Revision of ceramic head fracture after third generation ceramic-on-ceramic total hip arthroplasty.

We performed 24 revisions of fractures of third generation ceramic heads. The stem was not changed in 20 revisions; a new ceramic-on-ceramic bearing was used in four and a metal-on-polyethylene bearing in 16. The stem was changed in four revisions; a new ceramic-on-ceramic bearing was used in three and a metal-on-polyethylene bearing in one. During the follow-up of 57.5 months, complications occurred in five hips among the 20 stem retained revisions: a fracture of the new ceramic head in two, metallosis with pseudocyst in two, and femoral osteolysis with stem loosening in one. However, there were no complications in the four revisions where the stem was changed. Revision surgery after ceramic head fracture shows high rates of early complications. We recommend stem revision in cases of THA failure due to fracture of a modern ceramic head.

Elevation of fibrinogen due to loss of ovarian function enhances actin ring formation and leads to increased bone resorption.

The aim of the present study was to evaluate the effect of fibrinogen on number and function of osteoclasts (OC) consequently resulting in bone loss. It was hypothesized that the enhanced level of released fibrinogen due to loss of ovarian function caused bone loss by acting on OCs. Bone loss was induced by ovariectomy (OVX) in mice and analyzed by micro-CT. The effect of fibrinogen on OCs was evaluated by tartrate-resistant acid phosphatase, annexin V, actin staining, pit formation observed on dentine slices, and Western blotting. Exogenous fibrinogen increased OC survival, actin ring formation, and bone resorption in vitro. The effect of fibrinogen was dependent on ß(3)-integrin, which is a marker for mature OCs. Fibrinogen induced the activation of transforming oncogene from Ak strain (Akt), Ras-related C3 botulinum toxin substrate 1 (Rac1), and Rho family of GTPase (Rho) and the degradation of the Bcl-2 interacting mediator of cell death (Bim) in a manner similar to macrophage colony-stimulating factor (M-CSF). OVX increased plasma fibrinogen and serum M-CSF together with elevated actin ring formation and bone loss. The increased fibrinogen level due to loss of ovarian function may contribute, at least partly, to bone loss through the enhanced number and activity of OCs.

Midterm results of primary total hip arthroplasty using highly cross-linked polyethylene: minimum 7-year follow-up study.

The purpose of this study was to investigate the results of 113 total hip arthroplasties in 109 patients using highly cross-linked polyethylene (HXLPE) after midterm (minimum 7 years) follow-up retrospectively. The mean age at the time of operation was 57 years. Preoperative diagnosis was osteonecrosis in 81 hips and other diagnosis in 32 hips. There was no component loosening. Acetabular osteolysis was found in 12 hips (10.6 %). Mean linear HXLPE wear rate was 0.031 ± 0.012 mm/y. We analyzed the relationship between HXLPE wear rate and several variables influencing HXLPE wear. Only the cup position was related with wear rate of HXLPE significantly (P < .05). The results of total hip arthroplasties using HXLPE showed excellent results with decreased wear rate and low incidence of osteolysis after midterm follow-up.

Synergistic Effects of Beta Tri-Calcium Phosphate and Porcine-Derived Decellularized Bone Extracellular Matrix in 3D-Printed Polycaprolactone Scaffold on Bone Regeneration.

Bone-derived extracellular matrix (ECM) is widely used in studies on bone regeneration because of its ability to provide a microenvironment of native bone tissue. However, a hydrogel, which is a main type of ECM application, is limited to use for bone graft substitutes due to relative lack of mechanical properties. The present study aims to fabricate a scaffold for guiding effective bone regeneration. A polycaprolactone (PCL)/beta-tricalcium phosphate (ß-TCP)/bone decellularized extracellular matrix (dECM) scaffold capable of providing physical and physiological environment are fabricated using 3D printing technology and decoration method. PCL/ß-TCP/bone dECM scaffolds exhibit excellent cell seeding efficiency, proliferation, and early and late osteogenic differentiation capacity in vitro. In addition, outstanding results of bone regeneration are observed in PCL/ß-TCP/bone dECM scaffold group in the rabbit calvarial defect model in vivo. These results indicate that PCL/ß-TCP/bone dECM scaffolds have an outstanding potential as bone graft substitutes for effective bone regeneration.

Preparation and characterization of anodized titanium surfaces and their effect on osteoblast responses.

In this study, titanium (Ti) surface was modified by anodizing with a mixture of beta-glycerophosphate sodium and calcium (Ca) acetate, and the anodized surfaces were characterized by scanning electron microscopy, X-ray diffraction, and electron probe microanalysis. In vitro osteoblast response to anodized oxide was also evaluated. The anodic oxide produced was observed to have interconnected pores (0.5-2 microm in diameter) and intermediate roughness (0.60-1.00 microm). In addition, anodic oxide was observed to have amorphous and anatase oxide. Calcium and phosphorus ions were deposited on the Ti oxide during anodization. Osteoblast differentiation, as indicated by alkaline phosphatase production, was enhanced on anodized surfaces. It was thus concluded from this study that Ca phosphate can be deposited on Ti surfaces by anodization. It was also concluded that the phenotypic expression of osteoblast was enhanced by the presence of Ca phosphate and higher roughness on anodized Ti surfaces.

Cementless calcar-replacement hemiarthroplasty compared with intramedullary fixation of unstable intertrochanteric fractures. A prospective, randomized study.

BACKGROUND: Unstable intertrochanteric fractures in elderly patients are associated with a high rate of complications. The purpose of this investigation was to compare the results of long-stem cementless calcar-replacement hemiarthroplasty with those of treatment with a proximal femoral nail for unstable intertrochanteric fractures in elderly patients. METHODS: Fifty-eight elderly patients with an AO/OTA type 31-A2 intertrochanteric fracture of the femur were randomized into two treatment groups and were followed for a minimum of two years. The twenty-nine patients in Group I were treated with a long-stem cementless calcar-replacement prosthesis, and the twenty-nine patients in Group II were treated with a proximal femoral nail. The two treatment groups were comparable with regard to demographic and injury variables. RESULTS: There were no significant differences between the groups in terms of functional outcomes, hospital stay, time to weight-bearing, or general complications. Patients treated with a proximal femoral nail had a shorter operative time, less blood loss, fewer units of blood transfused, a lower mortality rate, and lower hospital costs compared with those treated with the long-stem cementless calcar-replacement prosthesis. CONCLUSIONS: In elderly patients with an unstable intertrochanteric femoral fracture, a proximal femoral nail provides superior clinical outcomes but no advantage with regard to functional outcome when compared with a long-stem cementless calcar-replacement arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level I.

Development of hybrid scaffolds using ceramic and hydrogel for articular cartilage tissue regeneration.

The regeneration of articular cartilage consisting of hyaline cartilage and hydrogel scaffolds has been generally used in tissue engineering. However, success in in vivo studies has been rarely reported. The hydrogel scaffolds implanted into articular cartilage defects are mechanically unstable and it is difficult for them to integrate with the surrounding native cartilage tissue. Therefore, it is needed to regenerate cartilage and bone tissue simultaneously. We developed hybrid scaffolds with hydrogel scaffolds for cartilage tissue and with ceramic scaffolds for bone tissue. For in vivo study, hybrid scaffolds were press-fitted into osteochondral tissue defects in a rabbit knee joints and the cartilage tissue regeneration in blank, hydrogel scaffolds, and hybrid scaffolds was compared. In 12th week after implantation, the histological and immunohistochemical analyses were conducted to evaluate the cartilage tissue regeneration. In the blank and hydrogel scaffold groups, the defects were filled with fibrous tissues and the implanted hydrogel scaffolds could not maintain their initial position; in the hybrid scaffold group, newly generated cartilage tissues were morphologically similar to native cartilage tissues and were smoothly connected to the surrounding native tissues. This study demonstrates hybrid scaffolds containing hydrogel and ceramic scaffolds can provide mechanical stability to hydrogel scaffolds and enhance cartilage tissue regeneration at the defect site.

Cellular biocompatibility and stimulatory effects of calcium metaphosphate on osteoblastic differentiation of human bone marrow-derived stromal cells.

In the present study, the in vitro biocompatibility of calcium metaphosphate (CMP) with human bone marrow stromal cells (HBMSCs) and its effect on osteoblastic differentiation have been investigated. Powder and disk forms of CMP do not exert a cytotoxic effect on the HBMSCs undergoing osteoblastic differentiation. In addition, the HBMSCs adhere to the surface of the CMP disk as successfully as to the culture plate or hydroxyapatite (HA) disk. The HBMSCs adhered to either the HA or CMP disk display an undistinguishable actin arrangement and cellular phenotypes, indicating that the CMP does not disrupt normal cellular responses. An analysis of the differentiation of the HBMSCs cultured on culture plate, the HA and the CMP disk shows that three matrices are capable of supporting osteoblastic differentiation of the HBMSCs as accessed by alkaline phosphatase (ALP) staining. Further molecular analysis of osteoblastic differentiation of HBMSCs reveals that the CMP disk has a better ability than the HA disk to induce an expression of osteoblast-related genes, including ALP, osteoprotegerin (OPG), a decoy receptor for RANK ligand, and osteopontin (OPN), a non-collagenous bone matrix protein. The results demonstrate that, in addition to favorable biocompatibility, the CMP can stimulate osteoblastic differentiation of the HBMSCs in vitro.

Cementless Metasul metal-on-metal total hip arthroplasty in patients less than fifty years old.

BACKGROUND: Durable results of total hip arthroplasty have been difficult to achieve in young patients. We reviewed the intermediate-term clinical and radiographic results in a series of active, higher-demand patients who were less than fifty years old when they underwent cementless total hip arthroplasty with the use of the Metasul metal-on-metal articulation. METHODS: Seventy total hip arthroplasties were performed in sixty-two patients who were younger than fifty years of age (average age, thirty-seven years). Two patients (two hips) had had a resection arthroplasty because of deep infection less than five years postoperatively and were excluded. Sixty patients (sixty-eight hips) were available for complete clinical and radiographic analysis after a mean duration of follow-up of seven years. RESULTS: The mean preoperative Harris hip score of 49 points improved to 95 points at the time of final follow-up; fifty-six patients (93%) had an excellent result. No component was seen to be loose radiographically at the time of final follow-up. Only one focal area of pelvic osteolysis in one patient and two small focal areas of femoral osteolysis in another patient were identified. The hip with focal pelvic osteolysis underwent revision surgery with a liner change and bone-grafting of the osteolytic lesion around a stable component. CONCLUSIONS: At a mean of seven years after arthroplasties with a Metasul metal-on-metal articulation, there was a low rate of osteolysis and aseptic loosening in this group of young patients. However, additional follow-up is necessary to determine any possible long-term deleterious effects associated with this metal-on-metal articulation.

Wear of retrieved UHMWPE hip liners.

After the gamma-irradiation sterilization, the most widely used orthopaedic grade polymer bearing liner material for the total joint replacement, ultra-high molecular weight polyethylene (UHMWPE), degrades through the progressive in vivo oxidation. The oxidative degradation makes UHMWPE brittle and leads to reduction of its mechanical properties. In this study, the effect of the in vivo post-irradiation ageing time on the wear of UHMWPE was investigated. Twelve retrieved polyethylene hip liners implanted for 3-16 years and then stored in the air for 1.5-8 years were used. Two types of the pin-on-disk wear testing were conducted. The uni-directional repeat pass rotating and the linear reciprocating wear testing were done with stainless steel disks against stationary polyethylene pins under 4MPa at 1Hz with bovine serum lubrication. Wear of the retrieved polyethylene hip liners does not have significant correlation with the in vivo or total ageing time. The linear reciprocal sliding motion generated a more pronounced wear than the uni-directional repeat pass sliding motion. This indicates that the kinematic motion significantly affects the wear of aged UHMWPE, having a brittle, white band region.

Liver X receptor activation inhibits osteoclastogenesis by suppressing NF-κB activity and c-Fos induction and prevents inflammatory bone loss in mice.

LXRs are nuclear receptors that function as important regulators of lipid homeostasis and inflammatory responses. LXR activation has been shown to suppress RANKL-induced osteoclast differentiation, but its underlying mechanisms and its influence on inflammatory bone destruction remain unclear. In this study, we report that the LXR agonists T0901317 and GW3965 inhibit osteoclastogenesis from primary BMMs in a dose-dependent manner. LXR activation suppressed RANKL-induced transcriptional activity of NF-κB without affecting IκBα degradation and the phosphorylation of p38. LXR agonists significantly suppressed RANKL-induced expression of c-Fos and NFATc1, which are crucial transcription factors for osteoclastogenesis. The activation of LXRs also inhibited RANKL-mediated AP-1 transcriptional activity. Furthermore, LXR activation attenuated PPARγ ligand-induced c-Fos expression, and LXR suppressed AP-1 promoter activity by PPARγ. The inhibitory effect of LXR activation on osteoclastogenesis was reversed by overexpression of c-Fos, suggesting that c-Fos is a downstream target of the antiosteoclastogenic action of LXRs. In addition to osteoclast differentiation, LXR activation accelerated apoptosis in mature osteoclasts by the induction of caspase-3 and -9 activity and Bim expression. Consistent with the in vitro effects we observed, the administration of a LXR agonist protected from bone loss induced by LPS in vivo. Together, our data provide evidence that LXRs may have potential as therapeutic targets for bone resorption-associated diseases.

Absence of herpes virus entry mediator (HVEM) increases bone mass by attenuating receptor activator of nuclear factor-κB ligand (RANKL)-induced osteoclastogenesis.

Herpes virus entry mediator (HVEM), which is constitutively expressed at a high level on myeloid lineage cells, is also expressed on bone marrow-derived macrophages, suggesting that it may play a role in bone metabolism by affecting osteoclasts (OC) derived from bone marrow-derived macrophages. To address this question, we evaluated bone mass by micro-computed tomography and the number and activity of OC by tartrate-resistant acid phosphatase (TRAP) and pit formation on dentine slices, comparing HVEM-knockout mice with wild-type mice. The absence of HVEM led to a higher bone mass and to decreased levels of serum collagen type I fragments and serum TRACP5b in vivo. In vitro HVEM deficiency resulted in a reduced number and activity of OC and an impaired receptor activator of nuclear factor-κB ligand signaling through reduced activation of nuclear factor-κB and of nuclear factor of activated T-cells cytoplasmic 1. Exogenous soluble HVEM decreased expression of TRAP, whereas soluble LIGHT (a ligand of HVEM) increased it, indicating the occurrence of a positive signaling through HVEM during osteoclastogenesis. Our findings indicate that HVEM regulates bone remodeling via action on OC. The higher bone mass in the femurs of HVEM-knockout mice could be, at least in part, due to attenuated osteoclastogenesis and bone resorption resulting from decreased receptor activator of nuclear factor-κB ligand signaling in the OC.

Evaluation of solid free-form fabrication-based scaffolds seeded with osteoblasts and human umbilical vein endothelial cells for use in vivo osteogenesis.

We investigated the feasibility of using solid free-form fabrication (SFF)-based scaffolds seeded with osteoblasts, derived from human adipose-derived stem cells, and human umbilical vein endothelial cells (HUVECs) to enhance osteogenesis. To accomplish this goal, SFF-based polycaprolactone/poly-lactic-co-glycolic acid/tricalcium phosphate scaffolds were fabricated using a multihead deposition system, which is one SFF technique. The blended polycaprolactone/poly-lactic-co-glycolic acid/TCP scaffolds were seeded with human osteoblasts and HUVECs and implanted into calvaria defects in rats. At 8 and 12 weeks after implantation, microcomputed tomography, real-time polymerase chain reaction, and histological assays (hematoxylin and eosin staining and Alizarin red staining) were conducted to determine the effects of SFF-based scaffolds on osteogenic potential. In vivo experiments indicated that the osteoblast-only and osteoblast-HUVEC group produced bone formation. Additionally, scaffolds in the osteoblast-HUVEC group had the largest area of new bone tissue. Therefore, we demonstrated through microcomputed tomography and histological assays that scaffolds seeded with both human osteoblasts and HUVECs were superior to other groups for effective bone formation.

Cell adhesion and proliferation evaluation of SFF-based biodegradable scaffolds fabricated using a multi-head deposition system.

Scaffolds composed of biodegradable polymers and biocompatible ceramics are being used as substitutes for tissue engineering. In the development of such techniques, scaffolds with a controllable pore size and porosity were manufactured using solid free-form fabrication (SFF) methods to investigate the effects of cell interactions such as cell proliferation and differentiation. In this study, we describe the adhesion of human bone marrow stromal cells (hBMSCs) and proliferation characteristics of various scaffolds, which consist of biodegradable materials, fabricated using a multi-head deposition system (MHDS) that we developed. The MHDS uses novel technology that enables the production of three-dimensional (3D) microstructures. Fabrication of 3D tissue engineering scaffolds using the MHDS requires the combination of several technologies, such as motion control, thermal control, pneumatic control and computer-aided design/computer-assisted manufacturing software. The effects of a polymer and ceramic on a tissue scaffold were evaluated through mechanical testing and cell interaction analysis of various kinds of scaffolds fabricated using polycaprolactone, poly-lactic-co-glycolic acid and tri-calcium phosphate for bone regeneration applications. Based on these results, the feasibility of application to the tissue engineering of SFF-based 3D scaffolds fabricated by the MHDS was demonstrated.

THA using an anatomic stem in patients with femoral head osteonecrosis.

Treating young patients with femoral head osteonecrosis (ON) remains challenging. Anatomic stems were introduced in the 1980s and 1990s to improve the proximal canal fit in an attempt to enhance long-term implant survival, an important aspect of treating young patients. We began using one design in 1993 and asked three questions to confirm whether the design criteria improved outcomes in patients with ON: (1) What is the long term survivorship of these implants?; (2) What is the amount and rate of wear?; and (3) What is the incidence of osteolysis? We retrospectively reviewed 56 patients (69 hips) who underwent THA for femoral head ON with a cementless anatomic stem proximally coated with hydroxyapatite. Four patients (four hips) were lost to followup and 16 patients (19 hips) died. In the remaining 36 patients (46 hips) the minimum followup was 10 years (mean, 11.2 years; range, 10-13 years). The mean age at operation was 48.6 years. The average Harris hip score at last followup was 87 points. Worst-case survivorship was 58.1% at 13 years and best-case was 93.3%. The average linear wear of the polyethylene liner was 2.02 mm and the average annual wear was 0.18 mm per year. Thirty-seven hips (80%) had femoral osteolysis and 14 (30%) had acetabular osteolysis. One patient who had extensive femoral osteolysis and stem loosening was revised at 11.2 years postoperatively. The high rates of polyethylene wear and osteolysis are of concern.

Ceramic liner fracture after cementless alumina-on-alumina total hip arthroplasty.

Advances in technology have reduced the risk of fracture of ceramic total hip arthroplasty implants, but concerns remain about fracture of both components. We retrospectively reviewed 133 patients (157 hips) who had cementless alumina-on-alumina total hip arthroplasties with a sandwich-type acetabular component. Six patients (seven hips) died and five patients (six hips) were interviewed by telephone (95% followup). The 122 patients (144 hips) examined had a minimum followup of 36 months (average, 45 months; range, 36-68 months). All acetabular cups and femoral stems were radiographically stable at the last followup. Five hips in five patients (3.5%) were revised because of ceramic liner fractures. Ceramic liner fractures occurred at a mean of 35 months (range, 24-48 months) postoperatively. Acetabular cups in the fracture group (n = 5) were more anteverted than those in the nonfracture group (n = 139). In three patients the fracture apparently occurred during squatting, resulting in hyperflexion and wide hip abduction. Early ceramic liner fracture was associated with impingement associated with excessive anteversion of the acetabular cup in Korean patients who habitually squat.

Early failure of hemispheric hydroxyapatite-coated acetabular cups.

UNLABELLED: Total hip arthroplasties with hydroxyapatite coatings have shown encouraging results after early-term followup. We presumed hydroxyapatite-coating on a smooth hemispheric press-fit acetabular cup would enhance bone osseointegration and maintain stability of cup after midterm (minimum 5-year) followup. Sixty-three patients had 70 consecutive total hip arthroplasties. Five patients (eight hips) died from problems unrelated to surgery. The remaining patients (62 hips) were followed up for an average of 7 years (range, 6-9 years). The mean age of the patients was 49 years (range, 23-61 years). The average Harris hip score improved from 59 points (range, 32-82 points to 82 points (range, 37-100 points) at final followup. There were seven acetabular component revisions. Of the 55 unrevised cups, 47 hips (85%) were stable by bony ingrowth, five hips (9%) were fibrous stable, and three hips (5%) were unstable with cup migration. Osteolysis around the cup was observed in 18 hips (33%). The average polyethylene wear rate was 0.15 mm/year. Survival rates of the cups at 6 and 8 years were 94.3% and 60.5%, respectively. Total hip arthroplasties using an hydroxyapatite-coated smooth hemispheric acetabular cup showed an unexpected high failure rate in terms of fixation, occurrence of osteolysis, and revision after midterm followup. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasty with the use of nonmodular cementless acetabular component.

Sixty-seven hips in 63 patients who underwent total hip arthroplasties with the use of the nonmodular cementless acetabular component and alumina-on-polyethylene bearing surface were available for complete clinical and radiographic review at a mean follow-up period of 7 (range 5-9) years. The mean age was 59 years (range 34-75) years. The mean preoperative Harris hip score of 50 points improved to 93 points at final follow-up. One (1.5%) hip required revision for a recurrent dislocation. No component was loose radiographically at final follow-up. The mean linear wear rate was 0.07 (range 0.01-0.23) mm/y. At a mean follow-up of 7 years, there was no aseptic loosening. Further follow-up, however, is necessary to determine the potential advantage of nonmodular acetabular component for the development of pelvic osteolysis.

Long-stem cemented calcar replacement arthroplasty for proximal femoral bone loss.

Revision total hip arthroplasty with accompanying bone defects may require calcar replacement prostheses to restore hip stability and function. Twenty-nine hips in 27 patients were followed for a mean of 41 months (range, 24-101 months). The average Harris Hip Score increased from 34 to 82 points. Acceptable cement mantles (A, B, C1) were present in all cases. Three femoral components (10.3%) were re-revised as a result of aseptic loosening. Two others (6.9%) were loose by radiographic criteria. Thus, 24 (82.8%) of the 29 index femoral components were rigidly fixed according to radiographic criteria, whereas 26 (89.7%) still were in place at the time of review. The results of this study suggest that long-stem cemented calcar-replacement prostheses with modern cementing technique are a reasonable option in femoral revision arthroplasties involving proximal bone loss.