This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF) Free
Right arrow Letters to the Editor: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowReprints and Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by BENZ, E. B.
Right arrow Articles by SPECTOR, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by BENZ, E. B.
Right arrow Articles by SPECTOR, M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Technorati  
What's this?
The Journal of Bone and Joint Surgery 78:588-93 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

Lymphadenopathy Associated with Total Joint Prostheses. A Report of Two Cases and a Review of the Literature*

ERIC B. BENZ, B.A.{dagger}, BRADFORD SHERBURNE, M.D.{ddagger}, JIHAD E. HAYEK, M.D.{ddagger}, KENNETH H. FALCHUK, M.D.§, CLEMENT B. SLEDGE, M.D.§ and MYRON SPECTOR, PH.D.§, BOSTON, MASSACHUSETTS

Investigation performed at the Department of Pathology, Deaconess Hospital, and the Departments of Medicine and Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston


   Introduction
Top
 Introduction
Case Reports
 Pathological Findings
 Discussion
 References
 
Local and regional lymphadenopathy that is caused by wear particles released from a joint-replacement prosthesis is becoming increasingly recognized as a possible complication of arthroplasty. Particles generated by the mechanical wear of a prosthesis can leave the site of the implant through lymphatic vessels and become engulfed by macrophages within the local and regional lymph nodes. The accumulation of cells containing particles causes the enlargement of a lymph node and the characteristic histological appearance of sinus histiocytosis8. The distention and prominence of the lymphatic sinuses are due to the presence of large numbers of either histiocytes derived from the cells that line the sinuses or macrophages derived from circulating monocytes. Multinucleated giant cells, resulting from the fusion of macrophages or histiocytes, might also be found in the dilated sinuses.

The accumulation of polyethylene, polymethylmethacrylate, and metal particles in the lymph nodes draining joints that have been replaced with a prosthesis has been found in studies of animals15,26 and humans2,3,10,14. Lymphadenopathy in patients who have had a joint replacement has been reported in a few of these studies8,17,22. The purposes of the present report are to document the development of lymphadenopathy after the dissemination of polyethylene particles in the lymphatic system in a patient who had a total hip replacement as well as in a patient who had a total knee replacement and to review the pathological response to polyethylene particles that leave the site of the implant. This report also provides a scientific basis for understanding the migration of particles from joints and a discussion of the clinical implications, such as the diagnostic confusion that can result from the finding of an enlarged lymph node.


   Case Reports
Top
 Introduction
 Case Reports
Pathological Findings
 Discussion
 References
 
CASE 1. A forty-nine-year-old woman had a total hip replacement in 1974 for congenital dislocation of the left hip. Revision arthroplasties were performed in 1976, 1981, 1985, and 1992 for aseptic loosening. The most recent revision, in January 1992, was performed for pain in the left hip and loosening of the prosthesis. Considerable loss of periprosthetic bone necessitated reconstruction with use of bulk femoral and acetabular allografts. Gross inspection of the polyethylene acetabular component showed slight wear. However, histological examination of the synovial and periprosthetic tissues revealed abundant shards of polyethylene within the macrophages and within the multinucleated foreign-body giant cells.

In November 1992, the patient had repair of a bilateral inguinal hernia. An enlarged inguinal lymph node, which measured 2.7 by 2.1 by 0.8 centimeter, was encountered during the left herniorrhaphy. The node was excised, and histopathological examination of frozen sections was performed. There was no evidence of an infection or malignant lesion.

CASE 2. A sixty-four-year-old woman had a total knee replacement on the left for rheumatoid arthritis in 1981. The history included tuberculosis, which had been diagnosed in 1968 after the biopsy of a tender erythematous nodule on the scalp.

In 1987, the left lower limb became erythematous and swollen. A biopsy of the skin showed a perivascular mononuclear infiltrate, and the patient was managed with antibiotics for a presumptive cellulitis. Subsequently, inguinal adenopathy developed, and an enlarged inguinal lymph node on the left that measured 3.5 by 2.0 by 0.8 centimeter was excised. Evaluation of the node with light microscopy showed sinus histiocytosis and lymphoid follicular hyperplasia. These changes were believed to reflect chronic lymphadenitis. There was no evidence of granulomas.

In April 1992, the cellulitis of the left limb and the left inguinal adenopathy recurred. A biopsy of an enlarged inguinal lymph node again showed marked follicular hyperplasia and sinus histiocytosis, with polarizable particles within the sinus histiocytes. Subsequently, a fistula draining copious pus developed in the left inguinal region. The infection resolved after treatment with penicillin.

In May 1992, the patient continued to have several enlarged non-tender inguinal nodes and an erythematous, swollen left limb. A computed tomography scan of the pelvis was made to evaluate the extent of the lymphadenopathy. The scan showed an enlarged inguinal node (1.2 by 0.8 centimeter) on the left (Fig. 1). The prosthesis was revised in the fall of 1992, and lysis with cavitation was found in the distal part of the femur and in the proximal part of the tibia. The lysis presumably had been caused by the mediators of inflammation that had been released by the macrophages as they phagocytosed polyethylene wear debris; certain mediators of inflammation (interleukin-1 and prostaglandin E2) are potent stimulators of bone resorption23.



View larger version (111K):
[in this window]
[in a new window]
  		Case 2. Computed tomography scan of the pelvis, showing an enlarged inguinal lymph node (arrows) on the left that measured 1.2 by 0.8 centimeter.

 


   Pathological Findings
Top
 Introduction
 Case Reports
 Pathological Findings
Discussion
 References
 
In each patient, the inguinal lymph nodes ipsilateral to the total joint prosthesis were grossly enlarged. Histological examination of tissue sections embedded in paraffin and stained with hematoxylin and eosin revealed reactive changes and sinus histiocytosis (Fig. 2). Follicular lymphoid hyperplasia was moderate in the first patient (Case 1) and extensive in the second patient (Case 2). In both patients, the trabecular and capsular sinuses were dilated with abundant, tightly packed macrophages that contained abundant, granular, eosinophilic cytoplasm (Fig. 3-A and 4-A). Under polarized light, angular shards of intensely birefringent particles were seen throughout the sinuses of the nodes in association with macrophages (Figs. 3-B and 4-B). The birefringence and needle-like morphology of the particles were consistent with polyethylene wear debris (Fig. 5).



View larger version (237K):
[in this window]
[in a new window]
  		Case 1. Photomicrograph of a specimen from an inguinal lymph node, showing abundant macrophages (histiocytes) that dilated the sinuses of the node, causing sinus histiocytosis. The surrounding lymphoid follicles are normal (hematoxylin and eosin, x 110).

 


View larger version (219K):
[in this window]
[in a new window]
  		Figs. 3-A and 3-B: Case 1. Figs. 3-A: Photomicrograph of a specimen from an inguinal lymph node, showing sinus macrophages (histiocytes) with abundant, granular, eosinophilic cytoplasm surrounded by normal lymphocytes (hematoxylin and eosin, x 450).

 


View larger version (209K):
[in this window]
[in a new window]
  		Figs. 4-A and 4-B: Case 2. Fig. 4-A: Photomicrograph of a specimen from an inguinal lymph node, showing several multinucleated giant cells surrounded by sinus macrophages (histiocytes) and normal lymphocytes (hematoxylin and eosin, x 450).

 


View larger version (219K):
[in this window]
[in a new window]
  		Fig. 3-B: Under polarized light microscopy, polyethylene particles were seen to have spread throughout the nodal sinuses (hematoxylin and eosin, x 450).

 


View larger version (221K):
[in this window]
[in a new window]
  		Fig. 4-B: Under polarized light microscopy, polyethylene particles within macrophages and multinucleated giant cells were seen (hematoxylin and eosin, x 450).

 


View larger version (201K):
[in this window]
[in a new window]
  		Case 2. Photomicrograph of a specimen from an inguinal lymph node, showing polyethylene particles, identified by their characteristic needle-like shape and bright birefringence under polarized light, within macrophages and multinucleated giant cells (hematoxylin and eosin, x 1100).

 
Examination of individual cells under high magnification revealed that the polyethylene particles were within the cytoplasm of macrophages. Light microscopy showed no evidence of metal particles within the specimen from either patient. The tissues could not be evaluated for the presence of bone cement because they had been processed in xylene, which dissolves polymethylmethacrylate.


   Discussion
Top
 Introduction
 Case Reports
 Pathological Findings
 Discussion
References
 
Total joint prostheses produce particulate debris through adhesive, abrasive, and fatigue (delamination) wear processes occurring at the articulating interface between metal and polyethylene, at the junctions of the modular portions of a modular total joint prosthesis, at the interface between the component and the cement, or at the interface between the implant and the bone. Polyethylene, polymethylmethacrylate, and metal particles are all capable of stimulating resorption of periprosthetic bone1,4,11,12,18,20,21,23,27,28. The adverse consequences of loss of periprosthetic bone have focused a great deal of attention on the problems caused by wear particles at the implant-bone interface. Much less attention has been focused on the pathological response to these particles at distant sites in the body.

The tissue response to wear particles is a foreign-body reaction, with varying amounts of macrophages and foreign-body giant cells10,26,28. Synovial macrophages readily engulf particles that are released into the joint space. When the production of particulate debris exceeds the phagocytic capacity of synovial macrophages, excess particles migrate into periprosthetic tissue, where they are ultimately phagocytosed by macrophages that release agents that stimulate the resorption of bone21, or they enter the lymphatic vessels27. There is evidence that macrophages laden with particles can also gain entry into the lymphatics9. Macrophages in the lymph nodes endocytose the free particles that are traveling within the lymphatic system. A steady influx of wear debris causes these macrophages to accumulate within the sinuses of the lymph node3. During a period of several years, macrophages containing particles may become so abundant that they cause dilatation of the nodal sinuses and enlargement of the node. The accumulation of histiocytes or macrophages within the sinuses of lymph nodes is described pathologically as sinus histiocytosis. The histopathological responses to polyethylene particles in lymph nodes and in periprosthetic tissue are comparable. At both sites, macrophages containing polyethylene have abundant, granular, eosinophilic cytoplasm with small central nuclei. Polyethylene particles that are smaller than three micrometers are seen within the individual cells, and larger particles are surrounded by foreign-body giant cells21.

Systemic Migration of Particles Derived from Implants
The literature contains numerous reports of the migration of particles, released from implants, to lymph nodes and to many organs. The spread of particles of silicone elastomer and liquid droplets from breast implants was well documented by Travis et al., who found the translocation of these particles to be due to migration through soft tissues, entry into the lymphatic system, and direct entry into the vascular system. Silicone particles have been found to migrate from breast implants through soft tissue to sites as distant as the groin5. Silicone lymphadenopathy in the axilla is common in patients who have breast implants25. The hematogenous dissemination of silicone to viscera has also been reported as a result of the injection of the material into soft tissue24. As reported in the orthopaedic literature, silicone lymphadenopathy has become a common finding in patients who have a finger-joint prosthesis made of silicone elastomer6,7.

The number of reports documenting the dissemination of particles from a total joint prosthesis into the lymphatic system is increasing, suggesting that this phenomenon may be more common than previously thought. Several studies of animals have documented the lymphatic spread of polyethylene particles to the regional lymph nodes15,26. Bos et al. found evidence from human autopsies that polyethylene, polymethylmethacrylate, and metal particles released from stable total hip replacements had spread to inguinal, para-iliac, and para-aortic lymph nodes as early as 1.5 years after the implantation of the prosthesis. Sinus histiocytosis in association with wear particles of polyethylene has been an incidental finding in lymph nodes biopsied at revision arthroplasty16 and in the staging of prostate2,8 and breast cancer17. Adenopathy related to an implant is not limited to total hip and knee prostheses. O'Connell and Rosenberg recently reported axillary histiocytic lymphadenopathy in association with polyethylene wear particles from a total shoulder replacement.

Kinetics of Migration of Particles from Joints and Bone
The kinetics of migration of particles from joints and osseous sites has been the subject of several investigations. Noble et al. investigated the leakage of particles, labeled with a radioisotope, from intra-articular sites of injection in the knees of rabbits. The particles included human serum albumin, carbonized microspheres, gold colloid, and ferric hydroxide, with sizes ranging from thirty nanometers to tens of micrometers. Approximately 1 per cent of the injected dose of ferric hydroxide (so-called inert) particles, which were less than one micrometer in diameter, migrated from the joint twenty-four hours after injection. The kinetics of migration (the rate of leakage) of particles from the joint space was related to the size of the particles. There was an order-of-magnitude difference in the rates of leakage (2.2 to 0.1 per cent after twenty-four hours) for particles ranging from less than 0.1 to 15.0 micrometers.

In another study, a canine model was used to investigate the spread of cell-sized radioactive microspheres from the distal part of the femur into the lymphatic system, venous drainage, and local tissue19. In that model, microspheres (fifteen micrometers in diameter) were injected into the medullary canal of the femur. The particles entered directly into the venous system within fifteen seconds of injection and were effectively filtered by the lungs, thus preventing dissemination into the arterial system. No migration of the particles from the femur into the lymphatic system was found after four days. However, similar microspheres that had been injected into soft tissue in the distal part of the femur were found in the iliac lymph nodes in two of nine animals after the same period of time. In neither of these animals were particles found in the lungs. A subsequent study13 demonstrated that particles as large as 100 micrometers, injected into the medullary canal of the distal part of the femur, migrated to the lungs within fifteen minutes after the injection. These results suggest that, under certain conditions, particles generated by wear might directly enter the venous system. Most of these particles would be filtered by the lungs, preventing hematogenous spread. Collectively, the investigations indicate that a considerable number of particles can be disseminated to various sites in the body within hours after their generation.

Clinical Implications
Lymphadenopathy secondary to the accumulation of wear particles in sinus macrophages may cause confusion regarding the appropriate diagnosis, especially in patients in whom a malignant lesion is suspected. Shinto et al. reported the case of a nineteen-year-old man who was first seen with pain in the right inguinal region and a palpable mass, measuring three by three centimeters, three years following a total knee replacement on the right after the resection of an osteosarcoma. A lymph node was biopsied because metastatic recurrence of the osteosarcoma was suspected. Histological examination revealed sinus histiocytosis caused by metal particles that had been released from the knee prosthesis. There was no evidence of a malignant lesion.

In the two patients in the present report, polyethylene particles were found in association with adenopathy of the inguinal nodes ipsilateral to the total joint prosthesis. The enlarged inguinal node in the first patient (Case 1) was an incidental finding at herniorrhaphy, and the inguinal adenopathy in the second patient (Case 2) was detected after the patient was first seen with an ipsilateral cellulitis. For both patients, histological examination revealed extensive sinus histiocytosis, with the presence of polyethylene in macrophages and foreign-body giant cells.

One of our patients (Case 2) had a second pathological process contributing to the development of lymphadenopathy. In addition to the sinus histiocytosis, extensive hyperplasia of the lymphoid follicles with abundant active germinal centers was seen. As polyethylene is not immunogenic, the lymphoid hyperplasia was solely a response to the skin infection. Polyethylene particles were not present within lymphoid follicles.

The ultimate fate of particles released from a total joint prosthesis is not known. The findings of a recent report suggest that metallic particles from an orthopaedic prosthesis may pass through the lymphatics and gain a systemic distribution14. Our ongoing study of specimens obtained at autopsy has not yet revealed metal or polyethylene particles distributed in end organs. However, the population sample from which we obtain specimens has been limited.

The clinical sequelae of polyethylene particles in the lymph nodes and other organs is not known. However, the fact that disseminated polyethylene particles cannot be removed focuses attention on investigations of the long-term response of the host to such particles.

NOTE: The authors thank Jerry E. Enis, M.D., for providing information about the patient who had a total knee prosthesis.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Brigham and Women's Hospital-Massachusetts Institute of Technology/Industry Consortium for Polyethylene Wear. The industry participants were Zimmer, Howmedica, Smith and Nephew Richards, DuPont-DePuy, and Johnson and Johnson.

{dagger}Harvard Medical School, Boston, Massachusetts 02115.

{ddagger}Department of Pathology, Deaconess Hospital, Deaconess Road, Boston, Massachusetts 02115.

§Departments of Medicine (K. H. F.) and Orthopedic Surgery (C. B. S. and M. S.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. Please address requests for reprints to Dr. Spector.


   References
Top
 Introduction
 Case Reports
 Pathological Findings
 Discussion
 References
 

  1. Amstutz, H. C.; Campbell, P.; Kossovsky, N.; and |and |Clarke, I. C.: Mechanism and clinical significance of wear debris-induced osteolysis. Clin. Orthop, 276: 7-18, 1992.
  2. Bauer, T. W.; Saltarelli, M.; McMahon, J. T.; and |and |Wilde, A. H.: Regional dissemination of wear debris from a total knee prosthesis. A case report. J. Bone and Joint Surg, 75-A: 106-111, Jan. 1993.[Free Full Text]
  3. Bos, I.; Johannisson, R.; Löhrs, U.; Lindner, B.; and |and |Seydel, U.: Comparative investigations of regional lymph nodes and pseudocapsules after implantation of joint endoprostheses. Pathol. Res. and Pract, 186: 707-716, 1990.
  4. Bullough, P. G.; Bansal, M.; Betts, F.; and |and |Salvati, E. A.: histological response to and the recovery of metal from around failed titanium alloy prostheses. In Proceedings of the British Orthopaedic Association. J. Bone and Joint Surg, 72-B(3): 533, 1990.
  5. Capozzi, A.; Du Bou, R.; and |and |Pennisi, V. R.: Distant migration of silicone gel from a ruptured breast implant. Case report.. Plast. and Reconstr. Surg, 62: 302-303, 1978.
  6. Christie, A. J.; Weinberger, K. A.; and |and |Dietrich, M.: Silicone lymphadenopathy and synovitis. Complications of silicone elastomer finger joint prostheses. J. Am. Med. Assn, 237: 1463-1464, 1977.[Abstract/Free Full Text]
  7. Corrin, B.: Silicone lymphadenopathy [letter]. J. Clin. Pathol, 35: 901-902, 1982.
  8. Gray, M. H.; Talbert, M. L.; Talbert, W. M.; Bansal, M.; and |and |Hsu, A.: Changes seen in lymph nodes draining the sites of large joint prostheses. Am. J. Surg. Pathol, 13: 1050-1056, 1989.[Medline]
  9. Harmsen, A. G.; Muggenburg, B. A.; Snipes, M. B.; and |and |Bice, D. E.: The role of macrophages in particle translocation from lungs to lymph nodes. Science, 230: 1277-1280, 1985.[Abstract/Free Full Text]
  10. Heilmann, K.; Diezel, P. B.; Rossner, J. A.; and |and |Brinkman, K. A.: Morphological studies in tissues surrounding alloarthroplastic joints. Virchows Arch. pathol. Anat, 366: 93-106, 1975.
  11. Herman, J. H.; Sowder, W. G.; Anderson, D.; Appel, A. M.; and |and |Hopson, C. N.: Polymethylmethacrylate-induced release of bone-resorbing factors. J. Bone and Joint Surg, 71-A: 1530-1541, Dec. 1989.[Abstract/Free Full Text]
  12. Howie, D. W.; Vernon-Roberts, B.; Oakeshott, R.; and |and |Manthey, B.: A rat model of resorption of bone at the cement-bone interface in the presence of polyethylene wear particles. J. Bone and Joint Surg, 70-A: 257-263, Feb. 1988.[Abstract/Free Full Text]
  13. Janssen, H. F.; Robertson, W. W.; and |and |Berlin, S.: Venous drainage of the femur permits passage of 100-µm particles. J. Orthop. Res, 6: 671-675, 1988.[Medline]
  14. Langkamer, V. G.; Case, C. P.; Heap, P.; Taylor, A.; Collins, C.; Pearse, M.; and |and |Solomon, L.: Systemic distribution of wear debris after hip replacement. A cause for concern?. J. Bone and Joint Surg, 74-B(6): 831-839, 1992.[Abstract/Free Full Text]
  15. Mendes, D. G.; Walker, P. S.; Figarola, F.; and |and |Bullough, P. G.: Total surface hip replacement in the dog. A preliminary study of local tissue reaction. Clin. Orthop, 100: 256-264, 1974.
  16. Noble, J.; Jones, A. G.; Davies, M. A.; Sledge, C. B.; Kramer, R. L.; and |and |Livni, E.: Leakage of radioactive particle systems from a synovial joint studied with a gamma camera. Its approach to radiation synovectomy. J. Bone and Joint Surg, 65-A: 381-389, March 1983.[Abstract/Free Full Text]
  17. O'Connell, J. X., and |and |Rosenberg, A. E.: Histiocytic lymphadenitis associated with a large joint prosthesis. Am. J. Clin. Pathol, 99: 314-316, 1993.[Medline]
  18. Peters, P. C. Jr.; Engh, G. A.; Dwyer, K. A.; and |and |Vinh, T. N.: Osteolysis after total knee arthroplasty without cement. J. Bone and Joint Surg, 74-A: 864-876, July 1992.[Abstract/Free Full Text]
  19. Robertson, W. W., Jr.; Janssen, H. F.; and |and |Walker, R. N.: Passive movement of radioactive microspheres from bone and soft tissue in an extremity. J. Orthop. Res, 3: 405-411, 1985.[Medline]
  20. Santavirta, S.; Hoikka, V.; Eskola, A.; Konttinen, Y. T.; Paavilainen, T.; and |and |Tallroth, K.: Aggressive granulomatous lesions in cementless total hip arthroplasty. J. Bone and Joint Surg, 72-B(6): 980-984, 1990.
  21. Schmalzried, T. P.; Jasty, M.; and |and |Harris, W. H.: Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space. J. Bone and Joint Surg, 74-A: 849-863, July 1992.[Abstract/Free Full Text]
  22. Shinto, Y.; Uchida, A.; Yoshikawa, H.; Araki, N.; Kato, T.; and |and |Ono, K.: Inguinal lymphadenopathy due to metal release from a prosthesis. A case report. J. Bone and Joint Surg, 75-B(2): 266-269, 1993.
  23. Spector, M.; Shortkroff, S.; Sledge, C. B.; and Thornhill, T. S.: Advances in our understanding of the implant-bone interface: factors affecting formation and degeneration. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 40, pp. 101-113. Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1991.
  24. Travis, W. D.; Balogh, K.; and |and |Abraham, J. L.: Silicone granulomas: report of three cases and review of the literature. Hum. Pathol, 16: 19-27, 1985.[Medline]
  25. Truong, L. D.; Cartwright, J., Jr.; Goodman, M. D.; and |and |Woznicki, D.: Silicone lymphadenopathy associated with augmentation mammaplasty. Morphologic features of nine cases. Am. J. Surg. Pathol, 12: 484-491, 1988.[Medline]
  26. Walker, P. S., and |and |Bullough, P. G.: The effects of friction and wear in artificial joints. Orthop. Clin. North America, 4: 275-293, 1973.[Medline]
  27. Willert, H. G.: Reactions of the articular capsule to wear products of artificial joint prostheses. J. Biomed. Mater. Res, 11: 157-164, 1977.[Medline]
  28. Witt, J. D., and |and |Swann, M.: Metal wear and tissue response in failed titanium alloy total hip replacements. J. Bone and Joint Surg, 73-B(4): 559-563, 1991.

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Technorati Technorati    What's this?


This article has been cited by other articles:


Home page
 JBJSHome page
C. R. Clark
Editorial. A Potential Concern in Total Joint Arthroplasty: Systemic Dissemination of Wear Debris
J. Bone Joint Surg. Am., April 1, 2000; 82(4): 455 - 455.
[Full Text]

Home page
 JBJSHome page
C. A. ENGH JR., K. D. MOORE, T. N. VINH, and G. A. ENGH
Titanium Prosthetic Wear Debris in Remote Bone Marrow. A Report of Two Cases
J. Bone Joint Surg. Am., November 1, 1997; 79(11): 1721 - 5.
[Full Text]

Home page
 JBJSHome page
T. W. Bauer
Editorial - Identification of Orthopaedic Wear Debris
J. Bone Joint Surg. Am., April 1, 1996; 78(4): 479 - 81.
[Full Text]

This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF) Free
Right arrow Letters to the Editor: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowReprints and Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by BENZ, E. B.
Right arrow Articles by SPECTOR, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by BENZ, E. B.
Right arrow Articles by SPECTOR, M.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Technorati  
What's this?