From the Cover: A new tubulin-binding site and pharmacophore for microtubule-destabilizing anticancer drugs

The recent success of antibody–drug conjugates (ADCs) in the treatment of cancer has led to a revived interest in microtubule-destabilizing agents. Here, we determined the high-resolution crystal structure of the complex between tubulin and maytansine, which is part of an ADC that is approved by the US Food and Drug Administration (FDA) for the treatment of advanced breast cancer. We found that the drug binds to a site on β-tubulin that is distinct from the vinca domain and that blocks the formation of longitudinal tubulin interactions in microtubules. We also solved crystal structures of tubulin in complex with both a variant of rhizoxin and the phase 1 drug PM060184. Consistent with biochemical and mutagenesis data, we found that the two compounds bound to the same site as maytansine and that the structures revealed a common pharmacophore for the three ligands. Our results delineate a distinct molecular mechanism of action for the inhibition of microtubule assembly by clinically relevant agents. They further provide a structural basis for the rational design of potent microtubule-destabilizing agents, thus opening opportunities for the development of next-generation ADCs for the treatment of cancer.Microtubule-targeting agents such as the taxanes and the vinca alkaloids represent a successful class of anticancer drugs (1). Vinblastine, for example, is a microtubule-destabilizing agent (MDA) that is widely used in combination therapy for the treatment of childhood and adult malignancies (2). The broad clinical application of MDAs, however, is hampered by their severe adverse effects (3). This problem has been very recently addressed by the use of antibody–drug conjugate (ADC) approaches, which have revived interest in the development of highly potent MDAs for therapeutic use (4–6).For several important MDAs, the molecular mechanism of action on tubulin and microtubules has so far remained elusive. Rhizoxin, for example, is a potent MDA that has been investigated in phase 2 clinical trials, but for reasons poorly understood, it has demonstrated only very limited clinical efficacy (7). At the molecular level, it is well established that rhizoxin interferes with the binding of vinblastine to tubulin; however, the exact location of its binding site has been a matter of debate (8–10). Interestingly, biochemical and mutagenesis data suggest that the structurally unrelated MDA maytansine (9, 11), which is part of an ADC that was recently approved by the FDA for the treatment of advanced breast cancer (11, 12), and the phase 1 drug PM060184 (13, 14) (Fig. 1A) share a common tubulin-binding site with rhizoxin (9, 13, 14). These two latter drugs have also been reported to interfere with the binding of vinblastine; however, as for rhizoxin, the exact binding sites and modes of action of maytansine and PM060184 have not been elucidated (9, 14–16).Open in a separate windowFig. 1.Structure of the tubulin–rhizoxin F complex. (A) Chemical structures of rhizoxin F, maytansine, and PM060184. (B) Overall view of the T₂R-TTL–rhizoxin F complex. Tubulin (gray), RB3 (light green), and TTL (violet) are shown in ribbon representation; the MDA rhizoxin F (orange) and GDP (cyan) are depicted in spheres representation. As a reference, the vinblastine structure (yellow, PDB ID no. 1Z2B) is superimposed onto the T₂R complex. (C) Overall view of the tubulin–rhizoxin F interaction in two different orientations. The tubulin dimer with bound ligand (α-tubulin-2 and β-tubulin-2 of the T₂R-TTL–rhizoxin F complex) is shown in surface representation. The vinblastine structure is superimposed onto the β-tubulin chain to highlight the distinct binding site of rhizoxin F. All ligands are in sphere representation and are colored in orange (rhizoxin F), cyan (GDP), and yellow (vinblastine). (D) Close-up view of the interaction observed between rhizoxin F (orange sticks) and β-tubulin (gray ribbon). Interacting residues of β-tubulin are shown in stick representation and are labeled.To establish the exact tubulin-binding site of rhizoxin, maytansine, and PM060184 and to clarify their specific interactions with the protein, we have investigated the structures of the corresponding ligand–tubulin complexes by X-ray crystallography. Our data reveal a new tubulin-binding site and pharmacophore for small molecules, and binding to this site is associated with a distinct molecular mechanism for the inhibition of microtubule formation.     

Bypass of the pre-60S ribosomal quality control as a pathway to oncogenesis

Ribosomopathies are a class of diseases caused by mutations that affect the biosynthesis and/or functionality of the ribosome. Although they initially present as hypoproliferative disorders, such as anemia, patients have elevated risk of hyperproliferative disease (cancer) by midlife. Here, this paradox is explored using the rpL10-R98S (uL16-R98S) mutant yeast model of the most commonly identified ribosomal mutation in acute lymphoblastic T-cell leukemia. This mutation causes a late-stage 60S subunit maturation failure that targets mutant ribosomes for degradation. The resulting deficit in ribosomes causes the hypoproliferative phenotype. This 60S subunit shortage, in turn, exerts pressure on cells to select for suppressors of the ribosome biogenesis defect, allowing them to reestablish normal levels of ribosome production and cell proliferation. However, suppression at this step releases structurally and functionally defective ribosomes into the translationally active pool, and the translational fidelity defects of these mutants culminate in destabilization of selected mRNAs and shortened telomeres. We suggest that in exchange for resolving their short-term ribosome deficits through compensatory trans-acting suppressors, cells are penalized in the long term by changes in gene expression that ultimately undermine cellular homeostasis.Ribosomopathies are a family of congenital diseases that are linked to genetic defects in ribosomal proteins or ribosome biogenesis factors. They are characterized by pleiotropic abnormalities that include birth defects, heart and lung diseases, connective tissue disorders, anemia, ataxia, and mental retardation (reviewed in ref. 1). Although each ribosomopathy presents a unique pathological spectrum, the inherited forms are characterized by bone marrow failure and anemia early in life, followed by elevated cancer risk by middle age. For example, although childhood anemia is one of the cardinal symptoms of the genetically inherited disease Diamond–Blackfan anemia, these patients have a fivefold higher lifetime risk of cancer than the general population and a 30- to 40-fold higher risk of developing acute myeloid leukemia, osteosarcoma, or colon cancer (reviewed in refs. 2, 3). Similarly, patients with X-linked dyskeratosis are predisposed to myeloid leukemia and a variety of solid tumors (4), whereas patients with 5q− syndrome are at higher risk of developing acute myeloid leukemia (reviewed in ref. 5). In the genetically tractable zebrafish model, heterozygous loss-of-function mutations in several ribosomal proteins cause development of peripheral nerve sheet tumors (6). Somatically acquired mutations in ribosomal proteins are also implicated in cancer: ∼10% of children with T-cell acute lymphoblastic leukemia (T-ALL) were found to harbor somatic mutations in the ribosomal protein of the large subunit (LSU) 10, 5, and 22 (RPL10, RPL5, and RPL22) (7). [Note that the proteins encoded by these genes are also named uL16, uL18, and eL22, respectively, under the newly proposed uniform ribosomal protein nomenclature (8).] A separate study identified heterozygous deletions in the region of chromosome 1p that contains RPL22 (eL22) in an additional 10% of patients with T-ALL (9). The model of ribosomal proteins as targets for somatic mutations in cancer is further supported by the finding that two ribosomal protein genes (RPL5/uL18 and RPL22/eL22) are included in the list of 127 genes identified as significantly mutated in cancer in the context of the first Cancer Genome Atlas pan-cancer analysis in 12 tumor types (10).Ribosomopathies present an intriguing paradox: Although patients initially present with hypoproliferative disorders (e.g., anemias, bone marrow failure), those who survive to middle age often develop hyperproliferative diseases (i.e., cancers). The link between ribosome defects and hypoproliferative disease phenotypes has been extensively studied: The current working hypothesis is that impaired ribosome biogenesis activates a “ribosomal stress” cascade, activating the cellular TP53 pathway and resulting in cell cycle arrest and cell death (11). However, activation of TP53 does not explain why ribosomal defects are associated with hyperproliferative diseases, particularly cancer. Mutations in the ribosomal protein gene RPL10/uL16 were recently identified in patients with T-ALL (7). The T-ALL–associated RPL10/uL16 mutations occurred almost exclusively in residue arginine 98 (R98), with the exception of one patient harboring the Q123P mutation, which lies adjacent to R98 within the rpL10/uL16 3D structure (Fig. 1). Both residues are at the base of an essential flexible loop in rpL10 that closely approaches the peptidyltransferase center in the catalytic core in the ribosome (12). In addition to its role in catalysis (13, 14), rpL10/uL16 plays an important role in the late stages of 60S subunit biogenesis. After initial production of the separate ribosomal subunits in the nucleus, immature and functionally inactive pre-60S subunits are exported to the cytoplasm, where they undergo additional maturation events (15), including incorporation of rpL10/uL16, before they can associate with mature 40S subunits and engage in protein synthesis (16). Among the critical set of final 60S maturation steps is the release of the antiassociation factor Tif6, followed by release of Nmd3, the primary export adaptor for the pre-60S subunit in yeast and in humans (17, 18). Tif6 release requires the tRNA structural mimic Sdo1p (19) and the GTPase Efl1, a paralog of eukaryotic elongation factor 2 (eEF2) (20). We have suggested that structural rearrangements of the internal loop of rpL10/uL16 coordinate this final maturation process, resulting in a test drive of the pre-60S subunit to ensure that only properly functioning subunits are allowed to enter the pool of translationally active ribosomes (13, 21). Defective ribosomes carrying mutations in rpL10/uL16 specifically fail in this test drive, leading to their degradation through a molecular pathway that is yet to be characterized. Beyond 60S maturation, rpL10/uL16 plays an important role in coordinating intersubunit rotation and controlling allosteric rearrangements within the ribosome, helping to ensure the directionality and fidelity of protein synthesis (13).Open in a separate windowFig. 1.Localization of rpL10 and the loop in the LSU. (A) rpL10/uL16 in the context of the crown view of the LSU. (B) Close-up view of rpL10/uL16 and the local environment. The flexible loop structure is indicated by dashed red lines, and the positions of R98 and Q123 are indicated. rpL10/uL16 is situated between helices 38 and 89, and it is located in close proximity to several functional centers of the LSU, including the peptidyltransferase center (PTC), aa-tRNA accommodation corridor, and elongation factor binding site. Images were generated using PyMOL.rpL10/uL16 is highly conserved among eukaryotes: The yeast and human proteins are interchangeable, and residue 98 is invariantly an arginine (22). Human RPL10/uL16 is located on the X chromosome, and is therefore expressed as a single-copy gene in males. Thus, the haploid yeast model is an excellent mimic of the situation in the cells of a patient with T-ALL. Yeast cells expressing rpl10-R98S, rpl10-R98C, and rpl10-H123P (corresponding to Q123 in human rpL10/uL16) as the sole forms of rpL10/uL16 displayed proliferative defects. Further, polysome profiling revealed increased ratios of free 60S and 40S subunits vs. monosomes, markedly reduced polysomes, and the presence of halfmers in these mutants, suggesting defects in both ribosome biogenesis and subunit joining (7). Tif6 and Nmd3 both accumulated in the cytoplasm in the mutant cells, indicating a defect in their release from the cytoplasmic 60S (7). Thus, all of the rpl10/uL16 mutations appeared to affect 60S biogenesis at the Efl1-dependent quality control step. Consistent with the yeast-based observations, mouse lymphoid cells expressing rpl10-R98S displayed slower proliferation rates than cells expressing WT RPL10/uL16 and conferred defective polysome profiles (7).The studies presented in the current report use the yeast rpl10-R98S mutant to elucidate the structural, biochemical, and trans-lational fidelity defects that may lead to carcinogenesis. This mutant perturbs the structural equilibrium of ribosomes toward the “rotated state.” At the biochemical level, this underlying structural defect alters the affinity of mutant ribosomes for a specific set of trans-acting ligands. In turn, the biochemical defects affect translational fidelity, promoting elevated rates of −1 programmed ribosomal frameshifting (−1 PRF) and impaired recognition of termination codons. Globally increased rates of −1 PRF result in a decreased abundance of cellular mRNAs that harbor operational −1 PRF signals (23, 24). These −1 PRF signal-containing mRNAs include EST1, EST2, STN1, and CDC13, which play central roles in yeast telomere maintenance (23). In rpl10-R98S cells, the steady-state abundances of these mRNAs are decreased, resulting in telomere shortening. A spontaneously acquired trans-acting mutant suppresses the ribosome biogenesis defects of the rpl10-R98S mutant, thereby reestablishing high levels of ribosome production and cell proliferation. Importantly, however, suppression of the biogenesis and growth impairment defects fails to suppress the profound structural, biochemical, and translational fidelity defects of rpL10-R98S ribosomes. These findings suggest that suppression of the growth defect results from bypassing the test drive. Although the suppressor mutation enables cells to grow at normal rates, genetic suppression comes at the cost of releasing functionally defective ribosomes into the translationally active pool. We propose two different but not mutually exclusive models for how somatically acquired rpL10/uL16 mutations may promote cancer: (i) Mutant ribosomes may drive altered gene expression programs, promoting T-ALL, or (ii) the suppressor mutations may themselves be the drivers of T-ALL.     

Structural investigation of ribosomally synthesized natural products by hypothetical structure enumeration and evaluation using tandem MS

Ribosomally synthesized and posttranslationally modified peptides (RiPPs) are a growing class of natural products that are found in all domains of life. These compounds possess vast structural diversity and have a wide range of biological activities, promising a fertile ground for exploring novel natural products. One challenging aspect of RiPP research is the difficulty of structure determination due to their architectural complexity. We here describe a method for automated structural characterization of RiPPs by tandem mass spectrometry. This method is based on the combined analysis of multiple mass spectra and evaluation of a collection of hypothetical structures predicted based on the biosynthetic gene cluster and molecular weight. We show that this method is effective in structural characterization of complex RiPPs, including lanthipeptides, glycopeptides, and azole-containing peptides. Using this method, we have determined the structure of a previously structurally uncharacterized lanthipeptide, prochlorosin 1.2, and investigated the order of the posttranslational modifications in three biosynthetic systems.Ribosomally synthesized and posttranslationally modified peptides (RiPPs) are a major class of natural products as revealed by the genome-sequencing efforts of the past decade (1). RiPPs are biosynthesized from genetically encoded and ribosomally produced precursor peptides, which typically consist of a core peptide that is transformed to the final product and an N-terminal extension called the leader peptide that is usually important for recognition by the posttranslational modification (PTM) enzymes (1). Because of the highly diverse PTMs, these compounds possess vast structural diversity and have a wide range of biological activities, thus representing a fertile ground for exploration. Furthermore, the ribosomal origin of RiPPs makes them particularly well suited for genome mining efforts. By using genome mining to explicitly avoid species harboring biosynthetic gene clusters identical to those that produce known compounds, a combination of strain prioritization and mass spectrometry (MS)-based analysis offers a new route to discovering natural products that can overcome the burden of rediscovery that has increasingly hampered discovery efforts (2, 3). One challenging aspect of high-throughput genome mining for new natural products is the difficulty to determine their molecular structures in high throughput. We present here a method that allows automated RiPP structure elucidation.In contrast to nonribosomal peptides that have an average molecular weight of less than 1,000 Da, as documented in the NORINE database (4), RiPPs in many cases have molecular weights larger than 2,500 Da. Molecules of this size are difficult to rapidly analyze by NMR spectroscopy, rendering MS the most convenient tool for RiPP structural characterization. Even when the precursor peptide sequences are known and the types of PTMs can be predicted based on the sequences of the biosynthetic enzymes (5–8), multiple possible PTM sites on the precursor peptide typically result in a myriad of structures that are often difficult to differentiate. This challenge is further exacerbated by the frequent occurrence of one or more cross-links in RiPPs, which complicates traditional tandem MS-based structure elucidation. One of the main difficulties is that the spectra only contain a small fraction of informative signals among a large number of less diagnostic signals that cloud spectrum interpretation. As the spectra often also vary significantly with different instrument settings (9), selection of the most suitable spectra for drawing conclusions is time consuming and sometimes introduces bias. Indeed, a number of incorrect structural assignments of RiPPs have been reported based on insufficient information content of tandem MS data (10–15). Here, we report use of hypothetical structure enumeration and evaluation (HSEE) for automated and unbiased interpretation of tandem MS data. The method is based on the prediction of a collection of hypothetical structures for a RiPP of certain mass and known biosynthetic information. By listing all of the theoretical daughter ions from this enumeration and automated evaluation of their matches with one or several experimental spectra, the most probable RiPP structure can be determined. We demonstrate here for multiple classes of known RiPPs with complex structures that HSEE is highly effective in analyzing tandem MS data and predicting the correct structure. In addition, we used HSEE to characterize a lanthipeptide whose structure was elusive despite our previous efforts, and to determine the directionality of thiazole-forming enzymes and lanthipeptide synthetases.     

Intercellular propagated misfolding of wild-type Cu/Zn superoxide dismutase occurs via exosome-dependent and -independent mechanisms

Amyotrophic lateral sclerosis (ALS) is predominantly sporadic, but associated with heritable genetic mutations in 5–10% of cases, including those in Cu/Zn superoxide dismutase (SOD1). We previously showed that misfolding of SOD1 can be transmitted to endogenous human wild-type SOD1 (HuWtSOD1) in an intracellular compartment. Using NSC-34 motor neuron-like cells, we now demonstrate that misfolded mutant and HuWtSOD1 can traverse between cells via two nonexclusive mechanisms: protein aggregates released from dying cells and taken up by macropinocytosis, and exosomes secreted from living cells. Furthermore, once HuWtSOD1 propagation has been established, misfolding of HuWtSOD1 can be efficiently and repeatedly propagated between HEK293 cell cultures via conditioned media over multiple passages, and to cultured mouse primary spinal cord cells transgenically expressing HuWtSOD1, but not to cells derived from nontransgenic littermates. Conditioned media transmission of HuWtSOD1 misfolding in HEK293 cells is blocked by HuWtSOD1 siRNA knockdown, consistent with human SOD1 being a substrate for conversion, and attenuated by ultracentrifugation or incubation with SOD1 misfolding-specific antibodies, indicating a relatively massive transmission particle which possesses antibody-accessible SOD1. Finally, misfolded and protease-sensitive HuWtSOD1 comprises up to 4% of total SOD1 in spinal cords of patients with sporadic ALS (SALS). Propagation of HuWtSOD1 misfolding, and its subsequent cell-to-cell transmission, is thus a candidate process for the molecular pathogenesis of SALS, which may provide novel treatment and biomarker targets for this devastating disease.Amyotrophic lateral sclerosis (ALS) is a fatal neuromuscular condition that afflicts as many as 1 of 350 males and 420 females over the age of 18 (1). In ALS, degeneration of upper and lower motor neurons causes progressive muscle paralysis and spasticity, affecting mobility, speech, swallowing, and respiration (2). Half of affected individuals die within 3 y, and less than 20% survive for more than 5 y (3); 90–95% of ALS cases are sporadic (SALS) in which some apparently facilitating gene mutations, such as repeat expansions in the gene that encodes ataxin-2 (4), have been identified. The remaining 5–10% of ALS cases are familial (FALS) and predominantly associated with Mendelian-inherited mutations in the genes encoding Cu/Zn superoxide dismutase (SOD1), TAR-DNA–binding protein 43 (TDP-43), fused in sarcoma/translocated in liposarcoma (FUS/TLS), C9ORF72, and other genes (reviewed in ref. 3).Despite the profusion of functionally diverse genes implicated in FALS and SALS, clinical and pathological similarities between all forms of ALS suggest the existence of a common pathogenic pathway that could be united by a single gene/protein (5). One of the mechanisms by which a mutant or wild-type (WT) protein can dominate pathogenesis of phenotypically diverse diseases is by propagated protein misfolding, such as that underpinning the prion diseases, which has been increasingly implicated in other neurodegenerative and systemic disorders (6, 7). A role for propagated protein misfolding in ALS is supported by the prion-like spatiotemporal progression of disease through the neuroaxis (8, 9). However, given the disparity in protein inclusion pathology between subtypes of ALS, a single unifying prion-like protein that could explain such a progression remains obscure.Whereas it is generally accepted SOD1 is not found in large perikaryal cytoplasmic inclusions outside of SOD1 FALS cases, misfolded SOD1 has been increasingly identified in SALS and non-SOD1 FALS (5, 10, 11). Indeed, we have reported that misfolded human wild-type SOD1 (HuWtSOD1) can be detected by spinal cord immunohistochemistry (IHC) in FALS secondary to FUS mutation, and in SALS patients with cytosolic WT TDP-43 accumulation (11). Moreover, in cell models, overexpression of WTTDP-43, or expression of mutant FUS or TDP-43, is associated with HuWtSOD1 misfolding (11). Collectively, these data are consistent with SOD1 being a molecular common denominator for all types of ALS. Furthermore, prion-like activity has been described for the cell-to-cell transmission of misfolding of mutant SOD1 (12), and we have reported that mutant SOD1 can confer its misfold on HuWtSOD1 (13). However, mutant SOD1 cannot explain propagation in SALS.To test if HuWtSOD1 participates in cell-to-cell transmission of protein misfolding, we make use of previously developed mouse mAb probes for misfolded/oxidized SOD1, recognizing either full-length human mutant or WT SOD1, generated against regions that are antibody-inaccessible in natively folded SOD1 (13–15). Misfolded SOD1 mAbs used in this work are 10E11C11 and 3H1, directed against an unstructured electrostatic loop [disease-specific epitope-2 (DSE2)], and 10C12, directed against a C-terminal dimer interface peptide in which the cysteine at position 146 is substituted by a cysteic acid residue to mimic oxidation of this residue (DSE1a) (13). The use of such antibody probes have enabled us to unambiguously determine the role of misfolded mutant G127X in the induced misfolding of HuWtSOD1, which upon misfolding acquires a marked increase in sensitivity to protease digestion, consistent with global loosening of structure (13). The finding that misfolded endogenous HuWtSOD1 was observed long after transfected G127X-SOD1 was degraded suggested that HuWtSOD1, once misfolded, is capable of triggering an intracellular propagated misfolding reaction (13). We now report for the first time that misfolded HuWtSOD1 can transit cell to cell both via exosomes, and release of protein aggregates and subsequent uptake in neuronal cells. In addition, misfolded HuWtSOD1 can sustain intercellular propagated misfolding in vitro and is detectable in the spinal cord of all ALS patients tested, regardless of the genetic etiology of the disease. Collectively, these data indicate that HuWtSOD1 is competent to participate in propagated misfolding, suggesting a common pathogenic mechanism linking FALS and SALS.     

Development of an Enhanced Interprofessional Chief Resident Immersion Training (IP-CRIT) Program

Using interprofessional faculty, the authors reviewed and enhanced the nationally renowned Chief Resident Immersion Training (CRIT) in the Care of Older Adults Program to include Triple Aim objectives and interprofessional competency-based content and developed the Interprofessional CRIT. Evaluations were positive and sustained. The authors educated chief residents about value-based care, linking them to key interprofessional staff to build team-based care. The authors addressed quality improvement issues identified by the Institute of Medicine and our health network. Chief residents are now better prepared to train medical students and residents using a team-based, patient-centered approach, and a culture of continual quality improvement toward improved care of older patients.     

Efficacité clinique et biologique du tocilizumab au cours de la maladie de Horton : à propos de trois observations et revue de la littérature

Introduction

Treatment of giant cell arteritis is based on prolonged corticosteroid therapy but adverse side effects are common especially in the elderly.

Case reports

We report three patients with giant cell vasculitis treated by tocilizumab, an interleukin-6 receptor antibody, owing to resistance or intolerance to corticosteroid therapy. A favorable outcome was rapidly observed both on clinical and biological data allowing a corticoid therapy sparing.

Conclusion

Tocilizumab is a promising treatment of giant cell arteritis but controlled trials are needed to confirm its efficacy.     

Wnt Signaling Regulates Pulp Volume and Dentin Thickness

Odontoblasts, cementoblasts, ameloblasts, and osteoblasts all form mineralized tissues in the craniofacial complex, and all these cell types exhibit active Wnt signaling during postnatal life. We set out to understand the functions of this Wnt signaling, by evaluating the phenotypes of mice in which the essential Wnt chaperone protein, Wntless was eliminated. The deletion of Wls was restricted to cells expressing Osteocalcin (OCN), which in addition to osteoblasts includes odontoblasts, cementoblasts, and ameloblasts. Dentin, cementum, enamel, and bone all formed in OCN‐Cre;Wls^fl/fl mice but their homeostasis was dramatically affected. The most notable feature was a significant increase in dentin volume and density. We attribute this gain in dentin volume to a Wnt‐mediated misregulation of Runx2. Normally, Wnt signaling stimulates Runx2, which in turn inhibits dentin sialoprotein (DSP); this inhibition must be relieved for odontoblasts to differentiate. In OCN‐Cre;Wls^fl/fl mice, Wnt pathway activation is reduced and Runx2 levels decline. The Runx2‐mediated repression of DSP is relieved and odontoblast differentiation is accordingly enhanced. This study demonstrates the importance of Wnt signaling in the homeostasis of mineralized tissues of the craniofacial complex. © 2014 American Society for Bone and Mineral Research.     

Lateral Patellar Facet Impingement After Primary Total Knee Arthroplasty: It Does Exist

The existence of the diagnosis “lateral patellar facet impingement” (LPFI) is controversial and the outcomes for surgical revision for symptomatic LPFI uncertain. We found that of the 3361 index knee revisions performed at our institution from 1995 to 2008, eleven were done for symptomatic LPFI. Their clinical histories and radiographic imaging were reviewed before and after revision TKA and were also compared to a group of control patients. We found no statistically significant differences between the groups in preoperative KS pain and function scores or radiographic features. However, the combined findings of pain in the subpatellar/lateral aspect of the knee post TKA and radiographic lateral facet contact were significantly associated with revision due to LPFI. Surgical revision results were variable, but ~ 2/3 of the patients were satisfied with the operation and had a significant improvement in KS function scores.     

Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC’s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79–100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.     

What Do We Know About Taper Corrosion in Total Hip Arthroplasty?

Mechanically assisted crevice corrosion (MACC) at metal/metal modular junctions in which at least one of the components is fabricated from cobalt-chromium alloy, has reemerged as a potential clinically significant complication in total hip arthroplasty. The clinical manifestation of MACC may include the development of an adverse local tissue reaction (ALTR), similar to what has been described in association with metal-on-metal bearing total hip and resurfacing arthroplasty. The clinical presentation of MACC-associated ALTRs may include pain and possibly late recurrent dislocations. Abnormal metal artifact reduction sequence magnetic resonance images and elevated serum metal levels (cobalt elevations out of proportion to chromium elevations) can be helpful in the diagnosis of these MACC-associated ALTRs.