Correspondence

More on Reaction to a Foreign Body after Hip Replacement

N Engl J Med 1996; 335:1690-1691November 28, 1996

Article

To the Editor:

Péoc'h and colleagues (July 11 issue)1 reported a systemic granulomatous reaction to a foreign body after a hip replacement. We recently reported a case of a sarcoid-like reaction to particulate debris from a failed total knee replacement in an ipsilateral inguinal lymph node and in periprosthetic tissue.2 The tissue had a pathological appearance similar to that reported by the authors.

The potential for systemic dissemination of degradation products from joint-replacement components is well known.3 One should be cautious, however, about identifying particulate material within tissues with the use of light-microscopical techniques alone. The composition of metallic and ceramic particles can be readily determined with the use of electron-microprobe analysis, an analytic technique with the capability of identifying the elemental composition of many submicrometer-size particles. In contrast, it is quite difficult to identify particulate polyethylene. We and others have observed birefringent material similar to that reported by Péoc'h et al. in the lymph nodes, spleen, and liver in patients without implants.3,4 Many of these birefringent particles have subsequently been identified (by electron-microprobe analysis) as silicates or other environmental contaminants.4

At our request, Péoc'h et al. provided us with representative tissue sections from their patient. Using electron-microprobe analysis, we determined that the particulate material in the spleen and liver was composed of titanium, aluminum, and vanadium, like the particles observed in the periprosthetic tissues. These particles have a composition similar to that of the titanium alloy in the implant (90 percent titanium, 6 percent aluminum, and 4 percent vanadium). The microprobe also identified large numbers of particles in the submicrometer range, which were not detected with the light microscope. The birefringent material reported by Péoc'h et al. as characteristic of polyethylene was consistent with calcite on electron-microprobe analysis. Calcite has been reported within giant cells and Schaumann's bodies in patients with sarcoidosis5 and can be seen in granulomas of diverse causes. We did not observe particles that could be convincingly identified as polyethylene in the sections from the liver and spleen samples.

Joshua J. Jacobs, M.D.
Robert M. Urban
Rush–Presbyterian–St. Luke's Medical Center, Chicago, IL 60612

5 References

1
Peoc'h M, Moulin C, Pasquier B. Systemic granulomatous reactionto a foreign body after hip replacement. N Engl J Med 1996;335:133-134
Full Text | Web of Science | Medline

2
Jacobs JJ, Urban RM, Wall J, Black J, Reid JD, Veneman L. Unusual foreign-body reaction to a failed total knee replacement: simulation of a sarcoma clinically and a sarcoid histologically: a case report. J Bone Joint Surg Am 1995;77:444-451
Web of Science | Medline

3
Bauer TW. Identification of orthopaedic wear debris. J Bone Joint Surg Am 1996;78:479-483
Web of Science | Medline

4
Urban RM, Jacobs JJ, Tomlinson MJ, et al. Particles of metal-alloys and their corrosion products in the liver, spleen, and para-aortic lymph nodes of patients with total hip replacement prostheses. Trans Orthop Res Soc 1995;20:241-241

5
Reid JD, Andersen ME. Calcium oxalate in sacroid granulomas: with particular reference to the small ovoid body and a note on the finding of dolomite. Am J Clin Pathol 1988;90:545-558
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Jacobs and Urban that caution should be used in determining the composition and origin of particulate debris in tissues. We did not demonstrate the presence of exogenous particles by light microscopy alone, and we found a high level of titanium with inductively coupled plasma mass spectrometry. We provided Jacobs and Urban with tissue specimens, and they confirmed the presence of titanium. It is difficult to determine the exact nature of the largest particles that we stated “corresponded to polyethylene” and that Jacobs and Urban found to be calcite. The actual presence of polyethylene is uncertain. In contrast, calcite could be associated with numerous granulomatous reactions without any specificity.1 With the possibility of systemic dissemination of wear particles from joint-replacement components2 taken into consideration, the systemic granulomatous reaction in our patient is unusual.

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

2 References

1
Val-Bernal JF, Sanchez-Quevedo MC, Corral J, Campos A. Cutaneous sarcoidosis and foreign bodies: an electron probe roentgenographic microanalytic study. Arch Pathol Lab Med 1995;119:471-474
Web of Science | Medline

2
Langkamer VG, Case CP, Heap P, et al. Systemic distribution of wear debris after hip replacement: a cause for concern. J Bone Joint Surg Br 1992;74:831-839
Web of Science | Medline

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