Bilateral L5 pedicle fracture with L5-S1 spondylolisthesis after single-level L4-5 posterior lumbar interbody fusion: illustrative case.

BACKGROUND: Single-level posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) is a commonly performed surgical procedure for L4-5 isthmic spondylolisthesis. Postoperative L5 pedicle fracture with rapidly progressive spondylolisthesis at L5-S1 segment after L4-5 PLIF/TLIF is quite rare, and the etiology remains unclear. This report describes this rare complication and proposes a possible etiology focusing on the lumbosacral sagittal imbalance characterized by an anteriorly shifted lumbar loading axis. OBSERVATIONS: The authors report a case complicated by L5 bilateral pedicle fractures and rapidly progressive spondylolisthesis at the L5-S1 segment very early after a single-level PLIF for L4-5 isthmic spondylolisthesis. Meyerding grade III anterolisthesis was observed at L5-S1 segment by 3 months after the initial surgery. Additional surgery was performed, and the fixation was extended to L4-ilium. Fracture healing was observed at 6 months postoperatively. LESSONS: This complication may have been caused by abnormal local shear forces on the posterior neural arch of L5 vertebra and L5-S1 intervertebral disc, which were triggered by the fusion surgery for L4 shear-type spondylolisthesis. L4 sagittal vertical axis is considered a reasonable parameter representing lumbosacral sagittal imbalance with an anteriorly shifted loading axis and may be a candidate for the predictive parameters of this rare complication.

Radiolucent lines do not affect the longevity of highly cross-linked polyethylene cemented components in total hip arthroplasty.

AIMS: We aimed to evaluate the long-term outcome of highly cross-linked polyethylene (HXLPE) cemented acetabular components and assess whether any radiolucent lines (RLLs) which arose were progressive. METHODS: We retrospectively reviewed 170 patients who underwent 187 total hip arthroplasties at two hospitals with a minimum follow-up of ten years. All interventions were performed using the same combination of HXLPE cemented acetabular components with femoral stems made of titanium alloy. Kaplan-Meier survival analysis was performed for the primary endpoint of acetabular component revision surgery for any reason and secondary endpoint of the appearance of RLLs. RLLs that had appeared once were observed over time. We statistically assessed potential relationships between RLLs and a number of factors, including the technique of femoral head autografting and the Japanese Orthopaedic Association score. RESULTS: The mean follow-up period was 13.0 years (10.0 to 16.3). Femoral head autografting was performed on 135 hips (72.2%). One acetabular component was retrieved because of deep infection. No revision was performed for the aseptic acetabular loosening. The Kaplan-Meier survival curve for the primary and secondary endpoints were 98.2% (95% confidence interval (CI) 88.6% to 99.8%) and 79.3% (95% CI 72.8% to 84.6%), respectively. RLLs were detected in 38 hips (21.2%), at a mean of 1.7 years (1 month to 6 years) postoperatively. None of the RLLs were progressive, and the presence of RLLs did not show a significant association with the survival and clinical score. RLLs were more frequently observed in hips without femoral head autografts than in those with autografts. CONCLUSION: The use of HXLPE cemented acetabular components in total hip arthroplasty demonstrated excellent clinical outcomes after ten years, and no RLLs were progressive, and their presence did not affect the outcome. Femoral head autografting did not negatively impact the acetabular component survival or the appearance of RLLs. Cite this article: Bone Joint J 2021;103-B(10):1604-1610.

An inflammatory polyp in the colon caused by the migration of a Kirschner wire following fixation of a pelvic fracture.

The migration of Kirschner wires (K-wires) is a rare complication. We herein present a case of an inflammatory polyp in the colon caused by the migration of a K-wire following fixation of a pelvic fracture. Surgery was carried out to remove the K-wire through an incision at the level of the left iliac bone. Simultaneous endoscopic clipping of the colonic wound was also performed. The patient's postoperative course was uneventful. Although very rare, migration of devices should be considered in patients with a previous history of orthopedic surgery.

Cytomegalovirus-associated gastric ulcer: a diagnostic challenge in a patient of fulminant hepatitis with steroid pulse therapy.

A 69-year-old woman presented with malaise. She had had organising pneumonia with the treatment of prednisolone. A diagnosis of fulminant hepatitis was made and steroid pulse therapy was initiated. Ten days later, a colonic resection with a colostomy was performed because of the perforated diverticulitis of the sigmoid colon. She presented with epigastric pain and melena after surgery. Despite the administration of the proton pump inhibitor, an endoscopy revealed multiple deep, punched-out ulcers of the stomach. Biopsy specimen showed cytomegalovirus (CMV) infection. The melena and CMV antigenemia was improved with ganciclovir; however the patient died from worsening of hepatic failure. We emphasise that CMV-associated gastric ulcers should be considered in the differential diagnosis of gastric ulcers in patients treated with immunosuppressive drugs.

[A case of 5-fluorouracil-induced hyperammmonia after chemotherapy for metastatic colon cancer].

A 79-year-old woman with colon cancer and multiple liver metastases was admitted to our hospital for systemic chemotherapy. She underwent first cycle of modified FOLFOX6 chemotherapy. She was confused on treatment day 5. Blood test revealed her serum ammonia level to be 121 microg/dl. We diagnosed 5-fluorouracil (5FU)-induced hyperammonemia. Conservative treatment resulted in improvement of metal status. The reason for hyperammonemia after administration of 5FU was the excess production of ammonium from metabolites of 5FU.

Clinical results of the wear performance of cross-linked polyethylene in total hip arthroplasty: prospective randomized trial.

To investigate the clinical results of cross-linked polyethylene (CLPE) and to compare the CLPE wear against zirconia and stainless steel heads, we studied the radiographic wear after a minimum 3-year follow-up in total hip arthroplasty (THA). Ninety-four hips were randomly implanted with a 22.225-mm head cemented THA-the group of non-CLPE against zirconia and CLPE against 2 different zirconias and stainless steel. The linear wear rate was significantly lower in the group of CLPE against zirconia (0.067, 0.059 mm/y) and against stainless steel (0.068 mm/y) compared with non-CLPE against zirconia (0.170 mm/y). In the short-term results, the wear performance of CLPE against zirconia was superior to that of non-CLPE; however, it did not show a better wear rate than CLPE against stainless steel. Furthermore, long-term investigations will be necessary for understanding CLPE wear in vivo.

Mechanical, setting, and biological properties of bone cements containing micron-sized titania particles.

In this study, polymethylmethacrylate-based composite cements containing 40-55.6 wt% micron-sized titania (titanium oxide) particles were developed, and their mechanical, setting, and biological properties evaluated. Three types of composite cement containing 40, 50, and 55.6 wt% silanized titania were designated ST2-40c, ST2-50c, and ST2-56c, respectively. In animal experiments, ST2-50c and ST2-56c were implanted into rat tibiae and solidified in situ. An affinity index was used to evaluate osteoconductivity. Compressive and bending strength of ST2-56c was 147.7+/-3.2 and 69.3+/-7.4; those of the other cements exceeded 100 MPa and 50 MPa, respectively. The affinity indices of ST2-56c were 42.1+/-12.9 at six weeks and 53.4+/-16.6 at 12 weeks, and were significantly higher than for ST2-50c and a commercial PMMA bone cement within 12 weeks. Our data indicate that bone cement containing micron-sized titania particles can be applied to prosthesis fixation as well as vertebroplasty, and ST2-56c is a good candidate cement.

In vivo evaluation of a porous hydroxyapatite/poly-DL-lactide composite for bone tissue engineering.

As reported previously, a porous composite of uncalcined hydroxyapatite (u-HA) and poly-DL-lactide (PDLLA) showed excellent osteoconductivity and biodegradability as a bone substitute in rabbit model. In this study, to investigate the usefulness of this composite as a scaffold loaded with cells, we estimated whether this material showed osteogenesis on implantation to extraosseous site. On loading with syngeneic bone marrow cells and implantation into rat dorsal subcutaneous tissue, osteogenesis with enchondral ossification was seen both on and in the material at 3 weeks after implantation. The osteogenesis in the u-HA/PDLLA had progressed, and newly formed bone tissue was found in the material by 6 weeks. To investigate the osteoinductive properties of the material, we implanted this porous composite material into extraosseous canine dorsal muscle. At 8 weeks, osteogenesis was seen in the pores of the material. Newly formed bone could be observed adjacent to the material. In addition, cuboidal osteoblasts adjacent to the newly formed bone were evident. Neither cartilage nor chondrocytes were found. These results might indicate that the material induced osteogenesis by intramembranous ossification. Conversely, similar porous PDLLA did not induce osteogenesis during the observation period. Therefore, porous HA/PDLLA, which has osteoconductive and osteoinductive properties, might be a useful material for use as a bone substitute and cellular scaffold.

Bioactive and bioresorbable cellular cubic-composite scaffolds for use in bone reconstruction.

We used a novel composite fibre-precipitation method to create bioactive and bioresorbable cellular cubic composites containing calcium phosphate (CaP) particles (unsintered and uncalcined hydroxyapatite (u-HA), alpha-tricalcium phosphate, beta-tricalcium phosphate, tetracalcium phosphate, dicalcium phosphate dihydrate, dicalcium phosphate anhydrate or octacalcium phosphate) in a poly-D/L-lactide matrix. The CaP particles occupied greater than or equal to 70 wt% (greater than or equal to 50 vol%) fractions within the composites. The porosities of the cellular cubic composites were greater than or equal to 70% and interconnective pores accounted for greater than or equal to 70% of these values. In vitro changes in the cellular geometries and physical properties of the composites were evaluated over time. The Alamar Blue assay was used to measure osteoblast proliferation, while the alkaline phosphatase assay was used to measure osteoblast differentiation. Cellular cubic C-u-HA70, which contained 70 wt% u-HA particles in a 30 wt% poly-D/L-lactide matrix, showed the greatest three-dimensional cell affinity among the materials tested. This composite had similar compressive strength and cellular geometry to cancellous bone, could be modified intraoperatively (by trimming or heating) and was able to form cortico-cancellous bone-like hybrids. The osteoinductivity of C-u-HA70, independent of biological growth factors, was confirmed by implantation into the back muscles of beagles. Our results demonstrated that C-u-HA70 has the potential as a cell scaffold or temporary hard-tissue substitute for clinical use in bone reconstruction.

A 5-7 year in vivo study of high-strength hydroxyapatite/poly(L-lactide) composite rods for the internal fixation of bone fractures.

The biocompatibility and biodegradation of hydroxyapatite (HA)/poly(L-lactide) (PLLA) composite bone implant rods were studied using two types of HA particles as reinforcing fillers, uncalcined-HA (u-HA) or calcined-HA (c-HA). Composite rods of u-HA/PLLA and c-HA/PLLA were implanted into the distal femurs of 25 rabbits. Four of these rabbits lived for more than 5 years after implantation, with one living for 7 years 4 months. Samples were retrieved after the rabbits died naturally and specimens were examined by light microscopy and scanning electron microscopy (SEM). For u-HA/PLLA, the shrinkage of the rods progressed further after 4 years, and some were almost completely resorbed. We could not find traces of the rod in some sections from more than 6 years. Remodeled bone encircled the residual material, and trabecular bone bonded directly to the rod was found toward the center. For u-HA/PLLA 30%, results were similar to u-HA/PLLA 40%, and the cross-sectional area had decreased by 4.0% at over 7 years. Most of the PLLA had been released from the rods. Neither obvious osteolytic nor osteoarthritic changes were found after 4 years.

Effect of alumina femoral head on clinical results in cemented total hip arthroplasty: old versus current alumina.

BACKGROUND: The wear rate of polyethylene against alumina was demonstrated to be lower than against metal, and the results of early clinical studies of alumina-on-polyethylene combination were as good as expected, but the long-term results of alumina ceramic heads were not as good, as reported by several authors. The purpose of this study was to assess the clinical results over 10 years of cemented total hip arthroplasty (THA) with two types of alumina head: old and current alumina. METHODS: We compared the clinical results of these two types of alumina used for cemented THA. The first type was old alumina (containing 7% yttria), and 77 hips with a 28-mm head (group I) were included. The second type was current alumina (highly purified alumina), and 50 hips with a 26-mm head (group II) and 88 hips with a 22-mm head (group III) were included. The mean follow-up was 17 years 4 months in group I, 12 years 3 months in group II, and 10 years in group III. RESULTS: The Kaplan-Meier survival analysis, with revision for any reason as the endpoint, predicted 10-year survival rates of 90.8%, 100%, and 97.5% for groups I, II, and III, respectively. The survival curves differed significantly only between groups I and II. The probabilities of 10-year survival of the pros-theses with radiological loosening as the endpoint were 77.2%, 91.6%, and 96.5%, respectively. The survival curves showed significant differences only between groups II and III. CONCLUSIONS: The old alumina showed a higher wear rate and rougher surface on the femoral head than did the current alumina in our previous study. The clinical results also indicated superiority of current alumina over old alumina. The difference in the size of the femoral head (26 vs. 22 mm) did not affect the clinical results.

In vivo evaluation of a porous hydroxyapatite/poly-DL-lactide composite for use as a bone substitute.

We investigated the biocompatibility, osteoconductivity, and biodegradability of a porous composite of hydroxyapatite (HA) and poly-DL-lactide (PDLLA) implanted into rabbit femoral condyles and compared it with porous HA. Six weeks after implantation, the HA/PDLLA was covered with bone and contacted the bone directly. The amount of newly formed bone in the pores was similar in both materials during the examined period. The newly formed bone in the HA/PDLLA tended to increase over 26 weeks, but that in the HA did not show a significant increase after 12 weeks. By 26 weeks, remodeling of the newly formed bone in the pores was seen and bone marrow tissue was found in the pores of the HA/PDLLA. The porous HA/PDLLA was resorbed much faster than the porous HA. Porous HA/PDLLA was resorbed continuously through bone formation and remodeling. Conversely, porous HA was scarcely resorbed throughout the period. HA/PDLLA is thought to be degraded almost completely after about 1 year, and in this study, porous HA/PDLLA showed excellent osteoconductivity and faster resorption than HA. Therefore, HA/PDLLA might be a desirable material for bone substitutes.

In vivo absorption of porous apatite- and wollastonite-containing glass-ceramic.

The behavior of porous apatite- and wollastonite-containing glass-ceramic (AW) in the bone marrow cavity was investigated. Cylinders of porous AW (4 mm in diameter and 20 mm long, mean porosity of 70% and mean pore diameter of 200 microm) were implanted into the bone marrow cavity of rabbit femurs, and analyzed by chronological radiograms and by scanning electron microscopy one, three, six, and 12 months later. The pores of porous AW are interconnected and homogeneously distributed, and its compressive strength is nearly equal to that of human cancellous bone. Bone formed in the pores at the center of the material by one month and bonded to the material directly. The volume of newly formed bone in the material pores reached a peak at three months, and decreased gradually after six months. The trabecular structures of AW were gradually remodeled by newly formed bone, while AW-bone bonding was maintained during bone remodeling and material absorption. AW was absorbed continuously, and at six and 12 months the residual material corresponded to about 64 and 30% of the starting material, respectively. Porous AW may therefore be useful as an absorbable bone substitute.

Displacement of a cemented socket after reduction of a dislocated total hip arthroplasty.

Acute displacement of the cemented acetabular component of a hip arthroplasty after attempted reduction of a dislocation is described. The causes of displacement of the socket, which was not radiologically loose, are discussed. Potential causes include impingement of the femoral head and the ceramic screw head overhanging the acetabular bone, which was used to fix the bone graft.

Histological and mechanical investigation of the bone-bonding ability of anodically oxidized titanium in rabbits.

The purpose of this study was to histologically and mechanically investigate the in vivo bone-bonding ability of anodically oxidized titanium (AO Ti) with an anatase crystal layer on its surface. AO Ti plates, anodically oxidized at 155 V in 1 M H2SO4, were implanted into the proximal metaphyses of mature rabbit tibiae for 4, 8, 16, and 24 weeks and investigated by light microscopy, scanning electron microscopy and detaching test. High bone-bonding ability, comparable to our previous study data of the bioactive titanium produced by sodium-free alkali and heat treatment, was observed at the early stages of implantation. However, no substantial increase was demonstrated. AO Ti plates bonded to bone directly, with no intervening soft tissue layer, and no breakage of the AO Ti layer was observed. The AO Ti layer was porous through to the titanium substrate, while the porosity was low. Apatite-like deposition into the pores of the AO layer was observed only in the superficial zone. The lack of improvement of bone-bonding ability in the later stages of implantation may be attributed to the low porosity and to the superficial ingrowths of apatite-like deposits into the pores of the AO Ti layer.

Phase stability after aging and its influence on pin-on-disk wear properties of Ce-TZP/Al2O3 nanocomposite and conventional Y-TZP.

Recently zirconia/alumina composites have been examined by many researchers as the new generation of bearing materials in total joint replacements. In this study, the phase stability of a Ce-TZP/Al(2)O(3) nanocomposite and conventional Y-TZP after aging, and its influence on wear resistance, were investigated. Very slight phase transformation was observed in both types of ceramics 18 months after the implantation of Ce-TZP/Al(2)O(3) or Y-TZP samples into rabbit tibiae. However, Y-TZP showed marked phase transformation (approximately 80%) after aging in an autoclave (121 degrees C) for 190 h or in physiological saline at 62 degrees C for 18 months, whereas the new composite remained almost resistant to degradation. According to the results of self-pairing pin-on-disk wear tests using ceramic specimens with or without autoclave aging, the wear factor was almost the same between Ce-TZP/Al(2)O(3) samples with and without aging (6.74 +/- 0.36 x 10(-8) and 6.04 +/- 0.95 x 10(-8) mm(3)/Nm, respectively). In contrast, although non-aged Y-TZP had the lowest wear factor (4.88 +/- 0.51 x 10(-8) mm(3)/Nm) of all specimens tested, aged Y-TZP showed 10-fold greater wear than nonaged Y-TZP. The present study suggests that Ce-TZP/Al(2)O(3) nanocomposite has much greater phase stability than Y-TZP, and that its wear properties are not influenced by aging.

Long-term study of high-strength hydroxyapatite/poly(L-lactide) composite rods for the internal fixation of bone fractures: a 2-4-year follow-up study in rabbits.

Biodegradation of hydroxyapatite (HA)/poly(L-lactide)(PLLA) composite bone implant rods was studied with the use of two types of HA particles as reinforcing fillers: uncalcined HA (u-HA) or calcined HA (c-HA). Composite rods of u-HA/PLLA and c-HA/PLLA containing 30 or 40% (w/w) HA were implanted in the distal femur of 21 rabbits, and specimens were examined by light microscopy, scanning-electron microscopy (SEM), and transmission-electron microscopy (TEM) 2-4 years later. For u-HA/PLLA, trabecular bone bonding directly onto the rod was maintained for up to 2 years. By 3 years, surface collapse had begun, and the implants were shrinking. By 4 years, they had shrunk further, with complete bone encapsulation. The u-HA particles were small and needle shaped in the peripheries, and TEM confirmed their resorption. The cross-sectional area after 4 years decreased by 23.3+/-8.4%. The mean ratio of bony ingrowth to the initial cross-sectional area around the shrunken rods was 6.7+/-1.3 %. The viscosity molecular weight of PLLA reduced from 2 x 10(5) to less than 1 x 10(3). Thus, most of the PLLA had released from the rods. The c-HA/PLLA implants also showed good osteoconductivity, but shrinkage and infiltration of histiocytes were less. No osteolytic or osteoarthritic changes were found.