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Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of avascular necrosis. The majority of the fractures (84 patients; 90%) followed one of the following four patterns: posteromedial (varus) impaction in 50 patients (54%), lateral (valgus) impaction in 13 (14%), isolated greater tuberosity in 15 (16%), and anteromedial impaction fracture in six (6%). Head orientation, impaction of the surgical neck and displacement of the tuberosity correlated strongly with the outcome. In fractures with posteromedial impaction, a poor outcome was noted as the articular surface displaced inferiorly increasing its distance from the acromion. A poorer outcome was noted as a fractured greater tuberosity displaced medially overlapping with the posterior articular surface. Lateral impaction fractures had a worse outcome than other patterns of fracture.

SummaryObjectiveOsteoarthritis (OA) is clinically characterized by degeneration of the joints and has been traditionally considered a primary disorder of articular cartilage, with secondary changes in the subchondral bone. The increased bone mass and generalized changes in bone quality observed in osteoarthritic patients suggest that OA may be a primary systemic bone disorder with secondary articular cartilage damage. The iliac crest is a skeletal site distant from the affected joint, with a minimal load-bearing function. To provide evidence that OA is a systemic disorder, we searched for differentially expressed genes in the iliac crest bone of patients suffering from hip OA.Material and methodsGene expression levels between bone samples collected at surgery from the iliac crest of patients undergoing total hip arthroplasty for primary OA and younger donors, who were undergoing spinal arthrodesis, were investigated by means of oligonucleotide microarrays. To verify data detected by microarrays technology, Real Time Reverse Transcription-Polymerase Chain Reaction (RT-PCR) assays were performed with specimens from osteoarthritic patients and donors, as well as from elderly donors who were undergoing arthroplasty for subcapital femoral neck fracture.ResultsThe microarray analysis surveyed 8327 genes and identified 83 whose expression levels differed at least 1.5-fold in the OA group (P

Biphasic calcium phosphates (BCPs) consist of a mixture of hydroxyapatite and β-tricalcium phosphate and are recommended as alternatives or additives to autogenous bone for orthopaedic and dental applications. There is clinical evidence showing particle release from bioceramics, which might impair the ability of human mesenchymal stem cells (hMSC) from bone marrow to proliferate or mature into a functional osteoblast phenotype. This study analyses the influence of BCP particles and their precursors, calcium-deficient apatite (CDA) particles, on in vitro hMSC behaviour. Both types of particles were efficiently internalized by hMSC. Cell viability, morphology and actin cytoskeleton reorganization were unaffected by exposure of hMSC to BCP or CDA particles. Direct exposure to BCP particles impaired hMSC osteogenic differentiation and bone matrix mineralization to a lesser extent than CDA, as assayed by evaluation of alkaline phosphatase activity, osteopontin secretion and mineralized nodule formation. The ability of bioceramic particles to affect osteogenic maturation through modification of soluble factors in media was assayed in an in vitro system that avoids direct cell–particle contact. Indirect exposure to CDA particles severely impaired hMSC osteogenic maturation owing to the uptake of Ca2+ from the culture media. Lower textural properties of BCP and the lack of calcium deficiency in its composition prevented Ca2+ uptake, allowing the development of a functional osteoblast phenotype.

Objetivo Analizar el proceso diagnostico y tratamiento del paciente politraumatizado con lesiones del aparato locomotor en un hospital espanol de tercer nivel sin unidad especifica estructurada funcionalmente para la atencion de estos pacientes. Material y metodo Estudio observacional retrospectivo. Se incluyeron todos los pacientes ingresados en la Unidad de Cuidados Intensivos (UCI) bajo el diagnostico de politraumatismo con lesiones del aparato locomotor entre enero de 2001 y mayo de 2003, 135 enfermos, de los cuales 120 pudieron ser evaluados. Se procedio al estudio de las historias clinicas, registrandose el mecanismo causal, diagnosticos, calculo del ISS (Injury Severity Score) y NISS (New Injury Severity Score), tratamientos aplicados y el momento en el que se realizaron, complicaciones desarrolladas y mortalidad. Se utilizo el software SPSS 11.0 para el analisis de los datos. Resultados La edad media fue 38 (rango 15-75 anos). Noventa y cinco (80%) eran hombres. Los mecanismos causales principales fueron el accidente de trafico y el atropello (65%). La estancia media en UCI fue 13,5 dias (rango 1-130). El 33% fue intervenido de las lesiones del aparato locomotor. La demora media en la estabilizacion de las fracturas fue 9,3 dias (rango 1-70). Treinta y tres pacientes (28%) desarrollaron complicaciones sistemicas inflamatorias, y 37 (31%) presentaron infecciones graves. Veintiun pacientes (18%) fallecieron en una media de 8,5 dias (rango 1-50 dias) despues de ingresar. Conclusiones La comparacion con los protocolos y resultados publicados por unidades especificas para politraumatizados en otros paises demuestra la conveniencia de una mayor protocolizacion y coordinacion multidisciplinar para mejorar la atencion de la patologia osteoarticular de estos pacientes en centros de referencia.

Purpose To analyze the diagnostic and therapeutic protocol used in multiple-trauma patients with musculoskeletal injuries at a Spanish tertiary referral hospital that lacks a specific unit endowed with the functional structure to treat these patients. Materials and methods Retrospective observational study. All patients admitted to the Intensive Care Unit (ICU) between January 2001 and May 2003 with a diagnosis of multiple trauma to the musculoskeletal system were included. There were a total of 135 patients, of which 120 could be evaluated. The patients’ clinical records were analyzed and a record was made of the mechanism of injury, ISS (Injury Severity Score) and NISS (New Injury Severity Score) calculations, treatment administered in each case and time of administration, any ensuing complications and mortality rate. The SPSS 11.0 software was used for data analysis. Results Mean age was 38 (range: 15-75 years). Ninety-five (80%) were male. The main mechanisms of injury were road accidents and pedestrian-motor vehicle collisions (65%). Mean ICU stay was 13.5 days (range: 1-130). Thirty-three percent were operated on for their musculoskeletal lesions. Main time-to-fracture stabilization was 9.3 days (range: 1-70). Thirty-three patients (28%) developed inflammatory systemic complications and 37 (31%) had serious infections. Twenty-one patients (18%) died 8.5 days (range 1-50 days) after their admission. Conclusions A comparison with protocols and results published by dedicated multiple-trauma units from other countries reveals the need for a greater degree of protocolization and multidisciplinary coordination to improve the treatment of the bone and joint pathologies of these patients in referral hospitals.

We have investigated a novel ultrafine grained (UFG) Zr obtained by severe plastic deformation (SPD) which resulted in a refinement of the grain size by several orders of magnitude. Compared to conventional Zr, higher hardness values were measured on UFG Zr. Polished surfaces having similar topographical features from both materials were prepared, as assessed by atomic force microscopy (AFM). Surface hydrophobicity of Zr, evaluated by measuring water contact angles, was unaffected by grain size reduction. In vitro biocompatibility was addressed on conventional and UFG Zr surfaces and, for comparative purposes, a polished Ti6Al4 V alloy was also investigated. Cell attachment and spreading, actin and β-tubulin cytoskeleton reorganisation, fibronectin secretion and cellular distribution as well as cell viability were evaluated by culturing human osteoblastic Saos-2 cells on the surfaces. The osteoblastic response to conventional Zr was found to be essentially identical to Ti6Al4V and was not affected by grain size reduction. In order to evaluate the ability of the surfaces to promote osteogenic maturation and bone matrix mineralisation, human mesenchymal cells from bone marrow were switched to the osteoblastic phenotype by incubation in osteogenic induction media. Compared to undifferentiated mesenchymal cells, alkaline phosphatase activity and formation of mineralisation nodules were enhanced to the same extent on both Zr surfaces and Ti6Al4V alloy after induction of osteoblastic differentiation. In summary, improved mechanical properties together with excellent in vitro biocompatibility make UFG Zr a promising biomaterial for surgical implants. © 2007 Elsevier Ltd. All rights reserved.

Titanium and its alloys are widely used as implant materials for dental and orthopaedic applications. To improve their wear and corrosion resistance, several surface modifications that give rise to an outer ceramic layer of rutile have been developed. It is expected that after a long period of functional loading, rutile debris will arise from these modified surfaces. We have compared the in vitro biocompatibility of subcytotoxic doses of rutile and titanium particles of phagocytosable size in primary cultures of human osteoblasts. Particles were visualized using a spectral confocal microscope by reflection. Both types of particles aggregated in the culture media and were efficiently internalized by osteoblasts as agglomerates. Treatment of isolated cultures of osteoblasts with rutile particles stimulated the release of IL-6, PGE2, and GM-CSF to a lesser extent than titanium. The influence of macrophages on the particle-induced stimulation of those local factors was analyzed by coculturing TPA-differentiated THP-1 cells with osteoblasts. Under these conditions, levels of IL-6 and PGE2 after treatment of cocultured osteoblasts with rutile particles were lower than after exposure to titanium. These results indicate that rutile debris shows a lower bioreactivity than titanium when tested in cultures of human osteoblasts and support the improved biocompatibility of titanium-based implants modified to create an outer layer of rutile on their surfaces.

We studied the effect of vitamin C on fracture healing in the elderly. A total of 80 elderly Osteogenic Disorder Shionogi rats were divided into four groups with different rates of vitamin C intake. A closed bilateral fracture was made in the middle third of the femur of each rat. Five weeks after fracture the femora were analysed by mechanical and histological testing. The groups with the lower vitamin C intake demonstrated a lower mechanical resistance of the healing callus and a lower histological grade. The vitamin C levels in blood during healing correlated with the torque resistance of the callus formed (r = 0.525). Therefore, the supplementary vitamin C improved the mechanical resistance of the fracture callus in elderly rats. If these results are similar in humans, vitamin C supplementation should be recommended during fracture healing in the elderly.

Objetivo Valorar la calidad de vida en personas con defecto congenito de femur. Material y metodo Se trata de un estudio transversal. La poblacion esta formada por 92 pacientes diagnosticados de femur corto congenito desde 1969. Los criterios de inclusion fueron tener 15 anos de edad o mas y tener datos de domiciliacion o de telefono de contacto. La calidad de vida se midio con el cuestionario de salud SF-12 aplicado de mayo a octubre de 2003 telefonicamente, previa peticion de consentimiento informado. Los resultados fueron comparados con una poblacion de referencia. Resultados Solo 39 pacientes se incluyeron en el estudio. La media de edad fue de 26,2 anos (hombres 24,8 anos; mujeres 27,6 anos). El 48,7% eran hombres y el 51,3% mujeres. No se detectaron diferencias en las medias de los componentes fisico (PCS) y mental (MCS) entre hombres y mujeres, ni entre los distintos estratos de edad. El 100% obtuvo una puntuacion MCS considerada como normal y el 20,5% obtuvo una puntuacion PCS anormal. Conclusion La calidad de vida de estos pacientes para el componente fisico es anormal en los pacientes mas jovenes. Sorprende que el componente mental sea normal en todos. Podria deberse al hecho de ser un trastorno que se padece desde el mismo momento del nacimiento, y no tener un impacto psicosocial tan fuerte como con otro tipo de problemas

Purpose To assess the quality of life in persons with a congenital short femur. Materials and methods This was a cross-sectional study. The study population was 92 patients diagnosed since 1969 with congenital short femur. Inclusion criteria were: patients should be over 15 years of age and possess a known address or telephone number. Quality of life was determined from May to October 2003 by means of telephone interviews, carried out after obtaining informed consent, using Health Questionnaire SF-12. The results were compared to those obtained in a reference population. Results Only 39 patients participated in the study, of whom 48.7% were male and 51.3% were female. Mean age: 26.2 years (men: 24.8 years; women: 27.6 years). No differences were detected between men and women, nor across different age groups, with reference to the mean physical (PCS) and mental (MCS) variables. One hundred percent of the population had a normal MCS and 20.5% had an abnormal PCS. Conclusion Quality of life based on PCS is abnormal in younger patients. It is surprising that MCS should be normal in all patients. This could be due to the fact that this condition is present from birth and therefore does not have such a strong psychosocial impact as other conditions.

We have evaluated the in-vitro biocompatibility of Ti6Al4V alloy coated by plasma spraying with an identical alloy. These surfaces are widely used in cementless prosthetic components, although osteoblasts behavior on this treated alloy has not been evaluated to date. Cross sectional examination revealed a thick and rough coating of identical composition without sign of delamination. Within the coating, small discontinuities and nonconnected pores were observed. Osteoblast response was evaluated by assessing cell adhesion, proliferation, and differentiation of primary cultures of human osteoblastic cells. Compared to the polished alloy, osteoblast adhesion measured as cell attachment and actin network reorganization was delayed on the plasma-sprayed surface. Cell proliferation and viability were also impaired on the rough surface. Several informative markers of osteoblastic differentiation such as procollagen I peptide, alkaline phosphatase, osteocalcin, osteoprotegerin, and mineralized nodule formation were evaluated and indicated that the plasma-sprayed alloy favored a more differentiated phenotype than polished alloy. Taken together, our in vitro results indicate that successful osseointegration of plasma spraying of Ti6Al4V with an identical alloy is mediated by modulation of osteoblastic differentiation and mineralization. © 2006 Wiley Periodicals, Inc.

El amplio desarrollo de la investigacion en el campo de la consolidacion osea ha propiciado la existencia de nuevas lineas de investigacion que, aunque actualmente no estan disponibles para su uso clinico, si tienen grandes perspectives de exito a medio y largo plazo. Entre estas nuevas tecnicas destacan los estimuladores locales y matrices inteligentes, las celulas mesenquimales o la terapia genica. En este articulo se presenta el estado actual de desarrollo de esta tecnologia emergente.

Los factores de crecimiento desempenan un papel clave en la consolidacion de las fracturas, asi como la regeneracion osea y cartilaginosa. El plasma rico en plaquetas es una forma actual de aplicar estos conocimientos para la mejora de la consolidacion. En este articulo se revisan los conocimientos actuales sobre los factores de crecimiento, asi como la experiencia de los autores en el plasma rico en plaquetas.

We have recently reported that thermal oxidation treatments of Ti6Al4V at 500 degrees and 700 degrees C for 1 h result in the formation of an outer "ceramic" layer of rutile that do not decrease the high in vitro corrosion resistance of the alloy. In the present work, surface roughness was measured and found marginally increased as a consequence of oxidation of the alloy at 700 degrees C, but not at 500 degrees C. We have evaluated the biocompatibility of the oxidized surfaces, by assessing cell adhesion, proliferation, and differentiation of primary cultures of human osteoblastic cells. Compared with polished alloy, both thermal treatments increased osteoblast adhesion measured as cell attachment, beta1 integrin and FAK-Y397 expression, as well as cytoskeletal reorganization. Compared with treatment at 500 degrees C, thermal oxidation at 700 degrees C enhanced cell adhesion. Treatment at 700 degrees C transiently impaired cell proliferation and viability, which were not altered in alloys oxidized at 500 degrees C. Several markers of osteoblastic differentiation such as procollagen I peptide, alkaline phosphatase, osteocalcin, and mineralized nodule formation were found either unaffected or differentially increased by alloys treated either at 500 degrees or 700 degrees C. In addition, thermal oxidation at 700 degrees C also increased osteoprotegerin secretion. Taken together, our results indicate that thermal oxidation treatments at 500 degrees or 700 degrees C for 1 h improve the in vitro biocompatibility of Ti6Al4V.

Objetivo y metodo En este trabajo se revisa el conocimiento adquirido a partir de los principales articulos publicados en los ultimos treinta anos, acerca del mejor momento para el tratamiento quirurgico y de los metodos de fijacion a emplear en las fracturas de los huesos largos en el politraumatizado, con el fin de mejorar los resultados en cuanto a la morbimortalidad global de estos pacientes. Conclusiones Los estudios revisados ponen de manifiesto la necesidad de aplicar protocolos de «tratamiento precoz definitivo» (early total care) y «cirugia ortopedica de control de danos» (damage control orthopaedic surgery), intentando estabilizar las fracturas en las primeras 24 horas para limitar la respuesta inflamatoria sistemica y permitir un control respiratorio adecuado de estos pacientes, disminuyendo asi las cifras de morbimortalidad y los costes de la atencion sanitaria.

Introduction:To analyse results and risk factors for osteosynthesis of displaced femoral neck fractures in patients older than 70 years.Patients and Methods:From 1992 to 2000, 183 consecutive patients over 70 with displaced femoral neck fractures were treated by closed reduction and fixation with cannulated screws and followed up prospectively for two years. Pain at rest and pain with walking, return to previous functional and walking ability, and need for additional surgery were evaluated.Results:Six patients died, while 149 were followed up for a minimum of two years: 82 (55%) were asymptomatic, 19 (12.8%) had mild pain, 39 (26.1%) required arthroplasty and 9 (6%) were too ill for further surgery. Poor quality reduction (p=0.008) and poor quality osteosynthesis (p= 0.064) were risk factors for failure. Fifty patients (33.6%) presented with non-union: 6/50 were asymptomatic, 34/50 required arthroplasty, and 10/50 were very ill. Ischaemic necrosis appeared in ten cases (6.7%) (five asymptomatic and five requiring arthroplasty).Conclusions:Reduction and fixation of displaced femoral neck fractures achieved good results in 68% of patients over 70, but re-operation became necessary in 32% of them; this made internal fixation advisable only for selected patients who were very active. The main risk factors were poor-quality reduction followed by poor osteosynthesis.

Our purpose was to compare the accuracy of ultrasonography (US) and magnetic resonance (MR) in the diagnosis of rotator cuff injuries (focusing on supraspinatus tears) using arthroscopy or open surgery findings. Using US and MR, we studied all painful shoulders seen during 1998 in our orthopaedic unit. Diagnosis was confirmed in 61 cases. The diagnosis of full thickness rotator cuff tear was highly specific on both imaging techniques (100% for US and 97.1% for MR) but was not as sensitive on US (57.7%) as on MR (80.8%). The diagnosis of partial tear was acceptably specific (67.9% for US and 75.5% for MR) but was not sensitive (overall, 12.5% for US vs 50% for MR). The specificity of a US diagnosis of a tear allows us to recommend surgery, thus making it a good imaging technique for the initial study of painful shoulders. The low sensitivity makes it necessary to undertake an additional MR study. If the MR also discovers no pathology, the sensitivity based on the US and MR images (92.7%) can be sufficient to avoid a false-negative diagnosis.

We have investigated prospectively the incidence of urinary tract infection (UTI) in 5320 orthopaedic patients. There were 74 UTIs (1.39%). Enterobacteriaceae was the most frequent etiological agent. Each infection increased the length of stay in hospital by more than 8 days. Statistically independent risk factors for the development of urinary infection were a preoperative stay of more than 4 days, inadequate preoperative preventive measures, central venous catheterization and urinary catheterization. Sex, age, or type of surgery had no statistical influence on the development of infection.

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment.

One of the problems associated with the modern biomaterials used in prostheses is osteolysis, which, although its exact origin is unknown, has been associated with wear particles. Osteoblasts seem to participate directly in this phenomenon. This paper investigates in vitro cellular response to the wear particles from the metal substrate and ceramic covering (alpha-alumina) of a new titanium yttrium aluminum alloy, MA 956, that has been proposed as a biomaterial because of its exceptional mechanical and electrochemical properties. The effect of different sizes (10 and 80 microm) of MA 956 and alpha-alumina particles on osteoblast function was studied in primary human bone cell cultures. Cells were harvested from trabecular bone fragments obtained during knee arthroplasty. Osteoblastic cell response to the particles was measured by assaying C-terminal type I procollagen (PICP), alkaline phosphatase, and osteocalcin secretion, with and without 1.25(OH)(2)D(3) stimulation, in the cell-conditioned medium. Both sizes of MA 956 and alpha-alumina particles decreased PICP secretion in nonstimulated osteoblastic cells, but this secretion was not affected in the cultures stimulated with 1.25(OH)(2)D(3). Only the 10 microm alpha-alumina particles inhibited alkaline phosphatase activity in 1.25(OH)(2)D(3)-stimulated and nonstimulated cultures. The rise in osteocalcin levels after 1.25(OH)(2)D(3) stimulation was lower in the presence of the 10 microm MA 956 particles than in the presence of alpha-alumina particles. Although both materials seem to have directly affected in vitro osteoblastic cell function, the increase in osteocalcin levels after 1.25(OH)(2)D(3) stimulation was lower after exposure to MA 956 particles than the increase observed after exposure to alpha-alumina particles. Therefore, it does not seem that osteocalcin stimulated bone resorption, suggesting that MA 956 would be less likely to provoke osteolysis.

Between 1972 and 1990, we performed 168 primary low-friction arthroplasties in 125 patients with acetabular protrusion. Twelve hips were lost to follow-up within eight years and eight which became infected were excluded from the final study. Of the 148 hips remaining, 62 with a mild protrusion were classified as group 1, 54 with moderate or severe protrusion as group 2 and, after 1985, 32 with moderate and severe protrusion which required bone grafts as group 3. The mean follow-up was 18.3 years (3 to 24) for group 1, 17.4 years (8 to 22) for group 2 and ten years (8 to 13) for group 3. There were 31 revisions of the cup, 12 in group 1 and 19 in group 2. According to the Kaplan-Meier analysis the overall rates at 20 years were 21 ± 10.79% in group 1 and 37 ± 11.90% in group 2. There have been 43 radiological loosenings: 22 in group 1, 21 in group 2 and none so far in group 3, at ten years. The overall loosening rates at 20 years were 42 ± 14.76% in group 1 and 49 ± 19.50% in group 2. The grafts were well incorporated in all group-3 hips, and the bone structure appeared normal after one year. The distance between the centre of the head of the femoral prosthesis and the approximate true centre of the femoral head was less in group 3 than in groups 1 and 2 (p < 0.01). According to the Cox proportional-hazards regression this was the single most important factor in loosening of the cup (odds ratio 1.11; 95% CI 1.05 to 1.18/mm). Better results were obtained in moderate and severe protrusions reconstructed with bone grafting than in hips with mild protrusion which were not grafted.

Bone loss with aging may be due, at least in part, to inadequate bone formation. Moreover, the process of bone aging is known to follow a different pattern throughout the skeleton. In this study, we examined the cell proliferation rate (area under the cell growth curve, AUC) and the secretion of C-terminal type I procollagen (PICP), alkaline phosphatase (ALP), and osteocalcin (OC) in primary cultures of osteoblastic cells from human trabecular bone. Osteoblastic cells were obtained for 168 donors (100 women and 68 men). Ninety-eight bone samples were obtained from subjects undergoing knee arthroplastia, 52 aged 50-70 years (64 +/- 5) and 46 over age 70 (73 +/- 2). Another 70 bone samples were obtained from subjects undergoing hip arthroplastia; 51 were 50-70 years old (64 +/- 4) and 19 were over 70 (75 +/- 5). Osteoblastic cells from the older donors had a lower proliferation rate and OC secretion than those from younger subjects. However, ALP secretion was higher in the former subjects, whereas PICP secretion was unchanged. Osteoblastic cells from hip had a lower proliferation rate than those from knee. PICP secretion was also lower and ALP secretion was higher in the former cells. In age-matched cell cultures, osteoblastic cells from the knee had higher proliferation rate and PICP secretion than osteoblastic cells from the hip. However, ALP secretion was lower in knee osteoblastic cells than those from hip only in the younger group. With aging, ALP secretion was found to increase in knee osteoblactic cells, whereas OC secretion decreased in osteoblastic cell cultures from the hip. Our findings suggest that bone loss with aging may be accounted for, at least in part, by a decreased osteoblastic cell proliferation and an increased osteoblastic maturation. In addition, our data indicate that these changes with aging do not occur similarly at different skeletal sites.

To study the cat's knee after anterior cruciate ligament reconstruction, we compared its neural and muscular activity with that in the normal and the unstable knee. We recorded the electric activity in the articular nerves (posterior -PAN and medial -MAN) and periarticular muscles (quadriceps and hamstring) while performing passive flexion, extension, external and internal rotation, and also anterior translation of the tibia at 30 degrees and 90 degrees of flexion. The same series of maneuvers was performed in the same knees after surgical section of the anterior cruciate ligament and then after anterior cruciate reconstruction. The electric activity recorded in the reconstructed knee was compared to that in the same knee before surgery and in the same unstable knee after anterior cruciate section. We observed that the reconstructed knee, compared to the injured knee, showed a decrease in articular nerves and quadriceps activity while it regained stability. This decrease converged to the recordings in the normal knee. However, differences in MAN, PAN and hamstring activity were still present in the reconstructed knee. This suggests that, although anterior cruciate reconstruction seems beneficial for restoring articular nerve and periarticular muscle activities to a certain degree, proprioception in the reconstructed knee does not match that in the normal knee.

To investigate the effect of 25-OH-vitamin D supplements (calcidiol) on fracture healing in the elderly, an experimental model with 15 18-month-old female Wistar rats was designed. An experimental fracture in the middle third of both femora of each rat was made. Then the rats were randomly assigned to two groups: one group was subcutaneously treated with 25-OH-vitamin D during all healing processes, and the other group (the control group) was not. After 5 weeks of healing, the animals were killed and both femora were extracted. Blood samples were collected before fracture and at death to determine the levels of 25-OH-vitamin D. All bones that were extracted were subjected to a torsion test to assess healing; a significantly greater maximum shear force before failure was supported in the treated group (p < 0.01). Moreover, a positive correlation (p < 0.01; r=0.55) was found between blood levels of 25-OH-vitamin D at death and the mechanical strength of the callus. Thus, the administration of 25-OH-vitamin D after the experimental fracture significantly improved the mechanical strength of the fractured bone. If similar results are found in the human, then treatment with 25-OH-vitamin D after the occurrence of a fracture would be a good way to improve fracture healing in the elderly.

We have studied the direct effects of polyethylene particles on osteoblastic function in primary human bone cell cultures. The cells were obtained from trabecular bone fragments of patients undergoing knee reconstructive surgery. When the cells reached confluency, they were subcultured into two flasks, one untreated (control culture) and the other treated with polyethylene particles, and incubated until confluency. Osteoblastic function was evaluated by assaying osteocalcin, alkaline phosphatase, and C-terminal procollagen type I, with and without 1,25(OH)2D stimulation, in the cell-conditioned medium. We found that addition of polyethylene to these osteoblastic cell cultures induced higher levels of secreted osteocalcin after 1, 25(OH)2D stimulation. Alkaline phosphatase levels increased whereas C-terminal procollagen type I levels decreased in the cell conditioned medium after polyethylene was added to the cultures. Treatment of the control cultures with 1,25(OH)2D stimulated alkaline phosphatase levels and decreased C-terminal procollagen type I. However, these osteoblastic markers in 1,25(OH)2D-treated cells did not change in cultures with polyethylene. This study demonstrates that polyethylene particles have a direct effect on osteoblastic markers in human bone cells in culture.

In this study, we have analyzed the direct effect of ultrahigh molecular weight polyethylene (polyethylene) on the osteoblastic cell growth in primary cultures. The cells were cultured from human bone samples obtained during reconstructive joint surgery. When cell cultures reached confluence (4-6 weeks) they were separated into three subcultures. One subculture was without particle addition (plain culture). In the other two subcultures, polyethylene or alumina was added. Two different sizes of particles were used,80 and160 microm. The subcultures were incubated until confluence. Proliferation of each subculture was measured by cell counts after 3, 6, 9 and 13 days, and the area under the curve (AUC) was calculated. Polyethylene particles of160 microm induced a decrease in growth, whereas alumina of the same size did not. Polyethylene and alumina particles of80 microm induced an inhibition in the osteoblastic cell growth;80 microm polyethylene induced a higher inhibition than alumina of the same particle size. In conclusion, we have observed a direct effect of polyethylene on osteoblastic cell growth. This study shows that polyethylene may decrease the growth rate of human osteoblastic cells in primary cultures. Smaller particles produce a more marked reduction.

We analyzed the progression of radiolucent lines around the acetabular cup after 452 Charnley low-friction arthroplasties that had been performed in 392 patients between 1971 and 1976. The average duration of follow-up was twenty years (range, eleven to twenty-five years) for the 442 hips (382 patients) that had the original component in place at ten years. The demarcation of the bone-cement interface was classified according to the system of Hodgkinson et al. We sought to determine if there was a relationship between the progression of the radiolucent line and the age, gender, and weight of the patient; the level of activity; the preoperative diagnosis; or the amount of wear of the acetabular cup. The demarcation increased over time in 138 (31 per cent) of the 452 hips. Radiographs made at the time of the latest follow-up showed migration of eleven (5 per cent) of the 233 acetabular cups with no demarcation on the initial postoperative radiograph, eighteen (11 per cent) of the 167 cups with type-1 demarcation, twelve (35 per cent) of the thirty-four cups with type-2 demarcation, and thirteen of the eighteen cups with type-3 demarcation. Preoperative acetabular protrusion, inflammatory arthritis, and severe acetabular dysplasia as well as a previous operation were associated with the extent of the radiolucent line on the most recent radiograph (p ≤ 0.05 for all). A high level of activity and more than two millimeters of wear of the acetabular cup also were related to the progression of the radiolucent line (p = 0.0004 and p < 0.0001, respectively). Kaplan-Meier survivorship analysis demonstrated that the greater the demarcation on the initial postoperative radiograph, the greater the risk of migration (p < 0.0001, Mantel-Cox test). Our data suggest that, after a Charnley low-friction arthroplasty, any cemented cup, even one with the least amount of demarcation (types 0 and 1), can migrate. As the type of the initial postoperative demarcation increases, so does the risk of migration of the cup, particularly when there is loss of the acetabular bone stock.

Sixty-three cases of femoral osteolytic cavities were analyzed in a consecutive series of 680 low-friction arthroplasties of the hip performed in 598 patients between 1971 and 1979. Follow-up evaluation averaged 15 years 9 months (range, 2-22 years). The total cumulative probability of osteolysis developing after 20 years was 11% according to survivorship analysis. The mean time of appearance of the osteolytic lesion was 9 years 3 months after operation. Most of the cavities were seen in Gruen zones 3, 5, and 7 in decreasing order. Osteolytic cavities were classified as follows: group 1, cavities in cases with radiographic definite stem loosening (20 cases); group 2, cavities in cases with an acetabular wear equal to or greater than 2 mm (22 cases); and group 3, cavities in cases combining both of the above-mentioned findings (21 cases). Cementing defects such as voids and thin mantles were less frequent in group 2 than in groups 1 and 3 (P < .005). Poor clinical results were more frequent in groups 1 and 3 (P < .05), in all instances). Focal cavities were more frequent in group 2, and multifocal and diffuse cavities were more frequent in groups 1 and 3 (P < .05). The average planimetric area on radiographic diagnosis was 0.81 cm2, and the average approximate volume was 1.86 cm3, with significant differences among the three groups of cavities. Progression of the cavity area and volume was linear over time (P < .001) and more aggressive in groups 1 and 3 than in group 2 (P < .05). Thus, loosening of the stem was a more deciding factor than acetabular wear in the progression of cavities.

Orthopedic surgery is described as an event with a high risk of thromboembolic diseases. This is probably a consequence of a synergistic combination of different risk factors in the patients subjected to this type of surgery, including age, immobilization, anesthesia and different hypercoagulable states. After surgery patients develop an acute-phase response that leads to changes in several plasma proteins. One of these proteins is the complement regulator C4b-binding protein (C4BP). We have recently shown that in some acute-phase patients C4BP is incorrectly controlled (with elevation of the C4BPΒ-containing isoforms), leading to a potential hypercoagulable state by decreasing the plasma levels of free (active) protein S. Here we have studied whether patients subjected to orthopedic surgery have an appropriate modulation of the C4BP isoforms during their postoperative acute-phase responses. We have analyzed the evolution of the C4BP isoforms in serial samples from 11 patients who have undergone knee (or hip) prosthesis surgery (mean age 70 years), or scoliosis surgery (mean age 18 years). Our data suggest a similar evolution of C4BP isoforms in all these patients, with an almost exclusive increase of C4BP isoforms lacking C4BPΒ polypeptides and steady levels of free protein S.

We performed a study in cats to describe and quantify the segmental sensory innervation of the anterior cruciate ligament of the knee. We also studied the patellar tendon to show that transport occurs from an extraarticular, dense connective tissue structure and to obtain comparable quantitative information. We injected a tracer (horseradish peroxidase HRP, coupled to wheat germ agglutinin WGA) in the anterior cruciate ligament and observed the reaction product in the articular nerves of the injected knee and in the cell bodies of ipsilateral dorsal root ganglia. In these experiments, we found an average of 26 (13-52) labeled neurons, mostly large, after injecting the anterior cruciate. More than half of the labeled neurons were found in the dorsal root ganglion of L7 (last lumbar segment in the cat). We counted an average of 204 (1 7-426) labeled neurons, mostly small, after injecting the patellar tendon. More than half of these labeled neurons were found in the L5 spinal ganglion. No product was observed in contralateral spinal ganglia. Surgical ablation of the medial and lateral articular nerves (MAN and IAN) before injecting HRP-WGA in the anterior cruciate ligament, showed that the remaining afferents in the posterior articular nerve (PAN) projected mainly to L7. After excision of PAN, the projection was maintained through MAN and LAN, mostly to L5. Our quantitative data show that the anterior cruciate ligament is poorly innervated, if compared to the patellar tendon. The anterior cruciate segmental sensory innervation is directed to L7 (corresponding to the main ventral root forming the sciatic nerve in the cat), but also to L5 and L6 (main femoral nerve ventral roots). These segmental data indicate that anterior cruciate innervation influences muscle tone regulation, not only of the hamstrings (neuromuscular system of the sciatic nerve), but also of the quadriceps muscle (neuromuscular system of the femoral nerve).

Changes occurring in the fixation of 113 porous-coated PCA uncemented femoral stems were studied in 90 patients who were operated on between 1984 and 1988. The average follow up was 5 years. Fixation was classified in radiographs as osteointegration, stable fibrous fixation or unstable. Four femoral components were revised. Metaphyseal osteoporosis was associated with those with a stem diameter greater than 13 mm. After 2 years, osteointegration was present in 73% and instability in 24% which was not related to the position of the stem. At the end of the follow up period, 20% of the stems showing osteointegration had changed and become unstable.

One hundred eighty low-friction arthroplasties of the hip in 164 patients in first-time revision surgery were operated between 1973 and 1985. This series used only cement fixation, and aseptic loosening and femoral stem fractures were the only indications for revision. The average follow-up period was 11.5 years. Intraoperative and postoperative complications were frequent: femoral shaft fracture (13 cases), femoral shaft perforation (12 cases), deep infection (14 cases), and dislocation (15 cases). Twenty-eight hips were rerevised or removed (resulting in a total cumulative probability of rerevision of 20% after 16 years, according to survivorship analysis). Nineteen cups were rerevised (13% after 16 years, according to survivorship analysis), and 24 femoral stems were rerevised (16% after 16 years, according to survivorship analysis). Radiographic cup and femoral loosening appeared in 29 and 36 cases, respectively (24 and 22% after 16 years, respectively, according to survivorship analysis). Good results were observed when there was a healthy and intact bone bed, whereas poor results were related to inadequate bone stock in the acetabulum and femur. Radiolucent lines were frequent in both components; radiolucent lines less than 2 mm wide were frequent in acetabular zone 1. Pistoning of the prosthesis and the cement within the bone and calcar pivot was the most frequent type of stem loosening.

Eighty consecutive low-friction arthroplasties in 64 patients with secondary arthritis due to severe acetabular dysplasia (Crowe grades III and IV) are analyzed. Two groups of patients were considered. In group I over 20% of the cup was not covered by the acetabulum and was reconstructed with a femoral head graft (32 cases; in group 2) a femoral head graft was not used because the cup was adequately covered (48 cases). The mean follow-up period was 9.4 years (range, 3–17 years) for group 1 and 8.8 years (range, 3–18 years) for group 2. Early complications were frequent (19%). To study long-term results only 78 hips were assessed since two patients were excluded due to deep infection. In these 78 hips, group 1 patients showed “better” results after 16 years (69.6% good results) than group 2 (nongraft procedures) 52.2%), but these differences were not significant ( P ≥.05). Early cup loosening was more frequent in group 2 than in group 1, and good coverage was obtained in 91% of the group 1 cups and in 71% of the group 2 cups ( P ≥.05). Acetabular cup loosening was not correlated with acetabular cup position. Bone-grafts appeared consolidated in all cases, but resorption areas were frequently observed. Radiographic stem aseptic loosening appeared in 10 cases, cortical hypertrophy in 7 cases, and endosteal osteolysis in 3 cases. Although limb discrepancy was frequent in both groups (75%), the average discrepancy was 1.7 cm.

Between 1971 and 1979, 680 low-friction arthroplasties of the hip were performed in 598 patients. The average duration of follow-up was twelve years and eight months. Sixty-one acetabular cups had loosening as seen on roentgenograms eighteen years postoperatively, resulting in a total cumulative probability of loosening of 19 per cent, according to survivorship analysis. In twenty-nine cups, the loosening appeared within ten years after the operation (early loosening) and in thirty-two, more than ten years after the operation (late loosening). Early loosening was associated with deficient structure of the bone of the acetabulum, a previous congenital dislocation of the hip, acetabular fracture, or acetabular protrusion in all instances (p < 0.01). Late loosening was associated with the depth of acetabular wear. Of the thirty-two cups that had more than two millimeters of wear, eighteen (56 per cent) had loosening on the roentgenograms (p < 0.001). In hips that had early loosening, migration was the most frequent finding, and its rate of progression was higher than in hips that had late loosening (p < 0.001). In late loosening, a complete bone-cement radiolucency of more than two millimeters was the most frequent finding. Clinical failure was seen in twenty-two (76 per cent) of the twenty-nine cups that loosened early and in nine (28 per cent) of the thirty-two cups that loosened late. The probability of extensive resorption of bone necessitates close observation of patients who have early loosening, while a reasonable period of observation is possible for those who have late loosening.

In a series of 2,050 low-friction arthroplasties, 61 cases (2.97%) of dislocation were analyzed. The mechanism of production was malposition of the components (group 1, 33%), deficiency of the abductor mechanism (group 2, 34%), or the association of both (group 3, 26%). Failure to find a cause was even more rare (group 4, 7%). The best treatment is prevention by careful surgical technique, since good results with different procedures have only been attained in 51% of dislocated hips.

Diamond-like carbon (DLC) coatings produced using the plasma-accelerating filtered pulsed arc discharge (FPAD) method display excellent adherence to the substrate and improve its corrosion resistance. This article reports the interactions of human osteoblastic cells with DLC and two DLC polymer hybrid (DLC-p-h) coatings deposited on smooth, matt and rough silicon wafers by the FPAD method. The DLC-p-h materials were DLC–polytetrafluoroethylene hybrid (DLC-PTFE-h) and DLC–polydimethylsiloxane hybrid (DLC-PDMS-h) coatings. The biocompatibility of the coatings was assayed by using mesenchymal stem cells, primary osteoblasts and Saos-2 cells. Human mesenchymal stem cells proliferated when cultured on DLC and DLC-PTFE-h, but their numbers diminished on DLC-PDMS-h. In all three cell types studied, phalloidin–TRITC staining disclosed cell-type organization typical of an actin cytoskeleton on DLC and DLC-PTFE-h, but minimal and disorganized stress fibers on cells cultured on DLC-PDMS-h. The microtubular cytoskeleton was similarly disorganized on DLC-PDMS-h. Cells on DLC-PDMS-h developed a peculiar form of membrane damage, with nuclear staining by propidium iodide associated with granular calcein staining of the cytoplasm. Active caspase-3 labeling was only seen in cells cultured on DLC-PDMS-h, indicating that these cells undergo apoptosis induced by defective cell adhesion. Results suggest that DLC-PDMS-h coatings might be useful in orthopedic applications where an implant or implant-facet should be protected against bone overgrowth while DLC and DLC-PTFE-h coatings might improve osseointegration.

Ultra-high molecular weight polyethylene (UHMWPE) is the key material for achieving excellent long-term results in total joint arthroplasties. Despite the fact that there has been a substantial amount of research and development over the years, new aspects of this material are still controversial and the most recent innovations have had a variable reception regarding clinical use. Advancements in conventional UHMWPE in the 1990s (nitrogen atmosphere irradiation, barrier package) were further improved by introduction of first-generation crosslinked polyethylene, as seen both from laboratory findings and clinical results. However, while clinical data on first-generation highly crosslinked polyethylene (HXLPE) showed reduced wear in the medium-term, academic and industrial research have helped to refine the material further, to overcome criticisms regarding residual oxidation and potential material fracture. Present concerns, although less nowadays, relate to the post-irradiation techniques used to stabilize the crosslinked polyethylene, namely annealing and remelting. Current topics of research interest include in vivo oxidation, second-generation highly crosslinked polyethylene, vitamin E doped or blended polyethylene, fracture mechanics, and consequences of wear. Some of these improvements derived from recent research are already available to the orthopedic community, and others will appear in the next few years. This review gives an overview of these topics, and the latest advancements are described in detail with a view to help the orthopedic surgeon make scientifically sound decisions when selecting material for total-joint implants. We conclude the review by affirming that today's state-of-the-art material is no longer conventional UHMWPE, but HXLPE.1.

We have evaluated the local bone response to metallic implants for endoprosthetic implants, over different periods of evolution, from one month to twelve months. The three metallic materials, that have been evaluated, are an alloy of Co-Cr, cpTi, and the MA 956 alloy on whose surface, a layer •-alumina, has been generated by oxidation. The experimental animals used were Wistard rats. The local bone response to the implanted materials, was carried out, using hispathological studies with optical microscopes and the evaluation of the bone/implant interface was studied with a scanning electron microscope (SEM). It was observed that the local bone response in the presence of an implant of titanium or of the alloy MA 956, with an alumina layer, was appropriate and rapid. The differenciation between the fibrous tissue and the bone tissue started from the first stages, at one or three months. This differentiation was definitely consolidated after six months. On the other hand, the local bone response in the presence of Co-Cr was slower, so that after six months the bone response was equivalent to that of the other implants at three months. It was necessary to wait for a year in order to reach a similar bone response among the three materials studied. Se ha evaluado la respuesta ósea local, a implantes metálicos de uso endoprotésico, a distintos tiempos de evolución, desde el mes hasta los doce meses. Los tres materiales metálicos evaluados han sido una aleación de Co-Cr, cpTi, y la aleación MA 956 sobre cuya superficie se ha generado una capa de •-alúmina, por oxidación. Los animales experimentales fueron ratas Wistard. La respuesta ósea a los materiales implantados se llevo a cabo mediante estudios histopatológicos por microscopía óptica, y la evaluación de la interfaz hueso-implante por microscopía electrónica de barrido. Se aprecia que la respuesta ósea local ante la presencia de un implante de titanio o de aleación MA 956, con capa de alúmina, fue adecuada y rápida, comenzando desde las primeras etapas, uno y tres meses, la diferenciación de tejido fibroso a tejido óseo. Esta diferenciación se ve consolidada de forma definitiva al cabo de los seis meses. Por el contrario, la respuesta del organismo ante la presencia de Co-Cr fue más lenta, de modo que a los seis meses la situación era equivalente a la de los otros implantes a los tres meses. Fue preciso esperar un año para alcanzar una situación similar entre los tres materiales estudiados.

Lung cancer is one of the main health problems in the developed world. Our aims were to determine the symptomatic time prior to a specific diagnosis, the clinical and histological characteristics of the cases of lung cancer diagnosed in a department of internal medicine, and to analyze the survival factors.We studied retrospectively all patients diagnosed with lung cancer in the internal medicine department in the period between January 2001 and September 2006 reviewing clinical records. We specifically recorded age, gender, smoking habit, time and type of symptomatic presentation, radiological manifestations, methods of histological diagnosis, tumour staging, and performance status measured by ECOG classification. We also evaluated the factors associated with the survival time.In this period 124 patients were diagnosed with lung cancer [mean age 68 +/-12 years, male 105 (85%), female 18 (15%), smokers 85%]. The mean symptomatic time before hospitalization was 74.5 +/-7 days. On hospitalization, respiratory symptoms were present in 40 (32%) patients. Tumour staging was carried out in 120 (97%) patients. In 96 (77%) patients non-small lung cancer was diagnosed, 62 (64%) in stage IV. In 28 (23%) patients small lung cancer was diagnosed, 22 (79%) in extended stage. Median time to diagnosis as an in-patient was 7 days. One hundred and thirteen (91%) patients died with a median survival time of 3 months. Factors associated with longer survival were the performance status and tumour stage.In this community, lung cancer is diagnosed late and in advanced stages, with a high mortality rate. A better performance status and lower tumour stages appear to be associated with longer survival.

To establish a protocol for the treatment of fragility fractures in the hospital setting based on treatment of osteoporosis.An intervention protocol was implemented in patients with fragility fractures based on (1) indicating the diagnosis of osteoporotic fracture in the summary of discharge; (2) "lifestyle recommendations"; and (3) therapy for osteoporosis. Thirty-one hospitals were involved and they were informed of the importance of protocol compliance. In the first phase, a retrospective study was conducted to establish the number of low-energy fractures treated and the percentage of them that had complied with the protocol (n = 887). Then, prospectively, the same data were collected for the patients managed for 1 year (n = 6,826) in three sections of 4-month intervals.The percentage of compliance increased from 8.2 to 57.2% in the first point, from 12.6 to 42.4% in the second, and from 10.3 to 43.2% in the third.The implementation of programs to improve osteoporosis treatment is very useful for ensuring adherence in the management of osteoporosis following admission due to fragility fracture.

Titanium (Ti) and its alloys have widespread uses as implant materials for orthopaedic and dental applications. To improve their surface characteristics, modifications that give rise to an outer ceramic layer of rutile have been developed. It is expected that after a long period of service, rutile particles will arise from these modified surfaces. Rutile particles have recently been proposed as reinforcement agents of substrates designed for bone tissue engineering applications. In this study, the ability of Ti and rutile particles to modulate secretion of soluble factors involved in bone turnover has been assayed in an in vitro co-culture system of macrophages and human osteoblasts that allows the exchange of soluble factors between both cell types without direct cell contact. Exposure of co-cultured macrophages to sub-cytotoxic doses of Ti or rutile particles did not modify the osteoblastic expression of surface RANKL or the secretion of OPG into the media. Both IL-6 and PGE 2 levels increased to a similar extent after treatment with rutile or Ti particles. M-CSF and GM-CSF levels were lower after treatment with rutile particles than with Ti. Experiments employing neutralising antibodies indicate that exposure of co-cultured macrophages to both Ti-based particles induces the release of M-CSF, GM-CSF, IL-6 and PGE 2 through up-regulation of IL-1β and TNF-α. We comparatively examined the response of co-cultured macrophages, osteoblasts or both types of cells after exposure to particles. The results indicate that interactions of osteoblasts with particles can modulate the extent of the response initiated by macrophages. Maximal levels of secretions of all tested factors were reached after exposure of co-cultured cells to Ti particles, which is suggestive of the lower bioreactivity of rutile particles.

Exchange surgery in late arthroplasty infection is directed against bacteria adhering to implants. Therapies based on antibiotics that are effective intracellularly have been proposed recently. We have combined both strategies to improve the cure rate.40 consecutive patients (16 hips, 24 knees) were diagnosed with late arthroplasty infection. The organisms isolated were 35 Staphylococcus, 19 of which were methicillin-resistant, 4 Enterococcus, 6 Gram-negative bacilli, and 4 Corynebacterium. The infections were managed by a combined therapy consisting of two-stage exchange surgery and two oral intracellularly-effective antibiotics. The antibiotics were selected according to bacterial sensitivity and intracellular and biofilm effectiveness. Second re-implantation surgery was delayed until clinical and analytical normalization. Patients were in hospital for only 1 week after each surgery, and were followed up prospectively on an outpatient basis (2-9 years). Cure of the infection was defined as absence of clinical, serological, and radiographic signs of infection during the whole follow-up.The infection was resolved in 38/40 patients (15/16 hips and 23/24 knees).Oral antibiotics that are effective intracellularly in combination with two-stage exchange surgery is a promising alternative for treating late arthroplasty infections. Oral antibiotics shorten hospitalization and reduce patient discomfort.

Pulmonary infection due to Nocardia sp. is an infrequent disease that affects principally to immunodefficient patients although it can be also seen in patients with normal immunity. Diagnosis is based in isolation of micro-organism in respiratory samples while clinical presentation and radiology are non specific. Treatment is made with trimethropim-sulfametoxazole (TMP/SMX), though resistance has developed in some patients. The recommended length of treatment is 6 weeks to 12 months depending on the immunitaly status. We present the case of a male patient of 81 years old affected with COPD and treated with glucocorticoids in a chronic basis, who was admitted because relapsing fever episodes during 3 months before, weight loss and new hard pulmonary infiltrates with Nocardia sp. cultured sputum, and evolution to clinical, radiological and microbiologic resolution with TMP/SMX treatment.

Oxidation of Ti6Al4V at 500°C for 1 h in air results in the formation of an outer ceramic layer that improves osteoblast behavior and decreases Ti and Al ion release. In this work, alumina blasted Ti6Al4V alloy has been thermally treated and its in vitro biocompatibility has been assessed. Roughness of the blasted alloy was not found significantly altered after heat treatment while chemical surface analysis indicated an increase in stable TiO2 and Al2O3 oxides. Cell attachment, spreading, cytoskeleton organization as well as cell proliferation, viability, and procollagen I peptide secretion of human primary osteoblasts, impaired on alumina blasted Ti6Al4V, were found to be greatly enhanced on the thermally oxidized blasted alloy. Other informative markers of the osteoblastic phenotype such as alkaline phosphatase, osteocalcin, osteoprotegerin, and mineralized nodule formation were evaluated and indicated that osteoblasts responded at the same extent on untreated and thermally treated blasted alloys. Taken together, our in vitro results indicate that thermal oxidation of alumina blasted Ti6Al4V may favor successful osseointegration by promoting early interactions of osteoblastic cells and the modified surface alloy. © 2006 Wiley Periodicals, Inc.