Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: People with Borderline Personality Disorder (BPD) have limited access to long term psychological therapies. Briefer interventions have been developed but trial evidence to support their use has not been reviewed. AIMS: To examine whether psychological interventions for adults with BPD of six months duration or less improve symptoms, mood, self-harm, suicidal behaviour, and service use. METHODS: The protocol was prospectively registered (PROSPERO CRD42017063777). Database searches were conducted up to April 2020. Inclusion, data extraction and risk of bias were assessed in duplicate. We identified 27 randomised controlled trials. We conducted random-effects meta-analyses sub-grouping data into delivery method, additional support, and comparison type. RESULTS: High levels of bias were found for attrition and reporting. Heterogeneity was high in some pooled data. Borderline symptom reductions were greatest for interventions including additional support (SMD. -1.23, 95% C.I. -2.13, -0.33). Planned generic support may be as effective as specialist interventions for borderline symptoms (SMD = -0.11, 95% C.I. -0.51, 0.29) and social functioning (SMD = -0.16., 95% C.I. -0.65, 0.33). Follow-up was limited and direct comparison with post-intervention results was unreliable. CONCLUSIONS: Short-term interventions may be effective. Access to additional support has an impact on outcomes. It is unclear if symptomatic change is sustained.

An unusual presentation of propylthiouracil-induced anti-MPO and PR3 positive ANCA vasculitis with associated anti-GBM antibodies, IgA nephropathy and an IgG4 interstitial infiltrate: a case report.

BACKGROUND: A number of disease processes can culminate in rapidly progressive glomerulonephritis, including pauci-immune focal segmental necrotising glomerulonephritis, usually seen with positive serum antineutrophil cytoplasmic antibodies (ANCA). Propylthiouracil (PTU) has been associated with drug-induced ANCA-associated vasculitis (AAV), with antibodies against myeloperoxidase (MPO) and proteinase 3 (PR3) present individually and together having been recognised. 'Double-positive' vasculitis with ANCA and anti-glomerular basement membrane (GBM) antibodies has also been reported in association with PTU treatment. We present a case of PTU-induced anti-MPO and PR3 positive ANCA vasculitis with associated anti-GBM antibodies, IgA nephropathy and an IgG4 interstitial infiltrate. CASE PRESENTATION: A 51-year-old man presented 2 weeks after re-commencing propylthiouracil (PTU) treatment for Graves' disease, with a severe acute kidney injury and haemato-proteinuria. He demonstrated positive titres for autoantibodies to PR3 (76.9 IU/mL), MPO (28.8 IU/mL) and GBM (94 IU/mL). Renal biopsy demonstrated numerous glomerular crescents, widespread IgG4-positive lymphoplasmacytic infiltrate and mesangial positivity for IgA. PTU was stopped and he was treated with steroids, plasma exchange and cyclophosphamide with sustained improvement in his renal function. CONCLUSIONS: This case of drug-induced AAV presented a unique and intriguing collection of serological and histological features. We propose that the PTU-induced AAV resulted in epiphenomena of anti-GBM antibody production and an IgG4-cell-rich tubulointerstitial infiltrate. It is uncertain whether the mesangial IgA deposition preceded or resulted from the AAV.

Negative pressure temporary abdominal closure without continuous suction: a solution for damage control surgery in austere and far-forward settings.

The use of topical negative pressure dressings in temporary abdominal closure has been readily adopted worldwide; however, a method of continuous suction is typically required to provide a seal. We describe a method of temporary abdominal closure using readily available materials in the forward surgical environment which does not require continuous suction after application. This method of temporary abdominal closure provides the benefits of negative pressure temporary abdominal closure after damage control surgery without the need for continuous suction or specialised equipment. Its application in damage control surgery in austere or far-forward settings is suggested. The technique has potential applications for military surgeons as well as in humanitarian settings where the logistic supply chain may be fragile.

TRALI is due to pulmonary venule damage from leucocytes with cholesterol crystal formation.

BACKGROUND: There are two presumed mechanisms for the pulmonary oedema in transfusion-related acute lung injury (TRALI). One is antibodies to leucocytes while the other is biologically active lipids. We evaluated the vascular injury due to the former. METHODS: The pulmonary vasculature was studied by light microscopy (LM) and scanning electron microscopy (SEM) in three fatal cases of TRALI and compared with that of two autopsied control patients. Lung tissue from two of the TRALI cases and both controls was studied by gas chromatography-mass spectroscopy (GC-MS) to identify crystals present in the former. RESULTS: All three TRALI cases exhibited massive pulmonary oedema by weight and light microscopy and extensive defects by SEM in the endothelium of venules of the lungs. Such endothelial defects were absent in controls. Thrombi, composed of crystals, were present in venules and small veins diffusely throughout the lungs in Case 1. Similar crystals were identified in Case 2. The crystals in the lung vessels were identified morphologically as cholesterol and were proximate to the cytoplasmic defects of the endothelial surfaces. By GC-MS, there were markedly elevated levels of cholesterol and fatty acids in the two TRALI lungs tested compared with the lungs of the two controls. CONCLUSIONS: Pulmonary damage in TRALI is related to formation of cholesterol crystals that appear to pierce endothelial membranes of venules. The endothelial defects lead to plasma extravasation into the alveoli causing TRALI.

In vivo comparative wear study of traditional and highly cross-linked polyethylene in total hip arthroplasty.

In this study, we compare the in vivo wear performance of electron beam-irradiated, postirradiation-melted, highly cross-linked polyethylene (HXLPE) and traditional UHMWPE via the Martell method. Seventy hips with HXLPE performed at the Massachusetts General Hospital had 138 radiograph pairs for wear analysis and a 31.2-month average follow-up (range, 24-44 months). An age-matched, sex-matched, and body mass index-matched subgroup of 111 hips with 214 acceptable radiograph pairs and a 4-year follow-up from our previously published study on traditional polyethylene performed at Rush-Presbyterian-St. Luke's Medical Center served as a control group. Martell wear analysis was performed for each group. Overall and steady-state wear rates were compared via a specialized t test. The steady-state wear in the HXLPE arm was observed after 2.0 years, was 0.007 mm/y, and was significantly less than the steady-state wear in the traditional arm (0.174 mm/y) (P = .003). Highly cross-linked polyethylene penetration rate was not affected by sex, age, activity, or body mass index by Mann-Whitney analysis.

The combination of pamidronate and calcitriol reverses particle- and TNF-alpha-induced altered functions of bone-marrow-derived stromal cells with osteoblastic phenotype.

Periprosthetic bone loss after total joint arthroplasty is a major clinical problem resulting in aseptic loosening of the implant. Among many cell types, osteoblasts play a crucial role in the development of peri-implant osteolysis. In this study, we tested the effects of calcitriol (1alpha,25-dihydroxy-vitamin-D3) and the bisphosphonate pamidronate on titanium-particle- and TNF-alpha-induced release of interleukin-6 and suppression of osteoblast-specific gene expressions in bone-marrow-derived stromal cells with an osteoblastic phenotype. We monitored the expression of procollagen alpha1[1], osteocalcin, osteonectin and alkaline phosphatase mRNAs by Northern blots and real-time reverse transcription and polymerase chain reaction analyses. The release of various cytokines was also analysed by ELISA. We found that calcitriol or pamidronate could only partially recover the altered functions of osteoblasts when added alone. Only a combination of these compounds restored all the tested functions of osteoblasts. The local delivery of these drugs may have therapeutic potential to prevent or to treat periprosthetic osteolysis and aseptic loosening of implants.

Problems with cementless total knee arthroplasty at 11 years followup.

One hundred two patients with 131 consecutive cementless total knee arthroplasties that retained the posterior cruciate ligament were followed up prospectively. The average age of the patients was 58 years (range, 32-75 years). The mean followup on the surviving knee arthroplasties was 11 years (range, 7-16 years). The patellar component was metal-backed in the first 112 (85%) knees, cementless all-polyethylene in the last 17 (13%) knees, and two knees had a prior patellectomy. Forty-four metal-backed patellar components (48%) were revised; nine were loose, and 35 had polyethylene wear through. Thirteen femoral components (12%) were revised because of femoral abrasion from a failed metal-backed patellar component. No other femoral component was revised, loose, or had osteolysis develop. Nine (8%) tibial components had failure of ingrowth; eight have been revised. Partial radiolucencies occurred in 53% of the tibias. Thirteen (12%) small osteolytic lesions developed, all around screws or screw holes in the tibial components. At an average of 11 years followup, cementless fixation yielded mixed results: cementless femoral fixation was excellent and metal-backed patellar components had a 48% patellar revision rate. Cementless tibial components had an 8% aseptic loosening rate and a 12% incidence of small osteolytic lesions. Based on these results, the authors have abandoned cementless fixation in total knee arthroplasty.

Second-generation cementless total hip arthroplasty. Eight to eleven-year results.

BACKGROUND: Second-generation cementless femoral components were designed to provide more reliable ingrowth and to limit distal osteolysis by incorporating circumferential proximal ingrowth surfaces. We examined the eight to eleven-year results of total hip arthroplasty with a cementless, anatomically designed femoral component and a cementless hemispheric acetabular component. METHODS: Ninety-two consecutive primary total hip arthroplasties with implantation of a femoral component with a circumferential proximal porous coating (Anatomic Hip) and a cementless hemispheric porous-coated acetabular component (Harris-Galante II) were performed in eighty-five patients. These patients were prospectively followed clinically and radiographically. Six patients (seven hips) died and five patients (seven hips) were lost to follow-up, leaving seventy-four patients (seventy-eight hips) who had been followed for a mean of ten years (range, eight to eleven years). The mean age at the time of the arthroplasty was fifty-two years. RESULTS: The mean preoperative Harris hip score of 51 points improved to 94 points at the time of final follow-up; 86% of the hips had a good or excellent result. Thigh pain was reported as mild to severe after seven hip arthroplasties. No femoral component was revised for any reason, and none were loose radiographically at the time of the last follow-up. Two hips underwent acetabular revision (one because of dislocation and one because of loosening). Kaplan-Meier survivorship analysis was performed with revision or loosening of any component as the end point. The ten-year survival rate was 96.4% +/- 2.1% for the total hip prosthesis, 100% for the femoral component, and 96.4% +/- 2.1% for the acetabular component. Radiolucencies adjacent to the nonporous portion of the femoral component were seen in sixty-eight (93%) of the -seventy-three hips with complete radiographic follow-up. Femoral osteolysis proximal to the lesser trochanter was noted in four hips (5%). No osteolysis was identified distal to the lesser trochanter. Periacetabular osteolysis was identified in twelve hips (16%). Five patients underwent exchange of the acetabular liner because of polyethylene wear. CONCLUSIONS: This second-generation cementless, anatomically designed femoral component provided excellent clinical and radiographic results with a 100% survival rate at ten years. The circumferential porous coating of this implant improved ingrowth and prevented distal osteolysis at a mean of ten years after the arthroplasty.

AMPA-evoked acetylcholine release from cultured spinal cord motoneurons and its inhibition by GABA and glycine.

The release of [(3)H]acetylcholine evoked by alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) and its inhibition mediated by GABA(A) and glycine receptors were studied in superfused cultured rat embryo spinal cord motoneurons prelabeled with [(3)H]choline. AMPA elicited tritium release, possibly representing [(3)H]acetylcholine release in a concentration-dependent manner. The release was external Ca(2+)-dependent and was sensitive to Cd(2+) ions, omega-conotoxin GVIA and omega-conotoxin MVIIC, but not to nifedipine, suggesting the involvement of N-, P/Q-, but not L-type Ca(2+) channels. The AMPA effect was insensitive to tetrodotoxin. The glutamate receptors involved are AMPA type since the AMPA-evoked [(3)H]acetylcholine release was blocked by LY303070 and was potentiated by the antidesensitizing agent cyclothiazide. Muscimol inhibited completely the AMPA effect on [(3)H]acetylcholine release; muscimol was potentiated by diazepam and antagonized by SR95531, indicating the involvement of benzodiazepine-sensitive GABA(A) receptors. Glycine, acting at strychnine-sensitive receptors, also inhibited the effect of AMPA, but only in part. The inhibitory effects of muscimol and glycine are additive. We conclude that glutamate can act at AMPA receptors sited on spinal motoneurons to evoke release of acetylcholine. GABA and glycine, possibly released as cotransmitters from spinal interneurons, inhibit glutamate-evoked acetylcholine release by activating GABA(A) and glycine receptors on motoneurons.

Posterior cruciate ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis.

BACKGROUND: Although initial reports on posterior cruciate ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis have been encouraging, a high rate of late instability necessitating revision has been reported recently. The purpose of the present prospective study was to analyze the results of posterior cruciate ligament-retaining total knee arthroplasty in patients with rheumatoid arthritis. METHODS: Seventy-two posterior cruciate ligament-retaining total knee arthroplasties in fifty-one patients with rheumatoid arthritis were studied prospectively. All procedures were performed with the Miller-Galante I prosthesis. Eighteen patients (twenty-four knees) died before the eight-year follow-up and one patient (two knees) was lost to follow-up, leaving forty-six knees (thirty-two patients) for review. These forty-six knees were evaluated clinically (with particular attention to posterior instability) and radiographically at annual intervals for a mean of 10.5 years (range, eight to fourteen years). RESULTS: Forty-four (95%) of forty-six knees had a good or excellent result at a mean of 10.5 years. However, nine (13%) of the original seventy-two knees had revision of the implant, with six of the revisions performed because of failure of a metal-backed patellar component. The rate of survival at ten years was 93% 4% with femoral or tibial revision for any reason as the end point and 81% 5% with any reoperation as the end point. There was no aseptic loosening in any knee. Posterior instability was identified clinically and/or radiographically in two (2.8%) of the original seventy-two knees; both unstable knees were in the same patient. CONCLUSION: Posterior cruciate ligament-retaining total knee arthroplasty yielded satisfactory clinical and radiographic results in patients with rheumatoid arthritis at intermediate-term follow-up (mean, 10.5 years). Therefore, we believe that it remains an excellent treatment option for these patients.

Long-term followup of the Miller-Galante total knee replacement.

One hundred seventy-two consecutive cemented Miller-Galante-I total knee arthroplasties in 155 patients were compared with 109 consecutive cemented Miller-Galante-II total knee arthroplasties in 92 patients. The average followup was 11 years (range, 8-15 years) and 9 years (range, 8-10 years), respectively. Of the 172 Miller-Galante-I arthroplasties, there have been 21 revisions; 15 patellar revisions; two included femoral revisions attributable to abrasion. Six additional well-fixed femoral and tibial components were revised: two for early instability, one for pain, one for periprosthetic fracture, and two for infection. No component had aseptic loosening or osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 84.1% +/- 4.1%. Of the 109 Miller-Galante-II arthroplasties, there have been no component revisions, no aseptic loosening, and no osteolysis. Using revision or loosening of any components as the end point, the Kaplan-Meier 10-year survivorship was 100%. The Miller-Galante knee systems showed excellent fixation with no loosening and no osteolysis at as many as 15 years. Additionally, there have been no component revisions for late instability at as many as 15 years. Finally, the high prevalence of patellofemoral complications with the Miller-Galante-I design has been obviated with the Miller-Galante-II design.

Cementless acetabular reconstruction after acetabular fracture.

BACKGROUND: Total hip arthroplasty in patients with posttraumatic arthritis has produced results inferior to those in patients with nontraumatic arthritis. The use of cementless acetabular reconstruction, however, has not been extensively studied in this clinical context. Our purpose was to compare the intermediate-term results of total hip arthroplasty with a cementless acetabular component in patients with posttraumatic arthritis with those of the same procedure in patients with nontraumatic arthritis. We also compared the results of arthroplasty in patients who had had prior operative treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture. METHODS: Thirty total hip arthroplasties were performed with use of a cementless hemispheric, fiber-metal-mesh-coated acetabular component for the treatment of posttraumatic osteoarthritis after acetabular fracture. The median interval between the fracture and the arthroplasty was thirty-seven months (range, eight to 444 months). The average age at the time of the arthroplasty was fifty-one years (range, twenty-six to eighty-six years), and the average duration of follow-up was sixty-three months (range, twenty-four to 140 months). Fifteen patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and fifteen patients had had closed treatment of the acetabular fracture (closed-treatment group). The results of these thirty hip reconstructions were compared with the intermediate-term results of 204 consecutive primary total hip arthroplasties with cementless acetabular reconstruction in patients with nontraumatic arthritis. RESULTS: Operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis. Of the patients with posttraumatic arthritis, those who had had open reduction and internal fixation of their acetabular fracture had a significantly longer index procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom the fracture had been treated by closed methods. Eight of the fifteen patients with a previous open reduction and internal fixation required an elevated acetabular liner compared with one of the fifteen patients who had been treated by closed means (p = 0.005). Two of the fifteen patients with a previous open reduction and internal fixation required bone-grafting of acetabular defects compared with seven of the fifteen patients treated by closed means (p = 0.04). The thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty-seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis. CONCLUSIONS: The intermediate-term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.

Locally delivered rhTGF-beta2 enhances bone ingrowth and bone regeneration at local and remote sites of skeletal injury.

The purposes of the present study were to determine if recombinant human transforming growth factor-beta-2 (rhTGF-beta2) enhances bone ingrowth into porous-coated implants and bone regeneration in gaps between the implant and surrounding host bone. The implants were placed bilaterally for four weeks in the proximal humeri of skeletally mature, adult male dogs in the presence of a 3-mm gap. In three treatment groups of animals, the test implant was treated with hydroxyapatite/tricalcium phosphate (HA/TCP) and rhTGF-beta2 in buffer at a dose per implant of 1.2 microg (n = 6), 12 microg (n = 7), or 120 microg (n = 7) and placed in the left humerus. In these same animals, an internal control implant treated only with HA/TCP and buffer was placed in the right humerus. In a non-TGF-beta treated external control group of animals (n = 7), one implant was treated with HA/TCP while the contralateral implant was not treated with the ceramic. In vitro analyses showed that approximately 15%, of the applied dose was released within 120 h with most of the release occurring in the first 24 h. The TGF-beta treated implants had significantly more bone ingrowth than the controls with the greatest effect in the 12 microg/implant group (a 2.2-fold increase over the paired internal control (P = 0.004) and a 4-fold increase over the external control (P < 0.001)). The TGF-beta treated implants had significantly more bone formation in the gap than the controls with the greatest effect in the 12 and 120 microg groups (1.8-fold increases over the paired internal controls (P = 0.003 and P = 0.012, respectively) and 2.8-fold increases over the external controls (P < 0.001 and P = 0.001, respectively)). Compared to the external controls, the internal control implants tended to have more bone ingrowth (1.9-fold increase, P = 0.066) and had significantly more bone formation in the gap (1.7-fold increase. P = 0.008). Thus, application of rhTGF-beta2 to a porous-coated implant-stimulated local bone ingrowth and gap healing in a weakly dose-dependent manner and stimulated bone regeneration in the 3-mm gap surrounding the contralateral control implant, a site remote from the local treatment with the growth factor.

The effects of particulate wear debris, cytokines, and growth factors on the functions of MG-63 osteoblasts.

BACKGROUND: Particle-challenged cells release cytokines, chemokines, and eicosanoids, which contribute to periprosthetic osteolysis. The particle-induced activation of macrophages and monocytes has been extensively studied, but only limited information is available on the response of osteoblasts to particulate wear debris. This study examines the effects of particulate wear debris, proinflammatory cytokines, and growth factors on osteoblast functions. METHODS: MG-63 osteoblasts were treated with metal particles (titanium, titanium alloy, and chromium orthophosphate) or polymeric particles (polyethylene and polystyrene) of phagocytosable sizes or were treated with exogenous cytokines and growth factors. The kinetics of particle phagocytosis and the number of engulfed particles were assessed with use of fluoresceinated particles. Cell proliferation was determined according to [3H]-thymidine incorporation, and cell viability was determined by either fluorescein diacetate uptake or trypan blue exclusion. Expressions of osteoblast-specific genes were quantified with Northern blot hybridization, and the secretions of osteoblast-specific proteins and cytokines were analyzed by enzyme-linked immunosorbent assays. RESULTS: MG-63 osteoblasts phagocytosed particles and became saturated after twenty-four hours. A maximum of forty to sixty particles per cell were phagocytosed. Each type of particle significantly suppressed procollagen alpha1[I] gene expression (p<0.05), whereas other osteoblast-specific genes (osteonectin, osteocalcin, and alkaline phosphatase) did not show significant changes. Particle-stimulated osteoblasts released interleukin-6 (p<0.05) and a smaller amount of transforming growth factor-beta1. Particles reduced cell proliferation in a dose-dependent manner without affecting cell viability (p<0.05). Exogenous tumor necrosis factor-alpha also enhanced the release of interleukin-6 (p<0.01) and transforming growth factor-beta1 (p<0.05), whereas the secretion of transforming growth factor-beta1 was increased by insulin-like growth factor-I and prostaglandin E2 as well. Insulin-like growth factor-I and transforming growth factor-beta1 significantly increased procollagen alpha1[I] gene expression in osteoblasts (p<0.05), while tumor necrosis factor-alpha and prostaglandin E2 significantly suppressed procollagen alpha1[I] gene expression (p<0.01). In contrast, neither exogenous nor endogenous interleukin-6 had any effect on other cytokine secretion, on proliferation, or on procollagen alpha1[I] gene expression. The transcription inhibitor actinomycin D reduced both procollagen alpha1[I] transcription and interleukin-6 production. Inhibitors of protein synthesis (cyclohexamide) and intracellular protein transport (brefeldin A and monensin) blocked the release of interleukin-6, but none of these compounds influenced the suppressive effect of titanium on procollagen alpha1[I] gene expression. CONCLUSIONS: MG-63 osteoblasts phagocytose particulate wear debris, and this process induces interleukin-6 production and suppresses type-I collagen synthesis. Osteoblast-derived interleukin-6 may induce osteoclast differentiation and/or activation, but the resorbed bone cannot be replaced by new bone because of diminished osteoblast function (reduced type-I collagen synthesis). Exogenous cytokines (tumor necrosis factor-alpha and interleukin-1beta), growth factors (insulin-like growth factor-I and transforming growth factor-beta1), and prostaglandin E2 can modify particulate-induced alterations of osteoblast functions.

p130/E2F4 binds to and represses the cdc2 promoter in response to p53.

p53 represses the transcription of cdc2 and cyclin B1, causing loss of Cdc2 activity and G(2) arrest. Here we show that the region -22 to -2 of the cdc2 promoter called the R box is required for repression by p53 but not for basal promoter activity. The R box confers p53-dependent repression on heterologous promoters and binds to p130/E2F4 in response to overexpression of p53. R box-dependent repression requires p21/waf1, and overexpression of p21/waf1 also represses the cdc2 promoter. These observations suggest that p53 represses the cdc2 promoter by inducing p21/waf1, which inhibits cyclin-dependent kinase activity, enhancing the binding of p130 and E2F4, which together bind to and repress the cdc2 promoter.

[Functional gait adaptations in patients with painful hip]. / Mécanismes d'adaptation fonctionnelle de la marche à une douleur invalidante de la coxo-fémorale.

PURPOSE OF THE STUDY: This prospective study was conducted to analyze the mechanisms of gait compensation in patients with painful hip and to search for correlations with preoperative clinical and radiographic findings. MATERIAL AND METHODS: Optoelectronic and multicomponent force-plate datas were used to calculate joint motion, moments and intersegmental forces for 26 patients with unilateral hip pain and 20 normal age and sex-matched patients. Height was similar in the two groups but mean weight in the study group (83 kg) was greater than in the controls (68 kg). The preoperative Harris score was 53 in the study group and 16 patients had a permanent flexion contracture of the knee (mean 15 degrees, range 5-30 degrees). Radiographically, there were 22 cases of osteo-arthritis hip disease and 4 cases of necrosis. RESULTS: Gait analysis showed a significant 0.66 +/- 0.06 m (12 p. 100) reduction in step length. Patients who had severe hip pain walked with a decreased dynamic range of motion (18 +/- 5 degrees, p<0.0001) with a curve reversal as they extended the hip. They also reduced dynamic range of motion of the knee and ankle. Patients who presented a reversal in their dynamic hip range of motion had a greater passive flexion contracture and a greater loss in range of motion during gait than those with a smooth regular pattern (p<0.0001). Patients with hip pain walked with significantly decreased external extension, adduction, and internal and external rotation moments (p<0.0001). They also unloaded the ipsilateral knee and ankle. The decreased hip extension moment was significantly correlated with an increased level of pain (p<0.0001). There was no correlation with radiological findings. DISCUSSION: Reversal of dynamic hip range of motion was interpreted as a mechanism to increase effective hip extension during stance phase through increased anterior pelvic tilt and lumbar lordosis. CONCLUSION: Patients with painful hip walked with a manner that was asymmetric. These gait modifications were related to hip limitation in passive motion and pain. Patients with flexion contracture adopted a compensatory gait mechanism. This study confirms relation between hip pain and forces across the hip joint.

Hybrid total hip arthroplasty with a precoated offset stem. Four to nine-year results.

BACKGROUND: Use of modern cementing techniques for fixation of femoral components in total hip arthroplasty has had excellent clinical and radiographic results in most patients. However, several authors have described early loosening of femoral components with roughened and precoated finishes. The purpose of this study was to examine the performance of the precoated Iowa stem, which has increased offset, and to compare the results with those of another cemented precoated femoral component with standard offset used at our institution. METHODS: We carried out a prospective analysis of 102 primary hybrid total hip arthroplasties (a cementless acetabular component and a cemented femoral component) performed with use of the Iowa femoral component in ninety-five patients at our institution. The Iowa stem was used in hips that required greater offset than is available with standard stems as determined by preoperative templating. The average age of the patients at the time of the index procedure was sixty-nine years. Sixteen patients (seventeen hips) died before the forty-eight-month minimum follow-up period had elapsed. Two patients were lost to follow-up, and radiographic follow-up was incomplete for one. The mean duration of clinical and radiographic follow-up of the remaining eighty-two hips in the seventy-six surviving patients was sixty-five months (range, forty-eight to 104 months). RESULTS: The average preoperative Harris hip score of 47 points (range, 16 to 69 points) improved to an average of 87 points (range, 24 to 100 points) at the time of the review. Two hips underwent femoral component revision. Four femoral stems were radiographically loose at an average of thirty-four months. Femoral osteolysis was seen in five hips (6 percent) at an average of fifty-four months postoperatively. No acetabular component was revised because of aseptic loosening. According to Kaplan-Meier analysis, the seven-year survival rate, with an end point of femoral revision, osteolysis, or stem debonding, was 90.6 percent (95 percent confidence interval, 0.87 to 0.94). CONCLUSIONS: The prevalence of revision, osteolysis, and loosening after total hip arthroplasty with the Iowa femoral component at our institution was higher than that seen in our series of Harris Precoat stems, which had a survival rate of 98.4 percent (95 percent confidence interval, 0.97 to 1.00) at ten years with the same end points. The design of the Iowa stem may make it difficult to achieve a good cement mantle, and, in combination with the geometry and increased offset of the stem, may compromise the long-term survival of this cemented femoral component.

Systemic metal-protein binding associated with total joint replacement arthroplasty.

The distribution of titanium [Ti] and chromium [Cr] in serum protein fractions of patients with and without total joint replacements containing Cr and Ti was studied. Three groups were evaluated: 10 patients with cobalt-chromium [CoCr] alloy prostheses and known elevated levels of Cr; 10 patients with Ti containing implants and known elevated levels of Ti; and 10 age matched controls without prostheses. Metal-protein binding was also examined by adding various concentrations of Cr(+3) (CrCl(3)) to control serum. Cr and Ti were bound to serum proteins within specific molecular weight ranges in both patient groups. Two molecular weight ranges were found to bind Cr (at approximately 70 and approximately 180 kDa) in patients with CoCr alloy prostheses, whereas a single molecular weight range (at approximately 70 kDa) was found to bind Ti in patients with Ti alloy implants. This metal-protein binding was reproduced in vitro by adding CrCl(3) at concentrations of approximately 100 and 1000 ppb Cr, which is orders of magnitude higher than that contained in the serum of patients with CoCr alloy implants ( approximately 3 ppb Cr). This suggests that protein binding is initiated in the periprosthetic space where metal concentrations are typically 2-3 orders of magnitude higher than that observed systemically in the serum. In vitro, high molecular weight proteins including immunoglobulins demonstrated the highest affinity to Cr. Determination of specific protein carriers of metal degradation products is an essential component in the assessment of the long-term biological affects of total joint replacement devices.

Fixation, polyethylene wear, and pelvic osteolysis in primary total hip replacement.

A multicenter retrospective review was performed analyzing 1081 primary total hip replacements in 944 patients using the Harris Galante-I cementless acetabular component with screw fixation. All patients were followed up for a minimum of 5 years with a mean followup of 81 months. Linear polyethylene wear averaged 0.11 mm/year (range, 0-0.86 mm/year). Pelvic osteolysis was seen in 25 patients (2.3%). Migration of the acetabular component was seen in four hips. A subgroup of patients was reanalyzed at a minimum followup of 10 years. The mean linear polyethylene wear rate remained 0.11 mm/year. In this group, only one socket had migrated. There was an association between wear rate and age. On average, younger patients had higher wear rates. The risk for having pelvic osteolysis develop and the need for revision surgery also was age-related. Twenty-two percent of hip replacements (15 hips) in patients younger than 50 years of age at the time of their index operation had pelvic osteolysis develop. In contrast, for patients older than 50 years of age at the time of surgery only 7.8% (eight hips) had osteolysis of the pelvis develop. For patients older than 70 years of age at the time of primary total hip replacement, none had pelvic osteolysis develop.

Cementless acetabular revision. Evaluation at an average of 10.5 years.

This study reviews the clinical and radiographic results of 138 consecutive cementless acetabular revisions in 131 patients performed for aseptic loosening at a mean of 10.5 years followup. Kaplan-Meier survivorship of these components was 84% at 11.5 years. Two components (1.8%) in two patients were considered aseptically loose based on radiographic criteria; one patient was symptomatic but the component was not revised because of the patient's poor health, and the other patient was asymptomatic. Pelvic osteolysis was present in 19 hips (17%), appearing at a mean of 103 months. All but two of these were small lesions (< 2 cm) at the periphery of the components. Nevertheless, the incidence of osteolysis has increased with time, and continued followup is warranted. Separation or fragmentation of the fiber-metal porous pads was uncommon (8.3%), but was significantly associated with pelvic osteolysis; this finding has not been reported before with this component. Five patients underwent late revision surgery (after 100 months), one for deep infection, one for periprosthetic femur fracture, and three for late recurrent dislocation. Harris hip scores averaged 81 points (good) at final followup, which is unchanged from the authors' last report on this group. Acetabular revision with a fiber-metal hemispherical component appears durable at a mean followup of more than 10 years.