Polymethylmethacrylate-induced inflammatory macrophages resorb bone

A Polymer for Application as a Matrix Phase in a Concept of In Situ Curable Bioresorbable Bioactive Load-Bearing Continuous Fiber Reinforced Composite Fracture Fixation Plates

The use of bioresorbable fracture fixation plates made of aliphatic polyesters have good potential due to good biocompatibility, reduced risk of stress-shielding, and eliminated need for plate removal. However, polyesters are ductile, and their handling properties are limited. We suggested an alternative, PLAMA (PolyLActide functionalized with diMethAcrylate), for the use as the matrix phase for the novel concept of the in situ curable bioresorbable load-bearing composite plate to reduce the limitations of conventional polyesters. The purpose was to obtain a preliminary understanding of the chemical and physical properties and the biological safety of PLAMA from the prospective of the novel concept. Modifications with different molecular masses (PLAMA-500 and PLAMA-1000) were synthesized. The efficiency of curing was assessed by the degree of convergence (DC). The mechanical properties were obtained by tensile test and thermomechanical analysis. The bioresorbability was investigated by immersion in simulated body fluid. The biocompatibility was studied in cell morphology and viability tests. PLAMA-500 showed better DC and mechanical properties, and slower bioresorbability than PLAMA-1000. Both did not prevent proliferation and normal morphological development of cells. We concluded that PLAMA-500 has potential for the use as the matrix material for bioresorbable load-bearing composite fracture fixation plates.

Delay of total hip arthroplasty to advanced stage worsens post-operative hip motion in patients with femoral head osteonecrosis

PURPOSE

Osteonecrosis of the femoral head (ONFH) is commonly detected in young patients and most surgeons tend to delay total hip arthroplasty (THA) until the end stage of the disease. We hypothesised that post-operative range of motion (ROM) of the hip as well as baseline ROM at the time of surgery decreases with the disease progression. The purpose of this study was to determine whether patients, who were operated at an advanced stage, have pre- and post-operative hip ROM similar to ROM of patients, who were operated at earlier stages.

METHODS

Eight hundred and fifty patients (850 hips) treated with THA for ONFH were classified according to pre-operative stages of Association Research Circulation Osseous (ARCO). Fifty-six patients were operated at stage 2, 458 at stage 3, and 336 at stage 4. Pre-operative and one year post-operative ROM was compared among the stages.

RESULTS

Pre-operative sum of hip ROM decreased with the progression of ARCO stage (P < 0.001) and correlated with the post-operative sum of hip ROM (correlation coefficient 0.661). Although hip ROM improved after THA in all stages, post-operative ROM in patients with lower pre-operative ROM did not improve to the same level as in those with a higher pre-operative ROM (P < 0.001).

CONCLUSIONS

The progression of ONFH negatively affected post-operative hip ROM as well as baseline hip ROM at the time of THA. Surgeons should consider a delay of THA negatively affects the hip ROM after the arthroplasty, when they determine the treatment modality for ONFH patients.

Inhibition of Dll4/Notch1 pathway promotes angiogenesis of Masquelet's induced membrane in rats

The Masquelet’s induced membrane technique for repairing bone defects has been demonstrated to be a promising treatment strategy. Previous studies have shown that the vessel density of induced membrane is decreased in the late stage of membrane formation, which consequently disrupts the bone healing process. However, relatively little is known about certain mechanisms of vessel degeneration in the induced membrane tissue and whether promotion of angiogenesis in induced membranes can improve bone regeneration. Here, we showed that the Delta-like ligand 4/ Notch homolog 1 (Dll4/Notch1) pathway was relatively activated in the late stage of induced membrane, especially at the subcutaneous site. Then, DAPT, a classical γ-secretase inhibitor, was applied to specifically inhibit Notch1 activation, followed by up-regulation of vascular endothelial growth factor receptor 2 (VEGFR2) and CD31 expression. DAPT-modified induced membranes were further confirmed to contribute to bone regeneration after autogenous bone grafting. Finally, in vitro experiments revealed that knocking down Notch1 contributed to the functional improvement of endothelial progenitor cells (EPCs) and that DAPT-treated induced membrane tissue was more favorable for angiogenesis of EPCs compared with the vehicle group. In conclusion, the present findings demonstrate that Dll4/Notch1 signaling is negatively associated with the vessel density of induced membrane. Pharmacological inhibition of Notch1 attenuated the vessel degeneration of induced membrane both in vitro and in vivo, which consequently improved bone formation at the bone defect site and graft resorption at the subcutaneous site.

Repairs to serious bone injuries may be improved by blocking a signaling pathway that causes newly forming membranes to fail. Masquelet’s technique involves placing acrylic spacers in areas of bone damage, inducing the formation of vascularised membranes which encourage the body to accept bone grafts. However, sometimes Masquelet’s membranes do not form correctly, leading to weaknesses in bone repairs and potential graft rejection. In experiments on rats, Qian Tang from Wenzhou Medical University, China, and coworkers found that a particular signaling pathway, D114/Notch1, was upregulated around 6 weeks post-operation, reducing blood vessel density and limiting new vessel growth, weakening the membranes. The team inhibited this pathway using an existing therapy that prevents blood clots. This treatment improved bone repairs by promoting the formation and function of blood vessels in membranes.

The biological response to orthopedic implants for joint replacement. II: Polyethylene, ceramics, PMMA, and the foreign body reaction

Novel evidence-based prosthetic designs and biomaterials facilitate the performance of highly successful joint replacement (JR) procedures. To achieve this goal, constructs must be durable, biomechanically sound, and avoid adverse local tissue reactions. Different biomaterials such as metals and their alloys, polymers, ceramics, and composites are currently used for JR implants. This review focuses on (1) the biological response to the different biomaterials used for TJR and (2) the chronic inflammatory and foreign-body response induced by byproducts of these biomaterials. A homeostatic state of bone and surrounding soft tissue with current biomaterials for JR can be achieved with mechanically stable, infection free and intact (as opposed to the release of particulate or ionic byproducts) implants. Adverse local tissue reactions (an acute/chronic inflammatory reaction, periprosthetic osteolysis, loosening and subsequent mechanical failure) may evolve when the latter conditions are not met. This article (Part 2 of 2) summarizes the biological response to the non-metallic materials commonly used for joint replacement including polyethylene, ceramics, and polymethylmethacrylate (PMMA), as well as the foreign body reaction to byproducts of these materials. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1685-1691, 2017.

Endoplasmic reticulum stress-mediated inflammatory signaling pathways within the osteolytic periosteum and interface membrane in particle-induced osteolysis

Aseptic loosening secondary to periprosthetic inflammatory osteolysis results from the biological response to wear particles and is a leading cause of arthroplasty failure. The origin of this inflammatory response remains unclear. We aim to validate the definite link between endoplasmic reticulum (ER) stress and particle-induced inflammatory signaling pathways in periprosthetic osteolysis. We examine the histopathologic changes of osteolysis and the expression of specific biomarkers for ER-stress-mediated inflammatory signaling pathways (IRE1α, GRP78/Bip, c-Fos, NF-κB, ROS and Ca(2+)). Moreover, pro-inflammatory cytokines (TNF-α, IL-1β and IL-6) and osteoclastogenic molecules (VEGF, OPG, RANKL and M-CSF) were assessed in clinical interface membranes and murine periosteum tissues. We found wear particles to be capable of inducing ER stress in macrophages within clinical osteolytic interface membranes and murine osteolytic periosteum tissues and to be associated with the inflammatory response and osteoclastogenesis. Blocking ER stress with sodium 4-phenylbutyrate (4-PBA) results in a dramatic amelioration of particle-induced osteolysis and a significant reduction of ER-stress intensity. Simultaneously, this ER-stress blocker also lessens inflammatory cell infiltration, diminishes the capability of osteoclastogenesis and reduces the inflammatory response by lowering IRE1α, GRP78/Bip, c-Fos, NF-κB, ROS and Ca(2+) levels. Thus, ER stress plays an important role in particle-induced inflammatory osteolysis and osteoclastogenic reactions. The pharmacological targeting of ER-stress-mediated inflammatory signaling pathways might be an appealing approach for alleviating or preventing particle-induced osteolysis in at-risk patients.

Blockade of JNK and NFAT pathways attenuates orthopedic particle-stimulated osteoclastogenesis of human osteoclast precursors and murine calvarial osteolysis

Particles released from orthopedic implants attract immune host defense cells to the bone-implant interface and contribute to development of inflammation. The inflammatory microenvironment supports recruitment and differentiation of osteoclasts, the primary culprit of osteolysis. Therefore, understanding the complex signals that contribute to osteoclastogenesis and osteolysis is a sensible approach to design strategies to inhibit bone loss. The signaling cascades that coordinate osteoclastogenesis have been widely investigated. These include MAP kinases, Akt/PI3K pathway, NF-κB signal transduction pathway, and NFAT pathway. We have recently reported that polymethylmethacrylate (PMMA) particles activate the NFAT pathway in murine osteoclast precursors and that NFAT inhibitors dose-dependently block PMMA-induced osteoclastogenesis. In the current study, we examined the role of JNK and NFATc1 in mice in response to PMMA particles using murine calvaria model. We show that locally administered MAPK/JNK inhibitor SP600125 and calcineurin/NFAT inhibitor cyclosporine-A effectively blocked PMMA-induced osteolysis in murine calvaria. To buttress the clinical relevance of JNK/NFATc1-based regulation of PMMA-induced osteoclastogenesis, we evaluated the effect of PMMA using human macrophages. We demonstrate that SP600125 and cyclosporine-A abolished particle-induced osteoclastogenesis in human osteoclast progenitors retrieved from patients undergoing total hip replacement. Thus JNK and NFATc1 appear to act as significant mediators of orthopedic particle-induced osteolysis in humans.

Polyethylene wear particles do not induce inflammation or gelatinase (MMP-2 and MMP-9) activity in fibrous tissue interfaces of loosening total hip arthroplasties

In vitro and in vivo studies have suggested that polyethylene wear particles are the main cause for osteolysis in prosthetic loosening. Elevated amounts of proteases including gelatinases (or matrix metalloproteinases MMP-2 and MMP-9) have been found in fibrous tissue interfaces of loosened total hip arthroplasties suggesting that proteolysis plays a role in osteolysis. The presence of proteases does not mean that they are active, because activity of proteases is highly regulated at the post-translational level. We investigated whether the activity of two major proteases that are active extracellularly and have been associated with loosening, MMP-2 and MMP-9, is involved in loosening of non-cemented hip implants with polyethylene acetabular components. Eight interface tissues retrieved during revision were studied with light and electron microscopy and by in situ zymography to localize MMP-2 and MMP-9 activity in combination with immunohistochemistry to localize MMP-2 and MMP-9 proteins. All interface tissues contained large amounts of polyethylene wear particles, either in large accumulations or dispersed in the extracellular matrix or intracellularly in fibroblasts. Particles were not encountered in association with MMP-2 or MMP-9 activity or leukocytes. Inflammation was never found. MMP-9 activity was restricted to macrophages and MMP-2 activity was restricted to microvascular endothelial cells mainly outside areas where particles were present. Our data indicate that wear particles do not induce activation of leukocytes or MMP-2 or MMP-9 activity. Therefore, aseptic loosening may not be particle induced but initiated by other mechanisms such as mechanical stress.

Continuous infusion of UHMWPE particles induces increased bone macrophages and osteolysis

BACKGROUND

Aseptic loosening and periprosthetic osteolysis resulting from wear debris are major complications of total joint arthroplasty. Monocyte/macrophages are the key cells related to osteolysis at the bone-implant interface of joint arthroplasties. Whether the monocyte/macrophages found at the implant interface in the presence of polyethylene particles are locally or systemically derived is unknown.

QUESTIONS/PURPOSES

We therefore asked (1) whether macrophages associated with polyethylene particle-induced chronic inflammation are recruited locally or systemically and (2) whether the recruited macrophages are associated with enhanced osteolysis locally.

METHODS

Noninvasive in vivo imaging techniques (bioluminescence and microCT) were used to investigate initial macrophage migration systemically from a remote injection site to polyethylene wear particles continuously infused into the femoral canal. We used histologic and immunohistologic staining to confirm localization of migrated macrophages to the polyethylene particle-treated femoral canals and monitor cellular markers of bone remodeling.

RESULTS

The values for bioluminescence were increased for animals receiving UHMWPE particles compared with the group in which the carrier saline was infused. At Day 8, the ratio of bioluminescence (operated femur divided by nonoperated contralateral femur of each animal) for the UHMWPE group was 13.95 ± 5.65, whereas the ratio for the saline group was 2.60 ± 1.14. Immunohistologic analysis demonstrated the presence of reporter macrophages in the UHMWPE particle-implanted femora only. MicroCT scans showed the bone mineral density for the group with both UHMWPE particles and macrophage was lower than the control groups.

CONCLUSIONS

Infusion of clinically relevant polyethylene particles, similar to the human scenario, stimulated systemic migration of remotely injected macrophages and local net bone resorption.

Surveillance of systemic trafficking of macrophages induced by UHMWPE particles in nude mice by noninvasive imaging

Macrophages constitute a major part of the cell response to wear particles produced at articulating and nonarticulating interfaces of joint replacements. This foreign body reaction can result in periprosthetic osteolysis and implant loosening. We demonstrate that ultra-high molecular weight polyethylene (UHMWPE) particles induce systemic trafficking of macrophages by noninvasive in vivo imaging and immunohistochemistry. The distal femora of nude mice were injected with 60 mg/mL UHMWPE suspension or saline alone. Reporter RAW264.7 macrophages that stably expressed the bioluminescent reporter gene and the fluorescence reporter gene were injected intravenously. Bioluminescence imaging was performed using an in vivo imaging system immediately after macrophage injection and at 2-day intervals. Compared with the nonoperated contralateral femora, at day 4, 6, and 8, the bioluminescent signal of femora containing UHMWPE suspension increased 1.30 +/- 0.09-, 2.36 +/- 0.92-, and 10.32 +/- 7.61-fold, respectively. The values at same time points for saline-injected control group were 1.08 +/- 0.07-, 1.14 +/- 0.27-, and 1.14 +/- 0.35-fold, respectively. The relative bioluminescence of the UHMWPE group was higher at all postinjection days and significantly greater than the saline group at day 8 (p < 0.05). Histological analysis confirmed the presence of reporter macrophages within the medullary canal of mice with implanted UHMWPE particles. The presence of UHMWPE particles induced enhanced bone remodeling activity. Clinically relevant UHMWPE particles stimulated the systemic recruitment of macrophages during an early time course using the murine femoral implant model. Interference with systemic macrophage trafficking may potentially mitigate UHMWPE particle-induced periprosthetic osteolysis.

Potential role of tartrate-resistant acid phosphatase 5b (TRACP 5b) as a surrogate marker of late loosening in patients with total hip arthroplasty: a cohort study

In a cohort study, the role of the active tartrate-resistant acid phosphatase (TRACP 5b), a marker of bone-resorbing osteoclasts, for the assessment of loosening after total hip arthroplasty (THA), was analyzed, as well as its correlation with osteolysis and multinucleated cell appearance in the retrievals. Eighty THA patients, who went consecutively to the orthopedic department, were asked to participate, and 54 accepted and were enrolled in the study. Finally, 46 subjects were analyzed, clinical-radiographic evaluation was considered the gold standard, serum TRACP 5b was blindly measured, and a cut-off was obtained, by performing a ROC Curve. Based on the gold standard, patients were split by 19 stable and 27 loosened subjects, and results were matched. TRACP 5b was significantly higher in loosened patients than in stable ones (p < 0.001). A good specificity (89.5%), positive predictive value (90.0%), and likelihood ratio (6.33) were calculated, that provided strong evidence of loosening with TRACP 5b levels higher than the cut-off. Moreover, TRACP 5b and osteolysis (Fisher's exact test, p = 0.03) were found significantly correlated. TRACP 5b has been proven a reliable marker, specifically related to resorbing-multinucleated cells, to ascertain late loosening in THA, and could support standard procedures, if confirmed by performing prospective studies.

Bioactive ceramic-reinforced composites for bone augmentation

Biomaterials have been used to repair the human body for millennia, but it is only since the 1970s that man-made composites have been used. Hydroxyapatite (HA)-reinforced polyethylene (PE) is the first of the 'second-generation' biomaterials that have been developed to be bioactive rather than bioinert. The mechanical properties have been characterized using quasi-static, fatigue, creep and fracture toughness testing, and these studies have allowed optimization of the production method. The in vitro and in vivo biological properties have been investigated with a range of filler content and have shown that the presence of sufficient bioactive filler leads to a bioactive composite. Finally, the material has been applied clinically, initially in the orbital floor and later in the middle ear. From this initial combination of HA in PE other bioactive ceramic polymer composites have been developed.

Comparison of two methods of fatigue testing bone cement

Two different methods have been used to fatigue test four bone cements. Each method has been used previously, but the results have not been compared. The ISO 527-based method tests a minimum of 10 samples over a single stress range in tension only and uses Weibull analysis to calculate the median number of cycles to failure and the Weibull modulus. The ASTM F2118 test regime uses fewer specimens at various stress levels tested in fully reversed tension-compression, and generates a stress vs. number of cycles to failure (S-N) or Wöhler curve. Data from specimens with pores greater than 1mm across is rejected. The ISO 527-based test while quicker to perform, provides only tensile fatigue data, but the material tested includes pores, thus the cement is closer to cement in clinical application. The ASTM regime uses tension and compression loading and multiple stress levels, thus is closer to physiological loading, but excludes specimens with defects obviously greater than 1mm, so is less representative of cement in vivo. The fatigue lives between the cements were up to a factor 15 different for the single stress level tension only tests, while they were only a factor of 2 different in the fully reversed tension-compression testing. The ISO 527-based results are more sensitive to surface flaws, thus the differences found using ASTM F2118 are more indicative of differences in the fatigue lives. However, ISO 527-based tests are quicker, so are useful for initial screening.

Alumina ceramic particles, in comparison with titanium particles, hardly affect the expression of RANK-, TNF-alpha-, and OPG-mRNA in the THP-1 human monocytic cell line

Particle-induced osteolysis is the most frequent cause of aseptic loosening after total joint replacement. We performed a study to illuminate the effect of ceramic particles with different diameters and concentrations on the mRNA expression of certain key regulators in particle-induced aseptic osteolysis (RANK, RANKL, OPG, and TNF-alpha) in THP-1 macrophage-like cells. Titanium particles were used as a positive control. RNA was analyzed by quantitative RTPCR. Our results demonstrate that alumina ceramic particles, regardless of particle size, caused only slight upregulations of RANK, TNF-alpha, and OPG mRNA, whose levels were significantly lower in comparison with those of titanium particles (p < 0.05). The continuous increasing tendency to time and particle-dependent mRNA expression of all the parameters stimulated by titanium particles was not found after stimulation with ceramic materials. Even after the concentration of ceramic particles was increased, only a mild upregulation of mRNA expression was found. Furthermore, we observed that the bioinert properties of ceramic particles did not change much in diameters ranging from 0.5 to 1.5 microm. At most of the measuring time points, there was no significant difference between the reactions of the large and small particles in this range. Our results support the theory about the relative bioinert properties of alumina ceramic particles.

The combined role of wear particles, macrophages and lymphocytes in the loosening of total joint prostheses

This review considers the causes of loosening of prosthetic joint replacement paying attention to the biological mechanisms rather than other effects that are physical, such as component fracture and other failure related to mechanical problems. Infection accounts for approximately 1.5 per cent of joint loosening and when it occurs it is a cause of serious concern to the surgeon. The loosening of prosthetic joints in the absence of infection is by far the most common reason for revision surgery and is known as aseptic loosening. While this may be multifactorial in terms of causation, and non-biological factors may contribute significantly in a particular individual, a significant part is undoubtedly played by the generation of wear debris, mainly from the bearing surfaces of the joint, and the cellular reaction to this in the implant bed. Phagocytic cells (macrophages and multinucleated giant cells) are the ones that remove foreign material from the tissues, and the ways in which these cells function in the interface between implant and bone are described. Mediators produced locally include numerous cytokines, enzymes and integrins. There is evidence for interactions between macrophages and locally recruited lymphocytes, which may or may not give rise to an immunologically mediated process.Sensitization of individuals having metal implants in place has been shown by positive skin tests or blood lymphocyte transformation tests and in these cases has been accompanied by loosening and failure of the replacement joint. The question remains as to whether this process is also present in a proportion of individuals with aseptic loosening in the absence of clearly defined clinical evidence of sensitization.Numerous studies performed by the author's group and, latterly, by others suggest that the cellular reactions detected in the tissues in cases of aseptic loosening are indeed those of contact sensitization. There is good evidence to show that a type IV cell-mediated immune reaction is taking place, with TH1 cell involvement and active antigen presentation. The extent to which sensitization is present in individual cases of aseptic loosening remains a subject for further work and this needs all the sophisticated molecular methods now available to modern biology to be applied in appropriate prospective clinical studies coupled with experimental models in vitro and in vivo. Immunological processes may play a more important part in joint loosening than previously considered.

Systemic trafficking of macrophages induced by bone cement particles in nude mice

Macrophages play an important role in the biological response to wear particles, which can result in periprosthetic osteolysis and implant loosening. In this study, we demonstrate that polymer particles induce systemic trafficking of macrophages by non-invasive in vivo imaging and immunohistochemistry. The distal femora of nude mice were injected with 10% (w/v) Simplex bone cement (BC) suspensions or saline (PBS). Reporter RAW264.7 macrophages which stably expressed the bioluminescent reporter gene fluc, and the fluorescence reporter gene gfp, were injected intravenously. Bioluminescence imaging was performed immediately and periodically at 2-day intervals until day 14. Compared to the non-operated contralateral femora, the bioluminescent signal of femora injected with BC suspension increased 4.7+/-1.6 and 7.8+/-2.9-fold at day 6 and 8, respectively. The same values for PBS group were 1.2+/-0.2 and 1.4+/-0.5, respectively. The increase of bioluminescence of the BC group was significantly greater than the PBS group at day 8 (p<0.05) and day 6 (p<0.1). Histological study confirmed the presence of reporter macrophages within the medullary canal of mice that received cement particles. Modulation of the signaling mechanisms that regulate systemic macrophage trafficking may provide a new strategy for mitigating the chronic inflammatory response and osteolysis associated with wear debris.

Biocompatibility issues with modern implants in bone - a review for clinical orthopedics

Skeletal defects may result from traumatic, infectious, congenital or neoplastic processes and are considered to be a challenge for reconstructive surgery. Although the autologous bone graft is still the “gold standard”, there is continuing demand for bone substitutes because of associated disadvantages, such as limited supply and potential donor side morbidity [1]. This is not only true for indications in orthopedic and craniomaxillofacial surgeries, but also in repairing endodontic defects and in dental implantology.

Before clinical use all new bone substitute materials have to be validated for their osseoconductive and - depending on the composition of the material also –inductive ability, as well as for their long-term biocompatibility in bone. Serving this purpose various bone healing models to test osteocompatibility and inflammatory potential of a novel material on one hand and, on the other hand, non-healing osseous defects to assess the healing potential of a bone substitute material have been developed. Sometimes the use of more than one implantation site can be helpful to provide a wide range of information about a new material [2].

Important markers for biocompatibility and inflammatory responses are the cell types appearing after the implantation of foreign material. There, especially the role of foreign body giant cells (FBGC) is discussed controversial in the pertinent literature, such that it is not clear whether their presence marks an incompatibility of the biomaterial, or whether it belongs to a normal degradation behavior of modern, resorbable biomaterials.

This publication is highlighting the different views currently existing about the function of FBGC that appear in response to biomaterials at the implantation sites. A short overview of the general classes of biomaterials, where FBGC may appear as cellular response, is added for clarity, but may not be complete.

Macrophages that have phagocytosed particles are capable of differentiating into functional osteoclasts

The aim of the current study was to determine whether human macrophages that have phagocytosed particles are capable of differentiating into osteoclastic bone-resorbing cells. Macrophages isolated from human peripheral blood were cultured with latex particles in the presence of receptor activator of nuclear factor (NF)-kappaB ligand (RANKL) and macrophage colony stimulating factor (M-CSF) on dentine slices and coverslips. After 24 h incubation, particles that had not yet been phagocytosed were removed by washing the slices. Histochemistry and immunohistochemistry was used to determine expression of macrophage and osteoclast markers and lacunae resorption, scanning electron microscopy, and transmission electron microscopy were used to examine cells with phagocytosed particles. Isolated macrophages on dentine slices were noted to contain a large number of particles inside, and no particles were identified outside of culture cells after washing. After 14 days of incubation, numerous tartrate-resistant acid phosphatase-positive multinucleated cells that contained particles in their cytoplasm, capable of extensive lacunae bone resorption, formed in these cultures. Our results clearly indicated that macrophages that have phagocytosed particles were still capable of differentiating into osteoclastic bone-resorbing cells. Macrophages that have phagocytosed wear particles in the pseudomembrane surrounding an implant not only produce cytokines but also may differentiate into functional osteoclasts, and influence bone resorption and loosening of a prosthesis.

Aseptic loosening of total joint replacements: mechanisms underlying osteolysis and potential therapies

Total joint replacement, although considered an excellent surgical procedure, can be complicated by osteolysis induced by implant particles and subsequent aseptic loosening of the implant. The pathogenesis of implant-associated osteolysis includes inflammatory and osteolytic processes. The sustained chronic inflammatory response initiated by particulate debris at the implant-bone interface is manifested by recruitment of a wide array of cell types. These cells include macrophages, fibroblasts, giant cells, neutrophils, lymphocytes, and--most importantly--osteoclasts, which are the principal bone resorbing cells. The 'cellular response' entails secretion of osteoclastogenic and inflammatory cytokines that favor exacerbated osteoclast activity and enhanced osteolysis. An appreciation of the complex network that leads to these cellular and inflammatory responses will form a foundation on which to develop therapeutic interventions to combat inflammatory periprosthetic bone loss.

In vitro and in vivo biological responses to a novel radiopacifying agent for bone cement

Iodixanol (IDX) and iohexol (IHX) have been investigated as possible radiopacification agents for polymethylmethacrylate (PMMA) bone cement, to replace the currently used barium sulphate and zirconia. IDX and IHX are both water-soluble iodine-based contrast media and for the last 20 years have been used extensively in clinical diagnostic procedures such as contrast media enhanced computed tomography, angiography and urography. One of the major reasons to remove the current radiopacifying agents is their well-documented cytotoxicity and their potential to increase bone resorption. Using in vitro bone resorption assays, the effect of PMMA particles plus IDX or IHX to induce osteoclast formation and lacunar resorption on dentine slices has been investigated. These responses have been compared with the in vitro response to PMMA particles containing the conventional radiopacifying agents, that is, barium sulphate and zirconia. In parallel, the in vivo reaction, in terms of new bone formation, to particles of these materials has been tested using a bone harvest chamber in rabbit tibiae. In vitro cell culture showed that PMMA containing IHX resulted in significantly less bone resorption than PMMA containing the conventional opacifiers. In vivo testing, however, showed no significant differences between the amounts of new bone formed around cement samples containing the two iodine-based opacifying agents in particulate form, although both led to fewer inflammatory cells than particles of PMMA containing zirconia. Our results suggest that a non-ionic radiopacifier could be considered as an alternative to the conventional radiopacifying agents used in biomaterials in orthopaedic surgery.

Wear particulate and osteolysis

Total joint replacements of the hip and knee are generally highly successful, with satisfactory longevity and clinical results. Using modern biocompatible materials, optimal component design, and meticulous surgical technique, survivorship of cemented or cementless joint replacements is approximately 15 years with more than a 90% probability. The host's biologic response is critical to implant longevity. Particulate disease refers to the host's adverse biologic response to wear debris and byproducts generated from the prosthesis. Initially, emphasis was placed on particulate polymethylmethacrylate (cement disease), but more recently polyethylene wear debris has been underscored. Debris from several materials in sufficient quantities and physicochemical forms, however, can generate an inflammatory cascade resulting in periprosthetic bone destruction (osteolysis), jeopardizing long-term success of the implant.

Protease expression in interface tissues around loose arthroplasties

To determine whether cathepsins and matrix metalloproteinase-1 are involved in accelerating tissue destruction, we examined, immunohistochemically, the expression of matrix metalloproteinase-1 and cathepsins B, D, L, and X in periprosthetic synovial-like interface tissues from 14 patients with failed prosthetic hips and in the synovial membranes of hips from 18 patients with rheumatoid arthritis and 25 patients with primary osteoarthritis. The expression levels of all these proteases in the interface tissue were higher than in the synovial membrane of osteoarthritis. The expression levels of cathepsins B and X in the interface tissue were higher than in the rheumatoid synovium. The results show similarities in the expression patterns of cathepsins D and L and matrix metalloproteinase-1 between aseptic prosthetic loosening and rheumatoid arthritis. In addition, these data suggest that the impact of cathepsins B and X on tissue degradation is more pronounced in aseptic prosthetic loosening than in rheumatoid arthritis.

Does endotoxin contribute to aseptic loosening of orthopedic implants?

Aseptic loosening of orthopedic implants caused by wear particles is a major clinical problem. This review examines the hypothesis that bacterial endotoxin contributes to aseptic loosening. Clinical findings support this hypothesis: bacterial biofilms exist on many implants from patients with aseptic loosening and antibiotics in bone cement reduce the rate of aseptic loosening. Three approaches were used to demonstrate that adherent endotoxin increases bioactivity of titanium particles. These experiments measured cytokine production and osteoclast differentiation in vitro and murine calvarial osteolysis in vivo. First, removal of >99.9% of the adherent endotoxin from titanium particles significantly ablates their biological activity. Second, adding lipopolysaccharide back to these "endotoxin-free" particles restores their biological activity. Third, cells or mice that are genetically hyporesponsive to endotoxin are significantly less responsive to titanium particles than are wild-type controls. Other investigators have confirmed and extended these results to include virtually all orthopedically relevant types of particles, including authentic titanium alloy particles retrieved from patients with loosening. Our recent studies suggest that adherent endotoxin on orthopedic implants may also inhibit initial osseointegration of the implants. Taken together, these studies suggest that bacterial endotoxin may have a significant role in induction of aseptic loosening.

Osteoclast-independent bone resorption by fibroblast-like cells

To date, mesenchymal cells have only been associated with bone resorption indirectly, and it has been hypothesized that the degradation of bone is associated exclusively with specific functions of osteoclasts. Here we show, in aseptic prosthesis loosening, that aggressive fibroblasts at the bone surface actively contribute to bone resorption and that this is independent of osteoclasts. In two separate models (a severe combined immunodeficient mouse coimplantation model and a dentin pit formation assay), these cells produce signs of bone resorption that are similar to those in early osteoclastic resorption. In an animal model of aseptic prosthesis loosening (i.e. intracranially self-stimulated rats), it is shown that these fibroblasts acquire their ability to degrade bone early on in their differentiation. Upon stimulation, such fibroblasts readily release acidic components that lower the pH of their pericellular milieu. Through the use of specific inhibitors, pericellular acidification is shown to involve the action of vacuolar type ATPases. Although fibroblasts, as mesenchymal derived cells, are thought to be incapable of resorbing bone, the present study provides the first evidence to challenge this widely held belief. It is demonstrated that fibroblast-like cells, under pathological conditions, may not only enhance but also actively contribute to bone resorption. These cells should therefore be considered novel therapeutic targets in the treatment of bone destructive disorders.

Particle disease. A comprehensive theory of periprosthetic osteolysis: a review

Aseptic loosening and osteolysis are considered the main long-term problems of hip arthroplasty. Pathogenesis of periprosthetic osteolysis is multifactorial, and both the biological and mechanical factors seem to play an important role. Bearing surfaces continuously generate excessive amounts of micron and submicron particles provoking an adverse inflammatory response of periprosthetic connective tissues. In general, a key role has been attributed to macrophages. Cytokines, growth factors, PGE2, and enzymes are secreted with activated periprosthetic cells resulting in formation of osteolytic granulomas. The final osteolytic step is taken predominantly by osteoclasts which are getting ready for action mainly by an osteoprotegerin ligand (RANKL) and TNFalpha. Rankl is expressed by activated macrophages, osteoblasts, and lymphocytes. In parallel, a repetitive hydraulic effect of the joint fluid is manifested on the susceptible bone.

Fibroblasts from the inner granulation tissue of the pseudocapsule in hips at revision arthroplasty induce osteoclast differentiation, as do stromal cells

BACKGROUND

It has previously been shown that many osteoclast precursors are included in the granulation tissue within the pseudocapsule obtained at revision arthroplasty from hips with osteolysis. In vitro culture of only cells isolated from the granulation tissue has been previously shown to generate many mature osteoclasts.

OBJECTIVE

To investigate the presence or otherwise of supporting cells, similar to stromal cells, which differentiate osteoclasts within the granulation tissue.

METHODS

Cells isolated from the granulation tissue were cultured alone, and after four weeks fibroblast-like cells (granulation fibroblasts) remained. Rat non-adherent bone marrow cells (NA-BMCs) were co-cultured with the granulation fibroblasts with or without 1alpha,25(OH)2D3 (10(-8) M) or heat treated ROS 17/2.8 cell conditioned medium (ht ROSCM), or both. Multinucleated cells (MNCs), which formed, were assessed by biochemical and functional characterisation of osteoclasts. Receptor activator of NFkappaB ligand (RANKL) was investigated by immunohistochemistry.

RESULTS

Co-culture of NA-BMCs and granulation fibroblasts caused the formation of tartrate resistant acid phosphatase (TRAP) positive MNCs, which had the calcitonin receptor (CTR), the Kat-1 antigen, which is specific to the surface of rat osteoclasts, and the ability to form pits in the presence of both 1alpha,25(OH)2D3 and ht ROSCM or in the presence of just ht ROSCM. RANKL was detected in fibroblast-like cells in the granulation tissue.

CONCLUSION

These data suggest that granulation fibroblasts support osteoclast differentiation, as do osteoblasts/stromal cells, and may play a part in aseptic loosening.

The role of osteoclast differentiation in aseptic loosening

The major cause of orthopaedic implant loosening is thought to be accelerated osteoclastic bone resorption due to the action of cytokines produced in response to phagocytosis of implant-derived wear particles. This accelerated osteoclastic bone resorption could be due to increases in any of the following processes: recruitment of osteoclast precursors to the local microenvironment, differentiation of precursors into mature multinucleated osteoclasts. activation of mature osteoclasts, and/or survival of osteoclasts. Our studies have focused on differentiation and survival to complement work by others who have focused on recruitment of precursors and activation. Taken together, our studies and those of other investigators provide strong evidence that increased recruitment of osteoclast precursors and their subsequent differentiation play major roles in wear particle-induced osteolysis. In contrast, increased osteoclast activation and survival appear to play minor roles. These studies suggest that development of therapeutic interventions that reduce either recruitment or differentiation of osteoclast precursors would improve the performance of orthopaedic implants.

Adherent endotoxin on orthopedic wear particles stimulates cytokine production and osteoclast differentiation

Aseptic loosening of orthopedic implants is thought to be caused primarily by osteoclast differentiation induced by bone resorptive cytokines produced in response to phagocytosis of implant-derived wear particles. This study examined whether adherent endotoxin on the wear particles is responsible for inducing osteoclast differentiation as well as production of interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor a (TNF-alpha). Removal of adherent endotoxin almost completely inhibited the responses to titanium (Ti) particles by both murine marrow cells and human peripheral blood monocytes. In vivo experiments showed that endotoxin removal reduced particle-induced osteolysis by 50-70%. Addition of lipopolysaccharide (LPS) to the "endotoxin-free" particles restored their ability to induce cytokine production and osteoclast differentiation in vitro. Moreover, marrow cells from mice that are hyporesponsive to endotoxin because of mutation of Toll-like receptor 4 induced significantly less cytokine production and osteoclast differentiation in response to Ti particles with adherent endotoxin than did marrow cells from normoresponsive mice. This mutation also resulted in significantly less particle-induced osteolysis in vivo. Taken together, these results show that adherent endotoxin is involved in many of the biological responses induced by orthopedic wear particles and should stimulate development of new approaches designed to reduce the activity of adherent endotoxin in patients with orthopedic implants.

Effect of particle size on macrophage-osteoclast differentiation in vitro

To determine whether particle size affects macrophage-osteoclast differentiation in vitro, latex beads of 0.1, 1, and 10 microm in diameter were added to a murine macrophage-UMR106 osteoblast-like cell coculture system. The extent of osteoclast differentiation was determined by assessing the number of tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells on glass coverslips and the extent of lacunar resorption on dentine slices. The addition of particles, 1 and 10microm in size, to the cocultures resulted in a significant increase in the number of TRAP-positive osteoclast-like cells and in the resorption pit surface area compared with findings in control cultures to which no particles had been added. Particles 0.1 microm in size also stimulated osteoclast formation relative to the control; however, the difference was not significant. These results indicate that particles, particularly these 1 and 10microm in size, sizes which were phagocytosable, significantly enhanced the process of macrophage-osteoclast differentiation and suggest that particle size plays an important role in periprosthetic osteolysis.

Osteoclast-like cells in an in vitro model of bone destruction by rheumatoid synovium

OBJECTIVE

Osteoclasts may be involved in the process of rheumatoid bone destruction. To test this hypothesis, we developed an in vitro model of bone destruction by osteoclast-like cells derived from cultured rheumatoid synovial tissue without using any inducers.

METHODS

Synovial tissues were obtained from rheumatoid arthritis and osteoarthritis patients and tissue pieces of about 2 mm(3) that contained synovial lining were cultured. Multinucleated cells derived from cultured synovial tissues were studied cytochemically and morphologically for osteoclast-specific markers.

RESULTS

Fibroblast-like and macrophage-like cells from the tissue pieces proliferated in the coexistence of lymphocytes. After 14 days of culture, multinucleated cells with tartrate-resistant acid phosphatase activity appeared. These cells expressed vacuolar H(+)-ATPase, the vitronectin receptor and cathepsin K. Although binding of (125)I-labelled salmon calcitonin was very low, the cells contained ringed structures of F-actin and showed strong bone-resorbing activity on ivory slices. Proliferation of macrophage-like cells and formation of multinucleated cells continued during 6 months of culture in the presence of fibroblast-like cells. The bone-resorbing activity of multinucleated cells derived from rheumatoid synovial tissue was much higher than that of cells from osteoarthritis synovial tissue, and was related to the disease activity of rheumatoid arthritis.

CONCLUSION

Our culture system reproduced in vitro the process of bone destruction by rheumatoid synovium, including the proliferation and fusion of precursor cells, polarization, activation and bone tissue resorption. This system may provide a tool for understanding the mechanisms of bone destruction in rheumatoid arthritis and for the development of new therapies to prevent bone destruction.

The effect of polyethylene particle chemistry on human monocyte-macrophage function in vitro

Osteolysis remains the most important problem in orthopedic implant failure. Wear debris from the implant contains polyethylene (PE) particulate which has been shown to activate monocyte-derived macrophages (MDM). Although the response of MDM has been shown to be influenced by the size, shape, and chemical type of PE, the effect of chemically altered PE on MDM has not been studied. In this study, human MDM were seeded onto glass coverslips coated with virgin high density (HD)PE and chemically modified HDPE (impregnated with ppm levels of CoCl(2) and oxidized by heat) mixed with type I collagen and cultured for 96 h. Light microscopic evaluation demonstrated consistent phagocytosis of the HDPE particulate that was confirmed by scanning electron and transmission electron microscopy with little evidence of cytotoxicity. Evaluation of pro-inflammatory mediator secretion by MDMs in response to the virgin and chemically modified HDPE revealed significant differences in interleukin (IL)-1, tumor necrosis factor (TNF)-alpha, and IL-6 secretion. A significant elevation of IL-1 secretion was observed after initial exposure to virgin HDPE particles compared with controls (p = 0.001). IL-1 secretion was also elevated in the low oxidized particle groups (p = 0.001), whereas the highly oxidized particles were not different than controls. Secretion of both IL-6 (p = 0.03) and TNF-alpha (p = 0.007) were significantly elevated by the low oxidized HDPE particles whereas the virgin and highly oxidized groups showed no difference. The different effects on MDM activation when HDPE surface chemistry was altered, highlight the importance of defining the particle properties when studying the role of MDM activation in in vitro systems and extrapolating these observations to the in vivo situation.

Wear particle diffusion and tissue differentiation in TKA implant fibrous interfaces

In the context of mechanical loosening, we studied the hypothesis that wear-particle migration in the fibrous membrane under tibial plateaus after total knee arthroplasty can be explained by the pumping effects of the interstitial fluid in the tissue. Further, as a secondary objective we investigated the possibility that interface-tissue differentiation is influenced by interstitial fluid flow and strain, as mechanical effects of interface motions. For comparative reasons, we analyzed a previously published simplified two-dimensional finite-element model, this time assuming biphasic tissue properties. We wanted to determine hydrostatic pressure and flow velocities in the fluid phase, in addition to stresses and strains, for time-dependent loading of the plateau. We found that fluid flow in the interface was extremely slow, except in the periphery. Hence, loosening due to particle-induced bone resorption appears improbable. The results, however, do support the idea that particles migrate with fluid flow, when such flow occurs. Where fibrous tissue tends to be prominent in reality, the fluid is repeatedly extruded and reabsorbed in the model. Where these values are low, fibrocartilage is commonly found. When material properties were varied to subsequently represent fibrocartilage and two stages of mineralization, the strains and fluid velocities is reduced. Fluid pressure, however, did not change. Our results refute the hypothesis that wear particles are pumped through the interface tissue below a TKA but support the hypothesis that interface tissue type and loosening processes are influenced by mechanical tissue variables such as tissue strain and interstitial fluid velocity.

Alumina-on-alumina total hip prostheses in patients 40 years of age or younger

To avoid the consequences of polyethylene wear in a high-risk population, 128 alumina-on-alumina total hip arthroplasties have been done in 104 consecutive patients. The maximum age of patients was 40 years. The main preoperative diagnoses were osteonecrosis and sequellae of congenital hip dislocation (71% of the hips). The same titanium alloy cemented stem was implanted in all of the hips. Four types of alumina acetabular component fixations were used: a cemented plain alumina socket (41 hips), a screw-in ring with an alumina insert (22 hips), a press-fit plain alumina socket (32 hips), and a press-fit titanium metal back with an alumina insert (33 hips). Eight patients (11 hips) died during the followup period. Sixteen revisions have been documented, 12 for acetabular aseptic loosening, three for bipolar loosening (two of which were septic), and one for unexplained pain. Eighty-eight hips in 74 patients have been followed up radiologically for 2 to 22 years. Wear was unmeasurable. Four additional sockets showed definite migration. The respective survival rates after 7 years were 94.1% for the cemented cup, 88.8% for the screw-in ring, 95.1% for cementless press-fit plain alumina socket and 94.3% for the metal-back press-fit component. The 10-year survival rate was 90.4% for the cemented socket and 88.8% for the screw-in ring. The 15-year survival rate was 78.9% for the cemented socket. Grafting was the only prognostic factor, with a survival rate of 62.6% after 10 years for the hips with a bone graft and of 90.1% for hips without a graft. The alumina-on-alumina bearing surfaces seem to be a valuable alternative to the standard metal-on-polyethylene system for young patients. However, an improvement in socket fixation is required to lengthen the life span of the prosthesis to match the life expectancy of this demanding population.

An injectable cementing screw for fixation in osteoporotic bone

With the aging population, osteoporosis and osteoporotic fractures are becoming more prevalent. Adequate screw fixation in this type of bone is difficult. Screws are often cemented in bone to help obtain purchase. However, current cementing techniques do not ensure implant stability. Here we present a new cannulated screw with side ports that can be injected with polymethylmethacylate (PMMA) for fixation in osteoporotic bone. We compared the ultimate holding power of this cannulated screw injected with PMMA to a solid screw with the same dimensions secured with PMMA by the standard technique. Both screws were placed into embalmed and fresh frozen lumbar vertebral bodies and pulled out using a mechanical testing system. The cannulated screw had a 278% greater holding power compared to the standard screw (p < 0.006). The cannulated screw provided a significant increase in holding power in osteoporotic bone. This novel screw is promising for fixation in osteoporotic bone and warrants clinical evaluation.

Fibroblastic stromal cells express receptor activator of NF-kappa B ligand and support osteoclast differentiation

Osteoclast formation in bone is supported by osteoblasts expressing receptor activator of NF-kappa B ligand (RANKL) and macrophage colony-stimulating factor (M-CSF) expression. Numerous osteotropic factors regulate expression levels of RANKL and the RANKL decoy receptor osteoprotegerin (OPG) in osteoblasts, thereby affecting osteoclast differentiation. However, not only in RANKL widely expressed in soft tissues, but osteoclasts have been noted in extraskeletal lesions. We found that cultured skin fibroblastic cells express RANKL, M-CSF, and OPG messenger (mRNA). Stimulation by 1 alpha,25 dihydroxyvitamin D3 [1,25(OH)2D3] plus dexamethasone (Dex) augmented RANKL and diminished OPG mRNA expression in fibroblastic cells and caused the formation of numerous osteoclasts in cocultures of skin fibroblastic cells with hemopoietic cells or monocytes. The osteoclasts thus formed expressed tartrate-resistant acid phosphatase (TRAP) and calcitonin (CT) receptors and formed resorption pits in cortical bone. Osteoclast formation also was stimulated (in the presence of Dex) by prostaglandin E2 (PGE2), interleukin-11 (IL-11), IL-1, tumor necrosis factor-alpha (TNF-alpha), and parathyroid hormone-related protein (PTHrP), factors which also stimulate osteoclast formation supported by osteoblasts. In addition, granulocyte-macrophage-CSF (GM-CSF), transforming growth factor-beta (TGF-beta), and OPG inhibited osteoclast formation in skin fibroblastic cell-hemopoietic cell cocultures; CT reduced only osteoclast nuclearity. Fibroblastic stromal cells from other tissues (lung, respiratory diaphragm, spleen, and tumor) also supported osteoclast formation. Thus, RANKL-positive fibroblastic cells in extraskeletal tissues can support osteoclastogenesis if osteolytic factors and osteoclast precursors are present. Such mesenchymally derived cells may play a role in pathological osteolysis and may be involved in osteoclast formation in extraskeletal tissues.

Production of TNF-alpha and bone resorbing activity by macrophages in response to different types of bone cement particles

We have compared the capacity of clinically relevant wear debris from seven different cement types to activate macrophages to produce TNF-alpha, IL-1beta, IL-6 and bone resorbing activity in vitro. The bone cements were: CMW 1 original (PMMA only); CMW 1RO (1 microm BaSO4; 9.2%); CMW copolymer bone cement 1 (10 microm BaSO4; 10%); CMW copolymer bone cement 2 (1 microm BaSO4; 10%); Palacos R (10 microm ZrO2; 15.6%); CMW Calcium phosphate cement 20% (10 microm tri-calcium phosphate; 20%) and CMW calcium phosphate cement 30% (10 microm tri-calcium phosphate; 30%). Cement debris was produced aseptically using a simple configuration wear test. The majority of particles were in the size range 0.1-0.5 microm for each cement type. The cement particles were co-cultured with the U937 macrophage cell line at ratios of 10 and 100 microm3 particle volumes to macrophage cell numbers for 24 h. At the 10:1 ratio the particles had no effect on the cells. At the 100:1 ratio, the major cytokine produced was TNF-alpha and there were no statistical differences between the different types of cement debris. The bone resorption activity of the co-culture supernatants was significantly greater than the control (U937 cells without particles) for particles of CMW 1RO, CMW copolymer bone cement 1, CMW copolymer bone cement 2 and Palacos R (P < 0.05, ANOVA). However there were no statistical differences between the levels of bone resoprtion evoked by these four cement types. The CMW1 original and CMW calcium phosphate containing cements failed to induce the macrophages to elaborate bone resorption activity at the 100:1 ratio. These data suggest that the addition of radio-opaque additives to bone cement may increase the capacity of the debris to induce osteolysis.

Titanium particles inhibit osteoblast adhesion to fibronectin-coated substrates

To illuminate the effect of titanium particles on osteoblast function, we compared the adhesion force of neonatal rat calvarial osteoblasts on fibronectin-coated glass after incubation with titanium particles (80% had diameters of less than 5 microm). The cells were incubated with the particles for 1.5-72 hours. Using a micropipette single-cell manipulation system, we showed that the adhesion force of the osteoblasts to fibronectin-coated glass (1.0 microg/ml) was significantly affected by the presence of particulate debris. The adhesion force of the cells incubated with titanium particles for less than 4 hours was not significantly affected by exposure to the particles; after 4 hours, however, it was significantly reduced relative to that of controls. Aspiration of particle-challenged osteoblasts into the micropipette demonstrated that the particles were not stripped from the cell surface and therefore confirmed that the osteoblasts had ingested them. During aspiration, the particles traveled through the cytoplasm rather than on the cell surface. When the osteoblasts were exposed to the particles and cytochalasin D, they exhibited much lower adhesion forces than did the controls or the cells exposed to titanium particles only; this indicates an important role of actin filaments in the osteoblastic response to particles. Staining for F-actin also indicated an influence of internalized titanium particulate on cytoskeletal arrangement and cell spreading. Furthermore, with standard Northern blotting techniques, levels of mRNA for collagen type I and fibronectin were significantly reduced as early as 4 hours after exposure to particles compared with levels in controls, and this effect continued to 72 hours. These data indicate that direct exposure of osteoblasts to titanium particles, which we propose to be ingested by the osteoblasts, can significantly decrease osteoblast adhesion force; this may lead to decreased cellular activity and gene expression of fibronectin and collagen type I in the presence of titanium wear debris.

Craniotomy revisited: techniques for improved access and reconstruction

OBJECTIVE

To describe simple modifications of the technique of opening and closure of the craniotomy to improve basal exposure and reconstruction.

METHODS

The modifications involve: a) additional soft-tissue dissection which is carried downward to the base of the ear and to the orbital rim, exposing the orbital rim and malar eminence without removing the bone; b) cutting the bone flap so that 'bridges' of bone remain that help to stabilize the flap when it is returned to the cranium at the end of the operation; c) the wedging of bone chips between the bone flap and native cranium at the time the bone is being reaffixed so as to provide firm stability by diminishing movement of the bone flap; d) the use of bone dust and bone chips mixed with the patient's blood to seal and bridge the gap between the bone flap and the native bone; e) reattachment of the temporalis muscle with the bone flap sutures. An 'inlay' technique of duraplasty is also described.

RESULTS AND CONCLUSION

These simple modifications of craniotomy provide better basal exposure and reconstruction with little additional operating time at no additional cost.

Effect of osteoprotegerin and osteoprotegerin ligand on osteoclast formation by arthroplasty membrane derived macrophages

OBJECTIVE

Osteoprotegerin ligand (OPGL) is a newly discovered molecule, which is expressed by osteoblasts/bone stromal cells. This ligand and M-CSF are now known to be essential for osteoclast differentiation from marrow and circulating precursors. This study examined whether OPGL and its soluble receptor osteoprotegerin (OPG), influenced osteoclast formation from human arthroplasty derived macrophages, to determine if the effects of OPGL and OPG on these cells could contribute to the osteolysis of aseptic loosening.

METHODS

OPGL (+/- dexamethasone/M-CSF) was added to cultures of macrophages isolated from the pseudomembrane of loosened hip arthroplasties incubated on glass coverslips and dentine slices. OPG was added to cocultures of arthroplasty derived macrophages and UMR106 osteoblast-like cells. Osteoclast differentiation in long term cultures was assessed by expression of macrophage (CD14) and osteoclast markers (tartrate resistant acid phosphatase (TRAP), vitronectin receptor (VNR) and lacunar resorption).

RESULTS

In the absence of osteoblastic cells, the addition of OPGL alone was sufficient to induce differentiation of macrophages (CD14(+), TRAP(-), VNR(-)) into TRAP(+) and VNR(+) multinucleated cells, capable of extensive lacunar resorption. OPG was found to inhibit osteoclast formation by arthroplasty macrophages in a dose dependent manner. OPG (100 ng/ml) more than halved the formation of TRAP(+) and VNR(+) cells and the extent of lacunar resorption in co-cultures of UMR106 cells and arthroplasty macrophages.

CONCLUSIONS

This study has shown that macrophages, isolated from the pseudomembrane surrounding loose arthroplasty components, are capable of differentiating into osteoclastic bone resorbing cells and that OPGL is required for this to occur. OPG inhibits this process, most probably by interrupting the cell-cell interaction between osteoblasts and mononuclear phagocyte osteoclast precursors present in the pseudomembrane.

Expression of gelatinase A and its activator MT1-MMP in the inflammatory periprosthetic response to polyethylene

Wear debris of polyethylene prosthetic components is known to induce a host granulomatous reaction which recruits numerous macrophages and multinucleated giant cells. By releasing cellular mediators of a nonspecific inflammatory reaction, activated phagocytic cells are thought to play a key role in osteolysis leading to aseptic loosening of the prosthesis. Matrix metalloproteinases (MMPs) have been implicated in this destructive process by their ability to degrade extracellular matrix components of bone and adjacent connective tissue. To investigate the roles of gelatinase A, its activator MT1-MMP, and the MMP inhibitors TIMP-1 and TIMP-2 in aseptic loosening of polyethylene prostheses, immunohistochemistry (IHC) and in situ hybridization (ISH) were performed on periprosthetic pseudosynovial interface tissues. Gelatinase A and MT1-MMP were strongly detected immunohistochemically in macrophages and multinucleated giant cells in contact with polyethylene wear debris. In contrast to MT1-MMP, gelatinase A mRNAs were not found in phagocytic cells but in surrounding fibroblasts, thereby suggesting cooperation between macrophages and fibroblasts in this process. While TIMP-1 was expressed essentially in hyperplastic pseudosynoviocytes as assessed by IHC and ISH, TIMP-2, MT1-MMP, and gelatinase A were colocalized in phagocytic cells. These data support the concept of progelatinase A activation involving a trimolecular complex (MT1-MMP-TIMP-2-gelatinase A) mechanism. Thus, this study demonstrated that gelatinase A and its activator might contribute to the aseptic loosening of polyethylene prostheses.

Bisphosphonates in bone cement inhibit PMMA particle induced bone resorption

OBJECTIVE

Wear particle induced bone resorption is thought to be one of the mechanisms that contribute to implant loosening. It has previously been shown that macrophages, in response to polymethylmethacrylate (PMMA) particles, differentiate into bone resorbing osteoclasts, and that this process is inhibited by a bisphosphonate, etidronate (EHDP). The aim of this study was to determine whether incorporating EHDP in bone cement could reduce PMMA associated bone resorption.

METHODS

Two concentrations of EHDP were mixed with PMMA monomer before polymerisation. Particles of PMMA (1-10 microns) were generated then added to mouse monocytes cocultured with UMR106 rat osteoblast-like cells and the extent of osteoclast differentiation was determined by assessing the extent of tartrate resistant acid phosphatase (TRAP) staining and measuring the amount of lacunar bone resorption.

RESULTS

The addition of PMMA to monocyte-UMR106 cocultures resulted in a marked increase in the number of TRAP positive osteoclast-like cells and a significant increase in the number of lacunar resorption pits compared with control cultures to which no particles had been added. After the addition of particles of PMMA + 20 mg EHDP, significantly fewer lacunar pits (p = 0.00006) and fewer TRAP positive cells were noted compared with cocultures containing PMMA particles alone.

CONCLUSIONS

These results indicate that by mixing a bisphosphonate with bone cement, it is possible to inhibit PMMA particle induced bone resorption. This bisphosphonate inhibition of PMMA biomaterial wear particle containing macrophage-osteoclast differentiation and bone resorption may provide a possible therapeutic strategy to prevent or to control the osteolysis of aseptic loosening.

Histologic and biochemical differences between osteolytic and nonosteolytic membranes around femoral components of an uncemented total hip arthroplasty

The unique design characteristics of an uncemented femoral component were used to study differences in the periprosthetic membranes in the presence and absence of osteolysis. A component (Omniflex, Osteonics, Allendale, NJ) that has a large midportion of the stem that does not contact bone was studied. A membrane forms, even in the absence of bone resorption, in Gruen zones 3 and 5 of this component. Analysis of this membrane showed noninflammatory fibrous tissue, no or minimal particulate debris, and few macrophages. In contrast, analysis of membranes from osteolytic regions around the same prosthesis demonstrated typical inflammatory characteristics. Collagenase, gelatinase, and stromelysin expression was high in osteolytic membranes but was low in tissues from noninflammatory regions without osteolysis. The data suggest a sequence of events in periprosthetic membrane formation. A noninflammatory membrane initially forms between the bone and the prosthesis. This membrane is transformed into an inflammatory membrane by the influx of particulate debris. Matrix metalloproteinases are selectively expressed in regions of osteolysis, implicating these enzymes in periprosthetic bone loss and suggesting a possible level for pharmaceutical intervention to prevent or treat osteolysis. Formation of the noninflammatory membrane around the distal part of the prosthesis of this or similar designs in the absence of bone resorption implies that these tissue samples could serve as useful negative control tissues to identify factors present in osteolytic periprosthetic membranes.

Acrylic bone cement induces the production of free radicals by cultured human fibroblasts

Arthroplasty with poly(methyl methacrylate) (PMMA) bone cement induces late loosening phenomena that compromise the prosthetic stability. As free radicals are inflammatory mediators and cytotoxic, it seemed useful to investigate whether PMMA induces the liberation of free radicals and/or cytotoxicity. The effect of PMMA interaction on cultured human fibroblasts was accessed by the cell viability test (MTT), and by the measurement of lipoperoxides in the incubation medium. The incubation with the medium exposed to PMMA induced a significant reduction in the viability and a significant increase in lipoperoxide liberation (vs control). These data suggest that PMMA is cytotoxic. This effect seems to be mediated by lipoperoxide and possibly by other free radicals, and may explain the peri-implant loosening phenomena that compromise the prosthetic stability.

Wear particulate species and bone loss in failed total joint arthroplasties

The aim of this study was to evaluate the relative contribution of polyethylene, metal, and polymethylmethacrylate (cement) particles to the overall bone loss in aseptic loosening. Twenty-four interface tissues with adjacent bone were obtained during 17 revision total joint arthroplasties (11 hips and six knees). Osteoclasts and macrophages were identified immunohistochemically on the bone surface. The length of the bone surface in contact with these cell types was measured and analyzed with reference to the particulate species present within the fibrous interface. The presence of abundant polyethylene particles significantly increased the proportion of the bone surface in contact with macrophages but did not have a significant influence on that of osteoclasts. Osteoclastic bone resorption was significantly more extensive in the presence of metal particles. In contrast, the presence of cement particles did not have a significant influence on macrophage or osteoclast coverage of the bone surface. These results highlight the significance of polyethylene particles in macrophage recruitment and subsequent osteolysis and suggest a different mechanism of bone loss related to metal, namely mediation through osteoclastic activities. The relative contribution of cement particles was negligible and needs reevaluation in light of evidence provided by others.

Human arthroplasty derived macrophages differentiate into osteoclastic bone resorbing cells

OBJECTIVE

In aseptic loosening, a heavy macrophage response to biomaterial wear particles is commonly found in arthroplasty tissues. The aim of this study was to discover if these cells contribute to the bone resorption of aseptic loosening by differentiating into osteoclasts.

METHODS

Macrophages were isolated from the pseudocapsule and pseudomembrane of loose cemented and uncemented hip arthroplasties at the time of revision surgery and then co-cultured on glass coverslips and dentine slices with UMR 106 rat osteoblast-like cells, both in the presence and absence of 1,25 dihydroxyvitamin D3 [1,25(OH)2D3]. Macrophages isolated from the synovial membrane of patients with osteoarthritis (OA) undergoing hip replacements were similarly studied as a control group.

RESULTS

After 24 hours incubation, most cells isolated from the above periprosthetic tissues strongly expressed macrophage (CD11b, CD14) but not osteoclast markers. However, after 14 days incubation, numerous multinucleated cells showing the phenotypic features of osteoclasts (that is, positive for tartrate resistant acid phosphatase, the vitronectin receptor, and capable of extensive lacunar resorption) formed in co-cultures of arthroplasty derived macrophages and UMR 106 cells, in the presence of 1,25(OH)2D3. The addition of an antibody to macrophage colony stimulating factor (M-CSF) considerably reduced macrophage-osteoclast differentiation and hence the lacunar resorption seen in these co-cultures. In contrast, OA synovial macrophage/UMR 106 co-cultures showed little or no evidence of macrophage-osteoclast differentiation and this was only seen when human M-CSF was added to the co-cultures.

CONCLUSION

This is the first report showing that human macrophages isolated directly from periprosthetic tissues surrounding loosened implants can differentiate into multinucleated cells showing all the functional and cytochemical characteristics of osteoclasts. In contrast with other macrophage populations, exogenous M-CSF is not required for this to occur. In the context of the heavy macrophage response to wear particles in periprosthetic tissues macrophage-osteoclast differentiation may represent an important cellular mechanism whereby osteolysis is effected in aseptic loosening.