Microalbuminuria and cardiovascular risk

As a part of long-term follow up (I) of 544 cemented Müller-curved stem total hip replacements (THR), implanted 1977 to 1983, 207 THR in 163 patients with rheumatoid arthritis (RA) were evaluated 9 to 15 years (11 on an average) postoperatively. The feed back rate was 96.9% so the results are very reliable. 18 cups were loosened (13 already changed), but no stem had to be changed for aseptic loosening. 2 THR (1.0%) had to be revised because of deep infection. Survival rate of Kaplan and Meier for aseptic loosening was 94.6% after 10 years, 83.5% after 15 years. The ARO multi-center-study 1995 (II) includes 3113 THR implanted 1987 and 1988. Within a follow-up period of 7 to 9 years the over all rate of aseptic changing for cemented cups (1.4%) was significantly lower than for uncemented cups (2.9%)--in RA even 1% versus 5.7%. The corresponding rates for stems was 1.0% (cemented) versus 1.8% (uncemented). We contributed 110 THR in 94 patients with RA with feed back of 100%. Because of deep infection one THR had to be changed and two were explanted. But no change of cup or stem because of aseptic loosening was observed. Also in the literature survival rates up to 97% after 10 years or 77% after 25 years even in younger patients with RA can be stated. CONCLUSIONS: Cemented THR shows good long-term-results in RA which with uncemented designs have also to be proved. As a consequence of analysing the (few) failures the cemented THR of Wessinghage with optimized bone-cement-implant-compound was introduced. We demand a high feed back rate in long-term follow-ups also with respect to quality management and comparing data.     

Low dose flunarizine protects the fetal brain from ischemic injury in sheep

This retrospective long-term study analyzes the clinical function, failures, and radiographic status of 131 Richards Series 2 prostheses in total hip arthroplasties (THAs) performed during 1981 and 1982. After a minimum follow-up period of 11 years, the results were evaluated. Sixty two (54%) patients with 71 THAs were available for follow-up; 44 (38%) patients with 49 THAs had died. Three patients with three THAs were lost to follow-up, and seven patients with eight THAs were unable to participate in the examination due to causes not related to their present hip status. Ten patients underwent revision THA during the observation period. The median hip functional index (HFI) was 8.6 preoperatively and 15.8 at follow-up. Hip functional index correlated to radiographic signs of loosening. With revision as endpoint, the Kaplan-Meier survivorship for all 131 hips was 93% after 10 years and 91% after 12 years. The radiographic examination at follow-up revealed 5 (8%) definite loose cups and 12 (19%) definite loose stems. Including the number of aseptic loosened cups and stems confirmed at revision, aseptic loosening was found in 6% of all cups and 13% of all stems. This radiographic evaluation confirmed that lack of containment of the cup and varus position of the stem were factors influencing the long-term stability of the prostheses, whereas etiology, type of arthritis, and ectopic ossification did not. A fixation and stability score that was modified for cemented prostheses was developed and was of value in detecting the prostheses at risk. The long-term results of the Richards Series 2 THA are acceptable and comparable with other long-term studies on conventional prosthetic designs. Ten percent to 20% revision THAs due to aseptic loosening can be expected. In addition, patients younger than age 60 at surgery and especially men were found to belong to a high-risk group with regard to revision THA. These patients must be evaluated carefully so that revision THA can be performed before the bone bed is destroyed.     

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)     

Cement versus cementless fixation in total knee arthroplasty

A prospectively studied group of 55 uncemented Press Fit Condylar total knee arthroplasties was compared retrospectively with a matched group of 51 cemented Press Fit Condylar total knee arthroplasties at a mean of 10 years after operation. For the cemented group, the pain and function scores improved from 32 and 45 preoperatively to 95 and 77, respectively. For the uncemented group the scores improved from 33 and 50 preoperatively to 93 and 60, respectively. There were 10 revisions in the uncemented group for femoral or tibial aseptic loosening or osteolysis compared with two revisions in the cemented group. Exclusive of problems related to patellar metal backing, survival to revision for aseptic failure or radiographic loosening was 72% in the uncemented group and 94% in the cemented group at 10 years. A significantly higher revision rate was found in the uncemented compared with cemented total knee arthroplasty of the Press Fit Condylar design.     

Results of an operative policy in the treatment of periprosthetic femoral fracture

OBJECTIVE: To determine the clinical outcome of patients with periprosthetic femoral fractures treated operatively. DESIGN: Retrospective analysis from 1986 to 1993. SETTING: Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland. PATIENTS: Forty-five patients identified from a computer database as being admitted to the Edinburgh Orthopaedic Trauma Unit with periprosthetic femoral fractures. MAIN OUTCOME MEASURES: Clinical outcome grade (good, fair, poor) dependent on integrity of fixation, refracture rate, and ability to perform activities of daily living analyzed against age, type of fracture, prosthetic alignment, loosening, and method of fixation. RESULTS: Type I fractures were more common in uncemented or loosely cemented prostheses, whereas type II fractures occurred predominantly in securely cemented prostheses. Type I fractures treated by revision had the poorest results. Outcome in type II fractures was equally good whether treated by internal fixation or by revision. Age, loosening, and prosthetic alignment did not influence outcome. The mortality rate in this series was 20%. CONCLUSIONS: If a prosthesis is loose, it should be revised, or treatment varies with fracture and prosthetic type. In type I fractures, an uncemented stem may be revised to a cemented one; however, a securely cemented prosthesis probably is better when fixed internally. Type II fractures should be fixed internally because there is less operative insult. Type III fractures probably are not related to the prosthesis and should be fixed internally according to normal practice. The results of an operative policy compare well with the results of conservative management and avoid the problems of long-term immobilization.     

Bone scan, gallium scan, and hip aspiration in the diagnosis of infected total hip arthroplasty

The difficulty in differentiating aseptic loosening from infection in painful total hip arthroplasty is well recognized. This prompted a review of the efficacy of the preoperative investigations used at the authors' institution. One hundred forty-four patients who underwent revision hip arthroplasty were reviewed. Seventy-two had sequential bone-gallium scan, and/or hip aspiration, and intraoperative Gram stain. These were compared to intraoperative culture as the gold standard. Twenty infected hips were detected on culture. For prediction of infection, the bone-gallium scan had a sensitivity of 38% and a specificity of 100%. Hip aspiration had a sensitivity of 57% and a specificity of 97%. The investigations combined gave a sensitivity of 64% and a specificity of 95%. Intraoperative Gram stain compared with subsequent culture yielded a sensitivity of 23% and a specificity of 100%. Uncemented hips were infected more frequently (47%) than cemented hips (9%), significant at P < .0001. It was concluded that bone-gallium imaging is not an effective method for investigating painful hip prostheses for sepsis and offers no additional advantage over hip aspiration. Intraoperative Gram stain also missed a large number of infections. Other modalities, such as indium-labeled-leukocyte imaging and capsular histologic examination, may be more efficacious. A significant difference in the number of infections found in cemented versus uncemented hips was shown, hence greater vigilance for infection is required when patients present with painful uncemented hip arthroplasties.     

Primary hybrid total hip arthroplasty: an interim followup

The senior authors' initial experience with primary hybrid hip replacement in patients with osteoarthritis was studied to evaluate the efficacy of the procedure. Hybrid total hip arthroplasty (uncemented Harris-Galante acetabular component and cemented Iowa precoated femoral component) was performed in 131 consecutive, nonselected hips in 118 patients with the diagnosis of primary osteoarthritis. Followup was performed at 8 to 9 years after the procedure. The average age at the time of the procedure was 68 years (range, 45-87 years). There were 50 men (55 hips) and 68 women (76 hips). At final followup 19 patients (22 hips) had died. The femoral component had been revised for aseptic loosening in 8 hips (6.1%). One additional hip showed definite radiographic loosening. Hence, the prevalence of radiographic femoral failure was 6.9% (9 hips). No acetabular component had been revised for aseptic loosening and no acetabular component had migrated. The senior author continues to perform hybrid total hip arthroplasty in all patients with primary osteoarthritis. However, design modifications have been made in the femoral component that is used.     

Aseptic loosening of the femoral implant after cemented total hip arthroplasty in dogs: 11 cases in 10 dogs (1991-1995)

Aseptic loosening of the femoral implant (ALFI) was diagnosed in 10 dogs that had undergone cemented total hip arthroplasty (THA). One dog had bilateral ALFI. Loosening developed at the stem-cement interface a mean of 30 months after THA. The most common clinical sign was intermittent subtle or non-weight-bearing lameness. On radiographs obtained after THA, the distal stem tip was in contact with the cortical endosteum in all dogs. Radiographic changes at the time of diagnosis of ALFI included asymmetric periosteal reaction along the femoral diaphysis (n = 11), radiolucent zone at the stem-cement interface (6), altered implant position (4), and femur fracture (1). Surgical revision resulted in a good or excellent outcome in 9 dogs. In 1 dog, the implant became infected. In another, aseptic loosening recurred. Aseptic loosening of the femoral implant was significantly more common when initial positioning of the implant resulted in contact between the distal tip of the implant and cortical endosteum than when there was no contact.     

Hybrid total knee arthroplasty

A prospective study of a hybrid total knee arthroplasty (TKA) with an uncemented femoral component and cemented tibial and patellar components was performed to combine the advantage of a press-fit femur while avoiding the problems in uncemented tibial and patellar implants. A total of 329 posterior cruciate-preserving TKA were studied at an average of 4.7 years after surgery: 84% of the knees had at most mild or occasional pain, 68% had good or excellent knee scores, and 62% could walk more than 1000 m. The function scores were 40% good or excellent in this collective, with an average age of 69.4 years at surgery. The component position and alignment were biomechanically correct. Radiolucent lines were observed regularly at the edges of the tibial and femoral components. There were no revisions for aseptic loosening. Hybrid TKA provides good results comparable to cemented TKA.     

Transforming growth factor-beta 1 and 2 in the synovial-like interface membrane between implant and bone in loosening of total hip arthroplasty

OBJECTIVE: Development of a synovial-like membrane in the implant-bone or cement-bone interface has been linked to aseptic loosening of total hip arthroplasties (THA). This tissue consists of a fibrous stroma containing blood vessels and macrophages, but with relatively few lymphocytes, compared to "autoimmune" rheumatoid synovitis. Our aim was to examine transforming growth factor-beta (TGF-beta) in the synovial-like membrane of the interface and pseudocapsular tissue of loose THA and compare it to control knee synovial membrane. METHODS: Twenty samples obtained from 10 patients with loose THA at revisions performed for aseptic loosening and 10 samples of knee synovial membrane as controls were analyzed for TGF-beta expression using rabbit antihuman TGF-beta 1 and TGF-beta 2 IgG in immunohistochemical staining. Results were quantitated by a semi-automatic VIDAS image analysis system. RESULTS: Immunoperoxidase staining disclosed TGF-beta in macrophages and fibroblasts and also in some vascular endothelial cells and in occasional lymphocytes. Image analysis showed an increased number of positive cells/mm2 of both TGF-beta 1 (2327 +/- 212 vs 946 +/- 136; p < 0.01) and TGF-beta 2 (2292 +/- 594 vs 311 +/- 113; p < 0.01) compared to the control tissue. Increased expression of both TGF-beta 1 and TGF-beta 2 was also shown in the pseudocapsule (3210 +/- 585 and 1796 +/- 214). Use of cement or type of alloy did not seem to have any great effect on local expression of TGF-beta. CONCLUSION: Profibrotic and immunosuppressive TGF-beta are increased in the synovial-like membrane in periprosthetic tissues around loose hip prostheses. They may play a role in the formation, maintenance, and growth of the interface tissue, and thus in the aseptic loosening of THA.     

Effect of nitric oxide, prostacyclin, and thromboxane on the vasospastic action of hydrogen peroxide on human umbilical artery

During the years 1991-1994, the Norwegian Arthroplasty Register recorded 1,324 primary hip arthroplasties implanted with the Boneloc cement. We have compared the survival until revision due to aseptic loosening for charnley (n 955) and Exeter (n 172) prostheses. The Boneloc cemented hips were also compared with high viscosity cemented hips implanted during the same period. In the Boneloc cemented group, the estimated probability of survival at 4.5 years of a Charnley femoral component was 74% and for an Exeter femoral component 97% (p < 0.0001). Using a Cox regression model with adjustment for age, gender, type of cement, systemic antibiotic and stratified for diagnosis, an 8 times higher risk of revision was found in Boneloc cemented Charnley femoral components than in Exeter femoral components (p < 0.0001). For the acetabular components, the difference between the Charnley and Exeter components with Boneloc cement was not statistically significant. In both the Charnley and the Exeter prostheses, the high viscosity cemented components had significantly better survival than the Boneloc cemented components. The Cox regression model showed that a Boneloc cemented Charnley femoral component had a 14 times higher risk of revision than a high viscosity cemented component (p < 0.0001), and for Exeter femoral components a 7 times higher revision risk was found in the Boneloc cemented components (p = 0.003). Our results confirm the previously reported inferior results of Charnley prostheses implanted with Boneloc cement and inferior results of Boneloc cemented Exeter prostheses as well, but less pronounced than for Charnley prostheses.     

A histologic and biochemical comparison of the interface tissues in cementless and cemented hip prostheses

Thirty-four membranes from 20 cementless and 14 cemented prostheses from 33 patients excised during revision arthroplasty were analyzed for foreign-body reactive processes. As a control, identical analyses were performed using adjacent pseudocapsular tissue taken from 12 patients during revision arthroplasty. Histologically, cementless membranes tended to contain more metal debris, and cemented membranes contained more foreign-body giant cells. Collagenase, gelatinase, prostaglandin E2, and interleukin-1 were measured in conditioned media taken from organ cultures of each interface membrane. Both cementless and cemented membranes released significant levels of gelatinase and collagenase, prostaglandin E2, and interleukin-1 into the conditioned media when compared with control tissues. However, the tissue concentrations were not significantly different between cementless and cemented membranes. Although histologic differences between cementless and cemented interface membranes exist, both share a similar capacity to release bioactive products that can induce bone resorption and cause aseptic loosening of the hip prostheses.     

Results after cemented total knee arthroplasty: a follow-up study over 5-to-14 years

Eighty-five cemented total knee arthroplasties were followed for five to fourteen years (mean 7.8 years). The clinical evaluation was excellent or good in 85% of this series. However, a complication developed in 15 knees (17.6%), and two thirds of these complications were found in the patello-femoral joint. One further case developed an infection (1.2%), and four others (4.7%) developed an aseptic loosening. Over all, 8 cases (9.4%) required revision surgery. Asymptomatic wear was seen to progress in some implants involving thin polyethylene, although their clinical results were rated as excellent. The outcome of the cemented knee arthroplasties was considered as acceptable at present, but improved surgical techniques and measures against polyethylene wear are required for future improvement in this surgery.     

Aseptic loosening of cemented, total hip alloplasty

The cemented low-friction arthroplasty of the hip (THR) has emerged as one of the most successful operations. About 3.500 THR's are inserted every year in Denmark, the clinical success rate at ten years being 90-95 percent. The most frequent long-term complication remains aseptic loosening of the prosthesis. This mechanism of failure is still a matter of discussion and it seems that aseptic loosening is a rather complex and multifactorial process. Our review deals with the various hypotheses with special reference to particulate debris generated at the prosthesis' surfaces and its active biological role in inducing aseptic loosening.     

Survivorship analysis of cemented total hip arthroplasty acetabular components implanted with second-generation techniques

The clinical and radiographic results of primary cemented total hip arthroplasty performed by a single surgeon, with particular emphasis on the performance of acetabular components implanted with so-called second-generation cement techniques, were studied. Seventy hips with 48 metal-backed and 22 polyethylene acetabular components were followed for a mean of 9 years (range, 5-11.5 years). The clinical results were evaluated using a recognized hip score. The fixation status of the cemented acetabular component was evaluated using two methods of measuring radiolucent lines at 5 years and at the last evaluation. Acetabular component loosening was defined as a circumferential radiolucent line, component migration, or revision for loosening. This study was unable to confirm the findings of others that demonstrated higher failure rates with cemented metal-backed components when compared with all-polyethylene components. The survival of cemented acetabular components with 28-mm head femoral prostheses was worse than the survival of cemented acetabular components with 22-mm femoral heads in other published reports, despite advances in cement techniques. Because of the high rate of loosening of cemented 28-mm-inner-diameter acetabular components at 5 and 10 years, the authors no longer use these cemented components for acetabular reconstruction.     

Revision of failed cementless total knee implants with cement

Between 1986 and 1996, 268 revision total knee replacements were performed. Revisions for aseptic loosening were reviewed prospectively. Sixty-three patients had implants revised for aseptic loosening. Thirty-six of the patients had revisions of cemented constructs, whereas 27 of the patients had revisions of cementless constructs. The average time before revision for the cemented group was 86 months. The average time to revision for the cementless group was only 43 months. Fifty-two percent of the patients in the cementless group had revision of their implants within 2 years of their index arthroplasty. The average pain free interval for the cementless group was only 11 months with 63% of the patients having no pain relief after their index arthroplasty. The average postoperative score for the cementless group was 88, whereas the average postoperative score for the cemented group was 82. Revision of failed cementless total knee implants with cement is a reliable procedure. Results are similar to those of cemented knees revised with cement.     

Automated seeded lesion segmentation on digital mammograms

The clinical results of eighty-four total hip arthroplasties performed through a transtrochanteric approach in sixty-seven patients who had a high dislocation of the hip (the femoral head completely out of the acetabulum), from 1976 to 1994, were reviewed. The acetabular component was placed in the true acetabulum and the femur was shortened at the level of the femoral neck, along with release of the psoas tendon and the small external rotators, in order to facilitate reduction of the components and to avoid neurovascular complications. Eleven hip prostheses (13 per cent) failed at a mean of 6.4 years (range, two months to sixteen years) postoperatively; the failure was due to aseptic loosening of both components in four hips, aseptic loosening of the stem only in three, late infection in three, and malpositioning of the acetabular component that caused recurrent dislocations in one. The other seventy-three hips were functioning well at the latest follow-up examination, two to twenty years (mean, 7.1 years) postoperatively. The overall cumulative rate of success was 92.4 per cent (95 per cent confidence interval, 89.5 to 95.3 per cent) at five years and 88.0 per cent (95 per cent confidence interval, 82.2 to 93.8 per cent) at ten years. We believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip.     

Porous-coated total hip replacement

Fifteen years of clinical experience with porous-coated prostheses demonstrated the durability of this type of fixation. This experience was documented by clinical follow-up study of the 393 cases treated by the senior author before 1985. Only six of these femoral components have been revised: three for loosening, two for stem breakage, and one for infection. Thus, the revision rate for the porous-coated stems was 1.5%. Porous-coated acetabular components were used in 227 of the arthroplasties. Five of these porous-coated cups have been revised: four for malposition leading to dislocation and one for late loosening secondary to osteolysis. Thus, the revision rate for these porous-coated acetabular components was 2.2%. Twenty bipolar and 146 cemented acetabular components were used in the remaining 166 cases treated before 1985. Eleven (7.5%) of the cemented acetabular components were revised. Revisions of the porous-coated components were rare in the first ten postoperative years. The clinical data were supplemented with analysis of postmortem specimens from 15 patients. Mechanical testing of the femoral specimens showed the relative micromotion at the porous surface to be exceptionally small (less than 40 microns). Seven of these postmortem retrievals involved cases with unilateral arthroplasties. In these cases, the contralateral normal femur also was removed, and a prosthesis identical to that in the in vivo implanted side was inserted to simulate the immediate postoperative condition. Dual-energy X-ray absorptiometry (DEXA) of the seven paired femora demonstrated that bone remodeling can be expected to produce a 5%-52% loss of periprosthetic bone mineral content, with the greatest loss occurring in the more osteoporotic patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sacrospinalis muscle-pedicle bone graft in posterolateral fusion for spondylolisthesis

From 1984 to 1995, 68 ankylosed elbows and 11 which were unstable after trauma were replaced in India by Baksi sloppy hinge prostheses. The mean age of the patients was 28.6 years (17 to 70) and the mean follow-up 9.6 years (2 to 13.5). Of the 68 ankylosed elbows, 59 (87%) regained a mean arc of painless movement of 88.5 degrees (27 to 115). The mean improvement of supination was 24 degrees and of pronation 16.5 degrees . There were 54 good results (80%), eight fair and three poor. There were two complete failures due to infection, and one due to a broken humeral stem. Of the 11 unstable elbows, the nine with good results had a mean arc of 125 degrees (15 to 140) of painless stable movement, with a mean improvement in supination of 26 degrees and of pronation of 19.5 degrees . There was one fair result and one failure due to loosening with subsequent late infection. There were significant complications in 14 cases with infection in seven and aseptic loosening in four. Patients with loosening or late removal of the prosthesis often retained reasonably stable elbow movement because periprosthetic fibrosis had connected the approximated bone ends, and muscle balance had been restored.