Clinical And Experimental Study On Joint Arthroplasty Associated With Diabetes Mellitus

Part1:Experimental study of periprosthetic osteolysis Induced by polyethylene particle on diabetic modelObjective: To study the effect of the high molecular weight polyethylene on the periprosthetic tissue in diabetic model, to analyse the pathogenesis of loosening arthroplasty. to investgate the effect of TNF-αin periprosthetic tissue.Methods: 16 femina New Zealand white rabbits, which is randomly divided into 2 groups, experimental group and control group ,was selected. First, induction of experimental diabetes in rabbit with streptozotocin was performed successfully ,every rabbit's lower limb was implanted a kirschner wire plug in femur by intercondylar notch. In experimental group, 15 mg polyethylene particles, dispersed in 1.5 ml normal saline solution, were injected into one knee joint. The other knee joint was injected 1.5 ml normal saline solution as control. This procedure was repeated 2,4,6,8,10, and12 weeks after the implantation. Both groups were given an X-ray examination 12 weeks to assess if there were periprosthetic osteolysis and loosening of the plugs. All animals were killed 2 weeks after the last injection. The distribution of polyethylene in the knee joint capsule was examined to understand if there was loosening of implants or tissue change around implants. Knee joint capsule tissues and periprosthetic tissues were examined by optical microscope. ELISA was used for the concentration of TNF-αmeasurement. The data were analyzed statistically by t-test analysis or analysis of variance with SPSS10.0 software .Results: three cases formed fibrous membrane and four cases formed new bone around prostheses in experimental group. Four cases formed new bone and three cases formed fibrous membrane in control group. The X-ray results indicated that the plugs were in distal medulla of femur. There was no sign of periprosthetic osteolysis, implants loosening or new bone formation. Optical microscope study indicated that in the experimental group, kirschner wire were surrounded by multinucleated foreign-body giant cells and osteoclast; synovial membrane proliferation was obvious; in the control group, there were no polyethylene particles and multinucleated foreign-body giant cells around plug in the marrow. New bone was found and osteoblast surrounding kirschner wire, normal synovial membrane was seen clearly. TNF-αin periprosthetic tissue in experimental group was 0.132±0.024pmol/g, but in control group, TNF-αwas 0.074±0.04 pmol/g (P<0.05). the concentration of TNF-αin experimental group was higher than that in control group.Conclusion: Maximing ultra high molecular weight polyethylene can restrain diabetic rabbit periprosthetic bone formation and increase the secretion of TNF-α,which may play an important role in the periprosthetic osteolysis.Part2:Effect of calcitonin on the bone mineral density and biomechanics around the artificial prosthesis in the rabbit of diabetic osteoporosis models.Objective: to investigate the influence of calcitonin on the bone mineral density and biomechanics around the artificial prosthesis in ovariectomized diabetic rabbit models.Methods: fourteen femina New Zealand white rabbits at the age of 5 months old were selected, which weight 2.24-2.65kg, averaging 2.26kg. First, to establish successfully the model of rabbit with diabetic osteoporosis by the compound method of ovariectomy plus streptozotocin. Osteotomy in the middle part of femur was performed in both groups, fixation of artificial prosthesis was done with 3.0 kirschner wire。After that, Rabbit models with diabetic osteoporosis were randomly divided into experimental group and control group. Rabbits in the experimental group were treated with calcitonin 6U intramuscular injection once every other day, but in the control group, intramuscular injection of normal saline solution 1.5ml once the next day. Rabbit models of two groups were sacrificed in 24 weeks . and the BMD of the region of interest (ROI) around the prosthesis were detected before and 8,16 and 24 weeks .After killing rabbits, experimental femur in both groups were removal completely and soft tissue were rejected. Determination of the pull-out and torsion bone biomechanics experiments of prosthesis respectively in both groups.Results: the BMD of ROI in the experimental group before operation was (0.1863±0.004g/ cm2 ) , 0.1953±0.005g/ cm2 in 24 weeks after operation; in control group before operation was (0.1865±0.002g/ cm2 ) , 0.1738±0.006g/ cm2 in 24 weeks after operation, and there were signifant difference between the two groups(P<0.05). biomechanical show that the pull-out strength in the experimental group was 312.68±8.73N/cm2,the control group was 205.43±12.45N/cm2, there were signifant difference between the two groups(P < 0.05). the torsion strength in experimental group was 80.47±2.51N/cm2,the control group was 38.52±0.64N/cm2 , there were signifant difference between the two groups(P<0.05).Conclusion: salmon calcitonin can reduce the bone turnover rate around prosthesis and decrease bone absorption in the rabbit of diabetic osteoporosis models, accelerate the bone formation around prosthesis, so as to increase the BMD, it can ameliorate the quanlity of bone around prosthesis, improve its biomechanics property, and increase the holding power between prosthesis and body mass. It is of significance for the prevention and treatment of aseptic loosening artificial prosthesis clinically. Part3:Clinic analysis of perioperative management of total knee arthroplasty in diabetic patientsObjective: To discuss the results of total knee arthroplasty for diabetic patients.Methods: The preventive and therapeatical measures during perioperative period and follow-up outcome in 73 patients with diabetes mellitus who had accepted total knee arthroplasty were analysed retrospectively.Result: the average blood glucose level was 13.2±1.2mmol/L,and was controlled to7.0±1.0mmol/L before operation , the average blood glucose level was 7.4±1.1mmol/L after operation. of all patients, only 3 knees (3.7%) developed delayed wound hearing; no deep joint infection occurred; 6 knees (8.2%) developed a urinary tract infection and 13.5%(11 knees) developed deep vein thrombosis. no other complations occurred. according to the hospital for special surgery (HSS) knee rating scale, the HSS scores were improved after the operation from average 27.6 points preoperatively to 84.2 points postoperatively. the excellent and good rate was 94.7%.Conclusion: the knee arthroplacty of diabetic patients could get the similar results as those common patients.blood sugar control is the key which may affect therapeutic efficacy, complication must be managed successfully during perioperational period.Part4:Clinic and radiographic study on diabetic patients who underwent total hip arthroplastyObject: to evaluate the clinic and radiographic results and to analyze the factors affecting the long-time results.Methods: from October 1995 to September 2005,123 diabetic patients who underwent total hip arthroplasty were treated,71 cases with complete clinic and radiography and follow-up results were obtained, but 17 cases lose contact, these patients were assessed according to Harris hip score and X-ray film and analyze clinic and radiographic results.Results: the average Harris score of pre-operation was 41.0±8.3 points, score of post-operation was 83.9±10.5. There was significant difference in pre-operation and post-operation. the excellent or good rate was 66.2%.there was a infected case in post-operation and there were 26 cases with looseness in X-film,3 case with clinic looseness.29 cases with arthroplasty looseness showed osteolysis at various degree, most of all, liner and expensile osteolysis coexist. Some cases showed discomfort or pain in middle part of femur. It is analyzed that it is associated with poor fixation or poor location.Conclusion: total hip arthroplasty has been applied successfully to treatment of diabetic case. But the cement prosthesis should be used in old–aged patients or severe osteoporosis patients. It is advisable that diabetic osteoporosis should be cured firstly, whether cementless or cemented prosthesis was used.