The Journal of Bone and Joint Surgery (American). 2005;87:28-36.
doi:10.2106/JBJS.A.02039pp
© 2005 The Journal of Bone and Joint Surgery, Inc.
Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip Joints
A Clinical and Histomorphological Study
Hans-Georg Willert, MD1,
Gottfried H. Buchhorn, Dipl-Ing1,
Afshin Fayyazi, MD2,
Renata Flury, MD3,
Markus Windler, PhD4,
Georg Köster, MD5 and
Christoph H. Lohmann, MD6
1 Klinikum der Universität Göttingen, Abteilung Orthopädie,
Robert-Koch-Strasse 40, D-37099 Göttingen, Germany. E-mail address for
G.H. Buchhorn:
gh-buchh{at}med.uni-goettingen.de
2 Städtisches Klinikum Pforzheim, Institut für Pathologie,
Kanzlerstrasse 2-6, D-75175 Pforzheim, Germany
3 Kantonsspital Winterthur, Institut für Pathologie, Brauerstrasse 15,
CH-8401 Winterthur, Switzerland
4 Zimmer, Sulzer Allee 8, gt CH-8404 Winterthur, Switzerland
5 Chirurgisch-Orthopädische Fachklinik Lorsch, Waldstrasse 13, D-64653
Lorsch, Germany
6 Klinikum der Universität Hamburg, Abteilung Orthopädie,
Martinistrasse 51, D-20357, Hamburg, Germany
Investigation performed at the Departments of Orthopaedics and
Pathology, Klinikum der Universität Göttingen, Göttingen,
Germany
A commentary is available with the electronic versions of this article,
on our web site
(www.jbjs.org)
and on our quarterly CD-ROM (call our subscription department, at
781-449-9780, to order the CD-ROM).
In support of their research or preparation of this manuscript, one or more
of the authors received grants or outside funding from Zimmer GmbH,
Winterthur, Switzerland. They did not receive payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. A
commercial entity (Zimmer GmbH) paid or directed, or agreed to pay or direct,
benefits to a research fund, foundation, educational institution, or other
charitable or nonprofit organization with which the authors are affiliated or
associated.
Background: Some patients who have a total hip replacement with a
second-generation metal-on-metal articulation have persistent or early
recurrence of preoperative symptoms. Characteristic histological changes in
the periprosthetic tissues suggested the development of an immunological
response. Therefore, in order to determine the relevance of these symptoms, we
performed a study of the clinical data and periprosthetic tissues associated
with endoprostheses with a metal-on metal articulation that had been retrieved
at revision.
Methods: Periprosthetic tissues as well as the clinical data on the
patients were obtained from the first nineteen consecutive revisions performed
at the treating hospitals. At the time of the revision, fourteen patients had
the metal-on-metal articulation exchanged for either an alumina-ceramic or a
metal-on-polyethylene articulation. Five patients received another
second-generation metal-on-metal total joint replacement. Five-micrometer
sections were prepared from the tissue samples, were stained with routine and
immunohistochemical methods, and were examined histologically. Histological
specimens from three groups of patients, two of which were treated with
non-metal-on-metal implants, served as controls.
Results: The majority of patients had persistence of their
preoperative pain or early recurrence of the pain after the original total hip
replacement, and often a pronounced hip joint effusion had developed after the
original replacement. Radiographic follow-up showed the development of
radiolucent lines in five hips and of osteolysis in another seven hips. At the
revision surgery, both the cup and the stem were found to be well fixed in
nine patients. The characteristic histological features were diffuse and
perivascular infiltrates of T and B lymphocytes and plasma cells, high
endothelial venules, massive fibrin exudation, accumulation of macrophages
with droplike inclusions, and infiltrates of eosinophilic granulocytes and
necrosis. Only a few metal particles were detected. Immunohistochemical
analysis demonstrated that the cellular reaction was still active. The
patients who received another second-generation metal-on-metal articulation at
the time of the revision had no decrease in symptoms. In the control group of
tissues obtained at revisions of endoprostheses without cobalt, chromium, or
nickel articulations, there were no similar signs of immune reactions.
Conclusions: These histological findings support the possibility of
a lymphocyte-dominated immunological response. Although the prevalence of this
reaction is low, the persistence or early reappearance of symptoms, including
a marked joint effusion and the development of osteolysis, after primary
implantation may suggest the possibility of such a reaction.
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