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Presented by Edward McCarthy, M.D. and prepared by Natasha Rekhtman, M.D., Ph.D.
Case 2: A 70 year old man had a total knee replacement a year prior to the onset of pain in his knee.
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1. Question
Week 204: Case 2
A 70 year old man had a total knee replacement a year prior to the onset of pain in his knee. A radiograph demonstrated a lucent area in the femur adjacent to the total knee prosthesis.images/EMC 11 19 04 case 2 Image1.jpg
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images/P3101628.jpgCorrect
Answer: Particle disease
Histology: Particle disease is the destruction of bone in the area of a prosthesis due to osteoclastic activity stimulated by the shedding of particles from total joint prosthesis. Particles are shed as part of a wear and tear process. They are usually from the polyethylene component. Polyethylene particles are shed and then phagocytosed by histiocytes and multinucleated giant cells. In turn, histiocytes stimulate the recruitment of osteoclasts which resorb bone. This bone resorption, which usually leads to loosening of the prosthesis, is known as particle disease. Most often, the total joint prosthesis must be replaced due to this extensive bone resorption. The histologic features of this lesion usually are diagnostic. Sheets of histiocytes are present. In addition, multinucleated giant cells containing refracture particles of polyethylene are visible. Polyethylene is easily demonstrated by using polarized light.
Discussion: The lesion is not osteomyelitis. Although total joint prostheses can be infected and become loose, an infected prosthesis and osteomyelitis are always accompanied by the infiltration of polymorphonuclear leukocytes. The absence of polys preclude the diagnosis of infection.
The lesion is not metastatic carcinoma. Although a patient in this age group should always be suspected of having a metastatic carcinoma when a lytic lesion is present, there is no evidence of a neoplasm in this material.
Incorrect
Answer: Particle disease
Histology: Particle disease is the destruction of bone in the area of a prosthesis due to osteoclastic activity stimulated by the shedding of particles from total joint prosthesis. Particles are shed as part of a wear and tear process. They are usually from the polyethylene component. Polyethylene particles are shed and then phagocytosed by histiocytes and multinucleated giant cells. In turn, histiocytes stimulate the recruitment of osteoclasts which resorb bone. This bone resorption, which usually leads to loosening of the prosthesis, is known as particle disease. Most often, the total joint prosthesis must be replaced due to this extensive bone resorption. The histologic features of this lesion usually are diagnostic. Sheets of histiocytes are present. In addition, multinucleated giant cells containing refracture particles of polyethylene are visible. Polyethylene is easily demonstrated by using polarized light.
Discussion: The lesion is not osteomyelitis. Although total joint prostheses can be infected and become loose, an infected prosthesis and osteomyelitis are always accompanied by the infiltration of polymorphonuclear leukocytes. The absence of polys preclude the diagnosis of infection.
The lesion is not metastatic carcinoma. Although a patient in this age group should always be suspected of having a metastatic carcinoma when a lytic lesion is present, there is no evidence of a neoplasm in this material.
