When math meets surgery: how to improve femoral interference screw alignment in ACL reconstruction. A cadaveric study.

Transtibial femoral tunnel drilling is still an alternative technique in ACL reconstruction. Femoral interference screw divergence is a potential pitfall associated with transtibial tunnel technique, as angles greater than 15° jeopardize graft fixation. Our mathematical model theorizes the proper degrees of knee flexion during femoral screw insertion and the correct screwdriver position to obtain a minimal divergence of the screw in the femoral tunnel. The cadaveric study confirms our method. Mathematical model: using rototranslation matrices, a correlation is demonstrated between the ACLtibial- guide angle, the knee flexion, and the screwdriver position. A theoretical minimal divergence between femoral interference screw and the femoral tunnel is obtainable following these assumptions: 1) knee hyperflexion during femoral screw insertion is obtained adding a flexion corresponding to the ACL-tibial-guide angle to the flexion while drilling the femoral tunnel; 2) screwdriver position (through the AM portal) is kept parallel to tibial plateau at a rotation of 15° medial to tibial sagittal plane. Cadaveric study: 24 cadaver knees were used. The transtibial tunnel was drilled with an 8 mm drill bit with the help of an ACL tibial guide set at 55°. To simulate femoral tunnel direction, a 2.4 mm K. wire was drilled through the femur with a transtibial 7 mm offset femoral drill guide. To simulate the femoral screw direction, a second 2.4 mm K. wire was drilled from the femoral entry point of the first wire through the femur, with a cannulated screwdriver. Screwdriver direction and knee flexion during the simulation were obtained following two different methods: GROUP A (mathematical model group, 12 knees), screwdriver direction and knee flexion were calculated following the mathematical model; in GROUP B (control group, 12 knees), knee hyperflexion and screwdriver medialization were manually obtained by a senior surgeon. The divergence between the femoral interference screw and the femoral tunnel was identified as the angle formed by the two wires, measured on the plane formed by the direction of the wires. Mean divergence angles between the K. wires were significantly different (p< 0.05) between the groups: GROUP 1 (mathematical rule): 7.25° (SD 2.2); GROUP 2 (free-hand technique): 17.3° (SD 2.9). Our study shows that a minimal divergence between the femoral tunnel and the screwdriver can be achieved simply by following a mathematical rule for correct intraoperative knee flexion and screwdriver position without the need for any specialized instrumentation. Namely, during femoral interference screw insertion through the anteromedial portal: 1) the correct knee flexion is the sum between the knee flexion angle while drilling the transtibial femoral tunnel AND the ACL tibial guide angle used during tibial tunnel drilling; 2) Correct screwdriver position is parallel to the tibial plateau, engaging the femoral tunnel with a position of 15° medial to tibial sagittal plane. This simple concept has clinical relevance in helping the surgeons in obtaining an optimal alignment between the femoral tunnel and the femoral interference screw during transtibial ACL reconstruction. Furthermore, following the assumptions of this study, a starting knee flexion angle around 70° during femoral tunnel drilling seems preferable for ACL reconstruction when the transtibial tunnel technique is used. Indeed, because ACL-tibial-guide angles range commonly from 50° to 60° and in vivo, the maximal intraoperative knee flexion attainable is 130°, a starting knee flexion around 70° is optimal to allows for adding flexion angles up to 60° before reaching the physiological limit value of 130°.

Periprosthetic osteolysis: a narrative review.

Periprosthetic osteolysis is still one of the major limitations of prosthetic joints longevity. The process of this "silent" iatrogenic disease involves both mechanical and biological factors that initiate a local immune response in the periprosthetic tissue that eventually lead to implant loosening and failure. There are many causes of the primary aseptic loosening inside the periprosthetic microenvironment, but the most important elements are the wear debris and the cell-particle interactions. Together with implant position, micromotion, bearings, joint fluid pressure, and increased load on the joints drive the pathogenesis of the disease. This narrative review aims to summarise recent studies describing the biological and mechanical factors in the pathogenesis of osteolysis and some of the current pharmacological attempts to "rescue" a failing implant.

Rehabilitation protocol after simultaneous anterior cruciate ligament reconstruction and high tibial osteotomy: introducing the concept of the individualized approach.

Postoperative rehabilitation after simultaneous anterior cruciate ligament reconstruction and opening wedge high tibial osteotomy is a complex concept. Different osteotomy techniques, extremely selected patients, high expectations in returning to previous sport activities, and the different individual physical profile and performances make traditional chronological criteria impractical and unfeasible. This study presents a novel rehabilitation in which functional objective criteria are considered the key factors for standardizing a 4-step protocol. Each step is "individualized", based on the patient's response to the healing processes and to the different training phases, allowing for a safe return to sports competitions. This definitively implies a strict collaboration between patient, surgeon, physician and physiotherapists, as well as thorough and detailed patient education. Due to the high versatility of these new rehabilitation concepts, the application of the "individualized" steps described in this study may be broadened to include different sports medicine knee injuries that may benefit from a specific, detailed and carefully patient-centered rehabilitation project.

Comparing different approaches in robotic-assisted surgery for unicompartmental knee arthroplasty: outcomes at a short-term follow-up of MAKO versus NAVIO system.

The popularity of unicompartmental knee arthroplasty (UKA) continues to grow among orthopaedic surgeons and robotic surgery may be helpful in obtaining a precise placement of the prosthetic components, thanks to the meticulous intra-operative computer study for simulating the prosthetic positioning. This may lead to longer implant survivorship as well as a reduction in intermediate and long-term prosthetic complications, despite the initial greater costs than those of manual UKA. In this preliminary study, from January 2017 and October 2017, 18 patients underwent UKA with MAKO robotic system assistance and 10 patients received UKA with NAVIO robotic system assistance. The two groups were homogeneous by age, BMI, degree of osteoarthritis involvement, and postoperative program. Patients were followed both clinically (Numeric Rating Scale NRS and Knee Injury Osteoarthritis Outcome Scores KOOS) and radiographically. At the end term follow up (2 years), no significant difference was observed for NRS and KOOS as well as for clinical parameters as an active range of motion. A significant discrepancy was detected regarding the duration of the surgery and time of using the robotic system, that appeared to be longer in the NAVIO group than that of MAKO group, likely due to the specific technical aspects that characterize these two different robotic systems. The main finding of this study is that favorable clinical and radiographical results may be obtained using a robotic approach (MAKO or NAVIO) for UKA positioning at a short follow up. Due to the lack of significant clinical differences observed between the two groups of patients at end term follow up, the "concept" of a robotic approach, more than a specific patented system, may be considered the key element for improving UKA technique and it is likely that in the near future the choice of a single specific robotic system will still be a "surgeon's preference". The results of the study add scientific evidence regarding the effective improvement of UKA results using different robotic approaches. They also show possible economic sustainability of this therapeutic strategy related to the optimal patients' performance obtained at short term follow up, suggesting that the robotic assistance may really become a key element for better long-term survivorship of unicompartmental knee arthroplasty.

Tips and tricks for writing a scientific manuscript.

An original scientific manuscript is the target for any researchers whose aim is to show the innovative results arising from the original intuitions that drove all their experiments. Time and patience are essential to decide how to present the data, how to conceive the tables and figures representing the main outcomes of the research, and how to read and mention the necessary references. Few basic rules may help in this difficult task. The first basic rule is: "do not follow the sequence of the paper". On the opposite, i) start writing the "Materials and Methods (or Patients and Methods when dealing with a clinical study)", ii) then write the "Results" section, iii) then, write the "Discussion" paragraph, in which the principal investigator explains the results and the innovations proposed, iv) then, write the "Introduction", which should be clear and concise. The last element to be written should be the "Abstract", which is the "interface" between the authors and the readers. The second basic rule is that any of the central chapters of the manuscript, i.e. "Materials and Methods" (MM), "Results" (R) and "Discussion" (D), should follow a methodical and sequential description of the topics in a "corresponding sequence of paragraphs". In other words, in the R and the D chapter sequence of the paragraphs should be linked to the sequence of the concepts described and discussed in the paragraphs of the MM chapter. Thus, a sequential description of concepts will be easily followed by the writers, facilitating both the authors in the organization of the data and the reader in finding a reasonable "answer" to all the aspects of the study mentioned in the MM chapter. In this article, these two rules are extensively described and several tips and tricks for each chapter are suggested to ease the composition of a scientific paper. Indeed, it may be possible to solve the complex problem of "writing a scientific paper" by means of separating it in main sections (chapters) and subsections (paragraphs) and dealing with them one by one. Naturally, this takes time and passion, but, as affirmed by Steve Jobs, "the only way to do great work is to love what you do".

Early events in Populus hybrid and Fagus sylvatica leaves exposed to ozone.

This paper aims to investigate early responses to ozone in leaves of Fagus sylvatica (beech) and Populus maximowiczii x Populus berolinensis (poplar). The experimental setup consisted of four open-air (OA) plots, four charcoal-filtered (CF) open-top chambers (OTCs), and four nonfiltered (NF) OTCs. Qualitative and quantitative analyses were carried out on nonsymptomatic (CF) and symptomatic (NF and OA) leaves of both species. Qualitative analyses were performed applying microscopic techniques: Evans blue staining for detection of cell viability, CeCl3 staining of transmission electron microscope (TEM) samples to detect the accumulation of H2O2, and multispectral fluorescence microimaging and microspectrofluorometry to investigate the accumulation of fluorescent phenolic compounds in the walls of the damaged cells. Quantitative analyses consisted of the analysis of the chlorophyll a fluorescence transients (fast kinetics). The early responses to ozone were demonstrated by the Evans blue and CeCl3 staining techniques that provided evidence of plant responses in both species 1 month before foliar symptoms became visible. The fluorescence transients analysis, too, demonstrated the breakdown of the oxygen evolving system and the inactivation of the end receptors of electrons at a very early stage, both in poplar and in beech. The accumulation of phenolic compounds in the cell walls, on the other hand, was a species-specific response detected in poplar, but not in beech. Evans blue and CeCl3 staining, as well as the multispectral fluorescence microimaging and microspectrofluorometry, can be used to support the field diagnosis of ozone injury, whereas the fast kinetics of chlorophyll fluorescence provides evidence of early physiological responses.

In vivo real-time recording of UV-induced changes in the autofluorescence of a melanin-containing fungus using a micro-spectrofluorimeter and a low-cost webcam.

An optical epifluorescence microscope, coupled to a CCD camera, a standard webcam and a microspectrofluorimeter, are used to record in vivo real-time changes in the autofluorescence of spores and hyphae in Aspergillus niger, a fungus containing melanin, while exposed to UV irradiation. The results point out major changes in both signal intensity and the spectral shape of the autofluorescence signal after only few minutes of exposure, and can contribute to the interpretation of data obtained with other fluorescence techniques, including those, such as GPF labeling, in which endogenous fluorophores constitute a major disturbance.

Morphology and biochemistry of non-glandular trichomes in Cistus salvifolius L. leaves growing in extreme habitats of the Mediterranean basin.

Here the functional roles of stellate and dendritic trichomes in Cistus salvifolius L leaves were studied by analysing i) both leaf surface and trichome morphology using scanning electron and light microscopy; and ii) the composition and localisation of polyphenols by coupling liquid chromatography with fluorescence spectroscopy and fluorescence microimaging. Red-coloured compounds were detected in the stalk cells and the channel in the trichome arm, and appeared to be released at the tip end of the trichome branch. We identified such metabolites as ellagitannins, namely punicalagin and two galloyl derivatives of punicalagin. These ellagitannins accounted for 4.3 % of leaf dry weight and their concentration in the leaf leachate averaged 289.4 mg L (-1). The trichome arms exhibited an appreciable orange-red autofluorescence (centred at 620 nm) when excited with UV light (at 365 nm) or emitted in the yellow waveband (peak centred at 566 nm) when stained with the Naturstoff reagent, and excited at 488 nm. The fluorescence signatures of the trichome arms were consistent with the presence of mono-hydroxy B-ring substituted flavonoids, which were identified as the mono- and di-coumaroyl derivative of a kaempferol 3-O-glycoside. Our data may provide some insights on the functional roles of stellate and dendritic trichomes in the response mechanisms of C. salvifolius to Mediterranean-type climate, based upon (i) the potential effect of released ellagitannins on the soil nitrogen dynamic and (ii) the ability of acylated kaempferol 3-O-glycosides to effectively absorb both the UV-B and UV-A wavelengths.

Phototherapy with turquoise versus blue light.

Preterm jaundiced infants were treated by phototherapy with a new turquoise fluorescent lamp. This was more effective in reducing plasma total bilirubin in relation to light irradiance than the ubiquitously used blue fluorescent lamp.

Gravitational unloading induces osteoclast-like differentiation of FLG 29.1 cells.

FLG 29.1 cells, cultured at 1xg, are able to switch on a differentiating process only when they are suitably induced by chemical factors. On the contrary, when FLG 29.1 cells are cultured in conditions of gravitational unloading, simulated by a Random Positioning Machine, the switching on of the differentiation process occurs in the absence of any added differentiating agent or any stimulating factor. The phenotypic characterization of the cells and quantitative measures of their bone resorption activity are consistent with a differentiation process through the osteoclastic pathway.

New vegetation indices for remote measurement of chlorophylls based on leaf directional reflectance spectra.

Directional reflectance (R) spectra from 380 to 780 nm for nadir illuminated leaves of four different plants (croton, Codiaeum variegatum; spotted eleagnus, Eleagnus pungens Maculata; Japanese pittosporum, Pittosporum tobira and Benjamin fig, Ficus benjamina Starlight) were acquired at a viewing angle of 30 degrees from the nadir direction. Chlorophyll-a and -b content of leaves covered a range of 1-60 and 0.5-21 microg/cm(2), respectively. In contrast with previous results from hemispherical reflectance measurements, directional reflectance data does not correlate well with chlorophyll concentration. This is mainly due to the external reflectance (R(E)) at the leaf epidermis, caused by the mismatch of the refractive index at the air-epidermis and epidermis-inner layer boundary. The external reflectance can be identified with the blue flat reflectance between 380 and 480 nm. The inner reflectance (R(I)), obtained by subtracting the external reflectance from the measured spectra, was found to be linearly related to the logarithm of the chlorophyll content. Good fitting of the log (Chl) versus R(I)(lambda) curves were obtained for R(I) in the green band (around 550 nm) and close to the inflection point in the red edge (around 700 nm). The coefficient of determination, r(2), of curve fitting improved (up to 0.97) when the normalised inner reflectance NR(I)(lambda)=R(I)(lambda)/R(I)(lambda(0)), with lambda(0)>or=750 nm, was used instead of the absolute reflectance. The best indices for Chl, Chl-a and Chl-b determination were R(I)(542)/R(I)(750), R(I)(706)/R(I)(750) and R(I)(556)/R(I)(750), respectively. However, since the content of Chl-a relative to Chl-b was almost constant for the plants investigated, the two last indices must be further validated on leaves with a high variability in the Chl-a:Chl-b ratio. The error in the determination of chlorophyll content was found to be of the order of 10%. This value was lower than those obtained by applying the vegetation indices previously suggested. Therefore, the normalised inner reflectance in the green and in the red edge represents a more suitable index for the chlorophyll determination than those up to now used.

The effect of decreasing temperature up to chilling values on the in vivo F685/F735 chlorophyll fluorescence ratio in Phaseolus vulgaris and Pisum sativum: the role of the photosystem I contribution to the 735 nm fluorescence band.

The effect of leaf temperature (T), between 23 and 4 degrees C, on the chlorophyll (Chl) fluorescence spectral shape was investigated under moderate (200 microE m-2 s-1) and low (30-35 microE m-2 s-1) light intensities in Phaseolus vulgaris and Pisum sativum. With decreasing temperature, an increase in the fluorescence yield at both 685 and 735 nm was observed. A marked change occurred at the longer emission band resulting in a decrease in the Chl fluorescence ratio, F685/F735, with reducing T. Our fluorescence analysis suggests that this effect is due to a temperature-induced state 1-state 2 transition that decreases and increases photosystem II (PSII) and photosystem I (PSI) fluorescence, respectively. Time-resolved fluorescence life-time measurements support this interpretation. At a critical temperature (about 6 degrees C) and low light intensity a sudden decrease in fluorescence intensity was observed, with a larger effect at 685 than at 735 nm. This is probably linked to a modification of the thylakoid membranes, induced by chilling temperatures, which can alter the spill-over from PSII to PSI. The contribution of photosystem I to the long-wavelength Chl fluorescence band (735 nm) at room temperature was estimated by both time-resolved fluorescence lifetime and fluorescence yield measurements at 685 and 735 nm. We found that PSI contributes to the 735 nm fluorescence for about 40, 10 and 35% at the minimal (F0), maximal (Fm) and steady-state (Fs) levels, respectively. Therefore, PSI must be taken into account in the analysis of Chl fluorescence parameters that include the 735 nm band and to interpret the changes in the Chl fluorescence ratio that can be induced by different agents.

Multispectral imaging autofluorescence microscopy for the analysis of lymph-node tissues.

Although histochemical and immunohistochemical methods are the standard procedures in diagnosis of lymphoproliferative disorders, useful improvements in evidencing histopathologic manifestations can be obtained with the introduction of tissue autofluorescence analyses. We used microspectrofluorometry and a Multispectral Imaging Autofluorescence Microscopy (MIAM) technique to analyze lymph-node biopsies from patients with lymphoadenopathy of different origins. Images of tissue autofluorescence were obtained by excitation at 365 nm of lymph-node sections and sequential detection with interference filters (50 nm bandwidth) peaked at 450, 550 and 658 nm. Monochrome images were combined together in a single red-green-blue color image. Most of the fluorescence was observed within the blue spectral band because of large contributions from extracellular collagen and elastin fibers as well as from reduced form of intracellular nicotinamide adenine dinucleotide (phosphate). Autofluorescence imaging shows morphological differences between neoplastic and non-neoplastic tissues. The reactive hyperplasia samples show the typical lymph-node organization with weak fluorescent follicles separated by high fluorescent connective trabeculae. In the neoplastic lymph nodes the loss of follicle organization is observed. Consequently, MIAM permits to discriminate between non-neoplastic and neoplastic tissues on the basis of their autofluorescence pattern. Multispectral imaging of tissue autofluorescence may present some advantages with respect to standard histochemical microscopy since it (1) does not require any chemical manipulation of samples; (2) gives real-time results performing the analysis immediately upon specimen resection; and (3) supplies a representation of the biological structure organization linked to endogenous fluorophores.

Bilirubin photoisomerization products in serum and urine from a Crigler-Najjar type I patient treated by phototherapy.

The relative compositions of the photoisomers of bilirubin-1X alpha (4Z, 15Z-bilirubin) in serum and urine of a patient with Crigler-Najjar type I syndrome treated by phototherapy are reported. High-performance liquid chromatography analysis reveals the presence of high serum levels of the configurational bilirubin photoisomer (4Z,15E-bilirubin) before the beginning of phototherapy (between 12 and 16% of the total bilirubin). The configurational photoisomer value increases during phototherapy with blue fluorescent lamps up to a photoequilibrium of about 25%, similar to that obtained in a bilirubin solution in vitro irradiated by the same lamps. This evidence suggests an inefficient serum excretion of the 4Z,15E-bilirubin. Indeed, its average half-life in serum of the Crigler-Najjar patient is found to be about 8 h. No detectable traces of the bilirubin structural isomer, lumirubin, are found in the serum. On the other hand, lumirubin represents the dominant bilirubin isomer excreted in the urine, as both 15Z and 15E configurations. Smaller amounts of 4Z,15E-bilirubin, 4E,15Z-bilirubin and native 4Z,15Z-bilirubin are observed in urine. The presence in urine of 4Z,15Z-bilirubin is probably due to a fast reversion of the configurational photoisomers to their native form. The half-life of the configurational photoisomers in urine kept at 38 degrees C is found to be of the order of a few minutes. Our study indicates that in Crigler-Najjar type I patients, mechanisms exist to excrete all bilirubin photoisomers. The lumirubin pathway seems to contribute markedly to bilirubin excretion in the urine, as occurs in jaundiced babies under phototherapy. However, the contribution of configurational isomers cannot be neglected.

Fibreoptic phototherapy in the management of jaundice in low birthweight neonates.

A fibreoptic phototherapy device has been compared with conventional white and special blue fluorescent phototherapy lamps to evaluate its efficacy in lowering serum bilirubin levels in low-birthweight neonates. Fibreoptic phototherapy was found to be as effective as white light and less effective than blue light, as assessed by (i) the bilirubin concentration after 24 h of phototherapy and at the end of phototherapy, (ii) the duration of phototherapy, (iii) the percentage daily decline rate and (iv) the overall percentage decline rate (p < 0.05). There were no failures of phototherapy and the need for re-exposure was low (4.7% of the total sample), with no difference between groups. The fibreoptic approach represents a promising way to aggregate synergically the most recent optical technologies and develop a modern, efficient and caring phototherapy system for low-birthweight infants.

Quantum yield and skin filtering effects on the formation rate of lumirubin.

Photocyclization of bilirubin to lumirubin in the skin of jaundiced infants exposed to blue-green light irradiation is considered to be the most important process for bilirubin elimination from the organism. The quantum yield phi LR of the bilirubin-->lumirubin photoreaction has been recently measured and found to vary with the excitation wavelength, with a peak at about 520 nm. The quantum yield phi ZE for the strongly competing reversible configurational photoisomerization of bilirubin has also been recently shown to be wavelength dependent and to decrease significantly in the long-wavelength part of the absorption band of bilirubin. These new data are taken into account to model the bilirubin photochemistry in vivo by using a simplified skin optical model based on the Kubelka-Munk theory. The rate kappa LR of formation of lumirubin has been evaluated for the case of a four-layer skin and for monochromatic and narrow-band coloured fluorescent lamps. The effects of long-wavelength increase in phi LR, decrease in phi ZE and skin optical losses all combine to shift significantly the optimal rate of formation of lumirubin towards the green. These results suggest that a significant improvement in phototherapy might be obtained with the introduction of new lamps emitting in the blue-green spectral region between 490 and 510 nm.

Evaluation of the quantum yield for E-->Z isomerization of bilirubin bound to human serum albumin. Evidence of internal conversion processes competing with configurational photoisomerization.

The quantum yield (phi zz) for the E--> photoisomerization of bilirubin (BR) bound to human serum albumin (HSA) under laser light irradiation has been evaluated with absorbance spectroscopy implemented by the high-performance liquid chromatography technique. The value at 458 nm is about 0.2, four times smaller than the value previously reported in the literature. As for the Z-->E configurational and the structural photoisomerization processes, the quantum yield varies with excitation wavelength, from 0.23 in the blue to 0.16 in the green. The sum of the quantum yields of the Z<-->E configurational photoisomerization reactions is 0.2-0.3 in the blue-green spectral region, thus giving direct evidence of the existence of internal conversion processes of the BR-HSA complex which compete with configurational photoisomerization. An evaluation of the quantum yields of the Z<-->E reactions for filtered broad-band light excitation in the 390-530 nm spectral region from data already published in the literature is also reported. Good agreement with our data of the quantum yields phi ZZ and phi ZE is found, despite the diversity of the experimental procedures in the two cases.

Wavelength-dependent quantum yield for Z----E isomerization of bilirubin complexed with human serum albumin.

The quantum yield, phi ZE, for configurational photoisomerization (4Z,15Z----4Z,15E) of bilirubin bound non-covalently to human serum albumin was determined (at 23 +/- 2 degrees C) by laser excitation and chromatographic analysis of products. Values obtained for photoexcitation at 465 nm were about one-half those previously reported. The quantum yield was dependent on excitation wavelength, decreasing from a value of 0.109 +/- 0.010 for excitation at 457.9 nm to a value of 0.054 +/- 0.005 for excitation at 514.5 nm. The wavelength dependence is consistent with rapid transfer of excitation energy between the two non-identical pyrromethenone chromophores of bilirubin in the singlet excited state. Since the quantum yields for photoisomerization and luminescence of bilirubin bound to serum albumin at room temperature are both low, internal conversion processes, rather than Z----E configurational isomerizations, are probably the major pathways for deactivation of photo-excited bilirubin.