Cellular response to prosthetic wear debris differs in patients with and without rheumatoid arthritis

Abstract

Objective: To examine whether patients with rheumatoid arthritis (RA) demonstrate patterns of prosthetic wear or cellular responses to implant wear debris different from those demonstrated by patients without inflammatory joint disease.

Methods: Thirty-eight patients who had undergone a primary revision of a total elbow arthroplasty for aseptic loosening between 1996 and 2008 were identified. Twenty-five of these patients had RA, and 13 did not have inflammatory arthritis. Clinical data, gross wear patterns of the removed prostheses, and histopathologic analyses of peri-implant tissue were compared between the patients with RA and those without RA.

Results: Evaluation of the retrieved prostheses showed that conformational change of the humeral polyethylene bushing was associated with the generation of polyethylene and metal particles. The amount and type of wear debris in periprosthetic tissues were similar in patients with and those without RA. Patients with RA who were not receiving anti-tumor necrosis factor (anti-TNF) therapy exhibited a histologic pattern of interstitial and sheet-like lymphocytic infiltrates associated with a high plasma cell composition, which was different from the predominantly perivascular infiltrates with few plasma cells seen in non-RA patients (P = 0.04). Patients with RA who were receiving anti-TNF therapy showed a mixed perivascular and interstitial pattern of infiltrates with variable cell composition.

Conclusion: Patients with RA exhibited a distinct cellular response to implant wear debris compared with patients without RA. This reaction was unrelated to differences in the type or amount of wear debris and was mitigated by anti-TNF therapy. These results suggest an intrinsic alteration in immunoregulation in RA and have implications for potential immunologic treatment of osteolysis in these patients.

Figure 1

A.) Humeral polyethylene bushing showing focal, severe conformational change (thin arrow). Moderate conformational change present on the opposite end of bushing (thick arrow). B.) Moderate metal loss on the proximal portion of the humeral stem (white arrow). C.) Small particulate polyethylene of high prevalence shown in polarized light at 10×. D.) Perivascular lymphocytic inflammation (40×) E.) Interstitial lymphocytic inflammation (40×) with visible plasma cells (thin arrow). Metallic debris being phagocytosed by foreign body giant cells (thick arrow). F.) Sheet-like lymphocytic infiltration with widespread plasma cells (thick arrow) at 40×. Metallic debris present across entire field (white star).

Figure 2

A.) Degree of conformational change, adjusted for cases of focally severe damage, did not vary with underlying diagnosis or use of anti-TNF therapy. Severe conformational change in the humeral polyethylene bushing is associated with higher polyethylene particle prevalence (B), larger polyethylene particle size (C), and a trend towards higher metal particle prevalence (D).

Figure 3

Prevalence of polyethylene particles (A), size of polyethylene particles (B), and prevalence of metal particles (C) did not vary with underlying diagnosis or anti-TNF therapy.

Figure 4

A.) Untreated RA patients show predominantly interstitial and sheet-like lymphocytic aggregates in response to foreign body wear debris. This is significantly different from non-RA patients. Treated RA patients show a mix of perivascular and interstitial aggregates in between non-RA and untreated RA patients. In patients with a high prevalence of polyethylene (B) or large particulate polyethylene (C), non-RA patients show exclusively a low plasma cell prevalence within lymphocytic aggregates. Untreated RA patients show exclusively a high plasma cell prevalence. D.) In patients with a high prevalence of metal particles, untreated RA patients show exclusively high plasma cell prevalence within lymphocytic aggregates. ≥ 50% of treated RA patients and non-RA patients showed a low plasma cell prevalence.