Greater trochanteric pain (GTP) is a regional pain syndrome characterized by lateral hip pain and tenderness. Its incidence after total hip arthroplasty (THA) is variable. Bursal inflammation, degenerative changes of the attachment of the gluteal muscles, direct operative trauma and biomechanical disturbance of the operated hip have been discussed as being related to GTP. The diagnosis is purely clinical because radiological and laboratory investigations show no definite pathology. Although most treatment modalities are conservative, some patients may develop refractory complaints leading to surgical intervention. In study I we studied the incidence of GTP in 172 consecutive patients who underwent THA during 2002 at Sundsvall Hospital. Patients with GTP (n=21, incidence 12%) were matched with controls from the same cohort. The THA outcome was assessed using the Western Ontario and McMaster Universities Arthrosis (WOMAC) Index. Trochanteric tenderness was studied using an electronic pressure algometer. We found an association between the occurrence of GTP and postoperative uncorrected lengthening of the operated limb of ≥ one centimetre. The WOMAC index revealed a reduction of the clinical outcome in the GTP group. In Study II we tested the value of using an algometer in the diagnosis of GTP after THA. We measured the pressure-pain threshold (PPT) over the greater trochanter and ilio-tibial band in 18 patients and 18 matched controls. Both groups were evaluated using the visual analogue scale (VAS). We found the algometer to have a good predictive validity and reproducibility. However, there was large inter-individual variability across subjects. The PPT ratio of 0.8 (affected vs. unaffected side) can be used as a cutoff ratio to establish GTP. There was no correlation between PPT measurements and VAS. Because of a low positive predictive value and large inter-individual variability, the pressure algometer has a limited value as a screening tool. In study III we proposed a new surgical treatment for refractory GTP after THA consisting of distal lengthening of the ilio-tibial band (ITB) by Z-plasty under local anaesthesia. This method was used in 12 women between March 2004 and June 2006. The patients were followed up by phone interview 3-4 months postoperatively and by an EQ-5D questionnaire and clinical examination including evaluation with the algometer at 1-3 years postoperatively. We found that the patients‘ quality of life was markedly improved following the operation (EQ-5D = 0.26 preoperatively vs. 0.67 postoperatively; p <0.005). There were no postoperative complications. In study IV we evaluated the accuracy of a commonly used clinical method of LLD measurement (anterior superior iliac spine-medial malleolus) by comparing it to a reliable radiological method (tear drop-lesser trochanter) in 139 patients before and after THA. We found the correlation between the clinical and radiological methods to be weak preoperatively (r=0.21, ICC= 0.33) while the correlation was moderate postoperatively (r= 0.45, ICC=0.62). It is therefore recommended that the radiological method be used to measure leg length discrepancy in patients who undergo THA.

Vid operation av primär total höftplastik finns det olika metoder för postoperativ smärtlindring. En tidigare genomförd studie på ett mellansvenskt sjukhus (nedan kallad ”höftprojektet”) visade att ”Local infiltration analgesia” (LIA) initialt minskade postoperativ smärta, underlättade mobilisering samt förkortade vårdtiden, jämfört med spinalt morfin. I denna studie genomfördes en långtidsuppföljning av höftprojektet med mätningar efter 6 respektive 12 veckor. Studiegruppen hade fått LIA vid operationsslutet och kontrollgruppen spinalt morfin. Båda grupperna hade en spinal bedövning under operationen. Denna långtidsuppföljning genomfördes med hjälp av journalgranskning och hade en deskriptiv och jämförande design med en kvantitativ ansats. Studiegruppen bestod av 40 patienter och kontrollgruppen 11 patienter. Studerade variabler var smärta mätt genom Visuell Analog Skala (VAS), behov av analgetika och mobilisering. Resultatet visade att det inte fanns någon signifikant skillnad mellan de båda grupperna när det gäller mobilisering under ett längre perspektiv. Det fanns dock en signifikant skillnad när det gäller smärta efter 3 månader, då studiegruppen uppgav en lägre grad av smärta än kontrollgruppen. / There are several methods for postoperative pain treatment after primary total hip replacement. It was shown in a earlier study at a Swedish hospital (below named as "the hip project") that "Local infiltration analgesia" (LIA) decreased pain, facilitated early postoperative mobility and earlier discharge from the hospital, compared with spinally administered morphine. Present study is a long term follow up of the hip project with two measures at 6 and 12 weeks. The study group was given LIA towards the end of the operation while the control group were given spinal morphine at the induction. Both groups had spinal analgesia during the surgery. The long term follow up was conducted by a comparative design and the data was collected from the patient’s charts and files. The variables were pain measured by Visual Analogous Scale (VAS), need of pain relieves and general mobility. The study group contained of 40 patients and the control group of 11. The result relived no significant differences between the two groups regarding long term mobility. There was, however, a significant difference in pain after 12 weeks; the study group had less pain that the control group.

Όταν οι κλινικοεργαστηριακές πληροφορίες είναι ανεπαρκείς για τη διά- γνωση σηπτικής φλεγμονής επί αρθροπλαστικής ισχίου, η Πυρηνική Ιατρική μπορεί να προσφέρει σημαντικά στη διαφοροδιάγνωση. Σκοπός της παρούσας προοπτικής μελέτης είναι ο έλεγχος της καταλληλότητας του σπινθηρογραφήματος με σημασμένα με 99mΤc μονοκλωνικά Fab-τμήματα αντισωμάτων ποντικού (IMMU-MN3, Leuko- Scan®) ως προς την ακριβή τοπογραφική εντόπιση και διάγνωση περιπροθετικών σηπτικών φλεγμονών επί αρθροπλαστικής ισχίου. Στο διάστημα 1/2001-2/2004 διερευνήθηκαν 21 ασθενείς με 21 αρθροπλαστικές ισχίου (12 ολικές αρθροπλαστικές χωρίς και 3 με τσιμέντο, 2 υβριδιακές αρθροπλαστικές, 3 αρθροπλαστικές διπλής κίνησης και 1 ημιολική) ως προς την πιθανότητα περιπροθετικής λοίμωξης και σηπτικής χαλάρωσης της αρθροπλαστικής. Ο χρόνος παρακολούθησης (follow up) ήταν κατά μέσο όρο 4,4 έτη (2-12). Οι ασθενείς αντιμετωπίσθηκαν με αναθεώρηση της αρθροπλαστικής σε ένα χρόνο (9 ασθενείς, 42,8%), επέμβαση τύπου Girdlestone (8 ασθενείς, 38,1%), χειρουργικό καθαρισμό και ροή-πλύση (3 ασθενείς, 14,3%) και αναθεώρηση της οστεοσύνθεσης με πλάκα-βίδες επί οστεοτομίας βράχυνσης του μηριαίου σε συγγενή πάθηση ισχίου (1 ασθενής, 4,7%). Ο μέσος όρος ηλικίας ήταν 63 έτη (42-78), με αναλογία άνδρες /γυναίκες 8:13. Aπαραίτητες προϋποθέσεις για να συμπεριληφθούν οι ασθενείς στη μελέτη ήταν: 1) Απουσία πιθανής εγκυμοσύνης, 2) Φυσιολογική νεφρική λειτουργία, 3) Μετεγχειρητικό διάστημα μετά την εμφύτευση της πρωτογενούς αρθροπλαστικής του ισχίου μεγαλύτερο από 12 μήνες, 4) Χρονικό διάστημα άνευ λήψεως αντιμικροβιακών φαρμάκων τουλάχιστον 3 εβδομάδων προ της διερεύνησης μέσω LeukoScan® και 5) Παθολογικά αυξημένες τιμές ταχύτητας καθίζησης ερυθρών αιμοσφαιρίων (ΤΚΕ) και C-αντιδρώσας πρωτεϊνης (CRP), επειδή οι φυσιολογικές τιμές ουσιαστικά αποκλείουν την πιθανότητα σηπτικής φλεγμονής επί αρθροπλαστικής ισχίου. Η επιλογή των ασθενών προς διαγνωστική διερεύνηση βασίσθηκε σε ένα «πρωτόκολλο παραγόντων κινδύνου» σε συνδυασμό με την κλινική υποψία της παρουσίας περιπροθετικής λοιμώξεως και σηπτικής χαλάρωσης. Ο έλεγχος των ασθενών περιελάμβανε κλινική αξιολόγηση (Harris Hip Score), κλασική ακτινολογική απεικόνιση και εργαστηριακές εξετάσεις αίματος (απόλυτος αριθμός λευκοκυττάρων, ποσοστιαία αναλογία πολυμορφοπυρήνων ουδετεροφίλων κοκκιοκυττάρων, ταχύτητα καθίζησης ερυθρών αιμοσφαιρίων και C-αντιδρώσα πρωτεϊνη). Κατά τη σπινθηρογραφική διερεύνηση, το 99mTc-Dynamic Bone Scan προηγήθηκε του LeukoScan® λόγω της υψηλής ευαισθησίας του ως προς την ανίχνευση φλεγμονωδών εστιών, το χαμηλό του κόστος και της ισχύουσας διαγνωστικής τακτικής σε αμφίβολες περιπτώσεις οστικής λοίμωξης. Tα ευρήματα του LeukoScan® διαβαθμίστηκαν σε 4 διακριτές κατηγορίες αποτελεσμάτων I-IV (I-άνευ αυξημένης καθήλωσης του ραδιοφαρμάκου, II-αυξημένη πρόσληψη στα μαλακά μόρια και φυσιολογική στο οστούν, III-ίση κατανομή σε μαλακά μόρια και οστούν, IV-μεγαλύτερη πρόσληψη στο οστούν ή μόνο σε αυτό). Οι κατηγορίες I και II αντιπροσωπεύουν αρνητικά LeukoScan®-αποτελέσματα, ενώ οι ΙΙΙ και ΙV θετικά αποτελέσματα. Ακολούθησε ιστοπαθολογική και μικροβιολογική εξέταση διεγχειρητικών δειγμάτων (αξιολογήθηκαν μόνο τα θετικά μικροβιολογικά αποτελέσματα) που ελήφθησαν από προκαθορισμένες περιοχές. Ιστοπαθολογικό κριτήριο περιπροθετικής σηπτικής φλεγμονής αποτέλεσε η ανεύρεση >5 ουδετερόφιλων πολυμορφοπυρήνων κοκκιο- κυττάρων κατά μέσο όρο για κάθε μεγάλο οπτικό πεδίο. Τα ευρήματα του LeukoScan® συσχετίσθηκαν με τα ιστοπαθολογικά και μικροβιολογικά αποτελέσματα και έγινε ονομαστική καταγραφή αληθών και λανθασμένων σπινθηρογραφικών διαγνώσεων. ΑΠΟΤΕΛΕΣΜΑΤΑ: Η προεγχειρητική αξιολόγηση των ασθενών ανέδειξε τους εξής μείζονες παράγοντες κινδύνου: Άλγος ισχίου ή/και άλγος μηρού (21 ασθενείς, 100%), παθολογικές εργαστηριακές εξετάσεις αίματος (21 ασθενείς, 100%), προηγηθείσες χειρουργικές επεμβάσεις (13 ασθενείς, 61,9%), λοίμωξη τραύματος του χειρουργημένου ισχίου (10 ασθενείς, 47,6%) και εστίες λοιμώξεως (9 ασθενείς, 42,8%). O προεγχειρητικός μέσος όρος του υπολογιζόμενου κλινικού Harris Hip Score ήταν 64 βαθμοί, από 28 έως 93 βαθμούς. Η ιστολογική και μικροβιολογική εξέταση των διεγχειρητικών δειγμάτων ανέδειξε την παρουσία περιπροθετικής λοίμωξης σε 17 αρθροπλαστικές, ενώ σε 4 αρθροπλαστικές δεν ανιχνεύθηκε σηπτική φλεγμονή. Η υπολογιζόμενη μέση τιμή των εργαστηριακών παραμέτρων φλεγμονής ήταν σχετικά με τον απόλυτο αριθμό λευκοκυττάρων 8,6 Κ/μl (3,9 – 14,5 Κ/μl), την ποσοστιαία αναλογία των πολυμορφοπυρήνων κοκκιοκυττάρων 64% (39 – 79%), την ταχύτητα καθίζησης ερυθρών αιμοσφαιρίων 56,3 mm (23 – 101 mm ) και την C-αντιδρώσα πρωτεϊνη 6,1 mg/dl (αρνητική τιμή – 40,5 mg/dl). Σε συνδυασμό με τα ιστολογικά και μικροβιολογικά ευρήματα προκύπτει για την ΤΚΕ ευαισθησία ίση με 1, ακρίβεια 0,8 και θετική προγνωστική αξία 0,8. Αντίστοιχα για την CRP προκύπτει ευαισθησία 0,94, ειδικότητα 0,25, ακρίβεια 0,8, θετική και αρνητική προγνωστική αξία 0,84 και 0,5 αντίστοιχα. Έγιναν 15 Dynamic Bone Scan εκ των οποίων 12 αληθώς θετικά, 1 αληθώς αρνητικό και 2 ψευδώς θετικά. Η σπινθηρογραφική διερεύνηση μέσω LeukoScan® που διενεργήθηκε σε 21 ασθενείς, ανέδειξε 17 αληθώς θετικά και 4 αληθώς αρνητικά αποτελέσματα. Στην κατηγορία-III ταξινομήθηκαν 7 θετικά και στην κατηγορία-IV 10 θετικά LeukoScan®. Στην κατηγορία-I ταξινομήθηκε 1 αρνητικό και στη κατηγορία-II 3 αρνητικά LeukoScan®. Από τη στατιστική ανάλυση προκύπτει για το σπινθηρογράφημα οστών τριών φάσεων ευαισθησία ίση με 1, ειδικότητα 0,33, ακρίβεια 0,86, θετική και αρνητική προγνωστική αξία 0,85 και 1 αντίστοιχα. Αντίστοιχα για το 99mTc- Sulesomab όλες οι στατιστικές παράμετροι είναι ίσες με 1. Σε τρεις ασθενείς διενεργήθηκε SPECT/CT-scan χωρίς επιπλέον χορήγηση ραδιοφαρμάκου, προς διερεύνηση της περιοχής των τροχαντήρων και ενισχύθηκε η ταξινόμηση των 99mTc-Sulesomab-ευρημάτων στην εκάστοτε κατηγορία. ΣΥΜΠΕΡΑΣΜΑ: Ακολουθώντας τον προτεινόμενο διαγνωστικό αλγόριθμο με τη σωστή επιλογή των ασθενών, το 99mTc-Sulesomab μπορεί να αποτελέσει σημαντική διαγνωστική επιλογή κατά τη διερεύνηση των σηπτικών φλεγμονών επί αρθροπλαστικών ισχίου, καθώς κάτω από τις παραπάνω προϋποθέσεις παρουσιάζει ευαισθησία, ειδικότητα, ακρίβεια, θετική και αρνητική προγνωστική αξία ίση με 1. Το SPECT/CT-scan προσφέρει διαγνωστικά όταν οι φλεγμονώδεις αλλοιώσεις εντοπίζονται πάνω από το όριο σώματος μηριαίας πρόθεσης-αυχένος μηριαίας πρόθεσης. / AIM: Nuclear Medicine can contribute in differential diagnosis of septic loosening of hip arthroplasty, when the clinical and laboratory findings are not clear. The aim of this study was to determine the ability of scintigraphy with 99mΤc–Sulesomab (LeukoScan®), to diagnose and localize periprosthetic septic lesions in patients with hip arthroplasty. MATERIALS AND METHODS: 21 patients with hip arthroplasty (12 cementless, 3 cemented, 2 hybrid, 3 bipolar total hip arthroplasties and 1 semiarthroplasty) were studied between 1/2001 up to 2/2004, for possible periprosthetic inflammation and septic loosening. The mean follow up period was 4,4 years (2-12). 9 patients (42,8%), were subjected in revision arthroplasty, 8 patients in Girdlestone procedure, 3 patients in surgical debridement and 1 patient, with congenital hip luxation who was primary subjected in femoral shortening osteotomy and fixation with plate and screws, in revision of the fixation. Then mean patient age was 63 years (42-78) and the male to female ratio was 8:13. All patients, in order to be evaluated, had to fulfill the following requirements: 1) absence of pregnancy, 2) normal renal function, 3) 12 months period after the implantation of the primary prosthesis, 4) 3 weeks period free of antibiotic therapy, before the investigation with Leukoscan and 5) abnormal high values of ESR and CRP, since normal values exclude septic loosening. Patients’ selection for diagnostic evaluation was based on a “high risk protocol” in combination with clinical suspicion of periprothetic infection and septic loosening. All patients were clinically evaluated using Harris Hip Score and were investigated with standard x-rays and blood tests, including total white cell number, percentage of neutrophile granulocytes, ESR and CRP. During scintigraphic studies, 99mTc-Dynamic Bone was done before LeukoScan®, because of its high sensitivity for detecting infectious areas, its low cost and the current diagnostic strategy for doubtful cases of bone infection. LeukoScan® findings were classified in four distinct categories I – IV (I – with normal radiopharmaceutical concentration, II – increased uptake in soft tissues and normal in bone, III – equal increased uptake in soft tissues and bone, IV – increased bony uptake). Categories I and II represent negative LeukoScan® findings, while III and IV were classified as positive. Histopathologic and microbiologic tests of intraoperative samples were done (only positive microbiologic tests were evaluated). Histopathologic criterion for periprothetic septic loosening was considered the finding of >5 neutrophile granulocytes per high energy field. LeukoScan® findings were matched with histopathologic and microbiologic results. RESULTS: Patients’ preoperative evaluation revealed the following risk factors: hip or thigh pain (21 patients, 100%), pathologic blood tests (21 patients, 100%), previous operations (13 patients, 61,9%), wound infection (10 patients, 47,6%) and other infectious regions (9 patients, 42,8%). Preoperative Harris Hip Score was 64 points (28 – 93). Histologic and microbiologic tests of intraoperative samples revealed periprothetic infection in 17 cases. Mean value of laboratory tests revealing infection with respect to total white cells number was 8,6 Κ/μl ( 3,9 – 14,5 Κ/μl ), percentage of neutrophile granulocytes 64% (39 – 79%), ESR 56,3 mm (23 – 101 mm) and CRP 6,1 mg/dl. ESR showed a sensitivity of 1, accuracy 0,8 and positive prognostic value 0,8. CRP had 0,94, 0,25 and 0,8 respective values, with positive prognostic value 0,84. 15 Dynamic Bone Scan were done, 12 were classified as positive, 1 true negative and 2 false positive. LeukoScan® were classified as 17 true positive and 4 true negative. 7 true positive tests were classified in category III and 10 in category IV. 1 negative LeukoScan® was classified in category I and 3 in category II. Dynamic Bone Scan showed a sensitivity 1, specificity 0,33, accuracy 0,86, positive and negative prognostic value 0,85 and 1 respectively. 99mTc-Sulesomab showed for all parameters value 1. CONCLUSIONS: Following the appropriate diagnostic algorithm and patient selection, 99mTc-Sulesomab can detect septic loosening, since it shows sensitivity, specificity, accuracy, positive and negative prognostic values of 1. SPECT/CT-scan offers significant diagnostic help when infection is localized above the neck of the femoral component.

Background: Total hip replacement (THR) with post-operative surveillance is recommended for debilitating osteoarthritis (OA). Using self-reported pain, function or walking performance is one alternative to address increasing surveillance demands. Objective: A cross-sectional cohort study to evaluate the associations of pain, function and performance with two radiographic markers of potential THR failure. Participants: 110 patients, median 6 years after THR surgery for OA. Methods: Questionnaires assessed demographics, co-morbidity, arthritis severity, pain, pain catastrophizing, and functional status. Performance was measured using the six minute walk test. THR outcome was assessed radiographically. Results: Few patients had pain, functional impairment or radiographic markers of potential THR failure. A larger percentage of patients with some intermittent pain (10.7 versus 8.6%) and pain iii after walking performance (40.0 versus 27.6%) had higher wear, but these differences were not significant. Conclusion: Measures of pain are potentially important for larger studies aiming to develop alternative methods of post-operative surveillance.

Background: Total hip replacement (THR) with post-operative surveillance is recommended for debilitating osteoarthritis (OA). Using self-reported pain, function or walking performance is one alternative to address increasing surveillance demands. Objective: A cross-sectional cohort study to evaluate the associations of pain, function and performance with two radiographic markers of potential THR failure. Participants: 110 patients, median 6 years after THR surgery for OA. Methods: Questionnaires assessed demographics, co-morbidity, arthritis severity, pain, pain catastrophizing, and functional status. Performance was measured using the six minute walk test. THR outcome was assessed radiographically. Results: Few patients had pain, functional impairment or radiographic markers of potential THR failure. A larger percentage of patients with some intermittent pain (10.7 versus 8.6%) and pain iii after walking performance (40.0 versus 27.6%) had higher wear, but these differences were not significant. Conclusion: Measures of pain are potentially important for larger studies aiming to develop alternative methods of post-operative surveillance.

Η αναθεώρηση μιας ολικής αρθροπλαστικής ισχίου λόγω χαλάρωσης του μηριαίου τμήματος της αποτελεί μια πρόκληση ακόμα και για πεπειραμένους χειρουργούς. Η άσηπτη χαλάρωση συνήθως σχετίζεται με κάποιο βαθμό οστικής απώλειας. Διερευνήσαμε εάν η πρόθεση Zweymüller SLR-Plus ®, μαζί με την βιολογική αναδόμηση με αλλομοσχεύματα του ελλειμματικού οστικού περιβάλλοντος του μηριαίου, θα επιτύγχανε επιβίωση, οστεοενσωμάτωση και σταθερότητα παρόμοια ή και καλύτερη από άλλες προθέσεις που χρησιμοποιούνται στη βιβλιογραφία για αναθεώρηση του μηριαίου τμήματος ΟΑΙ. Εξετάσαμε αναδρομικά 69 επιλεγμένους ασθενείς (70 ισχία) οι οποίοι υποβλήθηκαν σε αναθεώρηση του μηριαίου τμήματος με χρήση του SLR-Plus ® στειλεού σε μια περίοδο 10 ετών. Οι ενδείξεις για την αναθεώρηση περιελάμβαναν άσηπτη και σηπτική αποτυχία της βιολογικής στερέωσης, εσφαλμένη εμφύτευση, και περιπροθετικό κάταγμα. Επτά ασθενείς πέθαναν και τέσσερις χάθηκαν κατά το διάστημα παρακολούθησης. Πενήντα οκτώ από τους 69 ασθενείς (59 ισχία) ήταν διαθέσιμοι σε μέσο χρονικό διάστημα 8,3 ± 2,7 χρόνια (εύρος, 4-14 ετών) μετά τη χειρουργική επέμβαση αναθεώρησης. Υπήρχαν 14 άνδρες και 44 γυναίκες (μέση ηλικία, 69 έτη, εύρος, 42-89 ετών). Τέσσερις μηριαίες προθέσεις (7%) αναθεωρήθηκαν ξανά. Η 10ετής επιβίωση της πρόθεσης λαμβάνοντας ως αιτία αναθεώρησης την άσηπτη χαλάρωση ήταν 95% (95% C.I.: 86% -98%). Δεν παρατηρήθηκε περιπροθετική οστεόλυση του μηριαίου γύρω από την πρόθεση και 91% των SLR-Plus στειλεών εμφανίστηκε ακτινολογικά σταθερό είτε μέσω οστεοενσωμάτωσης είτε μέσω ινώδους στερέωσης. Με βάση τα στοιχεία επιβίωσης, πιστεύουμε ότι η χρήση του SLR-Plus® στειλεόυ είναι μια αξιόπιστη λύση για τους ασθενείς που υποβάλλονται σε χειρουργική επέμβαση αναθεώρησης ΟΑΙ, με απώλεια οστικής μάζας στο κεντρικό τμήμα του μηριαίου. / Revision after failed THA resulting from loosening of the femoral component can be challenging even for experienced surgeons. Aseptic loosening usually is associated with some degree of bone loss. We asked whether the Zweymüller SLR-Plus®, along with allograft reconstruction of the deficient femoral bone stock, would provide survivorship, osseointegration, and stability similar to or better than previously reported implants for femoral revision. We retrospectively reviewed 69 selected patients (70 hips) who underwent revision of the femoral component using the SLR-Plus® stem during a 10-year period. The indications for revision included aseptic and septic failure of biologic fixation, incorrect implantation, and periprosthetic fracture. Seven patients died and four were lost to followup. Fifty-eight of the 69 patients (59 hips) were available at a mean 8.3 ± 2.7 years (range, 4–14 years) after revision surgery. There were 14 men and 44 women (mean age, 69 years; range, 42–89 years). Four stems (7%) were rerevised. With rerevision for aseptic reasons, the survival at 10 years was 95% (95% confidence interval, 86%–98%). No femoral periprosthetic osteolysis occurred around the stem and 91% of stems appeared stable radiographically (osseointegration, fibrous). Based on the survival data, we believe the SLR-Plus® stems are reliable for patients undergoing hip revision surgery with central bone loss.

O presente estudo é uma coorte contemporânea de 49 pacientes (51 quadris) submetidos à reconstrução acetabular com enxerto ósseo liofilizado humano ou bovino, picado e impactado, associado a reforço acetabular. Foi realizado no Serviço de Ortopedia e Traumatologia do Hospital de Clínicas de Porto Alegre (HCPA), no período de maio de 1997 a fevereiro de 2005. Os pacientes foram divididos em dois grupos: o grupo 1 (n=26) foi composto pelos que receberam enxerto ósseo liofilizado de origem humana e o grupo 2 (n=25), por aqueles que receberam enxerto de origem bovina. O reforço utilizado em todos os casos foi da MDT® (SP-Brasil). O tempo médio de seguimento foi de 55 e 49 meses respectivamente. Os enxertos ósseos purificados e liofilizados foram produzidos pelo Banco de Tecidos do HCPA. A análise clínica baseou-se no escore de Merle d’Aubigné e Postel e a radiográfica, nos critérios de Conn et al.para osteointegração dos enxertos que avalia a radiolucência, a densidade, a formação de trabeculado ósseo e a migração do componente. Não foram encontradas diferenças clínicas ou radiográficas relevantes entre os grupos, obtendo-se em torno de 88,5 e 76% de integração do enxerto. Estes resultados são comparáveis aos relatados na literatura com o uso de enxerto alógeno congelado e estimulam a continuidade da pesquisa sobre enxertos liofilizados de origem humana e bovina. / Background: this is a cohort trial of 49 patients (51 hips) submitted to revision acetabular component of total hip arthroplasty, using impacted human and bovine freeze-dried cancellous bone grafts and reinforcement device. The study was carried out in the Hospital de Clínicas de Porto Alegre (HCPA) from May 1997 to February 2005. The aim of the study was to compare clinical and radiographic graft incorporation capability between human and bovine freeze-dried bone grafts. Patients and Methods: the patients were divided in two groups: Group 1 (n=26) was composed by those receiving human grafts, and Group 2 (n=25), bovine grafts. The follow-up average was 55 and 49 months. The grafts were purified and freeze-dried at the Tissue Bank of the HCPA.The clinical analysis was based on the score of Merle d’Aubigné and Postel; and the radiographic analysis in an established score based in Conn’s et al. criteria for radiographic bone incorporation. Results: no clinical or radiographic differences were observed between the groups and both groups showed an overall rate of 88.5 and 76% of graft integration. Conclusion: these results are comparable to those reported in the literature with the use of deep-frozen grafts. Therefore, bovine and human freeze-dried grafts can be safely and adequately used in acetabular revision in total hip arthroplasty.

A artroplastia é, em última análise, a opção final para o tratamento da osteoartrose. Com o aumento do número de indicações deste procedimento, a troca (artroplastia total de quadril de revisão – ATQR) dos componentes também passou a ser mais frequente. Os defeitos ósseos ou falhas ósseas são problemas que podem ser encontrados quando se realiza uma ATQR e, eles devem ser reparados, ou seja, o quadril do paciente a receber outra prótese necessita ser reconstruído. Para isto a grande maioria das técnicas empregadas requer o uso de enxerto ósseo e, devido a este motivo este tecido tem se tornado um dos tecidos mais transplantados na atualidade. Porém a demanda para utilização dos enxertos, na maioria provenientes de bancos de tecidos ósseos, tem aumentado, mas o suprimento é insuficiente. Portanto faz-se necessário a busca por novas tecnologias e alternativas aos bancos de tecidos. O enxerto bovino liofilizado (EBL) é uma destas opções, sua produção em livre demanda suas características físicas e químicas semelhantes ao osso humano e sua boa repercussão clínico-radiológica o torna uma alternativa viável. Este estudo tem o objetivo de verificar e quantificar a neoformação óssea com o uso do EBL pelo uso da avaliação histológica. Realizou-se um estudo de casos de Julho de 2000 a Abril de 2013 no Hospital de Clínicas de Porto Alegre (HCPA), onde se incluíram sujeitos que foram submetidos a uma cirurgia prévia cirurgia de ATQR onde foi utilizado o EBL os quais internaram posteriormente para uma segunda cirurgia de ATQR não relacionada a falha do enxerto e sim a falha da prótese. Nesta segunda cirurgia realizou-se a biópsia óssea. Quatorze sujeitos foram analisados, sendo 64,3% do sexo feminino. A média de idade dos pacientes foi 52,36±18,55. Neoformação óssea estava presente em 85,7% dos sujeitos, e constituiu 61,79% da área total de matriz óssea. O diagnóstico de absorção do EBL estava presente em 12 sujeitos. Uma forte correlação de proporção inversa foi constatada pelo teste de Pearson entre a porcentagem de osso neoformado e a porcentagem de EBL na área total de matriz óssea (p=0,001). Nenhuma resposta inflamatória foi encontrada. Concluiu-se que houve neoformação óssea adequada na grande maioria dos casos sendo o EBL uma boa estrutura osteocondutora, podendo ser considerado uma alternativa aos outros enxertos ósseos no tratamento das falhas ósseas. / Arthroplasty is, ultimately, the final option for the treatment of osteoarthritis. With the increasing number of indications of this procedure, the exchange (total hip arthroplasty revision surgery- THARS) also became more frequent. The bone defects are problems that can be encountered when conducting a THARS and this defect must be repaired, in other words, the patient's hip needs to be rebuilt before receive a new prosthesis. Most of techniques used to rebuild requires the use of bone graft, and because of this reason, this tissue has become one of the most transplanted tissues today. However the demand for the use of grafts, mostly from bone tissue banks, has increased, but the supply is insufficient. Therefore it is necessary to search for new technologies and alternatives to tissue banks. The bovine lyophilized xenograft (BLX) is one of these options; the production on free demand, its physical and chemical characteristics similar to human bone and its good clinical and radiological outcomes makes it a viable alternative. The aim of this study was to verify and quantify new bone formation by the histological analysis in subjects who received the BLX. This was a case series from July 2000 to April 2013 realized in the Hospital de Clínicas de Porto Alegre. This study included patients who underwent to a THARS where was used the BLX, which later was admitted to a second THARS surgery, not related to the xenograft failure but a mechanical failure of the implant. In this second surgery was performed the bone biopsy. Fourteen subjects were analyzed, 64.3% were female. The average age of patients was 52.36 ± 18.55 years. New bone formation was present in 85.7% of subjects, and constituted 61.79% of the total bone matrix. The diagnosis of BLX absorption was present in 12 subjects. A strong inverse correlation founded by the Pearson's test was observed between the proportion of new bone and the proportion of BLX (p=0.001). No inflammatory response was found. Was concluded that there was suitable bone formation in the vast majority of the cases, as well as the BLX is a good osteoconductive scaffold and can be considered an alternative to other bone graft in the treatment of bone defects.

O presente estudo é uma coorte contemporânea de 49 pacientes (51 quadris) submetidos à reconstrução acetabular com enxerto ósseo liofilizado humano ou bovino, picado e impactado, associado a reforço acetabular. Foi realizado no Serviço de Ortopedia e Traumatologia do Hospital de Clínicas de Porto Alegre (HCPA), no período de maio de 1997 a fevereiro de 2005. Os pacientes foram divididos em dois grupos: o grupo 1 (n=26) foi composto pelos que receberam enxerto ósseo liofilizado de origem humana e o grupo 2 (n=25), por aqueles que receberam enxerto de origem bovina. O reforço utilizado em todos os casos foi da MDT® (SP-Brasil). O tempo médio de seguimento foi de 55 e 49 meses respectivamente. Os enxertos ósseos purificados e liofilizados foram produzidos pelo Banco de Tecidos do HCPA. A análise clínica baseou-se no escore de Merle d’Aubigné e Postel e a radiográfica, nos critérios de Conn et al.para osteointegração dos enxertos que avalia a radiolucência, a densidade, a formação de trabeculado ósseo e a migração do componente. Não foram encontradas diferenças clínicas ou radiográficas relevantes entre os grupos, obtendo-se em torno de 88,5 e 76% de integração do enxerto. Estes resultados são comparáveis aos relatados na literatura com o uso de enxerto alógeno congelado e estimulam a continuidade da pesquisa sobre enxertos liofilizados de origem humana e bovina. / Background: this is a cohort trial of 49 patients (51 hips) submitted to revision acetabular component of total hip arthroplasty, using impacted human and bovine freeze-dried cancellous bone grafts and reinforcement device. The study was carried out in the Hospital de Clínicas de Porto Alegre (HCPA) from May 1997 to February 2005. The aim of the study was to compare clinical and radiographic graft incorporation capability between human and bovine freeze-dried bone grafts. Patients and Methods: the patients were divided in two groups: Group 1 (n=26) was composed by those receiving human grafts, and Group 2 (n=25), bovine grafts. The follow-up average was 55 and 49 months. The grafts were purified and freeze-dried at the Tissue Bank of the HCPA.The clinical analysis was based on the score of Merle d’Aubigné and Postel; and the radiographic analysis in an established score based in Conn’s et al. criteria for radiographic bone incorporation. Results: no clinical or radiographic differences were observed between the groups and both groups showed an overall rate of 88.5 and 76% of graft integration. Conclusion: these results are comparable to those reported in the literature with the use of deep-frozen grafts. Therefore, bovine and human freeze-dried grafts can be safely and adequately used in acetabular revision in total hip arthroplasty.

A artroplastia é, em última análise, a opção final para o tratamento da osteoartrose. Com o aumento do número de indicações deste procedimento, a troca (artroplastia total de quadril de revisão – ATQR) dos componentes também passou a ser mais frequente. Os defeitos ósseos ou falhas ósseas são problemas que podem ser encontrados quando se realiza uma ATQR e, eles devem ser reparados, ou seja, o quadril do paciente a receber outra prótese necessita ser reconstruído. Para isto a grande maioria das técnicas empregadas requer o uso de enxerto ósseo e, devido a este motivo este tecido tem se tornado um dos tecidos mais transplantados na atualidade. Porém a demanda para utilização dos enxertos, na maioria provenientes de bancos de tecidos ósseos, tem aumentado, mas o suprimento é insuficiente. Portanto faz-se necessário a busca por novas tecnologias e alternativas aos bancos de tecidos. O enxerto bovino liofilizado (EBL) é uma destas opções, sua produção em livre demanda suas características físicas e químicas semelhantes ao osso humano e sua boa repercussão clínico-radiológica o torna uma alternativa viável. Este estudo tem o objetivo de verificar e quantificar a neoformação óssea com o uso do EBL pelo uso da avaliação histológica. Realizou-se um estudo de casos de Julho de 2000 a Abril de 2013 no Hospital de Clínicas de Porto Alegre (HCPA), onde se incluíram sujeitos que foram submetidos a uma cirurgia prévia cirurgia de ATQR onde foi utilizado o EBL os quais internaram posteriormente para uma segunda cirurgia de ATQR não relacionada a falha do enxerto e sim a falha da prótese. Nesta segunda cirurgia realizou-se a biópsia óssea. Quatorze sujeitos foram analisados, sendo 64,3% do sexo feminino. A média de idade dos pacientes foi 52,36±18,55. Neoformação óssea estava presente em 85,7% dos sujeitos, e constituiu 61,79% da área total de matriz óssea. O diagnóstico de absorção do EBL estava presente em 12 sujeitos. Uma forte correlação de proporção inversa foi constatada pelo teste de Pearson entre a porcentagem de osso neoformado e a porcentagem de EBL na área total de matriz óssea (p=0,001). Nenhuma resposta inflamatória foi encontrada. Concluiu-se que houve neoformação óssea adequada na grande maioria dos casos sendo o EBL uma boa estrutura osteocondutora, podendo ser considerado uma alternativa aos outros enxertos ósseos no tratamento das falhas ósseas. / Arthroplasty is, ultimately, the final option for the treatment of osteoarthritis. With the increasing number of indications of this procedure, the exchange (total hip arthroplasty revision surgery- THARS) also became more frequent. The bone defects are problems that can be encountered when conducting a THARS and this defect must be repaired, in other words, the patient's hip needs to be rebuilt before receive a new prosthesis. Most of techniques used to rebuild requires the use of bone graft, and because of this reason, this tissue has become one of the most transplanted tissues today. However the demand for the use of grafts, mostly from bone tissue banks, has increased, but the supply is insufficient. Therefore it is necessary to search for new technologies and alternatives to tissue banks. The bovine lyophilized xenograft (BLX) is one of these options; the production on free demand, its physical and chemical characteristics similar to human bone and its good clinical and radiological outcomes makes it a viable alternative. The aim of this study was to verify and quantify new bone formation by the histological analysis in subjects who received the BLX. This was a case series from July 2000 to April 2013 realized in the Hospital de Clínicas de Porto Alegre. This study included patients who underwent to a THARS where was used the BLX, which later was admitted to a second THARS surgery, not related to the xenograft failure but a mechanical failure of the implant. In this second surgery was performed the bone biopsy. Fourteen subjects were analyzed, 64.3% were female. The average age of patients was 52.36 ± 18.55 years. New bone formation was present in 85.7% of subjects, and constituted 61.79% of the total bone matrix. The diagnosis of BLX absorption was present in 12 subjects. A strong inverse correlation founded by the Pearson's test was observed between the proportion of new bone and the proportion of BLX (p=0.001). No inflammatory response was found. Was concluded that there was suitable bone formation in the vast majority of the cases, as well as the BLX is a good osteoconductive scaffold and can be considered an alternative to other bone graft in the treatment of bone defects.