Bone infection: a clinical priority for clinicians, scientists and educators.

Bone infection has received increasing attention in recent years as one of the main outstanding clinical problems in orthopaedic-trauma surgery that has not been successfully addressed. In fact, infection may develop across a spectrum of patient types regardless of the level of perioperative management, including antibiotic prophylaxis. Some of the main unknown factors that may be involved, and the main targets for future intervention, include more accurate and less invasive diagnostic options, more thorough and accurate debridement protocols, and more potent and targeted antimicrobials. The underlying biology dominates the clinical management of bone infections, with features such as biofilm formation, osteolysis and vascularisation being particularly influential. Based on the persistence of this problem, an improved understanding of the basic biology is deemed necessary to enable innovation in the field. Furthermore, from the clinical side, better evidence, documentation and outreach will be required to translate these innovations to the patient. This review presents the findings and progress of the AO Trauma Clinical Priority Program on the topic of bone infection.

Coexisting lateral tibiofemoral osteoarthritis is associated with worse knee pain in patients with mild medial osteoarthritis.

OBJECTIVE: To examine the clinical impact of coexisting lateral osteoarthritis (OA) in knees with mild medial OA. DESIGN: In patients with Kellgren/Lawrence (K/L) grade 2 OA in the medial compartment (n = 100; age: 56-89 years; 80.0% female), anteroposterior knee radiography was used to assess the presence of lateral OA, using grading systems from the Osteoarthritis Research Society International (OARSI) atlas and the K/L classification. The Japanese Knee Osteoarthritis Measure (JKOM), knee range of motion (ROM), and performance-based functional measures (10 m walk, timed up and go and five repetition chair stand maneuvers) were evaluated. The outcomes were compared between patients with and without lateral OA using an analysis of covariance (ANCOVA) or nonparametric rank ANCOVA. Furthermore, ordinal logistic regression analysis was performed, with responses on individual JKOM pain questionnaires as the outcomes and lateral OA as the predictor. RESULTS: Knees with coexisting lateral OA had a significantly worse score of JKOM pain question compared with those without, after adjusting for covariates. The presence of lateral OA was significantly associated with knee pain while ascending/descending stairs and standing. These results were consistent between different definitions of the K/L and OARSI grading systems. The knee ROM and performance-based functional measures were not significantly different between patients with and without lateral OA. CONCLUSION: Knees with concomitant lateral and mild medial OA may be more symptomatic compared to those without lateral OA. These findings might help to define a clinically distinct subgroup based on a simple radiographic finding in mild knee OA.

Physiological exercise loading suppresses post-traumatic osteoarthritis progression via an increase in bone morphogenetic proteins expression in an experimental rat knee model.

OBJECTIVE: To evaluate the dose-response relationship of exercise loading in the cartilage-subchondral bone (SB) unit in surgically-induced post-traumatic osteoarthritis (PTOA) of the knee. DESIGN: Destabilized medial meniscus (DMM) surgery was performed on the right knee of 12-week-old male Wistar rats, and sham surgery was performed on the contralateral knee. Four weeks after the surgery, the animals were subjected to moderate (12 m/min) or intense (21 m/min) treadmill exercises for 30 min/day, 5 days/week for 4 weeks. PTOA development in articular cartilage and SB was examined using histological and immunohistochemical analyses, micro-computed tomography (micro-CT) analysis, and biomechanical testing at 8 weeks after surgery. Gremlin-1 was injected to determine the role of bone morphogenetic protein (BMP) signaling on PTOA development following moderate exercise. RESULTS: Moderate exercise increased BMP-2, BMP-4, BMP-6, BMP receptor 2, pSmad-5, and inhibitor of DNA binding protein-1 expression in the superficial zone chondrocytes and suppressed cartilage degeneration, osteophyte growth, SB damage, and osteoclast-mediated SB resorption. However, intense exercise had little effect on BMP expression and even caused progression of these osteoarthritis (OA) changes. Gremlin-1 injection following moderate exercise caused progression of the PTOA development down to the level of the non-exercise DMM-operated knee. CONCLUSIONS: Exercise regulated cartilage-SB PTOA development in DMM-operated knees in a dose-dependent manner. Our findings shed light on the important role of BMP expression in superficial zone chondrocytes in attenuation of PTOA development following physiological exercise loading. Further studies to support a mechanism by which BMPs would be beneficial in preventing PTOA progression are warranted.

Indels within promoter and intron 1 of bovine prion protein gene modulate the gene expression levels in the medulla oblongata of two Japanese cattle breeds.

Genetic differences which exist in the prion protein gene (PRNP) have been reported to influence susceptibility of humans, sheep and goats to prion diseases. In cattle, however, none of the known coding polymorphisms has a direct effect on bovine spongiform encephalopathy (BSE). It has been reported that 23-bp insertion/deletion (indel) polymorphisms within the promoter region have a tentative association to BSE susceptibility in German cattle, and a lower number of 24-bp repeat units in the open reading frame (ORF) was reported to reduce BSE susceptibility in transgenic mice. In this study, because of the hypothesis that bovine PRNP promoter polymorphisms cause changes in PRNP expression, we genotyped PRNP polymorphisms in the promoter and intron 1 using 218 genomic DNA samples from two Japanese cattle breeds. We also analysed the expression levels of prion in 40 animals by quantification of real-time PCR using mRNAs extracted from the medulla oblongata to study the relationship between PRNP genotypes and PRNP expression. We found a significant correlation between promoter indel polymorphisms and PRNP-mRNA expression (P(0.0413)) and therefore hypothesize that differences in polymorphisms could be one of the causes of differences in PRNP expression levels. We also report a novel difference in PRNP expression (P < 0.0001) between Japanese Black and Japanese Brown cattle breeds. There was no significant difference based on age and sex of the animals.

Effect of tibial component alignment on knee kinematics and ligament tension in medial unicompartmental knee arthroplasty.

OBJECTIVES: Unicompartmental knee arthroplasty (UKA) is one surgical option for treating symptomatic medial osteoarthritis. Clinical studies have shown the functional benefits of UKA; however, the optimal alignment of the tibial component is still debated. The purpose of this study was to evaluate the effects of tibial coronal and sagittal plane alignment in UKA on knee kinematics and cruciate ligament tension, using a musculoskeletal computer simulation. METHODS: The tibial component was first aligned perpendicular to the mechanical axis of the tibia, with a 7° posterior slope (basic model). Subsequently, coronal and sagittal plane alignments were changed in a simulation programme. Kinematics and cruciate ligament tensions were simulated during weight-bearing deep knee bend and gait motions. Translation was defined as the distance between the most medial and the most lateral femoral positions throughout the cycle. RESULTS: The femur was positioned more medially relative to the tibia, with increasing varus alignment of the tibial component. Medial/lateral (ML) translation was smallest in the 2° varus model. A greater posterior slope posteriorized the medial condyle and increased anterior cruciate ligament (ACL) tension. ML translation was increased in the > 7° posterior slope model and the 0° model. CONCLUSION: The current study suggests that the preferred tibial component alignment is between neutral and 2° varus in the coronal plane, and between 3° and 7° posterior slope in the sagittal plane. Varus > 4° or valgus alignment and excessive posterior slope caused excessive ML translation, which could be related to feelings of instability and could potentially have negative effects on clinical outcomes and implant durability.Cite this article: K. Sekiguchi, S. Nakamura, S. Kuriyama, K. Nishitani, H. Ito, Y. Tanaka, M. Watanabe, S. Matsuda. Bone Joint Res 2019;8:126-135. DOI: 10.1302/2046-3758.83.BJR-2018-0208.R2.

Oral steroid decreases the progression of joint destruction of large joints in the lower extremities in rheumatoid arthritis.

To identify the risk factors for destruction of large joints in the lower extremities in patients with rheumatoid arthritis (RA) during a 4-year follow-up period in a prospective study.We enrolled consecutive patients who participated in both 2012 and 2016. Clinical data, disease activity, and types of medication were collected in 2012. Standard anteroposterior radiographs of weight-bearing joints (hips, knees, and ankles) were taken in 2012 and 2016. Radiographic progression was defined as progression in the Larsen grade or the need for joint arthroplasty or arthrodesis. The association between baseline characteristics and the incidence of radiographic progression was statistically assessed.A total of 213 patient were enrolled, and, after exclusion, 186 patients were analyzed. Sixty 9 patients (37.1%) showed radiographic progression in 1 of the large joints in the lower extremities. Multivariate regression analysis showed that radiographic progression was associated with older age, higher disease activity, and the presence of radiographic destruction at the baseline. The lower dosage of oral prednisolone was a significant risk factor compared with higher dosage when used.Patients with the risk factors should be followed closely to limit the progression of large joint destruction in the lower extremities.

Distinct biomarkers for different bones in osteoporosis with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is known to cause secondary osteoporosis and fragility fractures. This study aimed to identify biomarkers predictive of bone mineral density (BMD) change at three anatomical sites in patients with RA. METHODS: We conducted a prospective longitudinal study in patients with RA. In 2012, we recruited 379 patients from an RA cohort, 329 of whom underwent evaluation of blood and urine biomarkers together with measurement of BMD in the lumbar spine, proximal femur, and distal forearm. The BMD in these three regions was reassessed in 2014. We performed multivariate linear regression analysis to identify those factors associated with BMD change. RESULTS: The averages of age, body mass index, and disease activity score in 28 joints (DAS28) at baseline were 63.2 (minimum to maximum, 32-85), 21.3 (12.3-30.0), and 3.2 (0.1-5.9), respectively. Univariate analysis showed that the annual BMD change was significantly associated with the use of steroid, bisphosphonate (BP) or vitamin D (VitD), and serum homocysteine in the lumber spine; DAS28, the use of BP or VitD, CRP, and anti-cyclic citrullinated peptide antibody (ACPA) in the proximal femur; and the dosage of MTX, the use of BP or VitD, and serum tartrate-resistant acid phosphatase 5b (TRACP-5b) in the distal forearm, respectively. CONCLUSIONS: Predictive biomarkers for BMD change in RA patients differ at each anatomical site. Practitioners should treat each anatomical site with different markers and prescribe osteoporosis drugs to prevent fractures for RA patients.

Scintillator-based transverse proton beam profiler for laser-plasma ion sources.

A high repetition rate scintillator-based transverse beam profile diagnostic for laser-plasma accelerated proton beams has been designed and commissioned. The proton beam profiler uses differential filtering to provide coarse energy resolution and a flexible design to allow optimisation for expected beam energy range and trade-off between spatial and energy resolution depending on the application. A plastic scintillator detector, imaged with a standard 12-bit scientific camera, allows data to be taken at a high repetition rate. An algorithm encompassing the scintillator non-linearity is described to estimate the proton spectrum at different spatial locations.

The role of endoxyloglucan transferase in the organization of plant cell walls.

The plant cell wall plays a central role in morphogenesis as well as responsiveness to environmental signals. Xyloglucans are the principal component of the plant cell wall matrix and serve as cross-links between cellulose microfibrils to form the cellulose-xyloglucan framework. Endoxyloglucan transferase (EXGT), which was isolated and characterized in 1992, is an enzyme that mediates molecular grafting reaction between xyloglucan molecules. Structural studies on cDNAs encoding EXGT and its related proteins have disclosed the ubiquitous presence in the plant kingdom of a large multigene family of xyloglucan-related proteins (XRPs). Each XRP functions as either hydrolase or transferase acting on xyloglucans and is considered to be responsible for rearrangement of the cellulose-xyloglucan framework, the processes essential for the construction, modification, and degradation of plant cell walls. Different XRP genes exhibit potentially different expression profiles with respect to tissue specificity and responsiveness to hormonal and mechanical signals. The molecular approach to individual XRP genes will open a new path for exploring the controlling mechanisms by which the plant cell wall is constructed and reformed during plant growth and development.

Hyperthermia in the treatment of psoriasis.

The effectiveness of commercially available, chemically generated, topical exothermic pads that elevate skin surface temperature from 42 to 43 degrees C was stressed in 22 patients with psoriasis. Control sites were treated with conventional modalities such as Goeckerman's regimen, as well as with occlusion with nonexothermic pads. Skin lesions in 19 patients disappeared after the use of hyperthermia. The average time required for complete regression in the treated areas was 27 days with hyperthermia, compared with 44 days with Goeckerman's regimen. There were no hyperthermic side effects. Seventeen patients whose skin lesions disappeared with the use of both hyperthermia and Goeckerman's regimen were subsequently reexamined. The hyperthermia produced an equal or longer duration of remission than did Goeckerman's regimen.

Multistep carcinogenesis of normal human fibroblasts. Human fibroblasts immortalized by repeated treatment with Co-60 gamma rays were transformed into tumorigenic cells with Ha-ras oncogenes.

Two normal mortal human fibroblast cell strains were transformed into immortal cell lines, SUSM-1 and KMST-6, by treatment with 4-nitroquinoline 1-oxide (4NQO) and Co-60 gamma rays, respectively. These immortalized cell lines showed morphological changes of cells and remarkable chromosome aberrations, but neither of them grew in soft agar or formed tumors in nude mice. The immortal cell line, KMST-6, was then converted into neoplastic cells by treatment with Harvey murine sarcoma virus (Ha-MSV) or the c-Ha-ras oncogene derived from a human lung carcinoma. These neoplastically transformed cells acquired anchorage-independent growth potential and developed tumors when transplanted into nude mice. All the tumors grew progressively without regression until the animals died of tumors. In addition, the tumors were transplantable into other nude mice. Normal human fibroblasts, on the other hand, were not transformed into either immortal or tumorigenic cells by treatment with Ha-MSV or c-Ha-ras alone. Our present data indicate that (1) the chemical carcinogen, 4NQO, or gamma rays worked as an initiator of carcinogenesis in normal human cells, giving rise to immortality, and (2) the ras gene played a role in the progression of the immortally transformed cells to more malignant cells showing anchorage-independent growth and tumorigenicity. In other words, the immortalization process of human cells seems to be a pivotal or rate-limiting step in the carcinogenesis of human cells.

Multi-step neoplastic transformation of normal human fibroblasts by Co-60 gamma rays and Ha-ras oncogenes.

As reported previously (Namba et al., 1985; Namba, 1985), normal human fibroblasts were transformed into immortal cells with abnormal karyotypes by Co-60 gamma-ray irradiation. These immortally transformed cells (KMST-6) showed no clonability in soft agar and were not tumorigenic. However, by treatment with Ha-ras oncogenes derived from a human lung carcinoma or Harvey murine sarcoma virus, the KMST-6 cells acquired elevated clonability in soft agar and transplantability in nude mice. All the tumors produced grew progressively without showing regression and killed the mice. The tumors were also serially transplantable into other mice. The Ha-ras oncogene alone did not convert normal human fibroblasts into either immortal or tumorigenic cells. Our current data suggest that gamma rays worked as an initiator of carcinogenesis in normal human cells, giving rise to chromosome aberrations and immortality, and the Ha-ras oncogene played a role in the progression of the immortally transformed cell population to a neoplastic one showing enhanced colony formation in soft agar and tumorigenicity in nude mice.

Agravitropic mutant for the study of hydrotropism in seedling roots.

Roots have been shown to respond to a moisture gradient by positive hydrotropism. Agravitropic mutant plants are useful for the study of the hydrotropism in roots because on Earth hydrotropism is obviously altered by the gravity response in the roots of normally gravitropic plants. The roots are able to sense water potential gradient as small as 0.5 MPa mm(-1). The root cap includes the sensing apparatus that causes a differential growth at the elongation region of roots. A gradient in apoplastic calcium and calcium influx through plasmamembrane in the root cap is somehow involved in the signal transduction mechanism in hydrotropism, which may cause a differential change in cell wall extensibility at the elongation region. We have isolated an endoxy loglucan transferase (EXGT) gene that is strongly expressed in pea roots and appears to be involved in the differential growth in hydrotropically responding roots. Thus, it is now possible to study hydrotropism in roots by comparing with or separate from gravitropism. These results also imply that microgravity conditions in space are useful for the study of hydrotropism and its interaction with gravitropism.

Coronary artery stenosis evaluated by combined carotid and coronary angiography in patients undergoing carotid endarterectomy.

The relationship between coronary artery stenosis and the postoperative outcome was investigated in patients who underwent carotid endarterectomy (CEA). The benefit of combined carotid and coronary angiography was also evaluated. Combined carotid and coronary angiography was performed in 72 patients treated with CEA (mean age 64.0 years). Fourteen patients with a history of ischemic heart disease (IHD) had a higher Gensini score for coronary artery stenosis than patients with no history of IHD (37.9 +/- 36.8 vs. 7.9 +/- 12.5, p < 0.0001). However, 39.7% of patients with no history of IHD had a Gensini score exceeding 6. Patients with diabetes mellitus had a significantly higher Gensini score than nondiabetic patients. Eleven patients (15.3%) underwent percutaneous transluminal coronary angioplasty and three (4.2%) underwent coronary artery bypass grafting during the CEA perioperative period. None of the patients who underwent combined angiography showed signs of IHD during or after CEA (mean follow-up period 30 months). Combined angiography was not performed in 189 previous patients. Of these, two died of acute myocardial infarction in the postoperative period, 11 manifested nonfatal IHD, and 18 succumbed to IHD (mean follow-up period 8 years). Although patients with a history of IHD manifested more severe coronary artery stenosis than patients without such a history, the possibility of coronary artery stenosis must be considered in patients with no history of IHD, especially those with diabetes mellitus. Combined carotid and coronary angiography and careful management of coronary artery stenosis can be expected to decrease the mortality and morbidity in patients treated with CEA.

Carotid endarterectomy for radiation-induced carotid artery stenosis.

A 60-year-old male presented with radiation-induced left carotid artery stenosis. Carotid endarterectomy was performed successfully without postoperative deficits. Carotid endarterectomy is the therapeutic management of choice for these lesions.

Hyperperfusion syndrome following carotid endarterectomy: evaluation using diffusion-weighted magnetic resonance imaging--case report.

A 65-year-old female developed hyperperfusion syndrome following carotid endarterectomy for severe stenosis of the left internal carotid artery. Transcranial Doppler monitoring showed a sharp increase in flow velocity in the middle cerebral artery (MCA). Diffusion-weighted magnetic resonance (MR) imaging demonstrated diffuse hyperintensity in the region of the left MCA, which diminished markedly 9 days later. The abnormal hyperintensity decreased as the patient's symptoms improved, suggesting that diffusion-weighted MR imaging can be used for evaluating the course of hyperperfusion syndrome.

[Activation of aerobic bacteria used as BOD measurement of seawater].

Waste of seawater used for cooling water for machines in some kinds of industries in a littoral district in Sakai City, comes under the application of BOD control of the pollution control ordinance in Osaka Prefecture. But unfortunately the BOD measurement method of seawater sample has not been established. In order to establish the measurement method, we studied the strength of activation of aerobic bacteria in the incubation water used and the dilution water. From our results it was proved that we can use the incubation seawater consisting of more than 10(3) cells/ml general bacteria count and more than 0.50 microgram/l ATP (Adenosin triphosphate) as the incubation water and the artificial seawater as the dilution water.

[On the antibacterial effect of hinokitiol against Staphylococcus aureus showing double zone phenomenon].

We studied the antibacterial effect of Hinokitiol against Staphylococcus aureus. As reference, we studied also the antibacterial effects of the oil and water from Thujopsis dolablata var. hondai Makino which contains Hinokitiol an important element of its antibacterial effect. Interestingly, Hinokitiol showed the double zone phenomenon, i.e., minimum inhibitory concentration of hinokitiol against MSSA was 15-125 micrograms/ml and against MSSA was 125 micrograms/ml. But when the concentration of Hinokitiol was diluted to 1.87-0.94 micrograms/ml, then the growth of MSSA was inhibited (Table 1 and Fig. 1). This phenomenon was observed the study on antibacterial effect using disk containing Hinokitiol (Fig/3). Similar phenomenon were observed also in the study using water from Thujopsis dolablata (Table 2 & Fig. 2). We deduce that Hinokitiol has a strong antibacterial effect against S. aureus. But this effect shows double zone effect. The antibacterial effect of Hinokitiol is more prominent against MRSA than MSSA.

[A study on hemolytic streptococci (group A, B, C and G) isolated from throat of the middle-aged and advanced-aged--especially as compared with elementary school children].

Hemolytic streptococci were isolated from throat of middle-aged and advanced-aged and these organisms were classified into groups A, B, C and G. 1) Persons 15 to 39 years old were included in one group and persons from 40 years of age upward were divided into 5 groups every 10 years. Comparison of these groups were done. Generally, group B organisms were most often isolated. The detection rate of group B organisms was higher in the older age group. The detection rates of group A and G organisms were approximately equal, but both organisms were isolated from a few persons. No organism of group C was isolated from males, while only two strains belonged to group C organism were isolated from females. 2) A number of strains of group A hemolytic streptococci were isolated from school children, particularly in the lower classes. But the proportion of group B organism to isolated streptococci showed an increase in upper classes, noticeably in females. 3) For middle-aged and advanced-aged, blood samples were obtained simultaneously on examination of the throat, and ASO value and ASK titer were determined. ASO values were higher in persons infected with groups A, C or G organisms than in persons infected with group B organism or no hemolytic streptococcus. ASK titers revealed a similar results to ASO values, though the relation between ASK titers and isolated hemolytic streptococci was less positive.

[A case of giant osteoma in the occipital bone].

A 51-year-old female patient, admitted with a chief complaint of dizziness, had bulging of the occipital area, which had started insidiously. On admission, a bony hard swelling with a smooth surface was noted in the left occipital region, extending over the midline of the skull. Plain X ray films revealed a uniform shadow of an osteoid mass inside the occipital bone. A tomogram indicated that the mass originated in the diploë or outer table of the skull, although there was no evidence of destruction of the inner table. CT scan revealed mixed density mass with high density of bone and an irregularly shaped low density area. In the T1-weighted images of MRI, the entire mass showed a low intensity, while in the T2-weighted image the mass showed 3 areas with different intensities. Bone scintigraphy was performed with 99mTc-MDP and revealed an image of accumulation in the mass. Carotid and vertebral angiograms were negative for evidence of feeding arteries to the mass, for tumor stain, and for occlusion of either sigmoid sinus or transverse sinus. The mass was diagnosed as a giant osteoma, and was totally removed. The excised tumor measured 10 x 9 x 5 cm, and inspection at operation revealed it to be composed of a fragile osteoid portion and a comparatively soft connective tissue portion. The histological diagnosis of the mass was that it was a spongy osteoma including a comparatively large amount of connective tissue. The postoperative recovery of the patient was satisfactory and her dizziness disappeared.(ABSTRACT TRUNCATED AT 250 WORDS)