Progressive glenoid bone loss caused by erosion in humeral head resurfacing.

BACKGROUND: Cementless surface replacement of the shoulder represents an alternative to conventional stemmed anatomic prostheses. Glenoid erosion is a well-known complication in hemiarthroplasty. However, there is limited data concerning radiographic evaluation and prognostic factors for this phenomenon. OBJECTIVES: The aim of our study was to determine the development of glenoid erosion following shoulder resurfacing using a new measurement technique and detect potential prognostic factors. MATERIALS AND METHODS: We performed a retrospective analysis on 38 shoulders undergoing humeral head resurfacing with a mean follow-up of 65.4 ± 43 months. Clinical and radiographic evaluation followed a standardized protocol including pre- and postoperative Constant score, active range of motion, and X­rays in true anteroposterior view. Three independent observers performed measurements of glenoid erosion. RESULTS: We found good interobserver reliability for glenoid erosion measurements (intraclass correlation coefficient [ICC] 0.74-0.78). Progressive glenoid erosion was present in all cases, averaging 5.5 ± 3.9 mm at more than 5 years' follow-up. Male patients demonstrated increased glenoid bone loss within the first 5 years (p < 0.04). The mean Constant score improved to 55.4 ± 23.6 points at the latest follow-up. Younger age was correlated to increased functional outcome. Revision rate due to painful glenoid erosion was 37%. CONCLUSIONS: Glenoid erosion can be routinely expected in patients undergoing humeral head resurfacing. Painful glenoid erosion leads to deterioration in functional outcome and necessitates revision surgery in a high percentage of cases.

Osteoarthritic changes in vervet monkey knees correlate with meniscus degradation and increased matrix metalloproteinase and cytokine secretion.

OBJECTIVE: Meniscus injury increases osteoarthritis risk but its pathobiology in osteoarthritis is unclear. We hypothesized that older adult vervet monkeys would exhibit knee osteoarthritic changes and the degenerative menisci from these animals would secrete matrix metalloproteinases (MMPs) and pro-inflammatory cytokines that contribute to the development of osteoarthritis. DESIGN: In a cross sectional analysis of healthy young adult (9-12 years) and old (19-26 years) adult female vervet monkeys, knees were evaluated in vivo with computed tomography (CT) imaging, and joint tissues were morphologically graded at necropsy. Meniscus explants were subsequently cultured to evaluate meniscal MMP and cytokine secretion. RESULTS: CT images revealed significant bony osteoarthritic changes in 80% of older monkeys which included increases in osteophyte number and meniscal calcification. Meniscus and cartilage degradation scores were greater in the older monkeys and were positively correlated (r > 0.7). Menisci from older animals exhibiting osteoarthritic changes secreted significantly more MMP-1, MMP-3, and MMP-8 than healthy menisci from younger monkeys. Older menisci without significant osteoarthritic changes secreted more IL-7 than healthy young menisci while older osteoarthritic menisci secreted more IL-7 and granulocyte-macrophage colony-stimulating factor than healthy older menisci. CONCLUSIONS: Aged vervets develop naturally occurring knee osteoarthritis that includes involvement of the meniscus. Degenerative menisci secreted markedly increased amounts of matrix-degrading enzymes and inflammatory cytokines. These factors would be expected to act on the meniscus tissue and local joint tissues and may ultimately promote osteoarthritis development. These finding also suggest vervet monkeys are a useful animal model for studying the progression of osteoarthritis.

[Classification of elbow stiffness and indications for surgical treatment]. / Einteilung der Ellenbogensteifen und Indikation zur operativen Behandlung.

An elbow can become stiff for a variety of reasons, such as intra-articular or extra-articular fractures, soft-tissue trauma, prolonged immobilization, thermal injury, infection, inflammatory arthritis, osteoarthrosis and heterotopic bone formation. Elbow stiffness is usually classified into extrinsic (affecting the capsule and extra-articular soft tissues), intrinsic (affecting the synovial and intra-articular structures) and mixed forms. Indications for operative treatment have to be considered in cases of failed conservative treatment with severe functional deficits. The choice of operative treatment has to be based on a thorough analysis of the underlying cause, the affected structures, the pathogenesis and the individual needs. Options are an arthroscopic or open arthrolysis, endoprostheses, hinged external fixators, interposition arthroplasty or combinations of these procedures.

[Complication management after unsuccessful operative shoulder stabilization]. / Komplikationsmanagement nach fehlgeschlagener operativer Schulterstabilisierung.

Operative repair of shoulder instability may fail because of multiple causes: a constitutional predisposition, a new trauma, incorrect diagnosis, inadequate operative techniques or inappropriate rehabilitation can be involved. The key to successful revision surgery is a thorough analysis of errors of the primary repair and the revision also has to deal with the decisive pathological factors. The management of revision surgery after failed surgery for patients with instability has to focus on the decisive pathological factors and has to take a higher complication rate and lower success rate than primary repairs into account.In agreement with the literature a retrospective investigation of 61 open revision surgeries after an average follow up of more 4 years showed recurrent dislocations in 6 patients (9.8%). One of these patients had an adequate trauma and a seizure as the cause of dislocation. After thorough examination three patients revealed signs of a primarily overlooked connective tissue disorder.

[The anatomical precontoured Meves compression plate: surgical treatment of clavicular nonunion]. / Die anatomisch präkonturierte Platte nach Meves: operative Behandlung von Klavikulapseudarthrosen.

BACKGROUND: Pseudarthroses of the clavicle after fractures of the medial third often present with local pain, compromised shoulder function, or neurovascular symptoms. Reconstruction of normal clavicular anatomy and solid fusion is a prerequisite for good clinical outcome after surgical treatment. In this study, 24 patients with clavicular pseudarthrosis were treated with the anatomical precontoured Meves plate. In 11 patients, additional bone grafting was done. METHOD: Nineteen patients could be reexamined with a mean follow-up of 74.5 months. In all of them, solid fusion was achieved. RESULTS: The Constant score improved from 70.4 points preoperatively up to 82.5 points postoperatively (89.3% age-related). Sixteen patients were satisfied or very satisfied with the operative result. CONCLUSION: In our patients, secure healing of clavicular nonunion was achieved with the anatomical precontoured Meves plate, with good or excellent clinical outcomes.

[Treatment of septic arthritis of the shoulder and periprosthetic shoulder infections. Special problems in rheumatoid arthritis]. / Behandlung von Schultergelenkinfektionen und periprothetischen Schulterinfekten. Spezielle Probleme bei der rheumatoiden Arthritis.

Infections of the shoulder joint are rare but nevertheless carry a high risk of complications. Successful therapy is mostly operative and should be planned according to the causes, stage, and expansion of the infection and the expected spectrum of bacteria. Moreover, the patient's general condition and previous illnesses must be considered. Patients with rheumatoid arthritis and immunotherapy are especially at risk for complications and require special attention. Shoulder infections and periprosthetic infections can be treated with arthroscopy, with open debridement, or, in the case of periprosthetic infections, with one- or two-stage exchange procedures. In cases of noncontrollable infections, resection arthroplasty or arthrodesis can be performed as a last resort. Results and possible complications are described herein, including those based on our own results.

A gene expression signature that distinguishes desmoid tumours from nodular fasciitis.

Nodular fasciitis (NF) is a rapidly growing cellular mass composed of fibroblasts/myofibroblasts, usually localized in subcutaneous tissues, that typically undergoes fibrosis and almost never recurs. Desmoid tumours (DTs) are rare forms of fibroblastic/myofibroblastic growth that arise in deep soft tissues, display a propensity for local infiltration and recurrence, but fail to metastasize. Given that both entities are primarily fibroblastic/myofibroblastic lesions with overlapping histological features, their gene expression profiles were compared to identify differentially expressed genes that may provide not only potential diagnostic markers, but also clues as to the pathogenesis of each disorder. Differentially expressed transcripts (89 clones displaying increased expression in DTs and 246 clones displaying increased expression in NF) included genes encoding several receptor and non-receptor tyrosine kinases (EPHB3, PTPRF, GNAZ, SYK, LYN, EPHA4, BIRC3), transcription factors (TWIST1, PITX2, EYA2, OAS1, MITF, TCF20), and members of the Wnt signalling pathway (AXIN2, WISP1, SFRP). Remarkably, almost one-quarter of the differentially expressed genes encode proteins associated with inflammation and tissue remodelling, including members of the interferon (IFN), tumour necrosis factor (TNF), and transforming growth factor beta (TGF-beta) signalling pathways as well as metalloproteinases (MMP1, 9, 13, 23), urokinase plasminogen activator (PLAU), and cathepsins. The observations provide the first comparative molecular characterization of desmoid tumours and nodular fasciitis and suggest that selected tyrosine kinases, transcription factors, and members of the Wnt, TGF-beta, IFN, and TNF signalling pathways may be implicated in influencing and distinguishing their fate.

The circadian system and melatonin: lessons from rats and mice.

The circadian system (CS) comprises three key components: (1) endogenous oscillators (clocks) generating a circadian rhythm; (2) input pathways entraining the circadian rhythm to the astrophysical day; and (3) output pathways distributing signals from the oscillator to the periphery. This contribution briefly reviews some general aspects ofthe organization of the rodent CS and pays particular attention to recent results obtained with various mouse strains, related to molecular mechanisms involved in entraining the endogenous clock and the role of the pineal hormone melatonin as a hand of the endogenous clock.

Melatonin: a clock-output, a clock-input.

In mammals, the circadian system is comprised of three major components: the lateral eyes, the hypothalamic suprachiasmatic nucleus (SCN) and the pineal gland. The SCN harbours the endogenous oscillator that is entrained every day to the ambient lighting conditions via retinal input. Among the many circadian rhythms in the body that are driven by SCN output, the synthesis of melatonin in the pineal gland functions as a hormonal message encoding for the duration of darkness. Dissemination of this circadian information relies on the activation of melatonin receptors, which are most prominently expressed in the SCN, and the hypophyseal pars tuberalis (PT), but also in many other tissues. A deficiency in melatonin, or a lack in melatonin receptors should therefore have effects on circadian biology. However, our investigations of mice that are melatonin-proficient with mice that do not make melatonin, or alternatively cannot interpret the melatonin message, revealed that melatonin has only minor effects on signal transduction processes within the SCN and sets, at most, the gain for clock error signals mediated via the retino-hypothalamic tract. Melatonin deficiency has no effect on the rhythm generation, or on the maintenance of the oscillation. By contrast, melatonin is essential for rhythmic signalling in the PT. Here, melatonin acts in concert with adenosine to elicit rhythms in clock gene expression. By sensitizing adenylyl cyclase, melatonin opens a temporally-restricted gate and thus lowers the threshold for adenosine to induce cAMP-sensitive genes. This interaction, which determines a temporally precise regulation of gene expression, and by endocrine-endocrine interactions possibly also pituitary output, may reflect a general mechanism by which the master clock in the brain synchronizes clock cells in peripheral tissues that require unique phasing of output signals.

Of rodents and ungulates and melatonin: creating a uniform code for darkness by different signaling mechanisms.

Melatonin synthesis in the mammalian pineal gland is one of the best investigated output pathways of the circadian clock because it can be readily measured and is tightly regulated by a clearly defined input, the neurotransmitter norepinephrine. In this system, a regulatory scenario was deciphered that is centered around the cyclic AMP pathway but shows peculiar species-specific differences. In rodents, the cyclic AMP-mediated, temporally sequential up-regulation of two transcription factors, the activator CREB (cyclic AMP-responsive element-binding protein) and the inhibitor ICER (inducible cyclic AMP-dependent early repressor), is the core mechanism to determine rhythmic accumulation of the mRNA encoding for the rate-limiting enzyme in melatonin synthesis, the arylalkylamine N-acetyltransferase (AA-NAT). Thus, in rodents, the regulation of melatonin synthesis bears an essential transcriptional component, which, however, is flanked by posttranscriptional mechanisms. In contrast, in ungulates, and possibly also in primates, AA-NAT appears to be regulated exclusively on the posttranscriptional level. Here, increasing cyclic AMP levels inhibit the breakdown of constitutively synthesized AA-NAT protein by proteasomal proteolysis, leading to an elevated enzyme activity. Thus, self-restriction of cellular responses, as a reaction to external cues, is accomplished by different mechanisms in pinealocytes of different mammalian species. In such a temporally gated cellular adaptation, transcriptionally active products of clock genes may play a supplementary role. Their recent detection in the endogenously oscillating nonmammalian pineal organ and, notably, also in the slave oscillator of the mammalian pineal gland underlines that the mammalian pineal gland will continue to serve as an excellent model system to understand mechanisms of biological timing.

Analysis of cell signalling in the rodent pineal gland deciphers regulators of dynamic transcription in neural/endocrine cells.

In neurons, a temporally restricted expression of cAMP-inducible genes is part of many developmental and adaptive processes. To understand such dynamics, the neuroendocrine rodent pineal gland provides an excellent model system as it has a clearly defined input, the neurotransmitter norepinephrine, and a measurable output, the hormone melatonin. In this system, a regulatory scenario has been deciphered, wherein cAMP-inducible genes are rapidly activated via the transcription factor phosphoCREB to induce transcriptional events necessary for an increase in hormone synthesis. However, among the activated genes is also the inhibitory transcription factor ICER. The increasing amount in ICER protein leads ultimately to the termination of mRNA accumulation of cAMP-inducible genes, including the gene for the Aa-nat that controls melatonin production. This shift in ratio of phosphoCREB and ICER levels that depends on the duration of stimulation can be interpreted as a self-restriction of cellular responses in neurons and has also been demonstrated to interfere with cellular plasticity in many non-neuronal systems.

Clock gene protein mPER1 is rhythmically synthesized and under cAMP control in the mouse pineal organ.

The mammalian clock gene Per1 is an important element of endogenous oscillators that control daily rhythms in central and peripheral tissues. Although such autonomous clock function is lost in the mammalian pineal gland during evolution, mPer1 mRNA and mPER1 protein were found to be strongly elevated in the mouse pineal organ during the dark period compared to daytime values. In vitro studies showed that mPer1 mRNA and mPER1 protein in mouse pineal gland are induced following the activation of a signalling pathway of fundamental importance for pineal physiology, the norepinephrine/cAMP/phosphoCREB cascade. mPER1 may function in the mouse pineal gland as a time-measuring molecule to participate in regulating rhythmic cellular responses in vivo.

Antisense experiments reveal molecular details on mechanisms of ICER suppressing cAMP-inducible genes in rat pinealocytes.

In the rat pineal gland neuronal signals determine the rhythmic synthesis of the hormone melatonin. Norepinephrine (NE) is the principal neurotransmitter that drives hormone synthesis by activating the cAMP signaling pathway. This activation depends on transcriptional and posttranscriptional regulatory mechanisms. The cAMP-dependent transcriptional regulation of the rate-limiting enzyme of melatonin synthesis, arylalkylamine-N-acetyltransferase (AA-NAT) involves the activating transcription factor (TF) CREB and the inhibitory TF ICER. By silencing elements of this cAMP-dependent neuroendocrine transduction cascade we wished to gain further insight into the role of ICER in the regulation of gene expression in rat pineal gland. Inhibition of specific kinases in primary pinealocyte cultures showed that ICER induction depends pivotally on the activation of cAMP-dependent protein kinase II. Eliminating ICER's impact by transfecting antisense constructs into pinealocytes revealed a predominant beta-adrenergic mechanism in regulating a cotransfected CRE-inducible reporter gene and notably, also the endogenous AA-NAT gene. Deciphering molecular details of the cAMP-dependent gene expression in mammalian pinealocytes provides a basis for understanding the general architecture of this signaling pathway that serves adaptive processes ubiquitously in the organism.

Exploration of a novel environment leads to the expression of inducible transcription factors in barrel-related columns.

Tactile information acquired through the vibrissae is of high behavioral relevance for rodents. Numerous physiological studies have shown adaptive plasticity of cortical receptive field properties due to stimulation and/or manipulation of the whiskers. However, the cellular mechanisms leading to these plastic processes remain largely unknown. Although genomic responses are anticipated to take place in this sequel, virtually no data so far exist for freely behaving animals concerning this issue. Thus, adult rats were placed overnight in an enriched environment and most of them were also subjected to clipping of different sets of whiskers. This type of stimulation led to a specific and statistically significant increase in the expression of the protein products of the inducible transcription factors c-Fos, JunB, inducible cyclic-AMP early repressor and Krox-24 (also frequently named Zif268 or Egr-1), but not c-Jun. The response was found in columns of the barrel cortex corresponding to the stimulated vibrissae; it displayed a layer-specific pattern. However, no induction of transcription factors was observed in the subcortical relay stations of the whisker-to-barrel pathway, i.e. the trigeminal nuclei and the ventrobasal complex. These results strongly suggest that a coordinated transcriptional response is initiated in the barrel cortex as a consequence of processing of novel environmental stimuli.

Melatonin limits transcriptional impact of phosphoCREB in the mouse SCN via the Mel1a receptor.

In the mouse, activity phase-shifts of the endogenous clock in the suprachiasmatic nucleus (SCN) are associated with phosphorylation of the transcription factor Ca2+/cAMP responsive element binding protein (CREB). CREB phosphorylation is induced by the retino-hypothalamic transmitter pituitary adenylate cyclase-activating polypeptide (PACAP). As detected by immunohistochemistry in SCN slices from wild-type mice, melatonin completely blocked PACAP-stimulated CREB phosphorylation at low concentrations (1 nM). In Mel1a melatonin receptor-deficient mice, the PACAP-induced CREB phosphorylation was inhibited only at melatonin concentrations of 100 nM. This inhibition was, however, blunted by blocking the Mel1b melatonin receptor. Thus, melatonin modulates PACAP-mediated retinal stimuli for clock entrainment primarily via the Mel1a melatonin receptor through molecular interaction within the cAMP-signalling pathway.

Transcription factor dynamics and neuroendocrine signalling in the mouse pineal gland: a comparative analysis of melatonin-deficient C57BL mice and melatonin-proficient C3H mice.

In rodents, the nocturnal rise and fall of arylalkylamine N-acetyltransferase (AANAT) activity controls the rhythmic synthesis of melatonin, the hormone of the pineal gland. This rhythm involves the transcriptional regulation of the AANAT by two norepinephrine (NE)-inducible transcription factors, e.g. the activator pCREB (phosphorylated Ca2+/cAMP-response element binding protein) and the inhibitor ICER (inducible cAMP early repressor). Most inbred mouse strains do not produce melatonin under standard laboratory light/dark conditions. As melatonin-deficient mice are often the founders for transgenic animals used for chronobiological experimentations, molecular components of neuroendocrine signalling in the pineal gland as an integral part of clock entrainment mechanisms have to be deciphered. We therefore compared calcium signalling, transcriptional events and melatonin synthesis in the melatonin-deficient C57BL mouse and the melatonin-proficient C3H mouse. Pineal glands and primary pinealocytes were cultured and stimulated with NE or were collected at various times of the light/dark (LD) cycle. Changes in intracellular calcium concentrations, the phosphorylation of CREB, and ICER protein levels follow similar dynamics in the pineal glands of both mouse strains. pCREB levels are high during the early night and ICER protein shows elevated levels during the late night. In the C57BL pineal gland, a low but significant increase in melatonin synthesis could be observed upon NE stimulation, and, notably, also when animals were exposed to long nights. We conclude that the commonly used C57BL mouse is not completely melatonin-deficient and that this melatonin-deficiency does not affect molecular details involved in regulating transcriptional events of melatonin synthesis.

Inducible cyclic AMP early repressor protein in rat pinealocytes: a highly sensitive natural reporter for regulated gene transcription.

Rhythmic activity of arylalkylamine N-acetyltransferase (AANAT) determines melatonin synthesis in rat pineal gland. The transcriptional regulation of AANAT involves the activating and inhibiting transcription factors of the cyclic AMP (cAMP)-signaling pathway, cAMP response element-binding protein and inducible cAMP early repressor (ICER), respectively. Activation of this pathway is centered around norepinephrine, stimulating beta(1)-adrenergic receptors, but various other transmitters can modulate melatonin biosynthesis. To compare the transcriptional impact of norepinephrine with that of other neurotransmitters on melatonin synthesis, we determined ICER protein levels in pinealocytes and, in parallel, hormone secretion. The dose-dependent inductions of ICER protein by norepinephrine, the beta(1)-adrenergic receptor agonist isoproterenol, vasoactive intestinal peptide, pituitary adenylate cyclase-activating polypeptide, and adenosine are correlated to regulatory dynamics in melatonin production. Importantly, ICER protein induction required lower ligand concentrations than the induction of melatonin biosynthesis. Although neuropeptide Y, glutamate, and vasopressin altered norepinephrine-stimulated hormone production without affecting ICER levels, the activation of voltage-gated cation channels increased ICER without affecting hormone synthesis. Sensitivity and versatility of ICER induction in pinealocytes make these neuroendocrine cells a valuable model system in which to study molecular interactions determining a regulated gene expression.

Transcription factors in neuroendocrine regulation: rhythmic changes in pCREB and ICER levels frame melatonin synthesis.

Neurotransmitter-driven activation of transcription factors is important for control of neuronal and neuroendocrine functions. We show with an in vivo approach that the norepinephrine cAMP-dependent rhythmic hormone production in rat pineal gland is accompanied by a temporally regulated switch in the ratio of a transcriptional activator, phosphorylated cAMP-responsive element-binding protein (pCREB), and a transcriptional inhibitor, inducible cAMP early repressor (ICER). pCREB accumulates endogenously at the beginning of the dark period and declines during the second half of the night. Concomitant with this decline, the amount of ICER rises. The changing ratio between pCREB and ICER shapes the in vivo dynamics in mRNA and, thus, protein levels of arylalkylamine-N-acetyltransferase, the rate-limiting enzyme of melatonin synthesis. Consequently, a silenced ICER expression in pinealocytes leads to a disinhibited arylalkylamine-N-acetyltransferase transcription and a primarily enhanced melatonin synthesis.

Signal transduction in the rodent pineal organ. From the membrane to the nucleus.

The rodent pineal organ transduces a photoneural input into a hormonal output. This photoneuroendocrine transduction leads to highly elevated levels of the hormone melatonin at night-time which serves as a message for darkness. The melatonin rhythm depends on transcriptional, translational and posttranslational regulation of the arylalkylamine-N-acetyltransferase, the key enzyme of melatonin biosynthesis. These regulatory mechanisms are fundamentally linked to two second messenger systems, namely the cAMP- and the Ca(2+)-signal transduction pathways. Our data gained by molecular biology, immunohistochemistry and single-cell imaging demonstrate a time- and substance-specific activation of these signaling pathways and provide a framework for the understanding of the complex signal transduction cascades in the rodent pineal gland which in concert not only regulate the basic profile but also fine-tune the circadian rhythm in melatonin synthesis.