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The Histological In-growth of Soft Tissue into the Nottingham Hood Prosthesis

The Histological In-growth of Soft Tissue into the Nottingham Hood Prosthesis. P Durani, I-H Jeon, TA McCulloch, A McLeod, WA Wallace Nottingham Shoulder & Elbow Unit Nottingham City Hospital. The Nottingham Hood. A polyester soft tissue reinforcement device

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The Histological In-growth of Soft Tissue into the Nottingham Hood Prosthesis

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  1. The Histological In-growth of Soft Tissue into the Nottingham Hood Prosthesis P Durani, I-H Jeon, TA McCulloch, A McLeod, WA Wallace Nottingham Shoulder & Elbow Unit Nottingham City Hospital

  2. The Nottingham Hood • A polyester soft tissue reinforcement device • Used as reinforcement for patients with shoulder arthroplasties complicated by medium or large tears of the rotator cuff (RCTs) • Introduced in 1987, number of modifications made since then • Used on a named patient basis for 10 years on humanitarian grounds – alternative option for patients with massive RCTs • 30 Nottingham Hoods inserted over the past 10 years

  3. Aim • Investigate the histological changes associated with the Nottingham Hood: • Amount of fibrous tissue ingrowth • Level of inflammatory reaction • How do the histological changes vary with length of time from implantation ?

  4. The Nottingham Hood Embroidered polyester – can be cut without fraying Middle Flange Posterior Flange Anterior Flange Holes for Hooks on stem

  5. Posterior Flange Sutured Humeral Stem Polyethylene Glenoid

  6. Method • 4 patients who have had shoulder prostheses with a Hood inserted for associated massive RCTs • Re-operations for various reasons • Excised material subject to histological analysis • Excised biopsy material obtained at: • 6 weeks, 5 months, 9 months and 14 years • Routine and polarised light microscopy has been used in all cases

  7. Results : Patient 1 • 87 yr old lady with severe arthritis; bilateral TSRs – satisfactory left TSR but unstable right TSR. • Suffered CVA, left sided hemi-plegia – became dependent on Right shoulder for ADLs • Right TSR revision: glenoid component removed, glenoplasty, humeral head relocated with a Nottingham Hood to retain it in position • Operated shoulder re-dislocated while nursing staff moving patient in bed • Re-op: glenoid reconstructed, Hood removed

  8. Polarised Light Microscopy: Patient 1 (at 6 weeks) Polyester material Thrombus

  9. High Power Microscopy : Patient 1 (at 6 weeks) Red blood cells Polyester material Fibrin

  10. Results : Patient 2 • 76 yr old lady with bilateral lower limb amputations after an accident at 17 years old • Severe arthritis of weight-bearing left shoulder : left TSR carried out • Several revisions: stabilised anteriorly with reinforcement from Nottingham Hood • Visualised at a re-operation 5 months later, and biopsy taken

  11. Intra-Op Macroscopic Features (at 5 months) Nottingham Hood In Situ Anterior flange of Hood

  12. Polarised Light Microscopy: Patient 2 (at 5 months) Fibrous tissue Polyester Material

  13. High Power Microscopy : Patient 2 (at 5 months) Collagen Fibrin Polyester material

  14. Results: Patient 3 • 73 year old man with severe arthritis, a complete rotator cuff tear and anterior dislocation of Left shoulder • Nottingham Hood inserted with a Left Neer prosthesis in 1989 • Revision operation 9 months later due to loose glenoid. Nottingham Hood removed at this time, and sent for histology.

  15. Routine Microscopy: Patient 3 (after 9 months) Fibrous tissue High Power: fibrous tissue ingrowth of polyester strands 4 strands ofpolyestermaterial

  16. Results: Patient 4 • 66 yr old with bilateral shoulder arthritis; right shoulder hemi-arthroplasty in 1988 • Co-existent massive RCT augmented with Nottingham Hood (early version) • Continued problems, Right revision hemi-arthroplasty in 2002 • Nottingham Hood (early version) removed and analysed; replaced with Nottingham Hood (latest version)

  17. Polarised Light Microscopy: Patient 4 (after 14 years) Surrounding Collagen Polyester material

  18. High Power Microscopy: Patient 4 (at 14 years) Fibrin Polyester fibres Fascia-like Collagen

  19. Masson-Trichome Stain : Patient 4 (after 14 years) Polyester Collagen

  20. Summary of Results

  21. Conclusion • Early organisational response to the insertion of the new material • Long-term incorporation into host tissues by fibrosis and scarring • Small fibrin and foreign body response lingers on • Suggests long-term implantation of polyester as reinforcement of RCTs is not associated with serious biological problems

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