Evaluation framework to assess orthopaedic procedures

Introduction & aims The demand for evidence of efficacy of treatments in general and orthopaedic surgical procedures in particular is ever increasing in Australia and worldwide. The aim of this study is to share the key elements of an evaluation framework recently implemented in Australia to determine the efficacy of bone-anchored prostheses. Method The proposed evaluation framework to determine the benefit and harms of bone-anchored prostheses for individuals with limb loss was extracted from a systematic review of the literature including seminal studies focusing on clinical benefits and safety of procedures involving screw-type implant (e.g., OPRA) and press-fit fixations (e.g., EEFT, ILP, OPL). [1-64] Results The literature review highlighted that a standard and replicable evaluation framework should focus on: • The clinical benefits with a systematic recording of health-related quality of life (e.g., SF-26, Q-TFA), mobility predictor (e.g., AMPRO), ambulation abilities (e.g., TUG, 6MWT), walking abilities (e.g., characteristic spatio-temporal) and actual activity level at baseline and follow-up post Stage 2 surgery, • The potential harms with systematic recording of residuum care, infection, implant stability, implant integrity, injuries (e.g., falls) after Stage 1 surgery. There was a general consensus around the instruments to monitor most of the benefits and harms. The benefits could be assessed using a wide spectrum of complementary assessments ranging from subjective patient self-reporting to objective measurements of physical activity. However, this latter was assessed using a broad range of measurements (e.g., pedometer, load cell, energy consumption). More importantly, the lack of consistent grading of infections was sufficiently noticeable to impede cross-fixation comparisons. Clearly, a more universal grading system is needed. Conclusions Investigators are encouraged to implement an evaluation framework featuring the domains and instruments proposed above using a single database to facilitate robust prospective studies about potential benefits and harms of their procedure. This work is also a milestone in the development of national and international clinical outcome registries.

Regional changes in choroidal thickness associated with accommodation

Purpose. To characterize the changes occurring in choroidal thickness (ChT) across the posterior pole during accommodation using enhanced-depth imaging optical coherence tomography (OCT). Methods. Forty participants (mean age 21 ± 2 years) had measures of ChT and ocular biometry taken during accommodation to 0, 3, and 6 diopter (D) stimuli, with the Spectralis OCT and Lenstar biometer. A Badal optometer and cold mirror system was mounted on both instruments, allowing measurement collection while subjects viewed an external fixation target at varying accommodative demands. Results. The choroid exhibited significant thinning during accommodation to the 6 D stimulus in both subfoveal (mean change, −5 ± 7 μm) and parafoveal regions (P < 0.001). The magnitude of these changes varied by parafoveal meridian, with the largest changes seen in the temporal (−9 ± 12 μm) and inferotemporal (−8 ± 8 μm) meridians (P < 0.001). Axial length increased with accommodation (mean change, +5 ± 11 μm at 3 D, +14 ± 13 μm at 6 D), and these changes were weakly negatively associated with the choroidal changes (r2 = 0.114, P < 0.05). Conclusions. A small, but significant thinning of the choroid was observed at the 6 D accommodation demand, which was greatest in the temporal and inferotemporal parafoveal choroid, and increased with increasing eccentricity from the fovea. The regional variation in the parafoveal thinning corresponds to the distribution of the nonvascular smooth muscle within the uvea, which may implicate these cells as the potential mechanism by which the choroid thins during accommodation.

Spatial and temporal distribution of tropical phytoplankton species and biomass in the Gulf of Carpenteria, Australia

The biomass and species composition of tropical phytoplankton in Albatross Bay, Gulf of Carpentaria, northern Australia, were examined monthly for 6 yr (1986 to 1992). Chlorophyll a (chl a) concentrations were highest (2 to 5.7 mu g l(-1)) in the wet season at inshore sites, usually coinciding with low salinities (30 to 33 ppt) and high temperatures (29 to 32 degrees C). At the offshore sites chi a concentrations were lower (0.2 to 2 mu g l(-1)) and did not vary seasonally. Nitrate and phosphate concentrations were generally low (0 to 3.68 mu M and 0.09 to 3 mu M for nitrate and phosphate respectively), whereas silicate was present in concentrations in the range 0.19 to 13 mu M. The phytoplankton community was dominated by diatoms, particularly at the inshore sites, as determined by a combination of microscopic and high-performance liquid chromatography (HPLC) pigment analyses. At the offshore sites the proportion of green flagellates increased. The cyanobacterium genus Trichodesmium and the diatom genera Chaetoceros, Rhizosolenia, Bacteriastrum and Thalassionema dominated the phytoplankton caught in 37 mu m mesh nets; however, in contrast to many other coastal areas studied worldwide there was no distinct species succession of the diatoms and only Trichodesmium showed seasonal changes in abundance. This reflects a stable phytoplankton community in waters without pulses of physical and chemical disturbances. These results are discussed in the context of the commercial prawn fishery in the Gulf of Carpentaria and the possible effect of phytoplankton on prawn larval growth and survival.

Development of a novel experimental model to investigate the influence of mechanics on bone healing

This dissertation proposed a novel experimental model combining a defect configuration with an active instrumented fixation device to investigate the influence of mechanics on bone healing. The proposed defect configuration aimed to minimise physiological loading within an experimental fracture gap and the instrumented fixator was used for the application of controlled displacements and in vivo stiffness monitoring of the healing process. This thesis has provided a novel approach to advance current knowledge and understanding of mechanobiology, which has been limited in previous experimental models.

Visual demands in modern Australian primary school classrooms

BACKGROUND The visual demands of modern classrooms are poorly understood yet are relevant in determining the levels of visual function required to perform optimally within this environment. METHODS Thirty-three Year 5 and 6 classrooms from eight south-east Queensland schools were included. Classroom activities undertaken during a full school day (9 am to 3 pm) were observed and a range of measurements recorded, including classroom environment (physical dimensions, illumination levels), text size and contrast of learning materials, habitual working distances (distance and estimated for near) and time spent performing various classroom tasks. These measures were used to calculate demand-related minimum criteria for distance and near visual acuity, contrast and sustained use of accommodation and vergence. RESULTS The visual acuity demands for distance and near were 0.33 ± 0.13 and 0.72 ± 0.09 logMAR, respectively (using habitual viewing distances and smallest target sizes) or 0.33 ± 0.09 logMAR assuming a 2.5 times acuity reserve for sustained near tasks. The mean contrast levels of learning materials at distance and near were greater than 70 per cent. Near tasks (47 per cent) dominated the academic tasks performed in the classroom followed by distance (29 per cent), distance to near (15 per cent) and computer-based (nine per cent). On average, children engaged in continuous near fixation for 23 ± 5 minutes at a time and during distance-near tasks performed fixation changes 10 ± 1 times per minute. The mean estimated habitual near working distance was 23 ± 1 cm (4.38 ± 0.24 D accommodative demand) and the vergence demand was 0.86 ± 0.07Δ at distance and 21.94 ± 1.09Δ at near assuming an average pupillary distance of 56 mm. CONCLUSIONS Relatively high levels of visual acuity, contrast demand and sustained accommodative-convergence responses are required to meet the requirements of modern classroom environments. These findings provide an evidence base to inform prescribing guidelines and develop paediatric vision screening protocols and referral criteria.

Leaf chlorophyll concentration relates to transpiration efficiency in peanut

Two pot experiments were conducted in two different seasons at the University of Agricultural Science, Bangalore, India, to study (a) the relationship between chlorophyll concentration (by measuring the leaf light-transmittance characteristics using a SPAD metre) and transpiration efficiency (TE) and (b) the effect of leaf N on chlorophyll and TE relationship in peanut. In Experiment (Expt) I, six peanut genotypes with wide genetic variation for the specific leaf area (SLA) were used. In Expt II, three non-nodulating isogenic lines were used to study the effect of N levels on leaf chlorophyll concentration–TE relationship without potential confounding effects in biological nitrogen fixation. Leaf N was manipulated by applying N fertiliser in Expt II. Chlorophyll concentration, TE (g dry matter kg−1 of H2O transpired, measured using gravimetric method), specific leaf nitrogen (g N m−2, SLN), SLA (cm2 g−1), carbon isotope composition (Δ13C) were determined in the leaves sampled during the treatment period (35–55 days after sowing) in the two experiments. Results showed that the leaf chlorophyll concentration expressed as soil plant analytical development (SPAD) chlorophyll metre reading (SCMR) varied significantly among genotypes in Expt I and as a result of N application in Expt II. Changes in leaf N levels were strongly associated with changes in SCMR, TE and Δ13C. In both the experiments, a significant positive relationship between SCMR and TE with similar slopes but differing intercepts was noticed. However, correction of TE for seasonal differences in vapour pressure deficit (VPD) between the two experiments resulted in a single and stronger relationship between SCMR and TE. There was a significant inverse relationship between SCMR and Δ13C, suggesting a close linkage between chlorophyll concentration and Δ13C in peanut. This study provides the first evidence for a significant positive relationship between TE and leaf chlorophyll concentration in peanut. The study also describes the effect of growing environment on the relationships among SLA, SLN and SCMR.

Evolution in design of integral leg prosthesis leads to improved outcomes

Developments of surgical attachments for bone-anchored prostheses are slowly but surely winning over the initial disbelief in the orthopedic community. Clearly, this option is becoming accessible to a wide range of individuals with limb loss. Seminal studies have demonstrated that the pioneering procedure relying on screw-type fixation engenders major clinical benefits and acceptable safety. The surgical procedure for press-fit implants, such as the Integral-Leg-Prosthesis (ILP) has been described Dr Aschoff and his team. Some clinical benefits of press-fit implants have been also established. Here, his team is once again taking a leading role by sharing the progression over 15 years of the rate of deep infections for 69 individuals with transfemoral amputation fitted with three successive refined versions of the ILP. By definition, a double-blind randomized clinical trial to test the effect of different fixation’s design is difficult. Alternatively, Juhnke and colleagues are reporting the outcomes of action-research study for a cohort of participants. The first and foremost important outcome of this study is the confirmation that the current design of the IPL and rehabilitation program are altogether leading to an acceptable rate of deep infection and other adverse events (e.g., structural failure of implant, periprosthetic factures). This study is also providing a strong insight onto the effect of major phases in redesign of an implant on the risk of infection. This is an important reminder that the development of a successful osseointegrated implant is unlikely to be immediate but the results of a learning curve made of empirical and sequential changes led by a reflective clinical practice. Clearly, this study provided better understanding of the safety of the ILP surgical and rehabilitation procedure while establishing standards and benchmark data for future studies focusing on design and infection of press-fit implants. Complementary observations of relationship between infection and cofounders such as loading of the prosthesis and prosthetic components used would be beneficial.Further definitive evidences of the clinical benefits with the latest design would be valuable, although an increase in health related quality of life and functional outcomes are likely to be confirmed. Altogether, the authors are providing compelling evidence that bone-anchored attachments particularly those relying on press-fit implants are an established alternative to socket prostheses.

Visual search and eye movements: Studies of perceptual span

In visual search one tries to find the currently relevant item among other, irrelevant items. In the present study, visual search performance for complex objects (characters, faces, computer icons and words) was investigated, and the contribution of different stimulus properties, such as luminance contrast between characters and background, set size, stimulus size, colour contrast, spatial frequency, and stimulus layout were investigated. Subjects were required to search for a target object among distracter objects in two-dimensional stimulus arrays. The outcome measure was threshold search time, that is, the presentation duration of the stimulus array required by the subject to find the target with a certain probability. It reflects the time used for visual processing separated from the time used for decision making and manual reactions. The duration of stimulus presentation was controlled by an adaptive staircase method. The number and duration of eye fixations, saccade amplitude, and perceptual span, i.e., the number of items that can be processed during a single fixation, were measured. It was found that search performance was correlated with the number of fixations needed to find the target. Search time and the number of fixations increased with increasing stimulus set size. On the other hand, several complex objects could be processed during a single fixation, i.e., within the perceptual span. Search time and the number of fixations depended on object type as well as luminance contrast. The size of the perceptual span was smaller for more complex objects, and decreased with decreasing luminance contrast within object type, especially for very low contrasts. In addition, the size and shape of perceptual span explained the changes in search performance for different stimulus layouts in word search. Perceptual span was scale invariant for a 16-fold range of stimulus sizes, i.e., the number of items processed during a single fixation was independent of retinal stimulus size or viewing distance. It is suggested that saccadic visual search consists of both serial (eye movements) and parallel (processing within perceptual span) components, and that the size of the perceptual span may explain the effectiveness of saccadic search in different stimulus conditions. Further, low-level visual factors, such as the anatomical structure of the retina, peripheral stimulus visibility and resolution requirements for the identification of different object types are proposed to constrain the size of the perceptual span, and thus, limit visual search performance. Similar methods were used in a clinical study to characterise the visual search performance and eye movements of neurological patients with chronic solvent-induced encephalopathy (CSE). In addition, the data about the effects of different stimulus properties on visual search in normal subjects were presented as simple practical guidelines, so that the limits of human visual perception could be taken into account in the design of user interfaces.

Evolution of cooperation by reciprocation within structured demes

The iterative two-person Prisoners’ Dilemma game has been generalised to theN-person case. The evolution of cooperation is explored by matching the Tit For Tat (TFT) strategy (Axelrod and Hamilton 1981) against the selfish strategy. Extension of TFT toN-person situations yields a graded set of strategies from the softest TFT, which continues cooperation even if only one of the opponents reciprocates it, to the hardest, which would do so only when all the remaining opponents cooperate. The hardest TFT can go to fixation against the selfish strategy provided it crosses a threshold frequencypc. All the other TFT are invadable by the selfish (D) or the pure defector strategy, while none can invadeD. Yet, provided a thresholdpc is crossed, they can coexist stably withD. AsN, the size of the group increases, the threshold pc also increases, indicating that the evolution of cooperation is more difficult for larger groups. Under certain conditions, only the soft TFT can coexist stably against the selfish strategyD, while the harder ones cannot. An interesting possibility of a complete takeover of the selfish population by successive invasions by harder and harder TFT strategies is also presented.

Assessing the sustainability of wheat-based cropping systems using APSIM: Model parameterisation and evaluation

Assessing the sustainability of crop and soil management practices in wheat-based rotations requires a well-tested model with the demonstrated ability to sensibly predict crop productivity and changes in the soil resource. The Agricultural Production Systems Simulator (APSIM) suite of models was parameterised and subsequently used to predict biomass production, yield, crop water and nitrogen (N) use, as well as long-term soil water and organic matter dynamics in wheat/chickpea systems at Tel Hadya, north-western Syria. The model satisfactorily simulated the productivity and water and N use of wheat and chickpea crops grown under different N and/or water supply levels in the 1998-99 and 1999-2000 experimental seasons. Analysis of soil-water dynamics showed that the 2-stage soil evaporation model in APSIM's cascading water-balance module did not sufficiently explain the actual soil drying following crop harvest under conditions where unused water remained in the soil profile. This might have been related to evaporation from soil cracks in the montmorillonitic clay soil, a process not explicitly simulated by APSIM. Soil-water dynamics in wheat-fallow and wheat-chickpea rotations (1987-98) were nevertheless well simulated when the soil water content in 0-0.45 m soil depth was set to 'air dry' at the end of the growing season each year. The model satisfactorily simulated the amounts of NO3-N in the soil, whereas it underestimated the amounts of NH 4-N. Ammonium fixation might be part of the soil mineral-N dynamics at the study site because montmorillonite is the major clay mineral. This process is not simulated by APSIM's nitrogen module. APSIM was capable of predicting long-term trends (1985-98) in soil organic matter in wheat-fallow and wheat-chickpea rotations at Tel Hadya as reported in literature. Overall, results showed that the model is generic and mature enough to be extended to this set of environmental conditions and can therefore be applied to assess the sustainability of wheat-chickpea rotations at Tel Hadya.

The development of a component to improve the loading safety of bone-anchored prostheses

Use of socket prostheses Currently, for individuals with limb loss, the conventional method of attaching a prosthetic limb relies on a socket that fits over the residual limb. However, there are a number of issues concerning the use of a socket (e.g., blisters, irritation, and discomfort) that result in dissatisfaction with socket prostheses, and these lead ultimately a significant decrease in quality of life. Bone-anchored prosthesis Alternatively, the concept of attaching artificial limbs directly to the skeletal system has been developed (bone anchored prostheses), as it alleviates many of the issues surrounding the conventional socket interface.Bone anchored prostheses rely on two critical components: the implant, and the percutaneous abutment or adapter, which forms the connection for the external prosthetic system (Figure 1). To date, an implant that screws into the long bone of the residual limb has been the most common intervention. However, more recently, press-fit implants have been introduced and their use is increasing. Several other devices are currently at various stages of development, particularly in Europe and the United States. Benefits of bone-anchored prostheses Several key studies have demonstrated that bone-anchored prostheses have major clinical benefits when compared to socket prostheses (e.g., quality of life, prosthetic use, body image, hip range of motion, sitting comfort, ease of donning and doffing, osseoperception (proprioception), walking ability) and acceptable safety, in terms of implant stability and infection. Additionally, this method of attachment allows amputees to participate in a wide range of daily activities for a substantially longer duration. Overall, the system has demonstrated a significant enhancement to quality of life. Challenges of direct skeletal attachment However, due to the direct skeletal attachment, serious injury and damage can occur through excessive loading events such as during a fall (e.g., component damage, peri-prosthetic fracture, hip dislocation, and femoral head fracture). These incidents are costly (e.g., replacement of components) and could require further surgical interventions. Currently, these risks are limiting the acceptance of bone-anchored technology and the substantial improvement to quality of life that this treatment offers. An in-depth investigation into these risks highlighted a clear need to re-design and improve the componentry in the system (Figure 2), to improve the overall safety during excessive loading events. Aim and purposes The ultimate aim of this doctoral research is to improve the loading safety of bone-anchored prostheses, to reduce the incidence of injury and damage through the design of load restricting components, enabling individuals fitted with the system to partake in everyday activities, with increased security and self-assurance. The safety component will be designed to release or ‘fail’ external to the limb, in a way that protects the internal bone-implant interface, thus removing the need for restorative surgery and potential damage to the bone. This requires detailed knowledge of the loads typically experienced by the limb and an understanding of potential overload situations that might occur. Hence, a comprehensive review of the loading literature surrounding bone anchored prostheses will be conducted as part of this project, with the potential for additional experimental studies of the loads during normal activities to fill in gaps in the literature. This information will be pivotal in determining the specifications for the properties of the safety component, and the bone-implant system. The project will follow the Stanford Biodesign process for the development of the safety component.

Leaf trait co-ordination in relation to construction cost, carbon gain and resource-use efficiency in exotic invasive and native woody vine species

Background and Aims: Success of invasive plant species is thought to be linked with their higher leaf carbon fixation strategy, enabling them to capture and utilize resources better than native species, and thus pre-empt and maintain space. However, these traits are not well-defined for invasive woody vines. Methods: In a glass house setting, experiments were conducted to examine how leaf carbon gain strategies differ between non-indigenous invasive and native woody vines of south-eastern Australia, by investigating their biomass gain, leaf structural, nutrient and physiological traits under changing light and moisture regimes. Key Results: Leaf construction cost (CC), calorific value and carbon : nitrogen (C : N) ratio were lower in the invasive group, while ash content, N, maximum photosynthesis, light-use efficiency, photosynthetic energyuse efficiency (PEUE) and specific leaf area (SLA) were higher in this group relative to the native group. Trait plasticity, relative growth rate (RGR), photosynthetic nitrogen-use efficiency and water-use efficiency did not differ significantly between the groups. However, across light resource, regression analyses indicated that at a common (same) leaf CC and PEUE, a higher biomass RGR resulted for the invasive group; also at a common SLA, a lower CC but higher N resulted for the invasive group. Overall, trait co-ordination (using pair-wise correlation analyses) was better in the invasive group. Ordination using 16 leaf traits indicated that the major axis of invasive-native dichotomy is primarily driven by SLA and CC (including its components and/or derivative of PEUE) and was significantly linked with RGR. Conclusions: These results demonstrated that while not all measures of leaf resource traits may differ between the two groups, the higher level of trait correlation and higher revenue returned (RGR) per unit of major resource need (CC) and use (PEUE) in the invasive group is in line with their rapid spread where introduced.

Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases

Background and purpose — Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment. Patients and methods — We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1–3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test. Results — There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29–52 and a 6-minute walk test improvement range of 37–84 meters. Interpretation — It is possible to combine TKR with osseointegrated implants.

Can the direct measurement of the load applied on the residuum of individuals with transfemoral amputation fitted with bone-anchored prosthesis help to improve the rehabilitation program?

To strive to improve the rehabilitation program of individuals with transfemoral amputation fitted with bone-anchored prosthesis based on data from direct measurements of the load applied on the residuum we first of all need to understand the load applied on the fixation. Therefore the load applied on the residuum was first directly measured during standardized activities of daily living such as straight line level walking, ascending and descending stairs and a ramp and walking around a circle. From measuring the load in standardized activities of daily living the load was also measured during different phases of the rehabilitation program such as during walking with walking aids and during load bearing exercises.[1-15] The rehabilitation program for individuals with a transfemoral amputation fitted with an OPRA implant relies on a combination of dynamic and static load bearing exercises.[16-20] This presentation will focus on the study of a set of experimental static load bearing exercises. [1] A group of eleven individuals with unilateral transfemoral amputation fitted with an OPRA implant participated in this study. The load on the implant during the static load bearing exercises was measured using a portable system including a commercial transducer embedded in a short pylon, a laptop and a customized software package. This apparatus was previously shown effective in a proof-of-concept study published by Prof. Frossard. [1-9] The analysis of the static load bearing exercises included an analysis of the reliability as well as the loading compliance. The analysis of the loading reliability showed a high reliability between the loading sessions indicating a correct repetition of the LBE by the participants. [1, 5] The analysis of the loading compliance showed a significant lack of axial compliance leading to a systematic underloading of the long axis of the implant during the proposed experimental static LBE.

Direct measurement of inner prosthesis loading during activities of daily living: Proposal for classification of functional outcome

Background The purpose of this presentation is to outline the relevance of the categorization of the load regime data to assess the functional output and usage of the prosthesis of lower limb amputees. The objectives are • To highlight the need for categorisation of activities of daily living • To present a categorization of load regime applied on residuum, • To present some descriptors of the four types of activity that could be detected, • To provide an example the results for a case. Methods The load applied on the osseointegrated fixation of one transfemoral amputee was recorded using a portable kinetic system for 5 hours. The load applied on the residuum was divided in four types of activities corresponding to inactivity, stationary loading, localized locomotion and directional locomotion as detailed in previously publications. Results The periods of directional locomotion, localized locomotion, and stationary loading occurred 44%, 34%, and 22% of recording time and each accounted for 51%, 38%, and 12% of the duration of the periods of activity, respectively. The absolute maximum force during directional locomotion, localized locomotion, and stationary loading was 19%, 15%, and 8% of the body weight on the anteroposterior axis, 20%, 19%, and 12% on the mediolateral axis, and 121%, 106%, and 99% on the long axis. A total of 2,783 gait cycles were recorded. Discussion Approximately 10% more gait cycles and 50% more of the total impulse than conventional analyses were identified. The proposed categorization and apparatus have the potential to complement conventional instruments, particularly for difficult cases.