Do Polyethylene Supra-Macroparticles Lead to Pseudotumor Formation in Metal-on-Polyethylene Total Hip Arthroplasty?

Ishida, Tsunehito; Tateiwa, Toshiyuki; Takahashi, Yasuhito; Nishikawa, Yohei; Shishido, Toetsu; Masaoka, Toshinori; Sano, Keiji; Yamamoto, Kenjiro

doi:10.1016/j.artd.2020.06.006

Cited by 4 publications

(10 citation statements)

References 23 publications

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“…Periarticular masses have been commonly reported to be associated with mechanically assisted crevice corrosion at the head-neck taper interface in large diameter metal-on-metal (MoM) THA [ [4] , [5] , [6] ]. Moreover, an ALTR with a similar mechanism has been reported in metal-on-polyethylene (MoP) bearings that this is related to mechanically assisted crevice corrosion [ [7] , [8] , [9] , [10] ]. In fact, metal hypersensitivity (eg, lymphocytic aggregates, granulomas [ 11 , 12 ]) may occur together with particle and ion reactions.…”

Section: Introductionmentioning

confidence: 79%

“…However, histological features may vary from case to case and be related to particle bioreactivity, which may depend on particle size, material composition, and concentration [ 14 ]. We previously pointed out that polyethylene supramacroparticles >100 μm in size potentially trigger periarticular mass formation via a foreign-body reaction to the polyethylene particles in MoP THA, in which cases showed no signs of an adverse reaction to metal debris or severe corrosion at the interface [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

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IL-17A–Mediated Immune-Inflammatory Periarticular Mass and Osteolysis From Impingement in Ceramic-On-Ceramic Total Hip Arthroplasty

et al. 2021

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We present a rare case of symptomatic adverse local tissue reaction in a 54-year-old female patient who had undergone total hip arthroplasty with ceramic-on-ceramic bearing. Inflammatory periarticular mass and osteolysis developed in the absence of cobalt chrome alloy interfaces and a modular neck component. On the pathologic images, there was no clear evidence of gross metal staining of tissues, metal corrosion, and ceramic or metal wear particles. However, there were impingement scars on the titanium alloy femoral neck and acetabular cup associated with a high combined anteversion angle of 75° (stem: 40° and cup: 35°), suggesting titanium debris release in vivo. Immunohistochemical staining proved a predominant infiltration of CD4+ T cells and the corresponding IL-17A response to metal. We conclude that neck-rim impingement may lead to the development of adverse local tissue reaction (periarticular mass and osteolysis) due to a metal hypersensitivity with the production of proinflammatory cytokines (IL-17A) by CD4+ T cells even in ceramic-on-ceramic total hip arthroplasty.

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Section: Introductionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

IL-17A–Mediated Immune-Inflammatory Periarticular Mass and Osteolysis From Impingement in Ceramic-On-Ceramic Total Hip Arthroplasty

et al. 2021

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“…Howie et al [ 10 ] also identified excessive polyethylene wear as the cause of bursal masses. We recently reported 2 cases of pseudotumor following MoP THA, and histological examination revealed a foreign body reaction to polyethylene particles with no adverse reaction to metal debris and no severe signs of corrosion at the head-neck junction [ 8 ]. Therefore, polyethylene wear particles might possibly contribute to the development of ALTR in our series.…”

Section: Discussionmentioning

confidence: 99%

“…As a result, when wear particles of a size that macrophages cannot phagocytose are generated, a foreign body giant cell-based reaction may occur [ 12 ], potentially promoting pseudotumor formation in the periprosthetic soft tissue. In our cases, all 4 patients receiving revision THA had a high wear rate of 0.14–0.30 mm/y (Table 2 ) and large polyethylene wear particles with a size of > 20 μm, with 2 of the 4 patients having supra-macroparticles of > 100 μm [ 8 ]. Thus, the long-term accumulation of wear and the presence of large polyethylene particles might have a role in the pseudotumor formation by stimulating a giant cell-based reaction.…”

Section: Discussionmentioning

confidence: 99%

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Do polyethylene wear particles affect the development of pseudotumor in total hip arthroplasty? A minimum 15-year follow-up

et al. 2023

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Background Adverse local tissue reactions have been problematic as an implant-related complication in total hip arthroplasty (THA). Despite the absence of significant metal wear and corrosion, granulomatous pseudotumor has been reported to be caused by polyethylene wear. We performed a long-term follow-up study investigating the relationship between polyethylene wear and pseudotumor formation in THA. Methods This study included 57 patients (64 hips) that underwent primary THA with metal-on-polyethylene or ceramic-on-polyethylene bearing over a minimum follow-up of 15 years. They were stratified into pseudotumor and non-pseudotumor groups and their linear wear rates of polyethylene liner and serum cobalt (Co) and chromium (Cr) ion levels were compared. Pseudotumor was diagnosed on metal artifact reduction sequence-MRI according to its composition and wall thickness using the Hauptfleisch classification. Results The incidence of pseudotumor was 34% (22/64 hips) at the mean follow-up of 16.9 years. Metal ion levels did not differ between the pseudotumor and non-pseudotumor groups, and none of the patients exceeded the Co/Cr ratio of 2.0 μg/L. Moreover, the wear rate in the pseudotumor group was 1.8 times greater than in the non-pseudotumor group (0.14 vs. 0.08 mm/year, P < 0.001). According to an analysis of the receiver operating characteristic curves, the cutoff level of the wear rate to discriminate between pseudotumor and non-pseudotumor patients at 15 years was 0.11 mm/year (area under the curve = 91%; sensitivity = 95%; specificity = 78%; accuracy = 87%). Conclusions Our results might provide new insights into excessive polyethylene wear potentially leading to the future development of both pseudotumor and osteolysis. Further studies are needed to clarify the direct relationship between polyethylene wear and pseudotumor and the mutual effects of osteolysis and pseudotumor in particle reactions.

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No Difference in Revision Rates and High Survival Rates in Large-head Metal-on-metal THA Versus Metal-on-polyethylene THA: Long-term Results of a Randomized Controlled Trial

Spierenburg,

de Vries,

Boomsma

et al. 2023

Clin Orthop Relat Res

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Background Pseudotumor formation is a well-known complication in metal-on-metal (MoM) THA. Pseudotumors combined with elevated serum ion levels and complaints from patients can lead to high revision rates. Long-term (> 10 years) results obtained from randomized trials comparing large-head MoM THA and conventional metal-on-polyethylene (MoP) THA are lacking regarding revision and survival rates, pseudotumor formation, functional outcomes, and serum ion levels. Questions/purposes At 10 years of follow-up, (1) what is the difference in survival and revision rates between large-head (38 to 60 mm) MoM THA and conventional 28-mm MoP THA? (2) What is the difference in pseudotumor formation between large-head MoM THA and MoP THA? (3) Is there a difference in functional outcome between large-head MoM THA and MoP THA? (4) What is the difference in serum ion levels between large-head MoM THA and MoP THA? Methods Between January 2006 and December 2008, 104 patients were randomized to receive either cementless MoM THA (50 patients) or cementless MoP THA (54 patients). In all, 78% (81 of 104) of patients completed the 10-year postoperative follow-up: 36 patients with MoM THA (72%; six patients lost to follow-up) and 45 with MoP THA (83%; four lost to follow-up). In the MoM group, 47% (17) were men, and the patients had a mean ± SD age of 60 ± 5 years. In the MoP group, 38% (17) were men, and the patients had a mean age of 61 ± 5 years. All baseline characteristics were similar between the groups. At 10 years of follow-up, all patient records were screened for revision surgery or complications, and the primary endpoint was survivorship free from revision for any cause at the 10-year follow-up interval, which we analyzed using a Kaplan-Meier survival analysis. All patients had a CT scan to determine the pseudotumor classification, which was reviewed by an independent radiologist. Functional outcome was measured using the patient-reported Oxford Hip Score and Harris Hip Score; the latter was assessed by a blinded nurse practitioner. Finally, serum ion cobalt and chrome concentrations were measured at 10 years postoperatively. Because the a priori sample size calculation for this randomized controlled trial was based on a different endpoint, a post hoc power analysis was performed for this long-term follow-up study, with survival as the primary outcome. It showed that considering the number of included patients, this study would have sufficient power (one-sided testing, alpha 0.05, power 80%) to discern a difference of 20% in the survival rate between the MoP and MoM groups (95% versus 75%). Results With the numbers available, there was no difference in survivorship free from revision for any cause between the MoP group and MoM group at 10 years (95% [95% CI 85% to 98%] versus 92% [95% CI 82% to 98%]; p = 0.6). A higher percentage of patients in the MoM group had pseudotumors on CT than those in the MoP group did, but pseudotumors were observed in both groups (56% [20 of 36] in the MoM group versus 22% [10 of 45] in the MoP group, relative risk 1.8 [95% CI 1.2 to 2.6]; p = 0.002). A higher proportion of elevated cobalt and chrome levels was found in the MoM group (19% and 14%, respectively) than in the MoP group (0% for both cobalt and chrome) (cobalt: RR 1.2 [95% CI 1.1 to 1.5]; p = 0.002; chrome: RR 1.2 [95% CI 1.0 to 1.3]; p = 0.01). In 25% of the patients with pseudotumors (5 of 20 patients), there were elevated serum cobalt levels. None of the 23 patients without pseudotumors had elevated cobalt levels (RR 1.3 [95% CI 1.0 to 1.7]; p = 0.01). There was no difference in functional outcome between study groups, nor a difference between patients with a pseudotumor and those without. Conclusion This study showed that the survival of patients with large-head MoM THA was high and comparable to that of those with MoP THA, which contrasts with the high revision rates reported by others. Although some patients with MoP THAs experienced pseudotumors, the risk of a pseudotumor was much greater in MoM hips, and serum ion levels were higher in patients who received an MoM THA. For these reasons and unknown future complications, continued surveillance of patients with MoM THAs seems important. Level of Evidence Level I, therapeutic study.

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Do Polyethylene Supra-Macroparticles Lead to Pseudotumor Formation in Metal-on-Polyethylene Total Hip Arthroplasty?

Cited by 4 publications

References 23 publications

IL-17A–Mediated Immune-Inflammatory Periarticular Mass and Osteolysis From Impingement in Ceramic-On-Ceramic Total Hip Arthroplasty

IL-17A–Mediated Immune-Inflammatory Periarticular Mass and Osteolysis From Impingement in Ceramic-On-Ceramic Total Hip Arthroplasty

Do polyethylene wear particles affect the development of pseudotumor in total hip arthroplasty? A minimum 15-year follow-up

No Difference in Revision Rates and High Survival Rates in Large-head Metal-on-metal THA Versus Metal-on-polyethylene THA: Long-term Results of a Randomized Controlled Trial

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