[Cemented stems in hip arthroplasty: history and evolution]. / Vástagos cementados en la artroplastía de cadera: historia y evolución.

Despite the favorable results in cemented femoral fixation, there is a growing tendency to use uncemented stems. Due to the successful results of cementless acetabular fixation, the most versatile and easy implantation technique, to the misinformation about the "cement disease" and the poor performance of cemented stems with a rough surface. However, the advantages of cemented femoral fixation are numerous: it can be implemented successfully in femurs of diverse morphology and quality of bone, the surgeon can position the implant with the desired femoral anteversion, without it being determined by th natural femoral anteversion, very low incidence of intraoperative and postoperative fractures, allows the addition of antibiotics in patients with a history or predisposition to infection and minimal risk of postoperative leg pain during walking.

Insufficiency subchondral fracture of the femoral head: report of 4 cases and review of the literature.

Insufficiency subchondral fractures are nontraumatic flattened lesions in the superolateral area of the femoral head, occurring in healthy adults. These lesions were recently described and are an infrequent cause of acute hip pain. We report on 4 patients who were diagnosed with an insufficiency subchondral fracture. All the patients showed radiographic progression of the lesion after 4 months, and 3 patients required a total hip arthroplasty. The etiology and the natural history of these rare lesions remain to be elucidated. These lesions should be differentiated from osteonecrosis and transient osteoporosis, because treatment and prognosis may differ.

Revision of the femoral prosthesis with impaction allografting and a Charnley stem. A 2- to 12-year follow-up.

Impacted morcellised bone allograft and a Charnley stem was used to revise 59 loose femoral components in 57 consecutive patients. Femoral bone loss was rated as Endo-Klinik grade 2 in nine patients, grade 3 in 41, and grade 4 in nine. The immediate postoperative radiographs and those taken at the most recent follow-up were compared for radiolucencies, subsidence and incorporation of the graft. One patient was lost to follow-up and two were not available for radiological analysis. The mean clinical follow-up in 58 procedures was 56.7 months (24 to 144) and the mean radiological review of 56 reconstructions was 54.4 months (24 to 144). An intraoperative femoral fracture occurred in one patient (1.7%) and was successfully treated by strut grafting and cerclage wiring. Extrusion of cement through perforations or incomplete hoop fractures was detected in the postoperative radiographs of ten procedures (17%); none of these patients sustained a complete fracture. Three patients had dislocations (5%) and two (3.5%) developed painful subsidence of the stem which required a further revision. The latest follow-up radiographs in 56 reconstructions showed a well fixed stem and radiological healing of the graft in 52 (93%), and definite loosening in four (7%). Of these four, two were revised again and two were asymptomatic after a follow-up of 120 months each. The mean subsidence in the 52 successful revisions was 0.38 mm (0 to 4). Impaction allografting with a Charnley stem restored bone stock and provided adequate fixation of the stem in 93% of the hips. There was a low rate of rerevision (3.5%) and a low incidence of intraoperative and postoperative complications.

Psoas abscess associated with infected total hip arthroplasty.

A 65-year-old man with a left uncemented total hip arthroplasty performed 11 years previously was admitted with a history of progressive low back pain, left hip pain, and sepsis that had begun 6 months earlier. On physical examination, a gross, fluctuant mass was palpated in the left thigh. A computed tomography (CT) scan revealed a 6.5 x 3 cm left retrofascial psoas abscess communicating with the hip joint. The patient underwent irrigation and débridement of the hip with removal of the components. The psoas abscess was drained through the iliopsoas bursa. A residual psoas abscess was drained percutaneously under CT guidance. Cultures isolated Escherichia coli, and the patient responded to 6 months of ciprofloxacin therapy. After 1 year, the patient had no evidence of infection. Pathways of infection spread, diagnosis, and treatment of a patient with this rare association are discussed with a review of the literature.

Effective bactericidal activity of tobramycin and vancomycin eluted from acrylic bone cement.

We studied the bioactivity of vancomycin and tobramycin eluted from methylmethacrylate bone cement. Aliquots of the drainage were obtained at 1, 6, 12 and 24 hours following total hip prosthetic implantation with vancomycin-tobramycin-loaded cement in 3 patients. The samples were analyzed with fluorescence polarization immunoassay and bioassay, using group B streptococcus for vancomycin and Escherichia coli for tobramycin. These bacteria were selected due to the effectiveness of vancomycin and poor effectiveness of tobramycin against group B streptococcus and conversely with E. coli. The immunodetection of vancomycin averaged 14 (1 hour), 9 (6 hours), 10 (12 hours) and 11 microg/mL (24 hours). The bioassay averaged 47, 36, 79 and 41 microg/mL (p = 0.03). The immunodetection of tobramycin averaged 43, 21, 18 and 14 microg/mL; and bioassay 30, 15, 15 and 12 microg/mL (p = 0.1). Both antibiotics eluted with a highly effective bactericidal activity. Our findings indicate that the presence of tobramycin has a synergistic-like effect on the bactericidal activity of vancomycin, which has not been previously reported. We recommend a combination of vancomycin and tobramycin with cement for the treatment of orthopedic infections caused by gram-positive organisms.

Pigmented villonodular synovitis of the hip: 2- to 23-year followup study.

Pigmented villonodular synovitis affecting the hip is rare. Seven new patients are presented and 117 cases from the literature are reviewed. Among the new patients, two refused treatment; in one patient, severe bone loss was observed after a radiographic followup of 21 years; the second patient showed no radiographic changes 2 years after diagnosis. One patient underwent a synovectomy and had a recurrence 9 years later, requiring a total hip replacement. The remaining four patients underwent synovectomy and primary total hip replacement with no recurrences detected after an average followup of 13 years (range, 2-23 years). Among 117 cases published, 62 patients (53%) did not have enough information for analysis. A metaanalysis using the remaining 55 patients was done. In nine patients (16%; nine of 55) the diagnosis was made with a preoperative biopsy. Treatment consisted of synovectomy in 26 patients (47%; 26 of 55), arthroplasty in 24 (43%; 24 of 55), arthrodesis in two (4%; two of 55), and hindquarter amputation in a patient misdiagnosed as having synovial sarcoma (2%; one of 55). Two patients (4%; two of 55) were not treated. Ten patients had a recurrence (19%; 10 of 53); nine in the synovectomy group (35 %; nine of 26) and one in the joint replacement group (4%; one of 24). Synovectomy is recommended for patients with preserved articular cartilage and total hip replacement is recommended for patients with secondary osteoarthritis. Removal of all macroscopic tumors including careful curetting of the osteolytic lesions should be done as they may constitute a source of recurrence.

Warfarin-associated intracapsular hemorrhage causing an acutely painful total hip arthroplasty: a rare complication of prolonged anticoagulant therapy.

Hemorrhage is the most prevalent adverse effect of oral anticoagulant therapy. The incidence of bleeding complications is related to the duration and range of therapy. A patient on long-term warfarin anticoagulation developed a spontaneous intracapsular bleed into a total hip arthroplasty that had been implanted 11 years before. Joint aspiration allowed early recognition with immediate resolution of symptoms. Diagnosis and treatment of this rare complication are discussed with a review of the literature.

Hereditary nonpolyposis colorectal cancer (Lynch syndrome II) in Uruguay.

PURPOSE: We updated an Uruguayan family with hereditary nonpolyposis colorectal cancer first described in 1977, incorporating knowledge of how the hMLH1 germline mutation has been established and shown to segregate in accord with the expected autosomal dominant mode of genetic transmission. METHODS: DNA-based molecular genetic testing was performed in conjunction with genetic counseling. Individuals were provided with their genetic test results, so that at-risk family members would be able to benefit from targeted management programs. RESULTS: We counseled 19 members of this kindred, 13 of whom were positive for the hMLH1 germline mutation. Specific recommendations for surveillance and management were provided. We were able to describe follow-up, including anecdotal cancer survival and pathology findings extending from the initial 1977 report of this family to the present. A remarkable sibship within this kindred was comprised of eight siblings, six of whom underwent resections for colorectal carcinoma between 1963 and 1971. Colon carcinomas before 1977 in this sibship were treated with classic hemicolectomies. Of those who had hemicolectomies for their first primary colorectal cancers, two had a second colon cancer primary, and two had a third colon cancer primary. CONCLUSIONS: Attention given to this extended family with hereditary nonpolyposis colorectal cancer has had a positive impact on the physician community in Uruguay, leading to the identification of additional families with hereditary nonpolyposis colorectal cancer.

Identificación inmunohistoquímica de los fenómenos degenerativos en la hernia de disco lumbar: expresión de ácida hialurónico, metaloproteasas 1 y 3, factor de crecimiento fibroblástico básico y CD34 / Immunohistochemical detection of degenerative phenomea in lumbar disc herniations

Los objetivos de este trabajo son identificar los niveles de expresión y distribución de las metaloproteasas (MMP) 1 y 3, observar su efecto sobre el ácido hialurónico (AH), estudiar la respuesta inflamatoria, analizar los procesos de angiogénesis en el disco detectando la proteína CD34 y el factor de crecimiento fibroblástico básico (FCF-b) y relacionar los hallazgos con parámetros clínicos y epidemiológicos de los enfermos. Se analizaron discos intervertebrales obtenidos en 34 discectomías por hernia de disco y de 10 discos control con técnica histológica de rutina y técnicas inmunohistoquímicas contra MMP-1 y MMP-3, AH, CD34 y FCF-b. Se observó aumento significativo del porcentaje de degeneración, vascularización, detección de AH, MMP-1, MMP-3, CD34 y FCF-b en los discos extruidos y secuestros, lo que sugiere una relación entre las etapas más avanzadas de herniación y las más intensas de degeneración. Los enfermos con antecedentes de tabaquismo presentaron hernias con mayores niveles de expresión de FCF-b, o que sugiere una asociación entre el hábito de fumar y la intensidad de la respuesta tisular. Se discuten los hallazgos observados con una revisión de la literatura sobre el tema. La degeneración discal estaría producida por fenómenos biológicos que representan una falla en la capacidad de reparación del tejido conectivo especializado

Identificación inmunohistoquímica de los fenómenos degenerativos en la hernia de disco lumbar: expresión de ácida hialurónico, metaloproteasas 1 y 3, factor de crecimiento fibroblástico básico y CD34 / Immunohistochemical detection of degenerative phenomea in lumbar disc herniations

Los objetivos de este trabajo son identificar los niveles de expresión y distribución de las metaloproteasas (MMP) 1 y 3, observar su efecto sobre el ácido hialurónico (AH), estudiar la respuesta inflamatoria, analizar los procesos de angiogénesis en el disco detectando la proteína CD34 y el factor de crecimiento fibroblástico básico (FCF-b) y relacionar los hallazgos con parámetros clínicos y epidemiológicos de los enfermos. Se analizaron discos intervertebrales obtenidos en 34 discectomías por hernia de disco y de 10 discos control con técnica histológica de rutina y técnicas inmunohistoquímicas contra MMP-1 y MMP-3, AH, CD34 y FCF-b. Se observó aumento significativo del porcentaje de degeneración, vascularización, detección de AH, MMP-1, MMP-3, CD34 y FCF-b en los discos extruidos y secuestros, lo que sugiere una relación entre las etapas más avanzadas de herniación y las más intensas de degeneración. Los enfermos con antecedentes de tabaquismo presentaron hernias con mayores niveles de expresión de FCF-b, o que sugiere una asociación entre el hábito de fumar y la intensidad de la respuesta tisular. Se discuten los hallazgos observados con una revisión de la literatura sobre el tema. La degeneración discal estaría producida por fenómenos biológicos que representan una falla en la capacidad de reparación del tejido conectivo especializado

Evaluation of simplified Frykman and AO classifications of fractures of the distal radius. Assessment of interobserver and intraobserver agreement.

In order to evaluate interobserver and intraobserver agreement of the Frykman and AO classifications and their variations between assessors with different levels of experience, three hand specialists, a fellow and two senior residents classified radiographs of 200 fractures of the distal radius in anteroposterior and lateral views. Reproducibility was assessed by the use of the proportion of agreement and kappa coefficient between pairs of observers. The Frykman classification showed moderate interobserver reproducibility (kappa = 0.43) and good intraobserver reproducibility (kappa = 0.61). The experience of the reviewers did not significantly affect either of these. The AO system showed regular interobserver reproducibility (kappa = 0.37) and moderate intraobserver reproducibility (kappa = 0.57). The younger group obtained higher intraobserver agreement than the senior. Possible causes for the low reproducibility of both classifications are discussed together with a review of the literature. We do not recommend the Frykman or AO classifications for clinical application because of their questionable reproducibility.

Repair of talar neck nonunion with indirect corticocancellous graft technique: a case report and review of the literature.

In this article, a case of talar neck fracture nonunion is presented. Union was accomplished with an indirect placement of a corticocancellous fibular graft through a posterolateral approach. The advantages and indications for this method of the treatment of talar neck nonunion are discussed, together with a review of the literature.