The limitations of our study include the following. First, the retrospective nature of this study resulted in a lack of all specimens derived from primary surgeries although we had all specimens from the revision surgeries. Second, the power of the study was relatively weak because of the small sample. Third, there was inconsistency in the history of previous contact with CoCr and lack of skin patch testing before primary implantation. However, most characteristic histologic and immunohistochemical findings indicative of DTH were present in the hips with MOM bearings almost exclusively. Fourth, in our patients with MOM bearings, we had no definitive information regarding previous contacts with Cr and Co ions (dental bridges, osteosynthesis material containing Co and Cr, etc), and we did not investigate any genetic predisposition for sensitivity to Co and Cr. However, we presumed the first sensitization of T lymphocytes was derived from continuous contact with released metal debris from the CoCr bearings after prosthesis implantation .
The histologic findings in the tissues retrieved from hips with MOM bearings differentiate them from the hips with COP bearings: extensive necrosis solely in nearly all hips with MOM bearings, fibrin exudation in the newly formed hip capsule, and a higher degree of diffuse and perivascular lymphocytic infiltration. These findings are consistent with the hypothesis that one of the causes of periprosthetic osteolysis and loss of biologic fixation of a THA with implantation of a prosthesis with MOM bearings could be a hypersensitivity reaction [22, 23, 38]. Extensive fibrin exudation was reported in a similar study . Necrosis [2, 18, 22, 37, 39] in the newly formed hip capsule was observed in studies of Metasul® bearings [36-39], whereas it was not a permanent feature in a study of Sikomet™ bearings . The increased lymphocytic infiltration in hips with MOM bearings compared with COP bearings that we observed is consistent with a report of Sikomet™ bearings .
Our histologic and immunohistochemical findings support the hypothesis that one of the major causes of periprosthetic osteolysis and loss of biologic fixation of THAs using the contemporary Zweymüller-Plus® prosthesis with low-carbide bearings could be a hypersensitivity reaction to CoCr alloy.
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