Tissue response to particulate polymethylmethacrylate in mice with various immune deficiencies

Application of a novel porous tantalum implant in rabbit anterior lumbar spine fusion model: in vitro and in vivo experiments

BACKGROUND

Some porous materials have been developed to enhance biologic fusion of the implants to bone in spine fusion surgeries. However, there are several inherent limitations. In this study, a novel biomedical porous tantalum was applied to in vitro and in vivo experiments to test its biocompatibility and osteocompatibility.

METHODS

Bone marrow-derived mesenchymal stem cells (BMSCs) were cultured on porous tantalum implant. Scanning electron microscope (SEM) and Cell Counting Kit-8 assay were used to evaluate the cell toxicity and biocompatibility. Twenty-four rabbits were performed discectomy only (control group), discectomy with autologous bone implanted (autograft group), and discectomy with porous tantalum implanted (tantalum group) at 3 levels: L3-L4, L4-L5, and L5-L6 in random order. All the 24 rabbits were randomly sacrificed at the different post-operative times (2, 4, 6, and 12 months; n = 6 at each time point). Histologic examination and micro-computed tomography scans were done to evaluate the fusion process. Comparison of fusion index scores between groups was analyzed using one-way analysis of variance. Other comparisons of numerical variables between groups were made by Student t test.

RESULTS

All rabbits survived and recovered without any symptoms of nerve injury. Radiographic fusion index scores at 12 months post-operatively between autograft and tantalum groups showed no significant difference (2.89 ± 0.32 vs. 2.83 ± 0.38, F = 244.60, P = 0.709). Cell Counting Kit-8 assay showed no significant difference of absorbance values between the leaching liquor group and control group (1.25 ± 0.06 vs. 1.23 ± 0.04, t = -0.644, P = 0.545), which indicated the BMSC proliferation without toxicity. SEM images showed that these cells had irregular shapes with long spindles adhered to the surface of tantalum implant. No implant degradation, wear debris, or osteolysis was observed. Histologic results showed solid fusion in the porous tantalum and autologous bone implanted intervertebral spaces.

CONCLUSION

This novel porous tantalum implant showed a good biocompatibility and osteocompatibility, which could be a valid biomaterial for interbody fusion cages.

The pathobiology and pathology of aseptic implant failure

Pathological assessment of periprosthetic tissues is important, not only for diagnosis, but also for understanding the pathobiology of implant failure. The host response to wear particle deposition in periprosthetic tissues is characterised by cell and tissue injury, and a reparative and inflammatory response in which there is an innate and adaptive immune response to the material components of implant wear. Physical and chemical characteristics of implant wear influence the nature of the response in periprosthetic tissues and account for the development of particular complications that lead to implant failure, such as osteolysis which leads to aseptic loosening, and soft-tissue necrosis/inflammation, which can result in pseudotumour formation. The innate response involves phagocytosis of implant-derived wear particles by macrophages; this is determined by pattern recognition receptors and results in expression of cytokines, chemokines and growth factors promoting inflammation and osteoclastogenesis; phagocytosed particles can also be cytotoxic and cause cell and tissue necrosis. The adaptive immune response to wear debris is characterised by the presence of lymphoid cells and most likely occurs as a result of a cell-mediated hypersensitivity reaction to cell and tissue components altered by interaction with the material components of particulate wear, particularly metal ions released from cobalt-chrome wear particles.Cite this article: Professor N. A. Athanasou. The pathobiology and pathology of aseptic implant failure. Bone Joint Res 2016;5:162-168. DOI: 10.1302/2046-3758.55.BJR-2016-0086.

Innate immune reactions in septic and aseptic osteolysis around hip implants

According to the long-standing definition, septic and aseptic total joint replacement loosening are two distinct conditions with little in common. Septic joint replacement loosening is driven by bacterial infection whereas aseptic loosening is caused by biomaterial wear debris released from the bearing surfaces. However, recently it has been recognized that the mechanisms that drive macrophage activation in septic and aseptic total joint replacement loosening resemble each other. In particular, accumulating evidence indicates that in addition to mediating bacterial recognition and the subsequent inflammatory reaction, toll-like receptors (TLRs) and their ligands, pathogen-associated molecular patterns (PAMPs) and danger-associated molecular patterns (DAMPS), play a key role in wear debris-induced inflammation and macrophage activation. In addition, subclinical bacterial biofilms have been identified from some cases of seemingly aseptic implant loosening. Furthermore, metal ions released from some total joint replacements can activate TLR signaling similar to bacterial derived PAMPs. Likewise, metal ions can function as haptens activating the adaptive immune system similar to bacterial derived antigens. Thus, it appears that aseptic and septic joint replacement loosening share similar underlying pathomechanisms and that this strict dichotomy to sterile aseptic and bacterial-caused septic implant loosening is somewhat questionable. Indeed, rather than being two, well-defined clinical entities, peri-implant osteolysis is, in fact, a spectrum of conditions in which the specific clinical picture is determined by complex interactions of multiple local and systemic factors.

Interaction of Materials and Biology in Total Joint Replacement - Successes, Challenges and Future Directions

Total joint replacement (TJR) has revolutionized the treatment of end-stage arthritic disorders. This success is due, in large part, to a clear understanding of the important interaction between the artificial implant and the biology of the host. All surgical procedures in which implants are placed in the body evoke an initial inflammatory reaction, which generally subsides over several weeks. Thereafter, a series of homeostatic events occur leading to progressive integration of the implant within bone and the surrounding musculoskeletal tissues. The eventual outcome of the operation is dependent on the characteristics of the implant, the precision of the surgical technique and operative environment, and the biological milieu of the host. If these factors and events are not optimal, adverse events can occur such as the development of chronic inflammation, progressive bone loss due to increased production of degradation products from the implant (periprosthetic osteolysis), implant loosening or infection. These complications can lead to chronic pain and poor function of the joint reconstruction, and may necessitate revision surgery or removal of the prosthesis entirely. Recent advances in engineering, materials science, and the immunological aspects associated with orthopaedic implants have fostered intense research with the hope that joint replacements will last a lifetime, and facilitate pain-free, normal function.

Do tissues from THA revision of highly crosslinked UHMWPE liners contain wear debris and associated inflammation?

BACKGROUND

Polyethylene wear debris is a major contributor to inflammation and the development of implant loosening, a leading cause of THA revisions. To reduce wear debris, highly crosslinked ultrahigh-molecular-weight polyethylene (UHMWPE) was introduced to improve wear properties of bearing surfaces. As highly crosslinked UHMWPE revision tissues are only now becoming available, it is possible to examine the presence and association of wear debris with inflammation in early implant loosening.

QUESTIONS/PURPOSES

We asked: (1) Does the presence of UHMWPE wear debris in THA revision tissues correlate with innate and/or adaptive immune cell numbers? (2) Does the immune cell response differ between conventional and highly crosslinked UHMWPE cohorts?

METHODS

We collected tissue samples from revision surgery of nine conventional and nine highly crosslinked UHMWPE liners. Polarized light microscopy was used to determine 0.5- to 2-μm UHMWPE particle number/mm2, and immunohistochemistry was performed to determine macrophage, T cell, and neutrophil number/mm2.

RESULTS

For the conventional cohort, correlations were observed between wear debris and the magnitude of individual patient macrophage (ρ=0.70) and T cell responses (ρ=0.71) and between numbers of macrophages and T cells (ρ=0.77) in periprosthetic tissues. In comparison, the highly crosslinked UHMWPE cohort showed a correlation between wear debris and the magnitude of macrophage responses (ρ=0.57) and between macrophage and T cell numbers (ρ=0.68). Although macrophages and T cells were present in both cohorts, the highly crosslinked UHMWPE cohort had lower numbers, which may be associated with shorter implantation times.

CONCLUSIONS

The presence of wear debris and inflammation in highly crosslinked UHMWPE revision tissues may contribute to early implant loosening.

Perivascular and diffuse lymphocytic inflammation are not specific for failed metal-on-metal hip implants

BACKGROUND

Several studies suggest that histologic findings from tissues obtained at revision arthroplasty for failed metal-on-metal (MOM) total hip implants may reflect an immune reaction to particles or ions in some patients. However, only a limited number of cases without MOM implants were reported as controls in those studies.

QUESTIONS/PURPOSES

The purpose of this study is to better define the extent and distribution of morphologic features attributed to an immune reaction in tissues sampled at revision surgery for failed nonMOM THA.

PATIENTS AND METHODS

As part of a multicenter, prospective study, we reviewed 612 capsular and interface tissues obtained from 130 patients at revision THA. The samples were selected from periacetabular regions (154 samples from 103 patients), femoral implant/cement-bone interface (154 samples from 79 patients), and from areas of the joint capsule that had an intraoperative gross appearance suggesting the possibility of either infection or metallosis (256 samples from 129 patients). All patients had more than one sample obtained. The extent and distribution of lymphocytes and plasma cells, acute inflammation, and visible particles of debris were graded using criteria similar to those described to grade inflammation around failed MOM implants.

RESULTS

We identified perivascular lymphocytes in 111 biopsy samples taken from 65 (50%) of 130 patients, and in 87 specimens from 57 (53%) of 107 patients thought to have aseptic loosening. Diffusely distributed lymphocytes were identified in 86 (66%) of 130 patients, and in 66 (62%) of the 107 hips with aseptic loosening, although few had the highest grade of inflammation. Increasing extent of diffuse and perivascular lymphocytes correlated with increasing extent of metal particles.

CONCLUSIONS

Mild lymphocytic inflammation, diffuse and especially perivascular, is common in tissues around failed nonMOM implants. Although extensive inflammation in an inflammatory pseudotumor pattern is rare, it does occur in some cases of failed metal-polyethylene hip arthroplasties. The importance of inflammation is unknown, but the extent of diffuse inflammation shows a positive correlation with metal debris, so it could reflect a reaction to particles or ions in some patients.

Distinct inflammatory gene pathways induced by particles

The biologic response to particulate load after arthroplasty has not been fully characterized but is believed mediated by proinflammatory cytokines released from mononuclear cells in the periprosthetic region. To investigate the contribution of lymphocytes to expression of proinflammatory genes induced by metal particles, we compared gene expression of mononuclear cells in response to metal and polymethylmethacrylate particles using cDNA microarray profiling. Peripheral blood mononuclear cells and monocytes were stimulated with polymethylmethacrylate and titanium particles of clinically relevant sizes. Polymethylmethacrylate elicited a six- to 12-fold increase in gene expression of tumor necrosis factor alpha, interleukin 1alpha, interleukin 1beta, interleukin 6, and interleukin 8 in purified monocytes and unfractionated peripheral blood mononuclear cells. Although the effect of titanium on stimulation of purified monocytes was modest, stimulation of lymphocyte-containing peripheral blood mononuclear cells by titanium particles resulted in monocyte-derived proinflammatory cytokine expression. In contrast to polymethylmethacrylate, titanium particles stimulated increased expression of T lymphocyte-derived cytokines, including interleukin 2, interferon gamma, interleukin 9, and interleukin 22, in peripheral blood mononuclear cell cultures. The induction of T cell activation by titanium particles suggests lymphocytes may contribute to the inflammation that mediates osteolysis in patients with metallic particulate debris after total joint replacement.

Neo-capsule tissue reactions in metal-on-metal hip arthroplasty

BACKGROUND

Modern-generation metal-on-metal articulations have a high wear resistance and may therefore be able to improve the long-term performance of artificial joints. However, the biological effects are still under debate. This study was undertaken to review the histopathological changes in neo-capsule tissues of different metal-on-metal hip arthroplasties.

METHODS

Neo-capsule tissue samples from 46 hips with modern second-generation metal-on-metal articulations (39 hip resurfacings and 7 non-cemented total hip replacements) with a variety of failure mechanisms were examined histopathologically and immunohistochemically.

RESULTS

A distinct lymphocytic infiltration was found in all cases with in situ times of more than 7 months, consisting of CD20-positive B-lymphocytes and CD3-positive T-lymphocytes and sometimes thinly distributed CD138-positive plasma cells without dominant T-cell or plasma cell infiltrates.

INTERPRETATION

This distinct lymphocytic infiltration has not been reported in tissue analyses of metal- or ceramic-on-polyethylene hip replacements, and may therefore be considered to be a characteristic histological pattern of tissue reactions on metal particles and/or ions around metal-on-metal bearings.

The cellular and molecular biology of periprosthetic osteolysis

The generation of prosthetic implant wear after total joint arthroplasty is recognized as the major initiating event in development of periprosthetic osteolysis and aseptic loosening, the leading complication of this otherwise successful surgical procedure. We review current concepts of how wear debris causes osteolysis, and report ideas for prevention and treatment. Wear debris primarily targets macrophages and osteoclast precursor cells, although osteoblasts, fibroblasts, and lymphocytes also may be involved. Molecular responses include activation of MAP kinase pathways, transcription factors (including NFkappaB), and suppressors of cytokine signaling. This results in up-regulation of proinflammatory signaling and inhibition of the protective actions of antiosteoclastogenic cytokines such as interferon gamma. Strategies to reduce osteolysis by choosing bearing surface materials with reduced wear properties should be balanced by awareness that reducing particle size may increase biologic activity. There are no approved treatments for osteolysis despite the promise of therapeutic agents against proinflammatory mediators (such as tumor necrosis factor) and osteoclasts (bisphosphonates and molecules blocking receptor activator of NFkappaB ligand [RANKL] signaling) shown in animal models. Considerable efforts are underway to develop such therapies, to identify novel targets for therapeutic intervention, and to develop effective outcome measures.

Abriebpartikel

The aseptic prosthetic loosening of hip and knee prosthesis is the most important cause of implant insufficiency. Bone loss as a result of the biological effect of wear particles is the main cause of such loosening. Wear particles develop their biological activity along different cellular pathways, above all via macrophages, foreign body giant cells as well as fibroblasts of the periprosthetic membrane. These cells induce particle-dependent bone resorption by means of proinflammatory cytokines, such as IL-1beta, TNF-alpha, IL-6 and PGE2. These factors induce the activation of osteoclasts as well as the suppression of osteoblasts. Neutrophil granulocytes and lymphocytes do not play an important role in the process of aseptic loosening. The different wear particles, such as ultra-high molecular weight polyethylene, metal particles, ceramic particles and polymethylmethacrylate can be morphologically recognized very easily. From the clinical point of view, the differentiation between acute or chronic implant infection and particle induced prosthetic loosening is very important, with the histomorphological differential diagnosis between septic and aseptic loosening and their combination being the key clinicopathological factor.

The central role of wear debris in periprosthetic osteolysis

Periprosthetic osteolysis remains the leading complication of total hip arthroplasty, often resulting in aseptic loosening of the implant, and a requirement for revision surgery. Wear-generated particular debris is the main cause of initiating this destructive process. The purpose of this article is to review recent advances in our understanding of how wear debris causes osteolysis, and emergent strategies for the avoidance and treatment of this disease. The most important cellular target for wear debris is the macrophage, which responds to particle challenge in two distinct ways, both of which contribute to increased bone resorption. First, it is well known that wear debris activates proinflammatory signaling, which leads to increased osteoclast recruitment and activation. More recently, it has been established that wear also inhibits the protective actions of antiosteoclastogenic cytokines such as interferon gamma, thus promoting differentiation of macrophages to bone-resorbing osteoclasts. Osteoblasts, fibroblasts, and possibly lymphocytes may also be involved in responses to wear. At a molecular level, wear particles activate MAP kinase cascades, NFkappaB and other transcription factors, and induce expression of suppressors of cytokine signaling. Strategies to reduce osteolysis by choosing bearing surface materials with reduced wear properties (such as metal-on-metal) should be balanced by awareness that reducing particle size may increase biological activity. Finally, although therapeutic agents against proinflammatory mediators [such as tumor necrosis factor (TNF)] and osteoclasts (bisphosphonates and molecules blocking RANKL signaling) have shown promise in animal models, no approved treatments are yet available to osteolysis patients. Considerable efforts are underway to develop such therapies, and to identify novel targets for therapeutic intervention.

Orbital floor reconstruction with poly-L/D-lactide implants: clinical, radiological and immunohistochemical study in sheep

In this study the reconstruction capacity of orbital wall in sheep was evaluated when poly-L/D-lactide (PLDLA96) implants were used for large blow-out defects in 18 sheep. The contralateral side, where the defects healed spontaneously, served as controls. The follow-up was 12, 16, 22 and 36 weeks. Healing was evaluated clinically, radiologically, histologically and immunohistochemically. Physiochemical properties of the implants were also studied. At first, the implants were surrounded by elastic capsules, which gradually ossified. At 36 weeks, 60% were still visible and deformed but surrounded by bone. Light microscopy revealed a low grade inflammatory reaction. Expression of Tn-c and cFn was intense throughout the study. Shear strength decreased gradually and was not measurable after 16 weeks. Crystallinity increased steadily from 1.5 to 29.30% and molecular weight decreased from 49,000 to 4186. In CT, the final bony defect was smaller in the reconstructed sides than in the controls. Based on this study it can be concluded that PLDLA96 implant provokes a local inflammation, which does not prevent bone healing. The deformation of the implant, however, indicates that this PLDLA96 plate is not suitable for orbital floor reconstruction.

Human leukocyte antigen and aseptic loosening in Charnley total hip arthroplasty

Human leukocyte antigen phenotypes and radiographic course were studied in 70 Japanese patients (90 hips) who had Charnley low friction arthroplasty. Of the 28 hips diagnosed as radiographically loose less than 15 years after surgery, seven hips (25.0%) were in patients who had a positive human leukocyte antigen A31(19). Of the 62 hips that were radiographically stable more than 15 years, two hips (3.2%) were in patients who had a positive human leukocyte antigen A31(19). Of the nine hips in patients who were positive to human leukocyte antigen A31(19), seven hips were diagnosed as radiographically loose (loosening rate was 77.8%) 15 years after surgery. On the other hand, of the 81 hips in the patients who were negative to human leukocyte antigen A31(19), only 21 hips were diagnosed as radiographically loose (loosening rate was 25.9%) 15 years after surgery. These data suggest that individual immune response to implant materials, linked to human leukocyte antigen, may participate in the process of aseptic loosening in Charnley low friction arthroplasty.

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.

Bone graft incorporation in radiographically successful human intervertebral body fusion cages

STUDY DESIGN

Biopsies were obtained from within radiographically successful human intervertebral body fusion cages to document the histology of remodeling bone graft.

OBJECTIVES

The purpose of this study is to describe the tissue within successful human interbody cages with special reference to the viability of bone and the presence or absence of debris particles.

SUMMARY OF BACKGROUND DATA

The use of interbody fusion cages is gaining rapid acceptance, but there is little histologic documentation of the nature of tissue within successful human interbody fusion cages.

METHODS

Needle biopsies were obtained of tissue within radiographically successful intervertebral body fusion cages at the time of pedicle screw removal for back pain or fusion of adjacent spinal level in nine spinal levels of eight patients. Preoperative diagnoses of these eight adult patients included disease conditions in the sagittal plane: spondylosis (5), degenerative disc disease (6), failed laminectomy and discectomy (2), radiculopathy (1), and spondylolisthesis (1). In all cases the cages had been packed with autograft (iliac crest 7, local 1) at the time of insertion. Cage implantation was performed with anterior (anterior lumbar interbody fusion 4, corpectomy and plate fixation 1), and posterior (posterior lumbar interbody fusion 4), segmental instrumentation (plate 1, or pedicle screws 8). All cases except one cervical case had posterolateral fusion or bilateral facet fusion. The cages were composed of carbon fiber-reinforced polymer (Brantigan cage; DePuy AcroMed, Raynham, MA, n = 5) or titanium mesh (Harms Cage; DePuy AcroMed, Raynham, MA, n = 4). Cages had been in situ from 8 to 72 months (mean 28 months). All nine biopsies from eight patients were obtained from within the center of the cages. Specimens were decalcified, routinely embedded in paraffin, stained with hematoxylin and eosin, and viewed qualitatively with transmitted and polarized light.

RESULTS

All needle biopsies were obtained from within the center of the cages, and no patient developed spinal instability after the biopsy. All nine biopsies showed small fragments of necrotic bone associated with viable bone and restoration of hematopoietic bone marrow. Numerous cement lines demarcated the edges of previous cycles of remodeling. The ratio of necrotic to viable bone varied greatly among cases. Small particles of debris were associated with four of the five carbon-fiber cages and one of the four specimens from titanium cages, but there was no visible bone resorption or inflammation.

CONCLUSIONS

Autogenous bone graft was incorporated in these radiographically successful human intervertebral body fusion cages. A few debris particles were observed, but there was no histologic evidence of particle-induced bone resorption or inflammation.

Osteolysis: basic science

Since the recognition of aseptic loosening by Charnley in the early 1960s, much information has been gained on the basic science of periprosthetic bone loss. Initially termed cement disease, it now generally is accepted that, in most instances, osteolysis is a manifestation of an adverse cellular response to phagocytosable particulate wear and corrosion debris, possibly facilitated by local hydrodynamic effects. Tissue explant, animal, and cell culture studies have allowed us to compile an appreciation of the complexity of cellular interactions and chemical mediators involved in osteolysis. Cellular participants have been shown to include the macrophage, osteoblast, fibroblast, and osteoclast. The plethora of chemical mediators that are responsible for the cellular responses and effects on bone include prostaglandin E2, tumor necrosis factor-alpha, interleukin-1, and interleukin 6. However, an increasing number of other proinflammatory and antiinflammatory cytokines, prostenoids, and enzymes have been shown to play important roles in this process. The ultimate goal of basic research is to develop novel strategies for evaluation and treatment of patients with osteolysis. Although initial animal studies are promising for possible pharmacologic treatment and prevention of osteolysis, well-controlled human trials are required before agents such as bisphosphonates can be recommended for general clinical use.

No lymphokines in T-cells around loosened hip prostheses

Research results have been contradictory about the role of lymphocytes and immune response in aseptic loosening of total hip replacement (THR). Conclusive evidence is still lacking in spite of extensive in vivo and in vitro studies. Our study was designed to check whether T-cells were activated and if they produced lymphokines in synovial membrane-like interface tissue around loosened THRs. Tissue sections were stabilized and permeabilized to allow the cytokine-specific antibodies to penetrate through the cell membrane and the membranes of intracellular organelles. This technique, combined with computer-assisted image analysis, permits the detection and quantitation of lymphokine-producing cells. We found that the number of T-cells was low, and none of the T-cells was activated, as shown by the absence of interleukin-2 receptor (IL-2R) immunoreactivity. There was no cell producing lymphokines, such as interleukin-2 (IL-2), interferon-gamma (IFN-gamma), and tumor necrosis factor-beta (TNF-beta). Our results suggest that T-cell-mediated immune response is not actively involved in aseptic loosening of THR.

The foreign body reaction to a biodegradable biomaterial differs between rats and mice

Before a biomaterial can be applied in the clinic, biocompatibility must be tested in in vivo models, by monitoring the foreign body reaction. In this study, we compared the foreign body reaction (FBR) to the biodegradable biomaterial hexamethylenediisocyanate crosslinked dermal sheep collagen (HDSC) between several strains of rats and mice. HDSC disks were implanted subcutaneously on the backs of AO, BN, F344, LEW, and PVG rats and on the backs of 129 SVEV, BALB/c, and C57BL/6 mice. Materials were explanted after 7, 14, 21, and 28 days and processed for (immuno) light and transmission electron microscopic evaluation. In all rat strains, giant cell formation and phagocytosis of HDSC bundles were comparable. In addition, in the PVG rat, many plasma cells infiltrated the HDSC disks. Only a few T cells were present in AO and PVG rats, whereas, in F344 and LEW rats, the presence of T cells was more pronounced. BN rats showed an intermediate T-cell infiltration. In mice, the FBR to HDSC was comparable between the different strains. Compared with rats, giant cell formation was limited, whereas stroma formation was more abundant. Phagocytosis of HDSC bundles rarely occurred in mice, whereas calcification was observed more often. It is concluded that the FBR to HDSC clearly differs between rats and mice. This has consequences for assessment studies on biocompatibility and also on fundamental biomaterial research.

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.

Alternate bearing surfaces in total joint arthroplasty: biologic considerations

The problem of periprosthetic osteolysis is currently the major limiting factor in joint arthroplasty longevity. Because this process has been shown to be primarily a biologic response to wear particles, corrosion products, or both, efforts to reduce particle generation are being undertaken. These efforts include the development of modified polyethylene and alternative articulating surfaces. These alternate bearing surfaces currently include ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal. Although these alternate bearings diminish or eliminate the generation of polyethylene particles, ceramic and metal particles are produced. The purpose of the current review is to discuss the literature that addresses the biologic response to these particles, locally and systemically.

A comparison of the inflammatory response to a polydimethylsiloxane implant in male and female Balb/c mice

The implantation of biomaterials elicits a host response that influences the long-term behavior of implanted medical devices. This foreign body response is governed by cells of the immune system. Because sexual dimorphism in the immune system is well-established, a comparative study of the foreign body response in male and female mice was initiated. Eight-week-old male and female Balb/c mice received two subcutaneous implants in the interscapular region of a smooth peroxide-catalyzed polydimethylsiloxane (PDMS) and were sacrificed at 2, 14, 42, 70, and 105 days after implantation (n = 6 per sex per time point). Controls for each time point underwent the surgical procedure but received no implant. Tissue from the implant or surgical site was fixed, processed, and paraffin-embedded for histopathological evaluation and immunohistochemical (IHC) staining for tumor necrosis factor-alpha TNF-alpha) and interleukin-1 beta (IL-1beta). In control animals, an inflammatory response was observed at 2 days that was decreased by 14 days and absent after 42 days. At 2 and 14 days after PDMS implantation, a mild to moderate inflammatory reaction was observed around implants. The peak response was seen at 14 days, and granulation tissue, composed primarily of fibroblasts, macrophages, and neutrophils, was first observed at this time. After 105 days, the implantation site was surrounded by mature connective tissue, which had minimal numbers of macrophages and neutrophils, with severity scores that did not differ significantly in males and females. The immunostaining for TNF-alpha and IL-1beta followed similar temporal patterns, with both reaching a peak at the two week time point and remaining elevated, compared to level of expression in the controls, throughout the 105 day observation period. Staining for both cytokines in the implanted animals was generally higher in females than in males, although this difference was significant only for IL-1beta. These results suggest subtle differences between males and females in the activity of peri-implant inflammatory cells.

Foreign-body reaction to dermal sheep collagen in interferon-gamma-receptor knock-out mice

This study was performed to gain more insight into the role of interferon-gamma (IFN-gamma), a potent macrophage activator, in the foreign-body reaction to hexamethylenediisocyanate-crosslinked dermal sheep collagen (HDSC). Because the results of earlier studies aimed at modulating the foreign-body reaction in AO rats by local or systemic treatment with anti-IFN-gamma were not completely unambiguous, we extended our investigations to IFN-gamma-receptor knock-out (KO) mice. Several parameters (i.e., macrophages, giant cells, T-cells, B-cells, granulocytes, expression of MHC class II, stroma formation, and degradation and calcification of the biomaterial) were compared between wild-type (WT) and KO mice. Remarkably, the foreign-body reaction was very similar in WT and KO mice. In both, giant cells were formed, but in contrast to previous results in AO rats, phagocytosis of HDSC bundles occurred hardly at all up to 9 weeks, and MHC class II expression was minimal. Stroma formation and vascularization were high and calcification occurred. T-cells comprised less than 1%; a few plasma cells were present in the KO mice at later time points. Granulocytes, mainly eosinophils, were present at all explantation time points. Because of the similar results in WT and KO mice, we question whether IFN-gamma plays a role at all in the foreign-body reaction in mice.

Immunohistochemical evaluation of interface membranes from failed cemented and uncemented acetabular components

Aseptic loosening of acetabular components is a primary factor compromising the long-term outcome of cemented and cementless total hip replacement. It is unknown whether the pathogenesis of the loosening process is identical for both types of fixation. The specific aim of this study was to determine whether there is a difference in the cellular and cytokine profiles of interface membranes removed from between the implant and the host bone from failed cemented (n = 5) and failed cementless acetabulae (n = 5). Routine histology and immunohistochemical evaluations were completed on each tissue specimen. The monoclonal antibodies used included those specific for cell types (macrophages, fibroblasts, T lymphocytes) and for cytokines (IL-1beta, IL-6, TNF-alpha). The patients were all revised for loosening. The time to revision was significantly longer for the cemented group (16.6 yr; 13-21 range) than for the cementless group (8.9 yr; 4-13 range). In all cases, slides from each group stained positively for each of the cell types and cytokines evaluated. Immunohistochemical analyses indicated a predominance of macrophages and ubiquitous staining for the cytokines IL-1beta and TNF-alpha within the membranes of both patient groups. The intensities of cytokine staining were similar for both patient groups. More regions of fibroblastic connective tissue were observed surrounding failed cementless components as compared to those of the cemented group. The clinical ramification of our findings is that, despite differences in the cellular composition of the periprosthetic membranes, the membranes from failed cemented and cementless implants contain cytokines, which have been shown to be capable of modulating the inflammatory response. These inflammatory mediators are likely to play a significant role in the development of osteolysis and prosthetic loosening.

Pathogenesis of bone loss after total hip arthroplasty

Bone loss with or without evidence of aseptic loosening is a long term complication after total hip arthroplasty (THA). It occurs with all materials and in all prosthetic systems in use or that have been used to date. Bone loss after THA can be a serious problem in revision surgery because bone deficiencies may limit reconstructive options, increase the difficulty of surgery, and necessitate autogenous or allogenic bone grafting. There are three factors adversely affecting maintenance of bone mass after THA: (1) bone loss secondary to particulate debris; (2) adaptive bone remodeling and stress shielding secondary to size, material properties, and surface characteristics of contemporary prostheses; and (3) bone loss as a consequence of natural aging. This chapter reviews the mechanisms of the primary causes of bone loss after THA.

Modulation of the tissue reaction to biomaterials. II. The function of T cells in the inflammatory reaction to crosslinked collagen implanted in T-cell-deficient rats

Unwanted tissue reactions are often observed resulting in events such as early resorption of the biomaterial, loosening of the implant, or a chronic (immunologic) response. From immunologic studies it is known that inflammatory reactions can be modulated by use of (anti)-growth factors or anti-inflammatory drugs. Before this can be employed with respect to biomaterials, the role of individual factors (humoral and cellular) has to be studied. In this part of the investigation, the role of T cells was studied by use of T-cell-deficient (nude) rats and control (AO) rats. Hexamethylenediisocyanate-crosslinked dermal sheep collagen (HDSC) was selected as the test material. The results showed that T cells or T cell-related factors played a prominent role in the attraction of macrophages and the formation of giant cells, their antigen presentation, and their phagocytotic capacity. As a consequence, degradation of HDSC was strongly delayed. This study also showed that infiltration of fibroblasts and creation of stromal areas in HDSC was restricted to areas subjected to degradation. However, in time, absence of T cells resulted in increased formation and maturation of autologous rat collagen. Results obtained suggest that the inflammatory reaction to biomaterials might be modulated by controlling T-cell activation.

Techniques to investigate cellular and molecular interactions in the host response to implanted biomaterials

Evaluation of the host response to implanted materials requires systematic, objective investigations of responses at both the cellular and molecular levels. This article explains the basis behind two technologies: antibody and molecular techniques, which will give valuable information when applied to investigations of cells and molecules involved in the host biomaterial interaction. Such investigations are well underway, and a number of groups are now studying well characterised cell markers or molecules to evaluate the host response to biomaterials. Here we outline current technologies for the development of antibodies as tools to study cell markers or molecules, including those for which reagents are not yet available and DNA based technologies, whose continued application should prove an invaluable adjunct to existing approaches. These technologies may be particularly valuable to investigations focusing on newly characterised cytokines, receptors or cell adhesion molecules and subsequently provide a way forward for the production of advanced biomaterials.

Loosening and osteolysis of cemented joint arthroplasties. A biologic spectrum

The purpose of this study was to characterize the cell types (using immunohistochemistry) and cytokine expression (using in situ hybridization) of tissues surrounding well fixed and loose cemented prostheses undergoing revision. Clinical and radiographic data were gathered prospectively for a series of cemented total joint replacements undergoing revision. Three groups were identified: (1) loose implants with osteolysis (10 specimens), (2) loose implants without osteolysis (11 specimens), and (3) well fixed implants (7 specimens). At surgery, a specimen was harvested from the bone cement interface. Immunohistochemical staining was performed using monoclonal antibodies to identify macrophages and lymphocyte subgroups. Human antisense probes were selected to identify the mRNA for specific cytokines using in situ hybridization. The percentage of positively staining cells was determined for each antibody or probe using a grid counting technique. Tissues from loose cemented prostheses with osteolysis contained significantly greater numbers of macrophages and T lymphocytes compared with tissues from loose and well fixed cemented prostheses without osteolysis. The number of interleukin-1 and interleukin-6 positive cells was highest in specimens with osteolysis and lowest in specimens from well fixed prostheses. These cytokines modulate the growth and differentiation of cells in the immune system and the monocyte and macrophage system and mediate the remodeling of bone and mesenchymal tissues. Specific cell populations and cytokine profiles appear to be involved in periprosthetic osteolysis; this information may be useful in planning strategies for prevention and treatment.

Metal on metal bearings in hip arthroplasty

Periprosthetic osteolysis caused by wear debris released from the bearing surface of polyethylene components is the major problem in contemporary hip arthroplasty. Several types of metal on metal prostheses were developed in the 1960s, but by the mid 1970s they were completely displaced by polyethylene bearings. There have been several generations of all metal components with significant variation in design, tolerances, and bearing surface quality. A number of these hips have survived for more than 25 years because of low wear rates and minimal osteolysis. Identification of the characteristics that contributed to long term function is important. The historical development and clinical results of metal on metal hip arthroplasties are presented. Factors that led to the abandonment of the metal on metal bearings are related to: (1) the early success of the Charnley prosthesis; (2) the frictional torque issue; (3) carcinogenesis concerns; (4) metal sensitivity concerns; (5) high infection rates; and (6) increased strain rates in periprosthetic bone and fatigue fractures of the acetabular floor. The accumulated experience to date enables one to evaluate all the factors with a different perspective and makes the use of newer metal on metal bearings a viable option in younger patients.

Metal versus polyethylene wear particles in total hip replacements. A review

Research has recently been focused on the development of hip replacements with alternative bearing surfaces with cobalt chrome alloy, to avoid the production of polyethylene wear particles in hip replacements and polyethylene wear debris mediated bone lysis. Cobalt chrome on cobalt chrome bearing surfaces are being reevaluated. Characterization of wear particles and studies on the reaction of the body to these particles, have played an important role in the determination of the factors that cause aseptic loosening and will therefore play an important role in the comparison of metal on polyethylene and metal on metal hip prostheses. In this paper, a comparison between the different aspects of metal and polyethylene wear particles is made using data from the literature and the authors' experience. The authors conclude that techniques need to be optimized to isolate and characterize individual metal wear particles from periprosthetic tissues and they advocate the performance of in vitro studies with these in vivo generated wear particles or comparable particles.