Well-fixed cementless stems are sometimes needed to be extracted in patients with complications including periprosthetic infection, stem-neck breakage or trunnionosis. The purpose of this study was to report the clinical outcome in patients undergoing re-implantation surgery following removal of a well-fixed porous-coated cementless stem by the femoral longitudinal split (FLS) procedure(Fig.1, Fig.2). We conducted a retrospective study and radiographic review of 16 patients who had undergone re-implantation following the FLS procedure to remove a well-fixed stem due to periprosthetic infection, stem-neck breakage or trunnionosis. The study group consisted of 2 men and 14women with an average age of 68.4 years. Mean follow-up was 33.1± 25.0 months. Operation time, intraoperative bleeding, complications, causes of re-operation and clinical score were evaluated and the Kaplan-Meier method was used to evaluate the longevity of the stem.Background
Methods
Various approaches have been reported for the total hip replacement (THR). In recent years, a muscle sparing approach with low postoperative muscle weakness and low dislocation risk has been frequently selected. However, such surgery has a learning curve. Thus, at the time of switching from the conventional approach to such approaches, invasion or infection risk may increase with the operation time extension. The purpose of this study is to clarify the change of invasiveness or latent infection rate with the change in approach in order to select the cases safely at the beginning of introducing a new approach in THR. In facility A, THR was performed with Dall's approach (Dall), but 1 surgeon changed Dall to anterolateral modified Watson-Jones approach (OCM) and another surgeon changed Dall to direct anterior approach (DAA). In facility B, all 3 surgeons changed posterolateral (PL) approach to OCM. The subjects are 150 cases in total, including the each last 25 cases operated with the conventional approach and the each first 25 cases operated with a new approach (Dall to OCM: 25 + 25, Dall to DAA: 25 + 25, PL to OCM: 25 +25 cases). And, differences in operative time, intraoperative bleeding volume, postoperative hospital stay, and postoperative hemoglobin, white blood cell count, lymphocyte count, creatine kinase (CK), C-reactive protein (CRP) were investigated.Purpose
Methods
The purpose of this study was to evaluate the outcome of vascularized iliac bone grafting for idiopathic osteonecrosis of the femoral head. We reviewed the clinical and radiological results of 35 operations performed on 29 patients who had osteonecrosis of the femoral head (ONFH) in which a pedicle iliac bone grafting was performed for minimum follow-up of 10 years. The average age was 35 years (range, 17 to 62 years). According to the Japanese Orthopaedic Association classification for ONFH, there were 28 stage 2, 7 stage 3-A, 17 type C-1 hips, and 18 type C-2 hips. After a bone tunnel of 1.5 × 5 cm was made in the anterior aspect of the femoral head and curettage of necrotic lesion was performed, the pedicle bone with the deep circumflex iliac artery (DCIA) was inserted into the anterolateral portion of the femoral head. The average follow-up period was 13 years and 6 months. Weight bearing was not allowed for 2 months after the operation. Survival rate of the femoral head was calculated by Kaplan-Meier methods, and collapse of the femoral head and configuration of the femoral head was investigated at final follow-up.Introduction
Methods
Although osteonecrosis of the femoral head has been observed in young adult patients with autoimmune diseases such as SLE and MCTD that are treated by corticosteroids, the pathogenesis of the osteonecrosis remains unclear. We established a rat model with osteonecrosis of the femoral head by injecting lipopolysaccharide (LPS) and corticosteroid, and assessed consequences of the histopathological alteration of the femoral head, the systemic immune response, and the lipid synthesis. Male Wistar rats were given 2 mg/kg LPS intravenously on days 0 and 1 and intramuscularly 20 mg/kg methylprednisolone on days 2, 3, and 4. The animals were sacrificed 1, 2, 3, or 4 weeks after the last injection of the methylprednisolone. Histopathological and biochemical analyses were performed every week. The bone samples were then processed for routine hematoxylin and eosin staining to assess the general architecture and injury of the tissue. The triglyceride and the total cholesterol concentrations in the PRP were measured. The levels of various cytokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, GM-CSF, IFN-γ, TNF-α) in blood samples were measured.Introduction
Methods
Total hip replacement for high dislocation of the hip joint remains technically difficult in terms of preparation of the true acetabulum and restoration of leg length. We describe our experience of cementless total hip replacement combined with a subtrochanteric femoral shortening osteotomy in 20 hips with Crowe grade IV dislocation with a mean follow-up of 8.1 years (4 to 11.5). There was one man and 17 women with a mean age of 55 years (44 to 69) at the time of the operation. After placment of the acetabular component at the site of the natural acetabulum, a cementless porous-coated cylindrical femoral component was implanted following a subtrochanteric femoral shortening osteotomy. The mean Japanese Orthopedic Association hip score improved from a mean of 38 (22 to 62) to a mean of 83 points (55 to 98) at the final follow-up. The mean lengthening of the leg was 14.8 mm (−9 to 34) in patients with iliofemoral osteoarthritis and 35.3 mm (15 to 51) in patients with no arthritic changes. No nerve palsy was observed. Total hip replacement combined with subtrochanteric shortening femoral osteotomy in this situation is beneficial in avoiding nerve injury and still permits valuable improvement in inequality of leg length.
We undertook a prospective study to evaluate the prognostic significance of the serum levels of vascular endothelial growth factor (VEGF) in predicting the survival of patients with osteosarcoma. The levels were measured by an enzyme-linked immunosorbent assay in 15 patients with osteosarcoma before commencing treatment. The patients were divided into two groups, with a high or a low serum VEGF level, and the incidence of metastases and overall survival rate were compared. No significant relationship was observed between the serum VEGF levels and gender, age, the size of the tumour or the response to pre-operative chemotherapy. Patients with a serum VEGF >
1000 pg/ml had significantly worse survival than those with a level <
1000 pg/ml (p = 0.002). The serum VEGF level may be useful in predicting the prognosis for survival in patients with osteosarcoma.
We evaluated triple-phase bone scintigraphy in the differential diagnosis of peri-prosthetic infection in 46 patients with a total hip replacement or bipolar hemiarthroplasty who were due for revision surgery. There were 18 men and 28 women, with a mean age at operation of 64.6 years (28 to 81). We defined peri-prosthetic infection as an increased uptake of radioisotope in all the phases of triple-phase bone scintigraphy and validated these results against the histological and/or microbiology results in every case. The positive and negative predictive values for the presence of infection were 83% and 93%, respectively. The diagnostic sensitivity was 88% and the specificity was 90%. This study indicates that triple-phase bone scintigraphy is a useful tool in the detection of peri-prosthetic infection and offers a cost-effective method of screening.
We report a case of peri-prosthetic tuberculous infection nine years after total hip arthroplasty in a patient with no history of tuberculosis before the procedure. Further investigation revealed active pulmonary tuberculosis which was thought to have spread haematogeneously to the arthroplasty. The infection did not respond to standard antituberculous drugs. Removal of the prosthesis and insertion of an antibiotic spacer were required.
We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months. The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained. Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip.
Patients with dislocation, severe subluxation of the hip joints were treated with cementless THA combined with subtrochanteric shortening femoral osteotomy. Total hip arthroplasty (THA) requiring subtrochanteric osteot-omy has been considered to lead to several complications. The aim of this paper is to assess the clinical results and complications of this procedure. An acetabular component was placed into position at the site of the true acetabulum. After femoral corrective shortening osteotomy for dislocation or severe sub-luxation of the hip joints, an AML cementless stem was tightly inserted into the femoral canal to achieve bony union and osteointegration with the implant. Twenty-one patients (23 hips; 2 men, 19 women) treated with cementless THA combined with subtro-chanteric femoral shortening osteotomy were enrolled in this study. The mean age was 55 years and the mean follow-up period was 4.5 years. The average elongation of the limb was 48 mm after subtrochanteric shortening femoral osteotomy. Solid union of the osteotomy was obtained within an average of 5.5 months after surgery. None of these patients developed sciatic nerve palsy. There were 4 cases of non-union of the osteotomy site and 3 of aseptic loosening of the femoral component related to intraoperative femoral fracture. Upward migration of the proximal part of the femur was related to poor preoperative bone quality. In order to diminish these complications, careful patient selection, accurate femoral reaming and suitable methods of bone cutting and augmentation of the oste-otomy site are necessary.
Concomitant tumour resistance (CTR) is a unique phenomenon in which animals harbouring large primary tumours are resistant to the growth of smaller metastatic tumours by systemic angiogenic suppression. To examine this clinically, in ten patients with osteosarcoma, we investigated the effects of removal of the primary tumour on the development of pulmonary metastases, the systemic angiogenesis-inducing ability and the serum levels of several angiogenesis modulators. We found that removal of the primary tumour significantly elevated systemic angiogenesis-inducing ability in five patients who had post-operative recurrence of the tumour. Post-operative elevation of the angiogenesis-induced ability was suppressed by the addition of an angiogenic inhibitor, endostatin. Also, primary removal of the tumour decreased the serum levels of vascular endothelial growth factor and endostatin. These findings suggest, for the first time, the presence of CTR in patients with osteosarcoma for whom postoperative antiangiogenic therapy may be used to prevent the post-operative progression of micrometastases.
We treated four patients with periacetabular malignant tumours by pelvic reconstruction with a free vascularised fibular graft after resection of the tumour. The mean follow-up period was 32 months (9 to 39). The diagnosis was chondrosarcoma in three patients and osteosarcoma in one. In two patients total resection of the hemipelvis was required and in the other two less, but still massive, resection was undertaken. All were treated with an immediate free vascularised fibular graft which included arthrodesis of the hip and reconstruction of the pelvic ring. One patient died. The other three have remained free from recurrence. Solid union of the graft was achieved between four and 14 months after surgery. Shortening of the involved limbs was less than 2 cm. The patients had no pain and were independent walkers without external support. Emotional acceptance was satisfactory. Our results suggest that reconstruction with the use of a free vascularised graft is an alternative to other types of reconstructive procedure after resection of periacetabular tumours.
We present the results in 12 patients of arthrodesis of the knee using a vascularised fibular graft after resection of a malignant bone tumour. At a mean follow-up of 95 months (60 to 178) all patients were free from disease although 11 had had at least one complication, with stress fracture of the graft in five patients, nonunion in two and deep infection requiring above-knee amputation in one. Despite the high rate of complications, satisfactory results can be obtained using this technique. Careful preoperative counselling is required.
