The Result of Revision Total Hip Arthroplasty in Patients with Metallosis Following a Catastrophic Failure of a Polyethylene Liner

BACKGROUND: Wear cannot be completely prevented after total hip arthroplasty. If severe polyethylene (PE) liner wear develops, the so-called catastrophic failure occurs and metallosis develops. We postulated that longevity of the new implant may be affected after revision surgery for metallosis following a catastrophic failure of a PE liner due to the substantial amount of PE wear particles and infiltration of the metal particles in this catastrophic condition. METHODS: Twenty-three hips of 23 patients were identified because they showed metallosis during revision total hip arthroplasties performed in Seoul National University Hospital between January 1996 and August 2004. They were followed for at least 6.5 years after the index revision total hip arthroplasty. The clinical and radiological results of revision total hip arthroplasties in these patients were evaluated. RESULTS: The median Harris hip score increased from 60 points before revision total hip arthroplasties to 90 points at the final follow-up. Osteolysis was detected at an average of 9.3 years after revision total hip arthroplasties in 13 hips and acetabular cup loosening at average 9.8 years after revision total hip arthroplasties in 9 hips. With radiographic evidence of osteolysis and loosening as the end points, the 15-year survival rates were 28.2% and 56.0%, respectively. CONCLUSIONS: The survival rate of revision total hip arthroplasty in patients with metallosis following a catastrophic failure of a PE liner was low.

Long-Term Results of Total Hip Arthroplasty with an Extensively Porous Coated Stem in Patients Younger than 45 Years Old

PURPOSE: This study analyzed the long-term results of cementless total hip arthroplasty using an extensively porous coated stem in patients younger than 45 years old. MATERIALS AND METHODS: The clinical and radiographic results of 45 hips from 38 patients who underwent cementless total hip replacement arthroplasty with an AML prosthesis were reviewed retrospectively. The average follow-up was 12 years (range, 10-15 years). RESULTS: The average Harris hip score at the time of final follow-up was 87.3 (range 77-94) points. Forty two hips (93.3%) showed excellent and good clinical results. Osteolysis occurred around the stem in 20 hips (44.4%) and around the cup in 26 hips (57.8%). Stress-mediated femoral resorption was observed in 33 hips (73.3%) at 10 years. There was no incidence of resorption progressing after 5 years postoperatively. There was no stem loosening. Five hips were revised for osteolysis, cup loosening and polyethylene wear. CONCLUSION: The long term results of total hip arthroplasty using an extensively porous coated stem were acceptable, and there was no case involving the progression of proximal bone resorption.

Clinical and radiographic study of orofacial alterations in patients with systemic sclerosis

Systemic sclerosis (SS) is an autoimmune disease with great repercussions on the hard and soft tissues of the orofacial region. The aim of this study was to investigate the relationship between mandibular osteolysis and mouth opening measurements, duration of disease and presence/absence of teeth. Twenty-five subjects were selected: 15 diagnosed with systemic sclerosis and 10 healthy controls. The SS patients were grouped according to the presence (group I) or absence (group II) of mandibular osteolysis. The healthy subjects served as the control group (III). All of them underwent panoramic radiography on Ortophos® equipment (Siemens) and were clinically examined, with mouth opening measurement. We observed that group I had a longer duration of the disease than group II (p = 0.003). Groups I and II presented the same mean mouth opening. There was an increasing correlation between mouth opening and duration of the disease in group I (p = 0.095), but this was not observed in group II (p = 0.596). There was no correlation between presence/absence of teeth and osteolysis (p > 0.999), or between presence/absence of teeth and side of osteolysis (p = 0.143). We could conclude that osteolysis seemed to develop in patients with a longer duration of the disease, but did not modify the degree of mouth opening in relation to patients without osteolysis, and the presence/absence of teeth was not significant. On the other hand, in the osteolysis cases, the longer the duration of the disease, the greater the opening of the mouth.

Quiste óseo aneurismático de la columna vertebral: reporte de un caso / Aneurysmal bone cyst of the spine: case report

El quiste óseo aneurismático es un tumor de naturaleza neoplásica indefinida, de comportamiento benigno, crecimiento rápido y ocasionalmente de comportamiento agresivo, cuyo tratamiento de elección es la resección completa, aunque existe el riesgo de sangrado transquirúrgico excesivo. Se presenta el caso de una paciente con deformidad en columna torácica, con parestesias y debilidad muscular progresivas en extremidades inferiores, que evolucionó hasta la parálisis de dichas extremidades e incontinencia de ambos esfínteres. Mediante estudios de gabinete se localizaron lesiones líticas en cuerpos vetebrales T7 a T9 e invasión a conducto raquídeo. Los estudios electrofisiológicos identificaron bloqueo completo de la vía somatosensorial. Previa biopsia incisional, se realizó resección de la lesión y estabilización de la columna toracolumbar. La paciente evolucionó sin mejoría de la función medular. Los hallazgos morfológicos correspondieron a quiste óseo aneurismático en T8. Esta lesión se localiza principalmente en huesos largos y con mucho menor frecuencia en la columna vertebral, donde puede provocar inestabilidad y compresión de la médula espinal. Es posible confundirla con otras neoplasias, por lo que el diagnóstico definitivo mediante biopsia es imprescindible a fin de establecer el plan terapéutico adecuado, que elimine el riesgo de recurrencia o secuelas neurológicas asociadas, y lograr la estabilidad adecuada de los segmentos vertebrales afectados.

The aneurysmal bone cyst (ABC) is a fast-growing tumor of undefined neoplastic nature. It is occasionally an aggressive benign lesion whose treatment of choice is a complete resection, even though the risk of profuse transoperative bleeding exists. We present a female patient with thoracic spine deformity, with progressive paresthesias and muscle weakness of lower extremities that evolved to paralysis of both lower extremities and sphincter incontinence. Based on radiographic films, lytic lesions were identified at T7 to T9 vertebrae as well as medullary space invasion. In electrophysiologic tests, a complete somatosensorial pathway block was reported. Prior to resection of the neoplastic lesion and thoracolumbar stabilization, an incisional biopsy was performed. There was no postoperative medullary functional improvement. Morphological findings corresponded to an aneurysmal bone cyst at T8. This lesion is mainly located in the long bones and less frequently of the spine, where instability and medullary compression may occur. It is possible to confuse this neoplasia with other lesions. Hence, definite diagnosis with biopsy is necessary for determining an adequate therapeutic plan to eradicate recurrence risk or associated neurologic sequelae, as well as to gain proper stability at the involved vertebral segments.

Coccidioidomicosis osteoarticular: estudio clinicopatológico de una serie de 36 pacientes mexicanos / Osteoarticular coccidioidomicosis clinical and pathological: study of 36 Mexican patients

Coccidioidomycosis (CM) is primarily a lung disease. Systemic spread occurs in 1% of cases and one of its manifestation is osteoarthritis. Aim. To describe the clinical and pathological characteristics of 36 patients with osteoarthritis by Coccidioides immitis (COA). Material and methods. The surgical pathology records of two medical institutions were reviewed; patients with clinical diagnosis of osteoarthritis and definitive histopathological diagnosis of COA were included in the study. Results were analyzed by contingence tables (RXC) and test. Results. Twenty six adults (19 men, seven women) and 10 children (seven males, three females) were studied. The analysis demonstrated a predominance of disease in men (72.2%, p - 0.008). There was no difference between males and females in relation to history of mycotic disease or diagnosis of lung disease after the diagnosis of COA. Bone involvement (76% of cases) was more frequent that pure joint lesions and the predominant radiological lesion was of lytic type. 30.5% of patients (11 cases) had multiple bone lesions and eight of them were men with multiple vertebral bone lesions. Discussion. The COA was the only manifestation of disease in 83% of the patients. Therefore is important to consider this etiology in patients of endemic area. The clinical and radiological spectrum of COA is wide and may include a dentigerous and synovial cyst or simulates metastatic disease. The recognition of the clinical manifestations of COA may contribute to an opportune diagnosis and treatment.

La coccidioidomicosis (CM) es una enfermedad primariamente pulmonar. La diseminación sistémica ocurre en 1% de los casos y una de sus manifestaciones es la osteoartritis. Objetivo. Conocer las características clínicas y patológicas de 36 pacientes con osteoartritis por Coccidioides immitis (OAC). Material y métodos. Se revisaron los archivos de patología quirúrgica de dos instituciones y se incluyeron aquellos pacientes que consultaron por enfermedad osteoarticular y cuyo diagnóstico final histopatológico fue de CM. Los resultados se analizaron con tablas de contingencia (programa RXC) y prueba de . Resultados. Se estudiaron 26 adultos (19 hombres, siete mujeres) y 10 niños (siete hombres y tres mujeres). La prueba de mostró un predominio de casos en hombres (72.2%, p = 0.008). No hubo diferencia entre hombres y mujeres en relación con antecedentes de enfermedad micótica ni en el diagnóstico de enfermedad pulmonar posterior al diagnóstico de OAM. El compromiso óseo (76% de los casos) fue más frecuente que las lesiones articulares puras y la imagen radiológica predominante fue la osteolítica. De los casos estudiados, 30.5% (11 casos) presentaban lesiones óseas múltiples. De estos 11 casos, ocho eran hombres que en su mayoría presentaban lesiones vertebrales dorsales bajas y lumbares. Discusión. En 83% de los pacientes que se presentaron por OAC, esta fue la única manifestación de la enfermedad. El espectro clínico y radiológico de OAC es muy amplio y puede presentarse como un quiste dentígero, un quiste sinovial o simular enfermedad metastásica. El reconocimiento de esta variedad de presentaciones clínicas en individuos de zonas endémicas puede contribuir a un diagnóstico oportuno y tratamiento específico.

Intraosseous foreign body creating osteolytic bone lesion mimicking malignancy

Necrotizing Fasciitis [NF], although uncommon soft tissue infection but it is a diagnostic and therapeutic challenge to the surgeons due to their higher associated morbidity and mortality. This aggressive infection caused by aerobic and anaerobic infections mainly affects the subcutaneous fat and fascia, and later on the overlying skin, while the underlying muscles are almost always spared. Our objective is to put a plan for optimal care of such patients. The current study reviews our experience with 20 patients of NF admitted and treated at Surgery Department in Shifa Hospital in Gaza during the period from February 1995 to February 2003. They were 12 males and 8 females with a mean of age 53.5 years. After establishment of the diagnosis of NF by clinical examination and intra-operative findings, all the necrotic tissues were debrided under general anesthesia followed by minor debridement as frequent as needed under analgesia, while reconstructive procedures e.g. skin grafting and secondary suturing performed according to the condition. The mean time between the beginning of the disease and the operation was 4.4 days.Among the 20 patients with NF, 13 patients [65%] had diabetes mellitus [D.M.]; the mortality rate between the diabetics was 61.5%. The perineum was the most frequent site for primary infection, eight cases [40%] followed by the valvar region, four cases [20%]. Seven patients died out of the twenty giving a mortality rate of 35% in this study. In Recognition of the need for early diagnosis and surgical treatment of this rapidly progressive surgical infection [NF] is necessary for successful management, especially for patients with perianal or valvar infections

Thyroid cancer with skull enlargement: a lesson learned?

A case of endemic goitre associated with thyroid cancer and huge enlargement of the scalp is reported in a Brazilian mulatto from an iodine deficient Central west region of the country. On admission, osteolytic metastases of follicular thyroid carcinoma were found scattered in the parietal bones. Impressive images from old files could illustrate and emphasize the hurdle-like role of poverty and inadequate social and cultural attitudes before the fight against cancer in regions with limited resources. Even in developed countries, goitres still occur in areas with iodine prophylaxis. Another concern is insufficiency of reliable data on the incidence and pattern of head and neck tumours in developing countries.

Hipercalcemia e lesões osteolíticas múltiplas em crianca com paracoccidioidomicose disseminada e tuberculose pulmonar / Hypercalcemia and multiple osteolytic lesions in a child with disseminated paracoccidioidomycosis and pulmonary tuberculosis

OBJETIVO: Descrever o caso de uma crianca com paracoccidioidomicose, que apresentou hipercalcemia associada a múltiplas lesões osteolíticas. DESCRIÇAO: Menino de 6 anos, internado com história de febre e hepatoesplenomegalia há 1 mês. A internacão, apresentava-se em regular estado geral, descorado, com linfonodomegalia generalizada e hepatoesplenomegalia. Os exames laboratoriais identificaram anemia (hemoglobina = 6,8 g/dl), eosinofilia (1.222/mm ), plaquetopenia (102.000/mm ) e hipoalbuminemia (albumina = 2,2 g/dl). Paracoccidioides brasiliensis foi identificado no mielograma. A partir da segunda semana de internacão, apresentou artralgia, hipoatividade e dificuldade à deambulacão, sendo constatada hipercalcemia (dosagem máxima de 14,9 mg por cento) e reducão da funcão renal, que duraram pouco mais de 2 semanas. No 42º dia de internacão, foram vistas, na radiografia de tórax, múltiplas lesões líticas em clavículas, escápulas, costelas e úmeros, com escorregamento epifisário de úmero bilateral. Apresentou nefrocalcinose e nefrolitíase, com reducão no clearance de creatinina e evidências de lesão tubular. No final do segundo mês de internacão, na cultura do lavado gástrico, foi identificado Mycobacterium tuberculosis. Recebeu tratamento para paracoccidioidomicose e tuberculose e está há mais de 3 anos em acompanhamento, sem nenhuma seqüela. COMENTARIOS: O desenvolvimento da hipercalcemia sintomática, levando à lesão renal e associada a lesões ósseas múltiplas e disseminadas, nunca foi descrito em paracoccidioidomicose. Embora tenha sido diagnosticada tuberculose pulmonar, que pode estar relacionada à hipercalcemia, a forma abrupta como se instalou e como se normalizou sem o tratamento específico para tuberculose sugere que a lise óssea foi o fator mais importante na gênese da hipercalcemia.

Effect of metabolic control on parathyroid hormone secretion in diabetic patients

The metabolic derangement caused by diabetes mellitus may potentially affect bone mineral metabolism. In the present study we evaluated the effect of diabetes metabolic control on parathyroid hormone (PTH) secretion during stimulation with EDTA infusion. The study was conducted on 24 individuals, 8 of them normal subjects (group N: glycated hemoglobin - HbA1C = 4.2 + or - 0.2 percent; range = 3.5-5.0 percent), 8 patients with good and regular metabolic control (group G-R: HbA1C = 7.3 + or - 0.4 percent; range = 6.0-8.5 percent), and 8 patients with poor metabolic control (group P: HbA1C = 12.5 + or - 1.0 percent; range: 10.0-18.8 percent). Blood samples were collected at 10-min intervals throughout the study (a basal period of 30 min and a 2-h period of EDTA infusion, 30 mg/kg body weight) and used for the determination of ionized calcium, magnesium, glucose and intact PTH. Basal ionized calcium levels were slightly lower in group P (1.19 + or - 0.01 mmol/l) than in group N (1.21 + or - 0.01 mmol/l) and group G-R (1.22 + or - 0.01 mmol/l). After EDTA infusion, the three groups presented a significant fall in calcium, but with no significant difference among them at any time. Basal magnesium levels and levels determined during EDTA infusion were significantly lower (P<0.01) in group P than in group N. The induction of hypocalcemia caused an elevation in PTH which was similar in groups N and G-R but significantly higher than in group P throughout the infusion period (+110 min, N = 11.9 + or - 2.1 vs G-R = 13.7 + or - 1.6 vs P = 7.5 + or - 0.7 pmol/l; P<0.05 for P vs N and G-R). The present results show that PTH secretion is impaired in patients with poorly controlled diabetes

Linfangiomatosis musculoesquelética / Skeletal lymphangiomatosis

La linfangiomatosis musculoesquéletica ha sido descripta esporádicamente en la bibliografía radiológica y ortopédica. Este caso documenta el espectro imagenológico de una enfermedad poco frecuente y ayuda a identificar un potencial patrón diagnóstico. Se presenta una paciente de 35 años de edad que consulta por dolor dorsolumbar inespecífico, es estudiada mediante Rx simple, Tomografía Computada (TC) y Resonancia Magnética (RM). Los hallazgos radiológicos evidenciados permitieron confirmar la naturaleza benigna de la enfermedad. La linfangiomatosis musculoesquelética es una entidad benigna poco frecuente de etiología desconocida, que compromete a los vasos sanguíneos y linfáticos, produce lesiones quísticas difusas a nivel del esqueleto axial y apendicular y se acompaña de afectación visceral. El empleo de los distintos métodos de imágenes permite realizar el diagnóstico correcto

Hemangioendotelioma epitelial / Epithelioid hemangioendothelioma with multiple site involvement

Se reporta un caso de hemangioendotelioma epitelial que se presenta con lesiones óseas múltiples, predominantemente en columna lumbar que provocaron su fijación quirúrgica para su estabilización, y nódulos pulmonares. El paciente tenía un diagnóstico previo de su patología pulmonar, no probado histológicamente, de histiocitosis X, que se confirmó por biopsia torácica a cielo abierto, correspondiendo a similar origen que las lesiones óseas. A pesar del tratamiento el paciente falleció por diseminación de su enfermedad y complicaciones quirúrgicas

Histiocitosis de células de Langerhans: hallazgos radiológicos en compromiso óseo / Langerhans cell histiocytosis: radiology findings in bone complications

La histicitosis de células de Langerhans es una enfermedad provocada por la excesiva proliferación de histiocitos de Langerhans. En la infancia determinan un cuadro sistémico que afecta la piel, pulmones y esqueleto. En niños pequeños (1-3 años) existe una combinación de compromiso visceral y óseo. En niños levemente mayo se caracteriza por lesiones líticas ósea, denominadas granulomas eosinófilos. En esta publicación presentamos cuatro pacientes portadores de ganulomas eosinófilos, la forma más habitual de esta enfermedad

The hemispherical porous acetabular component fixed by press-fit technique and additional screws

Seventy consecutive primary total hip arthroplasties in which a Harris-Galante porous-coated acetabular component had been used from October, 1986 to December, 1989 were reviewed for 5 to 9 years follow-up. We performed the retrospective, clinical and radiological analysis of the hemispheric, porous-coated, cementless acetabular component using press-fit and screw fixation. No component had detectable migration or any other position change. No acetabular fractures and no screw problems were noted. Initial peripheral gaps were observed in 11 cases (16%). Twelve cases had a postoperative polar gap less than 0.5 mm which were stabilized at 2 years postoperatively. Radiolucent line was present in at least one zone in 53% of cases and occurred most frequently in zones 1 and 3. No continuous radiolucent line greater than 2 mm was seen in any zone and radiolucent lines were stabilized 2-3 years postoperatively. Twelve hips (17.1%) had osteolysis of the acetabulum. No acetabular component was revised because of aseptic loosening. Revision arthroplasties were performed in 9 hips during follow-up. We concluded that the hemispheric porous-coated, acetabular components using press-fit and screw fixation had good results with a 5 to 9-year follow-up.

Osteólise e desgaste nos componentes acetabulares näo cimentados nas artroplastias do quadril / Osteolysis and cementless acetabular component wear in hip arthroplasties

Entre 1986 e 1992 foram avaliados 135 quadris, submetidos a artroplastia total com componentes acetabular nao cimentado de Harris-Galante. Foram estudados osteólise localizada e desgaste do polietileno, relacionados com idade, diâmetro da cabeça do componente femoral, artroplastia primária ou revisäo, componente femoral cimentado ou näo e espessura do polietileno. Em 46 por cento dos componentes acetabulares näo cimentados, foi encontrada osteólise localizada. Näo houve correlaçäo significante com a quantidade de desgaste do polietileno e osteólise, em que, na maioria dos casos, a espessura do polietileno utilizado foi igual ou superior a 10mm. O desgaste do polietileno foi de 0,14 + 0,02mm ao ano, superior às médias descritas na literatura para artroplastias cimentadas. A quatidade de desgaste do polietileno foi maior nas nastroplastias com cabeça femoral de 28mm de diâmetro.

Lesöes osteolíticas causadas por falha do componente acetabular modular näo cimentado em próteses totais do quadril: relato de três casos com diferentes falhas mecânicas / Osteolytic lesion due to failed modular acetabular cementless hip prosthesis: report of 3 cases with different causes of biomechanical failure

Foi feito um estudo retrospectivo sobre três casos operados no Hospital de Clínicas da UFPr pelo Grupo de Cirurgia do Quadril, em que foi observada osteólise maciça, apesar da técnica cirúrgica correta utilizada nas artroplastias totais de quadril. Em um componente acetabular foi utilizado um liner de polietileno do tipo ACS (Acetabular Cup System - DePuy, USA) e um componente femoral do tipo AML. Nos dois outros casos foram utilizados um componente acetabular e liner PCA (Howmedical, USA)e um componente femoral Nexus (Wright Medical, USA). A falha ocorreu aos 62, 46 e 36 meses, com desgaste acetabular acelerado ou dissociaçäo mecânica entre os componentes, seguido de osteólise maciça. A biomecânica das próteses de quadril modulares é discutida e as vantagens e desvantagens potenciais desses implantes säo ressaltadas.

Micetomas actinomicoticos en Santiago del Estero / Actinomycotic mycetoma in Province of Santiago del Estero

Presentamos cinco casos de micetomas actinomicóticos, en el Hospital Independencia de Santiago del Estero entre Abril de 1988 y Abril de 1990. Todos los pacientes procedían de áreas rurales de nuestra provincia, cuatro de ellos de sexo femenino y el restante de sexo masculino, las edades oscilaron entre 38 y 47 años, presentaban localización podal y referían antecedentes de traumatismo con espinas vegetales o elementos punzantes. En cuatro de los casos el agente etiológico recuperado fue: actinomadura madurae, el restante fue diagnosticado por el estudio anátomo-patológico del material extraído por resección quirúrgica al observar "granos" típicos de Streptomycosis somaliensis. Los casos producidos por Actinomadura madurae presentaban alteraciones osteolíticas, que fueron aumentando con el tiempo de evolución de las lesiones; el caso debido a Streptomycoces somaliensis no presentó compromiso óseo

Angiomatosis con osteolisis (Síndrome de Gorham) / Angiomatosis with osteolysis (Gorham syndrome)

El síndrome de Gorham se caracteriza por presentar nevos angiomatosos con disolución del hueso subyacente, produciendo la desaparición de la estructura ósea. Generalmente afecta a jóvenes en forma unilateral, comprometiendo cintura pelviana y escapular, y más raramente columna cervical y parrilla costal. La histología muestra linfangiomas disecantes o bien receptores estrogénicos. La evolución es en general mala, y en pocos casos autorresolutiva. Con respecto al tratamiento, los corticoides y citostáticos han dado poco resultado. Se puede intentar cirugía, hasta la amputación. Si bien este cuadro no reviste caracteres de malignidad, debido a su carácter agresivo debe ser diagnosticado y tratado correctamente. Se presentan dos pacientes: uno poseedor de un angioma y cuyo motivo de consulta fueron los dolores osteócopos; el otro, portador de una linfangioma que estaba diagnosticado como metástasis