Administration of enrofloxacin during late pregnancy failed to induce lesions in the resulting newborn foals.

BACKGROUND: A recent study demonstrated that enrofloxacin and ciprofloxacin cross the equine placenta without causing gross cartilage or tendon lesions in the 9-month fetus; however, long-term effects of in utero fluoroquinolone exposure remain unknown. OBJECTIVES: To assess effects of fetal exposure to enrofloxacin on the resulting foal's cartilage and tendon strength. STUDY DESIGN AND METHODS: Healthy mares at 280 days' gestation were allocated into four groups: untreated (n = 5), therapeutic treatment (7.5 mg/kg enrofloxacin, PO × 14 days, n = 6), supratherapeutic treatment (15 mg/kg, PO × 14 days, n = 6) and no mare treatment with treatment of the foals post-partum (n = 2). Mares were allowed to carry pregnancy to term, and foals were maintained on pasture for 5 weeks. After that foals were euthanized, and their articular cartilage and extensor and flexor tendons were examined macroscopically and histologically for lesions. Tendon strength was tested by loading until failure. RESULTS: Administration of enrofloxacin at recommended doses in late gestation did not result in cartilaginous lesions or clinical lameness in any foal by 5 weeks old. Tensile strength was greater in hind tendons than front tendons, but no difference was found between foals born from treated and control mares. Expectedly, osteochondral changes were present both in foals born from enrofloxacin-treated mares and in negative control foals with no apparent association with fluoroquinolone treatment during pregnancy. MAIN LIMITATIONS: Only one time point in gestation was evaluated, and mares treated in the study were healthy at time of treatment. Additionally, it is possible that the assessments performed herein were not sensitive enough to detect subtle or functional changes in the articular cartilage. Further studies are needed to determine if enrofloxacin administration during late pregnancy potentiates osteochondral alterations in the first year of life. CONCLUSIONS: While this study did not assess other stages of gestation or long-term foal outcomes, short-term administration of enrofloxacin to late gestation mares did not result in macroscopic or microscopic lesions in the resulting foals by 5 weeks of age.

Follistatin-like 3 is a mediator of exercise-driven bone formation and strengthening.

Exercise is vital for maintaining bone strength and architecture. Follistatin-like 3 (FSTL3), a member of follistatin family, is a mechanosensitive protein upregulated in response to exercise and is involved in regulating musculoskeletal health. Here, we investigated the potential role of FSTL3 in exercise-driven bone remodeling. Exercise-dependent regulation of bone structure and functions was compared in mice with global Fstl3 gene deletion (Fstl3-/-) and their age-matched Fstl3+/+ littermates. Mice were exercised by low-intensity treadmill walking. The mechanical properties and mineralization were determined by µCT, three-point bending test and sequential incorporation of calcein and alizarin complexone. ELISA, Western-blot analysis and qRT-PCR were used to analyze the regulation of FSTL3 and associated molecules in the serum specimens and tissues. Daily exercise significantly increased circulating FSTL3 levels in mice, rats and humans. Compared to age-matched littermates, Fstl3-/- mice exhibited significantly lower fracture tolerance, having greater stiffness, but lower strain at fracture and yield energy. Furthermore, increased levels of circulating FSTL3 in young mice paralleled greater strain at fracture compared to the lower levels of FSTL3 in older mice. More significantly, Fstl3-/- mice exhibited loss of mechanosensitivity and irresponsiveness to exercise-dependent bone formation as compared to their Fstl3+/+ littermates. In addition, FSTL3 gene deletion resulted in loss of exercise-dependent sclerostin regulation in osteocytes and osteoblasts, as compared to Fstl3+/+ osteocytes and osteoblasts, in vivo and in vitro. The data identify FSTL3 as a critical mediator of exercise-dependent bone formation and strengthening and point to its potential role in bone health and in musculoskeletal diseases.

Pressure distributions on the medial tibial plateau after medial meniscal surgery and tibial plateau levelling osteotomy in dogs.

OBJECTIVE: To evaluate the effect of medial meniscal release (MMR) and medial, caudal pole hemimeniscectomy (MCH) on pressure distribution in the cranial cruciate ligament (CCL) deficient canine stifle, and with tibial plateau levelling osteotomy (TPLO). ANIMALS: Twelve adult dogs. METHODS: In experiment one, six pairs of cadaveric canine stifles with an intact CCL were axially loaded with a servo-hydraulic material testing machine and pressure distributions were mapped and quantified using pressure sensitive films. Axial loading of each joint was then repeated following MMR, and again after MCH. In experiment two, six pairs of cadaveric canine stifles with or without TPLO were tested before and after CCL transection, and each MMR and MCH procedure using the same methods of experiment 1. RESULTS: In experiment one, MMR and MCH had significant effects on the pressure distribution resulting in a 2.5-fold increase in the percentage of surface area with pressure higher than 10 MPa. In experiment two, CCL transection resulted in a significant change in pressure distribution only in the stifle without TPLO (P<0.05). Both MMR and MCH resulted in a 1.7-fold increase in the percentage of area with peak pressure in the stifle with TPLO (P<0.05). CONCLUSIONS: Meniscal surgery results in a change in pressure distribution and magnitude within the medial compartment of the stifle. CLINICAL RELEVANCE: Compromised function of the meniscus by either MMR or MCH result in stress concentration which may predispose to osteoarthritis.

The effects of wire diameter and an additional lateral wire on pin and tension-band fixation subjected to cyclic loads.

Despite reports of frequent complications, pin and tension- band wire remains the most common repair of simple olecranon fractures and osteotomies. A recent mechanical study found wire diameter to be the key determinant of pin and tension-band construct strength; models with 1.25-mm wire were much stronger than those with standard 1.0-mm wire exposed to single loads to failure. Additionally, fixation strength was also increased when a lateral wire was used in combination with a standard figure-of-eight wire. The purpose of the present study was to assess any advantages provided by 1.25-mm wire or an additional lateral wire over 1.0-mm wire for pin and tension-band fixation subjected to cyclic loading. Pin and tension-band fixation was applied to plastic olecranon osteotomy models with three wire configurations: 1.0-mm figure-of-eight, 1.25-mm figure-of-eight, and combined 1.0-mm figure-of-eight and lateral. Cyclic load was applied while caudal osteotomy displacement was measured with an extensometer. The three groups were compared in terms of cycles to failure, mean minimum displacement, mean maximum displacement, and mean displacement per cycle. Models with an additional lateral wire survived significantly more cycles than those with a solitary 1.0-mm figure-of-eight wire, although caudal osteotomy displacements were not significantly different. Conversely, models with 1.25-mm wire allowed significantly smaller minimum and maximum displacements than those with 1.0-mm wire, but did not survive significantly more cycles. It therefore appears that clinical use of 1.25-mm wire may improve stability, while use of an additional lateral wire may improve durability.

Biomechanical and histomorphometric analyses of monocortical screws at placement and 6 weeks postinsertion.

Maxillofacial screws are increasingly being used in orthodontics to provide anchorage for tooth movement. The objective of this study was to determine the biomechanical stability as well as the bone tissue response of screws at 6 weeks postinsertion in a canine model. Seven skeletally mature male dogs received 102 screws (2 x 6 mm or 2 x 8 mm) at predetermined sites. Twenty screws became loose or were lost during the 6-week undisturbed healing period. Forty-eight screws were randomized for mechanical testing and 34 for histology. Peak pullout strength was recorded and approximately 80-microm sections were examined for histomorphometric parameters. Statistical analyses were conducted by analysis of variance and Tukey-Kramer method. Mean +/- SE peak pullout strengths for the various sites ranged from 153.5 +/- 37.6 N to 389.3 +/- 32.5 N with no significant (P < .05) differences at immediate placement and 6 weeks postinsertion. Bone contact ranged from 79% to 95%. Histomorphometric analyses indicated higher bone formation rate in the mandible than in the maxilla and a gradient of decreasing turnover with increasing distance from the screw interface. These results provide the clinical orthodontist with an estimate of the holding power of these screws and an understanding of early biological healing response associated with self-drilling screws.

Localized oxygen use of healthy and low back pain individuals during controlled trunk movements.

Individuals who have low back pain (LBP) have significantly different motion characteristics than healthy individuals. However, the cause of these differences is unknown. Oxygen use of the erector spinae muscle was examined while simultaneously monitoring motion characteristics to determine whether oxygen use differed between healthy and LBP individuals. Thirty volunteers were classified as healthy, structural, or muscular-based LBP. A near-infrared spectrometer monitored oxygen use and blood volume in the lumbar region. Results showed significant differences in oxygen use but not blood volume between healthy and LBP subjects with muscular-based disorders. Inability of the muscular group to use oxygen in a manner similar to the healthy group indicates different processes at the tissue level, indicating that differences in oxygen use may provide insight into why motion patterns differ between healthy and LBP groups.

In vitro biomechanical properties of 2 compression fixation methods for midbody proximal sesamoid bone fractures in horses.

OBJECTIVE: To evaluate 2 methods of midbody proximal sesamoid bone repair--fixation by a screw placed in lag fashion and circumferential wire fixation--by comparing yield load and the adjacent soft-tissue strain during monotonic loading. STUDY DESIGN: Experimental study. SAMPLE POPULATION: 10 paired equine cadaver forelimbs from race-trained horses. METHODS: A transverse midbody osteotomy of the medial proximal sesamoid bone (PSB) was created. The osteotomy was repaired with a 4.5-mm cortex bone screw placed in lag fashion or a 1.25-mm circumferential wire. The limbs were instrumented with differential variable reluctance transducers placed in the suspensory apparatus and distal sesamoidean ligaments. The limbs were tested in axial compression in a single cycle until failure. RESULTS: The cortex bone screw repairs had a mean yield load of 2,908.2 N; 1 limb did not fail when tested to 5,000 N. All circumferential wire repairs failed with a mean yield load of 3,406.3 N. There was no statistical difference in mean yield load between the 2 repair methods. The maximum strain generated in the soft tissues attached to the proximal sesamoid bones was not significantly different between repair groups. CONCLUSIONS: All repaired limbs were able to withstand loads equal to those reportedly applied to the suspensory apparatus in vivo during walking. CLINICAL RELEVANCE: Each repair technique should have adequate yield strength for repair of midbody fractures of the PSB immediately after surgery.

Biomechanical analysis of flat and oblique tibial tubercle osteotomy for recurrent patellar instability.

Both flat (Elmslie-Trillat) and oblique (Fulkerson) osteotomy techniques are successful in treating patellar instability episodes by moving the tibial tubercle medially. The oblique osteotomy also results in anterior displacement that decreases patellofemoral forces. Recent reports have described proximal tibial fractures occurring during early weightbearing after oblique osteotomy. We performed oblique and flat osteotomies on 13 pairs of fresh-frozen cadaveric knees. The knees were then tested to failure on a materials testing system by exerting a load through the quadriceps tendon at a rate of 1000 N/sec to simulate a stumble injury. The failure mechanism for flat osteotomies was more likely to be tubercle "shingle" fracture, while oblique osteotomies more frequently failed through a tibial fracture or fixation failure in the posterior tibial cortex. Mean load to failure was significantly higher in the flat osteotomy specimens (1639 N versus 1166 N), as was total energy to failure (224 N.m versus 127 N.m). There was no significant difference in stiffness (87 N/cm versus 74 N/cm). We recommend the flat osteotomy for patients with isolated recurrent patellar instability and the oblique osteotomy in patients who have concomitant patellofemoral pain or articular degenerative changes. When an oblique osteotomy is used, we recommend postoperative brace protection and restricted weightbearing until the osteotomy heals.

Viscoelastic behaviour of acrylic bone cements.

Local contact stresses at the bone-cement interface are thought to play an important role in the initiation of component loosening. A reduced-modulus bone cement can lower these local contact stresses. The viscoelastic properties of such a cement raised the question of long term subsidence of the implant system. In this study, the viscoelastic properties of a reduced-modulus bone cement were compared with standard polymethylmethacrylate, PMMA, bone cement using stress relaxation tests. Unconstrained stress relaxation tests were performed at 37 degrees C in an aqueous environment by applying 1%, 2.5%, and 5% strains on bone cement specimens and monitoring the diminishing load for 100 h. The initial rapid stress relaxation occurring over the first hour and the steady state stress relaxation occurring between 15 and 100 h were analyzed. A fast stress diminution occurred in PBMMA specimens indicating that, in a total hip arthroplasty application, PBMMA bone cement would transfer the stress quickly and distribute it over a larger area of endosteal bone surface. Steady state stress relaxation experiments showed a significant difference in 2.5% and 5% stress relaxation values (P < 0.05) between PMMA and PBMMA specimens, but not at the 1% stress values. Length measurements indicated that the viscoelastic PBMMA specimens demonstrated little recovery after 100 h of imposed strain whereas the elastic PMMA specimens showed substantial recovery. This seems to indicate relatively larger subsidence rates in unconstrained PBMMA specimens compared to PMMA specimens. In vivo, the cement is surrounded by endosteal bone at the outer side and by an implant on the inner side. Therefore, constrained creep tests are necessary to obtain the data required for an assessment of in vivo subsidence.

Effect of cement modulus on the shear properties of the bone-cement interface.

Shear tests of the bone-cement interface were performed in vitro using two types of bone cement, standard poly(methyl methacrylate) (PMMA) and a reduced-modulus formulation with poly(butyl methacrylate) beads in a methyl methacrylate matrix (PBMMA). Tests of shear properties were also calculated on cancellous bone and on each cement alone. The tests were done using the Iosipescu shear test method which generates a pure shear force in a zero-moment section of the specimen. With this method, shear properties can be determined at specified locations throughout the specimen. Tests were performed across the entire interface region, specifically in the middle of the region of cement bone interdigitation and at both the bone and cement ends of that region. Ultimate shear strengths and shear moduli were calculated. The shear modulus of the PBMMA is less than 3% that of PMMA. The strength and modulus of cancellous bone had a direct relation to the apparent density of the bone, as did the strength and modulus of the bone-composite interface and the composite region. Strength and modulus were dictated by the bone at the bone-composite interface, and by the cement at the cement composite interface. Through the composite region, the stiffer of the two materials in the composite determined the shear properties. Reduced-modulus bone cement substantially decreases the interfacial shear stresses at the bone-cement interface which should decrease the rate of resorptive bone remodelling at this interface.

Dye incorporation to enhance the laser ablation of standard and reduced-modulus bone cements.

Laser ablation of acrylic bone cement is an alternative method of cement removal that can be used during revision arthroplasty of cemented implants. This study investigated the feasibility of using a continuous-wave Argon ion laser (wavelength = 514 nm) with the addition of methylene blue or red dye no. 13 to enhance the ablation of two types of bone cements: polymethylmethacrylate and polybutylmethylmethacrylate. Six cement/dye combinations were studied while power (0.5, 0.75, and 1.0 W) and exposure times (30, 45, 60, and 90 seconds) were varied. The Argon laser was unable to ablate undyed polymethylmethacrylate or polybutylmethylmethacrylate. However, ablation was shown for both cements with either dye. The red dye had a stronger absorption peak at 514 nm than did the blue dye. Statistically larger ablation areas were seen for red polymethylmethacrylate than for blue polymethylmethacrylate (p < 0.013) at all levels tested. Ablation areas were larger in red than in blue polybutylmethylmethacrylate cement. Blue polybutylmethylmethacrylate cement produced larger ablation areas than did blue polymethylmethacrylate cements at all energy levels tested, with smaller surrounding damage areas. Red polybutylmethylmethacrylate cement also produced larger ablation areas than did red polymethylmethacrylate cement (at 0.75 and 1.0 W), again with smaller damage areas. Damage zones were smallest in red polybutylmethylmethacrylate cements at all test levels. These results suggest that, by using dyes to selectively alter the absorption characteristics of bone cement, laser ablation can be an effective method for cement removal. Changes in the chemical structure of the cement can also influence the response to laser treatment. Furthermore, the absorption spectra of the bone cement can be altered to maximize energy absorption at a wavelength that is not absorbed by bone tissue; this potentially minimizes damage to bone during revision surgery.

Articular Cartilage Optical Properties in the Spectral Range 300-850 nm.

Measurements of absolute total reflectance were recorded from weight-bearing (n=9) and nonweight-bearing (n=9) equine articular cartilage specimens from 300 to 850 nm using a spectrophotometer with integrating sphere attachment. Following correction of measured spectra for interfacial reflections and edge losses, Kubelka-Munk theory was applied to estimate absorption and scattering coefficient, one-dimensional light intensity distribution, and light penetration depth. Kubelka-Munk absorption coefficients ranged from ∼7 cm-1 at 330 nm to ∼1 cm-1 at 850 nm. A localized absorption peak was noted at ∼340 nm. Above 510 nm, weight-bearing cartilage demonstrated significantly higher absorption coefficients than nonweight-bearing tissue (paired t-test, p<0.05). Kubelka-Munk scattering coefficients ranged from ∼40 cm-1 at 360 nm to ∼6 cm-1 at 850 nm. No statistical differences in scattering coefficient were noted between weight-bearing and nonweight-bearing tissue. Penetration depths predicted by Kubelka-Munk theory ranged from 0.6 mm at 350 nm to over 3 mm at 850 nm. Stronger absorption in weight-bearing cartilage compared to nonweight-bearing tissue resulted in lower light penetration depths in weight-bearing cartilage at all wavelengths longer than 510 nm. © 1998 Society of Photo-Optical Instrumentation Engineers.

Coupling of skeletal muscle to a prosthesis for circulatory support.

A durable bond between the end of skeletal muscles and prosthetic structures could, with appropriate linkage, allow circulatory support power by synchronous and/or sequential contraction of several in situ conditioned muscles. Potential advantages relative to a myoplasty wrap involve 1) less traumatic dissection, 2) efficient linear force development, 3) selectable contraction rate, 4) greater stroke work, 5) independent control of muscle pre-load and end diastolic pressure, and 6) independent control of duration of muscle tension and ejection time. However, no existing means of tissue-prosthetic bonding appears adequate. Practicality would demand that full tension bearing capacity by the bond take no longer than muscle conditioning. A prosthesis was developed to achieve those goals. As scaled for this study, it is made of 7,200-7,800 unspun, unplaited, 22 to 26 microns diameter polyester fibers swaged into four taper needles for weaving through distal muscle. The other end is formed into a polyurethane sheathed kernmantel cord for distal fixation. Devices were implanted in six 3 to 4 kg rabbits (unilateral posterior tibial tendon replacement, random side selection with contralateral dissection/closure controls), and their tensile strength was tested at 30 days. All healed well; leg movements were normal after 1 week. Limbs were frozen at -70 degrees C between death and testing. Control failure occurred at 243 +/- 94 N and experimental at 163 +/- 44 N (p = 0.065, t-test); highest estimated requirement was 17.2 N. Interface strength was adequate by 30 days. Continued investigations, addressing other questions, are warranted.

Laser ablation of dyed acrylic bone cement.

Revision surgery of cemented implants is indicated when mechanical failure causes severe pain and/or loss of function for the patient. Successful revision arthroplasty of cemented implants requires complete removal of the existing cement. Removal of old cement is an arduous task often causing damage to the surrounding bone tissue. In this study, the authors investigate the use of an Argon laser and the addition of dyes to enhance the laser ablation of bone cement. Methylene blue and red dye #13 were each added separately to polymethylmethacrylate (PMMA) bone cement powder. A continuous wave Argon ion laser (lambda = 514 nm) was used for cement ablation. Cement samples were ablated at different power levels (1.5, 2.3, and 3.0 W) and exposure times (30, 60, 90, 120 sec). The results show that the Argon laser was unable to ablate undyed PMMA. However, the addition of either methylene blue or red dye #13 greatly improved cement ablation by altering the cements' absorption characteristics. Results of Student's t-tests show a statistical difference between red and blue dyed PMMA mean ablation areas at all energy levels tested (P < .0002). As expected, all red ablation areas were greater than blue ablation areas at each energy level tested since red dye absorbs more energy at 514 nm than methylene blue dye. The results of this study suggest that by selectively altering the absorption characteristics of PMMA, laser removal of bone cement can be achieved. In addition, this study also shows that bone tissue does not absorb visible light energy at 514 nm, suggesting that bone cement may be removed with minimal damage to the surrounding bone tissue.

Contact area and pressure distribution changes of the equine third carpal bone during loading.

Changes in contact area and pressure distribution with loading were evaluated on the proximal articulating surface of the equine third carpal bone using safranin-O dye staining and pressure sensitive film techniques. A significant increase in percentage contact area resulted as the applied load was increased from 3115 to 9000 N (54.93% +/- 7.99 vs 61.43% +/- 7.37 respectively, P = 0.016). The area in contact shifted towards the dorsal aspect of both the radial and intermediate facets of the third carpal bone. Changes were also detected in the mean pressure under the same loading conditions. There was a significant increase (P < 0.05) in the mean pressure on the dorsomedial to dorsolateral aspect of the radial facet and the dorsomedial to middle-lateral aspect of the intermediate facet with increased loading. A trend towards an increase (P < 0.10) in mean pressure was detected on the middle-medial aspect of the radial facet and the middle-medial to palmar-lateral aspect of the intermediate facet. There was no significant increase (P > 0.05) in mean pressure with an increase in load from 3115 to 9000 N at the palmar aspect of either facet. The increase in contact area and mean pressure with loading in the most dorsal and dorsomedial aspect of the radial facet may explain the large amount of third carpal bone trauma seen in this location in racing horses.

Initial mechanical stability of acetabular prostheses.

Secure initial stability is crucial for prostheses designed for biological ingrowth; without it, subsequent tissue ingrowth is impossible. Mechanical testing was performed in vitro to measure the interface shear stability of acetabular cup prostheses. Cemented, threaded, fined, and press-fit cups, both with and without supplemental screw fixation, were tested. A mechanically consistent polyethylene foam was used as a substrate to obviate the variations inherent in cadaver bones. Ramped, eccentric rim loads were applied using a servohydraulic materials testing system. Reaming, insertion, and loading variables were carefully controlled. Cups with external threads were significantly more stable than those fixed by fins or screws. Press-fit cups were significantly looser than all other tested designs. None of the uncemented prostheses approached the initial stability of cups secured with acrylic bone cement.

Limited internal fixation of the tibia with external fixation: an in vivo canine study.

This study reports the results of the healing of canine tibial osteotomies with external fixation alone or in combination with a single lag screw. Twelve dogs had a midshaft tibial osteotomy performed at a 45 degree obliquity. Half of the dogs had a six-pin, unilateral, medial, external half-frame applied after the osteotomy. The remaining six had an identical frame plus a lag screw placed perpendicular to the osteotomy site. When compared with their contralateral controls, the fixator-alone group had a 16.3% (p < 0.05) decrease in bone density, whereas no significant density change was seen in the group with the additional lag screw. Torsional stiffness was 29% higher in the osteotomies treated, and tested, with the lag screw, but this did not achieve statistical significance. Computed tomography scanning revealed that the surface area was increased by an average of 30-40% in both groups, relative to contralateral controls, but there was no difference between the two treatment groups. Three tibias in the group with external fixation alone, and two tibias in the screw group showed primary bone healing without evidence of callus formation. The combination of a semirigid external fixation construct with a lag screw resulted in increased torsional stiffness but healing equal to that seen with external fixation alone.

Tension band fixation of medial malleolus fractures.

A prospective study on tension band fixation of medial malleolus fractures was performed on 30 consecutive patients with 31 fractures from October 1987 until December 1990. All patients had at least a displaced medial malleolus fracture unreduced by closed methods. The fractures were classified into small, medium and large using a modified Lauge-Hansen classification. There were no nonunions or movements of wires postoperatively and only two patients had subjective complaints with reference to the wires that required hardware removal. There was one 2-mm malreduction and one patient with a wound slough and subsequent osteomyelitis. One fragment had 2 mm of displacement after fixation but went on to union. A biomechanical study was undertaken to compare fixation of the medial malleolus with K wires alone, K wires plus a tension band, and two cancellous screws. The tension band fixation provided the greatest resistance to pronation forces: for times stiffer than the two screws and 62% of the intact specimen. Tension band fixation of the medial malleolus is a biomechanically strong and clinically acceptable method of treatment for displaced medial malleolus fractures. This method of fixation may be especially useful for small fragments and in osteoporotic bone.

A reduced-modulus acrylic bone cement: preliminary results.

Excessive local contact stress is implicated as an important factor in the initiation of the loosening process after total joint arthroplasties. A reduced-modulus acrylic bone cement, which decreases the bone-cement interface stresses, was developed to test this hypothesis. The formulation consists of butylmethacrylate beads, having a glass transition temperature of 27 degrees C, in a methylmethacrylate matrix. This cement, polybutylmethylmethacrylate (PBMMA), has an elastic modulus one-eighth that of standard PMMA bone cement, 0.27 vs. 2.1 GPa, at body temperature. In vivo use in a pilot study using the sheep total hip arthroplasty model shows a reduction in the rate of loosening of femoral components when compared both radiographically and mechanically with PMMA controls.