Unusual foreign-body reaction to a failed total knee replacement: simulation of a sarcoma clinically and a sarcoid histologically. A case report.
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Bone Neoplasms↗
Biomedical subjects
R M Urban
Publications and source records attributed to R M Urban.
Enhancement of bone ingrowth by transforming growth factor-beta.
Enhancement of bone ingrowth with transforming growth factor-beta was evaluated in a canine model. Ten dogs had bilateral implantation of a titanium-fiber-metal-coated rod in the proximal part of the humerus. A three-millimeter gap between the outer surface of the porous coating and the surrounding cancellous bone was created to impair bone ingrowth. All of the implants were plasma-flame-sprayed with hydroxyapatite and tricalcium phosphate. In each animal, one implant was also treated with recombinant transforming growth factor-beta 1 while the other implant, which was not so treated, served as a paired control. Two doses of transforming growth factor-beta 1 were used: 335 micrograms in five animals and 120 micrograms in the other five. At four weeks, the amount of bone ingrowth in the implants that had been treated with 120 micrograms of transforming growth factor-beta 1 was threefold higher than that in the paired controls (p = 0.009), but with the numbers available there was no significant increase in bone ingrowth with the higher dose. The amount of new-bone formation in the three-millimeter gaps adjacent to the treated implants was twice that in the gaps of the paired controls, regardless of the dose. The differences between the treated and control implants with regard to the architecture of the new bone in the gap indicate that the mechanism of action of transforming growth factor-beta 1 may include both proliferation of osteoprogenitor cells and production of matrix by committed osteoblasts. Compared with the findings in a previous study in which this canine model was used, the data from the present investigation indicate that enhancement of bone ingrowth in implants that have been treated with a combination of a hydroxyapatite-tricalcium phosphate coating and transforming growth factor-beta 1 may exceed that obtainable with grafting of the gap with autogenous cancellous bone.
Animals↗
Local and distant products from modularity.
In this study, the local and distant distribution of solid and soluble products of corrosion from the head and neck junction of modular femoral total hip prosthetic components were characterized. Particulate corrosion products from retrieved implants and surrounding tissues were analyzed. Serum transport and urinary excretion of metal was measured in correlation with the degree of corrosion at the head and neck junction. Particles of metal oxides, metal chlorides, and chromium phosphate corrosion products were identified on implants of 10 designs from 6 manufacturers. The most abundant solid corrosion product on the implant and within the periprosthetic tissues (size range, < 1-200 micrometers) was an amorphous chromium orthophosphate hydrate-rich material. Serum cobalt and urine chromium concentrations were elevated significantly in patients with implants that had moderate to severe corrosion in comparison with those with no to mild corrosion. Solid corrosion products from modular femoral stems may accelerate articular wear via a 3-body mechanism. Phagocytosable particles of these corrosion products may stimulate macrophage-mediated periprosthetic bone loss. Systemic dissemination of metallic corrosion products raises the issue of systemic toxicity; however, no overt evidence of metal toxicity was observed in this study.
Adult↗
The susceptibility of smooth implant surfaces to periimplant fibrosis and migration of polyethylene wear debris.
The purpose of this investigation was to establish whether the tissue response and migration of polyethylene debris differed at noncemented smooth and porous implant surfaces. This was accomplished through 3 separate but closely related studies: (1) a canine cylindrical implant model with smooth and porous surfaces exposed to polyethylene debris; (2) a canine total hip arthroplasty model analyzing the interface between bone and femoral implants with various porous-coating configurations; and (3) a histologic analysis of autopsy-retrieved, human, noncemented hip prostheses with noncircumferential porous coating. The cylindrical implant model involved the placement of split cylinders, 1/2 porous and 1/2 smooth, into the distal femur and proximal tibia of 4 dogs. Four control implants and 10 test implants (chronically exposed to simulated polyethylene debris with a mean size of 4.7 microns) were examined histologically as long as 30 weeks after surgery. The canine hip study involved the study of 54 noncemented hip prostheses at periods of 1, 6, and 24 months. The prostheses possessed 4 different porous surface configurations: 1 with circumferential porous coating, 2 with noncircumferential coating, and 1 without porous coating. The human retrieval analysis involved the study of 7 cadaveric femora (age, 6 months-5 years) implanted with a straight titanium-alloy prosthesis possessing proximal pads of titanium fiber metal on the anterior, posterior, and medial aspects. With all implants in all 3 studies, there was the common finding of bone ingrowth at the porous implant surface and a fibrous interface or periprosthetic cavity around the portion of the implant that was smooth surfaced. The periprosthetic cavity typically was encapsulated by a thin continuous shell of trabecular bone. In addition, polyethylene debris was found to have preferentially migrated along the smooth implant surfaces. In the longer-term canine and human hip retrievals, polyethylene particles in the micron size range were present within histiocytes, whereas larger particles as much as 100 microns were found within foreign-body giant cells. Of importance for the implants from all 3 studies, with the exception of some pronounced cavities on the lateral aspect of the human hip prostheses, the periimplant cavities around the smooth surfaces were not detectable radiographically. This study clearly established a fundamental principle of relative barriers to particulate debris migration. Smooth implant surfaces are more susceptible than porous surfaces to the development of a fibrous tissue filled periimplant cavity and the subsequent migration of polyethylene wear debris.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Migration of corrosion products from modular hip prostheses. Particle microanalysis and histopathological findings.
Migration of solid corrosion products from the modular head-neck junction of fifteen total hip replacements to the periprosthetic tissues was studied. The devices and tissues were recovered at the time of a revision procedure or at autopsy after a mean of sixty-four months (range, eight to ninety-seven months). The prostheses had a cobalt-chromium-alloy head coupled with a cobalt-chromium-alloy or a titanium-alloy stem. The solid corrosion product was identified by electron microprobe analysis and Fourier transform infrared microprobe spectroscopy as a chromium orthophosphate hydrate-rich material. The product was present at the junction of the modular head and neck and as particles within the periprosthetic tissues as early as eight months postoperatively. In several hips, it was also present on the polyethylene bearing surface. The particles in the tissues ranged in size from less than one to 500 micrometers. They were present within histiocytes or were surrounded by foreign-body giant cells in the pseudocapsule of the hip joint; in the membranes of the femoral bone-implant interface; and at sites of femoral endosteal erosions, with and without loosening of the femoral component.
Adult↗
Effect of pegs and screws on bone ingrowth in cementless total knee arthroplasty.
The purpose of the present study was to assess the effects of pegs and screws on bone ingrowth into the tibial component in cementless total knee replacement. Left total knee replacements were performed in 21 mature male dogs with 3 cementless porous-coated tibial tray configurations (7 animals per group): (1) 4-peg design implanted with cortical screws passing through the pegs; (2) 4-peg design implanted without screws; and (3) pegless design secured by 4 cortical screws. The animals were allowed unrestricted activity and were euthanized 6 months postoperatively. The pegless components (Group 3) had the highest extent of bone ingrowth into the tray (90.3% +/- 9.4%), followed by the components with 4 pegs only (Group 2, 82.8% +/- 9.2%), and the components with 4 pegs and 4 screws (Group 1, 75.9% +/- 11.8%). The difference between Groups 1 and 3 was statistically significant (p < 0.05). The volume fraction of bone ingrowth in the tray did not differ among the 3 groups, with an overall mean of 22.5% (+/- 4.6%). At the posterolateral quadrant, Group 1 had significantly less bone ingrowth than Group 3 within the tray whether measured as the extent (63.6% +/- 20.5% versus 91.0% +/- 10.6%, p < 0.05) or volume fraction (19.1% +/- 8.8% versus 32.9% +/- 10.5%, p < 0.05). There were no between-group differences at the other quadrants. This study indicated that pegs provided no added benefit in a circumstance where sufficient initial fixation was obtained with screws.
Animals↗
A quantitative study of bone and soft tissues in cementless porous-coated acetabular components retrieved at autopsy.
The authors examined 11 cementless acetabular components of one design retrieved at autopsy and made observations concerning tissue ingrowth and local tissue reaction, radiographic-histologic correlation, and the distribution of particulate wear debris. The cups were hemispherical in design with a commercially pure titanium fiber-metal porous coating. All of the prostheses were implanted with screws. The implants were in place for an average of 41 months (range, 5 weeks to 75 months). Ten of the cups had bone ingrowth, with the average volume fraction being 12.1 +/- 8.2%. There were no differences in the amount of bone ingrowth when the component was partitioned into nine anatomic regions. However, there was more bone adjacent to screw holes through which screws were inserted compared with empty screw holes. As the number of radiolucent zones increased on the clinical radiographs less bone ingrowth was observed histologically. The amount of metal debris in holes with screws and holes without screws was similar. In the longest term cases, polyethylene debris was noted within empty screw holes, but no granulomatous reactions or osteolytic processes were observed.
Acetabulum↗
Revision, without cement, of aseptically loose, cemented total hip prostheses. Quantitative comparison of the effects of four types of medullary treatment on bone ingrowth in a canine model.
A model that replicated the radiographic and histological features of aseptic loosening of the femoral component of a total hip replacement that had been done with cement was created in thirty-seven dogs. A deep wound infection developed in one dog, and that dog was excluded from the study. Revision was performed without cement in twenty-nine dogs, which were then followed for six months. The remaining seven dogs were used for histological study only. The components that were used for revision were made from Ti-6-Al-4-V, and a titanium fiber-metal porous surface had been applied to the anterior, posterior, and medial surfaces of the proximal part of the stem. The femora were revised either with no graft material applied to the osseous defect; with hydroxyapatite/beta-tricalcium phosphate placed in the defect; with application of an autologous cancellous bone graft as part of a one-stage revision; or with application of an autologous cancellous bone graft as the first part of a two-stage revision, with implantation of the component four months later. The use of an autologous bone graft led to greater and more consistent ingrowth of bone. The greatest amount of bone ingrowth was found in the group in which the procedure had been done in two stages (18 +/- 4.1 per cent), followed by the group in which the prosthesis and the graft had been inserted in a single stage (15 +/- 5.0 per cent), the group that had been treated with hydroxyapatite/beta-tricalcium phosphate (10 +/- 9.1 per cent), and the control group, in which no graft had been used (7 +/- 7.0 per cent). Notably, all of the components in the animals in which an autologous graft had been used were well fixed by bone ingrowth, while the component in two of the animals in the group in which no graft had been used in one animal in the hydroxyapatite/beta-tricalcium phosphate group had only fibrous-tissue ingrowth. In contrast to the findings with respect to bone ingrowth, there was more medullary bone adjacent to the lateral aspect of the implant in the groups in which hydroxyapatite/beta-tricalcium phosphate or no graft had been inserted than in the groups that had had an autologous graft.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
Histology of porous-coated acetabular components. 25 cementless cups retrieved after arthroplasty.
25 hemispherical acetabular components retrieved from patients who had a total hip arthroplasty (THA) were studied histologically. All of the components had titanium fiber metal porous coatings and were implanted with adjuvant screw fixation, 18 in primary THA and 7 in revision THA. None of the cups had been removed because of infection or failure of fixation. The components had been in place an average of 30 (1-140) weeks. 18 cups had bone ingrowth into the porous coating. Up to one third of the available void space within the porous coating was occupied by bone, while the maximal proportion of the area of the bone-implant interface with bone ingrowth was over 80 percent. Bone ingrowth was more often observed at the dome and in the vicinity of sites of screw fixation than elsewhere. Peripherally, bone ingrowth was less consistent, and in isolated areas fibrocartilage and mineralized fibrocartilage were occasionally observed. The longer-term cases had more bone ingrowth than the shorter-term cases. Apparent metallic debris was observed within histiocytes adjacent to screw holes, and the amount of this material increased with duration of implantation.
Acetabulum↗
Efficacy of autograft and freeze-dried allograft to enhance fixation of porous coated implants in the presence of interface gaps.
Autogenous cancellous bone and freeze-dried allogeneic cancellous bone were tested in a total of 41 adult male mongrel dogs. In each humerus, an implant with a commercially pure titanium fiber metal porous coating was placed in an overreamed cavity so that a uniform 3-mm gap was present between the implant and host cancellous bone. Graft material was placed in the gap of one humerus while the gap of the other humerus was left empty and served as a paired negative control. Histologically, both autograft and allograft appeared to aid repair of the defect, but quantitatively only autograft enhanced new bone formation within the defect. Treatment with autograft significantly increased the amount of bone ingrowth within the implants by nearly three-fold at 4 weeks and eight-fold at 8 weeks. The enhancing effect was recognizable as early as 2 weeks. The strength of fixation was increased by nearly seven-fold at 4 weeks and two-fold at 8 weeks in the autograft group, but this was only statistically significant at 4 weeks. Treatment with allograft did not enhance bone ingrowth at any time period, but had a small positive effect on strength of fixation at 4 weeks.
Analysis of Variance↗
Experimental studies of bone remodeling in total hip arthroplasty.
Experimental studies of bone remodeling after total hip arthroplasty are reviewed. Most of the studies have been motivated by the introduction of cementless hip replacements in which porous coatings are used to provide fixation by bone ingrowth. Stress shielding is thought to be the main factor responsible for bone loss after hip replacement. Experimentally, design features related to (1) the nature of the bone-implant interface and (2) stem stiffness have been tested to determine if the effects of stress shielding can be decreased. The dominant long-term design feature controlling bone remodeling in hip replacement appears to be stem stiffness.
Animals↗
Remodeling and ingrowth of bone at two years in a canine cementless total hip-arthroplasty model.
Remodeling and ingrowth of bone in association with the use of uncemented femoral components were examined at two years in a canine total hip-arthroplasty model. Twenty-two dogs received a unilateral uncemented femoral stem that was made of Ti6A14V and was covered with one of three types of titanium porous coating: fiber-metal, beads, or plasma flame-spray. The amount and distribution of ingrowth of bone differed somewhat among the groups at two years, but the patterns of remodeling of bone in the medullary canal and cortex were similar. In general, about 15 to 18 per cent of the cortical bone was lost adjacent to the levels of the stem that were covered with the porous coating. Most of the loss of cortical bone was due to subperiosteal resorption proximally and endosteal resorption at the middle and distal levels of the stem. Increased cortical porosity accounted for only a small fraction of the loss of cortical bone. The amount of medullary bone increased proximally and distally, so that the loss of total bone mass was significantly only at the mid-part of the stem. The amount of loss of cortical bone was similar to that observed in a previous six-month study, suggesting that a steady state was achieved in the present model.
Animals↗
Measuring the volume fraction of bone ingrowth: a comparison of three techniques.
The need for quick, accurate, and reproducible methods to measure the amount of bone within porous metals has increased as the use of these materials has become more common within orthopedics. The purpose of this paper is to compare measurements of bone ingrowth using microradiography, stained histology, and backscattered electron imaging-scanning electron microscopy (BEI-SEM) in cementless, porous-coated acetabular components retrieved from human patients. BEI-SEM of bone ingrowth into porous metal provided excellent images for quantitative analysis. The stained sections and BEI-SEM images provided very comparable results, while microradiography consistently underestimated the porosity of the porous coating and overestimated the amount of bone ingrowth.
Acetabulum↗
Effects of radiation on fixation of non-cemented porous-coated implants in a canine model.
A non-weight-bearing porous-coated rod was implanted bilaterally in the proximal part of the humerus in thirty-five adult male mongrel dogs. In all of the animals, one limb was treated with radiation and the opposite limb served as the control. In twenty-one animals, the dose was 1000 centigrays (rads) and in fourteen, it was 500 centigrays. The strength of fixation and the volume fraction of ingrowth of bone were determined two, four, and eight weeks after the operation in the group that received 1000 centigrays and two and four weeks after the operation in the group that received 500 centigrays. Treatment with 500 centigrays had no significant effect on the strength of fixation or the amount of ingrowth of bone. In contrast, at two weeks, treatment with 1000 centigrays had reduced the strength of fixation to 50 per cent of the control value (p less than 0.01), although, at four and eight weeks, the strength of fixation was not significantly different than that in the control limb. The amount of ingrowth of bone in the irradiated limb was significantly reduced at two weeks (30 per cent of the control value) (p less than 0.01), four weeks (70 per cent of the control value) (p less than 0.05), and eight weeks (56 per cent of the control value) (p less than 0.05).
Animals↗
Bone ingrowth into the tibial component of a canine total condylar knee replacement prosthesis.
The purpose of this study was to evaluate the occurrence of bone ingrowth in a porous coated tibial component of a canine total condylar design knee replacement model. The entire undersurface of the tibial prosthesis was covered by a titanium fiber metal porous composite pad. Projecting from this surface were three short, cylindrical, fiber metal coated pegs that along with a posterior screw provided initial stabilization of the device. Left total knee replacements were performed on six dogs using alignment and cutting jigs to prepare the bony surfaces. The dogs were killed 6 months following surgery. Extensive bone ingrowth was present in all pegs of every tibial component. Bone ingrowth was present in 12% of the pad area of one component, 22.7 to 41.6% in four components, and 81.1% in another. The void spaces in other areas were filled with fibrous tissue or in the periphery of the device with fibrocartilage. Bone ingrowth in the pad was consistent in the vicinity of the pegs and was variable in regions not adjacent to the pegs, suggesting that the pegs exerted a strong influence on the pattern of bone ingrowth into the pad.
Animals↗
Calcium phosphate-coated porous titanium implants for enhanced skeletal fixation.
Porous titanium fiber implants for cementless skeletal fixation by bone ingrowth were treated with a calcium phosphate coating applied by a plasma flame-spray technique. In a paired experiment, treated and control implants were inserted in the humeri and olecranons of 36 adult dogs for periods of 1, 2, 4, and 6 weeks. After the animals were sacrificed, a biomechanical evaluation of the strength of skeletal fixation of the implants and a histologic evaluation of bone ingrowth was done. The mean shear strength of skeletal fixation at four weeks for the calcium phosphate-coated implants was 24% greater (P less than .01) than for paired controls. No difference in strength of fixation between treated and control implants was present at other time periods. The osteoconductive properties of the ceramic coating were demonstrated by bone forming in direct contact with the calcium phosphate coating on the metal fibers of the treated implants. No significant increase for the volume of bone ingrowth was established for treated implants compared to paired controls at any time period.
Animals↗
Effect of disodium etidronate (EHDP) on bone ingrowth in a porous material.
This study evaluated the effect of disodium etidronate (EHDP) on biomechanical and histologic characteristics of bone ingrowth in a porous material. EHDP was administered parenterally to six adult mongrel dogs at a dose of 2 mg/kg/day for eight weeks. Six additional dogs served as controls and were injected with saline. Porous titanium fiber composites were inserted into the proximal humeri and the left olecranons of all animals after the first four weeks of treatment. Upon completing a total of eight weeks of treatment, all animals were sacrificed and the bone-porous implant interfacial shear strength was determined by a pull-out test to failure. Mean shear strength of fixation for the EHDP-treated group was reduced by 76% compared to the control group (p less than 0.001). Bone ingrowth was mineralized in all of the control specimens. Mineralization of tissue ingrowth was inhibited, however, in all specimens from EHDP-treated animals. These findings suggest that cementless skeletal fixation of porous-coated implants by bone ingrowth may be delayed or prevented by the administration of EHDP.
Animals↗
Malignant neoplasms associated with orthopedic implant materials in rats.
The carcinogenic potential of 22 orthopedic prosthetic materials was studied by implantation in bone in Sprague-Dawley rats and evaluated by complete autopsy examination performed at the time of death or at the end of the 30 month experimental period. When the number of malignancies in these rats was compared with control and sham-operated animals, a small increase in sarcomata was observed in animals bearing metal alloy implants containing high contents of cobalt, chromium, or nickel. An increased incidence of lymphomata with bone involvement was also observed in rats bearing metal implants when compared with control and sham-operated animals.
Animals↗