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Borm PJ. The parallels between particle induced lung overload and particle induced periprosthetic osteolysis (PPOL). OPEN RESEARCH EUROPE 2022; 1:16. [PMID: 37645132 PMCID: PMC10445866 DOI: 10.12688/openreseurope.13264.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 08/31/2023]
Abstract
Background: When particles deposit for instance in the lung after inhalation or in the hip joint after local release from a hip implant material they can initiate a defense response. Even though these particles originate from inert materials such as polyethylene (PE) or titanium, they may cause harm when reaching high local doses and overwhelming local defense mechanisms. Main body: This paper describes the parallels between adverse outcome pathways (AOP) and particle properties in lung overload and periprosthetic osteolysis (PPOL). It is noted that in both outcomes in different organs , the macrophage and cytokine orchestrated persistent inflammation is the common driver of events, in the bone leading to loss of bone density and structure, and in the lung leading to fibrosis and cancer. Most evidence on lung overload and its AOP is derived from chronic inhalation studies in rats, and the relevance to man is questioned. In PPOL, the paradigms and metrics are based on human clinical data, with additional insights generated from in vitro and animal studies. In both organ pathologies the total volume of particle deposition has been used to set threshold values for the onset of pathological alterations. The estimated clinical threshold for PPOL of 130 mg/ml is much higher than the amount to cause lung overload in the rat (10 mg/ml),although the threshold in PPOL is not necessarily synonymous to particle overload. Conclusions: The paradigms developed in two very different areas of particle response in the human body have major similarities in their AOP. Connecting the clinical evidence in PPOL to lung overload challenges relevance of rat inhalation studies to the human lung cancer hazard. .
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Affiliation(s)
- Paul J.A. Borm
- Nanoconsult, Meerssen, The Netherlands
- University of Dusseldorf, Dusseldorf, 50224, Germany
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2
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Goodman SB, Gallo J. Periprosthetic Osteolysis: Mechanisms, Prevention and Treatment. J Clin Med 2019; 8:E2091. [PMID: 31805704 PMCID: PMC6947309 DOI: 10.3390/jcm8122091] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 11/28/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Clinical studies, as well as in vitro and in vivo experiments have demonstrated that byproducts from joint replacements induce an inflammatory reaction that can result in periprosthetic osteolysis (PPOL) and aseptic loosening (AL). Particle-stimulated macrophages and other cells release cytokines, chemokines, and other pro-inflammatory substances that perpetuate chronic inflammation, induce osteoclastic bone resorption and suppress bone formation. Differentiation, maturation, activation, and survival of osteoclasts at the bone-implant interface are under the control of the receptor activator of nuclear factor kappa-Β ligand (RANKL)-dependent pathways, and the transcription factors like nuclear factor κB (NF-κB) and activator protein-1 (AP-1). Mechanical factors such as prosthetic micromotion and oscillations in fluid pressures also contribute to PPOL. The treatment for progressive PPOL is only surgical. In order to mitigate ongoing loss of host bone, a number of non-operative approaches have been proposed. However, except for the use of bisphosphonates in selected cases, none are evidence based. To date, the most successful and effective approach to preventing PPOL is usage of wear-resistant bearing couples in combination with advanced implant designs, reducing the load of metallic and polymer particles. These innovations have significantly decreased the revision rate due to AL and PPOL in the last decade.
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Affiliation(s)
- Stuart B. Goodman
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St. M/C 6342, Redwood City, CA 94063, USA
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, I. P. Pavlova 6, 779 00 Olomouc, Czech Republic;
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Adams S, Wuescher LM, Worth R, Yildirim-Ayan E. Mechano-Immunomodulation: Mechanoresponsive Changes in Macrophage Activity and Polarization. Ann Biomed Eng 2019; 47:2213-2231. [PMID: 31218484 PMCID: PMC7043232 DOI: 10.1007/s10439-019-02302-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/07/2019] [Indexed: 12/31/2022]
Abstract
In recent years, biomaterial- and scaffold-based immunomodulation strategies were implemented in tissue regeneration efforts for manipulating macrophage polarization (a.k.a. phenotype or lineage commitment, or differentiation). Yet, most of our understanding of macrophage phenotype commitment and phagocytic capacity is limited to how physical cues (extracellular matrix stiffness, roughness, and topography) and soluble chemical cues (cytokines and chemokines released from the scaffold) influence macrophage polarization. In the context of immune response-tissue interaction, the mechanical cues experienced by the residing cells within the tissue also play a critical role in macrophage polarization and inflammatory response. However, there is no compiled study discussing the effect of the dynamic mechanical environment around the tissues on macrophage polarization and the innate immune response. The aim of this comprehensive review paper is 2-fold; (a) to highlight the importance of mechanical cues on macrophage lineage commitment and function and (b) to summarize the important studies dedicated to understand how macrophage polarization changes with different mechanical loading modalities. For the first time, this review paper compiles and compartmentalizes the studies investigating the role of dynamic mechanical loading with various modalities, amplitude, and frequency on macrophage differentiation. A deeper understanding of macrophage phenotype in mechanically dominant tissues (i.e. musculoskeletal tissues, lung tissues, and cardiovascular tissues) provides mechanistic insights into the design of mechano-immunomodulatory tissue scaffold for tissue regeneration.
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Affiliation(s)
- Sarah Adams
- Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, 43606, USA
| | - Leah M Wuescher
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, 43614, USA
| | - Randall Worth
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, 43614, USA
| | - Eda Yildirim-Ayan
- Department of Bioengineering, College of Engineering, University of Toledo, Toledo, OH, 43606, USA.
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA.
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Far Cortical Locking Fixation of Distal Femur Fractures is Dominated by Shear at Clinically Relevant Bridge Spans. J Orthop Trauma 2019; 33:92-96. [PMID: 30299380 DOI: 10.1097/bot.0000000000001341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Far cortical locking (FCL) constructs have been shown to increase axial interfragmentary displacement while limiting shear and have been specifically recommended in the treatment of distal femur fractures. However, there is no available data regarding their mechanical behavior within the range of bridge spans typically used for comminuted distal femur fractures. This biomechanical study of distal femur locked plate fixation assessed 4 methods of diaphyseal fixation for associated axial and shear displacement at bridge spans typically used in clinical practice. METHODS Distal femur locking plates were used to bridge simulated fractures in femur surrogates with 4 different methods of diaphyseal fixation (bicortical locking, bicortical nonlocking, near cortical locking, and FCL). Axial and shear displacement were assessed at 5 different bridge spans for each fixation method. RESULTS Diaphyseal fixation type was associated with the amount of shear (P = 0.04), but not the amount of axial displacement (P = 0.39). Specifically, FCL constructs demonstrated greater shear than bicortical locking (median 4.57 vs. 2.94 mm, P = 0.02) and bicortical nonlocking (median 4.57 vs. 3.41 mm, P = 0.02) constructs. CONCLUSIONS Unexpectedly, FCL constructs demonstrated greater shear than bicortical locking and nonlocking constructs and similar axial displacement for all fixation methods. Bridge span had a dominant effect on displacement that interacted negatively with more flexible FCL diaphyseal fixation. Potentially interactive construct features are best studied in concert. Given the complexity of these relationships, computational modeling will likely play an integral role in future mechanotransduction research.
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Otto Aufranc Award: Crosslinking Reduces THA Wear, Osteolysis, and Revision Rates at 15-year Followup Compared With Noncrosslinked Polyethylene. Clin Orthop Relat Res 2018; 476. [PMID: 29529656 PMCID: PMC6259699 DOI: 10.1007/s11999.0000000000000036] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Crosslinked polyethylene (XLPE) liners used for primary THA have demonstrated lower wear rates than noncrosslinked, conventional polyethylene (CPE) liners through the first decade of clinical service. However, little high-quality evidence is currently available regarding the second decade performance of these implants and it remains uncertain whether the onset of osteolysis has simply been delayed or if the wear associated with XLPE liners will remain low enough that osteolysis will not occur. It is also unknown how the potential reductions in wear and osteolysis will influence long-term revision rates. QUESTIONS/PURPOSES Do patients who underwent THA with XLPE liners demonstrate (1) a lower rate of revision for wear-related complications; (2) a reduced wear rate; and (3) a lower frequency of osteolysis compared with those with CPE liners? METHODS Over an 18-month period from 1999 to 2000, 226 patients who had 236 primary THAs consented to participate in a randomized controlled trial conducted at one institution. To be eligible for intraoperative randomization, patients had to be implanted with a 28-mm cobalt-chrome alloy femoral head, a 4-mm lateralized liner, and the same cup and stem design. Six patients with six THAs were excluded intraoperatively because they did not receive study components for reasons unrelated to the liner material. The remaining 230 THAs among 220 patients were randomized to XLPE liners or CPE liners. The mean age at surgery was 62 ± 11 years and there were no differences in age, gender, or body mass index among the groups. There was no differential loss to followup between the study groups; among patients not known to be deceased or having undergone revision, minimum 14-year radiographic followup is available for 85 THAs including 46 with XLPE and 39 with CPE liners. Polyethylene wear was measured radiographically using Martell's Hip Analysis Suite and areas of osteolysis were evaluated before revision or at most recent followup. Revision rates at 15 years using reoperation for any reason and revision for wear or osteolysis were calculated using cumulative incidence considering patient death as a competing risk. RESULTS The cumulative incidence of revision at 15 years using reoperation for wear-related complications as an endpoint was lower in the XLPE group than the CPE group (0%, 95% confidence interval [CI], 0%-0% versus 12%, 95% CI, 7%-19%; p < 0.001). Among unrevised THAs with minimum 14-year radiographic followup, the mean steady-state linear wear rate for THAs with XLPE liners was lower than the mean linear wear rate for the THAs with CPE liners (0.03 ± 0.05 versus 0.17 ± 0.09 mm/year; mean difference, 0.14; 95% CI, 0.11-0.17; p < 0.001). Osteolysis of any size was noted among 9% (four of 46) of the hips in the XLPE group and 46% (18 of 39) of the hips in the CPE group (odds ratio, 0.19; 95% CI, 0.07-0.51; p < 0.001). CONCLUSIONS This randomized study with followup into the second decade demonstrated reductions in revision, wear, and osteolysis associated with the use of XLPE. The low wear rates and absence of any mechanical failures among the XLPE liners at long-term followup affirm the durability of these components that did not incorporate antioxidants. Although osteolysis has not been eliminated, it occurs infrequently and has not caused any clinical problems to date. LEVEL OF EVIDENCE Level I, therapeutic study.
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Amirhosseini M, Andersson G, Aspenberg P, Fahlgren A. Mechanical instability and titanium particles induce similar transcriptomic changes in a rat model for periprosthetic osteolysis and aseptic loosening. Bone Rep 2017; 7:17-25. [PMID: 28795083 PMCID: PMC5544474 DOI: 10.1016/j.bonr.2017.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/30/2023] Open
Abstract
Wear debris particles released from prosthetic bearing surfaces and mechanical instability of implants are two main causes of periprosthetic osteolysis. While particle-induced loosening has been studied extensively, mechanisms through which mechanical factors lead to implant loosening have been less investigated. This study compares the transcriptional profiles associated with osteolysis in a rat model for aseptic loosening, induced by either mechanical instability or titanium particles. Rats were exposed to mechanical instability or titanium particles. After 15 min, 3, 48 or 120 h from start of the stimulation, gene expression changes in periprosthetic bone tissue was determined by microarray analysis. Microarray data were analyzed by PANTHER Gene List Analysis tool and Ingenuity Pathway Analysis (IPA). Both types of osteolytic stimulation led to gene regulation in comparison to unstimulated controls after 3, 48 or 120 h. However, when mechanical instability was compared to titanium particles, no gene showed a statistically significant difference (fold change ≥ ± 1.5 and adjusted p-value ≤ 0.05) at any time point. There was a remarkable similarity in numbers and functional classification of regulated genes. Pathway analysis showed several inflammatory pathways activated by both stimuli, including Acute Phase Response signaling, IL-6 signaling and Oncostatin M signaling. Quantitative PCR confirmed the changes in expression of key genes involved in osteolysis observed by global transcriptomics. Inflammatory mediators including interleukin (IL)-6, IL-1β, chemokine (C-C motif) ligand (CCL)2, prostaglandin-endoperoxide synthase (Ptgs)2 and leukemia inhibitory factor (LIF) showed strong upregulation, as assessed by both microarray and qPCR. By investigating genome-wide expression changes we show that, despite the different nature of mechanical implant instability and titanium particles, osteolysis seems to be induced through similar biological and signaling pathways in this rat model for aseptic loosening. Pathways associated to the innate inflammatory response appear to be a major driver for osteolysis. Our findings implicate early restriction of inflammation to be critical to prevent or mitigate osteolysis and aseptic loosening of orthopedic implants.
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Affiliation(s)
- Mehdi Amirhosseini
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Corresponding author.
| | - Göran Andersson
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Fahlgren
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Broomfield JAJ, Malak TT, Thomas GER, Palmer AJR, Taylor A, Glyn-Jones S. The Relationship Between Polyethylene Wear and Periprosthetic Osteolysis in Total Hip Arthroplasty at 12 Years in a Randomized Controlled Trial Cohort. J Arthroplasty 2017; 32:1186-1191. [PMID: 27998657 DOI: 10.1016/j.arth.2016.10.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/24/2016] [Accepted: 10/28/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Polyethylene acetabular components are common in hip arthroplasty. Highly cross-linked polyethylene (HXLPE) has lower wear than ultra-high molecular weight polyethylene (UHMWPE). Evidence suggests that wear particles induce inflammation causing periprosthetic osteolysis contributing to implant loosening with wear rates of 0.05 mm/y were considered safe. We aimed to compare incidence and volume of periacetabular osteolysis between HXLPE and UHMWPE using computed tomography. METHODS Initially, 54 hips in 53 patients were randomized to HXLPE or UHMWPE acetabular liner. At 10 years, 39 hips in 38 patients remained for the radiostereometric analysis' demonstrating significantly lower wear in the HXLPE group. At 12 years, 14 hips in 13 patients were lost to follow-up leaving 25 hips for computed tomography assessment. Images were reconstructed to detect osteolysis and where identified, areas were segmented and volumized. RESULTS Osteolysis was observed in 8 patients, 7 from the UHMWPE group and only 1 from the HXLPE group (Fisher exact, P = .042). There was no correlation between the amount of polyethylene wear and osteolysis volume; however, the radiostereometric analysis-measured wear rate in patients with osteolysis from both groups was significantly higher than overall average wear rate. CONCLUSION This data demonstrates lower incidence of periacetabular osteolysis in the HXLPE group of a small cohort. Although numbers are too low to estimate causation, in the context of lower wear in the HXLPE group, this finding supports the hypothesis that HXLPE may not elevate osteolysis risk, and hence does not suggest that HXLPE wear particles are more biologically active than those generated by earlier generations of polyethylene.
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Affiliation(s)
- John A J Broomfield
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Tamer T Malak
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Geraint E R Thomas
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Adrian Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Sion Glyn-Jones
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
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Mumith A, Coathup M, Chimutengwende-Gordon M, Aston W, Briggs T, Blunn G. Augmenting the osseointegration of endoprostheses using laser-sintered porous collars: an in vivo study. Bone Joint J 2017; 99-B:276-282. [PMID: 28148673 DOI: 10.1302/0301-620x.99b2.bjj-2016-0584.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/13/2016] [Indexed: 11/05/2022]
Abstract
AIMS Massive endoprostheses rely on extra-cortical bone bridging (ECBB) to enhance fixation. The aim of this study was to investigate the role of selective laser sintered (SLS) porous collars in augmenting the osseointegration of these prostheses. MATERIALS AND METHODS The two novel designs of porous SLS collars, one with small pores (Ø700 μm, SP) and one with large pores (Ø1500 μm, LP), were compared in an ovine tibial diaphyseal model. Osseointegration of these collars was compared with that of a clinically used solid, grooved design (G). At six months post-operatively, the ovine tibias were retrieved and underwent radiological and histological analysis. RESULTS Porous collars provided a significantly greater surface (p < 0.001) for the ingrowth of bone than the standard grooved design. Significantly greater extracortical pedicle formation was seen radiologically around the grooved design (length p = 0.002, thickness p < 0.001, surface area p = 0.002) than around the porous collars. However, the ingrowth of bone occurred from the transection site into the porous structure of both types of collar. A fivefold increase in integration was seen with the SP and a threefold increase in the LP design when compared with G (p < 0.001). CONCLUSION SLS porous collars allow the direct ingrowth of more bone and are better than current designs which rely on surface ongrowth and ECBB. Cite this article: Bone Joint J 2017;99-B:276-82.
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Affiliation(s)
- A Mumith
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - M Coathup
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - M Chimutengwende-Gordon
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - W Aston
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - T Briggs
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G Blunn
- University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
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Elkins J, Marsh JL, Lujan T, Peindl R, Kellam J, Anderson DD, Lack W. Motion Predicts Clinical Callus Formation: Construct-Specific Finite Element Analysis of Supracondylar Femoral Fractures. J Bone Joint Surg Am 2016; 98:276-84. [PMID: 26888675 PMCID: PMC5141368 DOI: 10.2106/jbjs.o.00684] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mechanotransduction is theorized to influence fracture-healing, but optimal fracture-site motion is poorly defined. We hypothesized that three-dimensional (3-D) fracture-site motion as estimated by finite element (FE) analysis would influence callus formation for a clinical series of supracondylar femoral fractures treated with locking-plate fixation. METHODS Construct-specific FE modeling simulated 3-D fracture-site motion for sixty-six supracondylar femoral fractures (OTA/AO classification of 33A or 33C) treated at a single institution. Construct stiffness and directional motion through the fracture were investigated to assess the validity of construct stiffness as a surrogate measure of 3-D motion at the fracture site. Callus formation was assessed radiographically for all patients at six, twelve, and twenty-four weeks postoperatively. Univariate and multivariate linear regression analyses examined the effects of longitudinal motion, shear (transverse motion), open fracture, smoking, and diabetes on callus formation. Construct types were compared to determine whether their 3-D motion profile was associated with callus formation. RESULTS Shear disproportionately increased relative to longitudinal motion with increasing bridge span, which was not predicted by our assessment of construct stiffness alone. Callus formation was not associated with open fracture, smoking, or diabetes at six, twelve, or twenty-four weeks. However, callus formation was associated with 3-D fracture-site motion at twelve and twenty-four weeks. Longitudinal motion promoted callus formation at twelve and twenty-four weeks (p = 0.017 for both). Shear inhibited callus formation at twelve and twenty-four weeks (p = 0.017 and p = 0.022, respectively). Titanium constructs with a short bridge span demonstrated greater longitudinal motion with less shear than did the other constructs, and this was associated with greater callus formation (p < 0.001). CONCLUSIONS In this study of supracondylar femoral fractures treated with locking-plate fixation, longitudinal motion promoted callus formation, while shear inhibited callus formation. Construct stiffness was found to be a poor surrogate of fracture-site motion. Future implant design and operative fixation strategies should seek to optimize 3-D fracture-site motion rather than rely on surrogate measures such as axial stiffness.
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Affiliation(s)
- Jacob Elkins
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - J. Lawrence Marsh
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Trevor Lujan
- Department of Mechanical and Biomedical Engineering, Boise State University, Boise, Idaho
| | - Richard Peindl
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - James Kellam
- Department of Orthopaedic Surgery, University of Texas Health Science Center, Houston, Texas
| | - Donald D. Anderson
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - William Lack
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
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Etiopathogenesis of osteolytic cysts associated with total ankle arthroplasty, a histological study. Foot Ankle Surg 2015; 21:132-6. [PMID: 25937414 DOI: 10.1016/j.fas.2015.02.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/12/2015] [Accepted: 02/28/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Osteolytic cyst formation after total ankle arthroplasty has been identified in recent years and is probably an important problem with longer follow-up. The aim of this study is to describe the outcome of a histological analysis of samples from periprosthetic intra-osseous cysts and joint capsules, retrieved during revision surgery after primary total ankle arthroplasty. METHODS All samples (n=22) were analyzed and scored using a semi-quantitative grading system. The main items of interest were polyethylene (PE) particles, metal particles, histiocytes, and giant cells. RESULTS All cyst samples contained PE particles. A similar number of PE particles were found in talar and tibial cysts. No significant correlation between the number of PE particles and time to reoperation was found. Metal particles were found in 16 cysts. CONCLUSIONS We suggest that PE particles are not the primary cause of osteolytic cyst formation but a secondary contributing factor probably accelerating the process of osteolysis. It is likely that implant design, biomechanical factors and local anatomic-physiological factors play an important role.
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Mann KA, Miller MA. Fluid-structure interactions in micro-interlocked regions of the cement-bone interface. Comput Methods Biomech Biomed Engin 2013; 17:1809-20. [PMID: 23480611 DOI: 10.1080/10255842.2013.767336] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Experimental tests and computational modelling were used to explore the fluid dynamics at the trabeculae-cement interlock regions found in the tibial component of total knee replacements. A cement-bone construct of the proximal tibia was created to simulate the immediate post-operative condition. Gap distributions along nine trabeculae-cement regions ranged from 0 to 50.4 μm (mean = 12 μm). Micro-motions ranged from 0.56 to 4.7 μm with a 1 MPa compressive load to the cement. Fluid-structure analysis between the trabeculae and the cement used idealised models with parametric evaluation of loading direction, gap closing fraction (GCF), gap thickness, loading frequency and fluid viscosity. The highest fluid shear stresses (926 Pa) along the trabecular surface were found for conditions with very thin and large GCFs, much larger than reported physiological levels (~1-5 Pa). A second fluid-structure model was created with a provision for bone resorption using a constitutive model with resorption velocity proportional to fluid shear rate. A lower cut-off was used, below which bone resorption would not occur (50 s(-1)). Results showed that there was initially high shear rates (>1000 s(-1)) that diminished after initial trabecular resorption. Resorption continued in high shear rate regions, resulting in a final shape with bone left deep in the cement layer, and is consistent with morphology found in post-mortem retrievals. Small gaps between the trabecular surface and the cement in the immediate post-operative state produce fluid flow conditions that appear to be supra-physiologic; these may cause fluid-induced lysis of trabeculae in the micro-interlock regions.
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Affiliation(s)
- Kenneth A Mann
- a Department of Orthopaedic Surgery, Musculoskeletal Science Research Center , SUNY Upstate Medical University , 3216 IHP, 750 East Adams Street, Syracuse , NY 13210 , USA
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Niu S, Cao X, Zhang Y, Zhu Q, Zhu J. The inhibitory effect of alendronate-hydroxyapatite composite coating on wear debris-induced peri-implant high bone turnover. J Surg Res 2013; 179:e107-15. [DOI: 10.1016/j.jss.2012.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 01/18/2012] [Accepted: 02/01/2012] [Indexed: 10/28/2022]
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13
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Koivu H, Mackiewicz Z, Takakubo Y, Trokovic N, Pajarinen J, Konttinen YT. RANKL in the osteolysis of AES total ankle replacement implants. Bone 2012; 51:546-52. [PMID: 22627031 DOI: 10.1016/j.bone.2012.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/12/2012] [Accepted: 05/09/2012] [Indexed: 02/08/2023]
Abstract
Peri-implant tissue reactions in failed total ankle replacement (TAR) are characterized by early developing peri-implant osteolysis. The hypothesis of the study was that this reaction is mediated by receptor activator of nuclear factor kappa B ligand (RANKL). Samples of peri-prosthetic tissues from failed TAR implants were stained for macrophages, RANKL, its receptor RANK and osteoprotegerin (OPG), and compared to control samples. The failed TAR implants were surrounded by implant capsule, synovial lining-like interface membrane or necrotic tissues. Infiltrating scavenger receptor I positive CD163(+) macrophages were frequent, in particular around necrotic soft tissues or bone sequestrate, and possibly in part formed due to ischemia and mechanical factors. In contrast, implant-derived wear debris was scanty. Still many RANK(+) macrophages were often seen in close contact with RANKL(+) mesenchymal cells, whereas OPG was mostly located at a distance in vascular endothelial cells. Foreign body giant cells were frequent. RANKL seems to stimulate locally accumulated CD163(+) RANK-expressing cells to fusion, which leads to the local formation of multinuclear foreign body giant cells (and probably of osteoclasts). Therefore, peri-implant osteolysis in early TAR implant failure seems to be caused by the RANKL-driven chronic foreign body inflammation directed against, not implant-derived particles, but against necrotic autologous tissues.
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Affiliation(s)
- H Koivu
- Department of Internal Medicine, Rheumaorthopaedic unit, Paimio Hospital, Turku University Hospital, Alvar Aallon tie 275, 21540 Preitila, Finland.
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14
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Alidousti H, Taylor M, Bressloff NW. Do capsular pressure and implant motion interact to cause high pressure in the periprosthetic bone in total hip replacement? J Biomech Eng 2012; 133:121001. [PMID: 22206418 DOI: 10.1115/1.4005455] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
When there is a debonding at the bone-implant interface, the difference in stiffness between the implant and the bone can result in micromotion, allowing existing gaps to open further or new gaps to be created during physiological loading. It has been suggested that periprosthetic fluid flow and high pressure may play an important role in osteolysis development in the proximity of these gaps. To explain this phenomenon, the concepts of "effective joint space" and "pumping stem" have been cited in many studies. However, there is no clear understanding of the factors causing, or contributing to, these mechanisms. It is likely that capsular pressure, gap dimensions, and micromotion of the gap during cyclic loading of an implant can play a defining role in inducing periprosthetic flow. In order to obtain a better understanding of the main influences on periprosthetic flows and the development of osteolysis, steady state and transient 2D computational fluid dynamic simulations were performed for the joint capsule of the lateral side of a stem-femur system, and a gap in communication with the capsule and the surrounding bone. It was shown that high capsular pressure may be the main driving force for high fluid pressure and flow in the bone surrounding the gap, while micromotion of only very long and narrow gaps can cause significant pressure and flow in the bone. At low capsular pressure, micromotion induced large flows in the gap region; however, the flow in the bone tissue was almost unaffected. The results also revealed the existence of high velocity spikes in the bone region at the bottom of the gap. These velocity spikes can exert excessive fluid shear stress on the bone cells and disturb the local biological balance of the surrounding interstitial fluid which can result in osteolysis development. High capsular pressure was observed to be the main cause of these velocity spikes whereas, at low capsular pressure, gap micromotion of only very long and narrow gaps generated significant velocity spikes in the bone at the bottom of the gaps.
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Affiliation(s)
- Hamidreza Alidousti
- School of Engineering Sciences, University of Southampton, Highfield, Southampton, UK
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15
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Olof S, Mats S, Olle M, Ake J, Torbjörn A, Henrik B. The Ringloc liner compared with the Hexloc liner in total hip arthroplasty. Orthop Rev (Pavia) 2011; 1:e16. [PMID: 21808678 PMCID: PMC3143985 DOI: 10.4081/or.2009.e16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 06/26/2009] [Accepted: 06/26/2009] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to compare the 10-year survival rate, pelvic osteolysis frequency and linear head penetration rate of the Hexloc and Ringloc liners used together with a partially threaded porous and hydroxyapatite coated cup and the Bi-Metric uncemented femoral stem. The 15-year results for the cup with the Hexloc liner are also reported. We included 332 consecutive hips (166 Hexloc and 166 Ringloc) on 281 patients in the study. Revisions of prosthesis components were recorded and pelvic osteolytic lesions were assessed using radiographs and computed tomography. The linear head penetration rate was measured using the Martell method. The 10-year survival rate of the liner with revision due to liner wear and/or osteolysis as endpoint was 88% for the Hexloc liner and 98% for the Ringloc liner. The 15-year survival rate of the Hexloc liner was 67%. Pelvic osteolysis was found in 27% of the Hexloc and 19% of the Ringloc hips. After 15 years, 53% of the Hexloc hips had developed an osteolytic lesion. The linear head penetration rate was 0.16 mm/year for the Hexloc liner and 0.12 mm/year for the Ringloc liner. This paper is the first to describe the rapidly deteriorating survival up to 15 years with the old generation gamma-in-air sterilized polyethylene used in Hexloc liners. The newer Ringloc liner with the ArCom™ polyethylene has superior clinical results but a linear wear rate and frequency of osteolytic lesions that is higher than expected.
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Affiliation(s)
- Sköldenberg Olof
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
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16
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De Jong PT, Tigchelaar W, Van Noorden CJF, Van der Vis HM. Polyethylene wear particles do not induce inflammation or gelatinase (MMP-2 and MMP-9) activity in fibrous tissue interfaces of loosening total hip arthroplasties. Acta Histochem 2011; 113:556-63. [PMID: 20656340 DOI: 10.1016/j.acthis.2010.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 06/06/2010] [Accepted: 06/08/2010] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Pieter T De Jong
- Department of Orthopedics, St. Jansdal Ziekenhuis, Harderwijk, The Netherlands
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17
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Johansson L, Edlund U, Fahlgren A, Aspenberg P. Fluid-induced osteolysis: modelling and experiments. Comput Methods Biomech Biomed Engin 2011; 14:305-18. [PMID: 21390935 DOI: 10.1080/10255842.2010.484808] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A model to calculate bone resorption driven by fluid flow at the bone-soft tissue interface is developed and used as a basis for computer calculations, which are compared to experiments where bone is subjected to fluid flow in a rat model. Previous models for bone remodelling calculations have been based on the state of stress, strain or energy density of the bone tissue as the stimulus for remodelling. We believe that there is experimental support for an additional pathway where an increase in the amount of the cells directly involved in bone removal, the osteoclasts, is caused by fluid pressure, flow velocity or other parameters related to fluid flow at the bone-soft tissue interface, resulting in bone resorption.
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Affiliation(s)
- Lars Johansson
- Department of Management and Engineering, Linköping University, Linköping, Sweden.
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18
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Fahlgren A, Bostrom MPG, Yang X, Johansson L, Edlund U, Agholme F, Aspenberg P. Fluid pressure and flow as a cause of bone resorption. Acta Orthop 2010; 81:508-16. [PMID: 20718695 PMCID: PMC2917576 DOI: 10.3109/17453674.2010.504610] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Unstable implants in bone become surrounded by an osteolytic zone. This is seen around loose screws, for example, but may also contribute to prosthetic loosening. Previous animal studies have shown that such zones can be induced by fluctuations in fluid pressure or flow, caused by implant instability. METHOD To understand the roles of pressure and flow, we describe the 3-dimensional distribution of osteolytic lesions in response to fluid pressure and flow in a previously reported rat model of aseptic loosening. 50 rats had a piston inserted in the proximal tibia, designed to produce 20 local spikes in fluid pressure of a clinically relevant magnitude (700 mmHg) twice a day. The spikes lasted for about 0.3 seconds. After 2 weeks, the pressure was measured in vivo, and the osteolytic lesions induced were studied using micro-CT scans. RESULTS Most bone resorption occurred at pre-existing cavities within the bone in the periphery around the pressurized region, and not under the piston. This region is likely to have a higher fluid flow and less pressure than the area just beneath the piston. The velocity of fluid flow was estimated to be very high (roughly 20 mm/s). INTERPRETATION The localization of the resorptive lesions suggests that high-velocity fluid flow is important for bone resorption induced by instability.
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Affiliation(s)
- Anna Fahlgren
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, LinköpingSweden,Correspondence:
| | | | - Xu Yang
- Hospital for Special Surgery, New York, NYUSA
| | - Lars Johansson
- Division of Mechanics, Department of Management and Enineering, Linköping University, LinköpingSweden
| | - Ulf Edlund
- Division of Mechanics, Department of Management and Enineering, Linköping University, LinköpingSweden
| | - Fredrik Agholme
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, LinköpingSweden
| | - Per Aspenberg
- Division of Orthopaedics, Department of Clinical and Experimental Medicine, Linköping University, LinköpingSweden
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19
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Powers CC, Ho H, Beykirch SE, Huynh C, Hopper RH, Engh CA, Engh CA. A comparison of a second- and a third-generation modular cup design: is new improved? J Arthroplasty 2010; 25:514-21. [PMID: 19361949 DOI: 10.1016/j.arth.2009.02.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 02/22/2010] [Indexed: 02/01/2023] Open
Abstract
The highly cross-linked polyethylene liners currently used with modular uncemented cups have substantially decreased wear and osteolysis at early follow-up. However, retroacetabular osteolysis has still been reported in some cases with DePuy Orthopaedic's (Warsaw, IN) second-generation Duraloc acetabular shell. DePuy's third-generation Pinnacle cup incorporates a different shell-liner locking mechanism. We compared the clinical outcome among a matched series of 42 Duraloc and 42 Pinnacle cups at a mean follow-up of 5.9 years. Although the Harris Hip Scores and wear rates were not statistically different between the 2 cup designs, retroacetabular osteolysis behind the central hole was absent among the Pinnacle cups but noted among 19% of the Duraloc cups.
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Affiliation(s)
- Cara C Powers
- Anderson Orthopaedic Research Institute, Alexandria, Virginia 22307, USA
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20
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Shon WY, Gupta S, Biswal S, Han SH, Hong SJ, Moon JG. Pelvic osteolysis relationship to radiographs and polyethylene wear. J Arthroplasty 2009; 24:743-50. [PMID: 18555652 DOI: 10.1016/j.arth.2008.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Accepted: 02/13/2008] [Indexed: 02/01/2023] Open
Abstract
The relationship of radiographic pelvic osteolysis to computed tomographic (CT) volume and polyethylene wear remains controversial. We evaluated the sensitivity and specificity of radiographs in detecting osteolysis considering CT scan as the true value, in 118 hips with cementless cups. Correlation between osteolysis volume in CT, area of osteolysis in radiograph, and linear wear of polyethylene was assessed. The sensitivity and specificity of anteroposterior radiographs for detection of osteolysis was 57.6% and 92.9%, respectively. Addition of oblique radiographs increased the sensitivity to 64.4% without changing the specificity. The sensitivity increased to 92.8% for lesion more than 1000 mm(3). There was good correlation between 2-dimensional (2D) osteolytic area in radiograph and 3-dimensional (3D) volume (r = 0.74) in CT scan and linear wear of polyethylene showed good correlation with 3D CT volume (r = 0.62) and 2D area in radiograph (r = 0.60). Thus radiographs are useful to screen clinically significant osteolysis.
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Affiliation(s)
- Won Yong Shon
- Department of Orthopedics, Korea University Guro Hospital, Seoul, Korea.
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21
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Hansson U, Toksvig-Larsen S, Ryd L, Aspenberg P. Once-weekly oral medication with alendronate does not prevent migration of knee prostheses: A double-blind randomized RSA study. Acta Orthop 2009; 80:41-5. [PMID: 19297788 PMCID: PMC2823246 DOI: 10.1080/17453670902804968] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Early migration of joint replacements is an effect of poor fixation and can predict late loosening. By reducing the bone resorption after implantation of a joint replacement, it should be possible to enhance the initial fixation of the implant. We studied the effect of once-weekly treatment with alendronate after knee replacement. PATIENTS AND METHODS We recruited 60 patients (60 knees) with gonarthrosis who were scheduled for a total knee replacement. They were operated on with identical implants and uncemented fixation. 30 patients were treated with a bisphosphonate (alendronate) and 30 patients underwent placebo treatment. The treatment started postoperatively and continued on a weekly basis for 6 months. The fixation of the implants was measured with repeated radiostereometry for 2 years. RESULTS There was no difference in migration of implants between the two groups. CONCLUSION With uncemented fixation of knee implants, no benefit of once-weekly treatment with alendronate, starting postoperatively, could be seen during a 2-year follow-up period.
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Affiliation(s)
- Ulrik Hansson
- 1Department of Orthopedics, Lund University HospitalLundSweden
| | | | - Leif Ryd
- 2Department of Orthopedics, Karolinska University HospitalHuddingeSweden
| | - Per Aspenberg
- 3Department of Orthopedics, Linköping University HospitalLinköpingSweden
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22
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Hoenders CSM, Harmsen MC, van Luyn MJA. The local inflammatory environment and microorganisms in “aseptic” loosening of hip prostheses. J Biomed Mater Res B Appl Biomater 2008; 86:291-301. [DOI: 10.1002/jbm.b.30992] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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23
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The B, Hosman A, Kootstra J, Kralj-Iglic V, Flivik G, Verdonschot N, Diercks R. Association between contact hip stress and RSA-measured wear rates in total hip arthroplasties of 31 patients. J Biomech 2007; 41:100-5. [PMID: 17942102 DOI: 10.1016/j.jbiomech.2007.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Revised: 06/23/2007] [Accepted: 07/11/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The main concern in the long run of total hip replacements is aseptic loosening of the prosthesis. Optimization of the biomechanics of the hip joint is necessary for optimization of long-term success. A widely implementable tool to predict biomechanical consequences of preoperatively planned reconstructions still has to be developed. A potentially useful model to this purpose has been developed previously. The aim of this study is to quantify the association between the estimated hip joint contact force by this biomechanical model and RSA-measured wear rates in a clinical setting. METHODS Thirty-one patients with a total hip replacement were measured with RSA, the gold standard for clinical wear measurements. The reference examination was done within 1 week of the operation and the follow-up examinations were done at 1, 2 and 5 years. Conventional pelvic X-rays were taken on the same day. The contact stress distribution in the hip joint was determined by the computer program HIPSTRESS. The procedure for the determination of the hip joint contact stress distribution is based on the mathematical model of the resultant hip force in the one-legged stance and the mathematical model of the contact stress distribution. The model for the force requires as input data, several geometrical parameters of the hip and the body weight, while the model for stress requires as input data, the magnitude and direction of the resultant hip force. The stress distribution is presented by the peak stress-the maximal value of stress on the weight-bearing area (p(max)) and also by the peak stress calculated with respect to the body weight (p(max)/W(B)) which gives the effect of hip geometry. Visualization of the relations between predicted values by the model and the wear at different points in the follow-up was done using scatterplots. Correlations were expressed as Pearson r values. RESULTS The predicted p(max) and wear were clearly correlated in the first year post-operatively (r = 0.58, p = 0.002), while this correlation is weaker after 2 years (r = 0.19, p = 0.337) and 5 years (r = 0.24, p = 0.235). The wear values at 1, 2 and 5 years post-operatively correlate with each other in the way that is expected considering the wear velocity curve of the whole group. The correlation between the predicted p(max) values of two observers who were blinded for each other's results was very good (r = 0.93, p < 0.001). CONCLUSION We conclude that the biomechanical model used in this paper provides a scientific foundation for the development of a new way of constructing preoperative biomechanical plans for total hip replacements.
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Affiliation(s)
- Bertram The
- Orthopaedic Surgery, University Medical Center Groningen, Hanzeplein 1, Postbus 30.001, 9700 RB Groningen, The Netherlands.
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24
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Ise K, Kawanabe K, Matsusaki T, Shimizu M, Onishi E, Nakamura T. Patient sensitivity to polyethylene particles with cemented total hip arthroplasty. J Arthroplasty 2007; 22:966-73. [PMID: 17920467 DOI: 10.1016/j.arth.2007.04.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Accepted: 04/27/2007] [Indexed: 02/01/2023] Open
Abstract
To determine whether sensitivity to polyethylene particles varies among patients, we studied 25 patients who had undergone total hip arthroplasty. We used pelvic radiographs to measure annual polyethylene wear and the area of osteolysis. The ratio of the area of osteolysis to the volumetric polyethylene wear was defined as sensitivity index. Adherent cells from peripheral blood were cocultured with polyethylene particles, and the amount of bone-resorptive cytokines was measured. The amount of interleukin-6, but not of interleukin-1beta or tumor necrosis factor-alpha, released from adherent cells in the in vitro experiment correlated with the in vivo sensitivity indices. This technique appears capable of predicting the development of polyethylene-induced osteolysis, allowing surgeons to avoid using polyethylene as the bearing surface in patients at risk for osteolysis.
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Affiliation(s)
- Kentaro Ise
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
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25
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Beksaç B, Tözün R, Baktiroglu S, Sener N, Gonzalez Della Valle A. Extravascular compression of the femoral vein due to wear debris-induced iliopsoas bursitis: a rare cause of leg swelling after total hip arthroplasty. J Arthroplasty 2007; 22:453-6. [PMID: 17400103 DOI: 10.1016/j.arth.2006.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Accepted: 04/05/2006] [Indexed: 02/01/2023] Open
Abstract
We present a patient with unilateral, spontaneous, late leg swelling that developed 4 years after total hip arthroplasty. The etiology was the compression of the internal iliac vein by a voluminous iliopsoas bursitis caused by polyethylene debris. The expansive lesion was detected by ultrasound, arthrography, and magnetic resonance imaging. An ultrasound-guided aspiration provided transient relief of the patient's symptoms. The patient later required surgical excision through an abdominal approach. A second recurrence was detected and treated with revision surgery. We present the diagnosis and the treatment of this rare cause of late, unilateral leg swelling after total hip arthroplasty together with a review of the literature.
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Affiliation(s)
- Burak Beksaç
- Hip and Knee Service, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York, USA
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26
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Sundfeldt M, Carlsson LV, Johansson CB, Thomsen P, Gretzer C. Aseptic loosening, not only a question of wear: a review of different theories. Acta Orthop 2006; 77:177-97. [PMID: 16752278 DOI: 10.1080/17453670610045902] [Citation(s) in RCA: 384] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Today, aseptic loosening is the most common cause of revision of major arthroplasties. Aseptic loosening accounts for more than two-thirds of hip revisions and almost one-half of knee revisions in Sweden. Several theories on the cause of aseptic loosening have been proposed. Most of these theories, however, are based on empiric observations, experimental animal models or anecdotal cases. In this review, we discuss the most common theories concerning aseptic loosening. It emerges from this review that aseptic loosening has a multifactorial etiology and cannot be explained by a single theory.
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Affiliation(s)
- Mikael Sundfeldt
- Department of Biomaterials/Handicap Research, Sahlgrenska University Hospital, University of Gothenburg, Sweden.
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27
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Rahbek O, Kold S, Zippor B, Overgaard S, Søballe K. Particle migration and gap healing around trabecular metal implants. INTERNATIONAL ORTHOPAEDICS 2005; 29:368-74. [PMID: 16132987 PMCID: PMC2231580 DOI: 10.1007/s00264-005-0008-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Accepted: 06/16/2005] [Indexed: 10/25/2022]
Abstract
Bone on-growth and peri-implant migration of polyethylene particles were studied in an experimental setting using trabecular metal and solid metal implants. Cylindrical implants of trabecular tantalum metal and solid titanium alloy implants with a glass bead blasted surface were inserted either in an exact surgical fit or with a peri-implant gap into a canine knee joint. We used a randomised paired design. Polyethylene particles were injected into the knee joint. In both types of surgical fit we found that the trabecular metal implants had superior bone ongrowth in comparison with solid metal implants (exact fit: 23% vs. 7% [p=0.02], peri-implant gap: 13% vs. 0% [p=0.02]. The number of peri-implant polyethylene particles was significantly reduced around the trabecular metal implants with a peri-implant gap compared with solid implants.
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Affiliation(s)
- O Rahbek
- Orthopedic Research Laboratory, Aarhus University Hospital, Nørrebrogade 44, Building 1A, 8000, Aarhus, Denmark.
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28
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Rahbek O, Kold S, Zippor B, Overgaard S, Soballe K. The influence of surface porosity on gap-healing around intra-articular implants in the presence of migrating particles. Biomaterials 2005; 26:4728-36. [PMID: 15763252 DOI: 10.1016/j.biomaterials.2004.11.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Accepted: 11/30/2004] [Indexed: 11/16/2022]
Abstract
The aim of the present study was to compare the effect of two different porous coatings on bone ongrowth and on the peri-implant migration of polyethylene (PE) particles. Porous-coated cylindrical implants with an either plasma-sprayed closed-pore coating (Pl) or titanium fiber metal open-pore coating (Fi) were inserted intra-articular in exact fit or with a 0.75 mm peri-implant gap. A weight-loaded implant device in the distal femur was used. We used a randomized paired design in eight dogs. PE particles were injected repeatedly intra-articular in the knee until the dogs were killed after 8 weeks. Fi implants had significantly more bone ongrowth 8 (0-21)% compared with Pl implants 0 (0-0)% in gap situations and reduced the number of peri-implant PE particles significantly. Among exact-fitted implants we found that peri-implant tissue around Pl implants consisted of significantly more fibrous tissue than around Fi implants. A sealing effect against the migration of PE particles was found for both Fi and Pl implants in exact fit.
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Affiliation(s)
- Ole Rahbek
- Orthopedic Research Laboratory, Aarhus University Hospital, Nørrebrogade 44, Building 1A, DK-8000 Aarhus C, Denmark.
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29
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Takayanagi S, Nagase M, Shimizu T, Kobayashi T, Shirakura K, Takagishi K. Human leukocyte antigen and aseptic loosening in Charnley total hip arthroplasty. Clin Orthop Relat Res 2003:183-91. [PMID: 12897609 DOI: 10.1097/01.blo.0000073340.50837.d8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Satoshi Takayanagi
- Department of Orthopaedic Surgery, Gunma University Faculty of Medicine, 3-39-22 Showa-machi, Maebashi-shi, Gunma-ken 371-8511, Japan.
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Abstract
Long-term clinical studies of total hip replacement suggest a direct relationship between bearing wear and periprosthetic osteolysis, particularly if polyethylene wear is greater than a threshold value of 0.1 mm per year. The current clinical trend to cross-linked polyethylene and hard-to-hard bearings attempts to ensure that bearing wear remains below this threshold. Fluid pressure generated in the hip during patient activity also has been implicated in the formation of periprosthetic lesions. Pressure fluctuation measured during manipulation of the hip at revision, or the identification of modular components that pump fluid during loading, suggest cyclic pressure may be a causative factor in bone resorption. Animal studies show the adverse effect of direct pressure on osteocytes. At more than 10 years followup, the low incidence of osteolytic lesions in retrospective reviews of successful cemented and cementless implant designs suggest that osteolysis is not an inevitable consequence of particle or pressure generation in the hip. If the quality of implant fixation prohibits fluid access to the surrounding bone, the rate of osteolysis is minimal. It is evident that whether the active factor in osteolysis is pressure, wear particles, or both, adverse periprosthetic effects can be minimized if access to the fixation interfaces in the hip is denied.
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Dumbleton JH, Manley MT, Edidin AA. A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002; 17:649-61. [PMID: 12168184 DOI: 10.1054/arth.2002.33664] [Citation(s) in RCA: 417] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The establishment of a polyethylene wear rate threshold for the development of osteolysis at the hip would allow surgeons to identify patients at risk for osteolysis and to implement selective, more frequent follow-up. We reviewed publications that met certain criteria for wear and osteolysis measurement. Based on this review, the incidence of osteolysis increases as the rate of wear increases. The literature indicates that osteolysis rarely is observed at a wear rate of <0.1 mm/y. We suggest that a practical wear rate threshold of 0.05 mm/y would eliminate osteolysis. This wear threshold suggests that the new cross-linked polyethylenes would reduce osteolysis, provided that in vivo wear rates mirror those observed in vitro. To facilitate future comparison of published data, we suggest that longitudinal wear studies adopt consistent edge detection-based wear measurement techniques and uniform osteolytic lesion classification and measurement schema.
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Matthews JB, Mitchell W, Stone MH, Fisher J, Ingham E. A novel three-dimensional tissue equivalent model to study the combined effects of cyclic mechanical strain and wear particles on the osteolytic potential of primary human macrophages in vitro. Proc Inst Mech Eng H 2002; 215:479-86. [PMID: 11726048 DOI: 10.1243/0954411011536073] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The effects of cyclic mechanical strain and challenge with physiologically relevant doses of submicrometre-size polyethylene (PE) particles on the osteolytic potential of primary human mononuclear phagocytes were investigated. Cells were seeded into a three-dimensional tissue matrix and co-cultured with particles (mean size 0.21 microm) at particle volume to cell number ratios of 7.5, 15, 30 and 100 microm3/cell. Matrices were then either cultured statically or subjected to 20 per cent cyclic compressional strain in the 'ComCell' for 16 h prior to the assessment of cell viability and quantification of the pro-inflammatory cytokine tumour necrosis factor alpha (TNFalpha). The MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazdium bromide) assay was shown to be too insensitive to detect changes in cell viability. However, when quantified by the adenosine triphosphate (ATP) assay, cell viability was demonstrated to be reduced following exposure to cyclic strain. Macrophages cultured in the static three-dimensional tissue equivalent model produced very high levels of TNFalpha in response to submicrometre PE particles at a ratio of 100 microm3/cell. Cyclic strain in the absence of particles gave only a small increase in TNFa production. However, the combined effects of strain and particle stimulation at a ratio of 30 microm3/cell resulted in the secretion of significantly more TNFalpha than was produced by macrophages subjected to strain alone, or the cells-only control. This synergy between cyclic strain and PE particle stimulation was only evident when the volume of particles was reduced below the volume that maximally stimulated cells. These results suggest that while cyclic strain may not be the primary factor responsible for macrophage activation and periprosthetic osteolysis, at low particle load, it may contribute significantly to the osteolytic potential of macrophages in vitro or in vivo.
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Affiliation(s)
- J B Matthews
- Division of Microbiology, The University of Leeds, West Yorkshire, UK
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Hilding M, Ryd L, Toksvig-Larsen S, Aspenberg P. Clodronate prevents prosthetic migration: a randomized radiostereometric study of 50 total knee patients. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:553-7. [PMID: 11145380 DOI: 10.1080/000164700317362163] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In a double-blind study, we randomized 50 patients to receive peroral clodronate medication or placebo from 3 weeks before until 6 months after a total knee replacement with a cemented NexGen implant. Migration of the tibial components was measured by radiostereometry at 1 year. Clodronate reduced prosthetic migration, as measured by maximum total point motion, from 0.40 mm to 0.29 mm (p = 0.01). This confirms that the early postoperative migration is related to bone resorption and thus the biology of the bone bed. Since early migration is related to late loosening, 6 months of clodronate medication might reduce the risk of loosening.
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Affiliation(s)
- M Hilding
- Department of Orthopedics and Center for Clinical Research, Uppsala University, Central Hospital of Västerås, Sweden.
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34
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Mjöberg B. Osteolysis and ceramic bearing surfaces. J Bone Joint Surg Am 2000; 82:1519-20; author reply 1520-1. [PMID: 11057497 DOI: 10.2106/00004623-200010000-00046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Sabokbar A, Crawford R, Murray DW, Athanasou NA. Macrophage-osteoclast differentiation and bone resorption in osteoarthrotic subchondral acetabular cysts. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:255-61. [PMID: 10919296 DOI: 10.1080/000164700317411843] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A macrophage infiltrate is commonly found in enlarging subchondral cysts in osteoarthrosis (OA) and the surrounding bone. To determine whether osteoclast differentiation by these cells contributes to the increase in the number of osteoclasts and bone resorption that accompanies OA cyst enlargement, we isolated macrophages from the wall of OA cysts and co-cultured them with osteoblast-like UMR106 cells in the presence or absence of 1,25(OH)2D3 and M-CSE After 14 days of incubation, co-cultures of UMR106 cells and cyst-derived macrophages showed evidence of osteoclast differentiation by expression of TRAP, VNR and formation of numerous lacunar pits. We found that, unlike osteoclast precursors in monocyte and other tissue macrophage populations, the addition of M-CSF to medium is not required for osteoclast differentiation. Our findings suggest that macrophage-osteoclast differentiation is one means whereby the osteolysis associated with the enlargement of OA cysts could be effected.
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Affiliation(s)
- A Sabokbar
- Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford, UK
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Li TF, Santavirta S, Virtanen I, Könönen M, Takagi M, Konttinen YT. Increased expression of EMMPRIN in the tissue around loosened hip prostheses. ACTA ORTHOPAEDICA SCANDINAVICA 1999; 70:446-51. [PMID: 10622476 DOI: 10.3109/17453679909000979] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Matrix metalloproteinases (MMPs) have been shown to play a role in aseptic loosening of total hip replacement (THR). Extracellular matrix metalloproteinase inducer (EMMPRIN) can upregulate expression of several MMPs but has little effect on their tissue inhibitor (TIMP). Using the avidin-biotin-peroxidase complex immunostaining method, we detected strong immunoreactivity of EMMPRIN in the lining-like layers, sublining area and vascular endothelium of synovial membrane-like interface tissue around loosened prostheses. In contrast, EMMPRIN staining was very weak in the synovial samples from patients with hip arthrosis. Double immunofluorescence labeling revealed EMMPRIN/MMP-1 double-positive cells in lining-like layers and the sublining area of interface tissue. Our findings indicate that EMMPRIN expression is upregulated in interface tissue, and that locally accumulated EMMPRIN may modulate MMP-1 expression. An imbalance in the activity of MMPs and TIMP may lead to tissue destruction and periprosthetic osteolysis. These biological responses, combined with mechanical stress caused by micromotion and oscillating fluid pressure, may eventually cause aseptic loosening of THR.
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Affiliation(s)
- T F Li
- Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Finland.
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Van der Vis HM, Aspenberg P, Tigchelaar W, Van Noorden CJ. Mechanical compression of a fibrous membrane surrounding bone causes bone resorption. Acta Histochem 1999; 101:203-12. [PMID: 10335363 DOI: 10.1016/s0065-1281(99)80019-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Early micromovement and migration of a prosthesis of a hip or knee predicts late clinical loosening of the prosthesis. Such migration is likely to be associated with mechanical compression of the fibrous membrane interpositioned between bone and prosthesis during movement. Compression of the fibrous membrane by loading may lead to locally high fluid pressures reaching the underlying bone tissue. It has been established that high fluid pressures can lead to bone resorption. This resorption may eventually lead to clinical loosening of the prosthesis. We developed an experimental model to study the effects of compression of a soft tissue layer located between a titanium implant and cortical bone. In twelve rabbits, this device was implanted in the proximal tibia and allowed to osseointegrate. Next, a layer of soft tissue was allowed to form between titanium and bone. Subsequently, in six rabbits a cyclic load of 60 times in 2 min per day during 2 weeks was applied, leading to compression of the interpositioned soft tissue layer only. In the other six rabbits no load was applied. In all six loaded specimens, osteocyte death and bone resorption was observed underneath the area where compression of the fibrous membrane was exerted to a depth exceeding the amplitude of the loading device. Furthermore, formation of fibrocartilage was observed in the loaded areas. Formation of fibrocartilage, osteocyte death or bone resorption did not occur in the controls. Our results indicate that compression of a fibrous membrane surrounding bone can lead to resorption of the underlying bone primarily because of osteocyte death and subsequent resorption of dead bone tissue. This may explain the observation that early migration of a hip or knee prosthesis is predictive of clinical loosening of the prosthesis.
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Affiliation(s)
- H M Van der Vis
- Academical Medical Center, University of Amsterdam, Department of Orthopedics, The Netherlands
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40
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Abstract
Distal migration of the femoral component of a total hip replacement by as little as 0.33 mm during the first 6 postoperative months is predictive of the need for revision many years later. Because the fate of the prostheses is defined so early, it is unlikely that wear particles initiate loosening. However, the progression from the stage of early migration to clinical loosening has unknown causes, of which particles may be one. Slight instability associated with migration will lead to locally high fluid pressures surrounding the migrating prosthesis. Recent experiments applied a moderate fluid pressure to an implant to bone interface. This induced osteocyte death near the implant and subsequent bone resorption. Thus, there is evidence that fluid pressure and ensuing flow could be a main cause of not only pain, but also osteolysis necessitating revision.
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Mjöberg B. Failed hip prostheses in hemodialysis patients: need for a new mechanism of prosthetic loosening? ACTA ORTHOPAEDICA SCANDINAVICA 1998; 69:329-330. [PMID: 9703417 DOI: 10.3109/17453679809000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Aspenberg P, van der Vis H. Fluid pressure may cause periprosthetic osteolysis. Particles are not the only thing. ACTA ORTHOPAEDICA SCANDINAVICA 1998; 69:1-4. [PMID: 9524506 DOI: 10.3109/17453679809002344] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Early prosthesis migration predicts late clinical failure, as also does the shape or position of, e.g., a femoral stem. These factors appear unrelated to wear particles. Thus, the initiation of the loosening process has other causes. After this process has started (i.e., the prosthesis migrates), particles may play a role, at least by inhibiting new bone formation at the membrane, but the hypothesis of pressure-induced bone resorption appears easier to support by animal experiments and accords with mechanical risk factors.
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Affiliation(s)
- P Aspenberg
- Department of Orthopedics, Lund University Hospital, Sweden
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