Implant based differences in adverse local tissue reaction in failed total hip arthroplasties: a morphological and immunohistochemical study

Abstract

BackgroundAdverse local tissue reaction (ALTR) is characterized by periprosthetic soft tissue inflammation composed of a mixed inflammatory cell infiltrate, extensive soft tissue necrosis, and vascular changes. Multiple hip implant classes have been reported to result in ALTR, and clinical differences may represent variation in the soft tissue response at the cellular and tissue levels. The purpose of this study was to describe similarities and differences in periprosthetic tissue structure, organization, and cellular composition by conventional histology and immunohistochemistry in ALTR resulting from two common total hip arthroplasty (THA) implant classes.MethodsConsecutive patients presenting with ALTR from two major hip implant classes (N = 54 patients with Dual-Modular Neck implant; N = 14 patients with Metal-on-Metal implant) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy and cellular composition was assessed using immunohistochemistry.ResultsLength of implantation was shorter in the DMN group versus MoM THA group (21.3 [8.4] months versus 43.6 [13.8] months respectively; p < 0.005) suggesting differences in implant performance. Morphologic examination revealed a common spectrum of neo-synovial proliferation and necrosis in both groups. Macrophages were more commonly present in diffuse sheets (Grade 3) in the MoM relative to DMN group (p = 0.016). Perivascular lymphocytes with germinal centers (Grade 4) were more common in the DMN group, which trended towards significance (p = 0.066). Qualitative differences in corrosion product morphology were seen between the two groups. Immunohistochemistry showed features of a CD4 and GATA-3 rich lymphocyte reaction in both implants, with increased ratios of perivascular T-cell relative to B-cell markers in the DMN relative to the MoM group (p = 0.032).ConclusionOur results demonstrate that both implant classes display common features of neo-synovial proliferation and necrosis with a CD4 and GATA-3 rich inflammatory infiltrate. Qualitative differences in corrosion product appearance, macrophage morphology, and lymphocyte distributions were seen between the two implant types. Our data suggests that ALTR represents a histological spectrum with implant-based features.

Adverse local tissue reaction (ALTR) associated with corrosion products in metal‐on‐metal and dual modular neck total hip replacements is associated with upregulation of interferon gamma‐mediated chemokine signaling

“…The MoM group included Smith & Nephew Birmingham THA, DePuy Pinnacle Ultamet, and Biomet M2a Magnum implant designs. The diagnosis of ALTR was confirmed using our previously published histopathological criteria and quantitated using the ALVAL scoring system described by Campbell et al For comparative purposes, a group of patients with MoP bearing surfaces and a diagnosis of peri‐implant osteolysis with no evidence for ALVAL ( n = 13) were also selected.…”

“…Despite recent advances in defining the spectrum of histopathological features associated with ALVAL, a mechanistic understanding of the cellular and molecular factors underlying this reaction remains to be elucidated. Characteristic features include a variable amount of perivascular and/or interstitial lymphocytic infiltrate and tissue necrosis/infarction . From a biomaterials standpoint, attention has been focused on corrosion products as putative initiating factors or mediators of the cellular responses.…”

Sequelae of large-head metal-on-metal hip arthroplasties

“…34 In most documented cases, metal wear particles have been found histologically. 35 The incidence of pseudotumours depends on the definition used and the type of pseudotumour, and their prevalence is estimated to be from 3% to over 60% (Table 2) for both well- and poorly-functioning MoM hips. 34,36-50 To date, it is not clear which implant type has the highest risk for development of a pseudotumour.…”

The biological response to orthopaedic implants for joint replacement: Part I: Metals

“…Hence, the serum chromium level remains normal or only slightly elevated in patients with corrosion at modular junctions, whereas the serum cobalt level rises due to its increased solubility. This fact can be used to distinguish a failed metal‐on‐metal articulation, which in general will have an equivalent rise in serum cobalt and chromium levels, from a failed modular junction, which in general will have a differential elevation of the serum cobalt level several fold above that of the serum chromium level …”