Biomedical subjects
Publications and source records attributed to J W Gardeniers.
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We evaluated the results of 27 acetabular reconstructions in 21 patients with secondary osteoarthritis resulting from congenital dysplasia of the hip in which the acetabular bone defects were restored with impacted morcellized bone-grafts in combination with a cemented cup. At an average follow-up of 7 years, 7 months (range, 5-15 years), 2 hips were revised. One cup was revised after 27 months for sciatic nerve problems; the other hip was revised for aseptic loosening of the cup at 12 years' follow-up. The cumulative survival of the acetabular reconstruction was 96.3% at 5- and 10-year intervals. Additionally, 2 hips (7.7%) showed stable radiolucent lines in zone III without migration of the cup. None of the cemented stems were revised. The bone impaction grafting technique is a safe and attractive method to restore bone deficiencies in dysplastic hips.
We report a long-term review of 41 acetabular reconstructions using impacted morsellized bone grafts and a cemented total hip arthroplasty (THA) in patients younger than 50 (22-49; average 38) years. Reconstruction was performed in 23 primary THA (19 patients) and 18 revision THA (17 patients). 3 patients were lost to follow-up and 3 (4 hips) died within 10 years of surgery; none had a revision. Thus, 34 hips (30 patients) were reviewed with an average follow-up of 13 (10-18) years. In 2 hips, a revision was performed for aseptic loosening of the acetabular component 7 and 11 years after surgery. One additional cup was revised after 12 years during a femoral stem revision due to wear and matching problems, but was well fixed. The survival rate of the acetabular reconstruction technique was 94% (95% CI: 90-98%).
Acetabular bone stock loss compromises the outcome in primary and revision total hip arthroplasty. In 1979, a biologic method was introduced with tightly impacted cancellous allografts in combination with a cemented polyethylene cup for acetabular reconstruction. With this technique, it is possible to replace the loss of bone and to repair normal hip mechanics and hip function with a standard implant. Based on the authors' 20 years experience, a review of the long-term data is presented in primary total hip arthroplasty with preexisting acetabular bone stock loss, primary total hip arthroplasty in rheumatoid arthritis, patients who had bone impaction when younger than 50 years, and in acetabular revisions. The survival rate with revision of the cup for aseptic loosening as the end point was 94% at 10 to 17 years, 90% at 10 to 18 years, 91% at 10 to 17 years, and 92% at 10 to 15 years. From biopsy specimens from humans and histologic data in animal experiments the incorporation of these impacted bone chips was proven. The acetabular bone impaction technique using large morselized bone chips (range, 0.7-1 cm) and a cemented cup is a reliable technique with favorable long-term outcome.
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The Judet acrylic femoral head hemiprosthesis was first implanted in 1946. We performed bilateral revision in one patient 45 years after implantation of a Judet prosthesis. Histological analysis of femoral neck remnants and joint capsule did not show aggressive osteoclastic bone resorption or signs of dynamic bone apposition as is frequently observed nowadays with failed total hip prostheses. Only limited tissue reaction was seen with some macrophages with a foamy cytoplasm. This case report confirms the extremely good tissue tolerance of PMMA, as reported by Judet in 1950, even after 45 years follow-up.
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The most common cause of failure of cemented and cementless total hip arthroplasties is aseptic loosening, a slow but progressive process that often results in loss of bone stock. The diagnosis of loosening of the prosthetic component is difficult and depends mainly on migration and change in position of the prosthesis and the appearance of clear zones around the prosthesis on X-ray photographs. The key problem in revision surgery is how to manage the periprosthetic bone loss. Controversy exists about the best treatment for bone stock defects. The various techniques are directed at restoration of the hip mechanics, restoration of the defects in the osseous wall, replacement of the resorbed bone and thus restoration of the functional stability of the joint.
Loosening of total hip replacements is often associated with severe loss of periprosthetic bone. The notion exists that the remaining bone is sclerotic, avascular, and displays little osteogenic activity, and that it therefore potentially compromises the revitalization of bone grafts used to restore bony defects. To verify this opinion we studied the bone characteristics in acetabular bone biopsies taken at primary total hip arthroplasty (PTH) and revision total hip arthroplasty (RTH) for a cemented PTH. In 6 PTH patients and in 10 RTH patients, acetabular bone biopsies were taken from the roof, the center, and the lower rim of each acetabulum. Specimens were evaluated by light microscopy and histomorphometrically measured for specimen size, bone area, perimeter, active osteoid perimeter, number of vessels, and osteoclasts. The vascularity and vitality appeared to be comparable in the RTH and PTH bone biopsies. However, the trabecular organization of the RTH bone differed from that of the PTH biopsies. In the PTH biopsies, the trabeculae were running perpendicular to the subchondral bone layer, whereas in the RTH biopsies the layers of bone were oriented parallel to the implant surface. There was abundant remodeling activity in the RTH bone, with large quantities of active osteoid and osteoclasts. These histologic parameters differed, but not statistically significant, from the PTH biopsies. In conclusion, we found that at revision, the acetabular bone was viable with sufficient vascularity and remodeling activity to provide an acceptable recipient host bone bed for revision surgery combined with bone grafting.
We report a long-term review of 60 acetabular components revised using impacted, morsellised bone allografts and a cemented polyethylene cup. The acetabular defects were cavitary (37) or combined (23). Follow-up was for a mean 11.8 years (10 to 15). Further revision was needed in five hips, two for septic and three for aseptic loosening. The overall survival rate at 11.8 years was 90%; excluding the septic cases it was 94%. Acetabular reconstruction with impacted morsellised cancellous grafts and cement gives satisfactory long-term results.
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Bone reactions were studied around a titanium, hydroxyapatite (HA)-coated Osteonics (Allendale, NJ) bipolar hip prosthesis, which was revised for severe midthigh pain 4 years after implantation. Inspection of the retrieved prosthesis using a dissecting microscope revealed scarce remnants of a coating-like material on the surface of the prosthesis; however, histology of this layer and histology of the bony side of the bone--HA interface failed to reveal any remnants of an HA coating. The interface was covered predominantly by trabecular bone, which closely followed the contour of the prosthesis, and was partly woven nonmineralized bone. At locations where mineralized bone faced the prosthesis, many small dark titanium wear particles were found. Similar particles were found in macrophages in the intertrabecular medullary space. Polyethylene wear particles were specifically located in macrophages in a soft tissue interface at more distal levels along the stem of the prosthesis. Although the observations presented in this case cannot be generalized, it clearly shows that the HA coating layer had completely disappeared after 4 years. More detailed retrieval studies and longer clinical follow-up studies are needed before a final evaluation of the behavior of HA coatings and long-term fixation of HA-coated prostheses can be made.
The popliteal pterygium syndrome is characterized by multiple anomalies of the face, genito-urinary system and extremities with autosomal dominant inheritance with variable expression. Also sporadic cases probably based upon spontaneous mutation can be recognized. The plastic, orthopaedic, and maxillofacial surgeon should be aware of the variable nature of the syndrome and should consult a medical geneticist. A coordinated team approach appears to be most adequate for diagnosis, counselling and treatment.
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Vesico-intestinal fissure or exstrophy of the cloaca is a rare but serious birth defect of the urogenital tract and distal part of the digestive tract. The most important hallmarks are: bladder exstrophy, fusion between bladder and the exstrophied iliocoecal region, short blind-ending colon and imperforate anus. In addition the lower part of the body shows defects of the abdominal wall, symphysis, upper urinary tract, the internal and external genitals, lumbosacral spine, spinal cord and the lower extremities. It is just after 1960 that corrective surgery started to become successful. Because of the complexity of the anomaly it seems that only management by a team of specialists in a centre for pediatric surgery guarantees optimal treatment. The quality of live of these children can still be improved by application of the newest surgical techniques and excellent cooperation between the different involved specialists. The defects, surgical treatment and results in eight patients with vesico-intestinal fissure, seen at the Universitair Centrum voor Chirurgie bij Kinderen Nijmegen (UCCKN) from 1974 till 1989 inclusive, are presented.
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