Ceramic-on-ceramic bearing fractures in total hip arthroplasty

Aims

Ceramic-on-ceramic (CoC) bearings in total hip arthroplasty (THA) are commonly used, but concerns exist regarding ceramic fracture. This study aims to report the risk of revision for fracture of modern CoC bearings and identify factors that might influence this risk, using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man.

Patients and Methods

We analysed data on 223 362 bearings from 111 681 primary CoC THAs and 182 linked revisions for bearing fracture recorded in the NJR. We used implant codes to identify ceramic bearing composition and generated Kaplan-Meier estimates for implant survivorship. Logistic regression analyses were performed for implant size and patient specific variables to determine any associated risks for revision.

Results

A total of 222 852 bearings (99.8%) were CeramTec Biolox products. Revisions for fracture were linked to seven of 79 442 (0.009%) Biolox Delta heads, 38 of 31 982 (0.119%) Biolox Forte heads, 101 of 80 170 (0.126%) Biolox Delta liners and 35 of 31 258 (0.112%) Biolox Forte liners. Regression analysis of implant size revealed smaller heads had significantly higher odds of fracture (chi-squared 68.0, p < 0.001). The highest fracture risk was observed in the 28 mm Biolox Forte subgroup (0.382%). There were no fractures in the 40 mm head group for either ceramic type. Liner thickness was not predictive of fracture (p = 0.67). Body mass index (BMI) was independently associated with revision for both head fractures (odds ratio (OR) 1.09 per unit increase, p = 0.031) and liner fractures (OR 1.06 per unit increase, p = 0.006).

Conclusions

We report the largest independent study of CoC bearing fractures to date. The risk of revision for CoC bearing fracture is very low but previous studies have underestimated this risk. There is good evidence that the latest generation of ceramic has greatly reduced the odds of head fracture but not of liner fracture. Small head size and high patient BMI are associated with an increased risk of ceramic bearing fracture. Cite this article: Bone Joint J 2017;99-B:1012–19.

L-arginine effects on Na+ transport in M-1 mouse cortical collecting duct cells--a cationic amino acid absorbing epithelium

The effect of L-arginine on transepithelial ion transport was examined in cultured M-1 mouse renal cortical collecting duct (CCD) cells using continuous short circuit current (Isc) measurements in HCO3-/CO2 buffered solution. Steady state Isc averaged 73.8 +/- 3.2 microA/cm2 (n = 126) and was reduced by 94 +/- 0.6% (n = 16) by the apical addition of 100 microM amiloride. This confirms that the predominant electrogenic ion transport in M-1 cells is Na+ absorption via the epithelial sodium channel (ENaC). Experiments using the cationic amino acid L-lysine (radiolabeled) as a stable arginine analogue show that the combined activity of an apical system y+ and a basal amino acid transport system y+L are responsible for most cationic amino acid transport across M-1 cells. Together they generate net absorptive cationic amino acid flux. Application of L-arginine (10 mM) either apically or basolaterally induced a transient peak increase in Isc averaging 36.6 +/- 5.4 microA/cm2 (n = 19) and 32.0 +/- 7.2 microA/cm2 (n = 8), respectively. The response was preserved in the absence of bath Cl- (n = 4), but was abolished either in the absence of apical Na+ (n = 4) or by apical addition of 100 microM amiloride (n = 6). L-lysine, which cannot serve as a precursor of NO, caused a response similar to that of L-arginine (n = 4); neither L-NMMA (100 microM; n = 3) nor L-NAME (1 mM; n = 4) (both NO-synthase inhibitors) affected the Isc response to L-arginine. The effects of arginine or lysine were replicated by alkalinization that mimicked the transient alkalinization of the bath solution upon addition of these amino acids. We conclude that in M-1 cells L-arginine stimulates Na+ absorption via a pH-dependent, but NO-independent mechanism. The observed net cationic amino acid absorption will counteract passive cationic amino acid leak into the CCD in the presence of electrogenic Na+ transport, consistent with reports of stimulated expression of Na+ and cationic amino acid transporters by aldosterone.

The corporate social responsiveness orientation of hospital directors: does occupational background make a difference?

The results of a survey of 184 directors from 15 hospitals are analyzed to determine their corporate social responsiveness orientation. They indicate that board members whose occupational background is not in health care exhibit greater concern for economic performance and the legal component of corporate responsibility than their counterparts whose occupational background is in health care. No significant differences between the two groups were observed with respect to the ethical and discretionary dimensions of corporate social responsibility. Some explanations as well as limited generalizations and implications are developed.

Selective targeting of magnetic albumin microspheres to the Yoshida sarcoma: ultrastructural evaluation of microsphere disposition

Magnetic albumin microspheres (1 micron average diameter) were selectively targeted to subcutaneous solid Yoshida sarcoma tumors (average size 450 mm2) in Holtzman rats. This was accomplished by placing an external magnet adjacent to the tumor while the microspheres were infused. Microspheres contained ultra-fine particles of Fe3O4 and no drug (placebo). Placebo microspheres were used due to the previously demonstrated rapid tumoricidal effect of targeted low-dose doxorubicin microspheres. Animals were killed 10 min, 60 min, 30 min, 24 hr and 72 hr after microsphere administration and tumors were examined by transmission electron microscopy to determine the in vivo disposition of the magnetically targeted microspheres. Using placebo microspheres, we have demonstrated microspheres endocytosed in endothelial cells as early as 10 min after infusion. By 30 min microspheres can be seen in the extravascular compartment, sitting adjacent to tumor cells and occasionally in tumor cells. By 24 hr the majority of microspheres have been endocytosed by tumor cells. Microspheres were still observed within tumor cells as late as 72 hr after administration. The rapid extravasation and cellular uptake of magnetically focused microspheres explains the extremely rapid tumoricidal effect previously observed when doxorubicin-containing microspheres were targeted to the tumor.

Selective targeting of magnetic albumin microspheres containing low-dose doxorubicin: total remission in Yoshida sarcoma-bearing rats

Magnetically responsive albumin microspheres containing doxorubicin hydrochloride were selectively localized in Yoshida sarcoma tumors. Tumors were implanted subcutaneously in the tail of Holtzman rats and allowed to grow to at least 200 mm2 size before initiation of experimental treatment. Drug-bearing microspheres at a dose level of either 0.5 or 2.5 mg/kg were infused proximal to the tumor via the ventral caudal artery. A bipolar permanent magnet was placed adjacent to the tumor during the infusion to effect localization. Control animals were treated with free doxorubicin infused intra-arterially at 5.0 mg/kg or 0.5 mg/kg. In other test groups animals received placebo microspheres localized in the tumor via influence of the external magnetic field, or drug-containing microspheres were infused without utilization of the magnet to effect localization. Of the 22 animals receiving magnetically localized doxorubicin microspheres 17 had total histological remission of the tumor. The remaining animals demonstrated marked tumor regression representing as much as 500-600 mm2 decrease in tumor size. While no deaths or metastases occurred in the groups receiving localized drug, animals treated with free doxorubicin, placebo microspheres or non-localized doxorubicin microspheres exhibited a significant increase in tumor size with metastases and subsequent death in 90-100% of the animals. No significant differences were noted in tumor regression/remission data between the 0.5 and 2.5 mg/kg dose levels of magnetically localized doxorubicin spheres. These results represent a significant advance in targeted chemotherapy in that 77% of the animals in the magnetically localized doxorubicin microsphere treatment groups exhibited total remission after only one regimen of drug therapy.

Tumor remission in Yoshida sarcoma-bearing rts by selective targeting of magnetic albumin microspheres containing doxorubicin

Magnetically responsive albumin microspheres containing doxorubicin and magnetite (Fe3O4) were selectively targeted to Yoshida sarcoma tumors in rats by utilizing an extracorporeal magnet. Tumor cells were inoculated subcutaneously in the tail of rats, and the tumors were allowed to grow to an average size of 9 X 45 mm prior to initiating treatment. Drug-bearing microspheres (0.5 mg of doxorubicin per kg of body weight) were infused proximal to the tumor through the ventral caudal artery while the tumor was exposed to an external magnetic field of 5500 Oe for 30 min. Control animals received free doxorubicin administered either intravenously (5 mg/kg) or infused intraarterially (5 and 0.5 mg/kg), drug-bearing microspheres infused intraarterially (0.5mg/kg), without the external magnet, or placebo microspheres with magnetic localization. Of the 12 animals treated with a single dose in the experimental group, 9 exhibited total remission of the tumor, representing a disappearance of tumors as large as 60 mm in length. Marked tumor regression was observed in the remaining three rats, and no deaths or metastases occurred in the experimental group. In contrast, significant increases in tumor size with widespread metastases occurred in all control groups and most rats died. These experiments indicate that targeting of oncolytic agents to solid neoplasms by magnetic microspheres may be a means of increasing the efficacy and decreasing the toxicity of antitumor agents.

Orally active esters of cephalosporin antibiotics. 3. Synthesis and biological properties of aminoacyloxymethyl esters of 7-[D(-)-mandelamido]-3-[[(1-methyl-1H-tetrazol-5-yl)thio]methyl]-3-cephem-4-carboxylic acid

The synthesis of six amino acid acyloxymethyl esters of cefamandole (1), a semisynthetic broad-spectrum cephalosporin antibiotic, is described. These esters were examined as potentially useful orally active antibiotic prodrugs. When tested for oral efficacy against Streptococcus pyogenes C203 in mouse protection tests, the esters were not notably more active than lithium cefamandole. Further studies demonstrated that significant blood and urine levels of 1 were not obtained after dosing 2a, 2b, and 2f orally at 17 mg/kg in mice. A study of the stability to chemical hydrolysis and the possible relationship of hydrolysis to the lack of oral absorption of these esters is also presented.