The Journal of Bone and Joint Surgery (American). 2005;87:1515-1521.
doi:10.2106/JBJS.D.02641
© 2005 The Journal of Bone and Joint Surgery, Inc.
Early Osteolysis Following Second-Generation Metal-on-Metal Hip Replacement
Youn-Soo Park, MD1,
Young-Wan Moon, MD1,
Seung-Jae Lim, MD1,
Jun-Mo Yang, MD1,
Geunghwan Ahn, MD1 and
Yoon-La Choi, MD1
1 Departments of Orthopedic Surgery (Y.-S.P., Y.-W.M., S.-J.L.), Dermatology
(J.-M.Y.), and Pathology (G.A., Y.-L.C.), Sungkyunkwan University School of
Medicine, Samsung Medical Center, 50 Ilwong-dong, Kangnam-ku 135-710, Seoul,
South Korea. E-mail address for Y.-S. Park:
yspark{at}smc.samsung.co.kr
Investigation performed at the Departments of Orthopedic Surgery,
Dermatology, and Pathology, Sungkyunkwan University School of Medicine,
Samsung Medical Center, Seoul, South Korea
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).
NOTE: The authors thank Professor Dong-June Chung, Department of
Polymer Science and Engineering, Sungkyunkwan University, for his help with
the analysis of the retrieved implants, and Eun-Kyung Bae, Samsung Biomedical
Research Institute, Sungkyunkwan University School of Medicine, for her
technical assistance in performing immunohistochemical staining.
Background: Total hip arthroplasty with use of metal-on-metal
bearings has been reintroduced as an alternative to the use of
metal-on-polyethylene bearings because of theoretical advantages such as
reduced wear and a lower prevalence of osteolysis. However, we observed early
osteolysis in a cohort of patients who had been managed with second-generation
metal-on-metal hip replacements and investigated the possible etiologic role
of metal hypersensitivity.
Methods: We retrospectively analyzed 165 patients (169 hips) who had
undergone primary cementless total hip replacement with a contemporary
metal-on-metal total hip design between 2000 and 2002. After a minimum
duration of follow-up of twenty-four months, nine patients (ten hips) had an
osteolytic lesion localized to the greater trochanter. Skin-patch tests for
hypersensitivity to metals were performed on the nine patients and on nine
randomly selected patients with total hip replacements who did not have
osteolytic changes and who were matched to the study cohort for age and
gender. Microbiological cultures, histopathologic examinations, and
immunohistochemical analysis were performed on samples of periprosthetic
tissue that were collected during revision arthroplasty on two hips with early
osteolysis.
Results: The patients with early osteolysis had a significantly
higher rate of hypersensitivity reaction to cobalt compared with controls (p =
0.031). The retrieved periprosthetic tissues showed no evidence of metallic
staining, but histologic analysis revealed a perivascular accumulation of
CD3-positive T-cells and CD68-positive macrophages and an absence of both
particle-laden macrophages and polymorphonuclear cells. Immunohistochemical
analysis demonstrated that bone-resorbing cytokines such as IL-1ß and
TNF- were produced mainly by infiltrating lymphocytes and activated
macrophages.
Conclusions: These findings raise the possibility that early
osteolysis in patients with this second-generation metal-on-metal hip
replacement is associated with abnormalities consistent with delayed-type
hypersensitivity to metal. A prospective study in which a large group of
patients is evaluated with multiple diagnostic methods is needed in order to
establish whether there is a causal relationship between metal
hypersensitivity and osteolysis.
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.
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