Outflow Graft Obstruction due to Local Aortic Dissection After Implantation of Left Ventricle Assist Device (HeartMate 3).

Left ventricular assist devices (LVADs) improve symptoms and outcomes in patients with advanced heart failure. We report the case of a patient with a freshly implanted HeartMate 3 LVAD, suffering abruptly on postoperative day 55 from pejoration of his heart failure with multiple episodes of low-flow alarm. Outflow graft obstruction (OGO) due to local aortic dissection was diagnosed with multimodality imaging. After a multidisciplinary discussion, a surgical approach was decided, and the patient benefited from a revision of his outflow graft.

Pre-selection blade size choice for the microsurgical clipping of cerebral artery aneurysms: A numerical study.

BACKGROUND: Brain strokes comprise the third leading cause of death worldwide. Microsurgical clipping is recognized as being one of the most effective approaches to the treatment of brain aneurysms. The incomplete closure of the distal-side aneurysm neck is the most common cause of the persistent filling of the dome. Since the diameter of the neck increases when the neck of the aneurysm is squeezed closed by the blades of the clip, the blades should be correspondingly longer. This study provided an assessment of whether the presurgical selection of clips using a 3D planning system is feasible in terms of selecting the most suitable clip for aneurysm occlusion. METHODS: The computational model was created based on computer tomography data obtained from nine brain aneurysms. The closing of the aneurysm was provided in two steps. The first the length of the blades used for closing corresponded to the length of the aneurysm neck as confirmed by the radiological measurements. The second the length of the blades was adjusted according to stage one, so as to determine the minimum required for the closure of all the gaps in the interior space of the aneurysm neck. RESULTS: No differences were detected between the radiological measurement of the aneurysm neck size and the measurements obtained from the reconstructed stereolithographic 3D models. It was observed that the size of the aneurysm neck increased following clipping by 40% to 60% of its original size. The larger the aneurysm neck, the greater the deformation of the aneurysm. CONCLUSION: Firstly, the 3D reconstruction of CT/MRI data did not result in any loss of accuracy and the measurement of the neck of the aneurysm was the same for both of the methods employed. The second, and more important, outcome was that the deformation of the neck of the cerebral aneurysm is at least 1.4x greater than its original size. This information is essential in terms of the pre-selection of the size of the clip.

Structural properties of the extracellular biopolymer (ß-D-xylo-α-D-mannan) produced by the green microalga Gloeocystis vesiculosa Nägeli.

Many species of microalgae produce a relatively diverse range of metabolites that are interesting for biotechnological applications, and among them exopolysaccharides attract attention due to their structural complexity, biological activities, biodegradability or biocompatibility. An exopolysaccharide of high molecular weight (Mp) of 6.8 × 105 g/mol was obtained by cultivation of the freshwater green coccal microalga Gloeocystis vesiculosa Nägeli 1849 (Chlorophyta). Chemical analyses revealed a dominance of Manp (63.4 wt%), Xylp and its 3-O-Me-derivative (22.4 wt%), and Glcp (11.5 wt%) residues. The results of the chemical and NMR analyses showed an alternating branched 1,2- and 1,3-linked α-D-Manp backbone terminated by a single ß-D-Xylp and its 3-O-methyl derivative at O2 of the 1,3-linked α-D-Manp residues. The α-D-Glcp residues were found mainly as 1,4-linked and to a lesser extent as the terminal sugar, indicating partial contamination of ß-D-xylo-α-D-mannan with amylose (∼10 wt%) in G. vesiculosa exopolysaccharide.

Development of an additively-manufactured functionally-graded expandable implant via the application of the adaptive response surface method: feasibility study on intramedullary humerus nail.

The paper introduces the concept of the rational design of a deployable humeral intramedullary nail plug based on a honeycomb structure used for the surgical treatment of humeral shaft fractures. The concept serves for to restore the axial alignment of bone fragments and to maintain stability via bone-nail friction and locking screws. The design nail plug was gained by optimisation process the Latin Hypercube Sampling Design algorithm and Multi-Objective Genetic Algorithm. It was shown that we can use statistical shape function combined by 3 D printing for designing of a new rationally designed implants.

The Injection Molding of Biodegradable Polydioxanone-A Study of the Dependence of the Structural and Mechanical Properties on Thermal Processing Conditions.

Recent years have observed a significant increase in the use of degradable materials in medicine due to their minimal impact on the patient and broad range of applicability. The biodegradable polymer Polydioxanone (PDO) provides a good example of the use of such one polymer that can represent the aforementioned medical materials in the field of medicine, due to its high level of biocompatibility and interesting mechanical properties. PDO is used to produce absorbable medical devices such as sutures and stents, and is also suitable for the fabrication of certain orthopedic implants. Polydioxanone can be processed using the injection molding method due to its thermoplastic nature; this method allows for the precise and easily-controllable production of medical materials without the need for toxic additives. A number of small commercial polymer implants have recently been introduced onto the market based on this processing method. It is important to note that, to date, no relevant information on the molding of PDO is available either for the scientific or the general public, and no study has been published that describes the potential of the injection molding of PDO. Hence, we present our research on the basic technological and material parameters that allow for the processing of PDO using the laboratory microinjection molding method. In addition to determining the basic parameters of the process, the research also focused on the study of the structural and mechanical properties of samples based on the thermal conditions during processing. A technological frame work was successfully determined for the processing of PDO via the microinjection molding approach that allows for the production of samples with the required homogeneity, shape stability and surface quality in a laboratory scale. The research revealed that PDO is a polymer with a major share of crystalline phases, and that it is sensitive to the annealing temperature profile in the mold, which has the potential to impact the final crystalline structure, the fracture morphology and the mechanical properties.

Biomechanics optimisation of the laminoplasty groove size and position: A numerical study.

BACKGROUND: This study is focused on the opening technique of the cervical vertebrae during laminoplasty which serves to substantially reduce the most severe adverse effects of the simple resection of posterior vertebral elements. This computational study aims to clarify by an optimisation approach what shape and position upon the lamina the groove should have. METHODS: The computational model was developed in the computational software COMSOL Multiphysics 5.6a based on a computer tomography data obtained from the C4 vertebra. For finding the optimal minimum or maximum of a function (surface), optimisation algorithms are developed following the Nelder-Mead algorithm. RESULTS: The reaction-opening force increases with a decreasing groove radius and an increasing position from the vertebra body. The created area increases with a decreasing groove radius and a decreasing position. As the opening happens mostly only above the groove, the opening area increases only in this location. Moreover, the von Mises stress peak value is almost twice as large as in the case of maximization of the opening area, which might result in breaking of the lamina as the thickness of the lamina would be reduced to its minimum. CONCLUSION: The groove radius and position can affect the opening force and the opening area in case of double door laminoplasty. The opening force is highly influenced by the groove position and radius. The best position for placing the groove is in the middle of the lamina and the radius of the groove should be as large as possible.

The stiffness variability of a silk fibroin scaffold during bone cell proliferation.

Complex assessment of gradual changes in scaffold morphology and stiffness is an essential step in bone filler development. Current approach, however, does not reflect long term cell proliferation effect as the mechanical tests are usually conducted on pristine materials without cells or cell influence on material stiffness is evaluated after one time period only. Here, biocompatible silk fibroin (SF) porous scaffolds envisioned for bone defect filling were prepared by dissolving of fibroin fibers, followed by dialysis, freeze-drying and final stabilization. Particular attention was devoted to the influence of bone cell proliferation up to 2 months on the stiffness of the material. The morphology of the material was studied in terms of its inner structure and the overall changes in the surface characteristics due to proliferation of MG 63 bone cell line. The SF scaffold stiffness significantly increased during first month followed by its decline during second month due to bone cell seeding. After 2 months, the SF scaffold was completely colonized, which resulted in a gradual decay of its structure. The length of degradation due to bone cell proliferation and mechanical behavior corresponded to the requirements set for reasonable filler material indicating that porous SF scaffolds comprise a promising biomaterial for bone regeneration.

The wettability of electron spun membranes by synovial fluid.

Aseptic loosening due to periprosthetic osteolysis has been accepted as one of the leading causes of revision procedures in patients with previous joint arthroplasty. Recently, several strategies for suppression of osteolysis were proposed, mostly based on biological treatment such as mitigation of chronic inflammatory reactions. However, these biological treatments do not stop the debris migration but only reduce the inflammatory reaction. To address this shortcoming, we propose the concept of ultrahigh molecular weighted polyethylene particles filtration storage by electrospun membranes. Firstly, the surface tension of synovial fluid (SF) is obtained by use of a pendant droplet. Secondly, the contact angle of the electrospun membranes wetted by two different liquids is measured to obtain the free surface energy using of the Owens-Wendt model. Additionally, the wettability of electrospun membranes by SF as a function of technology parameters is studied.

The opening size of the laminoplasty is dependent on the groove size: A numerical study.

BACKGROUND: The expansion of the cervical vertebrae lamina appears to be crucial to related surgical procedures. The dimensions of the groove influence the strain concentration within the lamina of the vertebra and, thus, the potential success or failure of respective surgical procedure. The aim of this computational study is to clarify both the role of the size of the groove with concern to both the open door and the double door laminoplasty techniques. METHODS: Finite element models were created via computer tomography with varying lamina groove dimensions. Displacements were applied to the models at the open side of the vertebral arch and the vertebral body was constrained prior to movement along all the axes. The maximal opening size measured on the inner side of the lamina and the percentage increase in the initial spinal areas were subsequently analyzed. FINDINGS: The elastic strain concentration value was observed for the groove in all cases, while the maximal principal elastic strain concentration value was observed at the opposite side to the groove cut into the lamina, also in all cases. The maximal area increase related to the 4 mm groove accompanied by the preservation of the ventral cortex of the bone. INTERPRETATION: The study suggested three conclusions a) the wider the groove, the greater is the opening potential, b) the maximal opening size following laminoplasty is not dependent on the depth of the bone cut for this type of groove, c) no benefit accrues in terms of the opening size following the cutting of a supplementary groove at the beginning of the lamina.

Congenital syphilis as a cause of death in a newborn in 31st week of pregnancy - significance of testing for syphilis during pregnancy.

OBJECTIVE: Description of a case of newborn death after acute caesarean section in 31st week of pregnancy because of mothers syphilitic infection. RESULTS: Fifteen-years-old primigravid woman in 31st week of pregnancy was admitted to a secondary level hospital due to a high risk of preterm labor. The pregnancy was terminated with an acute caesarean section because of pathological cardiotocograph record. The newborn died after 35 min of resuscitation. Blood samples from the umbilical cord and mothers blood taken by her gynecologist were positive for syphilis. In cooperation with a dermatologist, the treatment has been provided and reported to the National Referential Laboratory. The autopsy of the newborn had found severe pneumonia, necrotic lymphadenitis and pyocele. CONCLUSION: The dia-gnosis of congenital syphilis had been determined after the death of a preterm delivered newborn. Resuscitation had no chance to success because of syphilitic damage of the lungs.

Optimal structural pattern for maximal compliance using topology optimization based on phasefields: Application to improve skin graft meshing efficiency.

This article focuses on the problem of maximal compliance design of a hyper-elastic solid with the optimal design of human skin grafts as the application in mind. The solution method is a phasefield-based topology optimization method that supposes multiple local phasefields and a minimum distance constraint in order to prevent the phasefields from merging. Consequently, structurally disintegrating solutions such as by the coalescence of voids can be prevented. The method is used to find an optimal graft meshing pattern for a sample that is subjected to a biaxial extension of up to 150%, which corresponds to an expansion ratio of 1 : 2.25. Three prospective unitcell solutions that exhibit meta-material behavior are proposed for a periodic graft pattern. The results are a step toward improving the skin graft meshing efficiency. This work does not cover experimental validation.

Cement augmentation of odontoid peg fractures: the effect of cement volume and distribution on construct stiffness.

PURPOSE: The cement augmentation of a conventional anterior screw fixation in type II odontoid process fractures for elderly patients significantly increased stiffness and load to failure under anterior-posterior load in comparison with non-augmented fixation. The amount and quality of bone cement are usually taken ad hoc in clinical practise. In this study, we wanted to clarify the role of bone cement amount and its quality to the stiffness of odontoid and vertebrae body junction. METHODS: Finite-element method was used to achieve different scenarios of cement augmentation. For all models, an initial stiffness was calculated. Model (1) the intact vertebrae were virtually potted into a polymethylmethacrylate base via the posterior vertebral arches. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. (2) The odontoid fracture type IIa (Anderson-D'Alonzo classification) was achieved by virtual transverse osteotomy. Anterior screw fixation was virtually performed by putting self-drilling titanium alloy 3.5 mm diameter anterior cannulated lag screw with a 12 mm thread into the inspected vertebrae. A V-shaped punch was used for loading the odontoid in an anterior-posterior direction. The vertebrae body was assumed to be non-cemented and cemented with different volume. RESULTS: The mean cement volume was lowest for body base filling with 0.47 ± 0.03 ml. The standard body filling corresponds to 0.95 ± 0.15 ml. The largest volume corresponds to 1.62 ± 0.12 ml in the presence of cement leakage. The initial stiffness of the intact C2 vertebrae was taken as the reference value. The mean initial stiffness for non-porous cement (E = 3000 MPa) increased linearly (R2 = 0.98). The lowest stiffness (123.3 ± 5.8 N/mm) was measured in the intact C2 vertebrae. However, the highest stiffness (165.2 ± 5.2 N/mm) was measured when cement leakage out of the odontoid peg occurred. The mean initial stiffness of the base-only cemented group was 147.2 ± 8.4 N/mm compared with 157.9 ± 6.6 N/mm for the base and body cemented group. This difference was statistically significant (p < 0.0061). The mean initial stiffness for porous cement (E = 500 MPa) remains constant. Therefore, there is no difference between cemented and non-cemented junction. This difference was not statistically significant (p < 0.18). CONCLUSION: The present study showed that the low porous cement was able to significantly influence the stiffness of the augmented odontoid screw fixation in vitro, although further in vivo clinical studies should be undertaken. Our results suggest that only a small amount of non-porous cement is needed to restore stiffness at least to its pre-fracture level and this can be achieved with the injection of 0.7-1.2 ml of cement. These slides can be retrieved under Electronic Supplementary Material.

Computational modal analysis of a composite pelvic bone: convergence and validation studies.

The purpose of the present study was to describe the structural density and geometry of the bone, as well as its sensitivity to the resolution of finite element discretisation. The study introduces a novel way to validate biomechanical model of the bone by experimental modal analysis. The structural density and geometry of the model was obtained from a composite bone. A detailed investigation of the weight dependence of the bone on the mesh resolution was performed to obtain the best match with the real weight of the tested bone. The computational model was compared with the experimental results obtained from the modal analysis. The overall changes of the modal properties and bone weight in the model caused by different mesh resolutions and order of approximation were below 10%, despite the bone was modelled with simple isotropic material properties. The experimental modal analysis shows a great potential to be a robust verification tool of computational biomechanical models because it provides boundary conditions-free results. The sensitivity analysis revealed that the linear approximation of the density field is not suitable for the modelling of the modal response of composite bone.

Modal frequency and shape curvature as a measure of implant fixation: A computer study on the acetabular cup.

Modal parameters are often investigated in order to assess the initial fixation of an implant. Most of studies are focused on the natural frequencies and frequency response function. Usually the femoral stem is tested although the acetabular cup fixation is important as well. The results of implant stability assessment are inconsistent and seem to suggest that frequency as a stability indicator is not sufficiently sensitive. In this study the sensitivity of the modal properties to changes in the bone-implant interface was investigated with the help of the finite element method (FEM). A novel fixation index based on modal shape curvature was investigated as a potential measure of the implant fixation. Modal frequencies are sensitive to interface changes in some manner, but suffer from insensitivity to local changes at bone-implant interface. The sensitivity up to 44% of natural frequencies to stiffness change due insertion steps was observed. The tested damage indicators are able to detect localized small changes in peripheral stiffness (5% stiffness reduction) with 95% confidence under the noise up to 1%. The modal shapes and their curvatures have a great potential to be a robust fixation indicator.

Graft orientation influences meshing ratio.

OBJECTIVES: The technique of meshed skin grafting is known since 1960s. It was shown that there is a difference between the declared and real expansion ratio of the skin meshed graft. We hypothesize that the orientation of the Langer's lines in a split thickness skin graft is a key parameter in the resulting expansion ratio. METHODS: The skin graft meshing process was analyzed in two steps. In the first step, ex vivo uniaxial tests of human skin were performed. This served as an input for the constitutive model used for numerical simulations. In the second step, finite element analyses were performed so that stress distributions and expansion ratios could be determined. RESULTS: It was shown that peaks of true stress tended to be concentrated around the vertex of the mesh pattern region for all cases. The declared expansion was impossible to obtain for all expansion ratios having the meshing incision perpendicular to the Langer's lines. The highest difference between declared and real expansion ratio reaches 37%. CONCLUSIONS: With regard to literature dealing with expansion of skin grafts by meshing, a high scatter amongst data results is observed. This finding was also explained by our research, demonstrating the significance of Langer's lines and their relative orientation to the direction of meshing.

Biomechanical comparison of cemented versus non-cemented anterior screw fixation in type II odontoid fractures in the elderly: a cadaveric study.

BACKGROUND CONTEXT: Odontoid process fractures are the most common injuries of the cervical spine in the elderly. Anterior screw stabilization of type II odontoid process fractures improves survival and function in these patients but may be complicated by failure of fixation. PURPOSE: The present study aimed to determine whether cement augmentation of a standard anterior screw provides biomechanically superior fixation of type II odontoid fractures in comparison with a non-cemented standard screw. STUDY DESIGN: Twenty human cadaveric C2 vertebrae from elderly donors (mean age 83 years) were obtained. METHODS: Anderson and D'Alonzo type IIa odontoid fracture was created by transverse osteotomy, and fluoroscopy-guided anterior screw fixation was performed. The specimens were divided into two matched groups. The cemented group (n=10) had radiopaque high viscosity polymethylmethacrylate cement injected via Jamshidi needle into the base of the odontoid process. The other group was not augmented. A V-shaped punch was used for loading the odontoid in an anteroposterior direction until failure. The failure state was defined as screw cutout or 5% force decrease. Mean failure load and bending stiffness were calculated. RESULTS: The mean failure load for the cemented group was 352±12 N compared with 168±23 N for the non-cemented group (p<.001). The mean initial stiffness of the non-cemented group was 153±19 N/mm compared with 195±29 N/mm for the cemented group (p<.001) CONCLUSIONS: Cement augmentation of an anterior standard screw fixation of type II odontoid process fractures in elderly patients significantly increased load to failure under anteroposterior load in comparison with non-augmented fixation. This may be a valuable technique to reduce failure of fixation.

How does the surface treatment change the cytocompatibility of implants made by selective laser melting?

INTRODUCTION: The study investigates the potential for producing medical components via Selective Laser Melting technology (SLM). The material tested consisted of the biocompatible titanium alloy Ti6Al4V. The research involved the testing of laboratory specimens produced using SLM technology both in vitro and for surface roughness. The aim of the research was to clarify whether SLM technology affects the cytocompatibility of implants and, thus, whether SLM implants provide suitable candidates for medical use following zero or minimum post-fabrication treatment. Areas covered: The specimens were tested with an osteoblast cell line and, subsequently, two post-treatment processes were compared: non-treated (as-fabricated) and glass-blasted. Interactions with MG-63 cells were evaluated by means of metabolic MTT assay and microscope techniques (scanning electron microscopy, fluorescence microscopy). Surface roughness was observed on both the non-treated and glass-blasted SLM specimens. Expert Commentary: The research concluded that the glass-blasting of SLM Ti6Al4V significantly reduces surface roughness. The arithmetic mean roughness Ra was calculated at 3.4 µm for the glass-blasted and 13.3 µm for the non-treated surfaces. However, the results of in vitro testing revealed that the non-treated surface was better suited to cell growth.

Impact Force, Polar Gap and Modal Parameters Predict Acetabular Cup Fixation: A Study on a Composite Bone.

The balanced initial fixation of an implant makes up a crucial condition for its long-term survival. However, the quantification of initial fixation is no easy task and, to date, only qualitative assessments can be made. Although the concept of measuring fixation by means of vibration analysis is already widely used in dental implantology, the rigorous application of this method for the assessment of the fixation of femoral and acetabular components remains a challenge. Moreover, most studies on this subject have tended to focus solely on the femoral stem even though acetabular cup fixation is also important and even more difficult with respect to qualitative measurement. This study describes a comprehensive experiment aimed at assessing acetabular cup fixation. Fixation is expressed in terms of the impact force and polar gap variables, which are correlated with the modal properties of the acetabular implant during the various insertion stages. The predictive capabilities of modal frequencies and frequency functions were investigated by means of surrogate models based on the Gaussian process and functional principal component analysis. The prediction accuracy of the proposed models was in the range 82-94%. The results indicate that natural frequencies, reduced frequency, impact force and polar gap features provide great potential in terms of the prediction of implant fixation.

Failure of sternal wires depends on the number of turns and plastic deformation: combined experimental and computational approach.

OBJECTIVES: The number of turns at the end of a wire closure is not described or discussed in any cardiosurgical guidelines. The hands-on experience of the surgeon plays a significant role. The aim of this work was to clarify the relationship between the number of turns of the suture and the resulting strength of the sternal fixation. METHODS: The study was performed in 2 independent steps. The first step was a finite element simulation, where the stress and strain distribution of the sternal fixation was observed. The second step included the experimental set-up and the statistical evaluation of the results. RESULTS: Our study showed that the failure force rose linearly as the number of turns increased. The lowest average measured force was 370 N (3 turns); the highest was 430 N (7 turns). The failure modes were either untwisting of the wires or rupture of the closure, which is controlled by the number of turns. As the number of turns increases, superficial cracks can occur. CONCLUSIONS: Based on our results, the 5-turn option is the best solution for the closure. The failure force is still double the value reported in the literature, so there is a high safety margin for failure. The failure mode is untwisting; hence, no unexpected fracture can occur, and there is still an elastic core in the cross-section of the wire.

Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve.

OBJECTIVE: We aimed to analyse the incidence of prosthesis-patient mismatch (PPM) and elevated gradients after aortic valve in valve (ViV), and to evaluate predictors and associations with clinical outcomes of this adverse event. METHODS: A total of 910 aortic ViV patients were investigated. Elevated residual gradients were defined as ≥20 mm Hg. PPM was identified based on the indexed effective orifice area (EOA), measured by echocardiography, and patient body mass index (BMI). Moderate and severe PPM (cases) were defined by European Association of Cardiovascular Imaging (EACVI) criteria and compared with patients without PPM (controls). RESULTS: Moderate or greater PPM was found in 61% of the patients, and severe in 24.6%. Elevated residual gradients were found in 27.9%. Independent risk factors for the occurrence of lower indexed EOA and therefore severe PPM were higher gradients of the failed bioprosthesis at baseline (unstandardised beta -0.023; 95% CI -0.032 to -0.014; P<0.001), a stented (vs a stentless) surgical bioprosthesis (unstandardised beta -0.11; 95% CI -0.161 to -0.071; P<0.001), higher BMI (unstandardised beta -0.01; 95% CI -0.013 to -0.007; P<0.001) and implantation of a SAPIEN/SAPIEN XT/SAPIEN 3 transcatheter device (unstandardised beta -0.064; 95% CI -0.095 to -0.032; P<0.001). Neither severe PPM nor elevated gradients had an association with VARC II-defined outcomes or 1-year survival (90.9% severe vs 91.5% moderate vs 89.3% none, P=0.44). CONCLUSIONS: Severe PPM and elevated gradients after aortic ViV are very common but were not associated with short-term survival and clinical outcomes. The long-term effect of poor post-ViV haemodynamics on clinical outcomes requires further evaluation.