Tumors around implants

Incidence of Nonunion of the First Metatarsophalangeal Joint Arthrodesis After Failed Implant Arthroplasty: A Systematic Review

Joint arthroplasty of the first metatarsophalangeal (MTP) joint is an accepted surgical option for patients with hallux rigidus. However, this procedure has been reported to have a high complication rate and unpredictable survivorship. Implant arthroplasty failure is a devastating complication that results in significant osseous defect with altered biomechanics of the foot. Commonly, salvage options are limited to arthrodesis with bone grafting. However, outcomes are rarely reported. The purpose of this study is to investigate the fusion rates of first metatarsophalangeal joint arthrodesis after conversion from failed implant arthroplasty. A systematic review of electronic databases to find reports of conversion arthrodesis after failed implant arthroplasty was performed. Six studies involving a total of 76 patients with a weighted mean age of 54.9 met the inclusion criteria. Out of the 6 included articles, the nonunion rate was 16.5% at a weighted mean follow-up of 48.1 months. The nonunion rate in the current report is higher than reported nonunion rates of primary arthrodesis. More prospective studies with consistent and standard outcome measures are needed to further determine the success rate of this salvage procedure.Levels of Evidence: 4, Systematic Review of Level 4 Studies.

Angiosarcoma around total hip arthroplasty: case series and review of the literature

BACKGROUND

Angiosarcoma (AS) is a rare and malignant tumor which mainly arises in the skin and superficial soft tissue and less frequently in deep soft tissue and bones. Some cases of AS are described in association with vascular and orthopedic devices. Nonetheless, only a few cases of AS around THA are reported in the literature.

MATERIALS AND METHODS

We describe five cases of AS arising around total hip arthroplasty who received surgery at our institution (Istituto Ortopedico Rizzoli, Bologna, Italy), and we report the cases described in literature.

RESULTS

Foreign bodies such as polyethylene were demonstrated to have a carcinogenic role in animals, but reports of similar cases in humans are rare. Nevertheless, osteolysis induced by wear particles of polyethylene is a frequent event and could induce to desist form considering other more rare causes of osteolysis such as AS. This could be the reason why the diagnosis in several cases was significantly delayed. Common features of these cases could be helpful for doing a prompt diagnosis. The initial presentation is suggestive for septic or aseptic loosening with a massive osteolysis around the cup and/or the stem associated with peculiar aspects as bleeding and loss of weight. Frequently, needle biopsy is negative because foreign-body reaction might have "covered" the most relevant condition of epithelioid AS.

CONCLUSIONS

In conclusion in a patient who presents with uncontrollable bleeding, loss of weight and massive osteolysis, AS must be actually considered as possible diagnosis.

Biocompatibility of four common orthopedic biomaterials following neuroelectromyostimulation: An in-vivo study

Despite the worldwide high prevalence of total joint arthroplasty (TJA), life expectancy of prosthesis remains limited by mechanical and chemical constraint which promote wear debris production, surrounding tissues damage and finally prosthesis loosening. Such results could be amplified by neuro-myoelectrostimulation (NMES; widely used to reduce neuromuscular deficits observed following TJA surgery). It was previously described in an in vivo experiment that interactions between NMES and Ti6Al4V implant are deleterious for both implant and surrounding muscles. The purpose of the present study was to compare the biocompatibility of four common orthopedic biomaterials, two metallic (Ti6Al4V, CrCo) and two nonmetallic (PEEK, Al₂ O₃ ) alloys, fixed on rat tibial crest in which the surrounding muscles were electrostimulated. Muscle cell death rate was not found significantly increased, with or without electrical stimulation for nonmetallic implants. Contrary to Ti6Al4V alloy, the CrCo implant did not induce destruction of the surrounding muscle. However, cell viability decreased for both metallic alloys when NMES was applied but within a greater significant extent for Ti6Al4V implant. Otherwise, when NMES was applied, implant-to-bone adhesion significantly decreased for Ti6Al4V while no significant difference was found for PEEK, Al₂ O₃ , and CrCo. Statistical analyses reveal also a lesser adhesion strength for Ti6Al4V compared with CrCo when NMES was applied. Selecting the most suitable material in term of biocompatibility remains a major concern and non-metallic materials seems to be more appropriated in regard to electrical currents used for post TJA care. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1156-1164, 2018.

The taper disaster--how could it happen?

Corrosion of metallic implants in contact with body fluids is unavoidable, especially at interfaces where movement occurs or in gaps. Corrosion became clinically relevant with the introduction of large modular metal-on-metal total hip joint articulations (MoM THA) early in the 21st century. This review attempts to summarise the scientific knowledge about taper problems available at the time of introduction of these bearings, why this "disaster" could happen. It is speculated that changes to the taper connection made in the 1990s to increase the range of motion with small heads (28 and 32 mm) reduced the mechanical strength of this connection, which did not matter for small heads. With the use of large and very large metal heads in MoM articulations, which have a larger lever arm and can generate high friction in unfavourable situations, suddenly the taper interface exhibited corrosion problems on a previously unknown scale. It is speculated that due to the higher mechanical loading with larger heads, the taper connection became less forgiving with respect to assembly conditions, contamination, manufacturing tolerances and other factors, which are yet not known. Since no major clinical problems had been reported before the introduction of these bearings and the pre-clinical testing was very successful, the disaster took its course. The patient-implant-surgeon system is a very complex intrinsically hazardous system. Pre-clinical testing addresses few and defined factors and such, good results cannot be directly transferred to the clinical reality. A controlled stepwise introduction of innovations is required.

Total hip arthroplasty-related osteogenic osteosarcoma: case report and review of the literature

BACKGROUND

Orthopedic implant-related sarcoma is an exceedingly rare, but a known complication of total hip arthroplasty (THA).

CASE PRESENTATION

The authors describe clinical and radiologic features, histologic appearance, and treatment of osteogenic osteosarcoma located in the proximal femoral diaphysis associated with an unstable femoral prosthesis following THA in a 65-year-old male patient. The patient with HLA-B27 positive ankylosing spondylitis underwent arthroplasty 15 years ago.

CONCLUSIONS

The neoplastic process may be considered as an extraordinary complication of THA and might just be coincidental or the result of some derangement of the healing process in host tissue with no definitely proven hypothesis that the implants or their by-products are carcinogenic. The soluble chemical substances from the implanted prosthetic material are, at least in animals, suspected to play a vital role in the pathogenesis of the neoplastic transformation of the bone tissue. The presented case shall alert orthopedic surgeons to clinical, radiologic, and macroscopic similarities between a malignant tumor and benign lesions caused by wear debris at THA sites. At the examination of plane X-rays of patients with THA loosening, the differential diagnosis should always include osteogenic sarcoma, as well. To our knowledge, there have been only nine cases of THA-related osteogenic osteosarcomas described in the English-language literature.

Ceramic-on-ceramic total hip arthroplasty: minimum of six-year follow-up study

Background

This study examines the clinical and radiologic results of ceramic-on-ceramic total hip arthroplasties with regard to wear, osteolysis, and fracture of the ceramic after a minimum follow-up of six years.

Methods

We evaluated the results of a consecutive series of 148 primary ceramic-on-ceramic total hip arthroplasties that had been performed between May 2001 and October 2005 in 142 patients. The mean age was 57.2 years (range, 23 to 81 years). The mean follow-up period was 7.8 years (range, 6.1 to 10.1 years). Preoperative diagnosis was avascular necrosis in 77 hips (52%), degenerative arthritis in 36 hips (24.3%), femur neck fracture in 18 hips (12.2%), rheumatoid arthritis in 15 hips (10.1%), and septic hip sequelae in 2 hips (1.4%). Clinical results were evaluated with the Harris hip score, and the presence of postoperative groin or thigh pain. Radiologic analysis was done with special attention in terms of wear, periprosthetic osteolysis, and ceramic failures.

Results

The mean Harris hip score improved from 58.3 (range, 10 to 73) to 92.5 (range, 79 to 100) on the latest follow-up evaluation. At final follow-up, groin pain was found in 4 hips (2.7%), and thigh pain was found in 6 hips (4.1%). Radiologically, all femoral stems demonstrated stable fixations without loosening. Radiolucent lines were observed around the stem in 25 hips (16.9%), and around the cup in 4 hips (2.7%). Endosteal new bone formation was observed around the stem in 95 hips (64.2%) and around the cup in 88 hips (59.5%). No osteolysis was observed around the stem and cup. There were 2 hips (1.4%) of inclination changes of acetabular cup, 2 hips (1.4%) of hip dislocation, 1 hip (0.7%) of ceramic head fracture, and 1 hip (0.7%) of squeaking. The Kaplan-Meier survival rate of the prostheses was 98.1% at postoperative 7.8 years.

Conclusions

The ceramic-on-ceramic total hip arthroplasty produced excellent clinical results and implant survival rates with no detectable osteolysis on a minimum six-year follow-up study. The ceramic-on-ceramic couplings could be a reasonable option of primary total hip arthroplasty for variable indications.

Severe osteolysis and soft tissue mass around total hip arthroplasty: description of four cases and review of the literature with respect to clinico-radiographic and pathologic differential diagnosis

Periprosthetic osteolysis is a well known phenomenon caused by wear particle-induced bone resorption, particularly common and extensively reported in total hip arthroplasty. Its typical radiographic feature is a radiolucent area adjacent to an implant, sometimes associated with a soft tissue mass. Osteolytic changes may be caused by numerous other pathologic processes, including infection, metabolic disease, and neoplasia. Four cases of massive periprosthetic bone destruction associated with a large soft tissue mass around a failed total hip replacement are presented. In three cases, a diagnosis of periprosthetic osteolysis was correctly made and managed by revision surgery. However, in one case angiosarcoma of the ipsilateral hemipelvis went long unrecognized despite aggressive clinical course, requiring hind-quarter amputation and ultimately resulting in the patient's death. Periprosthetic malignancy in the form of either primary sarcoma or metastatic cancer is a very rare yet reported event in the setting of previous hip replacement, likely leading to catastrophic consequences when diagnosis is not established in a timely manner. The differential diagnosis of periprosthetic osteolysis should consider the entire spectrum of conditions that can present with radiolucent changes. Thorough review of patient's history and course of symptoms, along with careful evaluation of standard roentgenograms should be always performed and possibly integrated with imaging modalities such as CT, MRI, and bone scintigraphy in order to increase diagnostic accuracy. If uncertainty remains, biopsy should always be considered to rule out malignancy.

Serum metal ion exposure after total knee arthroplasty

All metal implants release metal ions because of corrosion. This has been studied and debated, especially in metal-on-metal total hip arthroplasties. Total knee arthroplasty implants have large metal surface areas and therefore substantial potential for corrosion. We determined changes in serum levels of metal ions in 41 patients after cemented unconstrained total knee arthroplasty without patellar resurfacing, 18 with unilateral total knee arthroplasty (median, 66 months after surgery) and 23 patients with bilateral total knee arthroplasties (75 and 50 months after first and second surgeries, respectively). Serum concentrations of chromium, cobalt, and molybdenum were analyzed and related to the number of total knee arthroplasties and compared with those of 130 control patients without implants. The median chromium, cobalt, and molybdenum concentrations were 0.92, 3.28, and 2.55 microg/L, respectively, in the unilateral total knee arthroplasty sample and 0.98, 4.28, and 2.40 microg/L, respectively, in the bilateral total knee arthroplasty sample. We observed no difference between the serum levels in patients with unilateral and bilateral arthroplasties, but the serum levels of chromium and cobalt of both study groups were greater than those of the control group (less than 0.25 microg/L). The patients who had total knee arthroplasty had molybdenum profiles that were similar to those of the control group (median, 2.11 microg/L).

Aseptic loosening, not only a question of wear: a review of different theories

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.

Malignant tumors at the site of total hip prosthesis. Analytic review of 46 cases

During the years 1974 to 2003, a total of 46 cases of malignant tumors at the site of total hip arthroplasty, 41 sarcomas, 4 lymphomas, and 1 epidermoid carcinoma, have been reported in the Western literature. Soft tissue sarcomas occurred in 31 and bone sarcomas in 10 cases. Malignant fibrous histiocytoma was the most common in 20 (65%) of all soft tissue sarcomas. The patients with malignant tumors had been operated on more often for secondary osteoarthritis and had more local complications than those in ordinary total hip arthroplasty series. Primary osteoarthritis was the indication in 63% and secondary osteoarthritis in 37% of the 38 reported cases. Tumor developed after 8 (17%) revisions. Deep infection complicated 4 (9%) of the cases. Four cases (9%) were preceded by a precondition for cancer, 2 postradiation necroses of the femoral head, 1 chronic sinus, and 1 Mafucci syndrome. Mean age of the patients at the time of first implantation was 59 years (range, 24-79 years). The mean latent period was 6 years (range, 0.5-20 years) from the first operation. Longer latency period did not correlate positively with the cancer risk. Sarcomas were highly aggressive. Of the 31 reported patients, 24 (77%) died within 1 year after the diagnosis. The number of reported sarcoma cases is low considering the total population behind the cases. In addition, one observed local sarcoma from Nordic cohorts was less than expected. Chronic, particle-induced inflammation around the prosthesis does not seem to increase the risk for carcinogenesis.

Disseminated osteosarcoma arising in the pelvis after total hip arthroplasty

The development locally of a malignant neoplasm after total hip arthroplasty is rare but increasingly recognized. Its significance is unclear. The association could be fortuitous. If not, the rarity of the complication argues that constitutional factors are likely to be important in pathogenesis. We describe a case of disseminated osteosarcoma of the hip developing 6.5 years after total hip arthroplasty and review the related literature.

Arthroplasty-associated malignant fibrous histiocytoma: two case reports

AIMS

Sarcoma localized to the site of an arthroplasty procedure is a rare occurrence, and detailed histological depictions and descriptions are limited. We report the clinicopathological findings in two cases of arthroplasty-associated malignant fibrous histiocytoma (MFH) and review the literature.

METHODS AND RESULTS

The patients were an elderly man and woman. Medical histories, radiographs and slides were reviewed. Immunohistochemistry, electron microscopy, cytogenetics, and electron dispersion spectroscopy were performed in one case. Both were destructive femoral bone tumours that appeared 2 and 8 years post-total hip arthroplasty, and pursued aggressive clinical courses. The histology was similar in both tumours, consisting of high-grade, pleomorphic sarcoma with numerous osteoclastic giant cells, prominent phagocytic activity, and entrapped particles of bone cement. Literature review disclosed 14 previous reports of arthroplasty-associated MFH, representing the most common phenotype. A number of materials and factors related to arthroplasty procedure, such as metal corrosion, wear debris, osteonecrosis, and chronic inflammation, have been implicated as causative agents.

CONCLUSIONS

Arthroplasty-associated MFH is a rare and aggressive tumour. Although the aetiology remains unclear, the small number of arthroplasty-associated sarcomas compared with the large number of joint replacement operations performed over the past four decades suggests a coincidental as opposed to a causal relation.

Sarcoma arising adjacent to a total hip arthroplasty

We present the case of a 79-year-old woman who developed a high grade spindle cell sarcoma adjacent to total hip arthroplasty 13 years after the index operation. MRI scan appeared to show a direct communication between the tumour and intra medullary canal through a breach in the femoral cortex.

Alternate bearing surfaces in total joint arthroplasty: biologic considerations

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