Mild aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL)-type reactions also present in patients with failed knee prostheses

Abstract

AimsMetal particles detached from metal-on-metal hip prostheses (MoM-THA) have been shown to cause inflammation and destruction of tissues. To further explore this, we investigated the histopathology (aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) score) and metal concentrations of the periprosthetic tissues obtained from patients who underwent revision knee arthroplasty. We also aimed to investigate whether accumulated metal debris was associated with ALVAL-type reactions in the synovium.MethodsPeriprosthetic metal concentrations in the synovia and histopathological samples were analyzed from 230 patients from our institution from October 2016 to December 2019. An ordinal regression model was calculated to investigate the effect of the accumulated metals on the histopathological reaction of the synovia.ResultsMedian metal concentrations were as follows: cobalt: 0.69 μg/g (interquartile range (IQR) 0.10 to 6.10); chromium: 1.1 μg/g (IQR 0.27 to 4.10); and titanium: 1.6 μg/g (IQR 0.90 to 4.07). Moderate ALVAL scores were found in 30% (n = 39) of the revised knees. There were ten patients with an ALVAL score of 6 or more who were revised for suspected periprosthetic joint infection (PJI), aseptic loosening, or osteolysis. R2 varied between 0.269 and 0.369 for the ordinal regression models. The most important variables were model type, indication for revision, and cobalt and chromium in the ordinal regression models.ConclusionWe found that metal particles released from the knee prosthesis can accumulate in the periprosthetic tissues. Several patients revised for suspected culture-negative PJI had features of an ALVAL reaction, which is a novel finding. Therefore, ALVAL-type reactions can also be found around knee prostheses, but they are mostly mild and less common than those found around metal-on-metal prostheses.Cite this article: Bone Joint Res 2024;13(4):149–156.

Prosthetic Metals: Release, Metabolism and Toxicity

“…180,181 The reported cases also focused only on the abnormally elevated levels of Co and Cr in the patients' blood. 181 Most patients with ALVAL manifest as persistent periarticular pain, especially persistent groin pain after THA, and further examination also reveals pathologic changes such as joint effusion and osteolysis. 180 Metals are also known to pose considerable risks of both carcinogenicity and mutagenicity.…”

“… 179 ALVAL has been shown to have a positive correlation with elevated Co and Cr concentrations, but no evidence with Ti, Al, V, and Mo has been found. 180 , 181 The reported cases also focused only on the abnormally elevated levels of Co and Cr in the patients’ blood. 181 Most patients with ALVAL manifest as persistent periarticular pain, especially persistent groin pain after THA, and further examination also reveals pathologic changes such as joint effusion and osteolysis.…”