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Burgos J, Hevia E, Sanpera I, García V, de Santos Moreno MT, Mariscal G, Barrios C. Elevated blood metal ion levels in patients undergoing instrumented spinal surgery: a systematic review and meta-analysis. Spine J 2024; 24:947-960. [PMID: 38437920 DOI: 10.1016/j.spinee.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND CONTEXT Elevated blood metal levels have been reported in patients after spinal surgery using metallic implants. Although some studies have suggested an association between heightened blood metal concentrations and potential adverse effects, estimates of the incidence of abnormal metal levels after spinal surgery have been inconsistent. PURPOSE The aims of this systematic review and meta-analysis were to assess: (1) mean differences in blood metal ion levels between patients undergoing spinal fusion surgery and healthy controls, (2) odds of elevated blood metal ion levels after surgery compared to presurgery levels, and (3) pooled incidence of elevated blood metal ions overall and by metal type. STUDY DESIGN Systematic review and meta-analysis. PATIENTS SAMPLE The patient sample included 613 patients from 11 studies who underwent spinal surgery instrumentation. OUTCOME MEASURES Blood metal ion concentrations and the incidence of patients with elevated metal levels compared with in those the control group. METHODS A comprehensive search was conducted in PubMed, EMBASE, Scopus, and Cochrane Library to identify studies reporting blood metal ion levels after spinal fusion surgery. Mean differences (MD), odds ratios (OR), and incidence rates were pooled using random effects models. Heterogeneity was assessed using I2 statistics, and fixed-effects models were used if no heterogeneity was detected. Detailed statistical analysis was performed using the Review Manager version 5.4 software. RESULTS The analysis included 11 studies, with a total of 613 patients. Mean blood metal ion levels were significantly higher after spinal fusion surgery (MD 0.56, 95% CI 0.17-0.96; I2=86%). Specifically, titanium levels were significantly elevated (MD 0.81, 95% CI 0.32-1.30; I2=47%). The odds of elevated blood metal ions were higher after surgery (OR 8.17, 95% CI 3.38-19.72; I2=41%), primarily driven by chromium (OR 23.50, 95% CI 5.56-99.31; I2=30%). The incidence of elevated chromium levels was found to be 66.98% (95% CI 42.31-91.65). CONCLUSION In conclusion, blood metal ion levels, particularly titanium and chromium, were significantly increased after spinal fusion surgery compared to presurgery levels and healthy controls. Approximately 70% of the patients exhibited elevated blood levels of chromium and titanium.
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Affiliation(s)
- Jesús Burgos
- Vithas Internacional, C/ de Arturo Soria, 107, Cdad. Lineal, 28043 Madrid, Spain
| | - Eduardo Hevia
- Spine Unit, University of Navarra Clinic, C. del Marquesado de Sta. Marta, 1, San Blas-Canillejas, 28027, Madrid, Spain
| | - Ignacio Sanpera
- Pediatric Orthopedics, Son Espases Hospital, Spain de Valldemossa, 79, Nord, 07120 Palma, Illes Balears, Spain
| | - Vicente García
- Spine Surgery Section, Araba University Hospital, Jose Atxotegi Kalea, s/n, Txagorritxu, 01009 Gasteiz, Araba, Spain
| | - María Teresa de Santos Moreno
- Neuropediatrics Unit, San Carlos Clinic Hospital, Calle del Prof Martín Lagos, S/N, Moncloa - Aravaca, 28040 Madrid, Spain
| | - Gonzalo Mariscal
- Mediterranean Observatory for Clinical and Health Research (OMEDICS), Carrer Quevedo 1, 46001, Valencia, Spain; Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain.
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, C/ de Quevedo, 2, Ciutat Vella, 46001 Valencia, Spain
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Ul Haq I, Khan TA, Krukiewicz K. Etiology, pathology, and host-impaired immunity in medical implant-associated infections. J Infect Public Health 2024; 17:189-203. [PMID: 38113816 DOI: 10.1016/j.jiph.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/20/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
Host impaired immunity and pathogens adhesion factors are the key elements in analyzing medical implant-associated infections (MIAI). The infection chances are further influenced by surface properties of implants. This review addresses the medical implant-associated pathogens and summarizes the etiology, pathology, and host-impaired immunity in MIAI. Several bacterial and fungal pathogens have been isolated from MIAI; together, they form cross-kingdom species biofilms and support each other in different ways. The adhesion factors initiate the pathogen's adherence on the implant's surface; however, implant-induced impaired immunity promotes the pathogen's colonization and biofilm formation. Depending on the implant's surface properties, immune cell functions get slow or get exaggerated and cause immunity-induced secondary complications resulting in resistant depression and immuno-incompetent fibro-inflammatory zone that compromise implant's performance. Such consequences lead to the unavoidable and straightforward conclusion for the downstream transformation of new ideas, such as the development of multifunctional implant coatings.
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Affiliation(s)
- Ihtisham Ul Haq
- Department of Physical Chemistry and Technology of Polymers, Silesian University of Technology, M. Strzody 9, 44-100 Gliwice, Poland; Joint Doctoral School, Silesian University of Technology, Akademicka 2A, 44-100 Gliwice, Poland; Programa de Pós-graduação em Inovação Tecnológica, Universidade Federal de Minas Gerais, Belo Horizonte 31270-901, MG, Brazil.
| | - Taj Ali Khan
- Division of Infectious Diseases & Global Medicine, Department of Medicine, University of Florida, Gainesville, FL, United States; Institute of Pathology and Diagnostic Medicine, Khyber Medical University, Peshawar, Pakistan.
| | - Katarzyna Krukiewicz
- Department of Physical Chemistry and Technology of Polymers, Silesian University of Technology, M. Strzody 9, 44-100 Gliwice, Poland; Centre for Organic and Nanohybrid Electronics, Silesian University of Technology, Konarskiego 22B, 44-100 Gliwice, Poland.
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Davies TC. The position of geochemical variables as causal co-factors of diseases of unknown aetiology. SN APPLIED SCIENCES 2022; 4:236. [PMID: 35909942 PMCID: PMC9326422 DOI: 10.1007/s42452-022-05113-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract The term diseases of unknown aetiology (DUA) or idiopathic diseases is used to describe diseases that are of uncertain or unknown cause or origin. Among plausible geoenvironmental co-factors in causation of DUA, this article focusses on the entry of trace elements, including metals and metalloids into humans, and their involvement in humoral and cellular immune responses, representing potentially toxic agents with implications as co-factors for certain DUA. Several trace elements/metals/metalloids (micronutrients) play vital roles as co-factors for essential enzymes and antioxidant molecules, thus, conferring protection against disease. However, inborn errors of trace element/metal/metalloid metabolisms can occur to produce toxicity, such as when there are basic defects in the element transport mechanism. Ultimately, it is the amount of trace element, metal or metalloid that is taken up, its mode of accumulation in human tissues, and related geomedical attributes such as the chemical form and bioavailability that decisively determine whether the exerted effects are toxic or beneficial. Several case descriptions of DUA that are common worldwide are given to illustrate our knowledge so far of how trace element/metal/metalloid interactions in the immune system may engender its dysregulation and be implicated as causal co-factors of DUA. Article highlights The importance of a proper understanding of geochemical perturbations in human metabolisms is emphasisedIt is proferred that such an understanding would aid greatly in the decipherment of diseases of unknown aetiology (DUA)The thesis presented may pave the way towards better diagnosis and therapy of DUA.
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Affiliation(s)
- Theophilus C. Davies
- Present Address: Faculty of Natural Sciences, Mangosuthu University of Technology, 511 Mangosuthu Highway, 4031, KwaZulu Natal, South Africa
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Edlinger C, Paar V, Kheder SH, Krizanic F, Lalou E, Boxhammer E, Butter C, Dworok V, Bannehr M, Hoppe UC, Kopp K, Lichtenauer M. Endothelialization and Inflammatory Reactions After Intracardiac Device Implantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1401:1-22. [DOI: 10.1007/5584_2022_712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The efficacy of convenient cleaning methods applicable for customized abutments: an in vitro study. BMC Oral Health 2021; 21:78. [PMID: 33602211 PMCID: PMC7890105 DOI: 10.1186/s12903-021-01436-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/09/2021] [Indexed: 11/29/2022] Open
Abstract
Background The demand for implant dentistry, which includes customized abutments, is increasing. A lot of pollutions are generated on the customized abutment surface following milling procedure. This study evaluated the surface topography and cleanliness of customized abutments after cleaning procedures, which are simply applicable in the dental clinic. Methods Thirty computer-aided design and computer-aided manufacturing internal connection type titanium abutments were produced, milled, and randomly divided into 3 groups: steam cleaning (control group), chlorhexidine (CHX) scrubbing (test group 1), and ultrasonic cleaning with CHX solution, acetone, and ethyl alcohol (test group 2). Each group was evaluated using microscopic and microbial analysis. Results Foreign bodies were observed on the abutment surfaces in control group and test group 1, but not in test group 2. Bacteria were observed on 40% of the agar plates following steam cleaning; most of the colonies consisted of Bacillus cereus and Staphylococcus warneri. Colony growth was absent following test group 1 and 2. Conclusion For customized abutments, cleaning with steam is ineffective. CHX scrubbing effectively eliminates only bacteria. Ultrasonic cleaning with CHX solution, acetone, and ethyl alcohol successfully removes both foreign bodies and bacteria. Thus, the ultrasonic cleaning method is conveniently applicable in the dental clinic for eliminating contamination of the customized abutment surface.
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Edlinger C, Paar V, Tuscher T, Jirak P, Motloch LJ, Kammler J, Blessberger H, Kraus J, Hoppe UC, Steinwender C, Kypta A, Lichtenauer M. Potential mechanisms of endothelialisation in individuals implanted with a leadless pacemaker systems: An experimental in vitro study. J Electrocardiol 2019; 55:72-77. [PMID: 31146075 DOI: 10.1016/j.jelectrocard.2019.04.012] [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: 02/07/2019] [Revised: 03/26/2019] [Accepted: 04/20/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Leadless pacemaker technology is a promising upcoming field in clinical rhythmology. Today, the most commonly used system in the clinical setting is the Micra™ leadless pacemaker system (Medtronic). In autopsies of patients who witnessed non-pacemaker associated death, unexpected ingrowth/encapsulation within the wall of the right ventricle was reported. The occurrence of a complete encapsulation was not expected and the process of endothelialisation remains unclear. We hypothesized, that a local inflammatory response might be the cause of these findings. The aim of our experimental in-vitro study was to investigate the effect of the Micra™ system and its single components on inflammatory processes. METHODS For this purpose, whole Micra™ pacemakers were incubated in heparin plasma from 25 healthy volunteers for 48 h at 37 °C. Furthermore, 1 g gold, steel, titanium, tungsten and nitinol wires were incubated in heparin plasma for 48 h at 37 °C as well (n = 10). To detect eventual inflammatory processes, interleukin- (IL) 1β, IL-6, and tumor necrosis factor alpha (TNF-α), the chemokine IL-8 were measured using enzyme-linked immunosorbent assay (ELISA). Additionally, the level of transforming growth factor beta 1 (TGF-β1) and vascular endothelial growth factor (VEGF) were analysed. RESULTS ELISA analyses showed that the whole Micra system leads to a significant increase in the inflammatory cytokine IL-6 which correlates with the data gained by the incubation of whole blood with the different wires. In particular, 0.5 g of tungsten showed a significant rise of IL-6 which could also be found for IL-1β and IL-8. CONCLUSIONS The in vitro study of the Micra system showed that the material composition led to an onset of inflammatory processes in whole blood. Consequently, one may speculate that the composition of Micra pacemaker may have a local inflammatory, though subclinical, effects in patients implanted with a Micra™ pacemakers.
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Affiliation(s)
- Christoph Edlinger
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria; Department of Cardiology, Heart Center Brandenburg, Bernau/Berlin, Germany; Brandenburg Medical School (MHB) "Theodor Fontane" Neuruppin, Germany
| | - Vera Paar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Thomas Tuscher
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Peter Jirak
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Lukas J Motloch
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Jürgen Kammler
- 1st Medical Department - Cardiology, General Hospital Linz, Johannes Kepler University School of Medicine, Linz, Austria
| | - Hermann Blessberger
- 1st Medical Department - Cardiology, General Hospital Linz, Johannes Kepler University School of Medicine, Linz, Austria
| | - Johannes Kraus
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Clemens Steinwender
- 1st Medical Department - Cardiology, General Hospital Linz, Johannes Kepler University School of Medicine, Linz, Austria
| | - Alexander Kypta
- 1st Medical Department - Cardiology, General Hospital Linz, Johannes Kepler University School of Medicine, Linz, Austria
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria.
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VanOs R, Lildhar LL, Lehoux EA, Beaulé PE, Catelas I. In vitro macrophage response to nanometer-size chromium oxide particles. J Biomed Mater Res B Appl Biomater 2013; 102:149-59. [PMID: 23997019 DOI: 10.1002/jbm.b.32991] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 04/05/2013] [Accepted: 05/28/2013] [Indexed: 12/13/2022]
Abstract
An increasing number of studies have reported adverse tissue reactions around metal-on-metal (MM) hip implants. However, the origin and mechanisms of these reactions remain unclear. Moreover, the biological effects of nanometer-size chromium oxide particles, the predominant type of wear particles produced by MM implants, remain mostly unknown. The purpose of this study was to analyze the cytotoxic effects of clinically relevant nanometer-size chromium oxide particles on macrophage response in vitro. J774.A1 macrophages were cultured with either 60 nm or 700 nm commercially available Cr2 O3 particles at different concentrations. Two different particle sizes were analyzed to evaluate potential volume effects. Cell mortality was analyzed by light microscopy, flow cytometry (annexin V-fluorescein isothiocyanate and propidium iodide assay), and using a cell death detection enzyme-linked immunosorbant assay (ELISA). Tumor necrosis factor alpha (TNF-α), monocyte chemotactic protein-1 (MCP-1), and macrophage inflammatory protein-1 alpha (MIP-1α) release was measured by ELISA, and gene expression was analyzed by quantitative real-time PCR. Results showed that, at high concentrations, Cr2 O3 particles of both sizes can be cytotoxic, inducing significant decreases in total cell numbers and increases in necrosis. Results also suggested that these effects were dependent on particle volume. However, TNF-α, MCP-1, and MIP-1α cytokine release and gene expression remained low. Overall, this study demonstrates that nanometer-size particles of Cr2 O3 , a stable form of chromium oxide ceramic, have rather low cytotoxic effects on macrophages. Therefore, these particles may not be the main culprit in the initiation of the inflammatory reaction in MM periprosthetic tissues. However, other parameters (e.g., potential intracellular damage) remain to be investigated.
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Affiliation(s)
- Robilyn VanOs
- Department of Mechanical Engineering, University of Ottawa, Ottawa, Ontario K1N 6N5, Canada
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Rochford E, Richards R, Moriarty T. Influence of material on the development of device-associated infections. Clin Microbiol Infect 2012; 18:1162-7. [DOI: 10.1111/j.1469-0691.2012.04002.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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The development of whole blood titanium levels after instrumented spinal fusion - is there a correlation between the number of fused segments and titanium levels? BMC Musculoskelet Disord 2012; 13:159. [PMID: 22925526 PMCID: PMC3495207 DOI: 10.1186/1471-2474-13-159] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 08/20/2012] [Indexed: 11/10/2022] Open
Abstract
Background Most modern spinal implants contain titanium and remain in the patient’s body permanently. Local and systemic effects such as tissue necrosis, osteolysis and malignant cell transformation caused by implants have been described. Increasing tissue concentration and whole blood levels of ions are necessary before a disease caused by a contaminant develops. The aim of the present study was the measurement of whole blood titanium levels and the evaluation of a possible correlation between these changes and the number of fused segments. Methods A prospective study was designed to determine changes in whole blood titanium levels after spinal fusion and to analyze the correlation to the number of pedicle screws, cross connectors and interbody devices implanted. Blood samples were taken preoperatively in group I (n = 15), on the first, second and 10th day postoperatively, as well as 3 and 12 months after surgery. Group II (n = 16) served as a control group of volunteers who did not have any metal implants in the body. Blood samples were taken once in this group. The number of screw-rod-connections and the length of the spinal fusion were determined using radiographic pictures. This study was checked and approved by the ethical committee of the University of Tuebingen. Results The mean age in group I was 47 ± 22 years (range 16 - 85 years). There were three male (20%) and twelve female (80%) patients. The median number of fused segments was 5 (range 1 to 11 segments). No statistically significant increase in the titanium level was seen 12 months after surgery (mean difference: -7.2 μg/l, 95% CI: -26.9 to 12.5 μg/l, p = 0.446). By observing the individual titanium levels, 4 out of 15 patients demonstrated an increase in titanium levels 12 months after surgery. No statistically significant correlation between fused segments (r = -0.188, p = 0.503) length of instrumentation (r = -0.329, p = 0.231), number of interbody devices (r = -0.202, p = 0.291) and increase of titanium levels over the observation period was seen. Conclusions Instrumented spinal fusion does not lead to a statistically significant increase in whole blood titanium levels. There seems to be no correlation between the number of pedicle screws, cross connectors and interbody devices implanted and the increase of serum titanium levels.
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Canullo L, Micarelli C, Iannello G. Microscopical and chemical surface characterization of the gingival portion and connection of an internal hexagon abutment before and after different technical stages of preparation. Clin Oral Implants Res 2012; 24:606-11. [DOI: 10.1111/j.1600-0501.2012.02499.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2012] [Indexed: 12/14/2022]
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