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Zhong Q, Pan X, Chen Y, Lian Q, Gao J, Xu Y, Wang J, Shi Z, Cheng H. Prosthetic Metals: Release, Metabolism and Toxicity. Int J Nanomedicine 2024; 19:5245-5267. [PMID: 38855732 PMCID: PMC11162637 DOI: 10.2147/ijn.s459255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
The development of metallic joint prostheses has been ongoing for more than a century alongside advancements in hip and knee arthroplasty. Among the materials utilized, the Cobalt-Chromium-Molybdenum (Co-Cr-Mo) and Titanium-Aluminum-Vanadium (Ti-Al-V) alloys are predominant in joint prosthesis construction, predominantly due to their commendable biocompatibility, mechanical strength, and corrosion resistance. Nonetheless, over time, the physical wear, electrochemical corrosion, and inflammation induced by these alloys that occur post-implantation can cause the release of various metallic components. The released metals can then flow and metabolize in vivo, subsequently causing potential local or systemic harm. This review first details joint prosthesis development and acknowledges the release of prosthetic metals. Second, we outline the metallic concentration, biodistribution, and elimination pathways of the released prosthetic metals. Lastly, we discuss the possible organ, cellular, critical biomolecules, and significant signaling pathway toxicities and adverse effects that arise from exposure to these metals.
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Affiliation(s)
- Qiang Zhong
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Xin Pan
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yuhang Chen
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Qiang Lian
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Gao
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yixin Xu
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Hao Cheng
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, People’s Republic of China
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Lützner J, Beyer F, Lützner C, Tille E, Postler AE. A Novel Multilayer-Coating for Total Knee Arthroplasty Implants is Safe - 10-Year Results From a Randomized-Controlled Trial. J Arthroplasty 2023; 38:90-95.e1. [PMID: 35921997 DOI: 10.1016/j.arth.2022.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This randomized-controlled trial was initiated to compare a new multilayer hypoallergenic coating system with the standard implant in total knee arthroplasty (TKA) in terms of serum metal ion levels, patient-reported outcomes (PROs), and implant survival. METHODS A total of 120 patients were randomized to receive a coated or standard TKA of the same knee system. Serum metal ion levels (ie, cobalt, chromium, molybdenum, and nickel) as well as knee function (Oxford Knee Score, OKS), quality of life (SF-36), and physical activity (UCLA activity scale) were assessed before surgery and until the 10 year follow-up. A total of 24 patients died and there was one revision in each group. This resulted in 85 patients who completed follow-up. RESULTS Both groups demonstrated equally good improvement in PROs after surgery and constant score values thereafter. The majority of patients had metal ion serum levels below detection limit. Only cobalt levels demonstrated a slight increase in the standard group at 5- and 10-year follow-up. However, all patients displayed values below 3 μg/L. The cumulative 10-year survival was 98% in both groups. CONCLUSION There were no problems with the new coating system. No relevant increase in metal ion serum levels were measured. A slight increase in cobalt serum levels in the standard TKA was noted, thus not reaching critical values. The new coating system demonstrated equally good PROs as the standard TKA. Excellent implant survival was observed in both groups. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Jörg Lützner
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Dresden, Germany
| | - Cornelia Lützner
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Dresden, Germany
| | - Eric Tille
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Dresden, Germany
| | - Anne Elisabeth Postler
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Dresden, Germany
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Clinical Outcomes, Metal Ion Levels, Lymphocyte Profiles, and Implant Survival Following Five Different Bearings of Total Hip Arthroplasty: A Mean 10-year Follow-up Study. J Arthroplasty 2022; 37:2053-2062. [PMID: 35490981 DOI: 10.1016/j.arth.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/15/2022] [Accepted: 04/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Different bearings have been used in total hip arthroplasty (THA), but the long-term performance is still controversial. The purpose of this study was to investigate whether there are differences when comparing THAs with 5 different bearings at a long-term follow-up of more than 10 years. METHODS From January 2010 to May 2012, 101 THA patients (134 hips) were divided into metal-on-metal group (MoM, 31 hips), metal-on-polyethylene group (MoP, 23 hips), ceramic-on-metal group (CoM, 21 hips), ceramic-on-ceramic group (CoC, 33 hips), and ceramic-on-polyethylene group (CoP, 26 hips). The mean follow-up period was 10.3 years. The Harris hip score (HSS), Western Ontario and McMaster Universities Osteoarthritis Index scores (WOMAC), range of motion (ROM), blood cell count, and liver-kidney function were measured. Serum and urine metal ion levels were measured using high-resolution inductively coupled plasma-mass spectrometry (ICP-MS) and a blood lymphocytes analysis was counted by flow cytometry. RESULTS No difference was observed in the HSS, WOMAC, ROM, blood cell count, or liver-kidney function among any of the 5 groups. Metal ion levels were significantly elevated in metal-containing bearings. Flow cytometry showed that no differences were found. Revision was performed due to pseudotumor in 3 patients. The implant survival rate was 96.7% and 93.3% for the MoM and CoC groups, which was significantly lower compared with other groups. CONCLUSIONS Metal ion levels were elevated significantly in metal-containing bearings, especially in MoM THA patients. The implant survival rate was significantly lower in CoC and MoM THAs, which was mainly due to pseudotumor formation. LEVEL OF EVIDENCE Therapeutic Level II.
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Abdel Hamid OI, Attia ME, Hirshon JM, El-Shinawi M, El-Hussaini M, El-Setouhy M. Psychiatric Disorders and Genotoxicity Following Primary Metal on Polyethylene Total Hip Arthroplasty and Their Correlation to Cobalt/Chromium Levels. Drug Healthc Patient Saf 2022; 14:97-111. [PMID: 35880007 PMCID: PMC9308046 DOI: 10.2147/dhps.s360643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Hip arthroplasty (HA) using implantable metal components is among the commonest orthopedic interventions. However, it can be followed by several complications following corrosion and the release of metal ions. Several studies proved that damaged genomic DNA may contribute to the pathophysiology of mental disorders. Aim The current work aims to evaluate the psychiatric disorders in metal on polyethylene hip arthroplasty (MOP-HA) patients and its correlation to cobalt/chromium (Co/Cr) levels and genotoxicity. Methods The work was a longitudinal follow-up study including 34 adults with unilateral primary MOP-HA meeting the inclusion and exclusion criteria. Preoperatively, 6, 12-months-postoperatively, patients were examined for cognitive impairment using mini-mental-state-examination (MMSE), depression using major-depressive-inventory (MDI), and blood samples were collected for estimation of Co/Cr, detection of genotoxicity by single-cell-gel-electrophoresis (comet assay) and serum 8-hydroxy-2'-deoxyguanosine (8-OHdG). Results Cognitive impairment was reported in 18.5% and 14.8% at 6-months, and 12-months postoperative, respectively. Depressive disorder was recorded in 22.2% at 6-months and 14.8% at 12-months postoperative. The marginal homogeneity tests proved a non-significant difference. There was a non-significant difference in preoperative, 6-months, 12-months postoperative MMSE, and MDI scores. There were significantly increased Co/Cr levels at 6-months postoperative. The levels decreased at 12-months postoperative, however, still significantly higher than preoperative values. There was a significant increase in serum 8-OHdG and the levels were positively correlated to cobalt levels at both 6 and 12-months-postoperative. There was a non-significant difference among preoperative, 6-months, and 12-months postoperative comet assay measurements. Conclusion From previous findings, we can conclude that will-functioning MOP hip arthroplasty can induce increased ion levels and positively correlated increase in biochemical markers of genotoxicity (8-OHdG).
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Affiliation(s)
- Omaima I Abdel Hamid
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed E Attia
- Orthopedics Departments, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Jon M Hirshon
- Department of Emergency Medicine, University of Maryland, School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Mohamed El-Shinawi
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Galala University, Galala City, Suez, Egypt
| | - Moustafa El-Hussaini
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Maged El-Setouhy
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Family and Community Medicine, Faculty of Medince, Jazan University, Jazan, Kingdom of Saudi Arabia
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Holy CE, Zhang S, Perkins LE, Hasgall P, Katz LB, Brown JR, Orlandini L, Fessel G, Nasseri-Aghbosh B, Eichenbaum G, Egnot NS, Marcello S, Coplan PM. Site-specific cancer risk following cobalt exposure via orthopedic implants or in occupational settings: A systematic review and meta-analysis. Regul Toxicol Pharmacol 2021; 129:105096. [PMID: 34896478 DOI: 10.1016/j.yrtph.2021.105096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
In 2020, the European Commission up-classified metal cobalt as Class 1B Carcinogen (presumed to have carcinogenic potential) based primarily on data from rodent inhalation carcinogenicity studies. This up-classification requires an assessment under the Medical Device Regulations of cobalt cancer risk from medical devices. We performed a systematic review and meta-analysis to evaluate site-specific cancer risks with cobalt exposure from either total joint replacement (TJR) or occupational exposure (OC). Results were stratified by exposure type (OC or TJR), exposure level (metal-on-metal (MoM) or non-MoM), follow-up duration (latency period: <5, 5-10 or >10 years), and cancer incidence or mortality (detection bias assessment). From 30 studies (653,104 subjects, average 14.5 years follow-up), the association between TJR/OC and cancer risk was null for 22 of 27 cancer sites, negative for 3 sites, and positive for prostate cancer and myeloma. Significant heterogeneity and large estimate ranges were observed for many cancer sites. No significant increase in estimates was observed by exposure level or follow-up duration. The current evidence, including weak associations, heterogeneity across studies and no increased association with exposure level or follow-up duration, is insufficient to conclude that there exists an increased risk for people exposed to cobalt in TJR/OC of developing site-specific cancers.
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Affiliation(s)
- Chantal E Holy
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, United States.
| | - Shumin Zhang
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, United States
| | - Laura E Perkins
- Abbott Vascular, 3200 Lakeside Dr, Santa Clara, CA, 95054, United States
| | | | - Laurence B Katz
- LifeScan Global Corporation, 20 Valley Stream Parkway, Malvern, PA, 19355, United States
| | - Jason R Brown
- Medtronic PLC, 8200 Coral Sea St NE, Minneapolis, MN, 55112, United States
| | - Luca Orlandini
- Smith and Nephew, Oberneuhofstasse 10D, 6340, Baar, Switzerland
| | - Gion Fessel
- Smith and Nephew, Oberneuhofstasse 10D, 6340, Baar, Switzerland
| | | | - Gary Eichenbaum
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, United States
| | - Natalie S Egnot
- Cardno ChemRisk, 20 Stanwix St, Pittsburgh, PA, 15222, United States
| | | | - Paul M Coplan
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, United States; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, United States
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Eichenbaum G, Wilsey JT, Fessel G, Qiu QQ, Perkins L, Hasgall P, Monnot A, More SL, Egnot N, Sague J, Marcello S, Connor K, Scutti J, Christian WV, Coplan PM, Wright J, Hastings B, Katz LB, Vreeke M, Calistri-Yeh M, Faiola B, Purushothaman B, Nevelos J, Bashiri M, Christensen JB, Kovochich M, Unice K. An integrated benefit-risk assessment of cobalt-containing alloys used in medical devices: Implications for regulatory requirements in the European Union. Regul Toxicol Pharmacol 2021; 125:105004. [PMID: 34256083 DOI: 10.1016/j.yrtph.2021.105004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 05/27/2021] [Accepted: 07/09/2021] [Indexed: 11/15/2022]
Abstract
In 2017, the European Union (EU) Committee for Risk Assessment (RAC) recommended the classification of metallic cobalt (Co) as Category 1B with respect to its carcinogenic and reproductive hazard potential and Category 2 for mutagenicity but did not evaluate the relevance of these classifications for patients exposed to Co-containing alloys (CoCA) used in medical devices. CoCA are inherently different materials from Co metal from a toxicological perspective and thus require a separate assessment. CoCA are biocompatible materials with a unique combination of properties including strength, durability, and a long history of safe use that make them uniquely suited for use in a wide-range of medical devices. Assessments were performed on relevant preclinical and clinical carcinogenicity and reproductive toxicity data for Co and CoCA to meet the requirements under the EU Medical Device Regulation triggered by the ECHA re-classification (adopted in October 2019 under the 14th Adaptation to Technical Progress to CLP) and to address their relevance to patient safety. The objective of this review is to present an integrated overview of these assessments, a benefit-risk assessment and an examination of potential alternative materials. The data support the conclusion that the exposure to CoCA in medical devices via clinically relevant routes does not represent a hazard for carcinogenicity or reproductive toxicity. Additionally, the risk for the adverse effects that are known to occur with elevated Co concentrations (e.g., cardiomyopathy) are very low for CoCA implant devices (infrequent reports often reflecting a unique catastrophic failure event out of millions of patients) and negligible for CoCA non-implant devices (not measurable/no case reports). In conclusion, the favorable benefit-risk profile also in relation to possible alternatives presented herein strongly support continued use of CoCA in medical devices.
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Affiliation(s)
- Gary Eichenbaum
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA
| | - Jared T Wilsey
- Smith & Nephew, 1450 E Brooks Rd, Memphis, TN, 38116, USA
| | - Gion Fessel
- Smith & Nephew, Oberneuhofstasse 10D, 6340, Baar, Switzerland
| | - Qing-Qing Qiu
- Stryker, 2825 Airview Boulevard, Kalamazoo, MI, 49002, USA
| | - Laura Perkins
- Abbott Vascular, 3200 Lakeside Dr, Santa Clara, CA, 95054, USA
| | | | - Andrew Monnot
- Cardno ChemRisk, 235 Pine Street Suite 2300, San Francisco, CA, 94104, USA
| | - Sharlee L More
- Cardno ChemRisk, 6720 S Macadam Ave Suite 150, Portland, OR, 97219, USA
| | - Natalie Egnot
- Cardno ChemRisk, 20 Stanwix Street Suite 505, Pittsburgh, PA, 15222, USA
| | - Jorge Sague
- Stryker, 2825 Airview Boulevard, Kalamazoo, MI, 49002, USA
| | | | - Kevin Connor
- Boston Scientific, 100 Boston Scientific Way, Marlborough, MA, 01752, USA
| | - James Scutti
- Boston Scientific, 100 Boston Scientific Way, Marlborough, MA, 01752, USA
| | | | - Paul M Coplan
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - John Wright
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA
| | - Bob Hastings
- Johnson & Johnson, 410 George St, New Brunswick, NJ, 08901, USA
| | - Laurence B Katz
- LifeScan Global Corporation, 20 Valley Stream Parkway, Malvern, PA, 19355, USA
| | - Mark Vreeke
- Edwards Lifesciences, One Edwards Way, Irvine, CA, 92614, USA
| | | | - Brenda Faiola
- Becton Dickinson, 1 Becton Drive, Franklin Lakes, NJ, 07417, USA; Rho, Inc., 2635 E NC Hwy 54, Durham, NC, 27713, USA
| | | | - Jim Nevelos
- Stryker, 2825 Airview Boulevard, Kalamazoo, MI, 49002, USA
| | - Mehran Bashiri
- Stryker Neurovascular, 47900 Bayside Parkway, Fremont, CA, 94538, USA
| | | | - Michael Kovochich
- Cardno ChemRisk, 30 North LaSalle St Suite 3910, Chicago, Illinois, 60602-2590, USA
| | - Kenneth Unice
- Cardno ChemRisk, 20 Stanwix Street Suite 505, Pittsburgh, PA, 15222, USA.
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Carcinogenic hazard assessment of cobalt-containing alloys in medical devices: Review of in vivo studies. Regul Toxicol Pharmacol 2021; 122:104910. [DOI: 10.1016/j.yrtph.2021.104910] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/03/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022]
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Zhu W, Zhang R, Liu S, Tian J, Lv X, Yu F, Xin H. The effect of nanoparticles of cobalt-chromium on human aortic endothelial cells in vitro. J Appl Toxicol 2021; 41:1966-1979. [PMID: 33959985 DOI: 10.1002/jat.4177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/19/2021] [Indexed: 11/08/2022]
Abstract
Despite advances in stent technology for vascular interventions, in-stent restenosis (ISR) remains a main complication. The corrosion of cobalt-chromium (CoCr) alloy coronary stents has been identified to be associated with ISR, whereas its role in ISR has not been elucidated. In the current work, CoCr nanoparticles, simulated corrosion products of CoCr alloy, were used to investigate their effect on the endothelial cells. It has been demonstrated that the cell viability declines and the cell membrane is damaged, indicating the cytotoxicity of CoCr nanoparticles. The expression of GRP78, CHOP, and cleaved-caspase12 proteins has increased when exposed to CoCr nanoparticles, suggesting that CoCr nanoparticles induced cell apoptosis through endoplasmic reticulum (ER) stress-mediated apoptotic pathway. An increased release of adhesion and inflammatory mediators was also induced by CoCr nanoparticles, including ICAM-1, VCAM-1, IL-1β, IL-6, and TNF-α. Our results demonstrated that CoCr nanoparticles could trigger apoptosis, adhesion, and inflammation. These findings indicated potential damaging effects of CoCr nanoparticles on the vascular endothelium, which suggested corrosion of CoCr alloy may promote the progression and development of ISR.
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Affiliation(s)
- Wenxiu Zhu
- Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China.,Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Rui Zhang
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Song Liu
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jiawei Tian
- Department of Emergency Internal Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaobing Lv
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Fei Yu
- Institute for Translational Medicine, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hui Xin
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Grzeskowiak RM, Schumacher J, Dhar MS, Harper DP, Mulon PY, Anderson DE. Bone and Cartilage Interfaces With Orthopedic Implants: A Literature Review. Front Surg 2020; 7:601244. [PMID: 33409291 PMCID: PMC7779634 DOI: 10.3389/fsurg.2020.601244] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022] Open
Abstract
The interface between a surgical implant and tissue consists of a complex and dynamic environment characterized by mechanical and biological interactions between the implant and surrounding tissue. The implantation process leads to injury which needs to heal over time and the rapidity of this process as well as the property of restored tissue impact directly the strength of the interface. Bleeding is the first and most relevant step of the healing process because blood provides growth factors and cellular material necessary for tissue repair. Integration of the implants placed in poorly vascularized tissue such as articular cartilage is, therefore, more challenging than compared with the implants placed in well-vascularized tissues such as bone. Bleeding is followed by the establishment of a provisional matrix that is gradually transformed into the native tissue. The ultimate goal of implantation is to obtain a complete integration between the implant and tissue resulting in long-term stability. The stability of the implant has been defined as primary (mechanical) and secondary (biological integration) stability. Successful integration of an implant within the tissue depends on both stabilities and is vital for short- and long-term surgical outcomes. Advances in research aim to improve implant integration resulting in enhanced implant and tissue interface. Numerous methods have been employed to improve the process of modifying both stability types. This review provides a comprehensive discussion of current knowledge regarding implant-tissue interfaces within bone and cartilage as well as novel approaches to strengthen the implant-tissue interface. Furthermore, it gives an insight into the current state-of-art biomechanical testing of the stability of the implants. Current knowledge reveals that the design of the implants closely mimicking the native structure is more likely to become well integrated. The literature provides however several other techniques such as coating with a bioactive compound that will stimulate the integration and successful outcome for the patient.
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Affiliation(s)
- Remigiusz M. Grzeskowiak
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - Jim Schumacher
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - Madhu S. Dhar
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - David P. Harper
- The Center for Renewable Carbon, Institute of Agriculture, University of Tennessee, Knoxville, TN, United States
| | - Pierre-Yves Mulon
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
| | - David E. Anderson
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, Knoxville, TN, United States
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Cobalt–Chromium Dental Alloys: Metal Exposures, Toxicological Risks, CMR Classification, and EU Regulatory Framework. CRYSTALS 2020. [DOI: 10.3390/cryst10121151] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
During the 20th century, metal alloys have assumed an important role as restorative materials. Among existing examples, cobalt–chromium (Co–Cr) alloys increasingly began to be used in medicine and especially in dentistry. Their success is mainly due to their mechanical properties such as stiffness, strength and corrosion resistance, thus allowing a high biocompatibility. There are quite meaningful data on the corrosion and toxicity of Co–Cr alloys for their use in restorative materials such as dental prostheses. Toxicological studies following Co and Cr exposures in the oral cavity are more difficult to conduct because there are many different situations leading to the release of metal ions and wear particles. Furthermore, the links between exposure and the appearance of local or systemic toxicity are not automatic. Since 2017, the European Union (EU) regulatory framework for Co–Cr alloys has been undergoing profound changes. A new EU Medical Devices Regulation (MDR) (2017/745) will be applied in May 2021 with the need to consider that Co metal is a new carcinogenic, mutagenic and toxic to reproduction (CMR) substance. On 18 February 2020, the 14th Adaptation to Technical Progress (ATP14) to the Classification, Labelling and Packaging (CLP) regulation was published, including the harmonised classification for Co metal as a CMR 1B substance. In this context, the use of Co might be forbidden if the medical devices are invasive and as soon as they include more than 0.1% (m/m) Co. This review provides a specific overview on Co–Cr dental alloys in terms of metal ions and wear particles release, toxicological risks, and the actual and new EU regulatory framework.
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Bozza N, Guindani N, Pezzotta G, Alberto F, Castelli CC. 15-year follow-up of MoM 36-mm THA: clinical, laboratory, and radiological (CT and MRI) prospective assessment. Hip Int 2020; 30:42-51. [PMID: 33267695 DOI: 10.1177/1120700020971662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is limited knowledge of the long-term results of metal-on-metal total hip arthroplasty (MoM THA), particularly concerning adverse local tissue reaction (ALTR), Co/Cr ions level and revision rate. Even if MoM bearing surfaces are no longer used, long-term data could help in defining the course and best management for these patients. The purpose of this study is to investigate the clinical outcomes, describe radiological findings including CT metal artefact reduction algorithm for orthopaedic implants (O-MAR) and MRI multi acquisition variable resonance image combination (MAVRIC) in 36-mm MoM THA. METHODS In this long-term prospective study, 46 consecutive patients with primary MoM THA (mono- or bilateral) were enrolled between 2004 and 2005. Pinnacle acetabular cup, Summit cementless stem with 36-mm metal head and Ultamet CoCr alloy liner (Depuy Inc.) were implanted, in the same centre by the same senior surgeon. Patients were reviewed at 5-, 10- and 15-years, including Co/Cr levels and standard radiographs at every follow-up, whilst the 15-year follow-up included hip sonography, MRI MAVRIC and CT O-MAR. RESULTS At 15 years, the overall survival rate of the implants (both stems and cups) was 83% (30/36). Revisions were performed in 9% (4/46) because of ALTR, 2% (1/46) septic loosening and 2% periprosthetic fracture. Both Cr and Co concentration increased over time, even though remaining at low level risk at 15 years: Co from 0.11 (+/- 0.18) to 4.29 (+/- 3.26) and Cr from 0.38 (+/- 0.32) to 1.37 (+/- 1.15). Functional scores in non-revised patients showed good to excellent results in more than 90%. Engh-score correlated with time from surgery (p = 0.017) and with sonographic, CT and RM findings (p < 0.05). Concordance has been found between CT and MRI findings (sign-rank test, p = 0.241; Intraclass Correlation Coefficients 0.987); however, no specific MRI or CT lesion patterns could be recognised among symptomatic and non-symptomatic patients. DISCUSSION The long-term rate of ALTR after 36-mm MoM THA was comparable with previous studies; a regular follow-up for those implants is mandatory. During follow-up Co-Cr levels increased over time and radiography was a suitable screening technique; the Engh score in particular, proved to be a reliable assessment tool. CT O-MAR and MRI with MAVRIC protocols may add valuable data in clinical practice, although MRI is significantly more efficient than CT in the identification of ALTR lesions, peri-articular effusion and in the evaluation of soft tissues.
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Affiliation(s)
- Nicola Bozza
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Nicola Guindani
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giuseppe Pezzotta
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ferrari Alberto
- Fondazione per la Ricerca Ospedale di Bergamo (FROM), Bergamo, Italy
| | - Claudio C Castelli
- Surgical Department, Orthopaedics and Traumatology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Qin HM, Herrera D, Liu DF, Chen CQ, Nersesyan A, Mišík M, Knasmueller S. Genotoxic properties of materials used for endoprostheses: Experimental and human data. Food Chem Toxicol 2020; 145:111707. [PMID: 32889016 DOI: 10.1016/j.fct.2020.111707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/13/2020] [Accepted: 08/22/2020] [Indexed: 12/28/2022]
Abstract
Approximately 2 million endoprostheses are implanted annually and metal ions as well as particles are released into the body from the materials which are used. This review describes the results of studies concerning genotoxic damage caused by artificial joints. DNA damage leads to various adverse long-term health effects in humans including cancer. Experiments with mammalian cells showed that metal ions and particles from orthopedic materials cause DNA damage. Induction of chromosomal aberrations (CA) was found in several in vitro experiments and in studies with rodents with metals from orthopedic materials. Human studies focused mainly on induction of CA (7 studies). Only few investigations (4) concerned sister chromatid exchanges, oxidative DNA damage (2) and micronucleus formation (1). CA are a reliable biomarker for increased cancer risks in humans) and were increased in all studies in patients with artificial joints. No firm conclusion can be drawn at present if the effects in humans are due to oxidative stress and if dissolved metal ions or release particles play a role. Our findings indicate that patients with artificial joints may have increased cancer risks due to damage of the genetic material. Future studies should be performed to identify safe materials and to study the molecular mechanisms in detail.
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Affiliation(s)
- Hong-Min Qin
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Denise Herrera
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Dian-Feng Liu
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Chao-Qian Chen
- Hip Surgery of Orthopedic Hospital, Affiliated Hospital of Panzhihua University, Panzhihua, 617000, Sichuan Province, China
| | - Armen Nersesyan
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Miroslav Mišík
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria
| | - Siegfried Knasmueller
- Institute of Cancer Research, Department of Internal Medicine I, Medical University of Vienna, 1090, Borschkegasse 8A, Vienna, Austria.
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Leonetti S, Tuvo B, Campanella B, Legnaioli S, Onor M, Bramanti E, Totaro M, Baggiani A, Giorgi S, Privitera GP, Piolanti N, Parchi PD, Casini B. Evaluation of Microbial Adhesion and Biofilm Formation on Nano-Structured and Nano-Coated Ortho-Prosthetic Materials by a Dynamic Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17031013. [PMID: 32033480 PMCID: PMC7036942 DOI: 10.3390/ijerph17031013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/18/2022]
Abstract
The bio-engineering technologies of medical devices through nano-structuring and coating was recently proposed to improve biocompatibility and to reduce microbial adhesion in the prevention of implantable device-related infections. Our aim was to evaluate the ability of new nano-structured and coated materials to prevent the adhesion and biofilm formation, according to the American Standard Test Method ASTM-E2647-13. The materials composition was determined by X-ray Fluorescence and Laser Induced Breakdown Spectroscopy. Silver release was evaluated by Inductively Coupled Plasma Mass Spectrometry analysis. The gene expression levels of the Quorum Sensing Las and Rhl system were evaluated by the ΔΔCt method. The Log bacterial density (Log CFU/cm2) on TiAl6V4 was 4.41 ± 0.76 and 4.63 ± 1.01 on TiAl6V4-AgNPs compared to 2.57 ± 0.70 on CoCr and 2.73 ± 0.61 on CoCr-AgNPs (P < 0.0001, A.N.O.V.A.- one way test). The silver release was found to be equal to 17.8 ± 0.2 µg/L after the batch phase and 1.3 ± 0.1 µg/L during continuous flow. The rhlR gene resulted in a 2.70-fold increased expression in biofilm growth on the silver nanoparticles (AgNPs) coating. In conclusion, CoCr showed a greater ability to reduce microbial adhesion, independently of the AgNPs coating. The silver release resulted in promoting the up-regulation of the Rhl system. Further investigation should be conducted to optimize the effectiveness of the coating.
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Affiliation(s)
- Simone Leonetti
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Benedetta Tuvo
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Beatrice Campanella
- Institute of Chemistry of Organometallic Compounds, National Research Council, via Giuseppe Moruzzi, 1-56124 Pisa, Italy; (B.C.); (S.L.); (M.O.); (E.B.)
| | - Stefano Legnaioli
- Institute of Chemistry of Organometallic Compounds, National Research Council, via Giuseppe Moruzzi, 1-56124 Pisa, Italy; (B.C.); (S.L.); (M.O.); (E.B.)
| | - Massimo Onor
- Institute of Chemistry of Organometallic Compounds, National Research Council, via Giuseppe Moruzzi, 1-56124 Pisa, Italy; (B.C.); (S.L.); (M.O.); (E.B.)
| | - Emilia Bramanti
- Institute of Chemistry of Organometallic Compounds, National Research Council, via Giuseppe Moruzzi, 1-56124 Pisa, Italy; (B.C.); (S.L.); (M.O.); (E.B.)
| | - Michele Totaro
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Angelo Baggiani
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Serena Giorgi
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Gaetano Pierpaolo Privitera
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
| | - Nicola Piolanti
- Orthopaedic and Traumatology Division, Azienda ospedaliera-Universitaria Pisana, via Roma, 67-56126 Pisa, Italy;
| | - Paolo Domenico Parchi
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
- Orthopaedic and Traumatology Division, Azienda ospedaliera-Universitaria Pisana, via Roma, 67-56126 Pisa, Italy;
| | - Beatrice Casini
- Department of Translational Research, N.T.M.S., University of Pisa, via San Zeno, 37/39-56127 Pisa, Italy; (S.L.); (B.T.); (M.T.); (A.B.); (S.G.); (G.P.P.)
- Correspondence: ; Tel.: +39-050-221-3590
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Lützner J, Günther KP, Postler A, Morlock M. Metal Ion Release after Hip and Knee Arthroplasty - Causes, Biological Effects and Diagnostics. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:369-382. [PMID: 31820432 DOI: 10.1055/a-0929-8121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
All metal implants in human bodies corrode which results in metal ions release. This is not necessarily a problem and represents for most patients no hazard. However, if a critical metal ion concentration is exceeded, local or rarely systemic problems can occur. This article summarizes the mechanisms of metal ion release and its clinical consequences. Several situations can result in increased metal ion release: metal-on-metal hip arthroplasties with increased wear, increased micromotion at taper interfaces, direct metal-metal contact (polyethylene wear, impingement), erroneously used metal heads after ceramic head fracture. Possible problems are in most cases located close to the concerned joint. Furthermore, there are reports about toxic damage to several organs. Most of these reports refer to erroneously used metal heads in revisions after a broken ceramic head. There is currently no evidence of carcinogenic or teratogenic effects of implants but data is not sufficient to exclude possible effects. Cobalt and chromium blood levels (favorably in whole blood) should be measured in patients with suspected elevated metal ions. According to current knowledge levels below 2 µg/l seem to be uncritical, levels between 2 and 7 µg/l are considered borderline with unknown biological consequences and levels above 7 µg/l indicate a local problem which should be further diagnosed. Metal ion levels always need to be interpreted together with clinical symptoms and imaging results.
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Affiliation(s)
- Jörg Lützner
- University Center of Orthopaedics and Trauma Surgery, TU Dresden
| | | | - Anne Postler
- University Center of Orthopaedics and Trauma Surgery, TU Dresden
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15
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Liu Y, Rath B, Tingart M, Eschweiler J. Role of implants surface modification in osseointegration: A systematic review. J Biomed Mater Res A 2019; 108:470-484. [DOI: 10.1002/jbm.a.36829] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/23/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Yu Liu
- Department of Orthopaedic Surgery RWTH Aachen University Clinic Aachen Germany
| | - Björn Rath
- Department of Orthopaedic Surgery RWTH Aachen University Clinic Aachen Germany
| | - Markus Tingart
- Department of Orthopaedic Surgery RWTH Aachen University Clinic Aachen Germany
| | - Jörg Eschweiler
- Department of Orthopaedic Surgery RWTH Aachen University Clinic Aachen Germany
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16
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Ekman E, Laaksonen I, Eskelinen A, Pulkkinen P, Pukkala E, Mäkelä K. Midterm risk of cancer with metal-on-metal hip replacements not increased in a Finnish population. Acta Orthop 2018; 89:575-579. [PMID: 29912603 PMCID: PMC6202763 DOI: 10.1080/17453674.2018.1487202] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Metal-on-metal (MoM) total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have been widely used during the early 21st century. We assessed the midterm risk of cancer of patients treated with modern MoM hip implants compared with patients with non-MoM hip implants and the general Finnish population with special interest in soft tissue sarcomas and basalioma due to the findings of our previous report. Patients and methods - All large-diameter head MoM THAs and hip resurfacings performed in Finland between 2001 and 2010 were extracted from the Finnish Arthroplasty Register (10,728 patients). Patients who underwent conventional THA formed the non-MoM reference cohort (18,235 patients). Data on cancer cases up to 2014 were extracted from the Finnish Cancer Registry. The relative risk of cancer in the general population was expressed as the ratio of observed to expected number of cases, i.e., standardized incidence ratio (SIR). Poisson regression analysis was used to compare the cancer risk between the cohorts. The mean follow-up was 7.4 years (1-14) in the MoM cohort and 8.4 years (1-14) in the non-MoM cohort. Results - The overall risk of cancer in the MoM cohort was comparable to the general Finnish population (SIR 0.9, 95% CI 0.9-1.0). Risk of basalioma in the MoM cohort was higher than in the general Finnish population (SIR 1.2, CI 1.1-1.4) and higher than in the non-MoM cohort in the stratified regression analysis (RR 1.2, CI 1.0-1.4, p = 0.02). The SIR of soft-tissue sarcoma in the MoM cohort was 1.4 (CI 0.6-2.8); the incidence was same as in the non-MoM cohort. Interpretation - Metal-on-metal hip implants are not associated with an increased overall risk of cancer during midterm follow-up.
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Affiliation(s)
- Elina Ekman
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku; ,Correspondence:
| | - Inari Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku;
| | | | | | - Eero Pukkala
- Faculty of Social Sciences, University of Tampere, Tampere; ,The Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital, Turku;
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18
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Lison D, van den Brule S, Van Maele-Fabry G. Cobalt and its compounds: update on genotoxic and carcinogenic activities. Crit Rev Toxicol 2018; 48:522-539. [PMID: 30203727 DOI: 10.1080/10408444.2018.1491023] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This article summarizes recent experimental and epidemiological data on the genotoxic and carcinogenic activities of cobalt compounds. Emphasis is on the respiratory system, but endogenous exposure from Co-containing alloys used in endoprostheses, and limited data on nanomaterials and oral exposures are also considered. Two groups of cobalt compounds are differentiated on the basis of their mechanisms of toxicity: (1) those essentially involving the solubilization of Co(II) ions, and (2) metallic materials for which both surface corrosion and release of Co(II) ions act in concert. For both groups, identified genotoxic and carcinogenic mechanisms are non-stochastic and thus expected to exhibit a threshold. Cobalt compounds should, therefore, be considered as genotoxic carcinogens with a practical threshold. Accumulating evidence indicates that chronic inhalation of cobalt compounds can induce respiratory tumors locally. No evidence of systemic carcinogenicity upon inhalation, oral or endogenous exposure is available. The scarce data available for Co-based nanosized materials does not allow deriving a specific mode of action or assessment for these species.
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Affiliation(s)
- D Lison
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Catholic University of Louvain, Brussels, Belgium
| | - S van den Brule
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Catholic University of Louvain, Brussels, Belgium
| | - G Van Maele-Fabry
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Catholic University of Louvain, Brussels, Belgium
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van Ochten JHM, Arbab D, Eysel P, König DP. Long - term survivorship and clinical results of the navigated withdrawn ASR ™. J Orthop 2018; 15:869-873. [PMID: 30166801 DOI: 10.1016/j.jor.2018.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022] Open
Abstract
Introduction Primary goals of the study were to present the mid - to long - term survivorship and clinical, radiological and metal serological results of the first stem - navigated ASR™ resurfacing at our clinic. Secondary goals were to determine the influence of stem - navigation on the outcome and risk factors for revision in our cohort. Methods From Mai 2006 to Mai 2009 46 ASR™ resurfacing hip systems have been implanted in 43 patients with a median age of 55 years. At final follow - up (33 patients with a mean follow -up of 89,6 months) guidelines were followed and HHS and HOOS were completed. Inclination, NSA and SSA were measured on radiographs and signs of loosening were graded. Risk factors for revision were compared in the non - revision and revision group. Results Mean cumulative survival of the prosthesis after 99,9 Months was 81,8%. At final follow - up 8 revisions were performed. Median HHS was 97, HOOS was 87,2. Four prostheses showed signs of loosening and nine heterotopic ossifications. All shaft components, except one, were placed in minimal valgus position to avoid risk for fracture. Age and diameter of the femoral component were significantly different between the non - revision and revision group. Discussion Survivorship is comparable to numbers found in other studies. Patients with complete final follow - up in general had good objective and subjective scores and few signs of loosening in the radiological follow - up. Navigation might have a positive effect on reduction of risk for fracture. Age and diameter of the femoral component seem to influence the outcome.
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Affiliation(s)
- Johannes H M van Ochten
- Center for Shoulder and Elbow Surgery, Städtisches Krankenhaus Nettetal, Sassenfelder Kirchweg 1, 41334, Nettetal, Germany
| | - Dariusch Arbab
- Department of Orthopedic Surgery, Klinikum Dortmund, Member Faculty of Health Witten/Herdecke University, Beurhausstraße 40, 44137, Dortmund, Germany
| | - Peer Eysel
- Department of Orthopedic and Trauma Surgery, University Hospital of Cologne, Joseph - Stelzmann - Straße 9, 50924, Köln, Germany
| | - Dietmar P König
- LVR Clinic of Orthopedic Surgery, Horionstraße 2, 41479, Viersen, Germany
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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Vierra BM, Blumenthal SR, Amanatullah DF. Modularity in Total Hip Arthroplasty: Benefits, Risks, Mechanisms, Diagnosis, and Management. Orthopedics 2017; 40:355-366. [PMID: 28598491 DOI: 10.3928/01477447-20170606-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 11/07/2016] [Indexed: 02/03/2023]
Abstract
Modular implants are currently widely used in total hip arthroplasty because they give surgeons versatility during the operation, allow for easier revision surgery, and can be adjusted to better fit the anatomy of the specific patient. However, modular implants, specifically those that have metal-on-metal junctions, are susceptible to crevice and fretting corrosion. This can ultimately cause implant failure, inflammation, and adverse local tissue reaction, among other possible side effects. Surgeons should be aware of the possibility of implant corrosion and should follow a set of recommended guidelines to systematically diagnose and treat patients with corroded implants. Ultimately, surgeons will continue to use modular implants because of their widespread benefits. However, more research is needed to determine how to minimize corrosion and the negative side effects that have been associated with modular junctions in total hip arthroplasty. [Orthopedics. 2017; 40(6):355-366.].
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Immunological Responses to Total Hip Arthroplasty. J Funct Biomater 2017; 8:jfb8030033. [PMID: 28762999 PMCID: PMC5618284 DOI: 10.3390/jfb8030033] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/19/2017] [Accepted: 07/25/2017] [Indexed: 12/12/2022] Open
Abstract
The use of total hip arthroplasties (THA) has been continuously rising to meet the demands of the increasingly ageing population. To date, this procedure has been highly successful in relieving pain and restoring the functionality of patients’ joints, and has significantly improved their quality of life. However, these implants are expected to eventually fail after 15–25 years in situ due to slow progressive inflammatory responses at the bone-implant interface. Such inflammatory responses are primarily mediated by immune cells such as macrophages, triggered by implant wear particles. As a result, aseptic loosening is the main cause for revision surgery over the mid and long-term and is responsible for more than 70% of hip revisions. In some patients with a metal-on-metal (MoM) implant, metallic implant wear particles can give rise to metal sensitivity. Therefore, engineering biomaterials, which are immunologically inert or support the healing process, require an in-depth understanding of the host inflammatory and wound-healing response to implanted materials. This review discusses the immunological response initiated by biomaterials extensively used in THA, ultra-high-molecular-weight polyethylene (UHMWPE), cobalt chromium (CoCr), and alumina ceramics. The biological responses of these biomaterials in bulk and particulate forms are also discussed. In conclusion, the immunological responses to bulk and particulate biomaterials vary greatly depending on the implant material types, the size of particulate and its volume, and where the response to bulk forms of differing biomaterials are relatively acute and similar, while wear particles can initiate a variety of responses such as osteolysis, metal sensitivity, and so on.
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Leyssens L, Vinck B, Van Der Straeten C, Wuyts F, Maes L. Cobalt toxicity in humans-A review of the potential sources and systemic health effects. Toxicology 2017; 387:43-56. [PMID: 28572025 DOI: 10.1016/j.tox.2017.05.015] [Citation(s) in RCA: 402] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/17/2017] [Accepted: 05/24/2017] [Indexed: 12/21/2022]
Abstract
Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B12, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co2+. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co2+ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.
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Affiliation(s)
- Laura Leyssens
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Bart Vinck
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Faculty of Humanities, University of Pretoria (South Africa), Department of Speech-Language Pathology and Audiology, Aula Theatre,University Road, Pretoria, 0001, South Africa.
| | - Catherine Van Der Straeten
- Faculty of Medicine, Imperial College London, Department of Surgery & Cancer, Musculoskeletal Sciences and Technology, Imperial College London, Charing Cross Campus,7L21 Lab Block, London SW7 2AZ, UK; Faculty of Medicine and Health Sciences, University of Ghent (Belgium), De Pintelaan 185, 9000 Ghent, Belgium.
| | - Floris Wuyts
- Antwerp University Research center for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology, University Hospital Antwerp, Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium; Department of Biomedical Physics, University of Antwerp (Belgium), Campus Groenenborger, Groenenborgerlaan 171, 2020 Antwerp, Belgium.
| | - Leen Maes
- Faculty of Medicine and Health Sciences, University of Ghent (Belgium), Department of Speech, Language and Hearing Sciences, University Hospital Ghent, policlinic 1 floor 2, De Pintelaan 185, 9000 Ghent, Belgium; Clinical audiology department, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium.
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Protective effects of Zn 2+ against cobalt nanoparticles and cobalt chloride-induced cytotoxicity of RAW 264.7cells via ROS pathway. Biochem Biophys Res Commun 2017; 486:357-363. [DOI: 10.1016/j.bbrc.2017.03.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 03/12/2017] [Indexed: 01/05/2023]
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Armstead AL, Simoes TA, Wang X, Brydson R, Brown A, Jiang BH, Rojanasakul Y, Li B. Toxicity and oxidative stress responses induced by nano- and micro-CoCrMo particles. J Mater Chem B 2017. [DOI: 10.1039/c7tb01372h] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Particles on the nano- and micro-meter scales present unique cell-specific cellular effects (i.e.cytotoxicity and oxidative stress).
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Affiliation(s)
- Andrea L. Armstead
- Department of Orthopaedics
- School of Medicine
- West Virginia University
- Morgantown
- USA
| | - Thiago A. Simoes
- Institute for Materials Research
- School of Chemical and Process Engineering
- University of Leeds
- UK
| | - Xianfeng Wang
- Department of Orthopaedics
- School of Medicine
- West Virginia University
- Morgantown
- USA
| | - Rik Brydson
- Institute for Materials Research
- School of Chemical and Process Engineering
- University of Leeds
- UK
| | - Andy Brown
- Institute for Materials Research
- School of Chemical and Process Engineering
- University of Leeds
- UK
| | - Bing-Hua Jiang
- Department of Pathology
- Anatomy and Cell Biology
- Thomas Jefferson University
- Philadelphia
- USA
| | - Yon Rojanasakul
- School of Pharmacy
- West Virginia University
- Morgantown
- USA
- Mary Babb Randolph Cancer Center
| | - Bingyun Li
- Department of Orthopaedics
- School of Medicine
- West Virginia University
- Morgantown
- USA
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Annangi B, Bonassi S, Marcos R, Hernández A. Biomonitoring of humans exposed to arsenic, chromium, nickel, vanadium, and complex mixtures of metals by using the micronucleus test in lymphocytes. MUTATION RESEARCH-REVIEWS IN MUTATION RESEARCH 2016; 770:140-161. [DOI: 10.1016/j.mrrev.2016.03.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 02/15/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
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Abstract
The placement of a hip prosthesis is one of the most common orthopedic surgical procedures. Some implants contain metal and are therefore capable of releasing metal particles like cobalt in patients who wear metal prostheses. Cobalt can be responsible of local toxicity (including metallosis, hypersensitivity reaction, and benign tumor) or systemic toxicity (including cardiomyopathy, polycythemia, hypothyroidism, and neurological disorders). To monitor potential toxicity of metal hip prostheses, an annual monitoring of patients implanted is recommended and includes clinical examination, radiological examination and blood cobalt determination. The cobalt concentration in blood allows to estimate the risk of toxicity and to evaluate the performance of the implant. The currently recommended threshold value is equal to 7 µg of cobalt per liter of blood. Our study, conducted on 251 patients over a period of 4 years, has shown that the cobalt concentration average was 2.51 µg/l in blood, with 51 patients having a cobaltemia higher than the threshold of 7 µg/l.
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Affiliation(s)
- Virginie Mistretta
- Service de toxicologie clinique, médico-légale, de l'environnement et en entreprise, CHU Sart-Tilman, 1 avenue de l'Hôpital, 4000 Liège, Belgique
| | - William Kurth
- Service de chirurgie de l'appareil locomoteur, CHU Sart-Tilman, 1 avenue de l'Hôpital, 4000 Liège, Belgique
| | - Corinne Charlier
- Service de toxicologie clinique, médico-légale, de l'environnement et en entreprise, CHU Sart-Tilman, 1 avenue de l'Hôpital, 4000 Liège, Belgique
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Mostofi S, Bonyadi Rad E, Wiltsche H, Fasching U, Szakacs G, Ramskogler C, Srinivasaiah S, Ueçal M, Willumeit R, Weinberg AM, Schaefer U. Effects of Corroded and Non-Corroded Biodegradable Mg and Mg Alloys on Viability, Morphology and Differentiation of MC3T3-E1 Cells Elicited by Direct Cell/Material Interaction. PLoS One 2016; 11:e0159879. [PMID: 27459513 PMCID: PMC4961286 DOI: 10.1371/journal.pone.0159879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/08/2016] [Indexed: 12/23/2022] Open
Abstract
This study investigated the effect of biodegradable Mg and Mg alloys on selected properties of MC3T3-E1 cells elicited by direct cell/material interaction. The chemical composition and morphology of the surface of Mg and Mg based alloys (Mg2Ag and Mg10Gd) were analysed by scanning electron microscopy (SEM) and EDX, following corrosion in cell culture medium for 1, 2, 3 and 8 days. The most pronounced difference in surface morphology, namely crystal formation, was observed when Pure Mg and Mg2Ag were immersed in cell medium for 8 days, and was associated with an increase in atomic % of oxygen and a decrease of surface calcium and phosphorous. Crystal formation on the surface of Mg10Gd was, in contrast, negligible at all time points. Time-dependent changes in oxygen, calcium and phosphorous surface content were furthermore not observed for Mg10Gd. MC3T3-E1 cell viability was reduced by culture on the surfaces of corroded Mg, Mg2Ag and Mg10Gd in a corrosion time-independent manner. Cells did not survive when cultured on 3 day pre-corroded Pure Mg and Mg2Ag, indicating crystal formation to be particular detrimental in this regard. Cell viability was not affected when cells were cultured on non-corroded Mg and Mg alloys for up to 12 days. These results suggest that corrosion associated changes in surface morphology and chemical composition significantly hamper cell viability and, thus, that non-corroded surfaces are more conducive to cell survival. An analysis of the differentiation potential of MC3T3-E1 cells cultured on non-corroded samples based on measurement of Collagen I and Runx2 expression, revealed a down-regulation of these markers within the first 6 days following cell seeding on all samples, despite persistent survival and proliferation. Cells cultured on Mg10Gd, however, exhibited a pronounced upregulation of collagen I and Runx2 between days 8 and 12, indicating an enhancement of osteointegration by this alloy that could be valuable for in vivo orthopedic applications.
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Affiliation(s)
- Sepideh Mostofi
- Department of Orthopedics and Orthopedic Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Ehsan Bonyadi Rad
- Department of Orthopedics and Orthopedic Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Helmar Wiltsche
- Institute of Analytical Chemistry and Food Chemistry, Graz University of Technology, 8010 Graz, Austria
| | - Ulrike Fasching
- Research Unit Experimental Neurotraumatology, Department of Neurosurgery, Medical University Graz, 8036 Graz, Austria
| | - Gabor Szakacs
- Helmholtz-Zentrum Geesthacht, Institute of Material Research, Geesthacht, Germany
| | - Claudia Ramskogler
- Institute of Materials Science and Welding; Graz University of Technology, 8010 Graz, Austria
| | - Sriveena Srinivasaiah
- Department of Orthopedics and Orthopedic Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Muammer Ueçal
- Research Unit Experimental Neurotraumatology, Department of Neurosurgery, Medical University Graz, 8036 Graz, Austria
| | - Regine Willumeit
- Helmholtz-Zentrum Geesthacht, Institute of Material Research, Geesthacht, Germany
| | - Annelie-Martina Weinberg
- Department of Orthopedics and Orthopedic Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Ute Schaefer
- Research Unit Experimental Neurotraumatology, Department of Neurosurgery, Medical University Graz, 8036 Graz, Austria
- * E-mail:
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Gibon E, Amanatullah DF, Loi F, Pajarinen J, Nabeshima A, Yao Z, Hamadouche M, Goodman SB. The biological response to orthopaedic implants for joint replacement: Part I: Metals. J Biomed Mater Res B Appl Biomater 2016; 105:2162-2173. [PMID: 27328111 DOI: 10.1002/jbm.b.33734] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 04/19/2016] [Accepted: 06/01/2016] [Indexed: 12/12/2022]
Abstract
Joint replacement is a commonly performed, highly successful orthopaedic procedure, for which surgeons have a large choice of different materials and implant designs. The materials used for joint replacement must be both biologically acceptable to minimize adverse local tissue reactions, and robust enough to support weight bearing during common activities of daily living. Modern joint replacements are made from metals and their alloys, polymers, ceramics, and composites. This review focuses on the biological response to the different biomaterials used for joint replacement. In general, modern materials for joint replacement are well tolerated by the body as long as they are in bulk (rather than in particulate or ionic) form, are mechanically stable and noninfected. If the latter conditions are not met, the prosthesis will be associated with an acute/chronic inflammatory reaction, peri-prosthetic osteolysis, loosening and failure. This article (Part 1 of 2) is dedicated to the use of metallic devices in orthopaedic surgery including the associated biological response to metallic byproducts is a review of the basic science literature regarding this topic. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2162-2173, 2017.
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Affiliation(s)
- Emmanuel Gibon
- Department of Orthopaedic Surgery, Stanford University, Stanford, California.,Laboratoire de Biomécanique et Biomatériaux Ostéo-Articulaires - UMR CNRS 7052, Faculté de Médecine - Université Paris7, Paris, France.,Department of Orthopaedic Surgery, Hopital Cochin, APHP, Université Paris5, Paris, France
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Florence Loi
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Jukka Pajarinen
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Akira Nabeshima
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Zhenyu Yao
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
| | - Moussa Hamadouche
- Department of Orthopaedic Surgery, Hopital Cochin, APHP, Université Paris5, Paris, France
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California
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In Vitro Analyses of the Toxicity, Immunological, and Gene Expression Effects of Cobalt-Chromium Alloy Wear Debris and Co Ions Derived from Metal-on-Metal Hip Implants. LUBRICANTS 2015. [DOI: 10.3390/lubricants3030539] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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31
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Tvermoes BE, Paustenbach DJ, Kerger BD, Finley BL, Unice KM. Review of cobalt toxicokinetics following oral dosing: Implications for health risk assessments and metal-on-metal hip implant patients. Crit Rev Toxicol 2015; 45:367-87. [DOI: 10.3109/10408444.2014.985818] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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32
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Posada OM, Tate RJ, Grant MH. Toxicity of cobalt-chromium nanoparticles released from a resurfacing hip implant and cobalt ions on primary human lymphocytesin vitro. J Appl Toxicol 2015; 35:614-22. [DOI: 10.1002/jat.3100] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Olga M. Posada
- Biomedical Engineering Department; University of Strathclyde; Wolfson Centre Glasgow UK
| | - R. J. Tate
- Strathclyde Institute for Pharmacy & Biomedical Sciences; University of Strathclyde; Glasgow G4 0RE UK
| | - M. H. Grant
- Biomedical Engineering Department; University of Strathclyde; Wolfson Centre Glasgow UK
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