The role of cytokines in aseptic loosening of total hip prosthesis]

The aim of this study was estimation of the secretory activity of macrophages isolated from granulomatotic tissue in aseptic total hip prosthesis loosening (particularly in regard to IL-6, TNF-alpha and OSM secretion). A considerable increase of IL-6 and TNF-alpha (proosteolytic cytokines) content was noted. At the same time a prominent decrease in OSM (an osteoprotective cytokine) was noted. The obtained results seem to suggest that the changed immunobiology of macrophages consisting of increase osteolytic activity and decreased osteoprotective abilities could be responsible for the loosening of hip prosthesis.     

髋关节置换后假体无菌性松动机制研究

髋关节置换包括全髋和半髋置换,是治疗髋关节严重病损的有效手段,但假体松动作为术后晚期出现的并发症是手术失败的主要原因.早期假体松动归因于应力遮挡引起的骨质重新塑形,晚期假体松动的原因主要是假体微动和磨损碎屑诱导骨溶解.近年研究发现假体松动与运动后假体摩擦产热、吸烟、滑液中IGF-I水平等有关.该文就近几年关于髋关节置换后假体发生无菌性松动的可能发生机制作一综述.     

The role of hereditary hemochromatosis in aseptic loosening following primary total hip arthroplasty.

Hereditary hemochromatosis (HH) results in increased iron absorption and subsequent deposition in tissue. This condition occurs predominantly in individuals of Northern European and Celtic origin with Ireland having one of the highest allele frequencies in the world. This study examines the hypothesis that homozygosity for either the C282Y or H63D mutations in the HFE gene may be associated with aseptic loosening following total hip arthroplasty (THA). Two groups of individuals were screened for the C282Y and H63D mutations associated with HH. Group 1 were individuals who had undergone primary hip arthroplasty and group 2 were individuals who had undergone revision hip arthroplasty for aseptic loosening. Exclusion criteria included rheumatoid or other inflammatory arthropathies and revision due to causes other than aseptic loosening. Significantly more patients in the revision THA group were homozygous for the C282Y genotype (P = 0.014). Aseptic loosening occurred earlier in these patients (P = 0.009), in particular in the patients who had clinical signs of hemochromatosis. No association was seen with the H63D mutation and revision THA. The incidence of HH in the group of primary THA patients was no higher than the background incidence. Patients who require primary THA and who are homozygous for the C282Y mutation have an increased risk of developing aseptic loosening, leading to revision THA. Moreover C282Y homozygosity appears to be associated with earlier aseptic loosening than in individuals without the C282Y mutation.     

Early aseptic loosening of a mobile-bearing total knee replacement

Background and purpose — Registry-based studies have reported an increased risk of aseptic tibial loosening for the cemented Low Contact Stress (LCS) total knee replacement compared with other cemented designs; however, the reasons for this have not been established. We made a retrieval analysis with the aim of identifying the failure mechanism.

Patients and methods — We collected implants, cement, tissue, blood, and radiographs from 32 failed LCS Complete cases. Damage to the tibial baseplate and insert was assessed. Exposure to wear products was quantified in 11 cases through analysis of periprosthetic tissue and blood. Implant alignment and bone cement thickness was compared with a control group of 43 non-revised cases.

Results — Loosening of the tibial baseplate was the reason for revision in 25 retrievals, occurring at the implant–cement interface in 16 cases. Polishing was observed on the lower surface of the baseplate and correlated to the level of cobalt, chromium, and zirconium in the blood. No evidence of abnormally high polyethylene wear was present. For each 1?mm increase in cement thickness the odds of failure due to aseptic loosening decreased by 61%. Greater varus alignment was associated with a shorter time to failure. The roughness, Ra, of a new LCS baseplate’s lower surface was 3.7 (SD 0.7) µm.

Interpretation — Debonding of the tibial component at the implant–cement interface was the predominant cause of tibial aseptic loosening. A thin cement layer may partly explain the poor performance. Furthermore, the comparatively low tibial surface roughness and the lack of a keeled stem may have played a role in the failures observed.     

Human leukocyte antigen and aseptic loosening in Charnley total hip arthroplasty

Human leukocyte antigen phenotypes and radiographic course were studied in 70 Japanese patients (90 hips) who had Charnley low friction arthroplasty. Of the 28 hips diagnosed as radiographically loose less than 15 years after surgery, seven hips (25.0%) were in patients who had a positive human leukocyte antigen A31(19). Of the 62 hips that were radiographically stable more than 15 years, two hips (3.2%) were in patients who had a positive human leukocyte antigen A31(19). Of the nine hips in patients who were positive to human leukocyte antigen A31(19), seven hips were diagnosed as radiographically loose (loosening rate was 77.8%) 15 years after surgery. On the other hand, of the 81 hips in the patients who were negative to human leukocyte antigen A31(19), only 21 hips were diagnosed as radiographically loose (loosening rate was 25.9%) 15 years after surgery. These data suggest that individual immune response to implant materials, linked to human leukocyte antigen, may participate in the process of aseptic loosening in Charnley low friction arthroplasty.     

Active metabolites of vitamin D in patients with coxarthrosis and with aseptic loosening of total hip endoprostheses

Summary The blood levels of the active metabolites of vitamin D—25-hydroxycholecalciferol (25(OH)D), 1,25 dihydroxycholecalciferol (1,25(OH)₂D), and 24,25 dihydroxycholecalciferol (24,25(OH)₂D) — were determined in 15 patients suffering from arthrosis of the hip and in 13 patients with aseptic loosening of total hip endoprostheses. Normal values were found in all but one patient with aseptic loosening, in whom 24,25(OH)₂D was not detectable. The difference between the two groups of patients was not statistically significant.     

Periprosthetic microvasculature in loosening of total hip replacement

This study was performed to quantitate vascularity in periprosthetic tissues of loose total hip replacements (THRs), because most likely revascularization and endothelial cells are important for implant osseointegration and loosening. Interface and pseudocapsular tissue samples obtained from loose THRs were stained with an immunohistochemical labelling (ABC technique) for von Willebrand factor. Non-inflammatory synovial samples served as controls. The results were quantitated by morphometry using the Kontron image analysis system. Evaluation of the mean endothelial index (EI; positively stained area m²/mm² of tissue) revealed that in the control samples synovium was better vascularized than was the case in the cellular areas of the periprosthetic pseudocapsule (P = 0.0008) and interface (P = 0.0004) of loose THRs. There was no significant difference between mean El of cellular areas in the interface and that of the pseudocapsule (P = 0.24). In the interface the vascularity was irregular. Vascular injury and decreased blood supply seem to occur at the implant-host interface, which may be one of the reasons for insufficient implant osseointegration and loosening.     

Oblong cup in the management of aseptic loosening of the acetabular component in total hip replacement.

BACKGROUND AND AIMS: At present, revision surgery of a total hip replacement is a major problem that must be dealt with by all orthopedic facilities. Aseptic loosening of the acetabular component is often associated with destruction of the original spherical shape of the acetabulum and the formation of bone defects. An orthopedist faces the challenge of acetabular revision and stable fixation of the new acetabular component in an effort to re-establish the functioning of the hip replacement. MATERIAL AND METHODS: The authors evaluated a group of 74 patients in whom they implanted an oblong revision cup due to aseptic loosening of the acetabular component from August 2000 until December 2003. The mean duration of the follow-up period was 63 months (ranging from 38 to 78 months). RESULTS AND CONCLUSIONS: The authors reported very good results from the use of this implant, where osteointegration and good functional outcome evaluated according to the Harris Hip Score (HHS) were achieved in 95% of cases. The long-term outcome should be the subject of further investigation.     

Stemmed revision arthroplasty for aseptic loosening of total knee replacement

Fifty-three failed knee replacements were revised using minimally constrained implants with smooth uncemented intramedullary stems and metal-backed tibial components. Polymethylmethacrylate was used only to replace lost bone near the surface of the implant. Excluding four knees which had serious postoperative complications, 91% had successful relief of pain, 84% had over 90 degrees of movement and 80% could walk for more than 30 minutes. Review of the radiographs showed that there were no progressive lucencies at the interface between bone and cement, and no subsidence of components or changes in alignment. At the uncemented stem-to-bone interface, thin white lines developed near the metal, and their significance is discussed. This revision technique is an effective treatment for aseptic failure of primary total knee arthroplasty.     

Increased urinary crosslink levels in aseptic loosening of total hip arthroplasty

The diagnosis of aseptic loosening in total hip arthroplasty is predominantly based on clinical and radiographic evaluation. Loosening is usually associated with increased bone resorption at the interface. In this study we wanted to evaluate the diagnostic value of bone markers in aseptic loosening. We compared 50 patients with proven component loosening during surgery with 50 age-, sex-, and implant-matched patients without clinical or radiological signs of loosening. We measured serum markers of bone formation (bone-specific alkaline phosphatase, osteocalcin [OC], procollagen type I propeptides) and bone resorption (collagen n-telopeptide [NTX], deoxypyridinoline [DPYD], pyridinoline [PYD]). We found significantly increased levels of NTX, DPYD, PYD, and OC in the loosening group. The other markers showed no significant difference between both groups. We conclude that determination of urinary crosslinks may offer a new and valuable diagnostic method in the detection of aseptic loosening in total hip arthroplasty.     

Increased interleukin-8 (IL-8) expression is related to aseptic loosening of total hip replacement

Aseptic loosening is an increasing problem in total hip replacement (THR). Chronic inflammatory reaction against implant wear particle results in collageno- and osteolysis, leading to loosening of the implant. Cytokines are known to play a major role in this particular inflammatory process [10]. The aim of the present study was to examine interleukin-8 (IL-8) in the synovial-like interface membrane (SLIM) and pseudocapsular tissue of THRs and to compare it to normal knee synovial membrane. Eleven patients suffering from aseptically loosened THRs were included. All the SLIM and pseudocapsular tissue samples were obtained during revision operations. Ten control samples of normal synovium were collected per arthroscopy from the superior recessus of the knee. For immunohistochemical IL-8 detection, polyclonal mouse anti-human immunoglobulin (Ig)G₁ IL-8-primary antibody was used with the alkaline phosphatase anti-alkaline phosphatase (APAAP) method. Results were quantitated using the Vidas image analysis system. The highest count levels (mean ± SEM) were detected in SLIM tissue (386 ± 82 cells/mm²). The difference was statistically significant compared with pseudocapsular tissue (193 ± 36 cells/mm²) and control samples (18 ± 5 cells/mm²). Count levels in control tissue were on average 5% of the SLIM tissues values. The present study determines for the first time the cellular origin of IL-8 in aseptically loosened THRs and also quantitates the IL-8-producing cells in the periprosthetic tissue. The results reveal a high rise in IL-8 concentration in SLIM and in synovial tissues. This finding moves us one step forward in solving the complex network of multiple factors affecting loosening of hip implants. Received: 10 November 1998     

Serum bone markers in patients with loosening of cemented total hip endoprosthesis]

Serum levels of bone markers N-mid osteocalcin (OCN-Mid) and Cross-Laps in 20 patients (8 men and 12 women) with loosening of at least one element of total hip endoprosthesis confirmed during operation were compared with age and sex matched group with OA. Marker levels were measured by direct chemoluminescency using Modular E-170. Statistical analysis were done with t-Student test (alpha = 0.05). There were no significant differences in OCN-Mid, Cross-Laps levels and OCN-Mid/Cross-Laps ratio between both groups. Implant loosening is a slow process taking place on a relatively small surface in comparison to whole skeleton, so bone markers have no clinical value in diagnostics of total hip loosening.