Dissemination of wear particles to the liver, spleen, and abdominal lymph nodes of patients with hip or knee replacement
Dissemination of wear particles to the liver, spleen, and abdominal lymph nodes of patients with hip or knee replacement
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DOI：
10.2106/00004623-200004000-00002
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发表时间：
2000-04-01
影响因子：
5.3
通讯作者：
Peoc'h, M
中科院分区：
文献类型：
--
作者：
Urban, RM;Jacobs, JJ;Peoc'h, M
背景：关节置换假体的磨损和腐蚀产生的颗粒的重要性主要是在颗粒引起的假体周围骨溶解和无菌性松动的局部影响的背景下被理解的。我们研究了全髋关节和全膝关节置换术患者中磨损颗粒的传播，以确定肝脏、脾脏和腹部主动脉旁淋巴结中假体磨损碎片的患病率和组织病理学反应。方法：分析了 29 名患者的尸检标本和两名置换失败的活体患者的活检标本，从 15 名未进行关节置换的患者的尸体中获取的组织标本作为对照。使用染色组织切片的光学显微镜来表征颗粒的浓度和相关的组织反应。通过电子微探针分析鉴定金属颗粒，使用油红-O染色和偏光显微镜研究聚乙烯颗粒。通过傅里叶变换红外光谱和热台热分析，在选定的病例中证实了聚乙烯颗粒的成分，尸检研究的 21 名患者曾进行过初次全关节置换术。其中 11 人使用髋关节假体的时间平均为 69 个月（范围为 43 至 171 个月），10 人接受膝关节置换术的时间平均为 84 个月（范围为 31 至 179 个月）。尸检研究的另外八名患者接受了髋关节置换术，其中一个或多个部件松动并进行了修正。初次关节置换术与死亡之间的平均时间为 174 个月（范围为 47 至 292 个月），最后一次翻修手术与死亡时间之间的平均时间为 71 个月（范围为 1 至 138 个月）。 结果：髋关节置换术失败的患者（八分之七）的肝脏或脾脏中的金属磨损颗粒比初次髋关节置换术的患者更常见（十一个中的两个）或膝关节置换术（十个中的两个）。这些患者中的大多数磨损颗粒的主要来源涉及辅助非轴承表面，而不是预期的两个主轴承表面之间的磨损。在一名活体患者中，机械故障髋关节假体中钛合金颗粒的扩散与内脏肉芽肿反应和肝脾肿大有关，需要手术和药物治疗。在可用于研究的 28 名植入患者中，68%（19）的主动脉旁淋巴结中检测到金属磨损颗粒，在所有 29 名植入后研究的患者中，38%（11）在主动脉旁淋巴结中检测到金属磨损颗粒。尸检发现，金属颗粒进一步扩散到肝脏或脾脏，通常在巨噬细胞小聚集体中发现，以浸润形式出现，没有明显的病理重要性。聚乙烯颗粒引起了类似的反应，在 28 名患者中 68%（19 名）的主动脉旁淋巴结和 29 名患者中 14%（4 名）的肝脏或脾脏中发现了聚乙烯颗粒。大多数播散的磨损颗粒的尺寸小于一微米，目前可用的方法缺乏检测极低浓度的亚微米聚乙烯颗粒所需的灵敏度和特异性，并且可能低估了肝脏和脾脏中聚乙烯磨损碎片的流行率。 结论：在这项研究中，金属和聚乙烯磨损颗粒的全身分布是一个常见的发现，无论是在先前植入失败的患者还是在最初使用全关节假体的患者中。机械故障重建后，肝脏或脾脏中颗粒的发生率更高。在大多数患者中，这些器官中磨损颗粒的浓度相对较低，并且没有明显的病理重要性。然而，在一种罕见的情况下，由于机械故障和肝功能受损的髋关节假体磨损碎片大量积累，肝脏、脾脏和腹部淋巴结中形成了肉芽肿。 临床相关性：这些发现强调了通过关节置换装置最大限度地减少颗粒碎片产生的必要性，以及外科医生需要考虑对可能产生大量颗粒碎片的患者进行快速翻修。血清和尿液痕量金属分析可以提供失败的早期确认，并有助于对有症状或失败的装置的患者进行翻修手术的时机进行帮助。
Background: The importance of particles generated by wear and corrosion of joint replacement prosthese, has been understood primarily in the context of the local effects of particle-induced periprosthetic osteolysis and aseptic loosening. We studied dissemination of wear particles in patients with total hip and knee replacement to determine the prevalence of and the histopathological response to prosthetic wear debris in the liver, spleen, and abdominal para-aortic lymph nodes.Methods: Postmortem specimens from twenty-nine patients and biopsy specimens from two living patients with a failed replacement were analyzed, Specimens of tissue obtained from the cadavera of fifteen patients who had not had a joint replacement served as controls. The concentration of particles and the associated tissue response were characterized with the use of light microscopy of stained histological sections. Metallic particles were identified by electron microprobe analysis, Polyethylene particles were studied with the use of oilred-O stain and polarized light microscopy. The composition of polyethylene particles was confirmed in sellected cases by Fourier transform infrared spectroscopy and hot-stage thermal analysis,Twenty-one of the patients studied post mortem had had a primary total joint replacement. Eleven of them had had a hip prosthesis for a mean of sixty-nine months (range, forty-three to 171 months), and ten had had a knee replacement for a mean of eighty-four months (range, thirty-one to 179 months). The other eight patients studied post mortem had had a hip replacement in which one or more components had loosened and had been revised. The mean time between the initial arthroplasty and the time of death was 174 months (range, forty-seven to 292 months), and the mean time between the last revision procedure and the time of death was seventy-one months (range, one to 138 months).Results: Metallic wear particles in the liver or spleen were more prevalent in patients who had had a failed hip arthroplasty (seven of eight) than in patients who had had a primary hip (two of eleven) or knee replacement (two of ten). The principal source of wear particles in the majority of these patients involved secondary nonbearing surfaces rather than wear between the two primary bearing surfaces as intended. In one living patient, dissemination of titanium alloy particles from a hip prosthesis with mechanical failure was associated with a visceral granulomatous reaction and hepatosplenomegaly, which required operative and medical treatment.Metallic wear particles were detected in the paraaortic lymph nodes in 68 percent (nineteen) of the twenty-eight patients with an implant from whom lymph nodes were available for study, In 38 percent (eleven) of all twenty-nine patients with an implant who were studied post mortem, metallic particles had been further disseminated to the liver or spleen, where they were usually found within small aggregates of macrophages occurring as infiltrates without apparent pathological importance. Polyethylene particles elicited a similar response, They were identified in the paraaortic lymph nodes of 68 percent (nineteen) of the twenty-eight patients and the liver or spleen of 14 percent (four) of the twenty-nine patients. The majority of the disseminated wear particles were less than one micrometer in size, Currently available methods lack the sensitivity and specificity necessary to detect very low concentrations of submicrometer polyethylene particles and probably underestimated the prevalence of polyethylene wear debris in the liver and spleen.Conclusions: In this study systemic distribution of metallic and polyethylene wear particles was a common finding, both in patients with a previously failed implant and in those with a primary total joint prosthesis. The prevalence of particles in the liver or spleen was greater after reconstructions with mechanical failure. In the majority of patients, the concentration of wear particles in these organs was relatively low and without apparent pathological importance. However, in one rare case, granulomas formed in the liver, spleen, and abdominal lymph nodes in response to heavy accumulation of wear debris from a hip prosthesis with mechanical failure and compromised hepatic function.Clinical Relevance: These findings underscore the necessity of minimizing the production of particulate debris by joint replacement devices and the need for the surgeon to consider expeditious revision in patients in whom large amounts of particulate debris may be generated. Serum and urine trace-metal analyses may provide early confirmation of failure and aid in the timing of a revision operation in a patient with a symptomatic or failed device.