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Gaillard-Campbell DM, Gross TP. Hypersensitivity to metals in metal-on-metal hip arthroplasty: a prospective study of one hundred and thirty five lymphocyte transformation tests. INTERNATIONAL ORTHOPAEDICS 2024; 48:693-698. [PMID: 37770674 PMCID: PMC10902022 DOI: 10.1007/s00264-023-05992-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 02/27/2022] [Indexed: 09/30/2023]
Abstract
BACKGROUND Metal allergy remains a controversial topic in the orthopaedic community. It is not known if or to what degree metal sensitivity contributes to inflammatory soft tissue failures, unexplained residual pain, or clinical complications after total joint replacement with metal prostheses. METHODS We investigated the efficacy of the lymphocyte transformation test (LTT) in predicting adverse outcomes in patients after receiving a metal joint replacement. Our study cohort consists of 135 metal-on-metal hip resurfacing arthroplasty cases performed between 2013 and 2015. All study patients had an LTT preoperatively. We retrospectively analyzed clinical outcomes and failures for our cohort. RESULTS There was no difference in LTT reactivity between men and women. Of the 135 patients tested, 46 (34.1% of cohort) tested positive to at least one of the materials comprising their implant, and 78 patients (57.8%) had at least one reactive score to any component of the LTT. After a minimum follow-up of two years, we did not observe an allergic response to the implant in any patients. There were no failures requiring revision. We observed a 2.2% rate of moderate residual pain; no patients with residual pain tested positive for metal sensitivity. When patients with moderate-high LTT reactivity (30.4% of cohort) were compared to the remainder of the study group, there was no difference in HHS or UCLA activity score. There was no correlation between blood metal ion levels and LTT reactivity. CONCLUSION We were unable to prove any predictive value of the LTT. We failed to identify hypersensitivity to metals in patients with metal-on-metal hip resurfacing arthroplasty.
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Affiliation(s)
| | - Thomas P Gross
- Midlands Orthopaedics & Neurosurgery, 1910 Blanding Street, Columbia, SC, 29201, USA
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Palazzuolo M, Bensa A, Bauer S, Blakeney WG, Filardo G, Riegger M. Resurfacing Hip Arthroplasty Is a Safe and Effective Alternative to Total Hip Arthroplasty in Young Patients: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12062093. [PMID: 36983096 PMCID: PMC10052473 DOI: 10.3390/jcm12062093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed at comparing resurfacing hip arthroplasty (RHA) and total hip arthroplasty (THA) in terms of rate of complications, revisions, functional outcomes, blood loss, operative time and metal ions levels. The search was conducted on three databases (PubMed, Cochrane and Web of Science) updated until 13 October 2022. The inclusion criteria were RCTs) written in the English language, with no time limitation, comparing RHA and THA. Among the retrieved 4748 articles, 18 RCTs were eligible for a total of 776 patients (mean age 53.1 ± 5.0). A meta-analysis was performed. RHA reported significantly lower blood loss compared to THA (p < 0.001) but with longer operative time (p < 0.001). No statistically significant difference was found between RHA and THA in terms of complications (12.08% and 16.24%, respectively) and revisions (6.32% and 6.14%, respectively). Both RHA and THA provide excellent clinical results in a population of young and active patients. Functional outcomes were not significantly different between the groups. Moreover, no significant difference in metal ion levels was found. These findings provide evidence concerning the safety and clinical effectiveness of RHA. Because of its bone-preserving properties, the lack of drawbacks and good outcomes, RHA appears to be a valid alternative to THA in young and active patients.
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Affiliation(s)
- Michele Palazzuolo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6600 Locarno, Switzerland
| | - Alessandro Bensa
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland
| | - Stefan Bauer
- Service d'Orthopédie et de Traumatologie, Chirurgie de l'Épaule, Ensemble Hospitalier de la Côte, 1110 Morges, Switzerland
- Department of Orthopedic Surgery, Royal Perth Hospital, Perth, WA 6000, Australia
| | - William G Blakeney
- Department of Orthopedic Surgery, Royal Perth Hospital, Perth, WA 6000, Australia
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Martin Riegger
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900 Lugano, Switzerland
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Ganesan N, Ronsmans S, Hoet P. Methods to Assess Proliferation of Stimulated Human Lymphocytes In Vitro: A Narrative Review. Cells 2023; 12:cells12030386. [PMID: 36766728 PMCID: PMC9913443 DOI: 10.3390/cells12030386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/10/2022] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
The ability to monitor lymphocyte responses is critical for developing our understanding of the immune response in humans. In the current clinical setting, relying on the metabolic incorporation of [3H] thymidine into cellular DNA via a lymphocyte proliferation test (LPT) is the only method that is routinely performed to determine cell proliferation. However, techniques that measure DNA synthesis with a radioactive material such as [3H] thymidine are intrinsically more sensitive to the different stages of the cell cycle, which could lead to over-analyses and the subsequent inaccurate interpretation of the information provided. With cell proliferation assays, the output should preferably provide a direct and accurate measurement of the number of actively dividing cells, regardless of the stimuli properties or length of exposure. In fact, an ideal technique should have the capacity to measure lymphocyte responses on both a quantitative level, i.e., cumulative magnitude of lymphoproliferative response, and a qualitative level, i.e., phenotypical and functional characterization of stimulated immune cells. There are many LPT alternatives currently available to measure various aspects of cell proliferation. Of the nine techniques discussed, we noted that the majority of these LPT alternatives measure lymphocyte proliferation using flow cytometry. Across some of these alternatives, the covalent labelling of cells with a high fluorescence intensity and low variance with minimal cell toxicity while maximizing the number of detectable cell divisions or magnitude of proliferation was achieved. Herein, we review the performance of these different LPT alternatives and address their compatibility with the [3H] thymidine LPT so as to identify the "best" alternative to the [3H] thymidine LPT.
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Affiliation(s)
- Nirosha Ganesan
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3000 Leuven, Belgium
| | - Steven Ronsmans
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Clinic for Occupational and Environmental Medicine, Department of Respiratory Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Peter Hoet
- Laboratory of Toxicology, Unit of Environment & Health, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, 3000 Leuven, Belgium
- Correspondence:
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Roach K, Roberts J. A comprehensive summary of disease variants implicated in metal allergy. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART B, CRITICAL REVIEWS 2022; 25:279-341. [PMID: 35975293 PMCID: PMC9968405 DOI: 10.1080/10937404.2022.2104981] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Allergic disease represents one of the most prominent global public health crises of the 21st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy - including allergic contact dermatitis - are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed - from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described.Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.
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Affiliation(s)
- Ka Roach
- Allergy and Clinical Immunology Branch (ACIB), National Institute of Occupational Safety and Health (NIOSH), Morgantown, WV, USA
| | - Jr Roberts
- Allergy and Clinical Immunology Branch (ACIB), National Institute of Occupational Safety and Health (NIOSH), Morgantown, WV, USA
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Impact of Preoperative Metal Patch Testing on Surgery Using Metal Implants. Arthroplast Today 2022; 14:170-174. [PMID: 35330665 PMCID: PMC8938599 DOI: 10.1016/j.artd.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 01/18/2022] [Accepted: 02/12/2022] [Indexed: 11/26/2022] Open
Abstract
Background Patients scheduled for metal implant surgery in some facilities in Japan undergo preoperative metal patch testing (MPT). However, few studies have reported the impact of MPT results on scheduled surgery; therefore, the value of preoperative MPT remains unknown. Material and methods In analysis 1,the preoperative MPT results requested by orthopedic surgeons from 4 institutions from 2014 to 2018 were retrospectively analyzed. In analysis 2, the medical records of all patients who underwent total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty/reverse shoulder arthroplasty between 2014 and 2018 were collected. The number of patients who underwent MPT and their surgical results were analyzed. Results In analysis 1, MPT was performed on 72 patients during the study period. The overall MPT positivity rate was 26.4% for the entire cohort in analysis 1. In 4 out of 19 MPT-positive cases, the results of MPT changed the treatment plan to use alternative materials or cancel the surgery. In analysis 2, 1087 patients underwent total hip arthroplasty, total knee arthroplasty, and TSA/RSA; only 16 patients underwent MPT. Aseptic loosening occurred postoperatively in 3 patients (0.3%), none of whom had a history of allergy, and none underwent preoperative MPT. Conclusion Metal allergy did not appear to be directly involved in aseptic loosening to any large or meaningful degree in our patient cohort. Only 1.5% of the patients underwent preoperative MPT; therefore, our results suggest this testing had limited benefit or utility. Further studies are needed to determine whether MPT is necessary in preparation for joint replacement.
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Uhler M, Braun S, Schroeder S, Renkawitz T, Kretzer JP. Wear investigation based on a novel, anatomic shoulder prosthesis with bearing materials inversion. J Mech Behav Biomed Mater 2022; 127:105080. [DOI: 10.1016/j.jmbbm.2022.105080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/30/2021] [Accepted: 01/08/2022] [Indexed: 11/26/2022]
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Bettiol P, Egan A, Cox C, Wait E, Brindley G. Pathological analysis of periprosthetic soft tissue and modes of failure in revision total joint arthroplasty patients. SAGE Open Med 2021; 9:20503121211047099. [PMID: 34589221 PMCID: PMC8474343 DOI: 10.1177/20503121211047099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives Implant failure leading to revision total joint arthroplasty can occur through a variety of different mechanisms which are typically associated with a soft tissue response adjacent to the implant that provide insight into the underlying etiology of implant failure. The objective of this study was to elucidate mechanisms of implant failure as they relate to histological classification and findings of adjacent periprosthetic tissue. Methods Histological analysis of soft tissue adjacent to the implant was performed in 99 patients with an average age of 64 years old and grouped into four categories based on the study conducted by Morawietz et al.:Type I (N = 47)Wear particle induced typeType II (N = 7)Infectious typeType III (N = 19)Combined type I and IIType IV (N = 26)Indeterminant typeModes of failure were categorized into five groupings based on the study conducted by Callies et al.: Instability (N = 35), Aseptic Loosening (N = 24), Hardware and/or Mechanical Failure (N = 15), Septic (N = 13), and Other failures (N = 12). We calculated odds ratios and conducted regression analysis to assess the relationship between modes of failure and histological findings as well as modes of failure and comorbidities. Results Hardware/mechanical failure was independently correlated with histological findings of anucleate protein debris, histiocytes, Staphylococcus epidermidis, and synovitis. Furthermore, hardware/mechanical failure was independently correlated with osteosarcoma as a co-morbidity. Septic failure was associated with histological findings of Enterococcus, granulation tissue, and tissue necrosis as well as comorbidities of Crohn's disease, deep venous thrombosis, lung disease, and rheumatoid arthritis. Infection was 5.8 times more likely to be associated with Type II histology. Aseptic loosening was associated with histologic findings of synovitis. Conclusion Our findings support the existing literature on periprosthetic tissue analysis in revision total joint arthroplasty which may improve surgeon understanding of the patholophysiological mechanisms that contribute to implant failure and revision surgery.
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Affiliation(s)
- Patrick Bettiol
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Alec Egan
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Cameron Cox
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Eric Wait
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - George Brindley
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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8
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Comparison of the long-term cause of failure and survivorship of four hundred and twenty seven metal-on-metal hip arthroplasties: resurfacing versus large head total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:3075-3081. [PMID: 34155524 PMCID: PMC8626394 DOI: 10.1007/s00264-021-05044-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022]
Abstract
Introduction Comparison of mid- to long-term cause of failure and survivorship of metal-on-metal (MoM) resurfacing hip arthroplasty (RHA) and large head total hip arthroplasty (THA) remains sparse. This study aimed to identify and compare the cause of failure and survivorship of MoM RHA and THA at a minimum ten year follow-up. Methods Four hundred twenty-seven MoM hip arthroplasties (286 THA and 141 RHA) were retrospectively analyzed at a mean follow-up of 13 ± three years. Causes of failure were reported as MoM specific (i.e., adverse reaction to metal debris (ARMD) and painful hip with ion elevation) or MoM non-specific (i.e., fracture, infection, and dislocation). Chromium (Cr) and cobalt (Co) ion levels and Co/Cr ratio were compared. Survivorship was compared according to the cause of failure with revision as the endpoint. Results The rate of ARMD was significantly higher in THA (OR = 2.9 [95%-CI: 1–7]; p = 0.02). No significant difference was detected in failure rate due to other causes between the two groups (p = 0.2–0.9). Ion levels and Co/Cr ratio were both significantly higher in THA (p < 0.01). Survivorship was significantly lower in THA compared to RHA at ten years [89% (95%-CI: 85%–91%) vs 96% (95%-CI: 91%–98%); p = 0.01] and 15 years [73% (95%-CI: 67%–78%) vs 83% (95%-CI: 73%–90%); p = 0.01]. Conclusion RHA survivorship was significantly higher at any time point. Failure rate due to ARMD was significantly higher in THA while no significant difference in other causes of failure was observed between the two groups. This result emphasizes the role of fretting corrosion at the head-neck junction (i.e., trunnionosis) with significantly higher ion levels and Co/Cr ratio dissociation in THA.
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9
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Blom LH, Elrefaii SA, Zachariae C, Thyssen JP, Poulsen LK, Johansen JD. Memory T helper cells identify patients with nickel, cobalt, and chromium metal allergy. Contact Dermatitis 2021; 85:7-16. [PMID: 33576045 DOI: 10.1111/cod.13809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/07/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patch testing is the gold standard for identifying culprit allergens in allergic contact dermatitis; however, it is laborious and positive reactions are difficult to quantitate. Development of complementary in vitro tests is, therefore, of great importance. OBJECTIVES This study aimed to improve the in vitro lymphocyte proliferation test (LPT) to detect allergic responses to nickel (Ni), cobalt (Co), and chromium (Cr). METHODS Twenty-one metal allergic patients with a positive patch test to Ni (n=16), Co (n=8), and Cr (n=3) and 13 controls were included. All were tested by a flow cytometric LPT. RESULTS Metal-reactive cells were identified as T helper (Th) cells with high expression of the memory marker CD45RO. Skin-homing (cutaneous lymphocyte-associated antigen positive [CLA+]) Ni-reactive memory Th (Thmem hi ) cells identified individuals with a positive patch test for Ni with 100% sensitivity (95% confidence interval [CI] 81%-100%) and 92% specificity (95% CI 67%-100%). Moreover, Co-specific Thmem hi cells expressing CCR6 identified patients with a positive patch test for Co with 63% sensitivity (95% CI 31%-86%) and 100% specificity (95% CI 77%-100%). In Cr allergic individuals, Cr-reactive Thmem hi cells tended to increased CLA and CCR6 expression. CONCLUSION Metal-reactive Th cells with high expression of CD45RO and coexpression of CLA and CCR6 improved the LPT, making it an attractive supplement to the patch test.
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Affiliation(s)
- Lars H Blom
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Sali A Elrefaii
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Lars K Poulsen
- Department of Dermatology and Allergy, Allergy Clinic, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Jeanne D Johansen
- Department of Dermatology and Allergy, National Allergy Research Centre, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
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Metal Hypersensitivity in Joint Arthroplasty. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202103000-00007. [PMID: 33720103 PMCID: PMC7963506 DOI: 10.5435/jaaosglobal-d-20-00200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/31/2021] [Indexed: 11/18/2022]
Abstract
Metal hypersensitivity in joint arthroplasty is a very controversial topic with limited evidence. With increasing numbers of joint replacements being done annually, a clear understanding of the pathogenesis, clinical picture, preimplant screening, postimplant workup, and treatment plan is crucial. This review article looked at all the available evidence regarding metal hypersensitivity and summarized the key findings. An algorithm was also proposed for preimplant screening, postimplant workup, and management.
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McLawhorn AS, Buller LT, Blevins JL, Lee YY, Su EP. What Are the Benefits of Hip Resurfacing in Appropriate Patients? A Retrospective, Propensity Score-Matched Analysis. HSS J 2020; 16:316-326. [PMID: 33380963 PMCID: PMC7749913 DOI: 10.1007/s11420-019-09729-4] [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] [Received: 06/04/2019] [Accepted: 09/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip arthritis is one of the major causes of disability worldwide. Hip resurfacing arthroplasty (HRA) has emerged in recent years as an alternative to total hip arthroplasty (THA), but complications of HRA have limited the patient population to younger male patients with primary osteoarthritis and large hip anatomy. How the functional benefits of HRA in this population compare with those of THA is not entirely clear. QUESTIONS/PURPOSES The primary aim of this study was to determine whether there were differences in hip disability and patient satisfaction with surgery between these two groups at 2 years after surgery, using patient-reported outcome measures (PROMs) and subjective measures of patient satisfaction. Additionally, we sought to determine whether there were differences in post-operative discharge disposition, revision rates, or adverse events. METHODS We searched an institutional database to identify patients undergoing unilateral HRA or THA between January 2007 and July 2011 who met today's recommended criteria for HRA: younger male patients with large-enough hip anatomy to make surgery viable (a femoral head of at least 48 mm in HRA patients and, in THA patients, an acetabular shell size of 54 mm, the minimum outer shell size that could accommodate a femoral head component of 48 mm; for matching purposes, acetabular shell size in THA was used as a surrogate for the femoral head size used in HRA). We used propensity score matching to control for potentially confounding pre-operative variables and administered the Hip Disability and Osteoarthritis Outcome Score (HOOS) survey, including its subdomains, at the 2-year mark. We also assessed differences between groups in Lower Extremity Activity Scale scores, 12-item Short Form Health Survey results, and answers regarding satisfaction with surgery. We calculated minimal detectable change, minimum clinically important change, and substantial clinical benefit using anchor-based techniques for multiple outcome measures. RESULTS There were 251 patients in each group. HRA patients scored significantly higher than THA patients on the 2-year HOOS sports and recreation (92 versus 87, respectively) and on rates of overall satisfaction (94% versus 89%, respectively). The HRA group also had a greater chance of achieving minimum clinically important change (18.75 points) in the HOOS sports and recreation subdomains than the THA group (97% versus 91%). No significant difference was found in 6-month adverse event rates. HRA patients also had a significantly shorter mean hospital stay, a higher rate of discharge to home, and a lower incidence of a "significant" limp after surgery. CONCLUSION HRA may provide a functional benefit in sports and recreation and greater satisfaction in patients who meet the current criteria for HRA. Because these benefits may be small, pre-operative counseling should focus on balancing the possible functional benefits against the longer-term risks associated with metal-on-metal bearings.
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Affiliation(s)
- Alexander S. McLawhorn
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Leonard T. Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, 340 W 10th St #6200, Indianapolis, IN 46202 USA
| | - Jason L. Blevins
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Yuo Yu Lee
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Edwin P. Su
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Dawson-Amoah KG, Waddell BS, Prakash R, Alexiades MM. Adverse Reaction to Zirconia in a Modern Total Hip Arthroplasty with Ceramic Head. Arthroplast Today 2020; 6:612-616.e1. [PMID: 32995410 PMCID: PMC7502561 DOI: 10.1016/j.artd.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 12/28/2022] Open
Abstract
Hypersensitivity reactions to zirconia (ZrO2) or similar ceramics is highly unusual. Owing to the stable oxide formed between the base metal and oxygen, ceramics are considered relatively biologically inert. We report the case of an otherwise healthy 50-year-old woman with a 5-year history of progressively worsening right hip pain who underwent a ceramic-on-polyethylene total hip replacement and subsequently developed hypersensitivity reaction. After metal allergy testing showed her to be highly reactive to zirconium, the femoral head was revised to a custom titanium implant and her symptoms resolved.
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Affiliation(s)
| | - Bradford S. Waddell
- Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
- Corresponding author. Hospital for Special Surgery LLC, 1 Blachley Road, Stamford, CT 06902, USA. Tel.: +1 404 352 1015.
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Charousset C, Lefebvre Y, Bonnevialle N, Joudet T, Audebert S, Berhouet J, Michelet A, Geais L, Godenèche A. Prevalence of metal hypersensitivity in patients with shoulder pathologies. J Shoulder Elbow Surg 2020; 29:1789-1795. [PMID: 32371039 DOI: 10.1016/j.jse.2020.01.100] [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: 11/18/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. METHODS The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. RESULTS A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. CONCLUSIONS This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.
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Affiliation(s)
| | - Yves Lefebvre
- Institut de l'Epaule de Strasbourg 16, allée de la Robertsau, Strasbourg, France
| | - Nicolas Bonnevialle
- Département de chirurgie orthopédique, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Thierry Joudet
- Department of Orthopaedic Surgery, Clinique chirurgicale du Libournais, Libourne, France
| | - Stephane Audebert
- Department of Orthopaedic Surgery, Clinique du Cambresis, Cambrai, France
| | - Julien Berhouet
- Service d'Orthopédie 1C, Centre Hospitalier Universitaire de Tours, Tours, France
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- Shoulder Friends Institute, Paris, France
| | | | | | - Arnaud Godenèche
- Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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14
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Samelko L, Petfield J, McAllister K, Hsu J, Hawkinson M, Jacobs JJ, Hallab NJ. Do Battlefield Injury-acquired Indwelling Metal Fragments Induce Metal Immunogenicity? Clin Orthop Relat Res 2020; 478:752-766. [PMID: 32229747 PMCID: PMC7282599 DOI: 10.1097/corr.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 08/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND A battlefield-related injury results in increased local and systemic innate immune inflammatory responses, resulting in wound-specific complications and an increased incidence of osteoarthritis. However, little is known about whether severe injuries affect long-term systemic homeostasis, for example, immune function. Moreover, it also remains unknown whether battlefield-acquired metal fragments retained over the long term result in residual systemic effects such as altered immune reactivity to metals. QUESTIONS/PURPOSES Does a retained metal fragment from a battlefield injury contribute to increased (1) adaptive metal-specific immune responses, (2) systemically elevated metal ion serum levels, and (3) serum immunoglobulin levels compared with combat injuries that did not result in a retained metal fragment? METHODS In this pilot study, we analyzed metal-immunogenicity in injured military personnel and noninjured control participants using lymphocyte transformation testing (LTT, lymphocyte proliferation responses to cobalt, chromium and nickel challenge at 0.001, 0.01 and 0.1-mM concentrations in triplicate for each participant), serum metal ion analysis (ICP-mass spectroscopy), and serum immunoglobulin analysis (IgE, IgG, IgA, and IgM ). Military personnel with a battlefield-sustained injury self-recruited without any exclusion for sex, age, degree of injury. Those with battlefield injury resulting in retained metal fragments (INJ-FRAG, n = 20 male, mean time since injury ± SD was 12 ± 10 years) were compared with those with a battlefield injury but without retained metal fragments (INJ-NO-FRAG, n = 12 male, mean time since injury ± SD was 13 ± 12 years). A control group comprised of male noninjured participants was used to compare measured immunogenicity metrics (n = 11, males were selected to match battlefield injury group demographics). RESULTS Military participants with sustained metal fragments had increased levels of metal-induced lymphocyte responses. The lymphocyte stimulation index among military participants with metal fragments was higher than in those with nonretained metal fragments (stimulation index = 4.2 ± 6.0 versus stimulation index = 2.1 ± 1.2 (mean difference 2.1 ± 1.4 [95% confidence interval 5.1 to 0.8]; p = 0.07) and an average stimulation index = 2 ± 1 in noninjured controls. Four of 20 participants injured with retained fragments had a lymphocyte proliferation index greater than 2 to cobalt compared with 0 in the group without a retained metal fragment or 0 in the control participants. However, with the numbers available, military personnel with retained metal fragments did not have higher serum metal ion levels than military participants without retained metal fragment-related injuries or control participants. Military personnel with retained metal fragments had lower serum immunoglobulin levels (IgG, IgA, and IgM) than military personnel without retained metal fragments and noninjured controls, except for IgE. Individuals who were metal-reactive positive (that is, a stimulation index > 2) with retained metal fragments had higher median IgE serum levels than participants who metal-reactive with nonmetal injuries (1198 ± 383 IU/mL versus 171 ± 67 IU/mL, mean difference 1027 ± 477 IU/mL [95% CI 2029 to 25]; p = 0.02). CONCLUSIONS We found that males with retained metal fragments after a battlefield-related injury had altered adaptive immune responses compared with battlefield-injured military personnel without indwelling metal fragments. Military participants with a retained metal fragment had an increased proportion of group members and increased average lymphocyte reactivity to common implant metals such as nickel and cobalt. Further studies are needed to determine a causal association between exposure to amounts of retained metal fragments, type of injury, personnel demographics and general immune function/reactivity that may affect personal health or future metal implant performance. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Lauryn Samelko
- L. Samelko, K. McAllister, J. J. Jacobs, Rush University Medical Center, Chicago, IL, USA
| | - Joseph Petfield
- J. Petfield, M. Hawkinson, San Antonio Medical Center, San Antonio, TX, USA
| | - Kyron McAllister
- L. Samelko, K. McAllister, J. J. Jacobs, Rush University Medical Center, Chicago, IL, USA
| | - Joseph Hsu
- J. Hsu, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Hawkinson
- J. Petfield, M. Hawkinson, San Antonio Medical Center, San Antonio, TX, USA
| | - Joshua J Jacobs
- L. Samelko, K. McAllister, J. J. Jacobs, Rush University Medical Center, Chicago, IL, USA
| | - Nadim J Hallab
- N. J. Hallab, Rush University Medical Center, Chicago, IL, USA
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15
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Colacchio ND, Wooten CJ, Martin JR, Masonis JL, Fehring TK. Dual Mobility for Monoblock Metal-on-Metal Revision-Is It Safe? J Arthroplasty 2020; 35:508-512. [PMID: 31662280 DOI: 10.1016/j.arth.2019.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision of monoblock metal-on-metal (MoM) total hip arthroplasty (THA) is associated with high complication rates. Limited revision by conversion to a dual mobility (DM) without acetabular component extraction may mitigate these complications. However, the concern for polyethylene wear and osteolysis remains unsettled. This study investigates the results of DM conversion of monoblock MoM THA compared to formal acetabular revision. METHODS One hundred forty-three revisions of monoblock MoM THA were reviewed. Twenty-nine were revisions to a DM construct, and 114 were complete revisions of the acetabular component. Mean patient age was 61, 54% were women. Components used, acetabular cup position, radiographic outcomes, serum metal ion levels, and HOOS Jr clinical outcome scores were investigated. RESULTS At 3.9 years of follow-up (range 2-5), there were 2 revisions (6.9%) in the DM cohort, 1 for instability and another for periprosthetic fracture. Among the formal acetabular revision group there was a 20% major complication rate (23/114) and 16% underwent revision surgery (18/114) for aseptic loosening of the acetabular component (6%), deep infection (6%), dislocation (4%), acetabular fracture (3%), or delayed wound healing (6%). In the DM cohort, there were no radiographic signs of aseptic loosening, component migration, or polyethylene wear. One DM patient had a small posterior metadiaphyseal femur lesion that will require close monitoring. There were no other radiographic signs of osteolysis. There were no clinically significant elevations of serum metal ion levels. HOOS Jr scores were favorable. CONCLUSION Limited revision with conversion to DM is a viable treatment option for failed monoblock MoM THA with lower complication rates than formal revision. Limited revision to DM appears to be a safe option for revision of monoblock MoM THA with a cup in good position and an internal geometry free of sharp edges or articular surface damage. Longer follow-up is needed to demonstrate any potential wear implications of these articulations.
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Affiliation(s)
| | - Clint J Wooten
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC
| | - John R Martin
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC
| | - John L Masonis
- Department of Orthopaedic Surgery, OrthoCarolina, Charlotte, NC
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16
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Abstract
Members of the International Skeletal Society compiled a glossary of terms for musculoskeletal radiology. The authors also represent national radiology or pathology societies in Asia, Australia, Europe, and the USA. We provide brief descriptions of musculoskeletal structures, disease processes, and syndromes and address their imaging features. Given the abundance of musculoskeletal disorders and derangements, we chose to omit most terms relating to neoplasm, spine, intervention, and pediatrics. Consensus agreement was obtained from 19 musculoskeletal radiology societies worldwide.
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17
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Hallab NJ, Jacobs JJ. Orthopedic Applications. Biomater Sci 2020. [DOI: 10.1016/b978-0-12-816137-1.00070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Chang JS, Haddad FS. Revision total hip arthroplasty for metal-on-metal failure. J Clin Orthop Trauma 2020; 11:9-15. [PMID: 32001977 PMCID: PMC6985013 DOI: 10.1016/j.jcot.2019.09.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
Metal-on-metal (MoM) arthroplasty systems became popular in the early-2000s due to presumed advantages of improved wear characteristics and superior stability. However, subsequent reports of abnormal soft-tissue reactions to MoM implants and national registry data reporting high failure rates raised concerns. Early outcomes of revision total hip arthroplasty (THA) for adverse reaction to metal debris (ARMD) were poor, leading to development of surveillance programs and a trend towards early revision surgery. Patients with MoM arthroplasties require surveillance, comprehensive history and physical examination, imaging with ultrasound or magnetic resonance imaging (MRI), and laboratory evaluation including metal ion levels. Operative strategies for revision THA vary from exchange of modular components to extensive debridement and reconstruction with revision components. Surgeons should be aware of the increased risks of dislocation and infection following revision THA for ARMD. However, there is growing evidence that early revision surgery prior to extensive soft tissue destruction results in improved outcomes and decreased re-operation rates. It is estimated that >1 million MoM articulations have been implanted, with a large proportion still in situ. It is imperative to understand the aetiology, presentation, and management strategies for these patients to optimise their clinical outcomes.
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Affiliation(s)
- Justin S. Chang
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,Corresponding author.
| | - Fares S. Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,The Princess Grace Hospital, 42-52 Nottingham Place, W1U 5NY, London, UK
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19
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Eltit F, Wang Q, Wang R. Mechanisms of Adverse Local Tissue Reactions to Hip Implants. Front Bioeng Biotechnol 2019; 7:176. [PMID: 31417898 PMCID: PMC6683860 DOI: 10.3389/fbioe.2019.00176] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022] Open
Abstract
Adverse Local Tissue Reactions (ALTRs) are one of the main causes of hip implant failures. Although the metal release from the implants is considered as a main etiology, the mechanisms, and the roles of the released products are topics of ongoing research. The alloys used in the hip implants are considered biocompatible and show negligible corrosion in the body environment under static conditions. However, modularity and its associated mechanically assisted corrosion have been shown to release metal species into the body fluids. ALTRs associated with metal release have been observed in hip implants with metal-on-metal articulation initially, and later with metal-on-polyethylene articulation, the most commonly used design in current hip replacement. The etiological factors in ALTRs have been the topics of many studies. One commonly accepted theory is that the interactions between the metal species and body proteins and cells generate a delayed type IV hypersensitivity reaction leading to ALTRs. However, lymphocyte reactions are not always observed in ALTRS, and the molecular mechanisms have not been clearly demonstrated. A more accepted mechanism is that cell damage generated by metal ions may trigger the secretion of cytokines leading to the inflammatory reactions observed in ALTRs. In this inflammatory environment, some patients would develop hypersensitivity that is associated with poor outcomes. Concerns over ALTRS have brought significant impact to both the clinical selection and development of hip implants. This review is focused on the mechanisms of ALTRs, specifically, the metal release process and the roles of the metal species released in the etiology and pathogenesis of the disease. Hopefully, our presentation and discussion of this biological process from a material perspective could improve our current understanding on the ALTRs and provide useful guidance in developing preventive solutions.
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Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Qiong Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
| | - Rizhi Wang
- Department of Materials Engineering, University of British Columba, Vancouver, BC, Canada.,School of Biomedical Engineering, University of British Columba, Vancouver, BC, Canada.,Centre for Hip Health and Mobility, Vancouver, BC, Canada
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20
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Lehtovirta L, Reito A, Lainiala O, Parkkinen J, Hothi H, Henckel J, Hart A, Eskelinen A. Host-specific factors affect the pathogenesis of adverse reaction to metal debris. BMC Musculoskelet Disord 2019; 20:195. [PMID: 31054584 PMCID: PMC6499989 DOI: 10.1186/s12891-019-2578-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background Adverse Reaction to Metal Debris (ARMD) is a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. Most failures are related to excessively wearing implant producing harmful metal debris (extrinsic factor). As ARMD may also occur in patients with low-wearing implants, it has been suggested that there are differences in host-specific intrinsic factors contributing to the development of ARMD. However, there are no studies that have directly assessed whether the development of ARMD is actually affected by these intrinsic factors. Methods We included all 29 patients (out of 33 patients) with sufficient data who had undergone bilateral revision of ASR MoM hips (58 hips) at our institution. Samples of the inflamed synovia and/or pseudotumour were obtained perioperatively and sent to histopathological analysis. Total wear volumes of the implants were assessed. Patients underwent MARS-MRI imaging of the hips preoperatively. Histological findings, imaging findings and total wear volumes between the hips of each patient were compared. Results The difference in wear volume between the hips was clinically and statistically significant (median difference 15.35 mm3, range 1 to 39 mm3, IQR 6 to 23 mm3) (p < 0.001). The median ratio of total wear volume between the hips was 2.0 (range 1.09 to 10.0, IQR 1.67 to 3.72). In majority of the histological features and in presence of pseudotumour, there were no differences between the left and right hip of each patient (p > 0.05 for all comparisons). These features included macrophage sheet thickness, perivascular lymphocyte cuff thickness, presence of plasma cells, presence of diffuse lymphocytic infiltration and presence of germinal centers. Conclusions Despite the significantly differing amounts of wear (extrinsic factor) seen between the sides, majority of the histological findings were similar in both hips and the presence of pseudotumour was symmetrical in most hips. As a direct consequence, it follows that there must be intrinsic factors which contribute to the symmetry of the findings, ie. the pathogenesis of ARMD, on individual level. This has been hypothesized in the literature but no studies have been conducted to confirm the hypothesis. Further, as the threshold of metal debris needed to develop ARMD appears to be largely variable based on the previous literature, it is likely that there are between-patient differences in these intrinsic factors, ie. the host response to metal debris is individual. Electronic supplementary material The online version of this article (10.1186/s12891-019-2578-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lari Lehtovirta
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.,Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
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21
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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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22
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Erickson J, Liu JX, Glickel SZ. Failure of Adjustably Aligned Modular Radial Head Arthroplasty With Head-Neck Dissociation and Metallosis. J Hand Surg Am 2019; 44:253.e1-253.e5. [PMID: 30292711 DOI: 10.1016/j.jhsa.2018.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 06/08/2018] [Accepted: 07/25/2018] [Indexed: 02/02/2023]
Abstract
Radial head arthroplasty was introduced in 1941 and the literature supports satisfactory overall midterm patient outcomes and acceptable complication profiles with several models. There are several previously described mechanisms by which radial head complications typically occur. We present the case of a rarely described mechanism of radial head implant failure: elbow synovitis and pain from partial dissociation and metallosis in an adjustably aligned, modular, monopolar, mixed metal, press-fit radial head arthroplasty.
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Affiliation(s)
- John Erickson
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Langone Medical Center Hospital for Joint Diseases, New York, NY
| | - James X Liu
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Langone Medical Center Hospital for Joint Diseases, New York, NY.
| | - Steven Z Glickel
- Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Langone Medical Center Hospital for Joint Diseases, New York, NY
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23
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Transition from metal-DTH resistance to susceptibility is facilitated by NLRP3 inflammasome signaling induced Th17 reactivity: Implications for orthopedic implants. PLoS One 2019; 14:e0210336. [PMID: 30653583 PMCID: PMC6336398 DOI: 10.1371/journal.pone.0210336] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Metal hypersensitivity has been recognized as an adverse biologic reaction that can compromise total joint arthroplasty (TJA) performance. However, the etiology of metal hypersensitivity responses in TJAs remains unclear. Metal implant debris is known to act as a danger signal that drives NLRP3 inflammasome activation. It remains unknown if implant debris induced inflammasome activation regulates T cell lineage in TJA metal hypersensitivity responses. In this study, we show both in vivo and in vitro that the pathogenesis of metal hypersensitivity responses to implant debris are largely dependent on activation of the inflammasome/caspase-1 pathway and subsequent production of IL-17A/F by CD4+ T cells. Inhibiting either the inflammasome pathway or IL-17A bioactivity in vivo and in vitro (in vivo using NLRP3 and Caspase-1 deficient mice or in vitro using blocking agents such as Capase-1 inhibitor, IL-1Ra and anti-IL-17A), significantly (p<0.05) mitigated metal-DTH paw inflammation as well as lymphocyte cytokine (IFN-γ and IL-17) and proliferation responses in metal-sensitized mice and primary human PBMCs. This study provides mechanistic insight into how in vivo exposure to orthopedic implant debris, and metals in general, elicits NLRP3 inflammasome activation that mediates the generation of IL-17A/F producing CD4+ T cells, leading to metal-delayed type hypersensitivity reactions.
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24
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D'Angelo F, Tanas D, Gallazzi E, Zagra L. Adverse reaction to metal debris after small-head diameter metal-on-metal total hip arthroplasty: an increasing concern. Hip Int 2018; 28:35-42. [PMID: 30755124 DOI: 10.1177/1120700018812993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: Failures due to adverse reaction to metal debris (ARMD) have become an area of common focus among surgeons performing hip replacements. Several authors have reported data on the prevalence of these masses, in both symptomatic and asymptomatic patients after either large-diameter head metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing arthroplasty, with a large variability of rate. To our knowledge, few data are reported on the association of this lesion with the use of small-head diameter MoM. METHODS: 15 hips that were revised for ARMD in small-head MoM THA were included in this study. We focused our attention on the difficulties of diagnosis and treatment and also on the histologic aspects of the harvested pathologic tissue. RESULTS: The histological examination of our cases showed a presence of lymphocytic infiltrate suggesting a delayed hypersensitivity reaction to the metal of type IV (ALVAL), but different from each other in term of the prevalence of the cellular component. Osteolysis and severe soft tissue damage were also observed. Revision resulted in remission of the lesion and successful implant. CONCLUSIONS: Our observation suggests that the evidence of ARMD should be considered even in case of small-head MoM arthroplasty and therefore these patients should be followed scrupulously with 2nd level diagnostic tools such as magnetic resonance imaging with metal artifact reduction sequence (MARS-MRI) and metal ion levels at least once. Further investigations are necessary to establish the real prevalence of this phenomenon in the whole population of small-head MoM THAs.
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Affiliation(s)
- Fabio D'Angelo
- 1 Department of Biotechnologies and Life Sciences, Division of Orthopaedics and Traumatology, University of Insubria, Italy
| | - Davide Tanas
- 1 Department of Biotechnologies and Life Sciences, Division of Orthopaedics and Traumatology, University of Insubria, Italy
| | - Enrico Gallazzi
- 2 Hip Department, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
| | - Luigi Zagra
- 3 IRCCS Istituto Ortopedico Galeazzi, Hip Department, Milan, Italy
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25
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Hasegawa M, Wakabayashi H, Sudo A. A case of bone necrosis with pseudotumor following metal-on-metal total hip arthroplasty. Arthroplast Today 2018; 4:291-294. [PMID: 30186907 PMCID: PMC6123320 DOI: 10.1016/j.artd.2017.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/19/2017] [Accepted: 09/21/2017] [Indexed: 11/30/2022] Open
Abstract
A case of bone necrosis with a pseudotumor following metal-on-metal total hip arthroplasty is presented. The patient showed no abnormal magnetic resonance findings 2 years postoperatively, but serum metal ion levels were elevated. The patient developed hip pain 3.5 years postoperatively, and bone necrosis with a pseudotumor was found. The present patient emphasized the fact that tissue necrosis associated with failed metal-on-metal bearing hip might not be limited to soft tissues, but bone necrosis could occur.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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26
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Smith DE, Golden AP, Stange AW, Barker E, Mroz M, Barón AE, Ghosh D, Maier L, Cragle D, Newman LS. Clinical and laboratory factors contributing to uninterpretable beryllium lymphocyte proliferation tests (BeLPT). Am J Ind Med 2018; 61:592-604. [PMID: 29574954 DOI: 10.1002/ajim.22842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND The beryllium lymphocyte proliferation test (BeLPT), has become the principal clinical test for detecting beryllium sensitization and chronic beryllium disease. Uninterpretable BeLPT results can occur in a small but significant proportion of tests from poor lymphocyte growth (PG) or over proliferation of lymphocytes (OP). The clinical and laboratory causes of uninterpretable results are not known. METHODS BeLPT data from the US Department of Energy-supported Former Worker Screening Program were analyzed for a 10-year period. Drivers of uninterpretable BeLPTs were investigated using multivariable models and classification techniques. RESULTS Three participant attributes were significantly associated with PG, while OP showed no significant associations. Serum lot for the lymphocyte growth medium accounted for 21% of the variation in PG and 16% in OP. CONCLUSION Serum lots influence the likelihood of having uninterpretable BeLPT. To better understand uninterpretable results and possibly reduce their occurrence, additional laboratory-related factors should be addressed.
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Affiliation(s)
- Derek E. Smith
- Cancer Center Biostatistics Core; University of Colorado; Anschutz Medical Campus; Aurora Colorado
| | | | | | | | | | - Anna E. Barón
- Department of Biostatistics and Informatics; Colorado School of Public Health; University of Colorado; Anschutz Medical Campus; Aurora Colorado
| | - Debashis Ghosh
- Department of Biostatistics and Informatics; Colorado School of Public Health; University of Colorado; Anschutz Medical Campus; Aurora Colorado
| | | | - Donna Cragle
- Oak Ridge Associated Universities; Oak Ridge Tennessee
| | - Lee S. Newman
- Center for Health, Work, and Environment, and Department of Environmental and Occupational Health and Department of Epidemiology, Colorado School of Public Health, University of Colorado; Anschutz Medical Campus; Aurora Colorado
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27
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Høl PJ, Kristoffersen EK, Gjerdet NR, Pellowe AS. Novel Nanoparticulate and Ionic Titanium Antigens for Hypersensitivity Testing. Int J Mol Sci 2018; 19:E1101. [PMID: 29642398 PMCID: PMC5979587 DOI: 10.3390/ijms19041101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 02/06/2023] Open
Abstract
Titanium is used in a wide variety of materials ranging from medical devices to materials used in everyday life. Adverse biological reactions that could occur in patients, consumers, and workers should be monitored and prevented. There is a lack of available agents to test and predict titanium-related hypersensitivity. The aim of this study was to develop two bioavailable titanium substances in ionic and nanoparticulate form to serve as antigens for hypersensitivity testing in vitro. Peripheral blood mononuclear cells from 20 test subjects were stimulated with the antigens and secretion of monocytic and lymphatic cytokines and chemokines were measured by a multiplex bead assay. Lymphocyte stimulation indices were also determined in a subset of test subjects by measuring CD69 and HLA-DR expression by flow cytometry. Cytokine profiling revealed that both antigens increased production of typical monocyte and macrophage secreted cytokines after 24 h, with significant increases in IL-1β, IL-7, IL-10, IL-12, IL-2R, IL-6, GM-CSF, TNF-α, IL-1RA, MIP-1α, MIP-1β, IFN-α, and IL-15. Lymphatic cytokines and chemokines were not significantly induced by activation. After seven days of stimulation, ionic-Ti (2.5 μg/mL) caused proliferation (stimulation index > 2) of CD4+ cells and CD8+ cells in all persons tested (N = 6), while titanium dioxide nanoparticles (50 μg/mL) only caused significant proliferation of CD4+ cells. Our preliminary results show that the experimental titanium antigens, especially the ionic form, induce a general inflammatory response in vitro. A relevant cohort of test subjects is required to further elucidate their potential for predictive hypersensitivity testing.
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Affiliation(s)
- Paul Johan Høl
- Department of Clinical Medicine, University of Bergen, N-5021 Bergen, Norway.
- Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 87, N-5021 Bergen, Norway.
| | - Einar K Kristoffersen
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway.
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, N-5021 Bergen, Norway.
| | - Nils Roar Gjerdet
- Department of Clinical Dentistry, University of Bergen, N-5009 Bergen, Norway.
| | - Amanda S Pellowe
- School of Engineering and Applied Sciences, Yale University, New Haven, CT 06511, USA.
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Warburton KJ, Everingham JB, Helms JL, Kazanovicz AJ, Hollar KA, Brourman JD, Fox SM, Lujan TJ. Wear testing of a canine hip resurfacing implant that uses highly cross-linked polyethylene. J Orthop Res 2018; 36:1196-1205. [PMID: 28941247 PMCID: PMC5866242 DOI: 10.1002/jor.23745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/13/2017] [Indexed: 02/04/2023]
Abstract
Hip resurfacing offers advantages for young, active patients afflicted with hip osteoarthritis and may also be a beneficial treatment for adult canines. Conventional hip resurfacing uses metal-on-metal bearings to preserve bone stock, but it may be feasible to use metal-on-polyethylene bearings to reduce metal wear debris while still preserving bone. This study characterized the short-term wear behavior of a novel hip resurfacing implant for canines that uses a 1.5 mm thick liner of highly cross-linked polyethylene in the acetabular component. This implant was tested in an orbital bearing machine that simulated canine gait for 1.1 million cycles. Wear of the liner was evaluated using gravimetric analysis and by measuring wear depth with an optical scanner. The liners had a steady-state mass wear rate of 0.99 ± 0.17 mg per million cycles and an average wear depth in the central liner region of 0.028 mm. No liners, shells, or femoral heads had any catastrophic failure due to yielding or fracture. These results suggest that the thin liners will not prematurely crack after implantation in canines. This is the first hip resurfacing device developed for canines, and this study is the first to characterize the in vitro wear of highly cross-linked polyethylene liners in a hip resurfacing implant. The canine implant developed in this study may be an attractive treatment option for canines afflicted with hip osteoarthritis, and since canines are the preferred animal model for human hip replacement, this implant can support the development of metal-on-polyethylene hip resurfacing technology for human patients. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1196-1205, 2018.
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Affiliation(s)
- Kevin J. Warburton
- Boise State University, 1910 University Drive, Boise, ID 83725-2085,
United States
| | - John B. Everingham
- Boise State University, 1910 University Drive, Boise, ID 83725-2085,
United States
| | - Jillian L. Helms
- Boise State University, 1910 University Drive, Boise, ID 83725-2085,
United States
| | | | - Katherine A. Hollar
- Boise State University, 1910 University Drive, Boise, ID 83725-2085,
United States
| | - Jeff D. Brourman
- WestVet Animal Emergency and Specialty Center, Garden City, ID
83714, United States, 5019 N. Sawyer Ave., United States
| | - Steven M. Fox
- Securos Surgical, 443 Main Street, Fiskdale, MA 01518
| | - Trevor J. Lujan
- Boise State University, 1910 University Drive, Boise, ID 83725-2085,
United States
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Bardakos NV. CORR Insights®: Frank Stinchfield Award: Identification of the At-risk Genotype for Development of Pseudotumors Around Metal-on-metal THAs. Clin Orthop Relat Res 2018; 476. [PMID: 29529652 PMCID: PMC6259710 DOI: 10.1007/s11999.0000000000000111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Nikolaos V Bardakos
- N. V. Bardakos Consultant Orthopaedic Surgeon, Asklepieion Hospital, Athens, Greece
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Park SH, Lu Z, Hastings RS, Campbell PA, Ebramzadeh E. Five Hundred Fifty-five Retrieved Metal-on-metal Hip Replacements of a Single Design Show a Wide Range of Wear, Surface Features, and Histopathologic Reactions. Clin Orthop Relat Res 2018; 476:261-278. [PMID: 29529655 PMCID: PMC6259711 DOI: 10.1007/s11999.0000000000000044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In 2010, a widely used metal-on-metal hip implant design was voluntarily recalled by the manufacturer because of higher than anticipated failure rates at 5 years. Although there was a large published range of revision rates, numerous studies had reported a higher risk of revision for excessive wear and associated adverse tissue reactions when compared with other metal-on-metal total hips. The reasons for this were suggested by some to be related to cup design features. QUESTIONS/PURPOSES From retrievals of ASR metal-on-metal implants and tissue samples obtained at revision surgery, we asked the following questions: (1) What were the common and uncommon surface features? (2) What were the common and uncommon linear and volumetric wear characteristics? (3) Were there common taper corrosion characteristics? (4) What aseptic lymphocytic vasculitis-associated lesion (ALVAL) features were present in the tissues? METHODS Five hundred fifty-five ASRs, including 23 resurfacings, were studied at one academic research center. Features of wear (eg, light and moderate scratching), damage (eg, deposits, gouges), and bone attachment on the porous coating were semiquantitatively ranked from 0 (none) to 3 (> 75%) based on the amount of a feature in each region of interest by the same experienced observer throughout the study. Visible features of head taper corrosion were ranked (Goldberg score) from 1 (none) to 4 (severe) by the same observer using a previously published scoring method. An experienced tribologist measured component wear depth using a coordinate measuring machine and quantified wear volume using previously validated methods. All available tissues were sampled and examined for features of ALVAL and scored from 0 to 10 by a single observer using a method they previously developed and published. A score from 0 to 4 is considered low, 5 to 8 is considered moderate, and 9 or 10 is considered high with regard to the risk of metal hypersensitivity features in the tissues. RESULTS The most common bearing surface features were light and moderate scratches and removal or postremoval damage. Discoloration and deposits were commonly observed on femoral heads (55% [305 of 553]) and less commonly on cups (30% [165 of 546]). There was no evidence of impingement or dislocation damage. There was typically a small amount of bone attachment in at least one of eight designated regions of interest (84% [460 of 546]); extensive or no bone attachment was uncommon. Edge wear was highly prevalent. The maximum wear of 469 cups (88%) occurred near the edge, whereas the maximum wear of 508 femoral heads (94%) occurred between the pole and 45° from the pole. The median combined head-cup wear volume was 14 mm (range, 1-636 mm). One hundred sixty-nine pairs (32%) had a combined wear volume of < 10 mm, 42 pairs (8%) had volumetric wear of > 100 mm, and 319 pairs (60%) had wear volume between 10 and 100 mm³. Seventy-four percent of tapers (390 of 530) received a Goldberg score of 4, 22% (116 of 530) a score of 3, < 5% (24 of 530) a score of 2, and none received a score of 1. The most frequent ALVAL score was 5 out of 10 (35 of 144 hips [24%]) and ranged from 2 (one hip) to 10 (nine hips); 92 of 144 (64%) had a moderate score, 17 of 144 (12%) had a high score, and 35 (24%) had a low score. CONCLUSIONS Although edge wear was prevalent, in most cases, this was not associated with high wear. The increased diameter and decreased coverage angle of the ASR design may have resulted in the observed high incidence of edge wear while perhaps decreasing the risk for impingement and dislocation. CLINICAL RELEVANCE The role of bearing wear in the revisions of metal-on-metal implants is controversial, because it is known that there is a large range of in vivo wear rates even within the same implant type and that patient variability affects local tissue responses to wear debris. The observations from our study of 555 retrieved ASR implant sets indicate that there was a wide range of wear including a subset with very high wear. The results suggested that the failure of the ASR and ASR XL was multifactorial, and the failure of different subgroups such as those with low wear may be the result of mechanisms other than reaction to wear debris.
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Affiliation(s)
- Sang-Hyun Park
- S.-H. Park, Z. Lu, P. A. Campbell, E. Ebramzadeh, The J. Vernon Luck, Sr, MD Orthopaedic Research Center, Orthopaedic Institute for Children and UCLA Department of Orthopaedic Surgery, Los Angeles, CA, USA R. S. Hastings, DePuy, Inc, Warsaw, IN, USA
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31
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Urish KL, Hamlin BR, Plakseychuk AY, Levison TJ, Higgs G, Kurtz S, DiGioia AM. Trunnion Failure of the Recalled Low Friction Ion Treatment Cobalt Chromium Alloy Femoral Head. J Arthroplasty 2017; 32:2857-2863. [PMID: 28478184 PMCID: PMC5572503 DOI: 10.1016/j.arth.2017.03.075] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/11/2017] [Accepted: 03/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Gross trunnion failure (GTF) is a rare complication in total hip arthroplasty (THA) reported across a range of manufacturers. Specific lots of the Stryker low friction ion treatment (LFIT) anatomic cobalt chromium alloy (CoCr) V40 femoral head were recalled in August 2016. In part, the recall was based out of concerns for disassociation of the femoral head from the stem and GTF. METHODS We report on 28 patients (30 implants) with either GTF (n = 18) or head-neck taper corrosion (n = 12) of the LFIT CoCr femoral head and the Accolade titanium-molybdenum-zirconium-iron alloy femoral stems. All these cases were associated with adverse local tissue reactions requiring revision of the THA. RESULTS In our series, a conservative estimate of the incidence of failure was 4.7% (n = 636 total implanted) at 8.0 ± 1.4 years from the index procedure. Failures were associated with a high-offset 127° femoral stem neck angle and increased neck lengths; 43.3% (13 of 30) of the observed failures included implant sizes outside the voluntary recall (27.8% [5 of 18] of the GTF and 75.0% [8 of 12] of the taper corrosion cases). Serum cobalt and chromium levels were elevated (cobalt: 8.4 ± 7.0 μg/mL; chromium: 3.4 ± 3.3 μ/L; cobalt/chromium ratio: 3.7). The metal artifact reduction sequence magnetic resonance imaging demonstrated large cystic fluid collections typical with adverse local tissue reactions. During revision, a pseudotumor was observed in all cases. Pathology suggested a chronic inflammatory response. Impending GTF could be diagnosed based on aspiration of black synovial fluid and an oblique femoral head as compared with the neck taper on radiographs. CONCLUSION In our series of the recalled LFIT CoCr femoral head, the risk of impending GTF or head-neck taper corrosion should be considered as a potential diagnosis in a painful LFIT femoral head and Accolade titanium-molybdenum-zirconium-iron alloy THA with unknown etiology. Almost half of the failures we observed included sizes outside of the voluntary recall.
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Affiliation(s)
- Kenneth L. Urish
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583,Corresponding Author: The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, PA 15212.
| | - Brian R. Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Anton Y. Plakseychuk
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Timothy J. Levison
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Genymphas Higgs
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Steven Kurtz
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Anthony M. DiGioia
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
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Caicedo MS, Solver E, Coleman L, Jacobs JJ, Hallab NJ. Females with Unexplained Joint Pain Following Total Joint Arthroplasty Exhibit a Higher Rate and Severity of Hypersensitivity to Implant Metals Compared with Males: Implications of Sex-Based Bioreactivity Differences. J Bone Joint Surg Am 2017; 99:621-628. [PMID: 28419029 DOI: 10.2106/jbjs.16.00720] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent studies indicate that females demonstrate an increased risk of experiencing adverse local tissue reactions, aseptic loosening, and revision after primary metal-on-metal hip resurfacing arthroplasty compared with males; the underlying biological mechanisms responsible for sex discrepancies in implant failure remain unclear. In addition to anatomical and biomechanical sex differences, there may be inherent immunological disparities that predispose females to more aggressive adaptive immune reactivity to implant debris, i.e., metal sensitivity. METHODS In this retrospective study, we analyzed sex-associated rates and levels of metal sensitization in 1,038 male and 1,575 female subjects with idiopathic joint pain following total joint arthroplasty (TJA) who were referred for in vitro metal-sensitivity testing. RESULTS Females demonstrated a significantly higher rate and severity of metal sensitization compared with males. The median lymphocyte stimulation index (SI) among males was 2.8 (mean, 5.4; 95% confidence interval [CI], 4.9 to 6.0) compared with 3.5 (mean, 8.2; 95% CI, 7.4 to 9.0) among females (p < 0.05). Forty-nine percent of females had an SI of ≥4 (reactive) compared with 38% of males, and the implant-related level of pain was also significantly (p < 0.0001) higher among females (mean, 6.8; 95% CI, 6.6 to 6.9) compared with males (mean, 6.1; 95% CI, 6.0 to 6.3). CONCLUSIONS In a select group of patients who had joint pain following TJA and no evidence of infection and who were referred for metal-sensitivity testing, females exhibited a higher level of pain and demonstrated a higher rate and severity (as measured by lymphocyte SI) of metal sensitization compared with males. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marco S Caicedo
- 1Orthopedic Analysis, Chicago, Illinois 2Departments of Orthopedic Surgery (J.J.J. and N.J.H.) and Immunology (N.J.H.), Rush University Medical Center, Chicago, Illinois
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Ayoub B, Putman S, Cholewinski P, Paris A, Migaud H, Girard J. Incidence of Adverse Reactions to Metal Debris From 28-mm Metal-on-Metal Total Hip Arthroplasties With Minimum 10 Years of Follow-Up: Clinical, Laboratory, and Ultrasound Assessment of 44 Cases. J Arthroplasty 2017; 32:1206-1210. [PMID: 27988181 DOI: 10.1016/j.arth.2016.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/28/2016] [Accepted: 11/05/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total hip arthroplasty with metal-on-metal (MoM) bearings has been suspected to cause adverse reactions to metal debris (ARMD), with the incidence varying greatly by implant type and patient gender. The prevalence of ARMD from small-diameter MoM bearings in women is unknown, especially after 10 years of follow-up (FU). METHODS Cementless 28-mm MoM total hip arthroplasty bearings (Metasul) were implanted consecutively in 42 active women between 1996 and 2002. They were reviewed after a minimum of 10 years' FU with clinical, laboratory, radiological, and ultrasound assessments. RESULTS Mean FU was 15.9 years (range, 13-18). The mean Postel-Merle d'Aubigné and Oxford scores were 16.9 (range, 13-18) and 15.1 (range, 12-24), respectively, at FU. Mean cup inclination angle was 46.3° (range, 35°-57°). No femoral osteolysis was detected, but limited acetabular osteolysis (11%) over the screw holes occurred in 5 cases. No liquid or solid synovial reactions or ARMD were apparent on ultrasound, even in the 5 cases of pelvic osteolysis. Mean chromium levels were 1.32 μg/L (range, 0.1-7.9) and cobalt levels were 1.85 μg/L (range, 0.35-13.6). Cobalt was >3 μg/L in only 3 cases. The 15.9-year survivorship was 95% (range, 94.1%-98.9%). CONCLUSION Reliable results were obtained with 28-mm MoM bearings, notably in young, active patients. This implant configuration requires very accurate positioning. No ARMD was seen in this group at 16 years' FU.
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Affiliation(s)
- Béchir Ayoub
- Université de Lille Nord de France, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Place de Verdun, Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille), Lille Cedex, France
| | - Sophie Putman
- Université de Lille Nord de France, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Place de Verdun, Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille), Lille Cedex, France
| | - Pierre Cholewinski
- Université de Lille Nord de France, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Place de Verdun, Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille), Lille Cedex, France
| | - Amandine Paris
- Université de Lille Nord de France, Lille, France; Service d'orthopédie pédiatrique, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
| | - Henri Migaud
- Université de Lille Nord de France, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Place de Verdun, Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille), Lille Cedex, France
| | - Julien Girard
- Université de Lille Nord de France, Lille, France; Service d'orthopédie C, Hôpital Roger Salengro, Place de Verdun, Centre Hospitalier Régional Universitaire de Lille (CHRU de Lille), Lille Cedex, France; Département de médecine du sport, Faculté de médecine de Lille, Université de Lille 2, Lille, France
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Liow MHL, Dimitriou D, Tsai TY, Kwon YM. Preoperative Risk Factors Associated With Poor Outcomes of Revision Surgery for "Pseudotumors" in Patients With Metal-on-Metal Hip Arthroplasty. J Arthroplasty 2016; 31:2835-2842. [PMID: 27387480 DOI: 10.1016/j.arth.2016.05.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/02/2016] [Accepted: 05/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision surgery of failed metal-on-metal (MoM) total hip arthroplasty (THA) for adverse tissue reaction (pseudotumor) can be challenging as a consequence of soft tissue and muscle necrosis. The aims of this study were to (1) report the revision outcomes of patients who underwent revision surgery for failed MoM hip arthroplasty due to symptomatic pseudotumor and (2) identify preoperative risk factors associated with revision outcomes. METHODS Between January 2011 and January 2013, a total of 102 consecutive large head MoM hip arthroplasties in 97 patients (male: 62, female: 35), who underwent revision surgery were identified from the database of a multidisciplinary referral center. RESULTS At minimum follow-up of 2 years (range: 26-52 months), at least one complication had occurred in 14 of 102 revisions (14%). Prerevision radiographic loosening (P = .01), magnetic resonance imaging (MRI) findings of solid lesions with abductor deficiency on MRI (P < .001), and intraoperative grading of adverse tissue reactions (P = .05) were correlated with post-revision complications. The reoperation rate of revised MoM THA was 7% (7 of 102 hips). Implant survivorship was 88% at 3 years. Metal ion levels declined in most patients after removal of MoM articulation. CONCLUSION Revision outcomes of revision surgery for failed MoM THA due to symptomatic pseudotumor demonstrated 14% complication rate and 7% re-revision rate at 30-month follow-up. Our study identified prerevision radiographic loosening, solid lesions/abductor deficiency on MRI, and high grade intraoperative tissue damage as risk factors associated with poorer revision outcomes. This provides clinically useful information for preoperative planning and perioperative counseling of MoM THA patients undergoing revision surgery.
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Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dimitris Dimitriou
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsung-Yuan Tsai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: Current status and future prospects. EFORT Open Rev 2016; 1:345-353. [PMID: 28461912 PMCID: PMC5367524 DOI: 10.1302/2058-5241.1.160014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Large-head metal-on-metal (MoM) bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing (HR), followed closely by large metal head total hip arthroplasty (THA). A worldwide increase in the use of MoM hip arthroplasty subsequently saw a sharp decline, due to serious complications.MoM was rapidly adopted in the early 2000s until medical device alerts were issued by government regulatory agencies and national and international organisations, leading to post-marketing surveillance and discontinuation of these implants.Guidelines for MoM hip implant follow-up differ considerably between regulatory authorities worldwide; this can in part be attributed to missing or conflicting evidence.The authors consider that the use of large-head MoM THA should be discontinued. MoM HR should be approached with caution and, when considered, should be used only in patients who meet all of the recommended selection criteria, which limits its indications considerably.The phased introduction of new prostheses should be mandatory in future. Close monitoring of outcomes and long-term follow-up is also necessary for the introduction of new prostheses. Cite this article: van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: current status and future prospects. EFORT Open Rev 2016;1:345-353. DOI: 10.1302/2058-5241.1.160014.
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Affiliation(s)
| | | | - Harmen B. Ettema
- Isala Clinics, Department of Orthopaedic Surgery and Traumatology, Zwolle, The Netherlands
| | - Cees C. Verheyen
- Isala Clinics, Department of Orthopaedic Surgery and Traumatology, Zwolle, The Netherlands
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Hasegawa M, Iino T, Sudo A. Immune response in adverse reactions to metal debris following metal-on-metal total hip arthroplasty. BMC Musculoskelet Disord 2016; 17:221. [PMID: 27209084 PMCID: PMC4875693 DOI: 10.1186/s12891-016-1069-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 05/11/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The purpose of the present study was to determine whether T cell-mediated type IV hypersensitivity reactions could be a major cause of adverse reaction to metal debris (ARMD) after metal-on-metal total hip arthroplasty (THA). METHODS Thirteen patients (1 man and 12 women; mean age 68 years, age range 60 to 83 years) with ARMD underwent revision surgery following metal-on-metal THA (15 hips). Lymphocyte stimulation testing was conducted. Periprosthetic tissue specimens underwent immunohistochemical studies. RESULTS Lymphocyte stimulation testing showed that five patients were nickel-sensitive, and one patient was also cobalt-sensitive. Immunohistochemical studies showed that T cells were dominant in five hips, and B cells were dominant in 10 hips. In four of the five patients with a positive lymphocyte stimulation test, the dominant lymphocytes were T cells, suggesting type IV hypersensitivity. The major cause of ARMD was not type IV hypersensitivity in the remaining nine patients. CONCLUSION Metal hypersensitivity does not appear to be the dominant biological reaction involved in the occurrence of ARMD.
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Affiliation(s)
- Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan.
| | - Takahiro Iino
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsuv, Mie, 514-8507, Japan
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37
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Berber R, Skinner JA, Hart AJ. Management of metal-on-metal hip implant patients: Who, when and how to revise? World J Orthop 2016; 7:272-9. [PMID: 27190754 PMCID: PMC4865716 DOI: 10.5312/wjo.v7.i5.272] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 01/12/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
The debate on how best to manage patients with metal-on-metal (MOM) hip implants continues. With over 1 million patients affected worldwide, the impact is far reaching. The majority of the aggressive failures of MOM hip implants have been dealt with by revision hip surgery, leaving patients with a much more indolent pattern of failure of devices that have been in situ for more than 10 years. The longer-term outcome for such patients remains unknown, and much debate exists on how best to manage these patients. Regulatory guidance is available but remains open to interpretation due to the lack of current evidence and long-term studies. Metal ion thresholds for concern have been suggested at 7 ppb for hip resurfacing arthroplasty and below this level for large diameter total hip arthroplasties. Soft tissue changes including pseudotumours and muscle atrophy have been shown to progress, but this is not consistent. New advanced imaging techniques are helping to diagnose complications with metal hips and the reasons for failure, however these are not widely available. This has led to some centres to tackle difficult cases through multidisciplinary collaboration, for both surgical management decisions and also follow-up decisions. We summarise current evidence and consider who is at risk, when revision should be undertaken and how patients should be managed.
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Fireman E, Shai AB, Alcalay Y, Ophir N, Kivity S, Stejskal V. Identification of metal sensitization in sarcoid-like metal-exposed patients by the MELISA® lymphocyte proliferation test - a pilot study. J Occup Med Toxicol 2016; 11:18. [PMID: 27076838 PMCID: PMC4830080 DOI: 10.1186/s12995-016-0101-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 03/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background Pulmonary function is often affected by the inhalation of metal particles. The resulting pathology might trigger various lung diseases, e.g., parenchymal lung fibrosis and granulomatous lung disorders. We previously demonstrated that 6 % of tissue-proven sarcoid patients had a positive beryllium lymphocyte proliferation test (BeLPT), thus correcting the diagnosis to chronic beryllium disease. The aim of this study was to examine if MEmory Lymphocyte Immnuno Stimulation Assay (MELISA®), currently used for non-pulmonary diseases, can identify metals other than beryllium that can also trigger sensitization and induce granulomatous disease. Methods This pilot study included 13 sarcoid-like patients who underwent MELISA®. Eleven patients also underwent BeLPT. Biopsy samples were tested for metal content by scanning electron microscope. Eleven study patients had been exposed to metals at the workplace and 2 had silicone implants. Results Two patients who had undergone BeLPT were positive for beryllium. MELISA® detected 9 patients (9/13, 69 %) who were positive for at least one of the tested metals: 4 reacted positively to nickel, 4 to titanium, 2 to chromium, 2 to beryllium, 2 to silica, and one each to palladium, mercury and lead. Conclusion It is proposed that MELISA® can be exploited to also identify specific sensitization in individuals exposed to inhaled particles from a variety of metals.
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Affiliation(s)
- Elizabeth Fireman
- Laboratory for Pulmonary and Allergic Diseases, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906 Israel ; Environmental and Occupational Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Bar Shai
- Laboratory for Pulmonary and Allergic Diseases, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906 Israel
| | - Yifat Alcalay
- Laboratory for Pulmonary and Allergic Diseases, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906 Israel
| | - Noa Ophir
- Laboratory for Pulmonary and Allergic Diseases, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906 Israel ; Environmental and Occupational Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Kivity
- Laboratory for Pulmonary and Allergic Diseases, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906 Israel
| | - Vera Stejskal
- Wenner Gren Center, University of Stockholm, Stockholm, Sweden ; Research Centre for Toxic Compounds in the Environment, Masaryk University, Brno, CzechRepublic
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Salvage of Monoblock Metal-on-Metal Acetabular Components Using a Dual-Mobility Bearing. J Arthroplasty 2016; 31:846-9. [PMID: 26404847 DOI: 10.1016/j.arth.2015.08.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/17/2015] [Accepted: 08/18/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Large-diameter, monoblock acetabular components have been used for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA). If revision is required, one solution is to retain the shell and use a dual-mobility bearing. METHODS We reviewed the results of 25 revision THAs including 11 hip resurfacing arthroplasty and 14 MoM THAs where a monoblock acetabular component was mated to a dual-mobility bearing. RESULTS At a mean of 29 months, there was one failure, an intraprosthetic dislocation of the dual-mobility bearing. There was a significant decrease in serum metal ion levels postoperatively. CONCLUSION Retention of a well-fixed, monoblock MoM acetabular shell and mating it to a dual-mobility bearing in the setting of revision surgery seems to be a reasonable, low-morbidity option at short-term follow-up in appropriately positioned cups.
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Haynes JA, Stambough JB, Barrack RL, Nam D. Conversion of a failed hip resurfacing arthroplasty to total hip arthroplasty: pearls and pitfalls. Curr Rev Musculoskelet Med 2016; 9:103-11. [PMID: 26803608 PMCID: PMC4762797 DOI: 10.1007/s12178-016-9326-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surface replacement arthroplasty (SRA) remains a viable alternative to total hip arthroplasty (THA) in appropriately selected, active adults with degenerative hip disease. However, orthopedic surgeons are facing a number of scenarios where revision of one or both components of an SRA is indicated. Indications for revision vary and impact the potential outcomes of conversion of a SRA to THA. While clinical outcomes are generally favorable, a growing body of data illustrates patients who undergo conversion of a SRA to THA to be at increased risk of requiring a repeat revision surgery and experiencing functional outcomes inferior to that of a primary THA. The results of patients undergoing conversion of a SRA to THA highlight the need for careful patient selection, thorough preoperative counseling, and technical precision when performing a SRA. Furthermore, a systematic approach to the failed SRA is necessary to ensure optimal clinical results.
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Affiliation(s)
- Jacob A Haynes
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
| | - Robert L Barrack
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
| | - Denis Nam
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA.
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Ricciardi BF, Nocon AA, Jerabek SA, Wilner G, Kaplowitz E, Goldring SR, Purdue PE, Perino G. Histopathological characterization of corrosion product associated adverse local tissue reaction in hip implants: a study of 285 cases. BMC Clin Pathol 2016; 16:3. [PMID: 26924942 PMCID: PMC4769839 DOI: 10.1186/s12907-016-0025-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/22/2016] [Indexed: 12/12/2022] Open
Abstract
Background Adverse local tissue reaction (ALTR), characterized by a heterogeneous cellular inflammatory infiltrate and the presence of corrosion products in the periprosthetic soft tissues, has been recognized as a mechanism of failure in total hip replacement (THA). Different histological subtypes may have unique needs for longitudinal clinical follow-up and complication rates after revision arthroplasty. The purpose of this study was to describe the histological patterns observed in the periprosthetic tissue of failed THA in three different implant classes due to ALTR and their association with clinical features of implant failure. Methods Consecutive patients presenting with ALTR from three major hip implant classes (N = 285 cases) were identified from our prospective Osteolysis Tissue Database and Repository. Clinical characteristics including age, sex, BMI, length of implantation, and serum metal ion levels were recorded. Retrieved synovial tissue morphology was graded using light microscopy. Clinical characteristics and features of synovial tissue analysis were compared between the three implant classes. Histological patterns of ALTR identified from our observations and the literature were used to classify each case. The association between implant class and histological patterns was compared. Results Our histological analysis demonstrates that ALTR encompasses three main histological patterns: 1) macrophage predominant, 2) mixed lymphocytic and macrophagic with or without features of associated with hypersensitivity/allergy or response to particle toxicity (eosinophils/mast cells and/or lymphocytic germinal centers), and 3) predominant sarcoid-like granulomas. Implant classification was associated with histological pattern of failure, and the macrophagic predominant pattern was more common in implants with metal-on-metal bearing surfaces (MoM HRA and MoM LHTHA groups). Duration of implantation and composition of periprosthetic cellular infiltrates was significantly different amongst the three implant types examined suggesting that histopathological features of ALTR may explain the variability of clinical implant performance in these cases. Conclusions ALTR encompasses a diverse range of histological patterns, which are reflective of both the implant configuration independent of manufacturer and clinical features such as duration of implantation. The macrophagic predominant pattern and its mechanism of implant failure represent an important subgroup of ALTR which could become more prominent with increased length of implantation.
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Affiliation(s)
- Benjamin F Ricciardi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Allina A Nocon
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | - Seth A Jerabek
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Gabrielle Wilner
- Division of Research, Hospital for Special Surgery, New York, NY USA
| | - Elianna Kaplowitz
- Division of Research, Hospital for Special Surgery, New York, NY USA
| | - Steven R Goldring
- Division of Research, Hospital for Special Surgery, New York, NY USA
| | - P Edward Purdue
- Division of Research, Hospital for Special Surgery, New York, NY USA
| | - Giorgio Perino
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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42
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Revell PA, Matharu GS, Mittal S, Pynsent PB, Buckley CD, Revell MP. Increased expression of inducible co-stimulator on CD4+ T-cells in the peripheral blood and synovial fluid of patients with failed hip arthroplasties. Bone Joint Res 2016; 5:52-60. [PMID: 26868893 PMCID: PMC4852791 DOI: 10.1302/2046-3758.52.2000574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty. METHODS In this prospective case-control study, PB and SF were obtained from 22 patients (23 hips) undergoing revision of MoM (n = 14) and MoP (n = 9) hip arthroplasties, with eight controls provided from primary hip osteoarthritis cases awaiting arthroplasty. Lymphocyte subtypes in samples were analysed using flow cytometry. RESULTS The percentages of CD4+ T-cell subtypes in PB were not different between groups. The CD4+ T-cells in the SF of MoM hips showed a completely different distribution of phenotypes compared with that found in the PB in the same patients, including significantly decreased CD4+ T-central memory cells (p < 0.05) and increased T-effector memory cells (p < 0.0001) in the SF. Inducible co-stimulator (ICOS) was the only co-stimulatory molecule with different expression on CD4+ CD28+ cells between groups. In PB, ICOS expression was increased in MoM (p < 0.001) and MoP (p < 0.05) cases compared with the controls. In SF, ICOS expression was increased in MoM hips compared with MoP hips (p < 0.05). CONCLUSIONS Increased expression of ICOS on CD4+ T-cells in PB and SF of patients with failed arthroplasties suggests that these cells are activated and involved in generating immune responses. Variations in ICOS expression between MoM and MoP hips may indicate different modes of arthroplasty failure.Cite this article: Professor P. A. Revell. Increased expression of inducible co-stimulator on CD4+ T-cells in the peripheral blood and synovial fluid of patients with failed hip arthroplasties. Bone Joint Res 2016;5:52-60. doi: 10.1302/2046-3758.52.2000574.
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Affiliation(s)
- P A Revell
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham B31 2AP, UK
| | - G S Matharu
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham B31 2AP, UK
| | - S Mittal
- University of Birmingham, Edgbaston, Birmingham B15 2WD, UK
| | - P B Pynsent
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham B31 2AP, UK
| | - C D Buckley
- University of Birmingham, Edgbaston, Birmingham B15 2WD, UK
| | - M P Revell
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Birmingham B31 2AP, UK
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CORR Insights(®): do patients with a failed metal-on-metal hip implant with a pseudotumor present differences in their peripheral blood lymphocyte subpopulations? Clin Orthop Relat Res 2015; 473:3915-7. [PMID: 26463565 PMCID: PMC4626502 DOI: 10.1007/s11999-015-4571-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/21/2015] [Indexed: 01/31/2023]
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44
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Material Science in Cervical Total Disc Replacement. BIOMED RESEARCH INTERNATIONAL 2015; 2015:719123. [PMID: 26523281 PMCID: PMC4615218 DOI: 10.1155/2015/719123] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/17/2015] [Indexed: 12/12/2022]
Abstract
Current cervical total disc replacement (TDR) designs incorporate a variety of different biomaterials including polyethylene, stainless steel, titanium (Ti), and cobalt-chrome (CoCr). These materials are most important in their utilization as bearing surfaces which allow for articular motion at the disc space. Long-term biological effects of implanted materials include wear debris, host inflammatory immune reactions, and osteolysis resulting in implant failure. We review here the most common materials used in cervical TDR prosthetic devices, examine their bearing surfaces, describe the construction of the seven current cervical TDR devices that are approved for use in the United States, and discuss known adverse biological effects associated with long-term implantation of these materials. It is important to appreciate and understand the variety of biomaterials available in the design and construction of these prosthetics and the considerations which guide their implementation.
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Nam D, Nunley RM, Ruh EL, Engh CA, Rogerson JS, Brooks PJ, Raterman SJ, Su EP, Barrack RL. Short-term Results of Birmingham Hip Resurfacing in the United States. Orthopedics 2015; 38:e715-21. [PMID: 26270759 DOI: 10.3928/01477447-20150804-60] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 11/04/2014] [Indexed: 02/03/2023]
Abstract
Previous data on the survivorship of the Birmingham Hip Resurfacing (BHR) implant have come from design surgeons and large national databases outside of the United States, and there is a lack of reported outcomes of surface replacement arthroplasty from US centers. A retrospective study was undertaken of 1271 hips treated with a BHR system (Smith & Nephew, Memphis, Tennessee) between June 2006 and September 2008 at 6 high-volume total joint centers in the United States. Demographic features, Harris Hip Score (HHS), and radiographic findings were recorded. Patients who did not have a 2-year follow-up visit were contacted by telephone. All patients were asked about complications, reoperations, or failure of the implants. Of the treated hips, 1144 (90%) had a minimum of 2 years of clinical follow-up (mean, 2.9 years; range, 1.8-4.2 years). Mean age was 52.3 years, and 75% of patients were men. Mean HHS improved from 55.8 preoperatively to 97.4 at the most recent follow-up (P<.001). There were 16 (1.4%) revisions to total hip arthroplasty (THA) for fracture (7), early dislocation (3), acetabular component malpositioning with pain (3; 1 with metallosis), infection (1), femoral loosening (1), and pseudotumor (1). There were 9 additional complications (0.8%) that did not require revision, including 3 dislocations treated with closed reduction, 2 fractures, 3 nerve injuries, and 1 pseudotumor. At 2 to 4 years of follow-up, the revision rate and the major complication rate with the BHR system were similar to those in previous reports of primary THA. Excellent clinical results were observed, but further follow-up is necessary to assess mid- and long-term results with the BHR system in US patients.
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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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Haddad FS, Konan S, Tahmassebi J. A prospective comparative study of cementless total hip arthroplasty and hip resurfacing in patients under the age of 55 years: a ten-year follow-up. Bone Joint J 2015; 97-B:617-22. [PMID: 25922454 DOI: 10.1302/0301-620x.97b5.34537] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years. Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14). Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores. No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years. We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems.
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Affiliation(s)
- F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK
| | - S Konan
- University College London, 250 Euston Road, London, NW1 2BU, UK
| | - J Tahmassebi
- University College London, 250 Euston Road, London, NW1 2BU, UK
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Toxicology of wear particles of cobalt-chromium alloy metal-on-metal hip implants Part I: Physicochemical properties in patient and simulator studies. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1201-15. [DOI: 10.1016/j.nano.2014.12.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 12/27/2022]
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Abstract
We report our failures with the use of the R3 metal-on-metal bearing. Forty six patients had an R3 acetabular system metal-on-metal THR in our centre between March 2007 and March 2009. All operations were performed using femoral components and appropriately matched femoral heads manufactured by Smith and Nephew. Twelve patients underwent revision surgery for adverse reaction to metal debris (ARMD). The median acetabular inclination was 40 degrees (range 21.1-49.1) and the median acetabular anteversion was 7.5 degrees (range 3.3-10.4). The median serum Cobalt was 9.9 µg/L (range 3.1-45) and the median serum Chromium was 5.8 µg/L (range 1.8-19.3). The time to revision was 39.2 months (range 13-53). Our current failure rate is 24%.
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50
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Complications Related to Metal-on-Metal Articulation in Trapeziometacarpal Joint Total Joint Arthroplasty. J Funct Biomater 2015; 6:318-27. [PMID: 26020592 PMCID: PMC4493514 DOI: 10.3390/jfb6020318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/18/2015] [Indexed: 02/08/2023] Open
Abstract
Adverse reactions to metal-on-metal (MoM) prostheses are well known from total hip joint resurfacing arthroplasty with elevated serum chrome or cobalt, pain and pseudo tumor formation. It may, however, also be seen after total joint replacement of the trapeziometacarpal joint using MoM articulation, and we present two cases of failure of MoM prostheses due to elevated metal-serum levels in one case and pseudo tumor formation in another case. Furthermore, we suggest a diagnostic algorithm for joint pain after MoM trapeziometacarpal joint replacement based on published experiences from MoM hip prostheses and adverse reactions to metal.
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