Aseptic loosening of the option stemmed tibial tray in the Zimmer NexGen LPS total knee arthroplasty system.

BACKGROUND: We investigated the relationship between the backside deformation of polyethylene (PE) tibial inserts and aseptic loosening of the Option stemmed tibial tray used with Zimmer NexGen posterior-stabilised (PS) devices. We hypothesized that explanted inserts used in PS designs would exhibit greater extents of PE backside deformation than those used in equivalent cruciate retaining (CR) designs and that PE inserts retrieved from total knee arthroplasties (TKAs) revised for aseptic tibial tray loosening would exhibit greater extents of backside deformation than TKAs revised for other reasons. METHODS: A total of 73 explanted fixed-bearing TKAs (42 CR and 31 PS) were examined. PE components underwent geometric examination with a coordinate measuring machine using validated techniques. Multiple regression modelling was used to identify variables associated with revision secondary to aseptic loosing and to determine factors associated with increased PE backside deformation. RESULTS: PE inserts retrieved from TKAs with aseptic loosening had significantly greater backside deformation than those retrieved from TKAs revised for other reasons (p < 0.001). Greater PE backside deformation was significantly associated with larger tray/insert clearance heights (p < 0.001), thinner inserts (p < 0.001) and PS TKAs (p = 0.001). CONCLUSION: PE backside deformation was significantly greater in the PS TKAs. This may provide one explanation for the increased rate of aseptic loosening reported with the Option tibial tray used with the Legacy Posterior Stabilised (LPS) system.

Erratum: Author Correction: The influence of HLA genotype on the development of metal hypersensitivity following joint replacement.

[This corrects the article DOI: 10.1038/s43856-022-00137-0.].

The influence of HLA genotype on the development of metal hypersensitivity following joint replacement.

Background: Over five million joint replacements are performed across the world each year. Cobalt chrome (CoCr) components are used in most of these procedures. Some patients develop delayed-type hypersensitivity (DTH) responses to CoCr implants, resulting in tissue damage and revision surgery. DTH is unpredictable and genetic links have yet to be definitively established. Methods: At a single site, we carried out an initial investigation to identify HLA alleles associated with development of DTH following metal-on-metal hip arthroplasty. We then recruited patients from other centres to train and validate an algorithm incorporating patient age, gender, HLA genotype, and blood metal concentrations to predict the development of DTH. Accuracy of the modelling was assessed using performance metrics including time-dependent receiver operator curves. Results: Using next-generation sequencing, here we determine the HLA genotypes of 606 patients. 176 of these patients had experienced failure of their prostheses; the remaining 430 remain asymptomatic at a mean follow up of twelve years. We demonstrate that the development of DTH is associated with patient age, gender, the magnitude of metal exposure, and the presence of certain HLA class II alleles. We show that the predictive algorithm developed from this investigation performs to an accuracy suitable for clinical use, with weighted mean survival probability errors of 1.8% and 3.1% for pre-operative and post-operative models respectively. Conclusions: The development of DTH following joint replacement appears to be determined by the interaction between implant wear and a patient's genotype. The algorithm described in this paper may improve implant selection and help direct patient surveillance following surgery. Further consideration should be given towards understanding patient-specific responses to different biomaterials.

Tibial tray debonding from the cement mantle is associated with deformation of the backside of polyethylene tibial inserts.

AIMS: The aim of this study was to investigate whether wear and backside deformation of polyethylene (PE) tibial inserts may influence the cement cover of tibial trays of explanted total knee arthroplasties (TKAs). METHODS: At our retrieval centre, we measured changes in the wear and deformation of PE inserts using coordinate measuring machines and light microscopy. The amount of cement cover on the backside of tibial trays was quantified as a percentage of the total surface. The study involved data from the explanted fixed-bearing components of four widely used contemporary designs of TKA (Attune, NexGen, Press Fit Condylar (PFC), and Triathlon), revised for any indication, and we compared them with components that used previous generations of PE. Regression modelling was used to identify variables related to the amount of cement cover on the retrieved trays. RESULTS: A total of 114 explanted fixed-bearing TKAs were examined. This included 76 used with contemporary PE inserts which were compared with 15 used with older generation PEs. The Attune and NexGen (central locking) trays were found to have significantly less cement cover than Triathlon and PFC trays (peripheral locking group) (p = 0.001). The median planicity values of the PE inserts used with central locking trays were significantly greater than of those with peripheral locking inserts (205 vs 85 microns; p < 0.001). Attune and NexGen inserts had a characteristic pattern of backside deformation, with the outer edges of the PE deviating inferiorly, leaving the PE margins as the primary areas of articulation. CONCLUSION: Explanted TKAs with central locking mechanisms were significantly more likely to debond from the cement mantle. The PE inserts of these designs showed characteristic patterns of deformation, which appeared to relate to the manufacturing process and may be exacerbated in vivo. This pattern of deformation was associated with PE wear occurring at the outer edges of the articulation, potentially increasing the frictional torque generated at this interface. Cite this article: Bone Joint J 2021;103-B(12):1791-1801.

Overnight switch from rasagiline to safinamide in Parkinson's disease patients with motor fluctuations: a tolerability and safety study.

BACKGROUND AND PURPOSE: When switching between monoamine oxidase type B (MAO-B) inhibitors, a 15-day suspension period is a precautionary measure to avoid a serotonin syndrome and hypertensive crisis. However, this indication results in a major inconvenience for parkinsonian patients because of the worsening of their clinical condition. In routine clinical practice, neurologists often perform a substitution of these two drugs without solution of continuity (i.e. overnight), to avoid worsening of fluctuations and prolonged OFF periods. Therefore, a safety open label study was performed to investigate the possible risks of switching overnight from rasagiline to safinamide. METHODS: The study population included 20 advanced patients with Parkinson's disease on stable treatment with rasagiline and levodopa (alone or in combination with other anti-parkinsonian medication). The possible occurrence of serotonin syndrome and hypertension was monitored through a strict clinical observation and a 24-h Holter recording (ABPM) performed twice, whilst subjects were on rasagiline and immediately after switching to safinamide. RESULTS: No cases of serotonin syndrome or hypertensive crisis occurred during the study. Changes that were not significant occurred in the primary end-point: 24-h mean blood pressure (BP) had a mild +4.4% increase in the ABPM2 versus ABPM1 (P = 0.17), 24-h systolic and diastolic BP values were slightly higher at ABPM2 compared to ABPM1 (respectively +3.3%, P = 0.13; and 5.4%, P = 0.08) and 24-h systolic BP variability was unchanged between the two ABPM evaluations (from 8.6 ± 2.9 to 8.9 ± 1.8; P = 0.27). CONCLUSION: The results of the present study confirm that the overnight switch from rasagiline to safinamide is safe and well tolerated by patients.

First operation in SPIDER and the path to complete MITICA.

The requirements of ITER neutral beam injectors (1 MeV, 40 A negative deuterium ion current for 1 h) have never been simultaneously attained; therefore, a dedicated Neutral Beam Test Facility (NBTF) was set up at Consorzio RFX (Padova, Italy). The NBTF includes two experiments: SPIDER (Source for the Production of Ions of Deuterium Extracted from Rf plasma), the full-scale prototype of the source of ITER injectors, with a 100 keV accelerator, to investigate and optimize the properties of the ion source; and MITICA, the full-scale prototype of the entire injector, devoted to the issues related to the accelerator, including voltage holding at low gas pressure. The present paper gives an account of the status of the procurements, of the timeline, and of the voltage holding tests and experiments for MITICA. As for SPIDER, the first year of operation is described, regarding the solution of some issues connected with the radiofrequency power, the source operation, and the characterization of the first negative ion beam.

Beam and installation improvements of the NIO1 ion source.

The NIO1 (Negative Ion Optimization phase 1) source can provide continuous beam operation, which is convenient for systematic parameter and equipment studies. Even in the pure volume production regime, the source yield was found to depend on conditioning procedures. Magnetic configuration tests continued adding magnets to the existing setup; the filter field component Bx has been progressively extended to span the -12 to 5 mT range, and as a trend, source performances improved with |Bx|. The progress of camera beam diagnostics and of the quality of the volume-produced H- beam is also shown. The status, off-line results, and reliability of a first NIO1 cesium oven are discussed; other upgrades in preparation (cavity ring down spectrometer, the end calorimeter, and conceptual tests of the energy recovery system) are also listed.

Effects of anabolic and catabolic nutrients on woody plant encroachment after long-term experimental fertilization in a South African savanna.

The causes of the worldwide problem of encroachment of woody plants into grassy vegetation are elusive. The effects of soil nutrients on competition between herbaceous and woody plants in various landscapes are particularly poorly understood. A long-term experiment of 60 plots in a South African savanna, comprising annual applications of ammonium sulphate (146-1166 kg ha-1 yr-1) and superphosphate (233-466 kg ha-1 yr-1) over three decades, and subsequent passive protection over another three decades, during which indigenous trees encroached on different plots to extremely variable degrees, provided an opportunity to investigate relationships between soil properties and woody encroachment. All topsoils were analysed for pH, acidity, EC, water-dispersible clay, Na, Mg, K, Ca, P, S, C, N, NH4, NO3, B, Mn, Cu and Zn. Applications of ammonium sulphate (AS), but not superphosphate (SP), greatly constrained tree abundance relative to control plots. Differences between control plots and plots that had received maximal AS application were particularly marked (16.3 ± 5.7 versus 1.2 ± 0.8 trees per plot). Soil properties most affected by AS applications included pH (H2O) (control to maximal AS application: 6.4 ± 0.1 to 5.1 ± 0.2), pH (KCl) (5.5 ± 0.2 to 4.0 ± 0.1), acidity (0.7 ± 0.1 to 2.6 ± 0.3 cmol kg-1), acid saturation (8 ± 2 to 40 ± 5%), Mg (386 ± 25 to 143 ± 15 mg kg-1), Ca (1022 ± 180 to 322 ± 14 mg kg-1), Mn (314 ± 11 to 118 ± 9 mg kg-1), Cu (3.6 ± 0.3 to 2.3 ± 0.2 mg kg-1) and Zn (6.6 ± 0.4 to 3.7 ± 0.4 mg kg-1). Magnesium, B, Mn and Cu were identified using principal component analysis, boundary line analysis and Kruskal-Wallis rank sum tests as the nutrients most likely to be affecting tree abundance. The ratio Mn/Cu was most related to tree abundance across the experiment, supporting the hypothesis that competition between herbaceous and woody plants depends on the availability of anabolic relative to catabolic nutrients. These findings, based on more than six decades of experimentation, may have global significance for the theoretical understanding of changes in vegetation structure and thus the practical control of invasive woody plants.

First experiments with the negative ion source NIO1.

Neutral Beam Injectors (NBIs), which need to be strongly optimized in the perspective of DEMO reactor, request a thorough understanding of the negative ion source used and of the multi-beamlet optics. A relatively compact radio frequency (rf) ion source, named NIO1 (Negative Ion Optimization 1), with 9 beam apertures for a total H(-) current of 130 mA, 60 kV acceleration voltage, was installed at Consorzio RFX, including a high voltage deck and an X-ray shield, to provide a test bench for source optimizations for activities in support to the ITER NBI test facility. NIO1 status and plasma experiments both with air and with hydrogen as filling gas are described. Transition from a weak plasma to an inductively coupled plasma is clearly evident for the former gas and may be triggered by rising the rf power (over 0.5 kW) at low pressure (equal or below 2 Pa). Transition in hydrogen plasma requires more rf power (over 1.5 kW).

A new deflection technique applied to an existing scheme of electrostatic accelerator for high energy neutral beam injection in fusion reactor devices.

A scheme of a neutral beam injector (NBI), based on electrostatic acceleration and magneto-static deflection of negative ions, is proposed and analyzed in terms of feasibility and performance. The scheme is based on the deflection of a high energy (2 MeV) and high current (some tens of amperes) negative ion beam by a large magnetic deflector placed between the Beam Source (BS) and the neutralizer. This scheme has the potential of solving two key issues, which at present limit the applicability of a NBI to a fusion reactor: the maximum achievable acceleration voltage and the direct exposure of the BS to the flux of neutrons and radiation coming from the fusion reactor. In order to solve these two issues, a magnetic deflector is proposed to screen the BS from direct exposure to radiation and neutrons so that the voltage insulation between the electrostatic accelerator and the grounded vessel can be enhanced by using compressed SF6 instead of vacuum so that the negative ions can be accelerated at energies higher than 1 MeV. By solving the beam transport with different magnetic deflector properties, an optimum scheme has been found which is shown to be effective to guarantee both the steering effect and the beam aiming.

Optics of the NIFS negative ion source test stand by infrared calorimetry and numerical modelling.

At National Institute for Fusion Science (NIFS), a multi-ampere negative ion source is used to support the R&D on H(-) production, extraction, and acceleration. In this contribution, we study the characteristics of the acceleration system of this source, in order to characterize the beam optics at different operational conditions. A dedicated experimental campaign was carried out at NIFS, using as main diagnostic the infra-red imaging of the beam profiles. The experimental measurements are also compared with 3D numerical simulations, in order to validate the codes and to assess their degree of reliability. The simulations show a satisfactory agreement with the experimental results.

Numerical simulations of the first operational conditions of the negative ion test facility SPIDER.

In view of the realization of the negative ion beam injectors for ITER, a test facility, named SPIDER, is under construction in Padova (Italy) to study and optimize production and extraction of negative ions. The present paper is devoted to the analysis of the expected first operations of SPIDER in terms of single-beamlet and multiple-beamlet simulations of the hydrogen beam optics in various operational conditions. The effectiveness of the methods adopted to compensate for the magnetic deflection of the particles is also assessed. Indications for a sequence of the experimental activities are obtained.

The Tribology of Explanted Hip Resurfacings Following Early Fracture of the Femur.

A recognized issue related to metal-on-metal hip resurfacings is early fracture of the femur. Most theories regarding the cause of fracture relate to clinical factors but an engineering analysis of failed hip resurfacings has not previously been reported. The objective of this work was to determine the wear volumes and surface roughness values of a cohort of retrieved hip resurfacings which were removed due to early femoral fracture, infection and avascular necrosis (AVN). Nine resurfacing femoral heads were obtained following early fracture of the femur, a further five were retrieved due to infection and AVN. All fourteen were measured for volumetric wear using a co-ordinate measuring machine. Wear rates were then calculated and regions of the articulating surface were divided into "worn" and "unworn". Roughness values in these regions were measured using a non-contacting profilometer. The mean time to fracture was 3.7 months compared with 44.4 months for retrieval due to infection and AVN. Average wear rates in the early fracture heads were 64 times greater than those in the infection and AVN retrievals. Given the high wear rates of the early fracture components, such wear may be linked to an increased risk of femoral neck fracture.

Shorter, rough trunnion surfaces are associated with higher taper wear rates than longer, smooth trunnion surfaces in a contemporary large head metal-on-metal total hip arthroplasty system.

Taper wear at the head-neck junction is a possible cause of early failure in large head metal-on-metal (LH-MoM) hip replacements. We hypothesized that: (i) taper wear may be more pronounced in certain product designs; and (ii) an increased abductor moment arm may be protective. The tapers of 104 explanted LH-MoM hip replacements revised for adverse reaction to metal debris (ARMD) from a single manufacturer were analyzed for linear and volumetric wear using a co-ordinate measuring machine. The mated stem was a shorter 12/14, threaded trunnion (n=72) or a longer, smooth 11/13 trunnion (n=32). The abductor moment arm was calculated from pre-revision radiographs. Independent predictors of linear and volumetric wear included taper angle, stem type, and the horizontal moment arm. Tapers mated with the threaded 12/14 trunnion had significantly higher rates of volumetric wear (0.402 mm3/yr vs. 0.123 mm3/yr [t=-2.145, p=0.035]). There was a trend to larger abductor moment arms being protective (p=0.055). Design variation appears to play an important role in taper-trunnion junction failure. We recommend that surgeons bear these findings in mind when considering the use of a short, threaded trunnion with a cobalt-chromium head.

Installation of a versatile multiaperture negative ion source.

Neutral Beam Injectors (NBI), which need to be strongly optimized in the perspective of DEMO reactor, request a thorough understanding of the negative ion source used and of the multi-beamlet optics. A relatively compact RF ion source, named NIO1 (Negative Ion Optimization 1), with 9 beam apertures for a total H(-) current of 130 mA, 60 kV acceleration voltage, is being installed at Padua, in Consorzio RFX, to provide a test bench for source optimizations in the framework of the accompanying activities in support to the ITER NBI test facility. NIO1 construction and status of the overall installation, including a high voltage deck and an optical cavity ring down spectrometer are here summarized and reported. Plasma and low voltage beam operations are discussed. Development of a sampling beam calorimeter (with small sampling holes, and a segmented cooling circuit) is also discussed.

Physics design of the injector source for ITER neutral beam injector (invited).

Two Neutral Beam Injectors (NBI) are foreseen to provide a substantial fraction of the heating power necessary to ignite thermonuclear fusion reactions in ITER. The development of the NBI system at unprecedented parameters (40 A of negative ion current accelerated up to 1 MV) requires the realization of a full scale prototype, to be tested and optimized at the Test Facility under construction in Padova (Italy). The beam source is the key component of the system and the design of the multi-grid accelerator is the goal of a multi-national collaborative effort. In particular, beam steering is a challenging aspect, being a tradeoff between requirements of the optics and real grids with finite thickness and thermo-mechanical constraints due to the cooling needs and the presence of permanent magnets. In the paper, a review of the accelerator physics and an overview of the whole R&D physics program aimed to the development of the injector source are presented.

Structural and functional comparison of the proboscis between tapirs and other extant and extinct vertebrates.

Tapirs (Perissodactyla: Tapiridae) are the only living vertebrates, beyond the order Proboscidea, found to possess a true proboscis, defined as a flexible tubular extension of the joint narial and upper labial musculature that serves, at least in part, to grasp food. Tapirs show only partial homology and analogy with elephants in the narial and upper labial structures, as well as in the skull bones and teeth. However, superficially similar extensions in other extant vertebrates differ greatly in anatomy and function. Therefore, they deserve new names: prorhiscis (e.g. Mammalia: Saiga tatarica), prorhinosis (e.g. Chondrichthyes: Callorhinchus spp.), prorhynchis (e.g. Osteichthyes: Campylomormyrus spp.) and progeneiontis (e.g. Osteichthyes: Gnathonemus spp.). Among non-mammalian vertebrates, no bird or reptile is known to possess a proboscis. Among fishes, there are various extensions of the rostrum, jaws, 'nose' and 'chin' that lack the required narial involvement. The skulls of extinct mammals within (e.g. deinotheres) and beyond (e.g. astrapotheres) the Proboscidea confirm that a proboscis evolved independently in several mammalian lineages before the Pliocene. This convergence with tapirs presumably reflects, in part, the advantages of concentrating the olfactory sensor on what is, effectively, the tip of a long mobile upper lip. However, the proboscis does not appear to have arisen de novo in any vertebrate post-Pliocene, and its continued evolution has apparently depended on the further development of its length, flexibility and innervations, as epitomized by elephants.

The clinical implications of elevated blood metal ion concentrations in asymptomatic patients with MoM hip resurfacings: a cohort study.

OBJECTIVE: To determine whether elevated blood cobalt (Co) concentrations are associated with early failure of metal-on-metal (MoM) hip resurfacings secondary to adverse reaction to metal debris (ARMD). DESIGN: Cohort study. SETTING: Single centre orthopaedic unit. PARTICIPANTS: Following the identification of complications potentially related to metal wear debris, a blood metal ion screening programme was instigated at our unit in 2007 for all patients with Articular Surface Replacement (ASR) and Birmingham MoM hip resurfacings. Patients were followed annually unless symptoms presented earlier. Symptomatic patients were investigated with ultrasound scan and joint aspiration. The clinical course of all 278 patients with 'no pain' or 'slight/occasional' pain and a Harris Hip Score greater than or equal to 95 at the time of venesection were documented. A retrospective analysis was subsequently conducted using mixed effect modelling to investigate the temporal pattern of blood Co levels in the patients and survival analysis to investigate the potential role of case demographics and blood Co levels as risk factors for subsequent failure secondary to ARMD. RESULTS: Blood Co concentration was a positive and significant risk factor (z=8.44, p=2×10(-16)) for joint failure, as was the device, where the Birmingham Hip Resurfacing posed a significantly reduced risk for revision by 89% (z=-3.445, p=0.00005 (95% CI on risk 62 to 97)). Analysis using Cox-proportional hazards models indicated that men had a 66% lower risk of joint failure than women (z=-2.29419, p=0.0218, (95% CI on risk reduction 23 to 89)). CONCLUSIONS: The results suggest that elevated blood metal ion concentrations are associated with early failure of MoM devices secondary to adverse reactions to metal debris. Co concentrations greater than 20 µg/l are frequently associated with metal staining of tissues and the development of osteolysis. Development of soft tissue damage appears to be more complex with females and patients with ASR devices seemingly more at risk when exposed to equivalent doses of metal debris.

Supplemental iodine as a key to reproduction in pandas?

Pandas are endemic to iodine-poor environments and appear to be specialized for a goitrogenic staple diet. In particular, the importance of thiocyanate in bamboos might possibly have been overlooked in captive breeding programs. Although excreted in urine, thiocyanate first antagonizes absorption of iodine by the thyroid (of parent, fetus and suckling juveniles) and the mammary glands. In livestock and humans, subclinical deficiency of iodine is known to result in reproductive problems (including retardation of the fetus and suckling infant) even where the mother appears to be unaffected beyond slight hyperplasia of the thyroid and subtle hypothyroidism as reflected by levels of thyroid hormones. We suggest that the possibilities of iodine deficiency or excess should be carefully considered wherever the reproductive rates of pandas are unsatisfactory.

Development of a versatile multiaperture negative ion source.

A 60 kV ion source (9 beamlets of 15 mA each of H(-)) and plasma generators are being developed at Consorzio RFX and INFN-LNL, for their versatility in experimental campaigns and for training. Unlike most experimental sources, the design aimed at continuous operation. Magnetic configuration can achieve a minimum ∣B∣ trap, smoothly merged with the extraction filter. Modular design allows for quick substitution and upgrading of parts such as the extraction and postacceleration grids or the electrodes in contact with plasma. Experiments with a radio frequency plasma generator and Faraday cage inside the plasma are also described.