The Journal of Bone and Joint Surgery 82:457 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Dissemination of Wear Particles to the Liver, Spleen, and Abdominal Lymph Nodes of Patients with Hip or Knee Replacement*
Robert M. Urban,  ,
Joshua J. Jacobs, M.D.,
Michael J. Tomlinson, D.V.M., PH.D.,
John Gavrilovic, PH.D. ,
Jonathan Black, PH.D. and
Michel Peoc'h, M.D.#
Investigation performed at the Department of Orthopedic Surgery,
The Rush Arthritis and Orthopedic Institute,
Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois
*One or more of the authors has received or will receive benefits
for personal or professional use from a commercial party related
directly or indirectly to the subject of this article. In addition,
benefits have been or will be directed to a research fund, foundation,
educational institution, or other nonprofit organization with which
one or more of the authors is associated. Funds were received in total
or partial support of the research or clinical study presented in
this article. The funding sources were National Institutes of Health
Grant AR39310, the Crown Family Chair in Orthopedic Surgery, and
Zimmer USA.
Department of Orthopedic Surgery, Rush-Presbyterian-St. Luke's
Medical Center, 1653 West Congress Parkway, Chicago, Illinois 60612.
E-mail address for R. M. Urban: rurban{at}rush.edu
McCrone Associates, 850 Pasquinelli Drive, Westmont, Illinois
60559.
IMN Biomaterials, 409 Dorothy Drive, King of Prussia, Pennsylvania
19406.
#Service D'Anatomie Pathologique, Centre Hospitalier Regional
et Universitaire, 38043 Grenoble, France.
Background: The importance of particles
generated by wear and corrosion of joint replacement prostheses
has been understood primarily in the context of the local effects
of particle-induced periprosthetic osteolysis and aseptic loosening.
We studied dissemination of wear particles in patients with total
hip and knee replacement to determine the prevalence of and the
histopathological response to prosthetic wear debris in the liver,
spleen, and abdominal para-aortic lymph nodes.
Methods: Postmortem specimens from twenty-nine
patients and biopsy specimens from two living patients with a failed
replacement were analyzed. Specimens of tissue obtained from the
cadavera of fifteen patients who had not had a joint replacement served
as controls. The concentration of particles and the associated tissue
response were characterized with the use of light microscopy of
stained histological sections. Metallic particles were identified
by electron microprobe analysis. Polyethylene particles were studied
with the use of oil-red-O stain and polarized light microscopy.
The composition of polyethylene particles was confirmed in selected
cases by Fourier transform infrared spectroscopy and hot-stage thermal
analysis.
Twenty-one of the patients studied post mortem had had a primary
total joint replacement. Eleven of them had had a hip prosthesis
for a mean of sixty-nine months (range, forty-three to 171 months), and
ten had had a knee replacement for a mean of eighty-four months
(range, thirty-one to 179 months). The other eight patients studied
post mortem had had a hip replacement in which one or more components
had loosened and had been revised. The mean time between the initial
arthroplasty and the time of death was 174 months (range, forty-seven
to 292 months), and the mean time between the last revision procedure
and the time of death was seventy-one months (range, one to 130
months).
Results: Metallic wear particles in the liver
or spleen were more prevalent in patients who had had a failed hip arthroplasty
(seven of eight) than in patients who had had a primary hip (two
of eleven) or knee replacement (two of ten). The principal source
of wear particles in the majority of these patients involved secondary
nonbearing surfaces rather than wear between the two primary bearing
surfaces as intended. In one living patient, dissemination of titanium
alloy particles from a hip prosthesis with mechanical failure was
associated with a visceral granulomatous reaction and hepatosplenomegaly, which
required operative and medical treatment.
Metallic wear particles were detected in the para-aortic lymph
nodes in 68 percent (nineteen) of the twenty-eight patients with
an implant from whom lymph nodes were available for study. In 38
percent (eleven) of all twenty-nine patients with an implant who
were studied post mortem, metallic particles had been further disseminated
to the liver or spleen, where they were usually found within small
aggregates of macrophages occurring as infiltrates without apparent
pathological importance. Polyethylene particles elicited a similar
response. They were identified in the para-aortic lymph nodes of
68 percent (nineteen) of the twenty-eight patients and the liver
or spleen of 14 percent (four) of the twenty-nine patients. The
majority of the disseminated wear particles were less than one micrometer
in size. Currently available methods lack the sensitivity and specificity
necessary to detect very low concentrations of submicrometer polyethylene
particles and probably underestimated the prevalence of polyethylene
wear debris in the liver and spleen.
Conclusions: In this study, systemic distribution
of metallic and polyethylene wear particles was a common finding,
both in patients with a previously failed implant and in those with
a primary total joint prosthesis. The prevalence of particles in
the liver or spleen was greater after reconstructions with mechanical
failure. In the majority of patients, the concentration of wear
particles in these organs was relatively low and without apparent
pathological importance. However, in one rare case, granulomas formed
in the liver, spleen, and abdominal lymph nodes in response to heavy
accumulation of wear debris from a hip prosthesis with mechanical failure
and compromised hepatic function.
Clinical Relevance: These findings underscore
the necessity of minimizing the production of particulate debris
by joint replacement devices and the need for the surgeon to consider
expeditious revision in patients in whom large amounts of particulate
debris may be generated. Serum and urine trace-metal analyses may
provide early confirmation of failure and aid in the timing of a
revision operation in a patient with a symptomatic or failed device.
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