Human monocyte response to particulate biomaterials generated in vivo and in vitro

Nanoplastics: Immune Impact, Detection, and Internalization after Human Blood Exposure by Single-Cell Mass Cytometry

The increasing exposure to nanoplastics (NPs) raises significant concerns for human health, primarily due to their potential bioaccumulative properties. While NPs have recently been detected in human blood, their interactions with specific immune cell subtypes and their impact on immune regulation remain unclear. In this proof-of-concept study, model palladium-doped polystyrene NPs (PS-Pd NPs) are utilized to enable single-cell mass cytometry (CyTOF) detection. The size-dependent impact of carboxylate polystyrene NPs (50-200 nm) is investigated across 15 primary immune cell subpopulations using CyTOF. By taking advantage of Pd-doping for detecting PS-Pd NPs, this work evaluates their impact on human immune-cells at the single-cell level following blood exposure. This work traces PS-Pd NPs in 37 primary immune-cell subpopulations from human blood, quantifying the palladium atom count per cell by CyTOF while simultaneously assessing the impact of PS-Pd NPs on cell viability, functionality, and uptake. These results demonstrate that NPs can interact with, interfere with, and translocate into several immune cell subpopulations after exposure. In vivo distribution experiments in mice further confirmed their accumulation in immune cells within the liver, blood, and spleen, particularly in monocytes, macrophages, and dendritic cells. These findings provide valuable insights into the impact of NPs on human health.

In Vitro Hydroxyapatite Nucleation in Cationically Cured Epoxy Composites with Pulverized Date Seed

Recently, driven by a growing focus on environmental sustainability and cost-effectiveness, researchers have shown a keen interest in creating useful materials from bio-wastes, particularly for their potential applications in the biomedical field. Current research has been conducted on the impact of date seed powder (DSP) on hydroxyapatite (HA) formation, specifically in relation to the promotion of bone health and regeneration. HA is an essential component of bone tissue and plays a crucial role in maintaining bone strength and structure. Date seed (DS) was used in two forms i.e., grains and powder, with unmodified and modified surface chemistries. Prepared composites were tested in vitro by soaking them in simulated body fluid (SBF). X-ray Diffraction (XRD) and Fourier Transform Infra-Red (FTIR) confirmed HA formation in all soaked samples. Thermogravimetric analysis (TGA) results indicated an improvement in thermal stability after soaking, suggesting a higher concentration of HA. Unsoaked samples were observed to have higher heat flow than soaked samples. The high gel content (GCs) over 90% and low hydrophilicity (less than 5%) of DSP-based composites were proven to be beneficial in HA nucleation. Antibacterial activity showed that the addition of DS filler yielded superior results compared to the pristine sample. Additionally, the modified samples demonstrated better antibacterial results than the unmodified ones.

A review on manufacturing processes of cobalt-chromium alloy implants and its impact on corrosion resistance and biocompatibility

Cobalt-Chromium (CoCr) alloys are currently used for various cardiovascular, orthopedic, fracture fixation, and dental implants. A variety of processes such as casting, forging, wrought processing, hot isostatic pressing, metal injection molding, milling, selective laser melting, and electron beam melting are used in the manufacture of CoCr alloy implants. The microstructure and precipitates (carbides, nitrides, carbonitrides, and intermetallic compounds) formed within the alloy are primarily determined by the type of manufacturing process employed. Although the effects of microstructure and precipitates on the physical and mechanical properties of CoCr alloys are well reviewed and documented in the literature, the effects on corrosion resistance and biocompatibility are not comprehensively reviewed. This article reviews the various processes used to manufacture CoCr alloy implants and discusses the effects of manufacturing processes on corrosion resistance and biocompatibility. This review concludes that the microstructure and precipitates formed in the alloy are unique to the manufacturing process employed and have a significant impact on the corrosion resistance and biocompatibility of CoCr alloys. Additionally, a historical and scientific overview of corrosion and biocompatibility for metallic implants is included in this review. Specifically, the failure of CoCr alloys when used in metal-on-metal bearing surfaces of total hip replacements is highlighted. It is recommended that the type of implant/application (orthopedic, dental, cardiovascular, etc.) should be the first and foremost factor to be considered when selecting biomaterials for medical device development.

An overview of the tribological and mechanical properties of PEEK and CFR-PEEK for use in total joint replacements

Poly-ether-ether-ketone (PEEK) and PEEK composites are outstanding candidates for biomedical applications, such as orthopedic devices, where biocompatibility and modulus match with surrounding tissue are requisite for long-term success. The mechanical properties can be optimized by incorporating fillers such as continuous and chopped carbon fibers. While much is known about the mechanical and tribological behavior of PEEK composites, there are few articles that summarize the viability of using PEEK reinforced with carbon fibers in orthopedic implants. This paper reviews biocompatibility, tribological, and mechanical studies on PEEK and their composites with carbon fibers, notably PEEK reinforced with polyacrylonitrile (PAN)-based carbon fibers and PEEK reinforced with pitch-based carbon fibers, for application in orthopedics and total joint replacements (TJRs). The main objectives of this review are two-fold. Firstly, this paper aims to assist designers in making informed decisions on the suitability of using PEEK and PEEK composites in orthopedic applications; as it is not well understood how these materials perform on the whole in orthopedics and TJRs. Secondly, this paper aims to serve as a centralized paper in which researchers can gain information on the tribological and mechanical advancements of PEEK and PEEK composites.

Isolation and characterisation of wear debris surrounding failed total ankle replacements

Aseptic loosening and osteolysis continue to be a short- to mid-term problem for total ankle replacement (TAR) devices. The production of wear particles may contribute to poor performance, but their characteristics are not well understood. This study aimed to determine the chemical composition, size and morphology of wear particles surrounding failed TARs. A recently developed wear particle isolation method capable of isolating both high- and low-density materials was applied to 20 retrieved periprosthetic tissue samples from 15 failed TARs of three different brands. Isolated particles were imaged using ultra-high-resolution imaging and characterised manually to determine their chemical composition, size, and morphology. Six different materials were identified, which included: UHMWPE, calcium phosphate (CaP), cobalt chromium alloy (CoCr), commercially pure titanium, titanium alloy and stainless steel. Eighteen of the 20 samples contained three or more different wear particle material types. In addition to sub-micron UHMWPE particles, which were present in all samples, elongated micron-sized shards of CaP and flakes of CoCr were commonly isolated from tissues surrounding AES TARs. The mixed particles identified in this study demonstrate the existence of a complex periprosthetic environment surrounding TAR devices. The presence of such particles suggests that early failure of devices may be due in part to the multifaceted biological cascade that ensues after particle release. This study could be used to support the validation of clinically-relevant wear simulator testing, pre-clinical assessment of fixation wear and biological response studies to improve the performance of next generation ankle replacement devices. STATEMENT OF SIGNIFICANCE: Total ankle replacement devices do not perform as well as total hip and knee replacements, which is in part due to the relatively poor scientific understanding of how they fail. The excessive production of certain types of wear debris is known to contribute to joint replacement failure. This is the first study to successfully isolate and characterise high- and low-density wear particles from tissues collected from patients with a failed total ankle replacement. This article includes the chemical composition and characteristics of the wear debris generated by ankle devices, all of which may affect their performance. This research provides clinically relevant reference values and images to support the development of pre-clinical testing for future total ankle replacement designs.

Nanoplastics affect the inflammatory cytokine release by primary human monocytes and dendritic cells

So far, the human health impacts of nano- and microplastics are poorly understood. Thus, we investigated whether nanoplastics exposure induces inflammatory processes in primary human monocytes and monocyte-derived dendritic cells. We exposed these cells in vitro to nanoplastics of different shapes (irregular vs. spherical), sizes (50-310 nm and polydisperse mixtures) and polymer types (polystyrene; polymethyl methacrylate; polyvinyl chloride, PVC) using concentrations of 30-300 particles cell^-1. Our results show that irregular PVC particles induce the strongest cytokine release of these nanoplastics. Irregular polystyrene triggered a significantly higher pro-inflammatory response compared to spherical nanoplastics. The contribution of chemicals leaching from the particles was minor. The effects were concentration-dependent but varied markedly between cell donors. We conclude that nanoplastics exposure can provoke human immune cells to secrete cytokines as key initiators of inflammation. This response is specific to certain polymers (PVC) and particle shapes (fragments). Accordingly, nanoplastics cannot be considered one homogenous entity when assessing their health implications and the use of spherical polystyrene nanoplastics may underestimate their inflammatory effects.

IL-17A-Mediated Immune-Inflammatory Periarticular Mass and Osteolysis From Impingement in Ceramic-On-Ceramic Total Hip Arthroplasty

We present a rare case of symptomatic adverse local tissue reaction in a 54-year-old female patient who had undergone total hip arthroplasty with ceramic-on-ceramic bearing. Inflammatory periarticular mass and osteolysis developed in the absence of cobalt chrome alloy interfaces and a modular neck component. On the pathologic images, there was no clear evidence of gross metal staining of tissues, metal corrosion, and ceramic or metal wear particles. However, there were impingement scars on the titanium alloy femoral neck and acetabular cup associated with a high combined anteversion angle of 75° (stem: 40° and cup: 35°), suggesting titanium debris release in vivo. Immunohistochemical staining proved a predominant infiltration of CD4+ T cells and the corresponding IL-17A response to metal. We conclude that neck-rim impingement may lead to the development of adverse local tissue reaction (periarticular mass and osteolysis) due to a metal hypersensitivity with the production of proinflammatory cytokines (IL-17A) by CD4+ T cells even in ceramic-on-ceramic total hip arthroplasty.

Hazard assessment of small-size plastic particles: is the conceptual framework of particle toxicology useful?

Humans are exposed to plastic particles, but there are no studies on environmental plastics in cell cultures or animals. The toxicological understanding arises from model particles like polystyrene, polyethylene or non-plastic particles like food-grade titanium dioxide. The majority of studies on polystyrene particles show toxicological effects on measures of oxidative stress, inflammation, mitochondrial dysfunction, lysosomal dysfunction and apoptosis. The toxic effects in cell cultures mainly occur at high concentrations. Polyethylene particles seem to generate inflammatory reactions, whereas other toxicological effects have not been assessed. There are very few studies on effects of polystyrene particles in animal models and these have not demonstrated overt indices of toxicity. Studies in animals are the likely way for hazard assessment of micro- or nanoplastics. However, co-culture systems that mimic the complex architecture of mammalian tissues can cost-efficiently determine the hazards of micro- and nanoplastics. Future studies should include low doses of micro- and nanoplastic particles, which are more relevant in the assessment of health risk than the extrapolation of effects from high doses to realistic doses. Based on studies on model particles, environmental exposure to micro- and nanoplastic particles may be a hazard to human health.

Evaluation of Aerosol Electrospray Analysis of Metal-on-Metal Wear Particles from Simulated Total Joint Replacement

Wear is a common cause for aseptic loosening in artificial joints. The purpose of this study was to develop an automated diagnostical method for identification of the number and size distribution of wear debris. For this purpose, metal debris samples were extracted from a hip simulator and then analyzed by the electrospray method combined with a differential mobility analyzer, allowing particle detection ranging from several nanometers up to 1 µm. Wear particles were identified with a characteristic peak at 15 nm. The electrospray setup was successfully used and validated for the first time to characterize wear debris from simulated total joint replacement. The advantages of this diagnostic method are its time- and financial efficiency and its suitability for testing of different materials.

The Inflammatory Effects of Breast Implant Particulate Shedding: Comparison With Orthopedic Implants

Currently, there is a dearth of information regarding the degree of particle shedding from breast implants (BIs) and what are the general biological consequences of BI debris. Thus, it is unclear to what degree BI debris compromises the long-term biological performance of BIs. For orthopedic implants, it is well established that the severity of biological reactivity to implant debris governs long-term clinical performance. Orthopedic implant particulate debris is generally in the range of 0.01 to 100 μm in diameter. Implant debris-induced bioreactivity/inflammation is mostly a peri-implant phenomenon caused by local innate immune cells (eg, macrophages) that produce proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, interleukin-6, and prostaglandin 2 (PGE2). In orthopedics, there have been few systemic concerns associated with polymeric implant debris (like silicone) other than documented dissemination to remote organs (eg, liver, spleen, etc.) with no known associated pathogenicity. This is not true of metal implant debris where normal (well-functioning) implants can induce systemic reactions such as delayed type hypersensitivity. Diagnostic analysis of orthopedic tissues has focused on innate (macrophage mediated) and adaptive (lymphocyte-mediated hypersensitivity) immune responses. Orthopedic implant debris-associated lymphocyte cancers have not been reported in over 40 years of orthopedic literature. Adaptive immune responses such as hypersensitivity reactions to orthopedic implant debris have been dominated by certain implant types that produce specific kinds of debris (eg, metal-on-metal total joint prostheses). Orthopedic hypersensitivity responses and atypical BI bioreactivity such as BI-associated anaplastic large cell lymphoma share crossover markers for diagnosis. Differentiating normal innate immune reactivity to particles from anaplastic large cell lymphoma reactions from delayed type hypersensitivity reactions to BI-associated implant debris remains unclear but vital to patients and surgeons.

Large tibial geode, which developed several years after a left medial Oxford unicondylar knee arthroplasty, treated with curettage and bone grafting

BACKGROUND

Tibial geodes are rare, and usually reported in association with rheumatoid arthritis. This case study reported the rare occurrence of a tibial geode in association with a left unicondylar knee arthroplasty (UKA). The patient, a 55-year-old male, was initially pleased with his UKA, which was performed at another institution. However, just over one year after the operation he began experiencing pain and discomfort. He did not present to the current institution until he was six years after UKA. This pain was movement and weight bearing related, although he still managed to maintain an active lifestyle working as a builder. After several years of follow-up, a computed tomography (CT) scan showed a significant increase in size of the geode.

METHODS

The patient initially did not want to undergo further surgery, as he was self-employed, but it was decided, in conjunction with the patient, that it was time to operate because the stability of the prothesis was in question. Transcortical and retrograde curettage of the geode was performed and one and a half femoral head allografts were used to fill the geode.

RESULTS

Follow-up since the operation showed good infilling of the geode and bone remodelling, with resolution of symptoms at 12 months.

CONCLUSIONS

This case report was the first to report a symptomatic tibial geode in close association with UKA, which did not lead to revision surgery to total knee arthroplasty (TKA), but instead was successfully treated with currettage and bone grafting.

Effects of Major Components of Synovial Fluid on the Morphology and Wear Rate of Polyetheretherketone (PEEK) Particles under an Accelerated Wear Process

Wear particle-induced biological responses are the major factors for the failure of total joint arthroplasties, but it is possible to improve the lubrication and reduce the wear of an artificial joint system. Polyetheretherketone (PEEK), with ultra-high molecular weight polyethylene, is a suitable bearing material due to its resistance to fatigue strain. However, the effects of major compositions of synovial fluid on the wear of PEEK are unclear. We characterized the effects of three major components of synovial fluid including albumin, globulin, and phospholipids on the morphology and wear rate of PEEK wear particles. Our results demonstrated that the concentrations of albumin and globulin could affect the morphology of PEEK wear particles. In addition, a higher concentration of globulin and phospholipids (12.5 mg/mL) resulted in an increase in the amount of wear particles by 2.8- and 1.7-fold, respectively. In contrast, increasing albumin caused a reduction of wear particle numbers. These results indicate increasing concentration of albumin or reducing concentration of globulin or phospholipids has a better effect on reducing the numbers of wear particles and provides a potential solution of reducing PEEK wear particles, thus it can be more effectively applied in other biomedical systems.

The Biologic Response to Polyetheretherketone (PEEK) Wear Particles in Total Joint Replacement: A Systematic Review

BACKGROUND

Polyetheretherketone (PEEK) and its composites are polymers resistant to fatigue strain, radiologically transparent, and have mechanical properties suitable for a range of orthopaedic applications. In bulk form, PEEK composites are generally accepted as biocompatible. In particulate form, however, the biologic response relevant to joint replacement devices remains unclear. The biologic response to wear particles affects the longevity of total joint arthroplasties. Particles in the phagocytozable size range of 0.1 µm to 10 µm are considered the most biologically reactive, particularly particles with a mean size of < 1 µm. This systematic review aimed to identify the current evidence for the biologic response to PEEK-based wear debris from total joint arthroplasties.

QUESTIONS/PURPOSES

(1) What are the quantitative characteristics of PEEK-based wear particles produced by total joint arthroplasties? (2) Do PEEK wear particles cause an adverse biologic response when compared with UHMWPE or a similar negative control biomaterial? (3) Is the biologic response affected by particle characteristics?

METHODS

Embase and Ovid Medline databases were searched for studies that quantified PEEK-based particle characteristics and/or investigated the biologic response to PEEK-based particles relevant to total joint arthroplasties. The keyword search included brands of PEEK (eg, MITCH, MOTIS) or variations of PEEK types and nomenclature (eg, PAEK, CFR-PEEK) in combination with types of joint (eg, hip, knee) and synonyms for wear debris or immunologic response (eg, particles, cytotoxicity). Peer-reviewed studies, published in English, investigating total joint arthroplasty devices and cytotoxic effects of PEEK particulates were included. Studies investigating devices without articulating bearings (eg, spinal instrumentation devices) and bulk material or contact cytotoxicity were excluded. Of 129 studies, 15 were selected for analysis and interpretation. No studies were found that isolated and characterized PEEK wear particles from retrieved periprosthetic human tissue samples.

RESULTS

In the four studies that quantified PEEK-based particles produced using hip, knee, and spinal joint replacement simulators, the mean particle size was 0.23 µm to 2.0 µm. The absolute range reported was approximately 0.01 µm to 50 µm. Rod-like carbon particulates and granular-shaped PEEK particles were identified in human tissue by histologic analysis. Ten studies, including six animal models (rat, mouse, and rabbit), three cell line experiments, and two human tissue retreival studies, investigated the biologic response to PEEK-based particles. Qualitative histologic assessments showed immunologic cell infiltration to be similar for PEEK particles when compared with UHMWPE particles in all six of the animal studies identified. However, increased inflammatory cytokine release (such as tumor necrosis factor-α) was identified in only one in vitro study, but without substantial suppression in macrophage viability. Only one study tested the effects of particle size on cytotoxicity and found the largest unfilled PEEK particles (approximately 13 µm) to have a toxic effect; UHMWPE particles in the same size range showed a similar cytotoxic effect.

CONCLUSIONS

Wear particles produced by PEEK-based bearings were, in almost all cases, in the phagocytozable size range (0.1-10 µm). The studies that evaluated the biologic response to PEEK-based particles generally found cytotoxicity to be within acceptable limits relative to the UHMWPE control, but inconsistent when inflammatory cytokine release was considered.

CLINICAL RELEVANCE

To translate new and advanced materials into clinical use more quickly, the clinical relevance and validity of preclinical tests need to be improved. To achieve this for PEEK-based devices, human tissue retrieval studies including subsequent particle isolation and characterization analyses are required. In vitro cell studies using isolated wear particles from tissue or validated joint replacement simulators, instead of manufactured particles, are also required.

Particle characterisation and cytokine expression in failed small-diameter metal-on-metal total hip arthroplasties

The peri-prosthetic tissue response to wear debris is complex and influenced by various factors including the size, area and number of particles. We hypothesised that the ‘biologically active area’ of all metal wear particles may predict the type of peri-prosthetic tissue response.

Peri-prosthetic tissue was sampled from 21 patients undergoing revision of a small diameter metal-on-metal (MoM) total hip arthroplasty (THA) for aseptic loosening. An enzymatic protocol was used for tissue digestion and scanning electron microscope was used to characterise particles. Equivalent circle diameters and particle areas were calculated. Histomorphometric analyses were performed on all tissue specimens. Aspirates of synovial fluid were collected for analysis of the cytokine profile analysis, and compared with a control group of patients undergoing primary THA (n = 11) and revision of a failed ceramic-on-polyethylene arthroplasty (n = 6).

The overall distribution of the size and area of the particles in both lymphocyte and non-lymphocyte-dominated responses were similar; however, the subgroup with lymphocyte-dominated peri-prosthetic tissue responses had a significantly larger total number of particles.

14 cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17, interferon (IFN)-γ, and IFN-gamma-inducible protein 10), chemokines (macrophage inflammatory protein (MIP)-1α and MIP-1ß), and growth factors (granulocyte macrophage colony stimulating factor (GM-CSF) and platelet derived growth factor) were detected at significantly higher levels in patients with metal wear debris compared with the control group.

Significantly higher levels for IL-1ß, IL-5, IL-10 and GM-CSF were found in the subgroup of tissues from failed MoM THAs with a lymphocyte-dominated peri-prosthetic response compared with those without this response.

These results suggest that the ‘biologically active area’ predicts the type of peri-prosthetic tissue response. The cytokines IL-1ß, IL-5, IL-10, and GM-CSF are associated with lymphocyte-dominated tissue responses from failed small-diameter MoM THA.

Cite this article: Bone Joint J 2015;97-B:917–23.

Synovial fluid differential cell count in wear debris synovitis after total knee replacement

BACKGROUND

Determining the cause of synovitis following total knee arthroplasty (TKA) can be challenging. The differential diagnoses include infection, hemarthrosis, instability, crystalline disease, wear debris or idiopathic causes. Wear particle synovitis can mimic periprosthetic infection with symptoms of pain and effusion. Radiographs and physical exam are often inconclusive in differentiating the two. Synovial fluid analysis is routinely used in evaluating periprosthetic infections. We examined the association between synovial white blood cell count and differentials, and polyethylene wear and osteolysis, to see if fluid analysis can aid in establishing the diagnosis of wear particle synovitis.

METHODS

A cell count and differential was obtained from synovial fluid samples from 54 TKAs undergoing revision for aseptic failure. Explanted polyethylene inserts were analyzed for linear and volumetric wear, oxidation (ketone peak height), and damage features. Analysis was performed to assess the relationship between cell counts and polyethylene wear indicators as well as severity of intra-operative and radiographic osteolysis.

RESULTS

Total and percent mononuclear (monocyte and lymphocyte) cell counts were found to be elevated in the presence of documented wear debris synovitis and an association was suggested between their levels and maximum ketone levels.

CONCLUSION

The present study implies that the differential cell count of knee fluid can help distinguish wear debris from infection as a source of synovitis following TKA and identifies the value of the mononuclear cell count as a possible tool to assess abnormal wear rates of the polyethylene insert. Further research into identifying the exact role of monocytes in the wear debris synovitis and osteolytic pathways is warranted.

LEVEL OF EVIDENCE

Level II, diagnostic study.

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

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

Human polyethylene granuloma tissues inhibit bone healing in a novel xenograft animal model

During revision of a conventional polyethylene joint replacement, surgeons usually remove the source of osteolysis (polyethylene) but cannot always remove all of the polyethylene granuloma tissues. We developed a human/rat xenograft model to investigate the effects of polyethylene granuloma tissues on bone healing. Human osteoarthritic and periprosthetic tissues collected during primary and revision hip arthroplasty surgeries were transplanted into the distal femora of athymic nude rats. After 3 weeks in vivo, there was a significant difference in the bone volume fraction (Vf ) between empty, primary, and revision defects (p = 0.02), with a lower Vf in defects with revision granuloma tissues compared to defects with primary osteoarthritic tissues. Polyethylene granuloma tissues in trabecular bone defects inhibited bone healing. Therefore, debridement around a metal-on-polyethylene hip replacement may shorten the time it takes to achieve secondary stability around a revision hip replacement.

Alternative bearing surfaces in total hip arthroplasty

Total hip arthroplasty continues to be one of the most effective surgical procedures currently available. The longevity of this otherwise very successful procedure is compromised by the wear of the bearing surface. In recent years, great advances have been made in the design of bearing surfaces that poise to offer extended performance to these artificial joints. The purpose of this review is to discuss the recent technologic advances in bearing surfaces and offer an insight to the potential benefits and concerns with the alternative bearing surfaces.

Increasing both CoCrMo-alloy particle size and surface irregularity induces increased macrophage inflammasome activation in vitro potentially through lysosomal destabilization mechanisms

Recent investigations indicate that innate immune "danger-signaling" pathways mediate metal implant debris induced-inflammatory responses, for example, NALP3 inflammasome. How the physical characteristics of particles (size, shape, and chemical composition) affect this inflammatory reactivity remains controversial. We examined the role of Cobalt-Chromium-Molybdenum (CoCrMo) alloy particle shape and size on human macrophage phagocytosis, lysosomal destabilization, and inflammasome activation. Round/smooth versus irregularly shaped/rough CoCrMo-alloy particles of ∼1 and 6-7 µm diameter were investigated for differential lysosomal damage and inflammasome activation in human monocytes/macrophages. While spherical/smooth 1 µm CoCrMo-alloy particles did not measurably affect macrophage IL-1β production, irregular 1 µm CoCrMo-alloy particles induced significant IL-1β increases over controls. Both round/smooth particles and irregular CoCrMo-alloy particles that were 6-7 µm in size induced >10-fold increases in IL-1β production compared to similarly shaped smaller particles (p < 0.05). Larger irregular particles induced a greater degree of intracellular lysosomal damage and a >3-fold increase in IL-1β versus similarly sized round/smooth particles (at an equal dose, particles/cell). CoCrMo-alloy particle-size-induced IL-1β production was dependent on the lysosomal protease Cathepsin B, further supporting lysosomal destabilization as causative in inflammation. Phagocytosable larger/irregular shaped particles (6 µm) demonstrated the greatest lysosomal destabilization (observed immunofluorescently) and inflammatory reactivity when compared on an equal dose basis (particles/cell) to smaller/spherical 1 µm particles in vitro.

In vitro macrophage response to nanometer-size chromium oxide particles

An increasing number of studies have reported adverse tissue reactions around metal-on-metal (MM) hip implants. However, the origin and mechanisms of these reactions remain unclear. Moreover, the biological effects of nanometer-size chromium oxide particles, the predominant type of wear particles produced by MM implants, remain mostly unknown. The purpose of this study was to analyze the cytotoxic effects of clinically relevant nanometer-size chromium oxide particles on macrophage response in vitro. J774.A1 macrophages were cultured with either 60 nm or 700 nm commercially available Cr2 O3 particles at different concentrations. Two different particle sizes were analyzed to evaluate potential volume effects. Cell mortality was analyzed by light microscopy, flow cytometry (annexin V-fluorescein isothiocyanate and propidium iodide assay), and using a cell death detection enzyme-linked immunosorbant assay (ELISA). Tumor necrosis factor alpha (TNF-α), monocyte chemotactic protein-1 (MCP-1), and macrophage inflammatory protein-1 alpha (MIP-1α) release was measured by ELISA, and gene expression was analyzed by quantitative real-time PCR. Results showed that, at high concentrations, Cr2 O3 particles of both sizes can be cytotoxic, inducing significant decreases in total cell numbers and increases in necrosis. Results also suggested that these effects were dependent on particle volume. However, TNF-α, MCP-1, and MIP-1α cytokine release and gene expression remained low. Overall, this study demonstrates that nanometer-size particles of Cr2 O3 , a stable form of chromium oxide ceramic, have rather low cytotoxic effects on macrophages. Therefore, these particles may not be the main culprit in the initiation of the inflammatory reaction in MM periprosthetic tissues. However, other parameters (e.g., potential intracellular damage) remain to be investigated.

The role of osteoblasts in peri-prosthetic osteolysis

Peri-prosthetic osteolysis and subsequent aseptic loosening is the most common reason for revising total hip replacements. Wear particles originating from the prosthetic components interact with multiple cell types in the peri-prosthetic region resulting in an inflammatory process that ultimately leads to peri-prosthetic bone loss. These cells include macrophages, osteoclasts, osteoblasts and fibroblasts. The majority of research in peri-prosthetic osteolysis has concentrated on the role played by osteoclasts and macrophages. The purpose of this review is to assess the role of the osteoblast in peri-prosthetic osteolysis.

In peri-prosthetic osteolysis, wear particles may affect osteoblasts and contribute to the osteolytic process by two mechanisms. First, particles and metallic ions have been shown to inhibit the osteoblast in terms of its ability to secrete mineralised bone matrix, by reducing calcium deposition, alkaline phosphatase activity and its ability to proliferate. Secondly, particles and metallic ions have been shown to stimulate osteoblasts to produce pro inflammatory mediators in vitro. In vivo, these mediators have the potential to attract pro-inflammatory cells to the peri-prosthetic area and stimulate osteoclasts to absorb bone. Further research is needed to fully define the role of the osteoblast in peri-prosthetic osteolysis and to explore its potential role as a therapeutic target in this condition.

Cite this article: Bone Joint J 2013;95-B:1021–5.

Evidence for active antigen presentation by monocyte/macrophages in response to stimulation with particles: the expression of NFκB transcription factors and costimulatory molecules

BACKGROUND

The macrophage and lymphocyte response to wear debris contributes to the failure of some joint replacements. Costimulatory molecule expression by particle-containing macrophages is an evidence for antigen presentation. The NFκB transcription factors are regulators of costimulatory molecules and are present in tissue near failed joint prostheses. The tissue localisation of NFκB and the expression of these factors and costimulatory molecules by U937 cells stimulated with nano- and microparticles are reported, together with the effects of an NFκB inhibitor (sc514).

MATERIALS AND METHODS

The tissue localisation of RelA, RelB, c-rel, p50, p52 and NF-IL6 was examined by immunohistochemistry in samples from 15 patients with failure of metal against polyethylene total hip replacements. The expression of these NFκB factors by U937 cells stimulated with microparticles (CoCr, diamond) and nanoparticles (diamond) was examined by quantified RT-PCR. Lipopolysaccharide provided positive controls while negative controls had no additions to culture. Inhibition of NFκB activity by sc-514 was studied. The expression of costimulatory molecules (CD80, CD86 and HLA-DR) was evaluated in parallel cell culture studies by tricolour flow cytometry.

RESULTS AND DISCUSSION

Immunohistochemistry of tissue showed the highest expression for NF-IL6 (32.56 ± 11.61 per cent), RelA (33.66 ± 9.98 per cent) and p52 (32.07 ± 12.90 per cent), then RelB (22.63 ± 7.49 per cent), c-rel (14.07 ± 6.72 per cent) and p50 (13.07 ± 5.99 per cent). NF-IL6 was localised to macrophages, RelB to RFD1+ dendritic cells. U937 cells showed an increased expression of all NFκB factors (p < 0.01) in response to CoCr and diamond microparticles. Only RelA and c-rel (p < 0.01) were increased by one diamond nanoparticle and p52 and c-rel (p < 0.01) by another nanoparticulate diamond. Inhibition by sc-514 of RelA, c-rel and p50 expression occurred with all four particles, p52 was decreased for all diamond particles (but not CoCr) and RelB was not inhibited with any of the particles. CD86 and HLA-DR expression were upregulated by microparticles (CoCr, diamond) (p ≪ 0.01) with lower levels (significant) of these molecules found with diamond nanoparticles. CD80 expression was much less than CD86 and HLA-DR. Costimulatory molecule expression in the bone-implant interface indicates antigen presentation by macrophages. Functional studies with U937 monocytes show the same molecules expressed on exposure to micro- and nanoparticles. Highest values occur with CoCr while the smallest diamond nanoparticles are the least stimulatory. NFκB expression gives an insight into the immunogenic potential of the different particles.

Periprosthetic tissues from third generation alumina-on-alumina total hip arthroplasties

The histological features of periprosthetic tissues are related to the bioreactivity of particles generated by the prosthesis. This study analyzed synovial-like pseudocapsules collected from 21 patients with alumina ceramic-on-ceramic hip arthroplasties and correlated histological features with wear of the ceramic bearings, duration of implantation and clinical factors such as neck-to-rim impingement. A histopathological classification system was developed for this purpose. The pseudocapsules were viable, with few foreign body type giant cells and occasional lymphocytes. This differs from tissues in polyethylene containing hip arthroplasties which often have extensive foreign body type inflammatory changes or from metal-on-metal hip arthroplasties in which extensive necrosis is common. Soft-tissue inflammation was not associated with failure of the hip arthroplasties, and may be clinically insignificant in alumina-on-alumina total hip arthroplasties.

Aggravation of inflammatory response by costimulation with titanium particles and mechanical perturbations in osteoblast- and macrophage-like cells

The interface between bone tissue and metal implants undergoes various types of mechanical loading, such as strain, compression, fluid pressure, and shear stress, from daily activities. Such mechanical perturbations create suboptimal environments at the host bone-implant junction, causing an accumulation of wear particles and debilitating osseous integration, potentially leading to implant failure. While many studies have focused on the effect of particles on macrophages or osteoprogenitor cells, differential and combined effects of mechanical perturbations and particles on such cell types have not been extensively studied. In this study, macrophages and osteoprogenitor cells were subjected to physiological and superphysiological mechanical stimuli in the presence and absence of Ti particles with the aim of simulating various microenvironments of the host bone-implant junction. Macrophages and osteoprogenitor cells were capable of engulfing Ti particles through actin remodeling and also exhibited changes in mRNA levels of proinflammatory cytokines under certain conditions. In osteoprogenitor cells, superphysiological strain increased proinflammatory gene expression; in macrophages, such mechanical perturbations did not affect gene expression. We confirmed that this phenomenon in osteoprogenitor cells occurred via activation of the ERK1/2 signaling pathway as a result of damage to the cytoplasmic membrane. Furthermore, AZD6244, a clinically relevant inhibitor of the ERK1/2 pathway, mitigated particle-induced inflammatory gene expression in osteoprogenitor cells and macrophages. This study provides evidence of more inflammatory responses under mechanical strains in osteoprogenitor cells than macrophages. Phagocytosis of particles and mechanical perturbation costimulate the ERK1/2 pathway, leading to expression of proinflammatory genes.

Molecular Biocompatibility Evaluation of Poly-L-Ornithine-Coated Alginate Microcapsules by Investigating mRNA Expression of Pro-Inflammatory Cytokines

Following a polyelectrolytical complex reaction, the poly-L-ornithine (PLO)-alginate microcapsules were prepared by coating PLO on calcium alginate beads which were produced by a high-voltage electrostatic droplet generator. The biocompatibility of the microcapsules at the molecular level was evaluated through investigating the mRNA expression of pro-inflammatory cytokines; that is, the effect of the PLO coating of alginate beads on the mRNA expression of TNF-α, IL-1β, and IL-6 were measured using the RT-PCR method. The resulting PLO-coated alginate microcapsules have a smooth surface with a mean diameter of 309µm. The molecular biocompatibility studies show that coating microcapsules with PLO has no significant effect on the biocompatibility of alginate microcapsules (p>0.05), and both alginate microcapsules and PLO-coated microcapsules are significantly different from the positive control (p<0.05); however, both are also capable of causing an inflammatory response at a molecular level since both are significantly different from the blank control (p<0.05). Furthermore, with the increase in concentration of microcapsules or co-cultured time, part of the mRNA expression of cytokines is significantly increased. The results also demonstrate that the method used in this study, co-incubating the microcapsules with macrophages and measuring the mRNA expression of cytokines by RT-PCR, may be a useful method for evaluating the biocompatibility of coating materials of microcapsules.

The John Charnley Award: an accurate and sensitive method to separate, display, and characterize wear debris: part 1: polyethylene particles

BACKGROUND

Numerous studies indicate highly crosslinked polyethylenes reduce the wear debris volume generated by hip arthroplasty acetabular liners. This, in turns, requires new methods to isolate and characterize them.

QUESTIONS/PURPOSES

We describe a method for extracting polyethylene wear particles from bovine serum typically used in wear tests and for characterizing their size, distribution, and morphology.

METHODS

Serum proteins were completely digested using an optimized enzymatic digestion method that prevented the loss of the smallest particles and minimized their clumping. Density-gradient ultracentrifugation was designed to remove contaminants and recover the particles without filtration, depositing them directly onto a silicon wafer. This provided uniform distribution of the particles and high contrast against the background, facilitating accurate, automated, morphometric image analysis. The accuracy and precision of the new protocol were assessed by recovering and characterizing particles from wear tests of three types of polyethylene acetabular cups (no crosslinking and 5 Mrads and 7.5 Mrads of gamma irradiation crosslinking).

RESULTS

The new method demonstrated important differences in the particle size distributions and morphologic parameters among the three types of polyethylene that could not be detected using prior isolation methods.

CONCLUSION

The new protocol overcomes a number of limitations, such as loss of nanometer-sized particles and artifactual clumping, among others.

CLINICAL RELEVANCE

The analysis of polyethylene wear particles produced in joint simulator wear tests of prosthetic joints is a key tool to identify the wear mechanisms that produce the particles and predict and evaluate their effects on periprosthetic tissues.

Factors to consider in joint prosthesis systems

In joint reconstruction, the techniques and materials that provide the best outcomes for patients have been debated. The main points of controversy relate to the use of hemiarthroplasties versus total joint prostheses with metal-on-metal versus metal-on-polyethylene articulations. This article investigates these areas as well as the applicability of the techniques and materials and the complications that can occur. Hypersensitivity to materials used in joint prostheses is relatively common but often unrecognized. Although the discussion applies to all joints, the temporomandibular joint (TMJ) is emphasized. For TMJ reconstruction, metal-on-polyethylene articulation in total joint prostheses provides better treatment outcomes than metal-on-metal articulation.

Actin and ERK1/2-CEBPβ signaling mediates phagocytosis-induced innate immune response of osteoprogenitor cells

Wear particles at the host bone-implant interface are a major challenge for successful bone implant arthoplasties. Current understanding of aseptic loosening consists of macrophage-mediated inflammatory responses and increasing osteoclastogenesis, which lead to an imbalance between bone formation and resorption. Despite its significant role in bone regeneration and implant osteointegration, the osteoprogenitor response to wear particles has been examined recent years. More specifically, the intracellular mechanism of osteoprogenitor mediated inflammation has not been fully elucidated. In this study, we examined the role of osteoprogenitors and the cellular mechanism by which metal wear particles elicit an inflammatory cascade. Through both in vivo and in vitro experiments, we have demonstrated that osteoprogenitor cells are capable of initiating inflammatory responses by phagocytosing wear particles, which lead to subsequent accumulation of macrophages and osteoclastogenesis, and the ERK_CEBP/β intracellular signaling is a key inflammatory pathway that links phagocytosis of wear particles to inflammatory gene expression in osteoprogenitors. AZD6244 treatment, a potent inhibitor of the ERK pathway, attenuated particle mediated inflammatory osteolysis both in vivo and in vitro. This study advances our understanding of the mechanisms of osteoprogenitor-mediated inflammation, and provides further evidence that the ERK_CEBP/β pathway may be a suitable therapeutic target in the treatment of inflammatory osteolysis.

Femoral head size does not affect ion values in metal-on-metal total hips

BACKGROUND

Metal-on-metal articulations can release substantial amounts of particles containing cobalt and chromium into the surrounding milieu, causing concern for cellular toxicity and adverse local soft tissue reactions. The diameter of the femoral head has been one of the variables that inversely affects wear of metal-on-metal total hip arthroplasty (THA). The oxidative stress of increased metal ions can be measured with serum markers. It is still controversial if larger femoral head diameters decrease wear rates in patients with metal-on-metal THA and if the increased metal ions alter the body's antioxidant status.

QUESTIONS/PURPOSES

We therefore (1) determined whole blood metal ions in patients with small (28 mm and 36 mm) and large (40 mm and 44 mm) diameter femoral heads; (2) measured oxidative stress markers (total antioxidants, nitrotyrosine, and peroxides); and (3) determined whether acetabular version or inclination influenced ion levels.

METHODS

One hundred four patients were retrospectively studied. We recorded Harris hip scores and UCLA activity scores. All patients were followed at 1 year.

RESULTS

The activity scores were similar in the two groups. There was no difference in metal ion levels or oxidative stress markers between patients with small- or large-diameter femoral heads. Acetabular inclination and anteversion had no effect on the metal ion levels.

CONCLUSIONS

The data suggest there is no difference in ion values in patients with large or small metal-on-metal THA and the increased metal ions do not alter the oxidant status of the patient.

Bone grafting, orthopaedic biomaterials, and the clinical need for bone engineering

As the population ages, the number of operations performed on bone is expected to increase. Diseases such as arthritis, tumours, and trauma can lead to defects in the skeleton requiring an operation to replace or restore the lost bone. Surgeons can use autografts, allografts, and/or bone graft substitutes to restore areas of bone loss. Surgical implants are also used in addition or in isolation to replace the diseased bone. This review considers the application of available bone grafts in different clinical settings. It also discusses recently introduced bioactive biomaterials and highlights the clinical difficulties and technological deficiencies that exist in our current surgical practice.

Polyethylene and metal wear particles: characteristics and biological effects

This paper first presents a brief overview about the mechanism of wear particle formation as well as wear particle characteristics in metal-on-polyethylene and metal-on-metal artificial hip joints. The biological effects of such particles are then described, focusing on the inflammatory response induced by each type of particles as well as on how metal wear products may be the source of a T lymphocyte-mediated specific immune response, early adverse tissue responses, and genotoxicity. Finally, some of the current in vivo models used for the analysis of tissue response to various wear particles are presented.

Cobalt ions induce chemokine secretion in a variety of systemic cell lines

BACKGROUND AND PURPOSE

Metal ion toxicity both locally and systemically following MoM hip replacements remains a concern. Cobalt ions have been shown to induce secretion of proinflammatory chemokines locally; however, little is known about their effect systemically. We investigated the in vitro effect of cobalt ions on a variety of cell lines by measuring production of the proinflammatory chemokines IL-8 and MCP-1.

METHOD

Renal, gastrointestinal, and respiratory epithelium and also neutrophils and monocytes were exposed to cobalt ions at 4, 12, 24, and 48 hours.

RESULTS

We found that cobalt ions enhanced the secretion of IL-8 and MCP-1 in renal epithelial cells, gastric and colon epithelium, monocytes and neutrophils, and small airway epithelial cells but not in alveolar cells. Secretion of IL-8 and MCP-1 was markedly elevated in renal epithelium, where a 16-fold and 7-fold increase occurred compared to controls. There was a 6-fold and 4-fold increase in IL-8 and MCP-1 secretion in colon epithelium and a 4-fold and 3-fold increase in gastric epithelium. Small airway epithelial cells showed a maximum increase in secretion of 8-fold (IL-8) and of 4-fold (MCP-1). The increase in chemokine secretion observed in alveolar cells was moderate and did not reach statistical significance. Monocytes and neutrophils showed a 2.5-fold and 2-fold increase in IL-8 secretion and a 6-fold and 4-fold increase in MCP-1 secretion at 48 and 24 hours, respectively.

INTERPRETATION

These data demonstrate the potent bioactivity of cobalt ions in a variety of cell types and the potential to induce a proinflammatory response.

Postmortem study of femoral osteolysis associated with metal-on-metal articulation in total hip replacement: an analysis of nine cases

BACKGROUND

Improved metal-on-metal articulations were reintroduced in total hip replacement to avoid the osteolysis sometimes seen with conventional ultra-high molecular weight polyethylene bearings. Osteolysis and local lymphocytic infiltration have been reported at revision of some metal-on-metal devices. We report similar and additional results in a study of second-generation metal-on-metal hip implants retrieved post mortem.

METHODS

Components and surrounding tissues were collected post mortem from seven patients with nine total hip replacements (Zweymüller SL stem with an Alloclassic cup) with Metasul metal-on-metal articulations. All available patient information was recorded. Radiographs of the hips were evaluated for osteolysis. Sections of joint capsule as well as of the femoral implant with surrounding bone were reviewed, and energy-dispersive x-ray analysis was used to evaluate the composition of wear products. The amount of wear was measured for each component (nine femoral heads and eight cup inserts), when possible, by a coordinate measurement machine with use of the dimensional method.

RESULTS

The patients died between three and ten years after arthroplasty, and six of the seven were asymptomatic at the time of death. One patient, with the highest rate of total wear (i.e., wear of femoral head and acetabular cup; 7.6 microm/yr), had increasing hip pain for one year, and histological analysis confirmed the radiographic findings of osteolysis. For two other patients, histological analysis confirmed the radiographic findings of asymptomatic osteolysis. For three patients, histological analysis revealed osteolysis that had escaped conventional radiographic analysis. Joint capsule tissue showed evidence of metallosis in all hips and local lymphocytic infiltration in eight hips. Energy-dispersive x-ray analysis revealed elements attributable to CoCrMo alloy in all hips and traces of corrosion products in three hips.

CONCLUSIONS

The postmortem findings of osteolysis and/or lymphocytic infiltration associated with eight clinically well-functioning, low wear devices (a total wear rate of <4 microm/yr) suggest there may be frequent, unappreciated femoral bone loss and local immunological response in patients with second-generation metal-on-metal hip implants. Compared with previous postmortem studies, our findings showed the extent of osteolysis was similar to that with metal-on-polyethylene articulations.

In vivo response to cross-linked polyethylene and polycarbonate-urethane particles

This study was undertaken to examine macrophage response to polycarbonate-urethane, a proposed alternative material to polyethylene in acetabular components of total hip arthroplasty. Polyethylene wear debris from total joint replacements has been linked to osteolysis and implant lifespan. It has been shown in vitro, that polyethylene particles cleaned of endotoxin generate less of an inflammatory cytokine response than endotoxin bound particles. Comparative particle induced effects on implant fixation were tested using endotoxin free cross-linked ultra-high molecular weight polyethylene (x-UHMWPE) and polycarbonate-urethane (PCU) particles with and without intraperitoneal injection (IP) of lipopolysaccharide (LPS) using a Ti-alloy femoral intramedullary nail rat model. MicroCT and mechanical testing assessment of peri-implant bone indicated significantly less bone and lower fixation strength, respectively, when the implant was surrounded by xUHMWPE particles compared to PCU particles (with and without LPS IP). This indicates particles of PCU may be less disruptive to bone-implant fixation than x-UHMWPE in vivo, under both LPS free and challenged conditions.

In vitro macrophage response to polyethylene and polycarbonate-urethane particles

This study was undertaken to compare macrophage response to polycarbonate-urethane (PCU), a proposed alternative material to polyethylene in acetabular components of total hip arthroplasty to cross-linked ultra-high molecular weight polyethylene (xUHMWPE) in the presence or absence of endotoxin. Polyethylene wear debris that is generated by total hip and knee replacements has been linked to osteolysis and limiting the lifespan of the implant. We added both lipopolysaccharide (LPS)-free and endotoxin-associated xUHMWPE and PCU particles to a human monocyte cell line (TH1) in culture and measured cell viability and tumor necrosis factor (TNF)alpha, interleukin (IL)-1beta, and prostaglandin E(2) (PGE(2)) in the medium after 24 h. Results indicate that particles (both xUHMWPE and PCU) free of endotoxin did not significantly induce secretion of TNFalpha, IL-1beta, or PGE(2) above basal levels. However, endotoxin-exposed PCU particles induced significantly less TNFalpha and IL-1beta than endotoxin-exposed xUHMWPE particles. This indicates that if endotoxin is available for binding to particles in vivo, then xUHMWPE may be more inflammatory to periprosthetic tissue and bone in part because of its affinity/reactivity with endotoxin when compared with PCU.

A review of the biologic effects of spine implant debris: Fact from fiction

BACKGROUND

Biologic-reactivity to implant-debris is the primary determinant of long-term clinical performance. The following reviews: 1) the physical aspects of spinal-implant debris and 2) the local and systemic biologic responses to implant debris.

METHODS

Methods included are: 1) gravimetric wear analysis; 2) SEM and LALLS; 3) metal-ion analysis; 4) ELISA, toxicity testing, patch testing; and 5) metal-lymphocyte transformation testing (metal-LTT).

RESULTS

Wear and corrosion of spine-implants produce particles and ions. Particles (0.01-1000 μm) are generally submicron ( <1 µm). Wear rates of metal-on-polymer and metal-on-metal disc arthroplasties are approximately 2-20 and 1 mm(3)/yr, respectively. Metal-on-metal total disc replacement components have significant increases in circulating metal (less than 10-fold that of controls at 4 ppb-Co and 3 ppb-Cr or ng/mL). Debris reactivity is local and systemic. Local inflammation is caused primarily by ingestion of debris by local macrophages, which produce pro-inflammatory cytokines TNFα, IL-1β, IL-6, and PGE2. Systemic responses associated with implant-debris have been limited to hypersensitivity reactions. Elevated amounts of in the liver, spleen, etc of patients with failed TJA have not been associated with remote toxicological or carcinogenic pathology to date. Implant debris are differentially bioreactive. Greater numbers are pro-inflammatory; the smaller-sized debris are more bioreactive by virtue of their greater numbers (dose) for a given amount of implant mass loss (one 100-μm-diameter particle is equivalent in mass to 1 million 1-μm-diameter particles). Elongated particles are pro-inflammatory (ie, aspect ratio of greater than 3). Metal particles are more proinflammatory than polymers, ceteris paribus.

CONCLUSION

Spinal arthroplasty designs have been in use for more than 20 years internationally; therefore, concerns about neuropathology, toxicity, and carcinogenicity are mitigated. Debris-induced inflammation still depends on the individual and the type of debris. The consequence of debris-induced inflammation is continued; vigilance by physicians is recommended monitoring of spinal implants using physical exams and testing of metal content and bioreactivity, as is planning for the likelihood of revision in younger individuals.

Increased force simulator wear testing of a zirconium oxide total knee arthroplasty

Total knee replacements provide cost effective treatment for debilitating conditions such as osteoarthritis. Their long term performance is governed by ultra-high molecular weight polyethylene (UHMWPE) wear which produces wear debris leading to osteolysis and aseptic loosening of the implant. An oxidised zirconium alternative to cobalt chrome is being used to reduce wear debris formation in the younger patients. Two TKRs of cobalt chrome and two of zirconium oxide coated zirconium were tested in a six degrees of freedom of motion, Stanmore-Instron force controlled knee wear simulator over 4 million increased force cycles. Oxidised zirconium was demonstrated to be more scratch resistant than CoCr. Increases in Ra (mean average roughness) of 12-fold compared to 1.9 fold rise for ZrO. The differences in roughness were accompanied by a 78%, statistically significant, reduction in wear of UHMWPE with the ZrO femoral components compared to the CoCr (p=0.037). Long term clinical results from the use of oxidised zirconium femoral components are awaited. However, it shows potential to reduce the wear rate.

Proinflammatory and osteoclastogenic effects of beta-tricalciumphosphate and hydroxyapatite particles on human mononuclear cells in vitro

Particulate wear debris can activate defence cells and osteoclasts at the bone-implant interface possibly leading to bone resorption and implant failure. Cellular responses and inflammatory effects have been reported for particulate hydroxyapatite (HA). However, the immunological effects of particulate beta-tricalciumphosphate (beta-TCP) have not been studied and the question of whether beta-TCP is more biocompatible in this regard as is HA remains to be determined. Therefore the present work investigates effects of endotoxin-free HA and beta-TCP particles of the same size (d(50)=1 microm) and dose (SAR 10:1) on human peripheral blood mononuclear cells in vitro. The production of proinflammatory cytokines (TNF-alpha, IL-1beta, IL-8) and cytokines connected to osteoclast and dendritic cell differentiation (OPG, RANKL, M-CSF, GM-CSF) was determined by ELISA. After 6 and 18 h of incubation HA and beta-TCP caused a quite similar induction of TNF-alpha, IL-1beta and IL-8. Effects of particles on the production of M-CSF and OPG were not detectable. However, in sharp contrast to HA, beta-TCP caused less induction of GM-CSF and not any of RANKL, both known for promoting dendritic cells and osteoclastogenesis respectively. Therefore these in vitro data suggest that wear debris of beta-TCP poses lesser risk of the detrimental effects of osteoclast induction known from HA.

Cobalt ions induce chemokine secretion in primary human osteoblasts

Chemokines are major regulators of the inflammatory response and have been shown to play an important role in periprosthetic osteolysis. Titanium particles have previously been shown to induce IL-8 and MCP-1 secretion in osteoblasts. These chemokines result in the chemotaxis and activation of neutrophils and macrophages, respectively. Despite a resurgence in the use of cobalt-chromium-molybdenum alloys in metal-on-metal arthroplasty, cobalt and chromium ion toxicity in the periprosthetic area has been insufficiently studied. In this study we investigate the in vitro effect of cobalt ions on primary human osteoblast activity. We demonstrate that cobalt ions rapidly induce the protein secretion of IL-8 and MCP-1 in primary human osteoblasts. This elevated chemokine secretion is preceded by an increase in the transcription of the corresponding chemokine gene. Using a Transwell migration chemotaxis assay we also demonstrate that the chemokines secreted are capable of inducing neutrophil and macrophage migration. Furthermore, cobalt ions significantly inhibit osteoblast function as demonstrated by reduced alkaline phosphatase activity and calcium deposition. In aggregate these data demonstrate that cobalt ions can activate transcription of the chemokine genes IL-8 and MCP-1 in primary human osteoblasts. Cobalt ions are not benign and may play an important role in the pathogenesis of osteolysis by suppressing osteoblast function and stimulating the production and secretion of chemokines that attract inflammatory and osteoclastic cells to the periprosthetic area.

Response of human osteoblasts exposed to wear particles generated at the interface of total hip stems and bone cement

Aseptic loosening of total hip replacement is mainly caused by wear particles. Abrasive wear occurs at articulating surfaces or as a consequence of micro-motions at the interface between femoral stem and bone cement. Direct impact of wear particles on osteolysis, the remodeling of the bone stock and a directly affected function of osteoblasts was described. The present study examined the response of human osteoblasts exposed to different wear particles, which were generated in a test device providing oscillating micro-motions at the interface between femoral stem and standard bone cement. Characterization of released particles was performed by quantifying the size distribution and the metal content of the wear debris. Human osteoblasts were incubated with particles obtained from hip stems with different material compositions (Ti-6Al-7Nb and Co-28Cr-6Mo) and rough and smooth surface finishings combined with standard bone cement (Palacos(R) R) containing zirconium oxide particles. Commercially pure titanium particles (cp-Ti) and particulate zirconium oxide (ZrO(2)) were used for comparative analyses. The results revealed significant (p < 0.05) reduction of the cell viability after exposure to higher concentration of metallic particles, particularly from Co-based alloys. In contrast, ZrO(2) alone showed significantly less adverse effects on the cells. When increasing metallic particle concentrations massive inhibition was also observed in the release of cytokines including interleukine-6 (IL-6) and interleukine-8 (IL-8), but the expression of Procollagen I and the cell viability showed the highest reduction after exposure to Co-based alloy particles from rough stems.

Intra-articular Botulinum Toxin Type A: a new approach to treat arthritis joint pain

There is a growing need for novel treatments of refractory arthritis joint pain as the aging population is expanding with many patients who are unable to undergo joint replacement surgery. We are studying the efficacy and safety of intra-articular injection of Botulinum Toxin Type A (IA-BoNT/A) into joints with arthritis pain. In several small open label studies, initial effects for IA-BoNT/A were encouraging because two thirds of the patients had more than 50% reduction in joint pain severity that was associated with a significant improvement in function. Importantly no serious adverse effects of IA-BoN/A were noted. Based on these initial results, we have completed two pilot randomized controlled trials in painful shoulder joints and painful knee joints. In the shoulder study, IA-BoNT/A produced a significant decrease in shoulder pain severity at one month (6.8-4.4 on VAS, p=.002) that was also significantly better than the non-significant change after IA-Saline placebo (1.6 unit difference favoring IA-BoNT/A, p=.014). In the knee study IA-BoNT/A produced a significant 48% decrease in McGill Total Pain Score at one month (p=.01 1) that was still significant at 3 mo after injection (p=.002). There was a strong placebo response in one third of those but the decrease in pain severity was not significant. We are currently conducting a RCT of IA-BoNT/A for painful prosthetic knee joints. Based on these initial studies of IA-BoNT/A we have gone 'back to the bench' to standardize a menu of pain behaviors for mice with acute inflammatory arthritis pain and chronic inflammatory arthritis pain. IA-BoNT/A significantly reduced arthritis joint tenderness (evoked pain score) in acute and chronic inflammatory arthritis and normalized impaired spontaneous wheel running in mice with chronic inflammatory arthritis but not in those with acute inflammatory arthritis. With these models of arthritis and pain behavior methods we will be able to screen potential intra-articular analgesics, define dose response curves and injection schedule, and study the relationships of articular pain and loss of function.

Highly crosslinked vs conventional polyethylene particles: relative in vivo inflammatory response

Crosslinked polyethylenes have been introduced to reduce wear and osteolysis. The osteolysis rate depends on many factors including the biologic activity of the wear particles. This study examines the relative inflammatory potential of highly crosslinked and non-crosslinked polyethylene particles. Polyethylene particles were crosslinked and characterized. Dose-response curves were generated for endotoxin-positive and endotoxin-negative particles at each degree of cross-linking using an in vivo model. The 10-MRad crosslinked polyethylene was more inflammatory than an identical dose (25 mg/mL) of non-crosslinked polyethylene (P = .05). Endotoxin increased the inflammatory response to crosslinked and non-crosslinked polyethylene in a similar fashion. These data suggest that the improved wear characteristics of highly crosslinked polyethylenes may be offset somewhat by the modestly increased inflammatory profile of the highly crosslinked compared with non-crosslinked particles.