Total hip arthroplasty: imaging evaluation

Crosslinking of CD28 receptors on resting T lymphocytes by B7 costimulatory molecules expressed by antigen-presenting cells (APCs) plays a critical role in T-cell activation. Human melanomas express major histocompatibility complex (MHC)-restricted tumor-associated antigens that can be recognized by cytotoxic T lymphocytes (CTL), yet they remain poorly immunogenic. One mechanism for the failure of T-cell response is the lack of expression of costimulatory molecules by human melanoma cells. We have transfected the B7-1 gene into three HLA-A2-expressing human melanoma cell lines, and studied their capacity to stimulate primary human T cells. B7-expressing melanoma cells were excellent inducers of T-cell proliferation, cytokine production, and cytolytic activity in allogeneic mixed lymphocyte cultures through a process dependent on the function of the T-cell receptor as well as interactions between B7:CD28, CD2:LFA-3, and LFA-1:ICAM-1. Subset analysis demonstrated that CD4+ T cells or addition of exogenous interleukin-2 was required for the induction of CD8+ CTL. Untransfected parental melanoma cells were inert as APCs in these cultures. Rotating stimulation of T cells with the three B7-expressing cell lines led to the generation of T-cell lines that were cytolytic for HLA-A2+ melanoma cells and other HLA-A2+ targets that were pulsed with HLA-A2-restricted MART-1 peptides. These data demonstrate that expression of B7-1 by human melanoma cells converts them into effective APCs for the in vitro induction of MHC-restricted, melanoma-specific CTL.     

Total hip arthroplasty complicated by tuberculous infection

A comparison between 34 adolescents in a court-referred program for prevention of delinquency and 89 students not in the program but from the same high school showed that the students in the program were more likely to receive the social support they desired. Given the program's low rate of recidivism, the role of social support needs to be replicated and explored further.     

Total hip replacement arthroplasty in the Netherlands

The total hip arthroplasty (THA) is an effective treatment of osteoarthritis of the hip joint. Each year, more than 16,000 THAs are performed in the Netherlands. The incidence of THA had doubled between 1980 and 1994. The medical indication has extended to younger and older patients. Due to the success of the THA the number of alternative treatments, such as arthrodesis and osteotomy decreased. The number of revision surgeries increased more than four folds, to 1,400 in 1994. Based on these data the increase of primary and revision hip arthroplasties is expected to continue, but it is unknown how much the exact increase will be. In view of the increased demand it is important to gain more insight into the numbers of primary and revision surgical procedures to be expected, so that a better estimation can be made of the health care capacity and financial resources required in the future.     

Total hip arthroplasty in patients who have chronic lymphocytic leukemia

Twenty patients who had chronic lymphocytic leukemia underwent 25 elective primary total hip arthroplasties at the Mayo Clinic. No patient had a postoperative prosthetic infection. No patient had an intraoperative or postoperative hemorrhagic complication. One patient had a revision for aseptic loosening. After an average follow-up period of 4.6 years, there were 84% good and excellent results. It is concluded that patients who have early-stage chronic lymphocytic leukemia may not be at increased risk for major perioperative or postoperative complications in total hip arthroplasty. The surgeon must remain vigilant for postoperative complications, but satisfactory clinical results can be obtained in this patient population.     

From the RSNA refresher courses. Total hip arthroplasty: radiographic evaluation

Expected appearances of total hip arthroplasty vary according to type of implant, its method of fixation (cemented, porous coating for bone ingrowth, press fit), and whether it is a revision. Cemented arthroplastic components normally may show 1-2-mm-wide radiolucent zones at cement interfaces. Definite loosening is diagnosed when progressive widening of the radiolucent zone, migration of a cemented component, or change in alignment is seen. In cementless arthroplasty, normal findings include calcar resorption, radiolucent zones up to 2 mm in width, cortical thickening, periosteal reaction, endosteal sclerosis, and even subsidence of the femoral component that stabilizes at less than 1 cm. The most reliable radiographic signs of loosening in cementless arthroplasty are progressive subsidence, migration, or tilt of the component. Because subsidence or change in alignment may be very subtle, serial radiography and measurement are often required for diagnosis. Other signs that indicate loosening include bead shedding (in porous-coated prostheses), extensive cortical hypertrophy, endosteal bone bridging at the stem tip, endosteal scalloping, and a radiolucent zone wider than 2 mm. In revision arthroplasty, wide radiolucent zones and subsidence are common. The diagnosis of revision failure is based on progressive widening of the radiolucent zones and change in component position after 12 months.     

Total hip arthroplasty in beta-thalassemia. Case report and review of the literature

A 60-year-old man with beta-thalassemia intermedia and degenerative joint disease was successfully treated by total hip arthroplasty. The operation was complicated by severe bleeding associated with marked bone marrow hyperplasia. Despite autologous cell salvage, massive homologous transfusion was required. Special orthopaedic and perioperative complications stem from beta-thalassemia syndromes. Management may be complicated by anemia, medullary hyperplasia, organ dysfunction associated with iron overload, and susceptibility to infection. The orthopaedic manifestations of beta-thalassemia may be mitigated by chronic transfusions.     

Total wrist arthroplasty

Although arthroplasty is a well-established procedure for many joints, its use in the wrist is less common, and the indications are less well defined. The standard procedure for the painful arthritic wrist remains radiocarpal arthrodesis. However, as technology and surgical procedures improve, wrist arthroplasty is being used more frequently. The authors provide a brief history of total wrist arthroplasty and review the arthroplasties most commonly used in the United States. Results with total wrist implants, the complications related to arthroplasty, technical aspects of the procedure, and salvage options are also discussed.     

Total hip arthroplasty with use of second-generation cementing techniques. An eighteen-year-average follow-up study

In this report, we present the results of a further follow-up of a series of 140 consecutive patients (161 hips) who had had a primary total hip arthroplasty with insertion of a bead-blasted monoblock femoral component with use of so-called second-generation cementing techniques. The average age of the patients at the time of the arthroplasty was sixty-one years (range, twenty-one to eighty-five years). Sixty-seven patients (seventy-seven hips) died less than seventeen years after the index operation. The remaining seventy-three patients (eighty-four hips) were followed for an average of eighteen years (range, seventeen to twenty years). No patient was lost to follow-up. In the entire group of 161 hips, over the twenty-year span of the study, eight femoral components (5 percent) and twenty-eight acetabular components (17 percent) had been revised because of aseptic loosening. Of the seventy-seven hips in the sixty-seven patients who died, four had been revised because of aseptic loosening of the acetabular component only; one, because of aseptic loosening of the femoral component only; and one, because of aseptic loosening of both components. Of the eighty-four hips in the seventy-three patients who were alive at least seventeen years after the index arthroplasty, twenty-four hips (29 percent) in twenty-one patients had had revision of one or both components for any reason. Twenty-three acetabular components (27 percent) and six femoral components (7 percent) had been revised because of aseptic loosening. An additional two hips (2 percent) in two patients were loose according to radiographic criteria but had not been revised. Of the sixty-five all-polyethylene acetabular components that had been inserted with cement and were in patients who were alive at least seventeen years postoperatively, fifteen (23 percent) had been revised because of aseptic loosening. An additional seventeen cups (26 percent) were loose according to radiographic criteria. Thus, a total of thirty-two cups (49 percent) had been revised because of loosening or were loose but had not been revised at the time of the latest follow-up. The femoral components that had been inserted with use of second-generation cementing techniques fared better than did the acetabular components that had been inserted with these techniques during the same time-period. We found that assessment of all postoperative radiographs rather than only those that had been made immediately postoperatively increased the accuracy of the grading of the cement around the femoral component. Subsequent radiographs frequently had been made at different projections, which revealed new findings, consisting primarily of previously undetected voids, areas of thin cement, and defects in the cement mantle. Thus, we now use all available radiographs to determine the grade of the cement.     

Total hip arthroplasty with an uncemented femoral component. Excellent results at ten-year follow-up

The contribution of brain edema to brain swelling in cases of traumatic brain injury remains a critical problem. The authors believe that cellular edema, the result of complex neurotoxic events, is the major contributor to brain swelling and that vasogenic edema, secondary to blood-brain barrier compromise, may be overemphasized. The objective of this study, therefore, was to quantify temporal water content changes and document the type of edema that forms during the acute and late stages of edema development following closed head injury (CHI). The measurement of brain water content was based on magnetic resonance imaging-determined values of tissue longitudinal relaxation time (T1-weighted imaging) and their subsequent conversion to percentage of water, whereas the differentiation of edema formation (cellular vs. vasogenic) was based on the measurement of the apparent diffusion coefficient (ADC) by diffusion-weighted imaging. A new impact-acceleration model was used to induce CHI. Thirty-six adult Sprague-Dawley rats were separated into two groups: Group I, control (six animals); and Group II, trauma (30 animals). Fast ADC measurements (localized, single-voxel) were obtained sequentially (every minute) up to 1 hour postinjury. The T1-weighted images, used for water content determination, and the diffusion-weighted images (ADC measurement with conventional diffusion-weighted imaging) were obtained at the end of the 1st hour postinjury and on Days 1, 3, 7, 14, 28, and 42 in animals from the trauma and control groups. In the animals subjected to trauma, the authors found a significant increase in ADC (10 +/- 5%) and brain water content (1.3 +/- 0.9%) during the first 60 minutes postinjury. This is consistent with an increase in the volume of extracellular fluid and vasogenic edema formation as a result of blood-brain barrier compromise. This transient increase, however, was followed by a continuing decrease in ADC that began 40 to 60 minutes postinjury and reached a minimum value on Days 7 to 14 (10 +/- 3% reduction). Because the water content of the brain continued to increase during the first 24 hours postinjury (1.9 +/- 0.9%), it is suggested that the decreased ADC indicated cellular edema formation, which started to develop soon after injury and became dominant between 1 and 2 weeks postinjury. The study provides supportive evidence that cellular edema is the major contributor to posttraumatic swelling in diffuse CHI and defines the onset and duration of the increase in cellular volume.     

Life expectancy after total hip arthroplasty

A total of 3,807 patients undergoing total hip arthroplasty (THA) between the years 1970 to 1995 were evaluated for mortality. Patient age groups were designated in 10-year intervals as follows: age <40; 41-50; 51-60; 61-70; 71-80; age >80. The life expectancy estimate of the patients with THA was calculated by the Kaplan-Meier method, and that of the normal population was obtained from standard life-tables. Statistical significance was evaluated using 95% confidence limits. A significant difference in life expectancy was found in patient age groups >60 (61-70, 71-80, >80) demonstrating significantly higher survival rates among THA patients when compared with the normal population.     

Ceramic endoprosthesis in total hip arthroplasty

Aluminia-on-aluminia hip prosthesis with titanium alloy stem was used in 255 cases, for 143 patients with cemented acetabular cup and 112 with an uncemented screw cup. The average age of the patients was 62 years. Of the patients, 35 were treated bilaterally. The indication for surgery was osteoarthritis in 186 cases, fractures and nonunions of the hip joint in 34 cases, and congenital dislocations of the hip joint in 16 cases. Previous surgery of the hip joint was recorded for 43 cases. All procedures were primary arthroplasties. Only personal clinical examinations together with radiographic studies were accepted as clinical data. Three patients failed to show up for routine follow-up evaluation and these were excluded from the series. Revision operation was classified as failure. The indications for revision were aseptic loosening, late infection, and fracture of the acrylic cement resulting in loosening of the acetabular or femoral component. The acetabular component was cemented in 143 patients and the mean follow-up period for these patients was 6.7 years (range, 1-12 years). In this series, a revision operation was undertaken for 16 patients (11%). In 12 cases, broken acrylic cement resulted in acetabular aseptic loosening. In the series of 112 patients with uncemented titanium screw cup, the mean follow-up period was 3.6 years (range, 1-7 years) and a revision operation was undertaken in seven cases (7%). In two, the indication was late infection; in one, technical failure; and in two, progression of Pigmented villonodular synovitis. Acetabular aseptic loosening resulted in revision in only two cases. With cementless acetabular component bone transplantation is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Total hip arthroplasty with cement in patients who have rheumatoid arthritis. A minimum ten-year follow-up study

One hundred and six consecutive total hip arthroplasties with cement were performed by one surgeon, at least ten years before the time of the present clinical and radiographic review, in seventy-five patients who had adult-onset rheumatoid arthritis. Two patients (three hips) were lost to follow-up. Seven (7 per cent) of the remaining 103 hips were revised. The revisions were performed because of infection (three hips), dislocation (two hips), or aseptic loosening (two hips). Of the ninety-eight hips that were not lost to follow-up or revised because of infection or dislocation, eight (8 per cent) had radiographic loosening of the acetabular component and two (2 per cent) had radiographic loosening of the femoral component. Although the prevalence of radiographic loosening of the acetabular component was four times greater than the prevalence of radiographic loosening of the femoral component, the prevalence of revision because of aseptic loosening of the acetabular component was identical to that for the femoral component (one component each). These results compared favorably with those of total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses. Loosening of the acetabular component was significantly associated with a younger age at the time of the index operation (p = 0.03) and with acetabular osteolysis (p = 0.0006). Of forty-eight hips in thirty-two patients who survived for at least ten years, 96 per cent (forty-six hips) were considered by the patients to have a satisfactory result. At the time of the latest follow-up, twenty-four (75 per cent) of the patients had no pain in the hip. Although eighteen patients (56 per cent) could walk without support at a minimum of ten years after the operation, we found that the functional results for patients who had rheumatoid arthritis were inferior to those observed for patients who had had a total hip arthroplasty with cement, performed by the same surgeon, for the treatment of other diagnoses.     

Total hip arthroplasty cemented femoral component distal stem centralizer. Effect on stem centralization and cement mantle

Samples of wheat harvested from 1988 to 1990 and stored in elevators in the south of Brazil (12 Brazilian, 4 Argentinian and 2 Uruguayan) were analysed in 1990 for 14 mycotoxins: deoxynivalenol (DON), nivalenol, diacetoxyscirpenol (DAS), T-2 and HT-2 toxins, T-2 triol, T-2 tetraol, aflatoxins B1, B2, G1, G2, ochratoxin A (OCHRA A), zearalenone and sterigmatocystin. One sample (1988 harvest) was contaminated with OCHRA A (0.04 microgram/g) and three other samples (1990 harvest) were contaminated with DON (0.40 microgram/g), DAS (0.30 microgram/g), T-2 (two samples, 0.35 and 0.36 gamma g/g) and T-2 tetraol (1.68 micrograms/g). Fusarium graminearum Schwabe was found in the 1990 samples with a relative incidence ranging from 1 to 22% and predominated in Argentinian and Uruguayan wheat (1990 harvest). Fusarium dimerum Penzig (8-75%) was the main Fusarium sp. in Brazilian wheat from the 1990 harvest.     

Outcome of the contralateral hip following total hip arthroplasty for osteoarthritis

Uncertainty about the generalizability of results from clinical trials is a nagging issue plaguing psychiatric research. The possible bias introduced by the use of subjects recruited from advertisements is one source of concern. Investigators question whether these subjects are representative of the types of individuals who seek treatment in clinical practice. This article compares and contrasts demographic characteristics, functional disabilities, symptomatologies, and the health beliefs and expectations of a cohort seeking treatment at a university outpatient clinic with a cohort of symptomatic volunteers recruited by advertisements. These two groups were alike in most variables; however, the clinical subjects reported more recent exposure to psychotropic medications and were more likely to indicate that they wanted psychotherapy. The symptomatic volunteers were slightly older, endorsed more psychiatric symptoms, drank more alcohol, and believed that combined pharmacology and psychotherapy would most help them. These findings suggest that the two cohorts were remarkably similar on most variables.     

Fat embolism syndrome following total hip arthroplasty

This is a case report of total hip arthroplasty in a healthy 38-year-old woman with the unusual complication of fat embolism with no evidence of hypotension or other intraoperative incidence. Prompt recognition of fat embolism and appropriate supportive therapy resulted in the successful resuscitation of the patient and an excellent functional hip joint.     

Porous-coated total hip arthroplasty in the young

OBJECTIVE: To evaluate whether thromboxane A2 participates in the ischemia-reperfusion injury associated with acute compartmental syndrome (ACS) and if by using a cyclooxygenase inhibitor this can be either reduced or abolished. DESIGN: To assess the role of thromboxane A2 in ACS, a tourniquet was applied for 2 hours to the hind limb of 12 dogs. Group 1 (n = 6) served as controls while group 2 (n = 6) was pretreated with lysine-acetyl-salicylate (Lysoprim). Blood thromboxane B2 levels and intracompartmental pressures were assayed prior to inflation of the tourniquet and at 5 minutes, 90 minutes, and 24, 72, and 144 hours after deflation. RESULTS: Five minutes after deflation, the compartmental pressure increased from 11.2 +/- 2.2 mm Hg to 16.1 +/- 3.3 mm Hg and 17 +/- 2.2 mm Hg (mean +/- SD) in groups 2 and 1, respectively. At 90 minutes and 24 hours, pressures were 17.1 +/- 3.3 mm Hg and 23.2 +/- 3.3 mm Hg (P<.01) and 15.3 +/- 2.6 mm Hg and 25.2 +/- 1.8 mm Hg (mean +/- SD) (P<.001), respectively, in groups 2 and 1. A similar effect, although of a lesser magnitude, was observed in the counterlateral limb. Thromboxane B2 levels increased from a mean (+/- SD) of 46 +/- 5.5 pg/0.1 mL to 132 +/- 7.5 pg/0.1 mL at 90 minutes in group 1, while remaining unchanged in group 2. CONCLUSIONS: Thromboxane A2 plays a major role in the ischemia-reperfusion injury of acute compartmental syndrome. By using a cyclooxygenase inhibitor both the levels of thromboxane and the compartmental pressures can be reduced.