The Journal of Bone and Joint Surgery (American). 2005;87:18-27.
doi:10.2106/JBJS.C.00949
© 2005 The Journal of Bone and Joint Surgery, Inc.
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An Unusual Lymphocytic Perivascular Infiltration in Tissues Around Contemporary Metal-on-Metal Joint Replacements

A.P. Davies, MD1, H.G. Willert, MD2, P.A. Campbell, PhD3, I.D. Learmonth, FRCS1 and C.P. Case, MRCPath1

1 Bristol Implant Research Centre, Avon Orthopaedic Centre, Southmead Hospital, Bristol, BS10 5NB, United Kingdom. E-mail address for A.P. Davies: andypdavies{at}hotmail.com
2 Klinikum der Universität Göttingen, Abteilung Orthopädie, Robert-Koch-Strasse 40, D-37099 Göttingen, Germany
3 Implant Retrieval Lab, Joint Replacement Institute, Orthopaedic Hospital, 2400 South Flower Street, Los Angeles, CA 90007

Investigation performed at Bristol Implant Research Centre, Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Sulzer Orthopedics and Centerpulse Orthopaedics, Switzerland. One or more authors received grants from registered charities, the Wishbone Trust of the British Orthopaedic Association, and the Royal College of Surgeons of England. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Sulzer Orthopedics). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Metal-on-metal bearing surfaces have been reintroduced for use during total hip replacement. To assess tissue reactions to various types of articulations, we studied the histological appearance of periprosthetic tissues retrieved from around metal-on-metal and metal-on-polyethylene total hip replacements and compared these findings with the appearance of control tissues retrieved at the time of primary arthroplasty.

Methods: Periprosthetic tissues were obtained at the time of revision of twenty-five cobalt chromium-on-cobalt chromium, nine cobalt chromium-on-polyethylene, and ten titanium-on-polyethylene total hip arthroplasties. Control tissues were obtained from nine osteoarthritic hips at the time of primary total hip arthroplasty. Each tissue sample was processed for routine histological analysis, and sections were stained with hematoxylin and eosin. Quantitative stereological analysis was performed with use of light microscopy.

Results: Tissue samples obtained from hips with metal-on-metal implants displayed a pattern of well-demarcated tissue layers. A prominent feature, seen in seventeen of twenty-five tissue samples, was a pattern of perivascular infiltration of lymphocytes. In ten of the tissue samples obtained from hips with metal-on-metal prostheses, there was also an accumulation of plasma cells in association with macrophages that contained metallic wear-debris particles. The surfaces of tissues obtained from hips with metal-on-metal prostheses were more ulcerated than those obtained from hips with other types of implants, particularly in the region immediately superficial to areas of perivascular lymphocytic infiltration. The lymphocytic infiltration was more pronounced in samples obtained at the time of revision because of aseptic failure than in samples retrieved at the time of autopsy or during arthrotomy for reasons other than aseptic failure. Total-joint-replacement and surface-replacement designs of metal-on-metal prostheses were associated with similar results. Tissue samples obtained from hips with metal-on-polyethylene implants showed far less surface ulceration, much less distinction between tissue layers, no pattern of lymphocytic infiltration, and no plasma cells. The inflammation was predominantly histiocytic. Tissues retrieved from hips undergoing primary joint replacement showed dense scar tissue and minimal inflammation.

Conclusions and Clinical Relevance: The pattern and type of inflammation seen in periprosthetic tissues obtained from hips with metal-on-metal and metal-on-polyethylene implants are very different. At the present time, we do not know the prevalence or clinical implications of these histologic findings, but we suggest that they may represent a novel mode of failure for some metal-on-metal joint replacements.


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