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Periprosthetic Tissue Metal Content but Not Serum Metal Content Predicts the Type of Tissue Response in Failed Small-Diameter Metal-on-Metal Total Hip Arthroplasties
C.H. Lohmann, MD1; H. Meyer, MD1; J.V. Nuechtern, MD2; G. Singh, FRCSEd(Orth)3; S. Junk-Jantsch, MD4; H. Schmotzer, PhD5; M.M. Morlock, PhD6; G. Pflüger, MD4
1 Department of Orthopaedic Surgery, Otto-Von-Guericke University, Leipziger Strasse 44, D-39120 Magdeburg, Germany. E-mail address for C.H. Lohmann: christoph.lohmannCH@med.ovgu.de
2 Department of Traumatology, University of Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
3 University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System, 1E Kent Ridge Road, 119228 Singapore
4 Evangelisches Krankenhaus, Hans-Sachs-Gasse 10-12, A-1180 Vienna, Austria
5 SigmaRC GmbH, Alte Steinhauserstrasse 1, 6330 Cham, Switzerland
6 Institute for Engineering, Technical University of Hamburg-Harburg, D-21071 Hamburg, Germany
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Investigation performed at the Department of Orthopaedic Surgery, Otto-Von-Guericke University, Magdeburg, Germany

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Sep 04;95(17):1561-1568. doi: 10.2106/JBJS.L.01273
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Tissue responses to periprosthetic metal wear debris are complex and poorly understood. There are two predominant tissue responses: a nonspecific macrophage-mediated granulomatous response and lymphocyte-dominated response, which has immunological memory and is mediated by T cells. Delayed hypersensitivity-type responses may accelerate aseptic loosening of arthroplasty implants. We hypothesized that the metal content of periprosthetic tissue but not of serum would be predictive of the type of tissue response to metal wear debris.


We examined twenty-eight total hip arthroplasty implant retrievals from twenty-seven patients who had undergone revision arthroplasty at one institution. Indications for revision were pain and/or osteolysis; one patient had recurrent dislocations. Tissue samples were analyzed microscopically and the metal (Co, Cr, and Ni) content was determined. Explanted prosthetic components were examined for linear wear. Intraoperatively, periprosthetic metallosis was observed in twelve cases and formation of a bursa (pseudotumor) was observed in thirteen. The acetabular cup was loose in eleven cases, the femoral stem was loose in five, and both components were loose in five.


The metal (Co, Cr, and Ni) content of the periprosthetic tissue ranged from 1.4 to 4604.0 μg/g. Histologically, macrophages containing metal particles as well as diffuse and perivascular lymphocytic infiltration were observed. Fibrin exudation was also visible. Tissues that displayed a predominantly lymphocytic response had a mean metal content of 222.2 ± 52.9 μg/g, whereas those that displayed a macrophage-dominated response had a metal content of 3.0 ± 0.9 μg/g; this difference was significant (p = 0.001). The mean serum metal content did not differ significantly between the two subgroups (60.7 ± 13.4 compared with 43.7 ± 3.8 μg/L, p = 0.105).


An association between periprosthetic tissue metal content and hypersensitivity appears likely but needs to be validated with larger-scale retrieval studies.

Clinical Relevance: 

This study contributes to the understanding of tissue responses to metal wear debris after joint replacement and the factors that are predictive of a type-IV lymphocyte-dominated hypersensitivity reaction.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Christopher H. Lohmann, MD
    Posted on September 18, 2013
    Response to Comment from Dr. Dangles
    Professor & Chairman, Department of Orthopaedics, Otto-Von-Guericke University, Magdeburg, Germany

    We appreciate the comment from Dr. Dangles. I apologize if our materials and Methods sections was not clear.

    The retrievals were from SMALL diameter MoM THA and not from LARGE diameter MoM THA like Birmingham Surface replacements. The acetabular component consisted of a sandwich type cup: outer shell titanium, UHMWPE, and a CoCr inlay with a 28 mm diameter.

    Chris J Dangles M.D.
    Posted on September 07, 2013
    Description of Implant in material and methods
    University of Illinois, Urbana-Champaign, USA

    I am confused as to what implant is being studied. "a layer of UHMWPE was interposed between the outer shell and the articulating surface". I thought the retrievals were metal on metal Birmingham resurfacing implants.

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