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The Journal of Bone and Joint Surgery, Vol 72, Issue 2 252-258, Copyright © 1990 by Journal of Bone and Joint Surgery, Inc
Aggressive granulomatous lesions associated with hip arthroplasty. Immunopathological studies
S Santavirta, YT Konttinen, V Bergroth, A Eskola, K Tallroth and TS Lindholm
Orthopaedic Hospital of the Invalid Foundation, Helsinki, Finland.
The local immunopathological response was analyzed in six patients who had
a revision of a total hip prosthesis because of an aggressive granulomatous
lesion and in six patients who had a revision because of common loosening
of the prosthetic stem. All twelve patients had had a total replacement
arthroplasty for primary osteoarthrosis. All of the prostheses had been
cemented. The aggressive granulomas consisted of well organized connective
tissue containing histiocytic-monocytic and fibroblastic reactive zones.
The granulomas were highly vascularized, and villous structures were
observed at many sites. In contrast, the areas around the loose cemented
stems were characterized by dense connective tissue. Immunohistological
evaluation revealed that most of the cells in the aggressive granulomatous
tissue were multinucleated giant cells and C3bi-receptor and nonspecific
esterase-positive monocyte-macrophages. This cytological finding suggests a
foreign-body-type reaction, compatible with the rapidly progressive lytic
nature of the lesion that was shown radiographically. There was a clear-cut
difference between aggressive granulomatosis and the more common lesion
accompanying prosthetic loosening--namely, the relative lack of activated
fibroblasts in granulomatosis. We suggest that granulomatosis involves an
uncoupling of the normal sequence of monocyte-macrophage-mediated clearance
of foreign material and tissue debris that is normally followed by
fibroblast-mediated synthesis and remodeling of the extracellular matrix.
We also suggest that aggressive granulomatosis in association with a
cemented hip prosthesis is a distinct entity, not only clinically and
radiographically, but also histopathologically.
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