1
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Barnhart MD, Pool R, Liska WD. Pleomorphic sarcoma secondary to proximal femoral epiphysiolysis with bone infarction over 4 years after cementless total hip replacement in a dog. Vet Surg 2024. [PMID: 39171795 DOI: 10.1111/vsu.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 06/13/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVE To report a capital physeal fracture as the result of a bone infarction with subsequent neoplastic transformation 4 years following total hip replacement. STUDY DESIGN Case report. ANIMALS Five-year-old female spayed golden retriever. METHODS The dog was initially presented for evaluation of a 2 week history of spontaneous right hind-limb lameness. Pelvic radiographs demonstrated a displaced capital epiphysis and proximal femur changes consistent with a bone infarction. A cementless total hip replacement was performed, and limb function returned to normal until 51 months after surgery. A radiolucency adjacent to the femoral stem at the greater trochanter, partial calcar resorption, and stable implants were present on pelvic radiographs acquired 52 months after surgery. Surgical exploration of the surgical site for tissue collection for histopathology and bacteria culture was performed 58 months following surgery. No bacterial growth occurred and histologic findings were nonspecific. A right hind-limb amputation was performed 61 months after total hip replacement due to the dog's progression to a non-weight-bearing lameness, Additional tissue samples were taken from the femur for histopathologic examination. RESULTS Histopathologic examination was consistent with a pleomorphic sarcoma. No metallic or polyethylene particulate debris was present. Nine months after surgery there was evidence of regional and distant spread of the neoplasia. CONCLUSION In similar cases, submitting the femoral head for histopathologic examination should be considered at the time of the hip replacement surgery. If bone infarction is diagnosed as a causative agent, given the possibility of malignant transformation, long-term serial radiographic monitoring should be given serious consideration.
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Affiliation(s)
| | - Roy Pool
- Department of Veterinary Pathobiology, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, Texas, USA
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2
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Huzum RM, Hînganu MV, Huzum B, Hînganu D. Advances in Molecular Research on Hip Joint Impingement-A Vascular Perspective. Biomolecules 2024; 14:784. [PMID: 39062498 PMCID: PMC11275018 DOI: 10.3390/biom14070784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/19/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
With the rise in longevity within the population, medicine continues to encounter fresh hurdles necessitating prompt actions, among which are those associated with hip joint aging. Age-related arthropathies encompass damage to bones' articulating extremities and their supporting structures, such as articular cartilage, and alterations in the quantity and quality of synovial fluid. This study aims to summarize the biomolecular methods of hip joint evaluation focused on its vascularization, using data correlated with biomolecular research on other joints and tissues, in order to reach an objective opinion of the study prospects in this field. Following a retrospective study on most modern biomolecular research methods on the synovium, the capsule, and the articular cartilage of the hip joint, we have hereby concretized certain future research directions in this field that will improve the qualitative and morphofunctional management of the hip joint at an advanced age, even within population categories at risk of developing various degenerative joint pathologies.
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Affiliation(s)
- Riana Maria Huzum
- Department of Radiology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Marius Valeriu Hînganu
- Department of Morpho-Functional Sciences I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Bogdan Huzum
- Department of Orthopedics and Traumatology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
| | - Delia Hînganu
- Department of Morpho-Functional Sciences I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 400347 Iasi, Romania;
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3
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Fokter SK, Ledinek Ž, Kljaić Dujić M, Novak I. Extreme Serum Titanium Concentration Induced by Acetabular Cup Failure: Unveiling a Unique Scenario of Titanium Alloy Debris Accumulation. Bioengineering (Basel) 2024; 11:235. [PMID: 38534509 DOI: 10.3390/bioengineering11030235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/12/2024] [Accepted: 02/24/2024] [Indexed: 03/28/2024] Open
Abstract
The majority of contemporary total hip arthroplasty (THA) implants are constructed from Ti alloys, which are generally believed to generate fewer adverse local tissue reactions (ALTRs) compared to CoCr alloys. This study presents a case of unusual primary THA failure where a substantial release of Ti alloy debris was observed. A 52-year-old active male underwent THA after post-traumatic aseptic necrosis of the femoral head in 2006. Seventeen years after the procedure, the patient presented with groin pain and a restricted range of motion. X-rays revealed the protrusion of the alumina ceramic head through the Ti6Al4V acetabular cup. Trace element analysis indicated significantly elevated levels of serum Ti, Al, and V. CT and MRI confirmed Ti alloy cup failure and a severe ALTR. During revision surgery, it was found that the worn-out ceramic head was in direct contact with the acetabular cup, having protruded through a central hole it had created over time. No acetabular liner was found. Histological analysis of his tissue samples showed wear-induced synovitis with areas of multinucleated foreign body giant cells and the accumulation of numerous metal particles but no acute inflammatory response. Six months after the revision THA, the patient has experienced favourable outcomes. This case provides an instructive illustration for studying the consequences of the substantial release of Ti alloy debris from orthopedic implants.
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Affiliation(s)
- Samo K Fokter
- Clinical Department of Orthopedic Surgery, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Slomškov trg 15, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Ljubljana, Kongresni trg 12, 1000 Ljubljana, Slovenia
| | - Živa Ledinek
- Department of Pathology, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - Milka Kljaić Dujić
- Department of Radiology, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - Igor Novak
- Clinical Department of Orthopedic Surgery, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
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4
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Tölken LA, Wassilew GI, Grolimund D, Weitkamp T, Hesse B, Rakow A, Siemens N, Schoon J. Cobalt and Chromium Ions Impair Macrophage Response to Staphylococcus aureus Infection. ACS Biomater Sci Eng 2024; 10:563-574. [PMID: 38108141 DOI: 10.1021/acsbiomaterials.3c01031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cobalt-chromium-molybdenum (CoCrMo) alloys are routinely used in arthroplasty. CoCrMo wear particles and ions derived from arthroplasty implants lead to macrophage-driven adverse local tissue reactions, which have been linked to an increased risk of periprosthetic joint infection after revision arthroplasty. While metal-induced cytotoxicity is well characterized in human macrophages, direct effects on their functionality have remained elusive. Synchrotron radiation X-ray microtomography and X-ray fluorescence mapping indicated that peri-implant tissues harvested during aseptic revision of different arthroplasty implants are exposed to Co and Cr in situ. Confocal laser scanning microscopy revealed that macrophage influx is predominant in patient tissue. While in vitro exposure to Cr3+ had only minor effects on monocytes/macrophage phenotype, pathologic concentrations of Co2+ significantly impaired both, monocyte/macrophage phenotype and functionality. High concentrations of Co2+ led to a shift in macrophage subsets and loss of surface markers, including CD14 and CD16. Both Co2+ and Cr3+ impaired macrophage responses to Staphylococcus aureus infection, and particularly, Co2+-exposed macrophages showed decreased phagocytic activity. These findings demonstrate the immunosuppressive effects of locally elevated metal ions on the innate immune response and support further investigations, including studies exploring whether Co2+ and Cr3+ or CoCrMo alloys per se expose the patients to a higher risk of infections post-revision arthroplasty.
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Affiliation(s)
- Lea A Tölken
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald 17489,Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald 17475, Germany
| | - Daniel Grolimund
- Swiss Light Source, Paul Scherrer Institute, Villigen-PSI 5232, Switzerland
| | | | - Bernhard Hesse
- Xploraytion GmbH, Berlin 10625, Germany
- ESRF-The European Synchrotron, Grenoble 38000, France
| | - Anastasia Rakow
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald 17475, Germany
| | - Nikolai Siemens
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald 17489,Germany
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald 17475, Germany
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5
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Protheroe D, Green R, Hayes M. Particulate synovitis granuloma complication following a first metatarsophalangeal joint silastic implant. BMJ Case Rep 2023; 16:e257031. [PMID: 38129094 DOI: 10.1136/bcr-2023-257031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
This case presents a known complication of particulate synovitis granuloma associated with a first metatarsophalangeal joint silastic implant. However, the degree of soft tissue granuloma enlargement is quite unique in size and its proliferative effect-invading the medulla cavity and infiltrating the outer cortex of bone. This case study aims to demonstrate its clinical presentation, imaging investigations, surgical excision and histopathology findings. The learning points emphasised within this manuscript draw attention to the procedure selection for a silastic implant, as well as its proposed mode of action and various potential associated complications. Surgery was based on careful analysis of overall function, prior surgery conducted and patient expectations to achieve a shared decision-making process.
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6
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Panez-Toro I, Heymann D, Gouin F, Amiaud J, Heymann MF, Córdova LA. Roles of inflammatory cell infiltrate in periprosthetic osteolysis. Front Immunol 2023; 14:1310262. [PMID: 38106424 PMCID: PMC10722268 DOI: 10.3389/fimmu.2023.1310262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Classically, particle-induced periprosthetic osteolysis at the implant-bone interface has explained the aseptic loosening of joint replacement. This response is preceded by triggering both the innate and acquired immune response with subsequent activation of osteoclasts, the bone-resorbing cells. Although particle-induced periprosthetic osteolysis has been considered a foreign body chronic inflammation mediated by myelomonocytic-derived cells, current reports describe wide heterogeneous inflammatory cells infiltrating the periprosthetic tissues. This review aims to discuss the role of those non-myelomonocytic cells in periprosthetic tissues exposed to wear particles by showing original data. Specifically, we discuss the role of T cells (CD3+, CD4+, and CD8+) and B cells (CD20+) coexisting with CD68+/TRAP- multinucleated giant cells associated with both polyethylene and metallic particles infiltrating retrieved periprosthetic membranes. This review contributes valuable insight to support the complex cell and molecular mechanisms behind the aseptic loosening theories of orthopedic implants.
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Affiliation(s)
- Isidora Panez-Toro
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Independencia, Santiago, Chile
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
| | - Dominique Heymann
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
- Nantes Université, Laboratory of Histology and Embryology, Medical School, Nantes, France
- The University of Sheffield, Dept of Oncology and Metabolism, Sheffield, United Kingdom
| | - François Gouin
- Department of Surgical Oncology, Centre Léon Bérard, Lyon, France
| | - Jérôme Amiaud
- Nantes Université, Laboratory of Histology and Embryology, Medical School, Nantes, France
| | - Marie-Françoise Heymann
- Nantes Université, Centre National de Recherche Scientifique (CNRS), UMR6286, US2B, Nantes, France
- Institut de Cancérologie de l’Ouest, Tumor Heterogeneity and Precision Medicine Laboratory, Saint-Herblain, France
| | - Luis A. Córdova
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Chile, Independencia, Santiago, Chile
- IMPACT, Center of Interventional Medicine for Precision and Advanced Cellular Therapy, Santiago, Chile
- Oral and Maxillofacial Surgery, Clínica MEDS, Santiago, Chile
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7
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Murthy S, Fritz J. Metal Artifact Reduction MRI in the Diagnosis of Periprosthetic Hip Joint Infection. Radiology 2023; 306:e220134. [PMID: 36318029 DOI: 10.1148/radiol.220134] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
A 54-year-old woman presented with progressive right hip pain after hip arthroplasty 9 years earlier. The emerging role of metal artifact reduction MRI in the noninvasive diagnosis of infectious synovitis as the surrogate marker for periprosthetic hip joint infection and differentiation from other synovitis types is discussed.
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Affiliation(s)
- Sindhoora Murthy
- From the Department of Radiology, New York University Grossman School of Medicine, 660 1st Ave, 3rd Floor, Room 313, New York, NY 10016
| | - Jan Fritz
- From the Department of Radiology, New York University Grossman School of Medicine, 660 1st Ave, 3rd Floor, Room 313, New York, NY 10016
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8
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Tschiche HR, Bierkandt FS, Creutzenberg O, Fessard V, Franz R, Greiner R, Gruber-Traub C, Haas KH, Haase A, Hartwig A, Hesse B, Hund-Rinke K, Iden P, Kromer C, Loeschner K, Mutz D, Rakow A, Rasmussen K, Rauscher H, Richter H, Schoon J, Schmid O, Som C, Spindler LM, Tovar GEM, Westerhoff P, Wohlleben W, Luch A, Laux P. Analytical and toxicological aspects of nanomaterials in different product groups: Challenges and opportunities. NANOIMPACT 2022; 28:100416. [PMID: 35995388 DOI: 10.1016/j.impact.2022.100416] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/15/2022] [Accepted: 08/14/2022] [Indexed: 06/15/2023]
Abstract
The widespread integration of engineered nanomaterials into consumer and industrial products creates new challenges and requires innovative approaches in terms of design, testing, reliability, and safety of nanotechnology. The aim of this review article is to give an overview of different product groups in which nanomaterials are present and outline their safety aspects for consumers. Here, release of nanomaterials and related analytical challenges and solutions as well as toxicological considerations, such as dose-metrics, are discussed. Additionally, the utilization of engineered nanomaterials as pharmaceuticals or nutraceuticals to deliver and release cargo molecules is covered. Furthermore, critical pathways for human exposure to nanomaterials, namely inhalation and ingestion, are discussed in the context of risk assessment. Analysis of NMs in food, innovative medicine or food contact materials is discussed. Specific focus is on the presence and release of nanomaterials, including whether nanomaterials can migrate from polymer nanocomposites used in food contact materials. With regard to the toxicology and toxicokinetics of nanomaterials, aspects of dose metrics of inhalation toxicity as well as ingestion toxicology and comparison between in vitro and in vivo conclusions are considered. The definition of dose descriptors to be applied in toxicological testing is emphasized. In relation to potential exposure from different products, opportunities arising from the use of advanced analytical techniques in more unique scenarios such as release of nanomaterials from medical devices such as orthopedic implants are addressed. Alongside higher product performance and complexity, further challenges regarding material characterization and safety, as well as acceptance by the general public are expected.
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Affiliation(s)
- Harald R Tschiche
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany.
| | - Frank S Bierkandt
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany
| | - Otto Creutzenberg
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Valerie Fessard
- French Agency for Food, Environmental and Occupational Health & Safety (ANSES), Fougères Laboratory, Toxicology of contaminants Unit, Fougères, France
| | - Roland Franz
- Fraunhofer Institute for Process Engineering and Packaging (IVV), Freising, Germany
| | - Ralf Greiner
- Department of Food Technology and Bioprocess Engineering, Max Rubner-Institut, Karlsruhe, Germany
| | - Carmen Gruber-Traub
- Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany
| | - Karl-Heinz Haas
- Fraunhofer Institute for Silicate Research (ISC), Würzburg, Germany
| | - Andrea Haase
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany
| | - Andrea Hartwig
- Karlsruhe Institute of Technology (KIT), Institute of Applied Biosciences (IAB), Food Chemistry and Toxicology, Germany
| | - Bernhard Hesse
- European Synchrotron Radiation Facility, Grenoble, France
| | - Kerstin Hund-Rinke
- Fraunhofer Institute for Molecular Biology and Applied Ecology (IME), Schmallenberg, Germany
| | | | - Charlotte Kromer
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany
| | - Katrin Loeschner
- National Food Institute, Technical University of Denmark, Lyngby, Denmark
| | - Diana Mutz
- German Federal Institute for Risk Assessment (BfR), Research Strategy and Coordination, Berlin, Germany
| | - Anastasia Rakow
- Charité - Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, Berlin, Germany; Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | | | - Hubert Rauscher
- European Commission, Joint Research Centre (JRC), Ispra, Italy
| | - Hannes Richter
- Fraunhofer IKTS - Institute for Ceramic Technologies and Systems, Hermsdorf, Germany
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Berlin, Germany
| | - Otmar Schmid
- Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany; Institute of Lung Health and Immunity, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Claudia Som
- Technology and Society Laboratory, Swiss Federal Laboratories for Materials Science and Technology (Empa), St. Gallen, Switzerland
| | - Lena M Spindler
- Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany; University of Stuttgart, Institute of Interfacial Process Engineering and Plasma Technology (IGVP), Stuttgart, Germany
| | - Günter E M Tovar
- Fraunhofer Institute for Interfacial Engineering and Biotechnology (IGB), Stuttgart, Germany; University of Stuttgart, Institute of Interfacial Process Engineering and Plasma Technology (IGVP), Stuttgart, Germany
| | - Paul Westerhoff
- Arizona State University, Tempe, AZ, United States of America
| | | | - Andreas Luch
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany
| | - Peter Laux
- German Federal Institute for Risk Assessment (BfR), Department of Chemical and Product Safety, Berlin, Germany
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9
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Martínez Villén G, Rodríguez Nogué L, García González E. Postoperative assessment and management of metallosis and periprosthetic osteolysis in patients treated with metal-on-polyethylene total wrist prostheses. J Hand Surg Eur Vol 2022; 47:952-958. [PMID: 35866419 DOI: 10.1177/17531934221113723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We analysed the relationship between serum metal ions, radiological periprosthetic osteolysis and the clinical features in a series of 25 patients treated with fourth-generation metal-on-polyethylene total wrist prostheses. The mean implant follow-up was 7 years. Our results show that titanium was the main elevated serum metal ion in patients with the prostheses that we used; elevated serum cobalt or chromium values were infrequent. The risk of loosening was higher in an implant older than 6 years, with more than five periprosthetic osteolysis points according to our radiograph zone system, and serum titanium values between 26 to 31 µg/L. The presence of metallosis pseudotumours does not guarantee but increases the risk of implant failure, which may be asymptomatic or associated with little pain.Level of evidence: IV.
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Affiliation(s)
- Gregorio Martínez Villén
- Department of Orthopaedic and Traumatology (Hand and Reconstructive Surgery Unit), Miguel Servet University Hospital, Zaragoza, Spain
| | - Luis Rodríguez Nogué
- Department of Orthopaedic and Traumatology (Hand and Reconstructive Surgery Unit), Miguel Servet University Hospital, Zaragoza, Spain
| | - Elena García González
- Department of Clinical Biochemistry, Miguel Servet University Hospital, Zaragoza, Spain
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10
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Schoon J, Hesse B, Tucoulou R, Geissler S, Ort M, Duda GN, Perka C, Wassilew GI, Perino G, Rakow A. Synchrotron-based characterization of arthroprosthetic CoCrMo particles in human bone marrow. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2022; 33:54. [PMID: 35691951 PMCID: PMC9189090 DOI: 10.1007/s10856-022-06675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/18/2022] [Indexed: 06/15/2023]
Abstract
Particles released from cobalt-chromium-molybdenum (CoCrMo) alloys are considered common elicitors of chronic inflammatory adverse effects. There is a lack of data demonstrating particle numbers, size distribution and elemental composition of bone marrow resident particles which would allow for implementation of clinically relevant test strategies in bone marrow models at different degrees of exposure. The aim of this study was to investigate metal particle exposure in human periprosthetic bone marrow of three types of arthroplasty implants. Periprosthetic bone marrow sections from eight patients exposed to CoCrMo particles were analyzed via spatially resolved and synchrotron-based nanoscopic X-ray fluorescence imaging. These analyses revealed lognormal particle size distribution patterns predominantly towards the nanoscale. Analyses of particle numbers and normalization to bone marrow volume and bone marrow cell number indicated particle concentrations of up to 1 × 1011 particles/ml bone marrow or 2 × 104 particles/bone marrow cell, respectively. Analyses of elemental ratios of CoCrMo particles showed that particularly the particles' Co content depends on particle size. The obtained data point towards Co release from arthroprosthetic particles in the course of dealloying and degradation processes of larger particles within periprosthetic bone marrow. This is the first study providing data based on metal particle analyses to be used for future in vitro and in vivo studies of possible toxic effects in human bone marrow following exposure to arthroprosthetic CoCrMo particles of different concentration, size, and elemental composition. Graphical abstract.
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Affiliation(s)
- Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany.
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Bernhard Hesse
- Xploraytion GmbH, 10625, Berlin, Germany.
- ESRF-The European Synchrotron, 38000, Grenoble, France.
| | - Remi Tucoulou
- ESRF-The European Synchrotron, 38000, Grenoble, France
| | - Sven Geissler
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Melanie Ort
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Georg N Duda
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Georgi I Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Giorgio Perino
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
| | - Anastasia Rakow
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, 17475, Greifswald, Germany
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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11
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Matar HE, Porter PJ, Porter ML. Metal allergy in primary and revision total knee arthroplasty : a scoping review and evidence-based practical approach. Bone Jt Open 2021; 2:785-795. [PMID: 34587776 PMCID: PMC8558451 DOI: 10.1302/2633-1462.210.bjo-2021-0098.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aims Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). Methods Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence. Results We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent. Conclusion Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785–795.
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Affiliation(s)
- Hosam E Matar
- Wrightington Hospital, Wigan, UK.,Nottingham Elective Orthopaedic Services, Nottingham University Hospital NHS Trust, Nottingham, UK
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12
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The Expression Levels of Toll-like Receptors after Metallic Particle and Ion Exposition in the Synovium of a Murine Model. J Clin Med 2021; 10:jcm10163489. [PMID: 34441785 PMCID: PMC8396889 DOI: 10.3390/jcm10163489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/21/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022] Open
Abstract
To date, the exact role of specific Toll-like receptors (TLRs) in regulating immune reactivity to metallic byproducts of orthopedic implants has not been fully clarified. In light of the situation, our objective in this investigation was to assess the expression levels of surface TLRs after metallic particle and ion exposure in an established animal model. Ten female BALB/c mice in each group received intra-articular injections of phosphate buffer (PBS) (control), metallic particles (MP), and metallic ions (MI), respectively. Seven days later, immunohistochemical staining was undertaken in the synovial layer of the murine knee joints using anti-TLR 1, 2, 4, 5, and 6 polyclonal antibodies. In addition to increased cellular infiltrates and a hyperplastic synovial membrane, the MP group showed significantly elevated TLR expression compared to the control group and had higher TLR 1-, 4-, and 6-positive cells than the MI group (p < 0.0167). TLR 4- and TLR 6-positive cells were significantly augmented for the MI group compared to the control group (p < 0.0167). Additionally, greenish corrosion particles found in the necrotic tissue suggested that metallic particles might release a certain level of locally toxic metallic ions in vivo.
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Perino G, De Martino I, Zhang L, Xia Z, Gallo J, Natu S, Langton D, Huber M, Rakow A, Schoon J, Gomez-Barrena E, Krenn V. The contribution of the histopathological examination to the diagnosis of adverse local tissue reactions in arthroplasty. EFORT Open Rev 2021; 6:399-419. [PMID: 34267931 PMCID: PMC8246109 DOI: 10.1302/2058-5241.6.210013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The histopathological examination of the periprosthetic soft tissue and bone has contributed to the identification and description of the morphological features of adverse local tissue reactions (ALTR)/adverse reactions to metallic debris (ARMD). The need of a uniform vocabulary for all disciplines involved in the diagnosis and management of ALTR/ARMD and of clarification of the parameters used in the semi-quantitative scoring systems for their classification has been considered a pre-requisite for a meaningful interdisciplinary evaluation. This review of key terms used for ALTR/ARMD has resulted in the following outcomes: (a) pseudotumor is a descriptive term for ALTR/ARMD, classifiable in two main types according to its cellular composition defining its clinical course; (b) the substitution of the term metallosis with presence of metallic wear debris, since it cannot be used as a category of implant failure or histological diagnosis; (c) the term aseptic lymphocytic-dominated vasculitis- associated lesion (ALVAL) should be replaced due to the absence of a vasculitis with ALLTR/ALRMD for lymphocytic-predominant and AMLTR/AMRMD for macrophage-predominant reaction. This review of the histopathological classifications of ALTR/ARMD has resulted in the following outcomes: (a) distinction between cell death and tissue necrosis; (b) the association of corrosion metallic debris with adverse local lymphocytic reaction and tissue necrosis; (c) the importance of cell and particle debris for the viscosity and density of the lubricating synovial fluid; (d) a consensus classification of lymphocytic infiltrate in soft tissue and bone marrow; (e) evaluation of the macrophage infiltrate in soft tissues and bone marrow; (f) classification of macrophage induced osteolysis/aseptic loosening as a delayed type of ALTR/ARMD; (g) macrophage motility and migration as possible driving factor for osteolysis; (h) usefulness of the histopathological examination for the natural history of the adverse reactions, radiological correlation, post-marketing surveillance, and implant registries. The review of key terms used for the description and histopathological classification of ALTR/ARMD has resulted in a comprehensive, new standard for all disciplines involved in their diagnosis, clinical management, and long-term clinical follow-up.
Cite this article: EFORT Open Rev 2021;6:399-419. DOI: 10.1302/2058-5241.6.210013
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Affiliation(s)
- Giorgio Perino
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lingxin Zhang
- Department of Pathology and Laboratory Medicine, Sinai Health System, Toronto, Canada
| | - Zhidao Xia
- Centre for Nanohealth, Swansea University Medical School, Singleton Park, Swansea, UK
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, University Hospital, Palacky University Olomouc, Czech Republic
| | - Shonali Natu
- Department of Pathology, University Hospital of North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - David Langton
- Orthopaedic Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Monika Huber
- Pathologisch-bakteriologisches Institut, Otto Wagner Spital, Wien, Austria
| | - Anastasia Rakow
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Janosch Schoon
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Enrique Gomez-Barrena
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Veit Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik-GmbH, Trier, Germany
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Diagnostic value of the CD 15 focus score in two-stage revision arthroplasty of periprosthetic joint infections : High specificity in diagnosing infect eradication. Z Rheumatol 2020; 81:342-351. [PMID: 33306153 DOI: 10.1007/s00393-020-00941-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The purpose of this study is to use the CD15 focus score (FS) to determine the sensitivity and specificity of bacterial infection persistence in spacer-based two-stage revision arthroplasty. METHODS The analysis comprises 112 cases that were subjected to revision due to the presence of infection upon replacement of a joint endoprosthesis. The histopathological data were collected in accordance with the synovial-like interface membrane (SLIM) classification and the CD15-FS and correlated with the microbiological data (MD). The quantifying evaluation of the CD15-FS was performed without knowledge regarding the microbiological data (MD). Correlation with the MD was performed after a 14-day cultivation period. RESULTS With a single evaluation (1 focus, field area: 1.2 mm2) with a score value of 42, the CD15-FS showed a sensitivity for the eradication of infections of 0.64 and a specificity of 0.79 (PPV = 0.5; NPV = 0.87). With tenfold evaluation (10 foci, field area: 12 mm2) with a score value of 220, the sensitivity for the eradication was 0.68, the specificity 0.91 (PPV = 0.7; NPV = 0.89). No statistically significant correlation between the score values and the different infectious species could be detected. Based on the MD in 112 cases the rate of infection eradication was 75%. Polymethylmethacrylate-particles (PMMA) were detected in the perispacertissue in 64 cases (58%). No significant correlation could be established between microbiological pathogen detection and the presence of PMMA. CONCLUSION In all cases (n = 112), periimplant synovial tissue (SLIM) with variable fibroblastic cellularity, capillary proliferation, leukocytic infiltration, fibrin deposition, new formation of woven bone and detection of PMMA particles was observed. These cases were classified as type IX perispacer synovialis/SLIM: type IX‑A with histopathological infection eradication and type IX‑B with histopathological infection persistence.
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Schoon J, Hesse B, Rakow A, Ort MJ, Lagrange A, Jacobi D, Winter A, Huesker K, Reinke S, Cotte M, Tucoulou R, Marx U, Perka C, Duda GN, Geissler S. Metal-Specific Biomaterial Accumulation in Human Peri-Implant Bone and Bone Marrow. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:2000412. [PMID: 33101844 PMCID: PMC7578891 DOI: 10.1002/advs.202000412] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/09/2020] [Indexed: 05/13/2023]
Abstract
Metallic implants are frequently used in medicine to support and replace degenerated tissues. Implant loosening due to particle exposure remains a major cause for revision arthroplasty. The exact role of metal debris in sterile peri-implant inflammation is controversial, as it remains unclear whether and how metals chemically alter and potentially accumulate behind an insulating peri-implant membrane, in the adjacent bone and bone marrow (BM). An intensively focused and bright synchrotron X-ray beam allows for spatially resolving the multi-elemental composition of peri-implant tissues from patients undergoing revision surgery. In peri-implant BM, particulate cobalt (Co) is exclusively co-localized with chromium (Cr), non-particulate Cr accumulates in the BM matrix. Particles consisting of Co and Cr contain less Co than bulk alloy, which indicates a pronounced dissolution capacity. Particulate titanium (Ti) is abundant in the BM and analyzed Ti nanoparticles predominantly consist of titanium dioxide in the anatase crystal phase. Co and Cr but not Ti integrate into peri-implant bone trabeculae. The characteristic of Cr to accumulate in the intertrabecular matrix and trabecular bone is reproducible in a human 3D in vitro model. This study illustrates the importance of updating the view on long-term consequences of biomaterial usage and reveals toxicokinetics within highly sensitive organs.
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Affiliation(s)
- Janosch Schoon
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Bernhard Hesse
- Xploraytion GmbHBerlin10625Germany
- European Synchrotron Radiation FacilityGrenoble38000France
| | - Anastasia Rakow
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Center for Musculoskeletal SurgeryCharité – Universitätsmedizin BerlinBerlin10117Germany
| | - Melanie J. Ort
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Adrien Lagrange
- Xploraytion GmbHBerlin10625Germany
- Department of Materials Science and EngineeringInstitute of Materials Science and TechnologiesTechnische Universität BerlinBerlin10623Germany
| | - Dorit Jacobi
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
| | | | - Katrin Huesker
- Endocrinology and Immunology DepartmentInstitute for Medical DiagnosticsBerlin12247Germany
| | - Simon Reinke
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
| | - Marine Cotte
- European Synchrotron Radiation FacilityGrenoble38000France
- CNRSLaboratoire d'archéologie moléculaire et structuraleLAMSSorbonne UniversitéParis75005France
| | - Remi Tucoulou
- European Synchrotron Radiation FacilityGrenoble38000France
| | | | - Carsten Perka
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
- Center for Musculoskeletal SurgeryCharité – Universitätsmedizin BerlinBerlin10117Germany
| | - Georg N. Duda
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
| | - Sven Geissler
- Julius Wolff InstituteCharité – Universitätsmedizin BerlinBerlin13353Germany
- Berlin Institute of Health Center for Regenerative TherapiesBerlin Institute of HealthBerlin10178Germany
- Berlin‐Brandenburg School for Regenerative TherapiesCharité – Universitätsmedizin BerlinBerlin13353Germany
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16
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Krenn S, Gutwald R, Bönigk M, Krenn V. Dental Apical Inflammation Score (DAIS): Histopathological scoring for the evaluation of the apical inflammatory activity and local bone destruction. Pathol Res Pract 2020; 216:153223. [PMID: 32992098 DOI: 10.1016/j.prp.2020.153223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate 210 periapical lesions with a newly created Dental Apical Inflammation Score/DAIS with regard to their inflammatory cell infiltration, bone tissue, epithelium, bacteria and foreign material. STUDY DESIGN Specimens were obtained from 51 different dental practices over a period of 11 months. These specimens were then sent in for histopathological routine diagnostics. RESULTS The DAIS classified 81 cases of Type 1 (acute inflammation = low, chronic inflammation = low), 79 cases of Type 2 (acute inflammation = low, chronic inflammation = high), 46 cases of Type 3 (acute inflammation = high, chronic inflammation = low) and 4 cases of Type 4 (acute inflammation = high, chronic inflammation = high). Bone tissue was found in 141 cases, signs for bacterial osteitis in 49 cases, cyst epithelium in 40 cases and foreign material in 27 cases. In 210 cases, cyst epithelium was evident in 27.2 % of Type 1, 15.2 % of Type 2, 8.7 % of Type 3 and in 50 % of Type 4 (p = .019). The 141 cases containing bone tissue showed signs of bacterial osteitis in 16.1 % of Type 1, 29.8 % of Type 2, 77.8 % of Type 3 and in 100 % of Type 4 (p < .001). In 64 cases, Bacteria was evident in 30 % of Type 1, 25 % of Type 2, 55 % of Type 3 and in 100 % of Type 4 (p = .013). CONCLUSION The DAIS could classify apical lesions with statistically significant differences. Bacterial osteitis in apical lesions was reported for the first time.
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Affiliation(s)
- S Krenn
- Danube Private University, Krems-Stein, Austria.
| | - R Gutwald
- Danube Private University, Krems-Stein, Austria
| | - M Bönigk
- Universitat Wien, Vienna, Austria
| | - V Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, GmbH. Germany
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17
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Kirchen N, Reich L, Waldstein W, Hopf T, Heller KD, Wienert S, Krenn V. [ARMD reaction patterns in knee arthroplasty : A novel hypothetical mechanism: hingiosis]. DER ORTHOPADE 2020; 49:183-189. [PMID: 31919555 DOI: 10.1007/s00132-019-03776-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are case descriptions of pronounced peri-implant inflammatory reactions and necrosis in non-infectious knee joint replacements with metal-polyethylene pairing. OBJECTIVES Due to the histopathological similarities to the dysfunctional metal-on-metal (MoM) hip joint replacement, MoM-like reactions in knee joint arthroplasty ("ARMD-KEP") are proposed and a histopathological comparison is made. MATERIALS AND METHODS This analysis evaluates five cases of "ARMD-KEP" using: (1) the SLIM consensus classification, (2) the particle algorithm, (3) the CD3 focus score and (4) the AVAL score. The comparison groups consist of 11 adverse cases of MoM hip and 20 cases of knee joint arthroplasty without adverse reaction. RESULTS The ARMD-KEP cases were identified as SLIM type VI. Their median ALVAL score was 10. The CD3 focus score confirmed an adverse reaction. Particle corrosion was found in two of five cases. CONCLUSIONS This data indicates that, in rare cases, an adverse MoM-like reaction may be present in knee replacements, with inflammatory and immunological expression similar to that of the adverse MoM reaction in the hip. The pathomechanisms can be discussed as follows: (1) secondary metal-metal contact, (2) dysfunctional loading of the coupling mechanism and (3) corrosion of the metal components. Much like trunnionosis in the hip, the term "hingiosis" is proposed for corrosion phenomena in dysfunctional conditions of coupled knee endoprosthetic systems.
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Affiliation(s)
- Niklas Kirchen
- MVZ für Histologie, Zytologie und Molekulare Diagnostik Trier, Max-Planck-Straße 5, 54296, Trier, Deutschland.
| | - Lars Reich
- Universität Klagenfurt, Klagenfurt, Österreich
| | - Wenzel Waldstein
- Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Thomas Hopf
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Deutschland
| | | | | | - Veit Krenn
- MVZ für Histologie, Zytologie und Molekulare Diagnostik Trier, Max-Planck-Straße 5, 54296, Trier, Deutschland
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18
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Schoon J, Ort MJ, Huesker K, Geissler S, Rakow A. Diagnosis of Metal Hypersensitivity in Total Knee Arthroplasty: A Case Report. Front Immunol 2019; 10:2758. [PMID: 31827473 PMCID: PMC6890602 DOI: 10.3389/fimmu.2019.02758] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/11/2019] [Indexed: 12/27/2022] Open
Abstract
Delayed type hypersensitivity (DTH) reactions are considered infrequent complications in arthroplasty, but have been recognized to be associated with devastating morbidity and substantial decrease in quality of life of affected patients. Chronic inflammation of artificial joints and associated loss of peri-implant bone often require revision surgery. Methods for the diagnosis of implant-related DTH are available but infrequently considered to the full extent. Sequential diagnostics based on exclusion of septic complications, local and systemic metal level determination, lymphocyte transformation testing (LTT), and local T cell subset analysis are required for an unequivocal DTH diagnosis. Here, we report on a patient with a history of chronic rheumatoid arthritis and an unfavorable outcome of unilateral knee arthroplasty. This case illustrates pitfalls and difficulties in the course of recurrent inflammation following joint replacement. In the early course, suspicion of low-grade bacterial infection led to three two-stage revisions. Afterwards, the joint was proven to be sterile. However, metal level quantification revealed release of especially cobalt and chromium from the joint, LTT indicated persisting cobalt and nickel sensitization and subset analysis of T cells from the synovium suggested DTH as a root cause for the inflammatory symptoms. This report aims to recommend the depicted diagnostic algorithm as an adequate tool for future DTH detection. Yet, systemic to local subset ratios for effector memory and regulatory T cells should be derived from sufficient patient numbers to establish it as a diagnostic marker. Moreover, future prospects regarding implant-related DTH diagnostics are discussed. Therapeutic options for the portrayed patient are proposed, considering pharmaceutical, cell-therapeutic and surgical aspects. Patients who experience peri-implant inflammation but do not have obvious mechanical or infectious problems remain a diagnostic challenge and are at high risk of being treated inadequately. Since potentially sensitizing materials are regularly used in arthroplasty, it is essential to detect cases of acute DTH-derived inflammation of an artificial joint at early postoperative stages. This would reduce the severity of inflammation-related long-term consequences for affected patients and may avoid unnecessary revision surgery.
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Affiliation(s)
- Janosch Schoon
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Melanie J Ort
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Katrin Huesker
- Immunology Department, Institute for Medical Diagnostics, Berlin, Germany
| | - Sven Geissler
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Anastasia Rakow
- Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Heterotopic Ossification in Orthopaedic and Trauma surgery: A Histopathological Ossification Score. Sci Rep 2019; 9:18401. [PMID: 31804584 PMCID: PMC6895226 DOI: 10.1038/s41598-019-54986-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/19/2019] [Indexed: 01/12/2023] Open
Abstract
Heterotopic Ossification (HO) is a potential long-term complication in orthopaedic surgery. It is commonly classified according to the Brooker classification, which is based on radiological findings. To our knowledge the correlation of histological features to the Brooker grade is unknown as is the association between HO and the indication for revision. The aim of this paper is to analyze the ossification grade of HO tissue in patients undergoing revision hip and knee arthroplasty and to propose a histologically based classification system for HO. We also assess the relationship between the grade of HO and the indication for revision (septic and aseptic revision). From January to May 2019 we collected 50 human HO samples from hip and knee revision arthroplasty cases. These tissue samples were double-blinded and sent for histopathological diagnostic. Based on these results, we developed a classification system for the progression of HO. The grade of ossification was based on three characteristics: Grade of heterotopic ossification (Grade 1–3), presence of necrosis (N0 or N1) and the presence of osteomyelitis (HOES-Score Type 1 to 5). Demographic data as well as surgical details and indication for surgery was prospectively collected from clinical records. Fifty tissue samples were harvested from 44 hips and 6 knee joints. Of these 33 exhibited Grade I ossifications (66%), followed by 11 Grade II (22%) and one Grade III (2%). Necrosis was noted in two tissue samples (4%) and 2 more had osteomyelitis findings according to HOES-Score. Six samples (12%) with radiologically suggestive of HO turned out to be wear-induced synovitis, SLIM Type 1. Of these cases 16 were septic (32%) and 34 aseptic (68%) revisions. Most of the HO tissue samples were classified as a low-grade. High-grade ossification-Score is rare. Higher grades of ossification seem to be associated with septic revision cases. Wear-induced synovitis potentially influences HO development. A histological scoring system for ossification grading can be derived from the data presented in this study.
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Jandl NM, Rolvien T, Gätjen D, Jonitz-Heincke A, Springer A, Krenn V, Bader R, Rüther W. Recurrent arthrocele and sterile sinus tract formation due to ceramic wear as a differential diagnosis of periprosthetic joint infection - a case report. Acta Orthop 2019; 90:501-504. [PMID: 31094272 PMCID: PMC6746295 DOI: 10.1080/17453674.2019.1616997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Nico Maximilian Jandl
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ,Orthopedic University Hospital Bad Bramstedt;; ,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg; ,Correspondence:
| | - Tim Rolvien
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ,Orthopedic University Hospital Bad Bramstedt;; ,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg;
| | - Daniel Gätjen
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ,Orthopedic University Hospital Bad Bramstedt;;
| | - Anika Jonitz-Heincke
- Department of Orthopedics, Biomechanics and Implant Technology Research Laboratory, Rostock University Medical Center, Rostock;
| | - Armin Springer
- Medical Biology and Electron Microscopy Center, Rostock University Medical Center, Rostock;
| | - Veit Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
| | - Rainer Bader
- Department of Orthopedics, Biomechanics and Implant Technology Research Laboratory, Rostock University Medical Center, Rostock;
| | - Wolfgang Rüther
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; ,Orthopedic University Hospital Bad Bramstedt;;
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Ort MJ, Geissler S, Rakow A, Schoon J. The Allergic Bone Marrow? The Immuno-Capacity of the Human Bone Marrow in Context of Metal-Associated Hypersensitivity Reactions. Front Immunol 2019; 10:2232. [PMID: 31620137 PMCID: PMC6759684 DOI: 10.3389/fimmu.2019.02232] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022] Open
Abstract
Arthroplasty ranks among the greatest achievements of surgical medicine, with total hip replacement termed “the operation of the century.” Despite its wide success, arthroplasty bears risks, such as local reactions to implant derived wear and corrosion products. Prevalence of allergies across Western society increases and along the number of reported hypersensitivity reactions to orthopedic implant materials. In this context the main focus is on delayed hypersensitivity (DTH). This mechanism is mainly attributed to T cells and an overreaction of the adaptive immune system. Arthroplasty implant materials are in direct contact with bone marrow (BM), which is discussed as a secondary lymphoid organ. However, the mechanisms of sensitization toward implant wear remain elusive. Nickel and cobalt ions can form haptens with native peptides to activate immune cell receptors and are therefore common T helper allergens in cutaneous DTH. The rising prevalence of metal-related allergy in the general population and evidence for the immune-modulating function of BM allow for the assumption hypersensitivity reactions could occur in peri-implant BM. There is evidence that pro-inflammatory factors released during DTH reactions enhance osteoclast activity and inhibit osteoblast function, an imbalance characteristic for osteolysis. Even though some mechanisms are understood, hypersensitivity has remained a diagnosis of exclusion. This review aims to summarize current views on the pathomechanism of DTH in arthroplasty with emphasis on BM and discusses recent advances and future directions for basic research and clinical diagnostics.
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Affiliation(s)
- Melanie J Ort
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sven Geissler
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anastasia Rakow
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Janosch Schoon
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Humboldt-Universität zu Berlin, Berlin, Germany
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Papadimitriou-Olivgeri I, Brown JM, Kilpatrick AFR, Gill HS, Athanasou NA. Solochrome cyanine: A histological stain for cobalt-chromium wear particles in metal-on-metal periprosthetic tissues. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2019; 30:103. [PMID: 31493091 PMCID: PMC6731196 DOI: 10.1007/s10856-019-6304-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/23/2019] [Indexed: 06/10/2023]
Abstract
Metal-on-metal (MoM) hip arthroplasties produce abundant implant-derived wear debris composed mainly of cobalt (Co) and chromium (Cr). Cobalt-chromium (Co-Cr) wear particles are difficult to identify histologically and need to be distinguished from other wear particle types and endogenous components (e.g., haemosiderin, fibrin) which may be present in MoM periprosthetic tissues. In this study we sought to determine whether histological stains that have an affinity for metals are useful in identifying Co-Cr wear debris in MoM periprosthetic tissues. Histological sections of periprosthetic tissue from 30 failed MoM hip arthroplasties were stained with haematoxylin-eosin (HE), Solochrome Cyanine (SC), Solochrome Azurine (SA) and Perls' Prussian Blue (PB). Sections of periprosthetic tissue from 10 cases of non-MoM arthroplasties using other implant biomaterials, including titanium, ceramic, polymethylmethacrylate (PMMA) and ultra-high molecular weight polyethylene (UHMWP) were similarly analysed. Sections of 10 cases of haemosiderin-containing knee tenosynovial giant cell tumour (TSGCT) were also stained with HE, SC, SA and PB. In MoM periprosthetic tissues, SC stained metal debris in phagocytic macrophages and in the superficial necrotic zone which exhibited little or no trichrome staining for fibrin. In non-MoM periprosthetic tissues, UHMWP, PMMA, ceramic and titanium particles were not stained by SC. Prussian Blue, but not SC or SA, stained haemosiderin deposits in MoM periprosthetic tissues and TSGT. Our findings show that SC staining (most likely Cr-associated) is useful in distinguishing Co-Cr wear particles from other metal/non-metal wear particles types in histological preparations of periprosthetic tissue and that SC reliably distinguishes haemosiderin from Co-Cr wear debris.
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Affiliation(s)
- I Papadimitriou-Olivgeri
- Department of Histopathology, NDORMS, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7HE, UK
| | - J M Brown
- Department of Histopathology, NDORMS, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7HE, UK
| | - A F R Kilpatrick
- Chemistry Research Laboratory, Mansfield Road, Oxford, OX1 3TA, UK
| | - H S Gill
- Department of Mechanical Engineering, University of Bath, Bath, BA2 7AY, UK
| | - N A Athanasou
- Department of Histopathology, NDORMS, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7HE, UK.
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