The use of biomaterials and implants for joint replacement, fracture fixation, spinal stabilization and other orthopedic indications has revolutionized patient care by reliably decreasing pain and improving function. These surgical procedures always invoke an acute inflammatory reaction initially, that in most cases, readily subsides. Occasionally, chronic inflammation around the implant develops and persists; this results in unremitting pain and compromises function. The etiology of chronic inflammation may be specific, such as with infection, or be unknown. The histological hallmarks of chronic inflammation include activated macrophages, fibroblasts, T cell subsets, and other cells of the innate immune system. The presence of cells of the adaptive immune system usually indicates allergic reactions to metallic haptens. A foreign body reaction is composed of activated macrophages, giant cells, fibroblasts, and other cells often distributed in a characteristic histological arrangement; this reaction is usually due to particulate debris and other byproducts from the biomaterials used in the implant. Both chronic inflammation and the foreign body response have adverse biological effects on the integration of the implant with the surrounding tissues. Strategies to mitigate chronic inflammation and the foreign body response will enhance the initial incorporation and longevity of the implant, and thereby, improve long-term pain relief and overall function for the patient. The seminal research performed in the laboratory of Dr. James Anderson and co-workers has provided an inspirational and driving force for our laboratory's work on the interactions and crosstalk among cells of the mesenchymal, immune, and vascular lineages, and orthopedic biomaterials. Dr. Anderson's delineation of the fundamental biologic processes and mechanisms underlying acute and chronic inflammation, the foreign body response, resolution, and eventual functional integration of implants in different organ systems has provided researchers with a strategic approach to the use of biomaterials to improve health in numerous clinical scenarios.
BACKGROUND: Although rare, allergic reactions to metal implants represent a diagnostic challenge in view of missing guidelines. OBJECTIVES: To develop an European expert consensus on characteristics of metal allergy reactions and the utility of various diagnostic tools in suspected metal implant allergy. METHODS: A nominal group technique (NGT) was applied to develop consensus statements. Initially an online literature database was created on a secure server to enable a comprehensive information. Twenty-three statements were formulated on potential aspects of metal implant allergy with a focus on diagnostics and grouped into five domains. For the consensus development, the panel of 12 experts initially did refine and reformulate those statements that were ambiguous or had unclear wording. By face-to-face (9/12) or virtual participation (3/12), an anonymous online voting was performed. RESULTS: Consensus (≥80% of agreement) was reached in 20/23 statements. The panel agreed that implant allergy despite being rare should be considered in case of persistent unexplained symptoms. It was, however, recommended to allow adequate time for resolution of symptoms associated with healing and integration of an implant. Obtaining questionnaire-aided standardized medical history and standardized scoring of patient outcomes was also considered an important step by all experts There was broad consensus regarding the utility/performance of patch testing with additional late reading. It was recognized that the lymphocyte transformation test (LTT) has to many limitations to be generally recommended. Prior to orthopaedic implant, allergy screening of patients without a history of potential allergy to implant components was not recommended. CONCLUSIONS: Using an expert consensus process, statements concerning allergy diagnostics in suspected metal implant allergy were created. Areas of nonconsensus were identified, stressing uncertainty among the experts around topics such as preoperative testing in assumed allergy, histological correlate of periimplant allergy and in vitro testing, which underscores the need for further research.
- MeSH
- Arthritis diagnosis etiology pathology therapy MeSH
- Arthroplasty, Replacement methods adverse effects MeSH
- Humans MeSH
- Joint Diseases * diagnosis etiology pathology therapy MeSH
- Orthopedic Procedures methods MeSH
- Osteotomy methods MeSH
- Prostheses and Implants adverse effects MeSH
- Arthritis, Rheumatoid diagnosis pathology therapy MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
Orthopedic implants heal well without complications in most patients but fail for unclear reasons in some individuals. This study determined the relevance of metal hypersensitivity in patients with failed orthopedic implants and those requiring orthopedic implant surgery. The study included 35 patients with failed orthopedic implants and 15 subjects scheduled for orthopedic implant surgery. The production of selected pro-inflammatory cytokines was measured in patients with failed orthopedic implants. Metal hypersensitivity was measured in all subjects using the MELISA® test. Of common metals in orthopedic alloys, the patients with failed orthopedic implants responded most frequently to nickel, chromium, titanium, iron, and molybdenum. Hypersensitivity to metals found in implants was measured in 40% of patients with failed implants. The study also showed that titanium exposure in patients with titanium hypersensitivity might lead to implant failure. Metal hypersensitivity testing should be offered to patients before surgery to minimize the risk of implant failure.
Autoři prezentují současně dostupné informace týkající se alergických reakcí po katetrizačním uzávěru defektů síňového septa. Popisují patogenezi reakce, možné typy nežádoucích alergických komplikací a jejich management.
The authors present currently available information regarding allergic reactions after catheter closure of atrial septal defects. The pathogenesis of the reaction, possible types of undesirable allergic complications and their management are described.
- MeSH
- Hypersensitivity diagnosis etiology MeSH
- Anaphylaxis etiology complications MeSH
- Heart Septal Defects, Atrial surgery therapy MeSH
- Foramen Ovale, Patent surgery therapy MeSH
- Dermatitis, Contact etiology complications MeSH
- Kounis Syndrome etiology drug therapy MeSH
- Humans MeSH
- Migraine Disorders etiology complications MeSH
- Nickel * adverse effects MeSH
- Prostheses and Implants adverse effects MeSH
- Septal Occluder Device * adverse effects MeSH
- Cardiac Tamponade etiology drug therapy complications MeSH
- Absorbable Implants MeSH
- Check Tag
- Humans MeSH
- Publication type
- Research Support, Non-U.S. Gov't MeSH
- MeSH
- Cautery methods MeSH
- Laser Therapy methods adverse effects MeSH
- Humans MeSH
- Minimally Invasive Surgical Procedures MeSH
- Sleep Apnea, Obstructive surgery MeSH
- Palate, Soft surgery MeSH
- Postoperative Complications epidemiology etiology MeSH
- Prostheses and Implants standards adverse effects MeSH
- Radiofrequency Ablation methods MeSH
- Uvula surgery MeSH
- Check Tag
- Humans MeSH
PURPOSE OF THE STUDY Periprosthetic joint infection is a major complication which in most of the cases requires a long-term administration of antibiotics and often necessitates undergoing multiple challenging surgeries. Bacterial adhesion to foreign material is one of the key risk factors associated with periprosthetic joint infection. The foreign material with large adhesion area might be also the UHMWPE (Ultrahigh molecular weight polyethylene) particles released during the wear process from the surface of articulating components. The purpose of this study is to evaluate potential adhesion areas of wear particles in relation to diverse distribution of the size and shapes of wear particles in periprosthetic tissue and to assess an increase in the risk of infectious complications associated with an increase in the adhesion area of wear particles. MATERIAL AND METHODS The size and morphology of model and real UHMWPE particles were determined with the use of light microscopy and scanning electron microscopy. By determining the morphological descriptors, the surfaces of individual particles for different distributions of polyethylene particles were calculated. When measuring the model wear particles, 6 model situations were simulated, in which comparisons with the control measurement by the BET (Brunauer-Emmet-Teller) method were made. RESULTS The variability of individual morphological descriptors demonstrates the effect on the total surface of particles. The calculated coefficient defines how many times the particle surface increases when corrected to the given descriptor (elongation, flattening, roughness, porosity). The total area of real wear particles at 1 year is 4,622 cm2, at 20 years it is 92,440 cm2. Based on our calculations, the area of particles where a biofilm is actually formed (approximately 50 bacteria may adhere to a particle of 3µm in diameter) is 809.5 cm2 at 1 year and 16,190 cm2 at 20 years. DISCUSSION According to the measurements, the size of the potential adhesion area of metal parts and polyethylene particles becomes equal already after several weeks of endoprosthesis usage and after a few years it is many times larger. The question is whether the risk of bacterial adhesion, i.e. also the risk of infectious complications of TEP actually increases. The clinical practice suggests that the number of infections e.g. 10, 15 or 20 years after the primary implantation is not statistically higher, despite the confirmed growth of potential adhesion area in the form of UHMWPE particles. This fact could be explained by a partially equal regulatory pathway of infection and polyethylene disease. The immune system stimulated by wear particles might better resist the hematogenic infection. CONCLUSIONS The study outcomes clearly indicate that the area of polyethylene wear particles considerably increases over time. In spite of the fact that only approximately 10% of wear particles show parameters (also with respect to the size of particles and bacteria) for potential bacterial adhesion, this area is many times larger than the area of metal parts of the endoprosthesis. Key words: UHMWPE particle, adhesion, biofilm, wear, TJR infection.
- MeSH
- Arthroplasty, Replacement adverse effects instrumentation MeSH
- Prosthesis-Related Infections etiology MeSH
- Humans MeSH
- Polyethylene adverse effects MeSH
- Polyethylenes adverse effects MeSH
- Prostheses and Implants adverse effects MeSH
- Prosthesis Failure * MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
Infekční endokarditida je zánětlivé onemocnění srdce postihující endokard chlopní, ale i umělé materiály implantované v srdečních dutinách. Onemocnění stále patří mezi nejzávažnější infekční choroby, jejichž problematika nabývá na významu kvůli změně spektra původců i klinického průběhu v souvislosti s přibývajícím počtem umělých srdečních implantátů v populaci. Dělení infekční endokarditidy dle typu postižení a epidemiologických souvislostí je důležité pro volbu správné iniciální empirické léčby i další léčebnou strategii. Cílenou antibiotickou terapii pak upřesňuje identifikace původce onemocnění, přičemž mezi ta nejčastější agens patří Staphylococcus aureus a viridující streptokoky. K diagnóze onemocnění spolu s průkazem přítomnosti patogenu v krvi slouží průkaz přítomnosti infekce v srdečních dutinách zobrazovacími metodami, především echokardiograficky. Léčba nezbytně vyžaduje komplexní přístup s úzkou mezioborovou spoluprací, měla by být navázána na komplexní centra disponující tzv. Endocarditis teamem. Prevence infekční endokarditidy zahrnuje základní hygienická opatření k předcházení bakteriemie aplikovaná na celou populaci a antibiotickou profylaxi aplikovanou na úzkou skupinu vysoce rizikových osob.
Infective endocarditis is an inflammatory heart disease which affects the endocardium, as well as artificial prosthetic materials within the heart cavities. The disease remains one of the most serious infectious diseases due to changes in its clinical course and microbial etiology in an era which has seen an increase in the use of artificial implants. Classifying infective endocarditis according to the type of condition and epidemiology factors is important for the correct choice of initial empirical treatment and subsequent treatment strategy. A targeted antibiotic regimen is then determined on the basis of identification of the causative agent. The most frequent agents affecting the endocardium include Staphylococcus aureus and the viridans streptococci. The diagnosis of infective endocarditis is based on microbiological findings, along with imaging methods, especially echocardiography, which demonstrate the presence of the infection within the heart cavities. The treatment of infective endocarditis requires a comprehensive approach in close interdisciplinary collaboration and should be provided in cooperation with Endocarditis Teams in specialised centres. The prevention of infective endocarditis includes basic sanitary measures applied across the whole population to prevent bacteraemia combined with antibiotic prophylaxis administered in a small group of high-risk individuals.
- MeSH
- Anti-Bacterial Agents MeSH
- Endocarditis, Bacterial diagnosis etiology physiopathology therapy MeSH
- Echocardiography, Transesophageal MeSH
- Echocardiography MeSH
- Endocarditis * diagnosis etiology classification physiopathology therapy MeSH
- Drug Therapy, Combination MeSH
- Blood Culture MeSH
- Humans MeSH
- Interdisciplinary Communication MeSH
- Prostheses and Implants microbiology adverse effects MeSH
- Single Photon Emission Computed Tomography Computed Tomography MeSH
- Heart Valve Prosthesis microbiology adverse effects MeSH
- Patient Care Team MeSH
- Check Tag
- Humans MeSH
Incidence infekční endokarditidy stimulačního systému (CDRIE) má v poslední dekádě narůstající trend v důsledku zvyšujícího se počtu implantací přístrojů, jako jsou kardiostimulátory, implantabilní kardiovertery-defibrilátory nebo přístroje pro srdeční resynchronizační léčbu. Jde o závažné onemocnění, které je spojeno s významnou morbiditou a mortalitou. Jednoroční mortalita je vysoká a činí kolem 25 %. Rizikovou skupinu tvoří zejména starší pacienti s přidruženými onemocněními. CDRIE se nejčastěji objevuje 6 měsíců od implantace. Nejčastějším etiologickým agens způsobující onemocnění jsou stafylokoky. Diagnostika není jednoduchá, protože klinický obraz je značně variabilní. Základními pilíři diagnostiky jsou echokardiografické vyšetření a průkaz mikrobiologického agens odběrem hemokultur. Terapie je komplexní a vyžaduje jak extrakci přístroje i elektrod, tak dlouhodobé podávání parenterálních antibiotik.
The use of cardiac implantable electronic devices has expanded dramatically over the past decade and infective endocarditis ofthese devices (CDRIE) is associated with high morbidity and mortality. 1 year mortality has not improve and remains at 25 %. Riskgroups are mainly older patients with multiple commorbidities. CDRIE occurs most often 6 month after implantation. Staphylococcalpredominate as the causative organism. Diagnosis of disease is not easy, clinical presentation is highly variable. Echocardiographyand blood cultures are the cornerstones of the diagnosis. CDRIE must be treated by prolonged antibiotic therapy and frequentlyrequires complete hardware removal.
- MeSH
- Anti-Bacterial Agents MeSH
- Antibiotic Prophylaxis MeSH
- Endocarditis * diagnosis etiology therapy MeSH
- Humans MeSH
- Prostheses and Implants adverse effects MeSH
- Retrospective Studies MeSH
- Check Tag
- Humans MeSH
- Publication type
- Review MeSH
