Perivascular and Diffuse Lymphocytic Inflammation are not Specific for Failed Metal-on-metal Hip Implants

BACKGROUND: Several studies suggest that histologic findings from tissues obtained at revision arthroplasty for failed metal-on-metal (MOM) total hip implants may reflect an immune reaction to particles or ions in some patients. However, only a limited number of cases without MOM implants were reported as controls in those studies. QUESTIONS/PURPOSES: The purpose of this study is to better define the extent and distribution of morphologic features attributed to an immune reaction in tissues sampled at revision surgery for failed nonMOM THA. PATIENTS AND METHODS: As part of a multicenter, prospective study, we reviewed 612 capsular and interface tissues obtained from 130 patients at revision THA. The samples were selected from periacetabular regions (154 samples from 103 patients), femoral implant/cement-bone interface (154 samples from 79 patients), and from areas of the joint capsule that had an intraoperative gross appearance suggesting the possibility of either infection or metallosis (256 samples from 129 patients). All patients had more than one sample obtained. The extent and distribution of lymphocytes and plasma cells, acute inflammation, and visible particles of debris were graded using criteria similar to those described to grade inflammation around failed MOM implants. RESULTS: We identified perivascular lymphocytes in 111 biopsy samples taken from 65 (50%) of 130 patients, and in 87 specimens from 57 (53%) of 107 patients thought to have aseptic loosening. Diffusely distributed lymphocytes were identified in 86 (66%) of 130 patients, and in 66 (62%) of the 107 hips with aseptic loosening, although few had the highest grade of inflammation. Increasing extent of diffuse and perivascular lymphocytes correlated with increasing extent of metal particles. CONCLUSIONS: Mild lymphocytic inflammation, diffuse and especially perivascular, is common in tissues around failed nonMOM implants. Although extensive inflammation in an inflammatory pseudotumor pattern is rare, it does occur in some cases of failed metal-polyethylene hip arthroplasties. The importance of inflammation is unknown, but the extent of diffuse inflammation shows a positive correlation with metal debris, so it could reflect a reaction to particles or ions in some patients.