ANATOMIC PATHOLOGY Single Case Report
Osteolysis After Silicone Arthroplasty S. L. HARBOLDT, M.D.,1 GRAHAM J. GUMLEY, M.D.,2 AND KAROLY BALOGH, M.D.3
consistent with silicone. The authors report a giant cell lesion of the bone that radiographically and microscopically mimicked a neoplasm. (Key words: Silicone synovitis; Silicone osteolysis; Silicone arthroplasty; Giant cell lesion of bone) Am J Clin Pathol 1992; 98:594-597
Alfred Swanson initiated silicone arthroplasty research,' first using implants in 1965 and publishing his initial clinical results in 1968.2'3 In subsequent years, hundreds of thousands of such implants restored function to hands, wrists, elbows, shoulders, feet, and temporomandibular joints. These implants replaced joints damaged by arthritis, avascular necrosis, or trauma, or served as spacers in procedures such as Keller's bunionectomy.3"5 Initially, silicone was thought to be biologically inert.12'6"8 However, in 1974, Aptekar and colleagues9 published the first report of foreign-body reaction to a silicone arthroplastic implant, and in 1980, Shereff and Jahss10 demonstrated bone erosions and cystic osteolysis associated with a silicone prosthesis. The first histopathologic description of a radiologically cystlike lesion in bone associated with a silicone prosthesis was published in 1984 by Ekfors and associates.'' The literature of surgery, radiology, and rheumatology now contains many reviews and case reports of silicone-induced lesions, but complications of silicone implant arthroplasty are rarely mentioned in the pathology literature."12 A bone lesion with exuberant proliferation of giant cells and fibroblasts and modest lymphocytic infiltrate may present a problem to the surgical pathologist unfamiliar
with the capacity of silicone to cause tumorlike giant cell lesions. We have seen such a case and now describe it. CASE REPORT Twenty-eight months after successful Silastic implant arthroplasty of the right lunate for avascular necrosis (Kienbock's disease), a 30-yearold woman returned to the clinic and reported 6 months of increasing pain of therightwrist. Physical examination showed a well-healed dorsal incision of the right wrist and tenderness around the distal ulna. A standard radiograph revealed well-circumscribed lytic lesions in the distal ulna and the triquetrum, as well as erosive changes in the radial styloid and the scaphoid (Fig. 1). A computed tomographic scan confirmed these findings and demonstrated a break in the cortex of the radial styloid with probable intraosseous extension. A regional bone scan with Technetium 99m MDP showed increased radiotracer uptake in these lesions. At surgery, a dorsal exposure of the wrist was made that demonstrated the previously placed Silastic lunate implant. The implant stem into the triquetrum was noted to be broken and both portions of the implant were removed. The implant appeared to be well encapsulated, although reactive synovitis was identified between the scaphoid and radius. Soft brown-yellow tissue protruded through a 3- to 4-mm perforation in the triangularfibrocartilage.There was apparent impingement between the distal ulna and the triquetrum. To correct this impingement, a Darrach distal ulnar resection was carried out with the addition of a Swanson Silastic distal ulnar implant. Soft tissues were reconstructed and a routine dressing was applied. The patient's immediate postoperative course was uncomplicated. She has been lost to follow-up.
From the Department of' Pathology. New England Deaconess Hospital, and2Department of Orthopaedic Surgery, Boston University School of Medicine. Boston, Massachusetts. Received December 12, 1991; revised manuscript accepted for publication January 22, 1992. Address reprint requests to Dr. Balogh: Department of Pathology, New England Deaconess Hospital, 185 Pilgrim Rd., Boston, Massachusetts 02215.
PATHOLOGIC FINDINGS
The surgical specimen consisted of polypoid and irregular fragments of soft yellow-tan tissue and scant spicules of bone measuring 2.4 X 1.8 X 1.1 cm in aggregate. The included prosthetic device was fragmented, firm, and rubbery. Microscopic examination of the tissue fragments
594
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
A young woman with a silicone lunate prosthesis for avascular necrosis developed painful lytic lesions in the distal ulna and the triquetrum. At reoperation, abundant reactive synovitis was found extending into those bone lesions. Histologic examination of the curetting samples revealed granulation tissue with histiocytes and many multinucleated giant cells containing refractile particles
HARBOLDT, GUMLEY, AND BALOGH
595
Silicone Osteolysis
0*
FlG. 1. Radiograph showing cystlike lytic lesions with peripheral sclerosis in the distal ulna and the triquetrum. The ulna minus deformity is incidentally noted.
revealed highly cellular granulation tissue with histiocytes and multinucleated giant cells containing particles consistent with silicone (Fig. 2). Similar particles lay between these cells. The particles did not stain with conventional histochemical techniques, were irregular in contour, and were refractile but not birefringent. The intracellular particles varied from about 10 to 50 nm, but the extracellular conglomerates measured up to 400 /mi. Immunohistochemical stains were performed but did not help to establish the diagnosis. Stains for keratin, epithelial membrane antigen, and S-100 protein were negative. Some histiocytes stained positively for a, antitrypsin. Vimentin was positive in the histiocytes, multinucleated giant cells, and fibroblasts. Factor VIII antigen was demonstrated in the endothelial cells of blood vessels. There was strong staining for leukocyte-common antigen in the lymphocytes.
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DISCUSSION Silicone rubber is a polymer of carbon, oxygen, hydrogen, and silica identified by the chemical name of poly-
FIG. 2. Microphotograph demonstrates multinucleated giant cells and histiocytes with irregular refringent intracytoplasmic particles. Notice the concomitant lymphocytic infiltrate (hematoxylin and eosin, X500).
Vol. 98 • No. 6
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
dimethylsiloxane.5 The length of polymer chains is directly proportional to the viscosity of fluid silicone, and crosslinking of the polymer chains produces solid substances with material properties similar to those of rubber.513 The silicone prostheses used before 1975 were made of relatively inflexible silicone and were subject to fracture, with resulting chemical complications. After that time, "highperformance" silicone implants were available. These broke less often, but other complications emerged. 3AI013 There is now extensive literature on the complications of silicone implants used in both orthopedic and plastic surgery. Reported systemic complications, some better documented than others, have included fever, malaise, delirium, acute pneumonitis, respiratory failure, renal failure, granulomatous hepatitis, lymphadenopathy, idiopathic thrombocytopenic purpura, systemic lupus erythematosus, scleroderma, and progressive systemic scle-
596
ANATOMIC PATHOLOGY Single Case Report
rosis. 1214 "' 6 Localized complications include infection, loosening, breakage, multinucleated giant cell reactions, detritic synovitis or osteolysis, and even erosion through soft tissues and s kin. 3 - 6 - 8 - 9 "- 131517 - 19 Before osteolytic lesions develop, standard x-ray films often demonstrate a "ground-glass" appearance of the bone. The ensuing lytic lesions are said to lack the discrete "internal rim" of cortical bone seen adjacent to symptomfree implants, but show instead a thin, reactive, sclerotic wall that, although sharply defined, may show endosteal widening and scalloping.413 The bone lesions appear more like benign tumors or an erosive arthritis than the cysts of osteoarthritis. 4 ' 681317 Schneider and associates20 have discussed a radiographic differential diagnosis.
Acknowledgments. The authors thank Edith Hurney for typing the manuscript and A. Pollak, M.D., Department of Radiology, Lahey Clinic Medical Center, for help in preparing the manuscript.
REFERENCES 1. Nalbandian RM. Correspondence. J Bone and Joint Surg 1983; 65A(2):280-281. 2. Swanson AB. Silicone rubber implants for replacement of arthritic or destroyed joints in the hand. Surg Clin North Am 1968;48(5): 1113-1127. 3. Swanson AB, Swanson GG, Maupin BK, Hynes DEM, Jindal P. Failed carpal bone arthroplasty: Causes and treatment. J Hand Surg 1989; 14(2, Part 2):417-424. 4. Christie AJ, Pierret G, Levitan J. Silicone synovitis. Semin Arthritis Rheum 1989; 19(3)166-171. 5. Gordon M, Bullough PG. Synovial and osseous inflammation in failed silicone-rubber prostheses. J Bone Joint Surg 1982;64A(4): 574-580. 6. Atkinson RE, Smith RJ. Silicone synovitis following silicone implant arthroplasty. Hand Clinics 1986; 2(2):291-299. 7. Eiken O, Ekerot L, Lindstrom C, Jonnson K. Silicone carpal implants: Risk or benefit? Scand J Plast Reconstr Surg 1985; 19: 295-304. 8. Rosenthal DI, Rosenberg AE, Schiller AL, Smith RJ. Destructive arthritis due to silicone: A foreign body reaction. Radiology 1983;149:69-72. 9. Aptekar RG, Davie JM, Cattell HS. Foreign body reaction to silicone rubber: Complication of a finger joint implant. Clin Orthop Rel Res 1974;98:231-232. 10. ShereffMJ, Jahss MH. Complications of silastic implant arthroplasty in the hallux. Foot Ankle 1980; 1(2):95-101. 11. Ekfors TO, Hannu A, Maki J, Aho AJ. Cystic osteolysis induced by silicone rubber prosthesis. Arch Pathol Lab Med 1984; 108:225227. 12. Travis WD, Balogh K, Abraham JL. Silicone granulomas: Report
A.J.C.P. .December 1992
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Microscopic examination shows that silicone implants do not adhere to tissues but rather become encapsulated by collagen fibers and by amorphous ground substance. 2 ' 813 ' 5 Despite this induced fibrous capsule, displaced silicone shards from 10 to 100 mm are seen, both intracellular^ and extracellularly. The particles are associated with a foreign body giant cell reaction, chronic inflammation, synovial hyperplasia, osteoclastic osteolysis, and cystlike lesions. 7 ' 9 '" It is fascinating to note that lytic cystlike lesions may exist without direct ingrowth of granulation tissue from joint margins, thereby invoking spread of the process through lymphatics or blood vessels in bone. 4 ' 513 Local, hematogenous, and lymphatic spread of silicone particles to remote sites have all been demonstrated. 12 Scanning electron microscopic examination has shown that even unused silicone prostheses have, on their otherwise smooth surfaces, foci with many embedded or freestanding particles of silicone measuring approximately 10 jum in diameter.13 Used prostheses have cracked or eburnated surfaces and partially attached or freestanding silicone particles up to 100 /urn below their surface.5'1319 The pathologic differential diagnosis includes giant cell tumor of the bone or tendon sheath, aneurysmal bone cyst, pigmented villonodular tenosynovitis, rheumatoid arthritis, lytic lesions of chronic advanced hyperparathyroidism ("brown tumor"), and granulomatous infections. The presence of silicone particles and history of silicone implant are critical in establishing the diagnosis. The pathogenesis of osteolysis with silicone implants is unknown. Some have suggested that the lysozymes of histiocytes and foreign-body giant cells may be ineffective in digesting silicone shards. These phagocytes may then not only expel the engulfed particles but also release neutral proteases that destroy connective tissue and induce chronic inflammation.3,7 Reports in the literature regarding the incidence of inflammatory complications of silicone arthroplasty are
conflicting. Some authors 71317 report a high incidence of complications. In fact, Peimer and associates13 found that from 30% to 90% of silicone wrist implants would fail on the basis of destructive synovitis rather than from fracture of the prosthesis. In contrast, others have stated that unfavorable tissue reactions and clinical complications of silicone implant arthroplasty are uncommon or even rare. 1520 Nalbandian' reported in his study of more than 2,000 Swanson's orthopedic surgical specimens that silicone synovitis was found in only 0.1%. Despite the divergent data on the frequency of complications, silicone is still used commonly in arthroplastic surgery, particularly of hinge-joint replacements. However, these prostheses are seldom placed in a site of significant mechanical stress, such as the lunate, and surgeons rarely use a second silicone prosthesis in a patient with silicone synovitis.616'17'21 Although these complicated cases have radiologic and pathologic features that mimic reactive or neoplastic lesions of the bone, they also have distinctive features that lead the informed pathologist to the correct diagnosis.
HARBOLDT, GUMLEY, AND BALOGH
597
Silicone Osteolysis
13. 14. 15. 16.
of three cases and review of the literature. Hum Pathol 1985; 16: 19-27. Peimer CA, Medige J, Eckert BS, Wright JR, Howard CS. Reactive synovitis after silicone arthroplasty. J Hand Surg 1986; 11 A:624638. Endo LP, Edwards NL, Longley S, Corman LC, Panush RS. Silicone and rheumatic diseases. Semin Arthritis Rheum 1987; 17:112118. Shergy WJ, Urbaniak JR, Polisson RP. Silicone synovitis: Clinical, radiologic and histologic features. South Med J 1989; 81(9): 1156— 1158. Weisman MH, Vecchione TR, Albert D, Moore LT, Mueller MR. Connective-tissue disease following breast augmentation: A pre-
17. 18. 19. 20. 21.
liminary test of the human adjuvant disease hypothesis. Plast Reconstr Surg 1988;82(4):626-630. Carter PR, Benton U, Dysert PA. Silicone rubber carpal implants: A study of the incidence of late osseous complications. J Hand Surg 1986;llA:639-644. Christie AJ. Silicone synovitis. Correspondence. Can J Surg 1986;29(3):147. Solitto RJ, Shonkweiler W. Silicone shard formation: A product of implant arthroplasty. J Foot Surg 1984;23(5):362-365. Schneider HJ, Weiss MA, Stern PJ. Silicone-induced erosive arthritis: Radiologic features in seven cases. AJR 1987; 148:923-925. Verhaar J, Vermeulen A, Bulstra S, Walenkamp G. Bone reaction to silicone metatarsophalangeal joint-1 hemiprosthesis. Clin Orthop Rel Res 1989;245:228-232.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Vol. 98-No.-6
Osteolysis After Silicone Arthroplasty S. L. HARBOLDT, M.D.,1 GRAHAM J. GUMLEY, M.D.,2 AND KAROLY BALOGH, M.D.3
consistent with silicone. The authors report a giant cell lesion of the bone that radiographically and microscopically mimicked a neoplasm. (Key words: Silicone synovitis; Silicone osteolysis; Silicone arthroplasty; Giant cell lesion of bone) Am J Clin Pathol 1992; 98:594-597
Alfred Swanson initiated silicone arthroplasty research,' first using implants in 1965 and publishing his initial clinical results in 1968.2'3 In subsequent years, hundreds of thousands of such implants restored function to hands, wrists, elbows, shoulders, feet, and temporomandibular joints. These implants replaced joints damaged by arthritis, avascular necrosis, or trauma, or served as spacers in procedures such as Keller's bunionectomy.3"5 Initially, silicone was thought to be biologically inert.12'6"8 However, in 1974, Aptekar and colleagues9 published the first report of foreign-body reaction to a silicone arthroplastic implant, and in 1980, Shereff and Jahss10 demonstrated bone erosions and cystic osteolysis associated with a silicone prosthesis. The first histopathologic description of a radiologically cystlike lesion in bone associated with a silicone prosthesis was published in 1984 by Ekfors and associates.'' The literature of surgery, radiology, and rheumatology now contains many reviews and case reports of silicone-induced lesions, but complications of silicone implant arthroplasty are rarely mentioned in the pathology literature."12 A bone lesion with exuberant proliferation of giant cells and fibroblasts and modest lymphocytic infiltrate may present a problem to the surgical pathologist unfamiliar
with the capacity of silicone to cause tumorlike giant cell lesions. We have seen such a case and now describe it. CASE REPORT Twenty-eight months after successful Silastic implant arthroplasty of the right lunate for avascular necrosis (Kienbock's disease), a 30-yearold woman returned to the clinic and reported 6 months of increasing pain of therightwrist. Physical examination showed a well-healed dorsal incision of the right wrist and tenderness around the distal ulna. A standard radiograph revealed well-circumscribed lytic lesions in the distal ulna and the triquetrum, as well as erosive changes in the radial styloid and the scaphoid (Fig. 1). A computed tomographic scan confirmed these findings and demonstrated a break in the cortex of the radial styloid with probable intraosseous extension. A regional bone scan with Technetium 99m MDP showed increased radiotracer uptake in these lesions. At surgery, a dorsal exposure of the wrist was made that demonstrated the previously placed Silastic lunate implant. The implant stem into the triquetrum was noted to be broken and both portions of the implant were removed. The implant appeared to be well encapsulated, although reactive synovitis was identified between the scaphoid and radius. Soft brown-yellow tissue protruded through a 3- to 4-mm perforation in the triangularfibrocartilage.There was apparent impingement between the distal ulna and the triquetrum. To correct this impingement, a Darrach distal ulnar resection was carried out with the addition of a Swanson Silastic distal ulnar implant. Soft tissues were reconstructed and a routine dressing was applied. The patient's immediate postoperative course was uncomplicated. She has been lost to follow-up.
From the Department of' Pathology. New England Deaconess Hospital, and2Department of Orthopaedic Surgery, Boston University School of Medicine. Boston, Massachusetts. Received December 12, 1991; revised manuscript accepted for publication January 22, 1992. Address reprint requests to Dr. Balogh: Department of Pathology, New England Deaconess Hospital, 185 Pilgrim Rd., Boston, Massachusetts 02215.
PATHOLOGIC FINDINGS
The surgical specimen consisted of polypoid and irregular fragments of soft yellow-tan tissue and scant spicules of bone measuring 2.4 X 1.8 X 1.1 cm in aggregate. The included prosthetic device was fragmented, firm, and rubbery. Microscopic examination of the tissue fragments
594
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
A young woman with a silicone lunate prosthesis for avascular necrosis developed painful lytic lesions in the distal ulna and the triquetrum. At reoperation, abundant reactive synovitis was found extending into those bone lesions. Histologic examination of the curetting samples revealed granulation tissue with histiocytes and many multinucleated giant cells containing refractile particles
HARBOLDT, GUMLEY, AND BALOGH
595
Silicone Osteolysis
0*
FlG. 1. Radiograph showing cystlike lytic lesions with peripheral sclerosis in the distal ulna and the triquetrum. The ulna minus deformity is incidentally noted.
revealed highly cellular granulation tissue with histiocytes and multinucleated giant cells containing particles consistent with silicone (Fig. 2). Similar particles lay between these cells. The particles did not stain with conventional histochemical techniques, were irregular in contour, and were refractile but not birefringent. The intracellular particles varied from about 10 to 50 nm, but the extracellular conglomerates measured up to 400 /mi. Immunohistochemical stains were performed but did not help to establish the diagnosis. Stains for keratin, epithelial membrane antigen, and S-100 protein were negative. Some histiocytes stained positively for a, antitrypsin. Vimentin was positive in the histiocytes, multinucleated giant cells, and fibroblasts. Factor VIII antigen was demonstrated in the endothelial cells of blood vessels. There was strong staining for leukocyte-common antigen in the lymphocytes.
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••*-4 * v *.w ' » v
%
• . * - • » , - • •
->*-4£< ^f£ « p
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DISCUSSION Silicone rubber is a polymer of carbon, oxygen, hydrogen, and silica identified by the chemical name of poly-
FIG. 2. Microphotograph demonstrates multinucleated giant cells and histiocytes with irregular refringent intracytoplasmic particles. Notice the concomitant lymphocytic infiltrate (hematoxylin and eosin, X500).
Vol. 98 • No. 6
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
dimethylsiloxane.5 The length of polymer chains is directly proportional to the viscosity of fluid silicone, and crosslinking of the polymer chains produces solid substances with material properties similar to those of rubber.513 The silicone prostheses used before 1975 were made of relatively inflexible silicone and were subject to fracture, with resulting chemical complications. After that time, "highperformance" silicone implants were available. These broke less often, but other complications emerged. 3AI013 There is now extensive literature on the complications of silicone implants used in both orthopedic and plastic surgery. Reported systemic complications, some better documented than others, have included fever, malaise, delirium, acute pneumonitis, respiratory failure, renal failure, granulomatous hepatitis, lymphadenopathy, idiopathic thrombocytopenic purpura, systemic lupus erythematosus, scleroderma, and progressive systemic scle-
596
ANATOMIC PATHOLOGY Single Case Report
rosis. 1214 "' 6 Localized complications include infection, loosening, breakage, multinucleated giant cell reactions, detritic synovitis or osteolysis, and even erosion through soft tissues and s kin. 3 - 6 - 8 - 9 "- 131517 - 19 Before osteolytic lesions develop, standard x-ray films often demonstrate a "ground-glass" appearance of the bone. The ensuing lytic lesions are said to lack the discrete "internal rim" of cortical bone seen adjacent to symptomfree implants, but show instead a thin, reactive, sclerotic wall that, although sharply defined, may show endosteal widening and scalloping.413 The bone lesions appear more like benign tumors or an erosive arthritis than the cysts of osteoarthritis. 4 ' 681317 Schneider and associates20 have discussed a radiographic differential diagnosis.
Acknowledgments. The authors thank Edith Hurney for typing the manuscript and A. Pollak, M.D., Department of Radiology, Lahey Clinic Medical Center, for help in preparing the manuscript.
REFERENCES 1. Nalbandian RM. Correspondence. J Bone and Joint Surg 1983; 65A(2):280-281. 2. Swanson AB. Silicone rubber implants for replacement of arthritic or destroyed joints in the hand. Surg Clin North Am 1968;48(5): 1113-1127. 3. Swanson AB, Swanson GG, Maupin BK, Hynes DEM, Jindal P. Failed carpal bone arthroplasty: Causes and treatment. J Hand Surg 1989; 14(2, Part 2):417-424. 4. Christie AJ, Pierret G, Levitan J. Silicone synovitis. Semin Arthritis Rheum 1989; 19(3)166-171. 5. Gordon M, Bullough PG. Synovial and osseous inflammation in failed silicone-rubber prostheses. J Bone Joint Surg 1982;64A(4): 574-580. 6. Atkinson RE, Smith RJ. Silicone synovitis following silicone implant arthroplasty. Hand Clinics 1986; 2(2):291-299. 7. Eiken O, Ekerot L, Lindstrom C, Jonnson K. Silicone carpal implants: Risk or benefit? Scand J Plast Reconstr Surg 1985; 19: 295-304. 8. Rosenthal DI, Rosenberg AE, Schiller AL, Smith RJ. Destructive arthritis due to silicone: A foreign body reaction. Radiology 1983;149:69-72. 9. Aptekar RG, Davie JM, Cattell HS. Foreign body reaction to silicone rubber: Complication of a finger joint implant. Clin Orthop Rel Res 1974;98:231-232. 10. ShereffMJ, Jahss MH. Complications of silastic implant arthroplasty in the hallux. Foot Ankle 1980; 1(2):95-101. 11. Ekfors TO, Hannu A, Maki J, Aho AJ. Cystic osteolysis induced by silicone rubber prosthesis. Arch Pathol Lab Med 1984; 108:225227. 12. Travis WD, Balogh K, Abraham JL. Silicone granulomas: Report
A.J.C.P. .December 1992
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Microscopic examination shows that silicone implants do not adhere to tissues but rather become encapsulated by collagen fibers and by amorphous ground substance. 2 ' 813 ' 5 Despite this induced fibrous capsule, displaced silicone shards from 10 to 100 mm are seen, both intracellular^ and extracellularly. The particles are associated with a foreign body giant cell reaction, chronic inflammation, synovial hyperplasia, osteoclastic osteolysis, and cystlike lesions. 7 ' 9 '" It is fascinating to note that lytic cystlike lesions may exist without direct ingrowth of granulation tissue from joint margins, thereby invoking spread of the process through lymphatics or blood vessels in bone. 4 ' 513 Local, hematogenous, and lymphatic spread of silicone particles to remote sites have all been demonstrated. 12 Scanning electron microscopic examination has shown that even unused silicone prostheses have, on their otherwise smooth surfaces, foci with many embedded or freestanding particles of silicone measuring approximately 10 jum in diameter.13 Used prostheses have cracked or eburnated surfaces and partially attached or freestanding silicone particles up to 100 /urn below their surface.5'1319 The pathologic differential diagnosis includes giant cell tumor of the bone or tendon sheath, aneurysmal bone cyst, pigmented villonodular tenosynovitis, rheumatoid arthritis, lytic lesions of chronic advanced hyperparathyroidism ("brown tumor"), and granulomatous infections. The presence of silicone particles and history of silicone implant are critical in establishing the diagnosis. The pathogenesis of osteolysis with silicone implants is unknown. Some have suggested that the lysozymes of histiocytes and foreign-body giant cells may be ineffective in digesting silicone shards. These phagocytes may then not only expel the engulfed particles but also release neutral proteases that destroy connective tissue and induce chronic inflammation.3,7 Reports in the literature regarding the incidence of inflammatory complications of silicone arthroplasty are
conflicting. Some authors 71317 report a high incidence of complications. In fact, Peimer and associates13 found that from 30% to 90% of silicone wrist implants would fail on the basis of destructive synovitis rather than from fracture of the prosthesis. In contrast, others have stated that unfavorable tissue reactions and clinical complications of silicone implant arthroplasty are uncommon or even rare. 1520 Nalbandian' reported in his study of more than 2,000 Swanson's orthopedic surgical specimens that silicone synovitis was found in only 0.1%. Despite the divergent data on the frequency of complications, silicone is still used commonly in arthroplastic surgery, particularly of hinge-joint replacements. However, these prostheses are seldom placed in a site of significant mechanical stress, such as the lunate, and surgeons rarely use a second silicone prosthesis in a patient with silicone synovitis.616'17'21 Although these complicated cases have radiologic and pathologic features that mimic reactive or neoplastic lesions of the bone, they also have distinctive features that lead the informed pathologist to the correct diagnosis.
HARBOLDT, GUMLEY, AND BALOGH
597
Silicone Osteolysis
13. 14. 15. 16.
of three cases and review of the literature. Hum Pathol 1985; 16: 19-27. Peimer CA, Medige J, Eckert BS, Wright JR, Howard CS. Reactive synovitis after silicone arthroplasty. J Hand Surg 1986; 11 A:624638. Endo LP, Edwards NL, Longley S, Corman LC, Panush RS. Silicone and rheumatic diseases. Semin Arthritis Rheum 1987; 17:112118. Shergy WJ, Urbaniak JR, Polisson RP. Silicone synovitis: Clinical, radiologic and histologic features. South Med J 1989; 81(9): 1156— 1158. Weisman MH, Vecchione TR, Albert D, Moore LT, Mueller MR. Connective-tissue disease following breast augmentation: A pre-
17. 18. 19. 20. 21.
liminary test of the human adjuvant disease hypothesis. Plast Reconstr Surg 1988;82(4):626-630. Carter PR, Benton U, Dysert PA. Silicone rubber carpal implants: A study of the incidence of late osseous complications. J Hand Surg 1986;llA:639-644. Christie AJ. Silicone synovitis. Correspondence. Can J Surg 1986;29(3):147. Solitto RJ, Shonkweiler W. Silicone shard formation: A product of implant arthroplasty. J Foot Surg 1984;23(5):362-365. Schneider HJ, Weiss MA, Stern PJ. Silicone-induced erosive arthritis: Radiologic features in seven cases. AJR 1987; 148:923-925. Verhaar J, Vermeulen A, Bulstra S, Walenkamp G. Bone reaction to silicone metatarsophalangeal joint-1 hemiprosthesis. Clin Orthop Rel Res 1989;245:228-232.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Vol. 98-No.-6
