Foreign Body Giant Cell Reaction Research Articles

Severe cutaneous foreign body giant cell reaction after temporomandibular joint reconstruction with Proplast-Teflon

Severe cutaneous foreign body giant cell reaction after temporomandibular joint reconstruction with Proplast-Teflon

Capsular Synovial-like Hyperplasia Around Mammary Implants Similar to Detritic Synovitis

Formation of a fibrous envelope around the implant, a so-called capsule with resultant contracture of the prosthesis, is an occasional complication of augmentation mammoplasty. The capsulectomy specimen contains mature scar tissue with mononuclear cells, histiocytes, and foreign body giant cells. We studied 15 capsulectomy specimens. Seven showed a striking form of papillary villous synovial-like hyperplasia similar to detritic synovitis, a form of proliferative synovitis caused by orthopedic prosthetic devices. There was an accompanying infiltration of the subcapsular surface by mononuclear cells, giant cells, and chronic inflammatory cells. This reaction was independent of the type of prosthetic device. In one case, foreign material consistent with polyurethane was demonstrated by histology and electron microscopy. Among eight cases without capsular synovial-like hyperplasia (CSH), two showed dense fibrous tissue with foamy macrophages, and the rest showed fat necrosis, foreign body giant cell reaction, and occasional evidence of foreign material, including silicone granulomas. We stained four of the CSH, two with silicone granulomas, and one sample with dense fibrous tissue with peanut agglutinin and antibodies against vimentin and S-100 protein. Selected cases were also stained for concanavalin A and cytokeratin. CSH stained for concanavalin A, peanut agglutinin, and vimentin but was negative for cytokeratin. Our cases showed a striking similarity in the staining pattern of CSH, detritic synovitis, and normal synovium. We conclude that CSH of the mammary prosthetic capsule is pathophysiologically similar to proliferative synovitis.

Tension pneumocephalus — A rare complication of radiotherapy in nasopharyngeal carcinoma

A patient with nasopharyngeal carcinoma (NPC) treated by radiotherapy developed tension pneumocephalus due to a naso-cranial fistula. The fistula was due to a pathological fracture at the base of skull affected by bone necrosis. The clinical features, neuro-radiological and post-mortem findings are presented. This is the first case report of pneumocephalus in association with NPC. The brain showed florid subarachnoid and intraventricular air collection under tension, low grade meningitis, foreign body giant cell reaction in the arachnoid membrane and multifocal cerebral infarction. Late radiation necrosis was also found in the left temporal lobe. The cause of the tension pneumocephalus in relation to radiation bone necrosis and the possible role of pneumocephalus in producing the multifocal cerebral infarction are discussed. The more common radiation necrosis of brain is also discussed. The pathogenesis of the pneumocephalus in this patient is distinctly different from the more common causes such as head injury and surgery.

Polymeric stenting in the porcine coronary artery model: Differential outcome of exogenous fibrin sleeves versus polyurethane-coated stents

Objectives. In a porcine coronary model, fibrin film soaked for 3 h in heparin was used as a circumferential coating on a tantalum stent to assess the effect of this naturally occurring biopolymer on arterial healing. The results were compared with those obtained with medical grade polyurethane-coated stainless steel stents.Background. Thrombus plays an important role in healing after arterial injury and may affect the development of neointimal hyperplasia. Manipulation of the initial thrombus may alter the healing response. To study this, we placed a template of fibrin in a porcine coronary artery restenosis model.Methods. Thirty-four fibrin film stents were delivered in 20 swine. Oversizing was avoided, to prevent deep arterial injury, by placement of optimally sized stents. Initial patency of the syented vessel was confirmed by angiography.Results. Three fibrin-stented swine died within 48 h; in each, the stent was occluded with a fibrin/red blood cell mass. In two of these three, a portion of the exogenous fibrin had become detached from the stent and partially occluded the lumen. Of the remaining 31 stents, all were patent at elective sacrifice at 28 days. Eightyfour percent had a diameter stenosis <50%, and the mean (± SD) diameter stenosis was 32.3 ± 13%. There was no evidence of significant foreign-body giant-cell reaction. These results contrasted with the medical grade polyurethane-coated stents placed according to the same protocol without oversizing. Twelve of these stents were placed; six swine died of thrombotic occlusion within the 1st 48 h. At elective sacrifice at 28 days, the remaining polyurethane-coated stents were occluded by marked neointimal hyperplasia.Conclusions. Fibrin film-coated stents seem promising as a template for modifying the local response to arterial injury and for potentially decreasing restenosis rates.

Polyethylene and metal debris generated by non-articulating surfaces of modular acetabular components

We report a prospective study of the liner-metal interfaces of modular uncemented acetabular components as sources of debris. We collected the pseudomembrane from the screw-cup junction and the empty screw holes of the metal backing of 19 acetabula after an average implantation of 22 months. Associated osteolytic lesions were separately collected in two cases. The back surfaces of the liners and the screws were examined for damage, and some liners were scanned by electron microscopy. The tissues were studied histologically and by atomic absorption spectrophotometry to measure titanium content. The pseudomembrane from the screw-cup junction contained polyethylene debris in seven specimens and metal debris in ten. The material from empty screw holes was necrotic tissue or dense fibroconnective tissue with a proliferative histiocytic infiltrate and foreign-body giant-cell reaction. It contained polyethylene debris in 14 cases and metal in five. The two acetabular osteolytic lesions also showed a foreign-body giant-cell reaction to particulate debris. The average titanium levels in pseudomembranes from the screw-cup junction and the empty screw holes were 959 micrograms/g (48 to 11,900) and 74 micrograms/g (0.72 to 331) respectively. The tissue from the two lytic lesions showed average titanium levels of 139 and 147 micrograms/g respectively. The back surfaces of the PE liners showed surface deformation, burnishing, and embedded metal debris. All 30 retrieved screws demonstrated fretting at the base of the head and on the proximal shaft. Non-articular modular junctions create new interfaces for the generation of particulate debris, which may cause granulomatous reaction.

Silicone Shedding from Artificial Urinary Sphincter in Children

Silicone is an inert material used in all genitourinary prosthetic devices. Silicone particle shedding has been documented in adults with penile prostheses and artificial urinary sphincters. We searched prospectively for silicone particles in the peri-prosthetic tissue and regional lymph nodes in 6 children who underwent removal or exchange of an artificial urinary sphincter. The peri-prosthetic fibrous capsule was biopsied and examined by light and polarizing microscopy. Regional lymph nodes were biopsied if clinically enlarged and evaluated in a similar manner. Lymph nodes from 2 children without an artificial urinary sphincter served as controls.An artificial urinary sphincter was in place from 3 to 10 years (mean 4.3 years) and none of the sphincters demonstrated infection or erosion. Silicone particles were found in the peri-sphincteric tissue of 3 patients, which induced foreign body giant cell reaction in 2 and eosinophilic infiltrate in 1. Focal histiocytic proliferation around the cuff was seen in another case without silicone migration. There was fibrosis around the sphincter in all cases. No silicone was found in the regional lymph nodes. Silicone shedding was documented in 50% of our patients. X-ray energy dispersive spectroscopy was not performed, raising the possibility that it was under-detected. Long-term effects of silicone in children with an artificial urinary sphincter are unknown and warrant further study.

Recurrent giant cell reaction to residual Proplast in the temporomandibular joint

Exuberant foreign-body inflammatory reaction to polytetrafluoroethylene implants of the temporomandibular joint, marketed as Proplast-Teflon implants, has been widely recognized. Presently, removal of these implants is generally advised. Extensive damage of the joint and surrounding structures has been reported, including severe bony degeneration, perforation into the middle cranial fossa, and cerebrospinal fluid leak. However, recurrent foreign-body giant cell reaction, presumably as a result of residual Proplast material, has not been reported. We review our experience with Proplast-Teflon implant removal from 112 joints in 71 patients over a 6-year period, including four joints with recurrent giant cell reaction at various times after removal. Emphasis is placed on the phenomenon of recurrence and on microsurgical techniques to facilitate implant removal.

Biocompatibility of tetracalcium phosphate cement when used as a bone substitute

We evaluated the biocompatibility of tetracalcium phosphate (4CP) cement, made of 4CP powder and 40 wt% copolymer of polyacrylic acid/itaconic acid and 10 wt% citric acid solution. Light and electron microscopic characteristics were studied 3, 10 and 30 d after implantation. Neither inflammation nor foreign-body giant cell reaction was observed in the tissue adjacent to the implanted material. After 30 d, this material was surrounded with newly formed bone. Ultrastructural examination showed that osteogenesis occurred directly on the surface of the material. These findings suggest that this 4CP cement is biocompatible and possesses osteoconductive properties.

Pilomatrix carcinoma.

Pilomatrix carcinoma, a malignant variant of pilomatrixoma, is extremely rare. The authors report 20 patients with pilomatrix carcinoma and review the pertinent literature. Tumors showing histologic features of pilomatrix carcinoma were selected from the files of the Armed Forces Institute of Pathology. Clinical data of the 20 selected patients were reviewed, and follow-up information was obtained. Sections stained with hematoxylin and eosin were studied in all patients. Special stains were used in selected patients. Pilomatrix carcinomas were asymptomatic dermal and subcutaneous masses with a predilection for the posterior neck and back. Tumors varied in size, from 1-10 cm (mean, 4.6 cm), and occurred more often in middle-age men, with a male:female ratio of 4:1 (mean age, 45 years). Histologically, pilomatrix carcinomas are characterized by sheets and islands of proliferating atypical basaloid cells with an infiltrating border. Transition to squamous cells, clear cells, areas of necrosis and mitoses often are seen. Keratinization with formation of keratin cysts, shadow cells, and trichohyalin and keratohyalin granules are found in all tumors, in conjunction with calcification and foreign body giant cell reaction, just as are seen in benign pilomatrixoma. Follow-up of 17 patients revealed local recurrence in 10 (59%), with multiple recurrences in 3. One patient had pulmonary metastasis, and one died of extensive local spread of the tumor. Pilomatrix carcinomas are locally aggressive tumors that have a tendency to recur, especially when they are incompletely excised. Greater anaplasia and deep soft tissue infiltration were associated with a higher incidence of recurrence and death. Wide excision is the preferred treatment. The role of radiation therapy is unclear.

Foreign body giant cell reactions and ossification associated with benign melanocytic naevi.

To assess the incidence of foreign body giant cell reactions and ossification in benign/melanocytic naevi; and to examine their pathological features to gain an insight into their pathogenesis. Intradermal (n = 185) and compound naevi (n = 110) from a routine histology service, together with 60 naevi submitted to an ophthalmic pathologist, were examined for foreign body reactions and ossification. Additional cases were identified prospectively in the course of routine reporting. The clinical and pathological features of positive cases were assessed. Foreign body reactions were identified in nine (4.9%) intradermal and four (3.6%) compound naevi, but in none of the naevi from around the eye. One intradermal naevus showed ossification. A further 11 naevi showing foreign body reaction and five showing ossification alone were identified prospectively. The 24 naevi showing a foreign body reaction had a similar age and sex distribution to controls but were more likely to occur on the head and neck. The reaction usually occurred deep to the naevus, sometimes in relation to a hair follicle, and fragments of hair or keratin were identified in most. Osteoid or bone was present within the reaction in five. In six other naevi, all from the head and neck of women, osteoid or mature bone was present deep to the naevus in the absence of a giant cell reaction. Foreign body giant cell reactions occur not uncommonly in relation to benign naevi, as a result of follicular damage, possibly due to trauma. The similar siting of foci of bone suggests that ossification occurs as a secondary phenomenon in these cases.

Inflammatory response to subcutaneously implanted Marlex ® and GORE-TEX ® in massively obese patients

In both vertical banded gastroplasty and in gastric banding, synthetic bands are used to reinforce the outlet from the pouch to the rest of the stomach. Two materials commonly used for these bands are polypropylene (Marlex ®) and polytetrafluoroethylene (GORE-TEX ®). As a measure of their suitability, human inflammatory response to subcutaneous implants was investigated. In a randomized series of 17 superobese patients a patch of GORE-TEX was implanted subcutaneously in one groin under local anaesthesia and Marlex mesh was implanted in the other groin. After about 2 months the implants were exstirpated and investigated in a single blind procedure by an experienced pathologist. Marlex gave a significantly greater chronic inflammatory reaction and fibrosis than GORE-TEX. The foreign body giant cell reaction was, however, significantly greater with GORE-TEX. The possible implications of these results are discussed.

The Arthroscopic Evaluation and Characteristics of Severe Polyethylene Wear in Total Knee Arthroplasty

Four hundred eighty-seven porous-coated anatomic (PCA) total arthroplasties were performed by the same surgeon between January 1982 and December 1989. Forty-three patients developed an effusion, pain, or decreased range of motion after a period of pain-free function. Average time to onset of symptoms was 4.5 years. Joint fluid aspirations were sterile and revealed the presence of high-density polyethylene crystals, best seen under a polarizing microscope. Thirty-three of these patients were arthroscopically evaluated. Extensive polyethylene wear and delamination were identified. Wear was most extensive on the medial tibial plateau. Patellar polyethylene wear was also identified. Substantial femoral component abrasions were present in areas where exposure of the tibial and patellar base plates had occurred. Diffuse granulomatous synovial tissue revealed an extensive foreign-body giant-cell reaction to polyethylene particles. In all patients, temporary symptomatic relief was obtained after arthroscopy. Thirty-two patients have, subsequently, had revision surgery. Intraoperative findings and biopsies at the time of revision confirmed the arthroscopic observations. Arthroscopy allowed the accurate diagnosis of polyethylene wear, provided temporary symptomatic relief, and facilitated preoperative revision planning. Polyethylene wear in PCA total knee replacements was related to patient characteristics (larger, younger, more active patients), nonconforming femotibial articular surfaces, thin polyethylene, heat-pressed polyethylene, and nonrigid mechanical attachment of polyethylene to metal base plate. Younger, more active, larger patients with total knee arthroplasties should be observed closely for evidence of polyethylene wear.

Histopathological studies of a new liquid embolization method using estrogen-alcohol and polyvinyl acetate: Experimental evaluations with a model of cortical arterial cannulation in the canine brain

This experimental report evaluates the histopathological effects of a new embolization method using estrogen-alcohol (E-A) and polyvinyl acetate solution (PVac) as tested on 21 mongrel dogs. Three other animals treated with normal saline served as controls. All agents were introduced through an isolated cortical artery. Estrogen-alcohol induced immediate occlusion of small vessels (<20 μmm), and then progressive obstruction of larger ones (200–300 μm) within several days. Animals treated with PVac showed vascular obliteration (> 100 μmm) and moderate chronic fibrosis. The effects of embolization using E-A followed by PVac were found to have the combined advantages of both materials, showing diffuse occlusion of the vascular network with less tissue reaction. Hyalinization of embolized vessels with extensive fibrosis occurred afterward. For 6 weeks there was no evidence of recanalization or foreign body giant cell reaction. This study shows that E-A and PVac are capable of producing vascular occlusions with only mild tissue reaction. Because they are easily controllable and have no adverse effects, they may be suitable for intravascular application in the central nervous system.

Metal wear and tissue response in failed titanium alloy total hip replacements

Thirteen total hip replacements with titanium alloy femoral components required revision for loosening at an average of two years after implantation. At revision the soft tissues around the implant were darkly stained and a proliferative membrane had invaded the cement-bone interface. The femoral components showed polishing of parts of their shot-blasted surfaces. Histology showed a fibroblastic reaction with abundant titanium lying free and within histiocytes, and a scanty foreign-body giant-cell reaction. Surface analysis of the removed femoral components and chemical analysis of the excised tissues is described. Tissue reaction in response to the metal-wear debris may have contributed to the early failure of these implants.

Foreign body giant cell reaction related to placement of tetracycline-treated polylactic acid: Report of 18 cases

Presented are 18 cases of foreign body giant cell reaction in mandibular third molar extraction wounds previously treated with 40 mg of dry tetracycline powder carried into the wound with a biodegradable polymer dressing. The lesions vary in intensity from local, soft tissue granulomas to osteolytic, central bone pathologies. Several reports of foreign body giant cell reaction to insoluble tetracycline preparations are cited, along with a brief review of the relationship between myospherulosis and various formulations of tetracycline powder in petroleum-based carrier vehicles. The authors suggest that the foreign body giant cell lesions reported here were initiated by micron-sized particles of insoluble tetracycline powder and were further aggravated by certain hydrophobic characteristics of the associated biodegradeable polymer. The authors caution against use of dry, powdered forms of topical antibiotics in fresh dental extraction wounds.

Primate Trabeculectomies With 5-Fluorouracil Collagen Implants

Bilateral trabeculectomies were performed on four normal cynomolgus monkeys. Highly purified bovine skin collagen implants with either 1 mg of 5-fluorouracil or physiologic saline (one each per monkey by randomized, masked assignment) were sutured under the scleral flaps. The randomization code was not broken until all clinical and histopathologic observations had been completed. Six weeks postoperatively, the 5-fluorouracil-treated eyes had more deeply open internal trabeculectomy ostia than the control eyes; however, the intraocular pressures were indistinguishable, the filtering blebs were only minimally different, and half of each group had trace or mild anterior subcapsular lenticular changes. Histologically, a multinucleated foreign body giant cell reaction was evident in all of the collagen implants, but the 5-fluorouracil-treated eyes had less vigorous or delayed reactions compared to the control eyes. The collagen implant appears to be a poor drug delivery system in this model of glaucoma filtering surgery, because it incites a granulomatous inflammatory reaction.

Histotoxicity of Cyanoacrylate Tissue Adhesives: A Comparative Study

Cyanoacrylate derivatives have been used as surgical adhesives for many years. Shorter-chain derivatives (methyl- and ethyl-cyanoacrylate) have proved to be histotoxic. Longer-chain derivatives (butyl- and isobutyl-cyanoacrylate) are much less histotoxic. Many surgeons continue to use ethyl-2-cyanoacrylate (Krazy Glue) despite the availability of a less toxic derivative, butyl-2-cyanoacrylate (Histoacryl). In this study, the histotoxicity and bone graft-cartilage binding ability of Krazy Glue and Histoacryl were compared. Bone grafts harvested from the anterior wall of the maxillary sinus were placed in a subcutaneous pocket and glued to auricular cartilage in the rabbit. Krazy Glue and Histoacryl were used in opposite ears, harvesting specimens at 1, 2, 4, 12, 24, and 48 weeks. The Krazy Glue-treated ears developed seromas with histologic evidence of acute inflammation, tissue necrosis, and chronic foreign body giant cell reaction. The Histoacryl-treated ears showed mild acute inflammation and mild foreign body giant cell reaction. The Krazy Glue was completely degraded within 12 months, while some Histoacryl was still present at 1 year. Histoacryl had minimal histotoxic effect and good bone graft-cartilage binding ability, whereas Krazy Glue demonstrated severe histotoxicity.

Cementless uncoated polyethylene acetabular components in total hip replacement. Review of five- to 10-year results

We reviewed the results of 545 consecutive total hip replacements using a cementless non-coated high-density polyethylene acetabular component combined with a cemented Müller stem at five to 10 years. In all, 421 patients (445 hips) were available for review, 118 by questionnaire and 303 by examination and radiography. Of these, 86% had a good or excellent result. We found a high rate of radiological loosening of the cup after the sixth year, and a high rate of clinical loosening after the eighth year. Loosening was commoner in women, in younger patients and where a smaller size of acetabulum had been used. Calcar resorption was significantly related to loosening of the acetabulum. Loosening appeared to be mainly due to polyethylene debris produced by micro-movement of the acetabulum against the bone, which had resulted in a giant cell foreign body reaction and subsequent bone erosion. We have abandoned the use of this prosthesis and suggest that direct contact between bone and polyethylene should be prevented by a coating of metal or some other material.

Cyanoacrylate for Bonding Bone and Cartilage: An Experimental Study

At the recent meeting of the Fifth International Symposium of the American Academy of Facial Plastic and Reconstructive Surgery in Toronto, Canada, Dean Toriumi, MD, and coworkers, Chicago, Ill, presented an experimental study evaluating the tissue response of ethyl-2-cyanoacrylate (Krazy Glue) and butyl-2-cyanoacrylate (Histoacryl) when used to glue a bone graft to cartilage. A rabbit ear model was used employing ethyl-2-cyanoacrylate on the right ear and butyl-2-cyanoacrylate on the left ear. Histologic analysis at 1 and 2 weeks, and at 1, 3, 6, and 12 months revealed the following: (1) Ethyl-2-cyanoacrylate produced an intense acute inflammation with some tissue necrosis and sterile abscess formation. This reaction subsided only to be replaced by chronic foreign body giant cell reaction with adhesive-filled inclusions. The adhesive was completely degraded within 1 year. (2) Butyl-2-cyanoacrylate produced a mild foreign body giant cell reaction that gradually diminished but, in some cases, persisted for over 1

Osteophytic reaction to a polytetrafluoroethylene temporomandibular joint implant: Report of a case

Alloplastic disk substitutes of polytetrafluoroethylene (PTFE) used in the management of late stage temporomandibular joint disease have often been accompanied by morbid tissue reactions and resultant destructive changes. Numerous clinicians have reported cases of severe radiographic and clinical bony destruction and degeneration accompanied by marked foreign body giant cell reactions in the adjacent soft tissues. The case reported here demonstrates just the opposite event. Osteophytic enlargement of the lateral portion of the zygomatic arch and glenoid fossa, with adaptation to the contours of the implant, along with severe condylar osteophytosis, was diagnosed through tomographic and CT imaging and was confirmed at surgery.