(Introduction)

Metal on Metal (MoM) THA bearing as the second generation Total Hip Arthroplasty, widely came into use in Japan since 2000s. And it was expected to be able to ensure long-term use, the range of motion in the joints after surgeries, and the resistance to the dislocation, because MoM THAhad been considered to be able to use the large diameter head for its lower wear. However, there are some reports that the metal wear debris from MoM bearing surface generates the elevated serum ion level in the blood and the incidence of pseudotumor may occur subsequent to the metal wear debris. We performed MoM THA for 291 joints in 234 patients in our hospital since May 2005. But now, we refrain to use this. In this time, we will describe two cases of pseudotumor after implantation of MoM THA.

Purpose of the study: We have tried to produce a new acetabular ring in order to obtain an early stability of cemented cup for acetabular protrusion in R.A. In this presentation, we intend to introduce this new support ring and report these results.

Materials and methods: The new support ring with double-hook we produced was made of pure titanium, and has eight screw holes in medial side and two screw holes in superolateral side. Size variation of this ring comprises 40mm, 42mm, 46mm, 48mm and 50mm in inner diameter. Width of the hook is 10.05mm and its thickness is 1.19mm. Hook length is 33.5mm. After the remaining bone defect is packed with morselizd and mushed allograft bone, proper support ring with double hook is selected. Straight portions of double hook are bent in order to fit to acetabular shape after bone grafts. If good fitting is achieved, this support ring was fixed to the acetabulum with three to five screws. Total hip arthroplasty with this support ring was performed in ten patients with eleven hips. Three cases were in male and seven in female. The age at surgery ranged from 46 to 73 years old with an average of 59.8 years.

Results: Setting angle of support ring ranged from 40 to 50 degrees with an average of 43.7 degrees. Follow-up period was from one year to three years with an average of two years one month. No loosening was encountered and no migration of support ring and cup was visualized on radiological findings. JOA(Japanese Orthopaedic Association) hip score which was adopted for clinical evaluation was 31.3+/−10.2 before surgery and 70.1+/−8.5 after surgery.

Discussion: Various types of reinforcement ring have been used with or without bone grafts for acetabular protrusion. I had prefered Ganz ring among them. Bending a hook of Ganz ring, however, is not easy as its hook portion is slightly thick. Accordingly, setting angle of the ring is often apt to be acute as it must be fitted to acetablualr shape. In superior cortical defect of the acetabulum, hook length is often insufficient because a hip center of the ring is in high position. Therefore, it is sometimes impossible to hook acetabular notch. We produced a new support ring with double-hook in order to solve these problems. As the hook was thinner in the new ring than in Ganz ring, it was easier to bend the hook. As the hook of of the new ring was longer than that of Ganz ring, it was possible to hook acetabular notch in spite of high hip center. Setting angle of the new rings was less than 50 degrees. Radiological findings and clinical results were good though follow-up period was short.

Our purpose is to use radiographs to compare callus formation with two types of intramedullary nailing for femoral shaft fractures: reamed interlocking (IL) and Ender nails.

Femoral shaft type A fractures according to AO classification were studied.

From 1991 to 1995, 27 patients with 27 fractures were treated with reamed IL nailing and 79 patients with 81 fractures were treated with Ender nailing. IL group included with an average of 22 (range, 16–28) years, and the Ender group included with an average of 28 (range, 15–72) years.

Patients had been followed for an average of 1.8 (range, 1–2.8) years after surgery. In all cases of IL group, the femoral canal was reamed. For type A3 fractures, an interlocking screw was inserted only at the distal site. For type A1 and A2 fractures, both proximal and distal locking screws were placed. In the Ender nailing cases, 3 to 5 Ender nails were inserted from medial or lateral side of the supracondylar or intertrochanteric regions of the femur as was dictated by the fracture site. All of these fractures were reduced by a closed technique. The measurement of postoperative callus area was calculated from the maximum cross-sectional area on the anteroposterior and lateral radiographs.

Fracture healing was successful in all patients. On the radiograph, the callus for the IL group appeared at a mean of 3.9 weeks after surgery, and at a mean of 2.8 weeks for the Ender group. In the IL and Ender groups, fracture healing was noted at a mean of 3.4 and 2.0 months, respectively. The mean area of callus formation in the IL and Ender nailing was 439.5mm2 and 699.4 mm2, respectively. To compare the two groups by using a Mann-Whitney U test, the significant differences were seen in the callus appearance period (p< 0.05) and in the callus area (p< 0.01).

Dynamization at the fracture site is reported to increase external callus formation.

Our results indicate that the elasticity of the fixation obtained with Ender nailing promotes callus formation.

Periprosthetic osteolysis has attracted attention as a cause of loosening after arthroplasty. The aim of the present study was to examine inflammatory cell localization and the occurrence of apoptosis in granulation tissue from patients who required revision arthroplasty due to loosening caused by osteolysis.

7 patients were studied comprising 3 patients who underwent FHR and 4 patients who underwent THR. Their mean age at the time of surgery was 63.6 years. The mean period from their previous operation to revision was 8.8 years.

Granulation tissue was collected from around the loosened implant fixed in 4% paraformaldehyde and embedded in paraffin. Sections were cut and were first stained with hematoxylin and eosin. Next, immunohistochemical studies were performed using the avidin-biotin complex method. CD45 was used as the primary antibody to detect T cells, and CD68 was used to detect macrophage-like cells. The activity of the macrophage-like cells was assessed with anti-I-NOS and anti-MMP-9.

Apoptosis was investigated using anti-single-stranded DNA (ssDNA). Using another granulation tissue was stored at −80%C, DNA was extracted, and the presence of DNA fragmentation was detected by agarose gel electrophoresis.

Vascularization and infiltration by a large number of inflammatory cells were seen along with large multinucleated osteoclas-like cells. Immunohistochemical studies revealed CD45-positive cells primarily around the blood vessels. The CD68-positive cells were mainly multinucleated cells. The multinucleated cells were i-NOS-positive in 4 patients, and were MMP-9-positive in 5 patients.

The nuclei of many of the multinucleated cells were positive for ssDNA. Agarose gel electrophoresis of DNA showed a marked ladder pattern at the 170 base pair region. This finding indicated DNA fragmentation or apoptosis.

Apoptotic cells were seen in granulation tissue harvested from around loosened implants suggesting that apoptosis may play a role in the pathophysiology of osteolysis.