Immunologic adverse reaction associated with low-carbide metal-on-metal bearings in total hip arthroplasty

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.

Fig. 1

Extensive necrosis is seen in the synovial membrane in association with Grade 3+ lymphocytic infiltration of the neocapsule from a revised THA with MOM bearings (Stain, hematoxylin and eosin; original magnification, ×200).

Fig. 2

Grade 3+ diffuse and perivascular lymphocytic infiltration of the neocapsule from a revised THA with MOM bearings is shown (Stain, hematoxylin and eosin; original magnification, ×400).

Fig. 3A–B

There was an excess of (A) T lymphocytes (CD3+) over (B) B lymphocytes (CD20+) at the acetabulum-cup interface seen with this revised THA with MOM bearings (Stain, EnVision™, HRP/DAB; original magnification, ×400).

Fig. 4A–B

(A) T suppressor (CD8+) and (B) T helper (CD4+) lymphocytes at the neocapsule from a revised THA with MOM bearings are shown (Stain, EnVision™, HRP/DAB; original magnification, ×400).