Objective To investigate the method and effectiveness of vacuum seal ing drainage (VSD) combined with debridement for treatment of deep infection after hip or knee replacement. Methods Between September 2006 and May 2010, 13 cases of deep infection after joint replacement surgery were treated, including 5 males and 8 females with an average ageof 62.5 years (range, 56-78 years). Infection occurred at 7 days to 1 year and 2 months (median, 14 days) after joint replacement surgery. The time from infection to admission was 8 days to 4 years and 6 months (median, 21 days). Purulent secretion with or without blood were observed in all patients; sinus formed in 5 cases; and unhealing of incision or drainage opening disunion were observed in 8 cases. The size of skin defect at secretion drainage or sinus opening site was 5 mm × 3 mm to 36 mm × 6 mm; the depth of drainage tunnel or sinus was 21-60 mm. The histopathological examination in 11 patients showed acute infection or chronic infection with acute onset in 10 cases, and tuberculosis in 1 case. In 6 cases of secretion culture, Staphylococcus aureus was isolated from 5 cases. After thorough debridement, wound irrigation was performed during the day and VSD during the night in 10 cases. VSD was merely performed in 3 cases. Results In 1 case after revision total hip arthroplasty, the wound bled profusely with VSD, then VSD stopped and associated with compression bandage, VSD proceeded again 3 days later with no heavy bleeding. All the patient were followed up 1 year to 4 years and 5 months (mean, 2 years and 11 months). Infection were controlled 7-75 days (mean, 43 days) after VSD in 10 cases. In these cases, prosthesis were reserved, no recurrent infection was observed, wound were healed, limb function were reserved. VSD was refused in 1 case because of hypersensitive of the pain at the vacuum site, infection control was failed and amputation at the thigh was proceeded. The effect was not evident in 1 case with tuberculosis infection, then the prosthesis was removed and arthrodesis was proceeded followed by complete union. In 1 case, infection was cured with VSD, recurrent infection happened after 9 months, antibiotic-impregnated cement spacer was used at end, and no recurrence was observed 1 year and 4 months later. Conclusion VSD combined with debridement can drainage deep infection sufficiently, promote wound healing, reduce recurrent infection rate, maximize the possibil ity of prosthesis preservation.
Objective Aseptic loosening of prosthesis is associated with peri prosthetical osteolysis caused by osteoclast activation. Receptor activator of nuclear factor kappa B (NF-κB) l igand (RANKL)/receptor activator of NF-κB (RANK) signalpathway is fundamental in osteoclast activation. To determine whether RANKL antibody can inhibit inflammatory osteolysis in a osteolysis model of mouse. Methods Sixty female BALB/c mice (aged 8-10 weeks, weighing 18-20 g) were selected. The skull bone piece was harvested from 20 mice as the donor of bone graft; the subcutaneous air pouches (2 cm × 2 cm) models were established on the back of the other 40 mice and the skull bone piece was inserted into the air pouches. The 40 mice were equally divided into groups A (negative control group), B (positive control group), C (low-dose RANKL antibody group), and D (high-dose RANKL antibody group). At 1 day after bone graft, 0.5 mL PBS was injected into the pouch of group A, 0.5 mL PBS containing titanium particle into groups B, C, and D. At 2 days before the titanium particle was injected, RANKL antibody (0.1 mL) were injected into the pouch of group C (50 μg/mL) and group D (500 μg/mL), respectively every day for 2 days, and 0.1 mL PBS into groups A and B. At 14 days after bone implantation, the pouchmembranes containing implanted bone were harvested for gross observation and histological analyse. Results All mice survived to the end of experiment, and incisions healed well. The gross observation showed that inflammatory responses, exudation, and vascular proliferation were obvious in group B, and were inconspicuous in groups A, C, and D. The histological analysis showed that significantly more infiltration of inflammatory cells, more obvious bone resorption, more bone collagen loss, and more positive staining area were observed in group B than in groups A, C, and D. There were significant differences in inflammatory cell number, pouch membrane thickness, bone collagen loss, and osteoclast content between group B and groups A, C, and D (P lt; 0.05). Conclusion RANKL antibody can directly blockRANKL/RANK signal pathway, which is an efficient therapy to inhibit bone absorption associated with implant wearing particles.
Objective To observe the effect of recombinant human osteoprotegerin (rhOPG) on osteoclasts which were stimulated by polyethylene particles and to investigate the feasibil ity of applying rhOPG for the prosthetic aseptic looseness. Methods The osteoclasts were isolated from the long bones of 5 New Zealand rabbits born within 24 hours, weighing 80-100 g, male or female, and were plated into the 24-well coversl ips (10 mm × 10 mm) and bone sl ices (8 mm × 8 mm × 50 μm) at the density of 1 × 105/mL. Based on the different concentration and density of rhOPG and polyethylene particles, the plates of culture were divided into 3 groups: the group with polyethylene particles of 1 × 109/mL (polyethylene group), the group co-cultured with polyethylene particles of 1 × 109/mL and rhOPG of 100 ng/mL (polyethylene/rhOPG group) and the control group . The glass cover sl ips and bone sl ices were exposed to HE, toluidine blue and tartrate-resistant acid phosphatase (TRAP) staining at 1, 3, 5 and 7 days, and TRAP positive multinucleated cells and bone resorption tips were counted. Scanning electron microscope was used to observe the pits of bone resorption. Results The osteoclast was rose-red when exposed to TRAP staining. For the number of the TRAP-positive osteoclasts, the polyethylene group witnessed an obviouse increase compared with the control group and the polyethylene/rhOPG group after 5 and 7 days of culture (P lt; 0.05). And no significant difference between the control group and the polyethylene/rhOPG group was evident (P gt; 0.05). The pits of bone resorption was blue-purple when exposed to toluidine blue staining. For the number of bone resorption pits in the bone sl ice, significant difference was evident between the polyethylene group and the control group after 5 and 7 days of culture (P lt; 0.05), and there was significant different between the polyethylene/rhOPG group and the polyethylene group 1, 3, 5 and 7 days after culture (P lt; 0.05). Conclusion rhOPG could inhibit the stimulated effect of polyethylene particles on osteoclasts, and might be used to prevent the prosthetic aseptic looseness after artificial joint substitution.
Objective To achieve threedimensional (3D) contour image of boneand articular cartilage for fabricating custommade artificial semiknee joint as segment bone allograft.Methods The distal femora of human and pig were scanned with Picker 6000 spiral X-ray computed tomography with 1.0 mm thick slice. The data obtained were treated in Voxel Q image workstation for 3D reconstruction with volume rendering technique. After being downloaded to personal computer at 0.1 mm interval, the transaxial 2D image data were converted into 2D digitized contour data by using image processing software developed by the team. The 2D digitized data were inputted into image processing software of Surfacer 9.0 (Imageware Company, USA), then the 3D wire frame and solidimages of femoral condyle were reconstructed. Subsequently， based on the clinical experience and the requirement of the design of artificial knee joint, the 3Dcontour image of bone or articular cartilage was extracted from the surrounding.Results The 3D contour image of bone or articular cartilage presented was edited and processed easily for the computer aided design(CAD) of custom-madeartificial knee joint.Conclusion The 3D contour image of boneand articular cartilage can be obtained by spiral CT scanning, and the digitized data can beapplied directly to CAD of custom-made artificial joint and subsequently rapidprototyping fabricating. In addition, the reconstruction method is simple and can be applied widely to clinical implant fabricating practice of dentistry and orthopaedics.
Objective To evaluate the selection of the type of prosthesis in revision hip arthroplasty. Methods There were 33 hips in our study,male in 7 hips and female in 26 hips.The average age of the patients were 59 years.The reasons ofthe revision included aseptic loosing in 22 hips, infection in 8 hips(2 infection hips with discharging sinuses),and acetabular erosion in 3 hips.The operationsfor revision were 13 cemented and 12 cementless acetabular prosthesis with autograft inmorselized form;the femoral revision were all selected in cemented prosthesis.The revision for infection hip were all cemented prosthesis of extensively porouse-coated. Results The average follow-up duartion was 3.9 years and 11 months.There was a radiolucency but no clinical instability accompanied in 2 hips and remaining moderate pain in4 hips.No dislocation and fracture were seen in the series.Harris score were improved to 82.4(68.88). Conclusion The commonest reason of revision hip arthroplasty was aseptic loosing.The acetabular prosthesis in revision could select cemented or cementless components and femoral prosthesis could select extensively coated stem.The cemented components could yield good results in infection hips revision.
Objective To evaluate the clinical results of cementless total hip replacement (THR) in treating osteoarthritis and identifying the factors affecting the results. Methods From January 1995 to December 1999, 76 patients(85 hips) with osteoarthritis of hip joint were treated. These patients were assessed according to Harris hip score and X-ray film. The average follow-up time was 49.3 months. Results The average Harris score in the patients was 90.9 points. The excellent or good rate was 91.9%(75/85). Pain in the thigh existed in 23 hips (27.5%). The femoral osteolysis occurred in 14 hips(16.5%). The radiographical result demonstrated femoral loosening in 2 hips. harris score became lower when the femoral component of osteoarthritis of hip jointl. Pain in the thigh may be related to the varus placement of femoral component and femoral osteolysis. Femorla osteolysis is one of important factors affectin the long-term outcomes.
In order to evaluate the long-term effect of total hip replacement (THR) in patients with steroid-induced femoral head necrosis, 40 cases of 50 hips received THR patients were followed up for an average of 8.5 years after operation. Evaluation was carried act according to Harris score system. In these cases, average score was seventy-five points. Revision rate among them was 2% after four years and 18% after five to eight and a half years, with as overall rate of 20%. It was found that the main reason for revision was looseness of the prosthesis. In this follow-up, it showed that besides foreigen body reaction, abnormal osseous remodelling was the main factor in long-term failure of this arthroplasty. It was also proved that it was a good selection to perform cemented total hip replacement in younger patients, which could improve living quality.
ObjectiveTo investigate the current problems and corresponding solutions regarding the use of antibiotic-impregnated cement spacer for the treatment of periprosthetic joint infection (PJI). MethodsA retrospective analysis was made on the clinical data of 27 patients with PJI who underwent two-stage revision with antibiotic-impregnated cement spacer between January 2001 and January 2013. There were 12 males and 15 females, with an average age of 62.7 years (range, 25-81 years). All arthroplasties were unilateral, including 19 hip PJI and 8 knee PJI. The mean duration from primary arthroplasty to PJI was 25 months (range, 3-252 months). After infection was controlled with the antibiotic-impregnated cement spacer combined with systematic antibiotics treatment, two-stage revision was performed. The effectiveness was evaluated. ResultsOne patient died of myocardial infarction at 2 days after surgery. Infection was controlled, and two-stage revision was successfully performed in 19 patients; deep venous thrombosis occurred in 1 of 3 patients who experienced hip spacer fractures, which was cured after conservative management. The spacers were removed and bacteria-sensitive antibiotics was used because of recurrent infections after the first-stage surgery in 7 patients; 3 patients gave up treatment because infection was not controlled, 4 patients received revision after infection was controlled. Twenty-three patients were followed up 1-5 years (mean, 2.3 years). The average Harris hip score and KSS score at 1 years after revision were significantly improved when compared with preoperative ones (P<0.05). In the 8 patients with gram-negative or fungus infection, 7 were found to have recurrent infection after the first-stage surgery; in the 12 patients with gram-positive infection, no recurrent infection was found. Failed treatment was observed in 1 patient with gram-positive and gram-negative infections and 2 with fungus infection, respectively. ConclusionAntibiotic-impregnated cement spacer has a satisfactory effectiveness for PJI. However, complication of spacer fracture should be noted, especially hip spacers. If the pathogen is gram-negative bacteria or fungus, the implanted spacer may increase the possibility of recurrent infection.
ObjectiveTo investigate the effects of fibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery. MethodsBetween July 1999 and March 2013, 76 patients with neoplasms of the proximal tibia underwent tumor resection, prosthetic replacement, and gastrocnemius medial head flap transfer. Among them, 38 patients underwent fibular head resection (group A) and 38 underwent fibular head preservation (group B). There was no significant difference in gender, age, side, tumor classification and stage, and disease duration between 2 groups (P>0.05). The complications and the position of the components were observed, and American society for bone tumors scoring system (MSTS93) was used to evaluate the joint function. ResultsAll patients were followed up 12-150 months (mean, 87 months). Incision infection occurred in 1 patient (2.63%) of group A and 6 patients (15.79%) of group B, showing significant difference (χ2=3.934, P=0.047). Necrosis of gastrocnemius medial head flap was found in 1 patient of group A and 2 patients of group B. Prosthetic loosening and instability of the knee were observed in 4 and 2 cases of group A and in 6 and 4 cases of group B, respectively. In groups A and B, there were 3 and 5 cases of local recurrence, 7 and 6 cases of distant metastasis, and 8 and 7 deaths, respectively. According to MSTS93, the results were excellent in 23 cases, good in 10 cases, fair in 3 cases, and poor in 2 cases, with an excellent and good rate of 86.84% in group A; the results were excellent in 21 cases, good in 11 cases, fair in 3 cases, and poor in 3 cases, with an excellent and good rate of 84.21% in group B; and no significant difference was found in the excellent and good rate between 2 groups (χ2=0.106, P=0.744). ConclusionFibular head resection in prosthetic replacement for neoplasms of the proximal tibia in limb salvage surgery is beneficial to intra-operative tissue coverage, and it can reduce trauma by skin transplantation and related complications. Good stability and motion of the joint can be obtained after operation.