At present, strong requirements in orthopaedics are still to be met, both in bone and joint substitution and in the repair and regeneration of bone defects. In this framework, tremendous advances in the biomaterials field have been made in the last 50 years where materials intended for biomedical purposes have evolved through three different generations, namely first generation (bioinert materials), second generation (bioactive and biodegradable materials) and third generation (materials designed to stimulate specific responses at the molecular level). In this review, the evolution of different metals, ceramics and polymers most commonly used in orthopaedic applications is discussed, as well as the different approaches used to fulfil the challenges faced by this medical field.

https://royalsocietypublishing.org/doi/pdf/10.1098/rsif.2008.0151

Biomaterials in orthopaedics.

Data are accumulating that emphasize the important role of the intestinal barrier and intestinal permeability for health and disease. However, these terms are poorly defined, their assessment is a matter of debate, and their clinical significance is not clearly established. In the present review, current knowledge on mucosal barrier and its role in disease prevention and therapy is summarized. First, the relevant terms ‘intestinal barrier’ and ‘intestinal permeability’ are defined. Secondly, the key element of the intestinal barrier affecting permeability are described. This barrier represents a huge mucosal surface, where billions of bacteria face the largest immune system of our body. On the one hand, an intact intestinal barrier protects the human organism against invasion of microorganisms and toxins, on the other hand, this barrier must be open to absorb essential fluids and nutrients. Such opposing goals are achieved by a complex anatomical and functional structure the intestinal barrier consists of, the functional status of which is described by ‘intestinal permeability’. Third, the regulation of intestinal permeability by diet and bacteria is depicted. In particular, potential barrier disruptors such as hypoperfusion of the gut, infections and toxins, but also selected over-dosed nutrients, drugs, and other lifestyle factors have to be considered. In the fourth part, the means to assess intestinal permeability are presented and critically discussed. The means vary enormously and probably assess different functional components of the barrier. The barrier assessments are further hindered by the natural variability of this functional entity depending on species and genes as well as on diet and other environmental factors. In the final part, we discuss selected diseases associated with increased intestinal permeability such as critically illness, inflammatory bowel diseases, celiac disease, food allergy, irritable bowel syndrome, and – more recently recognized – obesity and metabolic diseases. All these diseases are characterized by inflammation that might be triggered by the translocation of luminal components into the host. In summary, intestinal permeability, which is a feature of intestinal barrier function, is increasingly recognized as being of relevance for health and disease, and therefore, this topic warrants more attention.

/pdf/intestinal-permeability-a-new-target-for-disease-prevention-1k5hgcc958.pdf

Intestinal permeability – a new target for disease prevention and therapy

Study design Clinical practice guideline Objective To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain Summary of background data Management of patients with persistent and disabling low back pain remains a clinical challenge A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain Methods A multidisciplinary panel was convened by the American Pain Society Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group Results Investigators reviewed 3348 abstracts A total of 161 randomized trials were deemed relevant to the recommendations in this guideline The panel developed a total of 8 recommendations Conclusion Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

pus was available for culture.) The results in Bristol further supported a impression that the phage type of the staphylococcus was related to the severity 01 infection. Thus the troublesome Phage Type 80 Staphylococcus which was n isolated in 1953 by Rountree and Freeman (1955) in Australia3 has enhanced virulen. and so infection with it leads to sloughs and tissue damage with considerable toxaetf1 t 0S A little boy was admitted with a partial-thickness burn of about twenty per cent^

Management of Sepsis.

The pathogenesis of inflammatory bowel disease (IBD) is multifactorial with data suggesting the role of a disturbed interaction between the gut and the intestinal microbiota. A defective mucosal barrier may result in increased intestinal permeability which promotes the exposition to luminal content and triggers an immunological response that promotes intestinal inflammation. IBD patients display several defects in the many specialized components of mucosal barrier, from the mucus layer composition to the adhesion molecules that regulate paracellular permeability. These alterations may represent a primary dysfunction in Crohn's disease, but they may also perpetuate chronic mucosal inflammation in ulcerative colitis. In clinical practice, several studies have documented that changes in intestinal permeability can predict IBD course. Functional tests, such as the sugar absorption tests or the novel imaging technique using confocal laser endomicroscopy, allow an in vivo assessment of gut barrier integrity. Antitumor necrosis factor-α (TNF-α) therapy reduces mucosal inflammation and restores intestinal permeability in IBD patients. Butyrate, zinc, and some probiotics also ameliorate mucosal barrier dysfunction but their use is still limited and further studies are needed before considering permeability manipulation as a therapeutic target in IBD.

/pdf/intestinal-permeability-in-inflammatory-bowel-disease-29lofcdzjy.pdf

Intestinal Permeability in Inflammatory Bowel Disease: Pathogenesis, Clinical Evaluation, and Therapy of Leaky Gut

Disc prosthesis surgery is rapidly becoming an option in treating patients with symptomatic degenerative disc disease. Only short-term and midterm results are described in the literature. Most operated patients belong to the age group of 30-50 years. In these active patients, complications can be expected to increase with longer follow-up, similar to total joint replacements in the extremities. Reported here is a series of 27 patients from another institution, who presented with unsatisfactory results or complications after SB Charite disc replacement. The objective of this work was to describe the possible short- and long-term unsatisfactory results of disc prosthesis surgery. Twenty-seven patients were seen in a tertiary university referral center with persisting back and leg complaints after having received a Charite disc prosthesis. All patients were operated on in a neighboring hospital. Most patients were operated on at the L4-L5 and /or the L5-S1 vertebral levels. The patients were evaluated with plain radiography, some with flexion-extension x-rays, and most of them with computed tomography scans. The group consisted of 15 women and 12 men. Their mean age was 40 years (range 30-67 years) at the time of operation. The patients presented to us a mean of 53 months (range 11-127 months) following disc replacement surgery. In two patients, an early removal of a prosthesis was required and in two patients a late removal. In 11 patients, a second spinal reconstructive salvage procedure was performed. Mean follow-up for 26 patients with mid- and long-term evaluation was 91 months (range 15-157 months). Early complications were the following: In one patient, an anterior luxation of the prosthesis after 1 week necessitated removal and cage insertion, which failed to unite. In another patient with prostheses at L4-L5 and L5-S1, the prosthesis at L5-S1 dislocated anteriorly after 3 months and was removed after 12 months. Abdominal wall hematoma occurred in four cases. Retrograde ejaculation with loss of libido was seen in one case and erection weakness in another case. A temporary benefit was experienced by 12 patients, while 14 patients reported no benefit at all. Main causes of persistent complaints were degeneration at another level in 14, subsidence of the prosthesis in 16, and facet joint arthrosis in 11. A combination of pathologies was often present. Slow anterior migration was present in two cases, with compression on the iliac vessels in one case. Polyethylene wear was obvious in one patient 12 years after operation. In eight cases, posterior fusion with pedicle screws was required. In two cases, the prosthesis was removed and the segment was circumferentially fused. These procedures resulted in suboptimal long-term results. In this relatively small group of patients operated on with a Charite disc prosthesis, most problems arose from degeneration of other lumbar discs, facet joint arthrosis at the same or other levels, and subsidence of the prosthesis. It is to be expected that many more patients will be seen with late problems some years after this operation as the survivorship will decrease with time.

Complications of artificial disc replacement: a report of 27 patients with the SB Charité disc.

Artificial disc prosthesis show fair to good short- and mid-term results. Long-term results are becoming apparent now, however, the incidence of late complications with this procedure remain poorly understood. In this report we will analyse late complications and discuss our experiences with salvage operations in patients with persistent pain after SB Charite disc prosthesis implantation. Seventy-five patients with persistent leg and back pain after insertion of an artificial disc prosthesis were enrolled in the study. In this negative selection frequently occurring late-complications were subsidence, wear, adjacent disc degeneration, facet joint degeneration and migration. In 15 patients we performed a posterior fusion without disc removal, and in 22 patients we removed 26 prostheses and performed a posterior and anterior fusion. The visual analogue scale (VAS) and Oswestry were examined before the salvage operation and after a follow-up period of at least 1 year, which is not yet available in all patients. The VAS and Oswestry decreased in the posterior group (n = 10) respectively from 8.0 (SD 0.9) to 6.3 (SD 2.1) and from 57.0 (SD 17.0) to 44.6 (SD 20.4); and in the disc removal group (n = 14) respectively from 8.0 (SD 0.9) to 5.6 (SD 2.7) and from 56.3 (SD 14.0) to 43.0 (SD 20.7). Serious late complications may occur following total disc replacement. Removal of the SB Charite artificial disc is feasible but with inherent risks. Removal of the disc prosthesis gives slightly better results than posterior fusion alone after a follow-up of at least 1 year.

/pdf/complications-and-reoperations-of-the-sb-charite-lumbar-disc-4qbfmml1dy.pdf

Complications and reoperations of the SB Charité lumbar disc prosthesis: experience in 75 patients

Polyethylene wear and rim fracture in total disc arthroplasty.

Study Design. A clinical case series of 4 patients undergoing anterior lumbar revision due to failure of total disc replacement surgery. Objectives. To assess the clinical significance of polyethylene wear debris in salvage surgery after initial total disc replacement, the pattern and the mechanisms of polyethylene wear in the retrieved cores, and the extent of polyethylene debris in the periprosthetic tissues obtained from 4 patients. Summary of Background Data. Previous in vitro wear tests have demonstrated low wear rates for lumbar artificial discs, suggesting that implant wear may not be a clinically relevant issue with total disc replacement. However, only long-term clinical investigations with analysis of retrieved implants and periprosthetic tissue can ultimately establish the significance of polyethylene wear debris for total disc arthroplasty. Methods. Starting in 2004, we began routinely performing salvage procedures in patients with failed total disc replacements. We report on the short-term outcomes of 4 patients at our institution who were revised with a Charite prosthesis (DePuy Spine, Raynham, MA). Wear analysis of the retrieved prosthesis and histologic examination of the periprosthetic tissue were also performed. Results. All of the retrieved polyethylene cores showed evidence of wear, but the extent and severity varied among the 4 patients. Wear and fracture of the core were associated with osteolysis of the underlying sacrum in 1 patient. Histologic examination of the periprosthetic tissues confirmed the presence of wear debris lying in inflammatory fibrous tissue. In 3 of the 4 patients, implant wear was associated with an unfavorable biomechanical environment (e.g., subsidence, migration, undersizing, and adjacent fusion). The mechanisms of wear included adhesive/abrasive wear of the central domed region of the polyethylene core, as well as chronic rim impingement, resulting in rim fatigue and fracture. Conclusions. This study demonstrates the clinical significance of polyethylene wear debris and the potential for osteolysis with total disc replacements. The authors recommend that patients undergoing lumbar disc arthroplasty receive long-term follow-up to monitor the wear and functional status of their implants.

André van Ooij

Papers

Complications of artificial disc replacement: a report of 27 patients with the SB Charité disc.

Complications and reoperations of the SB Charité lumbar disc prosthesis: experience in 75 patients

Polyethylene wear and rim fracture in total disc arthroplasty.

Polyethylene wear debris and long-term clinical failure of the Charité disc prosthesis: a study of 4 patients.

Complications of Artificial Disc Replacement: A Report of 27 Patients with the SB Charité Disc