Joseph M. Mirra

The pathology of the joint tissues and its clinical relevance in prosthesis failure.

Thirty-four hip and knee total arthroplasty failures due to infection, loosening, intractable pain and dislocation were examined for synovial and capsular tissue debris. Simiquantitative assessments were made for metal polyethylene, acrylic and cellular debris and inflammation. The most important finding was that in the amounts normally shed into joints, debris particles do not appear to stimulate a polymorphonuclear response. The magnitude of this response correlates best with clinical and/or bacteriological evidence of infection. The quantity of acrylic particles could be correlated with clinical evidence of loosening. Since the correlation between infection and polymorphonuclear leukocytes, debris particles, and the reasons for failure is high, frozen section may aid the surgeon in determining the methods and timing of revision operations.

Tissue reaction to metal on metal total hip prostheses.

The periprosthetic tissue reaction to polyethylene wear debris in metal on polyethylene total hip replacements is strongly implicated as the cause of osteolysis. This has led to a renewed interest in metal on metal total hip replacements. However, little is known about the role of wear debris in failures of these prostheses. Capsular and interface tissues from 9 long and short term metal on metal total hip replacement retrievals were studied to assess the tissue reaction around these prostheses. As compared with metal on polyethylene cases, the extent of the granulomatous inflammatory reaction and the presence of foreign body type giant cells was much less intense in metal on metal cases, likely because of the lower numbers and overall smaller size of metal wear debris particles. This may lead to a better transport of the particles from the joint tissues and a lower incidence of periprosthetic osteolysis around metal on metal hip replacement.

The pathology of failed total joint arthroplasty.

In 94 cases of failed total hip and knee joint arthroplasties, acute and chronic inflammation, acrylic, metal, and polyethylene debris, and histiocytic reaction were assessed in a 0, 1+, 2+, 3+ semiquantitative manner. Chronic inflammation of 2+ to 3+ was not particularly useful in separating a reaction to wear debris from infection. At the time of frozen section, 2+ to 3+ acute inflammation (greater than 5 PMNs per high power field) was used with excellent follow-up bacteriologic correlation to delay replacement of the failed prosthesis until the infection was controlled. Acrylic (2+ to 3+) and excessive polyethylene wear debris correlated well with loosening. Dusky grey cells were the hallmark of metal-filled histiocytes. Mononuclear and multinuclear histiocytes (2+ to 3+) were correlated with excessive acrylic and/or polyethylene debris. The histologic features of metal particles, acrylic voids, polyethylene and teflon fibers and silastic globules illustrate the pathologic identification of these materials.

Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology. II. Juxtacortical cartilage tumors

Abstract In part I, we reviewed the varied clinical presentations, pathogenesis, histologic findings, radiologic findings, and treatment of intramedullary cartilaginous lesions of bone. In this section, we will evaluate our cases and consultations of juxtacortical cartilaginous tumors. Radiographic differential diagnosis includes the numerous juxtacortical lesions particularly osteochondroma, parosteal chondroma, Trevor’s disease, trauma (fracture and periostitis ossificans), and the low- and high-grade surface osteosarcomas. By emphasizing pathogenesis in conjunction with radiographic and histologic findings, pitfalls in diagnosis and subsequent treatment can be avoided in such cases.

Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology

Abstract We reviewed 845 cases of benign and 356 cases of malignant cartilaginous tumors from a total of 3067 primary bone tumors in our database. Benign cartilaginous lesions are unique because the epiphyseal plate has been implicated in the etiology of osteochondroma, enchondroma (single or multiple), periosteal chondromas and chondroblastoma. In the first part of this paper, we will review important clinical, radiologic and histologic features of intramedullary cartilaginous lesions in an attempt to support theories related to anatomic considerations and pathogenesis.

Malignant Fibrous Histiocytoma and Osteosarcoma in Association with Bone Infarcts

Four patients, two of them former caisson workers, had malignant tumors of bone associated with bone infarcts in the femur. One of the tumors was osteogenic sarcoma and the other three were malignant fibrous histiocytomas. Despite amputation and other treatment, only one patient survived.

Paget's disease of bone: review with emphasis on radiologic features, part I

Distinctive clinical, radiologic and pathologic features are seen in Pagets disease of bone. These distinct features can be divided into three phases; initial phase, midphase and late phase. The clinical features may vary from patients being asymptomatic (involving a single bone) to patients having severe, multiple bone involvement with systemic disease. Radiologically, there are unique features which can differentiate Pagets disease from other bone diseases. The radiologic features follows the histologic findings on light microscopy. The correlation of the different phases with the clinical, radiologic and pathologic features of Pagets disease allows for early accurate diagnosis and treatment.

Limb salvage from a multidisciplinary treatment approach for skeletal and soft tissue sarcomas of the extremity.

Multimodality management of extremity skeletal and soft tissue sarcomas with preoperative intra-arterial Adriamycin and radiation therapy, radical surgical resection and postoperative chemotherapy or chemo-immunotherapy has resulted in preservation of a functional extremity in 13 of 14 patients. Seven of 8 patients with Stage IIIA and IIIB soft tissue sarcomas, managed with preoperative intra-arterial Adriamycin and radiation therapy, followed by en bloc soft tissue resection and 6 patients with bone sarcomas managed by preoperative treatment, followed by bone resectionand replacement with cadaver bone allografts, remained free of disease from 4 to 34 months. The results of the combined modality approach were significantly better than the results obtained in patients managed by surgical resection alone, or by combination of operation with another single modality, both in terms of short term-recurrence free survival and salvage of a functional extremity.

The Role of Access of Joint Fluid to Bone in Periarticular Osteolysis: A Report of Four Cases*

In 1976, Harris et al. reported on four patients who had extensive, localized osteolysis after a total hip replacement14. This erosive or cavitary form of bone resorption has become a major problem that threatens the survival of otherwise successful total hip and knee replacements. Osteolysis has been associated with prosthetic arthroplasties since their introduction. Various etiologies of osteolysis have included infection5 and a foreign-body inflammatory reaction to particulate bone cement25, metal particles32,42, or polyethylene particles37. While there is substantial evidence that small particles and activated macrophages play an important role in osteolysis, the pathophysiology of this condition has been incompletely defined. The mechanism needs to account for osteolysis that occurs in the absence of a discernible periprosthetic particulate burden32, that develops around femoral endoprostheses inserted without cement27, and that occurs around metal-on-metal total hip replacements38,43. The lesions described in the present report are examples of a defined pathological entity know as osteoarthrotic cysts, or geodes3,35. This periarticular, cavitary form of bone resorption occurs in the absence of prosthetic implants. The findings presented here, combined with a review of the related pathology and pathophysiology, demonstrate that the most fundamental factor in the development of osteolysis in association with osteoarthrosis and total joint arthroplasty appears to be the access of joint fluid to bone. CASE 1. In 1990, radiographs of a seventy-four-year-old man demonstrated multiple cysts in the right femoral head (Fig. 1-A). Radiographs made in 1994 demonstrated dramatic enlargement of these cysts (Fig. 1-B). Pain gradually increased, and the patient had a total hip replacement. Examination of the femoral head revealed extensive full-thickness loss of articular cartilage and focal loss of subchondral bone; a thin fibrous membrane covered …

Histologic features relating to prognosis in synovial sarcoma

Although the American Joint Commission has classified all synovial sarcomas as “high grade” histologic subtypes can be identified. By histologically subclassifying synovial sarcoma tumors according to percent glandularity and mitotic rates, the authors were able to define high‐risk and low‐risk patients. Charts and original pathologic slides were reviewed on 45 synovial sarcoma patients. With a 41‐month median follow‐up, the low‐risk patients showed 100% survival, whereas the high‐risk patients showed 37% survival.