronic motion capture (MOCAP) system. The study's aim was to compare IMU and MOCAP measurements of dynamic pelvic orientation angles during different activities of daily life (ADL): gait, sit-to-stand (STS) transfers and block step-up (BS) transfers. A single IMU was attached onto the lower back in seventeen healthy participants (8F/9 M, age 19-31 years; BMI < 25) and optical skin markers were attached onto anatomical pelvic landmarks for MOCAP measurements. Comparisons between IMU and MOCAP by Bland-Altman plots demonstrated that measurements were between 2SD of the absolute difference and Pearson's correlation coefficients were between 0.85 and 0.94. Frontal plane pelvic angle estimations achieved a RMSE in the range of [2.7°-4.5°] and sagittal plane measurements achieved a RMSE in the range of [2.7°-8.9°] which were both lowest in gait. Waveform peak detection times demonstrated ICCs between 0.96 and 1.00. These results are in accordance to other studies comparing IMU and MOCAP measurements with different applications and suggest that an IMU is a valid tool to measure dynamic pelvic angles during various activities of daily life which could be applied to monitor rehabilitation in a wide variety of musculoskeletal disorders.

Assessment of physical function following total hip arthroplasty: Inertial sensor based gait analysis is supplementary to patient-reported outcome measures.

BACKGROUND: Functional outcome assessment after total hip arthroplasty often involves subjective patient-reported outcome measures whereas analysis of gait is more objective. The study's aims were to compare subjective and objective functional outcomes after total hip arthroplasty between patients with low and high self-reported levels of pre-operative physical function. METHODS: Patients undergoing total hip arthroplasty (n=36; m/f=18/18; mean age=63.9; SD=9.8 years; BMI=26.3; SD=3.5) were divided into a low and high function subgroup, and prospective measures of WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function score and gait were compared at baseline and 3 and 12 months post-operatively. FINDINGS: WOMAC function scores significantly improved in both low and high function subgroups at 3 months post-operatively whereas gait parameters only improved in patients with a low pre-operative function. Between 3 and 12 months post-operatively, WOMAC function scores had not significantly further improved whereas several gait parameters significantly improved in the low function group. WOMAC function scores and gait parameters were only moderately correlated (Spearman's r=0.33-0.51). INTERPRETATION: In a cohort of patients undergoing total hip arthroplasty, pre-operative differences in mean WOMAC function scores and gait parameters between low and high function subgroups disappeared by 3 months post-operatively. Gait parameters only improved significantly during the first 3 post-operative months in patients with a low pre-operative function, highlighting the importance of investigating relative changes rather than the absolute changes and the need to consider patients with high and low functions separately.

Crystallization and preliminary X-ray analysis of wild-type and K272A mutant glutamate 1-semialdehyde aminotransferase from Synechococcus.

Crystals of the pyridoxal-5'-phosphate dependent enzyme glutamate-1-semialdehyde aminotransferase (EC 5.4.3.8) from Synechococcus have been grown from polyethylene glycol solutions. The wild-type enzyme crystallizes in space group P2(1)2(1)2(1), with cell dimensions a = 68.4 A, b = 108.0 A, c = 122.6 A. The inactive mutant in which the cofactor-binding lysine 272 residue is replaced by alanine (K272A) gives monoclinic crystals of space group P2(1) with cell dimensions a = 67.1 A, b = 108.6 A, c = 124.5 A and beta = 115.7 degrees. These crystal forms diffract to 2.4 A and 2.7 A resolution, respectively.

Reduction of Uroporphyrinogen Decarboxylase by Antisense RNA Expression Affects Activities of Other Enzymes Involved in Tetrapyrrole Biosynthesis and Leads to Light-Dependent Necrosis.

We introduced a full-length cDNA sequence encoding tobacco (Nicotiana tabacum) uroporphyrinogen III decarboxylase (UROD; EC 4.1.1.37) in reverse orientation under the control of a cauliflower mosaic virus 35S promoter derivative into the tobacco genome to study the effects of deregulated UROD expression on tetrapyrrole biosynthesis. Transformants with reduced UROD activity were characterized by stunted plant growth and necrotic leaf lesions. Antisense RNA expression caused reduced UROD protein levels and reduced activity to 45% of wild type, which was correlated with the accumulation of uroporphyrin(ogen) and with the intensity of necrotic damage. Chlorophyll levels were only slightly reduced (up to 15%), indicating that the plants sustained cellular damage from accumulating photosensitive porphyrins rather than from chlorophyll deficiency. A 16-h light/8-h dark regime at high-light intensity stimulates the formation of leaf necrosis compared with a low-light or a 6-h high-light treatment. Transgenic plants grown at high light also showed inactivation of 5-aminolevulinate dehydratase and porphobilinogen deaminase, whereas the activity of coproporphyrinogen oxidase and the 5-aminolevulinate synthesizing capacity were not altered. We conclude that photooxidation of accumulating uroporphyrin(ogen) leads to the generation of oxygen species, which destabilizes other enzymes in the porphyrin metabolic pathway. This porphyrin-induced necrosis resembles the induction of cell death observed during pathogenesis and air pollution.

Restriction of Chlorophyll Synthesis Due to Expression of Glutamate 1-Semialdehyde Aminotransferase Antisense RNA Does Not Reduce the Light-Harvesting Antenna Size in Tobacco.

The formation of 5-aminolevulinate is a key regulatory step in tetrapyrrole biosynthesis. In higher plants, glutamate 1-semialdehyde aminotransferase (GSA-AT) catalyzes the last step in the sequential conversion of glutamate to 5-aminolevulinate. Antisense RNA synthesis for GSA-AT leads to reduced GSA-AT protein levels in tobacco (Nicotiana tabacum L.) plants. We have used these transgenic plants for studying the significance of chlorophyll (Chl) availability for assembly of the light-harvesting apparatus. To avoid interfering photoinhibitory stress, plants were cultivated under a low photon flux density of 70 [mu]mol photons m-2 s-1. Decreased GSA-AT expression does not seem to suppress other enzymic steps in the Chl pathway, indicating that reduced Chl content in transgenic plants (down to 12% of the wild-type level) is a consequence of reduced GSA-AT activity. Chl deficiency correlated with a drastic reduction in the number of photosystem I and photosystem II reaction centers and their surrounding antenna on a leaf area basis. Different lines of evidence from the transgenic plants indicate that complete assembly of light-harvesting pigment-protein complexes is given preference over synthesis of new reaction center/core complexes, resulting in fully assembled photosynthetic units with no reduction in antenna size. Photosynthetic oxygen evolution rates and in vivo Chl fluorescence showed that GSA-AT antisense plants are photochemically competent. Thus, we suggest that under the growth conditions chosen during this study, plants tend to maintain their light-harvesting antenna size even under limited Chl supply.

Kinetic Studies on the Xanthophyll Cycle in Barley Leaves (Influence of Antenna Size and Relations to Nonphotochemical Chlorophyll Fluorescence Quenching).

Xanthophyll-cycle kinetics as well as the relationship between the xanthophyll de-epoxidation state and Stern-Volmer type nonphotochemical chlorophyll (Chl) fluorescence quenching (qN) were investigated in barley (Hordeum vulgare L.) leaves comprising a stepwise reduced antenna system. For this purpose plants of the wild type (WT) and the Chl b-less mutant chlorina 3613 were cultivated under either continuous (CL) or intermittent light (IML). Violaxanthin (V) availability varied from about 70% in the WT up to 97 to 98% in the mutant and IML-grown plants. In CL-grown mutant leaves, de-epoxidation rates were strongly accelerated compared to the WT. This is ascribed to a different accessibility of V to the de-epoxidase due to the existence of two V pools: one bound to light-harvesting Chl a/b-binding complexes (LHC) and the other one not bound. Epoxidation rates (k) were decreased with reduction in LHC protein contents: kWT > kmutant >> kIML plants. This supports the idea that the epoxidase activity resides on certain LHC proteins. Irrespective of huge zeaxanthin and antheraxanthin accumulation, the capacity to develop qN was reduced stepwise with antenna size. The qN level obtained in dithiothreitol-treated CL- and IML-grown plants was almost identical with that in untreated IML-grown plants. The findings provide evidence that structural changes within the LHC proteins, mediated by xanthophyll-cycle operation, render the basis for the development of a major proportion of qN.

Reduced activity of geranylgeranyl reductase leads to loss of chlorophyll and tocopherol and to partially geranylgeranylated chlorophyll in transgenic tobacco plants expressing antisense RNA for geranylgeranyl reductase

The enzyme geranylgeranyl reductase (CHL P) catalyzes the reduction of geranylgeranyl diphosphate to phytyl diphosphate. We identified a tobacco (Nicotiana tabacum) cDNA sequence encoding a 52-kD precursor protein homologous to the Arabidopsis and bacterial CHL P. The effects of deficient CHL P activity on chlorophyll (Chl) and tocopherol contents were studied in transgenic plants expressing antisense CHL P RNA. Transformants with gradually reduced Chl P expression showed a delayed growth rate and a pale or variegated phenotype. Transformants grown in high (500 &mgr;mol m-2 s-1; HL) and low (70 &mgr;mol photon m-2 s-1; LL) light displayed a similar degree of reduced tocopherol content during leaf development, although growth of wild-type plants in HL conditions led to up to a 2-fold increase in tocopherol content. The total Chl content was more rapidly reduced during HL than LL conditions. Up to 58% of the Chl content was esterified with geranylgeraniol instead of phytol under LL conditions. Our results indicate that CHL P provides phytol for both tocopherol and Chl synthesis. The transformants are a valuable model with which to investigate the adaptation of plants with modified tocopherol levels against deleterious environmental conditions.

Patient-reported outcome measures versus inertial performance-based outcome measures: A prospective study in patients undergoing primary total knee arthroplasty.

BACKGROUND: Outcome assessment of total knee arthroplasty (TKA) by subjective patient reported outcome measures (PROMs) may not fully capture the functional (dis-)abilities of relevance. Objective performance-based outcome measures could provide distinct information. An ambulant inertial measurement unit (IMU) allows kinematic assessment of physical performance and could potentially be used for routine follow-up. AIM: To investigate the responsiveness of IMU measures in patients following TKA and compare outcomes with conventional PROMs. METHODS: Patients with end stage knee OA (n=20, m/f=7/13; age=67.4 standard deviation 7.7 years) were measured preoperatively and one year postoperatively. IMU measures were derived during gait, sit-stand transfers and block step-up transfers. PROMs were assessed by using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Society Score (KSS). Responsiveness was calculated by the effect size, correlations were calculated with Spearman's rho correlation coefficient. RESULTS: One year after TKA, patients performed significantly better at gait, sit-to-stand transfers and block step-up transfers. Measures of time and kinematic IMU measures demonstrated significant improvements postoperatively for each performance-based test. The largest improvement was found in block step-up transfers (effect size=0.56-1.20). WOMAC function score and KSS function score demonstrated moderate correlations (Spearman's rho=0.45-0.74) with some of the physical performance-based measures pre- and postoperatively. CONCLUSION: To characterize the changes in physical function after TKA, PROMs could be supplemented by performance-based measures, assessing function during different activities and allowing kinematic characterization with an ambulant IMU.