Antti Eskola

Aggressive granulomatous lesions associated with hip arthroplasty. Immunopathological studies.

The local immunopathological response was analyzed in six patients who had a revision of a total hip prosthesis because of an aggressive granulomatous lesion and in six patients who had a revision because of common loosening of the prosthetic stem. All twelve patients had had a total replacement arthroplasty for primary osteoarthrosis. All of the prostheses had been cemented. The aggressive granulomas consisted of well organized connective tissue containing histiocytic-monocytic and fibroblastic reactive zones. The granulomas were highly vascularized, and villous structures were observed at many sites. In contrast, the areas around the loose cemented stems were characterized by dense connective tissue. Immunohistological evaluation revealed that most of the cells in the aggressive granulomatous tissue were multinucleated giant cells and C3bi-receptor and nonspecific esterase-positive monocyte-macrophages. This cytological finding suggests a foreign-body-type reaction, compatible with the rapidly progressive lytic nature of the lesion that was shown radiographically. There was a clear-cut difference between aggressive granulomatosis and the more common lesion accompanying prosthetic loosening--namely, the relative lack of activated fibroblasts in granulomatosis. We suggest that granulomatosis involves an uncoupling of the normal sequence of monocyte-macrophage-mediated clearance of foreign material and tissue debris that is normally followed by fibroblast-mediated synthesis and remodeling of the extracellular matrix. We also suggest that aggressive granulomatosis in association with a cemented hip prosthesis is a distinct entity, not only clinically and radiographically, but also histopathologically.

Outcome of clavicular fracture in 89 patients

SummaryDuring 1982, 118 patients with clavicular fracture were treated in the Department of Orthopaedics and Traumatology, Helsinki University Central Hospital. Eighty-nine patients appeared for the follow-up examination in 1984. Eighty-three fractures were treated with immobilization in a sling. Four fractures were treated with plate fixation primarily and two patients were operated on for delayed union. The immobilization averaged 21 days, range 10–42 days. The follow-up was 2 years in all cases. The result was good in 65 cases, satisfactory in 20, and poor in 4 cases. Patients with primary dislocation of more than 15 mm or with shortening observed at the follow-up examination had statistically significantly more pain than patients without these findings.ZusammenfassungAn der Orthopädisch-traumatologischen Klinik der Universität Helsinki wurden 1982 118 Patienten mit Klavikulafraktur behandelt. Neunundachtzig dieser Patienten konnten im Jahre 1984 nachuntersucht werden. Dreiundachtzig Frakturen waren durch Immobilisation im Armtragetuch behandelt worden. Vier Frakturen wurden primär verplattet, und zwei Fälle wurden wegen verzögerter Heilung sekundär operiert. Die Dauer der Immobilisation betrug durchschnittlich 21 Tage (10–42 Tage). Die Beobachtungszeit war in allen Fällen zwei Jahre. Das Ergebnis der Behandlung war gut in 65 Fällen, befriedigend in 20 Fällen und schlecht in 4 Fällen. Patienten mit primärer Dislokation von mehr als 15 mm oder bei der Nachuntersuchung festgestellter Verkürzung hatten signifikant mehr Schmerzen als Patienten ohne derartige Befunde.

Aggressive granulomatous lesions in cementless total hip arthroplasty

We describe six patients with aggressive granulomatous lesions around cementless total hip prostheses. Two patients previously had a cemented prosthesis in the same hip. The Lord prosthesis was used in five patients, the PCA in one. Both prostheses were made of chrome-cobalt alloy. Pain on weight-bearing occurred on average 3.2 years after the cementless arthroplasty, and at that time radiography revealed aggressive granulomatosis around the proximal femoral stem and the acetabular component in five of the patients; one had a large solitary granuloma in the proximal femur. Revision was performed on average 4.8 years after the cementless arthroplasty. At that time all granulomas had grown large in size; while waiting for revision operation, two femoral stem components fractured. All the granulomas showed a uniform histopathology, which included histiocytosis; the cause for these lesions was thought to be plastic debris from the acetabular socket.

Immunopathological response to loose cementless acetabular components

The membranes surrounding seven loose cementless acetabular implants were shown to contain polyethylene particles, birefringent in polarised light. Three of these implants were made of titanium alloy and the membranes around these contained titanium particles as well. There was no metallosis around the four implants made of chromium-cobalt-steel alloy. Both titanium and polyethylene particles caused migration, adherence and phagocytosis of CD11b-positive, peroxidase-negative macrophages. There were no histological signs of activation of the specific immune response; neither interleukin-2 receptor-positive activated T cells nor PCA-1 plasmablasts/plasma cells were present in the tissues. In cases of simple loosening, resident mesenchymal fibroblast-like cells were active. In aggressive granulomatosis, there were many macrophages and multinucleated giant cells but little fibroblast reaction. The clinical relevance of the findings is that the use of cementless prostheses is not a guarantee against adverse tissue reactions.

The Results of Operative Resection of the Lateral End of the Clavicle

Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups. The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p < 0.01). Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity, and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p < 0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p < 0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular osteoarthrosis. We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters.

Aggressive granulomatous lesions after hip arthroplasty

We reviewed 19 patients who presented with aggressive granulomatosis around the femoral stem after hip replacement. All had experienced stress pain and had required revision arthroplasty on average 8.8 years after the primary operation. Fifteen patients were men and four were women; none had rheumatoid arthritis. One patient had an uncemented Moore hemiprosthesis; the others all had cemented total hip replacements. When first detected, the granulomatous lesions were multifocal in 13 patients. The first granuloma was in the region of the lesser trochanter in 10, and near the tip of the stem in only two. Speed of growth varied but on average there was doubling of the area on anteroposterior films in 2.2 years (range 6 months to 4.6 years). Aggressive granulomatous lesions in replaced hips are a distinct condition, different from simple loosening or infection; the lesions may grow rapidly, so revision surgery is indicated soon after diagnosis.

Operation for old sternoclavicular dislocation. Results in 12 cases

Twelve patients were operated upon after unsuccessful conservative treatment for complete dislocation of the sternoclavicular joint. Three methods were used; stabilisation using fascial loops, reconstruction with a tendon graft, and resection of the sternal end of the clavicle. The results were good in only four patients, three treated with a tendon graft and one by fascial loops. Another four patients had fair results, but all four treated by resection of the medial end of the clavicle had poor results, with pain and weakness of the upper extremity. In our opinion resection of the sternal end of the clavicle should not be used in old traumatic dislocation.

Surgery for ununited clavicular fracture

Twenty-four ununited, primarily conservatively treated clavicular fractures were treated operatively. The follow-up period averaged 3.5 years. In all cases, the primary displacement was at least equal to the clavicular thickness. The subjective outcome was good in 17 cases, satisfactory in six, and poor in one. In two cases, resection was performed. Our experience of rigid plate fixation and cancellous bone grafting was good with union in 20/22 cases. However, the operations are not uncomplicated and there is a risk of diminished muscle power and range of movement in the shoulder if the clavicle is shortened.

Sternoclavicular dislocation: A plea for open treatment

I report 12 cases of dislocation of the sternoclavicular joint. Eight cases were treated by closed reduction and redislocation occurred in five. The result was good in five out of these eight cases. Two cases with a redislocation and poor result were operated on: in one the sternoclavicular joint was successfully reconstructed with a palmaris longus tendon, and in the other the result was poor after medial resection of the clavicle. In four dislocations good results were obtained after primary open reduction, fixation with two Kirschner wires, and suture of the ruptured ligaments. Primary open reduction should probably be preferred in acute cases of sternoclavicular dislocation.

Cementless total replacement for old tuberculosis of the hip

We report the results of cementless total joint replacement in 18 patients with old tuberculosis of the hip, performed, on average, 34 years after the onset of infection. Mean follow-up was 3.5 years. Only seven of the patients had antituberculous drugs during or after the operation. Using the Mayo hip score, 15 patients had excellent or good results and two had a fair rating. One patient had the prosthesis removed more than one year postoperatively for late haematogenous staphylococcal infection and had a poor rating. All the patients had relief of hip-related pain. Despite the absence of any reactivation of tuberculosis in our series, we recommend the use of specific prophylaxis.