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Immunologic Adverse Reaction Associated with Low-carbide Metal-on-metal Bearings in Total Hip Arthroplasty

  • Clinical Research
  • Hip
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been reported in contemporary THAs with low-carbide metal-on-metal compared with metal-on-polyethylene couple bearings. Although a hypersensitivity reaction attributable to Co and Cr debris is reportedly a potential cause for failure of THAs with high-carbide bearings, there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings, although such hypersensitivity might be related to osteolysis.

Questions/purposes

We investigated whether there were differences in immunologic hypersensitivity reactions in retrievals from revised THAs with ceramic-on-polyethylene versus metal-on-metal bearing couples.

Patients and Methods

We compared newly formed capsule and periprosthetic interface membranes from revision surgery for aseptic failure from 20 patients with low-carbide bearings and 13 patients with ceramic-on-polyethylene bearings. For control tissue, we obtained samples from the hip capsule during the primary THA implantation in 13 patients with low-carbide bearings and seven with ceramic-on-polyethylene bearings. We examined the tissues with conventional histologic and immunohistochemical methods.

Results

Compared with tissue from the control subjects and patients with ceramic-on-polyethylene bearings, the tissues from patients with low-carbide metal-on-metal bearings were associated with (1) extensive necrosis and fibrin exudation in the newly formed hip capsule and (2) diffuse and perivascular lymphocytic infiltration of a higher degree than in the hips with ceramic-on-polyethylene bearings in conventional histologic examination, and (3) more T than B cells.

Conclusions

The conventional histologic and immunohistochemical findings in tissues retrieved from failed THAs with low-carbide metal-on-metal bearings are consistent with a link between hypersensitivity and osteolysis with low-carbide bearing couples.

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References

  1. Boss JH, Misselevich I, Behar J, Mendes DG. Histologic analysis of the periprosthetic tissues of long-term surviving cemented total hip arthroplasties. J Long Term Eff Med Implants. 1996;6:73–90.

    CAS  PubMed  Google Scholar 

  2. Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner-Wolf F, Kotz R. Serum cobalt levels after metal-on-metal total hip arthroplasty. J Bone Joint Surg Am. 2003;85:2168–2173.

    PubMed  Google Scholar 

  3. Campbell P, McKellop H, Mirra J, Nutt S, Dorr L, Amstutz HC. Metal-on-metal hip replacements: wear performance and cellular response to wear particles. In: Disegi JA, Kennedy RL, Pilliar R, eds. Cobalt-Base Alloys for Biomedical Applications. West Conshohocken, PA: ASTM; 1999:193–209.

    Chapter  Google Scholar 

  4. Davies AP, Willert HG, Campbell PA, Learmonth ID, Case CP. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am. 2005;87:18–27.

    Article  CAS  PubMed  Google Scholar 

  5. Delaunay CP. Metal-on-metal bearings in cementless primary total hip arthroplasty. J Arthroplasty. 2004;19(8 suppl 3):35–40.

    Article  PubMed  Google Scholar 

  6. Doorn PF, Mirra JM, Campbell PA, Amstutz HC. Tissue reaction to metal on metal total hip prostheses. Clin Orthop Relat Res. 1996;329(suppl):S187–S205.

    Article  PubMed  Google Scholar 

  7. Dorr LD, Wan Z, Sirianni LE, Boutary M, Chandran S. Fixation and osteolysis with Metasul metal-on-metal articulation. J Arthroplasty. 2004;19:951–955.

    Article  PubMed  Google Scholar 

  8. Firkins PJ, Tipper JL, Saadatzadeh MR, Ingham E, Stone MH, Farrar R, Fisher J. Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng. 2001;11:143–157.

    CAS  PubMed  Google Scholar 

  9. Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. Th1 type lymphocyte reactivity to metals in patients with total hip arthroplasty. J Orthop Surg. 2008;3:6.

    Article  Google Scholar 

  10. Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83:428–436.

    Article  PubMed  Google Scholar 

  11. Jacobs JJ, Hallab NJ. Loosening and osteolysis associated with metal-on-metal bearings: a local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006;88:1171–1172.

    Article  PubMed  Google Scholar 

  12. Jacobs JJ, Skipor AK, Doorn PF, Campbell P, Schmalzried TP, Black J, Amstutz HC. Cobalt and chromium concentrations in patients with metal on metal total hip replacements. Clin Orthop Relat Res. 1996;329(suppl):S256–S263.

    Article  PubMed  Google Scholar 

  13. Kalish RS, Askenase PW. Molecular mechanisms of CD8+T cell-mediated delayed hypersensitivity: implications for allergies, asthma, and autoimmunity. J Allergy Clin Immunol.1999;103:192–199.

    Article  CAS  PubMed  Google Scholar 

  14. Kelman P. Moderne Werstoffe in der Endoprothetik und Stellenwert in der Metall-Metall-Paarung: ist ein Heilungseffect nach Beschädigung der Oberflache möglich? In: Zweymüller KA, ed. Die Metall-Metall-Paarung von SIKOMET. Bern, Switzerland: Hans Huber; 1999:37–47.

    Google Scholar 

  15. Kobayashi K, Kaneda K, Kasama T. Immunopathogenesis of delayed-type hypersensitivity. Microsc Res Tech. 2001;53:241–245.

    Article  CAS  PubMed  Google Scholar 

  16. Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporary metal-on-metal total hip arthroplasty: five to nine-year follow-up. J Bone Joint Surg Am. 2006;88:1183–1191.

    Article  CAS  PubMed  Google Scholar 

  17. Kudo C, Yamashita T, Araki A, Terashita M, Watanabe T, Atsumi M, Tamura M, Sendo F. Modulation of in vivo immune response by selective depletion of neutrophils using a monoclonal antibody, RP-3: I. Inhibition by RP-3 treatment of the priming and effector phases of delayed type hypersensitivity to sheep red blood cells in rats. J Immunol. 1993;150:3728–3738.

    CAS  PubMed  Google Scholar 

  18. Kumar V, Cotran RS, Robbins SL. Disorders of the immune system. In: Kumar V, ed. Basic Pathology. Ed 6. Philadelphia, PA: Elsevier; 1997:94–96.

    Google Scholar 

  19. Lhotka C, Szekeres T, Steffan I, Zhuber K, Zweymuller K. Four-year study of cobalt and chromium blood levels in patients managed with two different metal-on-metal total hip replacements. J Orthop Res. 2003;21:189–195.

    Article  CAS  PubMed  Google Scholar 

  20. Lintner F, Bohm G, Huber M, Zweymuller K. [Synovial tissue following revision total hip replacement with metal-on-metal joints: histologic, immunohistologic and bacteriologic evaluation] [in German]. Osteologie. 2003;12:333–346.

    Google Scholar 

  21. Migaud H, Jobin A, Chantelot C, Laffargue P, Duquennoy A. Cementless metal-on-metal hip arthroplasty in patients less than 50 years of age: comparison with matched control group using ceramic-on-polyethylene after a minimum 5-year follow-up. J Arthroplasty. 2004;19(8 suppl 3):23–28.

    PubMed  Google Scholar 

  22. Milosev I, Trebse R, Kovac S, Cör A, Pisot V. Survivorship and retrieval analysis of Sikomet metal-on-metal total hip replacements at a mean of seven years. J Bone Joint Surg Am. 2006;88:1173–1182.

    Article  PubMed  Google Scholar 

  23. Minang JT, Areström I, Troye-Blomberg M, Lundeberg L, Ahlborg N. 31-Nickel, cobalt, chromium, palladium and gold induce a mixed Th1- and Th2-type cytokine response in vitro in subjects with contact allergy to the respective metals. Clin Exp Immunol. 2006;146:417–426.

    Article  CAS  PubMed  Google Scholar 

  24. Mirra JM, Marder RA, Amstutz HC. The pathology of failed total joint arthroplasty. Clin Orthop Relat Res. 1982;170:175–183.

    PubMed  Google Scholar 

  25. Pandit H, Vlychou M, Whitwell D, Crook D, Luqmani R, Ostlere S, Murray DW, Athanasou NA. Necrotic granulomatous pseudotumors in bilateral resurfacing hip arthroplasties: evidence for a type IV immune response. Virchows Arch. 2008;453:529–534.

    Article  CAS  PubMed  Google Scholar 

  26. Papanastasopoulos P, Repanti M, Damaskou V, Bravou V, Papadaki H. Investigating differentiation mechanisms of the constituent cells of sex-cord-stromal tumours of the ovary. Virchows Arch. 2008;453:465–471.

    Article  CAS  PubMed  Google Scholar 

  27. Park YS, Moon YW, Lim SJ, Yang JM, Ahn G, Choi YL. Early osteolysis following second-generation metal-on-metal hip replacement. J Bone Joint Surg Am. 2005;87:1515–1521.

    Article  PubMed  Google Scholar 

  28. Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke. 1995;26:982–989.

    CAS  PubMed  Google Scholar 

  29. Reinisch G, Judmann KP, Lhotka C, Lintner F, Zweymüller KA. Retrieval study of uncemented metal-on-metal hip prostheses revised for early loosening. Biomaterials . 2003;24:1081–1091.

    Article  CAS  PubMed  Google Scholar 

  30. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. J Bone Joint Surg Am. 2008;90:1869–1875.

    Article  PubMed  Google Scholar 

  31. Schmidt M, Weber H, Schön R. Cobalt chromium molybdenum metal combination for modular hip prostheses. Clin Orthop Relat Res. 1996;329(suppl):S35–S47.

    Article  PubMed  Google Scholar 

  32. Shanbhag AS, Kaufman AM, Hayata K, Rubash HE. Assessing osteolysis with use of high-throughput protein chips. J Bone Joint Surg Am. 2007;89:1081–1089.

    Article  PubMed  Google Scholar 

  33. Silva M, Heisel C, Schmalzried TP. Metal-on-metal total hip replacement. Clin Orthop Relat Res. 2005;430:53–61.

    Article  PubMed  Google Scholar 

  34. St John KR, Zardiackas LD, Poggie RA. Wear evaluation of cobalt-chromium alloy for use in a metal-on-metal hip prosthesis. J Biomed Mater Res B Appl Biomater. 2004;68:1–14.

    Article  PubMed  Google Scholar 

  35. Terashita M, Kudo C, Yamashita T, Gresser I, Sendo F. Enhancement of delayed-type hypersensitivity to sheep red blood cells in mice by granulocyte colony-stimulating factor administration at the elicitation phase. J Immunol. 1996;156:4638–4643.

    CAS  PubMed  Google Scholar 

  36. Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann CH. Metal-on metal bearings and hypersensitivity in patients with artificial hip joints: a clinical and histomorphological study. J Bone Joint Surg Am. 2005;87:28–36.

    Article  PubMed  Google Scholar 

  37. Willert HG, Buchhorn GH, Fayyazi A, Lohmann C. Histopathological changes around metal/metal joints indicate delayed type hypersensitivity: preliminary results of 14 cases. Osteologie. 2000;9:2–16.

    Google Scholar 

  38. Willert HG, Buchhorn GH, Gobel D, Koster G, Schaffner S, Schenk R, Semlitsch M. Wear behavior and histopathology of classic cemented metal on metal hip endoprostheses. Clin Orthop Relat Res. 1996;329(suppl):S160–S186.

    Article  PubMed  Google Scholar 

  39. Witzleb WC, Hanisch U, Kolar N, Krummenauer F, Guenther KP. Neo-capsule tissue reactions in metal-on-metal hip arthroplasty. Acta Orthop. 2007;78:211–220.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, General Hospital “Agios Andreas”, Patras, Greece

    Panagiotis Aroukatos MD, Maria Repanti MD, PhD & Vassiliki Bravou MD

  2. Department of Pathology, General Hospital “Agios Andreas”, 65-67 Haralabi Street, Patras, Achaia, 26224, Greece

    Thomas Repantis MD & Panagiotis Korovessis MD, PhD

Authors
  1. Panagiotis Aroukatos MD
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  2. Maria Repanti MD, PhD
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  3. Thomas Repantis MD
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  4. Vassiliki Bravou MD
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  5. Panagiotis Korovessis MD, PhD
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Correspondence to Panagiotis Korovessis MD, PhD.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Aroukatos, P., Repanti, M., Repantis, T. et al. Immunologic Adverse Reaction Associated with Low-carbide Metal-on-metal Bearings in Total Hip Arthroplasty. Clin Orthop Relat Res 468, 2135–2142 (2010). https://doi.org/10.1007/s11999-009-1187-x

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