HYPERSENSITIVITY IN ASEPTIC LOOSENING OF TOTAL HIP REPLACEMENTS

Aseptic loosening is seen in a significant proportion of cemented total hip replacements (THR). In a small subgroup of patients who suffer early loosening polyethylene debris is unlikely to be responsible. We recently reported one case of allergic contact dermatitis to N,N-dimethylparatoluidine (DMT), an accelerator used in bone cement. We have therefore investigated this using skin-patch tests to a variety of substances including metals, polyethylene and the separated individual components of Simplex cement.

We studied 70 patients, 15 with aseptic loosening less than two years after THR, 25 with satisfactory long-term cemented fixation, five with infected loosening of cemented THRs and 25 awaiting hip arthroplasty. We found seven positive reactions to DMT, all of them in patients with the rapid onset of aseptic loosening.

Allergy to DMT is recognised in the dental profession in respect of the ‘denture sore mouth’ syndrome, and could also be an occupational hazard since some industrial glues contain DMT. Our results suggest the need for awareness of possible previous dental or occupational exposure to the constituents of bone cement. We recommend the use of skin-patch testing in high-risk cases.

Hypersensitivity in aseptic loosening of total hip replacements. The role of constituents of bone cement

Aseptic loosening is seen in a significant proportion of cemented total hip replacements (THR). In a small subgroup of patients who suffer early loosening polyethylene debris is unlikely to be responsible. We recently reported one case of allergic contact dermatitis to N,N-dimethylparatoluidine (DMT), an accelerator used in bone cement. We have therefore investigated this using skin-patch tests to a variety of substances including metals, polyethylene and the separated individual components of Simplex cement. We studied 70 patients, 15 with aseptic loosening less than two years after THR, 25 with satisfactory long-term cemented fixation, five with infected loosening of cemented THRs and 25 awaiting hip arthroplasty. We found seven positive reactions to DMT, all of them in patients with the rapid onset of aseptic loosening. Allergy to DMT is recognized in the dental profession in respect of the 'denture sore mouth' syndrome, and could also be an occupational hazard since some industrial glues contain DMT. Our results suggest the need for awareness of possible previous dental or occupational exposure of the constituents of bone cement. We recommend the use of skin-patch testing in high-risk cases.

Callosities, corns, and calluses

Inappropriate shoes, abnormal foot mechanics, and high levels of activity produce pressure and friction that lead to corns and calluses. Most lesions can be managed conservatively by proper footwear, orthoses, and, if necessary, regular paring. The lesions usually disappear when the causative mechanical forces are removed. Surgery is rarely indicated and should be specifically aimed at correcting the abnormal mechanical stresses.

Stanmore compared with Charnley total hip replacement. A prospective study of 413 arthroplasties

From 1982 to 1987, we randomised prospectively 413 patients requiring primary total hip replacements to receive either a Stanmore or Charnley prosthesis. They were reviewed by an independent observer in an attempt to correlate a number of factors including femoral head size with longevity. There were 213 Stanmore hips and 200 Charnley prostheses. At five to ten years (mean 6.5) 76 patients had died and 16 arthroplasties had required revision. Seven were radiologically loose in asymptomatic patients. There was only one case of deep infection. We found no difference statistically in the clinical outcome or in the revision rate of 4% in the two types of prosthesis. The revision rate was greater for trainees than for senior operating surgeons, and there were recognisable technical errors in seven of the nine Stanmore, and four of the seven Charnley replacements which required revision. Retrospective radiological analysis of a random subset of 51 Charnely and 57 Stanmore femoral components showed no difference in femoral subsidence, but in 14 patients who had had bilateral replacements with one femoral component of each type, there was greater early subsidence of the Stanmore prosthesis. Our results confirm that conventional cemented total hip replacements give acceptable results in a general teaching unit, and we found no evidence of any effect of the size of the femoral head on wear or loosening at five to ten years.

STANMORE COMPARED WITH CHARNLEY TOTAL HIP REPLACEMENT

From 1982 to 1987, we randomised prospectively 413 patients requiring primary total hip replacements to receive either a Stanmore or Charnley prosthesis. They were reviewed by an independent observer in an attempt to correlate a number of factors including femoral head size with longevity. There were 213 Stanmore hips and 200 Charnley prostheses. At five to ten years (mean 6.5) 76 patients had died and 16 arthroplasties had required revision. Seven were radiologically loose in asymptomatic patients. There was only one case of deep infection.

We found no difference statistically in the clinical outcome or in the revision rate of 4% in the two types of prosthesis. The revision rate was greater for trainees than for senior operating surgeons, and there were recognisable technical errors in seven of the nine Stanmore, and four of the seven Charnley replacements which required revision. Retrospective radiological analysis of a random subset of 51 Charnley and 57 Stanmore femoral components showed no difference in femoral subsidence, but in 14 patients who had had bilateral replacements with one femoral component of each type, there was greater early subsidence of the Stanmore prosthesis.

Our results confirm that conventional cemented total hip replacements give acceptable results in a general teaching unit, and we found no evidence of any effect of the size of the femoral head on wear or loosening at five to ten years.

Prediction of clinical outcome of THR from migration measurements on standard radiographs. A study of cemented Charnley and Stanmore femoral stems

We report the theoretical basis of a method to measure axial migration of femoral components of total hip replacements (THR). The use of the top of the greater trochanter and a lateral point on the collar of the stem, allowing for variations of up to 10 degrees rotation of the femur in any direction between successive radiographs, gave a maximum error of 0.37 mm. At a more realistic 5 degrees rotational variation, the error was only 0.13 mm. These data were confirmed in an experimental study using digitisation of points and special software. We also showed that the centre of the femoral head, the stem tip, and the lesser trochanter provided less accurate landmarks. In a second study we digitised a series of radiographs of 51 Charnley and 57 Stanmore THRs; the mean migration rates were found to be identical. We then studied 46 successful stems with a minimum follow-up of eight years and 46 stems which had failed by aseptic loosening at different times. At two years, the successful stems had migrated by a mean of 1.45 +/- 0.68 mm, but the failed cases had a mean migration of 4.32 +/- 2.58 mm (p < 0.0001). Of the successful cases 76% had migrated less than 2 mm, while in the failed group 84% had migrated more than 2 mm. For any particular case migration of more than 2.6 mm at two years had only a 5% chance of continuing success and would therefore merit special follow-up. Only 24% of the eventually successful stems showed migration at the stem-cement interface, but this had happened in every failed stem. We conclude that it would be possible to evaluate a new cemented design of femoral stem over a two-year period by the use of our method and to compare its performance against the reported known standard of the Charnley and Stanmore designs.

Failure of the Ring polyethylene uncemented acetabular cup

We report a high rate of failure of the Ring polyethylene cementless cup caused largely by granulomatous osteolysis. We have reviewed 126 prostheses inserted from 1986 to 1992 at from 11 to 90 months after surgery. There was radiological evidence of osteolytic granulomas adjacent to the external surface of the cup in 32%, appearing on average at three years from operation. In a subgroup of 59 prostheses followed for at least four years the incidence of such changes was 54%. A total of 27 cups (22%) have required revision, 21 for granulomatous loosening at an average follow-up of five years. In the retrieved prostheses there was obvious polyethylene abrasion and histological examination confirmed the presence of polyethylene wear debris. We found no significant correlation of osteolysis with cup size, although smaller cups were predominant among those having revision.

Failure of the Ring polyethylene uncemented acetabular cup

We report a high rate of failure of the Ring polyethylene cementless cup caused largely by granulomatous osteolysis. We have reviewed 126 prostheses inserted from 1986 to 1992 at from 11 to 90 months after surgery. There was radiological evidence of osteolytic granulomas adjacent to the external surface of the cup in 32%, appearing on average at three years from operation. In a subgroup of 59 prostheses followed for at least four years the incidence of such changes was 54%. A total of 27 cups (22%) have required revision, 21 for granulomatous loosening at an average follow-up of five years. In the retrieved prostheses there was obvious polyethylene abrasion and histological examination confirmed the presence of polyethylene wear debris. We found no significant correlation of osteolysis with cup size, although smaller cups were predominant among those having revision.

An audit of orthopaedic training

The changing face of clinical practice in general, and of junior doctors' expectations in particular, will inevitably alter the length and nature of higher training. Greater awareness and tighter control of this will therefore be necessary. This analysis of the curricula vitae of 50 orthopaedic surgeons-in-training who were appointed to senior registrar posts at The Royal National Orthopaedic Hospital, has allowed identification of the 'normal' pattern of educational achievement against which individuals may now be assessed. This has potential wide-ranging educational and financial implications.

Danger to the popliteal artery in high tibial osteotomy

We report a case in which the popliteal artery was divided during upper tibial osteotomy performed with the knee in 90 degrees of flexion. This position is believed to allow it to fall safely back from the tibia, but we could find no published confirmation. We used duplex ultrasonography in ten healthy volunteers to measure the distance from the popliteal artery to the posterior surface of the tibia at various degrees of flexion of the knee. Our results showed that in 12 of 20 knees the popliteal artery was closer to the tibia in 90 degrees of knee flexion than in full extension. Surgeons performing upper tibial osteotomy should be aware that flexing the knee does not protect the popliteal artery from injury.

Danger to the popliteal artery in high tibial osteotomy

We report a case in which the popliteal artery was divided during upper tibial osteotomy performed with the knee in 90 degrees of flexion. This position is believed to allow it to fall safely back from the tibia, but we could find no published confirmation. We used duplex ultrasonography in ten healthy volunteers to measure the distance from the popliteal artery to the posterior surface of the tibia at various degrees of flexion of the knee. Our results showed that in 12 of 20 knees the popliteal artery was closer to the tibia in 90 degrees of knee flexion than in full extension. Surgeons performing upper tibial osteotomy should be aware that flexing the knee does not protect the popliteal artery from injury.

[Epitopes of the envelope of the hepatitis B virus: a structural approach]

Hepatitis B is a major public health problem. More than 300 million people are chronically infected by the virus. During infection very large quantities of complete virions and empty envelopes, consisting of spherical or filamentous lipoprotein particles, are present in the blood. DNA genome coding for envelopes is divided into three domains, preS1, preS2 and S. All available data suggest that the preS1 and preS2 products are exposed at the surface of the virions. These proteins are more immunogenic than S in terms of in vivo antibody response and the number of epitopes identified. The three dimensional mapping of antigenic sites of the HBV will provide important strategic information for vaccine development and identification of targets for immunorecognition or immunoregulation of the disease.

Proteoglycan depletion alone is not sufficient to stimulate proteoglycan synthesis in cultured bovine cartilage explants

Articular cartilage comprises a small number of cells embedded within a matrix primarily composed of collagen and proteoglycan (PG). The functional integrity of the tissue is highly dependent on the maintenance of matrix structure, which, in turn, is controlled by the chondrocytes. In normal tissue there is a slow but steady turnover of matrix components such that their levels remain constant. In certain diseased states the equilibrium is upset, resulting in a net loss of matrix components. The object of the present study was to artificially upset the synthetic/loss equilibrium by enzymic depletion and assess the ability of chondrocytes to respond by increasing PG synthesis. Cultured bovine articular cartilage explants were depleted using enzymes as follows; 10 U/ml Streptomyces hyaluronidase (induced a 30% loss of PG), 2000 U/ml testicular hyaluronidase (70% loss of PG) and 100 U/ml collagenase (35% loss of PG) and control (6% loss of PG). Collagenase also induced a 50% loss of collagen. Collagenase treatment induced a 50% stimulation of PG synthesis above control levels. Elevated synthesis levels were maintained for 9 days. Testicular hyaluronidase induced a brief elevation in PG synthesis on day 3 of culture. Streptomyces hyaluronidase treatment did not cause an alteration in the rate of PG synthesis above control levels. Histological examination indicated that collagenase-treated explants formed outgrowths consisting of rounded chondrocytes within a fine fibrous matrix which stained intensely with safranin-O, indicating a high concentration of PG. The production of repair-like outgrowths may explain the elevated PG synthesis rates measured. It appears, therefore, that collagen and matrix organization is more important than PG levels in the control of PG synthesis in articular cartilage explant cultures.

Knee function after patellectomy. A 12- to 48-year follow-up

We describe 83 knees (69 patients) which had had patellectomy for anterior knee pain (52), patellofemoral osteoarthritis (25) or comminuted fractures (6) between 1942 and 1978. The patients were questioned about their symptoms and the function of the operated knee 14 to 50 years after operation. In the group with anterior knee pain, 76% achieved good results and were satisfied with the operation. Only 54% of the osteoarthritis group had satisfactory relief of pain and most had progressive deterioration of function. Sixteen patients who had had unilateral patellectomy were assessed by dynamometry, ultrasound and radiography. The average quadriceps muscle power was 60% of that on the normal side although two patients had stronger muscles in their operated than in their unoperated legs.

An investigation into the discriminative stimulus and reinforcing properties of the CCKB-receptor antagonist, L-365,260 in rats

The discriminative stimulus properties of the selective CCKB-receptor antagonist, L-365,260 were evaluated in rats trained to discriminate diazepam (2 mg/kg) or morphine (5 mg/kg) from vehicle, using a two-lever food reinforced technique. In the diazepam drug discrimination, the benzodiazepine-receptor agonist FG8205 (0.063-2 mg/kg) produced dose-related drug associated responding, whereas L-365,260 (0.125-4 mg/kg) treated animals showed vehicle appropriate behaviour. In rats trained to discriminate morphine from saline, L-365,260 (0.063-4 mg/kg) produced saline lever responding. When a dose of 1 mg/kg L-365,260 was administered in combination with morphine, the dose response curve for drug lever responding was not significantly affected. This was in contrast to the effect produced by the opiate antagonist naloxone (0.3 mg/kg) which shifted the dose-response curve to the right. Another group of rats underwent training to discriminate a dose of 6 mg/kg L-365,260 from vehicle. None of the animals learned the discrimination within 50 daily training sessions. In addition, unlike morphine (3 mg/kg), or changing the training dose of cocaine, intravenous administration of L-365,260 (0.3-10 mg/kg) did not modify lever pressing or the number of injections received by rats trained to self administer cocaine (0.25 mg/injection). L-365,260 (0.1-3 mg/kg) produced a dose-related inhibition of pentagastrin-stimulated gastric acid secretion in vivo. When administered dissolved in a mixture of ethanol/propylene glycol/saline, the ID50 was 0.83 mg/kg, and when suspended in an ethanol/carboxymethylcellulose vehicle, it was 0.7 mg/kg. It was concluded: 1) that L-365,260 does not produce discriminative stimuli similar to either diazepam or morphine; 2) that the potentiation of morphine-induced behaviour by L-365,260 does not extend to the discriminative stimulus properties of morphine; 3) that L-365,260 itself does not produce readily discriminable interoceptive stimuli in rats; and 4) that L-365,260 does not substitute for the reinforcing drug cocaine.

Knee function after patellectomy. A 12- to 48-year follow-up

We describe 83 knees (69 patients) which had had patellectomy for anterior knee pain (52), patellofemoral osteoarthritis (25) or comminuted fractures (6) between 1942 and 1978. The patients were questioned about their symptoms and the function of the operated knee 14 to 50 years after operation. In the group with anterior knee pain, 76% achieved good results and were satisfied with the operation. Only 54% of the osteoarthritis group had satisfactory relief of pain and most had progressive deterioration of function. Sixteen patients who had had unilateral patellectomy were assessed by dynamometry, ultrasound and radiography. The average quadriceps muscle power was 60% of that on the normal side although two patients had stronger muscles in their operated than in their unoperated legs.

Proprioception after knee arthroplasty. The influence of prosthetic design

It is recognized that awareness of joint position in the knee deteriorates because of aging, anterior cruciate injury, or osteoarthrosis. Proprioception was studied in osteoarthritic and prosthetic knees, including both posterior cruciate ligament (PCL)-retaining and PCL-sacrificing designs. An improvement in proprioception was observed after knee arthroplasty. A PCL-retaining prosthesis was found to confer a greater improvement than a PCL-sacrificing design.

Suction tip contamination in the ultraclean-air operating theatre

The surgical suction tip forms a reservoir for microorganisms during total hip replacement in conventional operating theatres. We assessed the colonisation of the tip in an ultraclean-air operating theatre in 39 patients, and found that 41% of them had evidence of bacterial colonisation with one or more bacteria. To avoid contamination we suggest that the suction tip is changed before preparation of the femoral canal and insertion of cement and prosthesis.

The control of cell division in articular chondrocytes

Our objective was to investigate the factors that control chondrocyte division, namely, (1) steric hindrance caused by the surrounding matrix, (2) growth factors and (3) cell shape. Bovine articular cartilage explants and isolated chondrocytes were cultured in medium containing [3H]-TdR to measure DNA synthesis. The effect of enzyme treatment, growth factors and cell shape was investigated. Proteoglycan (PG) depletion did not stimulate DNA synthesis whilst disruption of the collagen architecture promoted incorporation of [3H]-TdR into DNA. DNA synthesis was also stimulated by IGF-1 in flattened chondrocytes but not in rounded cells. It was found that the control of chondrocyte division depends on several variably related factors that may act singly or together to induce cell division and that PG depletion alone is insufficient to induce DNA synthesis, but division was noted when PG depletion was accompanied by matrix disruption and cell shape changes. Cell shape appears to alter the chondrocytes ability to respond to IGF-1 as a mitogen.