STUDY: Destructive Arthritis Due to Silicone: A Foreign-Body Reaction

STUDY: Destructive Arthritis Due to Silicone: A Foreign-Body Reaction

EXCERPT: Pathologically, the lesions seen in
these patients may be described as neactive
giant-cell synovial papillary
hyperplasia with a mild mononuclear
cell infiltrate; the foreign-body reaction
may extend into bone and articular
cartilage, causing extensive destruction.


* breastimplantawareness.blogspot . com

w w w .BreastImplantAwareness.org/

* radiology.rsnajnls.org/cgi/reprint/149/1/69.pdf


Daniel I. Rosenthal, M.D.
Andrew E. Rosenberg, M.D.
Alan L. Schiller, M.D.
Richard J. Smith, M.D.
Destructive Arthritis Due to Silicone:
A Foreign-Body Reaction1
The authors report 3 cases of erosive anthritis
resulting from a foreign-body reaction
to a silicone implant in the wrist.
No patient had a history of inflammatory
arthritis. Radiographic changes included
well-defined lytic lesions with thin,
sclerotic margins, normal mineralization,
and loss of volume of the implant. Pathologically,
a destructive foreign-body reaction
was seen, with intra- and extracellular
silicone debris.
Index terms: Arthritis (Wrist and hand,
miscellaneous joint disorder, 43.780) #{14H9}and,
prosthesis, 43.454 #{14P9}rostheses #{14S9}ilicone #{14W9} rist,
prosthesis, 43.454
Radiology 149: 69-72, October 1983
1 From the Departments of Radiology (DIR.), Pathology
(A.E.R., A.L.S.), and Orthopaedics (R.J.S.),
Massachusetts General Hospital, Boston, Mass. Received
Dec. 21, 1982 and accepted March 31, 1983. sjh
S UBCUTANEOUS silicone implants are widely used in plastic surgery
for facial and breast neconstructions (1) and in orthopedic surgery
for reconstruction of the small joints of the hand and wrist (2),
carpal
replacement, and preparation of a soft-tissue bed for tendon grafts
and transfers. Overall results have been good; intact solid implants
are tolerated well by the body, usually eliciting only fibrous
encapsulation
and a mild foreign-body reaction (3, 4). However, several
authors have recently described severe giant-cell reactive synovitis
and lymphadenitis due apparently to shedding of silicone particles
(5-10) and manifested as recurrent pain and synovial thickening (5,
10), erythema about the involved joint (7), painful limitation of
motion
(9), and/or non-tender axillary adenopathy (7, 8) beginning four
months to several years after implantation. While fracture and
dislocation
of the prosthesis have been described (9), changes in the
adjacent bones have not been reported to our knowledge. We report
3 cases in which a silicone carpal implant produced severe
hyperplastic
synovitis, resulting in striking destructive arthritis.
CASE REPORTS
CASE I: This right-handed 17-year-old girl initially presented with
pain
and slight “morning stiffness” in her left wrist. Her other joints
were normal,
and her medical history was unremarkable. Radiographs taken in 1974
had
revealed an ulnar-minus variant and typical changes of osteonecrosis
of the
lunate (Kienb#{246}ck disease), prompting insertion of a lunate
implant made of
high-performance silicone (Silastic, Dow Corning) in 1975. There were
no
complications, and the patient did well for several years; however,
symptoms
developed insidiously over the next three or four years. In 1979 she
returned
complaining of pain near the ulnar styloid as well as clicking sounds
on
flexion and extension. Radiographs taken at that time (not shown)
demonstrated
flattening of the lunate implant compared to the postoperative views,
and multiple small lucent defects with thin, sclerotic margins were
seen in
the carpals, radial and ulnar styloids, and proximal metacarpals. The
soft
tissues appeared normal. In retrospect, early manifestations of this
process
were seen on radiographs taken in 1976 (not shown). On the present
admission,
6 years after surgery, further fragmentation of the implant was seen,
and
the cyst-like changes of the carpals, metacarpals, and distal radius
and ulna
were larger and more prominent (Fig. 1). On examination, the patient
was
afebrile and had a normal white cell count. Surgery revealed marked
synovial
hypertrophy with invasion of the scaphoid, capitate, and triquetrum.
The
scaphoid was broken into two pieces, and the implant was deformed,
flattened,
and deep yellow rather than its original opalescent white. The
prosthesis
was excised along with the proximal carpals and the synovium of the
wrist. Pathological examination revealed fragments of the fibrotic and
hyperplastic
papillary synovium as well as numerous multinucleated giant cells
containing pale yellow foreign bodies which were finely to coarsely
granular
and slightly refractile, consistent with silicone; these were
accompanied by
scattered plasma cells and lymphocytes. Large extracellular aggregates
of
silicone particles were also found embedded in fibrous tissue or
fibrin. The
foreign-body reaction had extensively permeated and destroyed the
cortical
and medullary bone and articular cartilage by means of subarticular
extension
and pannus formation.
CASE II: This 30-year-old woman had experienced 2 years of progresa.
b. C.
Figure 1. Case I.
70 #{1R49a}diology October 1983
d. C.
a. Initial radiograph demonstrating changes of Kienb#{246}ck
osteonecrosis. The lunate is flattened and abnormally dense and the
articular surface
is irregular.
b. Radiograph taken following replacement of the lunate by a silicone
implant. The rest of the wrist is normal.
C. Radiograph taken 6 years after implant surgery shows extensive
cortical erosion of the carpal bones and radial styloid as well as
cyst-like
lucent intraosseous defects with thin, sclerotic borders (arrow). The
first carpometacarpal joint, which is surrounded by a separate
synovial
space, is spared. The volume of the implant is markedly diminished.
d. Low-power view (100X) shows destruction of articular cartilage by
pannus containing foreign-body giant cells, a reaction to Silastic
particles
(arrow).
e. Higher-power view (250X) reveals histiocytes and giant cells
containing Silastic particles (arrow), as well as abundant
extracellular aggregates
surrounded by dense fibrous tissue.
sive pain and immobility of the right wrist
following a fall in 1973 but had no other
articular complaints. Radiographs showed
changes typical of Kienb#{246}ck disease of the
lunate (Fig. 2, a). Because of her progressive
disability, the lunate was replaced with a
Silastic prosthesis in May 1975 (Fig. 2, b).
There were no complications; however, in
February 1982 she returned complaining of
9 months of progressive enlargement of a
mildly tender soft-tissue mass contiguous
with the triquetrum and ulnar region of the
right wrist. Clinically, the lesion was mitially
thought to be a ganglion; however,
radiographs revealed progressive loss of
volume of the implant inserted 7 years
earlier. Multiple lucent defects with welldefined
thin, sclerotic margins, similar to
those seen in CASE I, were present in the
carpal bones; however, the soft-tissue mass
could not be seen on the radiograph (Fig. 2,
c). At surgery, a solid, yellowish brown
mass extending into the wrist joint was excised.
Microscopic examination revealed
hyperplastic papillary synovial tissue and
several foreign-body giant cells containing
phagocytized granular, slightly refractile
silicone particles. A mild lymphocytic and
plasma-cell infiltrate was also present, and
there were prominent extracellular collections
of Silastic particles encompassed by
fibrin or reactive fibrous tissue. Arthrography
showed that the synovium had a
markedly corrugated, nodular margin,
characteristic of general hyperplasia (Fig.
2, d). A second operation was performed to
remove the implant, which appeared to
have partly collapsed, and an intercarpal
arthrodesis was performed. Proliferative
synovitis was found to be present at surgery.
CASE III: This 59-year-old woman injured
her right wrist in August 1975, producing
pain which lasted for 7 months. At
that time, osteonecrosis of the lunate was
diagnosed radiographically (Fig. 3, a). Her
history was unremarkable, and she had no
C. d.
a. Preoperative radiograph taken two years after initial trauma
demonstrates osteonecrosis
of the lunate. The other bones are normal.
b. Radiograph taken following replacement of the lunate by a silicone
prosthesis. The rest
of the wrist is normal.
C. Seven years later, multiple cyst-like lucent defects and cortical
erosions involving the
scaphoid, triquetrum, and pisiform bone can be seen (arrows). The
volume of the implant
has diminished, suggesting shedding of silicone into the joint.
d. Arthrogram taken prior to removal of the implant demonstrates
nodular, irregular synovium,
consistent with hyperplasia.
Figure 2. Case II.
Volume 149 Number I Radiology #{14791}
other articular complaints. The lunate was
replaced in March 1976, using a Silastic
prosthesis (Fig. 3, b). There were no complications;
however, the patient was seen
again in September 1981 because of progressive
pain and loss of grip strength. Radiographs
taken at that time demonstrated
volar shift of the prosthesis and progressive
intercarpal collapse (Fig. 3, c and d). Multiple
lucent defects with thin, sclerotic
margins were noted within the triquetrum;
in addition, there were erosions of the ulnar
styloid which were not present on earlier
radiographs. The joint spaces were intact,
and there was no regional demineralization.
At surgery, the lunate was flattened,
deformed, and yellow, and there was extensive
synovial thickening within the
wrist. The implant was removed and a wrist
arthrodesis performed using cancellous
bone from the iliac crest.
DISCUSSION
To date, we know of 14 reported
cases of foreign-body giant-cell reactive
synovitis, including our 3 cases.
There have been 1 1 female patients and
3 males, which may simply reflect the
greater propensity of females to suffer
from rheumatoid arthritis and therefore
to require prostheses. In previous
reports, a history of rheumatoid anthnitis
may have obscured recognition
of destructive bone changes attributable
to silicone implantation and the
resultant reactive synovitis. Aptekar et
a!. have noted that symptoms produced
by a foreign-body reaction may be
mistaken for recurrence of rheumatoid
disease (5), and it would be reasonable
to ascribe progressive bone destruction
to the same cause. None of our patients
had inflammatory arthritis, so that the
destructive anthropathy must have
been a result of the reactive synovitis.
Although these lesions appear to be
rare, the frequency will likely increase
as more patients have implants in place
for longer periods of time. In addition
to the 3 cases reported here, we have
seen pathological material from 4 other
patients with foreign-body giant-cell
synovitis caused by silicone particles,
but without radiographic evidence of
bone destruction.
Pathologically, the lesions seen in
these patients may be described as neactive
giant-cell synovial papillary
hyperplasia with a mild mononuclear
cell infiltrate; the foreign-body reaction
may extend into bone and articular
cartilage, causing extensive destruction.
Giant cells containing phagocytized
Silastic particles are abundant, as
well as large extnacellulan collections of
particles. The silicone is recognizable
morphologically as pale yellow, faintly
refractile, non-birefringent particles of
varying size, which is related to
pathogenesis: in experimental animals,
particles measuring 0.001-1.5 mm3
produced a foreign-body response, but
larger pellets did not (10). Particles may
migrate for considerable distances,
being recognizable in intraosseous
locations remote from the prosthesis
(9) and in regional lymph nodes
(7).
Radiographically, the destructive
arthritis is characterized by well-defined
lytic areas, sometimes demarcated
by thin, sclerotic walls. Demineralization
is not prominent, and the joint
spaces are preserved until late in the
course of the disease. Although the
appearance is suggestive of multiple
cysts, the lytic bone lesions are filled
with hyperplastic synovial tissue. Since
the articular cartilage is intact, entry of
synovium into the bone presumably
occurs via vascular channels. The resulting
pattern is strikingly similar to
pigmented villonodular synovitis,
which has been thought by some to
represent a reaction to unknown
stimuli (11), but pathologically there is
no similarity.
CONCLUSION
These cases demonstrate another
potential complication of silicone implants.
Radiologists and orthopedic
surgeons should be aware that erosive
bone lesions developing in a patient
with a silicone implant may be the resuit
of a foreign-body reaction, especiafly
if the patient has no history of
inflammatory arthritis and if radiographs
show fragmentation or loss of
volume of the implant.
Figure 3. Case III. References
72 #{1R49a}diology October 1983
1. Davis PKB, Jones SM. The complications of
Silastic implants. Experience with 137 consecutive
cases. Br J Plast Surg 1971; 24:
405-411.
2. Swanson AB. Flexible implant arthroplasty
for arthritic finger joints: rationale, technique.
and results of treatment. J Bone Joint
Surg [Am] 1972; 54:435-455.
3. Swanson AB. Complications of silicone
elastomer prostheses. Letter to the editor.
JAMA 1977; 238:939.
4. Jakubik J, Trejbal J, Hasman L, Kluz#{225}kR,
Poupa J. Application of silicone implants
in plastic surgery in Czechoslovakia. Acta
Chir Plast (Praha) 1976; 18:169-175.
5. Aptekar RG, Davie JM, Cattell HS. Foreign
body reaction to silicone rubber. Complication
of a finger joint implant. Clin Orthop
1974; 98:231-232.
6. Ferlic DC, Clayton ML, Holloway M.
Complications of silicone implant surgery
in the metacarpophalangeal joint. J Bone
Joint Surg [Am] 1975; 57:991-994.
b. 7. Christie AJ, Weinberger KA, Dietrich M.
Silicone lymphadenopathy and synovitis.
Complications of silicone elastomer finger
joint prostheses. JAMA 1977; 237:1463-
1464.
8. Kircher T. Silicone lymphadenopathy: a
complication of silicone elastomer finger
joint prostheses. Hum Pathol 1980; 11:
240-244.
9. Gordon M, Bullough PG. Synovial and osseous
inflammation in failed silicone-rubber
prostheses. J Bone Joint Surg [Am] 1982;
64:574-580.
10. Worsing RA Jr. Engber WE, Lange TA.
Reactive synovitis from particulate Silastic.
J Bone Joint Surg [Am] 1982; 64:581-585.
11. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented
villonodular synovitis, bursitis and
tenosynovitis. A discussion of the synovial
and bursal equivalents of the tenosynovial
lesion commonly denoted as xanthoma,
xanthogranuloma, giant cell tumor or
d. myeloplaxoma of the tendon sheath, with
some consideration of this tendon sheath
itself. Arch Pathol 1941: 31:731-765. a. Preoperative radiograph shows
osteonecrosis of the lunate.
b. Radiograph taken following replacement of the lunate by a silicone
prosthesis.
C and d. AP (C) and oblique radiographs (d) taken 5 years later
demonstrate collapse of the Department of Radiology
implant as well as erosions and cysts involving the triquetrum (large
arrow) and ulnar Research Office
Massachusetts General Hospital
styloid (small arrow). Fruit St.
Boston, Mass. 02114