Biomaterial wear debris is a known contributing factor in aseptic loosening of total joint prostheses, particularly when cementless tibial trays are used in total knee arthroplasty (TKA). Local inflammatory response can lead to osteolysis and aseptic loosening of implants. The resulting lesions require careful clinical evaluation. This article presents a case of a 76-year old man with a remote history of prostate cancer and cigarette smoking who presented with acute onset left knee and tibia pain 15 years after TKA. Radiographs showed an osteolytic lesion in the distal tibial diaphysis and magnetic resonance imaging revealed a cystic lesion with evidence concerning for pathologic mid-shaft fracture. Biopsy of the lesion confirmed a foreign body reaction and revision TKA was performed. The patient was seen at 3-year follow-up without complication. The existing literature presents cases reporting osteolytic lesions of the distal femur and proximal tibial metaphysis due to polyethylene wear debris and foreign body reaction following TKA. We are unaware of case reports involving osteolysis of this etiology extending into the distal tibial diaphysis. We conclude that polyethylene wear debris with foreign body reaction should be considered in the differential diagnosis of an osteolytic lesion extending into the tibial diaphysis following TKA.
Total knee arthroplasty (TKA) with stemmed, cemented tibial components has replaced cementless modular ingrowth tibial trays fixed to the proximal tibia with cancellous screws. The use of the latter has been implicated in mechanical failure of the total knee secondary to the production of wear debris. The presence of particulate debris leads to a local inflammatory response that may result in osteolysis and implant loosening.
Biomaterial wear debris with an associated foreign body tissue reaction and osteolysis is a key contributing factor to aseptic loosening of total joint prostheses.1-5 The articular surface between the femoral component and ultra-high-molecular-weight polyethylene insert has been assumed to be the primary source of particulate debris leading to osteolysis and TKA implant failure. Wasielewski et al6 assert that multiple wear processes occur, and that the undersurface of the insert is an additional source of polyethylene debris contributing to tibial metaphyseal osteolysis, especially when there are screw holes directly below the tibial tray.
This article presents a case of a patient with a periprosthetic cyst-like osteolytic lesion of the tibia associated with ultra-high-molecular-weight polyethylene wear debris.
A 76-year-old man with a history of primary osteoarthritis of the left knee underwent total joint arthroplasty in 1992. His procedure and recovery were without complication.
In May 2007, the patient presented with acute onset of left tibia and knee pain. He had minimal pain at rest and night, no constitutional symptoms, and initial laboratory workup for infection was negative. The patient had a history of cigarette smoking and a remote history of prostate cancer treated with resection. Subsequent prostate-specific antigen tests were normal.
On examination, the patient had tenderness to palpation over the anterior left tibial shaft. The skin was intact without discoloration, masses, or effusion. He was stable to varus-valgus stress of the knee. Full range of motion (ROM) was present at the ankle and the patient was neurovascularly intact throughout the extremity. Radiographs showed lucency extending to the distal third of the tibial diaphysis (Figure 1).
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|Figure 1: AP (A) and lateral (B) radiographs of the left tibia showing periprosthetic osteolysis with diaphyseal involvement. |
Magnetic resonance imaging revealed a cystic lesion replacing the proximal two-thirds of the left tibial metaphysis and diaphysis with signal changes concerning for pathologic mid-shaft fracture. There was no extension of the lesion into soft tissues. An incisional biopsy showed no malignancy or infection (Figure 2).
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|Figure 2: Polarized light photograph of 100× hematoxylin eosin-stained tibial biopsy showing a collection of foamy macrophages, admixed foreign body giant cells, and tiny fragments of polarizable foreign material. Figure 3: The tibial polyethylene component showing marked surface effacement. |
With a histologic diagnosis of foreign body reaction, revision TKA was performed and tissue specimens confirmed the initial pathology. The tibial component recovered is shown in Figure 3.
The patient was seen at 3-year follow-up with stable implants, full ROM, and no discomfort.
The failure of femoral and tibial components in uncemented TKA can result from periprosthetic osteolysis associated with polyethylene wear debris and foreign body reaction.1-4 Cases of osteolysis and osteolytic cyst-like lesions have been reported in the distal femur as well as the tibial metaphysis; however, we are unaware of reports of osteolytic bone destruction extending distally into the tibial diaphysis. With the clinical data obtained on presentation of this patient in mind, the differential diagnosis of this painful, osteolytic lesion of the tibia includes: foreign body inflammation and osteolysis secondary to polyethylene-wear debris, osteomyelitis, benign neoplasia, and both primary and metastatic malignancy.
The differential diagnosis of malignant lesions is broad, but a correct diagnosis can often be attained by history, location of the tumor, and the radiographic characteristics of the lesion. Metastasis is the most common malignant lesion found in the elderly, with the breast, prostate, and lung acting as the most common sites of origin, followed by the kidney, thyroid, and gastrointestinal tract. Metastatic disease in this patient was of primary concern, given the patient’s age and history of prostate cancer. On radiographic review, however, the tibial lesion appeared lytic whereas prostatic metastases are typically osteoblastic. Metastases of lung and kidney origin often appear osteolytic.
Chondrosarcoma can occur in all age groups, but is consistently reported most commonly in the fourth decade or older. Arising in the axial skeleton and appendicular metaphases and diaphyses, destruction of cortical bone, periosteal reaction, endosteal scalloping, and soft tissue expansion are common radiographic features.7,8 Our patient lacked these key radiographic findings.
Osteosarcoma has a bimodal pattern of incidence. The first peak occurs in the second decade of life with a smaller peak occurring in late adulthood. Termed secondary osteosarcoma, the latter form is associated with underlying bone pathology such as Paget’s disease, infarct, or prior irradiation. Radiographic appearance may show areas of osteolysis in addition to blastic, mineralizing osteoid. Periosteal reaction and soft-tissue expansion also characterize this lesion.9
Multiple myeloma is the most common primary malignant bone tumor, typically presenting as bone pain and pathologic fracture in adults aged 50 to 80 years.10 As a monoclonal proliferation of plasma cells, lysis occurs as tumor cells infiltrate the marrow cavity and stimulate osteoclastic bone resorption. Adult round cell tumors such as myeloma and lymphoma are ruled out with biopsy.
Several other lesions including Ewing’s sarcoma, giant cell tumor, fibrous dysplasia, nonossifying fibroma, and other fibrotic tumors were considered in the differential diagnosis but were felt to be unlikely in this patient due to both his advanced age and radiographic appearance of the lesion.
Osteomyelitis is the great masquerader and can mimic foreign body reaction and neoplasia in the differential diagnosis of osseous pathology.11-13 Osteomyelitis can be classified as acute hematogenous, subacute hematogenous, and chronic. In adults osteomyelitis is a subacute or chronic problem resulting from an open injury to bone and soft tissue, either from traumatic or iatrogenic causes.14,15 In subacute osteomyelitis, onset is often insidious, and the presenting symptom on presentation is pain, with or without swelling and tenderness overlying the affected bone. Laboratory values may show a normal white blood cell count with normal differential, as well as a normal erythrocyte sedimentation rate.12,14,16 Radiographic changes associated with osteomyelitis may not become apparent for 2 weeks after the onset of infection, and changes may include periosteal reaction, osteolysis, and sequestra formation.15
Harris17 coined the term cement disease to describe the association of foreign body giant cell reaction with cemented joints. However, aseptic loosening of total joints with inflammatory changes has also been reported in uncemented prostheses.3 Both particulate polymethylmethacrylyate and particulate ultra-high molecular weight polyethylene generated from polyethylene wear have been shown to be associated with florid foreign-body reactions in animal models and humans. 3,4,18,19
In a mouse model, particulate wear debris has been shown to attract and activate macrophages, and, depending on the size of the particles, various levels of inflammation and osteolysis may occur corresponding with increased levels of nitric oxide, interleukin-1, interleukin-6, and TNF alpha production.20 On histologic examination, granulomatous reaction with giant cells and histiocytes scattered among the biomaterial debris characterize this response.3,4,19 In addition, particulate ultra-high-molecular-weight polyethylene is visualized in the specimen as positively birefringent fragments. Intraosseous foreign body reaction can be represented radiographically by extensive osteolytic cyst-like areas within the bone, and have been reported previously to occur adjacent to both femoral and tibial components.3,4
Biomaterial wear debris and an associated foreign body tissue reaction accompanied by osteolysis is a key contributing factor to aseptic loosening of total knee prostheses.1-5 The articular surface between the femoral component and ultra-high-molecular-weight-polyethylene insert has been assumed to be the primary source of particulate debris leading to osteolysis and TKA implant failure. Wasielewski et al6 asserted that multiple wear processes occur simultaneously, and that the undersurface of the insert is an additional source of polyethylene debris contributing to tibial metaphyseal osteolysis, especially when there are screw holes directly below the tibial tray. It is likely that the screw–bone interface was the pathway of polyethylene particle migration into the metaphysis and distally into the diaphysis of our patient. The resultant effect was osteolysis, cyst formation, pathologic fracture, and pain.
This article presents a case of a 76-year-old man who experienced failure of a cementless TKA secondary to osteolysis, with cystic changes extending distally into the tibial diaphysis. We believe that polyethylene-wear debris, the subsequent foreign body giant cell reaction, and the fracture that followed are responsible for our patient’s reports of pain and osteolytic changes seen radiographically. Implantable biomaterials will likely continue to improve, reducing the incidence of polyethylene wear, osteolysis, and aseptic loosening of implants. Long-term outcomes studies are needed to assess the in-vivo characteristics of new generation polyethylene components in relation to the longevity of contemporary total joint replacements.
- Engh GA, Dwyer KA, Hanes CK. Polyethylene wear of metal-backed tibial components in total and unicompartmental knee prostheses. J Bone Joint Surg Br. 1992; 74(1):9-17.
- Engh GA, Parks NL, Ammeen DJ. Tibial osteolysis in cementless total knee arthroplasty. A review of 25 cases treated with and without tibial component revision. Clin Orthop Relat Res. 1994; (309):33-43.
- Kane KR, DeHeer DH, Beebe JD, Bereza, R. An Osteolytic Lesion Associated with Polyethylene Wear Debris Adjacent to a Stable Total Knee Prosthesis. Orthop Rev. 1994; 23(4):332-337.
- Stewart MJ, Richardson TR. Giant-cell tumor of bone. J Bone Joint Surg Am. 1952; 34(2):372-386.
- Sanchis-Alfonso V, Alcacer-García J. Extensive osteolytic cystlike area associated with polyethylene wear debris adjacent to an aseptic, stable, uncemented unicompartmental knee prosthesis: a case report. Knee Surg Sports Traumatol Arthrosc. 2001; 9:173-177.
- Wasielewski RC, Parks N, Williams I, Surprenant H, Collier JP, Engh G. Tibial insert undersurface as a contributing source of polyethylene wear debris. Clin Orthop Relat Res. 1997; (345):53-59.
- Dahlin DC, Henderson ED. Chondrosarcoma, a surgical and pathological problem; review of 212 cases. J Bone Joint Surg Am. 1956; 38(5):1025-1125.
- Rogers LF. Bone tumors and related conditions. In: Juhl JH, Crummy AB, Paul L, eds. Paul and Juhl’s Essentials of Radiologic Imaging. 5th ed. Philadelphia, PA: Lippincott-Raven; 1987:85-384.
- Murphey MD, Robbin MR, McRae GA, Flemming DJ, Temple HT, Kransdorf MJ. The many faces of osteosarcoma. Radiographics. 1997; 17(5):1205-1231.
- Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc. 2003; 78(1):21-33.
- Cottias P, Tomeno B, Anract PH, Vinh TS, Forest M. Subacute osteomyelitis presenting as a bone tumor: a review of 21 cases. Int Orthop. 1997; 21(4):243-244.
- Juhn A, Healey JH, Ghelman B, Lane JM. Subacute osteomyelitis presenting as bone tumors. Orthopedics. 1989; 12(2):245-248.
- Lindenbaum S, Alexander H. Infections simulating bone tumors: a review of subacute osteomyelitis. Clin Orthop Relat Res. 1984; (184):193-203.
- Hayes CS, Heinrich SD, Craver R, MacEwen GD. Subacute osteomyelitis. Orthopedics. 1990; 13(3):363-366.
- Lobo J, McKee M. Musculoskeletal images. Chronic osteomyelitis. Can J Surg. 2003; 46(1): 47-49.
- Rasool MN. Primary subacute hematogenous osteomyelitis in children. J Bone Joint Surg Br. 2001; 83(1):93-98.
- Harris WH. Total hip replacement in the middle-aged patient. Contemporary cementing for fixation of the femoral component. Orthop Clin North Am. 1993; 24(4):611-616.
- Goodman SB, Fornasier VL, Kei J. The effects of bulk versus particulate ultra-high-molecular weight polyethylene on bone. J Arthroplasty. 1988; (3 Suppl):S41-46.
- Goodman SB, Fornasier VL, Kei J. Quantitative comparison of the histological effects of the particulate polymethylmethacrylate versus polyethylene in the rabbit tibia. Arch Orthop Trauma Surg. 1991; 110(3):123-126.
- Frick C, Dietz AC, Merritt K, Umbreit TH, Tomazic-Jezic VJ. Effects of Prosthetic Materials on the Host Immune Response: Evaluation of Polymethyl-methacrylate (PMMA), Polyethylene (PE), and Polystyrene (PS) Particles. J Long Term Eff Med Implants. 2006; 16(6):423-433.
Drs Vernon, Garvin, and McGarry and Mr Bollinger are from the Department of Orthopedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska.
Drs Vernon, Garvin, and McGarry and Mr Bollinger have no relevant financial relationships to disclose.
Correspondence should be addressed to: Brian A. Vernon, MD, Department of Orthopedic Surgery and Rehabilitation, University of Nebraska Medical Center, 42nd and Emile, Omaha, NE 68198-1080 (firstname.lastname@example.org).