The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures.

Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of avascular necrosis. The majority of the fractures (84 patients; 90%) followed one of the following four patterns: posteromedial (varus) impaction in 50 patients (54%), lateral (valgus) impaction in 13 (14%), isolated greater tuberosity in 15 (16%), and anteromedial impaction fracture in six (6%). Head orientation, impaction of the surgical neck and displacement of the tuberosity correlated strongly with the outcome. In fractures with posteromedial impaction, a poor outcome was noted as the articular surface displaced inferiorly increasing its distance from the acromion. A poorer outcome was noted as a fractured greater tuberosity displaced medially overlapping with the posterior articular surface. Lateral impaction fractures had a worse outcome than other patterns of fracture.

Identification of differentially expressed genes in trabecular bone from the iliac crest of osteoarthritic patients.

OBJECTIVE: Osteoarthritis (OA) is clinically characterized by degeneration of the joints and has been traditionally considered a primary disorder of articular cartilage, with secondary changes in the subchondral bone. The increased bone mass and generalized changes in bone quality observed in osteoarthritic patients suggest that OA may be a primary systemic bone disorder with secondary articular cartilage damage. The iliac crest is a skeletal site distant from the affected joint, with a minimal load-bearing function. To provide evidence that OA is a systemic disorder, we searched for differentially expressed genes in the iliac crest bone of patients suffering from hip OA. MATERIAL AND METHODS: Gene expression levels between bone samples collected at surgery from the iliac crest of patients undergoing total hip arthroplasty for primary OA and younger donors, who were undergoing spinal arthrodesis, were investigated by means of oligonucleotide microarrays. To verify data detected by microarrays technology, Real Time Reverse Transcription-Polymerase Chain Reaction (RT-PCR) assays were performed with specimens from osteoarthritic patients and donors, as well as from elderly donors who were undergoing arthroplasty for subcapital femoral neck fracture. RESULTS: The microarray analysis surveyed 8327 genes and identified 83 whose expression levels differed at least 1.5-fold in the OA group (P<0.005). Comparisons between Real Time RT-PCR data from OA and the two donor groups indicated differential expression of genes involved in bone cell functions in the group of OA patients. The genes identified, including CCL2, FOS, PRSS11, DVL2, AKT1, CA2, BMP6, OMD, MMP2, TGFBR3, FLT1, BMP1 and TNFRS11B, have known roles in osteoblast or osteoclast activities. CONCLUSIONS: The data from this study identify a set of genes, closely related to bone cell functions, in which differential regulation in osteoarthritic bone distant from the diseased subchondral bone might underlie the etiopathogenesis of OA as a generalized bone disease.

Calcium phosphate-based particles influence osteogenic maturation of human mesenchymal stem cells.

Biphasic calcium phosphates (BCPs) consist of a mixture of hydroxyapatite and beta-tricalcium phosphate and are recommended as alternatives or additives to autogenous bone for orthopaedic and dental applications. There is clinical evidence showing particle release from bioceramics, which might impair the ability of human mesenchymal stem cells (hMSC) from bone marrow to proliferate or mature into a functional osteoblast phenotype. This study analyses the influence of BCP particles and their precursors, calcium-deficient apatite (CDA) particles, on in vitro hMSC behaviour. Both types of particles were efficiently internalized by hMSC. Cell viability, morphology and actin cytoskeleton reorganization were unaffected by exposure of hMSC to BCP or CDA particles. Direct exposure to BCP particles impaired hMSC osteogenic differentiation and bone matrix mineralization to a lesser extent than CDA, as assayed by evaluation of alkaline phosphatase activity, osteopontin secretion and mineralized nodule formation. The ability of bioceramic particles to affect osteogenic maturation through modification of soluble factors in media was assayed in an in vitro system that avoids direct cell-particle contact. Indirect exposure to CDA particles severely impaired hMSC osteogenic maturation owing to the uptake of Ca2+ from the culture media. Lower textural properties of BCP and the lack of calcium deficiency in its composition prevented Ca2+ uptake, allowing the development of a functional osteoblast phenotype.

Tratamiento de las lesiones del aparato locomotor del paciente politraumatizado en un hospital universitario español de tercer nivel / Treatment of musculoskeletal injuries of multiple-trauma patients in a spanish tertiary referral hospital

Objetivo. Analizar el proceso diagnóstico y tratamiento del paciente politraumatizado con lesiones del aparato locomotor en un hospital español de tercer nivel sin unidad específica estructurada funcionalmente para la atención de estos pacientes.Material y método. Estudio observacional retrospectivo. Se incluyeron todos los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI) bajo el diagnóstico de politraumatismo con lesiones del aparato locomotor entre enero de 2001 y mayo de 2003, 135 enfermos, de los cuales 120 pudieron ser evaluados. Se procedió al estudio de las historias clínicas, registrándose el mecanismo causal, diagnósticos, cálculo del ISS (Injury Severity Score) y NISS (New Injury Severity Score), tratamientos aplicados y el momento en el que se realizaron, complicaciones desarrolladas y mortalidad.Se utilizó el software SPSS 11.0 para el análisis de losdatos.Resultados. La edad media fue 38 (rango 15-75 años). Noventa y cinco (80%) eran hombres. Los mecanismos causales principales fueron el accidente de tráfico y el atropello (65%). La estancia media en UCI fue 13,5 días (rango 1-130). El 33% fue intervenido de las lesiones del aparato locomotor. La demora media en la estabilización de las fracturas fue 9,3 días (rango 1-70). Treinta y tres pacientes (28%) desarrollaron complicaciones sistémicas inflamatorias, y 37 (31%) presentaron infecciones graves. Veintiún pacientes (18%) fallecieron en una media de 8,5 días (rango 1-50 días) después de ingresar.Conclusiones. La comparación con los protocolos y resultados publicados por unidades específicas para politraumatizados en otros países demuestra la conveniencia de una mayor protocolización y coordinación multidisciplinar para mejorar la atención de la patología osteoarticular de estos pacientes en centros de referencia

Purpose. To analyze the diagnostic and therapeutic protocol used in multiple-trauma patients with musculoskeletal injuries at a Spanish tertiary referral hospital that lacks a specific unit endowed with the functional structure to treat these patients.Materials and methods. Retrospective observational study.All patients admitted to the Intensive Care Unit (ICU) between January 2001 and May 2003 with a diagnosis of multiple trauma to the musculoskeletal system were included. There were a total of 135 patients, of which 120 could be evaluated. The patients’ clinical records were analyzed and a record was made of the mechanism of injury, ISS (Injury Severity Score) and NISS (New Injury Severity Score) calculations, treatment administered in each case and time of administration, any ensuing complications and mortality rate. The SPSS 11.0 software was used for data analysis.Results. Mean age was 38 (range: 15-75 years). Ninety-five (80%) were male. The main mechanisms of injury were road accidents and pedestrian-motor vehicle collisions (65%). Mean ICU stay was 13.5 days (range: 1-130). Thirty-three percent were operated on for their musculoskeletal lesions. Main time-to-fracture stabilization was 9.3 days (range: 1-70). Thirty-three patients (28%) developed inflammatory systemic complications and 37 (31%) had serious infections.Twenty-one patients (18%) died 8.5 days (range 1-50days) after their admissionConclusions. A comparison with protocols and results published by dedicated multiple-trauma units from other countries reveals the need for a greater degree of protocolization and multidisciplinary coordination to improve the treatment of the bone and joint pathologies of these patients in referral hospitals (AU)

Análisis de los casos de cáncer de pulmón diagnosticados en el Servicio de Medicina Interna del Hospital de Navarra: enero de 2001 a septiembre de 2006 / Analysis of lung cancer cases diagnosed in an Internal Medicine Department: from January 2001 to September 2006

Objetivos. Conocer el tiempo de existencia de clínica previa al diagnóstico del cáncer de pulmón, tipo de manifestaciones, características clínicas, radiológicas e histológicas de los distintos tipos de tumores y analizar los factores que pueden influir en la supervivencia. Material y métodos. Estudio retrospectivo de todos los pacientes diagnosticados de cáncer de pulmón en el Servicio de Medicina Interna del Hospital de Navarra en el periodo de enero 2001 a septiembre de 2006 mediante revisión de historias clínicas y contacto telefónico cuando fue necesario. Se recogieron específicamente la edad, el sexo, el consumo de tabaco, el tiempo y la clase de síntomas antes de la hospitalización, las manifestaciones radiológicas, los métodos de diagnóstico histológico, el estadio tumoral, y el estado de capacidad funcional (ECOG). También analizamos las curvas de supervivencia y, mediante regresión logística, los factores implicados. Resultados. Se estudiaron 124 pacientes [edad media de 68 ±12 años, 105 (85%) hombres y 18 (15%) mujeres, fumadores 85%]. El tiempo medio de clínica previa al ingreso fue de 74,5 ±7 días. La clínica de presentación de tipo respiratorio estuvo presente sólo en 40 (32%) ocasiones. Se realizó estadiaje por métodos radiológicos en 120 (96,8%) de los pacientes. Se diagnosticaron 96 (77,4%) tumores no microcíticos, de los cuales 62 (64%) estaban en estadio IV. De los 28 (22,6%) tumores microcíticos objetivados, 22 (79%) se encontraban en estadio no limitado. La mediana de tiempo hasta el diagnóstico fue de 7 días. Fallecieron 113 pacientes (91%), subiendo la mediana de supervivencia a tres meses. Los factores asociados a supervivencia más larga fueron el estadio tumoral poco avanzado y la clasificación ECOG más baja. Conclusiones. El cáncer de pulmón es una patología con alta tasa de mortalidad, que tarda mucho tiempo en diagnosticarse y suele hacerse cuando ya está en estadios avanzados. La instauración de tratamiento en estadios tempranos y el buen estado funcional de los pacientes parecen ser factores importantes asociados a la supervivencia

Background. Lung cancer is one of the main health problems in the developed world. Our aims were to determine the symptomatic time prior to a specific diagnosis, the clinical and histological characteristics of the cases of lung cancer diagnosed in a department of internal medicine, and to analyze the survival factors. Material and methods. We studied retrospectively all patients diagnosed with lung cancer in the internal medicine department in the period between January 2001 and September 2006 reviewing clinical records. We specifically recorded age, gender, smoking habit, time and type of symptomatic presentation, radiological manifestations, methods of histological diagnosis, tumour staging, and performance status measured by ECOG classification. We also evaluated the factors associated with the survival time. Results. In this period 124 patients were diagnosed with lung cancer [mean age 68 ±12 years, male 105 (85%), female 18 (15%), smokers 85%]. The mean symptomatic time before hospitalization was 74.5 ±7 days. On hospitalization, respiratory symptoms were present in 40 (32%) patients. Tumour staging was carried out in 120 (97%) patients. In 96 (77%) patients non-small lung cancer was diagnosed, 62 (64%) in stage IV. In 28 (23%) patients small lung cancer was diagnosed, 22 (79%) in extended stage. Median time to diagnosis as an in-patient was 7 days. One hundred and thirteen (91%) patients died with a median survival time of 3 months. Factors associated with longer survival were the performance status and tumour stage. Conclusions. In this community, lung cancer is diagnosed late and in advanced stages, with a high mortality rate. A better performance status and lower tumour stages appear to be associated with longer survival

Thermal oxidation enhances early interactions between human osteoblasts and alumina blasted Ti6Al4V alloy.

Oxidation of Ti6Al4V at 500 degrees C for 1 h in air results in the formation of an outer ceramic layer that improves osteoblast behavior and decreases Ti and Al ion release. In this work, alumina blasted Ti6Al4V alloy has been thermally treated and its in vitro biocompatibility has been assessed. Roughness of the blasted alloy was not found significantly altered after heat treatment while chemical surface analysis indicated an increase in stable TiO(2) and Al(2)O(3) oxides. Cell attachment, spreading, cytoskeleton organization as well as cell proliferation, viability, and procollagen I peptide secretion of human primary osteoblasts, impaired on alumina blasted Ti6Al4V, were found to be greatly enhanced on the thermally oxidized blasted alloy. Other informative markers of the osteoblastic phenotype such as alkaline phosphatase, osteocalcin, osteoprotegerin, and mineralized nodule formation were evaluated and indicated that osteoblasts responded at the same extent on untreated and thermally treated blasted alloys. Taken together, our in vitro results indicate that thermal oxidation of alumina blasted Ti6Al4V may favor successful osseointegration by promoting early interactions of osteoblastic cells and the modified surface alloy.

[Analysis of lung cancer cases diagnosed in an internal medicine department: from January 2001 to September 2006]. / Análisis de los casos de cáncer de pulmón diagnosticados en el Servicio de Medicina Interna del Hospital de Navarra: enero de 2001 a septiembre de 200.

BACKGROUND: Lung cancer is one of the main health problems in the developed world. Our aims were to determine the symptomatic time prior to a specific diagnosis, the clinical and histological characteristics of the cases of lung cancer diagnosed in a department of internal medicine, and to analyze the survival factors. MATERIAL AND METHODS: We studied retrospectively all patients diagnosed with lung cancer in the internal medicine department in the period between January 2001 and September 2006 reviewing clinical records. We specifically recorded age, gender, smoking habit, time and type of symptomatic presentation, radiological manifestations, methods of histological diagnosis, tumour staging, and performance status measured by ECOG classification. We also evaluated the factors associated with the survival time. RESULTS: In this period 124 patients were diagnosed with lung cancer [mean age 68 +/-12 years, male 105 (85%), female 18 (15%), smokers 85%]. The mean symptomatic time before hospitalization was 74.5 +/-7 days. On hospitalization, respiratory symptoms were present in 40 (32%) patients. Tumour staging was carried out in 120 (97%) patients. In 96 (77%) patients non-small lung cancer was diagnosed, 62 (64%) in stage IV. In 28 (23%) patients small lung cancer was diagnosed, 22 (79%) in extended stage. Median time to diagnosis as an in-patient was 7 days. One hundred and thirteen (91%) patients died with a median survival time of 3 months. Factors associated with longer survival were the performance status and tumour stage. CONCLUSIONS: In this community, lung cancer is diagnosed late and in advanced stages, with a high mortality rate. A better performance status and lower tumour stages appear to be associated with longer survival.

[A retroperitoneal mass in a young patient]. / Masa retroperitoneal en paciente varón joven.

A tumor of germinal cells should be considered in the differential diagnosis of a retroperitoneal mass in a young patient. Although, this kind of tumors are relatively uncommon, inducing less than 1% of all the tumors in the masculine sex, very often they may present as a retroperitoneal mass clinically characterized by a lumbar pain that sometimes may simulate a renal colic. Occassionally, physical examination of the testis may reveal a mass. Moreover, even in advanced stages the prognosis of germ cell tumor is favorable, and there are a series of tumor markers very helpful for the diagnosis and follow up of the tumor. We report a patient with a retroperitoneal mass presenting clinically as a renal colic.

Osteoblast response to plasma-spray porous Ti6Al4V coating on substrates of identical alloy.

We have evaluated the in-vitro biocompatibility of Ti6Al4V alloy coated by plasma spraying with an identical alloy. These surfaces are widely used in cementless prosthetic components, although osteoblasts behavior on this treated alloy has not been evaluated to date. Cross sectional examination revealed a thick and rough coating of identical composition without sign of delamination. Within the coating, small discontinuities and nonconnected pores were observed. Osteoblast response was evaluated by assessing cell adhesion, proliferation, and differentiation of primary cultures of human osteoblastic cells. Compared to the polished alloy, osteoblast adhesion measured as cell attachment and actin network reorganization was delayed on the plasma-sprayed surface. Cell proliferation and viability were also impaired on the rough surface. Several informative markers of osteoblastic differentiation such as procollagen I peptide, alkaline phosphatase, osteocalcin, osteoprotegerin, and mineralized nodule formation were evaluated and indicated that the plasma-sprayed alloy favored a more differentiated phenotype than polished alloy. Taken together, our in vitro results indicate that successful osseointegration of plasma spraying of Ti6Al4V with an identical alloy is mediated by modulation of osteoblastic differentiation and mineralization.

Alumina particles influence the interactions of cocultured osteoblasts and macrophages.

The purpose of the current study was to evaluate the effects of alumina particles on secretion of several cytokines involved in bone resorption in cocultures of macrophages and osteoblasts. To distinguish the contribution of each individual cell type, we have established a heterologous in vitro system that makes use of mouse J774 cells and primary cultured human osteoblasts. J744 cells decreased the production of TNF-alpha when they were cocultured with osteoblasts. Treatment of J744 cells with alumina particles increased TNF-alpha secretion, but the induction was lower when cells were cocultured with osteoblasts. Secretion of IL-6 by J744 cells was very low, and increased in the presence of osteoblasts. Alumina particles were only able to stimulate the release of IL-6 by J744 cells when cells were cocultured with osteoblasts. On the other hand, incubation of osteoblasts with alumina particles enhanced the release of IL-6 and GM-CSF. Coculturing osteoblasts with J744 cells induced them to release IL-6 and GM-CSF, and treatment with alumina further increased the secretion of both mediators by osteoblasts. According to these in vitro results, it seems rather plausible that alumina particles are able to initiate an inflammatory response in vivo.

Concentration-dependent effects of titanium and aluminium ions released from thermally oxidized Ti6Al4V alloy on human osteoblasts.

Thermal oxidation treatments of Ti6Al4V, at 500 and 700 degrees C, for 1 h result in the formation of an outer "ceramic" layer of rutile, which enhances osteoblast response. In the present study, we have measured in vitro Ti and Al ion release from Ti64 alloy in the as-received state and after thermal oxidation treatments at 500 or 700 degrees C, to culture medium under standard cell-culture conditions. Concentrations of both Ti and Al released from both thermal oxidation treatments were lower than from polished alloy. Al was released from the treated or untreated surfaces in substantially lower extent than Ti. Titanium and aluminium ions affected primary human osteoblast proliferation, metabolic activity, and differentiation in a dose-dependent manner. Treatments with individual Ti or Al metal ions in similar concentration ranges than released from the surfaces did not alter osteoblast response, which also remained unaffected after treatments with combinations of Ti plus Al applied in the proportional relations than detected in ion-release experiments. We then selected higher concentrations of Ti that impaired osteoblast proliferation and differentiation, while the proportional lower concentrations of Al did not alter osteoblast behavior. In spite of its inert character, it was found that Al significantly enhanced the deleterious effect of Ti on osteoblast differentiation. Therefore, thermal oxidation treatments of Ti6Al4V alloy may improve the biocompatibility of the alloy by reducing both Ti and Al release, and thus attenuating ion-mediated interference with osteoblast differentiation.

Masa retroperitoneal en paciente varón joven / A retroperitoneal mass in a young patient

Ante el hallazgo de una masa en retroperitoneo en un paciente joven se debe tener en cuenta entre los diferentes diagnósticos posibles, el tumor de células germinales. Estos tumores aunque son relativamente infrecuentes, constituyendo menos del 1% de todos los tumores en el sexo masculino, no es raro que debuten con masa retroperitoneal que simulan clínicamente un cólico renal o/y dolor lumbar. Siempre se debería realizar exploración de genitales externos aunque en un porcentaje no despreciable no encontramos masa testicular. Además el pronóstico es favorable, incluso en estadios avanzados, en un alto porcentaje, y poseemos una serie de marcadores tumorales útiles para el diagnóstico y seguimiento. Presentamos el caso de un paciente con clínica de cólico renal y masa retroperitoneal a estudio

A tumor of germinal cells should be considered in the differential diagnosis of a retroperitoneal mass in a young patient. Although, this kind of tumors are relatively uncommon, inducing less than 1% of all the tumors in the masculine sex, very often they may present as a retroperitoneal mass clinically characterized by a lumbar pain that sometimes may simulate a renal colic. Ocassionally, physical examination of the testis may reveal a mass. Moreover, even in advanced stages the prognosis of germ cell tumor is favorable, and there are a series of tumor markers very helpful for the diagnosis and follow up of the tumor. We report a patient with a retroperitoneal mass presenting clinically as a renal colic

Tratamiento de las fracturas de huesos largos en el paciente politraumatizado / Treatment of long bone fractures in the multiple injured patients

Objetivo y método. En este trabajo se revisa el conocimiento adquirido a partir de los principales artículos publicados en los últimos treinta años, acerca del mejor momento para el tratamiento quirúrgico y de los métodos de fijación a emplear en las fracturas de los huesos largos en el politraumatizado, con el fin de mejorar los resultados en cuanto a la morbimortalidad global de estos pacientes. Conclusiones. Los estudios revisados ponen de manifiesto la necesidad de aplicar protocolos de «tratamiento precoz definitivo» (early total care) y «cirugía ortopédica de control de daños» (damage control orthopaedic surgery), intentando estabilizar las fracturas en las primeras 24 horas para limitar la respuesta inflamatoria sistémica y permitir un control respiratorio adecuado de estos pacientes, disminuyendo así las cifras de morbimortalidad y los costes de la atención sanitaria

Aim and methods. We reviewed the principal articles published over the last 30 years regarding the best moment for surgical treatment and fixation methods for long bone fracture of patients with multiple injuries to optimize results in terms of overall morbidity and mortality in these patients. Conclusions. The literature confirmed the need for early total care and damage control orthopedic surgery protocols. An attempt should be made to stabilize fractures in the first 24 hours to limit the systemic inflammatory response and improve the respiratory control of these patients because it reduces morbidity, mortality, and health care costs

Osteoblast response to thermally oxidized Ti6Al4V alloy.

We have recently reported that thermal oxidation treatments of Ti6Al4V at 500 degrees and 700 degrees C for 1 h result in the formation of an outer "ceramic" layer of rutile that do not decrease the high in vitro corrosion resistance of the alloy. In the present work, surface roughness was measured and found marginally increased as a consequence of oxidation of the alloy at 700 degrees C, but not at 500 degrees C. We have evaluated the biocompatibility of the oxidized surfaces, by assessing cell adhesion, proliferation, and differentiation of primary cultures of human osteoblastic cells. Compared with polished alloy, both thermal treatments increased osteoblast adhesion measured as cell attachment, beta1 integrin and FAK-Y397 expression, as well as cytoskeletal reorganization. Compared with treatment at 500 degrees C, thermal oxidation at 700 degrees C enhanced cell adhesion. Treatment at 700 degrees C transiently impaired cell proliferation and viability, which were not altered in alloys oxidized at 500 degrees C. Several markers of osteoblastic differentiation such as procollagen I peptide, alkaline phosphatase, osteocalcin, and mineralized nodule formation were found either unaffected or differentially increased by alloys treated either at 500 degrees or 700 degrees C. In addition, thermal oxidation at 700 degrees C also increased osteoprotegerin secretion. Taken together, our results indicate that thermal oxidation treatments at 500 degrees or 700 degrees C for 1 h improve the in vitro biocompatibility of Ti6Al4V.

Internal fixation of displaced femoral neck fractures in patients older than 70 years.

INTRODUCTION: To analyse results and risk factors for osteosynthesis of displaced femoral neck fractures in patients older than 70 years. PATIENTS AND METHODS: From 1992 to 2000, 183 consecutive patients over 70 with displaced femoral neck fractures were treated by closed reduction and fixation with cannulated screws and followed up prospectively for two years. Pain at rest and pain with walking, return to previous functional and walking ability, and need for additional surgery were evaluated. RESULTS: Six patients died, while 149 were followed up for a minimum of two years: 82 (55%) were asymptomatic, 19 (12.8%) had mild pain, 39 (26.1%) required arthroplasty and 9 (6%) were too ill for further surgery. Poor quality reduction (p=0.008) and poor quality osteosynthesis (p= 0.064) were risk factors for failure. Fifty patients (33.6%) presented with non-union: 6/50 were asymptomatic, 34/50 required arthroplasty, and 10/50 were very ill. Ischaemic necrosis appeared in ten cases (6.7%) (five asymptomatic and five requiring arthroplasty). CONCLUSIONS: Reduction and fixation of displaced femoral neck fractures achieved good results in 68% of patients over 70, but re-operation became necessary in 32% of them; this made internal fixation advisable only for selected patients who were very active. The main risk factors were poor-quality reduction followed by poor osteosynthesis. (Hip International 2005; 15: 21-6).

Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe.

BACKGROUND: The purpose of this study was to assess current practices in blood management in elective orthopedic surgery in Europe. STUDY DESIGN AND METHODS: For this 225-center prospective survey, data were collected on 3996 patients. Actual perioperative blood loss was compared to preoperative estimates. Differences in Hb levels and other outcome variables for patients receiving allogeneic versus autologous transfusions were evaluated. The probability of allogeneic transfusion based on selected predictor variables was estimated. RESULTS: A total of 2640 (67%) hip and 1305 (33%) knee arthroplasty patients were evaluated. Estimated blood loss (median, 750 mL) was significantly lower than computed blood loss (median, 1944 mL). A total of 2762 (69%) patients received transfusions, including 1393 (35%) autologous-only and 1024 (25%) allogeneic-only. The probability of allogeneic transfusion decreased with increasing baseline Hb, but differentially so for men and women. Transfusion triggers were Hb levels of 8.93 +/- 1.83 g per dL for allogeneic transfusions, and 21 percent of these occurred when the Hb level was greater than 10 g per dL. Autologous blood transfusion was associated with a significantly lower rate (1%) of wound infections than allogeneic blood transfusion (4.2%). CONCLUSION: Accurate assessment of preoperative Hb levels, better estimation of perioperative blood loss, efficient use of autologous blood, adherence to transfusion guidelines, and pharmacologic alternatives contribute to effective and comprehensive blood and anemia management.

In vitro corrosion behaviour and osteoblast response of thermally oxidised Ti6Al4V alloy.

In this work, the influence of thermal oxidation treatments of Ti6Al4V at 500 degrees C and 700 degrees C for 1 h on the in vitro corrosion behaviour and osteoblast response is studied. The potential of these treatments, aimed to improve the wear surface performance as biomaterial, relies in the formation of an outer "ceramic" layer of rutile. The corrosion behaviour was evaluated in simulated human fluids by electrochemical impedance spectroscopy and anodic polarisation tests. The effect of these thermal oxidation treatments on osteoblastic behaviour was studied in primary cultures of human osteoblastic cells. Results show that thermal oxidation treatments do not decrease the high in vitro corrosion resistance of the Ti6Al4V alloy. Osteoblast adhesion studies indicate that thermal oxidation treatments do not impair the material biocompatibility. Moreover, the thermal oxidation at 700 degrees C enhances the in vitro osteoblastic cell attachment compared to the thermal oxidation at 500 degrees C.

Effects of polyethylene and alpha-alumina particles on IL-6 expression and secretion in primary cultures of human osteoblastic cells.

The effect of two biomaterials, polyethylene and alpha-alumina, on interleukin-6 (IL-6) secretion and expression has been studied in human osteoblasts in primary culture. Human osteoblastic cells were derived from fresh trabecular bone explants removed during total knee arthroplasty. On reaching confluence, cells were subcultured in 6 well plates; the resulting subcultures were incubated until confluence and polyethylene or alpha-alumina particles were added to some while the rest were left as controls. The IL-6 mRNA levels were assessed by reverse transcription (RT) followed by polymerase chain reaction (PCR). IL-6 secretion was measured in the conditioned medium. The IL-6 expression was higher in the presence of both biomaterials. Maximum expression occurred in response to a dose of 50 mg particles well with both biomaterials and was greater after polyethylene particle addition than after alpha-alumina particle addition at this dose. The maximum IL-6 secretion elicited by alpha-alumina was produced at 10 mg particles well while maximum response with polyethylene required 50 mg well. At a dose of 10 mg/well, alpha-alumina particles induced more secretion than 10 mg of polyethylene particles. Nevertheless, at a dose of 50 mg/well maximum secretion was produced with polyethylene particles. In conclusion and in our experimental conditions, polyethylene as well as alpha-alumina increased both the expression and the secretion of IL-6 in human osteoblastic cells in primary culture and stimulation from polyethylene appears stronger than that from alpha-alumina at the same dose.

Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings.

Our purpose was to compare the accuracy of ultrasonography (US) and magnetic resonance (MR) in the diagnosis of rotator cuff injuries (focusing on supraspinatus tears) using arthroscopy or open surgery findings. Using US and MR, we studied all painful shoulders seen during 1998 in our orthopaedic unit. Diagnosis was confirmed in 61 cases. The diagnosis of full thickness rotator cuff tear was highly specific on both imaging techniques (100% for US and 97.1% for MR) but was not as sensitive on US (57.7%) as on MR (80.8%). The diagnosis of partial tear was acceptably specific (67.9% for US and 75.5% for MR) but was not sensitive (overall, 12.5% for US vs 50% for MR). The specificity of a US diagnosis of a tear allows us to recommend surgery, thus making it a good imaging technique for the initial study of painful shoulders. The low sensitivity makes it necessary to undertake an additional MR study. If the MR also discovers no pathology, the sensitivity based on the US and MR images (92.7%) can be sufficient to avoid a false-negative diagnosis.