Histopathology

Mild foreign-body reactions were described among classic first generation McKee-Farrar, Huggler and Muller type MoM hips. In modern MoM hips, the term ALVAL was established to describe typical lymphocyte dominated histological reaction.

(Willert et al. 2005). Several other authors have further described histological changes

(Davies et al. 2005, Pandit et al. 2008, Campbell et al. 2010, Natu et al. 2012).

Although perivascular lymphocytic infiltration is typically seen in MoM hips, it is not a pathognomonic phenomenon, as infiltrates are also seen in non-MoM hips and knee replacements (Ng et al. 2011, Fujishiro et al. 2011).

Initially, ARMD was described to be hypersensitivity reactions (Willert et al.

2005), but further studies have suggested that lymphocytic hypersensitivity reaction is not the only mechanism for ARMD. T-cell-mediated type IV delayed hypersensitivity reaction (adaptive immunity, lymphocyte-dominated) and foreign body reaction (non-specific immunity, macrophage- and giant cell-dominated granulomatous reaction) have been suggested as the two main types of histological reactions seen to be associated with ARMD (Grammatopoulos et al. 2013, Bauer et al. 2014), with some of the tissues retrieved from MoM hips expressing both characteristics and sometimes referred to as “mixed type” (Berstock et al. 2014).

Several classifications for histologic findings have been presented (Davies et al. 2005, Campbell et al. 2010, Natu et al. 2012, Grammatopoulos et al. 2013). The most used scoring system, the ALVAL score (Campbell et al. 2010), is used to describe three histological findings seen in MoM hips: degree of abnormality in synovial lining (scored 0-3), number of lymphocytes and macrophages (0-4), and degree of tissue organization (0-3). The maximum total score is 10, indicating severe ALVAL, whereas a total score of 0 to 4 represents a mild reaction. Figure 2. describes two histolopathological images, one with high ALVAL score and one with low ALVAL score. Other features commonly described are tissue necrosis (Davies et al. 2005), thickness of lymphocytic cuff, type of lymphocytic infiltrate, histiocytes and the metal particle load (Natu et al. 2012).

In a hypersensitivity-type reaction, typical findings are diffuse perivascular T- and B- lymphocytic infiltration, plasma cells, disruption of periprosthetic tissue, necrosis, high endothelial venules, fibrin accumulation, few macrophages and sometimes eosinophiles (Willert et al. 2005, Bauer et al. 2014). Metal ions accumulating in the hip joint form complexes with proteins and activate Cd4+ and Cd8+ T-lymphocytes (Hallab and Jacobs 2009), leading to macrophage recruitment (Grammatopoulos et al. 2013). Lymphoid aggregates are sometimes present (Mittal et al. 2013). Diffuse chronic inflammation is typically T-lymphocyte-dominated, whereas lymphoid aggregates usually include both B- and T-cells (Mahendra et al. 2009, Natu et al.

2012, Mittal et al. 2013). Large numbers of macrophages are seldom seen along with large lymphocytic aggregations (Campbell et al. 2010).

Figure 2. A) The upper image shows a synovial tissue sample with a high aseptic lymphocytic vasculitis-associated lesion (ALVAL) score. The inflammatory cells seen are

predominantly lymphocytes, many of them in perivascular aggregates (thin arrows). Thick acellular areas can be seen (thick arrows). This sample received an ALVAL score of 9 (2 for synovial lining, 4 for inflammatory infiltrate and 3 for tissue organization).

B) The lower image shows a synovial tissue sample with a low ALVAL score. Disrupted synovial lining can be seen (thin arrows). Inflammatory cells are predominantly

macrophages (arrow heads). Marked loss of normal arrangement can be seen, with thick acellular areas (thick arrows). This sample received an ALVAL score of 5 (2 for synovial lining, 1 for inflammatory infiltrate and 2 for tissue organization). Hematoxylin and eosin staining, magnification of 200x.

A

B

After the acknowledgement of ARMD with MoM hips, it was suggested that hypersensitivity reactions are a response to Co, Cr or nickel ions (Pandit et al. 2008).

In older studies, sensitization towards Co and Cr has been reported in CoCr THAs (Granchi et al. 2000, Hallab et al. 2005). However, in a more recent study, enhanced lymphocytic response towards nickel was more common in patients with MoM hip resurfacing compared with controls, whereas lymphocytic reaction towards Co or Cr was not seen. The authors observed no difference in sensitization between patients with or without pseudotumors, which they suggested supports the idea that hypersensitivity is not the dominant (or at least not the only) mechanism for the formation of a pseudotumor. (Kwon et al. 2010).

Macrophage-dominated granulomatous reactions are characterized by macrophages with visible phagocytosed particles, foreign-body giant cell, fibroblasts, small blood vessels and typically only a small number of lymphocytes (Goodman 2007, Lohmann et al. 2013). Macrophages phagocytose metal debris and activate T-lymphocytes through antigen presentation (Hallab and Jacobs 2009). Both soluble (metal ions) and particulate metal debris may activate macrophage reaction (Hallab and Jacobs 2009). Phagocytized wear particles are transported to lysosomes where the acidic environment corrodes metal, leading to high local metal ion concentrations (Grammatopoulos et al. 2013). Co and Cr have been described to induce apoptosis (low concentrations) and necrosis (high concentrations) in macrophages (Huk et al.

2004). The Co and Cr concentrations in blood and synovial fluid, however, are considered insufficient to cause direct tissue damage. Instead, the damage may be caused by Co and Cr accumulating in phagosomes, where they reach toxic concentrations and result in the death of macrophages and the release of lysosomal enzymes. Lysosomal enzymes and the “metal ion wave” released after cell death cause damage to the surrounding tissues. (Xia et al. 2011, Grammatopoulos et al.

2013).

The lymphocyte-dominated reaction may progress and cause symptoms more rapidly than a macrophage-dominated reaction. The most extensive tissue damage has been reported in patients with a lymphocyte-dominated hypersensitivity type reaction and in the absence of high wear (Campbell et al. 2010). Additionally, a significantly shorter time from primary surgery to revision has been reported for hips with lymphocyte-dominated reaction compared with macrophage-dominated reaction. (Berstock et al. 2014). High implant wear appears to be a necessity for the development of a macrophage-dominated reaction, as most studies only report macrophage-dominated reactions in high wearing MoM hips (Campbell et al. 2010, Grammatopoulos et al. 2013, Berstock et al. 2014). For lymphocyte-dominated

reactions, only moderate (Grammatopoulos et al. 2013) to non-existent (Ebramzadeh et al. 2015) correlations between wear and ALVAL score have been reported, and typical ALVAL reactions have been reported both in low and high wearing hips (Campbell et al. 2010, Grammatopoulos et al. 2013, Berstock et al.

2014). Therefore, it seems that high implant wear may be associated with either macrophage- or lymphocyte-dominated reaction, whereas low implant wear would typically be associated only with lymphocyte-dominated reaction. However, contradicting results compared to previous studies have been presented, as the total metal content of periprosthetic tissue, but not the serum level, has been described to be significantly higher in tissues with lymphocytic reaction compared with macrophage-dominated reaction. In that study, serum metal ion levels were elevated in all 28 patients, but only one of the six macrophage-dominated tissue samples had high metal content and the contents in the other five were among the lowest in that study. (Lohmann et al. 2013). Further, it has been presented that lymphocyte-dominated reaction is associated with a smaller median size of wear debris particle and a larger total number of particles (Singh et al. 2015).