Evaluation of a pig femoral head osteonecrosis model

Background A major cause of osteonecrosis of the femoral head is interruption of a blood supply to the proximal femur. In order to evaluate blood circulation and pathogenetic alterations, a pig femoral head osteonecrosis model was examined to address whether ligature of the femoral neck (vasculature deprivation) induces a reduction of blood circulation in the femoral head, and whether transphyseal vessels exist for communications between the epiphysis and the metaphysis. We also tested the hypothesis that the vessels surrounding the femoral neck and the ligamentum teres represent the primary source of blood flow to the femoral head. Methods Avascular osteonecrosis of the femoral head was induced in Yorkshire pigs by transecting the ligamentum teres and placing two ligatures around the femoral neck. After heparinized saline infusion and microfil perfusion via the abdominal aorta, blood circulation in the femoral head was evaluated by optical and CT imaging. Results An angiogram of the microfil casted sample allowed identification of the major blood vessels to the proximal femur including the iliac, common femoral, superficial femoral, deep femoral and circumflex arteries. Optical imaging in the femoral neck showed that a microfil stained vessel network was visible in control sections but less noticeable in necrotic sections. CT images showed a lack of microfil staining in the epiphysis. Furthermore, no transphyseal vessels were observed to link the epiphysis to the metaphysis. Conclusion Optical and CT imaging analyses revealed that in this present pig model the ligatures around the femoral neck were the primary cause of induction of avascular osteonecrosis. Since the vessels surrounding the femoral neck are comprised of the branches of the medial and the lateral femoral circumflex vessels, together with the extracapsular arterial ring and the lateral epiphyseal arteries, augmentation of blood circulation in those arteries will improve pathogenetic alterations in the necrotic femoral head. Our pig model can be used for further femoral head osteonecrosis studies

Short-Term Radiographic Evaluation of a Tri-Tapered Femoral Stem in Direct Anterior Total Hip Arthroplasty

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has become increasingly popular, largely due to utilization of a true internervous and intermuscular plane. However, recent literature has demonstrated an increased rate of femoral implant subsidence with this approach. Hence, different femoral implants, such as the tri-tapered femoral stem, have been developed to facilitate proper component insertion and positioning to prevent this femoral subsidence. The purpose of this study was to evaluate the subsidence rate of a tri-tapered femoral stem implanted utilizing a DAA, and to determine if the proximal femoral bone quality affects the rate of subsidence. Methods. A retrospective analysis of 155 consecutive primary THAs performed by a single surgeon was conducted. Age, gender, primary diagnosis, and radiographic measurements of each subject were recorded. Radiological evaluations, such as bone quality, femoral canal fill, and implant subsidence, were measured on standardized anteroposterior (AP) and frog-leg lateral radiographs of the hip at 6-week and 6-month postoperative follow-up evaluations. Results. The average subsidence of femoral stems was 1.18 ± 0.8 mm. There was no statistical difference in the amount of subsidence based on diagnosis or proximal femora quality. The tri-tapered stem design consistently filled the proximal canal with an average of 91.9 ± 4.9% fill. Subsidence was not significantly associated with age, canal flare index (CFI), or experience of the surgeon. Conclusion. THA utilizing the DAA with a tri-tapered femoral stem can achieve consistent and reliable fit regardless of proximal femoral bone quality

Performance of the resurfaced hip. Part 1: the influence of the prosthesis size and positioning on the remodelling and fracture of the femoral neck

Hip resurfacing is an established treatment for osteoarthritis in young active patients. Failure modes include femoral neck fracture and prosthesis loosening, which may be associated with medium-term bone adaptation, including femoral neck narrowing and densification around the prosthesis stem.Finite element modelling was used to indicate the effects of prosthesis sizing and positioning on the bone remodelling and fracture strength under a range of normal and traumatic loads, with the aim of understanding these failure modes better.The simulations predicted increased superior femoral neck stress shielding in young patients with small prostheses, which required shortening of the femoral neck to give an acceptable implant–bone interface. However, with a larger prosthesis, natural femoral head centre recreation in the implanted state was possible; therefore stress shielding was restricted to the prosthesis interior, and its extent was less sensitive to prosthesis orientation. With valgus orientation, the implanted neck strength was, at worst, within 3 per cent of its intact strength.The study suggests that femoral neck narrowing may be linked to a reduction in the horizontal femoral offset, occurring if the prosthesis is excessively undersized. As such, hip resurfacing should aim to reproduce the natural femoral head centre, and, for valgus prosthesis orientation, to avoid femoral neck fracture

Decreased levels of insulin-like growth factor-1 and vascular endothelial growth factor relevant to the ossification disturbance in femoral heads spontaneous hypertensive rats.

Ossification disturbance in femoral head reportedly is seen in the Spontaneously Hypertensive rats (SHR) between ages of 10 and 20 weeks. We investigated serum and tissue levels of insulin-like growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) in SHR relevant to the ossification disturbance and osteonecrosis of the femoral head. Serum levels of IGF-1 and VEGF were significantly lower in SHR than in Wistar Kyoto rats (WKY) at weeks 5, 10, 15 and 20 (p<0.005). The incidence of histological ossification disturbance of the femoral head was higher in SHR (59%) than in WKY (40%) at week 20. Lower serum and local levels of VEGF in SHR appeared to be related to the incomplete ossification of the femoral heads. Immunohistochemical study showed significantly lower numbers of IGF-1 and VEGF positive chondrocytes in the femoral epiphyseal cartilage of SHR than in those of WKY at weeks 10, 15 and 20. Our results suggest that local and/or systemic levels of IGF-1 and VEGF between ages of 5 and 20 weeks might play roles in the pathogenesis of ossifi cation disturbance of the femoral head in SHR

Postoperative pain and morphine consumption after ultrasound-guided femoral and sciatic combined nerve block versus neurostimulation for femoral and sciatic combined nerve block or neurostimulation for femoral nerve block in primary elective total knee arthroplasty.

Abstract Congreso XXXVII National Meeting of the Spanish Society of Pharmacology with guest society: The British Pharmacological SocietyBackground and Aims: Total knee arthroplasty injuries are extremely painful and merit prompt attention to adequate postoperative analgesia. We aim to compare femoral and sciatic ultrasound-guided combined nerve block vs. neurostimulation for femoral and sciatic combined nerve block or for femoral nerve block in postoperative pain in primary elective total knee prosthesis. Summary of work and outcomes: A three arms, prospective longitudinal study of patients having primary elective unilateral knee prosthesis and randomly assigned to catheter insertion guided by ultrasound or neurostimulation was done: 1) Ultrasound-guided femoral and sciatic combined nerve block (USFSCN) (N=15); 2) Neurostimulation for femoral and sciatic combined nerve block (NSFSCN) (N=17); 3) Neurostimulation for femoral nerve block (NSFN) (N=11). Total analgesia (morphine) consumption after 48 hours was the primary endpoint. The postoperative pain intensity (visual analogue pain scale (VAS)) at post-anaesthetic recovery unit (PARU), 6, 24, 48 h, and during movement and postoperative complications were secondary outcomes. Results and discussion: 43 patients (68.3±8 years old, 77% female) subjected to elective unilateral knee prosthesis were enrolled. There were no differences in the demographic, anaesthetic and surgical variables between groups. Pain intensity was lower in the USFSCN group compared with NSFSCN and NSFN during the first 48 h post-surgery (% of intense pain at PARU/6h/24h/48h): USFSCN 0.8/1.4/3.2/1.6; NSFSCN 5.6/8.3/7.5/3; NSFN 7.2/5.3/6.4/5.4. The average consumption of morphine within 48 h after surgery was similar in the groups USFSCN and NSFSCN (3 mg vs. 3.11 mg), and significantly lower than NSFN (4.19 mg) (p<0.05). And the number of complications was significantly lower in the USFSCN group compared with NSFSCN and NSFN during the first 48 h of postoperative. Conclusion: Ultrasound-guided femoral and sciatic combined nerve block presented better analgesia and was more safety than neurostimulation for femoral and sciatic combined nerve block or for femoral nerve block in primary elective total knee arthroplasty.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Radial versus femoral access for rotational atherectomy: A UK observational study of 8622 patients

Background—Rotational atherectomy (RA) is an important interventional tool for heavily calcified coronary lesions. We compared the early clinical outcomes in patients undergoing RA using radial or femoral access. Methods and Results—We identified all patients in England and Wales who underwent RA between January 1, 2005, and March 31, 2014. Eight thousand six hundred twenty-two RA cases (3069 radial and 5553 femoral) were included in the analysis. The study primary outcome was 30-day mortality. Propensity scores were calculated to determine the factors associated with treatment assignment to radial or femoral access. Multivariable logistic regression analysis, using the calculated propensity scores, was performed. Thirty-day mortality was 2.2% in the radial and 2.3% in the femoral group (P=0.76). Radial access was associated with equivalent 30-day mortality (adjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.77–1.46; P=0.71), procedural success (OR, 1.04; 95% CI, 0.84–1.29; P=0.73), major adverse cardiac and cerebrovascular events (OR, 1.05; 95% CI, 0.80–1.38; P=0.72), and net adverse clinical events (OR, 0.90; 95% CI, 0.71–1.15; P=0.41), but lower rates of in-hospital major bleeding (OR, 0.62; 95% CI, 0.40–0.98; P=0.04) and major access site complications (OR, 0.05; 95% CI, 0.01–0.38; P=0.004), compared with femoral access. Conclusions—In this large real-world study of patients undergoing RA, radial access was associated with equivalent 30-day mortality and procedural success, but reduced major bleeding and access site complications, compared with femoral access

Aortic calcification and femoral bone density are independently associated with left ventricular mass in patients with chronic kidney disease

Background Vascular calcification and reduced bone density are prevalent in chronic kidney disease and linked to increased cardiovascular risk. The mechanism is unknown. We assessed the relationship between vascular calcification, femoral bone density and left ventricular mass in patients with stage 3 non-diabetic chronic kidney disease in a cross-sectional observational study. Methodology and Principal Findings A total of 120 patients were recruited (54% male, mean age 55±14 years, mean glomerular filtration rate 50±13 ml/min/1.73 m2). Abdominal aortic calcification was assessed using lateral lumbar spine radiography and was present in 48%. Mean femoral Z-score measured using dual energy x-ray absorptiometry was 0.60±1.06. Cardiovascular magnetic resonance imaging was used to determine left ventricular mass. One patient had left ventricular hypertrophy. Subjects with aortic calcification had higher left ventricular mass compared to those without (56±16 vs. 48±12 g/m2, P = 0.002), as did patients with femoral Z-scores below zero (56±15 vs. 49±13 g/m2, P = 0.01). In univariate analysis presence of aortic calcification correlated with left ventricular mass (r = 0.32, P = 0.001); mean femoral Z-score inversely correlated with left ventricular mass (r = −0.28, P = 0.004). In a multivariate regression model that included presence of aortic calcification, mean femoral Z-score, gender and 24-hour systolic blood pressure, 46% of the variability in left ventricular mass was explained (P<0.001). Conclusions In patients with stage 3 non-diabetic chronic kidney disease, lower mean femoral Z-score and presence of aortic calcification are independently associated with increased left ventricular mass. Further research exploring the pathophysiology that underlies these relationships is warranted