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Clinical Orthopaedics and Related Research®

Published in:

01-02-2011 | Symposium: Papers Presented at the Hip Society Meetings 2010

Perivascular Lymphocytic Infiltration Is Not Limited to Metal-on-Metal Bearings

Authors: Vincent Y. Ng, MD, Adolph V. Lombardi Jr, MD, Keith R. Berend, MD, Michael D. Skeels, DO, Joanne B. Adams, BFA

Published in: Clinical Orthopaedics and Related Research® | Issue 2/2011

Abstract

Background

Perivascular lymphocytic infiltration (PVLI) suggests an adaptive immune response. Metal hypersensitivity after THA is presumed associated with idiopathic pain and aseptic loosening, but its incidence and relationship to metallic wear leading to revision are unclear as are its presence and relevance in non-metal-on-metal arthroplasty.

Questions/purposes

We compared (1) incidence and severity of PVLI in failed hip metal-on-metal (MoM) to non-MoM implants and TKA; (2) PVLI in MoM and non-MoM hip arthroplasty based on reason for revision; and (3) PVLI grade to diffuse lymphocytic infiltration (DLI) and tissue reaction to metal particles.

Patients and Methods

We retrospectively examined incidence and severity of PVLI, DLI, and tissue reaction in periprosthetic tissue from 215 THA and 242 TKA revisions including 32 MoM hips.

Results

Perivascular lymphocytic infiltration was present in more TKAs (40%) than overall hip arthroplasties (24%) without difference in severity. Compared to non-MoM hips, MoM bearings were more commonly associated with PVLI (59% versus 18%) and demonstrated increased severity (41% versus 3% greater than mild). Histologically, PVLI correlated (r = 0.51) with DLI, but not tissue reaction. In THA, PVLI was most commonly associated with idiopathic pain (70%) and aseptic loosening (54%) in MoM, and infection in all hip revisions (53%).

Conclusions

Perivascular lymphocytic infiltration is more extensive in revisions of MoM and in aseptic loosening, idiopathic pain, or infection but is also present in TKA, non-MoM, and different reasons for revision. It correlates with other signs of metal hypersensitivity, but not with histologic measures of metal particulate load.

Level of Evidence

Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Back D, Young D, Shimmin A. How do serum cobalt and chromium levels change after metal-on-metal hip resurfacing? Clin Orthop Relat Res. 2005;438:177–181.CrossRefPubMed

Biant L, Bruce W, van der Wall H, Walsh W. Infection or allergy in the painful metal-on-metal total hip arthroplasty. J Arthroplasty. 2009;25:334.e311–316.

Brown C, Fisher J, Ingham E. Biological effects of clinically relevant wear particles from metal-on-metal hip prostheses. Proc Inst Mech Eng H. 2006;220:355–369.PubMed

Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz H. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010 May 11. [Epub ahead of print].

Campbell P, Shimmin A, Walter L, Solomon M. Metal sensitivity as a cause of groin pain in metal-on-metal hip resurfacing. J Arthroplasty. 2008;23:1080–1085.CrossRefPubMed

Campbell P, Wang M, Amstutz H, Goodman S. Positive cytokine production in failed metal-on-metal total hip replacements. Acta Orthop Scand. 2002;73:506–512.CrossRefPubMed

Carr A, DeSteiger R. Osteolysis in patients with a metal-on-metal hip arthroplasty. ANZ J Surg. 2008;78:144–147.CrossRefPubMed

Case C, Langkamer V, James C, Palmer M, Kemp A, Heap P, Solomon L. Widespread dissemination of metal debris from implants. J Bone Joint Surg Br. 1994;76:701–712.PubMed

Cipriano C, Issack P, Beksac B, Della Valle A, Sculco T, Salvati E. Metallosis after metal-on-polyethylene total hip arthroplasty. Am J Orthop. 2008;37:E18–E25.PubMed

10.

Clayton R, Beggs I, Salter D, Grant M, Patton J, Porter D. Inflammatory pseudotumor associated with femoral nerve palsy following metal-on-metal resurfacing of the hip: a case report. J Bone Joint Surg Am. 2008;90:1988–1993.CrossRefPubMed

11.

Counsell A, Heasley R, Arumilli B, Paul A. A groin mass caused by metal particle debris after hip resurfacing. Acta Orthop Belg. 2008;74:870–874.PubMed

12.

Dahlstrand H, Stark A, Anissian L, Hailer N. Elevated serum concentrations of cobalt, chromium, nickel, and manganese after metal-on-metal alloarthroplasty of the hip: a prospective randomized study. J Arthroplasty. 2009;24:837–845.CrossRefPubMed

13.

Davies A, Willert H, Campbell P, Learmonth I, Case C. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am. 2005;87:18–27.CrossRefPubMed

14.

Davis M, Mowad C, Scheinman P. Orthopedic prostheses: is there any point in patch testing? Dermatitis. 2004;15:210–212.PubMed

15.

De Haan R, Pattyn C, Gill H, Murray D, Campbell P, De Smet K. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br. 2008;90:1291–1297.CrossRefPubMed

16.

De Smet K, De Haan R, Calistri A, Campbell P, Ebramzadeh E, Pattyn C, Gill H. Metal ion measurement as a diagnostic tool to identify problems with metal-on-metal hip resurfacing. J Bone Joint Surg Am. 2008;90:202–208.CrossRefPubMed

17.

Doorn P, Mirra J, Campbell P, Amstutz H. Tissue reaction to metal on metal total hip prostheses. Clin Orthop Relat Res. 1996;329(Suppl):S187–S205.CrossRefPubMed

18.

Ghanem E, Parvizi J, Burnett R, Sharkey P, Keshavarzi N, Aggarwal A, Barrack R. Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008;90:1637–1643.CrossRefPubMed

19.

Glyn-Jones S, Pandit H, Kwon Y, Doll H, Gill H, Murray D. Risk factors for inflammatory pseudotumor formation following hip resurfacing. J Bone Joint Surg Br. 2009;91:1566–1574.CrossRefPubMed

20.

Hallab N, Anderson S, Stafford T, Glant T, Jacobs J. Lymphocyte responses in patients with total hip arthroplasty. J Orthop Res. 2005;23:384–391.CrossRefPubMed

21.

Hallab N, Merritt K, Jacobs J. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83:428–436.CrossRefPubMed

22.

Jacobs J, Gilbert J, Urban R. Corrosion of metal orthopaedic implants. J Bone Joint Surg Am. 1998;80:268–282.PubMed

23.

Jacobs J, Hallab N. Loosening and osteolysis associated with metal-on-metal bearings: a local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006;88:1171–1172.CrossRefPubMed

24.

Jacobs J, Skipor A, Campbell P, Hallab N, Urban R, Amstutz H. Can metal levels be used to monitor metal-on-metal hip arthroplasties? J Arthroplasty. 2004;19:59–65.CrossRefPubMed

25.

Jacobs J, Urban R, Hallab N, Skipor A, Fischer A, Wimmer M. Metal-on-metal bearing surfaces. J Am Acad Orthop Surg. 2009;17:69–76.PubMed

26.

Jasty M, Bragdon C, Jiranek W, Chandler H, Maloney W, Harris W. Etiology of osteolysis around porous-coated cementless total hip arthroplasties. Clin Orthop Relat Res. 1994;308:111–126.PubMed

27.

Kobayashi A, Bonfield W, Kadoya Y, Yamac T, Freeman M, Scott G, Revell P. The size and shape of particulate polyethylene wear debris in total joint replacements. Proc Inst Mech Eng H. 1997;211:11–15.PubMed

28.

Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporary metal-on-metal total hip arthroplasty: five to nine-year follow-up. J Bone Joint Surg Am. 2006;88:1183–1191.CrossRefPubMed

29.

Mabilleau G, Kwon Y-M, Pandit H, Murray DW, Sabokbar A. Metal-on-metal hip resurfacing arthroplasty: a review of periprosthetic biological reactions. Acta Orthop. 2008;79:734–747.CrossRefPubMed

30.

MacDonald S. Metal-on-metal total hip arthroplasty: the concerns. Clin Orthop Relat Res. 2004;429:86–93.CrossRefPubMed

31.

Mahendra G, Pandit H, Kliskey K, Murray D, Gill H, Athanasou N. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties: relation to implant failure and pseudotumor formation. Acta Orthop. 2009;80:653–659.CrossRefPubMed

32.

Milosev I, Pisot V, Campbell P. Serum levels of cobalt and chromium in patients with Sikomet metal-metal total hip replacements. J Orthop Res. 2005;23:526–535.CrossRefPubMed

33.

Morawietz L, Tiddens O, Mueller M, Tohtz S, Gansukh T, Schroeder J, Perka C, Krenn V. Twenty-three neutrophil granulocytes in 10 high-power fields is the best histopathological threshold to differentiate between aseptic and septic endoprosthesis loosening. Histopathology. 2009;54:847–853.CrossRefPubMed

34.

Pandey R, Drakoulakis E, Athanasou N. An assessment of the histological criteria used to diagnose infection in hip revision arthroplasty tissues. J Clin Pathol. 1999;52:118–123.CrossRefPubMed

35.

Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons C, Ostlere S, Athanasou N, Gill H, Murray D. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847–851.CrossRefPubMed

36.

Park Y, Moon Y, Lim S, Yang J, Ahn G, Choi Y. Early osteolysis following second-generation metal-on-metal hip replacement. J Bone Joint Surg Am. 2005;87:1515–1521.CrossRefPubMed

37.

Sieber H, Rieker C, Kottig P. Analysis of 118 second-generation metal-on-metal retrieved hip implants. J Bone Joint Surg Br. 1999;81:46–50.CrossRefPubMed

38.

Thomas P, Braathen L, Dorig M, Aubock J, Nestle F, Werfel T, Willert H. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammation. Allergy. 2009;64:1157–1165.CrossRefPubMed

39.

Willert H, Buchhorn G, Fayyazi A, Flury R, Windler M, Koster G, Lohmann C. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints: a clinical and histomorphological study. J Bone Joint Surg Am. 2005;87:28–36.CrossRefPubMed

40.

Witzleb W, Hanisch U, Kolar N, Krummenauer F, Guenther K. Neo-capsule tissue reactions in metal-on-metal hip arthroplasty. Acta Orthop. 2007;78:211–220.CrossRefPubMed

Title: Perivascular Lymphocytic Infiltration Is Not Limited to Metal-on-Metal Bearings
Authors: Vincent Y. Ng, MD
Adolph V. Lombardi Jr, MD
Keith R. Berend, MD
Michael D. Skeels, DO
Joanne B. Adams, BFA
Publication date: 01-02-2011
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 2/2011
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-010-1570-7

At a glance: The STEP trials

Springer Medicine

Perivascular Lymphocytic Infiltration Is Not Limited to Metal-on-Metal Bearings

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Questions/purposes

Patients and Methods

Results

Conclusions

Level of Evidence

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