Hip arthroplasty for osteonecrosis after renal transplantation.

The treatment of osteonecrosis in renal-transplant patients with hip arthroplasty was reviewed. From 1972 to 1988, the surgical treatment evolved from the use of cemented total hip arthroplasty (THA) to uncemented bipolar hemiarthroplasty to, most recently, porous-ingrowth THA. During this period, 46 patients had 77 hip arthroplasties. Cemented replacement was used in 32 hips, uncemented bipolar replacement in 32, and porous-ingrowth arthroplasty in 13. At the two- to 18-year follow-up evaluations, the average Harris hip rating was 89 points. Ratings averaged 82 points at 8.7 years in cemented hips, 91 points at six years in bipolar hips, and 90 points at 3.1 years in uncemented hips. Loosening occurred in 46% of hips with cemented total hip prostheses, 9% of hips with bipolar prostheses, and in no hips with porous-ingrowth components. Aseptic revision rates were 31%, 12.5%, and 0% respectively. Infection rates were 0%, 9%, and 10% respectively. Although the follow-up period was shorter for bipolar and uncemented THAs, uncemented bipolar hemiarthroplasty and porous-ingrowth THA may be reasonable alternatives for the renal-transplant patient with osteonecrosis rather than cemented THA, which has a high long-term failure rate. The early results of porous-coated hip arthroplasty are satisfactory in patients with a functioning renal transplant.

Evaluation of uncemented total hip arthroplasty in patients with avascular necrosis of the femoral head.

Thirty-seven uncemented primary porous coated anatomic (PCA) total hip arthroplasties (THA) that were performed in 33 patients for the diagnosis of avascular necrosis (AVN) between June 1984 and December 1986 were reexamined at four- to six-year follow-up periods. Final clinical evaluation showed an 86-point average Harris hip rating (range, 47-100 points), which had improved from an average preoperative rating of 42 points (range, 20-61 points). Thigh pain, which was usually not functionally limiting, occurred in 11 patients (25%), and seven patients (16%) had a moderate or severe limp. Nine patients (20%) required the use of a cane. Long-term radiographic evaluation in 37 hips demonstrated acetabular cup migration in one hip, acetabular lucencies in four hips (11%), and acetabular bead loosening in ten hips (27%). Femoral subsidence occurred in five hips (14%) and femoral bead loosening in 11 hips (30%). Thirty hips (81%) demonstrated radiographic evidence of stable bony ingrowth. No revisions were performed for aseptic loosening, but two prostheses were removed for infection. These results of uncemented THA in patients with AVN appear to be as good or better than the results reported for cemented arthroplasty in AVN at this interval of a follow-up period. This study supports the use of uncemented devices, especially with the newer designs and increasing surgical experience in this difficult patient population.

Dislocation after total hip arthroplasty. Causes and prevention.

In this prospective study, a technique of positioning the acetabulum by bony landmarks of the pelvis in the standing position was developed using a standing lateral preoperative roentgenogram with the X-ray tube centered over the trochanter. Since 1984, 441 total hip arthroplasties (THAs) were done through the posterior approach with a 1.14% dislocation rate through 1988 and no dislocations in 1989. To prevent impingement and dislocation, it was determined that the safest range for cup position was 30 degrees-50 degrees abduction and 20 degrees-40 degrees flexion from the horizontal. To measure postoperative cup position, a standing true lateral roentgenogram of the operated hip allowed direct measurement of cup flexion and was reproducible within 10 degrees. No special instruments are necessary for this technique, which can be used with any THA system.

Bone-grafting in total hip arthroplasty for protrusio acetabuli. A follow-up note.

The results of total hip arthroplasty with the use of medial and superior bone-graft augmentation in thirty-nine hips (thirty-two patients) that had protrusio acetabuli were previously reported after two to eight years (mean, 4.7 years) of follow-up. We followed the surviving patients for 10.9 to 17.4 years (mean, 12.8 years). The average Harris hip-rating was 72 points--an average drop of 17 points since the previous report. The average was 64 points for patients who had rheumatoid arthritis and 83 points for those who had another diagnosis. Radiographic evaluation demonstrated definite, probable, and possible loosening in about 20, 10, and 60 per cent of the hips, respectively. Of the six hips that had definite loosening, four (10 per cent of the total series) had progression of the protrusion (acetabular migration); operative revision was performed on two of those four hips and on two other hips, in which progression had ceased. Hips that had progressive protrusion demonstrated superior migration more often than medial migration. The rates of loosening and revision were similar to those in hips that did not have protrusio acetabuli. We concluded that augmentation of total hip arthroplasty with bone-grafting is effective in arresting the progression of protrusio acetabuli in most hips (90 per cent in our series).

Radiographic measurements in protrusio acetabuli.

The radiographic data of 48 hips in 40 patients with painful, progressive protrusio acetabuli treated with cemented total hip arthroplasty and medial acetabular reinforcement using autologous or homologous bone grafts were reviewed. Twelve separate measurements were performed on the preoperative, postoperative, and most recent radiographs of each case to determine which measurements were the most useful in diagnosing protrusio acetabuli and in following preoperative and postoperative migration. The minimum follow-up period was 10 years (mean, 12.3 years). Vertical migration and horizontal distance, two measurements utilizing an X-Y coordinate system based on the acetabular teardrop, were found to be most useful. The cases with postoperative progression demonstrated vertical migration more often than medial migration.

Immunohistologic analysis of the distribution of cell adhesion molecules within the inflammatory synovial microenvironment.

Antigen-independent binding of T lymphocytes to a variety of cell types has been shown to be mediated by receptor-ligand pairs of adhesion molecules. In forms of inflammatory synovitis (including rheumatoid arthritis), T cells home to synovium, become activated, and participate in the generation of chronic synovitis. Using indirect immunofluorescence assays on synovial frozen tissue sections and on synovial fibroblast cell lines, we studied the distribution of cell adhesion molecules on components of the synovial microenvironment in inflammatory synovitis. We reasoned that analysis of the cell types within synovium that express adhesion molecules might provide clues to lymphocyte-stromal interactions that occur in inflammatory synovitis. We found that antibodies against the lymphocyte function-associated antigen 3 (LFA-3) molecule and the intercellular adhesion molecule 1 (ICAM-1) both reacted with macrophage-like type A synovial cells and synovial fibroblasts, as well as with tissue macrophages and vessel endothelium. Using flow cytometry, we found that anti-LFA-3 and anti-ICAM-1 (but not antibodies against their ligands CD2 and LFA-1) reacted with synovial fibroblast cells cultured in vitro. Thus, these data demonstrate that the ligands for lymphocyte LFA-1 molecules (ICAM-1) and for T cell CD2 molecules (LFA-3) are widely distributed among cell types of the synovial microenvironment and provide numerous cell types with which lymphocytes can interact via these 2 adhesion pathways during the course of inflammatory synovitis.

Synovial microenvironment-T cell interactions. Human T cells bind to fibroblast-like synovial cells in vitro.

Synovitis in rheumatoid arthritis is characterized by infiltration of the synovium by T and B lymphocytes and monocytes, as well as by the proliferation of synovial lining cells, fibroblasts, and endothelial cells. To study synovial cell-T cell interactions in vitro, we established cultures of fibroblast-like synovial cells, and used these cells in a synovial cell-T cell binding assay. Using T cells at various stages of differentiation and activation, we found that human thymocytes and mitogen-activated peripheral blood T cells bound to fibroblast-like synovial cells, whereas fresh peripheral blood T cells did not. Moreover, activated T cells from inflammatory synovial tissue or from synovial fluid also bound to fibroblast-like synovial cells cultured in vivo. Antibodies against certain epitopes of the T cell CD2 (35.1) and synovial cell lymphocyte function-associated antigen-3 (LFA-3) (TS2/9) molecules inhibited synovial cell-thymocyte binding. However, these same anti-CD2 and anti-LFA-3 antibodies only partially inhibited synovial cell binding to activated normal peripheral blood T cells. Moreover, T cells from inflammatory synovium from rheumatoid arthritis and psoriatic arthritis patients also bound to synovial cells in vitro. These findings demonstrate that fibroblast-like synovial cells are capable of binding to human T cells in vitro, and suggest that during the course of inflammatory synovitis, synovial fibroblast-T cell interactions may occur in vivo.

High tibial osteotomy: a retrospective review of 72 cases.

Past experience has shown that the results of high tibial osteotomy are difficult to predict. The purpose of this review was to correlate preoperative findings with postoperative results to define more precisely the indications and contraindications and to improve results. Between 1970 and 1983, 72 high tibial osteotomies for osteoarthritis were done at Duke University Medical Center by one surgeon using a consistent surgical technique. Fourteen complications were identified in 72 knees. The only one causing a persistent problem was a fracture of the tibial plateau. Forty-five knees in 38 patients were available for follow-up at an average of six years (range 1.5 to 15.0 years). Results in 15 knees (33%) were classified as "good" (pain free), in 20 knees (44%) as "fair" (improved), and in ten knees (22%) as "poor" (unchanged or worse). Three patients with fair results subsequently had total knee arthroplasty at least nine years after the osteotomy, and two of those with poor results received total knee replacement within two years of the tibial osteotomy. Measurements obtained from standing roentgenograms revealed an average of 3 degrees of preoperative varus and 8 degrees of postoperative valgus, for an average correction of 11 degrees. There was no statistically significant correlation between preoperative measurements of joint space or alignment and postoperative result. This review indicates that preoperative standing films of the knee alone are not a reliable indication for patient selection.

Bone-grafting in total hip replacement for acetabular protrusion.

Since 1971 we have used homologous and autogenous bone grafts to reinforce the medial acetabular wall when doing a total hip replacement in patients with painful protrusio acetabuli. Thirty-two patients have been followed for a minimum of two years, the longest follow-up being eight years. All grafts appeared to have united roentgeno-graphically within three months, and the protrusion did not progress. In seven patients with a completely absent medial acetabular wall, a protrusio acetabuli ring was used to provide support until the bone graft had healed. Complications included one late dislocation, one pulmonary embolus, two trochanteric non-unins, two fractured trochanters, and one case of loosening of the femoral component. The results of this study suggest that bone-grafting is effective in arresting the progression of acetabular protrusion.

Wound infections in patients undergoing total hip arthroplasty. Ultraviolet light for the control of airborne bacteria.

Ultraviolet (UV) irradiation (1,537 A) during total hip arthroplasty will effectively reduce risk of airborne bacterial contamination of the operative field. An air sampling study at the operative site compared 28 total hip arthroplasties with UV lights on and 19 operations with UV lights off. The use of UV irradiation significantly reduced the average number of airborne bacteria over the operative site, although the results indicate that the number of airborne bacteria collected at the operative site in each conventional operating room without UV irradiation was quite low. Data confirmed the fact that airborne bacteria are a reflection of operating room personnel and their activities. With UV light, the rate of infection from possible airborne sources was 0.15% for 1,322 total hip patients. Thus, emphasis is now placed on those causes of infection that are not airborne.

Aseptic (avascular) necrosis of the femoral head in psoriasis.

Aseptic (avascular) necrosis of the femoral head associated with psoriasis is reported. The clinical histories of nine patients with avascular necrosis of the femoral head and one patient with bilateral humeral head osteonecrosis are summarized. Psoriasis was the only associated condition found in three of the patients. Only two patients had received systemic corticosteroids in significant amounts (greater than 1 gm of prednisone). Four patients had received methotrexate therapy for psoriasis. Other possible contributing factors including serum uric acid levels are discussed. Psoriasis should be added to the list of systemic diseases associated with aseptic (avascular) necrosis. Avascular necrosis of the femoral head should be considered in any patient with psoriasis and pain in the hip or thigh.

Metacarpophalangeal joint arthroplasty with silicone-Dacron prostheses (Niebauer type): six and a half years' experience.

Four hundred and forty-one silicone-Dacron arthroplasties done since 1968 were reviewed. Results were influenced by both durability and immediate fixation of the prosthesis, disease characteristics, speed of progression, the amount of hand stress, the extent of soft tissue release, and postoperative dynamic and protective splinting. Dislocations were eliminated by a woven tie-in holding the prosthesis to bone; prosthetic buckling was eliminated by soft tissue release, sufficient bone removal, and suture of the dorsal capsule to the extensor mechanism. Early prosthetic models fractured easier than did current ones. Seventeen percent of the combined 4, 5, and 6 year follow-up prostheses fractured, and 30% of the 6 year prostheses have fractured. Function was not affected, however, and protheses have not been replaced. We continue to use silicone-Dacron protheses with immediate tie-in to bone.