Is the so-called 'French paradox' a reality?: long-term survival and migration of the Charnley-Kerboull stem cemented line-to-line

We have evaluated the in vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements which were undertaken in 155 patients. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem before line-to-line cementing. We used the Ein Bild Roentgen Analyse femoral component method to assess the subsidence of the femoral component. At a mean of 17.3 years (15.1 to 18.3) 73 patients were still alive and had not been revised, eight had been revised, 66 had died and eight had been lost to follow-up. The mean subsidence of the entire series was 0.63 mm (0.0 to 1.94). When using a 1.5 mm threshold, only four stems were considered to have subsided. Our study showed that, in most cases, a highly polished double-tapered stem cemented line-to-line does not subside at least up to 18 years after implantation.

Impaction grafting in association with the Charnley-Kerboull cemented femoral component

We describe 129 consecutive revision total hip replacements using a Charnley-Kerboull femoral component of standard length with impaction allografting. The mean follow-up was 8.2 years (2 to 16). Additionally, extramedullary reinforcement was performed using struts of cortical allograft in 49 hips and cerclage wires in 30.

There was one intra-operative fracture of the femur but none later. Two femoral components subsided by 5 mm and 8 mm respectively, and were considered to be radiological failures. No further revision of a femoral component was required. The rate of survival of the femoral component at nine years, using radiological failure as the endpoint, was 98%. Our study showed that impaction grafting in association with a Charnley-Kerboull femoral component has a low rate of subsidence. Reconstruction of deficiencies of distal bone with struts of cortical allograft appeared to be an efficient way of preventing postoperative femoral fracture for up to 16 years.

[Early femoral osteolysis following Charnley-Kerboull total hip arthroplasty combining a 22-mm zirconia head on polyethylene]

PURPOSE OF THE STUDY

New bearings have been developed to reduce polyethylene wear. Zirconia ceramic is one proposal with attractive tribologic properties. The purpose of this prospective study was to evaluate the clinical and radiological results at least two years after implantation in a continuous series of total hip arthroplasties combining a zirconia head with polyethylene socket.

MATERIAL AND METHODS

The series included 56total hip arthroplasties performed in 51 patients (30 females and 21 males), mean age 52.2 +/- 12 years (25-76 years). Prostheses were implanted for primary degenerative disease (43%) and dysplasia (27%). The femoral component was a stainless steel stem with a Morse cone measuring 11degrees 25' for 27 hips and 5 degrees 40' for 28 hips. A 22-mm stabilized yttrium tetragonal polycrystalline zirconia head (Y-TZP) was used. The transtrochanteric approach was used for all arthroplaties with implantation of a cemented Charnley-Kerboull prosthesis. Clinical outcome was assessed with the Postel-Merle-d'Aubligné (PMA) score. Acetabular cup wear and periprosthetic osteolysis were measured on successive AP x-rays of the pelvis.

RESULTS

Mean follow-up was 32 months (24-48). None of the patients were lost to follow-up. Mean function score at last follow-up was 17.8 +/- 0.2 (16-18) versus 12.2 +/- 2.6 preoperatively (Wilcoxon, p < 0.0001). There were no cases of implant migration (femoral or acetabular). An endosteal defect by femoral osteolysis in the calcar femoral was observed in 19 of 55 cases. It appeared early between first and second post-operative year and did not progress later. Its surface remained less than 1 cm2 in all cases. We were unable to identify any factor predictive of these osteolytic lesions.

DISCUSSION

The short-term clinical results with this type of arthroplasty was comparable with earlier results described with classical Charnely-Kerboull implants using a metal-polyethylene bearing. The Merkel osteolysis observed in this series occurred early for one-third of the hips with no measurable polyethylene wear. We suggest surgeons should be cautious about using the zirconia head. We are continuing our surveillance of these patients.

Thickness of the cement mantle

No abstract.

Total hip arthroplasty for Crowe type IV developmental hip dysplasia: a long-term follow-up study

A consecutive series of 118 total hip arthroplasties was performed for Crowe type IV developmental hip dysplasia in 89 patients. The mean age of the patients was 52 years. All procedures were carried out through a transtrochanteric approach by the same surgeon. In all cases, the acetabular component was placed at the level of the true acetabulum. The mean lengthening of the operated limb was 3.8 cm. The average follow-up of the whole series was 12.8 years. At the last follow-up evaluation, 29 patients (35 hips) had died or were lost to follow-up at a mean of 11 years. Sixty patients (83 hips) were still alive at a mean follow-up of 16 years. At the time of last follow-up, the mean Merle d'Aubigné hip score was 17.4 compared with 10.6 preoperatively. The survival rate, with revision for any reason as the endpoint, was 78% at 20-year follow-up.

Total hip arthroplasty for the treatment of ankylosed hips : a five to twenty-one-year follow-up study

BACKGROUND

The purpose of the present retrospective study was to report the long-term results of total hip arthroplasty following a hip fusion. Special attention was paid to the resulting function of both the involved joint and the neighboring joints, as pain in the lower back or knee was the usual indication for conversion. The factors that were likely to influence the functional outcome were analyzed.

METHODS

Forty-five consecutive total hip arthroplasties were performed in forty-five patients from 1969 through 1993. The mean age of the patients at the time of the operation was 55.8 years (range, twenty-eight to eighty years). Ankylosis of the hip had been spontaneous in twenty patients and postoperative in twenty-five patients. The mean duration of the ankylosis had been thirty-six years (range, three to sixty-five years). The mean duration of follow-up was 8.5 years (range, five to twenty-one years). No patient was lost to follow-up.

RESULTS

The mean hip score, according to the scale of Merle d'Aubigné, was 16.5 1.5 points at the latest follow-up evaluation. Hip function was considered to be satisfactory for forty-one (91%) of the forty-five patients. The definitive score for walking ability was not achieved by the one-year evaluation; it improved notably for two to three years and then it remained stable. At the time of the latest follow-up, the mean arc of flexion was 88 degrees (range, 30 degrees to 130 degrees ). Forty-three (96%) of the forty-five patients had no pain in the involved joint. The only factor that was predictive of the final functional result with regard to walking ability was the intraoperative status of the gluteal muscles. Most patients had effective pain relief in the neighboring joints. The cumulative survival rate at eight years, with revision as the end point, was 96.7% (95% confidence interval, 90.2% to 100%).

CONCLUSIONS

The long-term effectiveness of total hip arthroplasty for the treatment of an ankylosed hip was clearly demonstrated in both the involved and the neighboring joints in the present study. However, the preoperative and intraoperative status of the gluteal muscles should be carefully evaluated when this procedure is being considered, as this was the only factor that was predictive of the final walking ability.

[Femoral reconstruction with massive allograft implanted in a split femur. Mid-term results of 18 reconstructions]

PURPOSE OF THE STUDY

Extensive loss of femoral bone subsequent to implant loosening raises an unsolved problem. The purpose of this work was to examine mid-term results of 18 iterative total hip arthroplasties with femoral reconstruction using massive allografts performed between 1986 and 1997.

MATERIALS AND METHODS

Using the Vives classification, the femoral bone lesions were grade 3 (n =2) and grade 4 (n =16). The reconstruction was achieved with radiated massive allografts measuring 11 to 35 cm implanted in a split host femur. Charnley-Kerboull implants with a long stem were cemented in the reconstructed femurs.

RESULTS

Mean follow-up was 4 years 10 months (range 2 to 9 years). Nine complications in 7 hips were observed: 6 trochanter nonunions, two recurrent prosthesis dislocations and 1 femoral fracture. At last follow-up, the functional result was excellent or very good in 12 hips (Merle d'Aubigné classification). A stable fixation persisted for 15 implants and 3 had loosened. Graft-host femur consolidation was achieved in all cases except 1. There were 3 cases with extensive resorption of the graft including 2 associated with loosening of the femoral component.

DISCUSSION

Reconstruction of the femur after extensive bone loss using a massive allograft appears to be a useful method for restoring bone tissue and providing immediate mechanical support for the femur.

The Kerboull acetabular reinforcement device in major acetabular reconstructions

Sixty consecutive revision total hip arthroplasties were performed with bulk allograft bone supported by the Kerboull reinforcement acetabular device in 53 patients from 1980 to 1987. The average age of the patients at the time of hip revision was 57.7 years. Acetabular bone loss according to the American Academy of Orthopaedic Surgeons grading system was Type III for 48 hips in 41 patients and Type IV for 12 hips in 12 patients. Three failures, defined as radiologic loosening of the socket, revised or not, were reported in this series at a mean 8-year followup. Eight patients died of unrelated causes at a mean of 5 years. No patient was lost to followup. The mean followup of the series was 10 years +/- 3 years. The mean preoperative Merle d'Aubigné hip functional score was 11.7 +/- 2.4 versus 17.4 +/- 0.6 at the latest followup. Consolidation of the graft was considered completed in all 60 hips and occurred by 12 months. Remodeling of the graft proceeded for 3 to 4 years. The survival rate at 13 years was 92.1% +/- 5% using loosening of the acetabular component as the end point. This study indicated that acetabular allograft reconstructions reinforced by the Kerboull acetabular device were able to provide satisfactory long-term clinical and radiologic results.

Human herpesvirus-6 and human herpesvirus-7 in the bone marrow from healthy subjects

BACKGROUND

Human herpesviruses (HHVs) 6 and 7 are recently discovered betaherpesviruses. Although HHV-6 has been associated with disordered hematopoiesis in bone marrow transplant recipients, little information is available on the presence of both viruses in the bone marrow from healthy subjects.

METHODS

We detected HHV-6 and HHV-7 DNA by means of polymerase chain reaction in bone marrow and peripheral blood samples from 18 healthy subjects who underwent total hip arthroplasty.

RESULTS

Genomic HHV-6 and HHV-7 DNA were detected in 11% and 67% of the blood samples, respectively, and in 28% and 50% of the bone marrow samples, respectively.

CONCLUSIONS

Both viruses may be present in the bone marrow without hematopoiesis disorder and can be transmitted through bone marrow infusion. Therefore, the causative role of these two viruses in some bone marrow diseases cannot be inferred simply from the detection of their genome in bone marrow by means of polymerase chain reaction.

[Radiographic assessment of polyethylene wear in machined versus molded polyethylene in total hip prosthesis]

PURPOSE OF THE STUDY

Wear of polyethylene acetabular components is an important issue in total hip arthroplasty. This study was designed to evaluate differences in polyethylene wear rates between machined and direct compression molded acetabular cups.

METHODS

Two hundred thirty-nine prostheses underwent radiographic evaluation using the technique of Chevrot-Kerboull. One hundred thirty-one were all-polyethylene cups machined from extruded bar stock, and one hundred eight were all-polyethylene cups direct compression molded. Both groups, all operated on in 1988, were similar in the acetabular and femoral components, were all cemented, and the acetabular components were all-polyethylene, non metal backed. The femoral components were all Charnley-Kerboull MK III type. Patient weight, average weight, the post-operative PMA score and the duration of the follow-up were similar for the two groups (mean 7.4 years).

RESULTS

Results showed a mean linear wear rate of 0.06 mm per year for compression-molded polyethylene and 0.08 mm per year for machined polyethylene. Results were not significantly different. The number of acetabular radiolucencies in zone I (5.5 versus 5.3 p. 100) and the amount of lysis of the proximal part of the femur did not differ between the two groups. The number of excessive wears did not differ either.

DISCUSSION AND CONCLUSION

Although polyethylene wear was lower with compression molded acetabular cups than with ram-extruded acetabular cups, results of this study suggest a non significant difference between the two types of components. A more controlled experiment would have to be performed to attribute a difference between two different types of UHMPE processing.

[Knee replacement arthroplasty in hemophilia: results, complications and predictive elements of their occurrence]

PURPOSE OF THE STUDY

Determine the effect of supplementation rate and HIV disease on results and complications in total knee replacement in hemophilia.

MATERIAL

Twenty-nine total knee arthroplasties were performed in twenty-one disabled patients with major hemophilia, from 1986 to 1995. All the implants were postero-stabilised prostheses. The average age of patients at the time of surgery was 40.8 years, average follow-up was 4.8 years. Preoperatively, all patients complained of severe pain, with stage IV or V arthropathies, according to Arnold classification. Twelve patients were HIV sero-positive.

METHOD

Functional and radiological results, and postoperative complication rate was analyzed in relation with mean deficient factor titer, HIV status, and periarticular soft tissues quality.

RESULTS

Results of the total knee arthroplasties, as determined by the IKS scoring system, were 86.2/100 for Pain, Motion, Stability and 88.7/100 for function. The average gain of motion was twenty-four degrees. One patient required amputation, and one an arthrodesis after deep infection. Postoperative complications, in addition to infections, included intra articular bleeding in nine patients, one peroneal nerve palsy, two instances of inhibition to factor VIII, four superficial skin necrosis, and one important gastric bleeding which required surgical treatment. A high titer of deficient factor (> 70 per cent of the average normal concentration) seemed correlated with a lower complication rate. In this study, surgery had no incidence on HIV disease evolution.

DISCUSSION

Authors emphasize the high level of postoperative infections (6/29), particularly in patients with HIV infection (5/12) frequently after superficial skin necrosis, as well as the high postoperative complication rate.

CONCLUSION

However good results were finally observed, association of HIV disease, insufficient deficient factor concentration, and altered quality of periarticular soft tissues increased particularly complication occurrence. With particular attention to these factors, and despite frequent complications, total knee arthroplasty in hemophilia restores good function and allows patients satisfaction.

Prevention of heterotopic ossification in hip arthroplasty. The influence of the duration of treatment

A retrospective study has been carried out to assess the effectiveness of indomethacin in preventing heterotopic ossification after total hip arthroplasty, and the effect of using it for different periods of time. One hundred and sixty-eight hips operated on in 1983 were not given indomethacin and acted as a control. One hundred and fifty hips operated on in 1988 were given indomethacin and divided into 3 groups: 42 received indomethacin for 5 days, 49 for 11 days and 59 for 45 days. The results indicate that ossification is significantly reduced in those patients receiving indomethacin for 5 and 11 days, but there was no additional reduction when it was given for 45 days. Treatment should begin on the night of operation and continued for 11 days while the patient remains in hospital.

[Functioning of a bone tissue bank in 1998]

Last few years, the french legislation and reglementation concerning donated human tissues, safety precautions, and human tissues' uses have been deeply modified. Therefore, tissue banks' organisation, processing of allograft tissue, and the way surgeons use frozen bone graft have changed. Accordingly, authors describe different obligations these activities implicate and practical consequences for tissue banks and surgeons. First, they recall 94' laws and the doctrinal and ethical principles essential to understand current laws and official standards. Then, they specify sanitary rules all tissue banks have to conform to. They detail the different approaches to recovery, processing, preservation and distribution of transplantable bone tissue and expose modalities of the financing by social organisms. It follows practical consequences in bank functioning: supplying, importation, internal organization. In conclusion, authors synthesize surgeon's responsibilities in that specific activity.

[Desmoid tumor of the thoracic wall. A case manifesting as painful stiffness of the shoulder]

BACKGROUND

Desmoid tumors are uncommon fibromatous tumors arising from musculoaponeurotic tissue characterized by spindle cell fibroblast and myofibroblast proliferation. The cause is unknown (trauma, hormonal factors, genetic anomaly...). Locally invasive, they tend to recur increasing morbidity or even mortality.

CASE REPORT

Stiff shoulder resulting from blockage of the scapulothoracic articulation was the inaugural sign. Three-phase bone scintigraphy demonstrated early uptake in the soft tissue in contact with the scapula. Magnetic resonance imaging and biopsy confirmed the diagnosis of desmoid tumor. Complete resection was performed. No adjuvant radiotherapy nor hormone treatment were given since no antiestrogen receptor antibodies were identified on the surgical specimen.

DISCUSSION

The clinical manifestation (stiff shoulder) and the scapular localization observed in this case are unusual for desmoid tumors. Initially tendinopathy of the shoulder, acromio-clavicular arthropathy and capsular retraction of the shoulder joint had been entertained. Early diagnosis and wide surgical resection are indicated in desmoid tumors.

Heterotopic ossification after total hip arthroplasty: risk factors and prevention

A retrospective review of 168 consecutive total hip arthroplasty procedures done in 1983 at the Cochin Teaching Hospital, Paris, France, was conducted to determine the rate of occurrence of heterotopic paraarticular ossification and to look for risk factors for this complication. None of the patients received preventive therapy for heterotopic ossification. Mean age was 66.2 years. The reason for arthroplasty was hip osteoarthritis in every case. The index operation was the first arthroplasty procedure. Heterotopic ossification was noted in 61.3% of patients and was high-grade in 8.3%. The rate of occurrence of heterotopic ossification was not influenced by age, gender, joint destruction, preoperative osteophytosis, duration of the arthroplasty or the occurrence of complications during or after the arthroplasty. However, severe ossification was more common in men that in women (12.7% men versus 5.7% women had grade III ossification) and in patients operated on by relatively inexperienced surgeons (28/8% grade II and III ossifications, versus 14.7% in patients operated on by experienced surgeons). The rate of occurrence of heterotopic ossification in the patients who had no risk factors (60.9%) was not significantly different from that in the overall study population. These data suggest that preventive strategies targeted to specific patient subgroups would probably be ineffective, and that routine preventive therapy of all total hip arthroplasty patients is warranted.

Education for outpatients with rheumatic diseases. Evaluation of short-term and medium-term results

This prospective study was conducted to evaluate the short- and medium-term impact of the outpatient education sessions that have been available at the Cochin Teaching Hospital since 1992. Each patient was asked to complete a ten-item anonymous questionnaire at the beginning of the education session (evaluation 0), immediately after the session (evaluation 1), after six months (evaluation 2) and after 12 months (evaluation 3). Mean numbers of correct answers per patient were calculated. Eight education sessions were evaluated (osteoarthritis, osteoporosis, rheumatoid arthritis, back pain, conservative treatments, surgical treatments, low-calorie diets and high-calcium diets). One hundred twenty-four patients completed the first two questionnaires, 94 (75.80%) completed the six-month questionnaire and 75 (60.5%) completed the 12-month questionnaire. Mean numbers of correct answers were as follows: 5.7 before the session, 7.3 after the session (p = 0.0001), 7.2 after six months (p = 0.0001), and 7.9 after 12 months (p = 0.0001). These results demonstrate that the education sessions significantly improved patient knowledge in the short and medium term. Their impact on quality of life is being evaluated.

[Idiopathic massive osteolysis of the femur. Syndrome called Gorham-Stout syndrome]

A case of massive osteolysis (disappearing bone disease, phantom bone, Gorham's massive osteolysis) was observed in a young african man with two lesions of the femur. This is a very rare syndrome characterized by an acute spontaneous resorption of bone, without any sign of malignant or infectious disorder. The lesion may develop in any part of the skeleton, with extensive bone loss, but is benign. Bone is replaced by haemangiomatous tissue. The diagnosis lead on the association of clinical, radiological and histological signs. The pathogenesis is still unknown and the treatment remains controversial. Osteolysis stops after a few years, but this is unpredictable; in our case, we have proposed prosthetic replacement, associated with bone grafting and irradiation.

[One stage revision of infected total hip replacements with replacement of bone loss by allografts. Study of 90 cases of which 46 used bone allografts]

We usually manage infected total hip replacements by a one stage revision. We have reviewed 90 cases operated on before 1988. Notable bone loss was frequently encountered and reconstructed using allografts. In all cases complete surgical debridement was performed and a cemented total hip replacement implanted. Bone allografts were used in 46 cases. Systemic antibiotics and antibiotic loaded cement were utilised. There were 17 failures (19%); one patient died soon after operation, there were 8 obvious infections (9%), 1 hip was thought to be infected although the prosthesis was not loose, and 7 femoral prostheses became loose of which 3 were due to mechanical failure and the remainder had no obvious explanation. Infection with staphylococcus aureus and pseudomonas had a statistical correlation with failure, but other factors including the preoperative status and the use of allografts did not appear to influence the result. Allograft femoral heads from the bone bank were found to be reliable for reconstruction of the acetabulum and small femoral defects. With major femoral bone loss we preferred massive irradiated cortical allografts. The quality of the bone reconstruction was probably the most important factor in the good functional results observed in 79% of cases. Effective surgical debridement and an appropriate antibiotic regime will allow a successful one stage revision procedure. The use of allografts gave a reliable reconstruction of the bone loss and was not associated with an increased rate of failure.

Histological patterns of bone and articular tissues after orthopaedic reconstructive surgery (artificial joint implants)

Revision surgery after failures of joint replacements leads to histological studies on joint and bone tissues close to the implanted material. Aspectic loosening is the main complication. The surgical pathologist has to identify wear debris (metal, polyethylene, polymethylmethacrylate, chiefly) which promotes a histiocytic granuloma. Some surgical procedures such as cup or resurfacing arthroplasties create a new articular surface and a bone remodeling or necrosis. Cemented joint prostheses show various membrane structures between bone and the cement mantle while there is an association of bone resorption and formation. Non-cemented, porous-coated joint prostheses induce little bone ingrowth, even in satisfactory clinical results. Mechanical factors are predominant in massive limb prostheses. For silicone elastomer implants or artificial ligaments, wear of material promotes many tissular reactions. Often used bone grafts show little creeping substitution process in case of homografts, even well-incorporated on X-rays. More retrieval specimen studies are necessary to delineate precise topographical histological lesions, including non-loosened joint implants.

[Desmoid fibroma of the abdominal wall. Apropos of a case]

A case of desmoid fibroma of anterior abdominal wall, an exceptional benign tumor, is reported. Based on results of CT scan imaging of this lesion, differential diagnosis of other expansive processes of abdominal wall are discussed. This benign tumor is a potentially serious lesion due to its infiltrating character and the high incidence of recurrence. The need for total surgical excision is emphasized.

[Septic arthritis caused by Campylobacter fetus]

The ten published cases of septic arthritis due to Campylobacter fetus and two more recent cases, one of which was a delayed septic complication of a total hip replacement, are discussed. In 83% of cases, febrile monoarthritis occurred which in 7 out of the 12 cases involved an already diseased joint in a subject over 70 years of age (half of the patients), who was frequently alcoholic and presented either cancer or hepatic cirrhosis and/or diabetes. Hyperleukocytosis of the blood was variable (55% of cases). The joint fluid, which contained a high level of deteriorated polynuclear cells, was routinely cultured on an enriched medium in an anaerobic or microerophilic atmosphere and in 10 out of 12 cases Campylobacter fetus was isolated within 15 days, even in the absence of previous antibiotic therapy. The arthritis, which showed little sign radiographically of destructiveness, was cured, leaving no sequellae in most cases. Treatment usually involved ampicillin or the tetracyclines, either alone or in association with the aminoglycosides.

[Mycobacterial infection of the hip following total prosthesis. Study of 6 cases]

The authors present 6 cases of mycobacterial infection of the hip after total hip replacement: 5 cases of tuberculosis and 1 case of Mycobacterium fortuitum infection. They emphasise the clinical, radiological, bacteriological and histological signs which are generally very characteristic and unequivocal. A review of the literature reveals the rarity of these infections, but stresses the need for a complete bacteriological survey to avoid missing the diagnosis. A routine medicosurgical therapeutic approach is proposed.

[Aseptic arthritis after total knee prosthesis]

In 3 patients who developed acute arthritis of the knee 3 months to 5 years after insertion of a total condylar prosthesis, it was possible to formally exclude an infectious cause. A number of cytological and histological arguments confirm that these were cases of foreign body arthritis (polyethylene debris and metal dust). These cases of arthritis responded to local steroid treatment combined with a Yttrium synoviorthesis, in the absence of any antibiotic treatment. The synoviorthesis was performed in order to eliminate the real foreign body granuloma which develops and which can contribute to the loosening of these prostheses.

[Partial decalcifying algodystrophy]

Partial decalcifying algodystrophy (PDA) appears in two forms: one, a radial form, affects, following a certain metameric topography, one or two radiuses of the hand or of the foot (two cases reported); the other, a zonal form, is more peculiar: only part of a condyle or of the femoral head, are demineralized for two to three months. The authors report 7 cases of this misleading zonal form, 2 of them after histological verification. The image leads to various diagnostic errors: osteitis or infectious osteo-arthritis, acute inflammation close to the bone, and especially malignant processes. However, zonal PDA has its own characteristics: demineralization, that becomes clear only during the second month, and quickly extends over a rather long sub chondral bone surface. Tomography is very useful: it demonstrates better the severe sub chondral osteoporosis and the retention of the bone sole, which becomes detached from the bone. Scintigraphy shows the massive localized or panregional hyperfixation and sometimes other infraradiological sites (hips, knee or ankle). Zonal osteoporosis remains partial and misleading for only 2 or 3 months, after which it becomes a classical panregional form. The rate of development is that of DA. Painful impotence quickly increases, with cure in 6 months.