ORIGINAL ARTICLE

Proposal for a histopathological consensus classification of the periprosthetic interface membrane

L Morawietz¹, R-A Classen¹, J H Schröder², C Dynybil², C Perka², A Skwara³, J Neidel⁴, T Gehrke⁵, L Frommelt⁵, T Hansen⁶, M Otto⁷, B Barden⁸, T Aigner⁹, P Stiehl¹⁰, T Schubert¹¹, C Meyer-Scholten¹², A König¹³, P Ströbel¹⁴, C P Rader¹⁵, S Kirschner¹⁵, F Lintner¹⁶, W Rüther¹⁷, I Bos¹⁸, C Hendrich¹⁹, J Kriegsmann⁶, V Krenn¹

¹ Institute für Pathologie, University Hospital Charité, Berlin, Germany
² Department for Orthopedic Surgery, University Hospital Charité, Berlin, Germany
³ Department for Orthopedic Surgery, University Hospital, Münster, Germany
⁴ Department for Orthopedic Surgery, Klinik Dr Guth, Hamburg, Germany
⁵ Endo-Klinik, Hamburg, Germany
⁶ Institute for Pathology, University Hospital, Mainz, Germany
⁷ Group Practice for Pathology, Trier, Germany
⁸ Department for Orthopedic Surgery, St-Augustinus Hospital, Düren, Germany
⁹ Institute for Pathology, University Hospital, Erlangen, Germany
¹⁰ Institute for Pathology, University Hospital, Leipzig, Germany
¹¹ Institute for Pathology, University Hospital, Regensburg, Germany
¹² Center for Rheumapathology, Johannes-Gutenberg-University, Mainz, Germany
¹³ Orthopedic Hospital, Göppingen, Germany
¹⁴ Institute für Pathology, University Hospital, Würzburg, Germany
¹⁵ Orthopedic Hospital König-Ludwig-Haus, University Hospital, Würzburg, Germany
¹⁶ Pathological-bakteriological Institute, SMZ Otto-Wagner-Spital, Wien, Austria
¹⁷ Department for Orthopedic Surgery, University Hospital, Hamburg, Germany
¹⁸ Institute for Pathology, Medical University of Lübeck, Germany
¹⁹ Orthopädisches Krankenhaus Schloss Werneck, Germany

Correspondence to:
Correspondence to:
Professor V Krenn
Charité University Hospital, Institute for Pathology, Schumannstrasse 20/21, D-10117 Berlin, Germany; veit.krenn{at}charite.de

Aims: The introduction of clearly defined histopathological criteria for a standardised evaluation of the periprosthetic membrane, which can appear in cases of total joint arthroplasty revision surgery.

Methods: Based on histomorphological criteria, four types of periprosthetic membrane were defined: wear particle induced type (detection of foreign body particles; macrophages and multinucleated giant cells occupy at least 20% of the area; type I); infectious type (granulation tissue with neutrophilic granulocytes, plasma cells and few, if any, wear particles; type II); combined type (aspects of type I and type II occur simultaneously; type III); and indeterminate type (neither criteria for type I nor type II are fulfilled; type IV). The periprosthetic membranes of 370 patients (217 women, 153 men; mean age 67.6 years, mean period until revision surgery 7.4 years) were analysed according to the defined criteria.

Results: Frequency of histopathological membrane types was: type I 54.3%, type II 19.7%, type III 5.4%, type IV 15.4%, and not assessable 5.1%. The mean period between primary arthroplasty and revision surgery was 10.1 years for type I, 3.2 years for type II, 4.5 years for type III and 5.4 years for type IV. The correlation between histopathological and microbiological diagnosis was high (89.7%), and the inter-observer reproducibility sufficient (85%).

Conclusion: The classification proposed enables standardised typing of periprosthetic membranes and may serve as a tool for further research on the pathogenesis of the loosening of total joint replacement. The study highlights the importance of non-infectious, non-particle induced loosening of prosthetic devices in orthopaedic surgery (membrane type IV), which was observed in 15.4% of patients.

Abbreviations: PE, polyethylene; PMMA, polymethyl methacrylate; TJA, total joint replacement

Keywords: total joint replacement; aseptic loosening; septic loosening; classification; histopathology

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• Del Pozo, J. L., Patel, R. (2009). Infection Associated with Prosthetic Joints. NEJM 361: 787-794 [Full Text]