Forty-one Wagner revision stems were implanted at the Orthopedic Department of the University of Tübingen between July 1990 and January 1993. We report the results of 37 patients at an average follow-up of 27 months (13-48 months) postoperatively. The main indication was stem loosening with considerable loss of bone. In addition, we used the implant 4 times in primary arthroplasty. At follow-up examination 33 patients (89%) were satisfied with the postoperative outcome. According to the Merle D'Aubigné score (12-point scale), 32 patients showed a poor functional result of less than 6 points preoperatively. Postoperatively, the results of 36 patients could be classified as very good to good. To categorise the radiological destruction of the implant bed, we used the femoral shaft defect classification of the DGOT (Deutsche Gesellschaft für Orthopädie und Traumatologie) in conjunction with the classification of Pak and Paproski [5, 11]. Twenty patients presented with trochanteric and calcar defects, and 11 patients with a combination of a calcar and shaft defect. We found a circular shaft defect in 2 patients. In 7 cases we assessed the bone remodelling postoperatively as very good, with strong newly formed bone structures, and in 25 cases as good, with remodelling of the old stem bed and bony structuring of the osteolyses. A secondary sinking in of the Wagner stem was seen in 7 cases. Only one stem had to be revised because of pain symptoms and loosening; in all other cases a secondary stabilisation of the revision-stem took place. With the Wagner revision stem, there is the possibility of achieving mechanical stability even in situations with massive bone loss. The evacuation of bone cement and granulation tissues is facilitated by the transfemoral approach, bony remodelling is accelerated, and bone grafting is often not necessary. As our short-term results show, the concept is a promising one. Nevertheless, we will be very careful in following these patients in the long term, as we have noticed stem sinkage in a small percentage of cases.
Implantation of a total hip replacement leads to resorption of bone, especially in the upper femoral shaft and this depends mainly on the design of the stem, and also on the survival time of the implant. Density of the periprosthetic bone was examined with the DEXA method in both femurs in 27 patients at a mean of 21 months after implantation of uncemented custom-made femoral stems. A loss of bone density between 5% and 21% was found which was independent of the survival time of the implant. The maximum decrease was at the upper medial part of the calcar. The negligible loss of bone density, compared to other reports, favours the use of a computer tomography assisted custom-made femoral stem.
The osteogenic potential of bone and bone matrix has been characterised only by its biological effects and the parameters influencing it. Recently, the osteoinductive ability of bone matrix had been defined chemically by the description of a bone morphogenetic protein (BMP), and the parameters of osteogenic factors from different species have now been recognised. The current state of isolation, purification and characterisation of these factors is summarised in this review. General aspects of the isolation and testing of BMP preparations, and the results of orthotopic application of BMP implants, including clinical cases, are reported.
In this study, a characterization of human bone-forming cells responsible for heterotopic ossification was carried out in vitro. The biological and biochemical cell characteristics of the heterotopic osteoblast-like (HOB) cells were compared with those of orthotopic osteoblast-like (OB) cells from normal bone and stromal bone marrow cells believed to contain a subpopulation of osteogenic precursor cells. We found that HOB's from the spongiosa of heterotopic ossification required less time until the beginning of migration and the achievement of confluence in vitro compared with OBs from femoral shaft spongiosa. The fraction of mitotically active cells assessed by a clonogenic assay was higher as well in HOB cells. The in vitro studies of mitogenesis and the efficiency of colony formation of osteogenic cells indicate that with increasing differentiation and relative age they become more dependent on growth factors in the medium, otherwise the morphology of osteoblast-like cells changes and they pass irreversibly into the postmitotic stage of the cell cycle. The activity of the alkaline phosphatase is distinctly higher in the HOB than in the OB cells, HOB cells exhibit a lower level of osteocalcin expression compared with OB cells. No significant difference was found between OB and HOB cells in the amount of procollagen of type I sequestered by the cells. After 30 days, HOB and OB cells formed a mineralized matrix on exposure to 2 mM beta-glycerophosphate. Since HOBs were isolated from heterotopic bone that had developed within 3-6 months after hip surgery, the differences in cellular behavior compared with OBs may be attributed to the relatively young age of HOB cells.
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