Defining the Macromolecules of Tomorrow through Synergistic Sustainable Polymer Research.

Transforming how plastics are made, unmade, and remade through innovative research and diverse partnerships that together foster environmental stewardship is critically important to a sustainable future. Designing, preparing, and implementing polymers derived from renewable resources for a wide range of advanced applications that promote future economic development, energy efficiency, and environmental sustainability are all central to these efforts. In this Chemical Reviews contribution, we take a comprehensive, integrated approach to summarize important and impactful contributions to this broad research arena. The Review highlights signature accomplishments across a broad research portfolio and is organized into four wide-ranging research themes that address the topic in a comprehensive manner: Feedstocks, Polymerization Processes and Techniques, Intended Use, and End of Use. We emphasize those successes that benefitted from collaborative engagements across disciplinary lines.

Enhanced Polyester Degradation through Transesterification with Salicylates.

Polyesters constitute nearly 10% of the global plastic market, but most are essentially non-degradable under ambient conditions or in engineered environments. A range of degradable polyesters have been developed as more sustainable alternatives; however, limitations of practical degradability and scalability have hindered their viability. Here, we utilized transesterification approaches, including in situ polymerization-transesterification, between a salicylate and a polyester to incorporate salicylate units into commercial polyester backbones. The strategy is scalable and practically relevant given that high molar mass polymers can be obtained from melt-processing of commercial polyesters using common compounders or extruders. Polylactide containing sparse salicylate moieties shows enhanced hydrolytic degradability in aqueous buffer, seawater, and alkaline solutions without sacrificing the thermal, mechanical, and O2 barrier properties of the parent material. Additionally, salicylate sequences were incorporated into polycaprolactone and a derivative of poly(ethylene terephthalate), and those modified polymers also exhibited facile degradation behavior in alkaline solution, further expanding the scope of this approach. This work provides insights and direction for the development of high-performance yet more sustainable and degradable alternatives to conventional polyesters.

Dendrite-Suppressing Polymer Materials for Safe Rechargeable Metal Battery Applications: From the Electro-Chemo-Mechanical Viewpoint of Macromolecular Design.

Metal batteries have been emerging as next-generation battery systems by virtue of ultrahigh theoretical specific capacities and low reduction potentials of metallic anodes. However, significant concerns regarding the uncontrolled metallic dendrite growth accompanied by safety hazards and short lifespan have impeded practical applications of metal batteries. Although a great deal of effort has been pursued to highlight the thermodynamic origin of dendrite growth and a variety of experimental methodologies for dendrite suppression, the roles of polymer materials in suppressing the dendrite growth have been underestimated. This review aims to give a state-of-the-art overview of contemporary dendrite-suppressing polymer materials from the electro-chemo-mechanical viewpoint of macromolecular design, including i) homogeneous distribution of metal ion flux, ii) mechanical blocking of metal dendrites, iii) tailoring polymer structures, and iv) modulating the physical configuration of polymer membranes. Judiciously tailoring electro-chemo-mechanical properties of polymer materials provides virtually unlimited opportunities to afford safe and high-performance metal battery systems by resolving problematic dendrite issues. Transforming these rational design strategies into building dendrite-suppressing polymer materials and exploiting them towards polymer electrolytes, separators, and coating materials hold the key to realizing safe, dendrite-free, and long-lasting metal battery systems.

Enhanced mechanical deep dewatering of dewatered sludge by a thermal hydrolysis pre-treatment: Effects of temperature and retention time.

This study investigated effects of the thermal hydrolysis pre-treatment on mechanical deep dewaterability of dewatered sludge to extend understanding of dewatering characteristics of thermally hydrolyzed sludge. Floc sizes of dewatered sludge were gradually reduced during the thermal hydrolysis pre-treatment at 170 °C and 185 °C with increasing retention time whereas longer retention time (>60 min) increased floc sizes of thermally hydrolyzed sludges at 200 °C due to formation of undesired refractory organic materials (ROMs), which might hinder the disintegration of dewatered sludge flocs. Similar trends were found for thermal hydrolytic solubilization of dewatered sludge. This demonstrated that the efficiency of the thermal hydrolysis pre-treatment at a higher temperature (200 °C) with longer retention time (≥60 min) could be strongly influenced by the formation of ROMs associated with changes of solid fractions and some free amino acids (i.e., ß-aminobutyric acid, 4-hydroxyproline, and cysteine). Since the trade-off between the degradation of dewatered sludge and the formation of ROMs determined mechanical deep dewaterability of thermally hydrolyzed sludge, the lowest residual weight and moisture content were observed for thermally hydrolyzed sludges at 200 °C with retention time range of 60 min (residual weight = 0.165; moisture content = 55.38%) to 90 min (residual weight = 0.160; moisture content = 59.87%). These observations were intimately correlated to variations of extracellular polymeric substances during the thermal hydrolysis pre-treatment, but not in accordance with the change pattern of capillary suction time (CST) values. This is evident that the CST value was inadequate to estimate mechanical deep dewaterability of thermally hydrolyzed sludge.

Bearing Change to Metal-On-Polyethylene for Ceramic Bearing Fracture in Total Hip Arthroplasty; Does It Work?

We evaluated the short-term to midterm results of reoperation with bearing change to metal-on-polyethylene (MoP) after ceramic bearing fracture in ceramic-on-ceramic total hip arthroplasty. Nine third-generation ceramic bearing fractures (6 heads and 3 liners) were treated with bearing change to MoP. Mean age at reoperation was 52.7 years. Mean follow-up was 4.3 years. During follow-up, 2 of 3 liner-fractured hips and 1 of 6 head-fractured hips showed radiologic signs of metallosis and elevated serum chromium levels. Re-reoperation with bearing rechange to a ceramic head was performed for the hips with metallosis. One liner-fractured hip had periprosthetic joint infection. Dislocation occurred in 3 hips. From our experience, bearing change to MoP is not a recommended treatment option for ceramic bearing fracture in total hip arthroplasty.

Alumina-alumina total hip arthroplasty for the sequelae of Legg-Calve-Perthes disease: A comparative study with adult-onset osteonecrosis.

BACKGROUND: Total hip arthroplasty (THA) for sequelae of Legg-Calve-Perthes disease (LCPD) involves specific concerns for deformity, leg length discrepancy (LLD), and relatively young age. Excellent long-term outcome has been proven after Alumina-Alumina (Al-Al) THA for relatively young patients, however, there was no study for Al-Al THA for LCPD sequelae. The aim of this study is to evaluate the results of Al-Al THA for LCPD sequelae and to compare the results with those for adult-onset ONFH, in which THA is necessitated in relatively young age and excellent long term outcome has been proven after Al-Al THA. METHODS: Between 1997 and 2007, 41 Al-Al THA were performed in 37 patients with LCPD sequelae and followed-up for mean 10.4 years. Mean age at THA was 43.6 years. Using the propensity score matching, 41 THAs in 37 patients were identified from 339 hips in 256 patients with ONFH. The medical record and radiographic data was retrospectively reviewed. RESULTS: During follow-up, no revision was performed in both group. Harris Hip Score increased from 66.7 ± 17.4 points to 96.8 ± 6.8 points in LCPD group and from 47.9 ± 18.4 to 96.6 ± 4.6 in ONFH group. LLD decreased significantly from 2.0 ± 1.2 cm to 0.2 ± 0.9 cm in LCPD group and from 0.5 cm to 0.1 cm in ONFH group. Postoperative LLD showed no difference in both groups. As for complication, rate of intraoperative femoral fracture was significantly higher in LCPD group than in ONFH group. Other postoperative complication showed no difference. CONCLUSIONS: Despite the higher rate of intraoperative femoral crack, outcomes of Al-Al THA for LCPD were comparable to those for ONFH. Similar to ONFH, Al-Al THA may be a reliable treatment option for LCPD.

Total hip arthroplasty performed in patients with residual poliomyelitis: does it work?

BACKGROUND: Patients with residual poliomyelitis can have advanced degenerative arthritis of the hip in the paralytic limb or the nonparalytic contralateral limb. Although THA is a treatment option for some of these patients, there are few studies regarding THA in this patient population. QUESTIONS/PURPOSES: We therefore reviewed a group of patients with residual poliomyelitis who underwent cementless THA on either their paralytic limb or nonparalytic limb to assess (1) Harris hip scores, (2) radiographic results, including implant loosening, (3) complications, including dislocation, and (4) limb length discrepancy after recovery from surgery. METHODS: From January 2000 to December 2009, 10 patients with residual poliomyelitis (10 hips, four paralytic limbs and six nonparalytic contralateral limbs) underwent THA using cementless prostheses. Harris hip scores, complications, and leg length discrepancy were determined by chart review, and confirmed by questionnaire and examination; radiographs were reviewed by two observers for this study. Followup was available for all 10 patients at a minimum of 3 years (median, 7 years; range, 3.4-13 years). Surgery was done at the same side of the paralytic limb in four hips and contralateral to the paralytic limb in six. RESULTS: All patients had pain relief and improvement in function; the Harris hip score improved from mean of 68 preoperatively to 92 at last followup (p = 0.043). However, only three patients had complete pain relief. One hip dislocated, which was treated successfully with closed reduction and a hip spica cast for 2 months. There was no loosening or osteolysis in this series. Leg length discrepancy improved after the index operation, but only in the THAs performed in the paralytic limbs. CONCLUSIONS: Cementless THA may be suitable for painful hips in adult patients with residual poliomyelitis. Nonetheless, these patients should be informed of the possibility of mild residual pain and persistent leg length discrepancy, particularly patients whose THA is performed on the limb that was not affected by polio (ie, the nonparalytic contralateral limb). LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Subchondral insufficiency fracture of the femoral head in elderly people.

We evaluated the clinical course of subchondral insufficiency fracture of the femoral head (SIFFH) and its characteristic findings with special regard to joint space narrowing (JSN). Thirty-one cases of SIFFH of mean age 68.9 yr initially underwent limited weight-bearing conservative treatment. During the follow-up period, the patients with intractable pain underwent total hip arthroplasty (THA). For radiographic evaluation, lateral center-edge angle, JSN and femoral head collapse (FHC) were documented, and the extent of FHC was classified as mild (<2 mm), moderate (2-4 mm), and severe (>4 mm). The progression or new development of FHC more than 2 mm was evaluated on sequential plain radiographs. The relationship between radiographic parameters and clinical outcomes were evaluated. THAs were performed in 15 cases (48.4%). There was no significant correlation between clinical outcomes and the extent of initial FHC. However, a significantly larger proportion of patients that underwent THA showed JSN and FHC progression compared to the symptom improvement group. The risk factor significantly associated with failed conservative treatment was JSN (P=0.038; OR, 11.8; 95% CI, 1.15-122.26). Clinical results of conservative treatment for SIFFH in elderly patients are relatively poor. The patients with JSN are at higher risk of failed conservative treatment.

Epidemiology of hip replacements in Korea from 2007 to 2011.

We analyzed national data collected by the Health Insurance Review and Assessment Service in Korea from 2007 to 2011; 1) to document procedural numbers and procedural rate of bipolar hemiarthroplasty (BH), primary and revision total hip arthroplasties (THAs), 2) to stratify the prevalence of each procedure by age, gender, and hospital type, and quantified, 3) to estimate the revision burden and evaluate whether the burden is changed over time. Our final study population included 60,230 BHs, 40,760 primary THAs, and 10,341 revision THAs. From 2007 to 2011, both the number and the rate of BHs, primary THAs increased steadily, whereas there was no significant change in revision THAs. Over the 5 yr, the rate of BHs and primary THAs per 100,000 persons significantly increased by 33.2% and 21.4%, respectively. The number of revision THAs was consistent over time. The overall annual revision burden for THA decreased from 22.1% in 2007 to 18.9% in 2011. In contrast to western data, there were no changes in the number and rate of revision THAs, and the rates of primary and revision THAs were higher for men than those for women. Although 5 yr is a short time to determine a change in the revision burden, there have been significant decreases in some age groups.

Innate Immune Training Initiates Efferocytosis to Protect against Lung Injury.

Innate immune training involves myelopoiesis, dynamic gene modulation, and functional reprogramming of myeloid cells in response to secondary heterologous challenges. The present study evaluates whether systemic innate immune training can protect tissues from local injury. Systemic pretreatment of mice with ß-glucan, a trained immunity agonist, reduces the mortality rate of mice with bleomycin-induced lung injury and fibrosis, as well as decreasing collagen deposition in the lungs. ß-Glucan pretreatment induces neutrophil accumulation in the lungs and enhances efferocytosis. Training of mice with ß-glucan results in histone modification in both alveolar macrophages (AMs) and neighboring lung epithelial cells. Training also increases the production of RvD1 and soluble mediators by AMs and efferocytes. Efferocytosis increases trained immunity in AMs by stimulating RvD1 release, thus inducing SIRT1 expression in neighboring lung epithelial cells. Elevated epithelial SIRT1 expression is associated with decreased epithelial cell apoptosis after lung injury, attenuating tissue damage. Further, neutrophil depletion dampens the effects of ß-glucan on macrophage accumulation, epigenetic modification in lung macrophages, epithelial SIRT1 expression, and injury-mediated fibrosis in the lung. These findings provide mechanistic insights into innate immune training and clues to the potential ability of centrally trained immunity to protect peripheral organs against injury-mediated disorders.

Revision total hip arthroplasty using an alumina-on-alumina bearing surface in patients with osteolysis.

We evaluated the outcomes of 64 consecutive revision total hip arthroplasties with an alumina-on-alumina bearing surface in 61 patients with osteolysis. No implants had been rerevised nor was osteolysis detected at a mean of 9.8 years (range, 7.0-13.1 years) postoperatively. There was 1 case of stem loosening but no cup loosening or alumina bearing fractures. Two surgical procedures were performed for an infection in 1 patient. Three dislocations occurred in 3 hips; all were treated with closed reduction and abduction bracing for 3 months. No further dislocations occurred. With any reoperation or radiographic evidence of osteolysis or loosening as the end point, the 7-year survival rate was 96.9% (95% confidence interval, 90.8%-100%). The alumina-on-alumina bearing surfaces used for revision total hip arthroplasty in patients with osteolysis were found to produce encouraging clinical results and implant survival rates at a minimum of 7 years postoperatively.

Medial placement of the acetabular component in an alumina-on-alumina total hip arthroplasty: a comparative study with propensity score matching.

PURPOSE: In an alumina-on-alumina total hip arthroplasty (THA), recommended with a small inclination angle <45°, the acetabular component (cup) may be positioned more medially to be covered almost completely by host bone. The purpose of this study was to identify the correlating factors and to evaluate the outcomes of medial placement of the cup in patients with alumina-on-alumina THAs. METHODS: Using the propensity score matching with age, gender, body mass index, initial diagnosis, and the length of follow-up as variables, 38 hips with a medialized cup and 38 hips with a non-medialized one were identified from 389 hips in 347 who patients underwent primary alumina-on-alumina THA and followed up for more than 7 years. Clinical and radiological outcomes were compared between the two groups. RESULTS: Preoperative acetabular medial wall thickness and the cup inclination angle were significantly smaller in the medialization group compared to the non-medialization group. Center edge angle, cup size, and coverage by host bone were not significantly different between the two groups. The hip center of rotation was significantly medialized in the medialization group. The Harris hip scores were not significantly different between the two groups. No component loosening or osteolysis was observed and no revision was required in either groups. CONCLUSIONS: Thin acetabular medial wall and a small inclination angle of the cup were the correlating factors of medial placement of the cup in patients who underwent an alumina-on-alumina THA. Medial placement did not lead to differences in the clinical or radiological outcomes.

Distal femoral cortical proliferative irregularity with excavation in a 6-year-old girl.

The distal femur is a common site for benign or malignant bone tumors in children or adolescents. Distal femoral cortical irregularities at the posterior aspect of the distal femoral metaphysis must be differentiated from malignant bone tumors because they might be misinterpreted as malignant neoplasm. Plain radiographs of a 6-year-old girl complaining of left knee pain for 4 weeks showed cortical proliferation with excavation on her distal femoral metaphysis. Computed tomography, magnetic resonance imaging and bone scan helped to differentiate the cortical irregularity from malignant lesions. Therefore unnecessary invasive surgery was avoided in this patient.

Factors Affecting the Clinical Course of Subchondral Fatigue Fracture of the Femoral Head.

Background: Subchondral fatigue fracture of the femoral head (SFFFH) is a rare disease, and its disease entity is established in recent decades. Although there are a few studies on SFFFH, most of them are case series involving around 10 cases, and the clinical course of SFFFH is still not well known. This study analyzed the factors affecting the clinical course of SFFFH. Methods: Patients who visited our institution from October 2000 to January 2019 were retrospectively evaluated. Of eligible cases, 89 hips (80 patients) were diagnosed with SFFFH and non-surgical treatment outcomes were analyzed. Radiographs and medical charts were reviewed for following factors: the degree of femoral head collapse, the interval between the onset of hip pain and the first hospital visit, hip dysplasia, osteoarthritic changes, sex, and age. Results: Hip pain decreased in 82 cases (92.1%) through non-surgical treatment, and 7 cases (7.9%) underwent surgery. Patients with good results of non-surgical treatment had improvement 2.9 months on average after the treatment. All cases without a collapsed femoral head (55 cases) had hip pain alleviation through non-surgical treatment. Cases with femoral head collapse of 4 mm or less and non-surgical treatment within 6 months from the onset of hip pain (22 cases) all had hip pain alleviation. Among 8 cases with femoral head collapse of 4 mm or less and non-surgical treatment after 6 months or more from the onset of hip pain, 3 underwent surgery and 1 had persistent hip pain. Those with femoral head collapse of over 4 mm (3 cases) all underwent surgery. The osteoarthritic changes, dysplastic hip, sex, and age were not statistically related to the success of non-surgical treatment. Conclusions: The success of non-surgical treatment for SFFFH can be affected by the degree of femoral head collapse and the timing of non-surgical treatment.

The Influence of Styrene Content in Solution Styrene Butadiene Rubber on Silica-Filled Tire Tread Compounds.

In tire tread applications, achieving enhanced abrasion resistance, wet grip, and rolling resistance is crucial for optimizing overall performance. To realize improvements in these attributes for silica-filled tire tread compounds, it becomes imperative to improve the dispersity of silica filler by investigating the effect of each component in the tire tread compound. In this work, we study the effect of styrene content within solution styrene butadiene rubber (SSBR) on the properties of tire tread compounds. A higher styrene segment within SSBR contributes to increased silica dispersion and crosslink density. Thus, tire tread compounds featuring SSBR with increased styrene content not only improve physical and mechanical properties, but also enhance major characteristics tailored for tire tread applications. These findings provide valuable insights into advancing the reinforced performance of tire tread compounds through the strategic utilization of SSBR enriched in styrene content.

Enhanced cellular responses of human bone marrow stromal cells cultured on pretreated surface with allogenic platelet-rich plasma.

The principal objective of this study was to evaluate the effects of surface pretreatment with platelet-rich plasma (PRP) on the cellular functions of human bone marrow stromal cells (hBMSCs). The surfaces of tissue culture plates (TCPs) were pretreated by adding PRP followed by centrifugation to bring platelets closer to the surface, followed by incubation for 60 min at 37°C. Then, hBMSCs were seeded onto TCP and TCP pretreated with PRP (TCP-PRP), followed by culture in osteogenic medium. Cell attachment, proliferation, and osteogenic differentiation were evaluated. Field emission scanning electron microscope (FE-SEM; JSM-7401F, JEOL Ltd., Japan) observations were conducted. The attachment of hBMSCs was significantly lower on TCP-PRP than on TCP. However, when the cell numbers were normalized with those observed on day 1 of culture, cellular proliferation on 5 days was significantly higher on TCP-PRP. Alkaline phosphatase activity, an index of early phase of osteoblastic differentiation, was significantly higher on TCP-PRP on day 14. Calcium deposition amount, an index of terminal osteoblastic differentiation, was also significantly higher on TCP-PRP on days 14 and 21. The results of von Kossa staining confirmed that, on day 21, the area of mineralized nodules was significantly larger on TCP-PRP. FE-SEM observation demonstrated that activated platelets and fibrin network covered the surface after PRP treatment. An increase in the number of hBMSCs and their cellular products was evident on the FE-SEM observation, and the fibrin network remained on day 21. Our results demonstrate that a PRP-treated surface enhanced early proliferation and late osteogenic differentiation of hBMSCs.

Synthetic peptide-conjugated titanium alloy for enhanced bone formation in vivo.

There are growing demands for bioactive titanium implants that could shorten the healing period, promote faster rehabilitation, and thereby increase the success rate of treating patients with poor bone quality. A synthetic receptor-binding peptide mimicking bone morphogenetic protein-2 (BMP-2) was covalently linked to a titanium alloy with two types of topography--machined (TiMA) and rough (TiGB)--by using a chemical conjugation process. In vivo osseointegration capacity was evaluated chronologically using histomorphometric analysis at 2, 4, and 8 weeks after implantation in the distal femurs of rabbits. In the histologic examinations, peri-implant bone formation was more active around TiGB than TiMA. Compared to the control groups (nonconjugated TiMA and TiGB) at 2, 4, and 8 weeks, the peptide-conjugated groups (TiMA-P and TiGB-P) had more mature new bone, thicker trabeculae, more rapid bone maturation, and higher affinity index (percentage of new bone contact length) in histomorphometric analysis. Particularly, differences in the affinity index between the peptide-conjugated and nonconjugated groups were more pronounced at the early phase of peri-implant healing (2 and 4 weeks). However, at 8 weeks, enhanced bone formation was less prominent according to peptide conjugation, especially in specimens with a rough surface. The titanium alloys in the rabbit femurs led to a significant increase of bone growth when modified with bioactive peptides, especially during the early phase of bone healing. These results confirm that biochemical modifications of titanium surfaces can enhance the rate of bone healing compared with that of untreated titanium surfaces.

Case report: multifocal subchondral stress fractures of the femoral heads and tibial condyles in a young military recruit.

BACKGROUND: Subchondral stress fractures of the femoral head may be either of the insufficiency-type with poor quality bone or the fatigue-type with normal quality bone but subject to high repetitive stresses. Unlike osteonecrosis, multiple site involvement rarely has been reported for subchondral stress fractures. We describe a case of multifocal subchondral stress fractures involving femoral heads and medial tibial condyles bilaterally within 2 weeks. CASE DESCRIPTION: A 27-year-old military recruit began having left knee pain after 2 weeks of basic training, without any injury. Subsequently, right knee, right hip, and left hip pain developed sequentially within 2 weeks. The diagnosis of multifocal subchondral stress fracture was confirmed by plain radiographs and MR images. Nonoperative treatment of the subchondral stress fractures of both medial tibial condyles and the left uncollapsed femoral head resulted in resolution of symptoms. The collapsed right femoral head was treated with a fibular strut allograft to restore congruity and healed without further collapse. LITERATURE REVIEW: There has been one case report in which an insufficiency-type subchondral stress fracture of the femoral head and medial femoral condyle occurred within a 2-year interval. CLINICAL RELEVANCE: Because the incidence of bilateral subchondral stress fractures of the femoral head is low and multifocal involvement has not been reported, multifocal subchondral stress fractures can be confused with multifocal osteonecrosis. Our case shows that subchondral stress fractures can occur in multiple sites almost simultaneously.

Alumina-on-alumina THA performed in patients younger than 30 years: a 10-year minimum followup study.

BACKGROUND: THA in patients younger than 30 years presents challenges because of uncertainties regarding the long-term survivorship of prostheses. Alumina-on-alumina bearings, which exhibit little long-term wear, may be a reasonable option but the long-term survivorship is unknown. QUESTIONS/PURPOSES: We determined (1) the survival rate of alumina-on-alumina bearings in patients younger than 30 years after a 10-year followup, (2) the incidence of audible hip clicking and squeaking, (3) radiographic evidence of osteolysis, and (4) the effects on pregnancy, childbirth, and career choice. METHODS: We retrospectively reviewed 62 patients who had 75 THAs with alumina-on-alumina bearings followed more than 10 years (average, 11.5; range, 10-13.5 years). Mean patient age at the time of surgery was 24 years (range, 18-30 years). All operations were performed using the same cementless implant at a single center. We determined survival, presence of osteolysis, and function (Harris hip score, WOMAC). RESULTS: The 10-year survival rate of alumina-on-alumina bearings in THAs, with revision for any reason as the end point, was 98.9%. Audible hip clicking and squeaking were identified in 10 hips and two hips, respectively. No osteolysis was detected. None of the 11 patients who became pregnant had been affected by their THA during pregnancy or childbirth. Seven of the 14 patients who were unemployed at the time of index surgery stated that their THA affected their job choice. CONCLUSIONS: We found a high 10-year survival of cementless alumina-on-alumina bearings in THAs in patients younger than 30 years. Lifetime events such as job choice, pregnancy, and childbirth should be considered when choosing THA for patients younger than 30 years. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Malignant fibrous histiocytoma at the site of an alumina-on-alumina-bearing total hip arthroplasty mimicking infected trochanteric bursitis.

Although the incidence of malignant tumors in patients undergoing total hip arthroplasties (THAs) is known to be lower than the general population, there exist several reports on the development of malignant tumors at the site of THAs. We report another case of malignant fibrous histiocytoma at the site of a THA, which was developed in an older patient who presented a cystic mass around the total hip prosthesis using a ceramic-on-ceramic bearing system, even without evidence of osteolysis or loosening of implants. This is the second case associated with an aluminum oxide prosthesis in English literature.