Malignant fibrous histiocytoma of bone at the site of a total hip arthroplasty. A case report

Sarcoma pleomórfico de alto grau associado a metalose em paciente com artroplastia total do quadril

Apesar da relação entre artroplastia de quadril e o desenvolvimento de sarcoma ter sido descrita pela primeira vez na literatura há cerca de quarenta anos, esta associação é extremamente rara. No presente relato de caso, descrevemos a associação entre implante ortopédico e sarcoma de partes moles em um homem de 79 anos submetido a artroplastia primária total do quadril (ATQ) por coxartrose há 24 anos. Foram descritas a evolução clínica e os achados radiográficos e histopatológicos da lesão. No intraoperatório da segunda cirurgia de revisão, foi evidenciada soltura dos componentes acetabular e femoral em associação com extensas áreas de necrose e de metalose. Foi realizado desbridamento da região do quadril e da coxa direita e retirada dos implantes. Devido à extensão da lesão e da necrose, não foi possível realizar nova reconstrução articular. O diagnóstico histopatológico de sarcoma pleomórfico indiferenciado de alto grau associado a extensas áreas de metalose foi estabelecido no tecido adjacente ao implante. O paciente evoluiu com metástases pulmonares e faleceu 6 meses após o diagnóstico. Apesar da raridade da associação, os sarcomas devem ser considerados no diagnóstico diferencial das solturas assépticas, particularmente na presença de metalose no tecido peri-implantar. Pelo nosso conhecimento o período de latência de 24 anos entre a ATQ primária e o estabelecimento do diagnóstico de sarcoma é um dos mais longos relatado até o momento.

Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making

Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip.

Inflammatory pseudotumor around metal-on-polyethylene total hip arthroplasty in patients with ankylosing spondylitis: description of two cases and review of literature

Inflammatory pseudotumor has been commonly reported in patients undertaking total hip replacement (THR) for different reasons. The precise etiology of this biological reaction and whether the primary disease has an influence on pseudotumor formation remain unclear. There seems to be a consensus that metal ions and debris do play an important role during this process. Recently, however, compared to metal particles along, immune response induced by metal particles attracts more attention. We present two cases of pseudotumor who have accepted THR for ankylosing spondylitis (AS) and later required revision surgery and hindquarter amputation, respectively. By thorough literature review, we tried to investigate the association between inflammatory pseudotumors and immunology.

Low-grade myxofibrosarcoma following a metal implantation in femur: a case report

Myxofibrosarcoma is a myxoid variant of malignant fibrous histiocytoma that most commonly involves the extremities of elderly people. However, a primary myxofibrosarcoma with bone invasion in young adults is extremely rare. Herein, we report the case of a 31-year-old male with a gradually enlarging left thigh mass, who had a history of left femur fracture and received an open reduction and internal fixation with titanium alloy plates and screws 33 months previously. Imaging investigations revealed an irregularly shaped soft tissue mass around the left femur shaft and a partial bone defect in the middle one-third of the left femur. Pathological examination of the resected specimen showed a multi-nodular appearance, abundant myxoid matrix and elongated curvilinear capillaries. Immunohistochemical studies revealed that the tumor cells was positive for VIM and MDM2, and was negative for CK, MSA, SMA, DES, S-100 and CD34. Labeling index of Ki-67 was 25%. Based on the morphological finding and immunostaining, it was diagnosed as a low-grade myxofibrosarcoma. The clinical and imaging examinations did not reveal the evidence of a primary cancer elsewhere, and the patient had no personal or family history of malignancy. To our knowledge, this is the first case of a primary myxofibrosarcoma developed following a fracture and metal implantation in young adults.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1745984882113605.

Pleomorphic spindle cell sarcoma (PSCS) formerly known as malignant fibrous histiocytoma (MFH): a complex malignant soft-tissue tumor

A presentation defining the nature, characteristics, causation, treatment and outcome of patients with lesions formerly known as malignant fibrous histiocytoma and now as pleomorphic spindle cell sarcoma is clearly a very difficult subject. Many authors do not believe that the tumor exists and instead describe them as forms of fibrosarcomas, fibromyxoid lesions, dedifferentiated chondrosarcomas or even leiomyosarcomas. The reasons for this confusion are presumably related to the fact that the malignant pleomorphic spindle cell sarcoma does not seem to be a distinct type of lesion with specific histologic and genetic characteristics. Instead, the tumor has at least four separate histologic variations and no specific gene signature and in fact does not seem to be either familial or ethnic in presentation. In view of the fact that the tumor was traditionally the most frequently encountered malignant soft-tissue neoplasm, the world of orthopedic oncology is clearly distressed by the problems that these patients have and is joined by the radiation oncologists and chemotherapists in seeking new solutions.

Malignant fibrous histiocytoma at the site of an alumina-on-alumina-bearing total hip arthroplasty mimicking infected trochanteric bursitis

Although the incidence of malignant tumors in patients undergoing total hip arthroplasties (THAs) is known to be lower than the general population, there exist several reports on the development of malignant tumors at the site of THAs. We report another case of malignant fibrous histiocytoma at the site of a THA, which was developed in an older patient who presented a cystic mass around the total hip prosthesis using a ceramic-on-ceramic bearing system, even without evidence of osteolysis or loosening of implants. This is the second case associated with an aluminum oxide prosthesis in English literature.

Severe osteolysis and soft tissue mass around total hip arthroplasty: description of four cases and review of the literature with respect to clinico-radiographic and pathologic differential diagnosis

Periprosthetic osteolysis is a well known phenomenon caused by wear particle-induced bone resorption, particularly common and extensively reported in total hip arthroplasty. Its typical radiographic feature is a radiolucent area adjacent to an implant, sometimes associated with a soft tissue mass. Osteolytic changes may be caused by numerous other pathologic processes, including infection, metabolic disease, and neoplasia. Four cases of massive periprosthetic bone destruction associated with a large soft tissue mass around a failed total hip replacement are presented. In three cases, a diagnosis of periprosthetic osteolysis was correctly made and managed by revision surgery. However, in one case angiosarcoma of the ipsilateral hemipelvis went long unrecognized despite aggressive clinical course, requiring hind-quarter amputation and ultimately resulting in the patient's death. Periprosthetic malignancy in the form of either primary sarcoma or metastatic cancer is a very rare yet reported event in the setting of previous hip replacement, likely leading to catastrophic consequences when diagnosis is not established in a timely manner. The differential diagnosis of periprosthetic osteolysis should consider the entire spectrum of conditions that can present with radiolucent changes. Thorough review of patient's history and course of symptoms, along with careful evaluation of standard roentgenograms should be always performed and possibly integrated with imaging modalities such as CT, MRI, and bone scintigraphy in order to increase diagnostic accuracy. If uncertainty remains, biopsy should always be considered to rule out malignancy.

Case report: Fibroxanthoma: a complication of a biodegradable screw

BACKGROUND

Biodegradable interference screws in anterior cruciate ligament (ACL) reconstruction have gained popularity because of their similar or superior fixation strength in comparison to metallic interference screws and because they do not cause imaging artifacts and do not need to be removed.

CASE DESCRIPTION

We report the case of a 23-year-old man who presented with slowly progressive firm swelling of 2 months' duration at the site of the tibial tunnel 3 years after ACL reconstruction using a biodegradable interference screw. After curettage and débridement, the material was sent for histopathologic examination, which was reported as a fibroxanthoma.

LITERATURE REVIEW

Reported complications are osteolysis around the screw, allergic reaction, sterile abscess formation, ganglion cyst formation, and intraarticular migration. A fibroxanthoma consists of fibroblasts and mononuclear or multinucleated cells with large lipid-filled histiocytes (foam cells). The cells are negative for S-100 and keratin and positive for anti-human macrophage marker HAM-56.

PURPOSES AND CLINICAL RELEVANCE

Use of biodegradable screws is associated with high healing rates and low complication rates; however, awareness of their potential complications may help in early recognition and prevention of associated morbidity.

Malignant fibrous histiocytoma secondary to a traumatic hematoma

We present a case of malignant fibrous histiocytoma located in the region of the temple that corresponded to the main site of a traumatic hematoma. There are reports of malignant transformation triggered by different kinds of wounds, but the malignant transformation in a subcutaneous hematoma is rare. For chronic expanding hematoma, magnetic resonance imaging or biopsy is recommended in determining whether it is malignant, especially when the mass is growing rapidly.

Angiosarcoma around a revision total hip arthroplasty and review of literature

Development of cancer in association with metallic implants is well recognized yet poorly understood. We report a case of angiosarcoma at the site of a revision total hip arthroplasty. We found only 3 previous reports on angiosarcoma associated with hip arthroplasty in English literature. Association between malignant tumor and hip arthroplasty deserves attention because this surgical procedure is so common that possible risk of a neoplasm should be quantified. Sarcoma is rare, and its possible causation by retained foreign body material has been reported only as single cases.

Malignant fibrous histiocytoma arising in the area of total hip replacement

A patient developed a rapidly progressive and extensive periprosthetic osteolysis after a cemented total hip arthroplasty for postradiation necrosis of pelvic bone and femoral head. Malignant tumor is one of the causes of periprosthetic bone loss. The biopsy confirmed the malignant fibrous histiocytoma (MFH). However, majority of periprosthetic bone loss is due to wear debris induced osteolysis. Usually, wear debris induced periprosthetic osteolysis is developed later and the progression is much slower than there of malignant tumor. Also wear debris induced osteolysis is confirmed by chronic inflammation with macrophages containing wear particles. When there is a rapidly progressive and extensive osteolysis a prosthesis following hip replacement arthroplasty, the physician should suspect the possibility of malignant tumor.

A citric acid-based hydroxyapatite composite for orthopedic implants

We describe a novel approach to process bioceramic microparticles and poly(diol citrates) into bioceramic-elastomer composites for potential use in orthopedic surgery. The composite consists of the biodegradable elastomer poly(1,8-octanediol-citrate) (POC) and the bioceramic hydroxyapatite (HA). The objective of this work was to characterize POC-HA composites and assess the feasibility of fabricating tissue fixation devices using machining and molding techniques. The mechanical properties of POC-HA composites with HA (40, 50, 60, 65wt.%) were within the range of values reported for tissue fixation devices (for POC-HA 65wt.%, S(b)=41.4+/-3.1, E(b)=501.7+/-40.3, S(c)=74.6+/-9.0, E(c)=448.8+/-27.0, S(t)=9.7+/-2.3, E(t)=334.8+/-73.5, S(s)=27.7+/-2.4, T(s)=27.3+/-4.9, all values in MPa). At 20 weeks, the weight loss of POC-HA composites ranged between 8 and 12wt.%, with 65wt.% HA composites degrading the slowest. Exposure of POC-HA to simulated body fluid resulted in extensive mineralization in the form of calcium phosphate with Ca/P of 1.5-1.7 similar to bone. POC-HA supported osteoblast adhesion in vitro and histology results from POC-HA samples that were implanted in rabbit knees for 6 weeks suggest that the composite is biocompatible. Synthesis of POC-HA is easy and inexpensive, does not involve harsh solvents or initiators, and the mechanical properties of POC-HA with 65wt.% HA are suitable for the fabrication of potentially osteoconductive bone screws.

Malignant tumors at the site of total hip prosthesis. Analytic review of 46 cases

During the years 1974 to 2003, a total of 46 cases of malignant tumors at the site of total hip arthroplasty, 41 sarcomas, 4 lymphomas, and 1 epidermoid carcinoma, have been reported in the Western literature. Soft tissue sarcomas occurred in 31 and bone sarcomas in 10 cases. Malignant fibrous histiocytoma was the most common in 20 (65%) of all soft tissue sarcomas. The patients with malignant tumors had been operated on more often for secondary osteoarthritis and had more local complications than those in ordinary total hip arthroplasty series. Primary osteoarthritis was the indication in 63% and secondary osteoarthritis in 37% of the 38 reported cases. Tumor developed after 8 (17%) revisions. Deep infection complicated 4 (9%) of the cases. Four cases (9%) were preceded by a precondition for cancer, 2 postradiation necroses of the femoral head, 1 chronic sinus, and 1 Mafucci syndrome. Mean age of the patients at the time of first implantation was 59 years (range, 24-79 years). The mean latent period was 6 years (range, 0.5-20 years) from the first operation. Longer latency period did not correlate positively with the cancer risk. Sarcomas were highly aggressive. Of the 31 reported patients, 24 (77%) died within 1 year after the diagnosis. The number of reported sarcoma cases is low considering the total population behind the cases. In addition, one observed local sarcoma from Nordic cohorts was less than expected. Chronic, particle-induced inflammation around the prosthesis does not seem to increase the risk for carcinogenesis.

[Metastasis on previous hip arthroplasty: three cases]

Three cases of metastasis on a previous total hip arthroplasty are reported. The hips had been operated a few years earlier for osteoarthritis. The patients then developed a carcinoma (kidney, prostate, breast) which disseminated producing bony metastases around the prosthesis which caused loosening. All three patients underwent a revision procedure for prosthesis replacement with a metaphysodyaphyseal implant. Carcinological resection was performed in one patient because the metastasis appeared to be unique. At last follow-up two years later, this patient was doing well.

Malignant fibrous histiocytoma at the site of a total hip arthroplasty

Malignant fibrous histiocytoma is the most frequent sarcoma in adults. Predisposing factors for malignant fibrous histiocytoma are Paget's disease, bone infarcts, malignant disorders of the hematopoetic system, or prolonged intake of corticosteroids. Malignant fibrous histiocytoma has been described as occurring with increasing frequency after endoprosthetic therapy and has been attributed to the implants or to their alloy constituents. Malignant fibrous histiocytoma at the site of an endoprosthesis of the hip constitutes a distinct rarity. To our knowledge, only 13 cases have been described to date. In this report, we present the case of a 66-year-old woman with rheumatoid joint disease. Eight years after primary endoprosthetic surgery, loosening of the implant with severe osteolysis of the surrounding bone required replacement surgery. Histopathologic evaluation of resected tissue revealed scar and granulation tissue and Grade 3 malignant fibrous histiocytoma. The patient died 1 year after revision arthroplasty because of diffuse pulmonary and cerebral metastases. In patients with loosening of a total hip endoprosthesis in combination with severe periprosthetic osteolysis an accompanying malignancy should be in the differential diagnosis. The histopathologic examination of the resected tissue should be obligatory.

Prosthetic implant associated sarcomas: a case report emphasizing surface evaluation and spectroscopic trace metal analysis

Advances with implantation of synthetic biomaterials in the setting of orthopedic surgery have clearly resulted in improvements in patient outcomes. However, all implants have been shown to have associated risks. For example, ionic and particulate debris from implants have been shown to engage in biological interactions with the native tissue, and have been associated with a wide range of metabolic, bacteriologic, immunologic, and oncogenic effects. The propensity of synthetic biomaterials to undergo degradation, producing an inflammatory reaction or other sequelae, has been well recognized. The use of porous implants, which allow for a greater interface area between native tissue and the prosthesis, may magnify the interaction between biologically active tissue and synthetic devices in some situations, giving rise to new and intriguing issues concerning biocorrosion and biocompatibility. In this article, we report the case of a high-grade conventional osteosarcoma occurring at the site of a modular porous-surfaced titanium and cobalt alloy total hip prosthesis 3 years after device implantation. Detailed spectroscopic trace metal analysis was performed and elevated levels of both vanadium and chromium, but not aluminum, nickel, or titanium were identified in the tumor.

Extraosseous cement granuloma associated with total hip replacement in 6 dogs

OBJECTIVE

To report the clinical, radiographic, and pathologic features of extraosseous cement granuloma (ECG), a low occurrence, long-term complication of total hip replacement (THR).

STUDY DESIGN

Retrospective clinical study. Sample Population-Six client-owned dogs.

METHODS

Medical records for 6 dogs that had a cemented modular THR and developed ECG were reviewed for the clinical, radiologic, and histopathologic findings of ECG. Morphologic and elemental analyses of retrieved particles were conducted in 2 dogs using scanning electron microscopy (SEM) and energy-dispersive x-ray spectroscopy (EDS).

RESULTS

Three golden retrievers and 3 Labrador retrievers had progressive lameness in the operated limb 4 to 7 years after THR and developed ECG. Other clinical features included an acute deterioration to non-weight bearing associated with pathologic fracture of the proximal femur in 2 dogs, and obstipation in 1 dog. In 5 dogs, there was a large caseous mass surrounding the proximal femur. Obstipation in 1 dog was caused by a similar mass adjacent to bone cement used for fixation of the acetabular cup. Radiographic changes included a multilobular soft tissue mass, containing irregular mineral densities, in the gluteal mass surrounding the proximal femur, THR interface deterioration, osteolysis, new bone formation, and implant subsidence were consistent with chronic aseptic loosening. The histopathologic diagnosis was sterile granuloma associated with a massive heterogeneous particulate burden, which was assumed to have resulted from severe wear of all prosthesis components.

CONCLUSIONS

ECG is a manifestation of severe aseptic loosening of cemented total hip replacement, with the generation of wear debris probably responsible for granuloma formation.

CLINICAL RELEVANCE

Because revision can offer a good prognosis in early aseptic femoral loosening, yearly radiographic monitoring of the recipients is recommended.

Disseminated osteosarcoma arising in the pelvis after total hip arthroplasty

The development locally of a malignant neoplasm after total hip arthroplasty is rare but increasingly recognized. Its significance is unclear. The association could be fortuitous. If not, the rarity of the complication argues that constitutional factors are likely to be important in pathogenesis. We describe a case of disseminated osteosarcoma of the hip developing 6.5 years after total hip arthroplasty and review the related literature.

Metal-associated angiosarcoma of bone: report of two cases and review of the literature

Angiosarcoma is an extremely rare bone tumor. The authors report two cases of patients with angiosarcoma that developed adjacent to a stainless steel plate used for fixation of a femur fracture. In both patients, the interval between fracture treatment and the development of the neoplasm was more than 40 years. A review of the literature found 36 previously reported cases of malignancy arising adjacent to an orthopaedic implant. Despite any evidence directly linking these implants to the development of cancer, continued vigilance is warranted.

Arthroplasty-associated malignant fibrous histiocytoma: two case reports

AIMS

Sarcoma localized to the site of an arthroplasty procedure is a rare occurrence, and detailed histological depictions and descriptions are limited. We report the clinicopathological findings in two cases of arthroplasty-associated malignant fibrous histiocytoma (MFH) and review the literature.

METHODS AND RESULTS

The patients were an elderly man and woman. Medical histories, radiographs and slides were reviewed. Immunohistochemistry, electron microscopy, cytogenetics, and electron dispersion spectroscopy were performed in one case. Both were destructive femoral bone tumours that appeared 2 and 8 years post-total hip arthroplasty, and pursued aggressive clinical courses. The histology was similar in both tumours, consisting of high-grade, pleomorphic sarcoma with numerous osteoclastic giant cells, prominent phagocytic activity, and entrapped particles of bone cement. Literature review disclosed 14 previous reports of arthroplasty-associated MFH, representing the most common phenotype. A number of materials and factors related to arthroplasty procedure, such as metal corrosion, wear debris, osteonecrosis, and chronic inflammation, have been implicated as causative agents.

CONCLUSIONS

Arthroplasty-associated MFH is a rare and aggressive tumour. Although the aetiology remains unclear, the small number of arthroplasty-associated sarcomas compared with the large number of joint replacement operations performed over the past four decades suggests a coincidental as opposed to a causal relation.

Orthopaedic implant-related sarcoma: a study of twelve cases

Sarcoma developing in association with a metallic orthopaedic prosthesis or hardware is an uncommon, but well recognized complication. We review 12 cases of sarcomas arising in bone or soft tissue at the site of orthopaedic hardware or a prosthetic joint. Nine patients were male, and three were female. Their ages ranged from 18 to 85 (mean 55) years at the time of diagnosis of the malignancy. Five patients had undergone hip arthroplasty for degenerative joint disease, four had been treated with intramedullary nail placement for fracture, two had staples placed for fixation of osteotomy, and one had hardware placed for fracture fixation followed years later by a hip arthroplasty. The time interval between the placement of hardware and diagnosis of sarcoma was known in 11 cases and ranged from 2.5 to 33 (mean 11) years. The patients presented with pain, swelling, or loosening of hardware and were found to have a destructive bone or soft tissue mass on radiography. Two sarcomas were located primarily in the soft tissue and 10 in bone. Seven patients developed osteosarcoma, four malignant fibrous histiocytoma, and one a malignant peripheral nerve sheath tumor. All sarcomas were high grade. Three patients had metastatic disease at the time of diagnosis. Follow-up was available on eight patients: five patients died of disease 2 months to 8 years (mean 26 months) after diagnosis; two patients died without evidence of disease 7 and 30 months after diagnosis; and one patient is alive and free of disease 8 years after diagnosis. Sarcomas that occur adjacent to orthopaedic prostheses or hardware are of varied types, but are usually osteosarcoma or malignant fibrous histiocytoma. They behave aggressively and frequently metastasize. Clinically, they should be distinguished from non-neoplastic reactions associated with implants, such as infection and a reaction to prosthetic wear debris.

Ceramic hip prostheses in young patients: a retrospective study of 74 patients

Zones of osteolysis occur in mobilized and in well-fixed prostheses with the classic ultrahigh molecular weight polyethylene-metal couple. However, since 1981 with the use of the ceramic couple in cemented hip prostheses in young patients, osteolysis has not been observed. The prostheses in patients with a longer followup do not show signs of wear in the bearing or signs of bone lysis in the well-fixed prostheses. Cementless prostheses with the same type of ceramic bearing have been used since 1990 in patients with more than 30 years of life expectancy, in an effort to eliminate loosening at the cement-bone interface. The cementless prostheses performed well with spot welds visible 3 months after the operation, which still are present at 7 years of followup. Lysis has not been observed behind the cup or around the stem. In the current series, head ruptures and accidents in the stem and neck junction produced by the modularity of the prostheses did not occur. The authors focus on the positive results shown by ceramic bearings and describe the results of 31 cemented, five hybrid, and 58 uncemented prostheses with ceramic bearings in patients younger than 50 years of age.

Pathologic supracondylar fracture due to osteolytic pseudotumor of knee following cementless total knee replacement

Wear debris of polyethylene, polymethylmethacrylate, and metal have been recognized to be associated with foreign body reactions, osteolysis, and aseptic prosthetic loosening after joint replacement arthroplasty. Further, foreign body reaction due to the presence of extensive wear debris can cause aggressive granulomatous lesions and pathologic fracture. To our knowledge, there has been no previous report of pathologic fracture of the femur due to an agressive pseudotumor. This report describes a case of pathologic supracondylar fracture of the femur 6 years and 5 months after cementless total knee replacement arthroplasty. The fracture occurred through an aggressive expanding soft tissue mass that was a tumorlike lesion secondary to polyethylene wear debris. The lesion was associated with massive osteolysis around the femoral component of the total knee prosthesis.

Cancer incidence in Finnish hip replacement patients from 1980 to 1995: a nationwide cohort study involving 31,651 patients

Nationwide, computer-based reporting of all arthroplasties performed in Finland was started in January 1980. Using data from these records, a cohort of 31,651 polyethylene-on-metal total hip arthroplasty (THA) patients was followed up for cancer, using Finnish Cancer Registry data, from 1980 to 1995. During follow-up, 2,367 cancers were observed. There were statistically significantly fewer cancers among the THA patients (standardized incidence ratio [SIR], 0.90; 95% confidence interval [CI], 0.87-0.93). SIRs for cancers of the lung (0.69) and stomach (0.77) were significantly below unity. There was no significantly increased risk at any site. The SIR for cancer overall in male THA patients was below unity during the first 3 years after THA but returned to unity thereafter. The low SIR among men during the first 3 years was largely because the lung cancer SIR was 0.47 (95% CI, 0.35-0.62). In women, the SIR remained around 0.93 throughout follow-up. The SIR for stomach cancer was below unity only in women (SIR, 0.67; 95% CI, 0.51-0.86). For cancer of the urinary bladder, the SIR during the first 3 years after THA was below unity but later slightly above it (SIR, 1.24 in relation to > or =3 years of follow-up; 95% CI, 0.99-1.52). For myeloma and leukemia, SIRs were greater than unity only for THA patients followed up for 3 to 9 years. The study findings, in contrast to previously reported findings, do not indicate that there is any increased risk of hematopoietic cancers after THA using polyethylene-on-metal prostheses. SIRs relating to soft tissue cancers and bone sarcomas did not differ significantly from unity. No sarcoma was observed at the site of a prosthesis. THA seems to play no major role in cancer causation.

Osteosarcoma at the site of bone infarction associated with total hip arthroplasty in a dog

OBJECTIVE

To report the occurrence of medullary bone infarction in both femoral canals after bilateral total hip arthroplasty (THA) and the subsequent unilateral development of an osteosarcoma at the site of bone infarction.

STUDY DESIGN

Clinical report.

ANIMAL POPULATION

An 8-month-old neutered male Samoyed dog.

METHODS

Serial physical and radiographic examinations performed at 1, 2, 3, and 5 years after THA. Bone biopsy specimens of the right distal femoral metaphysis were taken 5 years after THA, and a complete necropsy was performed at the time of euthanasia.

RESULTS

Bilateral medullary bone infarction was visible in the femoral canals 1 year after THA and remained visible on subsequent evaluations. An osteosarcoma developed in the right distal femoral metaphysis at the site of infarction, 5 years after THA, and was found to have metastasized widely throughout the body.

CONCLUSION

Bone infarction may occur in the femoral canal after canine THA.

CLINICAL RELEVANCE

Bone infarction may be a predisposing factor for the development of osteosarcoma in the femora of dogs with THAs.

Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature

The use of implantable biomaterials has become an integral part of aesthetic and reconstructive surgery of the face. Metals are used for fracture fixation devices, whereas polymers are used primarily for bone or soft-tissue substitution. This review of the scientific literature examines the risks and complications of these materials. First, we present an overview of commonly used materials. Second, we address general considerations of toxicity relevant to all biomaterials. Third, we present data from a large number of clinical series on the incidence of complications for individual materials used in specific applications.

Tumors around implants

In 1989, A. G. Apley recommended cautious surveillance of malignant tumors that developed in association with orthopaedic implants. This retrospective review of the Bristol Bone Tumour Register between 1980 and 1992 reports on 240 malignant soft tissue sarcomas. Eighteen developed in the thigh region of patients more than 50 years old, and 4 of these developed in the soft tissues around a hip arthroplasty.

Angiosarcoma occurring with chronic osteomyelitis and residual foreign material: case report of a late World War II wound complication

The case is reported of a World War II veteran who developed an angiosarcoma at the site of wounding 46 years previously. The wound was complicated by retained foreign material and chronic infection involving bone. The patient died, 6 weeks after tumour diagnosis, from a complication of the disease. There is slight but definite risk of tumour development in association with retained foreign material. This risk may be greater in older patients who have retained this foreign material for long periods and where the presence of the material is complicated by chronic infection.

Titanemia from total knee arthroplasty. A case resulting from a failed patellar component

The subject of this case report is a patient with elevated serum levels of titanium (77 parts/billion [ppb]; normal, 3.3 ppb) and vanadium (0.38 ppb; normal, 0.17 ppb) resulting from excessive wear of a metal-backed patellar component in a total knee arthroplasty. The patellar component was worn through both its polyethylene and metal backing as a result of abnormal contact between the patellar and femoral components. Scanning electron microscopic examination of the ingrowth surface of the patellar component indicated that particle debonding occurred as a result of overloading of the sintered neck regions at the particle-substrate interface, suggesting a possible damage during initial insertion of the device, which may have predisposed it to loosening and abnormal contact with the femoral component. Wear particles resulted in staining of the tissues within the knee and an inflammatory and immune response in the synovium consisting of giant cells and T lymphocytes. The serum metal levels were reduced 22 weeks after replacing the patellar component; however, the titanium level was still slightly elevated (8 ppb).

Periprosthetic metastatic carcinoma. Pitfalls in the management of two cases initially diagnosed as osteolysis

Periprosthetic osteolysis is a well-described phenomenon associated with total hip arthroplasty. Two cases are presented in which apparently healthy patients developed lytic lesions adjacent to cementless hip implants. Despite atypical features, the lesions were initially attributed to wear debris-induced osteolysis, and it was discovered during revision surgery that metastatic tumor was present. For one patient, if the initial diagnosis had been correct, subsequent surgery and related complications may have been avoided. It is important to consider the entire differential of radiolucent bone lesions whenever a patient presents with periprosthetic osteolysis. If revision surgery is not warranted on the basis of loosening, then a thorough medical examination, close follow-up evaluation, and/or biopsy should be performed to rule out metastatic disease.

Retention of asymptomatic bone plates used for orthognathic surgery and facial fractures

Over the past three decades there has been an improvement in biomaterials that has virtually replaced the use of stainless steel with titanium and its alloys. Based on the possibility of causing corrosion, toxicity, hypersensitivity, and stress protection, stainless steel should not be considered as a permanent implant in maxillofacial fixation. However, because of their superior corrosion resistance, noncarcinogenicity, hyposensitivity, nontoxicity, and excellent tissue compatibility, titanium and Ti-6Al-4V may be retained as permanent implants in maxillofacial fixation. The stress protection offered by such devices, and the possible complications associated with their removal, also support this concept. Finally, the costs incurred in removal do not justify the benefits derived.

Human breast sarcoma and human breast implantation: a time trend analysis based on SEER data (1973-1990)

Since the demonstration in the 1940s of foreign body induction of sarcomas in rodents, the safety of artificial implants in humans has been a matter of concern. In this study, we assess the risk for the development of breast sarcomas in women with silicone breast implants. Our analysis is based on the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program database for the years 1973-1990 and on estimates of breast implantation rates from about 1960 onward. We have divided the SEER data into two equal time periods, 1972-1981 and 1982-1990. For each time period, we estimated the average annual number of women in the United States who had received breast implants 10 or more years earlier. This analysis allows for a 10 year latency period for the induction of breast sarcoma. We calculated that the average number of women in the U.S. 10 or more years post breast implantation was 55,000 for the 1973-1981 period and 509,000 for the 1982-1990 period. We then examined the SEER data to observe whether there was a concomitant rise in the female breast sarcoma incidence rates between these two time periods. We found the mean age-adjusted incidence rate of breast sarcomas was 0.13 per 100,000 women for the initial 9-year period, 1973-1981, and 0.12 per 100,000 women for the latter 9-year period, 1981-1990.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of carcinogenicity and chronic toxicity associated with orthopedic implants in mice

The carcinogenicity and chronic toxicity of 316L stainless steel, nickel, Ti-6A1-4V, hydroxyapatite (HA)-coated Ti-6A1-4V, aluminum oxide containing yttrium oxide, and zirconium oxide containing yttrium oxide were evaluated by implanting solid rods of each material in the thigh muscle of C57BL/6N mice for 24 months. Nickel alloy showed high carcinogenic and toxic potencies, whereas other materials showed no evidence of them. Tumors retaining nickel alloys were malignant fibrous histiocytoma or fibrosarcoma. In some cases, lymphomata that seemed to develop spontaneously were found around the implants because lymphocytes were known to accumulate in chronic inflammatory lesions, and this phenomenon also might be applied to lymphoma.

Evaluation of wear in an all-polymer total knee replacement. Part 2: clinical evaluation of wear in a polyethylene on polyacetal total knee

In an effort to improve the long-term result of total joint replacement arthroplasty, we have investigated the use of a polymer-on-polymer articular replacement arthroplasty. Because of their known biocompatibility and previous use in orthopedic surgery, polyethylene and polyacetal (copolymer, Hoechst) were selected. Polyethylene served in its usual role as the concave member of the articulation; polyacetal formed the convex number. Formal wear testing using a multi-channel hip simulator demonstrated superior wear characteristics of the polymer-on-polymer configuration compared to a conventional chrome-cobalt versus polymer (polyethylene) configuration. A clinical series of relatively high-activity patients having a minimum five-year follow-up (N = 26) showed no specific unfavorable reaction to this material combination in a total knee replacement. Given certain potential advantages of polymeric materials, as well as some theoretical disadvantages of metallic materials, a polymer-on-polymer design for a large joint replacement may have some merit.

Total hip arthroplasty complicated by a malignant fibrous histiocytoma. A case report

Tumors associated with total hip arthroplasty are uncommon. The authors report the eighth case of a malignant fibrous histiocytoma associated with a total joint arthroplasty and discuss its etiology and significance.

Sagittal split osteotomy fixed with biodegradable, self-reinforced poly-L-lactide screws. A pilot study in sheep

Self-reinforced poly-L-lactide (SR-PLLA) screws were used to fix bilateral mandibular sagittal split osteotomies (SSO) in six sheep. No intermaxillary fixation was used postoperatively. The follow-up time was 16 weeks, after which the sheep were killed. Both sides of the mandible were photographed and radiographed. The bending strength of the osteotomy was measured on the left side of the mandible. Histological and microradiographic studies were performed on the right side of the mandible. The results showed that the SR-PLLA screws were strong enough to fix the SSO rigidly. The bending force needed to break the bone was greater than that for the average unoperated mandible. The histological and microradiographic studies showed uneventful healing of the osteotomies in all six sheep. The results indicate that this method should be suitable for rigid fixation of SSO and fractures of the mandible in human beings.

Fibrosarcoma in association with a total knee joint prosthesis

A case of fibrosarcoma of the proximal tibia, arising at the site of a cemented Richards total knee joint replacement with cobalt chrome alloy is reported. The patient, an 80-year-old man, received the endoprosthesis because of osteoarthritis of the knee 4 years ago. The literature on malignant tumours occurring in association with endoprostheses is summarized and briefly discussed.

Severe metallosis due to abnormal abrasion of the femoral head in a dual bearing hip prosthesis. A case report

The authors report on a patient with a case of severe metallosis due to an abnormal abrasion of the femoral head. A primary arthroplasty was performed using a dual bearing hip prosthesis with acetabular bone grafting by ceramic screws. At the time of the revision surgery the synovia was black, and an analysis using a scanning electron microscope and scanning electron microscope-electron probe micro-analyzer revealed numerous small particles of small alumina ceramic on the inner surface of the bearing insert of high-density polyethylene. These particles, which came from the broken ceramic screws due to proximal migration of the prosthesis, scraped the femoral head away. A line and area analysis of the black synovia revealed that the synovia contained metal particles of a cobalt-chromium alloy as well as a cobalt ion. The patient's serum showed elevated concentrations of cobalt, chromium, and molybdenum that dramatically reduced 2 months after the revision surgery.

New generation biodegradable plate for fracture fixation: comparison of bending strengths of mandibular osteotomies fixed with absorbable self-reinforced multi-layer poly-l-lactide plates and metallic plates--an experimental study in sheep

Eighteen osteotomies of sheep's mandibular corpus were fixed: nine with self-reinforced multi-layer poly-l-lactide (SR-PLLA) plates and nine with metallic plates. Both plates were fixed with similar metallic screws. The right corpus of each sheep acted as a control. Radiographic analysis was carried out at 3 weeks and at sacrifice (6, 12 or 24 weeks) when the bending force needed to break the osteotomy site was measured. At 6 and 12 weeks of follow-up the osteotomy fixed with the PLA-plate seemed to tolerate the bending force better but no significant differences were detected at 3 or 24 weeks. The results have been satisfactory and have led the authors to continue with the development of a SR-PLLA plate-and-screw device for fracture fixation.

The biologic responses to orthopedic implants and their wear debris

The use of artificial materials in the treatment of orthopaedic conditions, most notably arthritis, over the past few decades has been increasing dramatically. Such use makes an understanding of the tissue responses to the various materials necessary to determine their effectiveness and acceptability. This review concentrates on the studies of the biological responses to the materials that are used mainly in joint replacements and fixation of fractures. In-vivo and in-vitro experimental studies of various metals, polymers and ceramics and their constituents are first presented with discussions regarding their clinical importance. Studies of clinically successful implants are then presented to illustrate the expected morphological features of incorporation and acceptance by the host tissues. The local and systemic effects complicating the use of the implanted materials as well as the failure of the implant are then presented.

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.