[The cause of loosening in cemented hip joint prostheses. Light and electron microscopy study and laser microprobe mass analysis]

Foreign body reactions in lymph nodes of oncology patients with joint prostheses—light-, electron microscopic and immunohistological investigations

Foreign body reactions in lymph nodes caused by wear particles from joint prostheses can mimic different lymphadenopathies, including metastatic cancer. The knowledge of these alterations is particularly important for pathologists performing frozen section diagnosis for oncology patients. As recent investigations of pseudocapsules have revealed that most of the wear particles are submicron-sized, transmission electron microscopic investigations were additionally performed. The histological investigation of the pelvic lymph nodes of 22 oncology patients with joint prostheses showed that the bone cement wear prevailed. At least small amounts of polyethylene wear particles were also found in all cases. Metallic wear particles were detected in 90% of the cases. The wear particles induce a macrophage-rich foreign body reaction that can cause an architectural effacement of the lymph nodes. The electron microscopic investigations showed that submicron-sized wear particles prevail. Some of them form conglomerates in size ranges detectable by light microscopy. The immunohistochemical studies showed that the foreign body reactions comprised mature CD163- and PGM1-positive macrophages and few lymphocytes, predominantly T-lymphocytes. The knowledge of the characteristic alterations of regional lymph nodes seems important in order to avoid misinterpretations. Therefore, in particular the detection of intracytoplasmatic wear particles is helpful in this respect.

[Identification of wear particles of joint prostheses in tissues using laser microprobe mass analysis (LAMMA)]

The definite identification of wear particles from joint prostheses is of great importance for the development of joint replacement, as the type and quantity of different wear particles gives information on the wear resistance of implant materials. From the types of prostheses nowadays in use polyethylene wear of the sockets, bone cement wear, metallic and ceramic wear can be generated. Whereas polyethylene wear can be easily identified by its bright luminescence in polarized light and its characteristic configuration, the distinction of the small granular wear particles of the bone cement, metal and ceramic by light microscope is difficult. The laser microprobe mass analysis (LAMMA) is a method, which allows the analysis of single light microscopically detectable wear particles in tissues. Not only contrast medium particles of the bone cements (zirconium oxide or barium sulfate) but also metallic and aluminum oxide particles could be definitely identified within the pseudocapsules as well as in regional lymph nodes by LAMMA-analysis, whereby the bone cement wear predominated. In addition, the distinction between organic substances (as blood degradation products), which may appear similar to wear particles in configuration and colour, and the foreign material is also possible with this method.

Morphologic characteristics of periprosthetic tissues from hip prostheses with ceramic-ceramic couples: a comparative histologic investigation of 18 revision and 30 autopsy cases

Pseudocapsules and interface membranes from 18 revision cases having hip prostheses with ceramic-ceramic couples and 30 autopsy specimens (6 with ceramic-ceramic couples, 7 with ceramic-polyethylene combinations and 17 with metal-polyethylene combinations) were histomorphologically analyzed, including a semiquantitative grading of the wear particles and histologic changes. Unlike the revision cases, which usually showed ceramic wear particles in the adjacent tissues, only half of the autopsy cases revealed ceramic wear. As compared to the ceramic-polyethylene and metal-polyethylene couples, the alumina on alumina combinations showed a thinner synovial layer with reduced villous transformation and smaller infiltrates of macrophages and necroses, which can be explained by the absence of polyethylene wear. Metal-polyethylene couplings produced more than twice as many polyethylene wear particles with correspondingly more marked foreign body reaction than the ceramic-polyethylene couplings.

Therapy with pulsed electromagnetic fields in aseptic loosening of total hip protheses: a prospective study

Aseptic loosening is the most common problem of hip arthroplasties, limiting its long term success. We report a study of pulsed electromagnetic field (PEMF) treatment in 24 patients with this complication. At the end of treatment, six months and one year later, pain and hip movements improved significantly with the exception of flexion and extension. There was significant improvement in both isotope scans and ultrasonography, but not in plain X-ray. The decreased pain and improved function suggest that PEMF is effective in improving symptoms of patients with loose hip replacement. No improvement, however, can be expected in patients with severe pain due to gross loosening.

Tissue reactions to cemented hip sockets. Histologic and morphometric autopsy study of 25 acetabula

To gain an insight into the tissue reactions leading to noninfectious loosening, 25 autopsy specimens of acetabula with well-fixed cemented sockets were analyzed histomorphologically and morphometrically. The mean duration of the implant was 7 (0.2-16) years. With the exception of some focal direct bone-cement contacts, bone and cement were separated by a soft tissue membrane which increased in thickness with increasing duration of the implant. Necroses in the membrane were also commoner with advancing implant time. The soft tissue membranes developed increasingly dense infiltrates of histiocytes, mainly containing wear particles of the bone cement and--though less abundant--polyethylene. The cancellous bone adjacent to the soft tissue membrane showed an increasing histiocytic infiltration with an increasing duration of the implant. The trabecular bone showed remodeling with formation of a neocortical layer parallel to the border of the cement mantle.

Histopathological and microanalytical study of zirconium dioxide and barium sulphate in bone cement

AIMS

To report the appearances of zirconium dioxide and barium sulphate in interface membranes, synovium, and other tissues around joint prostheses.

METHODS

Histological sections from 23 specimens were reviewed by light microscopy and polarisation. Scanning electron microscopy and x ray microanalysis were performed on routinely processed paraffin wax sections.

RESULTS

Polyethylene, metals, and polymethylmethacrylate cement debris were easily recognisable. Almost all the cement remnants contained either zirconium dioxide or barium sulphate, confirmed by microanalysis. The contrast media had characteristic light microscopic appearances. Zirconium was identified in macrophages away from cement remnants.

CONCLUSION

The presence of radiographic contrast media in tissues around prosthetic joints is common but not widely recognised.

Cemented versus cementless hip arthroplasty. A review of prosthetic biocompatibility

The fibrous interface tissue between hip prostheses and surrounding bone is often morphologically and functionally synovial-like. The fibroblast is the major cell type; but also giant cells and macrophages are present, and their numbers are increased in the occasional adverse-type host reaction to the prosthesis. Adverse lytic reactions are often associated with methylmethacrylate debris, whereas in cementless cases, polyethylene and metallic (titanium) wear debris seem to cause adverse reactions. Osteoblasts, osteoclasts, and mesenchymal collagenase secreted by fibroblasts and macrophages play an important role in the process of prosthetic loosening. Methylmethacrylate is immunologically relatively inert, while it induces inflammatory mononuclear-cell migration. Both cemented and cementless prostheses cause a foreign-body type host response, including adaptive and reactive processes. This response includes the formation of fibroblast-like B-type lining cells, which are able to synthesize and secrete hyaluronate. Material surfaces of hip arthroplasty components also provide a unique environmental niche to which staphylococcal strains adhere and colonize. Antibiotic resistance is related to the material colonized rather than to the presence of an exopolysaccharide barrier; organisms bound to polyethylene and methylmethacrylate are more resistant than organisms that are bound to stainless steel. An understanding of prosthetic biocompatibility requires an appreciation of tissue cell, bacterial cell and host defense-system response to biomaterials. The site of implantation is a stage on which the "players" (bacteria, host cells, and organic moieties) interact and compete, and before which the host is a "responsive audience."

Histological patterns of bone and articular tissues after orthopaedic reconstructive surgery (artificial joint implants)

Revision surgery after failures of joint replacements leads to histological studies on joint and bone tissues close to the implanted material. Aspectic loosening is the main complication. The surgical pathologist has to identify wear debris (metal, polyethylene, polymethylmethacrylate, chiefly) which promotes a histiocytic granuloma. Some surgical procedures such as cup or resurfacing arthroplasties create a new articular surface and a bone remodeling or necrosis. Cemented joint prostheses show various membrane structures between bone and the cement mantle while there is an association of bone resorption and formation. Non-cemented, porous-coated joint prostheses induce little bone ingrowth, even in satisfactory clinical results. Mechanical factors are predominant in massive limb prostheses. For silicone elastomer implants or artificial ligaments, wear of material promotes many tissular reactions. Often used bone grafts show little creeping substitution process in case of homografts, even well-incorporated on X-rays. More retrieval specimen studies are necessary to delineate precise topographical histological lesions, including non-loosened joint implants.

Comparative investigations of regional lymph nodes and pseudocapsules after implantation of joint endoprostheses

Morphological alterations of pseudocapsules and regional lymph nodes were studied by light and electron microscopy and by Laser Microprobe Mass Analysis (LAMMA). The tissue specimens originated from 32 autopsies of patients with hip joint endoprostheses (time in situ: 3 weeks - 15 years, average: 6 years) and two cases with knee joint endoprostheses. Characteristic changes of the lymph nodes as well as of the pseudocapsules consisted in an infiltration by monocytic histiocytes with various intracytoplasmatic wear particles. The foreign material consisted mainly of the components of bone cement: polymethylmethacrylate (PMMA) and zirconium oxide, to a lesser degree of polyethylene from the articulating surfaces. In two cases with special types of prostheses ceramic or metallic wear particles could be detected too. Most of the wear particles were found in the ipsilateral parailiac lymph nodes and in the paraaortic lymph nodes bilaterally. In the cases with mostly stable prostheses small amounts of wear particles were found in the lymph nodes as soon as 1.5 years after insertion and their number increased in all groups of lymph nodes after longer duration of the implant. The phagocytosing histiocytes showed degenerative changes. At present it is not clear, if the cell damage is caused by the amount of phagocytosed wear particles alone or if specific toxic effects of certain substances are of importance.