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Objective Tanezumab, a monoclonal antibody against nerve growth factor, has demonstrated efficacy in clinical trials of chronic pain in osteoarthritis (OA) and chronic low back pain. Unexpected adverse events (AEs) described as osteonecrosis (ON) occurred during tanezumab development, leading the US Food and Drug Administration to impose a partial clinical hold for all indications except cancer pain. A blinded Adjudication Committee (AC) including orthopedic surgeons, rheumatologists, and an orthopedic pathologist reviewed and adjudicated joint-related AEs in the tanezumab clinical program. Methods The AC adjudicated all reported cases of ON as well as cases of total joint replacements (TJRs) not reported as ON for which radiographs obtained within 9 months of the surgery were available. The AC prespecified categories for joint safety events including primary ON, worsening OA (rapid progression of OA [RPOA], normal progression of OA, insufficient information to distinguish between rapid and normal progression of OA), other, or insufficient information to distinguish between primary ON and worsening OA or another diagnosis. Results The AC reviewed events in 249 of 386 patients with an investigator-reported AE of ON and/or a TJR. Two events were adjudicated as primary ON, 200 events were adjudicated as worsening OA (68 of which were classified as RPOA), 29 events had another diagnosis, 11 had insufficient information to distinguish primary ON from worsening OA, and 7 did not have committee member consensus. Conclusion Despite initial reports, tanezumab treatment was not associated with an increase in ON but was associated with an increase in RPOA. Higher doses of tanezumab, tanezumab administered with nonsteroidal antiinflammatory drugs, and preexisting subchondral insufficiency fractures were risk factors for RPOA in this cohort.

Introduction Patient-related factors impact the long-term survival of hip arthroplasty. This study evaluated whether there were differences in outcome measures between men and women undergoing total hip arthroplasty. Methods A retrospective study of prospectively collected data on 75 primary total hip arthroplasties in 72 patients was conducted. Medical history, physical examination, Harris Hip scores, and Quality of Life forms (SF-36) were obtained for each patient preoperatively and postoperatively. Preoperative radiographs were assessed using the Kellgren and Lawrence scoring system. Only patients with a minimum follow-up of 2 years were included. Results Preoperatively, women and men had comparable Kellgren and Lawrence scores and Harris Hip scores. Of the 8 subscores for the SF-36, only the Physical Functioning subscore was significantly different preoperatively. Similar results were noted postoperatively; again, only the Physical Functioning subscores were significantly different between men and women. Conclusions Physician assessments were not significantly different preoperatively and postoperatively for men or women. The results for the SF-36 were similar except for a significant difference in the Physical Functioning subscore preoperatively and postoperatively. According to the Medical Outcomes Trust, the SF-36 Physical Functioning score has been shown to be the best all-around measure of physical health.

A moderator and panel of five experts led an interactive session in discussing five challenging and interesting patient case presentations involving surgery of the hip. The hip pathologies reviewed included failed open reduction internal fixation of subcapital femoral neck fracture, bilateral hip disease, evaluation of pain after metal-on-metal hip arthroplasty, avascular necrosis, aseptic loosening secondary to osteolysis and polyethylene wear, and management of ceramic femoral head fracture.

Patellar instability (PI) after total knee replacement (TKR) is one of the more frequent complications following the procedure. It is nearly completely avoidable with attention to detail during the procedure and particularly at the time of trial reduction. PI may be the result of malalignment of any of the components, not just malalignment of the patellar component. Most patients do not present for TKR with PI. Therefore if PI is evident at the time of tiral reduction, a check for component malalignment should ALWAYS be carried out, and not an immediate default to lateral release. Preoperative PI increases the risk of postoperative PI. The surgeon must be prepared to do whatever is necessary to be certain that there is no PI when the surgery is finished. This can include lateral release, but in some cases, medialization of the tibial tubercle may be necessary. When PI is encountered in follow-up after TKR, a careful evaluation of component malalignment is essential, including rotational malalignment of the femoral or tibial components that might not be obvious of standard radiographs.

Twenty-four clinically successful, autopsy retrieved porous-coated anatomic total knee arthroplasty (TKA) specimens were evaluated to determine the structure and function of the patellar meniscus. Mean implant duration was 76 months (range: 11-135 months). Histological examination showed the patellar meniscus to be composed of dense fibrous tissue with scattered regions of chronic granulomatous response to polyethylene debris. Patellar wear and polyethylene exposed patellar surface area were correlated with implant duration (r = 0.47, P = .03; r = 0.52, P = .06). Postoperative patellar tilt was also associated with patellar component wear (r = 0.64, P = .03). No other clinical measures were significantly associated with patellar wear or exposed surface area. Additional research is needed to determine what role, if any, the patellar meniscus plays in TKA outcomes.

Cementless total hip replacement has been advocated for patients with osteonecrosis of the femoral head. This study examined the outcome of the femoral stem of four generations of an uncemented, proximally porous-coated, chrome-cobalt total hip prosthesis. There were 158 cases in 141 osteonecrosis patients (74 men, 67 women) who had a mean age of 46 years (range, 17-83 years). The mean follow-up was 103 months (range, 20-235 months). The femoral components of 144 cases were not revised and had a mean Harris hip score of 84 (+/-15) at final follow-up. Of the 14 revisions (8.9%), the primary reasons for revision were loosening or significant osteolysis. There were one infection and one chronic dislocation. Proximally porous-coated, anatomic, press-fit stems provide excellent long-term results in patients with osteonecrosis of the femoral head.

With the advent of cell-based therapies, biologics, and pharmaceuticals for the potential treatment of osteonecrosis, it is important to conduct evaluations using scientifically accepted outcomes measures. For the treatment of osteonecrosis, most studies have focused on pain relief, surgery, or the need for surgery, disease progression (advancing stage), and change in lesion size. Quantification of imaging techniques continue to gain in sophistication but have not yet been validated for use in clinical trials. Despite recent interest in using biomarkers or genetic markers in the diagnosis and analysis of disease progression, more research is needed to determine the sensitivity and specificity of these techniques with respect to osteonecrosis.

Since the 1970s, the mantra of those treating osteonecrosis of the femoral head was to save the head at all costs. Total hip arthroplasty (THA), the only effective surgical treatment once the head has mechanically and clinically failed, had a poor track record for young active patients. Recently, THA using highly cross-linked polyethylene, metal-on-metal bearing surfaces, or ceramic-on-ceramic bearing surfaces have given promising results, changing the "save-at-all-costs" paradigm. Operations that have a low success rate, high complication rate or morbidity, or compromise subsequent THA can no longer be justified. This includes femoral osteotomy and free vascularized fibular graft. Core decompression is justified, when indicated, because of its low morbidity and absence of complications with subsequent THA.

The evaluation of retrieved orthopaedic implants. removed at revision surgery or autopsy. contributes to our understanding of how implants behave in situ as well as how the human body responds to the implant and its biomaterials. Establishing an orthopaedic implant retrieval program requires knowledge of regulatory issues (IRB review. e.g.). personnel, equipment (saw. disposables. etc.), and financing. Maximizing the information that can be acquired from each explant is dependent upon adequate preparation including determining what questions are to be addressed, establishing standard operating procedures, and deciding which analyses will be performed. Analyses may include photographic. radiographic. biomechanical, histologic. And various spectroscopy techniques. The decision as to which analysis or analyses will be performed dictates how best to handle and process the retrieved specimens. There are many steps in the process of a successful implant retrieval beginning with approaching the patient a...

Recent studies have indicated that the rate of successful long-term outcome after primary total hip arthroplasty for patients with osteonecrosis may be improved with the use of later-generation porous-coated prostheses (biologic ingrowth fixation) and cement techniques (cement fixation). Less is known about the long-term outcome after revision arthroplasty in the same patient population. The purpose of this study was to characterize the clinical and radiographic outcomes of revision total hip arthroplasty in patients with osteonecrosis.We evaluated thirty-four osteonecrotic hips in thirty patients who had undergone revision of a femoral component of a prior total hip arthroplasty. There were nineteen men (twenty-two hips) and eleven women (twelve hips) with a mean age of forty-six years. Thirty one of thirty-four hips were implanted without cement. The cementless prostheses were of different stem lengths, but thirty of thirty-one were proximally porous coated. The mean duration of follow-up was 8.2 years. Prerevision radiographs were used to determine the degree of femoral bone loss according to the classification system of Della Valle and Paprosky. The need for revision was analyzed for correlation to known risk factors for osteonecrosis, age and gender of the patient, and degree of prerevision femoral deficiency. A clinical and radiographic evaluation of outcome was performed.This was the first revision for twenty-seven hips, the second for five hips, and the third for two hips. Preoperatively, the defects included four Type I, nine Type II, fifteen Type IIIA, two Type IIIB, one Type IV, and three unknown. The femoral component was rerevised in twelve of the thirty-four hips. One of the failures was the only fully porous-coated stem that was implanted. One of the three cemented implants failed, as compared with eleven of the thirty-one noncemented implants. Survival rates were 90.9% at five years, 54.8% at ten years, 54.8% at fifteen years, and 27.4% at twenty years. With the small sample size, no relationship could be identified with regard to frequency of re-revision and defects, associated risk factors, patient age, or gender.There was a high failure rate of revised, uncemented, proximally coated femoral components in patients with osteonecrosis of the femoral head at the time of the intermediate-term follow-up. The cause of failure could not be correlated with patient age, gender, risk factors for osteonecrosis, or femoral bone stock.Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Multiple classification systems for osteonecrosis of the hip have been developed to assist physicians in the diagnosis and treatment of this potentially debilitating disorder. The purpose of this analysis was to delineate the classification systems utilized in reports published since 1985 and, through a comparison of the most commonly used systems, to identify consistent factors that would allow for cross-publication comparisons to be made.We performed a PubMed search for reports of outcome studies concerning treatment methods for osteonecrosis of the hip. All studies of reported outcomes with greater than ten patients were included in the analysis. Various classification systems were tabulated to determine usage frequencies. The four most commonly used systems were then analyzed to determine common factors used for classification.One hundred and fifty-seven studies were available for analysis. Sixteen major classification systems that made use of more than one radiographic factor were identified, and nine of these systems had one to five modifications reported throughout the literature. Additionally, eleven other systems made use of single factors obtained from either magnetic resonance imaging or anatomic data. The review revealed that four classification systems accounted for greater than 85.4% of the reported studies. Parameters for these four systems were stratified to allow for uniformity of patient or study evaluation.This analysis of the reported classification systems for osteonecrosis of the femoral head revealed several similarities between the most commonly used systems. An analysis of patients can be made with any of the four major systems if specific data are collected according to various magnetic resonance imaging and radiographic findings. This approach will allow for easier comparison of studies across different centers.Prognostic Level III. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

The panel reviewed cases involving both revision and primary total hip arthroplasties. The panelists are Hugh Cameron and Allan Gross from Toronto, Charles Engh from Arlington, Aaron Rosenberg from Chicago, and Bernard Stulberg from Cleveland. The cases discussed brought up some controversial issues.

The etiology of osteonecrosis of the hip may have a genetic basis. The interaction between certain risk factors and a genetic predisposition may determine whether this disease will develop in a particular individual. The rationale for use of joint-sparing procedures in the treatment of this disease is based on radiographic measurements and findings with other imaging modalities. Early diagnosis and intervention prior to collapse of the femoral head is key to a successful outcome of joint-preserving procedures. The results of joint-preserving procedures are less satisfactory than the results of total hip arthroplasty for femoral heads that have already collapsed. New pharmacological measures as well as the use of growth and differentiation factors for the prevention and treatment of this disease may eventually alter our treatment approach, but it is necessary to await results of clinical research with long-term follow-up of these patients.

Metal alloys are used as prosthetic components in the orthopaedic and dental field. However, there is growing concern over the reported leaching of metal ions from implants. Ions released from metals have been thought to be associated with local immune dysfunction, inflammation, and tissue cell death. The objective of our study was to investigate whether nickel(II) and vanadium(V), present at a smaller percentage in most alloys, are cytotoxic to T-lymphocyte cell models. Jurkat T cells possess characteristics similar to human T-lymphocytes and proliferate at a faster rate. Jurkat T cells were incubated with control media alone or with concentrations of 1, 10, and 100 microg/mL of Ni(II) or V(V) for 24 h. Both types of metal ions reduced cell viability and proliferation in a dose-dependent manner. Ni(II) at 10 microg/mL and V(V) at 100 microg/mL activated Caspase-3 expression. Hoechst 33258 staining and transmission electron microscopy revealed chromatin condensation, as well as nuclear blebbing and fragmentation. Induction of DNA fragmentation by Ni(II) at 100 microg/mL was also indicated by agarose electrophoresis. Our observations indicate that Ni and V ions kill T cells via apoptotic and nonapoptotic pathways.

Purpose: To determine if cartilage particles increased the expression of TNF-α by articular chondrocytes. Type of study: In vitro experiment. Methods: Articular chondrocytes were obtained from patients undergoing primary total knee arthroplasty for osteoarthritis (n = 3) and from patients undergoing below-knee amputation for peripheral vascular disease (n = 3). Chondrocytes were then incubated with and without cartilage particles at a concentration of 5 μg/10 5 cells for 24 hours. TNF-α levels were then determined using reverse transcription polymerase chain reaction. Results: Both normal and osteoarthritic chondrocytes had low baseline expression of TNF-α under standard cell culture conditions. Expression was markedly increased in response to incubation with cartilage particles, and was statistically significant. Conclusions: Cartilage debris in the traumatized and osteoarthritic joint may increase the concentration of TNF-α in the joint, contributing to joint symptoms and cartilage destruction. Arthroscopic debridement and lavage may improve symptoms by washing these harmful components from the joint. Level of evidence: Level IV.

Currently, there is no consensus regarding the treatment of precollapse osteonecrosis, particularly for asymptomatic osteonecrosis. With approximately 10,000 to 20,000 new cases of osteonecrosis a year, no single surgeon or center has the kind of experience that is able to address the most important questions concerning this disease. The literature strongly documents that symptoms of osteonecrosis will progress. Although the literature also supports the progression of asymptomatic osteonecrosis to symptomatic osteonecrosis on to collapse, that support is less convincing. Progression is proportional to lesion size, with small lesions ( 30% of the femoral head) are less likely to be successfully treated by core decompression and small lesions (< 15% of the femoral head) are less likely to progress, asymptomatic lesions within these ranges can be observed. The literature supports the position that moderately sized lesions (15-30% of the femoral head) should be treated by core decompression (with or without bone grafting).

The treatment of large osteolytic lesions is a challenge during acetabular revisions. Periprosthetic bone loss can compromise the stability of new implants. The purpose of this study was to evaluate the 5- to 10-year clinical and radiographic results of morselized bone grafting for acetabular osteolysis during cementless acetabular revisions. Ninety-nine patients (108 hips) who had an acetabular revision hip arthroplasty for osteolysis were retrospectively reviewed. There were 44 men and 55 women who had a mean age of 66 years. At the index revision, the acetabular defects were debrided of granulomatous tissue and packed tightly with morselized cancellous femoral head allograft. All the revision acetabular components were implanted using cementless fixation. At a mean followup of 85 months (range, 60-118 months), the results of 103 of 108 hips (95%) were clinically and radiographically successful. The mean preoperative Harris hip score was 37 points, which improved to a mean of 91 points at the last followup. All cavitary defects had complete radiographic incorporation of the bone grafts except for two lesions. The results of this study indicate that morselized bone graft incorporates into cementless acetabular revisions. This treatment method provided a stable reconstruction in 98% of patients at a mean of 7 years followup.

Thirty knees in 27 obese patients were matched to 30 knees in 27 nonobese patients, with both cohorts followed for a mean of approximately 15 years. Nine of 30 obese knees were revised, whereas 3 of 30 nonobese knees were revised, with Knee Society objective scores being higher in the nonobese group. There were more polyethylene insert revisions in the nonobese group, which may have been accounted for by a trend of higher activity levels in this group. The authors concluded that at long-term follow-up, although not statistically significant, there was a trend for obesity to influence the rate of aseptic loosening. This may occur because of increasing stress at the bone-prosthesis interface, whereas increased activity levels in the nonobese patients may adversely affect the longevity of the polyethylene insert.

This review provides an update of the recent progress in etiology, pathogenesis, diagnosis, and treatment of osteonecrosis.Concerning pathogenesis, there is evidence that there is a genetic predilection for those who are exposed to the two leading etiologic associations for osteonecrosis: corticosteroids and alcohol. Studies concerning the treatment of osteonecrosis indicate that most preservative (ie, joint-sparing) procedures available today have better results in the precollapse stages of the disease and in smaller lesions. Therefore, researchers continue to develop and modify diagnostic techniques, particularly relating to MRI, for the identification and quantification of osteonecrotic lesions. Advances concerning bone grafting and arthroplasty procedures have resulted in improved clinical outcomes for this patient population. The future treatment of osteonecrosis may involve genetic or cell-based therapies.Although progress has been made, considerably more research is needed before we fully understand this disease. Hopefully, such research will lead to effective measures for saving the femoral head or, better yet, preventing osteonecrosis.

Objective The aim of this study was to test the effectiveness of nasal septal chondrocytes, propagated in microcarrier spinner culture, as an alternative tissue source of chondrocytic cells for cartilage grafts for head and neck surgery and for articular cartilage repair. Methods We harvested chondrocytes from 159 patients, ranging in age from 15 to 80 years and undergoing repair of a deviated nasal septum, and propagated the cells in a microcarrier spinner culture system. The nasal chondrocytes proliferated and produced extracellular matrix components similar to that produced by articular chondrocytes. Results In microcarrier spinner culture on collagen beads, chondrocyte numbers increased up to 14-fold in 2 weeks. After a month, the microcarriers seeded with nasal chondrocytes began to aggregate, producing a dense cartilage-like material. The newly synthesized extracellular matrix was rich in high molecular weight proteoglycans, and the chondrocytes expressed type II collagen and aggrecan but not type I collagen. Conclusion These studies support the feasibility of engineering cartilage tissue using chondrocytes harvested from the nasal septum. Injectable and solid formulations based on this technology are being evaluated for applications in craniomaxillofacial reconstructive surgery and for plastic and orthopedic surgery practices.

The Ehlers-Danlos syndromes (EDS) are a rare group of connective tissue disorders characterized by severe joint hypermobility and instability. Ten patients with 12 primary knee arthroplasties were identified. Average age at time of surgery was 43.3 years, with follow-up data acquired at an average of 65 months after surgery. Primary indications for surgery were tibiofemoral or patellar instability (n = 8) and arthritis (n = 4). Knee Society Functional scores averaged 29.6 before surgery and 51.3 at time of interview (P

We have evaluated a biomaterial to serve as a scaffold for the propagation and amplification of chondrocytes that promotes the original cellular phenotype of these cells. The goal of the present study was to investigate the use of thermally reversible polymer gels poly(NiPAAm-co-AAc), as a biocompatible supporting scaffold for the propagation of chondrocytic cells. The polymer gels at temperatures above its lower critical solution temperature (LCST) while liquefying at temperatures below its LCST of 34.5 C. Hence, the polymer, in its gelled form, has the ability to hold cells in situ, forming a matrix similar to the natural cellular environment or the extracellular matrix that comprises cartilage. We tested the hypothesis that the polymer gel promotes cell viability and function. Human osteoblast-like cells, nasal chondrocytes, and articular chondrocytes (1x105/150 ?l) were re-suspended in enriched DMEM media and were plated onto control (without gel) and gel containing 24-well plates. The plates were re-incubated at 37 C, 5% CO2 for the time-point of interest. Additional media was added to the plates and exchanged as needed. Following cell culture, cells were retrieved, enumerated, and cell viability was determined. Other aliquots of the cells were stained for morphological analysis while expression of chondrocyte markersmore » including collagen type II and aggrecan were determined using Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR). The polymer gel was not cytotoxic as the cell number retrieved from three-dimensional culture gel was found to be one to two times higher than that retrieved from monolayer culture. Chondrocytes propagated in the thermo-reversible polymers expressed enhanced or maintained expression of collagen type II and aggrecan. Collagen type I expression was decreased or unaltered. The N-isopropylacrylamide and acrylic acid copolymer gel has potential use as a cell culture substrate and as a cell delivery vehicle.« less

We have evaluated a biomaterial to serve as a scaffold for the propagation and amplification of chondrocytes that promotes the original cellular phenotype of these cells. The goal of the present study was to investigate the use of thermally reversible polymer gels poly(NiPAAm-co-AAc), as a biocompatible supporting scaffold for the propagation of chondrocytic cells. The polymer gels at temperatures above its lower critical solution temperature whereas liquefying at temperatures below its lower critical solution temperature of 34.5°C. Hence, the polymer, in its gelled form, has the ability to hold cells in situ, forming a matrix similar to the natural cellular environment or the extracellular matrix that comprises cartilage. We tested the hypothesis that the polymer gel promotes cell viability and function. Human osteoblast-like cells, nasal chondrocytes, and articular chondrocytes (1 × 105/150 μL) were resuspended in enriched Dulbecco's minimal essential media and were plated onto control (without gel) and gel containing 24-well plates. The plates were reincubated at 37°C, 5% CO2 for the time point of interest. Additional media was added to the plates and exchanged as needed. After cell culture, cells were retrieved, enumerated, and cell viability was determined. Other aliquots of the cells were stained for morphological analysis whereas expression of chondrocyte markers including collagen type II and aggrecan were determined using reverse transcriptase–polymerase chain reaction. The polymer gel was not cytotoxic because the cell number retrieved from three-dimensional culture gel was found to be one to two times higher than that retrieved from monolayer culture. Chondrocytes propagated in the thermo-reversible polymers expressed enhanced or maintained expression of collagen type II and aggrecan. Collagen type I expression was decreased or unaltered. The N-isopropylacrylamide and acrylic acid copolymer gel has potential use as a cell culture substrate and as a cell delivery vehicle. © 2003 Wiley Periodicals, Inc. J Biomed Mater Res 67A: 1310–1319, 2003

Osteonecrosis of the femoral head commonly occurs in middle-aged adults, with an average onset age of 38 years; 25% of patients are less than 25 years old [1]. There are approximately 20,000 new cases per year. Some patients are systemically ill, but the majority of patients are not. Due to the youth and long life expectancy of this patient population, the cost of this disease in terms of quality of life years lost, labor productivity lost, and expense of lifetime treatment is far higher than the incidence alone would suggest. The etiology of osteonecrosis of the femoral head (ONFH) remains unclear. Many factors with strong associations have been identified. The most common include: long term or high dose steroid use, moderate to heavy alcohol consumption, trauma, and blood clotting disorders. Despite the known associations, there remains a significant group (up to 40% of the total), in whom no association or causative factor can be found.

Infected wounds after total hip arthroplasty can be limb threatening. Management strategies are designed to eradicate infection, to obtain stable wound coverage, and to preserve the prosthesis. However, there is no general consensus for optimal management. The authors reviewed their 7-year combined orthopaedic and plastic surgical experience to provide a protocol for management. Ten patients (six women and four men) with a mean age of 60 years (range, 41-82 years) were studied. Primary hip diagnoses included arthritis (n = 8) and avascular necrosis (n = 2). Wound analysis included the size, depth, and infection as well as exposure of bone, joint capsule, and prosthetic components. Follow-up ranged from 1 to 6 years (mean, 3.9). Primary plastic surgical operations included a pedicle muscle flap (n = 4), debridement and local wound care (n = 3), and delayed wound closure (n = 3). Salvage of the total hip arthroplasty was achieved in 6 of 10 patients. Complete wound healing was achieved in 9 of 10 patients. The authors conclude that salvage of the infected hip prosthesis is accomplished best via early recognition, irrigation, debridement, and plastic surgery consultation. Management strategies include muscle flap coverage for complex wounds associated with exposure of prosthetic components, bone, or hardware; debridement with delayed closure or skin graft for large superficial wounds without deep structure involvement; and local wound care for small superficial wounds, poor surgical candidates with clean wounds, and when surgical options are not possible.

Background: Multiple treatment methods have been advocated for patellofemoral arthritis. The purpose of the present study was to report on our experience with the use of total joint replacement for the treatment of primarily severe patellofemoral arthritis of the knee in patients more than fifty-five years of age. Methods: Between January 1980 and December 1994, thirty knee replacements were performed in twenty-seven patients for the treatment of arthritis that primarily involved the patellofemoral joint. The Ahlback radiographic evaluation scale was used to grade the severity of arthritis; the mean score was 4.83 points (range, 4 to 5 points) for the patellofemoral compartment and 0.6 point (range, 0 to 1 point) for both the medial and lateral compartments. The patients included eighteen women and nine men who had a mean age of seventy-three years (range, fifty-nine to eighty-eight years). None of the patients had had any prior procedures on the knee, but all had been treated for a minimum of six months with nonoperative measures. The mean preoperative Knee Society score was 50 points (range, 20 to 64 points). Results: At a mean duration of follow-up of eighty-one months (range, forty-eight to 133 months), there were twenty-eight excellent, one good, and one poor result. The mean Knee Society objective score was 93 points (range, 67 to 100 points). The poor result was in a patient who sustained a rupture of the patellar tendon postoperatively as the result of a fall, which necessitated a tendon reconstruction. Conclusion: Total knee arthroplasty was found to be a viable treatment option in patients more than fifty-five years of age with primarily severe patellofemoral disease.

International Classification of Diseases coding of patient charts is used by hospitals to allow for billing of patients. Coding information also is used for assessing physician effectiveness. The purpose of the current study was to examine hospital coding for patients having total hip arthroplasty. One hundred consecutive primary total hip replacements were done at one medical center by two orthopaedic surgeons. Patient charts were coded by hospital coders according to the Health Care Finance Administration guidelines. Subsequently, an orthopaedist-based team did a secondary review of these charts and the two sets of codes were compared. The diagnostic codes were similar between the two groups for 87% (174 of 200 codes) of the cases. Comorbidities generally were undercoded by the hospital coders who reported 2.9 comorbidities per patient, whereas the secondary review reported 3.7 comorbidities per patient. The hospital coders found a complication rate of 1.2 per patient, whereas the secondary review revealed a rate of 0.4 per patient. Based on the results of the current study, the authors conclude that it is important to ensure three issues regarding the standard of coding and quality control: (1) the qualifications of the coders; (2) an interaction between coders and healthcare professionals to check that coding is accurate and reproducible; and (3) communication among various health professionals (including the primary surgeon) and coders to determine what actually are appropriate diagnoses, comorbidities, and complications.

The results of patients with rheumatoid arthritis who had revision hip arthroplasty have been studied infrequently. The purpose of this study was to review the authors' clinical and radiographic experiences and outcomes with revision hip arthroplasty. Revision total hip arthroplasties were done on 28 patients (30 hips). All hips had morselized bone grafting and four hips had bulk allografts for segmental defects. The mean age of the patients at the time of surgery was 50 years (range, 20-74 years). Patients were followed up for 4 to 15 years (mean, 7 years). At the latest followup, 14 hips (13 patients) of the 30 hips (47%) had good and excellent Harris hip score ratings. Mechanical failures included six hips (five patients) that had revision arthroplasty and two hips (two patients) that had resection arthroplasty. Six other hips (five patients) had poor Harris hip score ratings. The Kaplan-Meier survivorship curve for failure of the acetabular component revealed an 89% chance of survivorship curve for failure of the acetabular component revealed an 89% chance of survival at 60 months and a 44% chance of survival at 108 months. Based on the results of this study, revision hip arthroplasty for acetabular loosening with a cementless acetabular prosthesis has a low rate of success in patients with rheumatoid arthritis.

In this study, patients who played tennis after undergoing a total knee arthroplasty were analyzed in terms of their functional abilities and degree of satisfaction. The patients were recruited by means of a questionnaire that was sent to players from lists supplied by the United States Tennis Association. The study group consisted of 28 men and 5 women (46 total knee replacements) with a mean age of 64 years. Only 21% (7 of 33) of the patients’ surgeons approved of their patients undertaking tennis activity, with 45% (15 of 33) recommending only doubles tennis. At both 1 year and a mean of 7 years after arthroplasty, players were playing both singles and doubles tennis approximately three times per week (range, one to seven). All tennis players polled were satisfied with their knee arthroplasties and their ability to resume playing tennis. Because the study patients played at a high level, future studies are needed to determine the effect of tennis on the general population, which does not play at such a uniformly high level. The long-term (15 to 20 years) effect of tennis activity on the clinical and radiologic outcome of total knee arthroplasty also needs to be determined.

Both total knee alignment methods, the anatomic and classic, seek to achieve stability in flexion and extension. However, posterior femoral condyle referencing (anatomic alignment) combined with perpendicular tibial resection (classic alignment) results in a 3 degree relative internal rotation of the femoral component with lateral joint opening. The current cadaver study investigated the influence of total knee alignment methods and femoral component malrotation (3 degrees and 6 degrees internal and external malrotation) on femorotibial laxity. Varus and valgus excursion tests were done at 0 degrees, 30 degrees, 60 degrees, and 90 degrees knee flexion under vertical loading conditions of 150 N. None of the alignments produced increased laxity in extension. The largest laxity was found on the varus test at 60 degrees flexion with the femoral component at 6 degrees internal rotation. A 3 degree internal rotation of the femoral component showed increased varus laxity only for the combined alignment method. This finding shows that the femoral component position of the combined alignment method is a 3 degree relative internal malrotation and that an additional internal malrotation may compromise varus stability. Posterior femoral condyle referencing did not provide proper femoral component rotation. A ligament tensor may be helpful in determining femoral component rotation after soft tissue release in extension is performed.

Tanezumab, a monoclonal antibody against nerve growth factor, has demonstrated efficacy in clinical trials of chronic pain in osteoarthritis (OA) and chronic low back pain. Unexpected adverse events (AEs) described as osteonecrosis (ON) occurred during tanezumab development, leading the US Food and Drug Administration to impose a partial clinical hold for all indications except cancer pain. A blinded Adjudication Committee (AC) including orthopedic surgeons, rheumatologists, and an orthopedic pathologist reviewed and adjudicated joint-related AEs in the tanezumab clinical program.The AC adjudicated all reported cases of ON as well as cases of total joint replacements (TJRs) not reported as ON for which radiographs obtained within 9 months of the surgery were available. The AC prespecified categories for joint safety events including primary ON, worsening OA (rapid progression of OA [RPOA], normal progression of OA, insufficient information to distinguish between rapid and normal progression of OA), other, or insufficient information to distinguish between primary ON and worsening OA or another diagnosis.The AC reviewed events in 249 of 386 patients with an investigator-reported AE of ON and/or a TJR. Two events were adjudicated as primary ON, 200 events were adjudicated as worsening OA (68 of which were classified as RPOA), 29 events had another diagnosis, 11 had insufficient information to distinguish primary ON from worsening OA, and 7 did not have committee member consensus.Despite initial reports, tanezumab treatment was not associated with an increase in ON but was associated with an increase in RPOA. Higher doses of tanezumab, tanezumab administered with nonsteroidal antiinflammatory drugs, and preexisting subchondral insufficiency fractures were risk factors for RPOA in this cohort.

This study compared the results of limited femoral head resurfacing arthroplasty versus total hip arthroplasty (THA) for osteonecrosis. Thirty consecutive patients who had undergone a femoral head resurfacing procedure for osteonecrosis of the femoral head were compared with 30 consecutive patients who had undergone a THA. Both groups of patients had Steinberg stage III or IV disease with no acetabular cartilage involvement radiographically and by intraoperative inspection. At a 7-year mean follow-up for the resurfacing group and an 8-year mean follow-up for the THA group, the survival rate was 90% and 93% (P=.3). This study supports the femoral head resurfacing procedure as an alternative to THA for the time period studied.

Background: Osteonecrosis of the femoral head frequently leads to collapse of the articular cartilage and to disabling osteoarthritis, which ultimately may necessitate joint arthroplasty. One treatment method that has had moderate success is the so-called trapdoor approach, which involves excavation of diseased (necrotic) bone followed by bone-grafting. Augmentation of this procedure with various growth and differentiation factors may improve the outcome. We developed a canine model that mimics the clinical situation with trapdoor bone-grafting. The objective of this study was to evaluate the effect of the addition of osteogenic protein-1 on healing following the trapdoor procedure with strut-autografting. Methods: Thirty-four skeletally mature dogs were used in the experiment. After capsulotomy, a trapdoor was created in the anterolateral surface of the femoral head and a 2-cm-diameter subchondral area of bone was removed. In the phase-I experiments, seven dogs had no treatment of the defect (Group I) and nine dogs were treated with strut-grafting (Group II). In phase II, the procedure was modified by collapsing the trapdoor into the created defect intraoperatively in eighteen dogs, which were divided into three equal groups: six untreated defects were left collapsed (Group III), six were treated with bone graft (Group IV), and six were treated with bone graft augmented with osteogenic protein-1 (Group V). Results: Three of the seven femoral heads in Group I (untreated defect) and one of the nine heads in Group II (grafting without collapsing of the trapdoor) had evidence of cartilage collapse. Inspection of sagittal slices and radiographs revealed an unfilled residual defect in all Group-I heads, whereas all Group-II heads were well healed. The mean normalized stiffness value was significantly larger in Group II than it was in Group I. On visual inspection, depression was noted in all of the femoral heads in Group III (untreated defect; trapdoor left collapsed). In both Group IV and Group V (grafting without and with osteogenic protein-1), the trapdoor cartilage appeared to be essentially normal. Groups IV and V had more radiographic healing than did Group III. The defects in Group V (grafting with osteogenic protein-1) healed faster radiographically than did those in Group IV (grafting without osteogenic protein-1). Conclusions: Moderate-to-excellent healing was seen both radiographically and biomechanically by four months in the groups treated with grafting, with and without osteogenic protein-1, whereas untreated defects did not heal. Clinical Relevance: Symptomatic osteonecrosis of the femoral head is a clinical challenge. The animal model in the current study is a useful tool for the evaluation of methods to treat osteonecrosis of the femoral head. Studies investigating additional time-periods between implantation of osteogenic protein-1 and assessment of results as well as different doses of osteogenic protein-1 are warranted.

We assessed the correlation between activity level, length of implantation (LOI), and wear in total knee arthroplasty. Twenty-eight implants were retrieved at autopsy from 8 men and 15 women. Linear, volumetric, and visual wear and the presence or absence of creep were quantitated. Functional level was classified using the Knee Society, the standard Charnley classification, and the UCLA activity level scale. The average age at surgery was 68 years 14.0 SD and average LOI was 74 months 38 SD. The average linear and volumetric wear rates were 0.127 mm/y 0.104 SD and 31.80 mm 3 /y 42.8 SD. LOI (B coefficient 0.656 0.0 SE; P.001) correlated with linear, volumetric, and visual wear rates. Charnley C patients showed decreased volumetric wear in the lateral compartment (P.01). Decreased activity level (UCLA) correlated with areas of less extent and severity of creep (P.001 and P.001). Key words: total knee arthroplasty, polyethylene, wear, retrieval

Numerous studies have reported on the adverse outcome of patients who sustain job-related injuries. In addition, studies have reported poor outcomes in patients receiving Workers' Compensation who undergo elective surgery. This study sought to determine the influence of Workers' Compensation on the outcome of patients who had undergone primary total hip arthroplasty. Between January 1984 and December 1996, 44 patients (48 hips) were studied. Of these, 17 were men and five were women with a mean age of 45 years (range, 27-76 years) at the time of surgery. These patients were receiving compensation benefits and were matched directly with a group of 22 patients who had 24 arthroplasties and were not receiving compensation. After a mean final followup of 77 months (range, 25-125 months), the compensation group had a mean Harris hip score of 86 points (range, 54-95 points). The matched control group had a mean Harris hip score of 92 points (range, 79-100 points) at a mean final duration of followup of 80 months. Two patients (9%) had undergone revision surgery for aseptic loosening at 28 and 67 months. The percentage of patients with good or excellent results did not differ significantly between the two groups. Based on these findings, the authors think that Workers' Compensation does not negatively influence the outcome of total hip arthroplasty.

Background: The purposes of this study were to define the clinical, demographic, and radiographic patterns of atraumatic osteonecrosis of the distal part of the femur and the proximal part of the tibia at presentation and to report the outcome of treatment of this condition. Methods: Two hundred and forty-eight knees in 136 patients who were younger than the age of fifty-five years were treated at our institution between July 1, 1974, and September 15, 1998, for atraumatic osteonecrosis of the distal part of the femur or the proximal part of the tibia, or both. Demographic and radiographic features were characterized. The results of nonoperative treatment, core decompression, arthroscopic debridement, and total knee arthroplasty were evaluated. Results: There were 106 female patients and thirty male patients, and their mean age was thirty-six years (range, fifteen to fifty-four years) at the time of diagnosis. One hundred and one patients (74 percent) had involvement of other large joints, with eighteen (13 percent) presenting initially with knee symptoms. One hundred and one patients (74 percent) had a disease that affected the immune system; sixty-seven of them had systemic lupus erythematosus. One hundred and twenty-three patients (90 percent) had a history of corticosteroid use. Technetium-99m bone-scanning missed lesions in sixteen (29 percent) of fifty-six knees. Eight (20 percent) of forty-one initially symptomatic knees treated nonoperatively had a successful clinical outcome (a Knee Society score of at least 80 points and no additional surgery) at a mean of eight years. The knees that remained severely symptomatic for three months were treated with either core decompression (ninety-one knees) or total knee arthroplasty (seven knees). Seventy-two (79 percent) of the ninety-one knees treated with core decompression had a good or excellent clinical outcome at a mean of seven years. Efforts to avoid total knee arthroplasty with repeat core decompression or arthroscopic debridement led to a successful outcome in fifteen (60 percent) of twenty-five knees. Thirty-four (71 percent) of forty-eight knees treated with total knee arthroplasty had a successful clinical outcome at a mean of nine years. Conclusions: Atraumatic osteonecrosis of the knee predominantly affects women, and in our study it was associated with corticosteroid use in 90 percent of the patients. Evaluation should include standard radiographic and magnetic resonance imaging of all symptomatic joints. Prognosis was negatively related to large juxta-articular lesions. Nonoperative treatment should be reserved for asymptomatic knees only. Core decompression was successful (a Knee Society score of at least 80 points and no additional surgery) in 79 percent of the knees in which the disease was in an early stage. Total knee arthroplasty was successful in only 71 percent of the knees.

This study was designed to determine the effect of Si(3)N(4) disks and particulates on human osteoblast-like MG-63 cells in vitro. The MG-63 (10(5)/mL) cells were plated onto 24-well polystyrene plates fitted with either sintered reaction-bonded (SRBSN) or reaction-bonded (RBSN) 15-mm disks. Controls consisted of wells without Si(3)N(4) disks. Cells propagated at 37 degrees C, 5% CO(2) for 48 h on Si(3)N(4) disks and control polystyrene surfaces exhibited similar proliferative capacities (7000 and 4000 cpm/10(5) cells, respectively, p > 0.05). Cells incubated with 1, 10, or 100 microgram/ml of Si(3)N(4) particles (

Beta-1 integrin plays a major role in cell attachment and is believed to be involved in mediating the interactions of chondrocytes with their environment. We previously reported that articular chondrocytes propagated in microcarrier spinner culture proliferated and reexpressed their chondrocytic protein. The goal of the present study was to investigate the expression of beta-1 integrin by chondrocytes growing on the surface of microcarriers. Nasal chondrocytes (4 x 10(3)/cm(2)) were seeded on microcarriers and incubated at 37 degrees C, 5% CO(2), 60 rpm. Expression of chondrocyte markers and beta-1 integrin was determined using reverse transcriptase-polymerase chain reaction and immunocytochemical analyses. De novo synthesis of sulfate-containing proteoglycans was studied using 35SO(4) incorporation techniques. Like articular chondrocytes propagated in microcarrier spinner culture, nasal chondrocytes expressed high levels of collagen type II mRNA, whereas collagen type I mRNA levels were low. Aggrecan mRNA was detectable and levels of de novo 35SO(4) incorporation were high. Chondrocytes immunostained intensely for collagen type II and keratan sulfate but did not stain for collagen type I. beta-1 integrin mRNA levels were high, and the protein was immunolocalized to regions of cell-to-cell or cell-to-microcarrier contact. The fact the chondrocytes expressed high levels of beta-1 integrin raises the possibility that this integrin molecule has a role in the maintenance of the chondrocytic phenotype.

The search for biocompatible materials that can support the growth and phenotypic expression of osteoblasts and chondrocytes is a major challenge in the application of tissue engineering techniques for the repair of bone and cartilage defects. Chitosan, a copolymer of glucosamine and N-acetylglucosamine, may provide an answer to this search. Chitosan is the deacetylated product of chitin, a ubiquitous biopolymer found in the exoskeleton of insects and marine invertebrates. Little is known about the utility of chitosan in propagating human osteoblasts and chondrocytes. In this study, we test the hypothesis that chitosan promotes the survival and function of osteoblasts and chondrocytes. Chitosan (4%, w/v in 2% HAc) was coated onto plastic coverslips that had been fitted into 24-well plates. Human osteoblasts and articular chondrocytes were seeded on either uncoated or chitosan-coated coverslips at 1 x 10(5)/cells per well. Cultures were incubated at 37 degrees C, 5% CO(2) for a period of 7 days. Cell viability was assessed at that time using a fluorescent molecular probe. The phenotypic expression of osteoblasts and chondrocytes was analyzed by reverse transcriptase-polymerase chain reaction and immunocytochemistry. Osteoblasts and chondrocytes appeared spherical and refractile on chitosan-coated coverslips. In contrast, greater than 90% of cells on plastic coverslips were elongated and spindle shaped after 7 days of culture. Similar to cells propagated on uncoated control wells, greater than 90% of human osteoblasts and chondrocytes propagated on chitosan remained viable. Human osteoblasts propagated on chitosan films continued to express collagen type I whereas chondrocytes expressed collagen type II and aggrecan, as shown by reverse transcriptase-polymerase chain reaction analysis and immunostaining. The present in vitro work demonstrates the biocompatibility of chitosan as a substrate for the growth and continued function of human osteoblasts and chondrocytes. Chitosan may have potential use as a tissue engineering tool for the repair of osseous and chondral defects.

Enigmatic thigh pain remains a difficult problem to treat after total hip arthroplasty. This article reports on the use of strut cortical allografting for the treatment of recalcitrant enigmatic thigh pain following total hip arthroplasty in patients with a well-fixed cemented or cementless femoral component.

Callaghan has suggested that the most important factor in obtaining optimal results after total hip arthroplasty may be the ability to determine when to use cemented or cementless fixation. This article has presented the indications and relative contraindications for use of proximally porous-coated prostheses. Midterm results suggest that with appropriate patient selection, excellent clinical results can be achieved with currently available proximally porous-coated prostheses. Use of proximally coated prostheses is indicated for primary total hip arthroplasty in patients aged >70 years with good bone stock. Relative contraindications are based on interference with bone ingrowth or with the ability to achieve a congruent fit, both of which preclude establishment of rigid initial stability. These conditions include metabolic bone disease such as osteoporosis, osteomalacia, Gaucher's disease, sickle cell disorders, and Paget's disease; significant anatomical distortion, as seen in developmental dysplasia of the hip with anteversion, prior osteotomy, or intertrochanteric fracture; Dorr type C bone; and current treatment with radiation, chemotherapy, indomethacin, or diphosphonates. The same relative contraindications to use are applicable in revision situations. Further, proximally porous-coated prostheses should not be used for revision arthroplasty in the setting of massive bone loss, limited life expectancy, or inability to participate in protected weight bearing. These devices may be used successfully in revision arthroplasty when the hip has minimal or moderate bone loss, and occasionally in the setting of severe bone loss. As further information is revealed through the long-term (10-20 years) results of proximally coated prostheses, further refinements and knowledge of the indications and contraindications for the use of these prostheses will be revealed.

This study reports the minimum 5-year follow-up of our experience with the Porous-Coated Anatomic E (PCA-E) series femoral stem and the modular acetabular cup. A total of 115 consecutive total hip replacements using PCA-E series (Howmedica, Rutherford, NJ) were performed in 108 patients. Six patients whose hips were performing well clinically died before 5-year follow-up and were excluded from the final evaluation. The remaining 109 hips (102 patients) were assessed at a mean follow-up of 72 months (range, 60-84 months). The hip diagnoses were osteoarthritis in 73, osteonecrosis in 31, rheumatoid arthritis in 2, and hip dysplasia in 3. The mean age was 56 years (range, 24-83 years). Three hips were revised: 1 because of late hematogenous infection, 1 because of aseptic loosening of the femoral component, and 1 because of postoperative loosening of an acetabular component. The Harris hip scores improved from a mean of 50 points (range, 20-66 points) preoperatively to a mean of 92 points (range, 64-100 points) at final follow-up. The score differed in each Charnley functional class, with a mean of 93 points (range, 72-100 points) in 57 hips of class A (no other joint involvement); 90 points (range, 58-100 points) in 26 hips of class B (opposite hip involvement); and 85 points (range, 37-100 points) in 26 hips of class C (multiple joint involvement or severe systemic disease). Out of 106 hips that had a full radiographic evaluation performed, 103 femoral components revealed stable bony ingrowth, 2 revealed stable fibrous ingrowth, and 1 showed migration with progressive loosening. This patient with radiographic loosening has minimal symptoms and has not required or been offered further surgery (Harris hip score of 86 points). The low aseptic loosening rate (2%) at minimum 5-year follow-up compares favorably with any cemented or cementless series. The osteolysis that was seen was focal and localized. The short follow-up does not allow determination of progression. There were no cases of distal osteolysis. We attribute the improved results from reported first-generation experience to multiple factors, including increased number of sizes (9 vs 6), increased proportional metaphyseal size, improved polyethylene manufacture (ram extruded vs machined), improved acetabular locking mechanism, and change to 26-mm from 32-mm femoral heads.