Microvascular system of hip joint constituents with special reference to ultrastructural findings and early arteriosclerosis.

This study aimed to examine the ultrastructure of the arteries of the synovium, acetabular labrum, and ligamentum teres of the hip joint using light, scanning electron, and transmission electron microscopes to identify features of early arteriosclerosis. Tissues collected from three patients (under 40 years of age) with osteonecrosis of the femoral head were immersed in 8 N HCl at 60 °C for 20 min to digest collagen fibers for scanning electron microscopy. Tortuous arterioles and arteries were noted in the joint components, including the synovium, acetabular labrum, and ligamentum teres. The ultrastructure of the arterioles appeared normal; however, intimal thickening was found in most arteries. The thickened intima had abundant elastic fibers and many smooth muscle cells (which were of a synthetic phenotype because they had a few actin filaments and well-developed rough endoplasmic reticulum). This study illustrates that arteriosclerotic changes are present in tortuous arteries in the synovium, acetabular labrum, and ligamentum teres of the hip joint even from a relatively young age and suggests that meandering blood vessels may be the preferred foci of arteriosclerosis.

Histological evaluation of the acetabular labrum after bipolar hip hemiarthroplasty: a case report.

We report herein the microstructure of the acetabular labrum obtained from a patient with stem loosening but without bipolar cup migration who had undergone hemiarthroplasty for femoral neck fracture 18 years ago. We used light and scanning electron microscopy to investigate the influence of bipolar cup on acetabular labrum in vivo. Deparaffinized blocks were treated with 2 N NaOH to digest the cell matrix, allowing the collagen fibers, constituting the acetabular labrum, to be observed under scanning electron microscopy. Although chondrocyte atrophy was seen, the basic structure was not different from the normal tissue images of the elderly. However, in the deep part of the acetabular labrum, there was an area that was not stained with Alcian blue observed with light microscopy, and there was an amorphous tissue without type II collagen fibrils observed with scanning electron microscopy. These findings proved that the acetabular labrum has partially degenerated over the long term after bipolar hemiarthroplasty, and that the acetabular labrum can survive in vivo in such a condition. Given that hemiarthroplasty has a possibility to preserve the face-to-face tissue in the long term in vivo, it may be one of the valuable options for modern or future joint reconstruction surgery.

Three-dimensional architecture of the acetabular labrum in the human hip joint.

The acetabular labrum is frequently damaged with advancing age. As collagen fibers are the main sources of strength, knowledge of their ultrastructure is important to determine the cause of age-induced changes. We aimed to investigate the ultrastructure of collagen fibers constituting the acetabular labrum using scanning electron microscopy (SEM). Acetabular labrum samples obtained during total hip arthroplasty were studied. The samples were specially prepared to observe the steric construction of collagen fibrils constituting the acetabular labrum under light microscopy followed by SEM. The acetabular labrum was mostly composed of cartilage tissue, consisting of chondrocytes and collagen type II, with a layer of collagen type I. In adults, chondrocytes with a rich cytoplasm were surrounded by a dense network of fine type II collagen fibrils, and small bundles of type I collagen fibrils were interposed in the cartilage layer. In elderly individuals, the chondrocytes atrophied and both type I and II collagen fibrils were sparse. We suggest that cartilage has three to five layers, consisting of type I and type II collagen fibrils with a solid cartilage substrate. In elderly individuals, the density of chondrocytes decreases and the cellular shape and architecture of collagen fibrils also changes.

Morphofunctional and ultrastructural evaluation of hip joint development in human fetuses / Evaluación morfofuncional y ultraestructural del desarrollo de la articulación de la cadera en fetos humanos

SUMMARY: The normal sequential development of the hip joint (HJ) was considered for the evaluation of the morphological and ultrastructural aspects of the joint cartilage of the proximal femoral head epiphysis in human fetuses between 16 to 31 weeks of intra uterine life (IUL). Twenty human fetuses were fixed in 10 % formalin solution. Fetuses were divided into 4 groups (n=5): Group 1 (G1): 16-19 weeks IUL; Group 2 (G2): 20-23 weeks IUL; Group 3 (G3): 24-27 weeks IUL and Group 4 (G4): 28-31 weeks IUL. The right moieties of the HJ were subjected to light microscopy to determine the chondrocyte area, volume, and density and the extracellular matrix (ECM) density. The collagen component in ECM was qualitatively evaluated using Safranin-O and picrosirius techniques under polarized light. The left portions were analyzed using scanning electron microscopy (SEM). The advance of age revealed a gradual increase in chondrocyte area and volume and in ECM density, and a decrease in chondrocyte density. The apparent prevalence of type II collagen fibers in G1 and type III collagen fibers in G4, as well as a balance between type I and III collagen fibers in G2 and G3 suggest a process of cartilaginous evolution and repair. The pantographic organization of the collagen fiber meshes from the depth to the cartilage surface of the femoral head suggests that the arcade collagen network architecture starts at the fetal stage, regardless of the compressive forces applied. The morphological data may contribute not only to a better understanding of the maturation and cartilage organization in this area but also to serve as a theoretical basis for aspects related to diseases and joint malformations.

RESUMEN: El desarrollo secuencial normal de la articulación de la cadera (AC) se consideró para la evaluación de los aspectos morfológicos y ultraestructurales del cartílago articular de la epífisis proximal y de la cabeza femoral en fetos humanos entre 16 y 31 semanas de vida intrauterina (SVIU). Veinte fetos humanos fueron fijados en solución de formalina al 10 %. Los fetos se dividieron en 4 grupos (n = 5): Grupo 1 (G1), 1619 semanas de IUL; Grupo 2 (G2), 20-23 semanas SVIU; Grupo 3 (G3), 24-27 semanas SVIU y Grupo 4 (G4), 28-31 semanas SVIU. Las muestras derechas de la AC se sometieron a microscopía óptica para determinar el área, el volumen y la densidad de los condrocitos y la densidad de la matriz extracelular (MEC). El componente de colágeno en la MEC se evaluó cualitativamente utilizando técnicas de safranina-O y picrosirius bajo luz polarizada. Las muestras de la AC izquierda se analizaron utilizando microscopía electrónica de barrido (MEB). El avance de la edad reveló un aumento gradual en el área y el volumen de los condrocitos y en la densidad de la MEB, y una disminución en la densidad de los condrocitos. La aparente prevalencia de las fibras de colágeno tipo II en G1 y tipo III en G4, así como el equilibrio entre las fibras de colágeno tipo I y III en G2 y G3 sugieren un proceso de evolución y reparación cartilaginosa. La organización pantográfica de las mallas de fibra de colágeno desde la profundidad a la superficie del cartílago de la cabeza femoral sugiere que la arquitectura de la red de colágeno comienza en la etapa fetal, independientemente de las fuerzas compresivas aplicadas. Los datos morfológicos pueden contribuir no solo a una mejor comprensión de la organización de la maduración y el cartílago en esta área, sino también servir de base teórica para los aspectos relacionados con enfermedades y malformaciones articulares.

Exploring Active and Passive Contributors to Turnout in Dancers and Non-Dancers.

OBJECTIVE: Lower-extremity external rotation, or turnout, is a fundamental skill in dance. Active standing turnout has previously been measured using low-friction turnout disks. Turnout is influenced by passive range of motion (ROM) and strength, with passive ROM a function of bony morphology and ligamentous/capsular restraints. PURPOSE: Our study explored the relationship between standing active turnout and femoral bony morphology, hip passive ROM, and strength among dancers and non-dancers. METHODS: Cross-sectional cohort study. Twenty-three female dancers and 13 female non-dancers aged 18 to 30 yrs were recruited. Standing active turnout on reduced-friction disks, ultrasound images of femoral version, supine passive turnout, and hip abductor and external rotator strength were collected. RESULTS: Dancers demonstrated greater standing turnout (107° ± 18°) than non-dancers (92° ± 28°), but the difference was not statistically significant (p=0.054). A significant difference was found for femoral version (p<0.001), 4.7° ( ± 2.8°) for dancers vs 12.1° ( ± 4.6°) for non-dancers. Dancers demonstrated greater supine turnout, 102.7°±18.8°, compared to non-dancers, 84.3° ± 30.4° (p=0.031). Dancers were able to achieve greater peak force in turnout compared to non-dancers: 2.44 ± 0.44 N/kg and 1.72 ± 0.59 N/kg, respectively (p<0.0001). Supine total turnout was the best predictor of active turnout, contributing 48% of the variance (r=0.696, p<0.001). CONCLUSION: Our findings suggest supine turnout is the largest predictor for standing turnout. Investigating dancers and non-dancers independently, our finding were similar to previous studies suggesting the femoro-acetabular complex may be influenced by dance training, contributing to differences in bony morphology between dancers and non-dancers. Although strength did not significantly contribute to active standing turnout, dancers demonstrated greater peak force compared to non-dancers.

Could tendinosis be involved in osteoarthritis?

Ten patients, age 60 (48-75 years), with osteoarthritis (OA) of the hip and 10 patients, age 82.5 (60-90 years), with fracture of the collum femoris (FCF; minimum Garden stage III) underwent an open biopsy procedure from the internal obturator tendon in conjunction with a total hip replacement. The histological evaluation revealed that all tendon samples in the OA group revealed scar tissue; the corresponding was found in 50% of patients in the FCF group (P=0.02). There were also more GAGs (P=0.023) and calcium deposits (P=0.001) in the samples from the OA group. The ultrastructural evaluation revealed fewer small and medium-sized fibrils (P=0.001) and more non-collagenous extracellular matrix (ECM) (P=0.003) in the OA group. Taken together, the samples from the internal obturator tendon in the OA group revealed a more degenerative appearance with more scar tissue, change in fibril diameter distribution and more non-collagenous ECM. Our findings suggest that OA and periarticular tendinopathy are closely linked. Further research is needed to determine whether musculotendinous changes in the deep rotators are sequelae of joint pathology, or a contributing factor in the development of degenerative joint change.

Effects of simvastatin on osseointegration in a canine total hip arthroplasty model: an experimental study.

Simvastatin was recently demonstrated to stimulate bone morphogenetic protein-2 expression, leading to bone formation. The present study was designed to evaluate whether simvastatin administered by injection could promote osseointegration in a canine total hip arthroplasty model. Fifteen dogs were divided into 3 groups of 5 dogs each: group 1 (high-dosage simvastatin, 6.0 mg/[kg d]), group 2 (low-dosage simvastatin, 3.0 mg/[kg d]), and a control group (isotonic saline, 3.0 mg/[kg d]). Osseointegration was assessed by using the push-out test, scanning electron microscopy, energy-dispersive spectrometer microanalysis, and histomorphometric examination. The results showed higher mechanical strength, greater area of bone covering the femoral component, and higher bone-implant contact in group 1 than in the other 2 groups. Our findings indicate that simvastatin administered by injection could contribute significantly to osseointegration in a canine total hip arthroplasty model.

Polyethylene wear particles do not induce inflammation or gelatinase (MMP-2 and MMP-9) activity in fibrous tissue interfaces of loosening total hip arthroplasties.

In vitro and in vivo studies have suggested that polyethylene wear particles are the main cause for osteolysis in prosthetic loosening. Elevated amounts of proteases including gelatinases (or matrix metalloproteinases MMP-2 and MMP-9) have been found in fibrous tissue interfaces of loosened total hip arthroplasties suggesting that proteolysis plays a role in osteolysis. The presence of proteases does not mean that they are active, because activity of proteases is highly regulated at the post-translational level. We investigated whether the activity of two major proteases that are active extracellularly and have been associated with loosening, MMP-2 and MMP-9, is involved in loosening of non-cemented hip implants with polyethylene acetabular components. Eight interface tissues retrieved during revision were studied with light and electron microscopy and by in situ zymography to localize MMP-2 and MMP-9 activity in combination with immunohistochemistry to localize MMP-2 and MMP-9 proteins. All interface tissues contained large amounts of polyethylene wear particles, either in large accumulations or dispersed in the extracellular matrix or intracellularly in fibroblasts. Particles were not encountered in association with MMP-2 or MMP-9 activity or leukocytes. Inflammation was never found. MMP-9 activity was restricted to macrophages and MMP-2 activity was restricted to microvascular endothelial cells mainly outside areas where particles were present. Our data indicate that wear particles do not induce activation of leukocytes or MMP-2 or MMP-9 activity. Therefore, aseptic loosening may not be particle induced but initiated by other mechanisms such as mechanical stress.

Can ultrastructural particle location predict aseptic loosening? A biopsy study of nonloose hip implants one year postoperative using three bearing material combinations.

To find predisposing parameters for aseptic loosening the present study determined the ultrastructural morphology in the pseudosynovial membrane from non-loose hip arthroplasties to compare the intra- and extracellular distribution of wear particles one year after total hip replacement using three different bearing material combinations.A total of 37 patients from a larger prospective randomised trial of 225 patients had biopsies taken arthroscopically from the pseudosynovial membrane one year after insertion of identical endoprostheses except for the bearing materials, polyethylene-on-zirconia (n=15), alumina-on-alumina (n=13), and CoCr-CoCr (n=9), respectively. The granulomatous inflammation seen in biopsies from these well-fixated implants was qualitatively comparable to the pattern seen in aseptic loose implants. Wear particles were seen in the extracellular matrix and intracellularily in macrophages, fibroblasts, and in endothelial cells. It was not possible systematically to distinguish the morphology between the three groups, though in one patient with CoCr-CoCr bearing material necrotic tissue was seen and exclusively extracellular location was not found in this group. The transport mechanism may vary with these materials and particle number. At this initial stage after hip surgery, the present study did not provide evidence for different types of bearing materials having significant impact on ultrastructural morphology adjacent to hip arthroplasties within the first year after surgery.

Electron microscopic characteristics of beta2-microglobulin amyloid deposits in long-term haemodialysis.

The electron microscopic features of beta2-microglobulin amyloid, deposited in the synovial membrane, are presented and discussed. The patient, a 69-year-old woman underwent chronic hemodialysis for 3 years. Because of constant pain and destructive arthropathy, endoprosthesis of the hip joints were implanted. Extra- and intracellular filamentous-fibrillar amyloid deposits have been demonstrated in ultrathin sections. The extracellular amyloid deposits showed a loose, filamentous or fibrillar structure at the periphery and a dense central core. The loose, filamentous structure may represent an early stage of fresh, newly deposited beta2-microglobulin amyloid, while the condensed and fragmented amyloid filaments may be an advanced "mature" stage of amyloid deposition.

Ultrastructural cytochemical and ultrastructural morphological differences between human multinucleated giant cells elicited by wear particles from hip prostheses and artificial ligaments at the knee.

The authors investigated the ultrastructural cytochemical features of multinucleated and mononuclear cells in periprosthetic tissues associated with bone resorption (osteolysis) and those in tissues adjoining failed artificial ligaments having no relation to bone resorption. Clinical specimens of granulation tissue of each type, respectively numbering 4 and 3, were stained for tartrate-resistant acid phosphatase (TRAP) reactions and examined by light and electron microscopy. Both periprosthetic granulation tissues and those adjoining artificial ligaments contained TRAP-positive multinucleated and mononuclear cells. Near joint prostheses, multinucleated cells, including some giant cells, showed TRAP activity and cytoplasmic features resembling osteoclasts, while others had features consistent with foreign-body giant cells, and still others showed degenerative changes. Near artificial ligaments, TRAP-positive multinucleated cells lacked osteoclastic features. At both sites, TRAP-positive multinucleated cells had phagocytised wear particles. TRAP-positive mononuclear cells at both sites also showed phagocytic cytoplasmic features, but not osteoclastic cytoplasmic features. Human mononuclear phagocytes and multinucleated giant cells induced by wear particles possess TRAP activity. Those multinucleated giant cells at sites of osteolysis developed osteoclastic cytoplasmic features and have a phagocytic function.

Perinatal development of the rat hip joint with restrained fetal movement.

We compared the structures of the femoral head (FH) of neonates between normal and operated legs with restrained fetal movement using an exo utero technique. At embryonic day (E) 16.5, one hind limb was sutured onto the embryonic membrane and the fetuses were allowed to develop exo utero until the term (E22.5). There was no significant difference in the largest diameter of the FH between the non-operated and operated side FH in the operated neonates and the FH of the non-operated neonates. By scanning electron microscopy, roughness and collagen fiber bundles, which were detected on the surface of the operated side FH at E18.5, disappeared at E22.5. However, the operated side FH was deformed and the surface cell arrangement was more irregular than that of the controls at E22.5 by light microscopy. These results suggest that the abnormality of cell arrangement caused by the restraint of fetal movement may induce the deformity and irregularity of the FH surface, although this operation may not disturb the basic cellular activities such as cell proliferation as well as the secretion of cartilage ma-trix and collagen fibers. To further investigate the recovery process in the operated newborns after releasing the restraint, we bred them artificially for a considerable period after birth. The operated side FH surface of the neonate bred for 45 hours was smoother than that at E22.5 and similar to that of the non-operated side FH. This result suggests that the proper movement of the extremities after birth may recover the deformity caused by restrained fetal joint movement.

Back-scattered electron imaging of a non-vertebral case of hypervitaminosis A in a cat.

We describe a clinical case of hypervitaminosis A in a cat. The main lesions were bony fusions of both the hip and stifle joints, without spinal involvement. A post-mortem study using back-scattered scanning electron microscopy (BEI-SEM) revealed that exostoses had formed around the joints without articular surface involvement. The more recently formed areas of bony proliferation were composed mainly of chondroid tissue surrounded by different degrees of woven bone. As the bony reaction occurred, remodelling of the trabeculae was observed which lead to progressive substitution of chondroid tissue by woven bone surrounded by apposition of lamellar bone. No traces of calcified cartilage were observed in any of the bone sections evaluated.

Functional adaptation and ingrowth of bone vary as a function of hip implant stiffness.

The purpose of the present study was to test the hypothesis that cortical bone loss, trabecular bone density and the amount of bone ingrowth vary as a function of stem stiffness in a canine cementless hip replacement model. The study was motivated by the problem of cortical bone atrophy in the proximal femur following cementless total hip replacement. Two stem stiffnesses were used and both designs were identical in external geometry and porous coating placement. The high stiffness stem caused approximately 26% cortical bone stress-shielding and the low stiffness stem caused approximately 7.5% stress-shielding, as assessed by beam theory. Each group included nine adult, male canines who received unilateral arthroplasties for a period of six months. The animals with the low stiffness stems tended to lose less proximal cortical bone than the animals with high stiffness stems (4% +/- 9 as opposed to 11% +/- 14), but the difference was not statistically significant (p = 0.251). However, the patterns of bone ingrowth into the implant and change in medullary bone density adjacent to the implant were fundamentally different as a function of stem stiffness (p < 0.01). Most importantly, while the high stiffness group had peaks in these variables at the distal end of the stem, the low stiffness group had peak values proximally. These different patterns of functional adaptation are consistent with the idea that reduced stem stiffness enhances proximal load transfer.

[Flocking hip joint endoprosthesis]. / Flokirovannyi éndoprotez tazobedrennogo sustava.

The author indicates the similarity of a human tooth and an endoprosthesis in their action, which is the basis for developing a procedure of endoprosthesis and designing an endoprosthesis with dumping elements. The procedure has been developed during a long-term surgical experiment by examining the results by the following techniques: X-ray, bed testing, light and scanning electron microscope. Experimental results are convincing. For coating the prostheses, polytetrafluoroethylene velour is used in the experiment, but cauflene, the material of the same kind polytetrafluoroethylene, is employed in the clinical setting. The experiments yielded two inventions patented in the Russian Federation. This direction in their development seems to be fruitful in preventing the aseptic endoprosthetic instability that is the most common and severe complication after endoprosthesis and requires most frequently resurgery.

Application of numerical descriptors to the characterization of wear particles obtained from joint replacements.

The application of image analysis techniques to the characterization of wear particles from failed joint replacements has been described. Wear particles were extracted from periprosthetic tissues collected during revision surgery. Chemical digestive methods were used to separate the wear particles from the biological soft material. The particles isolated were examined by optical and scanning electron microscopy. Digitized particle images were analysed on a Macintosh computer by a specially developed software and by the image analysis program 'Prism'. The following numerical descriptors were used to characterize the particles: particle size, boundary fractal dimension and shape parameters such as form factor, roundness, convexity and aspect ratio. Elemental composition of the particles was determined by energy dispersive X-ray spectroscopy. Three selected types of wear particles were analysed and compared: titanium (Ti)-based and calcium (Ca)-based particles from a hip prosthesis and ultra-high molecular weight polyethylene (UHMWPE) particles from a knee prosthesis. The particles exhibited significantly different sizes and their shape numerical descriptors were also different. From the results obtained it appears that computer image analysis of wear particle morphology can be employed to determine the wear processes occurring in the joints. In some cases, the condition of the joint can also be assessed based on this analysis.

In vivo corrosion of cobalt-chromium and titanium wear particles.

Tissue reaction to wear particles from metal implants may play a major role in the aseptic loosening of implants. We used electron microprobe elemental analysis to determine the chemical composition of wear particles embedded in the soft tissues around hip and knee implants from 11 patients at revision surgery for aseptic loosening. The implants were made of cobalt-chromium-molybdenum alloy or titanium-aluminium-vanadium alloy. Histological examination showed a widespread giant-cell reaction to the particles. Elemental analysis showed that the chemical composition of the particles was different from that of the implanted alloys: cobalt and titanium were reduced, often down to zero, whereas chromium and aluminium persisted. Our findings indicate that corrosion is continually changing the shape, size and chemical composition of the implanted alloy. This may alter the biochemical environment of the tissue surrounding an implant to favour bone resorption.

Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement.

Wear particles from thirty-five membranes obtained during revision hip-replacement operations were studied after digestion of the soft tissue with papain. The particles were isolated and were characterized with use of light and scanning electron microscopic techniques, x-ray microanalysis, and an automated particle analyzer. The mean size of the polyethylene particles was 0.5 micrometer, and the metal particles were a mean of 0.7 micrometer, as determined with scanning electron microscopy. The automated particle analyzer revealed a mean particle diameter of 0.63 micrometer (more than 90 per cent of all particles were less than 0.95 micrometer) and a mean of 1.7 billion particles per gram of tissue, compared with only 143 million per gram of tissue for the control samples. X-ray microanalysis revealed metal debris in sixteen (46 per cent) of the thirty-five membranes after digestion. Thirteen (50 per cent) of the twenty-six membranes surrounding a titanium-alloy stem contained metal particles, compared with three of the nine membranes surrounding a chromium-cobalt stem. Metal debris was present in only one of the twelve membranes surrounding a titanium-alloy stem without a porous coating, compared with twelve of the fourteen membranes surrounding a titanium-alloy stem with a porous coating. This tenfold difference in prevalence was significant (p < 0.005). On the average, the total number of particles (expressed in millions per gram of tissue) associated with the bipolar acetabular components was twice that associated with the fixed acetabular components. In addition, there was a trend toward a larger mean size of the polyethylene particles in association with the bipolar cups. Our data indicate that particulate prosthetic debris in the tissues around failed femoral components that have been inserted without cement constitutes a class of particles that are predominantly less than one micrometer in size and are present in amounts of more than one billion particles per gram of tissue. Routine histological methods did not detect this class of wear debris and led to a gross underestimation of the amount of debris in these membranes.

Quantitative assessment of cartilage surface roughness in osteoarthritis using high frequency ultrasound.

Osteoarthritis (OA) is a common disease which affects nearly 50% of people over age 60. Histologic evaluation suggests that fibrillations approximately 20-150 microns are among the earliest changes in the articular cartilage. We propose a technique to quantify these surface fibrillatory changes in osteoarthritic articular cartilage by considering the angular distribution of the envelope-detected backscattered pressure field from an incident 30-MHz focused transducer. The angular distribution of the scattered acoustic field from an inosonifying source will directly relate to the distribution of surface fibrillatory changes. Data are presented for three different grades (400, 500 and 600 grit) of commercially available emory paper and three samples of osteoarthritic femoral head articular cartilage, which were visually assessed as having smooth, intermediate and rough surfaces, respectively. Our preliminary results indicate a probable monotonic relationship between articular cartilage roughening and the degree of broadening in the angle-dependent pressure amplitude. When applied to the emory paper, the technique indicates sensitivity to differences as small as approximately 5-10 microns in mean roughness. This procedure may provide an extremely sensitive and reproducible means of quantifying and following the cartilage changes observed in early osteoarthritis.

Tissue response in relation to type of wear particles around failed hip arthroplasties.

To establish the types of wear particles and associated tissue response around human prostheses the periprosthetic tissues around 50 hip arthroplasties revised for aseptic loosening of one or more components were examined by light microscopy, transmission electron microscopy, and energy-dispersing x-ray microanalysis. The tissues around cementless metal-on-bone and ceramic-on-ceramic prostheses contained few or no prosthesis wear particles. The tissues around metal-on-metal prostheses contained large numbers of metal particles and large numbers of macrophages, and occasional multinucleate giant cells. The tissues around cemented metal-on-polyethylene prostheses often contained large numbers of small and large polyethylene particles, variable numbers of cement particles, and occasional metal particles. Large numbers of macrophages and multinucleate giant cells were frequently seen in these tissues. Lymphocytes were occasionally seen in association with metal particles. Ultrastructural studies of the periprosthetic tissues confirmed the phagocytosis of submicroscopic wear particles by macrophages. Varying degrees of degenerative change in macrophages were seen in association with phagocytosis of metal particles. Large numbers of cytolysosomes were seen in cells in association with the accumulation of wear particles.