The Correlation of Wear with Histological Features After Failed Hip Resurfacing Arthroplasty

Abstract

The majority of pseudotumors are associated with increased implant wear. This increased wear is associated with soft-tissue necrosis and a heavy nonspecific foreign-body macrophage response coupled with a variable adaptive or specific immune response (ALVAL). A minority of pseudotumors are associated with low wear and a prominent immune response. These findings confirm that minimizing wear from metal-on-metal hip resurfacing arthroplasty prostheses would lead to a reduction in the incidence of pseudotumor. However, a small number of pseudotumors are still likely to occur, which may be due to an exacerbated adaptive immune response.

UHMWPE Wear Debris and Tissue Reactions Are Reduced for Contemporary Designs of Lumbar Total Disc Replacements

“…A 36-image (9 20 objective) composite, that spanned the entire tissue section, was created for each section under transmitted light to grade tissue reactions by at least two individuals (SYV, MJS) using a scoring system scaled from 0 to 3 ( Table 2). The scoring criteria were based on the Oxford method that is presently used for grading total joint arthroplasty tissues for macrophage and lymphocyte inflammation, aseptic lymphocyte-dominated vasculitis associated lesion (ALVAL), and necrosis [7,27] but modified to exclude ALVAL responses to metal wear debris and include hemosiderin deposition and vascularization, which are more predominant in spine tissue.…”

How Have New Bearing Surfaces Altered the Local Biological Reactions to Byproducts of Wear and Modularity?

“…A total of 34 publications fit our inclusion criteria (Appendix 1). [7,8,14], and others [19,26,27,29,34,40] have illustrated histologic features suggestive of an immune reaction in tissues around some failed metal-on-metal hip implants (see subsequently). These features are characteristic, but a failed metal-on-PE implant may demonstrate similar histologic findings [17,41].…”

“…Indeed, some cases of failed metal-on-metal arthroplasty do not show any features suggestive of an adaptive immune response and instead show the macrophage and giant cell reaction more consistent with an ''innate'' foreign body reaction essentially identical to that seen in most cases of failed metal-on-PE arthroplasty [26]. Recognizing that tissues around failed metal-on-metal implants show a range of findings, some authors have attempted to develop grading or scoring systems intended to provide an index that might reflect the continuum from an innate, macrophage reaction to an adaptive immune response [7,15,19,33]. Studies attempting to relate the extent of the histological reaction with the amount of wear of metal-on-metal implants have generally reported a low degree of correlation [19,24].…”

“…Recognizing that tissues around failed metal-on-metal implants show a range of findings, some authors have attempted to develop grading or scoring systems intended to provide an index that might reflect the continuum from an innate, macrophage reaction to an adaptive immune response [7,15,19,33]. Studies attempting to relate the extent of the histological reaction with the amount of wear of metal-on-metal implants have generally reported a low degree of correlation [19,24].…”

CORR Insights®: Can Wear Explain the Histological Variation Around Metal-on-metal Total Hips?

“…While low metallic wear rates (on the order of two to three microns per year) make it inherently difficult to establish correlation (much less causation) between metallic wear and histologic response, there is both confirmative [6] and equivocal/dissenting literature [7]. Notably, it does appear that pseudotumor/ALVAL formation is possible in the presence of low wear, and it is thus highly probable that individual host response plays a critical role in this pathologic process in conjunction with the myriad variables associated with implant design (alloy composition, corrosion properties and debris particle size, weight bearing axes).…”