Correspondence

Systemic Granulomatous Reaction to a Foreign Body after Hip Replacement

N Engl J Med 1996; 335:133-134July 11, 1996

Article

To the Editor:

A 61-year-old man was hospitalized because of an unexplained weight loss of 8 kg and fatigue. Eight years earlier, he had undergone a total hip arthroplasty on the left side (with a prosthetic femoral component of titanium and an acetabular shell of polyethylene) because of arthrosis.

The physical examination showed hepatomegaly and splenomegaly. A liver-biopsy specimen showed granulomatous hepatitis associated with rare intracytoplasmic dark particles initially misinterpreted as a formalin-pigment artifact. The results of clinical and laboratory studies ruled out infectious hepatitis, sarcoidosis, prior hepatic or biliary disease, vasculitis, inflammatory colitis, drug-induced hepatitis, and toxic effects of occupational or environmental exposure.

Because the patient's condition worsened and his abdominal lymph nodes were enlarged, a splenectomy was performed, with hepatic and lymph-node biopsies. All the specimens showed the same histologic pattern: the presence of macrophagic granulomatous reactions, with multinucleated giant cells engulfing exogenous particles (Figure 1Figure 1Noncaseating Granulomas in a Liver-Biopsy Specimen, Composed of Epithelioid Histiocytes, Lymphocytes, and Multinucleated Giant Cells (Hematoxylin–Erythrosin–Saffron, ×200).). Some of the particles were up to 7 μm in the greatest dimension, were refractile under polarization, and corresponded to polyethylene (Figure 2Figure 2Multinucleated Giant Cell in a Granuloma, Viewed under Polarized Light, Containing Polyethylene Particles (Large, Clear, and Refractile; Arrowhead) and Titanium Particles (Small and Dark, Arrows) (Hematoxylin–Erythrosin–Saffron, ×1000).). The others, which were dark and smaller (1 μm in the greatest dimension), were probably metallic (Figure 2). To identify the smaller particles, we placed various particulate metals on paraffin-embedded tissue, using inductively coupled plasma mass spectrometry. The titanium concentration was 100 times higher in the specimen from the patient than in the control specimen under the same conditions (33.7 μg per gram vs. 0.33 μg per gram).

The foreign-body granulomatous reaction was caused by the presence of these particles, which were produced through wear, as the hip prosthesis loosened. Eight months after the removal of the prosthesis, which was followed by treatment with prednisone (20 mg a day, with progressive diminution in the dose during a period of one month), the patient was better and had no signs of cholestasis, inflammation, or hepatomegaly.

Local foreign-body reactions due to frictional wear are most often asymptomatic and associated with arthroplastic materials. Distant granulomatous reactions are generally localized in regional lymph nodes and discovered by accident.1 This unusual systemic granulomatous reaction to particles produced by wear raises the question of the long-term biocompatibility of prosthetic materials.2 Physicians should be aware of the possibility of such reactions.

Michel Péoc'h, M.D.
Christophe Moulin, M.D.
Basile Pasquier, M.D.
Centre Hospitalier Universitaire, 38043 Grenoble, France

2 References

1. 1

   Albores-Saavedra J, Vuitch F, Delgado R, Wiley E, Hagler H. Sinus histiocytosis of pelvic lymph nodes after hip replacement: a histiocytic proliferation induced by cobalt-chromium and titanium. Am J Surg Pathol 1994;18:83-90
   CrossRef | Web of Science | Medline

2. 2

   Tang L, Eaton JW. Inflammatory responses to biomaterials. Am J Clin Pathol 1995;103:466-471
   Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Volker Braunstein, Christoph M Sprecher, Markus A Wimmer, Stefan Milz, Georg Taeger. (2009) Influence of head size on the development of metallic wear and on the characteristics of carbon layers in metal-on-metal hip joints. Acta Orthopaedica 80:3, 283-290
   CrossRef

2. 2

   C. B. B. Lim, R. D. Goldin, A. Darzi, G. B. Hanna. (2008) Characterization of materials eliciting foreign body reaction in stapled human gastrointestinal anastomoses. British Journal of Surgery 95:8, 1044-1050
   CrossRef

3. 3

   R. Brenard, P. Dumortier, M. Del Natale, B. Honhon, M. Van Den Berghe, C. Bataille, F. Rickaert, J. Henrion, M. O. Peny, J. Rahier. (2007) Black pigments in the liver related to gold and titanium deposits. a report of four cases. Liver International 27:3, 408-413
   CrossRef

4. 4

   R URBAN, M TOMLINSON, D HALL, J JACOBS. (2004) Accumulation in liver and spleen of metal particles generated at nonbearing surfaces in hip arthroplasty. The Journal of Arthroplasty 19:8, 94-101
   CrossRef

5. 5

   Michel Péoc'h, Véronique Ducros, Raphaelle Barnoud, Dominique Pasquier, Marie Hélène Laverriere, Basile Pasquier. (1998) Foreign body histiocytosis reaction after hip replacement with concomitant metastatic adenocarcinoma in the same lymph node. Human Pathology 29:1, 95-98
   CrossRef

6. 6

   (1996) More on Reaction to a Foreign Body after Hip Replacement. New England Journal of Medicine 335:22, 1690-1691
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