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Scientific Articles   |    
Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip JointsA Clinical and Histomorphological Study
Hans-Georg Willert, MD1; Gottfried H. Buchhorn1; Dipl-Ing1; Afshin Fayyazi, MD2; Renata Flury, MD3; Markus Windler, PhD4; Georg Köster, MD5; Christoph H. Lohmann, MD6
1 Klinikum der Universität Göttingen, Abteilung Orthopädie, Robert-Koch-Strasse 40, D-37099 Göttingen, Germany. E-mail address for G.H. Buchhorn: gh-buchh@med.uni-goettingen.de
2 Städtisches Klinikum Pforzheim, Institut für Pathologie, Kanzlerstrasse 2-6, D-75175 Pforzheim, Germany
3 Kantonsspital Winterthur, Institut für Pathologie, Brauerstrasse 15, CH-8401 Winterthur, Switzerland
4 Zimmer, Sulzer Allee 8, gt CH-8404 Winterthur, Switzerland
5 Chirurgisch-Orthopädische Fachklinik Lorsch, Waldstrasse 13, D-64653 Lorsch, Germany
6 Klinikum der Universität Hamburg, Abteilung Orthopädie, Martinistrasse 51, D-20357, Hamburg, Germany
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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Zimmer GmbH, Winterthur, Switzerland. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer GmbH) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Departments of Orthopaedics and Pathology, Klinikum der Universität Göttingen, Göttingen, Germany

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Jan 01;87(1):28-36. doi: 10.2106/JBJS.A.02039pp
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Abstract

Background: Some patients who have a total hip replacement with a second-generation metal-on-metal articulation have persistent or early recurrence of preoperative symptoms. Characteristic histological changes in the periprosthetic tissues suggested the development of an immunological response. Therefore, in order to determine the relevance of these symptoms, we performed a study of the clinical data and periprosthetic tissues associated with endoprostheses with a metal-on metal articulation that had been retrieved at revision.

Methods: Periprosthetic tissues as well as the clinical data on the patients were obtained from the first nineteen consecutive revisions performed at the treating hospitals. At the time of the revision, fourteen patients had the metal-on-metal articulation exchanged for either an alumina-ceramic or a metal-on-polyethylene articulation. Five patients received another second-generation metal-on-metal total joint replacement. Five-micrometer sections were prepared from the tissue samples, were stained with routine and immunohistochemical methods, and were examined histologically. Histological specimens from three groups of patients, two of which were treated with non-metal-on-metal implants, served as controls.

Results: The majority of patients had persistence of their preoperative pain or early recurrence of the pain after the original total hip replacement, and often a pronounced hip joint effusion had developed after the original replacement. Radiographic follow-up showed the development of radiolucent lines in five hips and of osteolysis in another seven hips. At the revision surgery, both the cup and the stem were found to be well fixed in nine patients. The characteristic histological features were diffuse and perivascular infiltrates of T and B lymphocytes and plasma cells, high endothelial venules, massive fibrin exudation, accumulation of macrophages with droplike inclusions, and infiltrates of eosinophilic granulocytes and necrosis. Only a few metal particles were detected. Immunohistochemical analysis demonstrated that the cellular reaction was still active. The patients who received another second-generation metal-on-metal articulation at the time of the revision had no decrease in symptoms. In the control group of tissues obtained at revisions of endoprostheses without cobalt, chromium, or nickel articulations, there were no similar signs of immune reactions.

Conclusions: These histological findings support the possibility of a lymphocyte-dominated immunological response. Although the prevalence of this reaction is low, the persistence or early reappearance of symptoms, including a marked joint effusion and the development of osteolysis, after primary implantation may suggest the possibility of such a reaction.

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    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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