Metal-on-Metal Bearings and Hypersensitivity in Patients With Artificial Hip Joints

Willert, H.‐G.; Buchhorn, Gottfried; Fayyazi, Afshin; Flury, Renata; Windler, Markus; Köster, Georg; Lohmann, Christoph H.

doi:10.2106/00004623-200501000-00006

Cited by 336 publications

(213 citation statements)

References 11 publications

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“…Periprosthetic soft tissue lesions around MOM hip implants have been reported by numerous authors using various terms including ALTR, ARMD, ALVAL, metallosis, and pseudotumor [1,17,23,24,33]. These soft tissue masses can be associated with major tissue destruction [24] and therefore early recognition and prompt revision are critical.…”

Section: Discussionmentioning

confidence: 99%

“…However, reports have emerged describing the presence of periprosthetic soft tissue lesions, which have been described interchangeably as adverse local tissue reactions (ALTR) [1], adverse reactions to metal debris (ARMD) [17], aseptic lymphocytic vasculitis-associated lesions (ALVAL) [33], metallosis [23], and pseudotumors [24]. Although these soft tissue masses are not malignant or infectious, they can be associated with catastrophic local tissue destruction [24] and complication rates of 50% after revision arthroplasty [6].…”

Section: Introductionmentioning

confidence: 99%

“…Histologically, the soft tissue lesions are characterized by lymphocytes, histiocytes, and necrosis [33] but also may exhibit metallic deposits and corrosion products [20]. Campbell et al [2] proposed a histologic scoring system which predicts the presence of a lymphocyte-predominant reaction in the soft tissues, known as ALVAL.…”

Section: Introductionmentioning

confidence: 99%

“…Campbell et al [2] proposed a histologic scoring system which predicts the presence of a lymphocyte-predominant reaction in the soft tissues, known as ALVAL. This is believed to reflect a type IV hypersensitivity reaction [33] that typically is either absent or low grade in patients with excess metal wear [2,17]. Schmalzried [28] first proposed the term ALTR to include all adverse responses resulting from wear-related and biologic causes.…”

Section: Introductionmentioning

confidence: 99%

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MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

Nawabi

Gold

Lyman

et al. 2013

Clin Orthop Relat Res

124

132

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Background Adverse local tissue reactions (ALTR) around metal-on-metal (MOM) hip arthroplasties are increasingly being recognized as a cause of failure. These reactions may be associated with intraoperative tissue damage and complication rates as high as 50% after revision. Although MRI can identify ALTR in MOM hips, it is unclear whether the MRI findings predict those at revision surgery.Questions/purposes We therefore (1) identified which MRI characteristics correlated with histologically confirmed ALTR (using the aseptic lymphocytic vasculitisassociated lesions [ALVAL] score) and intraoperative tissue damage and (2) developed a predictive model using modified MRI to detect ALVAL and quantify intraoperative tissue damage. Methods We retrospectively reviewed 68 patients with failed MOM hip arthroplasties who underwent preoperative MRI and subsequent revision surgery. Images were analyzed to determine synovial volume, osteolysis, and synovial thickness. The ALVAL score was used to grade tissue samples, thus identifying a subset of patients with ALTR. Intraoperative tissue damage was graded using a four-point scale. Random forest analysis determined the sensitivity and specificity of MRI characteristics in detecting ALVAL (score C 5) and intraoperative tissue damage. Results Maximal synovial thicknesses and synovial volumes as determined on MRI correlated with the ALVAL score and were higher in cases of severe intraoperative tissue damage. Our MRI predictive model showed sensitivity and specificity of 94% and 87%, respectively, for detecting ALVAL and 90% and 86%, respectively, for quantifying intraoperative tissue damage.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

Nawabi

Gold

Lyman

et al. 2013

Clin Orthop Relat Res

124

132

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“…Additional studies showing correlations between increased numbers of T H and T C cells and radiographic osteolysis [28,61] further implicate T cell involvement in bone remodeling. However, others only attribute a substantial involvement of T cells in the inflammatory Type IV hypersensitivity response to metal particles and/or ions [13,48,60,76]. Thus, understanding of adaptive immune responses contributing to osteolysis lacks a clear consensus.…”

Section: Adaptive Immune Response Includes Several Subgroups Of T Lymmentioning

confidence: 99%

Do Tissues From THA Revision of Highly Crosslinked UHMWPE Liners Contain Wear Debris and Associated Inflammation?

Baxter

Freeman

Kurtz

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Polyethylene wear debris is a major contributor to inflammation and the development of implant loosening, a leading cause of THA revisions. To reduce wear debris, highly crosslinked ultrahigh-molecular-weight polyethylene (UHMWPE) was introduced to improve wear properties of bearing surfaces. As highly crosslinked UHMWPE revision tissues are only now becoming available, it is possible to examine the presence and association of wear debris with inflammation in early implant loosening. Questions/purposes We asked: (1) Does the presence of UHMWPE wear debris in THA revision tissues correlate with innate and/or adaptive immune cell numbers? (2) Does the immune cell response differ between conventional and highly crosslinked UHMWPE cohorts?Methods We collected tissue samples from revision surgery of nine conventional and nine highly crosslinked UHMWPE liners. Polarized light microscopy was used to determine 0.5-to 2-lm UHMWPE particle number/mm 2 , and immunohistochemistry was performed to determine macrophage, T cell, and neutrophil number/mm 2 . Results For the conventional cohort, correlations were observed between wear debris and the magnitude of individual patient macrophage (q = 0.70) and T cell responses (q = 0.71) and between numbers of macrophages and T cells (q = 0.77) in periprosthetic tissues. In comparison, the highly crosslinked UHMWPE cohort showed a correlation between wear debris and the magnitude of macrophage responses (q = 0.57) and between macrophage and T cell numbers (q = 0.68). Although macrophages and T cells were present in both cohorts, the highly crosslinked UHMWPE cohort had lower numbers, which may be associated with shorter implantation times. Conclusions The presence of wear debris and inflammation in highly crosslinked UHMWPE revision tissues may contribute to early implant loosening.

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The Effect of Patch Testing on Surgical Practices and Outcomes in Orthopedic Patients With Metal Implants

et al. 2012

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To determine the effect of patch testing on surgical decision making and outcomes in patients evaluated for suspected metal hypersensitivity related to implants in bones or joints. Design: Medical chart review. Setting: Tertiary care academic medical center. Participants: All patients who had patch testing for allergic contact dermatitis related to orthopedic implants. Intervention: Patch testing. Main Outcome Measures: The surgeon's preoperative choice of metal implant alloy compared with patch testing results and the presence of hypersensitivity complications related to the metal implant on postsurgical follow-up. Results: Patients with potential metal hypersensitivity from implanted devices (N=72) were divided into 2 groups depending on timing of their patch testing: preimplantation (n=31) and postimplantation (n=41). History of hypersensitivity to metals was a predictor of positive patch test results to metals in both groups. Positive patch test results indicating metal hypersensitivity influenced the decisionmaking process of the referring surgeon in all preimplantation cases (n=21). Patients with metal hypersensitivity who received an allergen-free implant had surgical outcomes free of hypersensitivity complications (n=21). In patients who had positive patch test results to a metal in their implant after implantation, removal of the device led to resolution of associated symptoms (6 of 10 patients). Conclusions: The findings of this study support a role for patch testing in patients with a clinical history of metal hypersensitivity before prosthetic device implantation. The decision on whether to remove an implanted device after positive patch test results should be made on a case-bycase basis, as decided by the surgeon and patient.

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Metal-on-Metal Bearings and Hypersensitivity in Patients With Artificial Hip Joints

Cited by 336 publications

References 11 publications

MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

Do Tissues From THA Revision of Highly Crosslinked UHMWPE Liners Contain Wear Debris and Associated Inflammation?

The Effect of Patch Testing on Surgical Practices and Outcomes in Orthopedic Patients With Metal Implants

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