Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects.

BACKGROUND: Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation. METHODS: Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed. RESULTS: Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected. CONCLUSION: A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

[3D printing in the field of shoulder surgery]. / 3D-Druck im Bereich der Schulterchirurgie.

The 3D printing technology is a relatively new procedure with a high potential, especially in the field of shoulder surgery. The 3D printing procedures are increasingly being developed and also gaining new users. Principally, 3D printing procedures can be applied preoperatively in planning the surgical procedure, patient clarification and in teaching; however, the technology is increasing being used intraoperatively. In addition to intraoperative visualization of the models, 3D printing permits the use of individual and specific instruments and implants. This allows the precise transfer of the preoperative planning to the surgical procedure. Inaccuracies are mainly caused by soft tissues. The 3D printing can be beneficial in the fields of arthroplasty, shoulder instability as well as orthopedic trauma. The literature shows promising results in relation to duration of surgery, blood loss and clinical results of the procedure. On the other hand, it is still unclear which indications warrant the use of 3D printing. Other aspects that raise questions are the time of planning, the production time and the additional cost that the use of 3D printing entails. Nonetheless, 3D printing represents a meaningful enhancement of the portfolio of surgeons, which becomes highly beneficial and useful in complex situations. Furthermore, this procedure enables a certain amount of flexibility when reacting to certain circumstances.

[Complex joint reconstruction and joint transplantation with the FLOCSAT concept-planning and surgical implementation]. / Komplexe Gelenkrekonstruktion und Gelenktransplantation mit dem FLOCSAT-Konzept ­ Planung und chirurgische Umsetzung.

Cartilage defects in adult patients are so far incurable. Fresh osteochondral allograft (OCA) transplantation is based on the insertion of mature, living, mechanically sound hyaline cartilage into an osteochondral defect where it undergoes osseointegration. Intact hyaline cartilage of OCA does not cause immune reactions in the recipient. Many reports show that small OCA have good osseointegration and show good long-term results. These observations have been incorporated into the development of the fresh large (> 10 cm2) osteochondral shell allograft transplantation (FLOCSAT) concept, which is based on the following principles: 1) the thickness of the osseous layer should be kept as thin as possible (target < 6-8 mm) so that the transplant remains stable and fixable. This results in reduced segments of vascularization, simplified ossification and reduced immunogenic bone volume. 2) The bone surface is processed and enlarged (oscillating saw: pie crust technique, drill holes) and areas of sclerosis are simultaneously broken off. 3) Cell reduction and washing out of the bony layer with a pulsatile jet lavage. 4) Prevention of impaction and dessication: cartilage with its living chondrocytes are very sensitive to mechanical contusion and dessication. When introducing the transplant, the tissue must therefore be continually moistened and the pressure acting on the cartilage must be controlled. 5) Stable fixation: extensive uniplanar osteochondral transplants cannot be inserted by the press-fit method; therefore, fixation is carried out with small implants. In this publication we demonstrate how severe and complex posttraumatic or degenerative delayed problems can be solved using FLOCSAT.

[Evidence-based therapy for tendinopathy of the knee joint : Which forms of therapy are scientifically proven?] / Evidenzbasierte Therapie bei Tendinopathien am Kniegelenk : Welche Therapieformen sind wissenschaftlich belegt?

Tendinopathy in the region of the knee joint is a common pathological disorder. People active in sports, in particular, have a high probability of suffering from tendinopathy. Despite its high clinical relevance, the level of evidence of therapy options for tendinopathy in the knee region differs greatly. This review gives an overview of current evidence levels for therapy options in tendinopathy of the quadriceps, patellar and pes anserinus insertion tendons as well as of the distal iliotibial tract tendon. The treatment with platelet-rich plasma showed a significantly better outcome when used correctly and treatment with shock waves, operative treatment and sclerotherapy have also shown positive effects. Treatment with corticosteroid injections and with oral non-steroidal anti-inflammatory drugs (NSAID) showed positive short-term effects (follow-up ±4 weeks). No reasonable data are available for the treatment of tendinopathy in the knee region by acupuncture, fascial therapy or cryotherapy. The use of kinesio taping showed no significant relief from complaints compared with standard conservative treatment. The use of multimodal therapy without evidence is, therefore, particularly common in elite athletes.

[Partial and complete joint transplantation with fresh osteochondral allografts-the FLOCSAT concept]. / Partielle und komplette Gelenktransplantation mit frischen osteochondralen Allografts ­ das FLOCSAT-Konzept.

Cartilage defects in adult patients do not heal well. Fresh osteochondral allograft (OCA) transplantation is based on mature, living, mechanically sound hyaline cartilage attached to a bone interface, which is brought into an osteochondral defect, where it becomes osseointegrated. According to current knowledge, intact hyaline cartilage tissue is immune privileged and does not, in contrast to bone, meniscus or ligaments, cause an immune reaction. The technique has the unique advantage of transplanting viable, mature and mechanically stable hyaline cartilage into the affected area. An OCA is the only biological surgical technique for chondral and osteochondral lesions after failed cell-based techniques or autologous osteochondral transplantation.Fresh osteochondral allografts with mainly small cylindrical transplants show survival of 20 years and more. Based on this experience the FLOCSAT (fresh large [> 10 cm2] osteochondral shell allograft transplantation) concept with the thinnest possible (< 6-8 mm) bone thickness has been developed. Cells survive in special media at 4 °C for 4 weeks or more and are transplanted with a minimum of 70% living cells in a live/dead assay and cell density > 200 cells/mm2.FLOCSATs can replace parts or entire joints as uniplanar or multiplanar(n-planar)-FLOCSAT, as unipolar, bipolar or tripolar(n-polar)-FLOCSAT, and in combination with meniscus and/or ligaments (nMnL)-FLOCSAT (n number of structures).The FLOCSAT concept was applied successfully to knee, ankle and elbow joints. All transplants showed sound osseointegration. Cartilage failure was the reason for unsuccessful outcome. Challenges remain regarding graft availability, precise size matching, complex logistics, demanding surgical technique in complex geometries, and open questions in immunology and chimerism.

[Interdisciplinary extremity board in the treatment of complex injuries]. / Interdisziplinäres Extremitäten-Board in der Behandlung von Komplexverletzungen.

BACKGROUND: Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines. METHODS: After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6 months were subsequently descriptively analyzed. RESULTS: The agreed primary aim of an extremity board is the timely and transparent preparation of a high-quality holistic reconstruction plan for optimized treatment of a challenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40 years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2 patients were approved in an interdisciplinary team per session. CONCLUSION: The extremity board serves as a platform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables a high degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.

Accidental hypothermia as an independent risk factor of poor neurological outcome in older multiply injured patients with severe traumatic brain injury: a matched pair analysis.

PURPOSE: Patients with multiple injuries are particularly susceptible to accidental hypothermia which is correlated with an increased risk of post-traumatic complications and mortality; however, its impact on neurological outcome in cases where there is concomitant traumatic brain injury is underexplored. METHODS: We analyzed severely injured patients (ISS ≥ 16) including a moderate-to-severe traumatic brain injury (AISHead ≥ 3). The primary endpoint was objective neurological recovery, expressed as Glasgow Outcome Scale (GOS) score at time of discharge. Secondary endpoints were mortality, systemic inflammatory response syndrome (SIRS), sepsis, acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS). Statistical analysis included logistic regression (odds ratio). The significance level in all analyses was p = 0.05. RESULTS: We analyzed 278 patients (M age = 43 years, SD 19; M ISS = 32.8, SD 10.7). Mortality was 17% (n = 14). 102 patients (37%) were hypothermic on admission. Hypothermic patients were more severely injured (ISS 35.6 ± 11.1 vs. 31.2 ± 10.1, p = 0.001; APACHE II 18.1 ± 7.4 vs. 16.2 ± 7.3, p = 0.045) and had a higher transfusion requirement. Mortality rate in hypothermic patients was increased (23.5 vs. 13.1%, p = 0.03); however, hypothermia was not an independent predictor of mortality. Median GOS at discharge was 3 (IQR 3); in 47% of patients the outcome was favorable (GOS 4 or 5) and 36% it was poor (GOS 2 or 3). There were no differences in post-traumatic complications. Analysis of 73 matched pairs of hypothermic and normothermic patients could not prove hypothermia as an independent predictor of poor neurological outcome (OR 1.7, 95% CI 0.8-3.6, p = 0.1) in the total population. However, older patients (> 41 years) had a 4.2-times higher risk (95% CI 1.4-12.7; p = 0.01) of poor neurological outcome, if they were hypothermic on admission. CONCLUSIONS: Accidental hypothermia seems to have a negative impact on neurological recovery in older patients with multiple injuries including traumatic brain injury which outweighs potential benefits.

Fractures of the transverse processes of the fourth and fifth lumbar vertebrae in patients with pelvic ring injuries: indicator of biomechanical instability but not shock.

Aims: This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent. Patients and Methods: The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014. Results: A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p < 0.001) had a fracture of a TP. Patients with a fracture of a TP of L4 and/or L5 had a 5.5-fold risk (odds ratio (OR)) of having a biomechanically unstable pelvic injury. TP fractures (OR 1.6, p = 0.2) could not be confirmed as an independent predictor of haemodynamic instability. Conclusion: This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214-19.

ATP binding residues of sarcoplasmic reticulum Ca2+-ATPase.

ATP-binding residues in the N and P domains of sarcoplasmic reticulum Ca-ATPase have been investigated using mutagenesis in combination with a binding assay based on the photolabeling of Lys(492) with [g-(32)P] 2',3'-O-(2,4,6 trinitrophenyl)-8-azido-ATP and competition with nucleotide. In the N domain, mutations to several residues in conserved motifs, (438)GEATE, (487)FSRDRK, (515)KGAPE, and (560)RCLALA produce nucleotide-binding defects. Key residues include Thr(441), Glu(442), Phe(487), Arg(489), Lys(492), Lys(515), Arg(560), and Leu(562). In the absence of Mg(2+), Arg(489), Lys(492), and Arg(560) are most important, whereas in its presence Thr(441) and Glu(442) also play a crucial role. In the P domain, Asp(351) is striking for its strong electrostatic repulsion of the gamma-phosphate, especially in the presence of Mg(2+). Lys(352) is a key residue, and Asp(627) and Lys(684) must come close to the nucleotide. Thr(353), Asn(359), Asp(601), and Asp(703) interact only in the presence of Mg(2+). Asn(706) and Asp(707) are unimportant for nucleotide binding. The results identify several ATP binding residues in the N and P domains and suggest that Mg(2+) changes the nucleotide/protein interaction in both. Models of bound ATP and MgATP are presented.

Uncinate processes and Luschka joints influence the biomechanics of the cervical spine: quantification using a finite element model of the C5-C6 segment.

A fully three-dimensional finite element model of a C5-C6 motion segment of the human spine was developed and validated for the purpose of investigating the biomechanical significance of uncinate processes and Luschka joints. The original intact cervical model was modified to create two additional models. The first simulated the absence of Luschka joints by replacing the fissures with continuous annulus fibrosus and leaving the uncinate processes intact. The second model simulated a surgical resection of the uncinate processes, while leaving the Luschka joints intact. The results of these two models were compared with the intact model, which served as a baseline; thus, the relative contributions of these two structures to cervical motion were established. With use of our model, it was possible, for the first time, to provide quantitative data concerning the source of coupled motions in the lower cervical spine. In principle, the results from this model support the hypothesis of Penning and Wilmink. Our results indicate that the facet joints and Luschka joints are the major contributors to coupled motion in the lower cervical spine and that the uncinate processes effectively reduce motion coupling and primary cervical motion (motion in the same direction as load application), especially in response to axial rotation and lateral bending loads. Luschka joints appear to increase primary cervical motion, showing an effect on cervical motion opposite to that of the uncinate processes. Surgeons should be aware of the increase in motion accompanied by resection of the uncinate processes.

Finite element methods in spine biomechanics research.

The finite element method has been used in spine biomechanics research for nearly a quarter of a century. Recent developments have made it possible to simulate a variety of clinically relevant situations in an increasingly realistic manner, elevating the finite element method into a fully complementary partnership with experimental approaches for the investigation of clinical problems in the spine. These new developments are presented in a historical context to evaluate their potential impact on future spine biomechanics research.

Biomechanical analysis of bone mineral density, insertion technique, screw torque, and holding strength of anterior cervical plate screws.

The bone mineral density (BMD) of 99 cadaveric cervical vertebral bodies (C3-7) was determined using dual x-ray absorptiometry. The vertebral bodies were randomly assigned to receive either a unicortical (51 bodies) or bicortical (48 bodies) Caspar cervical plating screw. The initial insertion torque was measured using a digital electronic torque wrench, and the force required to withdraw the screw from the vertebral body was determined. The mean BMD for the total group of 99 was 0.787 +/- 0.154 g/cm2, the mean insertion torque was 0.367 +/- 0.243 newton-meters, and the mean pullout force was 210.4 +/- 158.1 newtons. A significant correlation was noted between BMD and torque (p < 0.0001, r = 0.42), BMD and pullout force (p < 0.0001, r = 0.54), and torque and pullout force (p < 0.0001, r = 0.88). Although the BMD of the unicortical and biocortical groups was equivalent (p = 0.92), the insertion torque and pullout force differed significantly (p = 0.02 and p = 0.008, respectively) for the unicortical and bicortical groups. A holding index for each screw and insertion technique was defined as the product of the BMD and insertion torque. The calculated holding index and resultant pullout force were significantly correlated for both techniques of screw insertion (r = 0.92), and a significant difference in holding index was observed with unicortical versus bicortical screw placement (p = 0.04). The determination of BMD and measurement of insertion torque to create a unique holding index provides an assessment of bone-screw interaction and holding strength of the screw, both of which impact on the resultant stability of cervical instrumentation. As the number of cervical plating systems increases, the determination of a holding index for various screws and insertion techniques may assist in the comparison of cervical instrumentation.

Biomechanical evaluation of Caspar and Cervical Spine Locking Plate systems in a cadaveric model.

There exist two markedly different instrumentation systems for the anterior cervical spine: the Cervical Spine Locking Plate (CSLP) system, which uses unicortical screws with a locking hub mechanism for attachment, and the Caspar Trapezial Plate System, which is secured with unlocked bicortical screws. The biomechanical stability of these two systems was evaluated in a cadaveric model of complete C5-6 instability. The immediate stability was determined in six loading modalities: flexion, extension, right and left lateral bending, and right and left axial rotation. Biomechanical stability was reassessed following fatigue with 5000 cycles of flexion-extension, and finally, the spines were loaded in flexion until the instrumentation failed. The Caspar system stabilized significantly in flexion before (p < 0.05) but not after fatigue, and it stabilized significantly in extension before (p < 0.01) and after fatigue (p < 0.01). The CSLP system stabilized significantly in flexion before (p < 0.01) but not after fatigue, and it did not stabilize in extension before or after fatigue. The moment needed to produce failure in flexion did not differ substantially between the two plating systems. The discrepancy in the biomechanical stability of these two systems may be due to differences in bone screw fixation.

Relationship of dietary regimens to success, efficiency, and cost of weight loss.

One hundred twenty-five subjects in a behaviorally oriented, weight loss program that used several dietary patterns were retrospectively grouped according to the percentage of time they followed one of four dietary regimens: (a) Group 1--partial fasting, 400 kcal; (b) group 2--600 kcal; (c) group 3--1,200 to 1,500 kcal; and (d) group 4--failure to diet. The groups were described and compared regarding program completion, i.e., success and cost of weight loss. Groups 1 and 2 did significantly better than the other two in nearly all respects. Group 1 did better than Group 2 on program completion; the reverse was true when success of those completing 75 and 100 per cent of the program was compared. Groups 1 and 2 did not differ significantly on success variables.

Prediction of load sharing among spinal components of a C5-C6 motion segment using the finite element approach.

STUDY DESIGN: A finite element model of the ligamentous cervical spinal segment was used to compute loads in various structures in response to clinically relevant loading modes. OBJECTIVE: To predict biomechanical parameters, including intradisc pressure, tension in ligaments, and forces across facets that are not practical to quantify with an experimental approach. SUMMARY OF BACKGROUND DATA: Finite element models of the cervical spine in their present form, because of inherent assumptions and simplifications, are not entirely satisfactory for studying the biomechanics of the intact, injured, and stabilized cervical spinal segment. METHODS: A three-dimensional finite element model of a C5-C6 motion segment was developed from serial computed tomographic scans of a ligamentous cervical spinal segment. This model included nonlinear ligament definition, fully composite intervertebral disc, fluid nucleus, and Luschka's joints. The model-based displacement predictions were in agreement with the experimental data. This model was used to predict load sharing and other related parameters in spinal elements in response to various loading modalities. RESULTS: In axial compression, 88% of the applied load passed through the disc. The interspinal ligament experienced the most strain (29.5%) in flexion, and the capsular ligaments were strained the most (15.5%) in axial rotation. The maximum intradisc pressure was 0.24 MPa in the flexion with axial compression mode (1.8 Nm + 73.6 N). The anterior and posterior disc bulges increased with the increase in axial compression (up to 800 N). CONCLUSIONS: The results provide new insight into the role of various elements in transmitting loads. The model represents significant and essential advancement in comparison with previous finite element models, making it possible for such models to be used in investigating a broad spectrum of clinically relevant issues.

Assessment of unicortical and bicortical fixation in a quasistatic cadaveric model. Role of bone mineral density and screw torque.

STUDY DESIGN: The stabilizing potential of the Caspar Trapezial Osteosynthetic Plate was studied using unicortical and bicortical screw placement in cadaveric cervical spines. OBJECTIVE: To determine if Caspar plates secured with unicortical screws provide the same degree of stability as those anchored with unlocked bicortical screws. SUMMARY OF BACKGROUND DATA: Previous work has demonstrated that bicortical cervical vertebral screws are superior to unicortical screws in terms of pullout strength and decreased wobble. However, these two methods of plate fixation have not been directly compared in a clinically relevant cadaveric model. METHODS: The immediate and post-fatigue stabilizing potential of Caspar plates secured with unicortical or bicortical screws was assessed using a model of complete segmental instability. RESULTS: Unicortical screw placement resulted in inadequate stabilization in half of the cervical specimens. CONCLUSIONS: Our results suggest that, for the Caspar screw, bicortical fixation provides greater flexion-extension stability.

A protocol to evaluate semi-rigid pedicle screw systems.

The objective of the current study was to develop an in vitro testing protocol to evaluate semi-rigid pedicle screw devices. A corpectomy model protocol exists to evaluate rigid spinal implants; however, semi-rigid devices are contraindicated for this condition. This paper describes a technique that simulates more closely the conditions a semi-rigid device would see in vivo. Finally, the new testing protocol is used to evaluate the DDS pedicle screw-cable system. Benefits and shortcomings of the new protocol are discussed.

Chlamydia trachomatis utilizes the host cell microtubule network during early events of infection.

The host cell cytoskeleton is known to play a vital role in the life cycles of several pathogenic intracellular microorganisms by providing the basis for a successful invasion and by promoting movement of the pathogen once inside the host cell cytoplasm. McCoy cells infected with Chlamydia trachomatis serovars E or L2 revealed, by indirect immunofluorescence microscopy, collocation of microtubules and Chlamydia-containing vesicles during the process of migration from the host cell surface to a perinuclear location. The vast majority of microtubule-associated Chlamydia vesicles also collocated with tyrosine-phosphorylated McCoy cell proteins. After migration, the Chlamydia-containing vesicles were positioned exactly at the centre of the microtubule network, indicating a microtubule-dependent mode of chlamydial redistribution. Inhibition of host cell dynein, a microtubule-dependent motor protein known to be involved in directed vesicle transport along microtubules, was observed to have a pronounced effect on C. trachomatis infectivity. Furthermore, dynein was found to collocate with perinuclear aggregates of C. trachomatis E and L2 but not C. pneumoniae VR-1310, indicating a marked difference in the cytoskeletal requirements for C. trachomatis and C. pneumoniae during early infection events. In support of this view, C. pneumoniae VR-1310 was shown to induce much less tyrosine phosphorylation of HeLa cell proteins during uptake than that seen for C. trachomatis.

A new semirigid implant for instrumentation of scoliosis: preliminary report.

A new set of pedicle screws, lamina and pedicle hooks, longitudinal rods and a titanium cable was developed to overcome the increasingly obvious hazards of overly rigid spinal instrumentation. Results of the first 12 consecutive scoliosis patients with this new system are reported, with an average follow-up time of 18 months. No major complications occurred. The average correction of the deformity was well within the range of more rigid systems. The new Dorsal Dynamic Spondylodesis (DDS) system proved to be easy to use, fast, powerful, safe, versatile, and biomechanically sound. Reduction of stress-shielding effects and protection of adjacent segments can be expected, and the system warrants future application in selected prospective cases with long-term follow-up.

Importance of Thr-353 of the conserved phosphorylation loop of the sarcoplasmic reticulum Ca2+-ATPase in MgATP binding and catalytic activity.

Mutants in which Thr-353 of the Ca(2+)-ATPase of sarcoplasmic reticulum had been replaced with alanine, serine, glutamine, cysteine, valine, aspartate, or tyrosine were analyzed functionally. All the mutations severely affected MgATP binding, whereas ATP binding was close to normal in the alanine, serine, glutamine, and valine mutants. In the serine and valine mutants, the maximum rate of phosphorylation from MgATP was 8- and 600-fold lower, respectively, compared with wild type. Replacement of Mg(2+) with Mn(2+) led to a 1.5-fold enhancement of the maximum phosphorylation rate in the valine mutant and a 5-fold reduction in the wild type. The turnover of the phosphoenzyme formed from MgATP was slowed 1-2 orders of magnitude relative to wild type in the alanine, serine, and valine mutants, but was close to normal in the aspartate and cysteine mutants. Only the serine mutant formed a phosphoenzyme in the backward reaction with P(i), and the hydrolysis of this intermediate was greatly enhanced. Analysis of the functional changes in the mutants in the light of the recent high resolution structure of the Ca(2+)-ATPase crystallized without the MgATP substrate suggests that, in the native activated state of the enzyme, the side chain hydroxyl of Thr-353 participates in important interactions with nucleotide and phosphate, possibly in catalysis, whereas the main chain carbonyl of Thr-353, but not the side chain, may coordinate the catalytic Mg(2+).