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Histological features of pseudotumor-like tissues from metal-on-metal hips.

Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC - Clin. Orthop. Relat. Res. (2010)

Bottom Line: A 10-point histological score was used to rank the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL) by examination of synovial lining integrity, inflammatory cell infiltrates, and tissue organization.Pseudotumor-like reactions can be caused by high wear, but may also occur around implants with low wear, likely because of a metal hypersensitivity reaction.Histologic features including synovial integrity, inflammatory cell infiltrates, tissue organization, and metal particles may help differentiate these causes.

View Article: PubMed Central - PubMed

Affiliation: J Vernon Luck Sr MD Orthopaedic Research Center, Orthopaedic Hospital/UCLA, 2400 S Flower Street, Los Angeles, CA 90007, USA. campbell@laoh.ucla.edu

ABSTRACT

Background: Pseudotumor-like periprosthetic tissue reactions around metal-on-metal (M-M) hip replacements can cause pain and lead to revision surgery. The cause of these reactions is not well understood but could be due to excessive wear, or metal hypersensitivity or an as-yet unknown cause. The tissue features may help distinguish reactions to high wear from those with suspected metal hypersensitivity.

Questions/purposes: We therefore examined the synovial lining integrity, inflammatory cell infiltrates, tissue organization, necrosis and metal wear particles of pseudotumor-like tissues from M-M hips revised for suspected high wear related and suspected metal hypersensitivity causes.

Methods: Tissue samples from 32 revised hip replacements with pseudotumor-like reactions were studied. A 10-point histological score was used to rank the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL) by examination of synovial lining integrity, inflammatory cell infiltrates, and tissue organization. Lymphocytes, macrophages, plasma cells, giant cells, necrosis and metal wear particles were semiquantitatively rated. Implant wear was measured with a coordinate measuring machine. The cases were divided into those suspected of having high wear and those suspected of having metal hypersensitivity based on clinical, radiographic and retrieval findings. The Mann-Whitney test was used to compare the histological features in these two groups.

Results: The tissues from patients revised for suspected high wear had a lower ALVAL score, fewer lymphocytes, but more macrophages and metal particles than those tissues from hips revised for pain and suspected metal hypersensitivity. The highest ALVAL scores occurred in patients who were revised for pain and suspected metal hypersensitivity. Component wear was lower in that group.

Conclusions: Pseudotumor-like reactions can be caused by high wear, but may also occur around implants with low wear, likely because of a metal hypersensitivity reaction. Histologic features including synovial integrity, inflammatory cell infiltrates, tissue organization, and metal particles may help differentiate these causes.

Clinical relevance: Painful hips with periprosthetic masses may be caused by high wear, but if this can be ruled out, metal hypersensitivity should be considered.

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Related in: MedlinePlus

Light micrograph showing typical histologic features of cases revised for suspected metal sensitivity, including a thick, mostly acellular tidemark area lined by fibrin (F) and thick, dense aggregates of lymphocytes at the rear of the tissue (arrows) (Stain, hematoxylin and eosin, original magnification ×40). This received an ALVAL score of 10 (3 for synovial lining, 4 for inflammatory infiltrate, and 3 for tissue organization).
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Fig3: Light micrograph showing typical histologic features of cases revised for suspected metal sensitivity, including a thick, mostly acellular tidemark area lined by fibrin (F) and thick, dense aggregates of lymphocytes at the rear of the tissue (arrows) (Stain, hematoxylin and eosin, original magnification ×40). This received an ALVAL score of 10 (3 for synovial lining, 4 for inflammatory infiltrate, and 3 for tissue organization).

Mentions: When comparing the histologic features in the tissues of patients revised for suspected high wear with those revised for pain and suspected metal sensitivity, the higher wear cases had a lower (p < 0.001) ALVAL score, fewer lymphocytes but more macrophages and metal particles (Table 2). Histologically, there was considerable variability in the amount and distribution of metal debris, the number and type and arrangement of inflammatory cells, and the degree of necrosis. Very few tissues demonstrated an intact synovial lining and there was often a layer of adherent fibrin, organized fibrin, or necrosis on the joint cavity side of the tissue. Macrophages and lymphocytes were present in all cases, but those with extensive infiltrates of macrophages tended to have smaller lymphocyte aggregates (Fig. 2). This was in contrast to the appearance of very large, dense lymphocyte aggregates, often arranged distal to the surface (Fig. 3), which were more often seen in association with small to moderate amounts of macrophages. The highest ALVAL scores occurred in patients revised for pain and suspected metal sensitivity. Most of the tissues had focal to moderate necrosis and one case had necrosis that dominated most of the tissue sections (Fig. 4).Table 2


Histological features of pseudotumor-like tissues from metal-on-metal hips.

Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC - Clin. Orthop. Relat. Res. (2010)

Light micrograph showing typical histologic features of cases revised for suspected metal sensitivity, including a thick, mostly acellular tidemark area lined by fibrin (F) and thick, dense aggregates of lymphocytes at the rear of the tissue (arrows) (Stain, hematoxylin and eosin, original magnification ×40). This received an ALVAL score of 10 (3 for synovial lining, 4 for inflammatory infiltrate, and 3 for tissue organization).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2914255&req=5

Fig3: Light micrograph showing typical histologic features of cases revised for suspected metal sensitivity, including a thick, mostly acellular tidemark area lined by fibrin (F) and thick, dense aggregates of lymphocytes at the rear of the tissue (arrows) (Stain, hematoxylin and eosin, original magnification ×40). This received an ALVAL score of 10 (3 for synovial lining, 4 for inflammatory infiltrate, and 3 for tissue organization).
Mentions: When comparing the histologic features in the tissues of patients revised for suspected high wear with those revised for pain and suspected metal sensitivity, the higher wear cases had a lower (p < 0.001) ALVAL score, fewer lymphocytes but more macrophages and metal particles (Table 2). Histologically, there was considerable variability in the amount and distribution of metal debris, the number and type and arrangement of inflammatory cells, and the degree of necrosis. Very few tissues demonstrated an intact synovial lining and there was often a layer of adherent fibrin, organized fibrin, or necrosis on the joint cavity side of the tissue. Macrophages and lymphocytes were present in all cases, but those with extensive infiltrates of macrophages tended to have smaller lymphocyte aggregates (Fig. 2). This was in contrast to the appearance of very large, dense lymphocyte aggregates, often arranged distal to the surface (Fig. 3), which were more often seen in association with small to moderate amounts of macrophages. The highest ALVAL scores occurred in patients revised for pain and suspected metal sensitivity. Most of the tissues had focal to moderate necrosis and one case had necrosis that dominated most of the tissue sections (Fig. 4).Table 2

Bottom Line: A 10-point histological score was used to rank the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL) by examination of synovial lining integrity, inflammatory cell infiltrates, and tissue organization.Pseudotumor-like reactions can be caused by high wear, but may also occur around implants with low wear, likely because of a metal hypersensitivity reaction.Histologic features including synovial integrity, inflammatory cell infiltrates, tissue organization, and metal particles may help differentiate these causes.

View Article: PubMed Central - PubMed

Affiliation: J Vernon Luck Sr MD Orthopaedic Research Center, Orthopaedic Hospital/UCLA, 2400 S Flower Street, Los Angeles, CA 90007, USA. campbell@laoh.ucla.edu

ABSTRACT

Background: Pseudotumor-like periprosthetic tissue reactions around metal-on-metal (M-M) hip replacements can cause pain and lead to revision surgery. The cause of these reactions is not well understood but could be due to excessive wear, or metal hypersensitivity or an as-yet unknown cause. The tissue features may help distinguish reactions to high wear from those with suspected metal hypersensitivity.

Questions/purposes: We therefore examined the synovial lining integrity, inflammatory cell infiltrates, tissue organization, necrosis and metal wear particles of pseudotumor-like tissues from M-M hips revised for suspected high wear related and suspected metal hypersensitivity causes.

Methods: Tissue samples from 32 revised hip replacements with pseudotumor-like reactions were studied. A 10-point histological score was used to rank the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL) by examination of synovial lining integrity, inflammatory cell infiltrates, and tissue organization. Lymphocytes, macrophages, plasma cells, giant cells, necrosis and metal wear particles were semiquantitatively rated. Implant wear was measured with a coordinate measuring machine. The cases were divided into those suspected of having high wear and those suspected of having metal hypersensitivity based on clinical, radiographic and retrieval findings. The Mann-Whitney test was used to compare the histological features in these two groups.

Results: The tissues from patients revised for suspected high wear had a lower ALVAL score, fewer lymphocytes, but more macrophages and metal particles than those tissues from hips revised for pain and suspected metal hypersensitivity. The highest ALVAL scores occurred in patients who were revised for pain and suspected metal hypersensitivity. Component wear was lower in that group.

Conclusions: Pseudotumor-like reactions can be caused by high wear, but may also occur around implants with low wear, likely because of a metal hypersensitivity reaction. Histologic features including synovial integrity, inflammatory cell infiltrates, tissue organization, and metal particles may help differentiate these causes.

Clinical relevance: Painful hips with periprosthetic masses may be caused by high wear, but if this can be ruled out, metal hypersensitivity should be considered.

Show MeSH
Related in: MedlinePlus