TY  - JOUR
A1  - Wimmer, Matthias D.
A1  - Randau, Thomas M.
A1  - Deml, Moritz C.
A1  - Ascherl, Rudolf
A1  - Forst, Raimund
A1  - Gravius, Nadine
A1  - Wirtz, Dieter
A1  - Gravius, Sascha
T1  - Impaction grafting in the femur in cementless modular revision total hip arthroplasty: a descriptive outcome analysis of 243 cases with the MRP-TITAN revision implant
JF  - BMC Musculoskeletal Disorders
N2  - Background: We present a descriptive and retrospective analysis of revision total hip arthroplasties (THA) using the MRP-TITAN stem (Peter Brehm, Weisendorf, GER) with distal diaphyseal fixation and metaphyseal defect augmentation. Our hypothesis was that the metaphyseal defect augmentation (Impaction Bone Grafting) improves the stem survival. 
Methods: We retrospectively analyzed the aggregated and anonymized data of 243 femoral stem revisions. 68 patients with 70 implants (28.8%) received an allograft augmentation for metaphyseal defects; 165 patients with 173 implants (71.2%) did not, and served as controls. The mean follow-up was 4.4 +/- 1.8 years (range, 2.1-9.6 years). There were no significant differences (p > 0.05) between the study and control group regarding age, body mass index (BMI), femoral defects (types I-III as described by Paprosky), and preoperative Harris Hip Score (HHS). Postoperative clinical function was evaluated using the HHS. Postoperative radiologic examination evaluated implant stability, axial implant migration, signs of implant loosening, periprosthetic radiolucencies, as well as bone regeneration and resorption. 
Results: There were comparable rates of intraoperative and postoperative complications in the study and control groups (p > 0.05). Clinical function, expressed as the increase in the postoperative HHS over the preoperative score, showed significantly greater improvement in the group with Impaction Bone Grafting (35.6 +/- 14.3 vs. 30.8 +/- 15.8; p <= 0.05). The study group showed better outcome especially for larger defects (types II C and III as described by Paprosky) and stem diameters >= 17 mm. The two groups did not show significant differences in the rate of aseptic loosening (1.4% vs. 2.9%) and the rate of revisions (8.6% vs. 11%). The Kaplan-Meier survival for the MRP-TITAN stem in both groups together was 93.8% after 8.8 years. [Study group 95.7% after 8.54 years; control group 93.1% after 8.7 years]. Radiologic evaluation showed no significant change in axial implant migration (4.3% vs. 9.3%; p = 0.19) but a significant reduction in proximal stress shielding (5.7% vs. 17.9%; p < 0.05) in the study group. Periprosthetic radiolucencies were detected in 5.7% of the study group and in 9.8% of the control group (p = 0.30). Radiolucencies in the proximal zones 1 and 7 according to Gruen occurred significantly more often in the control group without allograft augmentation (p = 0.05). 
Conclusion: We present the largest analysis of the impaction grafting technique in combination with cementless distal diaphyseal stem fixation published so far. Our data provides initial evidence of improved bone regeneration after graft augmentation of metaphyseal bone defects. The data suggests that proximal metaphyseal graft augmentation is beneficial for large metaphyseal bone defects (Paprosky types IIC and III) and stem diameters of 17 mm and above. Due to the limitations of a retrospective and descriptive study the level of evidence remains low and prospective trials should be conducted.
KW  - prosthesis
KW  - replacement
KW  - collarless
KW  - surgery
KW  - allografts
KW  - porous-coated stems
KW  - femoral revision
KW  - roentgenographic assessment
KW  - tapered stem
KW  - follow-up
KW  - modular
KW  - revision
KW  - hip
KW  - arthroplasty
KW  - impaction bone grafting
Y1  - 2013
U6  - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-122061
SN  - 1471-2474
VL  - 14
IS  - 19
ER  - 
TY  - THES
A1  - Majumder, Snigdha
T1  - Selective inhibition of NFAT in mouse and human T cells by CRISPR/Cas9 to ameliorate acute Graft-versus-Host Disease while preserving Graft-versus-Leukemia effect
T1  - Selektive Hemmung von NFAT in murinen und humanen T-Zellen durch CRISPR/Cas9 zur Linderung der akuten Graft-versus-Host-Erkrankung bei gleichzeitigem Erhalt des Graft-versus-Leukemia-Effekts
N2  - Allogenic hematopoietic stem cell transplantation (allo-HCT) is a curative therapy for the treatment of malignant and non-malignant bone marrow diseases. The major complication of this treatment is a highly inflammatory reaction known as Graft-versus-Host Disease (GvHD). Cyclosporin A (CsA) and tacrolimus are used to treat GvHD which limits inflammation but also interferes with the anticipated Graft-versus-Leukemia (GvL) effect. These drugs repress conventional T cells (Tcon) along with regulatory T cells (Treg), which are important for both limiting GvHD and supporting GvL. Both of these drugs inhibit calcineurin (CN), which dephosphorylates and activates the nuclear factor of activated T-cells (NFAT) family of transcription factors. Here, we make use of our Cd4cre.Cas9+ mice and developed a highly efficient non-viral CRISPR/Cas9 gene editing method by gRNA-only nucleofection. Utilizing this technique, we demonstrated that unstimulated mouse T cells upon NFATc1 or NFATc2 ablation ameliorated GvHD in a major mismatch mouse model. However, in vitro pre-stimulated mouse T cells could not achieve long-term protection from GvHD upon NFAT single-deficiency. This highlights the necessity of gene editing and transferring unstimulated human T cells during allo-HCT. Indeed, we established a highly efficient ribonucleoprotein (RNP)-mediated CRISPR/Cas9 gene editing for NFATC1 and/or NFATC2 in pre-stimulated as well as unstimulated primary human T cells. In contrast to mouse T cells, not NFATC1 but NFATC2 deficiency in human T cells predominantly affected proinflammatory cytokine production. However, either NFAT single-knockout kept cytotoxicity of human CD3+ T cells untouched against tumor cells in vitro. Furthermore, mouse and human Treg were unaffected upon the loss of a single NFAT member. Lastly, NFATC1 or NFATC2-deficient anti-CD19 CAR T cells, generated with our non-viral ‘one-step nucleofection’ method validated our observations in mouse and human T cells. Proinflammatory cytokine production was majorly dependent on NFATC2 expression, whereas, in vitro cytotoxicity against CD19+ tumor cells was undisturbed in the absence of either of the NFAT members. Our findings emphasize that NFAT single-deficiency in donor T cells is superior to CN-inhibitors as therapy during allo-HCT to prevent GvHD while preserving GvL in patients.
N2  - Die allogene hämatopoetische Stammzelltransplantation (allo-HCT) ist eine kurative Therapie zur Behandlung bösartiger und nicht bösartiger Knochenmarkerkrankungen. Die Hauptkomplikation dieser Behandlung ist eine hochgradige Entzündungsreaktion, die als Graft-versus-Host-Disease (GvHD) bekannt ist. Zur Behandlung der GvHD werden Cyclosporin A (CsA) und Tacrolimus eingesetzt, die die Entzündung eindämmen, aber auch den gewünschten Graft-versus-Leukämie-Effekt (GvL) beeinträchtigen. Diese Medikamente unterdrücken sowohl konventionelle T-Zellen (Tcon) als auch regulatorische T-Zellen (Treg), die sowohl für die Begrenzung der GvHD, als auch für die Unterstützung der GvL wichtig sind. Beide Medikamente hemmen Calcineurin (CN), das die Transkriptionsfaktoren der Familie der Nuclear Factor of Activated T-Cells (NFAT) dephosphoryliert und aktiviert. Hier nutzten wir unsere Cd4cre.Cas9+-Mäuse und entwickelten eine hocheffiziente, nicht-virale CRISPR/Cas9-Geneditierungsmethode mittels reiner gRNA-Nukleofektion. Mithilfe dieser Technik konnten wir zeigen, dass unstimulierte T-Zellen der Maus nach Ablation von NFATc1 oder NFATc2 die GvHD in einem Major-Mismatch-Mausmodell mildern. In vitro vorstimulierte T-Zellen von Mäusen konnten jedoch keinen langfristigen Schutz vor GvHD bei NFAT-Einzeldefizienz erreichen. Dies unterstreicht die Notwendigkeit der Gen-Editierung und des Transfers unstimulierter menschlicher T-Zellen während einer allo-HCT. In der Tat konnten wir ein hocheffizientes Ribonukleoprotein (RNP)-vermitteltes CRISPR/Cas9 gene-editing für NFATC1 und/oder NFATC2 nicht nur in vorstimulierten, sondern auch in unstimulierten primären menschlichen T-Zellen etablieren. Im Gegensatz zu T-Zellen von Mäusen wirkte sich der Mangel an NFATC2, nicht aber so sehr an NFATC1, in menschlichen T-Zellen überwiegend auf die Produktion proinflammatorischer Zytokine aus. Bei beiden NFAT-Single-Knockouts blieb jedoch die Zytotoxizität menschlicher CD3+ T-Zellen gegen Tumorzellen in vitro unangetastet. Darüber hinaus wurden die Treg von Maus und Mensch durch den Verlust eines einzelnen NFAT-Mitglieds nicht beeinträchtigt. Schließlich bestätigten NFATC1- oder NFATC2-defiziente Anti-CD19-CAR-T-Zellen, die mit unserer nicht-viralen "Ein-Schritt-Nukleofektionsmethode" erzeugt wurden, unsere Beobachtungen zu T-Zellen von Maus und Mensch. Die Produktion proinflammatorischer Zytokine hing hauptsächlich von der NFATC2-Expression ab, während die In-vitro-Zytotoxizität gegen CD19+-Tumorzellen in Abwesenheit eines der beiden NFAT-Mitglieder ungestört war. Unsere Ergebnisse unterstreichen, dass der Mangel eines einzelnen NFAT-Mitglieds in Spender-T-Zellen einer Therapie mit CN-Inhibitoren während einer allo-HCT überlegen ist. Hier könnten wir eine GvHD verhindern und gleichzeitig den GvL-Effekt in allo-HCT-Patienten erhalten.
KW  - Allogenic hematopoietic stem cell transplantation
KW  - CRISPR/Cas9
KW  - Graft-versus-host-disease
KW  - Graft-versus-leukemia
KW  - allografts
KW  - CRISPR/Cas-Methode
Y1  - 2023
U6  - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-293256
ER  -